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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
753
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:
n 41 (%)
23
6
3
5
2
2
(56)
(15)
(7)
(12)
(5)
(5)
4 (10)
34(83)
3 (7)
754
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)
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*
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
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
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*
0.005*
0.171
755
756
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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