Assertiveness of Community Pharmacists
Learning Objectives
After studying this chapter, the graduate pharmacy student should be able to:
- Differentiate between assertive, passive, and aggressive communication styles
- Apply assertiveness techniques in various pharmacy practice scenarios
- Analyze the theoretical foundations of assertiveness from cognitive and behavioral perspectives
- Develop strategies for assertive communication with patients, healthcare professionals, and colleagues
- Evaluate appropriate responses to criticism and conflict situations
- Create assertiveness plans for professional leadership and patient advocacy roles
Introduction: The Active Role of Assertive Pharmacists
Assertive pharmacists take proactive roles in patient care, initiating communication rather than waiting for questions, conveying therapeutic recommendations to other professionals, and resolving conflicts directly while maintaining respect. This chapter explores how assertiveness transforms pharmacy practice from reactive to proactive.
Self-Assessment Questions
- If asked to give a community speech on medication use, how would you respond?
- When patients are hostile, how do you typically react?
- How many patients and physicians know you by name?
- Do you initiate new prescription counseling or wait for questions?
- Do you proactively assess medication appropriateness during refill visits?
Defining Assertiveness
Assertiveness is the direct expression of ideas, opinions, and desires in an atmosphere of trust. It involves standing up for oneself while respecting others, facing conflicts directly, and seeking mutually agreeable solutions.
Three Communication Styles: Comparison and Contrast
Understanding assertiveness requires differentiating it from two common but problematic communication styles.
| Style | Definition | Motivation | Short-term Effect | Long-term Consequence |
|---|---|---|---|---|
| Passive | Avoiding conflict at all costs; not expressing true thoughts | Fear of disagreement; high need for approval | Avoids immediate conflict | Secret resentment; damaged self-esteem; victim mentality |
| Aggressive | Seeking to win through domination and intimidation | Desire to control; low frustration tolerance | Gets immediate compliance | Damaged relationships; subtle retaliation; poor team dynamics |
| Assertive | Direct expression with respect for others | Problem-solving; relationship preservation | Clear communication | Trust building; conflict resolution; professional growth |
The Power of Personal Responsibility
A critical aspect of assertiveness is acting consistently with personal standards rather than blaming others. As Mark Twain noted, "Nothing so needs reform as other people's habits." Assertive individuals focus on changing their own behavior—the only aspect they truly control—rather than attempting to change others.
Goal Reframing Example
Unassertive Goal: "I want physicians to appreciate pharmacists' role." (Focuses on changing others)
Assertive Reframe: "I will clearly communicate my professional contributions and demonstrate value through my actions." (Focuses on personal behavior)
Theoretical Foundations
Assertiveness training draws from cognitive and behavioral psychological theories explaining why people develop passive or aggressive patterns.
Behavioral Perspective
Passive or aggressive responses are reinforced through consequences: aggression often works short-term through intimidation; passiveness avoids immediate conflict anxiety. These reinforced patterns become habitual unless consciously changed.
Cognitive Perspective
Irrational beliefs interfere with assertiveness:
- Need for Approval: "Everyone should like me and approve of what I do"
- Over-responsibility: "I should always help others and be nice"
- Fixed Mindset: "This is just how I am" (personality as unchangeable)
- Perfectionism: "I must be perfectly competent or I'm a failure"
Cognitive Restructuring Example
Irrational Thought: "If I say no to working on my day off, my boss will get mad and that would be awful."
Restructured Thought: "I have the right to say no to working on my day off. I am not responsible for solving all my manager's staffing problems."
Core Assertiveness Techniques
Specific communication strategies help manage conflict situations effectively.
Essential Assertiveness Skills
- Providing Feedback: Focusing on behavior rather than personality; using descriptive "I" statements
- Inviting Feedback: Creating safe environments for others to offer constructive criticism
- Setting Limits: Taking responsibility for personal resource decisions without resentment
- Making Requests: Clearly asking for what you want while accepting potential refusal
- Being Persistent: Calmly repeating decisions (the "broken record" technique)
- Reframing: Examining others' perspectives and establishing common ground
- Ignoring Provocations: Focusing on problem-solving rather than personal attacks
- Responding to Criticism: Using techniques like fogging and appropriate agreement/disagreement
Effective Feedback Criteria
- Focuses on behavior rather than personality
- Is descriptive rather than evaluative
- Focuses on your reactions rather than others' intentions
- Uses "I" statements ("When you do X, I feel Y")
- Is specific rather than general
- Focuses on problem-solving rather than blame
- Occurs in private settings
Assertiveness with Patients
Patient interactions require specific assertive approaches that balance professionalism with empathy.
Key Assertive Patient Behaviors
- Initiating Communication: Coming out from behind counters; introducing yourself; proactively offering information
- Encouraging Patient Assertiveness: Helping patients prepare questions; providing checklists; actively soliciting concerns
- Managing Anger Effectively: Recognizing anger as often stemming from illness stress rather than personal grievance
- Turning Criticism into Feedback: Asking "What specifically upsets you?" to obtain useful information
- Setting Boundaries: Calmly stating "I want to hear your point of view, but I do not want to be called names"
Angry Patient Response Example
Patient: "These medications are ridiculously expensive! You people don't care about patients at all!"
Non-assertive: "I don't set the prices. You should talk to your insurance."
Assertive-Empathic: "You're right, medications can be expensive. Are you worried about whether you can afford them?" (Shows understanding while assessing real problem)
Assertiveness with Healthcare Professionals
Interprofessional communication requires persistence, preparation, and professional confidence.
Case Study 6.1: Physician Consultation
Pharmacist calling physician's office:
Nurse: "He's with a patient. What is it about?"
Pharmacist: "I am concerned about Mrs. Raymond's metformin. I need to speak with Dr. Stone directly."
Nurse: "I could talk to him and get back to you."
Pharmacist: "Thank you, but in this case I need to speak with him directly." (Calm persistence)
Effective Physician Communication
- Introduce Yourself: "This is John Landers, pharmacist at Main Street Pharmacy" (not "the pharmacist")
- State Purpose Clearly: "I'm calling about a problem Mrs. Raymond is having with her metformin"
- Present Problem Professionally: "She reports continuing diarrhea after three months, affecting her walking program"
- Offer Solutions: "You may want to consider switching to a sulfonylurea or thiazolidenedione"
- Be Prepared: Have references and specific recommendations ready
- Focus on Shared Goals: Emphasize mutual interest in patient wellbeing
Research Evidence: Physician Acceptance
Studies consistently show high physician acceptance rates (often 80-90%) when pharmacists make well-prepared therapeutic recommendations (Berardo et al, 1994; Gums et al, 1999; Klopfer & Einarson, 1990). Despite common fears of rejection, evidence supports assertive professional communication.
Assertiveness in Management Relationships
Supervisory roles require specific assertive approaches with employees, employers, and colleagues.
Case Study 6.2: Manager-Employee Feedback
Manager to pharmacist: "I overheard your conversation with Mrs. Raymond. I was upset because I didn't think you treated her with respect. I want you to treat patients with courtesy." (Specific, behavior-focused, using "I" statements)
Pharmacist: "We were so busy I didn't have time to fool around."
Manager: "I know it was hectic, but I want you to be more courteous even when busy." ("Broken record" technique)
Assertiveness with Employers/Supervisors
- Defining Professional Standards: Asserting necessary practice conditions to meet ethical obligations
- Responding to Criticism: Distinguishing between valid feedback and unfair judgments
- Getting Useful Feedback: Asking for specifics when criticism is vague
- Appropriate Agreement: Acknowledging valid points without excessive apology
- Appropriate Disagreement: Stating disagreement with unfair or inaccurate criticism
- Fogging Technique: Acknowledging possible truths while ignoring implied judgments
- Delayed Response: Taking time to think before responding to surprising criticism
Fogging Example
Supervisor: "You spent a lot of time talking with that patient about a simple OTC choice."
Pharmacist (fogging): "You're right. I did." (Acknowledges behavior without accepting implied criticism)
Supervisor: "Other pharmacists let clerks do that stuff."
Pharmacist (fogging): "You're probably right. They may not spend as much time as I do." (Acknowledges possible truth while maintaining personal standards)
Assertiveness with Colleagues
Peer relationships require balance between cooperation and personal boundary maintenance.
Case Study 6.4: Committee Chair Request
Association President: "You would be perfect for the job. It's extremely important."
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 a week."
Pharmacist: "That may be true, but I'm not willing to chair the committee right now." (Broken record)
President: "Why not? Perhaps we can resolve any problems."
Pharmacist: "The decision is personal. I won't be able to chair at this time." (Maintains boundary without over-explaining)
The Danger of Over-Explanation
Passive individuals often feel obligated to provide "justified" reasons for saying no, believing others must agree with their reasoning. Assertive individuals recognize their right to make personal decisions without requiring others' approval of their reasons.
Safety Culture and Assertiveness
Assertiveness plays a critical role in medication safety and quality improvement.
The "Culture of Silence" Problem
Research finds that over 60% of medication errors involve communication problems (JCAHO, 2005). More than half of healthcare workers report seeing colleagues make mistakes, yet less than 10% speak up (Maxfield et al, 2006). The 10% who do speak up report higher job satisfaction and commitment.
Safety Assertiveness Techniques
- Speaking Up About Concerns: Addressing potential errors before they occur
- Questioning Authority Respectfully: "I want to make sure I understand correctly..."
- Using Assertive Scripts: Prepared phrases for common safety situations
- Creating Psychological Safety: Encouraging others to voice concerns
- Modeling Safety Behaviors: Demonstrating that questioning is expected and valued
Advanced Practice Applications
For graduate pharmacy students, assertiveness has specific advanced applications in evolving practice roles.
Graduate-Level Assertiveness Competencies
- Clinical Leadership: Asserting pharmacist role in interprofessional teams and collaborative practice agreements
- Advocacy Skills: Asserting patient needs within healthcare systems and to policymakers
- Conflict Navigation: Managing disagreements about therapeutic approaches among professionals
- Boundary Establishment: Defining appropriate scope in expanded practice roles
- Change Leadership: Assertively guiding practice transformation and innovation
- Mentorship Assertiveness: Providing direct feedback to students and junior colleagues
- Research Assertiveness: Defending methodological choices and interpreting findings confidently
Critical Thinking Questions for Graduate Discussion
- How might assertiveness techniques need to be modified when communicating across significant power differentials (e.g., student to attending physician, staff pharmacist to medical director)?
- What ethical considerations arise when assertive communication conflicts with organizational hierarchies or cultural norms of deference to authority in healthcare settings?
- How can pharmacists balance assertiveness with cultural humility when working with patients from cultures that value different communication styles?
- In what ways might digital communication (email, messaging) require different assertiveness strategies compared to face-to-face interactions?
- How does assertiveness contribute to medication safety culture beyond individual patient interactions?
