Communications exam 1

Verbal communication includes...

-conversational tone, easy to understand language, pauses to check for understanding

- important for relaying information to pt, combo nonverbal and verbal comm is important

Passive listening style

Hearing bu tnot fully paying attention and little/no participation in conversation

Active listening style

Hearing, paying attention, showing understanding with affirmations and , asking specific questions

interactive/collaborative listening style

-actively listening, reflecting, problem solving, and giving feedback

-builds a rapport, more engaging for the PT and pharm., more info gained on both sides

-more involved and listener asks questions and suggestions etc

barriers to active listening

distractions, selective listening, inability to concentrate, fatigue (listeners fatigue)

Active listening examples

using the patient's own words, responding empathetically

Iceberg effect with passive, active and collaborative listening

-- active and passive, the patients questions and concerns are not fully addressed

-interactive listening forms deeper meaning below the surface

About Nonverbal Comms

-complex mix of behaviors, and environmental interactions, that are shown to a person

-non vocalized

-more than half of all communication

-hard to interpret w/o audible cues

Characteristics of Nonverbal Comms

Mirror effect, hard to fake, some pts rely exclusively on this, variability leads to misinterpretation.

*cultural factors chan affect interpretation of cues

7 elements of nonverbal comm.

-kinesics

-chronemic (time)

-proxemics (space)

-Oculesics (eyecontact)

-haptics (touch)

-objetics (physical objects)

-vocalics (voice speaking)

proxemics

use and structure of space and how ppl interact with their space and physical distance between others

intimate space

reserved for close and personal relationships and is most protected.

when people invade this space a person might feel anger, and anxious

personal space

more comfortable, casual conversations

social space

typical spacing in pharmacy practice, may need to reduce distance when bringing up sensitive topics however should avoid taking a patients intimate space

Public space

greater than 12 ft reserved for when ppl are speaking in a group,

chronemics

use of time, willingness to wait, influenced by culture, nature of the situation, psychosocial factors, interpersonal relationships, more waiting = more value reduces negative feeling about wait

oculesics

use of direct eye contact shows interest, attention, gauges truthfulness and emotions,

-culture values eye contact differently

-amount depends on PT response to it

haptics

touch; communicates care, reduces tension and improves rapport. touch differs between culture and depends on emotional context, relationship between individuals, and how comfortable individuals are in using touch

-too much = demeaning, touch used instead of verbal expressions, dont use if pt is uncomfortable with it, should be used carefully

objectics

use of objects in comm. clothes, name tags, chairs, medication information on boxes

vocalics

use of voice, tone and pitch and emphasizing certain words over others, important for phone conversations, can be taken seriously or seriously (sarcastic vs not)

Environmental factors effecting nonverbal communications

Decor, private consultation areas, colors, prescription counters, professional attire, appearance of pharmacy, related discussion objectics on

Distracting factors to nonverbal communication

lack of eye contact, looking at pt info, leaflets, having >1 convos happening at the same time, chewing gum, having patients sign a log while talking or explaining something.

Pharmacist nonverbal language

use of nonverbal cues can affect how comfortable and respected a patient feels during counseling.

-Concern → attentive facial expression, leaning slightly toward the patient, appropriate eye contact

Aggravation/frustration → sighing, crossed arms, impatient facial expressions, looking away

Disgust/disapproval → grimacing, shaking your head, judgmental expressions

Interest → eye contact, nodding, facing the patient, open posture, actively listening

nonverbal language for effective Pt counseling

smiling and friendly, direct/ non continuous eye contact, open and warm physical gestures, appropriate distancing, align position free of barriers, professional appearance

Pt- nonverbal behaviors

pharmacist should be aware of pt, cultural differences, body movement, facial expressions

empathy

the ability to sense others emotions, and to imagine what the other person might be thinking or feeling

- done w/o judging

- does not mean you have to agree with a person

- must understand what a person might be felling

steps in the process to showing empathy

motivation, attention, empathetic responding, trust, further exploration of thoughts and feelings --- active process and difficult

problems with empathy

cheap empathy, not listening, forcing interpretation, empathizing at the surface level and not with deeper issues, discounting pt feelings, generalizing

cheap empathy

a superficial, low-effort expression of understanding or concern that lacks genuine commitment, sacrifice, or follow-through

generalizing

"alot of people go through that" "happens to every one", makes the patient feel not as seen as they should be

How to express empathy

Major and slight paraphrasing, repeating back, framing

major paraphrasing

restate/summarize the deeper meaning of what the patient said.

slight paraphrase

Repeat the patient's basic message using slightly different words.

Framing

How something is presented has influence on the choices the patient makes about information

empathy in pharmacy

-understanding, appreciating, and responding to needs of others

-genuine concern for patients welfare

-verbal and nonverbal

-must not lose sight of the obligation to be empathetic regardless of situation

1) assessing needs of Pt

2)Pharmacist then has to respond appropriately

Behavioral change

Transition from past to new behavior, involves changing patient knowledge, beliefs, and attitudes about the past and new behaviors

(smoking, drinking, diet change, exercise)

Rxns to change

fear, depression, anger, blame, excitement, joy, scape goating, feeling alone, guilt.

Barriers to change talk.

-Lack of confidence and understanding about the change and what needs to happen

-inability to see the benefit and lack of involvement, complacency

- change is no longer possible,

Transtheoretical model of change (TTMC)

various approaches and theories to change, model is useful to determine how ready one is for change and how to intervene and assist in an individual making the change, an evolving cycle and cyclical process

5 stages of TTMC

1) precontemplation- not thinking about changing any time soon

2) contemplation- considering changing but not yet

3) preparation- getting ready to change soon

4) action- in the process of change

5) maintenance - changed already but keeping up with change

Precontemplation

not thinking about changing in the next 6 months, pt might not be aware on the need to change, never tried change, pros of old behavior out weight the cons

Dos and donts of precontemplation

do.. advise change, noninvasive questions, raise awareness of health consequence, empathy, dont make decision for the patient

Dont... persuade, cheer lead, tell the pt how bad the behavior is in a judging way

precontemplation: dramatic relief

becoming upset or emotional at the information

precontemplation: consciousness-raising

gaining and thinking about information that is relevant to ones health maintenance behaviors

contemplation

considering change,

-aware that change is needed and of benefits of change

-struggle with ambivalence of change

-low self efficacy

-high perceived temptations to stay the same

Goal at each stage of TTMC

move the patient to the next stage in the process and engage in the new behavior at maintenance

Dos and dont with contemplation

do... advise change, provide info, reasons for change,empathy, motivation, self evaluation, encouragement

Dont... apply action oriented interventions

5 R's of increasing motivation

relevance, risk, reward, roadblock, repetition

contemplation: social liberation

noticing that others in their environment are also making the change

contemplation: environmental re-evaluation

recognizing the harmful effects of not taking care of ones self physically, psychologically or socially

contemplation: self-re-evaluation

evaluation of ones attitude towards healthy vs unhealthy behaviors

preperation

ready for the change, patients aware of benefit and need of change, ready to take action, beginning to set goals and motivate self

dos of preparation

do... praise awareness and readiness, assess history of current and past behavior, assess history of previous efforts to change behavior, talk about strategic approaches to change

Strategies to support new behaviors : cognitive

review commitment to change and positive self talk and reinforcement

Strategies to support new behaviors: behavioral

use of cues and reminders, monitoring, rewards, social support

to let slip, slide

brief moment where a person strays from their target behavior. It does not mean the entire effort or progress has failed.

Action

actively engaging in target behavior for 6 months, high relapse risk, pt has changed and is practicing

dos of action

praise progession, evaluate current attempt to change, ask about social support, ID temptations and encourage alternate behaviors

relapse prevention

encourage new behavior, promote commitment and discuss benefits of new behavior. congratulate success and provide support

Action: reinforcement management

rewarding oneself or being rewarded by others for healthy nehaviors

Action: stimulus control

altering/ manipulating the environment to remove cues that trigger relapses in the behaviors and introducing cues to facilitate healthy behaviors

action: counterconditioning

developing and engaging in new healthy behaviors to take the place of a behavior

Maintanence

pt remains vulnerable to relapse: engages in the behavior for 6 months

DOs of maintenance

congratulate continued success, offer advice for relapse prevention, encourage alternate behaviors, positive reinforcement

counseling change

Routinely ID behavioral targeting for change. advise Pt to engage in the new behavior, asses stage at each interaction. tailor intervention messages (be a good listener, minimal intervention in absence of time for more intensive intervention), arrange a follow up

Motivational interviewing

Complements TTMC, negotiates behavior change with a patient, helps make a cmmitment to change. Pts are ambivalent to change, unaware that change is needed, misinterpret seriousness of the situation

Background of MI

alternate approach to substance abuse other than direct confrontation.,

-non-confrontational practice became standard

shows empathy, genuineness, and unconditional positive reward

MI application examples

substance abuse addictions, gambling addictions, childhood obesity, HIV risk behaviors, medication adherence, impulse buying, pain

MI structure (FRAMES)

F-- feedback

R--responsibility

A--advice

M--menu of options

E--empathetic style

S--support self efficacy

Feedback

Ask and provide personalized feedback

-ask permission to share results, provide risk level and meaning

-describe health, social, legal, or psychological risks associated with at risk use

-educate pt on harmful interactions

Responsibility and Advising

advice to reduce or quit use, ask permission to share about lower risk use

Menu of change options

Go through options, draw on past successes and support self efficacy, explore chalenges, affirm ideas and support self efficacy

Enhance motivation and elicit change talk by empathy and supporting self talk

utilize pro/con, change rulers, and contrast with lower number (scale of 1-10) and reinforce positive and help envision change

Referral to treatment (SBIRT)

Active linking of pts to resources when needed (state/town services, healthcare, federal, local)

SBIRT

S- screening

B I- brief intervention

R T- referral to treatment

Barriers to SBIRT

discomfort with the process, lack of privacy and confidentiality concerns, systemic approaches to ensure universal or targeted screening, lack of time and reimbursement, inadequate knowledge of referral programs and insurance coverage

Facilitating SBIRT

--Train pharmacists and integrate it into core workflow and documentation systems,

--engage with other staff, work with local community and insurance programs to ID referral programs

MI (motivational interviewing)

client centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence

Motivation...

the key to change, fluctuating, interactive, can be modified, the providers style influences the patient motivation

4 parts of MI

--collaboration/partnership

--acceptance and autonomy

--compassion

--evocation

collaboration/partnership

MI is done FOR or WITH someone not ON or TO someone, in partnership, change does not happen alone and provider and pt need eachother

acceptance and autonomy

be accepting of what the pt brings, no judgement, empathize with pt, freedom of choice, acknowledge strength and efforts

compassion

the wish to see others free from suffering actively promote the pts welfare to give priority to the pts needs,

evocation

providers goal is to call on the pts ability to make change with their own strength, providing positive reinforcement

OARS

Open-ended questions

Affirmations

Reflective listening

Summaries

Open-ended questions

questions that allow respondents to answer however they want

Affirmations

Positive statements about character strengths. positive messages from providers to pts

Reflective Listening

Listening to the client and then repeating, in your own words, what you think the client is telling you. allows for clarification

change talk DARN CAT

Desire

Ability

Reason

Need

Commitment

Activation

Taking steps

Change Talk

Talk that reflects movement of the person toward behavior change.

Sustain talk

Talk that represents and predicts movement away from change.

Readiness Ruler

A visual analog scale used with patients to assess their willingness for changing their behaviors.

MI strategy: life style

● Discussing patient's lifestyle from their perspective

● What does patient view healthy vs.unhealthy in his/her life? What aspectsneed to be changed?

MI strategy: typical day

Helps to tailor a dosing regimen to fit pt routines and improve medication ue

Goal of SBIRT

to identify and effectively intervene with those who are at moderate or high risk for psychosocial or health care problems related to their substance use.

Screening (SBIRT)

quickly assesses the severity of substance use and identifies the appropriate level of treatment-- ask two or more screening questions to ID substance use (ask frequency and concern)

Brief interventions (SBIRT)

-Conversation to motivate patients who screen positive to consider healthier decisions (e.g.cutting back, quitting, or seeking further assessment).

-nonjudgemental, or confrontational, directive, enhances motivation

-provide personalized feedback from screening results and state conccern

screening results

when positive move on to "brief intervention" of SBIRT

when negative give pt positive reinforcement but do not discuss further

Asynchronous telehealth

store-and-forward technology that collect images and data to be transmitted and interpreted later

synchronous telehealth

real-time aidio or video comms that connect the provider and the patient from different locations