Assertiveness Skills

Assertiveness is a way of thinking and behaving that allows a person to stand up for his or her rights while respecting the rights of others. Nonassertive people may be passive or aggressive. Passive individuals are not committed to their own rights and are more likely to allow others to infringe on their rights than to stand up and speak out. On the other hand, aggressive persons are very likely to defend their own rights and work to achieve their own goals but are also likely to disregard the rights of others. Additionally, aggressive individuals insist that their feelings and needs take precedence over other people’s. They also tend to blame others for problems instead of offering solutions.

Assertive attitudes and behaviors are at the heart of effective advocacy. A person with an assertive attitude recognizes that each individual has rights. These rights include not only legal rights but also rights to individuality, to have and express personal preferences, feelings and opinions. The assertive individual not only believes in his or her rights but is committed to preserving those rights. An assertive attitude is important in recognizing that rights are being violated. The passive person is so concerned with being liked and accepted that he or she may never recognize the need to advocate. The assertive person clearly expresses his or her rights or needs. They tend to face problems promptly and they focus on solutions rather than problems.  The following will enhance your assertiveness skills.

Assertive listening is one of the most important advocacy skills we will discuss. The goals of assertive listening are: (1) to let the other know that you want to understand his or her point of view; (2) to understand accurately what another is saying; and (3) to let the other know that he or she has been understood. Remember that understanding is different from agreement. You can understand what another is saying but still disagree with him or her.

You can let others know you are interested in hearing and understanding their points of view in several ways. You can tell them you are interested. Here are some examples of how you could phrase such a statement:

I’d like to hear your views on….
I’d like to understand your views on….
Could you tell me about them?
I’m confused about your stand on….
Would you tell me more about how you see the situation?
I think we are approaching this from two different perspectives.
What does the situation look like from your perspective? 
I ‘d like to hear your thoughts on

Looking directly at the other shows you are giving him, or her your attention. Leaning forward slightly communicates interest, while a relaxed, open posture communicates receptiveness to what the other party is saying.

Listening for accuracy takes concentration and requires you to give your full attention to what the other is saying. It is easier to listen for accuracy when you feel relaxed. If you are tense and your own thoughts are racing, excuse yourself for a minute and go to another room. Take a few deep breaths to relax and clear your mind before returning. Ask questions as they come up, especially if the answers are important to understanding additional points the other party is discussing. Saying “um hum” and nodding your head slightly will encourage the other to continue talking. Most people will discontinue talking without these mild encouragements.

Assertive Listening. You can test whether or not you have understood the other party by summarizing your understanding of what was said and asking for verification. This not only lets you know whether you have understood the other correctly, it also lets the other person know they have been understood. Some problem solving or negotiation sessions get stuck because people do not realize that they understand one another. Many times the issue is not confusion, but disagreement about what to do about the problem. Working out solutions is different from establishing an understanding and some issues remain unresolved because parties never get past the stage of establishing that all viewpoints are understood. Below are some examples of language you can use to test for understanding.

If I understand you correctly….
Is that what you meant?
I heard you say _____________, did I understand you correctly?
I heard you say ______________, did I understand you correctly?
Your view is _______________________, is that right?

Brain injury can interfere with the ability to process information. Consequently, it can impair the ability understand and make sense of complex information. This condition can be especially troublesome when such information is presented in a stressful context. It may become necessary to have statements or questions repeated or rephrased. Note taking on such occasions can be used to reinforce your understanding. Finally, you can test your understanding of the other party’s intentions by following the steps outlined above.

Nonverbal Assertiveness Even when we are silent we communicate a lot — through our eyes, facial expression, posture, gestures and personal appearance. Through these nonverbal behaviors we communicate who we are and how we feel. Others draw conclusions about our sincerity, credibility and emotional state based on our nonverbal behavior. Poor eye contact, slouching, nervous gestures and other nonassertive behaviors can convince others that what we have to say can be safely ignored. Awareness of our nonverbal behaviors is an important advocacy tool.

Elements of Nonverbal Behavior Nonverbal behaviors are harder to control than verbal behaviors, but with awareness and practice you can become effective in communicating non verbally as well as verbally. 

1. Eye contact. Eye contact means looking directly at another, focusing on his or her eyes. Direct eye contact is assertive. Children often play at seeing who can stare the other down. The one who can maintain eye contact the longest wins and gains a sense of power. We are not suggesting you try to out stare others, but looking directly at another while you are speaking strongly suggests, even demands, that you be listened to and taken seriously. Looking down while speaking to another suggests timidity and weakens you in the eyes of others. Looking to the side as you speak suggests avoidance and insincerity and jeopardizes your credibility.

Maintaining eye contact while the other is speaking shows your interest in listening. There are times when you will want to minimize eye contact while others are speaking, perhaps to avoid revealing your reaction to what is said or to give you time to think. When this occurs, concentrate on note taking since this also gives the impression that you are listening.

2. Posture. The moment you walk into a room, your posture and carriage communicate messages about your confidence, how you expect to relate to others, your energy level and emotional state. Slouching may say “Don’t notice me” or “I’m tired and can be easily worn down” or “I’m not interested in being here”. Slouching does not invite the other to take you seriously. A tense and rigid posture communicates you are in a heightened emotional state. It may be interpreted as anxiety or anger depending on your other nonverbal behaviors. This kind of posture makes you look out of control. An erect and relaxed posture while standing and sitting communicates confidence, self-control, energy and an expectation that you be taken seriously.

When sitting, leaning forward slightly communicates interest and a sense of purpose. Leaning back communicates disinterest or disagreement. Crossing your arms and legs suggests a tense and closed attitude while uncrossed arms and legs suggests a relaxed and open attitude.

3. Facial expression. We say a lot through our facial expressions. Our face tells others the degree to which we are alert, interested, in agreement, or relaxed. It reveals the types of emotions we feel. It is best to keep your facial expression as neutral as possible.

4. Gestures. Gestures can be used to accentuate and support your message or to distract and discredit. Nervous fidgeting and tense jerky movements are distracting. These types of gestures and movements make you look out of control and seriously diminish your persuasive power. If you have trouble controlling nervous and fidgety movements, channel your nervous energy by taking notes. Hand and arm movements can be used to emphasize what you say. Do not emphasize everything, however. Be judicious in your use of gestures. Keep your gestures relaxed, fluid and moderate in size. Gestures which are too large make you look grandiose while gestures which are too small make you look nervous.

5. Personal Appearance. Whether we like it or not how we dress affects credibility. It also affects how we feel. Being extremely overdressed or underdressed in relation to others makes most people uncomfortable. Dress appropriate to the situation. If you do not know how to dress for a particular situation, ask questions of people who should know such things. The way in which you dress carries distinct messages about power. When dressing for business it is best to dress neatly, conservatively and as professionally as possible.

6. Tone of Voice. There are many aspects of voice that affect the impact your words have on others. The most important of these and the easiest to control are loudness and speed. Nervousness can make us speak too softly to be heard or so loudly that we distract from our message. Speak loudly and slowly enough to be heard and understood. It is also important to control how you end your sentences. Raising the pitch of your voice at the end of a sentence makes the sentence sound like question. A slight lowering of pitch at the end of a sentence makes it sound like a statement. Make your statements sound like statements in order to strengthen your message.

7. Negotiation and Communication in Meetings. The resolution of many advocacy problems will involve one or more meetings with service providers and administrators. You will use all of the skills we have discussed; problem analysis, information gathering, action planning and assertive communication in preparing for and participating in these meetings. In this chapter we will discuss additional advocacy techniques and pointers that can help you become a more successful advocate in meetings and negotiations.

8. Whose Territory.  Where a meeting is held will have a subtle but powerful impact on you and everyone else who participates. People generally feel more comfortable and in control of the situation when they are in their own territory. Conversely they feel less comfort and less control when they are in someone else’s territory. Potential discomfort over being on someone else’s turf can be decreased by increasing familiarity with the individuals you will negotiate with and increasing familiarity with the site of the proposed meeting.

If you have control over where the meeting is held, request that it take place a neutral location. It’s a good idea to arrive at the meeting location early. This will give you a chance to become familiar with and feel more comfortable in the meeting space. Secondly, it will give you some control over the seating arrangement. Some seating arrangements create a sense of equality among participants at meeting whereas others create a power imbalance.

A round table has no head seat and thus creates a feeling of equality. Since there are no sides to a round table it also minimizes an “us versus them” atmosphere. A square table can also be used to equalize power. Although it is likely to enhance the feeling of taking sides. The head chair at an oblong table connotes power. If you are faced with an oblong table, sit in the head chair if possible. 

The person who sits behind a desk during a meeting enhances his or her power considerably. In addition, the desk can, create a sense of defensiveness and act as a barrier to open communication. If you can, try to get the other party out from behind his or her desk in order to equalize the power.

The Numbers Game

Before the meeting, find out who the other party plans to have present. You will want to know their names and roles within the organization. If the other side plans to have several people present, bring several people with you. Equalizing the number of people representing each side will help to equalize the power. It will also allow you to assign tasks to your supporters, taking some of the pressure off of you.

Controlling the Agenda

It’s a fact of life, every party to a meeting brings along his or her own agenda. It does not matter whether the meeting is formal or informal, planned or “spontaneous;” the other party will have an agenda or set of objectives they wish to accomplish and a strategy for accomplishing their objectives. They may not describe this agenda to you but they will have one nonetheless.

You must have a set of objectives and a plan to accomplish them also. If you do not, the other party will control the content and the outcome of the meeting. Use an advocacy plan as discussed earlier in this chapter to develop your objectives and strategy for the meeting.

When you get to the meeting, negotiate an agenda to which all parties agree. The agenda should state the issues to be discussed and the order in which they will be discussed. Frequently, it is a good idea to define issues that will not be addressed during the meeting. Sometimes, such items are raised in an effort to throw opponents off track. When such matters are raised, calmly explain that you are not prepared to discuss it at this time, and offer to schedule a meeting to discuss it. Ordering of items on the agenda is also important; you might want to tackle less controversial issues first if there are several issues to be decided. This will give everyone a sense of progress and accomplishment and will create a more cooperative basis for tackling more troublesome issues later.

It is also a good idea to agree on how long the meeting will last since you or other participants may have commitments later in the day. If time constraints will not allow all issues to be dealt with, arrange for an additional meeting so that you will not be pressured into unacceptable compromises because of time limitations.

Time to Think

As you developed your advocacy plan you listed your objectives, organized your information, identified the types of arguments the other party might use and thought of how you might respond to those arguments. Despite all of your preparation, surprises will occur. The other party may propose arguments you had not thought about, ask for information you don’t have or propose a solution you are not sure you are willing to try. If this occurs, ask for a short break to allow time to think about how you want to respond. Even after a break do not feel that you must respond immediately, ask for more time to research and consider your options.

It is also important to ask for a break if you feel you are losing emotional control. You will not negotiate at your best when your thinking is clouded by intense anger, anxiety or other emotions. Resist the temptation to simply walk out since you gain nothing by this and will seriously damage your credibility. Asking for a break is perfectly acceptable: so is asking that the meeting be adjourned until a later time. If you decide to take a break, leave the room otherwise, the other party is likely to engage you in small talk and deprive you of your opportunity to plan your next step.

Don’t Get Caught In These Traps

There are several strategies that are commonly used to throw opponents off track. Just being aware these strategies will better prepare you to handle them if they are used. 

Use of Jargon: It is common for professionals to use jargon. By this we mean technical terms, specialized words abbreviations that are not likely to be used in everyday conversation of the average person. In negotiations, professionals may intentionally use a lot of jargon in order make nonprofessionals feel ignorant, to keep them out of conversation or to diminish their credibility.

Resist the temptation to pretend you understand jargon. Ask that all terms you do not understand be defined in plain English and ask others to avoid using abbreviations with which you are not familiar. It is unfair to expect the average person to understand jargon. Do not allow yourself to feel less competent or less powerful just because you are not familiar with certain types of specialized jargon.

It’s also important to learn to say “I don’t know” comfortably. You should not be expected to know everything although, at times, you may be asked questions you are not expected to know the answers to in order to throw you off guard. Again, be sure to ask for clarification and/or more time.

Creating Guilt: Often the other party will attempt to convince you that the problem is your fault of the product of your own doing, when in fact it is not. If you feel it is your fault, you will get caught in a guilt trap. If the other party is able to make you feel responsible for the problem, he or she is getting ready to convince you that you, and you alone, are responsible for the solution. Resist this common and usually effective diversionary strategy. Such transparent attacks are irrelevant and you should say so. Instead of falling into such obvious traps, calmly steer the conversation back to the point.

Use of Ultimatums: The use of ultimatums is unwise. Do not do it. An ultimatum is the use of an uncompromising, “take-it-or-leave-it” position. It is likely to cut off valuable options and will definitely make you appear unreasonable, creating sympathy for the other party. Skilled advocates and negotiators do not use ultimatums.

If other party issues an ultimatum, question them about it. Ask what options and alternatives were considered before deciding on their position. Suggest that perhaps not all options were considered. Suggest that there may be additional positions to consider. Ask if there are any exceptions to the ultimatum. Try to think of examples where they would be likely to make exceptions to the ultimatum. Your goal in asking questions is to show that you are unwilling to accept a “take-it-or-leave-it” offer and want to explore additional alternatives. Furthermore, you want to jog the other party’s thinking so that they also are willing to look at possibilities beyond the ultimatum they have issued.

Communication and negotiation in meetings is complex, challenging and fascinating. We suggest that you build your own skills by attending meetings with other advocates and playing the role of observer and note taker. As an observer, the pressure will be off you and you will have more freedom to analyze and learn. As a side benefit, your presence provides support to the advocate and he or she may return the favor to you when it is your turn to advocate.

Writing Letters

We have all written letters — writing letters is nothing new. However, sometimes the idea of writing a letter as an advocate makes it impossible for intelligent people to put words on paper. This problem arises when a letter written as part of an advocacy effort is seen as radically different from a regular” letter”. The letters you will write as an advocate are simply business letters. Even if you have never written a business letter, you’ve read many and you know what they look like.

A second barrier that makes an advocacy letter seem difficult to write is the notion that you must tell your entire story in the letter. This notion makes the task of writing seem overwhelming. But in fact, it is unwise to tell your whole story in a letter. The idea that you must tell the whole story arises when you feel you must justify your position or request. This usually is not necessary.

As an advocate, most of your letters will be written to accomplish a fairly simple and specific objective such as: to request a meeting in which the problem will be discussed, to request information, to make an appointment to review a case file, or to thank others for their cooperation. A letter is the best way to make such requests, since it is more likely to get a response than a telephone request is. Such letters should be short and to the point. There will, of course, be some occasions when your objective requires a longer letter with more detail. For example, a letter filing a formal complaint, a letter to your lawyer, doctor of congressperson or to the editor of a newspaper may require more detail. But these letters too should be as concise as possible.

Materials and Style

Your advocacy letters are business letters and should be consistent with standards for good business correspondence. Save your prettiest stationery for writing to your friends. Instead use plain white typing paper or simple stationery with your name and address and telephone number imprinted. To ensure that your letter is legible and looks professional, type it or ask a friend to proof read it for you.

Use a business style in setting up your letter. When your letter is finished, check it very carefully to make sure you have not made any errors in spelling, grammar, punctuation or in typing. Careless errors will decrease your credibility and may cause your reader to conclude that you are not serious enough about your request to ensure your letter is correct.

Writing the Letter

It’s a good idea to make a short outline or list of points you want to include before you write your final copy. This will help you organize your thoughts and will result in a well organized letter. It will also help ensure that you don’t forget anything important.

The outline should contain the following points:

1. A sentence or two that states your purpose for writing the letter.
2. Sentences that provide further detail on your request.
3. A statement summarizing your request and asking for a response to your letter. Make sure to    include the date by which you want your response and information on how you want to be contacted.

Always keep a copy of the letter for your records. We recommend that you send the letter by certified mail and request a return receipt so that you know the letter was delivered and accepted. Keep the receipt as part of your record. It’s also a good idea to note the date by which you expect you, reply on your calendar.

If you do not receive a reply by the date requested, call to find out when the other party will respond to your request. If necessary, write a second letter, pointing out the fact that you have made a request but have not yet received a reply. When dealing with agencies or businesses you might want to send copies of your letters to regulatory or advocacy agencies. The Better Business Bureau, your legislators and congresspersons. In personal matters you might want to send copies to persons that have the ability to influence the person you have written to. In both instances this tactic creates an incentive for the other party to respond to you.

Adapted from: “Don’t Get Mad Get Powerful, A Manual for building Advocacy Skills,” MI P&A

Empathy vs. Anger

Empathy is the ability to communicate and lead by understanding others’ thoughts, perspectives, and feelings.

Benefits of being of being able to empathize with others include higher self-esteem, more self-confidence, stronger personal relationships, and improved working conditions.

We usually empathize most easily with people we know and care about.

Empathy is built through and understanding of ones self, or self-awareness. The more individuals can understand their own thoughts, feelings, and emotions, the more they can understand someone else’s.

Empathy is a learned behavior. Like all skills, empathy can be taught, practiced and enhanced.

To be human implies the ability to communicate, understand and get along with other human beings. The failure to read another persons’ feelings can be a major problem in the human experience. With empathy, humans can possess a higher degree of sensitivity towards others.

The absence of empathy is directly related to criminal behaviors and problems in managing anger and stress.

The roots of empathy sprout at a very your age (1 to 2 years old). Research has shown that, while infants possess a capacity to learn how to  be empathic, they must be shown how to use and develop and already existing abilities. Infants learn empathy from caregivers. In turn, infants learn how to understand other’s feelings. A lack of empathy in the parenting process results in a lack of empathy when children become adults.

Acceptance is the ability to recognize that family, friends, classmates and co-workers have a right to their feelings.

Improve your communication skills. This will lead to better understanding and increased empathy. Some basic tips to improve communication:

Learn to listen with your heart. Pay close attention to nonverbal messages. Nonverbal messages are so powerful because:

1) They tend to be more trusted.

2) They seem more emotionally charged.

3) They express universal feeling.

4) They are a more natural form of communication.

Empathy is one of the four pillars of anger management. The other three topics are stress, anger and communication. All anger management programs must include a Pre and Post Test for each participant.

George Anderson, MSW, BCD, CAMF, CEAP
Diplomate, American Association of Anger Management Providers
Anderson & Anderson®, The Trusted Name in Anger Management

Psychiatric Assessments for Disruptive Physicians, A Risk for Non-Impaired Doctors

JCAHO standards for physicians make a clear distinction between “disruptive physicians”, psychiatrically impaired physicians, substance abusers and/or sexual abusers. Unfortunately, some resources for “disruptive physicians” demand that all participants undergo a formal psychiatric examination whixh includes projective tests.

While assessments for all of the above issues may be necessary, the mental health assessment should be limited to suspected cases of nervous or mental disorders rather than anger management. Anger is not listed as a DSM-IV Diagnostic Disorder. According to the American Psychiatric Association, anger is a lifestyle issue and is therefore not responsive to psychotherapy or psychiatric intervention.

A mandated psychiatric assessment places inappropriately referred physicians at risk of being entered into the National Practitioner Data Bank. Once a physician is listed in this data bank, it is almost impossible to get any information removed.

Unfortunately, the stigma against mental illness continues to exist and can damage the career of any physicians. Physicians ordered to attend Coaching for Anger Management should insist on a program that is not psychiatrically bases.

George Anderson, MSW, BCD, CAMF, CEAP
Diplomate, American Association of Anger Management Providers
Anderson & Anderson®, The Trusted Name in Anger Management

The Behaviorally Disruptive Physician

Dr. Richard Ions, M.D.

It is difficult, if not impossible, to read a newspaper or watch the evening news without recognizing the degree to which violence permeates our world. Violence in the medical workplace does occur on a regular and continuing basis, and we often overlook its more subtle manifestations and its effects upon those around us.Physicians can consciously or unconsciously be perpetrators of disruptive behavior in the medical workplace, actions that are felt by others to represent anger, intimidation, and the threat of harm to others. We often fail to see the more subtle manifestations of our conduct, and the ways in which our thoughts, words and actions affect another. A pattern of such behavior may emerge in some physicians which has not been responsive to feedback from others, and attempts at corrective action may continue over time. The inherent problem is that of abuse of power and position for personal gain or to avoid blame or responsibility for adverse outcomes. An individual may create a reputation of being difficult to deal with or moody and others soon learn how to work around them without arousing their ire or reactions. For the purposes of this discussion, we will refer to them as behaviorally disruptive physicians.The expression of anger in the workplace by physicians is manifested in a variety of disruptive and maladaptive behaviors that tend to persist or reassert themselves over time. They are briefly summarized in Table I. A given problem physician will possess their own characteristic pattern of behaviors that result in conflict and concern in the hospital or office. Anger may be expressed with subtlety and persistence, or with sudden explosive dramatic outbursts. These actions may directly or indirectly affect the care given to patients. A great deal of time is consumed in adjusting to this individual, attempting to control them, and in efforts to assist those who feel injured.

Disruptive and Maladaptive Behaviors

TABLE I. Common behaviors in disruptive physicians

Inappropriate anger or resentments


-abusive language

-blames or shames others for possible adverse outcomes

-unnecessary sarcasm or cynicism

-threats of violence, retribution, or litigation

Inappropriate words or actions directed toward another person

-sexual comments or innuendoes

-sexual harassment

-seductive, aggressive, or assaultive behavior

-racial, ethnic, or socioeconomic slurs

-lack of regard for personal comfort and dignity of others

Inappropriate response to patient needs or staff requests

-late or unsuitable replies to pages or calls

-unprofessional demeanor or conduct

-uncooperative, defiant approach to problems

-rigid, inflexible responses to requests for assistance or cooperation

There are a variety of factors that can lead to such behavior by any professional in any medical establishment on occasion. Many professionals have experienced similar behavior in their homes during childhood and adolescence. Many others have directly suffered from abuse of power and position during their medical education or training. Indeed, some of the behavior that is no longer accepted was considered outrageous, but tolerated in the not too distant past. Numerous articles have appeared in the medical literature in recent years documenting the frequency and prevalence of medical student and medical resident abuse. Negative rolemodeling, particularly the use of public humiliation as a socialized and necessary element of medical training, is often used to justify current behavior. Physicians experience a great deal of pressure from peers and the public to meet exacting performance expectations. When something goes wrong, when a perfect result or outcome is in jeopardy, then blame is anticipated and expected. If we do not want to accept the blame, then we are prone to place it on others. In the long journey from high school to practicing physician, many sacrifices are required. Often we do not have as much time for the development of interpersonal skills as other students. Medical training has not historically provided education and experience in supervisory or team building, conflict resolution or effective leadership. We learn as we go, often from the mistakes we make along the way, unaware of or personal invulnerabilities or lack of sophistication. The medical workplace is the stage upon which numerous human dramas are played. Many tragic scenes occur wherein suffering, conflict, and death with their medical and psychological consequences are experienced each day.  In this highly charged environment there is a constant demand for faultless performance and flawless decision-making. Over time, we develop a hardening, a ritualized suppression of feelings in order to cope with the demands and stress. In the process we can become insensitive to the needs, feelings, and sensibilities of patients, peers, and coworkers while developing an emotional armoring against the criticism, barbs and comments of others. Our ability to utilize healthy adaptive mechanisms such as humor, altruism, sublimation and rationalization can be overcome. Each of us carries inherent personal vulnerabilities and weaknesses. Mechanisms that one utilized earlier I life may no longer be appropriate or effective. Our own image of ourselves may become distorted through denial, our compulsion with perfection, our obsession with being right, and our narcissistic defenses. We may lose the ability to see oneself as other people see us, becoming susceptible to a heroic fall, a metaphoric death due to the sin of hubris, or false pride. When it finally becomes necessary to take action and begin the process of coming to terms with a disruptive physician, be aware that the process is seldom easily or quickly completed. Initial steps involve the use of conflict resolution at the hospital or clinic level, using senior practice partners and appropriate administrative personnel. In many cases this approach will be successful. However in others, initial strategies that seek modification of behavior and corrective action will seem effective for short periods of time. Some professionals will return to old patterns of disruptive behavior and the concerned parties in the hospital or clinic will finally come to the conclusion that more intensive measures are necessary, and will require the use of additional leverage and the help of outside resources. The following outline depicts the most effective means for accomplishing the task of confronting the disruptive professional under such circumstances.


1.) Rarely will disruptive professionals independently seek help. They characteristically lack insight into the nature or severity of their problematic behavior. Following aggressive intervention and assessment, the majority develop at least partial insight. 2.) When it is necessary to proceed to confrontation, utilize a diverse team and choose a neutral meeting site.  Request each team member to specifically describe the problem behavior and its impact upon others. Emphasize the seriousness of the situation. 3.) Determine in advance acceptable outcomes from the confrontation. Identify the types of resources available. Decide whether an independent assessment is needed and the specialized components that will be required. Consider what treatment or therapy is acceptable in lieu of assessment. Seek acknowledgment of the problem behavior by the physician and responsibility to take corrective action. Offer assistance in obtaining help and make recommendations upon acceptable outcomes. Disclose what providers of assessment or treatment are acceptable. Identify any financial assistance or other support the professional can expect.


4.) Carefully review the alternatives that will be exercised if the professional refuses to comply with the recommendations. Review state and federal requirements. Reveal the team’s bottom lines only if the professional will not commit to an acceptable course of action in a reasonable period of time. Emphasize potential loss of privileges, liability insurance, or termination of employment or contract. Outline precisely due process provisions that are operable through organization bylaws or policies. Indicate when reports to state professional health program, state licensure board or national practitioner data bank may be made. Do not threaten actions you are not prepared to take.


5.) If the confrontation is successful, identify a peer to serve as a liaison and mentor in the process. Monitor progress in implementation of the agreed upon action plan. Develop clear rehabilitation goals. When appropriate, emphasize a plan for return to active practice when goals are met.

6.) Prior to professional re-entry or within a short period of time after information is obtained from assessment and/or treatment [with the physician’s written authorization], establish realistic re-entry expectations and conduct boundaries. Utilize peer monitoring and, if necessary, supervision in practice. Encourage or require continuing education in arrears of weakness.  Construct a clear and precise re-entry behavioral contract which specifies the consequences for failure to comply. Within the contract identify a mechanism for future conflict resolution.  Provide dignity and support for the professional as well as the workplace staff.

Independent assessment by professionals who are not associated with the hospital or clinic provides the most objective information. When the professionals that do such evaluation indicate at the outset that they will not be involved in any therapy or treatment of the referred party, then an additional conflict of interest is avoided. In our experience, disruptive professionals who have serious problems and have not responded to conservative measures are most effectively evaluated by a multi-disciplinary team of professionals that provide comprehensive and definitive evaluation for mental disorders, addictive disease, and covert medical illnesses. The time away from professional responsibilities as well as the time and expense of such a process can be therapeutic in and of itself. Reports should approach forensic standards, and evaluators must be prepared to represent and defend their work in the future if bottom lines need to be exercised.

Anderson & Anderson Publishes New Los Angeles Providers List

Anderson & Anderson, Inc., the Trusted Name in Anger Management, has published the updated Los Angeles County Anger Management Court Referral List for July 2008. This list has been sent to the Los Angeles County Superior Court, and all of its branches. This court list will remain in effect until December 2008.

The providers on this list are certified by Anderson & Anderson, and they have done the following: 1.) completed the 40 hour certification training, 2.) use the Conover Assessment and post-tests, and 3.) are using the Anderson & Anderson client workbooks and other Anderson & Anderson training material for their classes.

This court list is updated every six months to reflect the current status of anger management providers in L.A. County. Each court mandated anger management client receives a copy of this list, and he/she can choose which program to enroll in. The providers list, in its web-based form, is available on the Anderson & Anderson website:


Anderson & Anderson, Trusted Name in Anger Management

Anger Management Home Study Courses Not Appropriate for Disruptive Physicians

As the major provider of anger management and executive coaching for physicians in the nation, Anderson & Anderson and its network of providers are aware of the trends in requests for anger management and coaching services throughout the U.S. In response to the new JCAHO guidelines for “disruptive physicians”, some doctors and their attorneys are attempting to avoid addressing this serious patient safety issue by purchasing “Home Study” anger management courses which are actually designed as self-help classes for voluntary clients. Such programs are clearly attempts to avoid taking responsibility for their role in this important critical health care issue.

All reputable programs for “disruptive physicians” must begin with a comprehensive assessment, workbooks and focused intervention to address issues of stress management, communication, anger management, emotional intelligence, and motivation to change. Following the intervention, post-tests and aftercare are generally provided. The three major providers of acceptable resources for “disruptive physicians” include the following: P.A.C.E Program of University of California at San Diego, Department of Psychiatry of Vanderbilt University and Anderson & Anderson, Trusted Name in Anger Management of Los Angeles, CA.

George Anderson, MSW, BCD, CAMF, CEAP
Diplomate, American Association of Anger Management Providers
Anderson & Anderson®, The Trusted Name in Anger Management

Communication I

Anderson and Anderson Executive Coaching/Anger Management for Physicians and related health care professionals and workers offers the following series on improving communication skills as a response to The Joint Commission Alert below. Adapted and posted by Anderson faculty member, Tom Wentz, Ph.D., C.A.M.F.

Excerpts from, The Practice of Control:  Executive Coaching/Anger Management for Physicians by George Anderson, BCD, CAMF and John Elder, MA; Editor, Tom Wentz, PhD, CAMF. © 2008.

Joint Commission Alert: July 9, 2008.

Stop Bad Behavior among Health Care Professionals: Rude language, hostile behavior threaten safety, quality.

(OAKBROOK TERRACE, Ill. – July 9, 2008 ) Health care is a high-stakes, pressure- packed environment that can test the limits of civility in the workplace. A new alert issued today by The Joint Commission warns that rude language and hostile behavior among health care professionals goes beyond being unpleasant and poses a serious threat to patient safety and the overall quality of care.

Intimidating and disruptive behaviors are such a serious issue that, in addition to addressing it in the new Sentinel Event Alert, The Joint Commission is introducing new standards requiring more than 15,000 accredited health care organizations to create a code of conduct that defines acceptable and unacceptable behaviors and to establish a formal process for managing unacceptable behavior. The new standards take effect January 1, 2009 for hospitals, nursing homes, home health agencies, laboratories, ambulatory care facilities, and behavioral health care facilities across  the United States.

Health care leaders and caregivers have known for years that intimidating and disruptive behaviors are a serious problem. Verbal outbursts, condescending attitudes, refusing to take part in assigned duties and physical threats all create breakdowns in the teamwork, communication and collaboration necessary to deliver patient care. The Institute for Safe Medication Practices found that 40 percent of clinicians have kept quiet or remained passive during patient care events rather  than question a known intimidator. To help put an end to once-accepted behaviors  that put patients at risk, The Joint Commission Sentinel Event Alert urges health care  organizations to take action.

The Joint Commission Media Contact: Ken Powers, Media Relations Manager

“The single biggest problem in communication is the illusion that it has taken place.”

                                                                                           – George Bernard Shaw

Improving Communication with Others

Lack of communication is the root of many troubles, such as hurt feelings, mis- understandings, missed deadlines, and unsuccessful connections. Healthy communication in its broadest form is important in developing positive healthy relationships between family members and others. Skills for acquiring good communication techniques are emphasized in this series of blogs on improving communication skills.

Basic skills are very important and many people do not use them well. Poor communication skills result in unnecessary problems and misunderstandings in relationships.

Good communication requires two sets of abilities:

1.  Ability to hear the other person (Receiving – active listening).

2.  Ability to articulate messages accurately (Sending – assertive communication).

Four key communication skills for improving interpersonal relations are:

1.  To listen without judgment.
2.  To comprehend and acknowledge what has been said.
3.  To acknowledge the other person and their point of view (does not imply agreement, however it     does require recognition of the person and their message).
4.  To not impose your personal beliefs on someone else.

Good communication skills take patience and time to acquire. We encourage participants to use all of their newly learned skills in developing positive healthy relationships.

I.  What is Communication?

Communication Defined: At its root, communication is about clearly and respectfully articulating our needs and caring enough to listen to and understand the needs of others.

Human beings live in a single world of communication but divide that world into two parts: words and behavior (verbal and nonverbal). Words represent perhaps 10 percent of the total while behavior the other 90 percent.

The words used in communication, representing 10% percent of the total, emphasize the unidirectional aspects of communication, while behavior, the other 90 percent, stresses feedback on how people are feeling, ways of avoiding confrontation, and the inherent logic that is the birthright of all people.  Words are the medium… which in the final analysis deal in power, so that words become instruments of power. The nonverbal, behavioral part of communication is the provenance of the common man and the core culture that guides his/her life.” (E. Hall, 1983.)
Hall’s Three key points:

1.  Communication is 90% nonverbal and 10% verbal.
2.  Words are instruments of power. 
3.  The purpose of communication is as much to conceal thought as it is to reveal it.

Just as stress underlies all anger, stress also underlies most communication, whether it is the internal dialogue we have with ourselves or the interactions we have with others. Without good communication skills, we can not have healthy or productive relationships with ourselves or others.

Too often, we listen only to ourselves or fail to be aware of our stressors and related feelings. With others, we fail to recognize the important verbal and nonverbal signs that people are sharing about how they feel and what they need. When this happens, no one is heard. Communication breaks down. Assumptions are made. Worst, our needs and the needs of our family or colleagues go unmet and we all fail to perform at optimal levels. “Empathy builds on self-awareness; the more open we are to our own emotions, the more skilled we will be in reading feelings. Knowing our emotions; self-awareness, recognizing a feeling as it happens – is the keystone of emotional intelligence.”

Anger Management Presentation a Smashing Hit at Smith College

George Anderson’s presentation at the 90th Anniversity of The Smith College School for Social Work was the highlight of the three day conference. Anderson spoke contemparaneously about the Anderson & Anderson anger management curriculum. He explained the importance of defining anger management as a positive psychology class which teaches enhancement skills in recognizing anger, stress, assertive communication and emotional intelligence. He explained the importance of having Pre and Post Tests to determine the success or lack of success of each participant. Anderson outlined all of the components of the anger management intervention including: organizational anger management, anger management classes, executive coaching/anger management for physicians and other executives, civility training for attorneys, classes for divorcing couples, as well as anger management classes for human resource management referrals and court referrals.

Following this powerful presentation, George Anderson had an opportunity to meet and discuss his model with the Dean of the School of Social Work, Dr. Carolyn Jacobs, and Dr. Carol T. Christ, President of Smith College. Tentative plans are in the works for Anderson & Anderson to sponsor a Certification training in Los Angeles as a fund raiser for the Smith College for Social Work in December of 2008.

Nancy J. Anderson, M.A, MSW, BCD, CAMF

Joint Commission Alert: Stop Bad Behavior among Health Care Professionals

Rude language, hostile behavior threaten safety, quality.

Media Contact:    
Ken Powers
Media Relations Manager

(OAKBROOK TERRACE, Ill. – July 9, 2008 ) Health care is a high-stakes, pressure-packed environment that can test the limits of civility in the workplace. A new alert issued today by The Joint Commission warns that rude language and hostile behavior among health care professionals goes beyond being unpleasant and poses a serious threat to patient safety and the overall quality of care.

Intimidating and disruptive behaviors are such a serious issue that, in addition to addressing it in the new Sentinel Event Alert, The Joint Commission is introducing new standards requiring more than 15,000 accredited health care organizations to create a code of conduct that defines acceptable and unacceptable behaviors and to establish a formal process for managing unacceptable behavior. The new standards take effect January 1, 2009 for hospitals, nursing homes, home health agencies, laboratories, ambulatory care facilities, and behavioral health care facilities across the United States.

Health care leaders and caregivers have known for years that intimidating and disruptive behaviors are a serious problem. Verbal outbursts, condescending attitudes, refusing to take part in assigned duties and physical threats all create breakdowns in the teamwork, communication and collaboration necessary to deliver patient care. The Institute for Safe Medication Practices found that 40 percent of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator. To help put an end to once-accepted behaviors that put patients at risk, The Joint Commission Sentinel Event Alert urges health care organizations to take action.

“Most health care workers do their jobs with care, compassion and professionalism,” says Mark R. Chassin, M.D., M.P.P, M.P.H., president, The Joint Commission. “But sometimes professionalism breaks down and caregivers engage in behaviors that threaten patient safety. It is important for organizations to take a stand by clearly identifying such behaviors and refusing to tolerate them.”

To help put an end to intimidating and disruptive behaviors among physicians, nurses, pharmacists, therapists, support staff and administrators, the Sentinel Event Alert recommends that health care organizations take 11 specific steps, including the following:

• Educate all health care team members about professional behavior, including training in basics such as being courteous during telephone interactions, business etiquette and general people skills;

• Hold all team members accountable for modeling desirable behaviors, and enforce the code of conduct consistently and equitably;

• Establish a comprehensive approach to addressing intimidating and disruptive behaviors that includes a zero tolerance policy; strong involvement and support from physician leadership; reducing fears of retribution against those who report intimidating and disruptive behaviors; empathizing with and apologizing to patients and families who are involved in or witness intimidating or disruptive behaviors;

• Determine how and when disciplinary actions should begin; and

• Develop a system to detect and receive reports of unprofessional behavior, and use non-confrontational interaction strategies to address intimidating and disruptive behaviors within the context of an organizational commitment to the health and well-being of all staff and patients.

Addressing unprofessional behavior among health care professionals is part of a series of Alerts issued by the Joint Commission. Previous Alerts have addressed pediatric medication errors, wrong-site surgery, medication mix-ups, health care-associated infections and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found on The Joint Commission’s website:

Posted By: George Anderson, MSW, BCD, CAMF; and Tom Wentz, PhD, CAMF, Anderson and Anderson Faculty Member.

Sentinel Event Alert: The Joint Commission

Issue 40, July 9, 2008

Behaviors that undermine a culture of safety

Intimidating and disruptive behaviors can foster medical errors,(1,2,3) contribute to poor patient satisfaction and to preventable adverse outcomes,(1,4,5) increase the cost of care,(4,5) and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. (1,6) Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.

Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions.(2) Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients.(7, 8, 11) All intimidating and disruptive behaviors are unprofessional and should not be tolerated.

Intimidating and disruptive behaviors in health care organizations are not rare.(1,2,7,8,9)  A survey on intimidation conducted by the Institute for Safe Medication Practices found that 40 percent of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator.(2,10) While most formal research centers on intimidating and disruptive behaviors among physicians and nurses, there is evidence that these behaviors occur among other health care professionals, such as pharmacists, therapists, and support staff, as well as among administrators. (1,2) Several surveys have found that most care providers have experienced or witnessed intimidating or disruptive behaviors.(1,2,8,12,13) These behaviors are not limited to one gender and occur during interactions within and across disciplines.(1,2,7) Nor are such behaviors confined to the small number of individuals who habitually exhibit them.(2) It is likely that these individuals are not involved in the large majority of episodes of intimidating or disruptive behaviors. It is important that organizations recognize that it is the behaviors that threaten patient safety, irrespective of who engages in them.

The majority of health care professionals enter their chosen discipline for altruistic reasons and have a strong interest in caring for and helping other human beings. The preponderance of these individuals carry out their duties in a manner consistent with this idealism and maintain high levels of professionalism. The presence of intimidating and disruptive behaviors in an organization, however, erodes professional behavior and creates an unhealthy or even hostile work environment – one that is readily recognized by patients and their families. Health care organizations that ignore these behaviors also expose themselves to litigation from both employees and patients. Studies link patient complaints about unprofessional, disruptive behaviors and malpractice risk.(13,14,15) “Any behavior which impairs the health care team’s ability to function well creates risk,” says Gerald Hickson, M.D., associate dean for Clinical Affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center. “If health care organizations encourage patients and families to speak up, their observations and complaints, if recorded and fed back to organizational leadership, can serve as part of a surveillance system to identify behaviors by members of the health care team that create unnecessary risk.

Root causes and contributing factors

There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care.(10) Organizations that fail to address unprofessional behavior through formal systems are indirectly promoting it. (9,11) Intimidating and disruptive behavior stems from both individual and systemic factors.(4) The inherent stresses of dealing with high stakes, high emotion situations can contribute to occasional intimidating or disruptive behavior, particularly in the presence of factors such as fatigue. Individual care providers who exhibit characteristics such as self-centeredness, immaturity, or defensiveness can be more prone to unprofessional behavior.(8,11) They can lack interpersonal, coping or conflict management skills.

Systemic factors stem from the unique health care cultural environment, which is marked by pressures that include increased productivity demands, cost containment requirements, embedded hierarchies, and fear of or stress from litigation. These pressures can be further exacerbated by changes to or differences in the authority, autonomy, empowerment, and roles or values of professionals on the health care team, (5,7,16) as well as by the continual flux of daily changes in shifts, rotations, and interdepartmental support staff. This dynamic creates challenges for inter-professional communication and for the development of trust among team members.

Disruptive behaviors often go unreported, and therefore unaddressed, for a number of reasons. Fear of retaliation and the stigma associated with “blowing the whistle” on a colleague, as well as a general reluctance to confront an intimidator all contribute to underreporting of intimidating and/or disruptive behavior.(2,9,12,16) Additionally, staff within institutions often perceive that powerful, revenue-generating physicians are “let off the hook” for inappropriate behavior due to the perceived consequences of confronting them.(8,10,12,17) The American College of Physician Executives (ACPE) conducted a physician behavior survey and found that 38.9 percent of the respondents agreed that “physicians in my organization who generate high amounts of revenue are treated more leniently when it comes to behavior problems than those who bring in less revenue.”(17)

Existing Joint Commission requirements

Effective January 1, 2009 for all accreditation programs, The Joint Commission has a new Leadership standard (LD.03.01.01)* that addresses disruptive and inappropriate behaviors in two of its elements of performance:

EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and
inappropriate behaviors.

EP 5: Leaders create and implement a process for managing disruptive and inappropriate behaviors.

In addition, standards in the Medical Staff chapter have been organized to follow six core competencies (see the introduction to MS.4) to be addressed in the credentialing process, including interpersonal skills and professionalism.

Other Joint Commission suggested actions

1. Educate all team members – both physicians and non-physician staff – on appropriate professional behavior defined by the organization’s code of conduct. The code and education should emphasize respect. Include training in basic business etiquette (particularly phone skills) and people skills.(10, 18,19)

2. Hold all team members accountable for modeling desirable behaviors, and enforce the code consistently and equitably among all staff regardless of seniority or clinical discipline in a positive fashion through reinforcement as well as punishment.(2,4,9,10,11)

3. Develop and implement policies and procedures/processes appropriate for the organization that address:

o “Zero tolerance” for intimidating and/or disruptive behaviors, especially the most egregious instances of disruptive behavior such as assault and other criminal acts. Incorporate the zero tolerance policy into medical staff bylaws and employment agreements as well as administrative policies.

o Medical staff policies regarding intimidating and/or disruptive behaviors of physicians within a health care organization should be complementary and supportive of the policies that are present in the organization for non-physician staff.

o Reducing fear of intimidation or retribution and protecting those who report or cooperate in the investigation of intimidating, disruptive and other unprofessional behavior.(10,18 ) Non-retaliation clauses should be included in all policy statements that address disruptive behaviors.

o Responding to patients and/or their families who are involved in or witness intimidating and/or disruptive behaviors. The response should include hearing and empathizing with their concerns, thanking them for sharing those concerns, and apologizing.(11)

o How and when to begin disciplinary actions (such as suspension, termination, loss of clinical privileges, reports to professional licensure bodies).

4. Develop an organizational process for addressing intimidating and disruptive behaviors (LD.3.10 EP 5) that solicits and integrates substantial input from an inter-professional team including representation of medical and nursing staff, administrators and other employees.(4,10,18 )

5. Provide skills-based training and coaching for all leaders and managers in relationship-building and collaborative practice, including skills for giving feedback on unprofessional behavior, and conflict resolution.(4,7,10,11,17,20) Cultural assessment tools can also be used to measure whether or not attitudes change over time.

6. Develop and implement a system for assessing staff perceptions of the seriousness and extent of instances of unprofessional behaviors and the risk of harm to patients.(10,17,18 )

7. Develop and implement a reporting/surveillance system (possibly anonymous) for detecting unprofessional behavior. Include ombuds services(20) and patient advocates,(2,11) both of which provide important feedback from patients and families who may experience intimidating or disruptive behavior from health professionals. Monitor system effectiveness through regular surveys, focus groups, peer and team member evaluations, or other methods.(10) Have multiple and specific strategies to learn whether intimidating or disruptive behaviors exist or recur, such as through direct inquiries at routine intervals with staff, supervisors, and peers.

8. Support surveillance with tiered, non-confrontational interventional strategies, starting with informal “cup of coffee” conversations directly addressing the problem and moving toward detailed action plans and progressive discipline, if patterns persist. (4,5,10,11) These interventions should initially be non-adversarial in nature, with the focus on building trust, placing accountability on and rehabilitating the offending individual, and protecting patient safety.(4,5) Make use of mediators and conflict coaches when professional dispute resolution skills are needed.(4,7,14)

9. Conduct all interventions within the context of an organizational commitment to the health and well-being of all staff, (11) with adequate resources to support individuals whose behavior is caused or influenced by physical or mental health pathologies.
10. Encourage inter-professional dialogues across a variety of forums as a proactive way of addressing ongoing conflicts, overcoming them, and moving forward through improved collaboration and communication.(1,2,4,10)

11. Document all attempts to address intimidating and disruptive behaviors.(18 )


1.) Rosenstein, AH and O’Daniel, M: Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. American Journal of Nursing, 2005, 105,1,54-64

2.) Institute for Safe Medication Practices: Survey on workplace intimidation. 2003. Available online: (accessed April 14, 2008 )

3.) Morrissey J: Encyclopedia of errors; Growing database of medication errors allows hospitals to compare their track records with facilities nationwide in a nonpunitive setting. Modern Healthcare, March 24, 2003, 33(12):40,42

4.) Gerardi, D: Effective strategies for addressing “disruptive” behavior: Moving from avoidance to engagement. Medical Group Management Association Webcast, 2007; and, Gerardi, D:  Creating Cultures of Engagement: Effective Strategies for Addressing Conflict and “Disruptive” Behavior. Arizona Hospital Association Annual Patient Safety Forum, 2008

5.) Ransom, SB and Neff, KE, et al: Enhancing physician performance. American College of Physician Executives, Tampa, Fla., 2000, chapter 4, p.45-72

6.) Rosenstein, A, et al:  Disruptive physician behavior contributes to nursing shortage:  Study links bad behavior by doctors to nurses leaving the profession. Physician Executive, November/December 2002, 28(6):8-11. Available online: (accessed April 14, 2008 )

7.) Gerardi, D: The Emerging Culture of Health Care: Improving End-of-Life Care through Collaboration and Conflict Engagement Among Health Care Professionals. Ohio State Journal on Dispute Resolution, 2007, 23(1):105-142

8.) Weber, DO: Poll results: Doctors’ disruptive behavior disturbs physician leaders. Physician Executive, September/October 2004, 30(5):6-14

9.) Leape, LL and Fromson, JA: Problem doctors: Is there a system-level solution? Annals of Internal Medicine, 2006, 144:107-155

10.) Porto, G and Lauve, R: Disruptive clinical behavior: A persistent threat to patient safety. Patient Safety and Quality Healthcare, July/August 2006. Available online: (accessed April 14, 2008 )

11.) Hickson, GB: A complementary approach to promoting professionalism: Identifying, measuring, and addressing unprofessional behaviors. Academic Medicine, November 2007, 82(11):1040-1048

12.) Rosenstein, AH: Nurse-physician relationships: Impact on nurse satisfaction and retention. American Journal of Nursing, 2002, 102(6):26-34

13.) Hickson GB, et al: Patient complaints and malpractice risk. Journal of the American Medical Association, 2002, 287:2951-7

14.) Hickson GB, et al; Patient complaints and malpractice risk in a regional healthcare center. Southern Medical Journal, August 2007, 100(8 ):791-6

15.) Stelfox HT, Ghandi TK, Orav J, Gustafson ML:  The relation of patient satisfaction with complaints against physicians, risk management episodes, and malpractice lawsuits.  American Journal of Medicine, 2005, 118(10):1126-33

16.) Gerardi, D: The culture of health care: How professional and organizational cultures impact conflict management. Georgia Law Review, 2005, 21(4):857-890

17.) Keogh, T and Martin, W: Managing unmanageable physicians. Physician Executive, September/October 2004, 18-22

18.) ECRI Institute: Disruptive practitioner behavior report, June 2006. Available for purchase
online: (accessed April 14, 2008 )

19.) Kahn, MW: Etiquette-based medicine. New England Journal of Medicine, May 8, 2008, 358; 19:1988-1989

20.) Marshall, P and Robson, R: Preventing and managing conflict: Vital pieces in the patient safety puzzle. Healthcare Quarterly, October 2005, 8:39-44

* The 2009 standards have been renumbered as part of the Standards Improvement Initiative. During development, this standard was number LD.3.10.