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Practical Advice Paper

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,
Academic Staff, Skillslab Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands,
2

3
Dean, Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands

ABSTRACT
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

Introduction in these unequal relationships.[2] We see this culture in many

In this article we aim to introduce Leary’s Rose, a model of
inter-personal interaction,[1,2] 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[3]
and blame culture.[4] Such settings put people in unequal
relationship,[3] and Leary’s Rose gives practical suggestions
for what to do to enhance communication and negotiation
Access this article online
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DOI:
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countries around the world, and it is prevalent in most of
Southeast Asia.[3]
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,[5] stronger health care systems, and better health
outcomes.[6] However, disciplines that have to work together
effectively face some challenges.[7,8] These challenges are more
pronounced in social contexts characterised by a hierarchical
culture[9] or a culture of blame.[4]
In a hierarchical culture, the power distance between people

Address for correspondence:

Dr. Astrid Pratidina Susilo, Faculty of Pharmacy, University of Surabaya, Jalan Raya Kalirungkut, Surabaya 60293, Indonesia.
E-mail: pratidina@yahoo.com

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Susilo, et al.: LearyÊs Rose to Improve Negotiation Skills

is large.[3] 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. [3] The
more pronounced the hierarchical culture, the greater this
phenomenon is.[9] Power distance can constitute a formidable
barrier to effective inter-professional collaboration.[7,8]

Collaboration is also hard to achieve in a blame culture,

where errors are frequently hidden to avoid blame.[10] 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.[4,5,11]
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.[12] Inter-professional education
has an important role to play in this respect, and we therefore
advocate its inclusion in health professions curricula.[6,13] 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,[6,14] that have been shown to
be teachable.[13,15,16]
We introduce Leary’s Rose[1,2] 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].
Figure 1: Leary's Rose
induced to take a dependent position.[1] 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.[2] Leary’s Rose has also been used by teachers in
different arenas, including health professions education.[17,18]
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.[19] Leary’s Rose was used as a model to
train nurses with the needed negotiation skills.[20] 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.[1,2]

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
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,[1,2] a phenomenon that is frequently observed in
hierarchical cultures.[3] For example, when a senior physician

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Susilo, et al.: LearyÊs Rose to Improve Negotiation Skills
assumes a dominant position in a conversation (above), the
more junior physician is likely to keep silent and feel less
confident (below).[9]
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.[2]
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
56
Table 1: Example of scenario (1)
Mr. Smith is a pharmacist in his early thirties. He has noticed that one of his
patients, Mrs. Lee, has not collected the refill of her blood pressure medication,
captopril. Because the medication makes her cough a lot, Mrs. Lee does not feel
comfortable taking it. Mr. Smith knows that coughing is a common side effect of
captopril. Mrs. LeeÊs blood pressure is still quite high (170/90). Mr. Smith wants to
help Mrs. Lee by exploring possibilities for changing her medication. He calls Mrs.
LeeÊs general practitioner, Dr. Diana Foster, to discuss this. Dr. Diana Foster is a
senior general practitioner in the town.
Scenario 1 Scenario 2
Pharmacist Smith: Hello, this is Andrew Pharmacist Smith: Hello, this is Andrew
Smith calling, IÊm the pharmacist of Smith speaking, IÊm the pharmacist of
Century Pharmacy. May I speak to Doctor Century Pharmacy. May I speak to Doctor
Foster, please? Foster, please?
Dr. Foster: Speaking. What can I do for Dr. Foster: Speaking. What can I do for
you? you?
Pharmacist Smith: ItÊs about one of your Pharmacist Smith: ItÊs about one of your
patients, Mrs. Lee, aged 65 years. patients, Mrs. Lee, aged 65 years.
Dr. Foster: Yes? Dr Foster: Yes?
Pharmacist Smith: Her blood pressure is Pharmacist Smith: Her blood pressure is
170/90. She⁄. 170/90. She⁄.
Dr. Foster: Oh, she is a stubborn lady. I Dr Foster: Yes, I know her very well! She
keep telling her she will have a stroke if is a stubborn lady. I keep telling her she
she doesnÊt take her pills. She is really will have a stroke if she doesnÊt take her
quite hopeless. pills. SheÊs really quite hopeless.
Pharmacist Smith: But thereÊs something Pharmacist Smith: Yes, Dr Foster, IÊm well
you donÊt know about her. She,⁄. aware that you know your patient very
Dr. Foster: Excuse me, Mr. Smith. I well. ThatÊs why IÊd like to discuss with
actually do know everything about her. you what we can do to help her take her
SheÊs been my patient for more than 10 medication, thatÊs our common goal isnÊt
years. IÊm afraid I have to go to a meeting it. She says captopril makes her cough a
now. Goodbye. lot. ThatÊs why she doesnÊt take her pills
Pharmacist Smith did not have the regularly.
opportunity to convey his message. Dr Foster: Really? I didnÊt know that.
Pharmacist Smith: ThatÊs what she told
me. Do you think you could put her on
other medication, or should I ask her to
go and see you?
Dr Foster: I think IÊd better check her
medical record first and IÊll call you again
later. Would that be alright, because I
really have to go to a meeting right now.
Pharmacist Smith: Of course, thatÊs fine.
WeÊll talk again later. Thank you very
much.
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
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Susilo, et al.: LearyÊs Rose to Improve Negotiation Skills

Table 2: Example of scenario (2)

undergraduate, postgraduate and continuing professional
development programmes have taught us that Leary’s Rose
Nurse Eka is a young nurse in Indonesia. She has noticed that one of her patients,
Mr. Hadijaya, who has just recovered from a chest pain episode, seems very can be very helpful for professionals to become aware of their
anxious. This patient is scheduled to have a coronary stent placed tomorrow. Nurse default communication patterns. This tool can be used in both
Eka approached Mr Hadijaya and found out that he and his wife were not convinced simulated settings, such as class room or skills laboratory, and
that this procedure will be beneficial for him. They told Nurse Eka that a friend of
their familyÊs had undergone a similar procedure and still has to take medication
in real clinical settings, such as hospital wards.
regularly. Moreover, Mr Hadijaya has no insurance and the procedure is expensive.
Mr Hadijaya would like to refuse the procedure, but he is hesitant to say so to the The ability to recognise one’s natural communication pattern
doctors. Nurse Eka thinks that Mr Hadijaya needs more discussion regarding the and modify it when the communication is not going smoothly
procedures and other possible treatments. She calls the cardiologist, Dr Sekar
Saputri, to discuss this issue. depends on skills that can be trained in a safe, simulated
Scenario 1 Scenario 2
environment.[21] In training sessions in the classroom or
Nurse Eka: Good morning, Dr Nurse Eka: Good morning, Dr Saputri. This is skills laboratory, learners can role-play a negotiation process
Saputri. This is Nurse Eka calling. IÊm Nurse Eka calling. IÊm the nurse in ward 10. among professionals. The role plays can be video-recorded
the nurse in ward 10. Dr. Saputri: Good morning, Nurse Eka. What to help learners review their own performance.[22] To help
Dr. Saputri: Good morning, Nurse can I do for you?
Eka. What can I do for you? Nurse Eka: ItÊs about one of our patients, Mr.
learners understand what went wrong in a given encounter,
Nurse Eka: ItÊs about one of your Hadijaya, aged 65 years, who is scheduled for Leary’s Rose can be used as a feedback tool to illustrate what
patients, Mr. Hadijaya, aged 65 a procedure tomorrow was going on and to look for and try out alternative ways of
years, who is scheduled for a Dr. Saputri: Yes, the one who needs the stent
procedure tomorrow Nurse Eka: He seems very anxious⁄..He⁄.
reacting and communicating. The scenarios in Tables 1 and 2
Dr. Saputri: Yes, the one who needs Dr Saputri: Oh, heÊs been my patient for 5 could be used in role playing.
the stent years and he is always like that. Just give him
Nurse Eka: He seems very a sleeping pill and heÊll be fine tomorrow. In addition to being helpful in a simulated training
anxious⁄.He⁄. Nurse Eka: I think that he is anxious
Dr. Saputri: Oh, heÊs been my patient because he has some concern related to the environment, Leary’s Rose can also be used in real clinical
for 5 years and he is always like that. procedure. He is not sure of the benefit of the settings to facilitate work-based learning. During encounters
Just give him a sleeping pill and heÊll procedure and he has some financial issues. with real patients and co-workers, professionals inevitably
be fine tomorrow. Dr Saputri: Really? I didnÊt know that. Why
Nurse Eka: But this is different, donÊt you just explain further to him?
face challenges, which are easier to deal with if they
Doctor. I think you have not told him Nurse Eka: Perhaps it will be better if you and are able to use advanced communication or negotiation
everything about the procedure. I visit him and talk with him together. I think he skills.[23-26] In discussions of problematic encounters with peers
Dr. Saputri: Excuse me, Nurse Eka. and his wife also have some more questions
I have explained everything very related to the medication.
or supervisors, Leary’s Rose can serve as a tool to map the
clearly. May be he has just forgotten. Dr Saputri: Hem, IÊm quite busy in the clinic position one took in an interaction and to identify alternative
IÊm afraid I have to go to a meeting right now and I donÊt want to explain things responses. As advocated in experiential learning theory, real-
now. Goodbye. several times to him and again to his wife. life scenarios are rich sources for learning. Learners can reflect
Nurse Eka did not have the Nurse Eka: You donÊt need to do it now. Shall I
opportunity to convey her message. help arrange a meeting with him and his wife on their experiences and formulate specific learning objectives
at a time that is convenient for you, say this for future real life encounters.[26] Work-based learning can also
late afternoon? facilitate the transfer of skills, for in the workplace learners are
Dr Saputri: Okay⁄I can stop by around 3 pm.
Nurse Eka: Thank you very much. IÊll arrange confronted with a plethora of encounters presenting numerous
the meeting. opportunities for applying Leary’s Rose in different tasks.[27]
More elaboration of the application of Leary’s Rose both in
simulated and authentic settings is presented in [Table 3].
or to become aware of this tendency and take a different
approach which may be more propitious. Leary’s Rose helps For the optimal use of the Leary’s Rose, role plays scenarios
people become aware of a wider range of possible reactions usually picture situations in which conflicting ideas and
open to them during interactions and how they can choose hierarchy among professionals exist. When learners are
from among these reactions to better position themselves emotionally involved in the scenarios they can fall into a real
on the two axes. When people with a higher position in the clash, or stereotype the different professions. We propose
hierarchy assume the ‘above’ position, the other person does two strategies to avoid such a destructive experience:
not inevitably have to respond from the ‘below’ position. One strengthening the roles of teachers and structuring the
can choose to select a more equal position.[2] learning tasks.

Teachers, who should be trainers in communication skills

Application: How to use Leary’s Rose for health professionals, should discuss ground rules of role
as a training tool in inter-professional plays and feedback sessions to ensure safety of the learners.
education It should be underlined that role plays are learning processes
and therefore mistakes are allowed. Time out can be requested
Our experiences in different educational settings in by learners and teachers as necessary and teachers can use

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Susilo, et al.: LearyÊs Rose to Improve Negotiation Skills
Table 3: Examples of the use of Leary’s Rose in simulated and real clinical setting
Setting Simulated setting
Types of groups Students, professionals pursuing continuing education (e.g. in a
workshop)
Teacher Trainer in communication skills training
Venues Classroom or skills laboratory
Example of simple Learners are asked to watch a video of a discussion between a
learning strategy doctor and a nurse about a patient in which they have conflicting
idea. Learners are asked to analyse the encounter using LearyÊs
Rose.
Example of complex Learners are asked to play roles with simulated health professionals Learners are asked to formulate a learning objective and find the opportunity
learning strategy or among learners. Afterward they have to reflect their performance
using LearyÊs Rose. Feedback is also provided by teachers and
peers.
Preparation of learners Ground rules are set before role plays. Learners can be requested to Learners are asked to formulate learning objectives based on previous real life
formulate learning objectives
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.[28,29]
Learning tasks should be structured by step-by-step increasing
complexity and decreasing guidance in learning.[30] 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.[31,32] Role players can adjust
the difficulty of the interaction according to learners’ needs,[32]
for example by acting as defensive and superior counterpart
or collaborative partner. After learners are ‘ready,’ they can
try out negotiations in real encounters,[21] then Leary’s Rose
is used to reflect their experience.
Finally, Leary’s Rose can be applied within different theoretical
frameworks [33] and combined with other tools in inter-
professional collaboration.[34] For example one can combine
Leary’s Rose with Situation, Background, Assessment and
Recommendation (SBAR), a tool to help structure clinical
communication among professionals.[35] 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.
58
Real setting
Students in clinical rotation, residents, professionals
Mentor/supervisor/clinical instructor with prior training in communication skills
Workplace (e.g. inpatient ward, outpatient clinic)
Learners are asked to reflect on their prior negotiation experience from the
workplace and map them using the LearyÊs Rose
to practice them in the workplace in real negotiations with other health
professionals. This encounter is observed by clinical instructor or supervisors.
Afterwards, they are to reflect on their performance using LearyÊs Rose.
Feedback is also provided by teachers and peers.
encounters
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),
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Susilo, et al.: LearyÊs Rose to Improve Negotiation Skills
Health Professionals Education Quality Workshop in Bali, Indonesia
(2011) and Communication Skills Training for Pharmacists, University
of Surabaya, Surabaya, Indonesia (2011).
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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.
Source of Support: Nil. Conflict of Interest: No.
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