Relation between Head Nurse' Assertiveness and Their Decision Making Abilities at Tanta University

Background: Assertiveness plays an important role in all head nurses' activities and in reaching high abilities of making decision. Aim : The present study aimed to assess the relation between head nurses' assertiveness and their decision making abilities at Tanta University Hospitals. Research design : Descriptive correlational research design was used in this study. Setting: The study was conducted at Tanta University Hospitals (The Main, Emergency and Ophthalmic Hospitals). The study subjects : Consisted of 115 head nurses and a representative sample of 673 staff nurses working at Tanta University Hospitals. Tools : Three tools were used to collect data Tool I : Assertiveness Structured Questionnaire Sheet. Tool II: Head Nurse' Assertiveness as perceived by staff nurses. Tool III: Head Nurses ' Decision Making Abilities Questionnaire. Results : As total, majority (98.3%) of head nurses and more than three quarters (77.6%) of staff nurses reported that head nurses had high level of assertiveness. Regarding head nurses' overall decision making abilities, majority (93.0%) of head nurses had high level of decision making abilities . Conclusion : There was a positive correlation between head nurses' assertiveness, head nurses' assertiveness as perceived by staff nurses and head nurses 'decision making abilities. Recommendations: Head nurses need to support continuously of newly developed assertive behavior to solidify the new pattern of communication

Verbal style of assertiveness is that assertive head nurses always use the word "I" in every statement, have ability to saying" no", showed respect for others, showed their feelings and wants clearly, listen well without interrupting, maintain control on self, communicating with others with good eye contact (5) . Nonverbal style of assertiveness is defined as a variety of communicative behaviors that do not carry linguistic content and are the messages transmitted without using any words. Head nurses can act as a counter measure or an adjunct to verbal messages, they use different modalities, including; physical and environmental objects, touch, form of movement of the body, physical appearance (body type and clothing), space and distance, aspects of the voice and silences speaking Vol. 29. No. 2 (Suppl) ,May 2023 calmly (6) . Active orientation means that assertive head nurses think creatively and critically of the circumstances faced, use reflection, engage in analytical thinking, take greater responsibility for their own actions as organization members, allow staff nurses to discover new ways of working together that they experience as more effective (7) . Work habits require head nurses to use assertive behavior effectively and becoming more assertive in the workplace to effectively establish good teamwork, manage complex situations, deal with the challenges in their workplace, and aid in the development of confidence (8) . Assertiveness relating nursing staff is the head nurses' ability to show staff nurses at first hand, manage work issues, evaluate their needs, solve their problems, communicate effectively, demonstrate how to work and live by values and beliefs, enhance desire to training and learning, motivating them toward achievement, develop and provide them with the necessary tools to continue to improve and achieve quality in the work place (9) . Assertiveness in negotiating the system is that head nurses allow both parties to maintain self-respect, pursue happiness and satisfaction of their needs, and defend their rights and personal spaceall without abusing or dominating them and motivate both parties to work together toward a common goal rather than framing the conflict (10) . Assertiveness, self-confidence, and self-esteem are linked together and being competent and self-confident are the most important personal factors influencing job-related decision-making ability (11) . Head nurses' decision making ability is the ability to make decisions based on professional judgment, and act on these decisions within their own sphere of practice (12) . Decision making is defined as the process of selecting a logical choice from the available options (13) .It is widely agreed that the heart of management is the process of making decisions that include establishing a positive decision making environment, generating potential alternatives, evaluating the alternatives, deciding (choosing the alternative), checking the decisions and implementing the decisions (14) . Establishing a positive decision making environment is head nurses' ability to ascertain that working environment must be safe, healthy and well-equipped to attract them to their decision making ability's mainstream (15) .Generating potential alternatives is the ability to generate greater number of alternatives by increasing number of staff nurses working on problem to reach sound final decision. In evaluating the alternative step, the head nurses weigh the positives and negatives of each option, forecast the outcome of each option, determine which option is the best of that special situation and consider all the alternatives (16) . Deciding (choosing the alternatives) is the next step in the process of decision making in which head nurses have the ability to visualize and anticipate even reserve flexibility, think strategically, willing to work with others for making decisions to achieve common goals (17) . Checking the decisions is the head nurses' ability to consider the results of any decision they made and bear responsibility for the consequences of their decisions (18) . Finally, implementing the decisions is the ability of head nurses to put a plan for the implementation of decision, rely on argument, persuasion and logic to implement decision and then value the chosen solution (19) .
Significance of the Study Under the circumstantial of currently changing environment, both good decision making and appropriate assertiveness are essential for successful leader (20) . So, head nurses require being assertive to Vol. 29. No. 2 (Suppl) ,May 2023 communicate staff needs, ensure that performance issues are addressed constructively and to have the ability to look at problems objectively and make effective decisions. Where, unassertive head nurses are defensive without taking proper decision, tend to internalize tensions and feeling and can't face problems (7) . It is expected that such study examine head nurses' assertive behavior and their ability to make decisions will help to accomplish workplace tasks in a highly stressful situations. Aim of the study The aim of study is to: Assess the relation between head nurses' assertiveness and their decision making abilities at Tanta University Hospitals.
Research Questions: -What are the levels of assertiveness among head nurses at Tanta University Hospitals? -What are the decisions making abilities among head nurses at Tanta University Hospitals? -Is there a relation between head nurses' assertiveness and their decision making abilities?

Subjects and Method Subjects Research design
Descriptive correlational research design was used in this study.

Setting
The study was conducted at Tanta University Hospitals (The Main, Emergency and Ophthalmic Hospitals). Subjects The study subjects consisted of two groups as follows: -All (n= 115) available head nurses who were working in previously mentioned settings. -A representative sample (n = 673) of staff nurses was included from total subjects (N= 2245). The sample size and power analysis was calculated using Epi-Info software statistical package (21) . The criteria used for sample size calculation were as follows:  Study design was descriptive cross sectional.
 95% confidence limit.  Expected correlation between head nurses' assertiveness and their decision making abilities at 75% with a margin of 70%-80%.

Tools of data collection
To achieve the aim of present study, the following tools were used; Tool I: Assertiveness Structured Questionnaire Sheet (appendix I).
This tool developed by researcher and guided by Khalil (2014) (2) and recent related literature (22,23,24) to assess levels of head nurses' assertiveness. It consisted of two parts as follows: Part 1: Head nurses' personal characteristics: age, years of experience, department, marital status and qualification).
Part 2: Head Nurses ' Assertiveness Questionnaire. This part consisted of 55 items classified into 6 dimensions as follows: 1. Verbal and nonverbal styles as frankly express their opinion.
2. Active orientation as love the work they do.
3. Work habits as organize daily work and activities 4. Control of anxiety and fear as organize some routine procedures as not to impede them from their main duties.
5. Relating to nursing staff as evaluate the performance of subordinates. . 6. Negotiating the system as work and cooperate with others without causing any embarrassment to them.
Scoring system: Head nurses' responses were measured on three points Likert Scale ranged from 1-3 where (1) not done (2) sometime done and (3) always done. The total score was statistically calculated based on cut off point by summing of all categories and high scored factor indicated high assertiveness level.
Tool II: Head Nurse' Assertiveness as perceived by staff nurses questionnaire (appendix II).
It consisted of two parts as follow; Part 1: Staff nurses 'personal characteristics: age, years of experience, department, marital status and qualification.
Part 2: Head nurses' assertiveness scale: the same subscales of tool I was used to assess head nurses' assertiveness levels from the view point of staff nurses.

Tool III: Head Nurses ' Decision Making Abilities Questionnaire (appendix III).
This tool was developed by researcher guided by Marquis & Huston (2014) (25) and other recent related literature (26,27,28) to assess head nurses' decision making abilities. This tool included six subscales as follow; 1. Establishing positive decision making environment as define real problem before starting the decision making process.
2. Generating potential alternatives as tend to brainstorming to find multiple solutions to problems 3. Evaluating the alternatives as get help of the views of relevant expertise when it is difficult to make their own decision.
4. Choosing the alternative as have a good ability to focus precisely.
5. Checking the decision as do not leave the work they started until it is finished 6. Implementing the decision as put a plan for the implementation of the decision‫.ز‬ Scoring system: Head nurses' responses were measured on a five points Likert Scale ranged from 1-5 where (1) never to (5) always. The total score was statistically calculated based on cut off point by summing of all categories into levels of head nurses' decision making ability: -High Level of decision making ability ≥ 75%.
-Low level of decision making ability <60%.
Method 1. Official permission to conduct the study was obtained from Faculty of Nursing administrators of Tanta University Hospital and was submitted to the responsible authorities of the selected settings.
2. Ethical consideration: -Approval of the ethical committee at faculty of nursing was obtained. -The researcher introduced herself to the participants, a full explanation of the aim and method of the study was done to obtain their acceptance and cooperation as well as their informed consent. -The right to terminate participation at any time was accepted. -Assuring the nursing staff about the privacy and confidentiality of the collected data and explain that it was used for the study purpose only.
3. The study tools were developed and designed by researcher based on review of the related literature 4. The tools were translated into Arabic and reviewed with the supervisors and submitted to five experts in the area of specialty to check their content validity and clarity of questionnaire. The experts were; three assistant professor of Nursing Service Administration, two assistant professor of Psychiatric Mental Health Nursing from Faculty of Nursing, Tanta University.

The
experts' responses were represented in four points rating scale ranging from (4-1); 4=strongly relevant, 3=relevant, 2= little relevant, and 1=not relevant. Necessary modification were done including; clarification, omission of certain items and adding others and simplifying work related words.
-The face validity value of tool(I) part2: Head nurses' assertiveness questionnaire =98.5%.Tool (2) part 2: head nurses' assertiveness as perceived by staff nurses =98.5%.Tool 3 part (2): head nurses' decision making questionnaire = 99.7% (appendix IIII) 6. A pilot study was carried out on a sample (10%) of the subject (n=67), and they excluded from the main study sample during actual collection of data. A pilot study was carried out after the expert's opinions and before the actual data collection. The pilot study was done to test the clarity; sequence of items, applicability, and relevance of question and to determine the needed time to complete the questionnaire. According to feedback from pilot study, the tools were modified by the researcher. The estimated time needed to complete the questionnaire item from staff nurses was 15-20 minutes. 7. Reliability of tools was tested using Cronbach Alpha Coefficient (appendix IIII) . -Reliability of tool(I) part2: Head nurses' assertiveness questionnaire=(0.909), tool(II) part 2: head nurses' assertiveness as perceived by staff nurses =(0.853)and reliability of tool(III) part (2): head nurses' decision making questionnaire =(0.954) 8. Tool I was used to collect data from the head nurses about their assertiveness, tool II was used to collect data from the staff nurses viewpoints about their head nurses' assertiveness and tool III was used to collect data about the head nurses' decision making ability.
9. Data collection phase: the data was collected from head nurses and staff nurses by the researcher. The researcher distributed the questionnaire on their work setting individually and they completed the questionnaire in the presence of the researcher to ascertain that all questions were answered. The data was collected over period of two months started from March 2020 until June 2020.

Statistical analysis
Data were fed to the computer and analyzed using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp) Qualitative data were described using number and percent. The Kolmogorov-Smirnov test was used to verify the normality of distribution Quantitative data were described using range (minimum and maximum), mean, standard deviation and median. Significance of the obtained results was judged at the 5% level. The used tests were 1 -Chi-square test For categorical variables, to compare between different groups.

-Monte Carlo correction
Correction for chi-square when more than 20% of the cells have expected count less than 5.

-Mann Whitney test
For abnormally distributed quantitative variables, to compare between two studied groups.

-Pearson coefficient
To correlate between two normally distributed quantitative variables. Results Table (1): Shows distribution of head nurses' personal characteristics including age, years of experience, marital status, qualification, and hospitals. The age of head nurses were ranged between 29 -55 years old with mean age 42.10 ± 5.84. Head nurses' years of experience ranged between 7.0 -32.0 years with mean years 19.24 ± Vol. 29. No. 2 (Suppl) ,May 2023 5.79.High percent (73.9%) of head nurses had from15 -30years of experience, less than one quarter (22.6%) of head nurses had from5 -15 years of experience. Around two fifth (40%) of head nurses were working in emergency hospital, while the lowest percent (6.1%,5.2%,3.5%,2.6%,1.7%)were working in neuropsychiatric, cardiac CU ,neonatal ICU, oncology ,gynecology and obstetrics and endemic hospitals respectively. Majority (92.2% and86.1%) of head nurses were married as well as had bachelor degree in nursing, respectively. Table (2): Shows distribution of staff nurses' personal characteristics including age, years of experiences, marital status, qualification, and departments of hospitals. The age of staff nurses were ranged between 20.0 -57.0 with mean age 13.73 ± 11.24. Staff nurses' years of experience were ranged between 0.0 -38.0 with mean years 13.73 ± 11.24. More than one third 35.5% of staff nurses were from emergency hospitals while the lowest percent (8%, 7.7%, 6.1%, 4.2%, 3.1%, 3.0%, and 2.2%) were from neuropsychiatric, gynecology and obstetrics, internal medicine, neonatal ICU, oncology, cardiac CU and endemic hospitals). High percent 74.6% of staff nurses were married. Around half of staff nurses (44. 6%) had diploma degree and nearly one third of them (31. 5%) had technical health institute. Majority87. 8% of staff nurses hadn't attended training session. Figure (1): Illustrates that the majority (98.3%) of head nurses reported high level of assertiveness while none of them reported low level of assertiveness.

Figure (2):
Reveals that more than three quarters (77.6%) of staff nurses reported that their head nurses had high level of assertiveness, while minority (6.8%) of them reported that their head nurses had low level of assertiveness. Figure (3): Shows that the majority (93%) of head nurses had high level of decision making abilities, while minority (7%) of them had moderate level of decision making abilities.

Discussion
Assertiveness is one of the most important skills head nurses can learn today. It can be used in almost any situation at work as well as in their home and social life. Assertiveness changes the way head nurses communicate, changes the way they deal with conflict and changes their own relationships with themselves. It is the gateway to confidence, respect and making effective decisions (29) . So, this study aimed to study the relation between head nurses' assertiveness and their decision making abilities at Tanta University Hospitals. This study's discussion categorized under five parts; head nurses' assertiveness, head nurses' decision making abilities, correlation between head nurses' overall Head nurses 'overall assertiveness. The present study results revealed that the majority of head nurses and staff nurses reported that head nurses had high level of assertiveness .This study result may be due to those head nurses aware of verbal and non verbal communication, control their emotions and behavior, communicate the needs without threatening, frightening and pay attention to the feelings and needs of other nursing staff. This finding is supported by, Qtait (2023) (30) showed that the majority of the nurse managers working at Ain-Shams university hospitals were assertive. Also, Immanuel & Muo (2022) (31) reported that the highest percentage of head nurses was assertive. Moreover, in congruence with this, Beattie et al., (2019) (32) reported that the greater number of studied subjects at general hospital in United Status had assertive behavior Similarly, Mostafa et al., (2019) (33) (39) result who showed that the total level of decision making among the study head nurses was somewhat lower than half of head nurses had a low level of decision making and near to quarter had a high level. Also, kartoshkina, (2016) (40) reported that the highest percent of study participants had moderate level of decision making ability.

Correlations between study variables
The present study results revealed that there was a statistically significant positive correlation between head nurses overall assertiveness and their decision making abilities. This finding may be related to assertiveness enhancing head nurses' leadership skills, job satisfaction and achieving real independence, professional accomplishment, power and determination, and increased efficiency during the changes in condition and finally making decision more appropriately. This result is congruent with the study done by Sibiya (2018) (41) who explained that the head nurse can use verbal methods as questioning, facilitation, empathic statements, clarification, and summarizing in an appropriate instructive communication for effective decisions. Also, Brewer (2018) (42) concluded that nurses' communication skills in reporting clinical events were associated with their effective decision making and facilitated the determination of needed interventions and the management of a patient's condition.

Conclusion
Majority of head nurses at Tanta university hospitals reported high level of assertiveness. Also, more than three quarters of staff nurses reported that their head nurses had high level of assertiveness. Majority of head nurses reported high level of verbal and non verbal while, majority of staff nurses reported that their head nurses had high level of negotiation system. Regarding to head nurses' decision making abilities, majority of head nurses had high level of decision making abilities. There is a statistically positive correlation between communication as a proactive measure to address conflict issues and moving toward resolution. head nurses' assertiveness and their decision making abilities.