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~H. JohnBaldwin, PhD, is professorandchairman of behavioraland administra-tive pharmacy, Virginia P. Richmond,PhD, is associateprofessor and JamesC.McCroskey, PhD, is professor and chair-man, both of the department of speechcommunication, all of West VirginiaUniversity, Morgantown, WV 26506.Bruce A. Berger, PhD, is assistantprofessor of pharmacy care systems,Auburn University School of Phannacy,Auburn, AL 36849. Detailed informa-tion about the West Virginia Univer-sity's communication apprehension de-sensitization program or any of the toolsdescribed in this article is available fromthe authors.

Number- 10 Date - October, 1982

TheQuiet

Pharmacist

By H. JOHN BALDWIN, VIRGINIA P. RICHMOND,JAMES C. McCROSKEY, and BRUCE A. BERGER

Over the past decade or so, theimportance of communication be-tween the pharmacist and the publichas become an increasing concern inthe pharmacy profession. The ste-reotype of the pharmacist from the1940s into the 1970s was that of aclose-mouthed person hidden fromview behind a counter in the backcorner of the pharmacy, occupiedprimarily with typing labels andputting pills in little bottles.!

Current orthodoxy in pharmacypractice is in direct opposition tothis stereotype and stresses theneed for pharmacists to communi-cate effectively with their patients.

At a December 1981 meeting be-tween the American Associa tion ofColleges of Pharmacy and the sixnational pharmacy practitioner or-ganizations, "deficiencies in com-munication training and abilities"was identified as one of the majordeficiencies in current pharmacyschool curricula.2 While valuablecollege coursework and continuingeducation programs in communica-tion skills have proliferated duringthe past several years, the teachingof communication skills at best onlvsolves part of the problem. Effectivecommunication requires both thenecessary knowledge and skillsand a willingness or desire tocommunicate.

We can all recognize and observe

the quality and quantity of an indi-vidual's communication behavior. Aperson's desire or willingness tocommunicate, however, is not ob-servable, although the behavioralmanifestation-the avoidance ofcommunication-is observable. Thecommunication behavior of an indi-

vidual i.nfIuences how others per-ceive that individual.

Quiet People Perceived

We are all familiar with peoplewho "don't talk much." We termthem "shv," "introverted," "reti-cent," or simply "quiet."

Verbal behavior is extremely im-portant in the development of inter-personal relations and perceptions.In general, the more a person talks,the more positively that person willbe perceived. .

Unfortunately the quiet person isgenerally perceived by others in anegative light. The quiet individualis stereotyped as being less compe-tent, less communicatively compe-tent and less intelligent than thehighly verbal individual.

Quiet people are perceived as be-ing more anxious or apprehensiveabout communicating, less extro-verted and less composed than talk-ative individuals. They are per-ceived as people who have difficultyexpressing their opinions to othersand responding in an open and sen-

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sitiye way to communication fromothers. .

Talkative people are perceiv.ed' ashaYing leadership qualities and asbeing opinion leaders for others,whereas quiet people are not. Anopin.on leader is someone to whomwe turn for advice, information oropinions when we need to make adecision. Quiet people are unlikelyto go out of their way to offer opin-ions and, since they are perceived tobe less competent, they are less like-ly to be asked for their opinions.

Socially, quiet people are per-ceived to be less sociable andfriendly than are talkative people. Areduced level of communication ap-pears to be interpreted by most peo-ple, including quiet people them-s .Iyes, as a sign of unfriendliness.

Projecting the research resultsfrom the communication field to thepractice of pharmacy, the "quiet"pharmacist would not only be ex-pected to talk less with patients thanother pharmacists do, but also totalk less about professional con-cerns. The quiet pharmacist proba-bly would not be perceived as acredible source of information ondrugs or an intelligent person withwhom to interact about either pro-fessional or nonprofessional mat-ters. Thus, research suggests thatquiet pharmacists would not only beunwilling and unable to perform asignificant portion of their profes-sional role but that even when at-tempts are made to fulfill that role,

the ~robability of success would below.

ShynessCommunication researchers and

theorists make a distinction be-tween quiet individuals based onwhy they are unwilling to commu-nicate. In communication terms,shvness is described as "an attributewhich spans a wide behavioral-emotional continuum."*. At one end of the continuum isthe shyness adopted by an individ-ual who generally prefers solitude.These people probably do not seeshyness as a problem for them-selves, although the professionalproblems referred to <1boveprobablyexist.

In the middle of the continuum"..1repeople whose sh~'ness is .:1S50-

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ciated with lack of self-confidence,inadequate social skills, and embar-ras~ment at being the focus of atten-tion, all leading to the avoidance ofcommunication.

" At the extreme end are the'chronicallv' shy, who avoid com-munication to escape any risks ofdamaging self-esteem and to avoidthe extreme anxiety associated withsocial interaction.';;

Communication Apprehension

Communication apprehension(CA) has been the most studiedcause of people's desire to avoidcommunication. Communicationapprehension, as conceptualized byMcCroskey, is defined as "an indi-vidual's level of fear or anxiety asso-ciated with either real or anticipatedcommunication ~ith ~nother per-son or persons.'''

People who have a high degree ofanxiety about communication (highCA) will have a very low desire toengage in communication. They willavoid communication to avoid theanxiety that accompanies it, andthey often will not be concernedabout whether their attempts tocommunicate lead to successfulcommunication. People with a lowdegree of anxiety about com-munication (low CA) will attemptmore communication and often willwork to make that communicationeffective.

Fear or anxietY associated withcommunication may be generalizedor situation-specific. A person'sgeneralized communication appre-hension level is a personality-typetrait. A person with trait-like com-munication apprehension tends torespond to virtually all commu-nication situations with anxietY,regardless of the nature of the sitU-ation. The high communication ap-prehensive person is likely to feel ahigh degree of fear or anxiety aboutcommunicating, even in situationsin which an outside observer wouldsuggest there is no reason for suchfear or anxiety (e.g.. talking to an-other pharmacist, talking to a pa-tient, answering the telephone).

Situationally specific communica-tion .:1pprehension is produced bythe circums.tances surrounding aspecific communkation encounter.Probabh' the most common ,mxietv-. .

producing situation is being callecon to giye a speech. It is normal tcexperience a fairly high degree 0anxiety about public speaking. In ~national studv, it was found that thtnumber one fear was of speaking irpublic, experienced by more thar70% of the adult population.~

It has been reported that in thtclinical pharmacy educational setting, pharmacy students do not feecomfortable communicating witrpatients-let alone physicians.Much of this is undoubtedlv normal, but as the newness of the situation wears off and students gai:confidence in their ability to hand Ithe situation, the anxietv'is reducecFor the high communication apprehensive, however, the situation cor.tinues to produce high anxietyRegardless of how they actually perform, they believe thev have bee:unsuccessfuL which re[nfprces the~negative feelings about communication and reinforces their desire t,avoid it.

Almost evervbodv has some corr.munication apprehension in sorr.situations or with some person cpersons. This is normal. Howeve:approximately 20% of the populetion has high communication apprehension-a generalized anxie~:about yirtually all communicatio:situations.

Although studies with practid!1,pharmacists in various enviror.ments have not been complerecstudies with pharmacy students indicate that thev are simiiar to thegeneral population in regard to di::tribution of communication apprehension-approximately 20% r::pharmacy students have high CA.:Of these, almost half describe the.rr:selves as having a shyness probierr.and an additional one fourth describe themselves as shy but ind~cate their shyness is not ~problem.

Identifying the level of CAThere is a method by which vo:.

can assess your own level of corr,munication'apprehension. On pa,:;c27 is a Personal Report or Comrr.unication Apprehension (PRC.4.-composed of 2-+statements, repre-senting feelings about communi-...:ating in four types or situation~groups. meetings. incerpe:-sonJ(one-to-~meL ..md pubiic :;pe.1Ki:lg.

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Based on studies of more than40,000 individuals. the "normal"range of scores on the PRCA is52-79. One of five individuals in thegeneral population is highly com-muni"'ation apprehensive, and has aPRCA score greater than 79. Asstated earlier, these people have ageneralized anxiety about commu-nication, not just an anxiety in cer-tain situations. In general, however,for most people, public speaking ismore anxiety-producing than meet-ings, meetings more anxiety-producing than group, and groupsituations more anxiety-producingthan one-to-one interactions.

S\'stematic desensitization in-volve~ a two-step process:

First, people are taught to recog-nize tension in their bodies and re-lax that tension. A surprisingly largeproportion of the population hasnever learned to recognize whenthev are tense, much less how to reo'lie\;e that tension.

Once this process is learned, thesecond step can be implemented.This involves conditioning people torespond with relaxation in the pres-ence of stimuli that previously pro-duced tension. For persons withhigh CA, the person is asked toimagine a series of communicationsituations, progressing from thosethat previously have aroused littletension (you are talking to your bestfriend) to those that normally wouldcause great tension (you are about togive a speech on television and youhave lost your notes). The personlearns to relax completely whileimagini.ng one situation before mov-ing on to a more difficult one.

Svstematic desensitization hasbeen found to be an extremely effec-tive and longlasting method of re-ducing communication apprehen-sion. The technique has been usedwith pharmacy students, with a re-ported success rate of 73%.12Theprocess can take as little as six orseven hours and can be adminis-tered bv someone with a minimumof teaching.

Not everYone has access to formalsy!::tematic' desensitization proce-dures. There are, however, self-helpprocedures which can help the quietperson who wishes to overcomewhat he or she perceives to be aproblem.

First, develop a thorough under-standing of the process of humancommunication. A course in com-munication theorY (not a skillscourse) can help: as will readingbooks on communication theorY.

Second; learn to recogmze'ten-sion in the bodv and how to relaxthat tension. Relaxation tapes areavailable from the SpeechCommunication Association for thispurpose. ..

Third, learn to identify negativeself-statements. e.g., "I'll sound

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stupid," "Everybody's watchingme"; and negative thoughts yOt.:have when vou are communicating.Develop a list of coping statements:e.g., "They don't know any morethan I do," "Speak slowly." Practicesaying the coping statements tcyourself whenever you approach"difficult communication situation.

Need to ChangeOur best estimates are tha'

20-33% of pharmacists will try tcavoid communication wheneve:possible. Overcoming communication apprehension will not solve alof pharmacy's communication problems; however it is a step in the righdirection. Other deficiencies. barriers and considerations are obvioushinvolved when patients perceiv'fthat pharmacists only communicatEwith them les~ than a third of thEtime they have a prescriptiorfilled. 13

Pharmacy is, however, under-going an ideological change in-volving a greater degree of patieninvolvement. The profession-a,well as the public-has determinecthat patients want and need mor~information about the drugs the:take. Since the pharmacy fiekseems determined to fulfill thi,need, the reduction, of communication apprehension is one ste? irthat direction. If pharmacy student:and pharmacists are less apprehensive about communicating with pa-tients, then the above goal will bemore attainable. 0

References1. The Dichter Ins'itute ior :>'Ioti...anonal Research. Inc.

"Commun,eotin!\ the Value of Comorenens,,'e Pharmaceuncai ServIces to ,he Consumer:; Amencan Pharmaceuticai Association. Washin!:ton. DC. :9i3.

2. ..Im",c." touTrull of PhOmtOCtllllcal"UCDllO". ';0. 1&'19821." .

3. H./, Baldwin. /.C. :>.lcCros""\' and T./. Knutson. .\m,,'con lournoi of Phorn.oau'ICQI£aUCOllOn..3. 91 (\9791.

.. P.G. Zimaardu. P.A. Pilkon.s and R.~I. ="orwood. ?,vchoi,''iV;od.". S. 68 (\9i51. .

5. L Kell\'. Humoll ConrmunlCot,onRe>mrch.J. 99 (19821.6. B.A. senter. and H.). Baldwin. Conr.,u",ca"on ..\t"IT,"""

5/°' in Phormo,'1I;;tudtllts; A No'ionai S'udv. Finai Repor.to the Council ui SectIons. Ameneon AssOCI'non oi i::~I'ie~.. o. Pharmacv. 1982.

~, J.e. \lcCruske\'. 'Hunron C.'",.'U"IC.1/IO"Rt><OTCn..;. ~\19771. .

8. I.e. \lcCru,ke\' and V. Richmond. T/.. QUirt 0""C"""",,,,CO""" :-I,'pr';''''''UII alld 5i,v""". Gorsucn Scar.osauck. ::1uauuue. IA. 19!j().

°. D.L, Smnh. Cwod,o" Pho""o,,,,,,,,,j ;"uTn/ll. /1. "'"i19:-:i.

10. I.e. \lcCru,k,'\'. D.C. R.lph .nd I.E. Bamck. ;"'no':':"",'";;"""",'T i~. ,;CCI.;al.

11. 0,1. rl'<.le".n. C.'",n"""'/I""" a""O'II'''. :~. :°" ,!O~O'I:. S.A. !3en:er. ," "i.. .,'''''IC/II/ I.,,,,,,", ,,, e.'I/I,",a"'u,,,,.,, L"..

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Reducing Your CA

It is important to recognize thatco,_lmunication apprehension andcommunication skills are two sepa-rate and distinct dimensions of thecommunication process. There mayindeed be pharmacy students andpharmacists who lack communica-tion skills and avoid, or do poorlyin, communication situations forthis reason. There are others whoundoubtedly have good skills butare uncomfortable in communica-tion situations because of the anx-iety that is generated. Others haveboth communication apprehensionand poor skills.

For the skills-deficient pharma-cist, training and practice in com-munication skills is appropriate. Forthose with high communication ap-prehension, however, skills trainingis not sufficient. Indeed, traditionalspeech and communication skillscourses may make the problemworse rather than better. 10 As mightbe expected, high communicationapprehensives also tend to avoidcoursework in communications,6.8indicating that continuing educa-tion programs designed to improvecommunication skills would like-wise hold little appeal.

For those who experience' a highlevel of communication apprehen-sion, the recommended treatment issystematic desensitization, whichhas been reported to be an effective

behavior thera~! technique in re-dudng anxiety. .The underlying ra-tionale is that anxieties are learned,and anything that is learned can beunlearned.

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Personal Report of Communication ApprehensionDirections:This instrument is composed of 24 sJatements concerning your feelings about communication with otherpeople. Please indicate in the space provided the degree to which each statement applies to you by marking whetheryou (1) Strongly agree, (2) Agree, (3) Are undecided, (4) Disagree, or (5) Strongly disagree with each statement. Thereare no right or wrong answers. Many of the statements are similar to other statements. Do not be concerned aboutthis. v fork quickly; just record your first impression.

I-Strongly agree 2-Agree 3-Undecided

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 rela.xed 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.

4-Disagree S-Strongly disagree

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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, 3, 7, 10, 11, 13, 15, 18, 20, 22, 24

3. PRCA Score=72+Total I-Total 2Above 79 = High CA;Bduw 32 = Low CA.

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