Exploring Japanese nurses' perceptions of the relevance and use of assertive communication in healthcare: A qualitative study informed by the Theory of Planned Behaviour

Nurse Education Today 67 (2018) 100–107

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Exploring Japanese nurses' perceptions of the relevance and use of assertive communication in healthcare: A qualitative study informed by the Theory of Planned Behaviour

T

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Mieko Omuraa, , Teresa E. Stoneb, Jane Maguirec, Tracy Levett-Jonesc a

Faculty of Health and Medicine, The University of Newcastle, School of Nursing and Midwifery, University Drive, Callaghan, NSW 2308, Australia Faculty of Nursing, Chiang Mai University, 110 Intavaroros Road Sripum District, Muang, Chiang Mai 50200, Thailand c Faculty of Health, University of Technology Sydney, 235 Jones St, Ultimo, NSW 2007, Australia b

A R T I C LE I N FO

A B S T R A C T

Keywords: Assertiveness Communication Culture Nurse education Patient safety Qualitative Speaking up Theory of Planned Behaviour

Background: The hierarchical nature of healthcare environments presents a key risk factor for effective interprofessional communication. Power differentials evident in traditional healthcare cultures can make it difficult for healthcare professionals to raise concerns and be assertive when they have concerns about patient safety. This issue is of particular concern in Japan where inherent cultural and social norms discourage assertive communication. Aim: The aim of this study was to (a) explore nurses' perceptions of the relevance and use of assertive communication in Japanese healthcare environments; and (b) identify the factors that facilitate or impede assertive communication by Japanese nurses. Design: A belief elicitation qualitative study informed by the Theory of Planned Behaviour was conducted and reported according to the COnsolidated criteria for REporting Qualitative research. Settings and Participants: Twenty-three practicing Japanese registered nurses were recruited by snowball sampling from October 2016 to January 2017. Methods: Individual face-to-face semi-structured interviews were conducted and transcribed in Japanese and then translated into English. Two researchers independently conducted a directed content analysis informed by the Theory of Planned Behaviour. Participants' responses were labelled in order of frequency for behavioural beliefs about the consequences of assertive communication, sources of social pressure, and factors that facilitate or impede assertive communication in Japanese healthcare environments. Findings: Although person-centred care and patient advocacy were core values for many of the participants, strict hierarchies, age-based seniority, and concerns about offending a colleague or causing team disharmony impeded their use of assertive communication. Novice nurses were particularly reluctant to speak up because of their perception of having limited knowledge and experience. Conclusion: This study identified Japanese nurses' behavioural, normative, and control beliefs in relation to assertive communication. The findings will be used to inform the development of a culturally appropriate assertiveness communication training program for Japanese nurses and nursing students.

1. Introduction A body of research has identified the relationship between communication and patient safety (Kripalani et al., 2007; Lingard et al., 2004; Lyndon et al., 2011). For example, in the United States, communication errors were identified as the root cause of 1796 sentinel events in the years 2013 to 2015, and a causative factor for delays in treatment, medication errors and incorrect procedures (The Joint

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Commission, 2017). A search of the Japan Council for Quality Health Care (2017) database, using the term “communication” retrieved 524 adverse events from 2010 to 2017. Communication was often mentioned as a background factor in those incidents. Although nurses are well positioned to advocate for patients and prevent communication errors (Okuyama et al., 2014; Rainer, 2015), their lack of assertiveness and hesitation to speak up is a recurring patient safety issue (Maxfield et al., 2011). It is, therefore, crucial to understand the reasons for

Corresponding author. E-mail addresses: [email protected] (M. Omura), [email protected] (T.E. Stone), [email protected], @janemaguire9 (J. Maguire), [email protected], @ProfTLJ (T. Levett-Jones). https://doi.org/10.1016/j.nedt.2018.05.004 Received 30 July 2017; Received in revised form 10 January 2018; Accepted 12 May 2018 0260-6917/ © 2018 Elsevier Ltd. All rights reserved.

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behaviours identified only eight quantitative studies that met the inclusion criteria (Omura et al., 2017). The review concluded that face-toface and multi-methods programs in which didactic instruction reinforced by discussions and role-play, team training, and support from leaders optimised the effectiveness of assertiveness communication training programs. However, the authors were cautious about drawing conclusions about the transferability of the results as the impact of cultural and social barriers on assertive communication is poorly understood, and few studies have been undertaken outside Western settings. While studies suggest that assertiveness is a skill that can be improved by participating in training programs (Lin et al., 2004; Warland et al., 2014), numerous factors can influence speaking up behaviours. Healthcare professionals may be well intended and motivated, nevertheless, a fear of repercussions and concerns about how their colleagues may respond can act as a deterrent to assertiveness (Okuyama et al., 2014). Professional factors such as nurse-doctor power differentials and a limited understanding of the roles of team members can also cause nurses to be reluctant to speak up (Wilson et al., 2016; Zwarenstein and Reeves, 2002). In Japan, assertiveness training programs were first introduced in 1993. The term ‘assertiveness’ which initially was considered to be a foreign concept, now appears in fundamental nursing texts and has become increasingly used and familiar to Japanese healthcare professionals (Shijiki et al., 2017). While some researchers have reported positive outcomes from assertiveness communication training in Japan (Yamagishi et al., 2007), the main emphasis appears to be on the improved well-being of healthcare professionals (Nishina and Tanigaki, 2013; Shimizu et al., 2004; Suzuki et al., 2009a), with little attention being given to patient safety. There is, therefore, a need to more fully understand Japanese nurses' perceptions of use and relevance of assertive communication. These findings could be used to inform the development of culturally appropriate assertiveness communication training programs so that ultimately nurses will be more confident in speaking up when concerned about patient safety.

nurses' reticence to use assertive communication skills. The hierarchical nature of healthcare environments presents a key risk factor for assertive communication. The power differentials evident in traditional healthcare cultures can make it difficult for healthcare professionals to be assertive when they are concerned about patient safety. Although a range of communication tools, guidelines, and checklists have been developed, unless clinicians are confident in advocating for patients these tools are unlikely to have a significant impact on patient outcomes (Maxfield et al., 2011). Researchers have identified a number of barriers to assertive communication in healthcare including: a lack of motivation, confidence, skills, support, and control (Okuyama et al., 2014) as well as fear about how other people may respond (Attree, 2007; Suzuki et al., 2014). These issues are of particular concern in Japan where inherent cultural and social norms discourage assertive communication (Davies and Ikeno, 2002). The concept of ‘assertiveness’ has only come to prominence in Japan over the last decade; although there is a growing recognition of the impact of assertive communication on patient safety. Consequently, a small number of assertiveness training programs have been conducted in Japanese healthcare settings with results indicating a positive impact on nurses' self-esteem, well-being and workplace satisfaction (Shimizu et al., 2004), and a reduction in stress and burnout (Shimizu et al., 2003; Suzuki et al., 2009b; Yamagishi et al., 2007). However, there is little evidence that these assertiveness training programs have empowered nurses to raise concerns or advocate for patients about issues related to patient safety. These results suggest that there may be a need for culturally appropriate assertiveness communication training programs that reflect the specific needs, concerns, and perspectives of Japanese nurses, and that focus specifically on patient safety. The aim of this study was to (a) explore registered nurses' perceptions of the relevance and use of assertive communication in Japanese healthcare environments, and (b) to identify the factors that facilitate or impede assertive communication by Japanese nurses. 2. Background

3. Methods

For the purpose of this study, assertive communication refers to healthcare professionals being able to respectfully express their opinions and concerns regarding patient care to other members of the healthcare team, including those in positions of authority (Omura et al., 2017). Speaking up, a type of assertive communication, is a critical skill for healthcare professionals (Nacioglu, 2016; Rainer, 2015). Lack of assertiveness may lead to hesitation to speak up, resulting in vital patient information not being shared within the healthcare team. Further, unless healthcare professionals assertively articulate and escalate their concerns to appropriate members of the healthcare team, patient safety may be jeopardised, contributing to adverse incidents and patient harm (Okuyama et al., 2014). Generally, evidence of the effectiveness of assertiveness communication training programs is limited. A recent systematic review focusing on the outcomes of interventions designed to enhance healthcare professionals' and students' assertive communication or speaking up

3.1. Study Design The Theory of Planned Behaviour (TPB) (Ajzen, 1991) underpinned this study and the COnsolidated criteria for REporting Qualitative research (COREQ) (Tong et al., 2007) was used to report the findings. The TPB has been successfully used in a wide range of healthcare studies (Casper, 2007; Hackman and Knowlden, 2014). According to the TPB, planned behaviour is preceded by a behavioural intention, which, in turn, is determined by three predictor constructs: attitudes towards the behaviour, subjective norms and perceived behavioural control. These predictor constructs are formed by belief-based indicators including: behavioural beliefs about consequences of the behaviour, normative beliefs about expectations of others, and control beliefs about facilitators or inhibitors of the behaviour (Francis et al., 2004). A graphical

Fig. 1. The Theory of Planned Behaviour modified from Ajzen, 2006. 101

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representation of the TPB is presented in Fig. 1. It was anticipated that by exploring Japanese nurses' beliefs about the positive or negative consequences of speaking up, the approval or disapproval of people considered important to them, and beliefs about their ability to be assertive, we could potentially predict and explain their intentions and consequently, the likelihood that they would speak up assertively when concerned about patient safety.

Table 2 Demographic characteristics of participants (n = 23).

3.2. Ethical Considerations

Variables

Category

n

%

Age

21–25 26–30 31–35 36–40 41–50 51–60 Male Female Registered nurse Nurse manager Post graduate student Academic First 2–5 6–10 11–15 16–20 Over 21 years Critical care Medical surgical Aged care Mental health Community care Public health

1 4 5 5 2 6 9 14 11 5 6 1 1 3 5 7 1 6 6 1 1 10 4 1

4 17 22 22 9 26 39 61 48 22 26 4 4 13 22 30 4 26 26 4 4 43 17 4

Gender

Prior to contacting potential participants, ethics approval for the study was obtained from the university ethics committees in Australia and in Japan. Only nurses who provided written informed consent were recruited for the study. Confidentiality was assured by de-identifying the participants and using numerical codes instead of names.

Position

Years of experience as registered nurse

3.3. Participant Recruitment Registered nurses who were practicing or who had practiced in the last two years were included in the study. An announcement and a participant information statement were provided to potential participants by academic staff in two Japanese universities. These staff members were not members of the research team. Snowball sampling methods were then used, and potential participants were invited to contact the researchers if they wished to participate in the study.

Speciality

confirmed the translation. Two researchers (MO, TES) independently conducted a directed content analysis. The deductive approach used for the directed content analysis provided initial coding categories informed by the TPB. By comparing the rank order of frequency of identified subcategories, descriptive evidence of each category was reported (Hsieh and Shannon, 2005). Thus, participants' responses were labelled in order of frequency for behavioural beliefs about the advantages, disadvantages, and consequences of assertive communication, sources of social pressure, and factors that facilitate or impede assertive communication in Japanese healthcare environments.

3.4. Data Collection Audio-recorded, face-to-face individual interviews of approximately 30-minute duration were conducted from October 2016 to January 2017 at mutually convenient and private locations at the participants' workplace or university. Nine questions were asked using an interview schedule developed with reference to the TPB guidelines (Francis et al., 2004) (see Table 1). The interview transcripts were returned to participants for comment and/or correction if they requested it. Three participants requested this and subsequently, eight minor changes to the transcripts were made. Field notes were also taken during the data collection process.

4. Findings 4.1. Participants

3.5. Data Analysis Twenty-three registered nurses were recruited. Although we initially aimed to recruit 25 participants in accordance with Francis et al.'s (2004) recommendations, data saturation was achieved with 23 participants. The demographic characteristics of the participants are presented in Table 2.

It is acknowledged that the personal characteristics of researchers can influence their interpretation of qualitative data (Tong et al., 2007). In this study data collection was undertaken by the primary researcher (MO), a female PhD candidate and registered nurse qualified in both Australia and Japan. MO is a native Japanese speaker who also has sociolinguistic and strategic competence in English (Squires, 2008). She was supported by three experienced research supervisors located in Australia (TLJ and JM) and Japan (TES). The primary researcher (MO) transcribed and translated the interview data for consistency. An independent bilingual consultant

4.2. Advantages of Assertive Communication Participants' behavioural beliefs about the advantages of assertive communication when they had concerns about patient care are listed in Table 3. The most frequently reported advantage was improved patient

Table 1 Interview schedule depicting relationship between question and TPB construct. Question

Construct

1. 2. 3. 4. 5. 6. 7. 8.

What do you believe are the advantages of speaking up assertively when you have concerns about patients? What do you believe are the disadvantages of speaking up assertively when you have concerns about patients? In your view, what are the consequences of speaking assertively or not speaking assertively when you have concerns about patients? Are there any individuals or groups who would approve of your speaking up assertively when you have concerns about patients? Are there any individuals or groups who would disapprove of your speaking up assertively when you have concerns about patients? How do you think other people would view your decision to speak up assertively when you have concerns about patients? What factors or circumstances would enable you to speak up assertively when you have concerns about patients? What factors or circumstances would make it difficult or impossible for you to speak up assertively when you have concerns about patients? 9. Are there any other issues that come to mind when you think about assertively speaking your concerns about patients?

102

Behavioural beliefs (advantages) Behavioural beliefs (disadvantages) Behavioural beliefs (others) Normative beliefs (approval) Normative beliefs (disapproval) Normative beliefs (other) Control beliefs (enablers) Control beliefs (barriers) Control beliefs (others)

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Table 3 Behavioural beliefs about the positive consequences of assertive communication. Advantage

Participant quote

Frequency n = 23

Response %

Improved patient safety and care

The biggest advantage … is that the patients can be treated safely and securely. (P1) It leads to the smooth assistance of patients in nursing care. (P4) Different perspectives and approaches may emerge. (P2) I will first report to the doctor when such a concern arises, but I also try to tell the surrounding nurses, “something is not right”. Then, everyone's attention is directed to that patient, so it is not only me but other staff who will try to observe that patient with care. (P17) I have to get the other person to understand my own thinking, in order to do that, I also have to understand the other person as well. I think that it will lead to mutual understanding by exercising assertive communication. (P19) Things are accurately conveyed to the other party, and we can build such trusting relationships that we can understand each other. (P22) It seems like being able to talk straight away. When I visited a patient, and felt something was abnormal, I think that it is most important to be able to promptly communicate information… within the team. (P11) It is possible for the team to respond promptly when something happens that compromises safety. (P17)

13

57

12

51

9

39

6

26

Sharing of information and perspectives

Positive relationships

Timely communication

indicated that most healthcare professionals approved of them speaking up, and not surprisingly, they felt that nurses with similar opinions understood the importance of assertive communication. Some participants also described being held in esteem by junior staff and being respected by staff in authority when they spoke up about patient concerns. These details are presented in Table 6.

safety and quality care, closely followed by opportunities for sharing of information, perspectives, and ideas. Participants also recognised that assertive communication led to more timely communication and improved relationships between staff. In the tables below participants are identified with numerical codes; for example, P1 refers to participant 1. 4.3. Disadvantages of Assertive Communication

4.6. Disapproval of Assertive Communication The participants identified a number of perceived disadvantages of assertive communication. They indicated that assertiveness could lead to misunderstandings and arguments which had a negative impact on staff relationships and team dynamics. Three participants mentioned that communicating assertively could slow down the delivery of a message and thus cause communication delays. However, some of the participants felt there were no disadvantages to assertive communication. Participants' quotations supporting these themes are presented in Table 4.

Although seven participants had not experienced disapproval when speaking up, others described feeling pressured not to speak up by doctors and senior staff when there was a difference of opinion about patient care. These normative beliefs about disapproval are listed in Table 7. 4.7. Factors That Facilitate Assertive Communication Questions 7 to 9 elicited participants' control beliefs about the factors that either facilitated or inhibited assertive communication. The participants' described a number of situational facilitators that enabled them to communicate assertively such as a supportive environment, positive relationships, and effective role models. Many participants agreed that a supportive atmosphere enabled them to speak up and that experience and knowledge gave them the credibility and confidence to be assertive. Lastly, a small number of participants explained that the motivation to provide person-centred care was also a facilitator of assertive communication. Participant quotes representing these factors are presented in Table 8.

4.4. Consequences of Not Being Assertive In addition to the advantages and disadvantages of assertive communication, participants were asked about the consequences of not speaking up when they had concerns about patient care. In response, they described emotional reactions such as feelings of regret, discontent, stress, and worry. In addition, discord between staff and patient deterioration were identified as situational consequences of the failure to speak up. These details are presented in Table 5. 4.5. Approval for Assertive Communication

4.8. Factors That Inhibit Assertive Communication Questions 4 to 6 explored the participants' normative beliefs about whether other people would approve or disapprove of them being assertive, and potential sources of social pressure in regard to speaking up when they had concerns about patients. Nearly half of the participants

In regard to situational factors, the majority of the participants felt that healthcare hierarchies and power differentials associated with seniority and professional status were barriers to assertive

Table 4 Behavioural beliefs about negative consequences of assertive communication. Disadvantage

Participant quote

Frequency n = 23

Response %

Negative relationships (or disunity)

If it did not lead to a good result, I might lose my team members' trust. It may be difficult next time to unite [my team as others may say], “what he said was not right.” I feel hesitant to speak up again, too. (P2) We may hurt the other person a bit or we may worsen the relationship by asserting, when my way of communicating does not go well. (P20) There is not much disadvantage when communicating assertively; it is a win-win relationship. (P6) I do not really feel that there is any disadvantage. (P7) I shouldn't be wasting my time by respecting [the other person], for example, when [patient's] heart has already stopped. (p17) It is a style of conversation urging other people to answer. The conversation time will definitely be longer. (P21)

11

48

6

26

3

13

No disadvantages Communication delays

103

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Table 5 Behavioural beliefs about the consequences of not being assertive. Consequence

Internal Discontent

Situational Discord

Patient deterioration

Participant quote

Frequency n = 23

Response %

The stress builds up because I just worry about the same thing day after day, and I probably lose concentration and make mistakes because I think about that all the time. (P8) If I do not speak and it did not go well, if the patient got worse, I think that I will feel discontented with myself, or I would wish I could speak up. (P20)

6

26

We may have a little argument later or it will be hard to report something the next time. (P18) If you do not communicate like that (assertively), the other person does not understand what you are thinking, so it's hard to understand each other. (P19) There may be cases that I wished I had spoken sooner…, or patients deteriorated or got worse by not communicating. (P13) I could not easily convey my concern… as a result, things happened like I could not secure patient safety. (P17)

4

17

3

13

having a negative effect on the work culture can make Japanese nurses hesitant to be assertive (Davies and Ikeno, 2002). This is cited as one of the most significant factors that prohibit Japanese nurses from speaking up about their concerns (Suzuki et al., 2006). While some participants felt that assertive communication could save time, others felt that it is likely to lead to delays. These apparently opposing viewpoints may be better understood by considering Japanese perceptions of polite communication. When compared to Western countries, Japanese communication tends to be indirect and somewhat convoluted in manner (Davies and Ikeno, 2002), starting from the periphery and winding inward in circles, only gradually ‘getting to the point’ and identifying what is required (Bramble, 2008, p. 231). However, assertive communication is intended to be a clear, succinct, direct exchange, not a vague, winding series of conversations. It is, therefore, likely that some of the participants felt that speaking out was impolite and inappropriate in a Japanese work setting. Further adding to this complexity was the definition of assertive communication used when commencing the interviews which was ‘to respectfully express opinions and concerns regarding patient care’. Professional communication in Japan is already considered to be respectful and polite and it is possible that some of the participants felt that there was a contradiction between speaking up and professional, respectful communication. Nursing practice is not immune from the influence of the social pressure (Burns and Thompson, 2005). Close to half of the participants felt they were supported by people in their workplace when they did speak up and identify their concerns about patients. Correspondingly, about a third of participants stated that there was no one who disapproved of them speaking up. However, some of the participants disagreed noting that they felt pressured to conform rather than speak out, and like many nurses around the world, the participants found it difficult to be assertive with doctors. This is supported by previous research from the United States which identified that nurses felt it much harder to confront doctors than nurses or other health professionals (Maxfield et al., 2005). Undoubtedly, the difference in status between nurses and doctors is more pronounced in Japan. For example, one

communication. Many also suggested that they could not be assertive when making requests of other healthcare professionals who they perceived to be busy. A number of participants specified that intimidation and bullying prevented them from speaking up, and they also referred to factors such as their inexperience and physical or emotional distress as barriers. Situational and internal factors that inhibited assertive communication are reported in Table 9. 5. Discussion Beliefs about the advantages or disadvantages of speaking up affect nurses' attitudes and intentions in regard to assertive behaviours. Assertive communication is an emerging concept in Japanese healthcare. It is encouraging that participants in this study recognised the relationship between assertive communication and patient outcomes. It was evident that person-centred care and patient advocacy were core values for many of the participants and that, when discussing the advantages of assertive communication, they were primarily concerned with how it would impact patient outcomes. This accords with previous studies that identified that perceived risk to patient safety is an important motivation for speaking up (Okuyama et al., 2014; Schwappach and Gehring, 2014). For some of the participants the consequences of not speaking up were intense regret, discontent, frustration, and stress. One participant described how “motivation for the work may decrease when one has to continuously put up with a situation where one cannot or does not express one's opinion”. Previous studies support these findings and have noted that failing to speak up can lead to moral distress, low self-esteem, burnout, and staff resignation (Rainer, 2015; Suzuki et al., 2006). The impact of assertive communication on communication and team dynamics was a recurring theme in the data. Although some participants recognised that speaking out may result in mutual understanding, others felt that assertiveness was a potential risk to team harmony. Traditionally, Japanese people endeavour to maintain team unity or harmony, known as ‘wa’ (Bramble, 2008). Concerns about Table 6 Normative beliefs about approval from other people. Approval

Group Most staff Staff with similar opinions Juniors

Participant quote

Frequency n = 23

Response %

I guess most of my staff would approve. (P10) People who are working in the same workplace would approve. (P22) The staff who have the same opinion or who understand my opinions, e.g. the need of Echography, have the same feeling. (P19) They get a relatively favorable impression about me when they have similar opinions. (P20) Junior nurses say, “we are the Sato-san faction” and I am often told, “we think so” after I have spoken up. (P2) Young staff regard me positively. (P18)

11

48

4

17

3

13

3

13

Individual The nursing manager or chief of the ward always tell me that I respond well. (P17) Someone who tells me what his/her opinion is in the proper form rather than showing disapproval. (P7)

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Table 7 Normative beliefs about disapproval from other people. Disapproval

Group No disapproval Doctors

Staff with different opinion Senior staff

Participant quote

Frequency n = 23

Response %

I feel that I have never been hated or shown much disapproval [because of speaking up]. (P16) No, I don't think there is [anyone who disapproves of speaking up]. (P22) There were times that I don't know if the doctor is listening even though I told them [something]… There was no reply or response. (P13) There are often times when [what I say] is not accepted [by doctors]. (P18) It is difficult to speak up my feeling to people who do not have the same sense. (P17) Some people may have [different] idea that nurses should follow the instructions of doctors. (P19) Seniors… people who are older than me (P2) I have not had much experience… I think that I may have been viewed as cocky to say such a thing. (P23)

7

30

5

22

4

17

3

13

5

22

Individual A senior nurse used to be silent when I expressed my opinion. (P2) There was… someone who personally didn't like me much. (P11)

participant pointed out “a vertical relationship” that exists between doctors and nurses; another suggested that “in terms of authority of the treatment, doctors inevitably have greater power”; and yet another nurse stated that “compared to overseas nurses, Japanese nurses are unskilled in terms of asserting or making suggestions to doctors.” Also, problematic in the working environment for Japanese nurses is seniority, with age being more important than ability (Davies and Ikeno, 2002). Thus, junior nurses tend to obey senior staff without question and as one participant expressed in frustration, “It is hard for me to speak up against what a senior nurse said, so I accept everything he/she says even if I think differently.” As the Japanese proverb says, “The nail that sticks out gets hammered down.” The factors influencing this deep-rooted cultural belief in healthcare include hierarchy, seniority, and differences in the doctornurse status. However, a body of research attests to the importance of nurses being able to communicate assertively when they have concerns about patient care (Beyea, 2008; Okuyama et al., 2014; Rainer, 2015). Strategies to empower nurses to initiate conversations about these issues are required if the recognised barriers are to be overcome. Although some nursing literature on the generational differences in Western countries found that younger nurses are more likely to speak up (Hahn, 2011; Hendricks and Cope, 2013), our study identified that novice Japanese nurses are reluctant to speak up because they believe that they lack knowledge and experience. For this reason, those who are in an early stage of their career may need the most support and educational initiatives may be one strategy to address some of these concerns.

5.1. Limitations This was a cross-language qualitative study which may have had inherent risks. However, the primary researcher is fluent in both English and Japanese and was supported by three experienced researchers. Additionally, the study participants were recruited using snowball sampling method in two regions of Japan. Therefore, the findings are not necessarily representative of other regions of Japan where cultural diversity may influence nurses' attitudes towards assertive communication. Future studies with more diverse participant groups will strengthen and extend the findings from this study. 6. Conclusion This study identified Japanese nurses' beliefs in relation to assertive communication and speaking out to promote patient safety, along with implications for education, practice and future research. Although the majority of participants recognised the importance of assertive communication for safe practice, pressure from doctors and senior nursing staff, as well as other cultural barriers limited the extent to which they were willing to actually speak up. The findings point to the need for long-term strategies to address barriers to assertive communication, but also suggest that issues such as deficits in knowledge, skills, experience, and confidence could potentially be influenced by assertiveness training programs. This study has provided key insights into the types of issues that should be addressed in such programs in order to empower nurses to speak up and advocate for patients. However, organisational support is imperative for any long-term changes to the healthcare culture to be sustained. While this study was conducted in a Japanese healthcare

Table 8 Control beliefs about the factors that facilitate assertive communication. Facilitators

Situational Supportive environment Positive relationships Role model Internal Experience, knowledge

Person-centred

Participant quotes

Frequency n = 23

Response %

An atmosphere like “always listening to you” and “tell me any time.” (P11) An easy-to-speak up environment is necessary. (P20) It is easier to communicate more assertively if regular communication and trusting relationships have already been established. (P19) I believe that a trusting relationship is a prerequisite for communication. (P21) It becomes very easy to act positively when there is a role model and being shown an example that went well is valuable. (P1) A role model… a person who we want to be like who is assertive… I think that we would want to be more like that person. (P23)

15

65

13

57

3

13

5

22

3

13

When I have the clinical experience, I can express my opinion. When we understand what the doctors are doing or are able to imagine the reason why other nurses are doing certain things, it is easy to express an opinion and convey the difference with your own view. So, I guess it is hard for a new nurse to speak up. (P20) It is okay if I have enough knowledge and experience to speak up. (P22) It is our duty to speak our opinion when we put patient care first before defending oneself since we are doing our job. (P4) Our main purpose is patients. It is not ourselves who feel the most hurt, it's always patients who feel hurt. (P17)

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Table 9 Control beliefs about the power of factors to inhibit assertive communication. Inhibitors

Situational Hierarchy

Timing Poor relationships Intimidation Internal Lack of knowledge/experience

Physical/emotional stress

Participant quotes

Frequency n = 23

Response %

It is hard for me to speak up against what a senior nurse said, so I accept everything that he/she says even if I think differently. (P3) I think there is somewhat a culture that it is hard for nurses to speak to doctors. (P18) Because we cannot listen unless we have time to spare, it would be unpleasant if the timing is bad. (P5) It's like when the person who I am speaking is busy. In such time, I wonder I had better ask him/her again later. (P22) They (newcomers) may have relatively less opportunities to talk compared to the old days in terms of communication (P15) It is hard to do so (speak up) in a situation where you cannot understand the other person very well. (P19) I cannot say anything at all if I am told something like “It is not right” without even being given a chance to explain. (P16) When the attack was concentrated on me, I end up not being able to say anything out of respectful obedience. (P23)

20

87

16

70

16

70

14

61

10

43

4

17

It is very difficult to explain the situation if I don't understand the situation well. Even though I thought I explained how I felt, others seem to have understood it differently. (P9) When I entered as a new graduate, I hardly thought about it… I did just as I was told. (P18) It depends on my condition and also my physical condition. (P1) I am considerably stressed when things are tense. At such times, when my tension is heightened, I don't think communication works because I am not emotionally able to handle it. (P17)

environment, it is likely that similar hierarchical structures and power dynamics operate in healthcare settings across the world and may compromise patient safety. Thus, the international relevance of this study is significant.

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Author Contributions

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