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Assertiveness in nursing practice: An

action research and reflection project
a

Beverley Taylor , Beth Holroyd , Paul Edwards PhD Candidate ,

c

Anna Unwin & Joanne Rowley PhD Candidate

Foundation Chair in Nursing Southern Cross University, Lismore

campus, Lismore, New South Wales
b

Mental Health Nurse Coffs Harbour Health Campus, Coffs

Harbour, New South Wales
c

Nurse Educator Coffs Harbour Health Campus, Coffs Harbour,

New South Wales
d

Nurse Researcher Coffs Harbour Health Campus, Coffs Harbour,

New South Wales
Published online: 17 Dec 2014.

To cite this article: Beverley Taylor, Beth Holroyd, Paul Edwards PhD Candidate, Anna Unwin &
Joanne Rowley PhD Candidate (2005) Assertiveness in nursing practice: An action research and
reflection project, Contemporary Nurse, 20:2, 234-247, DOI: 10.5172/conu.20.2.234
To link to this article: http://dx.doi.org/10.5172/conu.20.2.234

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Copyright eContent Management Pty Ltd. Contemporary Nurse (2005) 20: 234247.

Assertiveness in nursing practice: An

action research and reflection project

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ABSTRACT

Key Words
action research;
reflective
practice;
assertiveness;
nursing practice

This article describes an action research project that highlighted reflective

processes, so hospital nurses could work systematically through problem solving
processes to uncover constraints against effective nursing care; and to improve the
quality of their care in light of the identified constraints and possibilities. Four
Registered Nurses (RNs) co-researched their practice with the facilitator and
over the research period identified the thematic concern of the need for
assertiveness in their work.The RNs planned, implemented and evaluated an
action plan and, as a direct result of their reflections and collaborative action,
they improved their nursing practice in relation to becoming more effective in
assertiveness in work situations.
Received 5 August 2005

Accepted 27 October 2005

BEVERLEY TAYLOR

PAUL EDWARDS

Foundation Chair in Nursing

Southern Cross University, Lismore campus
Lismore, New South Wales

PhD Candidate and Mental Health Nurse

Coffs Harbour Health Campus
Coffs Harbour, New South Wales

BETH HOLROYD

ANNA UNWIN

Mental Health Nurse

Coffs Harbour Health Campus
Coffs Harbour, New South Wales

Nurse Educator
Coffs Harbour Health Campus
Coffs Harbour, New South Wales

JOANNE ROWLEY
PhD Candidate and Nurse Researcher
Coffs Harbour Health Campus
Coffs Harbour, New South Wales

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Volume 20, Issue 2, December 2005

Assertiveness in nursing practice

INTRODUCTION

LITERATURE REVIEW

ursing in hospitals involves negotiating

complex interpersonal relationships and
working in a social and political context within
economic constraints, while balancing a multiplicity of tasks and roles. Nurses are busy clinicians who need to have a broad range of clinical
knowledge and skills, and they are accountable
to many people (Benner 1984; Benner and
Wrubel 1989; Taylor 1997, 2000). Hospital
nurses are caught up in the complexity and
busyness of daily work, but these constraints can
be managed effectively by reflective processes
(Freshwater 2002;Taylor 2000).
This article describes an action research
project that emphasised the value of reflective
practice through which nurses identified the
thematic concern of assertiveness at work.This
article describes the project in terms of its
background, methodology, methods, processes
and insights.The action plan the nurses generated and instituted for practising assertively is also
described.

Assertiveness is an important issue in nursing

practice. After a period of reflective practice,
when the nurses in this project identified their
need for assertiveness at work, the literature
was explored with the intention of assisting in
the creation of the action plan. Nursing literature repeats the call for nurses to become more
assertive (Gaddis 2004; Levesque 2003; Madden 1996; McNally 2002; Milstead 1996; Morris 2004; Kupperschmidt 1994; Larson 1997;
Pacquiao 2000; Pauly-ONeill 1997; Smith
1997). Education programs in assertiveness
knowledge and skills have been in vogue for
some time in nursing because nurses have
recognised the need for assertiveness in quality
nursing care (Benton 1999; Cardillo 2003;
Class 2001; Crouch 2003; Floyd 1999, 2001;
Habel 2004; Lyttle 2001; McCabe & Timmins
2003; Milstead 1996; Pearce 2004; Percival
2005, 2001, 2000; Stein-Parbury 2005;Woods
2003). All of these authors agree that assertiveness is important in nursing practice, but that it
is complex and requires time and practice to
make it effective.
This review describes some recent nursing
research into assertiveness (Addis & Gamble
2004; Jaime et al. 1998; McCartan & Hargie
2004a,b; Timmins & McCabe 2005). Timmins
and McCabe (2005) undertook a preliminary
pilot study to assess how assertive nurses are in
the workplace, in order to develop an instrument and report on the results.The researchers
distributed the 44-item questionnaire to 27 registered nurses and the results showed that nurses in the study responded strongly to items
allowing others to express opinions, complimenting others and saying no (Timmins and
McCabe 2005:61). The researchers concluded
that the nurses behave in a passive, nice way and
were less adept at disagreeing with others
opinions and providing constructive criticism
(Timmins and McCabe 2005:61). Even though
this project has been reported as a preliminary
pilot study, the results should be viewed cau-

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AIM, OBJECTIVES, SIGNIFICANCE

AND BACKGROUND
This project aimed to facilitate action research
and reflective practice processes in experienced
Registered Nurses in order to:
raise critical awareness of practice problems
they face everyday;
work systematically through problem solving
processes to uncover constraints against
effective nursing care; and
improve the quality of care given by hospital
nurses in light of the identified constraints
and possibilities.

The significance of the project was in improving

nursing care and in educating nurses in a
research process they can use for clinical problems that emerge daily in their practice.
The project originated through collaboration
between a School of Nursing and practice-based
nurses.

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Beverley Taylor et al.

tiously because of low sample numbers and the

tendency for questionnaire respondents to indicate nice or self-fulfilling behaviours, even if
they practice in a contrary way, by using active
assertion in their workplace.
Addis and Gamble (2004:452) aimed to
understand what nurses had learned from an
assertive outreach (AO) experience.The project
was informed by the phenomenological concepts of Heidegger and data were collected
through the use of semi-structured interviews
of five rural AO nurses working in one county
in England. The thematic analysis revealed that
nurses understood their experience of assertive
engagement as involving: having time; anticipatory persistence and tired dejection; pressure,
relief and satisfaction; being the human professional confluence; accepting anxiety and fear;
working and learning together; and bringing the
caring attitude. Thus it was shown that being a
rural AO nurse involves contradictory yet
rewarding experiences in practising assertive
behaviours with clients.
McCartan and Hargie (2004a:707) administered The Caring Assessment Instrument and
the Assertion Inventory to a convenience sample
of 94 nurses to find answers to their research
question, Assertiveness and caring: are they
compatible? The background to their project
was that numerous assertion studies suggest
that nurses are generally non-assertive, so they
wanted to determine whether positive and negative assertion behaviours were related to caring
skills. The researchers defined positive assertion as:
other-centred caring type behaviours such as
expressing positive feelings, initiating and
maintaining interactions, giving and receiving
compliments, and conveying empathy.
(McCartan & Hargie 2004a: 707708)
Negative (standard conflict) responses are often
viewed as self-centred skills and may be considered undesirable attributes in nursing (McCar236

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tan & Hargie 2004a:708). After analysis of the

nurses responses, they concluded that:
Overall the findings of the study suggest that
positive and negative assertive behaviours are
not related to caring skills The current
findings suggest that the presence of caring
attributes cannot be offered as a possible reason for non-assertion in nurses.
(McCartan & Hargie 2004a:707)
McCartan and Hargie (2004b) distributed the
Bem Sex-Role Inventory and the Assertion
Inventory to a convenience sample of 94 subjects, to determine the effects of nurses sex
role orientation on positive and negative assertion.The researchers reported that contrary to
earlier studies, the findings of the investigation
indicated that there was no significant relationship between assertion measurements and sexrole orientation (McCartan & Hargie 2004b:
45). The findings of the research projects by
McCartan & Hargie (2004a,b) demonstrate difficulties in making exact statements about
assertiveness and suggest that its success is relative to the contexts in which nurses enact it.
The research question posed by Jaime et al.
(1998:98) was whether assertiveness is a characteristic of the nursing profession. Their
descriptive study aimed to determine the
degree of assertiveness in nurses and to assess
the influence of personal characteristics, such as
age, sex, marital status, work experience and
place of employment. A questionnaire measuring the degree of assertiveness in professional
environments was distributed to 75 nurses
working in acute care settings in three Spanish
hospitals.The results showed qualitative differences according to personal characteristics
although these were not statistically significant,
and a high percentage of nursing professionals
showed low degrees of assertiveness (Jaime et
al. 1998:98). The researchers concluded that
given the low degree of assertiveness in the
research sample, assertiveness training was necessary to improve the quality of health care.

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Assertiveness in nursing practice

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Their conclusions assume that caring and

assertiveness are linked and that assertiveness is
essential in the provision of quality nursing care.
In summary, nursing research literature
emphasises the need for nurses to become more
assertive and to acquire the necessary knowledge and skills to make nurses assertiveness
more apparent in their workplaces.

water 1999), and education (Anderson &

Branch 2000; Clegg 2000; Cruickshank 1996
Freshwater 1999; Kim 1999; Platzer et al.
2000). Much of the literature focuses on the
work of nursing as practised in clinical contexts
(e.g., Freshwater 1998, 2002; Glaze 1999;
Heath 1998a,b; Johns 2000, 2003;Taylor 2004.
2003, 2002a,b;Wilkin 2002).

METHODOLOGY

Action research
Action research involves four stages of collectively planning, acting, observing and reflecting
(Dick 1995; Stringer 1996).This phase leads to
another cycle of action in which the plan is
revised, and further acting, observing and
reflecting is undertaken systematically to work
towards solutions to problems of a technical,
practical or emancipatory nature (Kemmis &
McTaggart 1988;Taylor 2000).
Nurses have been using action research
successfully in a variety of settings focusing
on differing thematic concerns (e.g., Keatinge
et al. 2000; Koch, Kralik & Kelly 2000;
Chenoweth & Kilstoff 1998). Action research
and reflective processes combine well methodologically because of their common interest
in making sense of experiences, in order to
progress to deeper insights and personal and
professional changes. Research using action
research and reflection has been successful in
giving nurses contextual answers to practice
issues such as dysfunctional nursenurse relationships (Taylor 2001b) and nurses tendencies
towards idealism in palliative care (Taylor et al.
2002).

In qualitative research, methodology usually

means the theoretical assumptions of how
knowledge is generated and validated, which
underlie the choice of methods. Given the collaborative nature of the project, a qualitative
approach was chosen, informed by reflective
practitioner concepts and action research.

Reflective practice
Taylor (2000:3) defines reflection as the throwing back of thoughts and memories, in cognitive
acts such as thinking, contemplation, meditation
and any other form of attentive consideration,
in order to make sense of them and to make
contextually appropriate changes if they are
required. Schn (1983) emphasised the idea
that reflection is a way in which professionals
can bridge the theorypractice gap, based on
the potential of reflection to uncover knowledge in and on action. He referred to tacit
knowledge, or knowing in action, as the kind of
knowledge of which practitioners may not be
entirely aware. When practitioners/clinicians,
such as nurses, are coached to make explicit
their knowing-in-action, they can inevitably use
this awareness to enliven and change their practice (Schn 1987).
Nursing has applied reflective practice ideas
to many of its disciplinary areas. In particular,
nursing has used reflective processes for some
time, for example, to improve practice and
practice development (Johns 2003; Stickley &
Freshwater 2002;Thorpe & Barsky 2001;Taylor
2000, 2002a,b), clinical supervision (Gilbert
2001; Heath & Freshwater 2000;Todd & Fresh-

ACCESSING PARTICIPANTS
Ethical implications
Full ethical clearance from the University and
the Health Campus Research Committee preceded the commencement of the project. As
this research encouraged nurses to share their
practice stories, likely risks were that the privacy and confidentiality of patients may have been

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Beverley Taylor et al.

breached and that nurses may have felt vulnerable in sharing their experiences, leading to
embarrassment or possible emotional catharsis,
such as tearfulness or anger. No group member
became emotionally upset beyond the ability of
the group to support them and. although the
project offered professional counselling at no
cost to self, no participant required this service.
Nurses are educated in the need for patient
confidentiality and they practice it daily in their
work. Even so, the researcher ensured that privacy and confidentiality measures were instituted and maintained. Stories written in journals
and shared in group meetings were devoid of
information which could identify patients, relatives and staff. Pseudonyms were used and identifying material was omitted or renamed to
protect the identities of people within the written transcripts of the stories. Reflective journals
remained the personal property of participants
and they were not be read or sighted by the
researcher unless it was a participants expressed
wish that this occurred. Reports and published
material describe the participants stories and
interpretations, according to the issues they
raised and the practice improvements they
caused, rather than to identify specific people,
places and situations.

Participant recruitment
A verbal and written explanation of the project
was given by the researcher at a regular meeting
of the Registered Nurses (RNs) working at the
hospital. Convenience sampling was used to target intentionally RNs interested in reflecting on
their practice in order to improve it. Four RNs
agreed to participate: three females and one
male, from 30 to 45 years of age, with from 10
to 15 years of clinical nursing experience.

The sequence of research activities was based

on previous projects (Taylor 2001a,b).The data
collection activities were embedded in the
group processes and they were that:
RNs were given opportunities to write journal reflections of practice experiences, by
using participant observation during the normal course of their work in ward areas. As
with all nursing care, the details of patients
care were completely confidential.
the reflections were shared in the group
meetings.
the individual and the group critically
analysed the content of all the shared practice
stories and identified common themes and
issues in nursing practice (Taylor 2000).This
means that the participants collectively discussed issues raised in the stories, decided on
the specific nature of issues and named those
issues as research themes.
a theme common to all of the reflections was
identified as the thematic concern (issue) as a
focus for the group. The thematic concern
was the need for assertion in workplace communication.
an action cycle of planning, assessing, observing and reflecting generated an action plan
for addressing and amending the identified
thematic concern.
the action plan was instituted in nursing
practice and the results of the changed
approach to the thematic concern were
noted, through continued planning, acting,
observing and reflecting.
the action plan underwent revision until it
achieved positive changes in successfully
managing the identified thematic concern of
assertion in nursing practice.

RESEARCH PHASES

Data collection and analysis

The research period occurred in five main
Over a 17-week period, the four RNs met phases:
weekly with the researcher/facilitator for one introductory processes;
hour to discuss clinical problems raised by them reflections on practice stories;
in their journal writing and group discussion. locating a thematic concern;
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generating, applying and revising the action

plan; and
improving assertion through reflective practice.

Phase One: Introductory processes

The introductory processes were from the first
to third meeting inclusive. In the first meeting,
each participant received a folder containing
documents relating to the research. Participants
read the Plain Language Statement about the
research and signed the Consent Form. Participants began talking about themselves, especially
where they work and what they hoped to
achieve from the research.The researcher/facilitator gave a brief introduction to the main ideas
within action research and reflective practice
and how the two combine well for research
into nursing practice. Participants discussed the
group processes and agreed that they would like
to be uninterrupted when telling a story, and
expressed the wish for confidentiality in the
group to be maintained to develop trust in the
group and to encourage disclosure. Participants
decided to meet weekly at the same day and
time and to use videoconferencing sometimes,
to reduce the researcher/facilitators road travel.
The second meeting was by videoconferencing and each participant spoke informally about
their week and how they were feeling generally.
This became an informal check-in icebreaker
each week. Participants were concerned about
having relatively little knowledge of research so
they were assured that the process would be
instructive in collaborative research processes.
Participants were asked to reflect on the following questions: Who influenced my childhood
(people, organisations, etc)? What rules for living did I learn? How have these rules for living
influenced my nursing practice? Participants
responded spontaneously to these questions and
they agreed to reflect on these questions during
the week.
In the third meeting, it was reiterated that no
persons name would appear in research reports

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of publications and that the use of a split pronoun approach (s/he) to writing would hide
the identity of the only male in the group. Participants read the Agendas and Minutes of the
previous meetings and noted handouts on Some
Background on Research and Reflection, and
the first reflective task of reflecting on childhood influences. Participants shared some of
their thoughts on the introductory reflecting
task. For example: A participant recognised personal difficulty in facing anger, relating to a
work situation in which confrontation of an
aggressive colleague was needed. The participant tried to secure a winwin situation and
remarked that it was important to be assertive
in the situation, especially in light of how nurses
might be perceived by other members of the
multidisciplinary team. It was noted that disciplines have different ways of communicating
and that it is far easier to talk with nurse colleagues than it is with other professionals, such
as teachers.

Phase Two: Reflections on practice

stories
The second phase of reflecting on practice stories was from the fourth to seventh meeting
inclusive. In the fourth meeting, participants
began sharing their practice stories. For example, a participant shared a story of being called
urgently to a medical ward by some nurses and
s/he did not know why, but guessed it related
to a clinical situation.When s/he arrived, there
was a young male patient in distress,in a dreadful situation. He was clammy, pale and had a
tracheostomy. S/he assessed that the mucous
coming copiously through his mouth and tracheostomy tube was indicative of pulmonary
oedema. At first s/he thought: What am I
doing here? I dont know what to do, but the
old ICU nurse kicked in and s/he took control
of the situation and organised the emergency
care and medical assistance. Since that time,
s/he has used that scenario to highlight the
case in the hospital, but s/he has felt powerless
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Beverley Taylor et al.

to cause changes as some people have a strangle

hold on the decisions. S/he also commented
that s/he was careful not to blame the nurses in
the situation, but wondered why they were trying to hide their lack of knowledge of what to
do and whether they were scared of getting
into trouble for doing something wrong, even
though they had done nothing wrong.
This led to a conversation of how nurses are
in life/death situations with so much to know in
order to act quickly to be effective clinically.
The researcher/facilitator suggested that the
participant who shared the story raise as many
questions as s/he can about the situation and
personal responses to it, but to leave the questions open-ended and unanswered. Another participant commented that, especially at acute
ward level, nurses are quick to notice other
nurses mistakes but do not tend to give praise
to one another.
In the fifth meeting, participants spoke
briefly about some reflections on the story of
the acutely ill male patient with pulmonary
oedema and other questions that might be asked
about the story. Participants continued sharing
their practice stories. A practice story related to
a busy shift in ICU, when a child with acute
leukaemia was admitted.The participant told of
the terror that s/he feels when a sick child
comes in, relating the sense of responsibility it
creates. The participant was relieved when the
childs care was allocated to a senior nurse who
s/he felt could handle it when the child needed a platelet transfusion. The participant
expressed the need s/he felt to check on the
infusion procedure for platelets, sensing that the
nurse may not have been aware of how to do the
task properly. The information was not in the
ward so s/he went to locate it elsewhere. The
platelets had come from hundreds of kilometres
away, the childs parents were there, the ICU
was fairly silent, the platelets were not going
through and the participant feared the platelets
would soon be coagulating. As the nurse in
charge of that shift, the participant took control
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of the situation by quietly suggesting to the

nurse that s/he get another filter, while the participant gently moved the platelets in the transfusion bag to minimise coagulation. The
participant expressed feelings of increasing
stress, especially as the parents asked if anything
was wrong, and s/he covered up by replying
that it was a faulty filter. The after hours NUM
was contacted by phone and s/he was not
impressed having to find another filter and
asked why it was necessary. The participant
could not speak out loud on the phone as the
ward was quiet and the parents were listening.
The participant thought: Why couldnt she (the
nurse caring for the child) admit she didnt
know (how to prepare the filter)? What do the
parents think? After the story the participant
asked herself: Why do I take so much responsibility for others? The participant felt so
annoyed at the nurse for not speaking up and
admitting that she did not know how to prepare
the filter, as it would have saved so much time,
energy and worry.
A participant commented that nursing is a
job in which nurses are under scrutiny and
pressure.The researcher/facilitator guided the
storytelling participant through questions as
prompts to get to a deeper level of reflection on
the incident. Where do my ideas come from historically? In other words, what are the values you hold
about nursing practice and from where do your values
come? The participant expressed a belief in the
need for quality care, and for maintaining a professional image of nursing. In the past, s/he has
seen things done badly, incorrectly and s/he
imagined what it might be like to be in the
same predicament. What do I continue to use these
values in my work? Its just me I just want a
good outcome. Whose interests do these values
serve? In other words, who benefits? Me and the
broader image of nursing I guess Im modelling the image (I want for nursing). What power
relations were involved in the story? This nurse is
close to (someone in authority). The participant realised s/he stayed quiet in not asking the

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nurse in the story if she knew the correct procedure for the filter, because of implicit power
relations, even though the participant was in
charge of the shift and s/he felt it reflected
badly on her/his ability to handle the shift.
In the sixth and seventh meetings, participants continued to share practice stories and to
work through deeper levels of reflection and
meaning by posing questions to themselves
about their personal and professional values and
interests.

Phase Three: Locating a thematic

concern
Phase Three lasted from meetings eight to 11
inclusive. After many practice stories were
shared in the second phase, it was time to locate
a common interest on which all of the participants could reflect and use an action research
approach to explore more deeply. In the eight
and ninth meeting, participants examined a
Table of practice stories to locate issues and
themes within them. Participants discussed
issues and interests that arose: for example,
their reactions to suicide of clients and acquaintances, the relative usefulness of being under
scrutiny and pressure in nursing work, the inexplicability of nurses intuition, and the role of
consumer representatives in bringing about policy changes.
In the tenth meeting, participants listed the
issues/themes generated in the group as: assertion/confrontation/conformity; bullying and
horizontal violence; Aboriginal issues; professional protection of self and others; professional
competency of self and others; slow change;
having a sense of belonging; being under scrutiny and pressure, documentation issues; self
blame and perfection; autonomy versus duty of
care; and role clarification/role valuing.
In the next meeting (11), participants agreed
that they would work as a whole group and
needed to find a thematic concern that was sufficiently generic to their practice so that they
could all see improvements in that area. After

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much fruitful discussion, the group decided that

the area most common to them all, with the
best chance of creating practice improvements,
was the thematic concern of assertion/confrontation/conformity. As participants had not
checked their understanding of what each person meant by assertion, they defined it individually so that the group had a working definition.
The responses were that assertion is about:
Participant 1: valuing others opinions while
giving ones own opinion, and not being
scared to do so.
Participant 2: not being passive but not being
aggressive, so there is balance and a middle
ground. It is me challenging myself. I prepare
myself emotionally and usually say: I feel that
...,I would prefer that ...
Participant 3: being at a similar level to make eye
contact, not towering over or being towered
over; with attention to appropriate use of personal space. It involves having an internal conversation to make sense of the concern and to
get it out in the right way. It involves honesty
in what I am saying and feeling, and having self
respect and self esteem, to not let people tread
all over me.
Participant 4: an issue of equality, of feeling valued and of feeling I have an opinion worth
telling others, and having them listen. It reflects
confidence, and the need to let go of emotions,
to find a common ground.
In discussion, participants noted that assertion is
context-specific, in that it depends on the situation as to how nurses react and find voice at
that time. Participants spoke of trying to learn
to listen, taking extra breaths before speaking
and not making preconceived conclusions to
assist assertive communication. We needed to
take a two-week break from meetings so participants agreed to do some homework reflecting

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on what is useful and not useful about assertion,

and on practice scenarios when they were
assertive and it went well, and when assertive
attempts did not go well.

ing the previous week at work. For example, a

participant said that s/he experienced an effective assertive episode when s/he confronted a
staff member who used to undermine her.
S/he pulled her aside quietly and privately
told her how s/he felt. The person hearing the
message received it well and expressed surprise
that she had that effect on the participant.
Things have been great since. The participant
reflected that s/he had rehearsed the scenario
and that s/he was pleased it went well.This discussion led to the insight that nurses need not
only to maintain basic courtesies in assertive
attempts, they must also maintain their self
respect and to remind themselves that they are
worthy as nurses and people. Following discussion, the action plan was amended to the second
and final version.

Phase Four: Generating, applying

and revising an action plan
Phase Four lasted from meeting 12 to 14 inclusive. In meeting 12, the group noted that they
often have opportunities in their work to assert
themselves by confronting issues as they occur,
thereby choosing to avoid conformity and not
speaking up. They discussed their reflections
about what is useful and not so useful about
assertion by reflecting on practice situations. As
each person spoke, other participants responded and encouraged openness in a trusting group
process.
For example, a participant said that s/he has
been giving the matter a lot of thought and had ACTION PLAN: Strategies for
realised that assertion is the initiation tool to improving assertion at work
get things started as it is the starting point of 1. Ask: What are the real issues? What do I
collaboration within the multidisciplinary team.
need to communicate effectively?
If the timing is not right, assertion loses its 2. Bring energy to the job. Dont go to work
impact. If the timing of assertion is wrong, the
tired, or sick, or with personal issues getassertive attempt comes off the wrong way.
ting in the way that is, be feeling OK
Courage and timing are needed to get assertive
when you go to work, to give it your full
attempts just right so they have maximal impact.
attention.
This point led to further comments by other 3. Get your emotions under control that is,
group members, such as: In the consultation
be aware of your bodily responses to
role, timing is important ... it is important not
assertive opportunities, such as to note
to patronise. Experienced health care staff
your heart rate is telling you it is important
already have considerable communicative skills,
to speak, wait your turn, and then speak.
and poorly timed or initiated attempts to assert 4. Get the facts ready dont go off halfmay be interpreted as patronising.
cocked.
The group then moved onto the next part of 5. Find a good place to talk if possible, for
the process which was to brainstorm ideas for
example, not on the move and walking in a
strategies for making assertion more effective.
busy and noisy setting. Suggest a time to
Given that brainstorming allows all ideas to be
talk and go aside into a quiet environment.
heard and noted, the original list was unedited 6. If an ideal time and place is not possible for
and it contained some accompanying discussion
effective communication, gauge the responthat arose at the time the ideas were shared.
siveness of the other person and decide
In meeting 13, discussion continued about
whether to speak up at that time, or to wait
the pros and cons of assertion and whether the
until a more conducive moment.
action plan had been helpful to participants dur- 7. Timing is important, so it may be better to
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Assertiveness in nursing practice

wait to communicate an assertive position.
For example, in professional group meetings when issues arise, it may be better to
wait, recognising the limitations of the context.
8. Effective assertion requires a listener. The
person to whom you are communicating
needs to know who you are and why they
should listen to you. Introduce yourself and
make sure the person knows who you are,
how you fit into the scheme of things, and
how you have the capacity to represent
clients needs and issues.
9. Recognise the communication style of the
other person, as little may be achieved if
there is aggression and firmly held misconceptions.
10. When meeting with other people who are
not in your immediate disciplinary group,
to minimise misinterpretations based on
lack of understanding of roles and intentions, sit down and begin by asking people
about their priorities, specifically what they
hope to achieve in the meeting that is,
their objectives before conveying your
own. In this way, it is possible to clarify
intentions and expectations, and to see if
objectives match, and thereby ascertain the
angle people are coming from.
11. Be prepared to go it alone without backup
and support, when asserting a position.
12. Maintain basic courtesies, such as conveying
respect, by addressing the person by name
and title.
13. Maintain your self-respect and remind
yourself that you are worthy as a nurse and
person.
14. Remember that communication has many
modes such as face-to-face, emails, letters,
phone calls, etc, and that all of these communication modes are important opportunities for assertion.
15. Use ongoing reflection and educational opportunities to further develop knowledge
and skills in assertion.

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By meeting 14, participants were well into the

action research part of the project because they
were actively enlisting the action plan and refining it through practice reflections. For example,
a participant told of a situation involving a student who had been at the hospital for 10 days of
clinical placement and wanted the participant to
write a report on her abilities.The student was
looking pleadingly at the participant. In this
case, the participant asserted that s/he could
not in all fairness write a report based on one
day of observation of her practice, so s/he
referred her to another staff member in a better
position to comment.The participant said that,
at work, s/he was aware of the groups research
discussions and the action plan, and s/he kept
thinking:Assertion!

Phase Five: Improving assertion

through reflective practice
In the last phase from meetings 15 to 17 inclusive, participants continued to share practice
stories and insights related to assertiveness. For
example, a participant shared a practice story of
how s/he applied some principles learned in a
Tai Chi workshop to a clinical situation, specifically to become ready for assertiveness. For
example, a young female patient was in need of
a stay in a clinical support unit before being
allocated support accommodation. Frequent
previous attempts to secure the admission to the
clinical unit had been unsuccessful because of a
huge waiting list. The participant phoned the
doctor and, in a relaxed manner, laid out the
situation and put it in terms of pressure of
beds, and as advantages for the young female
and also for the unit. S/he emphasised
improved outcomes and was successful in securing short-term admission that day, to her/his
amazement. When the group discussed the
story, they focussed on tone of voice on the
phone when transmitting an assertive message.
The relaxed tone was because the participant
thought the situation was hopeless so there was
nothing to lose by another plea. Participants
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Beverley Taylor et al.

see no benefit from doing research I did
not have the experience or maybe I was too
lazy It was so timely when I heard it
was action research action and research! I
thought: That sounds good! I have had experiences and I have something to say. The
meetings have all been valuable I now
have a different spin on research and academic. This research can help my practice. I can
see what I have learned here and I have put it
into practice. I had only known about medical model research and it seemed too long.
This action research is perfect for me,
because of doing it (researching) in a group.

agreed that if they are too earnest in their

requests, the voice can become crackly and does
not sound assertive. In addition, a participant
noted that if s/he is out of breath, confidence
decreases.
The last meeting (17) was by teleconference
and the group shared practice stories and
insights. Finally, the participants shared their
experiences of being involved in the action
research and reflection project, and their
responses were:

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I found the process interesting especially

in how to go about research ... the steps
involved. I found that I have a lot of stuff
buried inside I remembered practice stories from long ago and they are still stirring
up so much, that is surprising I need to
deal with it (the practice experiences) I
enjoyed talking at a deep level. I can see my
work experiences are full of opportunities
for research. I enjoyed the team work and the
friendship, trust and disclosure. (The participant talks regularly with a critical friend, to
aid reflections on his/her practice.)
I really enjoyed the process. I was surprised
by how I got into the reflection and I continued writing personal reflections. I did a lot of
personal journaling at home and (a family
member) enjoyed the insights into my life
s/he did not know before.When I put pen to
paper I was amazed at how the details came
flooding back the smells, emotions, feelings. It made me sit back and reflect about
work being (myself) I put my head down
and got on with things. I tend to be a happy
person and to dwell on things being
reflective is a positive way of dwelling on
things I enjoyed researching with three
other experienced nurses and fitting in
with the others (participants) and areas of
conversations.

The most valuable aspects of the research for

me has been the focus on practice reflection.
I have used reflective journalling previously
and always found it a useful tool, but in the
day-to-day business I have been forgetting to
incorporate reflection into my self-care. My
wish is for all nurses to give reflective journalling a go at least once, particularly the
analysis of the reflections. The research has
reminded me to reintroduce reflection more
regularly into my practice. The cohesive
group we formed during the research process has been a highlight for me. At all times I
felt safe to disclose my thoughts and the
members discussion and comments have
been both insightful and comforting. I believe
the project has fostered the formation of new
nursing bonds that can only be good for our
profession.
The researcher/facilitator thanked the group
for their comments and suggested that they now
had the knowledge and skills to undertake
action research themselves, whenever they had
practice issues that need deeper attention.

IMPLICATIONS AND CONCLUSION

The implications of the research are that action

research and reflection are practical research
I am very practically minded and value com- processes for nurses to examine their practice
monsense I am not academic and could issues and to improve nursing care. The action
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Assertiveness in nursing practice

research and reflective practice approach can be
used in a variety of ways to assist nurses to
reflect on practice issues and care improvements. This project shed light on the need for
assertiveness and ways in which to improve
assertiveness at work.
The nurses in this research generated an
action plan with practical strategies for improving assertiveness at work. The action plan is
available to other nurses who may find it useful
in improving their assertiveness at work. The
implications of this research for nurse teachers
are that assertiveness continues to be a difficult
skill to enact in the immediacy of the workplace. The communication skills within the
action plan from this research can be explored
in experiential teaching sessions.
In conclusion, the nurses in this research
realised that assertiveness is difficult, but that it
is possible when a reflective approach is taken
to practice.The implication of this research for
other nurses with whom it resonates is that they
too can make positive changes to their assertiveness, by paying focused attention to their daily
work practices.

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