Students' experience of the challenges of using assertive communication

Nursing has historically been a submissive profession within health care. Today, changes in healthcare policy, the evolving nursing role and negative healthcare events publicised in the media, have made it essential for contemporary nurses to be leaders within the clinical environment, using assertive communication styles in their exchanges with patients, relatives and other healthcare staff. Individuals in leaderships positions motivate others, set clear goals and make decisions, using listening skills and articulating clearly. The Nursing and Midwifery Council (NMC) (2018a; 2019) standards consider that leadership principles, such as assertiveness, are an integral component in the delivery of high-quality care and there is an expectation that students will engage with this from the start of their education.

The Willis Commission (2012) recognised that nurse educators and qualified nurses are in a unique position to lead nursing as a competent and compassionate workforce. Nursing students must be proficient in recognising, challenging and reporting poor care, working as equal partners alongside other health professionals (NMC, 2018b). This is consistent with Cumming and Bennett's (2012) position that leadership must exist at every level, with each individual viewing themselves as a leader who role models compassion in day-to-day care and who is committed to speaking up when things are wrong.

Nurses need to use firm, polite, assertive communication to address unsafe care at the time it occurs (Care Quality Commission, 2011). Hudek (2012) emphasised that assertiveness is integral to the creation of working environments within which, regardless of hierarchical position and profession, all team members are active, respected participants in discussions. Assertiveness is key for every nurse in all aspects of everyday nursing communication, although Johns (2013) stated that nurses find certain situations challenging, such as managing conflict. Nursing students need to perceive themselves as leaders, with a responsibility to use skills such as assertiveness effectively. The all-too-familiar perception, ‘I'm just a student nurse’, must be challenged and students need to develop their abilities to use assertiveness as a strategy to facilitate communication in delivering high-quality care.

In line with the nursing governing body's standards of proficiency (NMC, 2018a) students are required to demonstrate specific skills, knowledge and attributes, including skills relating to leadership, management and team working. Historically, there has been a heavier focus on leadership skills within the final stages of nursing programmes. However, despite the fact that leadership skills and communication skills are intrinsically linked, there has been insufficient emphasis placed on this link in previous nursing curricula. Universities and clinical areas need to better prepare students by supporting the development of key leadership skills (Edwards et al, 2018; Fuster Linares et al, 2020), including assertiveness, as a strategy to facilitate the delivery of high-quality care.

What is assertiveness?

Assertiveness is the ability to express ones' rights, thoughts and feelings without denying the rights of others, creating equality in relationships (Alberti and Emmons, 2017). In health care, it allows nurses to express their opinions confidently and without using aggressive, passive or manipulative behaviours (Bishop, 2013). It is important to emphasise that assertiveness is not a means for individuals to 'get their own way’, but rather a communication strategy that encompasses respect and openness to create balance, with recognition of what needs to be done in order to then act accordingly with fairness and empathy (Malik et al, 2014). Assertiveness is a key nursing skill and an attribute that underpins effective clinical leadership (Stanley, 2014; West et al, 2014). However, nurses have been criticised for lacking assertiveness skills, not always knowing how to achieve the delicate balance between speaking up, being aggressive or avoiding confrontation (Oxtoby, 2015).

Healthcare cultures

Healthcare cultures are complex, embedded with beliefs and behaviours of what is considered normal or acceptable by each professional group such as nurses (Fook and Askeland, 2007). To understand the use of assertiveness by nurses it is important to consider the historical beliefs and behaviours of the profession and the ensuing changes.

The historical attributes required of a ‘good’ nurse included loyalty, a commitment to ‘aid the physician’, obedience and servility (Begley, 2010:525). This created a culture within which nurses were not encouraged to use assertiveness or to challenge figures of authority. A lack of assertiveness could be a cultural issue that reaches beyond the nursing profession's view of itself, and is influenced by those who work alongside nurses, as well as by public expectation.

Study outline

The NMC (2018a) has retired the term ‘mentor’ in favour of using the terms ‘practice assessors’ and ‘supervisors’ to describe nurses who support student education in practice. However, the article uses the term ‘mentor’, as this was the term used by study participants.

The rationale for this qualitative study stemmed from concerns that nursing students do not perceive themselves as leaders, with a responsibility to use skills such as assertiveness effectively. Full ethical approval for the study was granted as part of the author's master's project from the university ethics committee.

The study set out to explore the experiences of third-year student nurses of using assertive communication in clinical practice, with the aim of considering the following questions:

• How do student nurses understand the use of assertive communication in their clinical practice?
• What challenges do student nurses encounter when using assertiveness?
• What clinical support do student nurses receive in their use of assertiveness?

Method

The study design consisted of analysing the accounts and perceptions of assertive communication of two cohorts: a group of students who had written reflective accounts and a second group that agreed to participate in a group discussion. The study consisted of three stages (Table 1):

• Stage 1: analysis of students' reflective accounts, to identify issues relating to students' use of assertiveness in a clinical situation
• Stage 2: identification of emerging themes from the accounts,
• Stage 3: discussion of the issues identified in the previous two stages.

The reflective account cohort had completed the course within the preceding 12 months, and no longer had student status: they were sent an email to explain the purpose and framework of the study, facilitating informed consent. This also limited any concerns relating to coercion or power relationships between participant and researcher, which could have been seen as a risk to their studies (Royal College of Nursing (RCN) (2011).

An opt-out approach to consent was used to create a pool of potential participants. From these, six narratives were selected using simple random sampling, based on the lottery method, which ensured that all documents had an equal and independent chance of being selected (Cohen et al, 2007). The six narratives were deemed to be a reasonable sample size to provide enough data to identify similarities and differences of views.

All students whose work had met the pass mark were considered. Although the higher graded work may have presented a higher level of academic clarity, there is a documented link between students who perform at a high academic level and high levels of reflexivity and emotional intelligence (Beauvais et al, 2011), and consequently a higher capability in managing social interactions (Por et al, 2011). This carries the risk that study subjects are naturally more comfortable with using assertive behaviours, and subsequently only considering these narratives could misrepresent the cohort as a whole.

Documents that had not met the minimum pass requirement were disregarded on the grounds that they were more likely to have not followed the assignment remit or have significant academic writing issues.

The second cohort of students consisted of seven students, who were invited to take part in a group discussion to explore the issues raised that emerged from the reflective narratives. Participants were identified using purposeful sampling, selecting a cohort that met the criteria for the study (Krueger, 1998), and who had been taught a session on assertiveness as part of their timetabled final-year studies. This ensured they had received the same academic input as the students who had provided reflective accounts in the other phase of this study. A face-to-face explanation of the study was followed up with information sent by email.

The discussion group were expected to manage themselves in a professional manner (NMC, 2018b); the ground rules, which involved promoting all participants' engagement and ability to share freely without threat to their confidentiality, and a definition of assertiveness, were displayed on posters at the discussion table, to keep the group focused on the topic. The definition of assertiveness provided to the students described it as:

‘… being able to express yourself with confidence without having to resort to passive, aggressive or manipulative behaviour … It requires listening and responding to the needs of others without neglecting your own interests or compromising your principles … An assertive response is invariably the preferable one, and leads to win-win situations where both parties feel good about themselves.’

Bishop, 2013:1

Data collection

An empirical social science research approach was adopted, supported by the collection of data relating to the students' direct experiences within the context of their social world of nursing (Punch, 2014). The study considered how adult nursing students understand and interact within the clinical world around them, allowing explanation, description and analysis of the meaning of the students' experiences of assertive communication.

The six reflective accounts selected had been written and submitted as part of students' final year assessment on the nursing degree programme and related to their experiences of using assertive communication in clinical practice.

The seven students selected for the group discussion took part in an in-depth semi-structured group discussion to uncover honest, rich and detailed information about their’ experiences of using assertiveness. Open-ended questions within a fluid questioning structure were employed to help them narrate their experiences, ensuring that all viewpoints were represented through the active participation of all students.

As part of the group discussion, the participating students were asked to identify on sticky notes examples of when nurses need to be assertive and rank these on an ‘easy-to-hard’ continuum. This visual approach encouraged the students to discuss their opinions and experiences in practice, increasing their voice within the research and adding to participant reflexivity (Butler-Kisber and Poldma, 2010).

The application of researcher reflexivity, as a nurse and educational practitioner, was important both during, as well as after, the group discussion and contributed to the overall development and analysis of data. As the group discussion unfolded, reflexivity drew out threads and listened to both what was and was not said (Johns, 2013)

Findings and discussion

Elements of interpretive phenomenological analysis (IPA) and discourse analysis were employed to handle the data. IPA explores how individuals interpret and make sense of their social and personal world and experiences (Smith and Osborn, 2003) and allowed examination of the students' perceptions of their clinical practice experiences. Discourse analysis identified themes and ideas while being sensitive to the language the participants used to add meaning to their stories (Punch, 2014). Clear identification of the descriptive words used, and application of reflection was used to give consideration to the themes identified.

The reflective accounts were read multiple times within each of the three stages of the amalgamated IPA and discourse analysis framework (Table 1). The documents were annotated while considering key reflective questions (see study outline) to promote trustworthiness.

Following transcription of the group discussion, the same analysis framework was employed as had been applied to the written reflections, with two additional criteria.

• Consideration of the emotion displayed within the participants' stories by noting their tone and voice, which would have been absent from the written format, in order to understand how their feelings and hopes affected the way they reacted, or may react in the future
• The transcribed narrative was emailed to the group for agreement of its authenticity.

The themes and issues that emerged within the written narratives and the discussion group were considered and are discussed in parallel. To give context and clarity to the students' stories, the written narratives are summarised in Table 2. For the purpose of ethical consideration and anonymity, identifiable details relating to the students, patients and trusts have been removed.

Assertiveness linked to responsibility

Sense of responsibility/duty

All the narratives discussed the sense of responsibility students felt while in clinical placement. The concept of ‘my duty of care’ was replicated across the documents and expressed explicitly through phrases such as ‘protect our service users’, ‘safeguard my patients’, ‘patient choice and safety’ and ‘make the safety of my patient my first priority’. There were also implicit references to the students' perceived duty to use assertiveness:‘I had to be assertive’ and ‘as a nurse I must …’ This could arise from the expectation that nurses today need to use assertiveness to raise patient safety concerns (Begley, 2010; NMC, 2018a; 2018b; 2019).

Responsibility as a theme emerged late within the group discussion process, prompted by the researcher out of interest because it had featured so significantly in the written reflections. One of the group retold her experience of speaking up about a mentor's poor practice. She described how her practice assessment document and the verification of her hours were subsequently, as she described it, ‘held ransom’ by her mentor, making her feel that her learning and assessment experience were significantly threatened. This issue was cited by Levett-Jones and Lathleen (2009), who identified that students felt the relationship with their mentor – and potential learning opportunities – were jeopardised when they confronted issues relating to patient safety. According to Duffy et al (2012), students regularly experience fear regarding the impact that whistleblowing on poor practice could have on their assessments.

The group openly discussed concerns about speaking up; increased stress, alienation from other nurses, failing a placement and concerns about future placements and employment, mirroring issues identified by Ion et al (2016). All seven of the group stated that they would speak up if they were aware of poor practice, regardless of ramifications for themselves, in order to ensure patient safety. However, some responded more emphatically than others, raising questions about how honest students can really be within the discussion, if they feel uneasy in terms of whether the researcher may have concerns about their fitness for practice.

Workplace rules

Students were able to reconcile the need to use assertiveness more easily when rules were in place and needed to be followed. Student 2 talked extensively about ward visiting rules. The ward's rules and protocol appeared to offer the student permission to be assertive:

‘I felt I was applying good nursing practice by maintaining the protocols of the ward and this made me feel confident.’

The concept of rules supporting the use of assertiveness was described within the group discussion when they explored the topic of carrying out medication rounds. Wearing a red tabard when administering medication was understood as a clearly defined rule, making others aware that the person wearing it is administering medications and it is their sole focus to promote safe medications management. Tomietto et al (2012) appeared to partially support this, stating that when a nurse wore a tabard the number of interruptions from other staff members actually increased, but the nurse carrying out the medication round had more authority to delegate these more swiftly.

Feelings of failure

Where poor practice was witnessed, students addressed this out of a sense of duty, which granted them permission to be assertive. However, they still found this an anxious and unpleasant experience. Student 1 described feelings of ‘failure’, despite the fact the poor practice had occurred when she had not been not in the room. She alluded to feeling that had she been more assertive at an earlier opportunity she could have headed this off.

Larijani et al (2010) found links between higher levels of assertiveness and lower levels of anxiety. Had the student felt able to seize an earlier opportunity to address the issue, she may not have felt so guilty about the ensuing care. Feelings of failure and guilt can reduce a student's feelings of worth, which undermines self-esteem.

Assertiveness linked to mentors

All students, from both the narratives and discussion group, acknowledged and described the central role of mentors in the overall quality of their clinical practice experience, positive or negative. The group discussion highlighted the multiple roles of mentors across a range of learning needs. The main roles identified were role modelling, reflection support and providing feedback, which are discussed below.

Role modelling

Student 2 described how she was able to approach a situation using assertive communication based on previously observing her mentor demonstrating this skill in a confident and compassionate manner that had led to a positive clinical outcome. Nurses should act as role models for their students, which includes promoting safe and effective practice. A mentor who demonstrates both professional values and clinical skill presents a powerful and influential learning mechanism for students (Keeling and Templeman, 2013). Hudek (2012) and Siviter (2013) suggested that students must actively seek out role models who demonstrate appropriate use of assertiveness. However, students do not choose the mentors to whom they are allocated on clinical placement.

Poroch and McIntosh (1995) identified that a large proportion of ‘traditional nurses’ do not use assertiveness effectively. The group discussion agreed with this in part, with comments that they felt that more recently qualified staff demonstrated higher levels of assertiveness than those who had been nursing longer. When offered a tentative hypothesis that this might be a result of graduate education, they thought that it was more to do with newly qualified nurses still feeling they could make a difference, and reflected the fact that those who had been qualified longer were more worn down and resigned to ‘the way it is’.

Due to the nature of working so closely with others in a highly emotive environment, nurses are susceptible to burn-out, a state of emotional exhaustion, cynicism and negative attitudes towards oneself (de Souza Pereira et al, 2015). This undermines a nurse's self-esteem and confidence and can have a negative impact on their ability to use and role model assertiveness (Poroch and McIntosh, 1995). This suggests that nursing students need role models who demonstrate the use of assertive communication and have the capacity to maintain and protect this skill, demonstrating resilience to maintain a healthy perspective, self-esteem and self-confidence.

If, while on placement, nursing students are encountering a variety of nurses with a range of skills, they need to be able to differentiate the practices they wish to emulate themselves and those they wish to avoid. Keeling and Templeman (2013) found that nursing students are able to use negative role-modelling experiences to enhance their own practice. Student 4 alluded to previous poor experiences and appeared to have been able to process these and facilitate improvement in their own practice.

Reflection support

All students in both cohorts identified reflection as an integral part of their practice. However, within the written narratives the ability to reflect independently varied between students. Student 1 described a situation with which she had felt uncomfortable and, when reflecting on this, considered her options, and then returned to the situation to implement her decision to speak up, exemplified through the process of both reflection-on-action, a cognitive process to review and understand her actions, and reflection-before-action to plan her next steps before taking them (Greenwood, 1998).

Student 4 had a more reflective approach and appeared to have responded to the situation more intuitively. She mentioned a previous occasion when she had a bad experience of speaking up. This experience, her demonstration of high self-confidence and a strong sense of the right thing to do, allowed her to respond instinctively using reflection-in-practice. This is not simply thinking about her actions while being assertive, but responding in the way she did because her previous reflection had shaped her ‘way of knowing’ (Johns, 2013). Her active approach was indicative of self-mentoring, where she had extracted learning and guided herself through the decision-making process (Law and Chan, 2015).

Student 5 reflected on the skills she had used, or felt that she had not used, when discussing the arrangements for a large family visiting a dying relative. Her reflection disclosed feelings of failure, anxiety and limited communication skills. At this point, the student felt she had failed at being assertive, focusing on the negative aspects of the situation and, in doing so, decreased her self-confidence and self-esteem – this leads to decreased ability to be assertive (Wadensten et al, 2009; Larijani et al, 2010). The student identified that she would have benefited from discussing the situation with her mentor afterwards.

Kaihlanen et al (2013) posited that the student–mentor relationship must be allowed time to use reflection as a learning opportunity. The student appears to have felt let down by her mentor and, perhaps, had she been afforded reflective opportunities before, during and after the episode of speaking up, as proposed by Law and Chan (2015), she may have felt more prepared, learnt positively from the experience and may have come away with a more balanced view of the situation. From an outsider's perspective she appeared to have taken all the blame for the poor outcome, and it is possible that some of this could have been apportioned to the family. Absorbing the burden and emotion of the situation without support could lead to the aforementioned phenomenon of burnout, decreasing her confidence and stunting her learning.

Providing feedback

The need for mentor feedback was demonstrated, in positive and negative descriptions of experiences, by all students, from both the narratives and the discussion group. Two in particular stood out, and provide insight into the mentor's and wider clinical environment's impact on supporting students in using assertive communication. Student 3 spoke honestly about the anxiety she had experienced when addressing a senior physiotherapist:

‘Despite my fears and concerns, I managed to step forward and affirm my views and advocated [for the patient].’

At first the terms ‘fears’ and ‘concerns’ might sound passive, but the use of ‘despite’ and ‘managed’ are used positively and the student's narrative highlights pertinent moments that allowed her to overcome these issues. But the most significant part of the story is not of the student speaking up to the physiotherapist, but that a ward manager from whom the student had sought advice had then said ‘thank you’ to the student.

The manager could have said ‘well done’, which would have validated the student's clinical concerns, making her feel validated as a competent clinician. By saying ‘thank you’ the manager also validated her as a member of the ward team. Feeling clinically competent and having a sense of belonging to the team boosted the student's sense of safety, self-esteem and confidence, and her feelings of empowerment then enabled her to communicate assertively with the physiotherapist, albeit she had had to force herself to do this.

Also significant is the fact that the student felt there was a hierarchy in place when addressing the physiotherapist. ‘Would not listen to me as I was a student nurse and was not qualified or as senior as her’, and yet she still felt compelled to communicate assertively. This suggests that empowering students is the key to diminishing the issues students experience relating to using assertiveness when there is a hierarchy, be it real or perceived.

Student 6 had a less positive experience of feedback from her mentor team. It is important to consider the relative truth of the reflective account. Because this was written as an assessed piece of work, the student may have wished to present herself in a positive light to her academic tutors. However, two issues should be considered.

• At face value, the story may be accurate
• On the other hand the story may not be accurate. However, if the student believes this is what happened, there is potential for her to feel confused about the events and the ensuing reflection.

The student's reflection described what appeared to be a competent decision to alert the GP of a deteriorating patient. She was then called to the nurse in charge to discuss her actions. Although not explicit, from the tone of the ongoing reflection, she appears to have been reprimanded or challenged about her decision to get urgent medical attention. The student acknowledged that she had felt very scared working autonomously with such an unwell patient, yet also had concerns about overstepping her student limitations, being ‘too confident’ and finally reflected for the future:

‘I will ensure openness, teamwork and act in a professional manner.’

According to Keeling and Templeman (2013), there is a direct link between theory and clinical practice, and self-esteem. Should the student subsequently have felt conflicted about the theory of using assertiveness and its practical use, her self-esteem would have been lowered. Using clinical skills and knowledge effectively is a significant part of the ability to be assertive and, in undermining this, the nurse in charge may have diminished the student's self-esteem and self-confidence, and affected her capacity to use assertiveness in future.

As with Student 3, the interactions are with the nurse in charge, but in this reflective account the student identified that her mentor was on holiday. Although all registered nurses have a responsibility to support student learning (NMC, 2018a), the absence of this student's mentor is significant. There was a consensus within the group discussion that, when a student was unsure of something, they should wait to speak to their mentor. The mentor was seen as the go-to person and, on the whole, as someone who was more willing to support a student's questions. Ferguson (2011) stated that newly qualified nurses place a high value on mentors who answer questions and provide extra information and support. Perhaps if the mentor of student 6 had been more accessible, the student would have felt more able to make her case and reflect more holistically on a frightening and challenging experience.

Mentorship in summary

The degree to which students require support with reflection to create a valuable learning experience varies. The mentor is in an ideal position to support the reflection-in-action process. However, reflective learning can be supported by anyone within the learning context of the student (Law and Chan, 2015). Therefore consideration should be given to the reflective support structures available for students. Students must have clear and accurate feedback from their mentors and mentoring teams to help give structure and meaning to the reflective process.

Assertiveness linked to student safety

The group discussion agreed with the description of a less positive experience of mentorship, as contributed by student 6, and included a frank discussion around not wishing to be ‘too known’ and making sure they ‘fitted in’. These are common concerns for students, as reported by Levett-Jones and Lathleen (2009), whose study used the phrase ‘don't rock the boat’, with Mooney (2007) suggesting that fitting in makes the individual more highly thought of by the team. The discussion group was unanimous that it takes them 2 minutes from walking onto a ward to gauge the environment and make a decision about how they intend to handle themselves. Timmins and McCabe (2005) described the notion that nurses change their behaviours to meet the expectations made of them.

The group said they noticed when there was a ‘clique’ culture on a ward and identified the relationships on the ward and there was a general feeling that, if anyone upset the dominant female, they literally upset the whole ward.

It is not uncommon, as described by Timmins and McCabe (2005), for assertiveness levels to drop in an attempt not to upset the ward equilibrium. Even the students within the discussion group who described themselves as comfortable in terms of using assertiveness agreed that on ‘some wards I am more myself … where I feel comfortable … and there isn't a clique’, suggesting that some ward cultures do not look favourably on students who practise assertive communication.

The discussion group highlighted common fears of using assertiveness to speak up, such as being viewed as a troublemaker (Mooney, 2007). The group went as far as to say that they did not want to be ‘hated on the ward’ for ‘standing up’. They also expressed fears of ‘getting it wrong and looking stupid’, and some worried that this may have ramifications for their assessment of skills or the placement as a whole, a sentiment described by Duffy et al (2012).

A summary of the study findings is presented in Table 3.

Implications for practice

A number of ways in which mentors can support students to use assertiveness, and enable them to feel more able to cope with the feelings of perceived and, in some cases real, hierarchy are suggested in Table 4. Students need multiple opportunities to reflect accurately and holistically on their own clinical practice and the practice of others, to help them develop confidence, understanding, self-awareness and competence (Contreras et al, 2020). A by-product of this is their understanding of, and ability to be assertive. Structures supporting reflection that provide nursing students with these opportunities are needed not simply to develop students' awareness of the use of assertiveness, but also to ensure that they learn how to support their own reflective processes for future development outside nurse education.

Johns (2013) suggested that sharing similar experiences within peer group reflective supervision helps not only individuals to learn from each other but also makes them stronger as a group. The use of assertiveness by nurses within the healthcare environment needs to be addressed culturally. The use of peer reflection and reflective debate could support students to use reflective action, whereby they are empowered to promote a sense of social justice for nursing students among health professional peers (Akinbode, 2013; Hutchinson, 2015). Students therefore benefit from opportunities to reflect that are incorporated as standard into their studies, which should extend beyond opportunistic one-to-one sessions with mentors and self-directed reflection.

Conclusion

As a new nursing curriculum is implemented across the country, it is pertinent to consider how the issues raised can be addressed. Structured in-class reflection could promote a sense of belonging and of value, and encourage students to have the confidence to speak up in a safe environment. A process such as this could provide the reflecting student with elevated self-esteem as they experience being listened to (Akinbode, 2013) and achieve learning for both the reflector and the supporters, by allowing attitudes and beliefs to be challenged and understood (Ekebergh, 2007), gaining an appreciation of how others think and reason (Moon, 2010).

Students feel more able, or willing, to use assertiveness where there is a clear sense of duty, such as the responsibility to protect patient safety in the NMC (2018b)Code, or where there are clear rules set out by the clinical environment. Students are able to learn from both positive and negative examples of professionalism. However, their future practice benefits from being able to identify a nurse as a role model, who not only demonstrates assertive communication, but also the attributes that maintain and protect this communication skill: resilience, compassion, reflexivity and high levels of self-esteem and self-confidence.

Students need reflection opportunities and honest, accurate, clear feedback to help them make sense of their experiences and to promote their self-esteem and self-confidence as a nurse. Mentors, or practice assessors and supervisors, are in an ideal position to support reflection as a structured and conscious process. It is also beneficial for students to discuss their experiences with their peers within the university environment. This process should help students to identify and process any feelings of guilt or concern within their practice, as well as help them identify what they have done well. Developing students' self-esteem and self-confidence will increase a sense of empowerment, which is necessary for students to assert their thoughts effectively.

Students need to be, and to feel, safe at a basic level before they will feel able to engage in assertive communication. This safety includes having a relationship with their mentor and feeling that they are part of the team, within which they can share their thoughts, feelings and ideas.

KEY POINTS

• Students who feel welcomed, safe and confident in their clinical environment will experience greater empowerment to use assertive communication
• Students need accurate and honest feedback to understand their clinical experiences and may need support to reflect on and understand how they can use this to be a more confident practitioner
• Students need role models who demonstrate not simply assertive behaviours, but also resilience, self-esteem, self-confidence and reflective processes

CPD reflective questions

If you are a qualified nurse:

• Consider how nursing students are welcomed into your clinical environment. How are they supported to be part of the team?
• How could you empower students by using reflection?

If you are a student:

• How do you feel about speaking up and sharing your opinion? Why do you feel this way?
• Think of a nurse with whom you have worked who you consider a role model. What is special about them?