Assertiveness is an interpersonal behaviour that refers to a person’s ability to express his/her beliefs, feelings, needs and opinions without undue anxiety and without denying or devaluing the rights of others (Alberti and Emmons, 1986). It is a way of thinking and behaving that involves open and direct communication while respecting oneself and others. In a nursing context, assertiveness is a communication style that is important to successful rela- tionships for the client, family, the nurse and other health care colleagues (Balzer-Riley, 2000). Its contribution to communication competence and good practice is widely recognized (Hargie and Dickinson, 2004). In fact, in critical or dangerous situations, ‘an assertive response can be vital and act as a life- saver for clients’ (Larijani et al., 2010, p.894). The following example illustrates the nurse’s assertive response as a means of ensuring safe practice.
Clinical scenario
Joan, a newly qualified staff nurse, had begun her first night in charge on the ward.
On administering medication with her colleague, she noticed that the dosage of a drug prescribed for a client was higher than the normal range. She decided to check this with the doctor on call before administering the medication. Joan explained the situation to the client and apologized for the inconvenience caused. Her colleague was impatient and said in an abrupt tone, ‘The client won’t sleep if she doesn’t get her medication now. The doctor will not come to the ward for ages.’ Joan responded calmly and said, ‘I appreciate the inconvenience it is causing the client; however, it is important that the client receives the correct and safe dosage.’ An hour later, the doctor arrived and confirmed that the prescribed dosage was within the normal range and was safe to administer. Joan subsequently informed the client and administered the medication. She also informed her colleague, who responded by muttering ‘what a fuss for nothing’. Joan considered her response and was satisfied that her response was appropriate and, more importantly, ensured the client’s wellbeing.
Choosing to be assertive
Few people, if any, manage to be assertive at all times and in all areas of their lives (McCabe and Timmins, 2006). For many it may be easier to refuse a request, state their needs or express an opinion with their family or friends rather than with their work colleagues. Studies of nurse assertiveness have reported that most nurses feel and act more assertively in situations outside of their work (Fulton, 1997). While there may be many reasons for this, one explanation is that the culture of nursing and the process of professional socialization may decrease nurses’ ability to be assertive (Mooney, 2007). As- sertiveness is also situation specific – that is, choosing whether to be assertive may be determined by the type of situation presented to the nurse (Rakos, 2003). For example, there may be situations where assertive behaviour may not always be the most appropriate or best response, particularly if there is a high risk of injury to self or others. In such situations, choosing a passive approach may be the best and safest response, as illustrated in the following scenario.
Clinical scenario
James, a qualified nurse, heard raised voices in the dayroom. On entering the room, he observed that there were several family members visiting their elderly father, Mr Green. As he said ‘hello’, he observed that they were excitable and loud. He wondered whether they had been drinking alcohol. James thought about asking them
to leave, as visiting hours had just ended; but given their mood, he considered it best and safer for all concerned to use a passive approach. He approached Mr Green and said ‘You have had a busy evening with all your family visiting you. I will come back in 5 minutes and help you to get ready for bed.’ One of the family members said loudly,
‘I suppose you want us to leave?’ James nodded but did not say anything. He returned shortly afterwards to find Mr Green’s family leaving the ward and shouting ‘goodbye nurse, we’re leaving now’. James was relieved they had left without an altercation.
As a concept, assertiveness is not culturally neutral; it has a cultural com- ponent, where the person’s culture correlates with their level of assertiveness (Yoshioka, 2000). For example, in collectivist cultures, factors such as hierarchy of roles, maintaining harmonious relationships and collective presentation of
‘face’ are considered important for maintaining good interpersonal relation- ships (Bond, 1986). Therefore, ‘placing emphasis on assertive behaviour, which by definition focuses on the individual, may be culturally inappropriate’ (Sully and Dallas, 2005, p.96). In practice, it is important that mental health nurses are mindful of this, particularly when working with clients, families and col- leagues from different cultural backgrounds where assertive behaviour may be contrary to the person’s cultural mores.
Modes of behaviour
In every interaction, the person responds by using a particular mode of behaviour, which is categorized as follows. For a greater description of all behaviours, see Dickinson (1982).
r Assertiveness
r Passive or submission behaviour r Manipulative or indirect behaviour r Aggressive behaviour
Modes of behaviour and OK-ness
Drawing from Eric Berne’s theory of transactional analysis and his concept of ‘Life Positions’, which he called ‘OK-ness’, each of the four modes of behaviours is underpinned by the person’s beliefs about his/her own self- worth and respect, as well as the worth and respect she/he has for others, as illustrated above. For example, assertive behaviour consists of the person’s belief that he/she is OK and equally that the other person is also OK; hence the assertive position is ‘I’m OK – You’re OK’ (Berne, 1975).
(continued)
Assertiveness
↓
Belief about Self and Others
↓
I’m OK – You’re OK
Passive behaviour
↓
Belief about Self and Others
↓
I’m not OK – You’re OK Aggressive behaviour
↓
Belief about Self and Others
↓
I’m OK – You’re not OK
Manipulative [Indirect]
behaviour
↓
Belief about Self and Others
↓
I’m OK – You’re not OK but I will pretend you’re OK
Source: Adapted from Berne (1975)
Assertiveness: ‘I’m OK – You’re OK’
This approach involves a way of thinking and being that acknowledges and respects the rights and responsibilities of oneself and others. Assertiveness comprises the following behaviours:
r acknowledging and accepting the strengths and limitations of being hu- man, for example being determined, feeling vulnerable
r using communication that is direct, clear and focused, for example ‘I get anxious when I speak to doctors’
r personalizing communication by using ‘I’ statements, for example ‘I feel’;
‘I think’; ‘I prefer’
r giving constructive criticism, for example ‘I feel irritated when you interrupt r me’seeking opinions of others, for example ‘what do you think about. . .?’
r endeavouring to negotiate and compromise, for example ‘what can we do to solve this?’
r accepting responsibility for behaviour, for example ‘I apologize for my im- patience this morning’
r setting limits clearly and respectfully, for example ‘no, I cannot keep secrets from other health care workers, we work as a team’.
Passive behaviour: I’m not OK – You’re OK
This approach is characterized by believing oneself as inferior and not as ca- pable as others, and comprises the following behaviours:
r allowing oneself to be treated with little respect, which is often referred to as being a ‘doormat’
r comparing oneself constantly with others, for example ‘she is so much better than I am’
r struggling to identify or state needs/wants, for example ‘I don’t mind, I’ll do whatever you think is best’
r finding it difficult to make decisions, for example ‘what do you think I should do, you decide’
r fearing upsetting others, apologizes excessively, for example ‘I really didn’t mean to. . .’; ‘I am sorry’
r avoiding confrontation, for example will do anything for a quiet life, often says yes when really wants to say no
r using self put-downs, for example ‘I’m hopeless at. . .’; ‘I could never be good at. . .’
r dismissing self-worth and value as a person, for example keeps thoughts, opinions, feelings to self
r using long rambling sentences that lack focus and the use of ‘I’.
Aggressive behaviour: I’m OK – You’re not OK
Aggressive behaviour is competitive, and is characterized by believing that oneself is better than or superior to than others, and comprises the following behaviours:
r finding it difficult to acknowledge mistakes and blames others, for example
‘if you hadn’t forgotten to remind me about. . .’
r using verbal attacks or sarcasm, employing threatening tones and body language, may include finger wagging, raised voice
r not inviting others to share their views, for example ‘my view is . . . I think. . .’
r taking over from others and making decisions with minimal consultation r using put-downs, for example ‘why did you that, I cannot believe you did
not know that. . .’
r giving heavy handed advice, for example ‘you should do it this way’.
Manipulative or indirect behaviour
Manipulative or indirect behaviour may appear subtle, indirect and covert, and comprises the following behaviours:
r lacking genuineness and consistency
r using devious strategies to get what he/she wants, for example making others guilty, ‘all I have done for you and now when I ask for one thing’
r using communication that is unclear and dishonest, for example ‘I might be able to help you if you support me, you know that I think very highly of you’
r giving mixed messages, for example being nice face-to-face, yet criticizing behind one’s back with colleagues
r using sarcasm as a form of indirect or passive aggression