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\def\RunningAuthor{Djoko Wahyono et al.}
\firstPage{933}
\articleType{Review Article}
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\title{Creative communication in networking services as the social skill of geriatric pharmacist}
\author{Yuhansyah~Nurfauzi\textsuperscript{1,2},  
            Djoko~Wahyono\textsuperscript{*}\textsuperscript{3},  
            Fita~Rahmawati\textsuperscript{3}, 
            Nanang~Munif~Yasin\textsuperscript{3}~\\[5pt]{\textsuperscript{1}Doctoral Program in Pharmaceutical Science, Faculty of Pharmacy, Gadjah Mada University, Yogyakarta, Indonesia }~\\{\textsuperscript{2}Department of Pharmacy, STIKES Al-Irsyad Al-Islamiyyah, Cilacap, Indonesia}~\\{\textsuperscript{3}Department of Pharmacology and Clinical Pharmacy, Gadjah Mada University, Yogyakarta, Indonesia}}

\begin{abstract}
The geriatric pharmacist is one of the professions that play an important role in providing drug services to the elderly. As specialist pharmacists, they are expected to be not only rich in clinical skills but also have good social skills to understand and meet the therapeutic needs of patients. On the other hand, the community views that pharmacists are very accessible, and caregivers trust them as a link with the health care network. Four electronic databases (PUBMED, Science Direct, Scopus and Google Scholar) have been used to explore relevant research. The research articles reviewed were original articles that stated creative communication in networking as an idea of the pharmacist and the application in service by the pharmacist. The articles were selected with several inclusion criteria, namely published between 2000-2019, designed with Randomized Controlled Trial (RCT) and/or qualitative studies, in English, and containing ideas or communication activities by pharmacists in networking services for patients or collaborating with another stakeholder. Exclusion criteria were articles which are research protocols, do not mention communication activities and efforts in creating a service network clearly and articles that only examine and assess economic aspects. Search results on 421 articles produced 13 articles that met the criteria for review, 9 articles from RCT and 4 articles from qualitative studies. Pharmacists can make oral, written and direct home visits when they provide advice. Pharmacists inform drugs through sign language, visual media and communication technology. Creative communication as a social skill plays an important role in networking services for doctors, nurses, patient families, caregivers and institutions related to services for the elderly.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Creative communication,\newline Geriatric pharmacist,\newline Elderly,\newline Network,\newline Social skills,\newline Pharmaceutical services
\end{keywords}
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\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Djoko~Wahyono~\\ Phone:\ +62811261953 ~\\  Email:\ djokowahyono@ugm.ac.id
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\section{Introduction}
Pharmacists need to master creative communication skills when providing pharmaceutical services\unskip~\citep{635751:14904280,635751:14904286}. Creativity in communication is evidence that clinical pharmacists need to have adequate social skills\unskip~\citep{635751:14904282}. In clinical settings, pharmacists need to master communication as part of social skills\unskip~\citep{635751:14904294}. In addition, current clinical practice pharmacy activities are closely related to the network of support and collaboration\unskip~\citep{635751:14904276}. Both activities in clinical pharmacy practice are applications of the patient-oriented paradigm in pharmaceutical services and require support in the form of good communication skills.

The application of communication skills in support of a patient-oriented paradigm can be seen clearly in pharmaceutical services for geriatric. The elderly need special attention, so the geriatric pharmacist requires individualization therapy skills \unskip~\citep{635751:14904272,635751:14904285}. Pharmacists can conduct home visits and counseling at elderly homes to simplify complex dosage regimens\unskip~\citep{635751:14904271,635751:14904296}. Pharmacists can also identify Drug Related Problems (DRPs) through Medication Review (MR) activities and communicate them with doctors\unskip~\citep{635751:14904277}. In addition, the elderly also require innovative services from community pharmacists. The greater role of pharmacists in serving the elderly in community pharmacy can be demonstrated by communicating pharmaceutical services well\unskip~\citep{635751:14904296}.

Pharmacist services for the elderly in the community involve many parties who are involved and thus require a network. For example, the service model in the community will be linked to institutions providing health services. Pharmacists also need to pay attention to the relationship of professional services such as a referral system for patients and health service supervisors. Other factors that need to be considered by pharmacists are related to social security, health insurance, the time span of service, place of service, duration of treatment, and payment system for professional services\unskip~\citep{635751:14904290}. The ability of pharmacists to establish networks is the result of creative communication. Furthermore, this ability is a social skill that is appropriate for pharmacists when expanding the scope of practice. However, not all pharmacists currently have high clinical confidence to practice in a wider scope\unskip~\citep{635751:14904276}. Therefore, the pharmacist steps in establishing a network when practicing in providing pharmaceutical services to the elderly need to be detailed.

This systematic review aims to reveal the creative efforts of pharmacists when communicating the pharmaceutical services provided to the elderly to the parties concerned. Research that has been widely reviewed previously does not show in detail the occurrence of communication with doctors\unskip~\citep{635751:14904277}. On the other hand, pharmacists must also have the social skills needed to build trust through good communication with patients and their families\unskip~\citep{635751:14904273}. However, there is no systematic review linking the creative communication carried out by pharmacists in networking services for geriatric patients. Thus, a review of social skills will reveal in detail the creative forms of communication in the networking services of the geriatric pharmacist, both to patients, other health care workers, families, and other stakeholders involved. The results of this review will have implications for more optimal geriatric pharmacist practices because it is based on the needs of elderly patients and other parties revealed through good communication.
    
\section{Materials and Methods}
This systematic review was compiled based on studies related to communication and networking in geriatric pharmacist activities when providing pharmaceutical services to the elderly. 

\textbf{Study identification}

The systematic review was conducted to obtain research relevant to the purpose of writing. The research articles reviewed are original articles that stated creative communication in networking as an idea of the pharmacist and the application in service by the pharmacist. The articles were selected with several inclusion criteria, namely published between 2000-2019, designed with a Randomized Controlled Trial (RCT) and/or qualitative study, in English, and containing ideas or communication activities by pharmacists in networking services for patients or collaborating with another stakeholder. Exclusion criteria are articles that are research protocols, do not clearly state communication and networking services activities, and articles that only examine and assess economic aspects. Four electronic databases (PUBMED, Science Direct, Scopus, and Google Scholar), were first traced in May 2019. Keywords used in the search are shown in Table~\ref{tw-5fa2aa638b96}. 


\begin{table*}[!htbp]
\caption{\boldmath {Search terms used to identify relevant studies} }
\label{tw-5fa2aa638b96}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.4723999999999999\linewidth-2\tabcolsep}p{\dimexpr.5276000000000001\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Database & Search Terms\\
\tblmidrule 
PUBMED (2000-2019) &
  "Health Services for the Aged"[Mesh] AND "Pharmaceutical Services"[Mesh] \\
Science Direct (2000-2019)  &
  "Health Services for the Aged" AND "Pharmaceutical Services"\\
Scopus (2000-2019) &
  "Health Services for the Aged" AND "Pharmaceutical Services"\\
Google Scholar (2000-2019) &
  "Health Services for the Aged" AND "Pharmaceutical Services"\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
\textbf{Data extraction}

The data is extracted independently by using a data extraction form, which includes the details of studies, namely the authors and year, setting, pharmaceutical service models, forms of creative communication carried out in networking services, and communication objects.
    
\section{Results and Discussion }
\textbf{Screening and assessment of selected studies}

The process of evaluating articles produced by searching several databases for producing. Selected articles are shown in Figure~\ref{f-be62a6ae9f78}.


\bgroup
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\caption{\boldmath {Prisma diagram of retrieved studies}}
\label{f-be62a6ae9f78}
\end{figure}
\egroup
\textbf{Characteristics of studies}

Of the total of 13 articles reviewed, 9 articles came from RCT research designs, while 4 articles came from qualitative studies. Research originating from RCTs will reveal the creative efforts of pharmacists in communicating pharmaceutical services. The communication is aimed at related parties as a series of interventions that have been carried out for elderly patients. Four other research articles included in this review come from qualitative studies\unskip~\citep{635751:14904270,635751:14904271,635751:14904292,635751:14904296}. Qualitative study designs often use interviews and focus group discussions that can reveal new ideas as creativity from pharmacists that are applied to establish communication in networking services. In detail, the characteristics of the 13 studies are shown in Table~\ref{tw-2776bb03f78a}. This systematic review attempted to explore creative forms of communication carried out by the geriatric pharmacist. Creative communication provides values for communicating with patients to improve relational and emotional dynamics\unskip~\citep{635751:14904281,635751:14904291}. The relational dynamics that will be seen are in the networking services performed by pharmacists. The series of creative communication in networking services is a social skill that pharmacists need to have. Social skills are the ability to manage relationships with others. Leaders who have social skills have a strong support network that can be called upon when needed. They build, manage, and lead teams effectively. Social skills enable these leaders to persuade others\unskip~\citep{635751:14904293} easily. Pharmacists often become communicators between elderly patients with doctors and other health workers and other parties and become leaders when dealing with drug services. Therefore, active efforts are needed to maintain relationships with patients and other parties related to patients. However, there is no systematic review that shows the creative communication carried out by pharmacists in networking services for the elderly. This research has revealed detailed forms of communication applied by pharmacists in various countries in accordance with the character of pharmaceutical services to the elderly. Creative communication efforts have been demonstrated by pharmacists in implementing pharmaceutical service practices in various settings. Pharmacists who practice in the nursing home and primary care need to communicate the new role of their profession to nurses so that interventions to be given to patients can be accepted by nurses\unskip~\citep{635751:14904287,635751:14904289}. Most of the communication made by pharmacists is done with doctors\unskip~\citep{635751:14904274,635751:14904275,635751:14904278,635751:14904283,635751:14904287,635751:14904288,635751:14904289,635751:14904292,635751:14904296}, but there is also what is done to fellow pharmacists in the team\unskip~\citep{635751:14904287}. 

Pharmacists who practice in other community-based services such as pharmacies, clinics, and hospitals have also developed various strategies in communicating to implement networking services, even to the patient's home\unskip~\citep{635751:14904279,635751:14904283,635751:14904295} for patients and their caregivers.

The success obtained by the pharmacist in communicating his practice can be seen from various receipts of related parties who are the object of communication. For example, research in the setting of general medical practice in Scotland shows the acceptance of all doctors involved in research on the


\begingroup
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\caption{\boldmath {Characteristics of the studies} }
\label{tw-2776bb03f78a}
\def\arraystretch{1.1}\\\endfirsthead \hline \noalign{\vskip3pt} \noalign{\textit{Table \thetable\ continued}} \noalign{\vskip3pt} \hline \endhead \hline \noalign{\vskip3pt} \noalign{\textit{\hfill Continued on next page}} \noalign{\vskip3pt} \endfoot \endlastfoot 
\tbltoprule \rowcolor{kwdboxcolor}Authors, Year & Setting & Pharmaceutical service models & Creative communication in networking services & Communication objects\\
\tblmidrule 
\unskip~\citep{635751:14904289} &
  The nursing home, Queensland and new south wales, Australia &
  Clinical pharmacy service  &
  Written and telephone communication as well as creating media wallcharts and bulletins, direct visits to introduce the new role of the pharmacist profession to nurses through the Facilitated focus group; indirect communication with General Practitioners followed by focus groups and a number of personal interviews in order to carry out medication review to patients. \mbox{}\protect\newline  &
  Patients, nurses and general practitioners \\
\unskip~\citep{635751:14904283} &
  General medical practices, Grampian, Scotland &
  Pharmaceutical care  &
  Conduct a home visit to communicate and meet the patient's information needs for the drug and its dosage.  \mbox{}\protect\newline Communication with doctors is carried out for networking services of medication review, solving prescribing problems, monitoring, and preventing adverse drug reactions.  \mbox{}\protect\newline  &
  Patients and general practitioners\\
\unskip~\citep{635751:14904284} &
  General clinics at the hospital, Singapore &
  Pharmacist consultation based on the Health Belief Model &
  Consultations by pharmacists with patients are accompanied by interviews with patients and their families in outpatient clinics.  \mbox{}\protect\newline The knowledge that is communicated includes drug indications, how to administer specific drugs (inhalers and insulin), as well as disease management (side effects, diet, use of drugs without a prescription).  \mbox{}\protect\newline If there is no family, the pharmacist supervises the caregiver. \mbox{}\protect\newline  &
  Patients, family, and caregiver\\
\unskip~\citep{635751:14904287} &
  Primary care clinics, Washington, USA &
  An interdisciplinary team of geriatrics specialist &
  Geropharmacist, who is part of the Senior Resource Team (SRT), communicates the findings of the medication review to the geriatrician and then educates nurses about psychoactive drugs. \mbox{}\protect\newline The pharmacist who is part of the team communicates drug changes, drug withdrawal, and matters that must be considered by the elderly by telephone. \mbox{}\protect\newline  &
  Geriatrician, nurses, patients, and other pharmacists\\
\unskip~\citep{635751:14904275} &
  Primary care, Netherland &
  Pharmaceutical care  &
  The communication is carried out by the pharmacist in the context of networking services for a medication review, which is carried out by 2 methods, namely academic detailing, and written feedback.  \mbox{}\protect\newline Pharmacists and doctors discuss each other recommendations, including things that must be considered by elderly patients in the academic detailing method.  \mbox{}\protect\newline In the written feedback method, the pharmacist records all the recommendations and sends them to the doctor's office.  \mbox{}\protect\newline  &
  General practitioners\\
\unskip~\citep{635751:14904279} &
  Hospital, Uppsala, Sweden &
  A comprehensive pharmacist intervention &
  The pharmacist who conducts a medication review submits advice to the doctor regarding drug selection, dosage, and monitoring. Pharmacists communicate advice to patients in a patient-centered way.  \mbox{}\protect\newline Counseling is given to patients during hospitalization and when going home from the hospital. After being discharged from the hospital, the pharmacist established a network with a doctor in primary care. \mbox{}\protect\newline  &
  Doctors, nurses, families, caregivers, and patients.\\
\unskip~\citep{635751:14904288} &
  General practices and community pharmacies, East and North Yorkshire, UK &
  Pharmaceutical care &
  Pharmacists measure the level of patient knowledge in order to adjust communication techniques in education to be provided.  \mbox{}\protect\newline Doctors are involved in collaborative services that will be applied by pharmacists for the elderly. Pharmacists carry out pharmacy services until the home visit. \mbox{}\protect\newline  &
  Doctors and patients \\
\unskip~\citep{635751:14904278} &
  Hospital, Uppsala, Sweden &
  A comprehensive pharmacist intervention &
  Pharmacists focus on communicating verbally about insight into prescription drugs that are right for the elderly to the healthcare team. Pharmacists establish close working relationships with doctors and nurses. Pharmacists also establish extensive communication with patients. After the patient is discharged from the hospital, follow up is continued by telephone. \mbox{}\protect\newline  &
  Doctors, nurses, families, caregivers, and patients\\
\unskip~\citep{635751:14904296} &
  Community pharmacy, United Kingdom &
  Personalised pharmaceutical care &
  Pharmacists make home visits and provide good advice to the elderly. The pharmacist communicates with the doctor so as not to prescribe drugs that are contraindicated and interact. Pharmacists communicate verbally about pharmaceutical services to the elderly. In addition, pharmacists also use posters and leaflets to communicate their services. \mbox{}\protect\newline  &
  Doctors and patients\\
\unskip~\citep{635751:14904274} &
  Hospital, Ireland &
  Education for doctors with e-learning &
  Pharmacists establish communication about the services they carry out not only with doctors but also with several institutions that care for the care of the elderly and their families. \mbox{}\protect\newline  &
  Doctors, hospitals, pharmacies, nursing homes, and patients' families.\\
\unskip~\citep{635751:14904292} &
  Primary care, Sweden &
  Interdisciplinary team  &
  Pharmacists provide tutorials for doctors and nurses by academic detailing in order to communicate medication review. \mbox{}\protect\newline  &
  Doctors and nurses\\
\unskip~\citep{635751:14904271} &
  Community pharmacy, Scotland &
  Pharmaceutical care &
  Pharmacists provide counseling at the patient's home to simplify complex dosages. Pharmacists prepare special boxes for medicine. Pharmacists also advise the national chronic medication service to provide opportunities to talk to patients and carry out medication reviews. \mbox{}\protect\newline  &
  Patients and national chronic medication service\\
\unskip~\citep{635751:14904270} &
  Community pharmacy, Scotland &
  Pharmaceutical care &
  Pharmacists communicate with elderly patients who have limited vision using sign language, images, videos from the internet, text messages, and e-mail. Pharmacists also provide counseling at the patient's home to simplify complex dosages. &
  Patients and carers\\
\tblbottomrule 
\end{longtable}
\endgroup
\makeatletter\@ifundefined{TwoColDocument}{}{\twocolumn}\makeatother 
 creative process carried out by pharmacists\unskip~\citep{635751:14904283}. In Singapore, physician acceptance to pharmacist intervention reached 76\% \unskip~\citep{635751:14904284}, while in Sweden, it reached 75\%\unskip~\citep{635751:14904279}. A doctor's acceptance of medication review by pharmacists, which is quite important is the prescription changes that are not appropriate for elderly patients. The percentage of changes in prescribing reached 39\% in Australia\unskip~\citep{635751:14904289} and 32\% in the United States\unskip~\citep{635751:14904287}. Even in Switzerland, 34\% of doctors feel comfortable with the prescription they provide to the elderly with the education of pharmacists about the prescription appropriateness criteria\unskip~\citep{635751:14904274}.

In Singapore, families who accompany elderly patients or caregivers are one of the priorities of the pharmacist's communication object. Activities that prove the pharmacist's creativity in communicating with the elderly and family or his caregiver are shown by increasing patient compliance. This success is inseparable from the efforts of pharmacists to use medication reminder methods, medication aides, and link the time of drug use with routine habits or meal times. Creative communication is also shown when the pharmacist provides education, not only by increasing knowledge but also to improve patient perception of the disease and the benefits of treatment\unskip~\citep{635751:14904284}.

A study revealed the role of a geropharmacist in the United States that integrates specialist services with other parties related to the therapy of psychoactive drugs in the elderly\unskip~\citep{635751:14904287}. As part of the team, Geropharmacist uses its social expertise well in networking services so that it can be well received by primary care providers. Although not directly communicating with patients, creative efforts are made by giving briefings to all primary care providers, including other pharmacists who will contact patients by telephone.

A long series is shown by the efforts of pharmacists in networking services in Sweden\unskip~\citep{635751:14904278,635751:14904279}. The pharmacist communicates medication reviews to the doctor in the selection of drugs, dosages, and monitoring needed. Communication is carried out to various parties involved since the patient was admitted to the hospital. When the pharmacist provides advice, the patient's perspective is actively sought to suit the needs. This is done after the pharmacist has a semi-structural interview with all patients or relatives and caregivers. In fact, telephone follow-up is still carried out by pharmacists to patients after 2 months of being discharged from the hospital. Pharmacists creatively communicate by telephone to relatives or caregivers of patients 2 months after the patient is discharged from the hospital. The timing of 2 months with the reason that at this time, they get the opportunity to foster new motivation to patients. The pharmacist also communicates all matters related to the medicine of elderly patients to the doctor in primary care. 

Innovative educational efforts have been carried out by pharmacists in order to communicate pharmaceutical services. Education is needed so that the established network services can be conveyed properly to the parties concerned. The communication made by the pharmacist to nurses and doctors even makes the two professions conduct interprofessional dialogue when conducting medication reviews for elderly patients\unskip~\citep{635751:14904292}. In addition, the objects of communication in networking services are the patient, the patient's family, and other health care institutions making the pharmacist really required to act as a reliable communicator. Therefore, it is appropriate for social skills to get the attention of the pharmacist himself or from the policymaker that deals with the pharmacist.

The limitations of this review are only based on research in developed countries. Pharmacists in developing countries will face the same situation because the elderly population throughout the world is increasing equally. The forms of communication reviewed are universal values because they are based on the specific needs of elderly patients. Therefore, the principles that emerge from creative communication in networking services can be used anywhere by the geriatric pharmacist.\textbf{\space }
    
\section{Conclusions}
Creative communication carried out by pharmacists plays an important role in networking services when providing pharmaceutical services for the elderly. The character of the elderly who have a variety of unique needs requires the pharmacist to communicate his services to be well-received by patients, patients' families, related parties, and other health workers. The forms of creative communication that can be applied are counseling about drugs for elderly patients verbally, in writing, and through direct home visits. When providing drug information, pharmacists communicate in various ways such as sign language, using various media visually, or utilizing communication technology. Pharmacists also pay attention to the patient's family and caregiver if the elderly find it difficult to communicate coherently. Pharmacists carry out networking services to doctors and nurses directly through presentations and tutorials, academic detailing, or indirectly through written feedback, using creative media such as bulletins and wall charts and communication technology. In addition, pharmacists also communicate the services they provide to institutions and institutions related to services for the elderly. 
\section*{Acknowledgement}The author would like to thank the Research Directorate of Gadjah Mada University for supporting funding in this study. 
    

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