The utility of nonverbal communication in the profession of pharmacy

Soc. S~i. & Med.. Vol. 13A, pp. 733 to 736 Pergamon Press Ltd 1979. Printed in Great Britain

THE UTILITY OF NONVERBAL C O M M U N I C A T I O N IN T H E P R O F E S S I O N O F P H A R M A C Y * PAUL L. RANELLIt Fellow of the American Foundation for Pharmaceutical Education, School of Pharmacy, 425 North Charter Street, University of Wisconsin-Madison, Madison, WI 53706, U.S.A. Abstract--The nonverbal communication relationship between a pharmacist and 243 subjects was investigated by using 18 black and white, 35 mm, 2 x 2 in., slides depicting a male pharmacist in a neighborhood pharmacy setting. A five-point modified Likert questionnaire measured the subject's attitude toward the pharmacist by scoring certain distance and position control slides to the nonverbal communication dimensions of likability and advice potential. Results indicate the subjects had a significantly more positive attitude toward the pharmacist when he was closer, in an eye level position, and when he was not screened by any obstacle such as a sales counter or prescription work area.

INTRODUCTION Verbal communication accounts for only 7% of the communication of feelings, while nonverbal communication accounts for the remaining 93%[15]. Even though the verbal portion of communication accounts for only 7%, its importance has been well documented in the medical and health care area [6, 12, 18]. However, some of the components which caused an increase or decrease in patient satisfaction or an increase or decrease in patient medication compliance might be more closely related to a nonverbal rather than a verbal framework. Since the nonverbal communication elements are such a great part of the communication of feelings and the possibility exists that the present health care communication studies are testing for not only a verbal but a nonverbal phenomenon, it seems evident that research about the effect nonverbal communication has upon the ,health care delivery system is necessary. The importance of nonverbal communication research for health care professionals has been demonstrated in dentistry[3, 20], medicine [24], physical therapy [19], nursing [21], psychotherapy 1-4, 8, 23] and social work [11]. Pharmacy's undertakings regarding the professional worth of nonverbal communication and communication, in general, have been well-established; however, little empirical proof exists to reinforce these important established, guidelines [ 1, 5, 17]. It is clear pharmacy needs improvement in its communication skills department and improvement in just the verbal communications area is not sufficient for increasing evidence in nonverbal research suggests what the communicator does is as significant as what he says [7]. Thus, the pharmacist must be aware of his nonverbal communicative behavior in order to positively reinforce his concern for patient welfare. .The pharmacist forms an important communication * The research for this manuscript was conducted at Wayne State University College of Pharmacy and Allied Health Professions in Detroit, Michigan 48202, U.S.A. t Mr Ranelli is a Ph.D. student and research assistant in social studies of pharmacy at the University of Wisconsin-Madison School of Pharmacy.

link between the patient and the health care system. For the patient to receive the optimal health care benefit, effective communication between the pharmacist and the patient is essential. Therefore, the influence the pharmacist has upon the patient can be consciously influenced by the pharmacist's understanding of the nonverbal communication process. Since a communicator's posture, orientation and distance from his subject are significant indexes of the communicator's liking for his subject [13], the present nonverbal communication study focused on the pharmacist's distance from the patient and his position in relation to the patient. Negative attitudes are elicited or inferred if the distance between the two is more or less than the implicitly permitted limits. In the United States, Hall reports [9], distances from (a) touching to 18 in. are typical for intimate interpersonal situations, (b) distances from 2.5 to 4 ft are typical of casual-personal interaction, (c) distances 7-12 ft are characteristic of social-consultative situations, and (d) distances of 30ft and more are characteristic of public interaction situations. Since the pharmacist-patient relationship would be seen by the pharmacist and by the interpersonal distance researcher as a social personal interaction, the distances of 2.5~4 ft (Casual-Personal Distance, CPD) and 7-12 ft (Social-Consultative Distance, SCD) were chosen for the study. As Hall states[10] keeping someone "at arm's length" is one way of expressing Casual-Personal Distance. Discussed at thisdistance are subjects of personal interest and involvement. Obviously the health care need of a patient is an example of a subject of personal interest. Social-Consultative Distance provides for flexibility of involvement so that people can come and go without having to talk. Since the average pharmacy prescription work area places the pharmacist and patient within this distance, the provision to provide flexibility of involvement is met so that people can come and go without having to talk. In addition to the pharmacist's distance from the patient, the phai'macist's position was also' under study. The physical evaluation of the prescription work area is unique to the iSractice of pharmacy since no other health practitioners communicate from this position. Therefore, the measurement of person per-

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Table 1. Description of the six control poses in the eighteen actual practice slides Slide No. 5 17 13

Casual-Personal Distance 2.5-4 ft Pharmacist without any obstacle-~ye level Pharmacist behind sales counter only--eye level, obstacle Pharmacist behind prescription work area only--elevated, obstacle

ceptions included measures from both the eye level position and the elevated prescription work area. METHOD

Eighteen black and white, 35 mm, 2 x 2 in., slides were prepared depicting a male pharmacist in a neighborhood, actual pharmacy practice, setting. The pharmacist was photographed standing in specific places and positions [9, 10, 14]. As shown in Table 1, 6 of the 18 slides were control slides while the other 12 slides, called distractors, contained non-control variables. Either there was no obstacle between the camera and the pharmacist, or the pharmacist's generally accepted territory of the prescription work area and the, sales counter were used as an obstacle between the camera and its subject. The prescription work or sales counter were included as obstacles because it was suspected that furniture arrangement would influence the attitude of the subject toward the pharmacist[16, 24]. Great care was taken while photographing the pharmacist for the six control slides so the model would be able to duplicate as much as possible the same facial expression. This was done to avoid possible rating errors resulting from different facial expressions. The subjects (n = 243) that were tested included pharmacists (n = 26), pharmacy students (n = 133), and consumers (n = 84). The five-point modified Likerr scale's likability and advice potential statements were randomly organized so that there existed an equal number of each (Appendix A). Modifications of the t h r e e n o n v e r b a l communication dimensions established by Mehrabian[15] and Waldron[22] provided continuums for the construction of the questionnaire. All the attitude judgments were made by the subject while viewing his or her respective slide set. HYPOTHESES, RESULTS, AND CONCLUSIONS

The four null hypotheses tested were (a) no difference exists between the attitudes of the pharmacists and pharmacy students and the attitudes of the consumers, (b) the distance between the subject and pharmacist will not influence the subject's attitude toward the practitioner, (c) the subject's attitude toward his or her practitioner will not be influenced by the pharmacist's position (i.e. elevated or eye level) and (d) the sales coufiter or prescription work area obstacle will not affect the subject's attitude toward his or her pharmacist. The mean scores for each of the hypoth-

Slide No 7 12 3

Social-Consultative Distance 7-12 ft Pharmacist without any obstacle---eye level Pharmacist behind sales counter only--eye level, obstacle Pharmacist behind ,prescription work area only--elevated, obstacle

eses were calculated in the same manner, The questionnaires were scored assigning the value five to the most positive response. Therefore, the higher the mean score, the more positive was the feeling the test participants had toward the pharmacist. By testing the different groups across each variable (i.e. distance, position and obstacle), using a t-test for group comparisons, it was found that there was n o difference among the consumers and pharmacists-pharmacy students in their perceptions of the pharmacist. Furthermore, as shown in Table 2, by using t-tests for paired comparisons the distance between the subject and the pharmacist may influence the subject's attitude toward the practitioner (t = 3.21, P < 0.001). Also, the position hypothesis (t = 4.91, P < 0.001) and the obstacle hypothesis may be rejected (t = 5.17, P < 0.001). Having a significantly more positive attitude t o w a r d t h e pharmacist when he was closer, at eye level, and without an obstacle demonstrated how subjects would like to interact with their pharmacist. This data, therefore, lends empirical support to the notion that the nonverbal communicative behavior of the pharmacist can alter the attitudes of a subject toward that particular pharmacist. DISCUSSION

The subjects had a more positive attitude toward the pharmacist when he was closer, at eye level, and without an obstacle. It seems evident that these results, coupled with the fact that the reaction to the pharmacist did not differ between pharmacistpharmacy students and consumers, have the potential Table 2. Comparison of the perceptions of the pharmacist Variable

Mean

SD

t

df

At two control distances Distance Casual-Personal (2.5~,ft) 3.35 0.779 3.21" 242 Social-Consultative (7-12 ft) 3.18 0.728 At an elevated or eye level position Position Pharmacist--Eye Level 3.35 0.682 4.91" 242 Pharmacist--Elevated 3.09 0.862 With or without obstacle manipulation Furniture Arrangement Pharmacist without obstacles 3.47 0.814 5.17" 242 Pharmacist with obstacles 3.16 0.756 Note: n = 243, *significant at the 0.001 level.

Nonverbal communication in the profession of pharmacy to affect patient pharmacist interactions. This study is an attempt to combine the theoreticgl aspects of nonverbal c o m m u n i c a t i o n with the practical aspects of pharmacy. Therefore in trying not to compromise the actual p h a r m a c y practice setting, some alterations were made in the theoretical design. For example, there is no actual practice p h a r m a c y slide where the pharmacist is elevated without an obstacle (see Table 1). In a practical sense, it is rare having a pharmacist elevated without an obstacle; therefore a theoretical constraint was violated to have results applicable to p h a r m a c y practice. This a p p r o a c h combines the i m p o r t a n t qualities of theoretical and practical research giving practicing pharmacists information they may use in their professional setting. M o r e explorations of this kind should be undertaken, so that the p h a r m a c y - p a t i e n t relationship may benefit from further health care c o m m u n i c a t i o n research. Both the patient and pharmacist will benefit from this knowledge of n o n v e r b a l communication. One result of this dual benefit may be to positively increase the medication compliance of patients. These results could also have dramatic effects upon pharmacy store design. According to Barritt [2], the pharmacist needs to do more teaching and counseling of patients, even though the architecture of m a n y pharmacies makes this nearly impossible. W h e t h e r the results help alter the present prescription work area or help initiate plans to construct adequate patient waiting a n d consultation areas, the patient will benefit. An application of the results should improve pharmacy services, and therefore, improve patient care by suggesting a need for further research in n o n v e r b a l communication and by suggesting a need for nonverbal communication theory in p h a r m a c y undergraduate and post-graduate, continuing education.

REFERENCES

I. American Pharmaceutical Association--Academy of Pharmacy Practice. Professional Body Language. American Pharmaceutical Association, Washington DC, 1976. 2. Barritt E. R. Professional survival: adjusting to academia by degrees. Am. Pharm. 6, 24, t978. 3. Baseheart J. R. Nonverbal communication in the dentist-patient relationship. J. prosth. Dent. 34, 4, 1975. 4. Bateson G., Jackson D. D., Haley J. and Weakland J. Toward a theory of schizophrenia. Behav..Sci. 1, 251, 1956.

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5. Dichter Institute for Motivational Research. Comprehensive Pharmaceutical Services to the Consumer: An Analysis of Public Re,qard for the Pharmacist and Comprehensive Pharmaceutical Services. American Pharmaceutical Association, Washington DC, 1973. 6. Francis V., Korsch B. M. and Morris M. J. Gaps in the doctor-patient communication: patients' response to medical advice. New Engl. J. Med. 280, 535, 1969. 7. Hackney H. Facial gestures and subject expression of feelings. J. counsel. Psychol. 21, 173, 1974. 8. Haley J. Strategies of Psychotherapy. Grune & Stratton, New York, 1963. 9. Hall E. T. A system for the notation of proxemic behavior. Am. Anthrop. 65, 1003, 1963. 10. Hall E. T. Silent assumptions in social communication. Disord. Commun. 42, 41, 1964. 11. Lackie B. Nonverbal communication in clinical social work practice. Clin. Soc. Wk 5, 43, 1977. 12. Ley P., Bradshaw P. W., Kincey J. A. and Atherton S. T. Increasing patients' satisfaction with communications. Br. J. soc. clin. Psychol. 15, 403, 1976. 13. Mehrabian A. Interference of attitudes from the posture, orientation and distance of the communicator. J. consult. Clin. Psychol. 32, 296, 1968. 14. Mehrabian A. Significance of posture and position in the communication of attitude and status relationships• J. consult. Clin. Psychol. 71, 359, 1969. 15. Mehrabian A. Silent Messages. Wadsworth. Belmont CA, 1971. 16. Mehrabian A. Effects of furniture arrangement, props, and personality on social interaction. J. Personality Soc. Psyehol. 20, 18, 1971. 17. Millis J. S. (Chairman) Pharmacists.for the Future: The Report of the Study Commission on Pharmacy. Health Administration Press, Ann Arbor MI, 1975. 18. Parkin D. M. Survey of the success of communications between hospital staff and patients. Publ. HIth, London. 90, 203, 1976. 19. Perry J. F. Nonverbal communication during physical therapy. Phys. Ther. 55, 593, 1975. 20. Schabel R. W. Dentist-patient communication--a major factor in treatment prognosis. J. prosth. Dent. 21, 3, 1969. 21. Sweeney M. A. Evaluating the non.verbal communication skills of nursing students. J. Nurs. Educ. 16, 5, 1977. 22. Waldron J. Judgement of like-dislike from facial expression and body posture. Percept. Mot. Skills 41, 779, 1975. 23. Weakland J. H. The ~'double-bind" hypothesis of schizophrenia and three-party interaction. In The Etiolofty of Schizophrenia (Edited by Jackson D. D.). Basic Books, New York, 373, 1960. 24. White A. G. The patient sits down: a clinical note. Psychosom. Med. 15, 256, 1953.

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PAUL L. RANELLI APPENDIX

A

: A n example of the pharmacy survey slide questionnaire Slide No. 1. 2. 3. 4. 5. 6. 7. 8. 9, 10, 11. 12. 13. 14. 15, 16. 17. 18.

Statement to rate likable would not accept advice from unlikable likable would accept advice from likable would not accept advice from would accept advice from unlikable would not accept advice from would not accept advice from would accept advice from unlikable likable would accept advice from would not accept advice from unlikable would accept advice from

unlikable would accept advice from likable unlikable would not accept advice from unlikable would accept advice from would not accept advice from likable would accept advice from would accept advice from would not accept advice from likable unlikable would not accept advice from would accept advice from likable would not accept advice from