Presentation on communication skills.ppt
- 1. COMMUNICATION S KILLS Communication is, at its most basic, the sending and receiving of messages. The physical senses of sight, hearing, touch, smell and taste are part of day-to- day communication but in pharmacy practice, sight, hearing and occasionally touch are used. Individually, our communicating style is shaped by our experience of language, culture, social status, personality, interests, abilities and disabilities. When working as a pharmacist, we modify our personal style of communicating to fit the culture and language of the pharmacy profession. In this section, the importance of empathy, developing rapport and verbal and non-verbal aspects of communication are discussed.
- 2. Empathy At the heart of all effective communication is empathy. Empathy is defined as the ability to see and feel the way another person does . For example, a pharmacist may need to discuss paracetamol dosing with a mother who is anxious about her child’s illness. If this pharmacist can understand how frightening it may be to have a febrile, distressed infant who has been refusing to eat, then they are likely to be more attentive and sympathetic to the mother’s concerns. This would enable the pharmacist to choose suitable words and non-verbal messages to provide support to the mother.
- 3. When feelings are not shared and empathy has not developed, communication can be impaired. If, for example, a hospital pharmacist is not able to identify a patient’s fear of hospitals, they would be unlikely to obtain a reliable medication history. If this pharmacist could identify with and acknowledge the patient’s concerns, they would be more likely to obtain the required information. While some people are naturally empathetic, for others, it is an attribute that needs to be developed through awareness and practice.
- 4. Every individual is unique and special, and it takes effort, patience and practice to develop the skills to react suitably to the uniqueness of every person we meet. Careful listening, close observation and reflecting on our interactions with others, especially those we find more challenging, can help develop our understanding of others and our ability to share with and understand others. The significance of empathy is that it enables rapport (a sympathetic relationship based on understanding) to develop and this is an important first step in establishing successful and interactive communication.
- 5. Non-verbal Communication Non-verbal messages begin to be received and interpreted as soon as something catches our attention. For example, when two people first meet, before a word is spoken, impressions are formed from information gained through sight, sound, smell and sometimes touch, such as through shaking hands. What is the expression on their face? How are they dressed? How old are they? What perfume are they wearing? Do they appear hostile or friendly? and much more. This can have a significant impact on how people react during new encounters. Further contact with an individual will augment and support this first impression or may lead to modification, as more information is received and processed.
- 6. For example, if two young, blonde, well- tanned women come to a pharmacy, the pharmacist could assume that they are tourists visiting India and could be seeking treatment for gastroenteritis. These assumptions may or may not be accurate. Our pharmacist decides his customers have recently arrived in India and need his professional assistance.
- 7. Non-verbal communication includes messages conveyed through body posture. For example, someone who is sitting with their legs and arms crossed in front of their body signals a ‘closed’ body posture and this will hinder the flow of communication. A stance with feet together and uncrossed legs and arms (an open body posture) tends to ease communication. A very casual stance, for example, slouching, would suggest lack of interest and inattention. Other non-verbal signals such as looking away, fidgeting, being preoccupied with another activity or allowing other people to interrupt can also signal inattentiveness and inhibit communication. In Exercise 1 , the influence ofnon- verbal information is explored.
- 8. Facial expression is an important indicator of emotional state. People instinctively observe the face to gain information which is not provided verbally. For example, does the person look angry, happy, worried, relaxed, friendly, and so on. Eye contact (or eye avoidance) can indicate the level of attention, and suggest honesty or confidence, but this may vary in different cultures. The meaning of spoken language is modified by non-verbal information like loudness, the pitch, tone or how rapidly the message is delivered. For example, the statement ‘what a day’ spoken lightly in a higher pitch would mean that something unexpectedly positive has occurred, while spoken slowly and emphasising ‘what’ suggests a difficult time.
- 9. It is important that pharmacists are aware of the non-verbal messages they are transmitting to others, especially if these are likely to inhibit communication. Being able to recognise personal internal psychological states, being aware of how these states may be communicated non- verbally and then being able to modify non-verbal information is a useful approach to develop. Case Study 1 provides an example of how personal awareness can be used to modify non-verbal communication. In a professional setting, the interpretation and use of non-verbal messages can assist our work. By interpreting non-verbal signals from others and then modifying our approach to take account of their feelings, we can improve the opportunities for effective interaction.
- 10. For example, if someone is restless, looking down and avoiding our eyes, we may interpret this as being embarrassed or ill-at-ease. We could change our style of language, soften our voice, adopt an open body posture, smile more to try to make the other person feel more comfortable. Verbally acknowledging the discomfort of another and offering an option to improve a delicate situation can be helpful. For example ‘I’m sorry there is not much privacy here to discuss such a personal matter. If you like, I can see if an office is free.’ Non-verbal mannerisms vary from culture to culture, region to region, country to country. There are inter- gender differences in the meaning of non-verbal messages and differences between people of different age groups. Being aware of potential differences can help avoid misinterpretation or causing offence. This is especially important when working away from our home territory or culture.
- 11. Diagrams are another form of non-verbal messages used to convey information. Pictograms (a picture which represents a concept or object) have recently been developed to communicate medical and medication information to people who are illiterate. The US Pharmacopeia website provides examples. Pictograms could be used in place of medicine labels ( see Exercise 2 ) or to show how to administer a dosage form such as eye drops. Examples of advice sheets for different pharmaceutical products are provided in the PharmWeb website (listed at the end of this chapter). As there may be differences in interpretation of diagrams between cultures and countries, the interpretation should be checked with the recipient.
- 12. Verbal Communication Verbal communication occurs through the meaning of words which may be spoken or written. Meaning can be subtly modified by non-verbal qualities; for example, the tone of voice or the typeface used. This is one aspect of spoken communication which we are usually least aware of and least in control of. We can, for example, convey irritation through voice tone without realising it. Interpretation of a message can be confusing when word meaning and non-verbal qualities conflict. If, for example, a very jaundiced patient responds to a standard query ‘How are you feeling today?’ with ‘I’m fine, thank you’, the meaning of the words is likely to be discounted. Emphasis too can create differences in meaning. For example: ‘Did YOU remember to take your medicine this morning?’ is likely to sound accusatory, but if spoken without emphasis, becomes a neutral inquiry.
- 13. Writing is less sensitive to non-verbal modification than spoken language, but differences in writing style can be used to modify meaning. For example, an informal and personal style is commonly used in email messages, while forbusiness letters, the presentation and style is formal. Written fonts can convey subtle messages and do differ in their ease of reading. For example, a writing style like italics suggests the personalised style of handwriting, while a format like Arial is considered one of the more legible font styles. With written materials, all aspects of the composition such as word selection, writing style and presentation should be carefully selected for the audience.
- 14. Language: To be reliable, communication should be in a language which both the speaker and the audience are fluent in and comfortable with. Medicine and pharmacy have a shared professional language that uses Greek and Latin terms which are very different from everyday terms with the same meaning. Choosing the appropriate terms is important to both communciate effectively and to convey suitable verbal messages. For example, most patients would not understand the term ‘myocardial infarction’ but they will know what is meant by a ‘heart attack’. Similarly, but in reverse, a pharmacist discussing a patient’s alopecia with a doctor is more likely to be respected as a fellow health professional than one who discusses a patient’s hair loss. Developing vocabularies for both professional and everyday terms is useful for sucessful professional pharmacy communication.
- 15. Differences in the pronunciation of medical terms and medicine names can cause confusion and is a source of error. Pharmacists have an important role to help promote, teach and standardise pronunciation. Both spoken dictionaries ( see the Merck website ) and phonetically spelt ones( see thedrugs.com website ) are available for medicine names. The abbreviations and terms used for prescribing medicines represent a specialised type of communication shared by the medical and pharmacy professions. However, prescribing terms can be interpreted differently, and this has led to dosing errors and, in some cases, death. The notation ‘qd’ is commonly used in North America to mean ‘once daily’, but has been confused with ‘qds’ which in other countries means four times a day.
- 16. • Some health organisations provide a dictionary of prescribing terms and abbreviations to be used by their staff to reduce the risk of interpretational errors. • Identifying confusing terms or abbreviations and checking the meaning with the author is the safest method to avoid these potential fatal errors.
- 17. Interactive communication: Two activities are principally involved in communication: the sending and the receiving of messages. A passive, one- way verbal process, like a traditional lecture, is considered an inefficient communication and learning method in most situations. (In reality, it is a two-way process, with the audience sending non-verbal messages such as listening attentively or yawning and chatting to neighbours, which may influence the lecturer). Effective communication and learning sessions are essentially two-way, interactive processes. Both parties will actively participate in speaking and listening in turn, interpreting the meaning of what is happening and comparing this to their personal experience.
- 18. At its simplest, when sending a message, the sender first forms a concept in their mind of what they want to communicate. This image will be based on the many and varied aspects of their personality and experience. They then form the concept into a verbal message and speak. The listener will then receive the words, the tone, emphasis and other non-verbal messages such as facial expressions, body position and hand movements and interpret the message within the framework of their experience. We assume that if a message we have communicated seems clear to us it will be interpreted correctly by the listener.
- 19. However, when people come from different language, cultural or educational backgrounds, interpretations can vary a great deal. Even two people from similar backgrounds will experience misunderstandings from time to time. The best way to ensure that a message is correctly understood is to ask the listener to repeat the message using their own words. If this differs from the intended meaning, then through discussion, a common understanding can be reached.
- 20. Listening skills: Developing good listening skills is important to promote clear interactive communication and to obtain reliable information. Good listeners are able to maintain their attention and not be distracted by external preoccupations (for example, the telephone) or internal diversions (thoughts on an unrelated topic such as an assignment due tomorrow). Non-verbal cues such as maintaining eye contact (but not staring or gazing) can demonstrate attention, as can nodding, verbally echoing the person’s significant words or asking questions.
- 21. Good listeners will also use statements which back up and support the speaker, for example ‘Ah, now I see what you mean’, and this helps keep the conversation interactive and flowing. If a speaker wanders offthe topic, it may be appropriate to politely interrupt and re-introduce the topic from the point of departure. When giving key information, it is an important practice to check for correct understanding by asking the listener to identify the main points of the message. While this may appear like an interrogation or be demeaning, if the purpose is carefully explained then the listener will not be offended and can assure the speaker that their message has been correctly understood ( see Case Study 2 ).
- 22. Stages in verbal communication: In pharmacy practice, communication is usually short, often lasting only a few minutes. It is important that the time available is used well. The communication structure described below and demonstrated in Case Study 2 shows how time can be used to good effect. The purpose of the INTRODUCTION is to establish a connection between the parties who are communicating. It can promote rapport, build empathy and trust, engage interest and encourage an open interaction. The introduction involves the exchange of everyday courtesies and general enquiries. If a patient or caregiver appears distressed, this can be acknowledged and discussed to build up rapport and gain commitment and attention. During the OPENING, the topic to be covered is introduced and briefly explained
- 23. The BUSINESS stage is when the main messages are delivered or information is obtained. It is important that a personal RECONNECTION is made as a preparation for ending the interaction. It is helpful at this point to make sure the details and relevance of the material are understood and clarification provided if needed. During the CLOSURE, non-verbal messages can be important in signalling the end of a session (for example, gathering up papers or packing medicines and handing them over). Concluding courtesies will round off the encounter positively, and both parties will then separate.
- 24. Written Communication There are different writing styles which are appropriate for different purposes. For example, a paper published in a professional journal must conform to the format required by that journal in order to be accepted for publication. Patient information leaflets (PILs) for medicines require a detailed and precise style in easily understood terms. Notation on a patient’s medication chart, for example, ‘take with food’, is required to be concise and legible and may need to conform to local standards. All forms of professional writing require clarity and precision. Short sentences and paragraphs, unambiguous words or statements and precise sentence structure are important qualities. Words need to be carefully chosen, with correct spelling and grammar, and presented in an easy-to-read handwriting or font.
- 25. Written messages require a logical structure. There should be a brief, clear introduction outlining the purpose of the article, statement or paragraph. The body should present ideas in a clear, logical structure. A concluding summary will repeat the main messages and clarify any action to follow. Pharmacists are trained to use a particular style for the dosage instructions written on medication labels. While these may be second nature to us, they can be unclear or confusing for patients. The common expression ‘Take one tablet daily’ gives no indication about the time at which the tablet should be taken or when in relation to food. ‘Take two tablets daily’ does not identify whether the tablets should be taken together or spaced apart. Using more complete instructions and verbally checking understanding can prevent potentially dangerous misunderstandings.
- 26. Special Situations Face-to-face interviewing: Interviews can be used to obtain information, for example, to obtain medication history, to assess a student’s understanding of a subject during an oral examination or for screening job applicants. Case Study 3 describes the use of interview techniques to obtain medication history. In any interview situation, there is a power difference between the interviewer and the interviewee (person being interviewed) which can be intimidating. The interviewee is also likely to be in unfamiliar surroundings while the interviewer is in a known environment, often of their choice. To obtain reliable information, it is important that the interviewee is at ease with both the environment and the interviewer. Spending time to develop rapport is important.
- 27. During an interview, NON-VERBAL MESSAGES conveyed through body posture are influential. Sitting at the same level as an interviewee is less intimidating than standing over them, especially if they are seated or lying in bed. Sitting also enables the interviewer to present an open body posture, and side-by- side seating is less threatening than face-to- face. The physical environment is important and in hospitals the provision of privacy can be challenging.
- 28. During the introduction, the PURPOSE of the interview is clearly identified. Sometimes it may be necessary to obtain consent from a patient to proceed. OPEN QUESTIONS are helpful to capture a wide range of information and are less likely to be influenced by the expectations of the interviewer. CLOSED QUESTIONS are suitable for verifying information. When used excessively, closed questions can make an interviewee feel they are being interrogated, while open questions give the interviewee the opportunity to express themselves in their own way. When the information to be gathered appears complete, it is important that the content is CHECKED.
- 29. A common and useful approach is to verbally summarise the information for the interviewee to confirm and comment on. If there is a large quantity of information or if it is complex, providing a written copy for the interviewee may be appropriate. If this is not suitable, then organising the information under different topics and providing a brief account of each may be helpful.
- 30. During an interview, difficult situations may occur which can be challenging for the interviewer. If, for example, an interviewee attempts to divert the discussion away from the topic, a skilled interviewer will politely interrupt and re-introduce the topic. If after further attempts the interviewee continues to digress, it may be more productive to politely stop the interview and perhaps return at a later time when the interviewee may be more co-operative. When topics which may be threatening or embarrassing to the interviewee are covered, the conversation may cease to flow. It may be necessary to DIGRESS to a subject the interviewee will be comfortable with for a short time or provide reassurance and supportive comments.
- 31. Encouraging a reluctant interviewee or controlling a vociferous one requires skill. Sometimes pharmacists may be placed in particularly difficult situations such as facing an angry, disturbed or threatening patient. Ways to handle less familiar or particularly challenging situations can be explored through role plays with classmates or colleagues. This provides a process which is safe for all, can provide useful insights and can be fun. In professional practice, the opportunity to interview in a wide range ofsituations and then to reflect on these (what went well, what didn’t work and how performance could be improved) is a most useful life-long learning approach.
- 32. Providing information : Providing information about medicines is a common role for clinical pharmacists. Messages can be verbal, written, pictorial or a demonstration with verbal support. Actively engaging the client will aid their learning.
- 33. The first stage in the successful delivery of information is to CHECK the client’s knowledge level and their information requirements. Information can then be adapted to maintain the client’s interest, be relevant, complement information given by another health professional or to address inaccurate perceptions. The length or AMOUNT of information required to be provided is important. Most verbal messages provided in pharmacy practice are short, often five minutes or less. Written information can be used to provide detail and to serve as a record of the verbal information. Well-presented medicine information will cover the most important points for treatment safety and effectiveness. For health professionals, an in-depth explanation based on current medical literature may be required.
- 34. The structure of the message should be PLANNED. If a person has a particular interest or concern, this is best acknowledged early to enhance rapport and arouse interest. People are more likely to remember information that is delivered early and late in a session. Placing key messages at the beginning and end of a session is a useful technique. Repetition of information using different words helps to reinforce learning. Messages should be clearly delivered using language suitable for the recipient. Short sentences are more easily understood and encourage interaction and discussion.
- 35. If complex information needs to be communicated, this is best built up gradually with frequent checks to ensure client understanding The final step is to check if the client understands the message and then reinforce the key points by SUMMARISING them. While this may seem repetitious, it is a well-established sucessful learning technique. Case Study 4 provides an example
- 36. COMMUNICATION IN PROFESSIONAL PRACTICE People interact best when they feel comfortable with their surroundings. Hospital wards or busy dispensary counters are very difficult environments for effective communication. Small attempts to increase privacy such as drawing the curtains or lowering the voice so that others can’t overhear are important. Clothing and presentation are important to convey non-verbal messages that have an impact on the development of first impressions. A clean, pressed, white coat gives the appearance of professionalism and, if other clinical staff dress similarly, this may promote better inter-professional communication.
- 37. Communication with Medical and Health Professionals During the establishment of a clinical pharmacy service, inter- professional communication can be challenging. Once a service is well-accepted, pharmacists may be required to establish their credibility with new staff members or with a ward area in which they do not usually practice. Resolving or preventing medicine-related problems and carefully handling the potential friction this role may cause can be challenging to a new pharmacist or a new clinical pharmacy service. Patient welfare is the focus of any medical team and one which pharmacists need to share.
- 38. Doctors and nurses who are unfamiliar with clinical pharmacy may feel that the pharmacist is a threat to some of their own roles and power. Focusing on the needs of patients, adding pharmaceutical/pharmacological value to an established service, acknowledging the abilities of other staff and supporting their roles are effective diplomatic approaches to help overcome resistance and barriers. When interacting with any busy health professional, it is important to avoid trivia and focus on the most significant issues in patient care. If, for example, a pharmacist discussed with a physician the importance of administering an analgaesic dose of aspirin with food, but omitted to discuss a potentially fatal interaction with the patient’s coumarin anti-coagulant, he or she would be unlikely to earn the respect of the medical team.
- 39. Spoken messages: Spoken messages can occur in person or over the telephone. Commonly, they are used to obtain information about a patient or their treatment, to provide medicine information to a practitioner or to clarify or recommend modifications in a patient’s therapy. Skills and confidence in handling difficult situations can initially be developed through role plays. Role Play 1 aims to explore and develop the student’s information gathering skills. Telephone skills are an important aspect of professional life. Telephone conversations differ from face-to-face contact as there are fewer non-verbal cues which can represent a distraction.
- 40. The skill and confidence required to manage spontaneous situations like answering the telephone can be developed through practice with self-reflection. When initiating a telephone conversation, an effective skill is to maintain some control of the process by keeping the content focused and ending the call when the purpose is achieved. Preparation may be useful, for example, jotting down the main points on a piece of paper or preparing a structure for the call. Role Play 2 can be practised as a telephone conversation and covers a potentially challenging situation.
- 41. Case note annotation: Comments in a patient’s case notes convey important information to those caring for the patient and provide a record of the patient’s hospital management. In a busy ward, when a pharmacist records important information, this can be easily overlooked. Alerting the appropriate staff member verbally is important. This provides an opportunity for discussion and clarification of a complex message and reduces the possibility of misunderstanding. Case note entries can be of legal importance when prescribing could harm the patient.
- 42. Entries into case notes are required to conform to standards for clarity and precision. The entry should be dated and have a short informative heading. Short, clear statements should identify the issue, provide reasoning or an explanation, and the recommendation of any action which may be required. The author’s name, position and contact telephone, cell phone or pager number should be included. In many hospitals, pharmacists use a coloured pen (green is traditional) or an identification mark to distinguish their entries. Case Study 5 gives an example of a case note annotation with a verbal interaction.
- 43. Communication with Patients Medication history interviews : To review current medical treatment and identify suitable additional treatments, medical professionals will require complete and reliable medication history. Research has established that in routine practice, pharmacists provide the most accurate history when compared to other health professionals. It is an important role that pharmacists are well-prepared to fulfil.
- 44. A well-prepared, structured approach helps to obtain relevant complete information and avoid omissions. The following information is commonly recorded: currently or recently prescribed medicines medicines purchased without prescription (OTC) vaccinations alternative or traditional remedies description of reactions and allergies to medicines medicines found to be ineffective adherence to past treatment courses and the use of adherence aids
- 45. Labelling medicines : Medicine labels are concise messages to identify and aid the effective and safe use of medicines. A common standard is that all containers of medicines should be clearly labelled to identify: the medicine (by generic or trade name) dosage form, number of dosage units supplied, strength number of dose units to be taken at a time and its frequency any specific administration guidance or precautions; for example, take at least 30 minutes before food the patient's name date of dispensing batch numbers and expiry dates for non-prescription medicines and medicines not likely to be used immediately
- 46. Patient information leaflets (PILs) : Patient information leaflets are used to outline key information to assist patients and their caregivers in the effective and safe use of a medicine. The following information is commonly included: trade and generic names indications for which the medicine is being taken precautions or contraindications administration advice information on the action required if a dose is missed common and serious side effects medicine interactions action to be taken if a side effect is experienced storage information name and contact details of the institution providing the information author and date of publication
- 47. PILs should include all essential information without making a document too lengthy or the typeface too small. Common usage terms should be used for medical indications and written to be understood by people with basic (for example, newspaper) reading ability. All sheets need to be regularly reviewed and updated to reflect current knowledge and practice. Examples of PILs are those provided by the US National Library of Medicine and from a pharmaceutical company on the Xenical website.
- 48. Patient medication sheets or cards: When patients are taking several medicines, a handwritten or computer- generated medication summary can improve compliance and understanding (an example is provided in Fig. 6.1Chapter 6, Patient Counselling ). A tabular form presents the information clearly. The dose timing can be identified as a specific time (for example, 7:00 AM), a meal time (breakfast) or a phase of the day (morning). Other information such as the purpose of the medicine, when treatment is to stop, specialised advice (for example, take with food) as well as information specific to the person, such as adverse reactions experienced or the use of adherence aids, can be recorded. Keeping medication sheets upto- date and accurate is a common problem, especially when a patient is attending different clinics or medical practitioners.
- 49. Medication counselling for patients: Effective patient counselling can help patients use their medicines safely and reliably. All the principles of effective verbal communication are important to the success of an encounter and are covered in Chapter 6, Patient Counselling .
- 50. Developing Communication Skills through Practice The best way to develop professional communication skills is by observing others, regular practice with reflection and discussion with colleagues. Role plays are useful to develop confidence and to practice specific skills or situations before approaching patients or health professionals. As competence develops, a pharmacist can move from lower skilled tasks like obtaining information to the higher skilled activity of giving information. For example, a recently qualified pharmacist may start by taking medication history under supervision, then on their own. When competent, they could start providing medication counselling, initially under supervision and then alone.
- 51. They may progress to working in a medicine information service, providing in-depth information for the medical profession. A structured approach with supervision until competency is achieved helps foster skills and develops confidence. It also helps in maintaining service quality and value.
- 52. Special Considerations for Indian Pharmacists Pharmacists in India face considerable communication challenges which require innovation and creativity to manage successfully. Lack of familiarity with modern therapy may prevent some patients from benefitting from their medicines unless clearly explained and discussed. For example, they may not understand that a course of antibiotics must be completed even though the symptoms have resolved. There may be problems with contaminated or counterfeit medicines, expired or poorly stored batches, unpredictable supply, and so on. All of these require the greatest degree of vigilance and, often, considerable communication skills to resolve
- 53. There are other great challenges which are encountered with an educationally and culturally diverse population. Examples are finding appropriate symbols or diagrams to support verbal messages for illiterate and innumerate patients, communicating with patients when a common language is not shared or the provision of patient medicine information in the local language. Pharmacists have a critical role to play in ensuring the safe and effective use of medicines. The more skilled a pharmacist is as a communicator, the more influence he or she will have and the greater their contribution will be to the health and welfare of those for whom they provide a service.
- 54. CASE STUDYS
- 55. CASE STUDY MESSAGES 1 : MODIFYING NON – VERBAL Feroz Haroom works as a pharmaceutical representative for a well- respected pharmaceutical company. This day has been particularly frustrating. Early in the morning, a workers demonstration caused traffic delays so he missed his first appointment and is now 15 minutes late for the next. He is feeling stressed, angry and frustrated.When Feroz telephoned ahead to confirm his delay, the pharmacy manager said he could not spare more time so the visit would be for five minutes. Feroz identifies the key points he needs to cover and nearing the hospital, he checks his appearance in the car mirror. His face looks pinched and tense. Knowing it is important to appear confident and relaxed, Feroz takes several deep breathes and remembers the warm welcome of his last meeting with the pharmacy manager. He checks his appearance again as he leaves the car, nods, straightens his tie and feels confident the meeting will go well.