Assertiveness is the ability to express your ideas, interests, thoughts, feelings, beliefs, and needs freely, clearly, confidently, and honestly, without denying or violating others’ rights (Alberti & Emmons, 2008; Oducado, 2021). Assertiveness is an important skill that nurses must learn to acquire and need to develop (Oducado, 2021; Yoshinaga et al., 2018). With the advancements and developments in healthcare, nurses are expected to exhibit assertiveness to work with other health care professionals effectively, thereby impacting positively patient safety and outcome (Okuyama et al., 2014a). Being the largest workforce in the hospital settings, nurses are uniquely positioned to speak up for changes in the care plan of their patients if they see it deemed necessary (Hall, 2016). In other words, nurses need to speak up or call the attention of the healthcare team member when they see a problem with regards to patient care, when standard processes are not followed, or when improper practices are observed. However, being assertive and speaking up can be challenging for nurses, and that silence still prevails in many nursing situations (Okuyama et al., 2014b; Rainer, 2015; Schwappach & Richard, 2018).
The importance of assertiveness in nursing cannot be overemphasized. Firstly, assertiveness is necessary for establishing a trusting nurse and patient relationship and communicating effectively with patients and members of the health team (Larijani et al., 2017; Mushtaq, 2018). Assertiveness is required for openness to speak up, is instrumental in ensuring patient safety, and is integral to professional accountability (Nacioglu, 2016; Reid & Bromiley, 2012). Additionally, nurses are ethically, morally, and legally bound to question an inappropriate or incorrect doctor’s order and speak up to protect patient’s rights and safety (Rainer, 2015; Reuter & Fitzsimons, 2013). Patient advocacy is an important nursing responsibility (Gerber, 2018). Nurses have the critical role as patient advocates, serving as voices of their patients (Palatnik, 2016). The State Practice Acts in other countries like the United States of America mandate that nurses act as patient advocates (Gerber, 2018). The Code of Ethics of Filipino Registered Nurses explicitly states that nurses should take appropriate steps to safeguard the rights and privileges of their patients (Board of Nursing of the Philippines, 2004). Being assertive means nurses are defending and safeguarding the rights of their patients. Nurses have to be assertive enough to preserve their rights as well as the rights of their clients (Mushtaq, 2018). Lastly, assertiveness is a means which can be used to combat negative and stressful situations like mobbing, conflict situations, to communicate better, and to enhance empowerment (Asi Karakas & Okanli, 2015; Deltsidou, 2009).
Given the importance of assertiveness in nursing, identifying variables that influence or promote assertiveness is therefore necessary. Some prior studies conducted elsewhere studied the factors affecting assertiveness among nursing students (Ibrahim, 2011; Larijani et al., 2017). Other scholars investigated the effectiveness of assertiveness training on nurses (Asi Karakas & Okanli, 2015; Kanade, 2018; Nakamura et al., 2017; Shimizu et al., 2004; Yoshinaga et al., 2018) and nursing students (Omura et al., 2019). Variables such as self-esteem (Binuja, 2020; Maheshwari & Gill, 2015; Shrestha, 2019) and psychological empowerment (Azizi et al., 2020; Bostanabad et al., 2018; Ibrahim, 2011) were found to be associated with assertiveness. However, for most studies, these variables were correlated with general assertiveness and not specifically with workplace assertiveness of nurses. Studies have also shown that leadership, managerial, and administrative support influenced speaking-up and voicing behaviors (Darawad et al., 2020; Lee et al., 2021; Okuyama et al., 2014a; Wong et al., 2010), but the role of leader empowering behaviors on assertiveness has not been investigated. Besides, the studies earlier cited were conducted in other countries and not in the context of Filipino nurses.
Although there has been growing research on nurses’ assertiveness abroad, there is a scarcity of published research looking into the factors associated with nurses’ assertiveness in a generally collectivist culture like the Philippines. In general, the Filipino culture and their Asian counterparts are predisposed to be conformist, collective, and group-oriented instead of individualistic and assertive (Niikura, 1999). Assertiveness is frowned upon as it can be suggestive of pride, and some Filipino traits work against it. Alongside this backdrop, this study was conducted to determine the influence of self-esteem, psychological empowerment, and empowering leader behaviors on staff nurses’ workplace assertiveness.
A cross-sectional study design was adopted.
Sample and Setting
The participants were registered nurses with staff nurse positions (N = 403) from two randomly selected tertiary hospitals in the Western Visayas part of the Philippines. Tertiary or teaching and training hospitals were chosen since these hospitals had a greater number of nurses compared to other hospital levels. The Slovin’s formula n = N/(1+Ne2) cited in Almeda et al. (2010) was used to compute the sample size yielding the desired sample size of 201. Also, priori power analysis using G*Power 3.1 software suggested that a sample size of 84 staff nurses would already be sufficient to achieve a statistical power of 0.80 in bivariate correlation analysis with 0.05 alpha and 0.30 medium effect size (Faul et al., 2009). However, to enhance the geographical diversity per hospital unit or department, the researcher included more than the desired sample size. A total of 230 questionnaires were randomly distributed and administered to staff nurses; 223 responded, obtaining a response rate of 97%. This study only involved staff nurses. Nurses occupying supervisory positions, trainees, volunteers, over 65 years old and employed in other hospitals were excluded from the study.
Data were gathered using four validated self-reported scales used among nurses in studies conducted in other countries. The authors of the scales granted permission to use the instruments in the current study through email correspondence.
Self-esteem Scale (SES) (Rosenberg, 1965). The 10-item SES was used to measure nurses’ global self-worth. Nurses were asked to rate each item using a 4-point scale (1 = strongly disagree to 4 = strongly disagree). The SES had a fairly acceptable internal consistency of 0.75 in nursing samples (McMullen & Resnick, 2013) and 0.77 among Filipino youths and adolescents (Reyes et al., 2017).
Psychological Empowerment Scale (PES) (Spreitzer, 1995). This 12-item scale with four subscales (meaning, competence, self-determination, and impact) was used to measure nurses’ psychological empowerment. All items were answerable in a 5-point Likert scale format (1 = strongly disagree to 6 = strongly agree). Studies conducted among nurses reported fairly high Cronbach’s alpha values of 0.80 and above (Shapira Lishchinsky & Benoliel, 2019; Uner & Turan, 2010).
Leader Empowering Behavior Questionnaire (LEBQ) (Konczak et al., 2000). This scale was administered to measure staff nurses’ perception of the empowering behaviors of their leader. The LEBQ by Konczak et al. (2000) originally consisted of 17 items, but Bester et al. (2015) recently added two items. The 19-item version of the scale was utilized in this study, consisting of six subscales: accountability for outcomes, self-directed decision-making, information sharing, skills development, delegation of authority, and coaching for innovative performance. Nurses responded using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The LEBQ was previously pilot-tested among Filipino nurses (Oducado, 2019). Konczak et al. (2000) reported reliability coefficients that range between 0.82 and 0.88.
Workplace Assertive Behavior Questionnaire (WABQ) (Timmins & McCabe, 2005a, 2005b). This scale was utilized to assess nurses’ assertiveness in the workplace. The participants were asked to indicate how often they use the eight assertive behaviors towards their nursing colleagues or co-staff nurses, the nursing management (head nurses or supervisors), and the medical personnel (doctors or physicians). Nurses were asked to answer using a 5-point Likert scale (1 = never to 5 = always). Timmins and McCabe (2005a, 2005b) stated an acceptable internal consistency (α = 0.88) of items within the questionnaire.
For all the scales in this study, higher scores indicate a higher level of self-esteem, psychological empowerment, leader empowering behaviors, and assertiveness in the workplace. The personal characteristics of nurses were also collected.
To make sure that the result of this study will be culturally sensitive and to increase its scientific accuracy, the instruments were subjected to face and content validation and pilot testing. Seven local experts with master’s or doctoral degrees and relevant experience and training in nursing, management, and psychology evaluated the items in the instruments to be relevant, clear, and culturally appropriate. A survey instrument validation rating scale was used in the validation of instruments (Oducado, 2020). Pilot testing was done among 30 nursing staff in another hospital. Preliminary reliability testing and actual survey revealed acceptable to high internal consistency values of SES (α = 0.87, α = 0.71), PES (α = 0.88, α = 0.88), LEBQ (α = 0.91, α = 0.89) and WABQ (α = 0.95, α = 0.92). Five participants during the pilot test were interviewed to share their comments about the instruments. No further changes were made to the instruments as per the acceptable result of pilot testing.
The survey was conducted between June to July of 2019. Before actual data gathering, administrative clearance to conduct the study was obtained from the Hospital Director through the Director of Nursing. In coordination with the Nursing Service Office, the researcher and trained data gatherers distributed the survey instruments inside a sealed envelope to staff nurses either before they go on duty or after shift. Staff nurses were briefly oriented regarding the purpose of the study, were allowed to ask questions, and were given the opportunity to refuse to join the study. The participants were asked to answer the forms at their most convenient time and place and were asked to return them sealed to the researcher or data gathers to ensure confidentiality of responses. The researcher allocated sufficient days for data collection to allow the adequate representation of staff nurses despite shifting schedules of staff nurses, and the participants were given ample time to answer the survey. During retrieval, the completeness of data entry was checked.
After data checking and cleaning, the responses were encoded and computer-processed via the IBM Statistical Package for the Social Sciences (SPSS) software version 23. Frequency (n), percentage (%), mean (M), and standard deviation (SD) were used to quantify and describe the data. Kolmogorov-Smirnov (p = 0.20) and Shapiro-Wilk (p = 0.31) indicated that data do not significantly deviate from normal distribution. The Pearson’s r correlation coefficient was used to determine the relationship between the key variables of the study. The correlation coefficient was interpreted following the work of Schober et al. (2018): + 0.90-1.00 = very strong positive (negative) correlation, + 0.70-0.89 = strong positive (negative) correlation, + 0.40-0.69 = moderate positive (negative) correlation, + 0.10-0.39 = weak positive (negative) correlation, and + 0.00 to 0.10 = negligible positive (negative) correlation. A p-value equal to or less than 0.05 was considered the level of acceptable significance.
The study was reviewed and approved by the Ethics Committee of the West Visayas State University. A written informed consent form was obtained from all participants. No personal identifiers were collected to protect the anonymity of the participants and the confidentiality of the data. This report is part of a larger study exploring Filipino nurses’ assertiveness.
Table 1 shows that the mean age was 32.34 years (SD = 8.14), and the average number of years of nursing work experience was 7.36 years (SD = 6.41). The majority were female (n = 153, 68.6%) and Bachelor’s degree holders (n = 150, 67.3%). There was an almost equal number of participants from public (n = 113, 50.7%) and private (n = 110, 49.3%) hospitals. There were 126 (56.5%) staff nurses assigned in specialty areas and 97 (43.5%) in medical and surgical units. Overall, the composite scores of the key variables in this study were above midpoint (Table 2). The composite score of nurses’ self-esteem was 32.06 (SD = 3.65), whereas the composite scores of the measures of psychological empowerment and leader empowering behaviors were 4.22 (SD = 0.43) and 3.86 (SD = 0.51), respectively. Assertiveness in the workplace had a composite score of 3.61 (SD = 0.55). The correlation between variables is presented in Table 3. There was a positive, weak, significant correlation between nurses’ level of self-esteem (r = 0.216; p = 0.001) and assertiveness and staff nurses’ perception of the empowering behaviors of their leaders (r = 0.269; p = 0.000) and assertiveness. Moreover, statistical analysis revealed a positive, moderate, significant correlation between psychological empowerment (r = 0.455, p = 0.000) and assertiveness in the workplace.
|Years of experience||7.36||6.41|
|Bachelor’s degree with Master’s units||73||32.7|
|Type of hospital||Public||113||50.7|
|Hospital unit||Specialty Areas||126||56.5|
|Medical and Surgical||97||43.5|
|Leader Empowering Behaviors||3.86||0.51|
|Accountability for outcomes||4.07||0.63|
|Delegation of authority||3.85||0.58|
|Coaching for innovative performance||3.62||0.72|
|Assertiveness in the Workplace||3.61||0.55|
|Toward nursing colleagues||3.78||0.55|
|Toward medical personnel||3.65||0.65|
|Toward management personnel||3.40||0.68|
|Independent variables||Pearson’s correlation (r)||p-value|
|Leader Empowering Behaviors||0.269||0.000*|
|Accountability for outcomes||0.355||0.000*|
|Delegation of authority||0.262||0.000*|
|Coaching for innovative performance||0.173||0.010*|
The present study looked into the influence of self-esteem, psychological empowerment, and leader empowering behaviors on nurses’ workplace assertive behaviors. This study demonstrated that self-esteem had a positive, weak, yet significant correlation with nurses’ workplace assertiveness. Healthy self-esteem is important to learning to be assertive, or being assertive can lead to high levels of self-esteem. Healthy self-esteem represents a critical asset or necessary quality in developing assertiveness (Darjan et al., 2020). It can be difficult for nurses to assert themselves when nurses have low self-esteem. Those with low self-esteem are likely to encounter problems defending their opinions or making decisions for themselves (Darjan et al., 2020). Studies among Japanese and Indian nurses found that nurses’ self-esteem improved after assertiveness training (Kanade, 2018; Shimizu et al., 2004). Similarly, a significant positive correlation between assertive behavior and self-esteem was reported in a study conducted in India among nurses (Binuja, 2020; Maheshwari & Gill, 2015) and in Nepal among nursing students (Shrestha, 2019). This study proposes that efforts should be made to improve and to achieve healthy and balanced self-esteem among nurses to better communicate and assert themselves in the workplace.
This study also found that psychological empowerment was significantly related to assertiveness in the workplace with a moderate positive correlation. Results of the current study also indicated a significant correlation between all the components of psychological empowerment and workplace assertiveness. This finding indicates that a higher level of psychological empowerment, such as giving nurses the authority to make decisions and enhancing their competence, results in higher levels of assertiveness. This finding is relatively consistent with that of the study of Azizi et al. (2020) and Ibrahim (2011). The authors found a significant positive relationship between psychological empowerment and assertiveness with samples of midwifery and nursing students in Iran and nursing students in Egypt. A similar finding was reported among Iranian neonatal nurses (Bostanabad et al., 2018). The result of this study suggests the importance of empowering nurses for them to act more assertively. Accordingly, it is necessary to pay attention to improving nurses’ competence, independence, and autonomy, likewise creating better opportunities for nurses to appreciate the impact and value of their work for them to exhibit assertiveness.
Finally, it was shown in this study that there was a positive, weak, but significant relationship between leader empowering behaviors and workplace assertiveness of staff nurses. It has been disclosed that managerial and organizational support enables nurses to become more assertive, empowered, and speak up against unsafe practices, and the process of becoming assertive or learning to speak up tends to be influenced by the management’s approach toward nurses (Darawad et al., 2020). Garon (2012) likewise discovered that the strongest theme for nurses to speak up was related to a climate of openness that is generally created by the leaders (managers and administration). The role of a supportive working culture in facilitating nurses’ ability and willingness to voice concerns was also noted in another study (Mansour et al., 2020). Correspondingly, the study of Wong et al. (2010) revealed that authentic leadership influenced nurses’ trust in their manager, which predicted voicing behavior. Review studies similarly noted that hospital administrative support and attitude of leaders or superiors were actors influencing health care professionals and nurses’ speaking-up behavior for patient safety (Lee et al., 2021; Okuyama et al., 2014a). The finding of this current study indicates the valuable role of nurse leaders and managers in supporting nurses to exhibit assertive behaviors. Nurses tend or are likely to assert themselves when assertive behavior is supported in the workplace. It is, therefore, vital for the nursing management to set up empowering conditions at work, such as increasing nurses’ accountability, autonomy, and self-directed decision-making to support nurses’ assertive behaviors. In the process of becoming more assertive, managerial and organizational support should also be in place to grant nurses the necessary power, autonomy, and access to resources to exercise assertive behaviors (Darawad et al., 2020).
Some shortcomings were encountered in this study that could be addressed by future scholars. This research was limited among nursing staff in two tertiary hospitals. Caution is recommended when results of the present study are extrapolated with all Filipino nurses and nurses working in other countries and other healthcare sectors. It might be useful to replicate the study on a larger scale involving nurses from different countries. Another limitation is the study design (cross-sectional) has temporal limitations and cannot establish causality between the variables. The use of survey questionnaires is subjected to self-reported bias. Validating self-reported data through method triangulation may be conducted in future studies. There may also be other factors influencing nurses’ assertiveness, such as personality and emotional intelligence not included in this analysis. Nevertheless, this research has contributed to a better understanding of the factors influencing nurses’ assertiveness in the workplace.
This research highlighted that higher levels of self-esteem, psychological empowerment, and empowering behaviors of the leader result in higher workplace assertiveness among nursing staff. Nurse leadership behaviors and empowerment play vital roles in staff nurses’ assertiveness. The results suggest that empowered nurses are assertive nurses. Also, helping nurses nurture healthy self-esteem and improve their confidence can potentially lead to better assertive behaviors in the workplace and assist nurses in setting and maintaining healthy boundaries. Nurses’ evaluation of themselves and empowering conditions significantly contribute to nurses’ assertiveness or their chosen method of communicating with others in social interactions. Understanding and looking into these factors can help the nursing management develop strategies to build and improve nurses’ assertiveness. Interventions and necessary platforms aimed at enhancing nurses’ self-worth should be initiated. At the same time, efforts must be directed towards fostering greater empowerment at the individual and organizational levels to promote assertiveness in the workplace.