Yonago Acta medica 2013;56:63–68

Original Article

Trial and Evaluation of Assertion Training Involving Nursing Students
Yuko Nishina* and Shizuko Tanigaki†*Department of Nursing Care Environment and Mental Health, School of Health Science, Tottori University Faculty of Medicine,
Yonago 683-8503, Japan and †Graduate School of Health Sciences, Okayama University, Okayama 700-8558, Japan

ABSTRACT

express their feelings, ideas and beliefs, both honestly
and frankly, in a manner appropriate to the situation.1
Along with the concept of assertion, Hiraki introduced
methods for assertion training designed specifically for
the Japanese. Hiraki’s methods are widely utilised inclinical psychology involving a wide range of people,
including nurses, teachers, counselors, children, students
and the general public.
The purpose of assertion training is to establish
better interpersonal relationships. Previous studies highlighted the beneficial effects on nurses received having
undertaken assertion training (assertiveness training)as: improved assertiveness,2 reduced stress at work3 andimproved self-esteem.4 The author, having learned theconcept of assertion from books and training (seminars),
felt the necessity for nursing students to understand theconcept of assertion because nursing is considered aprocess involving important and sensitive interpersonal
relations,5, 6 including daily conversations with patientsand their families. Day to day life requires that nursing
students develop strategies to establish and maintainbetter relationship with all those they have contact with.
Good communication is crucial to the well being of
nursing students, allowing them to cooperate with thevarious specialists and patients they interact with andit is important for the students themselves to establish
better relationships with others close to them, in order tomaintain their own mental well being.
The purpose of the present study was to design
and implement assertion training with students, and toclarify the effects that assertion training had on its participants. The reasons for including nursing students inthe design of the assertion training program were: i) it
was important for them to be spontaneous and active ina participatory setting for the better learning of assertionand ii) in cognitive-behavioral therapy programs, suchas assertion training, practical experience (experimental
learning1) is regarded as important, and so it was considered that experimental learning would be better promoted in a participatory setting.

BackgroundThe concept of assertion and conceptual/practical methods of assertion (assertiveness) training were originally developed in the United States andEurope. These principles were embraced and adaptedin Japan in 1970’s. However, only a few studies relating to assertion (assertiveness) have been undertaken
thus far in Japan, especially so in the domain of nursing students in comparison with other countries. The
purpose of this study was to design and implement assertion training with nursing students and to clarify its
effects.
Methods The participants were all volunteers, invited from a class of 3rd year nursing students. Ten students (intervention group) participated in the assertion
training comprised of five sessions in February 2006.
Fifty-six students (control group) were participatedonly in the questionnaire. Both groups were asked tocomplete the same questionnaire twice, before and after the assertion training. The questionnaire measured
levels of assertiveness, social skills, self-esteem, social support and satisfaction with university life. The
results and variances, both before and after assertion
training, between the intervention group and the control group were analyzed. The effectiveness of the assertion training was determined by changes in pre andpost training questionnaire scores.
Results
The scores for social skills in the control
group had a tendency to decline while the scores forsocial skills in the intervention group remained constant.
Conclusion Although there were no statistically significant results in the intervention group, the present
study highlights areas appropriate for further study.
Key words

assertion; assertiveness; nursing student;
communication; self-esteem

The concept of assertion and conceptual/practical methods of assertion training (assertiveness training) wereoriginally developed in the United States and Europe.
According to Hiraki,1 the person accredited with introducing “assertion” principles to Japan, assertion is aself-motivated form of expression in which a person ora group, respectfully and through speaking assertively,

Corresponding author: Yuko Nishina, MNS, RN, PHN
nishina@med.tottori-u.ac.jp
Received 2013 April 2
Accepted 2013 June 13
Abbreviations: J-RAS, Japanese version of Rathus Assertiveness
Schedule; KiSS-18, Kikuchi’s Scale of Social Skills: 18 items

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Y. Nishina and S. Tanigaki
Table 1. Schedule and details of questionnaire surveys and assertion training
Date

Detail2005 Deccember

Implementation of a questionnaire survey before intervention
Session (time)

Purpose of the sessions

2006 February 02
1st session (90 min)Sharing the objectives of the training program		
Reflecting on one’s routine self-expression		
Understanding the concept of assertion
2006 February 09
2nd session (90 min)Confirming the fundamental human right to be assertive		Reflecting on whether one is able to execute one’s right as a human being
2006 February 13
3rd session (90 min)
Understanding ideas underlying assertion		
Learning ways to assertively self-express
2006 February 15
4th session (90 min)
Understanding the existence of non-verbal assertion		
Understanding emotional expressions
2006 February 18
5th session (240 min)
Having practical experience (role-playing)
		 Instructed by a trainer certified by the Psychotechnological Institute of Japan
2006 April

Implementation of a questionnaire survey after intervention

Thus, in the present study, which was designed andimplemented together with students, we aimed to clarify
the beneficial effects of assertion training on communication abilities and mental health of the nursing students.

ate mental health. Details of the scales and question
items are as follows:
Assertiveness scale, J-RAS
The original Rathus Assertiveness Schedule (RAS) was
developed by Rathus,7 and its Japanese version (J-RAS)
was created by Shimizu et al.,8 the reliability and validity of which has been verified. The J-RAS scale consistsof 30 items with 6 choices. Scores range from –90 to 90
points, with higher scores indicating higher degrees ofassertiveness.

SUBJECTS AND METHODS
Subjects

The participants in this study were all volunteers, invited from a class of 3rd year nursing students from the
School of Health Science, Tottori University Faculty of
Medicine. All participants consented of their own accord
to take part in the study (n = 90). Of these participants,
students who did not complete the questionnaire twice
were excluded (n = 12). We also excluded those who had
previously attended seminars on assertion (n = 9). In
addition, because all students in the intervention groupwere female, male students were excluded from the control group (n = 3). As a result, a total of 66 students wereextracted as the study subjects. The number of students
who participated in assertion training was 10, and thenumber of those who responded to questionnaire before
and after assertion training (control group) was 56.

Social-skills scale, KiSS-18
Kikuchi’s Scale of Social Skills: 18 items (KiSS-18),
developed by Kikuchi,9 is widely used in Japan, and thereliability and validity of which has been verified. The
scale comprises 18 items with 5 choices. Scores range
from 18 to 90 points, with higher scores indicating greater social skills. The definition of social skills is “skills tofacilitate interpersonal relationships”, and our previous
study suggested that there is a correlation between assertiveness and social skills.10, 11 Also, it has been reported
that social skills are correlated with: the degree of sociability among female junior college students,9 groupactivity skills among junior high school students, andcommunication skills among colleagues.9

Survey methods

A self-rating questionnaire survey was conducted before
and after assertion training. All subjects received an
outline of the study’s objectives and methods in writing.
The subjects then responded to the questionnaire which
was duly collected and analyzed. Table 1 shows theschedule of the surveys and intervention program.
Assertiveness and social-skills scales were used toevaluate communication abilities. A self-esteem scale,acknowledging both levels of social-support cognitionand satisfaction with university life, were used to evalu-

Self-esteem scale
The scale, developed by Rosenberg, is being widely usedwithin and outside Japan. The present study used theJapanese version.12 The scale consists of 10 items with 5
choices. Scores range from 10 to 50 points, with higherscores indicating higher levels of self-esteem.
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Assertion training for nursing students

Social support
Questions regarding social support were created basedon investigation criteria devised by Kubo et al.13 The
frequency of consultations from each social support
provider (i.e., family, friends, and others) was assessed.
Each question has 4 response options, and scores range
from 3 to 12 points, with higher scores indicating higher
degrees of social-support cognition (the degree of one’s
recognition that one is able to ask others for help).

training trainers certified by the institute (Nisseikencertified trainers). At the final session of our assertion
training, a Nisseiken-certified trainer was invited as an
instructor for the overall review of the first 4 sessions:
we attempted to enhance students’ learning through theintroduction of role-playing experience. The trainer was
consulted prior to the session, in order to provide and exchange information regarding students’ learning. We informed the trainer of the study objectives and methods,
and obtained consent in advance.

Degree of satisfaction with university life
Subjects were asked to choose between 4 response options (from “Not satisfied” to “Very satisfied”) for answering “Overall, how much are you satisfied with youruniversity life?” Higher scores indicated higher degrees
of satisfaction with university life.

Statistical analyses

Basic statistics of scores for each scale were calculated
before and after intervention. We compared the averages of the ranks between the intervention and control
groups, using the Mann-Whitney U test. To examine theeffects of the intervention, the Wilcoxon rank-sum test
was used. Due to the total number of subjects being low
and there being a difference in the number of subjects
between groups, a distribution-free test was used. The
level of significance was set at 0.05 for all analyses.

Intervention methods

Subjects were informed of the study objectives andmethods and volunteers were selected to participate inassertion training. A total of 5 training sessions werescheduled, and the session dates were determined together with students. Table 1 shows the program schedule and purposes of each session.
The assertion training was implemented with “Assertion training—for smooth self-expression” by Hiraki1
as a reference book. The authors developed the 5-session
program. A short lecture and orientation were provided
at the beginning of each session, followed by group
work, group discussion and short roll-playing activities.
Participatory learning was regarded as important so
subjects were required to read the reference book in advance of each session. For the final session, an assertion
training trainer from the Psychotechnological Instituteof Japan introduced and guided a role play exercise withthe participants. The objectives of assertion training presented to the intervention group were to: i) reflect on theway of their routine self-expression, ii) consider ways ofself-expression based on equal interpersonal relationships and iii) confirm that their feelings and opinions
can be expressed with confidence. Of the 10 participants,
7 attended all 5 sessions, and the other 3 were each absent from 1 session, but analyses were performed involving all participants. When a participant was absent froma session, this session was reviewed at the beginning of
the next session, and self-study using the reference book
was promoted, thereby making up for the absence.

Ethical considerations

Prior to the study, the study protocol was submitted to
the Ethics Committee of Tottori University, and approval(No.583) was obtained. Subjects were explained that: i)the study would only be undertaken with the subjects’
consent, ii) questionnaires would be conducted withsubjects’ identity being protected and iii) participation/
non-participation in or withdrawal from the study would
not influence subjects’ grades in any way. An agreement
document was signed by all participants to confirm theirintention to participate. We then explained that subjects
could withdraw from the study at any time, and distributed withdrawal documents.
RESULTS
Subject attributes

The mean (SD) ages were 21.1 (0.7) and 21.2 (0.9) years
in the intervention and control groups, respectively.
Comparing mean scores in the intervention andcontrol groups before intervention

The mean (SD) scores for assertiveness were –7.0 (20.6)
and –10.5 (17.7) points in the intervention and control
groups, respectively. The mean (SD) scores for social
skills were 54.3 (9.6) and 57.2 (8.6) points in the intervention and control groups, respectively. The mean
(SD) scores for self-esteem were 34.7 (5.7) and 30.3 (6.3)
points in the intervention and control groups, respectively. The mean (SD) scores for social support were
9.11 (1.17) and 8.71 (1.50) points in the intervention andCooperation with an assertion training trainer certified by the Psychotechnological Institute of Japan

Assertion training developed by the Psychotechnological Institute of Japan is implemented by assertion65

Y. Nishina and S. Tanigaki
Table 2. Comparisons between the groups before assertion training

Age		
Communication ability
AssertivenessSocial skills
Mental healthSelf-esteem
Social support
Satisfaction with university life

Intervention group (n = 10)
Mean (SD)Control group (n = 56)
Mean (SD)P value

21.1 (0.7)–7.0 (20.6)
54.3 (9.6)
34.7 (5.7)
9.11 (1.17)
3.20 (0.63)

21.2 (0.9)–10.5 (17.7)
57.2 (8.6)
30.3 (6.3)
8.71 (1.50)
2.86 (0.67)

0.771
0.405
0.659
0.022*
0.451
0.138*P < 0.05.*

control groups, respectively. The mean (SD) scores forthe degree of satisfaction with university life were 3.20
(0.63) and 2.86 (0.67) points in the intervention and control groups, respectively. Comparisons of the means of
the ranks showed a significant difference in the score forself-esteem (P < 0.05) (Table 2).
Results of the Wilcoxon rank-sum test to compare
the means between pre- and post-intervention

satisfaction with university life increased by 0.50 points,
there were not significant. Compared with the scores in
the control group, the scores for assertiveness and social skills in the intervention group remained constant(Fig. 1).
In the control group, the scores for social skills had
a tendency to decline (P = 0.051). Also in the control
group, the scores for the degree of satisfaction with university life increased significantly (P < 0.05) (Table 3).

In the intervention group, the scores for assertiveness increased by 8.3 points and the scores for social skills increased by 4.8 points, there were not significant though.
Also in the intervention group, the scores for self-esteem
increased by 0.7 points, the scores for social support
declined by 0.01 points and the scores for the degree of

DISCUSSION
In assertion training, effective learning can be promoted
through students’ pre-session preparation; learning
through practical experience in a participatory setting
was regarded as important. A difference in self-esteem

Fig. 1. Scores for each assessment scale before and after intervention.

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Assertion training for nursing students
Table 3. Changes in communication abilities and mental health of the participants
Intervention group (n = 10)
P value
BeforeAfter 		intervention
intervention		Control group (n = 56)
BeforeAfterintervention
intervention

P value–7.0 (20.6)
54.3 (9.6)

1.3 (26.9)
59.1 (6.9)

0.307
0.446

–10.5 (17.7)
57.2 (8.6)–9.8 (19.3)
55.8 (8.0)

0.661
0.051

Mental health Self-esteem
34.7 (5.7)
Social support
9.11 (1.17)
Satisfaction with university life 3.20 (0.63)

35.4 (6.8)
9.10 (1.20)
3.70 (0.48)

0.539
1.000
0.414

30.3 (6.3)
8.71 (1.50)
2.86 (0.67)

31.2 (5.9)
8.84 (1.33)
3.43 (0.68)

0.144
0.583
0.019*

Communica- Assertivenesstion ability Social skill

Data, mean (SD).
* P < 0.05.
Significant differences are not noted in the intervention group.

was noted between the intervention group and the control group before intervention, suggesting that training
participants had higher-level of self-esteem. It can besuggested that students are willing to participate in assertion training would have increased levels of selfesteem.
In prior studies, the assertiveness of those in nursing professions improved after participating in assertion
training.2, 3 A significant improvement in the assertiveness of participants in the present study was not found.
Social skills did not show a significant improvement,
either. In contrast, the scores for social skills had a tendency to decline in the control group, so the assertion
training could maintain the social skills in the intervention group. Because assertiveness is correlated withsocial skills,10, 11 social skills could remain constant innursing students that undergo assertion training.
Previous studies have suggested beneficial effects
of assertion training on mental health and well-being.
The benefits include reduced stress3 and improved selfesteem.4 But the present study did not produce beneficial
effects on mental health of participants. It was not determined why the degree of satisfaction with university life
increased in the control group in the present study.
The number of participants in the present study was
low and there were several obstacles to the study. The
characteristics of the intervention group and those of
the control were not alike. And the possibility of factors
which might have influenced communication abilities
and mental health of the participants cannot be denied.
This suggests that there are limitations to the benefits
that the general use of assertion training among nursing
students can achieve.
The present study also suggests that it is advisable
to improve intervention program, including the evaluations method of their techniques and effects. Firstly, inthis study, the self-esteem of the intervention group was
high, due to the participants being willing volunteers,
therefore future studies would benefit from having larger

intervention groups that would include a greater numberof students with low self esteem to better determine theeffects that an assertion training program has on nursing
students. Secondly, previous studies have demonstrated
the benefits that follow-up sessions have to assertion
training, future studies should therefore include thefollow-up session in the program. Finally, research in thepresent study focused on assertion in the daily lives of
the nursing students; future studies should include several sessions which focusing issues relating to the practical training of nursing students. The practical training
course that nurses undergo is one of the most importantlearning opportunities that nursing students have. Oneof the problems that nursing students face during thistime is effective communication with various specialists,
nurses, patients and their family members. Further study
would clarify the effects of assertion training on thecommunication abilities in nursing practice. In conclusion, the present trial study suggests future possibilities
for the further study of assertion training for nursing
students.
Acknowledgments: We would like to express our deep gratitude to
the nursing students who cooperated in our study, and those who
participated in our assertion training. We also acknowledge the cooperation of Mr. Yukitoshi Kuroki (former teacher of a secondary
school attached to Kobe University, and current teacher of Kakogawa Yamate Junior High School), an assertion training trainer
certified by the Psychotechnological Institute of Japan, who comprehended the study objectives, instructed in our assertion training(role-playing), and markedly contributed to our study.
The authors declare no conflict of interest.
REFERENCES
1 Hiraki N. [Assertion training – for smooth self-expression].
Tokyo: Kaneko Shobo; 2009. Jananese. NCID: BN10254248.
2 Katsuhara Y, Mashino S. Development and evaluation of anassertiveness training program for Japanese nurses. Hyogo
Kenritsu Kango Daigaku Kiyo. 2001;8:71-85. Japanese withEnglish abstract. NAID: 110000558787.
3 Lee S, Crockett MS. Effect of assertiveness training on levels

67

Y. Nishina and S. Tanigaki

4

5

6
7
8

2003;25:35-42. Japanese with English abstract. NAID:
110001261752.
9 Kikuchi A. Notes on the researches using KiSS-18. Iwate
Kenritsu Daigaku Shakaifukushi Gakubu Kiyo. 2004;6:41-51.
Japanese with English abstract. NAID: 110004677435.
10 Nishina Y, Tanigaki S, Norikoshi C. The relationships between mental health condition, communication skills, and selfesteem of nursing students. Yonago Igaku Zasshi. 2010;61:6774. Jananese with English abstract. NAID: 40017139241.
11 Nishina Y, Tanigaki S. Factors related to intragroup conflict inthe workplace among visiting nurses. Nihon Kango Kenkyu
Gakkai Zasshi. 2009;32:113-21. Japanese with English abstract. NAID: 10026505444.
12 Yamamoto M, Matsui Y, Yamashiro Y. [The structure ofperceived aspects of self]. Kyoiku Shinrigaku Kenkyu.
1982;30:64-8. Japanese. NAID: 110001892417.
13 Kubo, M. The relationships between burnout and social support among human service workers. Osaka Kyoiku Daigaku
Kiyo Dai IV Bumon. 1999;48:139-47. Japanese with English
abstract. NAID: 110000119419.

of stress and assertiveness experienced by nurses in Taiwan,
Republic of China. Issues Ment Health Nurs. 1994;15:419-32.
PMID: 8056571.
Shimizu T, Kubota S, Mishima N, Nagata S. Relationship between self-esteem and assertiveness training among Japanesehospital nurses. J Occup Health. 2004;46:296-298. NAID:
110003722961.
Peplau HE. Interpersonal relations in nursing: a conceptual
frame of reference for psychodynamic nursing. Tokyo: IgakuShoin; 2001. Japanese. Translated by Inata Y, Kobayashi F,
Takeyama M, Tsuru N, Hokama K. NCID: BN00703618.
Travelbee J. Interpersonal aspects of nursing. Tokyo: IgakuShoin; 2003. Japanese. Translated by Hasegawa H, Fujieda T.
NCID: BN00672445.
Rathus SA. A 30-Item schedule for assessing assertive behavior. Behavior Therapy. 1973;4:398-406. DOI: 10.1016/S00057894(73)80120-0.
Shimizu T, Morita S, Takezawa M, Shazuki A, Kubota S,
Mishima N, et al. Development of the Japanese version of theRathus assertiveness schedule. Sangyo Ika Daigaku Zasshi.

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