THE QUIET PHARMACIST
By H. JOHN BALDWIN, VIRGINIA P. RICHMOND, JAMES C. McCROSKEY, and
BRUCE A. BERGER
Over the past decade or so, the importance of communication between the pharmacist and the public has become an increasing concern in the pharmacy profession. The stereotype of the pharmacist from the 1940s into the 1970s was that of a close-mouthed person hidden from view behind a counter in the back corner of the pharmacy, occupied primarily with typing labels and putting pills in little bottles.1
Current orthodoxy in pharmacy practice is in direct opposition to this stereotype and stresses the need for pharmacists to communicate effectively with their patients.
At a December 1981 meeting between the American Association of Colleges of Pharmacy and the six national pharmacy practitioner organizations, "deficiencies in communication training and abilities" was identified as one of the major deficiencies in current pharmacy school curricular.2 While valuable college course work and continuing education programs in communication skills have proliferated during the past several years, the teaching of communication skills at best only solves part of the problem. Effective communication requires both the necessary knowledge and skills and a willingness or desire to communicate.
We can all recognize and observe the quality and quantity of
an individual's communication behavior. A person's desire or willingness
to communicate, however, is not observable, although the behavioral manifestation-the
avoidance of communication-is observable. The communication behavior of
an individual influences how others perceive that individual.
Quiet People Perceived
We are all familiar with people who "don't talk much." We term them "shy," "introverted," "reticent," or simply "quiet."
Verbal behavior is extremely, important in the development of interpersonal relations and perceptions. In general, the more a person talks, the more positively that person will be perceived.
Unfortunately the quiet person is generally perceived by others in a negative light. The quiet individual is stereotyped as being less competent, less communicatively competent and less intelligent than the highly verbal individual.
Quiet people are perceived as being more anxious or apprehensive about communicating, less extroverted and less composed than talkative individuals. They are perceived as people who have difficulty expressing their opinions to others and responding in an open and sensitive way to communication from others.
Talkative people are perceived as having leadership qualities and as being opinion leaders for others, whereas quiet people are not. An opinion leader is someone to whom we turn for advice, information or opinions when we need to make a decision. Quiet people are unlikely to go out of their way to offer opinions and, since they are perceived to be less competent, they are less likely to be asked for their opinions.
Socially, quiet people are perceived to be less sociable and friendly than are talkative people. A reduced level of communication appears to be interpreted by most people, including quiet people themselves, as a sign of unfriendliness.
Projecting the research results from the communication field
to the practice of pharmacy, the "quiet" pharmacist would not
only be expected to talk less with patients than other pharmacists do,
but also to talk less about professional concerns. The quiet pharmacist
probably would not be perceived as a credible source of information on
drugs or an intelligent person with whom to interact about either professional
or nonprofessional matters. Thus, research suggests that quiet pharmacists
would not only be unwilling and unable to perform a significant portion
of their professional role but that even when attempts are made to fulfill
that role, the probability of success would be low.
Shyness
Communication researchers and theorists make a distinction between quiet individuals based on why they are unwilling to communicate. In communication terms, shyness is described as "an attribute which spans a wide behavioral emotional continuum."'
At one end of the continuum is the shyness adopted by an individual who generally prefers solitude. These people probably do not see shyness as a problem for themselves, although the professional problems referred to above probably exist.
In the middle of the continuum "are people whose shyness is associated with lack of self-confidence, inadequate social skills, and embarrassment at being the focus of attention, all leading to the avoidance of communication.
"At the extreme end are the 'chronically' shy, who avoid
communication to escape any risks of damaging self-esteem and to avoid
the extreme anxiety associated with social interaction."5
Communication Apprehension
Communication apprehension (CA) has been the most studied cause of people's desire to avoid communication. Communication apprehension, as conceptualized by McCroskey, is defined as "an individual's level of fear or anxiety associated with either real or anticipated communication with another person or persons."7
People who have a high degree of anxiety about communication (high CA) will have a very low desire to engage in communication. They will avoid communication to avoid the anxiety that accompanies it, and they often will not be concerned about whether their attempts to communicate lead to successful communication. People with a low degree of anxiety about communication (low CA) will attempt more communication and often will work to make that communication effective.
Fear or anxiety associated with communication may be generalized or situation-specific. A person's generalized communication apprehension level is a personality-type trait. A person with trait-like communication apprehension tends to respond to virtually all communication situations with anxiety, regardless of the nature of the situation. The high communication apprehensive person is likely to feel a high degree of fear or anxiety about communicating, even in situations in which an outside observer would suggest there is no reason for such fear or anxiety (e.g., talking to another pharmacist, talking to a patient, answering the telephone).
Situationally specific communication apprehension is produced by the circumstances surrounding a specific communication encounter. Probably the most common anxiety -producing situation is being called on to give a speech. It is normal to experience a fairly high degree of anxiety about public speaking. In a national study, it was found that the number one fear was of speaking in public, experienced by more than 70% of the adult population.8
It has been reported that in the clinical pharmacy educational setting, pharmacy students do not feel comfortable communicating with patients-let alone physicians. Much of this is undoubtedly nor mal, but as the newness of the situation wears off and students gain confidence in their ability to handle the situation, the anxiety is reduced for the high communication apprehensive, however, the situation continues to produce high anxiety regardless of how they actually perform, they believe they have been unsuccessful, which reinforces their negative feelings about communication and reinforces their desire avoid it.
Almost everybody has some communication apprehension in some situations or with some person or persons. This is normal. However, approximately 20% of the population has high communication apprehension-a generalized anxiety about virtually all communication situations.
Although studies with practicing pharmacists in various environments
have not been completed studies with pharmacy students indicate that they
are similar to the general population in regard to distribution of communication
apprehension-approximately 20% of pharmacy students have high CA. Of these,
almost half describe themselves as having a shyness problem and an additional
one fourth describe themselves as shy but indicate their shyness is not
a problem.
Identifying the Level of CA
There is a method by which you can assess your own level of communication apprehension. On page 27 is a Personal Report of Communication Apprehension (PRCA) composed of 24 statements, representing feelings about communicating in four types of situations groups, meetings, interpersonal (one-to-one), and public speaking.
Based on studies of more than 40,000 individuals, the "normal"
range of scores on the PRCA is 52-79 . One of five individuals in the general
population is highly communication apprehensive, and has a PRCA score greater
than 79. As stated earlier, these people have a generalized anxiety about
communication, not just an anxiety in certain situations. In general, however,
for most people, public speaking is more anxiety-producing than meetings,
meetings more anxiety-producing than group, and group situations more anxiety-producing
than one-to-one interactions.
Reducing Your CA
It is important to recognize that communication apprehension and communication skills are two separate and distinct dimensions of the communication process. There may indeed be pharmacy students and pharmacists who lack communication skills and avoid, or do poorly in, communication situations for this reason. There are others who undoubtedly have good skills but are uncomfortable in communication situations because of the anxiety that is generated. Others have both communication apprehension and poor skills.
For the skills-deficient pharmacist, training and practice in communication skills is appropriate. For those with high communication apprehension, however, skills training is not sufficient. Indeed, traditional speech and communication skills courses may make the problem worse rather than better.10 As might be expected, high communication apprehensives also tend to avoid course work in communications,6.8 indicating that continuing education programs designed to improve communication skills would likewise hold little appeal.
For those who experience a high level of communication apprehension, the recommended treatment is systematic desensitization, which has been reported to be an effective behavior therapy technique in reducing anxiety.11 The underlying rationale is that anxieties are learned, and anything that is learned can be unlearned.
Systematic desensitization involves a two-step process:
First, people are taught to recognize tension in their bodies and relax that tension. A surprisingly large proportion of the population has never learned to recognize when they are tense, much less how to relieve that tension.
Once this process is learned, the second step can be implemented. This involves conditioning people to respond with relaxation in the presence of stimuli that previously produced tension. For persons with high CA, the person is asked to imagine a series of communication situations, progressing from those that previously have aroused little tension (you are talking to your best friend) to those that normally would cause great tension (you are about to give a speech on television and you have lost your notes). The person learns to relax completely while imagining one situation before moving on to a more difficult one.
Systematic desensitization has been found to be an extremely effective and long lasting method of reducing communication apprehension. The technique has been used with pharmacy students, with a reported success rate of 73%.12 The process can take as little as six or seven hours and can be administered by someone with a minimum of teaching.
Not everyone has access to formal systematic desensitization procedures. There are, however, self-help procedures which can help the quiet person who wishes to overcome what he or she perceives to be a problem.
First, develop a thorough understanding of the process of human communication. A course in communication theory (not a skills course) can help, as will reading books on communication theory.
Second, learn to recognize tension in the body and how to relax that tension. Relaxation tapes are available from the Speech Communication Association for this purpose.*
Third, learn to identify negative self-statements, e.g., "I'll
sound stupid," "Everybody's watching me"; and negative thoughts
you have when you are communicating. Develop a list of coping statements:
e.g., "They don't know any more than I do," "Speak slowly."
Practice saying the coping statements to yourself whenever you approach
a difficult communication situation.
Need to Change
Our best estimates are that 20-33% of pharmacists will try to avoid communication whenever possible. Overcoming communication apprehension will not solve all of pharmacy's communication problems; however it is a step in the right direction. Other deficiencies, barriers and considerations are obviously involved when patients perceive that pharmacists only communicate with them less than a third of the time they have a prescription filled.13
Pharmacy is, however, undergoing an ideological change involving
a greater degree of patient involvement. The profession-as well as the
public-has determined that patients want and need more information about
the drugs they take. Since the pharmacy field seems determined to fulfill
this need, the reduction of communication apprehension is one step in that
direction. If pharmacy students and pharmacists are less apprehensive about
communicating with patients, then the above goal will be more attainable.
References
1. The Dichter Institute for Motivational Research, Inc. "Communicating the Value of Comprehensive Pharmaceutical Services to the Consumer," American Pharmaceutical Association, Washington, DC, 1973.
2. American Journal of Pharmaceutical Education, 46, 188 (1982).
3. H. J. Baldwin, J.C. McCroskey and T.J. Knutson. American Journal of Pharmaceutical Education, 43, 91 (1979)
4. P.G. Zimbardo, P.A. Pilkonis and R.M. Norwood. Psychology Today, 8, 68 (1975).
5. L. Kelly, Human Communication Research, 3, 99 (1982).
6. B.A. Berger, and H.J. Baldwin, Communication Apprehension in Pharmacy Students: A National Study. Final Report the to Council of Sections, American Association of Colleges of Pharmacy, 1982.
7. J. C. McCroskey, Human Communication Research, 4, 78 (1977).
8. J. C. McCroskey and V. Richmond, The Quiet Ones Communication Apprehension and Shyness. Gorsuch Scarisbuck, Dubuque, IA, 1980.
9. D. L. Smith, Canadian Pharmaceutical Journal, 11, 300, (1977).
10. J. C. McCroskey, D. C. Ralph, and J. E. Barrick, The Speech Teacher, 19, 32 (1970).
11. D. J. Pedersen, Communication Education, 29, 299 (1980).
12. B. A. Berger, et al. American Journal of Pharmaceutical Education (Fall 1982, in press).
13. L. A. Morris, Medical Care, 20, 396 (1982).
ABOUT THE AUTHORS
H. John Baldwin, Ph.D., is professor and chairman of behavioral and administrative pharmacy, Virginia P. Richmond, Ph.D., is associate professor and James C. McCroskey, Ph.D., is professor and chairman, both of the department of speech communication, all of West Virginia University, Morgantown, WV, 26506. Bruce A. Berger, Ph.D., is assistant professor of pharmacy care systems, Auburn University School of Pharmacy, Auburn, AL 36849.
Personal Report of Communication Apprehension
Directions: This instrument is composed of 24 statements concerning
your feelings about communication with other people. Please indicate in
the space provided the degree to which each statement applies to you by
marking whether you (1) Strongly agree, (2) Agree, (3) Are undecided, (4)
Disagree, or (5) Strongly disagree with each statement. There are no right
or wrong answers. Many of the statements are similar to other statements.
Do not be concerned about this. Work quickly; just record your first impression.
1-Strongly agree 2-Agree 3-Undecided 4-Disagree 5-Strongly disagree
_____ 1. I dislike participating in group discussions.
_____ 2. Generally, I am comfortable while participating in group discussions.
_____ 3. I am tense and nervous while participating in group discussions.
_____ 4. I like to get involved in group discussions.
_____ 5. Engaging in a group discussion with new people makes me tense and nervous.
_____ 6. I am calm and relaxed while participating in group discussions.
_____ 7. Generally, I am nervous when I have to participate in a meeting.
_____ 8. Usually, I am calm and relaxed while participating in meetings.
_____ 9. I am very calm and relaxed when I am called on to express an opinion at a meeting.
_____ 10. I am afraid to express myself at meetings.
_____ 11. Communicating at meetings usually makes me uncomfortable.
_____ 12. I am very relaxed when answering questions at a meeting.
_____ 13. While participating in a conversation with a new acquaintance, I feel very nervous.
_____ 14. I have no fear of speaking up in conversations.
_____ 15. Ordinarily I am very tense and nervous in conversations.
_____ 16. Ordinarily I am very calm and relaxed in conversations.
_____ 17. While conversing with a new acquaintance, I feel very relaxed.
_____ 18. I'm afraid to speak up in conversations.
_____ 19. I have no fear of giving a speech.
_____ 20. Certain parts of my body feel very tense and rigid while giving a speech.
_____ 21. I feel relaxed while giving a speech.
_____ 22. My thoughts become confused and jumbled when I am giving a speech.
_____ 23. I face the prospect of giving a speech with confidence.
_____ 24. While giving a speech I get so nervous, I forget facts
I really know.
To Compute Your PRCA Score:
1. Total separately the following items: 2, 4, 6, 8, 9, 12, 14, 16, 17, 19, 21, 23
2. Total separately the following items: 1, 3, 5, 7, 10, 11, 13, 15, 18, 20, 22, 24
3. PRCA Score=72+Total 1-Total 2
Above 79 = High CA;
Below 52 = Low CA.