In 2016, a study across 12 higher education institutions with 130 participants explored and evaluated the development of assertiveness skills for students undertaking the Specialist Practice Qualification (SPQ) in district nursing (Green, 2016). Adopting a mixed methods approach, the scoring from completed assertiveness tools during the SPQ programme was analysed alongside transcripts from qualitative interviews.
Analysis of quantitative data, at three time points across the 12-month programme, demonstrated improving scores with statistical significance. The qualitative analysis of interview transcripts revealed the transformational nature of the SPQ programme for participants. Transformation included an enhanced understanding of the underpinning theories in relation to assertiveness, improved advocacy skills and enhanced personal leadership qualities. The study clearly demonstrated that implementing a specific focus on the development of leadership qualities, on any course or programme, can enhance the assertiveness skills of the participants.
Assertiveness is a key skill that reinforces the ability of an individual to clearly and effectively express their thoughts and opinions, while respecting the rights and feelings of others (Mushtaq, 2018). The assertiveness of every member of a clinical team, across all areas of practice, contributes to that team's capacity for optimised team working and care delivery. Assertiveness enhances communication and ensures a positive working environment for all. Specifically, within community nursing, assertiveness across team members ensures that best quality, person-centred patient care is delivered and that the safety of patients and team members is sustained.
While enhanced assertiveness is a critical skill for many professions, it is crucial within nursing (Al-hawaiti et al, 2025). Evidence suggests that assertiveness can be developed, enhanced and improved. Some people appear to be inherently assertive, while others are not. Everyone can develop or enhance their assertiveness skills, providing they have guidance and support. There is interesting research that suggests an individual's inherent assertiveness may be influenced by their position within their family group (Hall and Warner, 1977).
‘Assertiveness enhances communication and ensures a positive working environment for all. Specifically, within community nursing, assertiveness across team members ensures that best quality, person-centred patient care is delivered and that the safety of patients and team members is sustained.’
Hall and Warner's (1977) research explored relationships between birth order, family size and assertiveness across a sample of 140 college students. Findings revealed that there were no significant differences in assertiveness among the male sample for their birth order and family size. However, female firstborns and females from families with three or fewer siblings demonstrated significantly higher levels of assertiveness than later born females and females from larger families. These findings may be of particular significance within nursing, as it is a female-dominated profession. Evidence suggests that effective assertiveness can provide a range of benefits, personally, professionally and in the delivery of care.
The impact on personal autonomy
Assertiveness plays a crucial role in enhancing personal autonomy (Ach and Pollmann, 2022). It enables an individual to effectively express their thoughts, feelings and boundaries clearly and confidently, while maintaining respect from others. Assertive individuals are more readily able to confidently articulate their beliefs, opinions and desires without fear of judgment.
Assertiveness embeds a sense of authenticity, which reinforces an individual's autonomy. Alongside this, assertive people demonstrate improved decision-making skills; they implement choices that are based on their personal values and priorities, rather than external pressures. In this way, assertiveness helps an individual to resist external manipulation or coercion, thus ensuring that decisions align with their personal goals. Assertive people set and enforce boundaries, while effectively communicating their limits. When assertiveness is demonstrated effectively, assertive individuals gain further confidence in their handling of situations, with their self-assurance further strengthening their autonomy. Assertiveness promotes healthy interpersonal dynamics that are based on mutual respect. Assertive people do not rely on others for validation or to support their decision making.
‘Assertiveness is a key skill that empowers individuals to maintain control over their lives, personally and professionally, enabling them to make independent choices and to interact with others in a way that reinforces their personal autonomy. Nurses who are assertive report lower levels of stress and burnout; they can assert their needs, set boundaries and manage workload expectations, leading to improved job satisfaction.’
Assertive people demonstrate lower levels of stress, with their concerns addressed directly rather than being suppressed (Maheshwari and Gill, 2015). Assertiveness is a key skill that empowers individuals to maintain control over their lives, personally and professionally, enabling them to make independent choices and to interact with others in a way that reinforces their personal autonomy.
Nurses who are assertive report lower levels of stress and burnout; they can assert their needs, set boundaries and manage workload expectations, leading to improved job satisfaction. Research supports the idea that assertiveness in nursing can act as a buffer against the negative impacts of workplace stress (Al-hawaiti et al, 2025). Assertiveness is linked to enhanced empowerment for nurses; by expressing their thoughts and opinions clearly, nurses are more in control of their professional lives, enhancing job satisfaction and their professional identity.
The impact of assertiveness on compassion
Nurses who demonstrate assertiveness can express themselves clearly and effectively; by doing this, they create an environment based on transparency and trust. In this situation, patients feel understood and supported, fostering and embedding a compassionate relationship. Assertiveness effectively enables nurses to maintain their professional boundaries, ensuring the provision of compassionate care without compromising their emotional wellbeing.
The balance of the provision of compassionate care while feeling emotionally safe, helps to prevent nurse burnout, promoting the delivery of sustained, quality care (Maheshwari and Gill, 2015). Assertive communication enables a nurse to express empathy clearly and effectively; they can understand and acknowledge their patient's emotional needs and provide appropriate support while respecting the patient's autonomy. Assertiveness reduces misunderstandings or emotional tension by encouraging respectful conversations, thus maintaining a compassionate environment for both patients and staff.
The impact of assertiveness on team working
Assertive communication in team settings promotes and embeds enhanced collaboration. Nurses who feel confident to express their ideas, to ask questions and to offer solutions contribute to a more coordinated and efficient team. All team members in this situation feel psychologically safe. Within any team, members may have a range of differing perspectives. Assertiveness—clear and transparent communication, where all parties are respected—helps manage and resolve conflicts constructively, leading to a more harmonious and productive team dynamic.
Assertive nurses are more likely to clarify their roles and responsibilities within the team, which reduces confusion and ensures tasks are appropriately delegated and completed. Assertiveness is an essential element of leadership within nursing. Nurse leaders who model assertiveness, foster a culture of open communication, support and respect among team members (Omura et al, 2017).
Assertiveness is crucial for effective interprofessional working, particularly in healthcare settings where collaborative teams from different disciplines are required to work together to provide comprehensive patient care. Interprofessional working may involve professionals from a range of different fields—such as doctors, nurses, physiotherapists, social workers and pharmacists—coming together to address the needs of the patient. Assertiveness in this context enables effective communication, respect and collaboration among diverse professionals.
Assertiveness ensures that each team member's ideas, concerns and perspectives are heard; thereby allowing individuals to express their thoughts openly, without being aggressive or passive. This is an essential element in making sure that all voices are considered in the decision-making process. In interprofessional teams, where members may have different approaches or expertise, assertiveness helps prevent misunderstandings and promotes a healthy dialogue (Lee et al, 2023). In multiprofessional working, respect for each other's roles and contributions is crucial. Assertiveness fosters and embeds respect; it allows team members to communicate their needs and boundaries, while recognising and acknowledging the expertise and opinions of others. This creates a more collaborative, less hierarchical environment.
The impact of assertiveness on care delivery
Assertiveness enables clear communication, with patients, their families, carers and other healthcare professionals within the multidisciplinary team, leading to a better understanding of the individual patient's care needs. Assertiveness allows for an honest exploration of patient and carer expectations and understanding, and improves care delivery.
Assertive nurses are able to effectively advocate for their patients across a range of situations and hierarchies; this may involve other healthcare professionals, local authority colleagues, care agencies and a range of healthcare providers. Assertive nurses effectively voice their concerns, always ensuring that the patients receive the most appropriate care at the time that they need it. Assertive nurses have better decision-making skills; this ensures enhanced input in meetings, with concerns voiced and suggestions made, to ensure better patient results. Assertiveness engages nurses in the education and empowerment of their patients; it enables an understanding of care options and supports patients and their carers to engage with and participate in their treatment plans. Assertiveness can increase patient satisfaction and impacts on patient concordance with treatment plans.
Barriers to assertiveness in nursing
As discussed, while assertiveness is an essential skill for nurses, they can face barriers that prevent them from expressing themselves effectively. Research indicates that hierarchical structures, gender norms and a fear of retribution are common barriers that prevent nurses from being assertive (Gendreau, 2019).
Such barriers are often present in clinical settings where authority figures, such as physicians, may dominate decision-making processes. In addition, nurses from different cultural backgrounds may face additional challenges in expressing their assertiveness because of cultural expectations that surround authority, power and communication styles. Research in multicultural settings highlights the need for culturally sensitive assertiveness training that ensures that all nurses are equipped to communicate effectively in diverse environments (Bahreman and Swoboda, 2016).
Training and development to enhance assertiveness skills
Many studies highlight the effectiveness of assertiveness training programmes tailored for nurses (Omura et al, 2017). Programmes often include techniques such as role-playing, scenario-based learning and feedback, allowing nurses to practice and refine their assertiveness skills. Research suggests that assertiveness training leads to improved confidence, communication skills and job satisfaction (Omura et al, 2017). Online education and simulation-based training provides innovative approaches for teaching assertiveness to nursing students and professionals. Research indicates that these methods are effective in teaching assertiveness because they offer a safe and controlled environment for practising these skills (Lee et al, 2023).
The vital role of assertiveness in nursing
Assertiveness is an essential skill for nurses. Evidence from the Elaine Bromiley case of 2007 (Cadogan, 2007) clearly demonstrated that nurses involved in the case were fully aware of the implications of Elaine's deteriorating condition, yet they failed, or were unable to, ensure that their voice was heard.
Nurses are confronted by a myriad of situations on a daily basis, where their assertiveness can change outcomes for their patients. They owe it to themselves, and to their profession, to ensure that their assertiveness skills are optimised. The benefits of assertiveness include clear communication, enhanced patient advocacy, better empathy and improved team collaboration, underpinned by working in a psychologically safe environment. Assertiveness contributes to better patient outcomes and a supportive, effective work environment. The development of assertiveness is a personal life skill, but also a key component of the delivery of high-quality care that nurtures compassion and underpins a well-functioning team.