Empowering Voices in Healthcare: The Role of Assertiveness Training in Enhancing Team Communication

Abstract

Background

Effective communication is critical in healthcare for patient safety and teamwork. Assertiveness, often mistaken for aggressiveness, enables professionals to express concerns confidently while maintaining respect. Despite its importance, assertiveness training is not explicitly emphasized in medical and nursing guidelines. This systematic review evaluates the impact of assertiveness communication training, explores barriers to its implementation, and examines different training methods, particularly in the shift toward virtual learning.

Methods

A systematic review was conducted using Ovid MEDLINE, EMBASE, and Cochrane Library (2000-present). Studies were selected based on PICOS criteria: population (hospital-based healthcare professionals), intervention (assertiveness training), comparison (no training), outcomes (communication improvements, barriers identified), and study design (quantitative and qualitative). The Critical Appraisal Skills Programme (CASP) checklist was used for quality assessment. Due to heterogeneity in interventions, a narrative synthesis and thematic analysis were performed.

Results

Eight studies met inclusion criteria (two randomized control trials, one cohort, one case-control, two quasi-experimental, two cross-sectional). Most demonstrated that assertiveness training improves “speaking up” behaviors and confidence. Barriers included hierarchical structures, fear of repercussions, and cultural constraints. Simulation-based and face-to-face training were more effective than brief workshops or online modules. Risk of bias was assessed, revealing variations in study quality.

Conclusion

Assertiveness training enhances communication and patient safety but faces barriers to implementation. Hierarchical structures and lack of standardized evaluation methods hinder broader adoption. Integrating assertiveness training into medical and nursing curricula and fostering open communication environments could improve outcomes. Future research should focus on standardizing training frameworks and assessing long-term impact.

Introduction

Effective communication is essential in health-care settings, as it directly influences patient safety, care quality, and outcomes. Among the various com-munication skills, assertiveness plays a crucial role in enhancing clarity, reducing misunderstandings, and promoting a collaborative work environment. Assertive communication enables healthcare profes-sionals to confidently express their concerns, needs, and opinions in a clear and respectful manner, with-out resorting to aggression or passivity. This ensures that critical information is communicated effectively among healthcare team members, which is particu-larly important in high-pressure healthcare settings. Given its potential to improve teamwork and patient outcomes, assertive communication is increasingly recognized as a key component in healthcare training and practice.

Effective communication in healthcare is crucial for patient safety, yet poor communication remains a significant contributor to medical errors. A critical but often overlooked component of communication is assertiveness—the ability to express concerns con-fidently and respectfully. Assertive communication is essential in hierarchical healthcare environments, where fear of challenging unsafe practices can lead to avoidable errors, ineffective team collaboration, and compromised patient outcomes. Hesitation to speak-up, particularly in high-pressure situations, can exac-erbate these risks, underscoring the need for assertive-ness-focused training programs.

Assertive communication empowers healthcare professionals to express views and concerns clearly, fostering effective collaboration in complex clinical settings. Conversely, communication failures are linked to increased patient safety risks, reduced qual-ity of care, and preventable treatment delays. For ex-ample, nearly half of anesthesia-related injury claims stem from poor team communication.² Additionally, a Marie Curie report highlights that poor communica-tion costs the National Health Service (NHS) over one billion pounds annually and contributes significantly to patient safety issues.³ Routine care assessments also indicate that 22% of patient-reported incidents result from communication breakdowns.⁴

Recognizing its importance, assertiveness train-ing is gaining traction as a strategy to enhance team dynamics and patient safety. Training methods in-clude workshops, role-playing, and online courses,^5,6 aiming to equip healthcare workers with the skills to assert themselves appropriately in critical clinical sce-narios. However, the effectiveness of these programs varies. While some studies report improvements in communication and reduced errors, others highlight limited long-term benefits.^7–9 The diversity in training approaches–regarding format, duration, and target groups–further complicates assessments of their im-pact. Quantitative measures, such as communication effectiveness, and qualitative feedback on partici-pants' confidence levels reveal mixed outcomes.⁹

Notably, in the UK, professional regulatory bodies like the General Medical Council (GMC) and Nursing and Midwifery Council emphasize communi-cation in clinical practice guidelines but omit explicit references to assertiveness.^10,11 Research also indicates that healthcare professionals within the NHS often exhibit avoidant rather than assertive communication patterns.¹²

Although several systematic reviews have eval-uated assertiveness training, gaps remain. Previous reviews primarily focused on quantitative outcomes, lacking comprehensive analyses of qualitative data.^8,9 Moreover, the COVID-19 pandemic has accelerated the shift to virtual training formats,¹³ necessitating updated research to determine the most effective methods for teaching assertiveness in contemporary healthcare settings. This review specifically examines assertiveness training among hospital-based health-care professionals, including doctors, nurses, and healthcare assistants, to assess its impact on commu-nication and teamwork.¹⁴

Methodology

Study Design

This systematic review aimed to evaluate the impact of assertiveness training on the communica-tion skills of healthcare workers in hospital settings. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIS-MA) guidelines to ensure transparency and rigor in the reporting and methodology of the review pro-cess.¹⁵ The primary objective was to examine whether assertiveness communication training enhances com-munication skills among healthcare professionals, specifically doctors, nurses, and healthcare assistants, working in hospitals. Secondary objectives included evaluating the comparative effectiveness of various training delivery methods (virtual vs. face-to-face) and identifying barriers to the effective implementa-tion of assertiveness skills in practice (Fig. 1).

Fig. 1.

Preferred reporting items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart.

Search Strategy and Information Sources

A comprehensive and reproducible search strategy was employed to capture the relevant liter-ature. The literature search was conducted by Ata Mohajer-Bastami (AM-B) across multiple databases, including Ovid MEDLINE, EMBASE, and the Co-chrane Library, from January 2000 to the present. These databases were chosen to ensure a broad spec-trum of published studies in the healthcare and com-munication training fields. The search terms utilized encompassed variations and synonyms for "assertive-ness," "communication,” “training," and "healthcare professionals," ensuring that no relevant studies were overlooked. The following search strategy was used: (assertive NEAR/2 communicat* OR assertive* OR communicat*) AND (train* OR teach* OR educat* OR program* OR session* OR workshop* OR “staff develop*” OR “professional develop*”) AND (doctor OR physician* OR medic OR nurse* OR “healthcare person*" OR "“allied health*” OR “health person*") AND (“patient safety” OR “medical error” OR be-haviour OR behavior OR skill*) AND (hospital OR "healthcare setting” OR “healthcare team").

Inclusion and Exclusion Criteria

The inclusion criteria for this review were as follows: (1) Studies that delivered assertiveness communica-tion training. (2) Studies that involved doctors, nurses, or health-care assistants as participants. (3) Studies that assessed the impact of assertiveness training on communication skills. (4) Articles published in English. (5) Studies published from the year 2000 onward to the present, ensuring the inclusion of research re-flecting the adoption of guidelines like the GMC's Good Medical Practice (1995). (6) International studies were included to capture a global perspective on the issue. Studies were excluded based on the following criteria: (1) Research involving medical or nursing students, as the focus was on practicing healthcare profes-sionals. (2) Duplicate publications of the same study. (3) Studies not addressing assertiveness or communi-cation as key variables. The decision to include studies published from 2000 onward was made based on the assumption that the widespread integration of the GMC's Good Medical Practice and similar frameworks would have influenced the healthcare environment by this time. As healthcare standards and education evolved, research conducted from 2000 onward was more likely to reflect the contemporary state of professional practice and the application of assertiveness training in clinical settings.

Data Extraction and Synthesis

The data extraction process was carried out by AM-B, and the findings were presented using a nar-rative synthesis approach. This method was selected to accommodate both qualitative and quantitative data, facilitating the exploration of various aspects of the studies, including different types of training programs, delivery methods, and reported outcomes. The high heterogeneity of the included studies, such as differences in training formats, participant popula-tions, and assessment measures, necessitated the use of a narrative synthesis. This approach allowed for a comprehensive, flexible, and in-depth exploration of the evidence, particularly in identifying common themes and patterns across diverse studies.

A thematic analysis was also conducted to iden-tify recurring themes and highlight the critical factors influencing the success or limitations of assertiveness training. This analysis provided a deeper understand-ing of the barriers to effective implementation and the facilitators that may enhance the training's impact on healthcare professionals' communication abilities. Key factors such as training delivery method, pro-gram duration, and participant engagement were ex-amined to better understand what constitutes effective assertiveness training in the healthcare context.

Quality Assessment

To ensure the inclusion of only methodologi-cally robust studies, each included study underwent a rigorous quality appraisal using the Critical Apprais-al Skills Programme (CASP) checklist. The CASP checklist is a well-established tool designed to as-sess the validity, reliability, and relevance of various study designs, including randomized controlled trials (RCTs), cohort studies, and qualitative research. The checklist addresses critical aspects such as random-ization, risk of bias, and the clarity of reporting, and allows for an assessment of the study's overall quality and the certainty of the evidence presented. Studies were rated on their methodological rigor, and those with higher quality were given greater weight in the synthesis. Studies that failed to meet a satisfactory standard of quality based on the CASP criteria were excluded from the review.¹⁶

Data Presentation

Data extracted from the studies were synthesized in tabular format, summarizing key variables such as the type of assertiveness training (e.g., workshop, on-line program), the delivery method (virtual vs. face-to-face), the target population (e.g., doctors, nurses), and the reported outcomes on communication skills. A narrative synthesis was used to integrate the results, providing a detailed account of the effectiveness of assertiveness training on communication skills and highlighting key barriers or enablers to successful im-plementation.

Secondary Objectives

In addition to the primary objective, secondary objec-tives were also explored, including: (1) Comparative effectiveness of training delivery methods: This focused on evaluating whether vir-tual training programs are as effective as face-to-face programs in enhancing communication skills, particularly in light of the increasing shift toward virtual learning in the post-COVID healthcare en-vironment. (2) Future recommendations for medical education: This objective aimed to identify insights into the most effective methods of teaching assertiveness to healthcare professionals and provide recom-mendations for incorporating such training into medical and nursing curricula. (3) Barriers to implementing assertiveness training: The review sought to identify challenges health-care professionals face in applying assertiveness skills within their clinical roles, including organi-zational, cultural, and interpersonal factors. By focusing on healthcare workers within hos-pital environments, this review targets settings where communication-related adverse patient outcomes are more prevalent, thus underscoring the importance of improving communication skills in these high-stakes contexts.

Results

Risk of Bias and Evidence Grading

The studies included in this review were rigor-ously appraised using the CASP checklist. This tool assessed various aspects of methodological quality, including randomization, blinding, sample size ade-quacy, and reporting clarity. The overall risk of bias was low to moderate across the included studies, with the most common limitations being small sample sizes and a lack of long-term follow-up data. The cer-tainty of evidence was graded based on study design and methodological rigor, with RCTs receiving the highest confidence levels, followed by quasi-experi-mental studies and qualitative research.

Diversity in Outcomes

The most commonly used training methods were based on simulation-based learning, with four out of eight papers utilising this method, although two of these had simulations embedded amongst other methods including lectures and group discussions. Outcomes were most commonly measured based on questionnaire or survey results before and after the implementation of the intervention, three of the papers utilised an assessor grading performances in clinical simulations and one paper analysed emerged themes based on interview answers from participants. Of the eight included studies:

• Six studies demonstrated a positive impact of as-sertiveness training on communication outcomes.

• Two studies found no significant effect, primarily due to the seniority and prior experience of partici-pants.

• The most successful interventions incorporated practical, scenario-based exercises that allowed participants to practice assertiveness in realistic clinical settings (Table 1).

Table 1.

Studies with quantitative study design

Paper number	Title	Authors / year	Study design	Intervention's specifics	Outcome
Paper 1	Simulation-Based Education to Train Learners to "Speak Up" in the Clinical Environment	Oner et al., 2018	Randomized control trial	The intervention focussed on a one-off, simulation-based intervention that involved the assertiveness/advo-cacy/CUS/two-challenge rule (AACT) education method. The simulation was conducted in person.	Although there was no difference in speaking up scores between intervention and control groups overall, simulation-based AACT training among postpartum nurses was associated with a statistically significant increase in the likelihood of speaking up during a challenging simulated clinical encounter. An individual assessor graded each individual's performance in a clinical scenario simulation to measure for any improvements.
Paper 2	The Impact of a 22-Month Multistep Implementation Program on Speaking-Up Behavior in an Academic Anesthesia Department	Walther et al., 2022	Cohort study	A 22-month multimodal implemen-tation programme was conducted, consisting of an awareness cam-paign, an online course, and simulation-based team training exercises.	A 22-month multimodal programme designed for strengthening speak-up skills was successfully implemented. The perceived levels of assertive communication and speak-up behaviour were higher than benchmark values. Outcomes were measured by having participants answer a 'safety attitudes questionnaire' before and after the intervention and compared the scores relevant to speaking up.
Paper 3	An Educational Intervention to Increase "Speaking-Up" Behaviors in Nurses and Improve Patient Safety	Sayre et al., 2012	Quasi-experimental study	This intervention included a com-bination of in-person clinical sce-narios, encouragement of personal reflection exercises, and small-group peer exercises and discussion.	This study demonstrated that an educational intervention focused on speaking-up behaviours can increase a nurse's perception of their own ability to speak up and improve patient safety. The results of this study also have implications for physicians. Physicians may be an intimidating force of authority for many nurses.
Paper number	Title	Authors / year	Study design	Intervention's specifics	Outcome
Paper 4	Relationship between burnout and communication skill training among Japanese hospital nurses: a pilot study	Shimizu et al., 2003	Case-control study	A basic and advanced training pro-gramme day consisted of group discussions, lectures, and role-playing clinical scenarios.	This study concluded that assertiveness communication training delivered to hospital nurses found an increase in personal accomplishment, however not an improvement in emotional exhaustion or depersonalisation. The participants found that 'accepting valid criticisms' and 'negotiation' were skills that improved. A questionnaire, which was the Japanese version of the Maslach Burnout Inventory, was conducted on participants before and after the intervention and the scores were then compared.
Paper 5	Improving Anesthesiologists' Ability to Speak Up in the Operating Room: A Randomized Controlled Experiment of a Simulation-Based Intervention and a Qualitative Analysis of Hurdles and Enablers	Raemer et al., 2016	Randomized control trial	A 50-minute workshop on speaking up was delivered.	This study concluded that the educational intervention delivered to non-training anesthetic doctors did not improve speak up behaviours. Outcomes were measured by the authors analysing recorded videos of an experimental scenario and graded before and after the intervention.
Paper 6	Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safety	Pian-Smith et al., 2009	Quasi-experimental study	During debriefing after an initial clinical scenario, participants were taught in person about the 'two challenge rule' and communication techniques.	The intervention improved speaking-up culture amongst the trainees. Outcomes were measured by two assessors watching recorded videos of the clinical scenarios and ratings were assigned on a 5-point scale.

CUS: concerned, uncomfortable, safety issue.

Quantitative Studies

A total of six quantitative research papers were identified. The methods of the highlighted papers included quasi-experimental studies (n = 2), cohort studies (n = 1), case-control studies (n = 1) and RCTs (n = 2). One of the six papers was published after 2019, the starting year of the COVID pandemic. Four of the papers considered the method of teaching de-livery and its effectiveness in the results.

Paper 1 was a RCT delivered to labour nurses and postpartum nurses respectively aiming to de-termine whether a simulation-based assertiveness training programme would improve speaking up in the clinical setting. The results demonstrated that al-though there was not an overall significant difference between the groups who did and did not receive the intervention, there appeared to be a statistically signif-icant increase in the likelihood of postpartum nurses speaking up in a challenging clinical encounter, how-ever this was not demonstrated for the labour nurses.¹⁷

Paper 2 was an independent cohort study which considered a teaching programme to improve asser-tiveness communication and 'speak-up' behaviors which was identified as an important aspect in patient safety and reduction of medical errors. The study was limited to its time of implementation of nearly two years. Furthermore, it was a single-centre study with a relatively small response rate which made it less gen-eralisable to healthcare workers who work in different departments with their own organisational cultures.¹⁸

Paper 4 was a case-control study with the pri-mary objective to ascertain improvement in burn-out amongst nurses following the intervention of assertiveness training. Paper 4was included for this review because of the analysis of subjects following the intervention and was found two communication skills in 'negotiation' and 'accepting valid criticism' had improved following the training programme. The long-term changes in communication skills were con-sidered for future research.¹⁹

Paper 5 was another RCT which aimed to assess whether a simulation-based educational intervention would be sufficient to improve speak-up behaviours in clinical settings, however the study concluded that this intervention was ineffective to this particular group.²⁰

Papers 3 and 6 were both quasi-experimental studies that demonstrated heterogenicity in their methodologies. Paper 3 aimed to conclude whether an educational intervention, which comprised of clinical scenarios, reflections and team-based small group support could improve speaking-up behaviours in nurses. The authors found that this tailored education-al intervention delivered to nurses had a significant difference in speaking-up behaviors. Interestingly, the paper demonstrated that healthcare workers who have a greater authority, with the example given of physi-cians, can be a barrier to assertiveness for nurses.²¹

Paper 6 focused on delivering a brief educa-tional intervention as a rubric for challenging others using a conversational technique. The participants were all trainee anesthetists and underwent a recorded clinical simulation before and after the intervention followed by a debrief and each clinical scenario was independently reviewed. The authors concluded that using a brief intervention as well as clinical simula-tion generated better performances in speaking up and improved language patterns used by the participants.²²

Qualitative Studies

A total of two papers were identified which used a form of qualitative assessment or qualitative meth-odology in assessing the usefulness of assertiveness communication training (Table 2). None of the papers were conducted after 2019 in the post-COVID time.

Table 2.

Studies that used a qualitative study design

Paper number	Title	Authors	Year Published	Study Design	Intervention's Specifics	Outcome
Paper 1	Development of assertive communication skills in nursing preceptorship programmes: a qualitative insight from newly qualified nurses.	Mansour & Mattukoyya	2019	Cross-sectional survey with thematic analysis	This paper focussed on what newly-qualified nurses had learnt from their preceptorship programme within their first year of work experience.	The opinions of nurses across different hospitals concluded in what ways nurses felt a preceptorship programme could enhance assertiveness communication skills. Outcomes were measured by analysing answers of participants from a cross-sectional survey using open-ended questions.
Paper 2	Exploring Japanese nurses' perceptions of the relevance and use of assertive communication in healthcare: A qualitative study informed by the Theory of Planned Behaviour	Omura M, Stone TE, Maguire J, Levett-Jones T	2018	Japanese nurses were individually interviewed to better understand their beliefs and consequences of using assertiveness communication and highlighting perceived barriers that impede assertiveness communication in the workplace	No specific intervention was conducted but rather this paper aimed to gather insight of the perception of nurses on the usefulness of relevance of assertiveness communication in healthcare, which would be used to inform a culturally appropriate assertiveness communication training programme.	This study identified the beliefs of nurses in relation to assertiveness communication and patient safety. Data was analysed by conducting a thematic analysis on answers based on face-to-face semi-structured interviews of participants.

Paper 1 aimed to examine and qualitatively as-sess the viewpoints of newly starting nurses on how nursing preceptorship programmes can contribute to shaping and improving their assertiveness communi-cation skills. It acknowledges the important views that learning and improving assertiveness communication stems from a multifaceted combination of different factors, including the perceived support of the work culture and how speaking up is addressed in the pre-ceptorship programme.²³

Paper 2 aimed to assess the perception of nurses of the relevance of assertiveness communication in healthcare environments as well as identifying barri-ers and enablers in doing so. The paper concluded that although majority of the participants identified the use of assertive communication important for safe clinical practice; hierarchical pressure from senior nurses and doctors, as well as certain cultural barriers, limited their use of this skill in everyday practice.²⁴

Thematic Analysis

1. Improving Patient Safety

   • '... emphasized the importance of speaking up and saying no to doing anything that is outside the competency of my practice if I have not had my competency signed.'²³
   • 'The biggest advantage ... is that the patients can be treated safely and securely.’²⁴
   • 'It leads to the smooth assistance of patients in nursing care.²⁴
2. Hierarchy in Healthcare as Perceived Barrier

   • '... speaking up across authority gradients is clearly a difficult skill that requires on-going work to overcome deeply ingrained barriers.²²
   • 'We very rarely hear about positive change from speaking up The fact that [you are] a newly qualified nurse doesn't bode well when "speaking up. 23
   • 'Some people may have [different] idea that nurs-es should follow the instructions of doctors.²³
3. Helpfulness of having an intervention/education on assertiveness

   • 'I've been qualified a year and still have precep-torship study days to be completed due to cancel-lation. This has impacted on the process of speak-ing up and the importance of change to create the best environment for the patient.’²³
   • 'When I have the clinical experience, I can ex-press my opinion.²⁴
   • 'It is okay if I have enough knowledge and expe-rience to speak up.²⁴

A thematic analysis of qualitative studies identified three recurring themes:

1. Improving Patient Safety: Assertiveness training improved confidence in “speaking up,” contribut-ing to safer clinical environments.

2. Hierarchy as a Barrier: The hierarchical nature of healthcare often inhibited assertive communica-tion, particularly among junior staff.

3. Impact of Training: Tailored interventions, such as simulation-based learning, were effective in fos-tering assertive behaviors.

The narrative synthesis highlighted that sim-ulation-based and face-to-face training modalities were the most effective in improving communication outcomes. However, evidence suggested that these interventions were less impactful among senior staff, emphasizing the importance of targeting training at earlier career stages.

Discussion

This review has identified that assertiveness communication training can have a positive impact on the communication skills of healthcare staff. The het-erogeneity of both the interventions delivered and the outcome measures made a narrative synthesis more feasible. Additionally, the inclusion of quality and certainty of evidence provides critical context to these findings.

Quality and Certainty of Evidence

The quality and certainty of the evidence were assessed using the CASP checklist. RCTs offered the highest confidence due to robust methodologies, in-cluding randomization, clear reporting, and detailed descriptions of interventions.²⁵ However, small sample sizes and a lack of long-term follow-up limited their generalizability. Quasi-experimental and cohort stud-ies demonstrated moderate-quality evidence, though they were prone to confounding factors and selection biases.²⁶ What was particularly interesting was that al-though 2 papers showed no improvement to outcome, those two papers were of higher quality study as they were both RCTs.²⁷ Although fewer in number, the studies with a stronger evidence showed no improve-ment. Sample sizes ranged from 19–117, however, no correlation was found between increasing sample size and likelihood of effective intervention, with the two papers showing no difference having sample sizes of 70 and 71 respectively. Perhaps recruiting a larger sample size across different hospitals and across dif-ferent regions will give more reliable and robust out-comes for future research.

Qualitative studies provided valuable insights into perceived barriers and enablers of assertiveness training but were limited by their subjective nature and reliance on self-reported data.²⁸ The certainty of evidence for these studies was lower, but their find-ings were instrumental in highlighting the contextual challenges of assertiveness training implementation.

Impact of Assertiveness Training

Six of the eight studies demonstrated improve-ments in communication outcomes following asser-tiveness training.²⁹ Training formats such as simula-tion-based and face-to-face sessions were found to be the most effective, particularly among junior health-care professionals.³⁰ However, interventions targeting more senior staff, such as senior anesthetists, were less effective, suggesting that newly learned behaviors may be harder to integrate at advanced career stages.³¹

Interestingly, training that incorporated practical exercises, role-playing, and simulation in realistic settings yielded the most favorable outcomes.³² This aligns with findings from other educational literature, emphasizing the importance of experiential learning in fostering behavioral change.²⁵

Of the studies which did not show any impact, the intervention was delivered as a one-off; one be-ing a short 50-minute workshop and the other being a single simulation. The other studies that did find a positive impact utilized either a longer duration of in-tervention delivery or wider interventions embedded including group discussions and workshops.²⁶

Implementation for Healthcare Environments

In healthcare, assertiveness is indispensable to foster clear communication and enhance patient care. Following are areas where it should be implemented:

Healthcare professionals

1. Doctors: Improving communication during mul-tidisciplinary team meetings (MDT) and handling communication between different colleagues and family members effectively.²⁹

2. Nurses: Empowering nurses to raise concerns about patient safety and ensure that they are in-volved in clinical decisions.²⁸

3. Junior staff and trainees: Encouraging to discuss issues on workloads, mistreatment and suboptimal supervision without the fear of consequences.³¹

Multidisciplinary team meetings

Enabling all members within the multidisci-plinary team to discuss their concerns on patient mis-management, minimizing hierarchical barriers.²⁵

Emergency situations

Helping staff communicate clearly and effective-ly in order to enhance patient safety.²⁷

Managing difficult patients and patient relatives

Ensuring healthcare providers are equipped with skills to communicate well with aggressive patients or patient relatives without becoming defensive and whilst maintaining professionalism.³²

Leadership and management

Collaborate with managers, addressing conflicts and assisting in decision making regarding organisa-tional and individuals' needs.²⁵

Addressing bullying and discrimination

Empowering staff to address and report inci-dences of bullying and/or discrimination.²⁸

Handover and documentation

Ensure clear and precise communication during handovers to reduce errors.³¹

Teaching and education

For educators to implement assertiveness com-munication skills within the curriculum, particularly empowering them to ask questions without fear of judgement.³⁰

Current evidence suggests that junior doctors, nurses, and healthcare assistants benefit the most from assertiveness training, as they often face hierarchical barriers that hinder their ability to speak up in clinical settings. Training should also be emphasized for pro-fessionals working in high-risk environments such as intensive care units, operating theatres, and emergen-cy departments, where rapid and clear communication is critical to patient outcomes. Additionally, assertive-ness training may be particularly valuable in areas involving frequent multidisciplinary collaboration, such as oncology, palliative care, and perioperative teams, where effective communication can enhance decision-making and coordination of care. Expanding assertiveness training to include conflict resolution and interprofessional communication strategies can further strengthen team dynamics and patient safety across various clinical settings.

Barriers to Implementation

A recurring theme was the role of hierarchical structures in healthcare as a significant barrier to as-sertiveness. Junior staff often reported difficulty in "speaking up" due to perceived authority gradients and fear of repercussions.²⁹ Cultural factors, such as traditional deference to seniority, further exacerbat-ed this issue.²⁸ These barriers highlight the need for systemic changes to complement individual training initiatives, including fostering a culture of open com-munication and psychological safety.³¹

Studies which conducted surveys on participants particularly highlighted the importance of hierarchy to healthcare staff, with the studies utilizing only nurses as participants all highlighting this particular barrier.²⁵

With these barriers noted, possible suggestions to tackle these may include highlighting the impor-tance of patient safety over fear of staff hierarchy. The nursing preceptorship programme is a good ex-ample of this as newly qualified nurses were able to learn and reflect on real examples they witnessed and how more senior staff had handled such cases, includ-ing speaking up to other staff in the MDT (for exam-ple, senior doctors) when there are concerns of patient safety. This could further be overcome by having those more senior members of staff deliver the educa-tional programmes or simulation-based interventions, in order to emphasize that patient safety come above hierarchy within the hospital. Other cultural factors are extremely important to consider, thus highlighting the importance of gathering insight of staff before implementing any form of training programme, there-fore can be dynamically tailored to suit the relevant staff, as highlighted in the qualitative paper.^26,30

Thematic Analysis

Thematic analysis of qualitative studies identi-fied three key themes:

1. Improving patient safety: Assertiveness training improved participants' ability to speak up, directly contributing to safer clinical environments.²⁹

2. Hierarchy as a barrier: Professional hierarchies and cultural norms often discouraged assertive communication.²⁸

3. Helpfulness of training: Participants reported that structured training sessions were effective in enhanc-ing their confidence and communication skills.²⁵

To effectively address these barriers, assertive-ness training should be integrated with broader orga-nizational strategies that foster a culture of open com-munication and psychological safety. Future studies should assess not only immediate improvements in speaking-up behaviors but also long-term outcomes, such as sustained confidence in assertive communica-tion, reductions in adverse events, and the impact of training on interprofessional collaboration. Addition-ally, research should explore how different training formats such as longitudinal interventions versus single-session workshops—affect skill retention and real-world application in clinical practice.

Limitations of the Review

This review was limited by the heterogeneity of both interventions and outcomes, which precluded the use of meta-analysis. The lack of standardized metrics for measuring assertiveness and communica-tion further complicates the interpretation of results. Additionally, the small sample sizes and single-centre designs of many studies reduced the generalisability of findings.³²

Implications for Future Research and Practice

The findings underscore the importance of early and targeted assertiveness training interventions, partic-ularly for junior staff. Future research should focus on:

1. Standardizing Training Programs: Developing universal frameworks to improve comparability across studies.²⁷

2. Longitudinal Studies: Evaluating the long-term impact of assertiveness training on commu-nica-tion and patient safety.³¹

3. Addressing Systemic Barriers: Investigating strat-egies to mitigate the effects of hierarchical struc-tures on communication.²⁹

Simulation-based and face-to-face interventions should be prioritized, as they consistently demon-strated superior outcomes. Consideration should also be given to integrating assertiveness training into undergraduate and postgraduate medical curricula to instill these skills early in professional development. Training amongst multi-disciplinary teams could pro-vide useful data however with hierarchy an identified barrier as previously mentioned, this may provide limitations to future research.³⁰

Conclusion

This systematic review highlights that asser-tiveness training programs can significantly improve communication skills among healthcare staff, partic-ularly junior professionals. Despite the variability in interventions, nearly all studies demonstrated positive outcomes. Barriers such as hierarchical culture and fear of repercussions remain critical challenges to ad-dress. Embedding assertiveness training into the core curriculum for medical and nursing education and fostering a supportive culture within healthcare orga-nizations could further enhance the impact of these interventions.