Nurses are the largest part of the occupational health system [1,2]. Nursing in the intensive care unit is a dynamic profession that requires a wide range of behavioral, functional, and clinical skills, including clinical competence, in addition to applying knowledge, experience and professional, legal and ethical, standards [6,7]. Clinical competence is the essence of professional nursing and consists of a combination of technical and communication skills, knowledge, attitudes, values and abilities that underpin effective and superior performance at the level of a profession or a clinical position [3,9].
In the new millennium, which is the age of accountability, due to the increasing awareness and expectation of the public about receiving quality services, health service delivery systems are forced to increase the effectiveness of the human resources employed in these systems [15]. Among the different dimensions of competence, communication has been identified as one of the essential areas of interprofessional collaboration and has been emphasized on by researchers as one of the essential competencies and integral part of interprofessional training and teamwork skills. Achieving this requires an effort to implement interprofessional communication skills training in team-based therapy [20,21]. Studies show low levels of assertiveness in the nursing community which results in weak communication skills that can have a negative impact on nurses' behavioral and clinical performance [31]. Nurses in health care organizations need to communicate effectively and interact with everyone involved in the health system in order to provide appropriate care and take safe action [16].
Findings suggest that strengthening interdisciplinary relationships to overcome current problems in health care systems to deliver high quality patient care requires a good communication system [33]. Therefore, assertiveness is a communication style that is nowadays considered as an important behavior for nursing profession and is one of the essential skills in the modern workplace to provide quality care and the key to successful communication with clients, families and co-workers [16,34]. In the nursing profession, the ability to provide a decisive response in critical or potentially hazardous situations is a vital and life-saving skill [24] and given the critical communication role that nurses play in the health care system, especially in intensive care units, this context is essential and it is necessary to incorporate decisive behaviors into their curricula [16,33]. Therefore, due to the necessity of determination in the professional affairs of nurses and the importance of teaching this skill, a comprehensive and coherent study vacancy is felt in Iran. To fil this gap, the present study was conducted to determine the effect of assertiveness program on clinical competency of ICU nurses.

 

In this clinical trial, 70 nurses of intensive care units in Hajar and Kashani hospitals of Shahrekord in 2018 were divided into two groups of experimental (n=35) and control (n=35). The experimental group received assertiveness skill training during 6 sessions of 1.5 h (three times a week) (Table 1), while the control group did not receive the training. In both groups, data were collected before, immediately and three months after the intervention using the CIRN Nurses' standard of competence questionnaire along with demographic data. Data analysis was done using SPSS 17 (SPSS Inc., Chicago, IL., USA).  P-value<0.05 level was considered significant.
 

Table 1. The overall content of assertiveness training program sessions

A total of 70 nurses working in intensive care units of teaching hospitals of Shahrekord University of Medical Sciences participated in this study. According to the research findings, the majority of nurses in the intervention group (82.9%) and the control group (97.1%) were women. The mean age was 34-39 years. The variables including marital status, educational level, work experience, employment status before intervention were homogeneous in both groups. The results of the t-test and Chi-square test did not show a significant difference (P<0.05) (Table 2).

Table 2. Absolute Frequency Distribution and Frequency Percentage of Demographic Characteristics of Participants in Control and Intervention Groups

The results of Kolmogorov-Smirnov test showed that the dependent variable in the three stages of measurement was followed by the normal distribution, so the assumption of normality of the data was confirmed (Table 3).
 

Table 3. Results of the Normal Analysis of the Distribution of Dependent Variable Data in the Test and Control Groups in Three Measurement Steps

Results (Table 4) showed that there was no significant difference between the mean scores of clinical competency of the two groups before and after the intervention (P<0.05). However, this difference was significant at baseline and at 3-month follow-up based on t-test (P<0.05). Analysis of variance with repeated observations showed a significant difference in the trend of mean scores in the three measurement stages (before the intervention, immediately after the intervention and three months after the intervention) (P<0.001).
 

Table 4. Mean, standard deviation, independent t-test, and repeated measures ANOVA of the variable Clinical Competence in the intervention and control groups in three stages of measurement.

The purpose of this study was to evaluate the impact of assertiveness program on clinical competency of ICU nurses. The results showed that the mean scores of clinical competency of the nurses in the experimental group were significantly increased immediately after the intervention and in the three-month follow-up assessment.
Clinical competence in the nursing profession has different dimensions and domains. Different results have been obtained in studies of the impact of assertiveness on clinical competence. In an experimental study, Jang and Kim examined the impact of assertiveness training on assertive behaviors, problem solving ability, and interpersonal relationships in nursing students. The pre and post intervention results in the experimental group showed that assertiveness training is effective in promoting decisive behaviors, problem solving ability and changing interpersonal relationships [43], which is consistent with the results of the present study. Communication is one of the effective factors in the process of clinical competency in nursing [44]. Safadi et al. have also emphasized on the concept of interaction with hospital staff, physicians, other members of the health team, patients and their families, while emphasizing on the concept of interaction [22]. So it can be said that education that can affect the professional communication will also have an effect on clinical competence. The findings of this study were not in line with Kang and Lee's study which aimed to determine the effect of assertiveness skill training on effective communication and career leaving factors in nurses. The results of their study showed that assertiveness skill training has no effect on improving interpersonal relationships and reducing nurses' conflicts [46]. The reason for the discrepancy of the results of this study with the present study may be due to differences in teaching style, different teacher skills and research units.
Not and Sores of Italy, in a study aimed at influencing decisive education for students with no decision-making power. Their results showed that decisive training affects decisive abilities and improves individuals' ability to collect useful information for decision making [50].
In fact, courageous individuals seem to be capable of problem solving, greater decision making ability, creative and critical thinking ability, and the ability to communicate effectively and constructively. Given the critical communication role of nurses in intensive care units, reinforcing the determination of individuals to perform more effectively and provide better quality care will certainly have a positive impact on their clinical competencies.
However, the results of this study showed that assertiveness training increases the clinical competency of critical care nurses. Researchers of this study hope that according to the results of this study, effective steps can be taken to improve nurses' quality of care and mental health.

 

This article is part of a Master's Degree thesis in Intensive Care Nursing, Shahrekord University of Medical Sciences under code IR.SKUMS.REC.186 and was registered with the Iranian clinical trial registration number IRCT20091215002861N14 in 2018. The researchers would like to extend their sincere gratitude to the Vice-Chancellor for Research of Shahrekord University of Medical Sciences, the respected professors of Shahrekord Nursing and Midwifery Faculty, the officials of Hajar and Kashani Hospitals of Shahrekord and all the nurses who participated in this research.

 

The authors of this study would like to express their gratitude to the Vice Chancellor for Research of Shahrekord University of Medical Sciences, Iran.

 

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.