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10 tips on being appropriately assertive in your surgery

In the pressured and under-resourced modern NHS, GPs are at ever-increasing risk of the negative impacts arising from not being listened to and becoming overburdened.

However, it is important to remember your personal health and wellbeing is your most valuable asset, and is vital to your ability to perform well as a modern day GP and enjoy your wider life. All GPs need to be able to ensure their voice is heard at work and manage the complex demands made at work by being appropriately assertive to perform well at work and avoid burnout.

Here are my 10 tips on how to develop the necessary assertiveness skills.

1. Understand why it’s difficult to be assertive

Human beings have evolved as social beings that co-operate and help each other. Research has shown that from childhood, most people have strong instincts to help each other. Healthcare professionals are likely to have a higher levels of values orientated to helping others as this in part motivates them to pursue this challenging career. So for most GPs it is quite hard to say no, as it causes a degree of emotional pain or discomfort, and in some people causes significant anxiety.

Furthermore, the current under-resourced NHS and social care environment has led to greater needs by patients and staff and the emotional charge that is attached. The greater risk and raised consequences of complaint and litigation has increased the anxiety about entering into challenging situations with colleagues and patients.

2. Understand the potential impact of not being assertive

In today’s competitive work environment, in group situations people can be apprehensive about speaking up for themselves and putting forward their views. This can lead to a feeling of disempowerment and frustration at work.

However, if you repeatedly say yes to everything it’s easy to get overloaded, as demand outstrips capacity at most practices. This can lead to you perceiving yourself as weak and lacking in control of your environment. You may then feel resentment of yourself and resentment of others. Neither is healthy, and can lead to conflict with colleagues and patients.

3. Remind yourself of your value and what’s important to you at the start of each day

As a busy GP, your day will be full of many pressing professional and personal demands, which will normally exceed your capacity. It is important to step back and take an objective view of the value you offer to your practice and patients. Most GPs have a huge range of complex skills and make a positive impact on patients and colleagues around them each day.

It is easy for you to take it for granted, but being objective and being grateful about it daily can help maintain a positive mind-set.

Furthermore, understanding your values and your priorities is the framework which allows you to better decide the 90% of requests you say ‘yes’ to, and 10% of requests you may need to say ‘no’ to each day.

Some GPs may find it helpful to follow guidance to set up their framework. For example, the productivity expert David Allen has a system called ‘Getting Things Done’ that is used by many busy doctors. He has a tool for understanding your values and priorities that you may find useful.

4. Understand the rules of conduct at work

It is helpful to have a clear understanding of the rules that govern how people behave at work. These will be covered in your practice agreement, job description, employee contract and handbook, as well as practice policies, GMS/PMS/APMS contract and wider NHS Constitution and policies.

It is helpful to know these rules, so when you encounter challenges, you understand what everyone’s responsibilities are and how to seek help.

It is always better to do this early, as problems left tend to become more emotionally charged and then more difficult to deal with.

5. Know your limits

Developing and respecting your personal boundaries is an important step towards managing stress and frustration that is an inevitable part of GP surgery life. Taking on extra surgery, QOF, prescribing, CQC or LES work and missing important family events, or continuing to answer your NHS emails late at night despite the effect it will have on good sleep, leads to GP burnout. Reflect on and write down what you can realistically expect of yourself and be comfortable with your personal limitations. We are all limited by our personal make-up and the fact there are only 24 hours in a day – there is no getting around those things, even though the QOF deadlines may be imminent.

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The whole practice benefits from good direct communication with you. Being chronically tired or angry leads to low mood and stops you being the best doctor you can be, which in turn leads to low job satisfaction and burnout. Many of us will be working up to 65 years of age or maybe later. It’s a marathon, not a sprint, so pace yourself!

6. Practice the habit of saying ‘no’ very nicely

Most people will accept you saying ‘no’ to them and feel better about it if you give a reason, offer an alternative or offer a future solution. For example:

‘Apologies, I cannot make the CCG meeting tonight as I have arrangements with my family.’

‘Sorry, I cannot complete your insurance form during this consultation, but it may be better for you to ask your private consultant to complete it.’

‘Sorry I cannot complete your form this week as I am very busy with patient care but I have some admin time next week when I will do it.’

‘Thanks for the suggestion, please send me an email so I can deal with this next week during my admin session.’

Like all habits, it’s a question of starting small and practising, then remembering to do it. It may be worth practising and role playing this at home with your family or friends, to get good at it. Prepare for challenging meetings or consultations by asking yourself, what is the situation, what am I trying to achieve, and what is the best way to communicate it.

7. Start from a position of abundance

You have 10 hours of time at work to use each day and 90% of the time you will actually be saying ‘yes’ to requests. Starting with the mindset that you have plenty of time and energy, and are positively managing it, has a positive powerful effect on you and others around you.

This starting position of abundance reinforces positive thoughts and emotions for you that increase your job satisfaction when helping patients and colleagues. Patients and colleagues will tend to ask you less, as they know that when they need your input you will be able to respond to their important needs.

It may sound counterintuitive to you, but give it a try, you may be surprised how such a positive mindset can impact on how you act and feel.

8. Be aware of the difference between being assertive and aggressive

Sometimes GPs do not speak up in team situations as there is a perception that voicing opinions is being pushy or difficult. This is unhelpful, as being happy and assertive is really all about giving your views, but also allowing others to speak and reaching a shared solution.

It is the difference between saying, for example, ‘I disagree with your view that changes to the triage system will improve things, but would like to learn more about why you do,’ which relays your legitimate concern while still showing you are open to change, and, ‘I think your idea about appointment changes is rubbish,’ which can be perceived as aggressive and demeaning, and closes the opportunity for further dialogue.

9. You are always learning, so write it down

Most of us are constantly learning and forgetting assertiveness skills as you go through the natural ups and downs of your professional life. Re-learning the skills, reflecting on your work, trying things, seeing what works for you and recording it is a good way of developing new skills and having a resource that you can refer back to and use when things are tough.

10. Be kind to yourself

It’s not easy. It takes time to change habits of working and do things differently when you have such a full-on job and busy life. But with patience and consistent small efforts, most people can get to a better place through developing and maintaining appropriate assertiveness skills at their work.

Dr Sohail Butt is a sessional GP in Surrey