|PRACTICAL ADVICE PAPER
|Year : 2013 | Volume
| Issue : 1 | Page : 54-59
Leary's rose to improve negotiation skills among health professionals: Experiences from a Southeast Asian culture
Astrid Pratidina Susilo1, Valerie van den Eertwegh2, Jan van Dalen2, Albert Scherpbier3
1 Academic Staff, Faculty of Pharmacy, University of Surabaya, Indonesia
2 Academic Staff, Skillslab Faculty of Health, Medicine and Life Sciences, Maastricht University, Netherlands
3 Dean, Faculty of Health, Medicine and Life Sciences, Maastricht University, Netherlands
|Date of Web Publication||31-May-2013|
Astrid Pratidina Susilo
Faculty of Pharmacy, University of Surabaya, Jalan Raya Kalirungkut, Surabaya 60293
Source of Support: The programme was funded by The Arthur Vining Davis Foundations., Conflict of Interest: None
Context: Although inter-professional collaboration is important for patient safety, effective collaboration can be difficult to achieve, especially in settings with a strong hierarchical or blame culture. Educational Model: Leary's Rose is a model that gives insight into the hierarchical positions people take during a negotiation process. The assumption behind this tool is that the default reaction we intuitively choose is not always the most effective. Becoming aware of this default reaction makes it possible to choose to behave differently, in a more effective way. We propose to use this model to make health professionals more aware of their attitudes and communication styles when negotiating and provide them with a tool to improve communication by modifying their natural responses. Application: Leary's Rose can be used in simulated and authentic work-based educational settings. To train the communication skills of nurses to be the patients' advocates, for example Leary's Rose was used in role plays in which nurses have to negotiate in the patients' interest with the doctor while they have to maintain partnership relationship and avoid opposition with the doctor.
Keywords: Collaboration, education, hierarchy, inter-professional, Leary′s Rose
|How to cite this article:|
Susilo AP, Eertwegh Vv, Dalen Jv, Scherpbier A. Leary's rose to improve negotiation skills among health professionals: Experiences from a Southeast Asian culture. Educ Health 2013;26:54-9
|How to cite this URL:|
Susilo AP, Eertwegh Vv, Dalen Jv, Scherpbier A. Leary's rose to improve negotiation skills among health professionals: Experiences from a Southeast Asian culture. Educ Health [serial online] 2013 [cited 2020 Aug 8];26:54-9. Available from: http://www.educationforhealth.net/text.asp?2013/26/1/54/112803
| Introduction|| |
In this article we aim to introduce Leary's Rose, a model of inter-personal interaction, , and show how it can be used to improve negotiation skills. Since negotiation plays a central role in any kind of collaboration, it is a key skill for inter-professional collaboration among healthcare team members.
The model is a practical tool for inter-professional education, especially in settings characterised by a strong hierarchical  and blame culture.  Such settings put people in unequal relationship,  and Leary's Rose gives practical suggestions for what to do to enhance communication and negotiation in these unequal relationships.  We see this culture in many countries around the world, and it is prevalent in most of Southeast Asia. 
We start by describing the context in which we found Leary's Rose to be a valuable educational tool. We then introduce Leary's Rose as a practical tool in negotiation skills training for health professionals and discuss how it can be implemented to make health professionals' negotiation skills more effective.
| Context: The challenges of inter-professional collaboration|| |
Inter-professional collaboration is important for patient safety,  stronger health care systems, and better health outcomes. However, disciplines that have to work together effectively face some challenges. , These challenges are more pronounced in social contexts characterised by a hierarchical culture  or a culture of blame. 
In a hierarchical culture, the power distance between people is large.  This means there is a power gap between those considered to be 'lower' and 'higher' in the hierarchy, such as young and old people, junior and senior staff members, patients and doctors, and nurses and physicians.  The more pronounced the hierarchical culture, the greater this phenomenon is.  Power distance can constitute a formidable barrier to effective inter-professional collaboration. ,
Collaboration is also hard to achieve in a blame culture, where errors are frequently hidden to avoid blame.  In such a culture, the fear of being blamed or of being perceived as a whistleblower drives people to favour behaviours that are aimed at protecting themselves and their work. A climate where professionals are primarily concerned with saving their reputation is not conducive to collaboration driven by patient safety concerns. Unfortunately, there are many hospitals in Southeast Asia and throughout the world that have not yet succeeded in creating a safe environment where professionals are willing to view mistakes as valuable opportunities for learning to foster a safer health care system. ,,
| Educational Model: Leary's Rose as a negotiating tool for health professionals|| |
To overcome the challenges we have described, changes are needed at the individual, organisational and cultural level. These changes can be introduced and achieved by policy reforms and through education.  Inter-professional education has an important role to play in this respect, and we therefore advocate its inclusion in health professions curricula. , Inter-professional education enables students and professionals to become aware of, explore, and understand other professionals' points of view, learn to express their opinion in a clear and assertive way and establish a joint agenda with members of different professions working together in the best interests of patients. Inter-personal skills for effective inter-professional work should not be seen as fixed personality traits but as effective communication skills, , that have been shown to be teachable. ,,
We introduce Leary's Rose , as a practical training tool to improve the negotiation skills of health professionals. [Figure 1] shows a simplified model of Leary's Rose, derived from Timothy Leary, a psychiatrist who created this diagnostic personality tool in 1957 [Figure 1].
The 'original' model consisted of a circle divided into different sections representing different types of personalities. Since humans are social creatures, Leary argued, human personality is the result of interacting with others. Moreover, when one interacts with people a particular way, it induces them to respond and interact another way. If one person takes a dominant position, for example the other person will be induced to take a dependent position.  Leary's model was adapted by Van Dijk, who developed a simplified version of Leary's Rose, which is used for inter-personal training in organisations.  Leary's Rose has also been used by teachers in different arenas, including health professions education. ,
In Indonesia, a country in Southeast Asia, we developed a communication skills training programme for nurses to enhance their contribution in the informed consent process. Nurses contribute as patients' advocates in informed consent, ensuring that patients make voluntary informed decisions. In this role, nurses need to raise patients' concerns with doctors and negotiate for the patients' interests.  Leary's Rose was used as a model to train nurses with the needed negotiation skills.  The examples in this article were adopted from the course.
Leary's Rose maps different positions that people can take in a negotiation process in order to give insight into ways to foster collaboration instead of opposition and to maintain equality and mutual respect in relationships among professionals and between professionals and patients. At the centre of Leary's Rose are two axes. The vertical axis represents the hierarchical positions each party can take in an interaction: 'above' means higher in the hierarchy and 'below' means lower in the hierarchy. The horizontal axis represents the way the interaction is perceived by the actors, ranging from interacting 'together' at one end to acting 'against' one another at the other end of the spectrum. ,
The natural tendency of humans predicates that if one person takes the 'above' position, the other person will be inclined to take the 'below' position. Likewise, if the interaction of one person reflects a subordinate position (below), the other person will be likely to respond by stepping into the 'above' position, , a phenomenon that is frequently observed in hierarchical cultures.  For example, when a senior physician assumes a dominant position in a conversation (above), the more junior physician is likely to keep silent and feel less confident (below). 
The positions on the horizontal axis have a different effect. In an interaction, people can choose a position somewhere between the extremes of 'collaboration' and 'opposition.' If one party takes the 'together' position, the other party too will naturally tend to assume a more collaborative attitude. Similarly, if one party interacts in a defensive way, reflecting a perception of the other party as 'the enemy' or 'against,' the other party will intuitively react by becoming defensive or 'against' as well. 
A simple way to promote effective collaboration is to refer to a common goal that is pursued by both parties. This can be done by avoiding words like 'I' and 'you,' and instead using 'we.' In so doing, health professionals can move beyond 'my patient' or 'your patient' to the concept of 'our patient.'
In [Table 1], two scenarios are presented as examples, both set in a similar context but with different approaches to the negotiation [Table 1].
Scenario 1 shows how both the general practitioner and the pharmacist assume the 'against' position. Perceiving herself to be under attack, the general practitioner makes a defensive statement, putting herself in the 'above' position.
Pharmacist: But there is something you don't know about her. She,….
Dr Foster: Excuse me, Mr. Smith. I actually do know everything about her. She's been my patient for more than 10 years.
Scenario 2 shows how the situation can change from adversarial to collaborative. Mr. Smith acknowledges Dr. Foster's view by expressing agreement. In response to this together position, Dr. Foster also moves in this direction, and welcomes collaboration. By choosing not to react defensively to a defensive statement, Mr. Smith has succeeded in breaking out of the 'against' type of interaction, taking Dr. Foster with him to the 'together' side of the axis. Moreover, although Dr. Foster initially assumed an 'above' position, Smith refused to be pushed into a 'below' position.
Pharmacist Smith: Yes, Dr. Foster, I'm well aware that you know your patient very well. That's why I would like to discuss with you what we can do to help her take her medication, that's our common goal isn't it.
We provide another scenario as an example from our course in the Indonesian setting [Table 2].
The nurse and the cardiologist are in the position of 'against' and 'above' when both of them are acting defensively.
Nurse Eka: I think you have not told him everything about the procedure.
Dr. Saputri: Excuse me, Nurse Eka. I have explained everything very clearly.
This situation can be changed into collaboration when one of them starts moving into the 'together' position.
Nurse Eka: Perhaps it will be better if you and I visit him and talk with him together.
Leary's Rose does not support a stereotypical view on personalities, which would assume that people are predestined by their personality to always react in a similar way. Although Leary explained that people have a natural tendency to respond in a certain way when confronted in an interaction, the crucial point he wanted to make is that everyone has a choice to either act in accordance with their natural tendency or to become aware of this tendency and take a different approach which may be more propitious. Leary's Rose helps people become aware of a wider range of possible reactions open to them during interactions and how they can choose from among these reactions to better position themselves on the two axes. When people with a higher position in the hierarchy assume the 'above' position, the other person does not inevitably have to respond from the 'below' position. One can choose to select a more equal position. 
| Application: How to use Leary's Rose as a training tool in inter-professional education|| |
Our experiences in different educational settings in undergraduate, postgraduate and continuing professional development programmes have taught us that Leary's Rose can be very helpful for professionals to become aware of their default communication patterns. This tool can be used in both simulated settings, such as class room or skills laboratory, and in real clinical settings, such as hospital wards.
The ability to recognise one's natural communication pattern and modify it when the communication is not going smoothly depends on skills that can be trained in a safe, simulated environment.  In training sessions in the classroom or skills laboratory, learners can role-play a negotiation process among professionals. The role plays can be video-recorded to help learners review their own performance.  To help learners understand what went wrong in a given encounter, Leary's Rose can be used as a feedback tool to illustrate what was going on and to look for and try out alternative ways of reacting and communicating. The scenarios in [Table 1] and [Table 2] could be used in role playing.
In addition to being helpful in a simulated training environment, Leary's Rose can also be used in real clinical settings to facilitate work-based learning. During encounters with real patients and co-workers, professionals inevitably face challenges, which are easier to deal with if they are able to use advanced communication or negotiation skills. ,,, In discussions of problematic encounters with peers or supervisors, Leary's Rose can serve as a tool to map the position one took in an interaction and to identify alternative responses. As advocated in experiential learning theory, real-life scenarios are rich sources for learning. Learners can reflect on their experiences and formulate specific learning objectives for future real life encounters.  Work-based learning can also facilitate the transfer of skills, for in the workplace learners are confronted with a plethora of encounters presenting numerous opportunities for applying Leary's Rose in different tasks.  More elaboration of the application of Leary's Rose both in simulated and authentic settings is presented in [Table 3].
|Table 3: Examples of the use of Leary's Rose in simulated and real clinical setting|
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For the optimal use of the Leary's Rose, role plays scenarios usually picture situations in which conflicting ideas and hierarchy among professionals exist. When learners are emotionally involved in the scenarios they can fall into a real clash, or stereotype the different professions. We propose two strategies to avoid such a destructive experience: strengthening the roles of teachers and structuring the learning tasks.
Teachers, who should be trainers in communication skills for health professionals, should discuss ground rules of role plays and feedback sessions to ensure safety of the learners. It should be underlined that role plays are learning processes and therefore mistakes are allowed. Time out can be requested by learners and teachers as necessary and teachers can use this time out when a role player does not want to give up a position that can induce conflict. Difficult situations occur in role plays that can be turned into precious learning moments using strong reflection. Feedback should focus on improvement of learners and should be started with self assessment. ,
Learning tasks should be structured by step-by-step increasing complexity and decreasing guidance in learning.  Prior to role plays, learners can start with watching demonstrations of encounters such as through videos, then use Leary's Rose to map the negotiations they watched. This provides safety for the early learning processes. Then, Leary's Rose is used to reflect on their experience used as counterparts in the role play to control complexity of learning. , Role players can adjust the difficulty of the interaction according to learners' needs,  for example by acting as defensive and superior counterpart or collaborative partner. After learners are 'ready,' they can try out negotiations in real encounters,  then Leary's Rose is used to reflect their experience.
Finally, Leary's Rose can be applied within different theoretical frameworks  and combined with other tools in inter-professional collaboration.  For example one can combine Leary's Rose with Situation, Background, Assessment and Recommendation (SBAR), a tool to help structure clinical communication among professionals.  Using SBAR, a nurse can call the doctor to discuss a patient's issue. The nurse states the purpose of her calling (situation) then tells the doctor the current problem of the patient (background). Afterwards, she provides her own opinion about the problem (assessment) and finally requests the doctor's recommendation (recommendation). During encounters, the nurse can emphasise the word 'our patient' rather than 'my patient' or 'yours' as advocated in Leary's Rose to stimulate collaboration and use phrases like 'Perhaps it will be better if we visit him together and have further discussion' in providing a recommendation.
| Conclusion|| |
Leary's Rose can serve as a tool in negotiation skills training for health professionals, especially in hierarchical contexts and in settings with a strong blame culture. As a learning tool, it can help professionals become aware of their default communication patterns in encounters and show them how they can break out of their patterns and take different approaches. We have discussed some ways in which Leary's Rose can contribute to communication skills training in different educational settings. It may be obvious, but we would like to stress that Leary's Rose is not the answer to all problems in training or in real life. Sometimes the stakes are too high or the resistance to change too strong. Like any tool, Leary's Rose presupposes a minimal willingness to learn.
This article is based on our experiences in using Leary's Rose in communication skills courses that was designed in combination with other research-informed educational principles. Other components in the course design also influence transfer of learning. Therefore, the effectiveness of Leary's Rose in different training contexts merits further investigation. Teachers are advised to creatively tailor the adoption of Leary's Rose to their own context and constantly evaluate their teaching strategies.
| Acknowledgement|| |
The authors thank Bert van Dijk for his permission to use the Leary's Rose in this article. The authors are also thankful for Mereke Gorsira and Starlet Susilo for the English editing. Part of this material has been used in the communication skills courses in the first author's doctoral study of Nurses, Informed Consent and Communication Skills Training. The evaluation of the course was presented in AMEE Conference in Lyon, France (2012). This material, including the scenarios, was also used in an European Inter-professional Education Network (EIPEN) workshop in Ghent, Belgium (2011), Health Professionals Education Quality Workshop in Bali, Indonesia (2011) and Communication Skills Training for Pharmacists, University of Surabaya, Surabaya Indonesia (2011).
| References|| |
|1.||Leary T. Interpersonal Diagnosis of Personality, A Functional Theory and Methodology for Personality Evaluation. New York: The Ronald Press Co.; 1957.p.59-68 |
|2.||van Dijk B. Influence others? Start with yourself. On behaviour and Leary's Rose. Zaltbommel: Thema; 2009 p. 8-45 |
|3.||Hofstede G, Hofstede GJ, Minkov M. Cultures and Organizations: Software of the mind: Intercultural cooperation and its importance for survival. 3 rd ed. New York: McGraw Hill; 2010. p. 53-88 |
|4.||Susilo AP, Nurmala I, van Dalen J, Scherpbier A. Patient or physician safety? Physicians' views of informed consent and nurses' roles in an Indonesian setting. J Interprof Care 2012;26:212-8. |
|5.||Wachter RM. Understanding Patient Safety. USA: McGraw-Hills Company; 2008. p. 99-177 |
|6.||WHO. Framework for Action on Interprofessional Education and Collaborative Practice. Geneva: WHO; 2010. p. 23-35 |
|7.||Lingard L, Espin S, Evans C, Hawryluck L. The rules of the game: Interprofessional collaboration on the intensive care unit team. Crit Care 2004;8:R403-8. |
|8.||Leonard M, Graham S, Bonacum D. The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13 Suppl 1:i85-90. |
|9.||Claramita M, Nugraheni MD, van Dalen J, van der Vleuten CP. Doctor-patient communication in Southeast Asia: A different culture? Adv Health Sci Educ Theory Pract 2013;18:15-31. |
|10.||Khatri N, Brown GD, Hicks LL. From a blame culture to a just culture in health care. Health Care Manage Rev 2009;34:312-22. |
|11.||McDonald S, Ahern K. The professional consequences of whistleblowing by nurses. J Prof Nurs 2000;16:313-21. |
|12.||Grol R, Implementation of changes in practice. In Grol R, Wensing M. Improving Patient Care. The implementation of change in clinical practice. 1 st ed. London: Elsevier; 2005. p. 7-14 |
|13.||Barnsteiner JH, Disch JM, Hall L, Mayer D, Moore SM. Promoting interprofessional education. Nurs Outlook 2007;55:144-50. |
|14.||Adler RB, Rodman G. Understanding human communication. 9 th ed. New York: Oxford University Press Inc.; 2006. p.18-28 |
|15.||Aspegren K, Lonberg-Madsen P. Which basic communication skills in medicine are learnt spontaneously and which need to be taught and trained? Med Teach 2005;27:539-43. |
|16.||Berkhof M, van Rijssen HJ, Schellart AJ, Anema JR, van der Beek AJ. Effective training strategies for teaching communication skills to physicians: An overview of systematic reviews. Patient Educ Couns 2011;84:152-62. |
|17.||Tillema HH, Knol WE. Collaborative planning by teacher educators to promote belief change in their students. Teachers Teach Theor Pract 1997;3:29-45. |
|18.||Schaub-de JM, Cohen-Schotanus J, Verkerk M. What students learn from a professional development course? Med Teach 2009;31:1037-8. |
|19.||Susilo AP, van Dalen J, Scherpbier A, Tanto S, Yuhanti P, Ekawati N. Nurses' roles in informed consent in a hierarchical and communal context. Nurs Ethics 2013. [In Press] |
|20.||Susilo AP, van Merriënboer J, van Dalen J, Claramita M, Scherpbier, A. From Lecture to Learning Tasks: Use of the 4C/ID Model in a Communication Skills Course in a Continuing Professional Education Context. J Contin Educ Nurs 2013:1-7. |
|21.||Duvivier RJ, van Dalen J, Rethans J. Communication Skills. In: van Berkel H, Scherpbier A, Hillen H, van der Vleuten C, editors. Lessons from Problem-based Learning. New York: Oxford University Press; 2010. p. 97-106. |
|22.||Kurtz S, Silverman J, Draper J. Teaching and learning communication skills in medicine. 2 nd ed. Oxon: Radcliffe Publishing Ltd.; 2004. p. 83-5. |
|23.||Duvivier RJ, van Dalen J, van der Vleuten CP, Scherpbier AJ. Teacher perceptions of desired qualities, competencies and strategies for clinical skills teachers. Med Teach 2009;31:634-41. |
|24.||Rollnick S, Kinnersley P, Butler C. Context-bound communication skills training: Development of a new method. Med Educ 2002;36:377-83. |
|25.||Aggarwal R, Mytton OT, Derbrew M, Hananel D, Heydenburg M, Issenberg B, et al. Training and simulation for patient safety. Qual Saf Health Care 2010;19 Suppl 2:i34-43. |
|26.||Yardley S, Teunissen PW, Dornan T. Experiential learning: Transforming theory into practice. Med Teach 2012;34:161-4. |
|27.||Merrienboer JJ, Kester L, Paas K. Teaching complex rather than simple tasks: Balancing intrinsic and germane load to enhance transfer of learning. App Cogn Psychol 2006;20:343-52. |
|28.||Joyner B, Young L. Teaching medical students using role play: Twelve tips for successful role plays. Med Teach 2006;28:225-9. |
|29.||Nestel D, Tierney T. Role-play for medical students learning about communication: Guidelines for maximising benefits. BMC Med Educ 2007;7:3. |
|30.||Van Merrienboer JJ, Kirschner PA. Ten steps to complex learning: A systematic approach to four-component instructional design. New Jersey: Lawrence Erlbaum Associate; 2009. p. 41-77. |
|31.||Lane C, Rollnick S. The use of simulated patients and role-play in communication skills training: A review of the literature to August 2005. Patient Educ Couns 2007;67:13-20. |
|32.||Bokken L, Rethans JJ, Scherpbier AJ, van der Vleuten CP. Strengths and weaknesses of simulated and real patients in the teaching of skills to medical students: A review. Simul Healthc 2008;3:161-9. |
|33.||D'Amour D, Ferrada-Videla M, San Martin RL, Beaulieu MD. The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. J Interprof Care 2005;19 Suppl 1:116-31. |
|34.||Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. Qual Saf Health Care 2009;18:137-40. |
|35.||Shannon SE, Long-Sutehall T, Coombs M. Conversations in end-of-life care: Communication tools for critical care practitioners. Nurs Crit Care 2011;16:124-30. |
[Table 1], [Table 2], [Table 3]