Communication Skills

Assertiveness

Ahmad Kadhum Al-J

A Lecture for : 4th stage pharmacy college Students

Reference : Communication Skills in Pharmacy Practice A Practical Guide for Students and Practitioners 5th Ed.
ASSERTIVE pharmacists try to resolve conflicts with others in a direct manner but in
a way that conveys respect for others.

Assertiveness is perhaps best understood by comparing it with two other response

styles: passivity and aggression

 Assertiveness is a style of response that focuses on

resolving conflicts in relationships in an atmosphere of
mutual respect
 directly and honestly convey . This type of communication
allows people to stand up for their own rights or what they
believe in without infringing on the rights of others.

 The focus is on problem solving rather than turning the

conflict into a “win/lose
 PASSIVE BEHAVIOR ASSERTIVE BEHAVIOR AGGRESSIVE Behavior

 Avoid conflict at all cost  Assertive behavior is the direct  Seek to “win”
 Will not say what they really expression of ideas, opinions, and  Promote their own interests
think out of fear that others desires  Indifferent or hostile to the
may not agree  When Conflicts arise they are feelings, thoughts, or needs of
 “hide” from people faced and solutions of mutual others
 They put the needs or wants accord are sought  Constantly perceive
of other people above their  conveys their concern and themselves to be in
own respect for others threatening situations,
 Great deal of anxiety in  lead to growth and increased  Easily angered and have a low
relationships. understanding and respect for tolerance
 They worry others, in spite of differences
 High need for approval.
 Problems arise when people
who behave passively feel
secretly angry
 See themselves as victims .It
is this view that is damaging
to their self-esteem
  many aspects of our culture (media, television, movies, politicians) reinforce the notion
that the way you get your way is to use aggressive behaviors.
 aggressive individuals may “win” certain interpersonal battles in the short term (because
others feel intimidated and allow aggressive persons to get what they want ), but their behavior often
leads to negative long term consequences.

 Thus, to be more effective in the long run, you must learn how to focus your energies
using assertive, not aggressive, behaviors

 In Assertive Behavior Problems arise when conflict leads us to view others as

“opponents,” when power differences are exploited, or when problem-solving
discussions become unfocused with side issues brought in to derail the
conversation.

 A critical factor in being assertive is the ability to act in ways that are consistent with
the standards we have for our own behavior.
the only power we have to effect change in any relationship is to change our own behavior.

For example, you may wish that your boss, who tends to be very negative during annual performance
evaluations of staff, was more supportive of your work. However, just hoping that she would be more
positive in her evaluations will not resolve this issue. You must take active steps to change how you respond
to her criticisms rather than waiting for her to change her approach .
Research has shown that a number of skills are needed for assertive communication.
These include :

initiating and maintaining conversations,

encouraging assertiveness in others,

responding appropriately to criticism,

giving negative feedback acceptably,

expressing appreciation or pleasure,

making requests,

setting limits or refusing requests,

conveying confidence both verbally and nonverbally, and

expressing opinions and feelings appropriately.

Cognitive theories hold that people respond passively or aggressively because they have
irrational beliefs that interfere with assertiveness.
• 1. Fear of rejection or anger from others and
need for approval (everyone should
like me and approve of what I do) these beliefs are excessively perfectionistic,
they are considered irrational.
• 2. Over-concern for the needs and rights of
These beliefs involve:

others (I should always try to help others and be In the passive person they create anxiety
nice to them),
In aggressive person they leading to angry,
aggressive behavior, with frequent “blaming”
• 3. Belief that problems with assertiveness are due of others for normal human failings.
to unalterable personality
characteristics and are, therefore, unchangeable Cognitive restructuring, an assertiveness
(this is just how I am), and technique, teaches people to identify self-
defeating thoughts that produce anxiety or
• 4. Perfectionist standards (I must be perfectly inappropriate anger
competent. If I am not, then I am a failure. Others
must also be perfectly competent and deserve to
be severely criticized if they are not.)
Assertiveness Techniques
PROVIDING INVITING
FEEDBACK FROM
FEEDBACK OTHERS

MAKING
SETTING LIMITS
REQUESTS

BEING IGNORING
PERSISTENT PROVOCATIONS

RESPONDING TO
CRITICISM
 PROVIDING FEEDBACK

• Letting others know how you respond to their behavior can help to
avoid misunderstandings

• providing honest feedback when you have a negative reaction to another

person’s behavior is difficult to accomplish without hurt feelings.

• Many times, you must tell people that you are upset use techniques to make
the communication less threatening.
• Feedback focuses on a person’s behavior rather than personality. individual can
change.
•
• Feedback is descriptive rather than evaluative. less threatening than judging why
you assume it was done.
•
• Feedback focuses on your own reactions rather than the other person’s
intentions. Assigning “blame” or assuming malevolent intent behind the behavior is
not part of constructive feedback.

• Feedback uses “I” statements that take the form “When you [do or say]_____,
I feel ___.” For example, “When you are late for work, I feel frustrated and
angry” is less damaging than “You’re irresponsible. You don’t care about the
patients who are waiting and the co-workers covering for you when you’re
late.”
• Feedback is specific rather than general. It focuses on behavior
that has just occurred and avoids dragging in past behavior. It
also does not over-generalize from the specific instance that has
upset you (e.g., “you always do ___”).

• Feedback focuses on problem solving. The intent is not to let off

steam. The intent is to solve a problem in a relationship so that the
relationship can be improved.

• Feedback is provided in a private setting

 INVITING FEEDBACK FROM OTHERS

 we need to invite feedback from others in order to improve our interpersonal

communication skills.

 Your ability to hear criticism or suggestions without defensiveness or anger, encourage

people to be honest in their communications with you.

 They also allow you to identify areas of your professional practice that may need
improvement
SETTING LIMITS
setting limits on how we will spend our personal time and money is a source of frustration.

We have difficulty saying “no” to any request. As a result, we feel overwhelmed and, often,
angry at others for “taking advantage” of us.

Being assertive in setting limits means

Being assertive in setting limits does not mean that you stop saying “yes” to requests

If you need time to decide, delaying a response is appropriate

Whether you give reasons or not does not change the fact that you have the right to make
the decision on how you will spend personal time and financial resources .
MAKING REQUESTS

in a management position, clearly communicating your expectations of

others is an important part of carrying out the goals of the organization.

In equal relationships, making requests, including asking for help, is an

important part of honest communication.

We must trust that others will be able to respond to our requests in an

assertive manner, including saying “no.” Thus, we must not overreact when
someone turns down our request in an assertive way
 BEING PERSISTENT

One important aspect of being assertive is to be persistent in assuring

that your rights are respected.

Often when you have set limits or said “no,” people will try to coax
you into changing your mind. If you continue to repeat your decision
calmly, you can be assertive without becoming aggressive and without
giving in This response of calmly repeating your decision is often
called the “broken record” response (Smith, 1975).
It will stop even the most manipulative person without assigning
blame or escalating the conflict.
 IGNORING PROVOCATIONS

Interpersonal conflict may elicit various ways of trying to “win” by attempting

to humiliate or intimidate others respond in an aggressive or sarcastic manner.

Interpersonal conflicts between health professionals are often marked by

struggles for power and autonomy (often called “turf battles”).

• Ignoring the critical comments

 RESPONDING TO CRITICISM
criticism is particularly distressing because we typically hold two common irrational
beliefs:
(1) that we must be loved or approved of by virtually everyone we know, and
(2) that we must be completely competent in everything we do and never make
mistakes.

Since such perfectionist standards are impossible to achieve, we are constantly

faced with feelings of failure or unworthiness.

In some cases, we may even have a desire to “get even” by launching into a
counterattack on the person levying the criticism.

.
 Assertiveness and Patients
• some pharmacists seem to hide behind , avoid the potential conflicts
• Encouraging patients to be more assertive is also an important skill in improving
your communication with them.

• Even normally assertive patients may experience enough anxiety in communication

with providers that they forget to ask questions or bring up concerns they have.

• A particularly difficult situation that you will face in pharmacy practice is responding to
an angry or critical patient.

• When you hear criticism from patients, it is important to keep in mind that their
feelings of hostility may be greatly magnified by the life stresses they are experiencing

• keep in mind that some (do not assume all) patient anger arises from frustrations about
being ill, and not from personal grievances against you.
 1 // understand what it is like for them and to respond empathically.

An empathic response when patients react with shock and dismay at the cost of their
medications will probably be more helpful than an attempt to justify the cost.
Saying, “You’re right. These medications are expensive. Are you worried
about whether you can afford them?”

 2 // Another skill that is useful in responding to patient criticism is to get

patients to turn criticism into useful feedback.
For example, if a patient tells you that your pharmacy does not seem to care about
the customer, it is important to find out specifically what is causing the problem.
Asking “What specifically is it that upsets you?” may give you feedback that would
be useful in improving your pharmacy operation
There will be times with angry patients where you will need to stand up
for yourself.

If a patient persists in aggressive behavior in spite of your efforts to

focus on understanding and problem solving, you will want to set limits
without becoming aggressive.

You can calmly tell an angry patient “I want to hear your

point of view, but I do not want to be called names.
When you are ready to talk without yelling and
swearing, I will listen.”
Pharmacist: This is John Landers, the pharmacist at Central Pharmacy. I’d like to speak to Dr.
Stone please.
Nurse: He’s with a patient right now. What is it you wish to speak to him about?
Pharmacist: I am concerned about Mrs. Raymond’s prescription for metformin. I will need to
speak to Dr. Stone about it. Please have him call me as soon as he comes out from the patient
examination.
Nurse: It might be quicker if you tell me what the problem is. I could talk to Dr. Stone and
get back to you
Pharmacist: Thank you, but in this case I would like to talk to Dr. Stone directly.
Nurse: He’s very busy today and we’re running behind schedule.
Pharmacist: I know he has a busy schedule but I must speak with him as soon as possible.
Please ask him to call
If you have determined that you need to speak directly with the prescribing physician,
you will be most effective if you are persistent with receptionists and nurses in your
request.
Messages transmitted through third parties may not be the most effective means

 The pharmacist was assertive. He showed respect for the nurse and yet was
persistent in stating his request. He did not argue about the issue of which
method of communication was quicker. He calmly restated his request without
anger or apology.
Scenario 1
a. Dr. Stone, this is the pharmacist at Main Street Pharmacy. I’m
sorry to bother you—I know you’re busy—but I think there’s a
problem with Mrs. Raymond’s prescription for metformin.

b. Dr. Stone, this is John Landers, the pharmacist at Main Street

Pharmacy. I’m calling about a problem Mrs. Raymond is having
with her prescription for metformin.

In (a), the pharmacist did not introduce himself, which makes him an
anonymous employee of a pharmacy rather than a professional with an
individual identity.
Also, in (a), he subtly “apologizes” for calling, which makes him seem
insecure and unassertive
 Scenario 2
a. Did you know that Mrs. Raymond is still having diarrhea from the
metformin? Do you want to change her prescription?

b. I spoke with Mrs. Raymond today. She reports that she continues to
have diarrhea after three months on the medication. She has stopped
her walking program and is reluctant to leave the house because of the
diarrhea. The effect on her life is so serious that you may want to
consider switching her to a sulfonylurea .

Response (b) is better.

The pharmacist is not putting the

physician on the spot
 Is it necessary to call or ask ?
 Use medical terms
 speak to the physician as a fellow health professional.
 Focus on the goal you share with the physician, which is to
help the patient.
 When changes in therapy are agreed to, it should be clear
how the changes will be implemented (e.g., who will
inform the patient) and
 what the monitoring plan will be to verify that the
patient’s problem has been resolved.
 suggested alternative . When identifying potential
problems, you should be prepared to identify alternatives
to try to resolve the problem
 checked references before making the phone call or
sending the written communication.
• You are faced with many barriers to communicating effectively with physicians.

• Physicians may not accept recommendations and may, in fact, seem ungrateful

• Unfortunately, you are not always going to get a “pat on the back”

• While pharmacists seem to fear that physicians will not respond positively to therapeutic
recommendations, the research evidence suggests just the opposite.

• Research from a number of different pharmacy practice environments indicates that,

when pharmacists make suggestions to physicians for important therapeutic changes in a
patient’s drug treatment, in the vast majority of cases, pharmacist recommendations
are accepted and implemented by physicians .
  pharmacist to persist .
 Research has found that more than 60% of medication errors are caused
by problems in interpersonal communication (JCAHO, 2005).
 More than one-half of health care workers in one survey reported seeing
colleagues cutting corners or making mistakes, yet less than 10% reported
saying anything about what they observed
“culture of safety” should be followed .

The “culture of silence” in the face of medical error that has historically governed
collegial relationships is no longer tolerated in health care organizations.
 Assertiveness and Employees
MANAGER SPEAKING WITH STAFF PHARMACIST

Manager: I overheard your conversation with Mrs. Raymond this afternoon when you became impatient with her
for not understanding instructions. I was upset because I didn’t think you treated her with respect. I want you to
treat patients with courtesy and not get so impatient and judgmental with them.
Pharmacist: Well, she had been complaining about how slow we were and then wouldn’t pay attention when
I was explaining the directions. I just got fed up.
Manager: I know that patients can be irritating, but I want you to treat them with respect.
Pharmacist: Well, we were so busy then that I just didn’t have time to fool around.
Manager: I know it was hectic and you were feeling rushed today, but even then I want you to be more
courteous.
Pharmacist: Well, it would certainly be easier to take time to be nice if you’d get enough pharmacists in here to
cover the workload. Furthermore, if you’d train the techs better, they could be a lot more help to us.
Manager: Those things may be true, but right now I want to resolve the problem in the way you communicate
with patients when you are irritated or hurried. I want you to agree to treat patients with respect, regardless of
how busy we get. Will you do that?
Pharmacist: That’s easier said than done.
Manager: Will you do it?

Manager was both an assertive and empathic

 They must make clear to all employees what is expected in the way of patient care
 Use of the “broken-record” response
He would not let himself be dragged off the point.
 He did not become defensive when the pharmacist attacked his performance as a manager
 observed about a specific behavior . The manager did not label the pharmacist as being rude or
thoughtless.
 Focusing feedback

 He made “I” statements to provide feedback and define expectations, including “I overheard your
conversation
 over-generalized based on what he observed (“You always”) should be avoided
 Too often, employees feel that the only time they get any feedback from their bosses is when they have
done something wrong, which makes it much harder to accept the negative comments

 Many of the same guidelines that are useful in giving negative feedback apply
as well to praise. A personal statement, such as telling a clerk, “I really appreciate your willingness
to stay late tonight to help out” is more meaningful than a general statement (e.g., “You’re a good
clerk”)
 Assertiveness and Colleagues

President: You would be perfect for the job. It is extremely important and I must
have someone who knows the issues and stays on top of things.
Pharmacist: I appreciate that, but I won’t be able to chair the committee this
year.
President: I’ll help with the workload. It shouldn’t take more than an hour or so a
week.
Pharmacist: That may be true, but I’m not willing to chair the committee right
now.
President: Why not? Perhaps there is something we can do to resolve the
problems you seem to think will come up in chairing the committee.
Pharmacist: The decision is really a personal one. I won’t be able to chair the
committee at this time.
 “broken record” response. He calmly repeated his “no

 The danger for passive people in giving an explanation is that

they seem to believe that the president must agree that the decision is
“justified” before they feel they have the right to say “no.”
 Different responses
a. “Well, I’d really like to. I don’t know. I guess I could if it doesn’t take too much
time.” (( Yes , because you found it difficult to say “no.”))

b. “Why don’t you ask Jim? He’d be good. If you can’t find anyone else, maybe I
could do it.” (( if no one else will do it, you will feel that you must do it. ))

c. “I’ve given enough time to this organization. Everyone always comes to me.
Let someone else do some work for a change.”
(( Aggressive. history of passive responses . Blame ))
d. “I’m interested in the committee, but I’m not sure I have time. Let me think
about it tonight and I’ll call you in the morning with my decision.”
(( Response (d) seems most honest and assertive. We typically feel that we must respond
immediately to situations that arise. Often the best response is to delay a response.))
 Assertiveness and Employers

When you are criticized, it is important to distinguish between

(a) the truths people tell you about your behavior, and
(b) the judgments (the “wrong” or “bad” indictments) that they attach to your
behavior.

Often their judgments are arbitrary and are based on values you do not share.
Even when you agree with the judgments made by someone criticizing you and
think you were wrong, you must separate the foolish or careless thing you did
from yourself as a person.
 We often “do as we are told” rather than identifying our goals in communication with
supervisors and being persistent in pursuing those goals

 For some of us, our first response to criticism is to counterattack .such responses mean we
never have to deal with the possibly valid concerns others have about our behavior—we
can always change the subject to their problems.

 for passive individuals, the initial response to criticism is to apologize excessively, give
excuses, and generally act as if it is a catastrophe if someone is upset with us.

 Neither a passive nor aggressive response fosters problem solving.

The following are five responses that are helpful in various types of situations
where criticism is levied.

• GETTING USEFUL FEEDBACK

• AGREEING WITH CRITICISM

• DISAGREEING WITH CRITICISM

• FOGGING

• DELAYING A RESPONSE
 AGREEING WITH CRITICISM DISAGREEING WITH CRITICISM

• if Criticism was valid, the most straightforward • If it is too broad; it is a personal attack rather than
response is to acknowledge the mistake a criticism of specific behavior, or it is based on
value
• avoid “Yes, but . . .” responses that try to judgments .
excuse behavior but lead to increased annoyance • state your disagreement and tell why
usually leads to an escalation of the conflict
It is important to say to him:
If you made a mistake or were wrong, acknowledge that.
When you acknowledge mistakes and apologize for “You’re right, I was late this morning, and for that
them, people have difficulty maintaining their anger. I apologize. But it is not true that I am always late.

However, if you continue to make the same mistakes, the I know I was late one day last month but that is the
apologies will seem insincere and manipulative since you only other time I can recall being late in the two
have not taken steps to prevent the problem When you years I have worked here. And it is not true that I do
have issued a sincere apology, it also helps to report on not care about our patients. I think the way I practice
efforts or changes you will make so the problem is not shows them my concern.”
repeated.
GETTING USEFUL FEEDBACK
DELAYING A RESPONSE
• Uncovering the problem
• first be certain that you Few conflict situations call for an immediate
understand response. If you are too surprised or upset to
the exact nature of the problem. If think clearly about what you want to say, then
a patient says that people in your delay a response.
pharmacy
don’t care about customers, find Tell the person: “I want time to think about
out exactly what happened that what you’ve told me, and then I’d like to sit
was upsetting down with you and try to clear up this problem.
and led to this conclusion. Could we discuss the situation this afternoon at
• In order to know how to improve the end of my shift?
your service, you must have
specific feedback that points out
what changes might be indicated.
 FOGGING
Fogging involves acknowledging the truth or possible truths in what people tell
you about yourself while ignoring completely any judgments they might have
implied by what they said.
Manuel Smith (1975) outlined fogging as a basic assertive response to criticism.
Supervisor: You spent a lot of time Such a response allows you to
talking with that patient about a simple OTC look at truths about your behavior
choice. without accepting the implied
Pharmacist: You’re right. I did. criticisms
Supervisor: The other pharmacists let
clerks do a lot of that sort of stuff.
Pharmacist: You’re probably right. They A fogging response differs from agreeing
may not spend as much time as I do on with the criticism. Agreeing with criticism
OTC consultations includes acknowledging that you were
wrong or behaved irresponsibly; you admit
that your behavior failed to meet your own
goals for yourself
 Thank you
See you next week
Ahmad Kadhum Al-J