Relation of assertiveness and anxiety among Iranian ...

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brill and Richey. More than half of the nursing and midwifery ... provide a suitable and assertive response in critical or dan- gerous situations is a vital skill and a ...
Journal of Psychiatric and Mental Health Nursing, 2010

Relation of assertiveness and anxiety among Iranian University students T. T. L A R I J A N I 1 p h d , M . A G H A J A N I 2 m s c , A . B A H E I R A E I 3 p h d & N . S . N E I E S TA N A K 4 m s c 1

Assistant Professor, Department of Psychiatric Nursing, and 2Nurse, and 3Assistant Professor, Department of Reproductive Health, and 4Lecturer, Department of Psychiatric Nursing, Tehran University of Medical Sciences, Tehran, Iran

Keywords: anxiety, assertiveness, Iranian University students Correspondence: A. Baheiraei Department of Reproductive Health Tehran University of Medical Sciences PO Box 15745-1453 Tehran Iran E-mail: [email protected] Accepted for publication: 10 June 2010 doi: 10.1111/j.1365-2850.2010.01607.x

Accessible summary

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The findings from the present study revealed that less than 30% of nursing and midwifery students have high assertiveness and only half of them have low anxiety. Assertiveness and anxiety have negative correlations in nursing and midwifery students and affect the mental health and educational and occupational performance of the students. Many factors such as years of education and working while studying influence the level of assertiveness in the students. The anxiety in students had a significant relation with the father’s level of education, family income, etc.

Abstract The simultaneous existence of low assertiveness and high anxiety in nursing and midwifery students leads to the disruption of study performance. There exists little information concerning their assertiveness. The purpose of this study was to determine the relation of assertiveness and anxiety in nursing and midwifery students. In this correlational, cross-sectional study, 173 nursing students (68 males and 105 females) and 77 midwifery students were recruited from the Tehran University of Medical Sciences in Iran. Data were collected using a questionnaire including personal-social factors, the Spielberger Trait Anxiety Inventory and the Assertion Inventory of Gambrill and Richey. More than half of the nursing and midwifery students (59.5% and 59.7%, respectively) had moderate assertiveness. Also, 43.3% and 36.4% of them had moderate and high levels of anxiety. Pearson correlation test revealed that assertiveness and anxiety had negative correlations in nursing (r = -0.51, P < 0.001) and midwifery (r = -0.449, P < 0.001) students. Some demographic variables had significant correlations with assertiveness and anxiety among the students. Considering the relation of assertiveness and anxiety and its effects on mental health and educational and occupational performance, students should be informed of the required skills for positive interaction with others and to increase assertiveness and decrease anxiety.

Introduction The simultaneous existence of low assertiveness and high anxiety in students of nursing and midwifery results in the disruption of study performance, delay in learning, weak© 2010 Blackwell Publishing

ening ability and limiting ingenuity; and it not only threatens well-being but also prevents them from achieving a healthy and productive life (Worley 1997). Assertiveness is one of the most important and fundamental social skills consisting of interpersonal and 1

T. T. Larijani et al.

behavioural skills (Gist et al. 1991). In fact, assertiveness means that people should express their positive and negative feelings while respecting others’ rights (Paterson et al. 2002). Assertiveness is a way to certify and preserve the value, dignity and respect of one’s self and others. Furthermore, the level of assertiveness presents the level of personal confidence (Gaddis 2007). Because of the positive results of assertiveness, it is considered as one of the valuable behaviours in the field of nursing and midwifery. Results of assertiveness include the increase in management skills (Milstead 1996) and job satisfaction (Creech & Boyle 1985), achieving true independence (Keenan 1999), obtaining professional opportunities (Parkin 1995), gaining power and authority (Begley & Glacken 2004), preventing patient negligence (Poroch & Mc Intosh 1995), alleviating stress (Bower 1999), increase in efficiency during a situation change (Benton 1999) and a much wider knowledge and awareness about the methods of responding (Mc Cartan & Hargie 2004). In the field of nursing and midwifery, the ability to provide a suitable and assertive response in critical or dangerous situations is a vital skill and a lifesaver for patients. According to Begley and Glacken, the health services of the 21st century require nurses who are assertive in meeting the needs of their patients (Begley & Glacken 2004). With an assertive behaviour one can correlate suitably and respect patients’ rights without harming professional relations (Gaddis 2007). Alumni of nursing and midwifery also need high assertiveness to be able to obtain a job, develop and promote in it and increase their self-confidence (Kamile et al. 2006). Poyrazli and colleagues state that nonassertiveness in students is considered as a barrier to their relationship with tutors, advisers and classmates (Poyrazli et al. 2002). According to the report of Goldsmith and McCall, in 40% of the cases low assertiveness in students can lead to learning incapability and the decrease of practical efficiency (Goldsmith & Mc Fall 1975); whereas students with high levels of assertiveness experience less compatibility problems and less loneliness. These students also have more self-esteem in their education (Lin et al. 2004). On the other hand, anxiety disorders are the most common type of psychological disorders as more than 23 million people in the United States are affected by it each year (Carson 2000). Other researches in Iran also report the outbreak of psychological disorders among 12.75% to 30.4% of students (Bagheri Yazdi et al. 1995, Dastjerdi & Khazaei 2001). Iranian students face problems such as anxiety, depression, enmity, aggression and low assertiveness (Dadjo 1997). A study on depression in Iranian students found gender, interest in major, future stability and family history to be related factors to depression. Another 2

study reported that nursing students are unsatisfied with certain aspects of their major and experience anxiety because of lack of knowledge and expertise in the field (Sharif & Masoumi 2005, Bayati et al. 2009). Every day within a clinical environment, nursing and midwifery students witness the pain, sorrow and sadness of other people. Special situations in hospitals such as patients’ moans and sighs, their sickness and death, sleeplessness, misgivings and interpersonal relationship disorders in all levels lead to an increase in nurses’ stress and anxiety. This stress and anxiety also affects other nurses and midwifes thus overshadowing the overall performance, caring procedure and quality of the whole system (AntaiOtong 1995). Previous studies state that in general, nurses and midwives are not assertive (Mc Cartan & Hargie 2004). This lack of assertiveness causes weakness in the nursing system, such that Castledine mentions his concern regarding nursing in society this way: ‘Nursing has a vague, unstable, transient role and compared with the job of a doctor, they consider themselves as losers’ (Castledine 1997). Dragon referring to Timmins and Mc Cabe states that nurses and midwives feel an inequality because of their gender and the dominance of doctors (Timmins & Mc Cabe 2005). According to Farrell, nursing is an ‘oppressed discipline’ (Farrell 2001). On the other hand, nursing is redefining itself and in this new definition, it attempts to become independent of the physicians’ territory. Special roles of nurses and midwifes have taken part of the authority and power away from doctors (Finlay 2000). Mc Cabe and Timmins believe that it is not clear whether today’s nurses are assertive or not? (Mc Cabe & Timmins 2003). There exists little information concerning the assertiveness of nursing and midwifery students (Beck & Srivastava 1991). Therefore, considering the change in nurses’ traditional roles and current situations, research on assertiveness of today’s nurses is an important issue. In addition, assertiveness has a cultural component (Furnham 1979, Yoshioka 2000), where a difference in students’ culture correlates with their assertiveness (Lesure-Lester 2001). Also according to Paterson and colleagues, the relation between assertiveness and anxiety with interpersonal relationships is not well documented (Paterson et al. 2002). Factors such as the role of culture, the importance and the effects of this issue on students’ mental health and patient care, the uncertainty in assertiveness and its relation with anxiety, were considered prior to the study. This research was designed and conducted with the purpose of determining the relation of assertiveness and anxiety among nursing and midwifery students at Tehran University of Medical Sciences. © 2010 Blackwell Publishing

Assertiveness and anxiety in students

Methods A cross-sectional study was conducted in Tehran, Iran. All qualified nursing and midwifery students of the Tehran University of Medical Sciences participated in this study in 2008. After defining the sample size, considering the limited number of male nursing students and midwifery students, all of them participated in the study through the census method and the rest were selected from female nursing students of different years with ration. A total of 173 undergraduate nursing students (68 male and 105 female) and 77 undergraduate midwifery students were studied. This study was approved by the ethics committee of the Tehran University of Medical Sciences in Iran. The questionnaire used for this study consisted of three parts. The first part was personal-social factors including 25 questions (such as age, gender, birth order, year of study, study topic, etc.). The second part was the Spielberger Trait Anxiety Inventory employing the Likert scale made up of 20 multiple-choice questions (almost never, sometimes, often and almost always). For example, 1 Almost Never I lack selfconfidence

2 Sometimes 1

3 Often 2

4 Almost Always 3 4

Measure of hidden anxiety often defines the overall and usual feelings in a person and is used for identifying worried and anxious characters. The participants’ anxiety was studied in three levels of mild (20–42), moderate (43– 64) and severe (65–80). The third part was the Assertion Inventory of Gambrill and Richey (1975). The reason behind selecting this measure was its exclusiveness in defining the degree of student’s unhappiness in special cases and also the existence of many positive and negative social cases (Mc Cartan & Hargie 2004). This questionnaire consisted of several sets of questions: rejecting a request, expressing limitations, requesting, being a pioneer in starting a social interaction, expressing positive feelings, accepting criticism, accepting their difference with other people and self-expression when needed and being able to give negative responses. This inventory, again employing the Likert scale, consisted of 40 questions with five possible answers (I will not be upset to I will be very much upset) which was graded from 1 to 5. For example, Degree of Discomfort ——

Situation Turn off a talkative friend

Response Probibility ——

The overall grade was in the range of 40 to 200, where a low grade represents high assertiveness and a high grade © 2010 Blackwell Publishing

represents low assertiveness. The assertiveness of the participants’ were divided into three levels of high (75% and above), moderate (25 to 75%) and low (below 25%). The data were analysed using spss 11.5 (SPSS, Inc., Chicago, IL, USA) using Pearson, Valis Croscal and Mann– Whitney tests. The P-value was set at 0.05 for significant differences.

Results Most of the nursing and midwifery students were 20–24 years of age (36.4% and 39%, respectively), single (91.3% and 87%), having a family of more than five members (71.7% and 61%), their fathers being self-employed (50.9% and 47.9%) and their mother working as a housewife (92.5% and 89.6%). Furthermore, most of them were involved in the decision-makings of the family (93.6% and 92.2%) and were not employed during their study time (87.9% and 98.7%). More than half the students expressed that their families have a positive impression about their major (59.7% and 52.6%) (Table 1). The average assertiveness of nursing students was 94.09 ⫾ 21.81 and for midwifery students was 92.62 ⫾ 21.12. Most of them (59.5% and 59.7%) had moderate assertiveness; less than 30% had high assertiveness and the rest (11.6% and 11.7%) had low assertiveness. Results showed that only half of the students of nursing and midwifery had low anxiety (Table 2). Table 1 Distribution of personal and educational characteristics of nursing and midwifery students at Tehran University of Medical Sciences in 2008 Major

Characteristics Age (years) 18–20 20–22 22–24 24 and above Year of study Freshman Sophomore Junior Senior Interested in the field of study Absolutely Relatively Not at all Place of living Dormitory Private house Rented house Participation in family decisions Yes No

Midwifery

Nursing

%

n

%

22.1 39 32.5 6.5

17 30 25 5

23 36.4 30.1 9.8

41 63 52 17

23.4 22.1 22.1 32.5

18 17 17 25

32.9 27.7 18.5 20.8

57 48 32 36

42.9 44.2 13

33 34 10

38.7 49.7 11.6

67 86 20

53.2 42.9 3.9

41 33 3

68.8 30.1 1.2

119 52 2

92.2 7.8

71 6

93.6 6.4

162 11

n

3

T. T. Larijani et al.

students and the interest in their field of study (P < 0.05) and participating in family decisions (P < 0.03) for students of midwifery. Concerning the relation of students characteristics with hidden anxiety, higher education of fathers (P = 0.03), interest in the field of study (P < 0.05), sufficiency of family income (P < 0.004) and positive impression of the family about the students’ major (P = 0.004) had a significant relation with low anxiety (Table 4). In students of nursing the Pearson’s coefficient showed a significant relation between age and assertiveness (P = 0.004) and a weak, inverse and significant relation with anxiety (P = 0.04).

The relation between anxiety and assertiveness showed that there was a relatively strong, inverse and significant relationship between the assertiveness value and the hidden anxiety value in students of nursing (P < 0.001) and students of midwifery (P < 0.001) (Table 3). The results of statistical tests revealed a significant relation between the assertiveness value and the years of education (P = 0.04), working while studying (P < 0.05) and participating in family decisions (P < 0.01) for nursing

Table 2 Distribution of hidden anxiety in nursing and midwifery students at Tehran University of Medical Sciences in 2008 Major Midwifery

Nursing

Discussion

Anxiety

%

n

%

n

Low Moderate High Total Mean (SD)

63.6 35.1 1.3 100

49 27 1 77 41.81 (9.72)

56.6 41.6 1.7 100

98 72 3 173 41.28(9.57)

This study showed that more than half of the nursing and midwifery students (59.5% and 59.7%, respectively) had moderate assertiveness. If we consider the students with high assertiveness as assertive and students with low or

Table 3 Distribution of assertiveness with respect to anxiety in nursing and midwifery students at Tehran University of Medical Sciences in 2008 High Major

Test result

Nursing

P P P P P P

Midwifery

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