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Assertiveness process of Iranian nurse leaders:A groundedtheory studyGholamhossein Mahmoudirad, rn, msc, phd(cand),1 Fazlollah Ahmadi, rn, phd,1 Zohreh Vanaki, rn, phd1 andEbrahim Hajizadeh, msc, phd2Departments of 1Nursing and 2Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IranAbstract The purpose of this study was to explore the assertiveness process in Iranian nursing leaders. A qualitativedesign based on the grounded theory approach was used to collect and analyze the assertiveness experiencesof 12 nurse managers working in four hospitals in Iran. Purposeful and theoretical sampling methods wereemployed for the data collection and selection of the participants, and semistructured interviews were held.During the data analysis, 17 categories emerged and these were categorized into three themes: “task generation”,“assertiveness behavior”, and “executive agents”. From the participants’ experiences, assertivenesstheory emerged as being fundamental to the development of a schematic model describing nursing leadershipbehaviors. From another aspect, religious beliefs also played a fundamental role in Iranian nursing leadershipassertiveness. It was concluded that bringing a change in the current support from top managers and improvingself-learning are required in order to enhance the assertiveness of the nursing leaders in Iran.nhs_451 120..127Key words assertiveness, grounded theory, nurse leader, religious beliefs, tasks.INTRODUCTIONNurse leaders have to confront upper managers openly andnegotiate with them on professional matters (Chan, 2002).A good leader also can confidently state one’s personal andgroup members’ needs in an effective manner (Office ofStudent Activities, Leadership and Involvement, 2008); suchabilities are characteristic of assertive leaders (Davar, 1999;Chan, 2002). Assertiveness is an essential quality in everyleader (Davar, 1999) and work on leadership perceptions haslikewise underscored the importance of assertiveness (Judgeet al., 2002; Lett, 2002; Ames & Flynn, 2007).Assertiveness occurs when “. . . an individual providerasserts his/her opinion during critical times” (Thomas et al.,2004: 9). Freeman and Adams (1999) argued that assertivenessis an interpersonal behavior that promotes equality inhuman relationships by assisting individuals to express theirrights, thoughts, and feelings while recognizing and respectingthe others’ rights. To put it in another way, assertivenesscan be defined as the extent of forcefulness used by individualsto express themselves and to get things done in order toachieve the organizational objectives (Davar, 1999). Assertiveleaders clearly describe behavior and its consequencesin comparison to attributing motivation to others. They alsodirect their feedback and observations to the appropriateperson (William Croom Association, 1998). They also takeresponsibility (Daly et al., 2004) and understand that theymust leverage every opportunity for sending consistent messagesabout what they expect from others in the workplace(William Croom Association, 1998).Viewing the literature of assertiveness in nursing, Baillie(1999) indicated several unit managers’ perspectives on staffnurses’ weaknesses in their communication strategies, such asrelating to assertiveness. Timmins and McCabe (2005a) consideredthat their participants were less skillful at expressingtheir own needs, a matter which is at the core of assertivebehavior. The expression of opinions, disagreement withopinions, provision of constructive criticism, and making ofsuggestions were less frequently carried out. In a study byKilkus (1993), the nurses who worked in mental health,nursing education, or nursing administration reported thehighest levels of assertiveness; they were typically identifiedwith more autonomous and independent responsibility andbehavior.The barriers that prevent nurses from being assertive area lack of knowledge about their personal and professionalrights, concern about what others will think about theirbehavior, and anxiety related to a lack of confidence andpoor self-esteem (Poroch & McIntosh, 1995). In addition, thegeneral atmosphere might be a facilitator and simultaneouslya barrier to assertiveness skills (Timmins & McCabe, 2005a).The socialization process also influences assertiveness.Kilkus (1993) suggested that the factors influencing assertivenesslevels might vary from person to person as they mightCorrespondence address: Fazlollah Ahmadi, Nursing Department, Tarbiat ModaresUniversity, Nasr Bridge, Tehran, PO Box 14155-4838, Iran. Email: ahmadif@modares.ac.irReceived 30 September 2008; accepted 9 December 2008Nursing and Health Sciences (2009), 11, 120–127© 2009 The AuthorsJournal Compilation © 2009 Blackwell Publishing Asia Pty Ltd.doi: 10.1111/j.1442-2018.2009.00451.xdiffer in their personal or professional characteristics. Forexample, a person’s gender might have an influence on theperson’s assertiveness, simply because the socializationprocess of men and women is different in Western societies.Professional socialization also could influence assertiveness(Mooney, 2007).Although assertiveness is an essential quality in everyleader (Davar, 1999), only a few studies could be found aboutassertiveness in the nursing leadership literature.As nursingleaders are usually selected from staff nurses, it can be concludedthat recognizing the factors that influence nurses’assertiveness can be used to understand nurse leaders’ assertivenessbehavior. For instance, Chan (2002) suggested thatthe culture of nursing has encouraged passiveness rather thanassertiveness. As a result, nurse leaders show less assertivebehaviors in their career.Although there is some evidence of the barriers to the useof assertiveness skills, there is little information about thefactors that might facilitate their use (Timmins & McCabe,2005b). Therefore, it is important that the factors that allowthe promotion or inhibition of assertive behaviors by nursesin their work settings be identified (Freeman & Adams,1999; Lyndon, 2006). Such significance was doubled for theresearchers in this study because few studies prioritizedassertiveness in the Iranian nursing context.BACKGROUND IN IRANOur clinical experiences in Iran indicated that the assertivebehaviors of nursing leaders could be influenced by culturaland religious factors.For instance, sometimes nursing leaders,without viewing the organizational atmosphere and theauthority of the top managers, expressed their ideas aboutpatients’ and staff members’ rights. They were not worriedabout the consequences of these kinds of expressions. Theyrelated their behaviors to their religious beliefs as talkingabout the staff members’ and patients’ rights was consideredto be a duty corroborated by religious doctrine.However, based on the international literature, a set ofsocial and psychological processes are expected to be influentialin the emergence of assertive behaviors (Kilkus, 1993;Gilmartin, 2000; Mooney, 2007).Thus, the authors consideredthat assertiveness is a quality that must be acquired throughsuch processes. The aim of this study was to explore the
assertiveness process of Iranian nursing leadership so that
the results of this study can be used for the training and
improvement of the assertiveness of Iranian nursing leaders.
METHOD
A qualitative design with a grounded theory approach was
used for the data collection and analysis of the experiences of
Iranian nurse leaders.
Ethical issues
The study was approved by the research council affiliated
with Tarbiat Modares University, Tehran, Iran. Next, permission
was obtained from the hospital directors to interview
the nurse managers in their work setting.All the participants
were informed about the purpose of the study. They were
informed that participation in the study was voluntary and
that they could refuse to participate or withdraw from the
study at any time without penalty.Moreover, they were reassured
that their responses would be confidential. Lastly, those
who agreed to participate in the study were asked to sign an
informed consent document. The interviews were conducted
in private rooms by the main researcher and recorded on
audiotapes.
Sampling
The participants initially were recruited by purposeful sampling,
which was followed by a theoretical sampling (Coyne,
1997). The sample consisted of 12 nurses (four men, eight
women) in four hospitals in Iran. They had experienced different
levels of nursing management positions. Their age
range was 36–52 years, with an average age of 45.8 years.
Their work experience range was between 12 and 27 years
(mean = 19 years) and their mean managerial experience was
8.3 years.
Data collection
The semistructured interviews were employed to collect
in-depth data in 2007. The major questions in the interviews
were as follows:
1 Would you please share with me your experiences of
communication in your workplace?
2 Would you please talk about the factors that are influential
in choosing your preferred communicative behaviors?
The interviews lasted between 40 and 90 min. The data were
collected until data saturation in the data analysis was
reached; that is, when interviewing yielded only repeated
information and nothing new was found. It is worth noting
that the data variability also was explained by the analysis
(Speziale & Carpenter, 2007).
Data analysis
To analyze and interpret the data, Glaser’s (1992) grounded
theory approach was used in developing a theory.All of the
interview content was transcribed verbatim and then the text
was read several times. Meaning units were identified and
condensed in order to clarify the meaning of the content.
After that, they were subsequently labeled using an open
code.Then, the codes were grouped thematically into 17 categories.
Comparisons were made within and among the c
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