For nurses the past decade has been one of consciousness raising. The revitalization of the women's movement has sharpened our focus on issues close to our social and professional hearts. We have added new concepts and words to our vocabulary: sexism, chauvinism, consciousness raising, androgyny and assertiveness. We have come to an acute and somewhat painful recognition of our subservient status as women and as nurses.
We have seen volumes of literature advocating greater equality between the sexes - from mass market paperbacks to scholarly articles. Nursing literature has recently begun to address the unique aspect of this problem for nurses. The nurse who finds her frustration rooted in her bench-warming status on the health care team can certainly find her plight echoed in the literature as well as in the conversation of her colleagues.
Fortunately, many nursing schools have recognized the issue of the subservient status of nurses, and have taken some steps to address this issue in their curricula. Nursing faculty have recognized a need to help students experiment with changing roles and cope with the problems of interpersonal rights and ineffective dependent behaviors. Even though Stein wrote about ineffective communication patterns between doctors and nurses as long ago as 1968, many of us still recognize those patterns developing in the students of 1980. Kramer (1974) tells us that we need to find some way to ease the traumatic transition from dependence to independence and thus reduce the reality shock for our new graduates.
The tool which some schools have used to encourage the development of less dependent behaviors has been assertiveness training. Such training is designed to help students improve their ability to communicate, strengthen their self-image, and thereby improve their professional and personal effectiveness. Traditionally, the format for assertiveness training has been the classroom, i.e., through lectures, discussions, small group work, seminars, and workshops.
However, it is my contention that we have not used the format of nursing education that could be most effective in teaching assertiveness skills - the clinical lab. I support structured classroom teaching of assertiveness skills because much of the information adapts well to the classroom. Nevertheless, I feel that for students to learn to use their assertiveness training effectively, they must be encouraged to practice it in the "real world" - and what better place than in the "real world" of the hospital or clinic? Where else are there so many examples of communication and status struggles among the nurse and clients, colleagues, administrators and physicians? Educators have long known that learning takes on greater and more lasting significance when a person can immediately transfer knowledge from the classroom to the job. This principle is certainly applicable to behavior skills.
In addition, learning a new behavior takes time. It is highly unlikely that a person can attend an assertiveness workshop one day, and then use the training appropriately in every situation the next day. Hutchings and Colburn (1979) are two nurses who teach assertiveness training to nurses in a one-day seminar format. They admit that although the program is effective and popular, it does not provide adequate time for assimilation of the material. They tell us that becoming an assertive person isn't easy; it takes energy, concentration, support from others, and lots of practice. Numerof (1980) agrees and points out that there is a tendency in the concentrated seminar format to focus on the preplanned outline. This encourages the participant to intellectualize the concept, but not to internalize it. Again, I contend that the clinical lab is the perfect opportunity for students and teachers to experience, practice and internalize these concepts and behaviors.
So the question remains: how can the nurse educator best use the clinical experience to help students learn to use the concepts of assertiveness training?
Several suggestions come to mind:
1. Include the use of assertiveness skills as part of your clinical objectives. This lets the students know that you value these skills and that you expect them to display appropriate assertive behavior. It may also give the less confident student the necessary sanction and encouragement to experiment with a new behavior.
2. Be a role model. Let students observe you interact with clients, staff, colleagues, and other students using effective assertive behavior. This enables them to see how assertive behavior can result in improved communication. Moreover, students will be able to see that the sky doesn't fall in when you refuse a request or express annoyance or assert your right to be respected and listened to.
3. Develop a reward system for assertive behavior. This can be effective because it is in exact contrast with the traditional system of rewarding nurses for passive, dependent behavior (e.g., praising a nurse for "not making waves" or being "a good nurse who follows the company line"). Its not only important for the teacher to give verbal pats on the back for effective assertive behavior, but it is perhaps even more important for peers to reward each other. Herman (1978) tells us that it is essential that we have good emotional support and honest feedback, that we be available for one another, and that we share the successes as well as the stresses.
One could also structure this reward system in a more formal way. For example, the teacher could devote a certain portion of the postclinical conference to student examples where assertive behavior was used effectively. This sort of positive reinforcement can only help to increase self-esteem and therefore encourage assertive behavior.
4. Require a clinical project which involves the implementation of change. The planning, documentation and implementation of change require leadership and assertiveness skills. Students will find themselves interacting with staff and patients in an effort to obtain data for need analysis, to create alternatives, to present the proposed change to the staff or administration and finally to implement it. Each step in this process requires the student to assert one or several of what Sonya Herman (1978) calls the "Nurse's Bill of Rights." This is a very practical and realistic approach to using assertiveness skills to effect change.
5. Use Role-Play. Since students will not experience all the possible situations in which assertive behavior techniques can be used, the nurse educator can fill these experiential gaps with role play. This could most logically be done periodically during the postclinical conference. Two or three students could be responsible for enacting a short roleplaying "drama," preferably drawn from an actual situation. Examples of categories might be refusing or making requests, expressing anger or annoyance, denning one's limits, or giving and receiving compliments (Hutchings & Colburn, 1979).
6. Use assertiveness exercises. Exercises work well with role-play and can also be appropriate to a pre- or postconference situation or as a homework assignment. Here are some specific suggestions:
a. Use questionnaires, such as "Determining your Androgyny Quotient" (Bern, 1976); "Assessing your Assertiveness Profile" (Osborn & Harris, 1975); "A Guideline: Steps to Assertive Behavior" (Bloom, 1976).
b. Have each student stand and say ten good things about herself (Hutchings & Colburn, 1979).
c. Plan a session on giving and receiving compliments.
d. During self-evaluation sessions, encourage each student to assess and assert her positive qualities,
e. Have students explain the differences between aggressive and assertive behaviors and give examples of each.
7. Don't fall into the trap of victim vs. vietimizer. Rather than concentrating on our conscious or unconscious role of victim, Numerof (1980) suggests that it is more productive to identify and own up to our own behaviors which put us in a victim role. A certain "us/them" or "have/have-not" dichotomy makes it too easy to put the blame on "them" (supervisors, physicians, administrators), thereby ignoring our responsibility for our own passive behaviors. We must help our students recognize that passive behavior is used by some nurses to provide secondary gains, such as decreased accountability, avoidance of risks, and low expectations from others. If we expect more responsibility for ourselves and our students then we must use assertive behavior patterns which express our expectations.
8. Recommend some helpful reading. Encourage each student to read Sonya Herman's book "Becoming Assertive: A Guide for Nurses." It touches many aspects of the unique assertiveness skills required by nurses and also provides examples as well as scripts for assertive behaviors. Other helpful books and articles are listed in the reference section of this paper.
Some of you who are reading this may be saying to yourselves, "How can I fit in one more focus into clinical lab time? There's already not enough time!" Tb you I would propose that in the long run you will find that students who can effectively use assertive behaviors will usually become more competent and more self-confident practitioners who will be able to communicate more effectively with staff, with clients and with you. Effective communication means more efficient communication and less time spent on misunderstandings and confusion. Moreover, Herman (1977) tells us that assertiveness is one answer to the problem of job dissatisfaction of nurses. This benefit could apply to the student experience as well. Increased self confidence helps the student become more capable of structuring her own learning environment and therefore meeting her learning needs. Remember that a passive, nonassertive nurse generally does not have the risk-taking behaviors which initiate change, nor does she feel accountable for her nursing practice. In addition, she reflects poorly on her educational institution.
In closing, I would offer one final point: students who learn to use assertive bebehaviors in the clinical situation will also use these skills with you! Don't be surprised if while "trying their new assertive wings" they come to question the structure of the course or your role as teacher. Assertive students are more likely to give you feedback and evaluation, both positive and negative. Hopefully, you will not find this threatening, but will come to enjoy this more lively, reciprocal dialogue. An openness and flexibility to student input and ideas will encourage a student-centered approach to nursing education and can only enrich your professional life.
- Bern, S. (1978). Beyond androgyny: Some presumptuous prescriptions for a liberated sexual identity. In Psychology of women: future directions of research. New York: Psychological Dimensions.
- Bloom, L. (1976). The new assertive woman. New York: Dell Publishing Company.
- Herman, S. (1977). Assertiveness: One answer to job dissatisfaction for nurses (pp 281-290). In R. Alberti (Ed.), Assertiveness: innovations. applications, issues. San Luis Obispo, CA: Impact Publishing.
- Herman, S. (1978). Becoming assertive: a guide for nurses. New York: D. Van Nostrand Co.
- Hutchings, H., & Colburn, L. (1979, JuneX An assertiveness training program for nurses. Nursing Outlook, pp 394-397.
- Kramer, M. (1974). Reality shock. St. Louis: The CV. Mosby Company.
- Numerof, R.E. (1980, October). Assertiveness training. American Journal of Nursing, pp 1796-1799.
- Osborn, S., ft Harris, G. (1975). Assertiveness training for women. Springfield. IL: Charles C.Thomas.