Nurse Education Today 67 (2018) 100–107

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Nurse Education Today

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Exploring Japanese nurses' perceptions of the relevance and use of assertive T

communication in healthcare: A qualitative study informed by the Theory of
Planned Behaviour
⁎
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
b
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

A R T I C LE I N FO A B S T R A C T

Keywords: Background: The hierarchical nature of healthcare environments presents a key risk factor for effective inter-
Assertiveness professional communication. Power differentials evident in traditional healthcare cultures can make it difficult
Communication for healthcare professionals to raise concerns and be assertive when they have concerns about patient safety.
Culture This issue is of particular concern in Japan where inherent cultural and social norms discourage assertive
Nurse education
communication.
Patient safety
Aim: The aim of this study was to (a) explore nurses' perceptions of the relevance and use of assertive com-
Qualitative
Speaking up munication in Japanese healthcare environments; and (b) identify the factors that facilitate or impede assertive
Theory of Planned Behaviour 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 sam-
pling 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 as-
sertiveness communication training program for Japanese nurses and nursing students.

1. Introduction
A body of research has identified the relationship between com-
munication and patient safety (Kripalani et al., 2007; Lingard et al.,
2004; Lyndon et al., 2011). For example, in the United States, com-
munication 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
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 men-
tioned 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: mieko.omura@uon.edu.au (M. Omura), teriston@yamaguchi-u.ac.jp (T.E. Stone), jane.maguire@uts.edu.au, @janemaguire9 (J. Maguire),
tracy.levett-jones@uts.edu.au, @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.
M. Omura et al.
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 ad-
vocating for patients these tools are unlikely to have a significant im-
pact on patient outcomes (Maxfield et al., 2011). Researchers have
identified a number of barriers to assertive communication in health-
care 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 em-
powered 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 pro-
grams that reflect the specific needs, concerns, and perspectives of Ja-
panese nurses, and that focus specifically on patient safety.
The aim of this study was to (a) explore registered nurses' percep-
tions 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
For the purpose of this study, assertive communication refers to
healthcare professionals being able to respectfully express their opi-
nions 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 pa-
tient 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 commu-
nication training programs is limited. A recent systematic review fo-
cusing on the outcomes of interventions designed to enhance healthcare
professionals' and students' assertive communication or speaking up
Fig. 1. The Theory of Planned Behaviour modified from Ajzen, 2006.
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Nurse Education Today 67 (2018) 100–107
behaviours identified only eight quantitative studies that met the in-
clusion criteria (Omura et al., 2017). The review concluded that face-to-
face and multi-methods programs in which didactic instruction re-
inforced 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 un-
derstood, and few studies have been undertaken outside Western set-
tings.
While studies suggest that assertiveness is a skill that can be im-
proved 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, never-
theless, 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 profes-
sionals (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 im-
proved 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 as-
sertive 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.
3. Methods
3.1. Study Design
The Theory of Planned Behaviour (TPB) (Ajzen, 1991) underpinned
this study and the COnsolidated criteria for REporting Qualitative re-
search (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 facil-
itators or inhibitors of the behaviour (Francis et al., 2004). A graphical
M. Omura et al. Nurse Education Today 67 (2018) 100–107

representation of the TPB is presented in Fig. 1. Table 2

It was anticipated that by exploring Japanese nurses' beliefs about Demographic characteristics of participants (n = 23).
the positive or negative consequences of speaking up, the approval or Variables Category n %
disapproval of people considered important to them, and beliefs about
their ability to be assertive, we could potentially predict and explain Age 21–25 1 4
26–30 4 17
their intentions and consequently, the likelihood that they would speak
31–35 5 22
up assertively when concerned about patient safety. 36–40 5 22
41–50 2 9
3.2. Ethical Considerations 51–60 6 26
Gender Male 9 39
Female 14 61
Prior to contacting potential participants, ethics approval for the Position Registered nurse 11 48
study was obtained from the university ethics committees in Australia Nurse manager 5 22
and in Japan. Only nurses who provided written informed consent were Post graduate student 6 26
Academic 1 4
recruited for the study. Confidentiality was assured by de-identifying
Years of experience as registered nurse First 1 4
the participants and using numerical codes instead of names. 2–5 3 13
6–10 5 22
11–15 7 30
3.3. Participant Recruitment
16–20 1 4
Over 21 years 6 26
Registered nurses who were practicing or who had practiced in the Speciality Critical care 6 26
last two years were included in the study. An announcement and a Medical surgical 1 4
participant information statement were provided to potential partici- Aged care 1 4
Mental health 10 43
pants by academic staff in two Japanese universities. These staff Community care 4 17
members were not members of the research team. Snowball sampling Public health 1 4
methods were then used, and potential participants were invited to
contact the researchers if they wished to participate in the study.
confirmed the translation. Two researchers (MO, TES) independently
3.4. Data Collection conducted a directed content analysis. The deductive approach used for
the directed content analysis provided initial coding categories in-
Audio-recorded, face-to-face individual interviews of approximately formed by the TPB. By comparing the rank order of frequency of
30-minute duration were conducted from October 2016 to January identified subcategories, descriptive evidence of each category was
2017 at mutually convenient and private locations at the participants' reported (Hsieh and Shannon, 2005). Thus, participants' responses were
workplace or university. Nine questions were asked using an interview labelled in order of frequency for behavioural beliefs about the ad-
schedule developed with reference to the TPB guidelines (Francis et al., vantages, disadvantages, and consequences of assertive communica-
2004) (see Table 1). The interview transcripts were returned to parti- tion, sources of social pressure, and factors that facilitate or impede
cipants for comment and/or correction if they requested it. Three assertive communication in Japanese healthcare environments.
participants requested this and subsequently, eight minor changes to
the transcripts were made. Field notes were also taken during the data 4. Findings
collection process.
4.1. Participants
3.5. Data Analysis
Twenty-three registered nurses were recruited. Although we in-
It is acknowledged that the personal characteristics of researchers itially aimed to recruit 25 participants in accordance with Francis
can influence their interpretation of qualitative data (Tong et al., 2007). et al.'s (2004) recommendations, data saturation was achieved with 23
In this study data collection was undertaken by the primary researcher participants. The demographic characteristics of the participants are
(MO), a female PhD candidate and registered nurse qualified in both presented in Table 2.
Australia and Japan. MO is a native Japanese speaker who also has
sociolinguistic and strategic competence in English (Squires, 2008). She 4.2. Advantages of Assertive Communication
was supported by three experienced research supervisors located in
Australia (TLJ and JM) and Japan (TES). Participants' behavioural beliefs about the advantages of assertive
The primary researcher (MO) transcribed and translated the inter- communication when they had concerns about patient care are listed in
view data for consistency. An independent bilingual consultant Table 3. The most frequently reported advantage was improved patient

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

1. What do you believe are the advantages of speaking up assertively when you have concerns about patients? Behavioural beliefs (advantages)
2. What do you believe are the disadvantages of speaking up assertively when you have concerns about patients? Behavioural beliefs (disadvantages)
3. In your view, what are the consequences of speaking assertively or not speaking assertively when you have concerns about patients? Behavioural beliefs (others)
4. Are there any individuals or groups who would approve of your speaking up assertively when you have concerns about patients? Normative beliefs (approval)
5. Are there any individuals or groups who would disapprove of your speaking up assertively when you have concerns about patients? Normative beliefs (disapproval)
6. How do you think other people would view your decision to speak up assertively when you have concerns about patients? Normative beliefs (other)
7. What factors or circumstances would enable you to speak up assertively when you have concerns about patients? Control beliefs (enablers)
8. What factors or circumstances would make it difficult or impossible for you to speak up assertively when you have concerns about Control beliefs (barriers)
patients?
9. Are there any other issues that come to mind when you think about assertively speaking your concerns about patients? Control beliefs (others)

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Table 3
Behavioural beliefs about the positive consequences of assertive communication.
Advantage Participant quote Frequency Response
n = 23 %

Improved patient safety and care
Sharing of information and
perspectives
Positive relationships
Timely communication
The biggest advantage … is that the patients can be treated safely and securely. (P1) 13 57
It leads to the smooth assistance of patients in nursing care. (P4)
Different perspectives and approaches may emerge. (P2) 12 51
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 9 39
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 6 26
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)

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 im-
proved 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
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 communica-
tion. Participants' quotations supporting these themes are presented in
Table 4.
4.4. Consequences of Not Being Assertive
In addition to the advantages and disadvantages of assertive com-
munication, 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, dis-
content, stress, and worry. In addition, discord between staff and pa-
tient 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
Questions 4 to 6 explored the participants' normative beliefs about
whether other people would approve or disapprove of them being as-
sertive, and potential sources of social pressure in regard to speaking up
when they had concerns about patients. Nearly half of the participants
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 partici-
pants also described being held in esteem by junior staff and being
respected by staff in authority when they spoke up about patient con-
cerns. These details are presented in Table 6.
4.6. Disapproval of Assertive Communication
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 fac-
tors 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 as-
sertive communication. Participant quotes representing these factors
are presented in Table 8.
4.8. Factors That Inhibit Assertive Communication
In regard to situational factors, the majority of the participants felt
that healthcare hierarchies and power differentials associated with se-
niority and professional status were barriers to assertive

Table 4
Behavioural beliefs about negative consequences of assertive communication.
Disadvantage Participant quote Frequency Response
n = 23 %

Negative relationships (or disunity)
No disadvantages
Communication delays
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 11 48
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) 6 26
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. 3 13
(p17)
It is a style of conversation urging other people to answer. The conversation time will definitely be longer. (P21)

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Table 5
Behavioural beliefs about the consequences of not being assertive.
Consequence Participant quote Frequency Response
n = 23 %

Internal
Discontent 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 6 26
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)
Situational
Discord We may have a little argument later or it will be hard to report something the next time. (P18) 4 17
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)
Patient deterioration There may be cases that I wished I had spoken sooner…, or patients deteriorated or got worse by not communicating. (P13) 3 13
I could not easily convey my concern… as a result, things happened like I could not secure patient safety. (P17)

communication. Many also suggested that they could not be assertive having a negative effect on the work culture can make Japanese nurses
when making requests of other healthcare professionals who they per- hesitant to be assertive (Davies and Ikeno, 2002). This is cited as one of
ceived to be busy. A number of participants specified that intimidation the most significant factors that prohibit Japanese nurses from speaking
and bullying prevented them from speaking up, and they also referred up about their concerns (Suzuki et al., 2006).
to factors such as their inexperience and physical or emotional distress While some participants felt that assertive communication could
as barriers. Situational and internal factors that inhibited assertive save time, others felt that it is likely to lead to delays. These apparently
communication are reported in Table 9. 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
5. Discussion
convoluted in manner (Davies and Ikeno, 2002), starting from the
periphery and winding inward in circles, only gradually ‘getting to the
Beliefs about the advantages or disadvantages of speaking up affect
point’ and identifying what is required (Bramble, 2008, p. 231). How-
nurses' attitudes and intentions in regard to assertive behaviours.
ever, assertive communication is intended to be a clear, succinct, direct
Assertive communication is an emerging concept in Japanese health-
exchange, not a vague, winding series of conversations. It is, therefore,
care. It is encouraging that participants in this study recognised the
likely that some of the participants felt that speaking out was impolite
relationship between assertive communication and patient outcomes. It
and inappropriate in a Japanese work setting. Further adding to this
was evident that person-centred care and patient advocacy were core
complexity was the definition of assertive communication used when
values for many of the participants and that, when discussing the ad-
commencing the interviews which was ‘to respectfully express opinions
vantages of assertive communication, they were primarily concerned
and concerns regarding patient care’. Professional communication in
with how it would impact patient outcomes. This accords with previous
Japan is already considered to be respectful and polite and it is possible
studies that identified that perceived risk to patient safety is an im-
that some of the participants felt that there was a contradiction between
portant motivation for speaking up (Okuyama et al., 2014; Schwappach
speaking up and professional, respectful communication.
and Gehring, 2014).
Nursing practice is not immune from the influence of the social
For some of the participants the consequences of not speaking up
pressure (Burns and Thompson, 2005). Close to half of the participants
were intense regret, discontent, frustration, and stress. One participant
felt they were supported by people in their workplace when they did
described how “motivation for the work may decrease when one has to
speak up and identify their concerns about patients. Correspondingly,
continuously put up with a situation where one cannot or does not
about a third of participants stated that there was no one who dis-
express one's opinion”. Previous studies support these findings and have
approved of them speaking up. However, some of the participants
noted that failing to speak up can lead to moral distress, low self-es-
disagreed noting that they felt pressured to conform rather than speak
teem, burnout, and staff resignation (Rainer, 2015; Suzuki et al., 2006).
out, and like many nurses around the world, the participants found it
The impact of assertive communication on communication and
difficult to be assertive with doctors. This is supported by previous
team dynamics was a recurring theme in the data. Although some
research from the United States which identified that nurses felt it much
participants recognised that speaking out may result in mutual under-
harder to confront doctors than nurses or other health professionals
standing, others felt that assertiveness was a potential risk to team
(Maxfield et al., 2005). Undoubtedly, the difference in status between
harmony. Traditionally, Japanese people endeavour to maintain team
nurses and doctors is more pronounced in Japan. For example, one
unity or harmony, known as ‘wa’ (Bramble, 2008). Concerns about

Table 6
Normative beliefs about approval from other people.
Approval Participant quote Frequency Response
n = 23 %

Group
Most staff I guess most of my staff would approve. (P10) 11 48
People who are working in the same workplace would approve. (P22)
Staff with similar opinions The staff who have the same opinion or who understand my opinions, e.g. the need of Echography, have the same feeling. (P19) 4 17
They get a relatively favorable impression about me when they have similar opinions. (P20)
Juniors Junior nurses say, “we are the Sato-san faction” and I am often told, “we think so” after I have spoken up. (P2) 3 13
Young staff regard me positively. (P18)
Individual
The nursing manager or chief of the ward always tell me that I respond well. (P17) 3 13
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 Participant quote Frequency Response
n = 23 %

Group
No disapproval I feel that I have never been hated or shown much disapproval [because of speaking up]. (P16) 7 30
No, I don't think there is [anyone who disapproves of speaking up]. (P22)
Doctors 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. 5 22
(P13)
There are often times when [what I say] is not accepted [by doctors]. (P18)
Staff with different opinion It is difficult to speak up my feeling to people who do not have the same sense. (P17) 4 17
Some people may have [different] idea that nurses should follow the instructions of doctors. (P19)
Senior staff Seniors… people who are older than me (P2) 3 13
I have not had much experience… I think that I may have been viewed as cocky to say such a thing. (P23)
Individual
A senior nurse used to be silent when I expressed my opinion. (P2) 5 22
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 ham-
mered down.” The factors influencing this deep-rooted cultural belief in
healthcare include hierarchy, seniority, and differences in the doctor-
nurse 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 is-
sues are required if the recognised barriers are to be overcome. Al-
though 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 edu-
cational initiatives may be one strategy to address some of these con-
cerns.
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 re-
searchers. 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 as-
sertive 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 com-
munication 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 poten-
tially 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 Participant quotes Frequency Response
n = 23 %

Situational
Supportive environment An atmosphere like “always listening to you” and “tell me any time.” (P11) 15 65
An easy-to-speak up environment is necessary. (P20)
Positive relationships It is easier to communicate more assertively if regular communication and trusting relationships have already been established. (P19) 13 57
I believe that a trusting relationship is a prerequisite for communication. (P21)
Role model It becomes very easy to act positively when there is a role model and being shown an example that went well is valuable. (P1) 3 13
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)
Internal
Experience, knowledge When I have the clinical experience, I can express my opinion. When we understand what the doctors are doing or are able to imagine 5 22
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)
Person-centred It is our duty to speak our opinion when we put patient care first before defending oneself since we are doing our job. (P4) 3 13
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 Participant quotes Frequency Response
n = 23 %

Situational
Hierarchy 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. 20 87
(P3)
I think there is somewhat a culture that it is hard for nurses to speak to doctors. (P18)
Timing Because we cannot listen unless we have time to spare, it would be unpleasant if the timing is bad. (P5) 16 70
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)
Poor relationships They (newcomers) may have relatively less opportunities to talk compared to the old days in terms of communication (P15) 16 70
It is hard to do so (speak up) in a situation where you cannot understand the other person very well. (P19)
Intimidation 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) 14 61
When the attack was concentrated on me, I end up not being able to say anything out of respectful obedience. (P23)
Internal
Lack of knowledge/experience 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, 10 43
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)
Physical/emotional stress It depends on my condition and also my physical condition. (P1) 4 17
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.
Author Contributions
• Conception and study design: Mieko Omura, Teresa E. Stone, Tracy
Levett-Jones, Jane Maguire,
• Analysis and interpretation of data: MO, TES
• Drafting and critical revision: MO, TES, TLJ
Acknowledgement
The first author received an Australian Government Research
Training Program (RTP) Stipend Scholarship.
Appendix A. Supplementary Data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.nedt.2018.05.004.
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