ASSERTIVE TRAINING

Assertive Behavior

Assertive behavior promotes equality in

human relationships, enabling us to act in our
own best interests, to stand up for ourselves
without undue anxiety, to express honest
feelings comfortably, to exercise personal
rights without denying the rights of others
(Alberti & Emmons, 2001).
 ASSERTIVE COMMUNICATION
• Assertive behavior helps us feel good about
ourselves and increases our self-esteem.
• It helps us feel good about other people and
increases our ability to develop satisfying
relationships with others.
• This is accomplished out of honesty,
directness, appropriateness, and respecting
one’s own basic rights as well as the rights of
others.
• Honesty is basic to assertive behavior.
Assertive honesty is not an outspoken
declaration of everything that is on one’s
mind.
• It is instead an accurate representation of
feelings, opinions, or preferences expressed in
a manner that promotes self-respect and
respect for others.
• Direct communication is stating what one
wants to convey with clarity and candor.
• Hinting and “beating around the bush” are
indirect forms of communication.
• Communication must occur in an appropriate
context to be considered assertive.
• The location and timing, as well as the manner
(tone of voice, nonverbal gestures) in which
the communication is presented, must be
correct for the situation.
 BASIC HUMAN RIGHTS
• A number of authors have identified a variety
of “assertive rights” (Davis, McKay, &
Eshelman, 2008; Lloyd, 2002; Powell &
Enright, 1990; Schuster, 2000; Sobel &
Ornstein, 1996).
• Following is a composite of 10 basic assertive
human rights adapted from the aggregation of
sources:
1. The right to be treated with respect.
2. The right to express feelings, opinions, and
beliefs.
3. The right to say “no” without feeling guilty.
4. The right to make mistakes and accept the
responsibility for them.
5. The right to be listened to and taken seriously.
6. The right to change your mind.
7. The right to ask for what you want.
8. The right to put yourself first, sometimes.
9. The right to set your own priorities.
10.The right to refuse justification for your
feelings or behavior.
• In accepting these rights, an individual also
accepts the responsibilities that accompany
them.
• Rights and responsibilities are reciprocal
entities. To experience one without the other is
inherently destructive to an individual.
• Some responsibilities associated with basic
assertive
• human rights are presented in Table 15–1.
 Assertive Rights and Responsibilities

Rights Responsibilities
• 1. To be treated with • To treat others in a way that
respect . recognizes their human dignity
• To accept ownership of our
• 2. To express feelings,
feelings and show respect for
opinions, and beliefs. those that differ from our own
• 3. To say “no” • To analyze each situation
individually, recognizing all
human rights as equal (others
have the right to say “no,” too)
• 4. To make mistakes • To accept responsibility for own
mistakes and to try to correct
them
• 5. To be listened to. • To listen to others
• 6. To change your mind. • To accept the possible
consequences that the
change may incur; to
accept the same
flexibility in others
• 7. To ask for what you
• To accept others’ right
want.
to refuse your request
• 8. To put yourself first,
• To put others first,
sometimes.
sometimes
• 9. To set your own priorities • To consider one’s limitations
as well as strengths in
directing independent
activities; to be a
dependable person
• 10. To refuse to justify
• To accept ownership of own
feelings or behavior
feelings/behavior; to accept
others
 RESPONSE PATTERNS
Individuals develop patterns of responding to
others. Some of these patterns that have been
identified include:
1. Watching other people (role modeling).
2. Being positively reinforced or punished for a
certain response.
3. Inventing a response.
4. Not being able to think of a better way to
respond.
5. Not developing the proper skills for a better
response.
6. Consciously choosing a response style.
• The nurse should be able to recognize his or
her own pattern of responding, as well as that
of others.
• Four response patterns will be discussed here:
• Nonassertive
• Assertive
• Aggressive
• Passive–aggressive.
 Non-assertive Behavior
• Individuals who are nonassertive (sometimes
called passive) seek to please others at the
expense of denying their own basic human
rights.
• They seldom let their true feelings show and
often feel hurt and anxious because they allow
others to choose for them.
• They seldom achieve their own desired goals
(Alberti & Emmons, 2001).
• They come across as being very apologetic and
tend to be self-deprecating.
• They use actions instead of words and hope
someone will “guess” what they want.
• Their voices are hesitant, weak, and expressed
in a monotone.
• Their eyes are usually downcast.
• They feel uncomfortable in interpersonal
interactions.
• All they want is to please and to be liked by
others.
• Their behavior helps them avoid unpleasant
situations and confrontations with others;
• However, they often harbor anger and
resentment.
 Assertive Behavior
• Assertive individuals stand up for their own
rights while protecting the rights of others.
• Feelings are expressed openly and honestly.
• They assume responsibility for their own
choices and don’t allow others to choose for
themselves.
• They maintain self-respect and respect for
others by treating everyone equally and with
human dignity.
• They communicate tactfully, using lots of “I”
statements.
• Their voices are warm and expressive, and eye
contact is intermittent but direct.
• These individuals desire to communicate
effectively with, and be respected by, others.
• They are self-confident and experience
satisfactory and pleasurable relationships with
others.
 Aggressive Behavior
• Individuals who are aggressive defend their own
basic rights by violating the basic rights of others.
• Feelings are often expressed dishonestly and
inappropriately.
• They say what is on their mind, often at the expense
of others.
• Aggressive behavior commonly results in a putdown
of the receiver. Rights denied, the receiver feels
hurt, defensive, and humiliated (Alberti & Emmons,
2001).
• Aggressive individuals devalue the self-worth
of others on whom they impose their choices.
• They express an air of superiority, and their
voices are often loud, demanding, angry, or
cold, without emotion.
• Eye contact may be “to intimidate others by
staring them down.”
• They want to increase their feeling of power
by dominating or humiliating others.
• Aggressive behavior hinders interpersonal
relationships.
 Passive–Aggressive Behavior
• Passive–aggressive individuals defend their
own rights by expressing resistance to social
and occupational demands (American
Psychiatric Association [APA], 2000).
• Sometimes called indirect aggression, this
behavior takes the form of passive,
nonconfrontive action (Alberti & Emmons,
2001).
• These individuals are devious, manipulative,
and sly, and they undermine others with
behavior that expresses the opposite of what
they are feeling.
• They are highly critical and sarcastic.
• They allow others to make choices for them,
then resist by using passive behaviors, such as
procrastination, dawdling, stubbornness, and
“forgetfulness.”
• They use actions instead of words to convey
their message, and the actions express covert
aggression.
• They become sulky, irritable, or argumentative
when asked to do something they do not want
to do.
• They may protest to others about the
demands but will not confront the person who
is making the demands. Instead, they may
deal with the demand by “forgetting” to do it.
• The goal is domination through retaliation.
• This behavior offers a feeling of control and
power, although passive–aggressive
individuals actually feel resentment and that
they are being taken advantage of.
• They possess extremely low self-confidence.
 BEHAVIORAL COMPONENTS OF
ASSERTIVE BEHAVIOR
• Alberti and Emmons (2001) have identified
several defining characteristics of assertive
behavior:
 1. Eye contact.
Eye contact is considered appropriate when
it is intermittent (i.e., looking directly at the
person to whom one is speaking but looking
away now and then).
Individuals feel uncomfortable when someone
stares at them continuously and intently.
Intermittent eye contact conveys the message
that one is interested in what is being said.
 2. Body posture.
• Sitting and leaning slightly toward the other
person in a conversation suggests an active
interest in what is being said.
• Emphasis on an assertive stance can be
achieved by standing with an erect posture,
squarely facing the other person.
• A slumped posture conveys passivity or
nonassertiveness.
 3. Distance/physical contact.
• The distance between two individuals in an
interaction or the physical contact between them
has a strong cultural influence.
• For example, in the United States, intimate distance
is considered approximately 18 inches from the
body.
• We are very careful about whom we allow to enter
this intimate space.
• Invasion of this space may be interpreted by some
individuals as very aggressive.
 4. Gestures.
• Nonverbal gestures may also be culturally
related.
• Gesturing can add emphasis, warmth, depth,
or power to the spoken word.
 5. Facial expression.
• Various facial expressions convey different
messages (e.g., frown, smile, surprise, anger,
fear).
• It is difficult to “fake” these messages.
• In assertive communication, the facial
expression is congruent with the verbal
message.
 6. Voice.
• The voice conveys a message by its loudness,
softness, degree and placement of emphasis,
and evidence of emotional tone.
 7. Fluency.
• Being able to discuss a subject with ease and
with obvious knowledge conveys assertiveness
and self-confidence.
• This message is impeded by numerous pauses
or filler words such as “and, uh . . .” or “you
know . . .”
 8. Timing.
• Assertive responses are most effective when
they are spontaneous and immediate.
However, most people have experienced times
when it was not appropriate to respond (e.g.,
in front of a group of people) or times when
an appropriate response is generated only
after the fact (“If only I had said . . .”).
• Alberti and Emmons (2001) state that “ . . . it is
never too late to be assertive!” It is correct
and worthwhile to seek out the individual at a
later time and express the assertive response.
 9. Listening.
• Assertive listening means giving theother
individual full attention, by making eye
contact, nodding to indicate acceptance of
what is being said, and taking time to
understand what is being said before giving a
response.
 10. Thoughts.
• Cognitive processes affect one’s assertive
behavior. Two such processes are
(1) An individual’s attitudes about the
appropriateness of assertive behavior in
general and
(2) the appropriateness of assertive behavior for
himself or herself specifically.
 11. Content
• Many times individuals do not respond to
• an unpleasant situation because “I just didn’t
know what to say.” Perhaps what is being said
is not as important as how it is said.
• Emotions should be expressed when they are
experienced.
• It is also important to accept ownership of
those emotions and not devalue the worth of
another individual to assert oneself.
 EXAMPLE:
• Assertive: “I’m really angry about what you
said!”
• Aggressive: “You’re a real jerk for saying
that!”
 TECHNIQUES THAT PROMOTE
ASSERTIVE BEHAVIOR
• The following techniques have been shown to
be effective in responding to criticism and
avoiding manipulation by others.
• 1. Standing up for one’s basic human rights
• EXAMPLE: “I have the right to express my
opinion.”
• 2. Assuming responsibility for one’s own
statements.
• EXAMPLE:
• “I don’t want to go out with you tonight,”
instead of
• “ I can’t go out with you tonight.”
• The latter implies a lack of power or ability.
• 3. Responding as a “broken record.”
• Persistently repeating in a calm voice what is
wanted.
• Example:
• Telephone salesperson: “I want to help you
save money by changing long-distance
services.”
• Assertive response: “I don’t want to change
my long-distance service.”
• Telephone salesperson: “I can’t believe you
don’t want to save money!”
• Assertive response: “I don’t want to change
my long-distance service.”
• 4. Agreeing assertively.
• Assertively accepting negative aspects about
oneself; admitting when an error has been
made.
• Example:
• Ms. Jones: “You sure let that meeting get out
of hand. What a waste of time.”
• Ms. Smith: “Yes, I didn’t do a very good job of
conducting the meeting today.”
• 5. Inquiring assertively.
• Seeking additional information about critical
statements.
• Examples:
• Male board member: “You made a real fool of
yourself at the board meeting last night.”
• Female board member: “Oh, really? Just what about
my behavior offended you?”
• Male board member: “You were so damned pushy!”
• Female board member: “Were you offended that I
spoke up for my beliefs, or was it because my beliefs
are in direct opposition to yours?”
• 6. Shifting from content to process.
• Changing the focus of the communication
from discussing the topic at hand to analyzing
what is actually going on in the interaction.
• Example:
• Wife: “Would you please call me if you will
be late for dinner?”
• Husband: “Why don’t you just get off my
back! I
• always have to account for every minute of my
• time with you!”
• Wife: “Sounds to me like we need to discuss
some other things here. What are you really
angry about?”
• 7. Clouding/fogging.
• Concurring with the critic’s argument without
becoming defensive and without agreeing to
Change.
• Example:
• Nurse 1: “You never come to the Nurses’
Association meetings. I don’t know why you even
belong!”
• Nurse 2: “You’re right. I haven’t attended very
many of the meetings.”
• 8. Defusing.
• Putting off further discussion with an angry
individual until he or she is calmer.
• Example:
• “You are very angry right now. I don’t want to
discuss this matter with you while you are so
upset.
• I will discuss it with you in my office at 3 o’clock
this afternoon.”
• 9. Delaying assertively.
• Putting off further discussion with another
individual until one is calmer.
• Example:
• “That’s a very challenging position you have
taken, Mr. Brown.
• I’ll need time to give it some thought. I’ll call
you later this afternoon.”
• 10. Responding assertively with irony.
• Example:
• Man: “I bet you’re one of them so-called
‘women’s libbers,’ aren’t you?”
• Woman: “Why, yes. Thank you for noticing.”
THOUGHT-STOPPING TECHNIQUES
• Assertive thinking is sometimes inhibited by
repetitive, negative thoughts of which the
mind refuses to let go.
• Individuals with low self-worth may be
obsessed with thoughts such as, “I know he’d
never want to go out with me.
• I’m too ugly (or plain, or fat, or dumb)” or “I
just know I’ll never be able to do this job well”
or “I just can’t seem to do anything right.”
• This type of thinking fosters the belief that
one’s individual rights do not deserve the
same consideration as those of others, and
reflects nonassertive communication and
behavioral response patterns.
• Thought-stopping techniques, as described
here, were developed by psychiatrist Joseph
Wolpe (1990) and are intended to eliminate
intrusive, unwanted thoughts.
 Method

• In a practice setting, with eyes closed, the

individual concentrates on an unwanted recurring
thought. Once the thought is clearly established
in the mind, he or she shouts aloud: “STOP!”
• This action will interrupt the thought, and it is
actually removed from one’s awareness.
• The individual then immediately shifts his or her
thoughts to one that is considered pleasant and
desirable.
• It is possible that the unwanted thought may
soon recur, but with practice, the length of
time between recurrences will increase until
the unwanted thought is no longer intrusive.
• Obviously, one cannot go about his or her
daily life shouting, “STOP!” in public places.
• After a number of practice sessions, the
technique is equally effective if the word
“stop!” is used silently in the mind.
 ROLE OF THE NURSE
• It is important for nurses to become aware of
and recognize their own behavioral responses.
Are they mostly nonassertive? Assertive?
Aggressive? Passive–aggressive?
• Do they consider their behavioral responses
effective?
• Do they wish to change?
• Remember, all individuals have the right to
choose whether or not they want to be
assertive.
• The ability to respond assertively is especially
important to nurses who are committed to further
development of the profession.
• Assertive skills facilitate the implementation of
change—change that is required if the image of
nursing is to be upgraded to the level of
professionalism that most nurses desire.
• Assertive communication is useful in the political
arena for nurses who choose to become involved
at both state and national levels in striving to
influence legislation and, ultimately, to improve
the system of health care provision in our country.
• Nurses who understand and use assertiveness
skills themselves can in turn assist clients who
wish to effect behavioral change in an effort to
increase self-esteem and improve
interpersonal relationships.
• The nursing process is a useful tool for nurses
who are involved in helping clients increase
their assertiveness.
 Assessment

• Nurses can help clients become more aware of

their behavioral responses.
• Many tools for assessing the level of
assertiveness have been attempted over the
years.
• None have been very effective. Perhaps this is
because it is so difficult to generalize when
attempting to measure assertive behaviors.
• Box 15–2 (everyday situations that may
require assertiveness)and Figure 15–1(an
assertive quiz) represent examples of
assertiveness inventories that could be
personalized to describe life situations of
individual clients more specifically.
• Obviously, “everyday situations that may
require assertiveness” are not the same for all
individuals.
 Diagnosis

• Possible nursing diagnoses for individuals

needing assistance with assertiveness include:
• 1. Coping, defensive
• 2. Coping, ineffective
• 3. Decisional conflict
• 4. Denial, ineffective
• 5. Personal identity, disturbed
• 6. Powerlessness
• 7. Rape-trauma syndrome
• 8. Self-esteem, low
• 9. Social interaction, impaired
• 10. Social isolation
 Outcome Identification/Implementation

• The goal for nurses working with individuals needing

• assistance with assertiveness is to help them develop more
• satisfying interpersonal relationships. Individuals who
• do not feel good about themselves either allow others to
• violate their rights or cover up their low self-esteem by
• being overtly or covertly aggressive. Individuals should be
• given information regarding their individual human
• rights.
• They must know what these rights are before
they
• can stand up for them.
• Outcome criteria would be derived from
specific nursing
• diagnoses. Some examples include the
following.
• Timelines are individually determined.
• 1. The client verbalizes and accepts
responsibility for his
• or her own behavior.
• 2. The client is able to express opinions and
disagree
• with the opinions of others in a socially
acceptable
• manner and without feeling guilty.
• 3. The client is able to verbalize positive aspects
about
• self.
• 4. The client verbalizes choices made in a plan
to maintain
• control over his or her life situation.
• 5. The client approaches others in an
appropriate manner
• for one-to-one interaction.
• In a clinical setting, nurses can teach clients the
• techniques to use to increase their assertive
responses.
• This can be done on a one-to-one basis or in
group situations.
• Once these techniques have been discussed,
• nurses can assist clients to practice them
through roleplaying.
• Each client should compose a list of specific
• personal examples of situations that create difficulties
• for him or her. These situations will then be simulated
• in the therapy setting so that the client may practice
• assertive responses in a non-threatening environment.
• In a group situation, feedback from peers can provide
• valuable insight about the effectiveness of the
• response.