The Texas Tech University – HSC – School of Pharmacy is accredited by The Accreditation Council For Pharmaceutical Education (ACPE) as a provider of continuing Pharmaceutical Education. Course Administered By: J&D Educational Services, Inc PO Box 130909 The Woodlands, Texas 77393-0909 Voice: 1-866-747-5545 Fax: 1-281-298-8335 www.jdeducation.com

INTERPERSONAL RELATIONSHIPS AND COMMUNICATION IN A PHARMACY SETTING A Knowledge Based Program for Technicians By Jeff Blackburn, MBA – Healthcare Administration, C.Ph.T.

ACPE No. 0096-9999-09-018-H05-T Release Date: 4/6/2009 Expiration Date: 4/6/2012 Total number of pharmacy continuing education hours: 6 hours (0.6 CEU’s)

Course Cost:

$19.00 (to be paid at time of testing)

Average time to Complete:

Approximately Six hours including testing

Course Value:

Six Contact Hours

Reading:

44 Pages

Final Exam:

50 Questions

Completion Requirements:

Answer 70% of questions correctly. Complete Eval.

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Table of Contents I.

Introduction

II.

Importance of Communication Skills

III.

Model of Communication

IV.

Potential Barriers to Pharmacy Technician Communication

V.

Verbal Communication Skills

VI.

Nonverbal Communication Skills

VII.

Written Communication

VIII.

Conclusion

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Course Objectives: 1. Explain the importance of communication skills. 2. Briefly discuss the principles of communication. 3. Give an overview of one model of communication. 4. Discuss some of the potential barriers to communication. 5. Give an overview of verbal communication skills. 6. Give an overview of nonverbal communication skills. 7. Give an overview of written communication skills.

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Introduction Communicating with someone is far from “just talking” to him. In fact, people may hold several false assumptions regarding communication. For example, many people assume that when children learn to talk, they also learn to communicate well. Another is that good communication is part of one’s personality, that good communication skills come naturally. These are just a couple of misconceptions about communication skills. At some point, if it has not happened already, communication skills will become an important part of the success you have as a pharmacy technician. As you continue to develop in your profession, you must also learn to evaluate your communication skills and improve them when necessary. Personality is a factor in communication style, but people can learn to be better communicators. Although there are necessary skills to master, you should definitely by yourself when you are talking to others, especially in a professional setting. People can pick up on whether or not you are sincere. Trying to fake an interest in someone else’s life is usually transparent. If a co-worker or customer senses your lack of interest, they are unlikely to cooperate with you or give you the information you need. Pharmacy technicians interact with people from all different backgrounds, all in the same day. You may have to talk to customers/patients/, nurses, pharmacists, and other pharmacy technicians, depending on your chosen practice site. This course focuses on communications with customers/patients and employees / employers. After a discussion of the principles of communication skills and a review of a model of communication, sections in this course are devoted to oral communication, barriers to communication, nonverbal communication, education, and written communication. Some of you may feel you already know everything you need to know, but applying communication techniques in a pharmacy is different than in social settings, so hopefully you will pick up a few good ideas to help you develop professionally. As you read, try to leave you assumptions aside and envision how you can use these skills in you daily communication.

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Principles of Communication Interpersonal communication is a common but complex practice that is essential to health care providers. This section describes the process of interpersonal communication as it relates to pharmacy practice and helps determine what happens when one person tries to express an idea or exchange information with another individual. In our personal and professional lives, we need to interact with many people. Some of these interactions are successful, while others are not. In most communication encounters, we typically do not have the opportunity to stop and analyze the situation. However, to improve our communication skills we need some ability to assess a particular situation quickly. Components of the Communication Model Communication encompasses a broad spectrum of media, for example, mass communication (TV, radio), small-group communication, and large-group communication (lectures, speeches). This course will focus on one-to-one interpersonal communication. This specific form of communication is best described as a process in which messages are generated and transmitted by one person and subsequently received and translated by another.1 This model includes five important elements: sender, message, receiver, feedback, and barriers. The Sender In the interpersonal communication process, the sender transmits a message to another person. The Message The message is the element that is transmitted from one person to another. Messages can be thoughts, ideas, emotions, information, or other factors and can be transmitted both verbally and nonverbally. For example, by looking down at the ground and mumbling rather than speaking clearly, the speaker might be expressing embarrassment, shyness, or hesitancy to talk with you. As we will discuss later in greater detail, the nonverbal component of communication is important. Research has found that in some situations 55% or more of a message is transmitted through its nonverbal component. In most situations, senders formulate or encode messages before transmitting them. However, in some cases, messages are transmitted spontaneously without the sender thinking about them, such as a glaring stare or a burst of laughter.

1

Shannon CE, Weaver W. The Mathematical Theory of Communication. Urbana: University of Illinois Press, 1949.

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The Receiver The receiver (the person being spoken to) receives the message from the sender. As the receiver, you “decode” the message and assign a particular meaning to it, which may or may not be the intended meaning. In receiving and sending messages, you should consider both the verbal and the nonverbal components of the message. Feedback Feedback is the process whereby receivers communicate back to senders their understanding of the sender’s message. In most situations, receivers do not passively absorb messages; they respond to hem with their own verbal and nonverbal messages. By using verbal and nonverbal communication, the receiver feeds back information to the sender about how the message was translated. In the feedback loop, the initial receiver becomes the sender of feedback, and the initial sender becomes the receiver of feedback. In the interpersonal communication process, individuals are thus constantly moving back and forth between the roles of sender and receiver. Feedback can be simple, such as nodding your head, or complex, such as repeating a set of complicated instructions to make sure that you interpret correctly. Feedback allows communication to be a two-way interaction rather than a one-way monologue. During the communication process, most of us tend to focus on the message and frequently miss the opportunity for feedback. As receivers of messages, we fail to provide appropriate feedback to the sender about our understanding of the message. On the other hand, as senders of messages, we fail t ask for feedback from the receiver or in some cases ignore feedback provided by others. Consequently, we are led to think that a particular communication was more effective than it really was. Being sensitive to others can strengthen our ability to receive and provide useful feedback. Barriers Communication is usually affected by a number of interferences or barriers. These barriers affect the accuracy of the communication exchange. For example, a loud vacuum cleaner running in your pharmacy while you are waiting on a customer could make it even more difficult to understand what your customer is trying to communicate. Other barriers might be a safety glass partition between you and the customer (especially in a drive-through pharmacy) or telephones ringing in the background. Barriers can be so detrimental to communication that we will devote an entire section to them later in this course. Responsibilities As a sender, you are responsible for ensuring that the message is transmitted in the clearest form, in terminology understood by the other person, and in an environment favorable to clear transmission. In other words, try and know who you are speaking to

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and communicate in such as way that is clear and comfortable to the receiver. To check whether the message was received as intended, you need to ask for feedback from the receiver and clarify any misunderstandings. Your obligation as the sender of a message is not complete until you have determined that the other person has understood the message correctly. As a receiver, you have the responsibility of listening to what is being transmitted by the sender. To ensure accurate communication, you should provide feedback to the sender by describing what you understood the message to be. Many times, we rely on our assumptions that we understand each other and thus feel that feedback is not necessary. However, without appropriate feedback, misunderstandings frequently occur. Of concern is that as pharmacy technicians dealing with customer/patients, pharmacists, nurses, and other healthcare providers, we cannot afford these misunderstandings. If we do not fully understand the instructions of a supervising pharmacist, for example, these misunderstandings might result in harm to the patient. To become more effective, efficient, and accurate in our communication, we must strive to include explicit feedback in our interactions with others. The Meaning of the Message The communication model shows how messages originate from a sender and are received by a receiver. The sender delivers the message and the receiver assigns a meaning to that message. The critical component in this process is that the receiver’s assigned a meaning must be the same as the message intended by the sender. In other words, we may or may not interpret the meaning of the various verbal and nonverbal messages in the same way as the sender intended. Words and Their Context In general, individuals assign meaning to verbal and nonverbal messages based on their past experiences and previous definitions of these verbal and nonverbal elements. If two persons do not share the same definition or past experiences, misunderstanding may occur. The most common example of this is evident in different languages and dialects of the world. Different words mean different things to different people bas on the definitions learned. For example, “football” to an American means a sport using an oval ball, but “football” to a European means a sport using a round ball (soccer). An example of this misunderstanding occurs in health care when we speak in medical terminology that may have different (or possible no) meaning to our patients/customers. Another example if the huge number of acronyms we use in healthcare. It is easy to forget that many people have not idea what these mean. Another important factor is that people assign meanings based on the context that they perceived the sender is using. Often patients/customers understand the words that we are using but place them in a different context. Thus, they may assign a meaning to our message that is different from the one intended.

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The social context also influences how messages are received and interpreted. The type of relationship that you have with your customer/patient or co-worker can determine the level of acceptance they have regarding the information provided. In summary, people base their interpretation of verbal and nonverbal messages on a variety of factors. These factors include their definitions and perceptions of the words, symbols, and nonverbal elements used by the sender. In reality, the final message is not what is said, but what the receiver perceives was said. Misunderstandings Minimizing misunderstandings can be very difficult in a healthcare setting. We often assume that the receiver will interpret our message accurately. To improve the communication process, we must remember that people assign meanings to messages based on their background, values, and experiences. If other persons have different backgrounds, values, and experiences, they may assign a different meaning to our intended message. Many of our problems in communication occur because we forget that individual experiences are never identical. In actual practice, we have enough common experiences with people we deal with on a daily basis that we can understand each other fairly well. A key to preventing misunderstanding is anticipating how other people may translate your message. In many communication interactions, the more you know about other people and the more you are able to understand them, the easier it will be to anticipate how they may interpret the meaning of the message. Using Feedback to Check the Meaning of the Message Predicting how a person will translate a particular message is difficult. Providing feedback to check the meaning of the message may alleviate some communication misunderstandings. As senders of messages, we should ask others to share their interpretation of the message. We typically do not ask for feedback from customers or co-workers to check their perceptions of the meaning of our messages. Verifying the fact that the receiver interpreted the intended meaning of our verbal and nonverbal messages accurately takes additional time and is sometimes awkward. Most people rely on their own intuition as to whether their intended message was received correctly. Unfortunately, relying on our intuition is not as effective as obtaining explicit feedback to measure understanding. The preceding paragraph describes ways to minimize misunderstanding from the sender’s perspective. However, the receiver can also alleviate some misunderstanding by offering feedback to the sender. After receiving the message, the receiver should indicate in some way what she understands the message to be. It could be something as simple as a nod, or perhaps summarizing key information.

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Perceptions Perception is important in the process of communication because we tend to interpret messages based on our perception of 1) what we believe the message says and 2) the individual sending the message. Thus, perceptual barriers need to be identified and minimized or we will misinterpret what we hear. We need to recognize how fragile the communication process is during professional communication and to value the use of feedback. One skill that minimizes perceptual differences is to use terms and concepts that are familiar to the patient. It is very easy for patients to misunderstand when you use medical terminology or language that is overly abstract, such as “drink a lot of fluid.” What does “a lot” mean? A glass? A cup? Broad, nonspecific directions do not really help people understand what you want to communicate. You may also recognize gender differences and cultural differences that may lead to misperceptions. Individuals Our perception of the message is also influenced by our perception of the individual sending the message. How we perceive the sender affects the interpretation of the message. We respond using our perception of that individual as our reference point because we tend to be influenced by a person’s cultural background, status, gender, or age. These perceptions are further influenced by any bias we have or stereotype we hold of certain groups of individuals. The following statements are examples of such generalizations: • •

“Nurses always complain about pharmacist.” “Elderly people do not comply with their medication regimens.

Sometimes we do not see the person as a unique individual but as a representative of a particular group. We build “perceptual barriers” to the communication process not based on fact but on our inferences based on stereotypes. Unfortunately, these barriers inhibit true communication between individuals. Summary The communication model reveals that you must recognize that communication is more than merely speaking to others. You must make sure that the messages you transmit to others are received accurately. There is no guarantee that the meaning of your message will by translated as intended. You need to make sure that you enhance your listening skills so that you can become a better receiver of messages as well.

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Barriers to Communication Within the communication process, numerous barriers exist that may disrupt or even eliminate communication. Given the large number of potential barriers that exist in pharmacy practice settings, it is a wonder that any communication takes place at all. The key is to identify when barriers exist and then develop strategies that minimize them. As discussed earlier, the communication process involves five essential elements, the sender, the message, the receiver, feedback and barriers. If any of these elements is not working properly, there may be a break down in communications. The message must be clearly sent by the sender and received accurately by the receiver. Feedback that verifies understanding must also be related. The fifth element, barriers, is often overlooked. Many things seem to get in the way when you try to communicate with someone else. Some issues are rather obvious, while others are not. Minimizing communication barriers typically require a two-stage process: first, you must be aware that they exist. Second, you need to take appropriate action to overcome them. To become an effective communicator, it is essential that you realize when you are not communicating effectively with another person and then try to analyze why effective communication is not taking place. Environmental Barriers The environment in which communication takes place is critical in pharmacy practice, and distractions within the environment often interfere with this process. One of the most obvious barriers in most community practice settings is the height of the prescription counter separating patients from pharmacy personnel. These prescription counters exist for three primary reasons: 1) They provide an opportunity for pharmacy staff to look over the store area periodically. 2) They provide an opportunity for patients to identify where the pharmacy is located. 3) They provide a private area in which the staff can work. Unfortunately, in some situations, patients cannot see pharmacy personnel behind these strategically placed partitions or counters. It is difficult for patients to talk with individuals they cannot even see. These counters may intimidate some patients and inhibit communication because the pharmacy staff is standing over them. Many pharmacies provide areas where the counter is lower to facilitate patient interactions. Crowded, noisy prescription areas also inhibit one-to-one communication in many practice settings.2 Many pharmacies tend to have significant background noise, such as people talking or music playing. These noises interfere with your ability to communicate 2

Beardsley RS, Johnson CA. Wise G. Privacy as a factor in patient counseling. Journal of American Pharmaceutical Association NS17: 366-368, 1977.

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with customer/patients. In addition, other people may be within hearing range of your conversation, which limits the level of perceived privacy for the interaction. Noise also interferes with your ability to use the phone effectively whey trying to communicate with customers and others. Personal Barriers Many personal characteristics can lead to distractions in communication. Lack of confidence in your personal ability to communicate effectively may influence how you communicate. If you believe that you do not have the ability to communicate will or are rather shy, you may avoid talking to others. Many people feel that an effective communication style is something you are born with and may use shyness as an excuse to avoid interacting with others. Unfortunately, people do not realize that communication skills can be learned and developed. However, like other skills, they require practice and reinforcement. Positive reinforcement is critical since many times you may experience negative reinforcement in your attempts to communicate. For example, what might happen if you get into a heated argument with a customer who appears to be unreasonable and rude? Would you be excited to talk to the next customer? Probably not. What might happen if you felt you were taken advantage of by a colleague when you agreed to do something that you really did not want to do? Would you feel like avoiding this individual in the future? These negative experiences may influence you personal desire to communicate and your self-esteem regarding interactions with others. As with most situations, future is based on past experiences – if you have had good experiences in the past, you will be more confident when facing future encounters. You must remember that there are not expert communicators: no one communicates perfectly 100% of the time. There will always be situations where communication could have gone better; you should not be discouraged when it does not go as planned. However, you must still strive to improve your communication skills by constant practice and reflection on your strengths and weaknesses. Another personal barrier for many people is personal shyness. Individuals with high levels of shyness tend to avoid interpersonal communication in most situations, including interactions with customers, co-workers or others. These individuals have a high level of anxiety associated with communication with others. Many people feel that personal shyness is culturally based or may be linked to the inability to speak a second language. However, it goes beyond cultural issues and affects many native-born individuals as well. Overcoming this barrier requires time and effort, and, many times, professional assistance. Another personal barrier to communication is the internal conversation you may have within yourself while talking with others. For example, while you are listening to someone, you may be thinking to yourself about how you want to deal with this situation. You might be thinking, “What is this person talking about?” or “I’m too busy to deal with her right now.” This internal conversation may limit your ability to listen effectively as you focus on your own thoughts rather than on what the other person is saying. Often these internal conversations result in prejudging others or coming to a hasty conclusion

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about the perceived problem and suggested solution. Internal messages are essential, because they allow you to sort things out while you are communicating. However, they become distracting if allowed to take precedence over what the person is actually communicating. It is difficult to recognize when you are more preoccupied with your own thoughts than with listening to the other person. It is essential to become aware of this habit because it can inhibit your ability to listen and can make you appear to be disinterested and rude. Another potential personal barrier involves emotional objectivity. While talking to patients/customer, you may be tempted to take on their emotional burdens. Many customers whom you will serve have multiple, complex problems, and you may be enticed to try and help them resolve emotional issues. You should remain empathic towards your customers, but not get so involved that you carry their emotional burdens as well. Culturally based factors may also serve as personal barriers to effective communication. For example, in some cultures it is not proper to engage in eye contact during communication. Such behavior would be labeled as disrespectful; while in other cultures, direct eye contact is appropriate and is almost required. Other barriers related to culture include: • • • • •

Definitions of illness (some patients may not perceive themselves to be ill) Perceptions of what to do when ill (some cultures stress self-reliance rather than seeking help) Health-related habits or customs (eating habits) Health-seeking behavior (some cultures place more reliance on folk medicine) Perceptions of health care providers (based on possible distrust of the health care system or past negative experiences)

It is important to recognize that these and other cultural barriers may exist in the customers you serve. Other personal barriers exist in situations where you may not be completely sure how to respond. For example, you may not know exactly what to say when a cancer patient expresses a fear of dying. Or you may feel awkward when you need to talk to your superior about a stick personnel problem at work. These personal fears or anxieties may put tremendous pressure on you to “say the right thing” and cause you to avoid interacting with others. Experience has shown that many times people tend to blow these types of situations out of proportion, making issues larger and more difficult than they really are, and once they overcome their anxiety and eventually interact with others, the situations often turn out better than expected.

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Conclusion Interpersonal communication, because of its complexity and human involvement, is a fragile process. Messages become helpful to others only when they are accurately received and understood. If messages are distorted or are incorrect, they actually may be harmful to interpersonal relationships. Barriers may lead to distortion of messages and misunderstandings between you and others. It is important to recognize the potential barriers involving the environment and personal issues, and then develop strategies to minimize or remove them.

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Verbal Communication Skills As we can see from the model of communication, there are many components to an interaction with another person. In order to have an interaction, we must be able to act as senders and receivers of messages. In order to do this, we must develop certain skills. They include listening, responding, phrasing questions, and assertiveness. There are other equally valuable skills that are also necessary in communicating verbally, but we are going to focus on skills most useful in a pharmacy setting. Listening When we think about skills of effective communication, we probably think first of the skills involved in speaking clearly and forcefully, in having an effect on other based on what we say. However, an equally critical part of the communication process, and perhaps the most difficult to learn, is the ability to be a good listener. The best way to show your commitment to developing and maintaining relationships with those you work with, whether customers/patients or co-workers, is to listen to them. Listening, like communication in general, does not come naturally to most people. The first step to listening is to stop talking. In order to listen to someone, you must have an environment that is conducive to communication. Both nonverbal and oral communication can give someone the impression that you are in fact listening to them. Central to this idea is that you should not be distracted when you are listening to someone. In a busy pharmacy, it can be difficult to stop all tasks in order to listen to a customer or co-worker, but unless the customer has your undivided attention, you will have a difficult time understanding them. Besides trying to do two things at once, other communication habits can interfere with your ability to listen well. Planning ahead to what you will say next interferes with actively trying to understand the meaning of the communication. Jumping to conclusions before the sender has completed his message can lead to only hearing parts of messages. Focusing only on content, judging the person or the message as it is being conveyed, faking interest, communicating in stereotyped ways – all cause us to miss much of the meaning in the message people send us. When listening to another person, one must attempt to truly understand her point of view and then convey that understanding to her. Several methods exist for demonstrating understanding. By responding to the person in a manner that demonstrates that understanding, you are communicating that you have in fact heard what she has to say. In a health care setting, it is common want to solve problems or to want to tell people how to handle their situations.

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Types of Responses Empathy Empathy is communicating back to the sender that you understand their feelings, and then a caring, trusting relationship can be established. Empathy conveys understanding in a caring, accepting, nonjudgmental way. An empathic response goes beyond an understanding response to address the feelings that underlie a statement. This type of response demonstrates not only that you heard and understood what the person said but also that you recognize the emotions that led her to say what she did. Empathy is a useful tool. It can be most helpful when you may feel that you do not know what to say or that you cannot do anything to help the person. By recognizing and responding to the feelings the person has, you are demonstrating true listening and also caring. It is important to note that empathy is difficult if not impossible to fake. People can easily see through a false attempt at empathy and are likely to respond negatively to it. Unless you are genuine in your willingness to understand and relate to another person, empathy will be difficult to master. Another essential condition is respect for and acceptance of the sender as an autonomous, worthwhile person. If you convey an ongoing positive feeling for people, they may be more open with you since they do not fear being judged. One of the biggest blocks to effective communication is our tendency to judge each other. If we think that another will judge us negatively, we feel less willing to reveal ourselves. Acceptance and warmth, if it is genuine, will allow people to fee free to be more open in their communication with you. The main difference between an empathic response and a paraphrase (discussed later) is that empathy serves primarily as a reflection of the sender’s feelings rather than focusing on the content of the communication. In most cases, an empathic response is a beginning to a dialogue. It is not the only thing you will say to the patient. As you first recognize people’s feelings and demonstrate your understanding, people will be reassured of your sincere caring about his or her concern. Empathy Can Be Learned This is a widespread belief that empathic communication skills are not something one can learn. The belief is based on the notion that you either are an empathic person or you are not. As with any new behavior, learning to alter existing habits or responding is very difficult. Pharmacy technicians who are not accustomed to conveying their understanding of the meaning of illness or treatment for their customers/patients will at first feel awkward using empathic responses. As with any new skill, being an empathic listener must be practiced before it becomes a natural part of how we relate to others.

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However, empathic communication skills can be learned if individuals have value systems that place importance on establishing therapeutic relationships. As health care providers, we must develop communication skills that allow us to effectively convey our understanding and caring. Judging A judging response is made when one tells someone that he should not have the feelings he does about a particular situation. Alternately, a judging response may also tell someone that he should feel a certain way. Judging responses are not effective because they invalidate a person’s feelings. While conveying understanding seems so obviously a part of good communication, a judging response can happen even if you are well meaning. You might say something as simple as “You shouldn’t worry.” Any message from you that indicates you think the sender is “wrong” or should not feel the way they do will indicate that it is not safe to confide in you. Reassuring Another type of response that is less desirable is a reassuring response. “Don’t worry about it; I’m sure you’ll manage to figure out something” is an example of a reassuring response. Like the judging response, it tends to invalidate the feelings a person is having. Although given with the best intentions of making someone fell better; a reassuring response is not usually helpful. It is unlikely that you are truly able to know how things will work out. Therefore, by suggesting that everything will be all right, you are offering false reassurance. This type of response is often given when one is unsure how to respond. In that situation, it is usually better to respond empathically. Another word for this is called placating. Probing Another type of common response is the probing response. Probing responses are usually in the form of a question designed to elicit additional information. Although probing questions do have their place, a probing response to a situation where a person may be upset is not the best option. For example, if a customer is upset because he feels that he is spending too much for a prescription; your response might be “How much are you spending each month.” This response does not address the patient’s main concerns about the cost of his medication. Rather, it redirects the interaction. Healthcare professionals often use this response in an attempt to help the patient solve the problem at hand. Although well intentioned, this type of response does not give the patient the satisfaction of feeling understood. In gather information, a probing question is helpful, but when you are trying to convey that you are listening to someone, it falls short. Often people simply want to be able to express their feelings and know that we understand.

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Generalizing A generalizing response is one that, as the name suggests, generalizes what the sender may be feeling. This response takes the focus away from the person. Another way in which we try to reassure people is by telling them “I’ve been through the same thing and I’ve survived.” While it is comforting to know that others have had similar experiences, this response may take the focus away from the customer’s experience and onto your own experience before they have had a chance to talk over their own immediate concerns. It can also lead you to stop listening because you jump to the conclusion that, since you have had an experience similar to the sender, she is feeling the same way you felt. This may not, of course, be true. Distracting A distracting response is a response that does not acknowledge what the person has said. Many times we get out of situations we don’t know how to respond to by simply changing the subject. Like the other responses discussed here, this type does little to convey that you care about the patients feelings. Often this response is used when one has difficulty dealing with the subject matter at hand or does not feel comfortable exploring the issue at hand. Again, an empathic response is most likely to make the person feel at ease and understood. Advising This type of response suggests what a person should do. For example, the pharmacy technician may say, “You should find a better health insurance company; one that covers prescriptions.” As healthcare professionals, many times we cannot help but offer advice. After all, part of our job is helping people. However, unless there is something you can do to directly solve the problem; you should refrain from advising responses. You may find offering alternatives is a way of helping the person identify their own solution. Often there is little, if anything, you can do to solve the patient’s problem, but conveying that you have heard and understood it can go a long way in helping him or her feel better. Understanding As the name implies, this type of response allows a person to convey his understanding of a message. This can be considered a response in which paraphrasing is used such as “I understand you feel the prescription prices are too high.” You are paraphrasing what the customer has already said in order to demonstrate an understanding of the patient’s statement. This can be a helpful tool. In fact, it is essential that you understand the message you are attempting to receive. Therefore, if clarification is necessary, you will be sure to get it. This type of response can help minimize misunderstanding. Only in this type of response is there any indication that you truly understand the basis of the sender’s

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concern. By using such a response, you convey understanding without judging as right or wrong, reasonable or unreasonable. In practice, this type of response should be used with caution. You may not completely understand the patient’s concern or situation, and implying that you do may make the patient feel uncomfortable. Like the generalizing response, although you may have had similar experiences, you will never be able to fully appreciate the sender’s experience. To say you understand or suggest that you do may offend some people. Phrasing Questions The way a question is phrased impacts the amount and type of information one receives in response. A close-end question, for example, is a question that is phrased to elicit a “yes” or “no” response. One example of a closed-end question is “Have you had prescriptions filled with us before?” The customer responding to this question may either say “yes” or “no” but is unlikely to provide any additional information. Close-ended questions are useful when you are following up on information you already have. There are times when a close-ended question is appropriate, such as when probing for additional information or when you need to have something confirmed. An example of this may be when you check your understanding of information a customer has provided. You might say “Is the address on your prescription correct?” Contrast this style of question with an open-ended one. An open-ended question is a question that allows the person responding to elaborate on the topic. This is particularly useful when you would like to get as much information as possible. One way to phrase an open-ended question is to begin with the word “how.” For example, “How were you getting your refills before this?” provides the customer with the opportunity to talk about their previous experience and well help you understand where they are coming from. When asking customers, or even co-workers, open-ended questions, one should avoid beginning with the word “why.” For example, asking a customer “Why didn’t you call for a refill before you ran out of medication?” may put her on the defensive. The customer may feel you are accusing her or suggesting that she is in some way at fault. To follow open-ended questions, probing questions can be used. A probing question helps you gather information along the lines of the open-ended question. Often, these are closed-ended questions, yet they can also be open-ended. One type of question that is common among healthcare professionals but is best to avoid is the leading question. A leading question is phrased such that it prompts a patient to answer a certain way. Healthcare professionals use these questions inadvertently, because they have an idea in mind about what the patient is experiencing. For example, when a pharmacy technician says to a patient, “You don’t have any questions for the pharmacist, do you?” he implies that the patient should say that she does not in fact have any questions for the pharmacist. Contrast this with the following way of phrasing the same question. If the pharmacy technician were to say “Would you like to ask the

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pharmacist any questions?” the patient is likely to perceive that he or she does have the option of speaking with the pharmacist. It is of particular significance to avoid leading questions when discussing sensitive subjects such as noncompliance. For example, if a patient is consistently late refilling their medications and complaining about the high cost, a pharmacy technician might be tempted to ask “It’s not like you can’t afford this medication is it?” The patient might become flustered and respond “No, of course not.” Although the technician may feel he was asking if she had financial concerns about her medication, the patient perceived the question as judgmental and was unable to respond truthfully. Had the technician phrased the question differently, such as “Is it sometimes difficult to pay for the medication all at once?” perhaps the patient would have felt more comfortable discussing her financial situation with him. This would have allowed the pharmacy to solve the problem by working out a payment schedule or by having the pharmacist contact the physician for a less expensive therapeutic option. Assertiveness Assertiveness is perhaps best understood by comparing it with two other response styles: passively and aggression. Often aggression is confused with assertion, but it is a very different behavior. These three styles of responding are described below. Passive Behavior This response is designed to avoid conflict at all cost. Passive or nonassertive persons will not say what they really think out of fear that others may not agree. Passive individuals “hide” from people and wait for other to initiate conversation. They put the needs or wants of other people above their own. They tend to have a great deal of anxiety in relationships. They worry about how others will respond to them and have a high need for approval. Problems arise when people who behave passively feel secretly angry or resentful toward others. Passive persons may see themselves as victims who are subject to the manipulation of others. It is this view that is damaging to their self esteem. Aggressive Behavior Aggressive people seek to “win” in conflict situations by dominating or intimidating others. Aggressive persons promote their own interests or points of view but are indifferent or hostile to the feelings, thoughts, or needs of others. Often aggression seems to work as others back down in order to avoid prolonging or escalating the conflict. Because aggressive behavior may have beneficial effectiveness in the short term, individuals may be reluctant to give up aggressive strategies. Often people who turn to aggression to reach their goals have a distorted view such that they constantly perceive themselves to be in threatening situations, to be under personal attack, or to be plagued by others trying to thwart their efforts. Such individuals are easily angered and have a low tolerance for frustration. They seem to believe that they should not have to experience frustration. Rather than the rational experience of disappointment, the

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aggressive person responds with indignant anger. Rather than helping to resolve the problems, “getting it off your chest” usually serves to escalate the anger and aggression. While others may give in to the intimidation of aggressive individuals initially, they can also act in subtle ways to “get even”. For example, patients who do not feel they are treated with respect in a community pharmacy may not return to that pharmacy and may tell friends about their negative experience. Employees who feel helpless and undervalued can sabotage the goals of their employers in a variety of indirect ways. Thus, aggressive individuals may “win” certain interpersonal battles in the short term, but their behavior often leads to negative long-term consequences. Unfortunately, many aspect of our culture (media, television, movies, politicians) reinforce the notion that he way you get your way is to use aggressive behaviors. You push your personal agenda without regard to other individuals’ perspectives. Although, people may achieve their own personal objectives using aggressive approaches, these strategies do no build trusting relationships, which is a key element to working in a professional practice. To be more effective in the long run, you must learn how to focus your energies using assertive, no aggressive behaviors. Assertive Behavior Assertive behavior is the direct expression of an idea, opinions, and desires. The intent of assertive behavior is to communicate in an atmosphere of trust. Conflicts that arise are faced and solutions of mutual accord are sought. Assertive individuals initiate communication in a way that conveys their concerns and respect for others. The goal of communication is to stand up for oneself and to solve interpersonal problems in ways that do not damage relationships. Assertiveness requires that your respect others, as well as yourself. Conflict is inevitable in human relationships. While conflict is usually viewed as undesirable, the process of resolving conflict can lead to growth and increased understanding and respect for others, in spite of differences. Problems arise when conflict leads us to view others as “opponents”, when power differences are exploited, or when problem-solving discussions become unfocused with side issues brought in to derail the conversation. A critical factor in being assertive is the ability to act in ways that are consistent with the standards we have for our own behavior. When we tell ourselves that other people “make” us feel or act a certain way, we are not taking responsibility for our own behavior. Instead of changing ourselves, we try (unsuccessfully) to get others to change. As Mark Twain said, “nothing so needs reform as other people’s habits.” However, the only power we have to effect change in any relationship is to change our own behavior. For example, you may wish that your boss, who tends to be very negative during performance reviews, was more supportive of your work. However, just hoping that she would be more positive in her evaluation will not resolve the issue. You must take active

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steps to change how you respond to her criticism rather than waiting for her to change her approach. Too often, our goals in communication are defined in terms of what we want others to do rather than what we will do. For example, we might say that we want pharmacists to appreciate the role of the pharmacy technician in patient care. Redefining this goal would have us focus on what specific things we can do to improve our working relationships with pharmacists. If we tell others our goal in providing pharmaceutical care services and show them by our behavior what we want to achieve, many will come to respect our position. However, even if we fail to convince a pharmacist that the role we play in patient care is of value, it does not mean that we have failed in reaching the goals we have set for our own communication. When our goals focus on what we will do, we have control over our ability to meet these goals. Research has shown that a number of skills are needed for assertiveness communication. These include initiating and maintaining conversations, encouraging assertiveness in others, responding appropriately to criticism, giving negative feedback acceptably, expressing appreciation or pleasure, making requests, setting limits or refusing requests, conveying confidence both verbally and nonverbally, and expressing opinions and feelings appropriately. Assertiveness Techniques3 There are a number of communication techniques or strategies that are useful in responding to situations that tend to be conflict-ridden. Providing Feedback Letting others know how you respond to their behavior can help to avoid misunderstandings, and also help to resolve the conflicts that are inevitable in relationships. However, providing honest feedback when you have a negative reaction to another person’s behavior is difficult to accomplish without hurt feelings. Many times you must tell people that you are upset by what they did in order to improve your relationship in the long run. When you choose to convey negative feedback to others, use techniques to make the communication less threatening. Criteria for useful feedback include: • • •

Feedback focuses on a person’s behavior rather than personality. By focusing on behavior, you are directing the feedback to something the individual can change. Feedback is descriptive rather than evaluative. Describing what was said or done is less threatening than judging why you assume it was done. Feedback focuses on your own reactions rather than the other person’s intentions. Assigning blame is not part of constructive feedback.

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Tindall WN, Beardsley RS, Kimberlin CL. Communication Skills in Pharmacy Practice, Malvern, PA: Lea & Febiger, 2007.

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Feedback uses “I” statements that take the form “When you [do or say] _______. I fell _____.” For example, when you are late for work, I feel frustrated and angry” is less damaging than “You’re irresponsible. You don’t care about your co-workers covering for you when you are late.” Feedback is specific rather than general. It focuses on behavior that has just occurred and avoids dragging past behavior. It also does not over-generalize from the specific instance that has upset you (e.g., “you always do ___”). Feedback focuses on problem solving. The intent is not to let off steam. The intent is to solve a problem in a relationship so that the relationship can be improved. Feedback is provided in a private setting.

Inviting Feedback From Others We need to work on providing feedback in an appropriate manner. At the same time, we need to invite feedback from others in order to improve our interpersonal communication skills. If you manage other pharmacy technicians, you should let employees know that you welcome suggestions from them on how to improve pharmacy operations. Your ability to hear criticism or suggestions without defensiveness or anger, to admit when you have made a mistake, and to encourage feedback from others (even when it is negative) encourages people to be honest in their communications with you. They also allow you to identify areas of your professional practice that may need improvement and promote better relationships with others. Setting Limits For some people, setting limits on how we will spend our time is a source of frustration. We have difficulty saying “no” to any request. As a result, we feel overwhelmed and often angry at others for “taking advantage” of us. Being assertive in setting limits means that you take responsibility for the decisions you make on how to spend personal resources without feeling resentful toward others for making requests. Being assertive in setting limits does not mean that you stop saying “yes” to requests. You will no doubt continue to help others, even though doing so may be an inconvenience, because of the value system you hold and your desire to help others when they need help. When faced with a request, the first step is to decide how much you are willing to do in meeting this request. If you need time to decide, delaying a response is appropriate as long as you get back to the person within the time frame you specify. Often a response may not be “yes” or “no”, but an offer to partially meet the request. Saying “no” or setting limits may be particularly difficult if you believe that the other person must agree that you have a good reason for saying “no.” If feelings of guilt trap you, you may not want to provide specific reasons fro your decision. Whether you give reasons or not does not change the fact that you have the right to make the decision on how you will spend personal time and resources.

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Making Requests Asking for what you want from others in a direct manner is also necessary in healthy relationships. If you are in a management position, clearly communicating your expectation of others is an important part of carrying out the goals for your organization. In equal relationships, making requests, including asking for help, is an important part of honest communication. We must trust that others will be able to respond to our requests in an assertive manner, including saying “no”. We must not overreact when someone turns down our request in an assertive way. Being Persistent or Broken Record One important aspect of being assertive is to be persistent in assuring that your rights are respected. Often when you have set limits or said “no”, people will try to coax you into changing your mind. If you continue to repeat your decision calmly, you can be assertive without becoming aggressive and without giving in. This response of calmly repeating your decision is often called the “broken record’ response. This type of response can be difficult to employ when the other party responds aggressively. With this response, you are merely stating your position; not attempting to escalate the interaction into an argument. Neither are you conceding your point and allowing the other person to declare victory. This response will stop even the most manipulative person without assigning blame or escalating the conflict. Reframing Frames are “cognitive shortcuts that people use to help make sense of complex information”4 Reframing techniques described by Kaufman and colleagues include: • • • • •

Focusing on developing effective communication around a set of limited objectives. Examine the potential validity of the other person’s perspectives. Establish a common ground. Search for areas of agreement and focus on desired outcomes with a long-term perspective. Identify opportunities to explore solutions not yet pursued and opportunities for “trade-offs” or compromises. Identify differences that cannot be bridged and at the same time explore conflict reduction actions that can still be taken.

Ignoring Provocations Interpersonal conflict may elicit various ways of trying to “win” by attempting to humiliate or intimidate others. For example, patients who are angry or feeling helpless 4

Kaufman S., Elliot M, Shmueli D. Frames, framing, and reframing. The Conflict Resolution Information Source. September 2003.

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may lash out with personal attacks. Pharmacy technicians who feel unfairly criticized may respond in an aggressive or sarcastic manner. Interpersonal conflicts between health professionals are often marked by struggles for power and autonomy (“turf battles”). Ignoring the critical comments of others and focusing exclusively on solving underlying problems can do much to keep conflict from escalating to the point that relationships are damaged. Responding to Criticism For some of us, criticism is particularly devastating because we typically hold two common irrational beliefs: • •

That we must be loved or approved by virtually everyone we know. That we must be completely competent in everything we do and never make mistakes.

Since such perfectionist standards are impossible to achieve, we are constantly faced with feelings of failure or unworthiness. In some cases, we may even have a desire to “get even” by launching into a counterattack on the person levying criticism. The only way to counteract such feelings and to begin to cope reasonably with criticism is to begin to challenge the underlying irrational beliefs that lead us to fear the disapproval of others. Using Assertiveness to Deal with Difficult Situations Often you will be faced with situations in which people are being difficult. Examples may include with a patient is upset with something that has happened in the pharmacy or an employee is unhappy with an administrative decision. In each of these cases, in order to keep the situation from escalating into an argument, depending on your personality, you may be tempted to concede your point and allow the other person to have his or her way. In the extreme, this would be considered passive behavior. Although passive behavior is effective in avoiding conflict, it can create other problems by leaving situations unresolved. Some people may choose to handle the situation by fueling it and allowing it to escalate. This type of behavior would be considered aggressive. A mature, professional approach would be to handle these situations and other like them with assertiveness. Assertiveness allows you to maintain your position without responding aggressively to a situation. The following techniques can help you develop ways to respond assertively.5 Fogging Fogging is a technique with which you acknowledge the truth about a statement yet ignore the implicit value judgment contained with it. For example:

5

Tindall WN, Beardsley RS, Kimberlin CL. Communication Skills in Pharmacy Practice, Malvern, PA: Lea & Febiger, 2007.

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Supervisor: “You certainly spend a lot of time talking to patients when they pick up their prescriptions.” Pharmacy Technician: “You’re right, I do.” Supervisor: “Most technicians don’t spend that much time with customers.” Pharmacy Technician: “You’re probably right. They may not spend as much time as I do.” Such a response allows you to look at truths about your behavior without accepting the implied criticisms. The response makes it clear that your own standards guide your behavior without provoking a confrontation with the person levying the criticism. A fogging response differs from agreeing with the criticism (discussed later). Acknowledging the Truth Another technique is acknowledging the truth in criticism. When someone confronts you with a criticism or complaint, the natural tendency is to try to explain why you did what you did. This can sound defensive and may escalate the situation. For example, if a patient complains about the long wait for her prescription, you could respond by explaining that each prescription is processed in the order it was received and that there are several steps involved in filling a prescription. However, it is unlikely that the patient is interested in learning about the processing of a prescription. Rather, she is frustrated by the length of time it will take her to complete her task of picking up the prescription. By acknowledging that the wait is long, you are demonstrating that you understand her concern, but you are neither apologizing for it nor making excuses. In apologizing for the wait, you are behaving less assertively in your attempts to avoid conflict with this patient. If you begin to explain to the patient the entire process for accurately and safely filling a prescription in an attempt to justify your position, it will appear that you are becoming defensive about the situation. This would illustrate a more aggressive response to the patient. The truth of the matter is that the patient may have to wait a long time for her prescription. In responding to her, acknowledging the truth of the situation will be beneficial. The patient will notice that you are not attempting to disagree with her or change her mind about her perception of the situation. She will also notice that you are not going to be able to do anything to change the situation. Disagreeing with Criticism In contrast to those times when a criticism is valid, when you are confronted with criticism that is unfounded, it is equally important to disagree with it. Often criticism is not justified or is not appropriate because it is too broad; it is a personal attack rather than a criticism of specific behaviors, or it is based on value judgments that you do not agree with. If you consider criticism unfair or unreasonable, it is important to state your disagreement and tell why. For example, you came in late to work this morning and your boss is fuming. During his attack, he says “You’re always late. Nobody around here cares about the patients waiting to get prescriptions filled.”

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It is important to day to him: “You’re right, I was late this morning, and for that I apologize. But it is not true that I am always late. I know I was late one day last month but that is the only other time I can recall being late in the two years I have worked here. And it is not true that I do not care about the patients. I think the way I work shows them my concern.” Not speaking against something you consider to be a personal injustice or untruth leads to feelings of resentment and a loss of self-esteem for having kept quiet. Agreeing with Criticism If you consider the criticism you receive to be valid, the most straightforward response is to acknowledge the mistake. If it is possible to counteract any of the damage, then that is done. In any case, avoid “Yes, but…” responses that try to excuse behavior but lead to increased annoyance on the part of the other person. “Yes, I am late for work a lot, but the traffic is so bad” usually leads to an escalation of the conflict (“You’ll just have to leave home earlier!”). If you made a mistake and were wrong, acknowledge that. When you acknowledge mistakes and apologize for them, people have difficulty maintaining their anger. However, if you continue to make the same mistakes, the apologies will seem insincere and manipulative since you have not taken steps to prevent the problem from reoccurring. When you have issued a sincere apology, it also helps to report on efforts or changes you will make so the problem is not repeated. Getting Useful Feedback When you find that a criticism is vague, it is best to get useful feedback in order to understand the nature of the criticism. For example, if your supervisor tells you that “You don’t know anything about customer service,” it would be easy to become upset and disregard the comment entirely. However, the supervisor probably has something in mind that he would like you to work on. By asking the supervisor, “What specifically do I need to work on?” you will get the precise information you need. You can then use one of those assertive response techniques to deal with the situation. However, without an understanding of the true concerns, you would be unable to respond to the situation in an assertive way. Delaying a Response If the criticism takes you by surprise and you are confused about how to respond, give yourself time to think about the problem before responding. Few conflict situations call for an immediate response. If you are too surprised or upset to think clearly abut what you want to day, the delay a response. Tell the person: “I want time to think about what you’ve told me, and then I’d like to sit down with you and try to clear up this problem. Could we discuss this situation later in the day?”

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Conclusion Assertive responses, such as the types reviewed in this section are useful in many situations. With practice, they will come naturally to you and not feel so awkward. Being assertive allows you to avoid conflict and at the same time hold your position. This section has reviewed basic verbal communication skills, including listening, responding, phrasing questions, and assertiveness. These skills can be used to overcome many barriers to communication, both personal and environmental. We move now to a discussion of nonverbal communication skills. As we have seen from the model of communication, these too can play a dramatic role in the way messages are sent and perceived.

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Nonverbal Communication Skills In addition to specific oral questioning techniques, nonverbal cues help people interpret the meaning behind your words. Whether you are aware of it or not, people routinely consider the words they hear within the context of the accompanying nonverbal communication. Nonverbal communication can be defined as a message or messages that are conveyed without using language. It includes everything from the way you stand to the maintenance of eye contact as you are talking to someone. Sometime nonverbal communication can give someone an impression about the message you are trying to send that is different with your intentions. Words normally express ideas, whereas nonverbal expressions convey attitudes and emotions. A large measure of how you relate to others and how they relate to you is not based on what is said, but on what is not said. You may not speak or even have the desire to communicate, and yet be engaged in a communication process. You are constantly providing “messages” to those around you by your dress, facial expression, body movements, and other aspects of your appearance and behavior. Nonverbal expressions include kinesics, proxemics, and elements of the physical environment in which communication takes place. This chapter describes the various components of nonverbal communication and discusses how it plays an important role in effective communication. Nonverbal versus Verbal Communication6 Nonverbal communication involves a complete mix of behaviors, psychological responses, and environmental interactions through which we consciously or unconsciously relate to another person. It differs from verbal communication in that the medium of exchange is neither vocalized language not written word. The importance of nonverbal communication is underlined by the findings of behavioral scientists, who have reported that approximately 55% to 95% of all communication can be attributed to nonverbal sources.7 Awareness and skilled use of your nonverbal abilities can make the difference between fulfilling, successful interpersonal relationships and frustrated nonproductive interaction. Nonverbal communications are unique for three reasons. First, they mirror innermost thoughts and feelings. This “mirror effect” is constantly is constantly at work, whether or not you are aware of it. Second, nonverbal communication is difficult, if not impossible to “fake” during an interpersonal interaction. Third, your nonverbal communication must be consistent with your verbal communication or people will be suspicious of the intended meaning of your message. This difference between your verbal and nonverbal messages may result in a less than successful communication. In nonverbal communication, we perceive and interpret a given nonverbal message or “cue” in a personal manner. Various interpretations emerge from the different social, 6

Tindall WN, Beardsley RS, Kimberlin CL. Communication Skills in Pharmacy Practice, Malvern, PA: Lea & Febiger, 2007. 7 Mehrabian A. Silent Messages. Belmont, CA. Wadsworth, 1971.

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psychological, cultural and other background variables of the senders and receivers of nonverbal messages. For example, a simple nod of the head or a specific hand gesture may mean something to one person but something completely different to another. Therefore, nonverbal “cues” can and often do have multiple interpretations. However, within a given society, groups of nonverbal cues generally result in interpretations that are usually universally agreed upon. Cue clusters are combinations of nonverbal acts that communicate certain global messages. For example, a customer who gives you a pleasant sounding “thank you”, and a warm smile at the end of your interaction is probably more pleased with the interaction than a customer who abruptly turns around and quickly walks away mumbling something under his breath. Without a doubt, cue clusters contribute significantly to what is being communicated nonverbally. On the other hand, the specific “reasons” behind a person’s nonverbal behaviors (for example, why a patient turned abruptly and walked away) usually cannot be determined from the nonverbal communication alone. You may sense that a patient seems upset. However, you do not know whether the cause is distress over something you said, discouragement at being ill, dismay over the cost of the medication, a desire to hurry to get back to work, or a myriad of other things that may be on the patient’s mind that would explain his or her behavior. When analyzing nonverbal communication, avoid focusing on just one cue. Look at all of the nonverbal cues that you are receiving and use verbal communication to fully understand the meaning of the verbal behavior. Specific Nonverbal Cues Kinesics Kinesics is the method by which messages are conveyed through one’s posture. The way one holds one’s body sends a message to others with whom we are interacting. Think about going for a job interview. During that interview, you sit straight in the chair and keep your hands folded in your lap. This will generally present a professional, mature image to your prospective employer. Contrast this with a person who slouches down in the chair and is tapping her foot throughout the entire interview. It is possible that the person slouching is nervous about the interview, but the message that she is sending is that she is not interested in obtaining the position. One of the best known examples of kinesics is the position of your arms. Keeping your arms crossed in front of your body suggests that you are not open to hearing another dialogue. In your interactions with patients/customers, giving them the impression that your attention is elsewhere can be easy with kinesics. By maintaining eye contact, ceasing other tasks, and maintaining a relaxed but professional posture, you will be sending the desired message of interest and concern for the patient. The manner in which you use arms, legs, hands, head, face, and torso may have a dramatic impact on the messages that you send. In general, individuals from various societies use different body movements to communicate certain messages. In this country, for example, it is common for two men to shake hands when meeting each other.

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A handshake is a way by which we nonverbally indicate friendship or acceptance of the other person. The handshake stems from much earlier time when a man who extended his hand to another was communicating the fact that he held no weapon to do harm. However, in some cultures it is more appropriate to bow to each other rather than shake hands. Proxemics Proxemics refers to the messages that are conveyed by the use of space and distance. Usually, different types of communication occur at different distances. A message that is sent to another person from very far away is likely to be a public one because it is one that the sender will have to shout. One example of such a message may be greeting a classmate who is quite a distance down the hall from you. More private types of communication occur at closer distances. When you are sharing a secret with your best friend, you are probably quite close to him or her, which enable you to quietly convey your message without being overheard. In between these two extremes is the distance that is comfortable in social or professional situations. This distance varies among cultures. In the United States, a comfortable distance is approximately 2 to 4 feet. Of course individuals have their own preferences as well. There are no clear cut guidelines about what is too close or too far away. Distance is generally negotiated during an interaction. If someone feels that you are invading his personal space, he will back away from you. Instead of moving closer to him, allow him to define the distance between you. Finding the comfortable distance from which to talk with customers or other healthcare professionals will make productive interactions easier. Haptics Haptics refers to the messages that are conveyed through touch. Touch is an integral portion of human communication. It is the first form of communication that babies sense and is used to show caring and support for those around us. Healthcare professionals, for example, on a regular basis offer a handshake as a greeting or a reassuring hand on a patient’s shoulder providing comfort during a time of emotional distress. Even a pat on the back or a high five given to a child can help create warmth in a relationship. A word of caution is needed. Not all patients respond will to touch. Cultural and personal differences will dictate the extent to which you incorporate touch into your interactions. Conclusion The use of nonverbal cues can reinforce your verbal messages. Thus, it is essential to be aware of all the messages you are sending to your receiver. Each dimension of nonverbal communication discussed here is important, but the most important seems to be kinesics. That concept will prove to most true when working with patients/customers.

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Environmental Nonverbal Factors A number of environmental factors play important roles in communicating nonverbal messages to customers. For example, the colors used in the pharmacy’s décor, the lighting, and the uses of space have all been documented as important nonverbal communication factors.8 Within the community practice setting, the use of the prescription counter is an important environmental factor. The counter and related shelving serve to keep the prescription dispensing process from the public’s view. However, they can also serve as a communication barrier between the pharmacist and the patient. The general appearance within the pharmacy setting conveys nonverbal messages to customers. Dirt, clutter, and general untidiness carry negative nonverbal messages. These messages influence customer perceptions about your professional role and your level of interest in serving patients. In addition, the physical characteristics of pharmacy employees also send nonverbal messages to customers. Professional staff should dress appropriately. You want to convey a friendly appearance, but you also want to convey professional competence. Your appearance and the appearance of your fellow employees can enhance or distract from the sense of professionalism within you practice site. Distracting Nonverbal Communication One of the most distracting nonverbal elements is lack of eye contact. It is frustrating to talk to somebody who is not looking at you. Unfortunately, many pharmacy technicians unconsciously do no look at customers when talking to them. Their tendency is to look at the prescription, the prescription container, or the computer while talking. This behavior may indicate to customers that you are not totally confident about what you are saying or that you really do not care about speaking to them. Lack of eye contact also limits your ability to receive feedback about the messages that you are giving. For instance, does the customer have questioning look, an expression of surprise, or an expression of understanding? If you do not look at customers while they are talking, they may get the impression that you are not interested in what they are saying. Using good eye contact does not mean that you continually stare at customers, because that may make them feel uncomfortable as well. The key is that you spend most of the time looking at them. Another potentially distracting nonverbal element is facial expression. An inadvertent facial expression may send a message that you did not intend to transmit. For example, if you roll your eyes as a customer explains something to you, you may be communicating a feeling of disinterest or lack of concern. This is especially damaging when your facial expression are not consistent with your verbal expressions. For example, if you say “Go ahead I am listening, tell about it!” but your eyes are distracted by something else in the pharmacy, you may be communicating mixed messages. The customer hears you say that you are interested, but your nonverbal behavior communicates otherwise. In these

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Beardsley RS, Johnson CA. Wise G. Privacy as a factor in patient counseling. Journal of American Pharmaceutical Association NS17: 366-368, 1977.

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situations, people will tend to believe your facial expressions and nonverbal messages more than the verbal aspects of your communication. Another potential distraction may be your tone of voice. People interpret the message not only by the words you use, but also by the tone of voice you use. For example, a comment in a sarcastic or threatening tone of voice will produce a different effect than the same phrase spoken with an empathic tone. In addition, conveying a message in a dull, monotone voice may convey a lack of interest on your part. Detecting Nonverbal Cues in Others Assessing the meaning behind the nonverbal messages of other is difficult, because we tend to interpret nonverbal cues based on our personal orientation and experiences. The meaning of the nonverbal messages that we receive may or may not be the meanings intended by the sender. For example, we may sense a hint of anger in a customer’s voice when in actuality they are using their normal speaking voice and they are not angry at all. The key is to identify situations where we might be misinterpreting their nonverbal cues based on these differences. We need to avoid making false assumptions or jumping to conclusions based on inaccurate interpretations of nonverbal cues. Conclusion As mentioned earlier, the first step in improving interpersonal communication is recognizing how you communicate with others. In the nonverbal area, this selfawareness involves being constantly aware of your nonverbal behavior. Once you have discovered what aspects you need to change to become more effective, the next step is finding strategies to overcome these distracting elements. One thing that should be mentioned here is that potentially distracting behaviors can be overcome by using nonverbal elements to project different messages. For example, you may find that you naturally cross your arms while talking to others. You can overcome the possible perception that you are acting defensively by using other nonverbal elements, such as: • • •

Smiling Using a friendly tone of voice Moving closer

The total message received by the customer is the combination of all these nonverbal cues, both positive and negative, and not just one isolated component. Nonverbal communication is an enormously important part of interpersonal communication. You should concentrate on your own nonverbal communication, as well as the various nonverbal cues provided by others. In this way, you can become a more effective, skilled communicator. Developing an awareness of your own nonverbal messages and detecting the nonverbal messages in others are important steps in developing skilled nonverbal communication.

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Written Communications Written communication can take many forms in the practice of pharmacy. In the course of your practice, you may find occasion to write a letter to a vendor or other healthcare professional. You may also be called upon to submit reports in writing regarding pharmacy policies and procedures, medication errors, or inventory matters. Needless to say, you will want these documents to appear professional and well written. Each document may be slightly different and should be tailored to your specific needs. One of the most important points to remember in preparing any written communication is that if spelling or grammatical errors are present, they severely detract from the effectiveness of the message. It is very tempting to rely on electronic spell checking and grammar checking devices because of their convenience, and these tools are quite useful. Unfortunately, they may not reveal all of the errors in a document. Words such as “know” and “no” are both correctly spelled here but would not appear and would not appear in an electronic check for spelling. As you know, they have different meanings and cannot be used interchangeably. Many such examples can be found in the English language. As an exercise, you may want to think of as many of these words as you can in order to familiarize yourself with them. Then, when you are typing, it may jog your memory to double-check your work even after the spell check. The following table list a few examples to get you started: First Variation

Second Variation

First Variation

Second Variation

Ascent Buy Sight Ewe Four There All Arc Bail Base Beat Bored Cell Click Made Ode Pray Wait

Assent By Site You For Their Awl Ark Bale Bass Beet Board Sell Clique Maid Owed Prey Weight

Heard To Patients Weather Ad Allowed Assistance Ate Bare Be Berry Brake Hi Knows One Plain Read Waist

Herd Too Patience Whether Add Aloud Assistants Eight Bear Bee Bury Break High Nose Won Plane Reed Waste

Grammatical errors may also be reviewed through an electronic screening process. It may seem at times that these are tedious, catching every minor error. Generally speaking, using one is worth the extra time. Few of us recall the detailed grammatical 33

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rules we learned in grade school. It is certainly wise to make use of the electronic tools available in this area, but always remember to read the document out loud to yourself, looking for items that may have been missed. In addition to the importance of an error-free document, a well-organized document is much more powerful than the one that does not make its point. Organization is the key. Let’s take the example of a written letter to a vendor in order to explore this concept further. These components of structure and organization apply to most other forms of written communication as well. When you write to a vendor, it will likely be on behalf of your employer. Perhaps you have identified a problem that you feel should be brought to the vendor’s attention. Although there are many communication choices these days, it is sometimes difficult to speak to a vendor for any length of time at your convenience. Also, we should not underestimate the impact of a written document. Having a written “document of record” can have a greater impact then a simple conversation. Therefore, make use of the written communication seems appropriate. For the purposes of this course, the term letter includes: faxes, emails, and written documents sent through the postal service or another courier. A letter to a vendor should include the following area: 1. 2. 3. 4. 5.

Statement of the problem. Potential solutions. Specific recommendations for the solution. Support for your recommendation. Description of follow-up.

First, a concise statement of the problem is the way to begin such correspondence. Making reference to the problem in the first sentence will show the vendor the importance of your letter and encourage her to keep reading. Going into detail about the circumstances of the problem is usually unnecessary. The vendor does not need to know too much detail regarding the method by which you have uncovered the problem. Further, offering a detailed explanation is also unnecessary. Unless the problem is quite complicated, you should be able to describe it in one or two sentences. Maintaining objectivity is also important in describing the problem. Avoid placing blame on the vendor, even if it is there mistake. The goal of the letter is to help resolve the problem, not play the “blame game”. After you have identified and described the problem, you should offer potential solutions. Again, this information should be presented in the most concise fashion possible. The letter should only take a few minutes to read, because the vendor is unlikely to take more time than that. In phrasing our options, maintain an objective and neutral tone. This means that you are offering suggestions to the vendor rather than telling her what to do. If the tone of the letter suggests that the vendor has no idea how to conduct their business, it will leave her with a negative impression of you and your suggestions. In offering your suggestions, explain briefly why each will help address the problem at hand. An

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explanation of your reasoning will help the vendor to understand your train of thought and will reassure her that you have in fact given thought to the problem. Once you have described one or two options, let the vendor know which of the alternatives you would suggest. Make this a clear statement so no confusion exists regarding your choice. The solution should be fully explained in detail. To give your recommendation more weight, you can supplement it with your rational. The final component of such a letter is the explanation of the necessary follow-up. Because you are initiating the correspondence and bringing the problem to the vendor’s attention, it is your responsibility to follow-up and make sure the corrective action has been taken. This can be accomplished via a telephone call a few days later or by additional written correspondence. Inclusion of the five components described above in a concise letter to a vendor will help the vendor have a clear understanding of the problem and of the solution. A well-written, well-organized letter is a powerful tool in communicating your point of view to another professional. These components of organization and structure apply to other forms of written communication as well. Keep in mind how much easier a reading assignment is when it is short and the important information is presented clearly. When to Put Something in Writing There is always a question of when to put your message in writing versus simply communicating verbally. Here are a few guidelines: 1. You discussed the issue before, but other parties either dismissed or overlooked what you thought were clear directions or mutual agreements. In this situation, you should document what you need done and make sure it is sent to the correct parties. 2. You need to establish a policy or procedure. A written policy tends to carry more weight with employees than verbal instructions. 3. If something important has been misinterpreted, it might be necessary to clarify your instructions in writing. 4. An incident has occurred that increases risk for you or the organization. Patient or employee accidents, medication errors, loud altercations, and disciplinary actions all increase the risk of litigation to you or the organization. Document these situations clearly, including only what you observed, not suppositions or assumptions. 5. When facts or agreements may be disputed later, write a memo to the record, or a memo documenting what was said, various parties’ responsibilities, progress toward a goal, or the reasons why progress is less than expected.

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Communication

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Conclusion In this course we have reviewed basic communication skills that may be used in various interactions. The careful consideration of nonverbal communication, the phrasing of questions, appropriate use of empathy, and assertiveness are all useful tools when interacting with employers, colleagues, and patients/customers. As with any new skills, communication skills require practice. As mentioned at the beginning of the course, few people are able to instinctively communicate effectively. As you work in your pharmacy practice and grow in experience, you will also gain insight into communicating with patients and co-workers. You will develop you own style and gain confidence in you ability to communicate effectively with others.

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J&D Educational Services Final Exam

1. Interpersonal communication is a common but complex practice that is essential to healthcare providers. a. True b. False 2. In the communication model, _________ is the process whereby receivers communicate back to senders their understanding of the sender’s message. a. b. c. d.

The sender The message Feedback Barriers

3. ____________ interfere and affect the accuracy of the communication exchange. a. b. c. d.

The sender The message Feedback Barriers

4. ________________ transmits a message to another person. a. b. c. d.

The sender The message Feedback Barriers

5. _______________ is the element that is transmitted from one per to another. a. b. c. d.

The sender The message Feedback Barriers

6. Research has found that in some situations ___ or more of a message is transmitted through its nonverbal component. a. b. c. d.

35% 55% 65% 75%

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7. In receiving and sending messages, you should focus solely on the verbal message being sent in order to avoid confusion. a. True b. False 8. Feedback can be: a. b. c. d.

Nodding your head Repeating back a set of instructions Both A and B None of the above.

9. Which of the following can be considered a barrier? a. Vacuum cleaner running while you are waiting on a customer b. Safety glass partition c. A ringing telephone d. All of the above 10. In the communication model, the sender delivers the message and the receiver assigns a meaning to that message. a. True b. False 11. People assign meanings to messages based on: a. b. c. d.

Their background Values Experiences All of the above

12. Fortunately, predicting how a person will translate a particular message is easy and precise. a. True b. False 13. We respond using our perception of that individual as our reference point because we tend to be influenced by a person’s: a. Cultural background b. Status c. Gender d. All of the above

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14. The first stage of the process to minimize barriers is: a. b. c. d.

Get your point across Be aware that they exist Don’t be fooled by nonverbal feedback All of the above.

15. The second stage of the process to minimize barriers is: a. Take appropriate action to overcome them b. Get your point across c. None of the above d. All of the above 16. “A crowded, noisy prescription area” is an example of: a. b. c. d.

Feedback Personal barrier Environmental barrier All of the above

17. Lack of confidence in your ability to communicate is an example of a: a. b. c. d.

Feedback Personal barrier Environmental barrier All of the above

18. Personal shyness is an example of a: a. b. c. d.

Communication model Personal barrier Environmental barrier All of the above

19. Which of the following is an environmental barrier? a. b. c. d.

emotional objectivity poor eye contact pharmacy prescription counter personal shyness

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20. Which of the following is not a culture related barrier? a. b. c. d.

Internal conversation Health related habits Perceptions of healthcare All of the above

21. Some of the skills that are needed for good communication include: a. b. c. d.

listening responding phrasing questions All of the above

22. An equally critical part of the communication process, and perhaps the most difficult to learn, is the ability to be a good listener. a. True b. False 23. __________________ conveys understanding in a caring, accepting, nonjudgmental way. a. b. c. d.

Empathy Listening Feedback None of the above

24. Unfortunately, empathy is a hereditary trait and cannot be learned. a. True b. False 25. ___________ is a type of response that is often given when one does not know how to respond. a. b. c. d.

Judging Reassuring Probing None of the above

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J&D Educational Services Final Exam

26. _________ is a type of response designed to elicit additional information. a. b. c. d.

Judging Reassuring Probing None of the above.

27. _____________ is a type of response made when one tells someone that he should not have the feelings he does about a particular situation. a. b. c. d.

Judging Reassuring Probing None of the above

28. ____________ is a type of response that suggests what a person should do. a. b. c. d.

Generalizing Distracting Advising Understanding

29. ____________ is a type of response that generalizes what the sender may be feeling. a. b. c. d.

Generalizing Distracting Advising Understanding

30. _____________ is a response that does not acknowledge what the person has said. a. b. c. d.

Generalizing Distracting Advising Understanding

31. ________________ is a type of response that allows a person to convey his understanding of a message. a. Generalizing b. Distracting c. Advising d. Understanding

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32. A __________ question is a question that is phrased to elicit a response of either “yes” or “no”. a. b. c. d.

Open-ended Close-ended Leading None of the above

33. A __________ question is a question that allows the person responding to elaborate on the topic. a. b. c. d.

Open-ended Close-ended Leading None of the above

34. Assertiveness and aggressive behavior are basically the same concept. a. True b. False 35. ___________ behavior is the direct expression of an idea, opinion, and desires. a. Passive b. Aggressive c. Assertive d. None of the above 36. ____________ behavior is designed to avoid conflict at all cost. a. b. c. d.

Passive Aggressive Assertive None of the above

37. ____________ behavior seeks to “win” in conflict situations by dominating or intimidating others. a. b. c. d.

Passive Aggressive Assertiveness None of the above

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38. A critical factor in being assertive is the ability to act in ways that are consistent with the standards we have for our own behavior. a. True b. False 39. ___________ is a type of assertive response that you take responsibility for the decisions you make on how to spend personal resources without feeling resentful toward others making request. a. Reframing b. Setting limits c. Making request d. Broken record 40. ___________ is a type of assertive response of calmly repeating your decision. a. b. c. d.

Reframing Setting limits Making request Broken record

41. ____________ is a technique with which you acknowledge the truth about a statement yet ignore the implicit value judgment contained with it. a. b. c. d.

Delaying response Agreeing with criticism Fogging Getting useful feedback

42. If the criticism take you by surprise and you are confused about how to respond, you should: a. b. c. d.

Agree with the criticism Disagree with the criticism Use fogging Delay your response

43. You may not speak or even have the desire to communicate, and yet be engaged in a communication process. a. True b. False

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J&D Educational Services Final Exam

44. Which of the following is true about nonverbal communication? a. It mirrors innermost thoughts and feelings b. Is difficult to “fake” c. Must be consistent with your verbal communication or people will be suspicious of the intended meaning of your message. d. All of the above 45. ___________ is the method by which messages are conveyed through one’s posture. a. Haptics b. Proxemics c. Kinesics d. None of the above 46. ________________ refers to the messages that are conveyed through touch. a. b. c. d.

Haptics Proxemics Kinesics None of the above

47. _____________ refers to the messages that are conveyed by the use of space and distance. a. b. c. d.

Haptics Proxemics Kinesics None of the above

48. Facial expression can potentially be a distracting nonverbal element. a. True b. False 49. In a written communication for your employer, spelling and grammar are not really important. a. True b. False 50. As with any new skills, communication skills require practice a. True b. False

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