NursingAssertiveness.pdf

How We Can Enhance Nurses’ Assertiveness: A Literature Review
Ayako Okuyama1* Cordula Wagner2,3 and Bart Bijnen4,5

1Department of Total Health Promotion Science, Graduate School of Medicine, Osaka University, Osaka, Japan
2EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
3NIVEL Netherlands Institute for Health Services Research, Utrecht, The Netherlands
4Institute for Education and Training, VU University Medical Centre, Amsterdam, The Netherlands
5Foreest Medical School, Medical Centre Alkmaar, Alkmaar, The Netherlands
*Corresponding author: Ayako Okuyama, Department of Total Health Promotion Science, Graduate School of Medicine, Osaka University, 1-7 Yamadaoka, Suita,
Osaka, 565-0871, Japan, Tel : +81-6-6879-2555; E-mail: [email protected]

Received date: June 10, 2014, Accepted date: August 25, 2014, Published date: August 28, 2014

Copyright: © 2014 Okuyama A et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Objective : Assertiveness is important for effective team building in nursing. This article aims at evaluating the
results of the previous studies on nurses’ assertiveness in each decade in to discuss the possible ways for
enhancing nurses’ assertiveness.

Methods : Five databases (PubMed, MEDLINE, CINAHL, Web of Science, and the Cochrane Library) were
searched for English-language articles published from 1946 to December 2012. Article which described the
assertiveness of nurses and relevant factors related to assertiveness in a clinical setting or evaluated assertiveness
training.

Results : Twenty-five studies in 26 articles were identified. In the 1970s and 1980s, research demonstrated that
nurses perceived they are submissive helper and were less assertive. These studies indicated that educational
achievement was regarded as a key factor in nurses’ assertiveness. The study in 1990s demonstrated that at least
one population of nurses was assertive. The studies after 2000 suggested that nurses behave in a passive way,
conforming to the stereotype of a ‘nice’ nurse, and were less likely to disagree with others. A sense of responsibility
for patients, managers’ leadership, organisational culture, and relationship between colleagues were reported as
influencing factors of nurses’ assertiveness.

Conclusion : Recently, the number of nurses who are trained in higher educational institutions has increased.
Despite this, nurses still experience some difficulties assessing themselves. Nurses should understand their role at
the recent health care environment as a professional. Nurse managers should take a leadership to avoid nurses’
concerns of voicing their opinions in to improve nurses’ assertiveness.

Keywords: Assertiveness; Interdisciplinary communication; Quality
of health care; Systematic review

Introduction
Nursing surveillance and monitoring activities are essential for the

patient care [1]. Nurses require the competence of clinical grasp (e.g.
what is happening to a patient) and clinical forethought (e.g.
prediction for patient condition) for providing patient appropriate
care [2]. Nurses are expected to show clinical leadership at the patient
bedside to provide direction and support to patients and the health
care team for integrating the care they provide to achieve positive
patient outcomes [3]. If necessary they assert their opinions to other
team members for changing the care plan for their patients [2]. On the
other hand, it has been shown that those who are aware of a problem
often either speak up and are ignored or do not speak up at all [4,5].

Assertiveness is a style of communication that enables nurses to
build effective team relationships. Collaboration with other team
members needs both a high level of assertiveness (meeting the own
need) and a high level of cooperation (meeting the other’s need) [6].

Assertiveness is described as expressing thoughts and feelings without
denying the rights of others [7]. Nurses’ ability to be assertive when
they are unsure or concerned about medical procedures, the treatment
of patients, or symptoms of patients is key in reducing risk and
preventing major medical errors [8]. Assertive people inform others of
their needs and feelings, and communicate their message effectively
without causing offence to others [9]. When nurses act assertively,
they are more likely to provide patients appropriate care, and in doing
so, improve the quality of patient care [2,9].

Traditionally, nurses tend to be female and their role involves
assisting a doctor. As they play a supporting role, they are often placed
lower in the medical hierarchy, and it makes nurses difficult to assert
their own opinions for the patient care. Recently nurses’ role in the
clinical setting is changing. Since the Institute of Medicine published
the report of ‘The Future of Nursing: leading change, advancing
health’ in 2011, nurses are expected to act as partners with other health
care professionals and to lead in the improvement and redesign of the
health care system [10]. In addition, nurses are crucial in preventing
medical errors, reducing rates of infection, and even facilitating
patients’ transition from hospital to home [10]. It means that nurses

Nursing and Care Okuyama et al., J Nurs Care 2014, 3:5http://dx.doi.org/10.4172/2167-1168.1000194
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are expected to acquire assertiveness in to work effectively with
other health care professionals.

Lyndon conducted a literature review of nurses’ assertiveness and
teamwork, and reported that two studies of assertiveness showed
conflicting results [11]: Gerry in 1989 found that nurses rated
themselves more assertive outside of work than at work and
demonstrated a trend toward conflict avoidance [12], while Kilkus in
1993 found that nurses had mean scores in the moderately assertive
[13]. She concluded that findings regarding nurses’ assertiveness were
mixed [11]. She evaluated the results of the previous studies on nurses’
assertiveness using only six articles, and did not take into account the
changes of nurses’ work environment. Therefore, this review aims at
evaluating the results of the previous studies on nurses’ assertiveness
each decade in to discuss the possible ways for enhancing nurses’
assertiveness.

Methods
This review was conducted as a part of systematic review for health

care professionals’ voicing behaviour. In the process of the literature
review, we found two types of articles pertaining to clinicians’
communication behaviour: the first focussed on speaking-up
behaviour related to patient safety (i.e. when clinicians are aware of
risky or negligent actions of others within health care teams) and the
second investigated the assertiveness of nurses more generally, without
focusing on patient safety issues. This article summarises the literature
on the latter type of assertiveness in nurses and discusses a strategy to
enhance team communication. Our findings on speaking up
behaviours in situations related to patient safety are reported
elsewhere [14].

Search methods

Relevant articles published in English from 1946 until December
2012 were searched using PubMED, MEDLINE, the Cumulative Index
to Nursing and Allied Health Literature (CIHNAL), Web of Science,
and the Cochrane Library (date last searched 24 December 2012).
Combinations of terms were used to find articles related to
assertiveness (i.e. speak* up, speak* out, assertive*), inter-professional
relations (i.e. inter-professional relations, doctor-nurse relationships),
health personnel (i.e. health personnel, patient care team, nursing-
supervisory, attitude of health personnel, professional role,
professional practice), and patient safety (i.e. risk management, safety,
medical errors, malpractice, professional misconduct, quality of health
care, outcomes and process assessment, program evaluation, quality of
health care, outcome and process assessment, program evaluation,
quality assurance, consumer satisfaction, doctor’s practice patterns,
nurse’s practice patterns, practice management) . Medical Subject
Headings were used where available. The search was conducted with
the assistance of experts in the use of such databases.

Moreover, a manual search (that involved reading the title of each
paper in the journal’s archives) was conducted to find relevant papers
on organisational research and nursing management in the Journal of
Nursing Management and the Journal of Organizational Behavior. The
referenced articles listed in each of the selected publications were also
examined.

To obtain a wide variety of research evidence, this review prioritised
articles that appeared to be relevant to nurses’ assertiveness rather than
particular study types or articles that met particular methodological
standards [15]. Both quantitative and qualitative studies were included

in this review. Articles that were selected for use in the review either
described the assertiveness of nurses and relevant factors related to
assertiveness in a clinical setting. In addition, articles which evaluated
the assertive training using the comparative study design were also
selected, while articles that described training programmes without
any results or expert validation were excluded. Review article of
nurses’ assertiveness were also excluded, and here original articles
which mentioned in the review were used for the analysis. At first, we
searched for assertive behaviour associated with doctors, medical
residents, and nurses. However, we did not find any research articles
on the assertive behaviour of doctors and medical residents, using our
criteria. Therefore, this article deals with only the literature concerning
assertive behaviour in nurses.

Two independent reviewers (AO, and a research assistant) reviewed
the titles and abstracts of citations generated by the search to assess
their eligibility for further review based on the selection criteria. They
selected relevant articles for possible inclusion. Cohen’s kappa was
calculated to assess the degree of agreement between both reviewers.
The reviewers assessed all of the selected articles in relation to the
criteria and decided independently which articles to include in this
study. In the case of disagreement between the two reviewers, the
article was discussed with the other two authors (CW, BB).

Search outcome

The initial search identified 2,941 citations. Most of the excluded
2,649 articles were based solely on expert opinions and commentary,
or did not study assertiveness in health care teams. In total, 292 articles
meeting the inclusion criteria were selected for detailed review (Figure
1). Following a title and abstract review by the aforementioned two
reviewers, Cohen’s kappa was calculated as 0.64.

Twenty articles dealt with the assertiveness of nurses. In addition,
five other articles were retrieved from article reference lists, and one
article was found using a manual search. In total, 25 studies in 26
articles were identified for this study. Nine articles (35%) were
published after the year 2000. Fifteen studies (60%) came from the
U.S., and of the remaining ten, eight originated from Japan, Australia,
Canada, and Ireland (two from each of these countries).

Quality appraisal

The following criteria were used to assess primary study quality: (1)
the aims and objectives of the research are clearly stated, (2) the design
is clearly specified and appropriate for the aims and objectives of the
research, (3) the researchers provide a clear account of the process by
which their findings were reproduced, (4) the researchers include
enough data to support their interpretations and conclusions, and (5)
the method of analysis is appropriate and adequately executed [15]. In
addition, we evaluated the study on the training intervention using the
modified Best Medical Education Coding sheet (e.g., study design,
participants allocation, outcome level (Kirkpatrick level))[16]. The
results of the study appraisal are shown in each table.

Data abstraction

Two reviewers independently abstracted the data from the selected
articles (e.g. study aim, design, method, results, and country where the
study was conducted).

Synthesis

Nurses’ assertiveness may influence on the trend of the times (e.g.
nurses’ work environment), therefore, themes emerged for each
decade that research on assertiveness was conducted. As a result, the

Citation: Okuyama A, Wagner C, Bijnen B (2014) How We Can Enhance Nurses’ Assertiveness: A Literature Review. J Nurs Care 3: 194. doi:
10.4172/2167-1168.1000194

Page 2 of 9

J Nurs Care
ISSN:2167-1168 JNC, an open access journal

Volume 3 • Issue 5 • 1000194

http://dx.doi.org/10.4172/2167-1168.1000194

evidence was summarised per decade. A meta-analysis could not be
conducted because of the heterogeneity of the data.

Figure 1: Article selection process.

Results and Discussion

Nurses’ assertiveness in the 1970s and 1980s
In this period, six articles that investigated nurses’ assertiveness met

our criteria and were thus selected (Table 1) [12,17-21]. According to
these researchers, nurses were less assertive, predominantly because
they were female, experienced traditional training framed within a
hierarchical structure, and perceived themselves as submissive helpers.
Studies in this era investigated mainly the relationship between
individual characteristics (e.g., age, level of education, job position)
and assertiveness. In this decade, the educational background of
nurses was regarded as a key factor in their assertiveness. Nurses were
mainly educated at a nursing school (e.g., diploma programme), while
doctors were educated at a higher level of academic success than did
nurses. Nurses who accepted their professional role, had confidence
based on their knowledge and nursing experience, showed more
assertiveness [12,18]. However, it should be noted that small sample
sizes and a lack of a robust experimental design limit the
generalizability of these findings. In addition, four out of six studies
were carried out in the U.S.. Assertiveness of nurses who have different
cultural background can work differently in other countries.

Author (s),
Year, Country

Aim of study Sample size and
description

Measurements and analysis Main results Study appraisal*

Gerry [12] To explore nurses’
assertiveness at work and in
general life situations.

99 nurses from three
hospitals.

Combination of scales from the
Assertiveness Inventory, Rathus
Assertiveness Schedule,
College Self Expression Scale,
Pearson correlations. Semi-
structured interview: content
analysis.

Nurses are found to be less
assertive at work than in general life
situations. Senior nurses are more
assertive than staff nurses. Factors
which promote assertive are
knowledge, confidence, and
experience. Inhibitive factors are
traditional training and a hierarchical
structure.

1. Yes

2. Yes

3. Yes

4. Yes

5. Weak

Farley [17] To compare interpersonal
communication

86 nurses from 47
hospitals.

Power Orientation Scale, Social
Style Profile, t-test.

Nurse administrators held more
positive orientations to three of the
six power orientations, and were
perceived to communicate more
assertively than staff nurses.

1. Yes

2. Yes

3. Yes

4. Weak

5. Yes

Kinney [18] To examine the relationship
of conception and
personality.

101 nurses in a
university.

Nursing Role Conception Scale,
Ego Development Sentence
Completion Test, Personal
Attributes Questionnaire, Adult

Assertiveness was significantly
related to professional role
conception.

1. Yes

2. Yes

3. Yes

Citation: Okuyama A, Wagner C, Bijnen B (2014) How We Can Enhance Nurses’ Assertiveness: A Literature Review. J Nurs Care 3: 194. doi:
10.4172/2167-1168.1000194

Page 3 of 9

J Nurs Care
ISSN:2167-1168 JNC, an open access journal

Volume 3 • Issue 5 • 1000194

http://dx.doi.org/10.4172/2167-1168.1000194

Self-Expression Scale,
Spearman rank correlation
analysis.

4. Weak

5. Weak

Athayde [19] To compare assertiveness
levels in two different cities.

116 nurses in San
Francisco and the
Huston.

8 original operating situations, a
nonparametric statistical test.

Nurses employed in San Francisco
were more assertive than those in
Houston. As a result of the small
study sample, a number of
demographic factors were not
consistently related to assertiveness
when subjects in the two cities were
compared. In both geographical
areas, a high level of assertiveness
was associated with collegiate
nursing education.

1. Yes

2. Weak

3. Yes

4. Yes

5. Yes/No

Gluck &
Charter [20]

To find nurses who need
continuing education for
interpersonal effectiveness.

A random sample of
125 nurses from 268
nurses at a VA
hospital.

16 Personality Factor
Questionnaire, ANOVA.

Nurses with 21 or more years’
experience were found to be
significantly less assertive than
nurses with one to five years of
experience.

1. Yes

2. Yes

3. Yes

4. Weak

5. Yes

Miller [21] To evaluate nurses’
assertiveness during nurse
practitioner training.

64 nurses. Rathus Assertive Scale,
Spielberger Sate-Trait Anxiety
Scale, Spence Helmreich
Attitude Toward Women Scale,
Bem Sex Role Inventory, t-test.

The nurse practitioner students
became more assertive during and
after the training.

1. Yes

2. Yes

3. Weak

4. Weak

5. Yes

Table 1: Characteristics of selected studies from the 1970s and 1980s

*Study appraisal: 1) the aims and objectives of the research are
clearly stated; 2) the researchers design is clearly specified and
appropriate for the aims and objectives of the research; 3) the
researchers provide a clear account of the process by which their

findings were reproduced; 4) the researchers display enough data to
support their interpretations and conclusions, and 5) the method of
analysis is appropriate and adequately executed.

Author, Year,
Country

Aim of study Sample size and
description

Measurements and
analysis

Main results Study appraisal*

Poroch &
McIntosh [9]

To investigate the barriers
of assertiveness.

200 nurses randomly
sampled from a hospital.

Assertiveness Behaviour
Inventory Tool, original
Barriers to Assertive Skills in
Nurses, Pearson’s
correlation, t-test, Chi-
squared statistic, ANOVA.

Nurses considered themselves to
have moderate to low assertiveness
skills. Junior nurses are more
assertive than senior nurses (t = 2.75,
p = 0.00). A significant negative
correlation was found between the
level of assertiveness and the
perception of barriers inhibiting
assertive behaviour (e.g. fear
punishment from colleagues and
uncertainty about the differences
between assertive and aggressive
behaviour).

1. Yes

2. Yes

3. Yes

4. Weak

5. Yes

Johnson [22] To examine the
relationship between
assertiveness and self-
esteem.

164 nurses from
members of the NSW
Operating Theatre
Association in Australia
and the Australian
Institute of Radiography.

Rathus Assertiveness
Schedule, the Health
Employees Assertiveness
Scale, Rosenberg Self-
Esteem Scale, the Self-
Esteem Components Scale,
and demographic
characteristics, Pearson
correlation.

There were positive correlations
between each of the assertiveness
scales and each of the self-esteem
scales (p < 0.05). 1. Yes 2. Yes 3. Yes 4. Yes 5. Weak Kilkus [13] To determine assertiveness levels. 500 nurses randomly from the list of active licensees registered with Rathus Assertiveness Schedule, demographic characteristics, ANOVA. Majority of nurses in this study are assertive. Nurses older 60 years old were less assertive. Nurses who have 1. Yes 2. Yes 3. Yes Citation: Okuyama A, Wagner C, Bijnen B (2014) How We Can Enhance Nurses’ Assertiveness: A Literature Review. J Nurs Care 3: 194. doi: 10.4172/2167-1168.1000194 Page 4 of 9 J Nurs Care ISSN:2167-1168 JNC, an open access journal Volume 3 • Issue 5 • 1000194 http://dx.doi.org/10.4172/2167-1168.1000194 the Minnesota State Board of Nursing. higher levels of education were more assertive. 4. Yes 5. Yes Kruse [23] To compare the assertiveness levels of staff nurses and nurse leaders. 200 staff nurses and 200 nurse leaders. Rathus Assertiveness Schedule, demographic characteristics, t-test. Staff nurses with a mean age of 40 years, employed full time, higher educational level, possessed more assertive behaviours than nurse leaders did (t = 2.51, p = 0.02). 1. Yes 2. Yes/No 3. Weak 4. Weak 5. Yes Lavin [24] To examine the relationship between assertiveness, self- esteem, and management style. 77 female registered nurses at medical surgical units in 10 acute hospitals. Cooper Smith Self Esteem Inventory, Tennessee Self Concept Scale, Assertion Inventory, Thomas Kilmann Conflict Mode Instrument, correlation coefficient analysis. Assertiveness was positively related with self-esteem and two conflict management styles (collaboration and competition). 1. Yes 2. Yes 3. Yes 4. Yes 5. Yes Table 2: Selected study characteristics in the 1990s *Study appraisal: 1) the aims and objectives of the research are clearly stated; 2) the researchers design is clearly specified and appropriate for the aims and objectives of the research; 3) the researchers provide a clear account of the process by which their findings were reproduced; 4) the researchers display enough data to support their interpretations and conclusions, and 5) the method of analysis is appropriate and adequately executed. Nurses’ assertiveness in the 1990s In the 1990s, larger studies were conducted (Table 2)[10,13,22-24]. A large study reported that nurses in the U.S. appeared more assertive than non-nurses (e.g. teacher) did [13]. This study demonstrated that at least one population of nurses (e.g. staff nurses) was assertive, even when the previous nursing literature assumed that nurses were typically unassertive. In addition, there was a positive correlation between academic degree level and assertiveness [23]. This indicates that the academic degree level of nurses may affect their assertiveness in this era. Other studies indicated a positive relationship between assertiveness and self-esteem [21,24]. Self-esteem reflects a person’s overall emotional evaluation of his or her own worth. These findings support the role of confidence and self-esteem in enhancing the assertiveness of nurses. Nurses’ assertiveness after 2000 Researchers tended to focus on the assertive behaviour of nurses at work (Table 3) [25-30]. Nurses in fields such as midwifery were found to be more assertive than some of their colleagues [30]. They suggested that nurses behave in a passive way, conforming to the stereotype of a ‘nice’ nurse, and were less likely to disagree with the opinions of others or to provide constructive criticism to others. Fear associated with communicating effectively in a work setting was not mediated by age or educational level. In addition, DeMarco et al. found that nurses in a non-staff role were more assertive than staff nurses [27], but they did not define a non-staff role. We therefore conclude that the status and experience of nurses can influence their assertiveness in health care settings. Autho r, year, Aim of study Sample size and Measurem ents and analysis Main results Study apprais al* count ry descriptio n Garon [25] To explore nurses’ perceptions of assertivene ss 33 registered nurses in California. Focus group interviews, thematic content analysis. Taught at home, culture and language, doing the right thing, education, relationship with peers, managers and administrative/ executives, organisational culture, transmission and reception, and outcomes after speaking up influenced assertiveness. 1. Yes 2. Yes 3. Yes 4. Yes 5. Yes Wong [26] To test the relationship between leadership style and communica tion behaviour. 280 registered nurses working in acute care hospitals. Authentic Leadership Questionna ire, Personal and Social Identificatio n, Trust in Manageme nt Scale, Utrecht Work Engageme nt Scale, Helping and Voice Behaviours Scale, Internation al Survey of Hospital Staffing, and Organizatio nal of Patient Outcomes, structural equation analysis. Authentic leadership significantly influenced staff nurses’ trust in their manager and work engagement, which in turn predicted voice behaviour and perceived unit care quality (χ2 = 17.24, df = 11, p = 0.10, IFI = 0.99, CFI = 0.99, RMSEA = 0.045). 1. Yes 2. Yes 3. Yes 4. Yes 5. Yes Citation: Okuyama A, Wagner C, Bijnen B (2014) How We Can Enhance Nurses’ Assertiveness: A Literature Review. J Nurs Care 3: 194. doi: 10.4172/2167-1168.1000194 Page 5 of 9 J Nurs Care ISSN:2167-1168 JNC, an open access journal Volume 3 • Issue 5 • 1000194 http://dx.doi.org/10.4172/2167-1168.1000194 DeMar co [27] To develop a scale. 738 registered nurses in Massachus etts. Silencing the Self Scale, Nurse Workplace Scale, and demograph ic items, factor analysis, and t-test. Silencing behaviour is not significantly different by age (p = 0.28) or education (p = 0.11). Nurses in a non-staff role had lower scores than did staff nurses (p < 0.005). 1. Yes 2. Yes 3. Yes 4. Yes 5. Yes Timmi ns & McCa be [28] To describe the assertivene ss of nurses and midwives. 1500 nurses and midwives registered with the National Nursing Board of Ireland. Original questionnai re (44 items): Assertive behaviour to indicate the frequency with which they use them with three groups of nursing colleagues (nursing manageme nt, medical colleagues and other healthcare staff), demograph ic characterist ics, open- ended questions of influencing factors of assertivene ss, content analysis. Assertive behaviour was used more frequently with nursing/midwifery colleagues than with management/ medical colleagues. Responsibility to patient and knowledge emerged as supporting factors for using assertive behaviour. Mangers, the work atmosphere, and fear were viewed as obstacles. 1. Yes 2. Yes 3. Yes 4. Yes 5. Yes Timmi ns & McCa be [30] To describe assertive behaviour and the associated factors. 27 registered nurses from participants of nursing course, pilot study. Questionna ire (44 items, same as in Timmins & McCabe 2005a) Nurses behave in a passive way, conforming to the image of a ‘nice’ nurse. Colleagues were frequently reported as well as management, confidence and the atmosphere in the workplace as facilitator of assertive behaviour. 1. Yes 2. Yes 3. Yes 4. Weak 5. Yes Colleagues, management and atmosphere were also reported as militating factors. Table 3 : Selected study characteristics after year 2000. *Study appraisal: 1) the aims and objectives of the research are clearly stated; 2) the researchers design is clearly specified and appropriate for the aims and objectives of the research; 3) the researchers provide a clear account of the process by which their findings were reproduced; 4) the researchers display enough data to support their interpretations and conclusions, and 5) the method of analysis is appropriate and adequately executed. Several factors have been found as influencing factors of nurses’ assertiveness. A sense of responsibility for patients and nursing knowledge were correlated with levels of assertiveness [30]. In addition, leadership qualities in managers, organisational culture, and relationships between colleagues play an important role in fostering assertiveness [26,30]. Managers’ leadership positively influenced staff nurses’ trust in their manager and their engagement in work, which in turn predicted assertiveness and quality of patient care [26]. In addition to these factors, nurses expressed concern towards how colleagues deal with their complaints and issues [25]. Staff nurses reported that they felt their message was ignored when they expressed themselves in an emotional way. As a result, they reported feeling disenfranchised and unimportant, which did not facilitate assertiveness [25]. They also reported that they wanted to know that their concerns were taken seriously [25]. In to enhance the assertiveness of nurses, it is important for hospital managers and nurse managers to provide appropriate feedback to nurses regarding their communication. The home environment, education, and culture can all influence nurses’ attitudes towards communication [25]. For example, assertiveness is less likely to be accepted in traditional Asian families, while American students are encouraged to be assertive [25]. Hospital managers and senior staff members should thus consider cultural backgrounds when assessing the standard of communication of staff members. Effectiveness of assertiveness training To enhance assertiveness of nurses, the several training programmes have been conducted through the decades (Table 4) [31-39]. Most of the studies reported that nurses’ self-reported assertiveness were improved after the intervention. However, no studies have evaluated the assertiveness of nurses in a clinical setting. Future studies should therefore investigate the efficacy of assertiveness training in a clinical setting. Author, year, country Sample size and description Measurements …