Patient Empowerment Using Electronic Telemonitoring With Telephone Support in the Transition to Insulin Therapy in Adults With Type 2 Diabetes: Observational, Pre-Post, Mixed Methods Study.

BACKGROUND: Initiation of insulin therapy for the management of type 2 diabetes can be an unwelcome and distressful development for patients. Current evidence suggests that telemonitoring can help improve glycemic control in type 2 diabetes and can support empowerment to self-manage diabetes. This telemonitoring intervention was underpinned by an empowerment approach. OBJECTIVE: This study aimed to evaluate the clinical effectiveness and feasibility and the patients' and health care providers' experiences of a 12-week telemonitoring intervention with telephone support for patients commencing insulin therapy. This paper focuses on the impact on patient empowerment. METHODS: An observational, pre-post, multimethod, and triangulation design was employed to study a 12-week automated electronic telemonitoring intervention with telephone support from a diabetes clinical nurse specialist (CNS). Forty patients were recruited from the clinic as they were about to commence insulin therapy. In the quantitative arm, biometric data (hemoglobin A1c [HbA1c] and weight) and psychosocial data (diabetes empowerment scale [DES] scores and diabetes distress scale [DDS] scores) were gathered by the research team at baseline (T1), the end of the intervention (T2), and 3 months postintervention (T3). Data on hospital admission and general practitioner (GP) visits were collected for the duration of the study. In the qualitative arm, separate focus group interviews were conducted with the CNS team supporting the intervention (n=2) and patients (n=16). RESULTS: Of 39 patients who completed the intervention, 23 (59%) were male. The mean age of the sample was 62.4 years (range 37-80 years). The mean HbA1c (mmol/mol) decreased significantly between T1 and T2 (mean difference [MD] -17.13; P<.001) and T1 and T3 (MD -18.16; P<.001), with no significant impact on weight. In the focus groups, patients reported an increased awareness to self-manage diabetes and feelings of safety and comfort. There were 13% (5/39) of patients who had hypoglycemia on two or more occasions. A significant increase in the mean DES score occurred between T1 and T2 (MD 0.62; P=.001) and T1 and T3 (MD 0.72; P<.001). The mean DDS score decreased between T1 and T2 (MD -0.64; P=.002) and T1 and T3 (MD -0.6; P=.002). The mean patient satisfaction with the intervention was above 4 out of possible 5 on all items on the Telemedicine Satisfaction and Usefulness Questionnaire. We observed a reduction in diabetes clinic attendances and GP visits. A significant increase in workload was reported by the CNS team. CONCLUSIONS: This intervention had an empowering effect for patients in the self-management of type 2 diabetes and has the potential to meet the need for safer and more effective care in insulin initiation in the community setting. We observed a significant increase in workload for health care staff. Telemonitoring needs to be streamlined with health care delivery and accompanied by adequate support services.

Children and young people's experiences and perceptions of self-management of type 1 diabetes: A qualitative meta-synthesis.

The aim of this review was to conduct a meta-synthesis of the experiences and perceptions of self-management of type 1 diabetes of children and young people living with type 1 diabetes (CYPDs). Six databases were systematically searched for studies with qualitative findings relevant to CYPDs' (aged 8-18 years) experiences of self-management. A thematic synthesis approach was used to combine articles and identify analytical themes. Forty articles met the inclusion criteria. Two analytical themes important to CYPDs' experiences and perceptions of self-management were identified: (1) negotiating independence and (2) feeling in control. The synthesis contributes to knowledge on contextual factors underpinning self-management and what facilitates or impedes transition towards autonomous self-management for CYPDs.

Key word signing: Parents' experiences of an unaided form of augmentative and alternative communication (Lámh).

Parents' experiences of using Lámh, a key word signing approach used in Ireland, were captured through in-depth face-to-face interviews with parents of children with a range of intellectual disabilities. It emerged that Lámh provides child users with one of the rudiments of inclusion, that is, a means of engaging with others. A number of factors can potentially influence the engagement achieved, namely ongoing family commitment to the sustainment of Lámh, available communication partners, accessibility, appropriate Lámh training, speech and language therapy support and the existence of a Lámh signing environment external to the home. The child's family, education and community need to commit to Lámh in order to support a child user become an active member of their community.

Building resilience in the face of adversity: navigation processes used by older lesbian, gay, bisexual and transgender adults living in Ireland.

AIMS AND OBJECTIVES: To explore resilience processes among older lesbian, gay, bisexual and transgender adults. BACKGROUND: Older lesbian, gay, bisexual and transgender identities have frequently been viewed from a deficit, vulnerability and pathological perspective; consequently, the natural resilience processes that underpin the lives of many older lesbian, gay, bisexual and transgender people goes unrecognised, with few studies focusing on the processes they use in building resilience. DESIGN: The design of the study is qualitative and exploratory. METHODS: Data were collected through in-depth, face-to-face interviews. Thirty-six lesbian, gay, bisexual and transgender people participated in the interviews. The mean age of the interview participants was 60·3 years. Thematic analysis was used to analyse the data. RESULTS: Nine processes were identified that enhanced participants resilience, namely: 'Making a decision to accept oneself and not be defined by lesbian, gay, bisexual and transgender identity'; 'Acquiring an empowering perspective'; 'Learning to let go and moving on'; 'Leaving oppressive social environments'; 'Experiencing affirming relationships with family and others'; 'Accessing formal supports'; 'Maintaining connections with lesbian, gay, bisexual, and transgender people'; 'Remaining positive and being thankful for life' and 'Remaining active and keeping busy'. These processes fostered the development of characteristics, such as: courage and strength; a positive sense of self and an optimistic outlook on life. CONCLUSION: This study provides evidence of the considerable strength among this group of people, highlighting how adversity has engendered in participants a set of resilience skills, adding to the emerging body of research into resilience and older lesbian, gay, bisexual and transgender people. RELEVANCE TO CLINICAL PRACTICE: Nurses not only need to be aware of the life histories of older lesbian, gay, bisexual and transgender people but they also need to assess their strengths and offer sensitive services that promote and support resilience among this population.

Older LGBT people's experiences and concerns with healthcare professionals and services in Ireland.

BACKGROUND: The specific healthcare needs and concerns for older lesbian, gay, bisexual and transgender (LGBT) persons have not been explored to any degree within Ireland. AIMS AND OBJECTIVES: The aim of this paper, which is part of a larger study, is to detail older LGBT persons' usage, experiences and concerns with accessing healthcare services, disclosing their LGBT identity to professionals, preferences for care and their suggestions for improvement in services, including nursing services. DESIGN: A mixed methods research design combining quantitative survey and qualitative interview approaches of equal significance was used. METHODS: 144 respondents completed an 84-item questionnaire concerning their use of healthcare services, experiences and needs. The qualitative phase involved in-depth interviews where 36 participants' experiences and concerns around health services were explored more in-depth. Quantitative data were analysed using descriptive statistics. Qualitative analysis employed the constant comparative process to generate the leading themes. RESULTS: Only one in three participants believed that healthcare professionals have sufficient knowledge of LGBT issues, and less than half (43%) felt respected as an LGBT person by healthcare professionals. Although 26% had chosen not to reveal their LGBT status for fear of a negative response, many positive encounters of coming out to healthcare professionals were relayed in the interviews. LGBT persons have specific concerns around residential care, particularly in relation to the perception that the Irish healthcare services emanate a heteronormative culture. CONCLUSIONS: Irish healthcare services need to reflect on how they currently engage with older LGBT persons at both an organisational and practitioner level. Consideration needs to be given to the specific concerns of ageing LGBT persons, particularly in relation to long-term residential care. IMPLICATIONS FOR PRACTICE: Healthcare practitioners need to be knowledgeable of, and sensitive to, LGBT issues.

Job satisfaction among public health nurses: a national survey.

BACKGROUND: Despite increasing interest in nurses' job satisfaction relatively few studies have investigated job satisfaction among public health nurses. AIM: To establish current level of job satisfaction among public health nurses and identify the main contributing variables/factors to job satisfaction among this population. DESIGN: Quantitative descriptive design. A simple random sample of 1000 public health nurses was conducted yielding a response rate of 35.1% (n = 351). Data was collected using the Index of Work Satisfaction Questionnaire. Descriptive and inferential statistics were deployed. RESULTS: Low levels of job satisfaction among public health nurses emerged. Professional status, interaction and autonomy contributed most to job satisfaction while pay and task-related activities contributed least. Age and tenure were the only biographic factors that correlated significantly with job satisfaction. CONCLUSION: Public health nurse managers/leaders need to find creative ways of improving the factors that contribute to job satisfaction and address robustly those factors that result in low job satisfaction. IMPLICATIONS FOR NURSING MANAGEMENT: The critical issue for public health nurse managers is to determine how job satisfaction can be improved. Greater collaboration and consultation between managers and public health nurses can be regarded as a useful way to begin this process, especially if contemporary nursing is to embrace a responsive approach within the profession.

Young children's perspectives of ideal physical design features for hospital-built environments.

Recently, increased recognition has been attributed to the requirement to include the views of child patients in the planning of new health care services so that contemporary buildings can be designed to enhance future experience. This is important, especially since the voices of young children are so often under-represented or represented through adult proxies. The purpose of this article is to share young children's perspectives of what constitutes ideal physical design features for hospital-built environments. Using a participatory art-based approach, data were collected from 55 children (aged five-eight years) across three children's hospitals in Ireland. Emergent findings revealed three broad themes: personal space, physical environment and access. This study is important for nurses, clinicians and environmental designers because it outlines what a supportive child health care environment should constitute. Hospital environments need to be constructed not just to be child friendly, but to also respect children's right to dignity, privacy, family support and self-control.

Meeting the information needs of children in hospital.

The provision of information is an individual entitlement and a prerequisite to enabling children to understand their illness, make choices about their health care and be involved in decision-making processes around these choices. However, limited evidence exists on children's perspectives of information provision while an inpatient in hospital. The aim of this paper is to describe the process of information exchange between health professionals and children in hospital. Informed by an ethnographic design, data were collected using multiple methods, including semi-participant observations, interviews and participatory activities. Forty-nine children aged six to 16 years, with a variety of medical and surgical conditions, admitted to one children's ward at one children's hospital participated in the research. Findings revealed that children encountered a variety of information management experiences. The key message for health professionals is that there is a need to develop child- and family-focussed strategies for assessing children's information needs in order to determine their preferences for information (amount, format, from whom, etc.), to develop a method for gaining an appreciation of parents' and health professionals' beliefs about the optimal amount and type of information to relay to children, and to achieve consensus about who is best placed to transmit this information to children.

Lesbian, gay, bisexual and transgender older people in Ireland: mental health issues.

International policy initiatives have highlighted the need to include older lesbian, gay, bisexual and transgender (LGBT) issues in the provision of appropriate health and social care. However, empirical studies in the area remain sparse. The aim of this study was to investigate the experiences and needs of LGBT people over the age of 55 years living in Ireland and this article reports on specific mental health issues. Mixed methods were used involving 144 surveys and 36 semi-structured in-depth interviews. The findings revealed that a significant number of the survey respondents had experienced a mental health problem at some point in their lives with interview participants providing further details of their concerns. It is recommended that policy makers address the mental health needs of older LGBT people in future strategic directives and develop standards of care that support the principles of equality, inclusion and respect for diversity.

Employing an ethnographic approach: key characteristics.

AIM: Nurses are increasingly embracing ethnography as a useful research methodology. This paper presents an overview of some of the main characteristics we considered and the challenges encountered when using ethnography to explore the nature of communication between children and health professionals in a children's hospital. BACKGROUND: There is no consensual definition or single procedure to follow when using ethnography. This is largely attributable to the re-contextualisation of ethnography over time through diversification in and across many disciplines. Thus, it is imperative to consider some of ethnography's trademark features. DATA SOURCES: To identify core trademark features of ethnography, we collated data following a scoping review of pertinent ethnographic textbooks, journal articles, attendance at ethnographic workshops and discussions with principle ethnographers. REVIEW METHODS: This is a methodological paper. DISCUSSION: Essentially, ethnography is a field-orientated activity that has cultural interpretations at its core, although the levels of those interpretations vary. We identified six trademark features to be considered when embracing an ethnographic approach: naturalism; context; multiple data sources; small case numbers; 'emic' and 'etic' perspectives, and ethical considerations. CONCLUSION: Ethnography has an assortment of meanings, so it is not often used in a wholly orthodox way and does not fall under the auspices of one epistemological belief. Yet, there are core criteria and trademark features that researchers should take into account alongside their particular epistemological beliefs when embracing an ethnographic inquiry. IMPLICATIONS FOR PRACTICE/RESEARCH: We hope this paper promotes a clearer vision of the methodological processes to consider when embarking on ethnography and creates an avenue for others to disseminate their experiences of and challenges encountered when applying ethnography's trademark features in different healthcare contexts.

Engaging with children in research: Theoretical and practical implications of negotiating informed consent/assent.

At the outset of an ethnographic inquiry, we navigated national and international resources to search for theoretical and practical guidance on obtaining parents and children's informed consent/assent. While much theoretical guidance debating ethical issues to children's participation in research was found, a paucity of published papers offering practical guidance on assent processes and/or visual representations of child assent forms and information sheets was discovered. The purpose of this article is to describe our experiences, both theoretically and practically, of negotiating the process of obtaining informed consent and assent with parents and children for a non-therapeutic qualitative research study. We hope this article instigates a platform for others to explicate their experience and contributes to the construction of a coherent body of knowledge which will clearly delineate important elements that must be considered when negotiating children's agreement to participate in research.

Hepatitis C virus in primary care: survey of nurses' attitudes to caring.

AIM: This paper is a report of a study measuring attitudes of primary care nurses towards caring for people with hepatitis C. BACKGROUND: Hepatitis C is a major public health problem. Attitudes to caring for people with hepatitis C vary and can have an impact on nursing care practices. International literature has identified discriminating practices amongst healthcare professionals including nurses. There is limited research examining primary care nurses' attitudes to caring for people with hepatitis C. METHODS: A cross-sectional postal census survey of 981 nurses working in one health board region in the Republic of Ireland was conducted during the period March 2006 to June 2006. RESULTS: A response rate of 57.1% (n=560) was achieved. Exploratory factor analysis of an attitude scale identified three latent variables: 'infection control behaviour', 'caring' and 'fear'. Attitudes were generally positive towards caring for persons with hepatitis C; however, 51.7% of respondents would use additional infection control precautions if caring for someone with known hepatitis C. Younger nurses and those educated to degree level and above held significantly more positive attitudes to caring. Nurses agreed that they have a central role in managing and treating people with hepatitis C; however, many agreed that they lack the knowledge and skills to care for persons with hepatitis C. CONCLUSIONS: Negative attitudes can result in discriminatory experiences for persons with hepatitis C or at risk. Nurses require ongoing education on hepatitis C to improve knowledge, to limit concerns and ensure adherence to infection control guidelines.

Hepatitis C virus infection in primary care: survey of registered nurses' knowledge and access to information.

AIM: This paper is a report of a study conducted to compare knowledge of hepatitis C virus infection amongst three groups of registered nurses working in primary care, to identify their current sources of information and access to educational resources. BACKGROUND: Hepatitis C virus infection is a public health problem; no vaccine exists to prevent the disease. Previous studies identified limitations in nurses' knowledge of hepatitis C virus infection and the impact on care. Limited research has been conducted in primary care. METHODS: A cross-sectional postal census survey of 981 nurses working in one Irish health board region was conducted March-June 2006. Questionnaires measured knowledge of hepatitis C virus infection. Data were collected on demographics, current working practices, information resources and previous education. RESULTS: The response rate was 57·1% (n = 560). A minority (27·3% 145/531) of respondents agreed they were well informed about the virus. Almost 40% reported having contact with clients with the virus; however, information and service provision differed. Factors influencing higher knowledge included: contact with clients with hepatitis C virus infection (P < 0·0001), working in the addiction services (P < 0·0001), educated to degree level and above (P < 0·010) and previously attending education programmes (P < 0·0001). Only 21·5% (119/553) of respondents had attended any form of education on hepatitis C virus infection. CONCLUSION: Gaps in nurses' knowledge exist and can limit information and advice. Educational and information resources need to be developed for registered nurses working in primary care; care for clients with hepatitis C virus infection is not the sole remit of the addiction services.

Communication between children and health professionals in a child hospital setting: a Child Transitional Communication Model.

AIM: This paper is a report of a further analysis of data from an ethnographic study of the nature of communication between children and health professionals in a child hospital setting. BACKGROUND: There is a paucity of research on the nature of communication between health professionals and child patients. Additionally, theory has not been developed to any great extent in the communication literature on children. METHOD: Using an ethnographic approach, fieldwork took place in one specialized children's hospital during 2005. Forty-nine children, aged 6-16 years, with a variety of medical and surgical conditions, participated. Data were collected through semi-participant observations, unstructured interviews, participatory activities and documentary evidence. FINDINGS: Health professionals positioned children as either passive bystanders or active participants in the communication process. These two positions, passive bystander and active participant, signified the extent of children's inclusion or exclusion in the communication process and the degree to which children's communication needs were met or not. A Child Transitional Communication Model presented in this paper draws on multiple theoretical perspectives to explain why health professionals placed children as either a passive bystander or an active participant in the communication process. CONCLUSION: Children prefer to oscillate between a passive bystander and active participant position within the communication process, depending on their needs at any given point in time. This challenges the insistence for stronger child participation in all matters that affect them, in isolation of debates surrounding children's need for support/protection and any potential negative consequences of children's active participation.

'Visible-ness': the nature of communication for children admitted to a specialist children's hospital in the Republic of Ireland.

AIM: This article presents the core concept of 'visible-ness' that emerged from an ethnographic study, which explored the nature of communication, for children (for ease of reading children refers to children and young people), admitted to a children's hospital in the Republic of Ireland. BACKGROUND: The importance of engaging with both child and family has been espoused as fundamental in promoting 'family'-centred care. To date, studies have almost exclusively explored parents' and nurses' perspectives of the nature of parent participation and nurse-parent interactions and relationships. Although there is evidence of an emerging body of knowledge, which explores children's perspectives of their information, and communication needs, little is known empirically about the communication process between children and members of the health care team in inpatient hospital settings. DESIGN: The principles of ethnography underpinned the study design. METHOD: Fieldwork took place over four months in one 35-bedded children's ward. Forty-nine children, ranging in ages from 6 to 16 years with a variety of medical and surgical conditions, participated. Various modes of data collection were employed, namely semi-participant observations, unstructured interviews, draw and write technique and a child-friendly 'stick a star' quiz. RESULTS: The core concept to emerge was that of 'visible-ness'. 'Visible-ness' existed along a continuum consisting of two polar ends, 'being overshadowed' and 'being at the forefront'. These polar ends illuminated the degree to which children were, or wanted to be, included in the communication process and the extent to which children's agenda was addressed. CONCLUSION: This study provides empirical insight into children's experiences of communication in an inpatient hospital setting. A key recommendation calls for the development of communication assessment strategies to determine the 'ideal' position children would like to occupy, at any given point in time, along the 'visible-ness' continuum. RELEVANCE TO PRACTICE: This study emphasises the need for all health professionals to embrace the individualism of each child patient with regard to their specific communication needs.

Impressions of nursing before exposure to the field.

AIMS AND OBJECTIVES: This paper reports on non-mature general nursing students' perceptions of nursing as a career prior to their first clinical placement. BACKGROUND: It is widely recognised that the first clinical practice experience serves a dual role, that of validating students' choice of career and shaping their perceptions of nursing. This study sought to explore 23 first year non-mature (<23 years) nursing students' perceptions of nursing as a career prior to their first clinical exposure. The students accessed the programme via two different modes of recruitment. METHOD: This qualitative descriptive study used focus group interviews as a means of data collection. Interviews were held within 10 weeks of entry into nursing. Data were analysed using the five stages of framework analysis. Ethical approval was obtained. RESULTS: Mode of recruitment did not influence students' perceptions of nursing. The students unanimously identified caring as the essence of nursing. They also acknowledged the role of the media in shaping theirs and society's perception of nursing. Male students expressed concern regarding the negative connotations associated with their career choice. Student participants could not appreciate the totality of the curriculum content at this stage of their course. CONCLUSIONS: Caring remains the essence of nursing. Educators need to take cognisance of first year students' abilities to appreciate the link between theory and practice. This may be enhanced by the employment of teaching strategies that role-model this link for students. Recruiters must be proactive in addressing the challenges facing males in choosing nursing as a career. RELEVANCE TO CLINICAL PRACTICE: An insight into how nursing students perceive nursing prior to their first clinical placement is important for clinicians. This information is valuable in terms of providing registered nurses with an understanding of the students' perspective and the associated supports required by nursing students on first clinical placements.

Choosing nursing as a career: a qualitative study.

It is widely accepted that nursing as a career is viewed favourably by society in that it offers job security, mobility and career variety. The main reason for choosing nursing in the 21st century remains the desire to help and care for others, as this paper demonstrates. The findings presented here are part of an on-going longitudinal study which is exploring whether mode of selection into nursing has an impact on a number of variables, of which, career choice is one. The aim of this paper is to identify why non-mature under-graduate students choose nursing as a career and to determine what factors influence this decision. An exploratory-descriptive design, employing a qualitative approach was used. Following receipt of ethical approval, data were collected using focus group interviews and content analysis was employed. Participants were students on a general nursing programme delivered in a large Irish Higher Education Institute. Interviews took place within the first 3 months of the programme, prior to the first clinical placement. It emerged that although nursing was not everybody's first career choice, all participants had sought a career which involved caring. Family or friends in the profession played a role in influencing participants' career selection.

Clinical education facilitators' and post-registration paediatric student nurses' perceptions of the role of the clinical education facilitator.

In Ireland the past two decades have witnessed the introduction of various clinical 'support' personnel under various titles into clinical areas. However, an identifiable gap remains with a degree of ambiguity over who has prime responsibility for clinical teaching. Now, a new post has emerged, that of clinical education facilitators (CEFs). To date this role has not been empirically explored. The purpose of this study was to explore the CEF role from the perspective of facilitators themselves and post-registration paediatric nursing students, one cohort the CEFs have responsibility for. Using an exploratory descriptive design focus group interviews were employed to collect data from a volunteer sample. The CEF role emerged as diverse, complex and multifaceted with the CEF coordinating factors in the clinical environment to make it function as an effective learning environment for students. Four main strategies were employed: facilitating transition, maximising learning opportunities, preparing the clinical environment and providing support. This study offers preliminary evidence towards clarification of the nature and purpose of the CEF role. The central recommendation is the urgent need to define the role so all stakeholders share a common understanding of the activities of the role holder.

Clinical education facilitators: a literature review.

AIMS AND OBJECTIVES: The aim of this literature review, set within an Irish context, is to present a broad overview of former and existing clinical support personnel, explore the concept of facilitation and examine what is known about the role of the clinical education facilitator. BACKGROUND: The importance of providing a supportive clinical environment to enhance clinical teaching and learning is strongly portrayed in the literature. While the past two decades have borne witness to various clinical support personnel, the literature identifies conflicting demands that these personnel face. No suggestions are advanced as to how to overcome these difficulties, which inevitably influence the quality and quantity of their clinical teaching role. An identifiable gap exists over who has prime responsibility for clinical teaching. It is timely that alternative possibilities for organizing clinical teaching are investigated. A new post emerging in practice settings is that of the clinical education facilitator who is meant to be the key linchpin in clinical areas for reducing the theory-practice gap. METHOD: Relevant literature for this review was sourced using the computerized databases CINAHL, Medline and Synergy. Manual searching of relevant nursing journals and sourcing of secondary references extended the search. Government reports and other relevant documents were obtained through pertinent websites. RESULTS: Papers that explicitly examined the concept of facilitation and explored the posts of clinical education facilitators were included; six research papers were accessed and reviewed. In addition seven non-empirical papers were included. CONCLUSIONS: It is clear that considerable lack of role clarity resides over what constitutes clinical facilitation and the role of the clinical facilitator. Thus, it is paramount to strengthen this support role with Irish empirical evidence. RELEVANCE TO CLINICAL PRACTICE: A major advantage in having a ward-based clinical education facilitator is the benefit of having access to someone who can concentrate solely on clinical education and support with attempts to narrow the theory-practice divide.

Irish nursing students' changing levels of assertiveness during their pre-registration programme.

BACKGROUND: Stress and bullying have been found to be common problems in a number of studies of Irish nursing and midwifery. Victims of bullying need high levels of assertiveness to enable them to withstand the stress of victimization. It was deemed important to measure nursing students' level of assertiveness prior to, and near completion of, their pre-registration education programme. Aim. To ascertain nursing students' perceived levels of assertiveness prior to, and nearing the completion of, their three-year pre-registration programme. METHODS: Ethical approval was given. The students commencing general nurse education programmes in two schools in Southern Ireland agreed to take part (n=72). A questionnaire adapted from a number of assertiveness scales, and tested for validity and reliability in this population, was used to collect data. RESULTS: In general, students' reported assertiveness levels rose as they approached completion of their three-year education programme. DISCUSSION: The resource constrained health service of the 21st century requires nurses who are assertive to meet the needs of its users. Nursing students' assertiveness skills could be augmented through concentrated efforts from nurse educationalists and clinicians to reduce the communication theory practice gap in nurse education today. To address the multi-dimensional nature of assertiveness, strategies to increase assertiveness should operate at the individual, interface and organisational level. CONCLUSIONS: The students in this study reported an increase in levels of assertiveness as they approached completion of their three-year education programme. To function as effective, safe practitioners registered nurses need to be assertive, therefore education in assertiveness should be an integral part of their preparation. The precise composition and mode of delivery of this education requires exploration and evaluation.