Methods: After institutional approval, we recruited nurses and interdisciplinary participants through social media and electronically administered the Rathus Assertiveness Scale (Jenerette & Dixon, 2010), in addition to asking demographic questions, after receiving informed consent. The Simple Rathus Assertiveness Scale – Short Form (SRAS-SF) was used to measure participants’ self-reported levels of assertiveness; it has strong reliability with a Cronbach’s alpha of .81 (Jenerette & Dixon, 2010). In addition to the SRAS-SF, we included questions about participants’ exposure to four main types of workplace aggression: verbal, sexual, physical, and ‘threatening circumstances’ which we described as colleagues gossiping, withholding information, spreading rumors, and/or belittling others.
Results:
Of 190 participants, 84% identified as female, 67% were nurses, 7% were physicians (MDs)/nurse practitioners (NPs), and 10% were unlicensed patient care personnel; we excluded responses from non-clinical participants. Measures of central tendencies indicated participants’ assertiveness was below average (41.7) in comparison to population assertiveness (45). Descriptive analyses demonstrated frequent exposure to WPV overall, which increased with age and experience but decreased among gender; males had 74% less exposure than females to colleague bullying, 81% less sexual harassment, 88% less sexual assault, and 64% less physical assault. Only 34% of all participants reported never experiencing sexual harassment; 56% who had were harassed by a supervisor. Physical assaults were perpetrated mostly by patients or family members (97%). Most participants (67%) experienced threatening circumstances (e.g. bullying) within the past year (68%), perpetrated mostly by colleagues (71%) of whom 64% were not supervisors; younger participants reported being bullied more frequently than older participants.
Accounting for unequal group sizes, nonparametric analyses found significant differences between participant assertiveness, with MD/NP reporting higher assertiveness than nurses in several categories (p=.023, .026). Assertiveness also differed among clinical specialty; pediatrics and women’s health personnel demonstrated less assertiveness than emergency and internal medicine personnel in several instances (p=.006, .02, .036). Controlling for age and experience, analyses of covariance (ANCOVA) found significant differences in reported assertiveness and frequencies of verbal harassment (p=.018), sexual assault (p=.036), threatening circumstances (p=.026), but insignificance in physical assault frequency (p=.775). Post-hoc power analysis was 100% for this sample (N=190) and internal consistency (Cronbach’s alpha) decreased to .51.
Conclusion:
Results indicate reported assertiveness and frequency of exposure to workplace violence are linked, yet our methods of analyses limits further inferences. We recommend replicating this study with additional, more homogenous participants, and employing additional multivariate analyses to determine mediating and moderating effects of nurse assertiveness on the phenomena of workplace violence.
All workplace violence is concerning, but most alarming here are substantial reports of nurse-to-nurse microaggressions and belittling behavior. Nurses – female nurses in particular - continue to experience all-source violence at unacceptably high rates, and reported sexual harassment via supervisors in this study further indicates lack of progress in eliminating professional oppression and subjugation. Exposure to WPV increased with age and tenure, yet younger participants reported being bullied by coworkers the most, indicating nursing is still eating its young. Healthcare providers (MDs/NPs) were more assertive than nurses, however, average assertiveness in this study was lower than the general population. Considering the innumerable critical, life-saving decisions required of nurses every hour of every day, milquetoast assertiveness in this sample is troubling.
Physical assault appeared to be equal-opportunity violence, experienced by participants in the workplace regardless of reported assertiveness. Considering 97% of physical violence directed toward participants was patient- or family member- perpetuated, we believe opportunities present for prevention though its causes are more multifaceted and nebulous and likely beyond the scope of this study.
Foucault asserted that power must be investigated from the ground upward (Bradbury-Jones et al., 2008). Our results indicate power differentials likely exist at nurse-to-nurse ground levels and are similarly disparate at nurse-to-authority levels, as violence exposures diverged further according to role, gender, and clinical specialties. Society’s #MeToo movement exists in nursing as well, and nursing needs a significant shift in its approach to power and assertiveness, especially considering our results indicate sexual harassment still occurs, is experienced primarily by females, and is primarily perpetrated by authority figures.
We posit here that the global nursing shortage will continue if nursing remains a violent profession, even if covariate causes (lack of faculty, pay inequity, etc.) are ameliorated. Nurses experiencing violence will experience poor health, emotional burnout, and post-traumatic stress if these violent trends continue.