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Nurse Education in Practice 14 (2014) 752e756

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Nurse Education in Practice


journal homepage: www.elsevier.com/nepr

Midwifery education in practice

Assertiveness training for undergraduate midwifery students


Jane Warland*, Lois McKellar, Monica Diaz
School of Nursing and Midwifery, University of South Australia, Adelaide, Australia

a r t i c l e i n f o

a b s t r a c t

Article history:
Accepted 23 September 2014

Assertiveness can be dened as an interpersonal behaviour that promotes the fact all people in a relationship are equally important. All health professionals including midwives must work with and care for
people. At times this will include facilitating interactions that require skilful negotiation and assertiveness. Yet embedding assertiveness education into undergraduate midwifery curricula has not been
widely adopted.
This paper explores one method of delivering assertiveness training in an undergraduate midwifery
course and provides comment on the effectiveness of this strategy in developing assertiveness skills in a
cohort of undergraduate midwifery students.
We used an assertiveness survey which was administered immediately before and 3e4 months after
an assertiveness training workshop.
All students (n 55) attending the training day were invited to participate. Of these 41 (77% response)
chose to participate in the pre intervention survey and 32 participated (9 students lost to follow-up) in
the follow up survey.
There was an overall improvement in self-perceived assertiveness scores following the assertiveness
training workshop.
These ndings provide encouraging evidence that educational institutions that offer specic and
targeted assertiveness education will be rewarded with more assertive graduates.
2014 Elsevier Ltd. All rights reserved.

Keywords:
Assertiveness
Undergraduate education
Midwifery

Background
Assertiveness can be dened as an interpersonal behaviour that
maintains boundaries whilst allowing people in relationship to
express their needs clearly and directly. Assertive behaviour is seen
when an individual gives expression to their rights, thoughts and
feelings in a way that does not degrade but recognises and respects
the rights, thoughts and feelings of others (Begley and Glacken,
2004; Slater, 1990).
Assertiveness may sometimes be confused with aggression,
particularly in the workplace. However, the main difference between assertiveness and aggression is in the approach taken to a
situation or problem. A person exhibiting assertive behaviour will
tackle the problem rather than the person, so that all involved are
respected (Slater, 1990). In contrast, a person exhibiting aggressive
behaviour will have little regard for the thoughts and feelings of

* Corresponding author. School of Nursing and Midwifery, Division of Health


Sciences, University of South Australia, Adelaide 5001, Australia. Tel.: 61 08
83021161; fax: 61 08 83022168.
E-mail address: jane.warland@unisa.edu.au (J. Warland).
http://dx.doi.org/10.1016/j.nepr.2014.09.006
1471-5953/ 2014 Elsevier Ltd. All rights reserved.

others in their quest to achieve a solution to a problem (Slater,


1990). A positive correlation exists between assertiveness, job
satisfaction and role clarity (Lounsbury et al., 2003) as well as the
ability to deal with stress and bullying in the workplace. Assertiveness skills therefore, can be used to counteract workplace
bullying, as well as ameliorate stressful situations and increase
empowerment (Begley, Glacken, 2004).
There have been a few studies exploring the benets of assertive
behaviour for nurses, (Kilkus, 1993; Lawton, Stewart, 2005; Sudha,
2005) however, this is less well explored in the midwifery profession. One of the core competencies of a registered midwife is to act
as an advocate to protect the rights of woman in relation to maternity care (NMBA, 2006). This involves acknowledging and
respecting the woman's right to be involved as an active participant
in her care as well as advocating for her as she makes decisions,
whilst maintaining her dignity and privacy. Therefore, the ability to
be assertive when advocating for women is key to the midwife's
role. At times this will include facilitating interactions that require
skilful negotiation and assertiveness. It is not uncommon to nd
midwives dealing with highly aroused partners and/or family
members, as well as having to support and look after the needs of
the woman herself and deal assertively with colleagues. In order for

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J. Warland et al. / Nurse Education in Practice 14 (2014) 752e756

midwifery students to be well prepared for their role as a midwife it


is important that they are equipped with skills to safely manage
their own behaviour and the behaviour of others.
Midwifery is a predominately female profession. Femininity has
been traditionally associated with non-assertiveness, caring and
nurturing behaviours, however, the role of a midwife is also professional and autonomous. These factors may act to reduce a midwife's capacity to behave in an assertive manner (Timmins and
McCabe, 2005a, b). As nurses and midwives move away from
traditional stereotypes (Jinks and Bradley, 2004), it is increasingly
being recognized that caring and assertive behaviours can co-exist
(McCartan; Hargie, 2004). Indeed, much literature supports the fact
that assertive behaviour in clinical practice enables effective safe
professional communication (Garon, 2012) as well as a sense of
personal empowerment (Laschinger et al., 2009).
Although specic individual assertive behaviours and skills have
been examined in many settings, little empirical evidence exists
about the manner in which assertive skills are acquired and used by
nurses and midwives in the workplace. Those studies which have
been conducted indicate that assertiveness skills are not necessarily innate and therefore, may be learned (Arslan et al., 2013;
Kilpatrick, Forchuk, 1992; Lee, Crockett, 1994; Lin et al., 2004.)
This paper explores one method of delivering assertiveness training
in an undergraduate midwifery course. We provide comment on
the effectiveness of this strategy in developing assertiveness skills
in a cohort of undergraduate midwifery students.
Instrument
Following a review of the relevant literature, we identied
several assertiveness scales (Galassi et al., 1974; Gambrill, Richey,
1975; Rathus, 1973). We chose an assertiveness questionnaire
developed by Begley and Glacken (2004) which had been specifically created for use with Irish undergraduate nursing students.
We adapted it for use with undergraduate midwifery students by
changing the word patient to woman. The questionnaire
included 28, 4 point Likert questions with the options always,
often, rarely and never. The questions were designed to determine students' current level of assertiveness both in the workplace
and in social settings and had been validated both by the developers (Begley& Glacken, 2004) and through a similar study to
ours (Deltsidou, 2009). In addition to the assertiveness questionnaire students were also asked their age range and enrolment
status (i.e. domestic or international).
Approach
The study was designed to measure midwifery student's assertiveness immediately prior to the start of the one-day assertiveness
training workshop and assess whether or not this changed when
the students returned to the University after a clinical placement. A
pre and post intervention survey was administered. The rst
baseline survey was administered face-to-face immediately prior to
the workshop commencing. A second post-intervention survey
consisting of the same questions was administered when students
attended University for their post clinical placement debrief
workshop. This workshop occurred approximately three to four
months after the assertiveness training workshop.
The workshop
Assertiveness training programmes are designed to improve an
individual's assertive beliefs and behaviours, which can help the
individual change how they view themselves and establish selfcondence and reduce social anxiety (Lin et al., 2008). The

workshop was run by the Principal Consultant of a local Counselling and Consultancy Service. She holds qualications in social
work, and has extensive experience in facilitating such training.
The one day workshop consisted of: lectures, role-plays, and
facilitated discussion. Topics included:
#
#
#
#

Denition of assertiveness
Overcoming difculties in becoming assertive
Steps in giving assertive criticism
The role of emotional intelligence, stress, fear, control, power,
respect, self-condence, and resilience in determining
assertiveness
Role plays included small groups practising:

# differentiating between assertive, non-assertive and aggressive


verbal and non-verbal behaviour
# assertively:
B telling others how they felt
B expressing negative feelings
Groups discussed the following over the course of the day:
# identifying stereotypes (especially female)
# the inuence of positional power on one's ability to assert
oneself
# what can inuence people's views of assertive communication
# discussion of a coroner's report (Lock, 2012) in which the midwives involved did not respond assertively to the emerging
situation and a baby died as a result (Table 1).
The facilitator of the workshop also conducted a workshop
evaluation using satisfaction measures. Students were given six
evaluation questions which asked for their response using5 point
Likert scales. 41 students (77% response) participated in the evaluation survey. There was greater than 98% broad agreement
(Strongly agree/Agree) on all questions with the remaining 1 or 2
students holding a neutral opinion (Table 2).
Population
The sample population consisted of 53 students. The students
were mainly direct entry students, registered nurses undertaking our undergraduate midwifery program receive credit for
this course. All students attending the workshop were invited to
participate. Of these 41 (77% response) chose to participate in the
pre intervention survey and 32 participated (9 students lost to
follow-up) in the follow-up survey after their clinical placement.
Table 1
Participant demographics.
Age group
19e24 years
25e30 years
31e36 years
37e42 years
>43 years
Missing
Enrolment status
International student
Domestic student
Missing
All were female.

n 41 (%)
23
6
3
5
2
2

(56)
(15)
(7)
(12)
(5)
(5)

4 (10)
34(83)
3 (7)

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J. Warland et al. / Nurse Education in Practice 14 (2014) 752e756

Table 2
Workshop participation evaluation data.

Table 3
Assertiveness scores.

Question

5 (High)

Subject matter
Interest level
Objectives
Presentation
Learning value
Participant involvement

34
22
28
31
23
29

7
18
13
8
17
10

3
1
2
1
2

1 (low)

Total
41
41
41
41
41
41

Ethical considerations
Ethics approval was gained from the University's Human
Research Ethics Committee. Shortly before the workshop began the
students were informed about the study by one of the investigators
(JW). Those who indicated they were interested were given a
participant information sheet and if they were still interested they
completed a consent form and the questionnaire. Students were
reassured that their participation was not compulsory, and that
their grade for the unit would not be affected, either by their
participation or non-participation. The assertiveness training
workshop was not linked in any way with unit assessment.
Data analysis
The assertiveness score was calculated by allocating 1 to 4
points to the answers to each question (Table 3) where 1 was
allocated to an unassertive answer and 4 for the most assertive
answer to each question. Most questions scored 1 for always and 4
for never, however, some questions were reverse scored when
always was the most assertive answer. The reversed scored
questions are indicated in bold on Table 3. The higher the students
scored the more assertive they perceived themselves to be.
Data were entered into SPSS version 19. Mean assertiveness
scores were calculated and comparisons made between students'
responses pre and post workshop using ManneWhitney U.
Results
Pre workshop assertiveness scores
Prior to the workshop the mean assertiveness score was 68.8
(range 53e92) (Table 3). The lowest mean score was to question 15
(I am careful to avoid hurting other people's feelings). The highest
mean score for all questions was to question 3 (I nd it difcult to
compliment and praise friends and acquaintances) (Table 3). Note
this was a reverse scored question indicating that the participants
considered that they rarely or never found this difcult.
Post workshop assertiveness scores
Following the workshop the mean assertiveness score was 75.5
(range 62e99). The lowest mean score remained with question 15.
The highest mean score for all questions was to question 9 (I would
feel uncomfortable paying a compliment to a junior colleague). The
mean score for this question was close to 4, indicating that most
participants had answered never to this reverse scored question.

Question

Time

Average
score

Exact sig.
(2 tailed)

1. At work I tend to keep my


feelings to myself
2. I feel uncomfortable asking
a colleague to do a favour
for me
3. I nd it difcult to compliment
and praise friends and
acquaintances
4. If a senior colleague made an
unreasonable request, I
would refuse
5. I enjoy starting conversations
with acquaintances and
strangers
6. I nd criticism from friends and
acquaintances hard to take
7. I want to know what my rights
are in the work place
8. If a friend makes an unreasonable
request, I would nd it difcult
to refuse
9. I would feel uncomfortable paying
a compliment to a junior colleague
10. If I was busy, I would ignore the
demands of a senior colleague
11. When I know a friend's opinion
is wrong, I would disagree with
him/her
12. At work I feel unsure what to say
when I am praised
13. I tend to be over-apologetic to
friends and acquaintances
14. I try to avoid conict at work

Pre
Post
Pre
Post

2.1
2.3
2.4
2.8

0.225

Pre
Post

3.5
3.6

0.393

Pre
Post

2.6
2.9

0.067

Pre
Post

2.5
2.95

0.009*

Pre
Post
Pre
Post
Pre
Post

2.4
2.6
3.3
3.6
2.5
2.9

0.276

Pre
Post
Pre
Post
Pre
Post

3.5
3.7
1.6
1.65
2.75
2.95

Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
Post

2.5
2.7
2.1
2.3
1.6
1.8
1.5
1.6
2.7
2.5
2.7
3.0
3.1
3.3

Pre
Post

2.5
2.5

0.978

Pre
Post

2.2
2.4

0.328

Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
Post

2.6
3.0
2.65
2.9
2.5
2.7
2.8
3.4
2.1
2.2
1.95
2.3
1.8
2.0
2.45
2.6

0.008*

15. I am very careful to avoid


hurting other people's feelings
16. In a group I make the decisions
17. I would ask for constructive
criticism about my work
18. When I am with friends, I am
frank and honest about my
feelings
19. If a colleague upsets a woman
(client), I would challenge
him/her about it
20. If I disagreed with a decision made
by a senior colleague, I would tell
him/her
21. At work I avoid asking questions for
fear of sounding stupid
22. I feel uncomfortable asking friends to
do favours for me
23. When someone pays me a compliment,
I feel unsure of what to say
24. If I was impressed by the actions of a
senior colleague, I would tell him/her
25. I tend to be over-apologetic to
colleagues
26. I tend to be over-concerned about my
woman's (client) welfare
27. I would feel uncomfortable expressing
annoyance at a senior colleague
28. I am a follower, rather than a leader

0.011*

0.053
0.039*

0.248
0.730
0.193

0.234
0.385
0.262
0.256
0.506
0.019*
0.282

0.145
0.346
0.001*
0.487
0.029*
0.280
0.270

Bold text is reversed scored.

Overall assertiveness scores


Overall the mean assertiveness scores prior to the workshop
was 68.8 and this improved to 75.5 (p .0002) following the
workshop. There was an improved score noted to 26 of the 28 individual questions between the pre and post-test, with the mean

score for question 19 remaining the same and the mean score for
question 16 dropping slightly. When examining the statistically
signicant changes to individual questions there was a general
tendency for the students to report increased level of assertiveness

J. Warland et al. / Nurse Education in Practice 14 (2014) 752e756

pre and post the workshop, however, this change was only statistically signicant to questions 2, 5, 8, 17, 21, 24 and 26 (Table 3).
Of importance is the signicant improvement (p .008) to
question 21 At work I avoid asking questions for fear of sounding
stupid as well as question 24 (p .001) If I was impressed by the
actions of a senior colleague, I would tell him/her.
Age
We divided the cohort into two age groups one under (n 23)
and the other over (n 17) 25 years of age (1 student did not give
her age and so was excluded from this analysis). There was a statistically signicant (p .005) improvement in mean assertiveness
score (from 68.15 to 75.49) in the students who were less than 25.
Whilst there was also an improvement in the overall mean score in
the group who were older than 25 (from 69 to 73.5) this was not
statistically signicant (Table 4). There was no difference between
perceived areas of strengths and weaknesses in assertiveness with
both age groups, having question 15 as their lowest score prior to
the workshop and question 9 as the most assertive both before and
after the workshop.
Discussion
There was an overall improvement in self-perceived assertiveness scores following the assertiveness training workshop. This
provides encouraging evidence that educational institutions that
provide specic and targeted assertiveness education will be
rewarded with more assertive graduates.
The link between assertiveness and maturity is well understood
(Goldman and Olczak, 1981; Twenge, 2001). However, when this
was assessed we found a statistically signicant improvement in
the younger students' scores and whilst there was also an
improvement in the overall assertiveness score in the older group
this was not statistically signicant. As the over 25's did not start
with a higher score this may indicate that the older student is more
resistant to change. Alternatively the type of training may have
better suited the younger students. Whatever the reason it would
be important for future research to assess how to better facilitate
the needs of older students as they learn this vital skill.
When learning assertiveness, some students may have to
wrestle with cultural mores and expectations from their family of
origin and education (Hijazi et al., 2011). Much of their earlier
socialisation may have been based on what others expected that
they 'should', 'ought', 'must' do, with some having little opportunity prior to the workshop to develop assertive skills (Hijazi
et al., 2011). Unfortunately the numbers of international (mainly
Asian and South East Asian) students in the cohort were too small
(n 4) to determine any distinct cultural difference in this
groups' assertiveness levels. Further research to determine the
effect of an assertiveness training for these students is therefore
warranted.
Table 4
Comparison of overall and age related mean level of assertiveness pre and 3 months
post assertiveness workshop.
Group

Time

Mean
score

Minimum
score

Maximum
score

Exact sig.
(2-tailed)

Overall score

Pre
Post
Pre
Post
Pre
Post

68.8
75.5
68.15
75.49
68.8
73.5

39
29
23
17
14
12

53
62
53
62
56
62

92
99
92
99
83.5
86

0.002*

Age less than 25


Age older than 25

0.005*
0.171

755

Howard (2001) noted that improved assertiveness may impact


negatively on the students' personal and social lives. With Mc Cabe
and Timmins (2003) going so far as to suggest that the students
may need to be supported as they learn to deal with such issues. In
this study students appeared to nd new condence in the workplace as demonstrated by their signicantly improved responses to
questions 21 and 24. Many students also reected their positive
evaluation of the workshop on their personal life by making comments such as:
I identied that I need to be more condent and actually know
when to step up and express my concerns when necessary without
undermining my peer's authority. It was useful for my personal
growth
I believe this training is very useful as it will allow me to better my
assertiveness when working in the work place as well as my personal life.
Identied barriers that may prevent nurses from being assertive
include lack of knowledge about personal/professional rights,
concern about what others will think about their behaviour and
anxiety due to a lack of condence and poor self-esteem (Poroch
and McIntosh, 1995). Our study demonstrated an improvement in
understanding rights in a group who already seemed to understand
these rights (pre score 3.3 to post score 3.6: maximum score 4). We
also found a signicant improvement in students being prepared to
ask questions, even if this was at the expense of sounding stupid.
It would therefore appear that our students may have overcome
some of the barriers to becoming assertive.
Limitations
It is recognised that there would be a natural improvement in
assertiveness over time, with both life experience and maturity.
However, the improvement in the overall perceived assertiveness
score in this study occurred over a relatively short period of time
(relative to a life-time) and thus most of the improvement can
probably be attributed to the specic education on assertiveness
the students received.
The assertiveness education package was one developed by an
individual consultant especially for our students, therefore the
study may not be easily replicated in other schools of Nursing and
Midwifery, neither are the results necessarily generalizable to other
Nursing and Midwifery schools.
Those students who did not complete the post-workshop survey
could perhaps be assumed to be less assertive than those who
chose to remain in the study and if this was the case their nonparticipation could have been responsible for the increase in
assertiveness score. However, the mean assertiveness score of
those who did not participate in the post workshop survey was
actually a little higher (69.18) than the remaining respondents,
indicating that if these students had participated the postworkshop score could have been even higher.
Conclusions
Assertiveness is an important skill for midwives to develop.
Holding these skills enables midwives to advocate for the woman,
improves inter-professional communication, and personal condence. Providing assertiveness training is therefore an important
part of any undergraduate midwifery programme. However, dedicated assertiveness training is not always part of higher education
and can be costly.

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J. Warland et al. / Nurse Education in Practice 14 (2014) 752e756

Although the benets of teaching this topic have not yet been
empirically tested, our pre and post intervention study demonstrates that there are signicant and immediate benets for student
midwives, especially in gaining condence in asking questions and
not being afraid to compliment their superiors on a job well done.
Whilst our students reported feeling more assertive this may
not necessarily translate to changed personal behaviours in the
clinical environment. It would be important for future studies to
explore this and also if there are any barriers to change that the
students experience when they attempt to put assertive skills into
practice. Further research is also required to determine more
effective methods for enabling older students to improve their
assertiveness scores. More research is also needed on whether or
not different cultural groups require a different approach when
teaching them these skills.
Outlining how we approached this particular teaching session
may prove to be a useful guide for those involved in teaching
assertiveness to undergraduate midwifery students. Overall the
students evaluated the workshop as valuable and we found that
they self-reported increased assertiveness scores three months
following the assertiveness training workshop.
Acknowledgements
Students undertaking the perinatal mental health course in
2013: for generously agreeing to take part in this research during a
very busy year.
Maurissa Ailion who designed and delivered the assertiveness
training.
Prof Adrian Esterman for his assistance with data analysis.
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