Communicating With Patients
Koula Asimakopoulou, Tim Newton, Sasha Scambler and Suzanne Scott
This chapter will provide you with an understanding of why good communication is important in dental settings by:
- Considering theoretical models of communication and health behaviour, which have attempted to explain who is responsible for communication in the dental environment and the purpose of communication.
- Describing the basic principles underpinning good clinical communication skills.
- Breaking down the components of verbal, paralinguistic and non‐verbal communication.
- Describing a tool used to measure communication skills in the dental surgery.
- Describing a simple communication method used to change behaviour in healthcare settings in day to day practice.
When you have read this chapter you should be able to:
- Explain some of the features underlying communication in healthcare settings.
- Describe some models of health communication.
- List some of the key verbal, non‐verbal and paralinguistic skills that are important in good dentist–patient communication and note ways in which these can be assessed.
- Describe some of the processes involved in giving patients bad news.
- Outline the role of motivational interviewing in helping patients change their oral health behaviour.
What Is Communication?
Communication is the process of imparting and sharing information. Some communication theorists describe communication in terms of a sender (i.e. the person emitting the information), a receiver (i.e. the person for which the information is meant), and a channel through which such information might be transferred (e.g. a consultation).
We usually communicate in more ways than simple verbal utterances and frequently with more than one recipient at the same time. Often, it is not really what we say, but the way we say it that tells (or fails to tell) the recipient what we have in mind. Gestures, posture, pitch, eye contact and proximity are only some of the factors that might help recipients interpret any verbal statements we make. Laughing at someone’s joke tells the person you enjoyed listening to it. Not laughing when laughter is expected will also convey a message.
We propose that communication is the transfer of information between senders and receivers, using one or several channels, settings, verbal and non‐verbal cues, all of which may contribute differently to the outcomes of the communication event.
The Purpose of Communication in Healthcare Settings
Ong et al. (1995) suggest that there are three purposes behind communication between doctors and patients. These are:
- Creating a good interpersonal relationship.
- Exchanging information.
- Making treatment‐related decisions.
Only one third of the process of a successful consultation involves talking about treatment. According to Ong et al., the main functions of a consultation between healthcare practitioners (HCPs) and patients are to create a good interpersonal relationship and exchange information. It is those two processes that will help frame the part of the consultation that involves offering the patient treatment. In other words, it could be argued that it is pointless to offer the patient treatment options and involve them in relevant treatment‐related decisions unless the dentist has created a relationship that is conducive to such an exchange. Exchanging information, in a manner which the patient can understand and engage with, is also an important factor of a successful consultation.
It must be noted that Ong et al. primarily described doctor–patient, rather than dentist–patient communication. It could be rightly suggested that consultations taking place in dental settings are quite different from those happening in medical settings. As Newton and Brenneman (1999) note:
- The general dental practice setting involves much more treatment than any medical encounter.
- During inspection of the oral cavity, verbal communication is compromised.
- Patients visiting a dentist are much more likely to be anxious than patients visiting a general medical practitioner.
As a result, findings from the medical setting literature may not be directly transferable to a dental setting. At the same time, we argue that dental clinical examinations and consultations do not happen in a vacuum; dentists work on people’s dentition, but to the extent to which the oral cavity resides within the person, a more holistic view of the consultation is necessary. In this sense, and given the paucity of research findings which have arisen from work in dental settings, we take the view that medical encounter setting findings, such as Ong et al.’s suggestions about the purposes behind HCP–patient communication, are applicable here.
Models of Communication in Healthcare Settings
The extent to which HCPs engage with the consultation process along the lines proposed by Ong et al. (1995) will often be determined by the way HCPs see the positions that they and their patients occupy within the health system. Positions here have to do with concepts such as responsibility and power, i.e. deciding who has the most responsibility and/or power in a healthcare consultation. It is proposed that patients’ and HCPs’ inherent models of ‘who should do what’, or in other words, the different roles that patients and HCPs occupy within the surgery, will influence what gets communicated and how information is conveyed.
Researchers such as Roter and Hall (2004) identified four different HCP–patient communication relationships that might explain how information is communicated in healthcare settings and by whom. Conceived in terms of who is responsible for communication in the dental surgery, they correspond to the following four models:
- The ‘traditional’ medical model. This model proposes that the dentist knows what is best for the patient. The patient is seen to be a passive recipient of care whose role is to listen to the expert HCP and where patients are expected to do what the dentist tells them to do. The dentist’s role is that of an expert clinician; they know what is best in terms of dental care, have the knowledge and skills to deliver it, and are in a strong position to be an authority figure within their surgery. In this model, patient responsibility for the communication is low, whilst the dentist carries all of that responsibility.
- The ‘patient as expert’ model. Here it is proposed that although dentists might be technical experts, what is important is the expertise of the person presenting with the health problem. In this model, patients are perceived as experts in their condition. This expertise arises from the fact that it is patients rather than dentists who have lived with the health problem and will have to live with the treatment consequences. They know what symptoms they are experiencing, how severe these are and what impact they have on their daily lives. They also know how well or not they can live with any treatment side effects and consequences. Because of this expertise that, according to the model, only the patient possesses and can communicate, it is patients rather than dentists who should be responsible for leading the communication in the consultation. In this model, clinician responsibility for communication is low.
- The consumerist model. As the name would suggest, the dental surgery and the consultation are seen as a market place, with the dentist providing services for sale and the patient being the potential consumer of such services. In this model, dental care is seen as a service that is purchased by a patient who is predominantly a consumer. As such, it is the patient‐purchaser who is primarily responsible for the verbal exchange during such a sale of goods and services, whilst the dentist has a more passive role.
- The transformed medical model. This approach sees both dentists and patients as experts, albeit in different fields. The model acknowledges that dentists are technical experts who have the knowledge and skills to deliver expert healthcare. On the other hand, patients are seen as experts in their own life, their symptoms and the impact of those symptoms on their oral health. It is therefore proposed that patients can inform the consultation by bringing in information which will help the expert technician fit the clinical service they are about to provide to that particular patient, with their particular anxieties, feelings and activities of daily living. In this model, patients and dentists are seen as equals where expertise and knowledge from both parties need to be combined in order to ensure that the work delivered will meet the psychosocial and clinical needs of the person seeking it. Here, responsibility for the communication episode is shared between HCP and patient.
Clearly there is not an ‘one size fits all’ model which dentists should all adopt for ever more. Things that are beyond a dentist’s personal control, such as the length of time they are given to spend with patients (and the length of the queue in their waiting room!), the sort of patient they are treating (e.g. a middle class, middle‐aged, professional as opposed to a working class, of limited education, elderly person with dementia and dental anxiety), the reason why they are seeing the patient (e.g. an urgent referral because the patient is in excruciating pain as opposed to a routine dental check‐up) and the patient’s experience of dentists and expectations of what their and the dentist’s role might be in the surgery, might all constrain (or in some cases enable) the dentist’s choice of a communication model. In fact, research work from the medical field (see Asimakopoulou (2007) and Newton and Asimakopoulou (2008)) has highlighted the dangers of advocating that any model applied in a ‘one size fits all’ approach is best for patients.
Some limited but illustrative evidence from the dental field further supports the idea that patient participation in a dental visit is not as straightforward as these models would suggest. In a recent Dutch study with emergency dental patients, patient participation during the dental consultation was examined in a naturalistic setting (Schouten, Hoogstraten and Eijkman, 2003). Eighty‐three dental patients receiving emergency dental care had their consultations videotaped. Numerous variables were assessed to include the dentist’s communicative behaviour (i.e. the dentist’s verbal behaviour during the opening phase of the consultation, during examination and treatment and finally at the closing stage of the session), the number and type of questions the patient asked and the patient’s self‐reported desire for information and wish to participate in the consultation. The findings were interesting and resembled those seen in medical settings. What was found was that although patients expressed the need for more information about their dental treatment, this wish was not translated into an increased number of questions being asked of the dentist. The medical settings communication literature tells a similar story; it is often the case that most patients want answers to several questions, yet they do not feel able or willing to ask these questions themselves! In the Schouten et al. study, it was found that although patients self‐reported that they wished to participate in the decision‐making process about dental treatment, they also said that they felt more comfortable handing over responsibility for problem‐focused decision‐making regarding their treatment to their dentist. So, it would appear that some participation is something that patients appreciate; however, when it comes to important decisions about treatment, they expect responsibility to be passed back onto their treating dentist.
Dentist–Patient Communication: Basic Components and their Assessment
Work from medical settings has been helpful in shaping our understanding of the sort of communication behaviours that take place in a consultation between HCPs and patients. On a general level, Roter and Hall (1989) describe two sorts of tasks that HCPs undertake in successful communication encounters in healthcare settings. These are what they broadly describe as ‘instrumental tasks” and, second, ‘socio‐emotional tasks’. Both are seen as equally important if communication between HCPs and patients is going to be effective.
As one would expect, ‘instrumental tasks’ have to do with the basic instruments HCPs use when they communicate. Giving patients information, for example, is one of them. Asking patients questions and answering theirs is another example. Conversation that is designed to convey to the patient that the HCP is technically competent is the final type of instrumental task in the Roter and Hall model. Alongside instrumental tasks, these researchers argue that there are tasks whose aim is to look after the psychosocial aspects of the communication encounter. These are the sorts of things dentists might say in order to build a partnership with a patient; things like making social conversation, often at the start of the consultation; giving some positive talk about things patients have done well since you last saw them; and finally showing them that over and above being a dentist, the person about to treat them is also, generally, interpersonally competent. These ‘socio‐emotional tasks’ are some of the behaviours that Roter and Hall suggest are as important as ‘instrumental’ activities in ensuring a successful communication encounter.
Although Roter and Hall have suggested this dichotomy of breaking down tasks in any communication encounter, numerous additional research papers have been written on the subject. The question of what should be the primary purpose of a consultation in particular has attracted a lot of attention, especially in the medical literature. For example, researchers have looked at medical consultations as a function of the HCP demographics such as gender, age, experience and so on, and how these influence whether the consultation is consultative (patient‐centred) or directive (physician‐led). Possible interactions between HCP communication styles and patient characteristics have also been investigated. The resulting effects of the combination of these factors on patient outcomes, such as satisfaction with the consultation and adherence to HCP advice, have also attracted a lot of attention. The general message seems to be that, quite unsurprisingly, male and female practitioners seem to approach the medical consultation differently. This difference is said to affect how patients respond to them, how satisfied they are and how well they adhere to medical recommendations.
Roter and Hall (2004) have written a detailed, critical review on the extent to which a HCP’s gender might be related to how patient‐centred a consultation might be. They combined the results of two meta‐analytic reviews on the effects of HCP gender on communication in medical encounters. They found that female HCPs’ consultations were longer than those of their male counterparts by about 2 minutes. During that time, female HCPs were said to perform more of those behaviours that are typically considered patient‐centred. They asked more psychosocial questions, engaged in more active partnership behaviours (that is, behaviours to suggest that HCP and patient are equal partners) and more positive talk, and a lot of their consultation was focused on how patients felt. In return, these HCPs’ patients were found to be speaking more than those treated by male practitioners, and disclosing more biomedical and psychosocial information about themselves.
So it would appear that a consultative, patient‐centred, socio‐emotional centred consultation, usually favoured by female HCPs, leads to patients being more talkative and disclosing more about themselves. This is not necessarily a positive outcome though. There is no convincing evidence as yet that patients are always happier having been through a consultative rather than a directive consultation. There is also no unequivocal evidence that patients will leave the consultation and adhere to a greater extent to medical advice when they have experienced a more satisfying consultation in the healthcare setting. For example, whereas some researchers have shown that a highly directive style on the part of the physician can enhance patient satisfaction (e.g. Savage and Armstrong, 1990), others (e.g. Bradley, Sparks and Nesdale, 2001) have argued the exact opposite, i.e. that it is consultative communication styles are seen as more satisfactory by patients. For example, Swenson et al. (2004)interviewed 250 adult patients who had viewed video clips of consultations that were either patient‐centred or highly doctor‐led. A third of these patients preferred a directive style. Amongst other predictors, older patients and those who described their own doctor as directive were more likely to prefer a directive consultation style. Directive doctors were also rated as more to the point and knowledgeable. At the moment, there is no one consultation style universally favoured by patients and which leads to elevated levels of patient satisfaction and adherence.
The picture is equally unclear in findings arising from research in dental settings. We know that female patients, older patients and patients who score low on neuroticism (that is, a measure of anxiety) tend to rate their dentist more highly in terms of how satisfied they are with the consultation, than others (Newton and Brenneman, 1999). The same authors also report evidence to show that patients tend to prefer an authoritative and more experienced dentist. At the same time, research work shows that patients are more satisfied when they are given a degree of choice in terms of the treatment they receive.
In some now fairly dated but nevertheless relevant research, Lefer, Pleasure and Rosenthal (1962) compared two groups of denture patients. Group A were offered a choice of either an individualised set of dentures made especially for them, or an ‘average’ set of dentures made to fit most people. Group B were not offered a choice but were given a set of individualised dentures made especially for them. The group given a choice of denture (Group A) were not only more satisfied with their dentures but also less likely to complain about them or refuse to wear them. This was despite the fact that most of Group A chose the ‘average’ set.
It would appear that there is no clear‐cut evidence here to help one decide the sort of communication style that any patient would find best in any dental setting. Nevertheless, work has been carried out to show what kind of behaviours might be typical in a dentist–patient communication. If, rather than trying to prescribe what should go on in a dental surgery, we knew what communication episodes routinely take place in practice, we might be able perhaps to start assessing their frequency of occurrence and start observing them, recording them and trying to find out which work best, and under what circumstances. In doing so, we could start making predictions about what patterns of consultation seem to be predicting outcomes such as satisfaction with the dental consultation and adherence to oral health advice. Newton and Brenneman’s (1999) work in this respect is particularly important.
Building on Newton’s (1995) theoretical model of dentist–patient communication which sees the latter as consisting of three broad stages (opening, examination/treatment and closing), Newton and Brenneman developed a measure to assess communication in the dental surgery. Known as the Communication in Dental Settings Scale (CDSS), the measure seeks to assess components of the dentist–patient communication separately for each of the three stages of the consultation as identified by Newton (1995).
There are 13 separate communication behaviours assessed by the questionnaire, scored on a Likert scale from ‘Unacceptable’ (scoring 0) to ‘Good’ (scoring 3) with 1 and 2 used to indicate ‘Poor’ and ‘Acceptable’ performance respectively. Total scores range from 0 to 39 with a higher total indicating better communication. The authors provide detailed guidance on how observers should allocate these points to each communication component, taking the view that a more patient‐centred style is preferable. For example, where the dentist is assessed on discussing treatment options and plans, a dentist who was prescriptive, never involved the patient and never offered treatment alternatives would score 0, whereas a dentist who discussed treatment plans and options, considered the pros and cons of each and actively involved the patient in forming a final decision would score the maximum score of 3.
The list of behaviours assessed by the CDSS appears in Box 4.1. The scale has been tested and found to be both reliable and valid for use in clinical dental settings. As such, not only does it serve as a useful tool in breaking down the dentist–patient consultation into distinct tasks, it also offers a useful way to formally assess communication skills in dental settings.
Verbal, Paralinguistic and Non‐Verbal Communication
As can be seen, communication in healthcare settings is a far from straightforward topic to describe and evaluate. In an attempt to understand the topic better, researchers interested in communication often break down the topic into three subtopics. These examine:
- The exchanged utterances, in other words, what gets said. This is broadly termed ‘verbal communication’.
- Those aspects of speech that are not words but which convey information, such as tone of voice, confirmatory noises. These aspects of the communication event are called ‘paralinguistic communication’.
- The behaviours and environmental factors that contribute to a communication event but are not actual words and yet people often interpret without conscious awareness. These aspects are studied under the term ‘non‐verbal communication’.
The next section shows that some verbal, paralinguistic and non‐verbal behaviours are more helpful than others in supporting a directive or consultative style respectively.
Verbal communication refers to the actual words that are used and can be broken down into three communication subtypes.
- Information seeking.
- Information provision.
- Aids to dentist and patient understanding.
The first category has to do with questions that aim to elicit information from the patient. As such, these questions can be ‘open’ (e.g. ‘How are you?’), ‘focused’ (e.g. ‘What sort of pain is it?’) or ‘closed’ (e.g. ‘Do you brush every day?’). Open questions allow maximum scope for the patient to engage with the HCP as they do not in any obvious way restrict what information the patient delivers. Closed questions, on the other hand, invite either a ‘Yes’ or a ‘No’ response and as such are highly directive; here, patient involvement is limited in that the sort of information they offer has already been pre‐defined by the person asking the question. Focused questions are something like a happy medium where although the patient is allowed some leeway in how much information they convey to their dentist, the dentist has limited the conversation to a specific topic. Obviously, there is a time and place for each; it is not proposed that only open questions ever get asked and that patients are never directed. However, some questions (e.g. open) are more suited to some stages of the consultation (e.g. the opening phase) than others.
Interestingly, there are three more categories of question that are relevant when considering verbal communication issues, mainly because they are best avoided at all times. These are: leading questions, i.e. questions that imply a specific answer (‘You don’t really floss twice a day do you?’); compound questions, which ask more than one question in one and can potentially confuse the patient (and the dentist!) (‘Do you brush and floss daily?’ – where an answer of ‘Yes’ could be said to apply to one but not the other of the two behaviours that are enquired about); and, finally, questions that contain jargon (e.g. ‘You seem to be showing the typical symptomatology of chronic periodontitis to me, what do you think?’).
The second category of verbal communication behaviour involves the dentist providing information. Information provision is not a simple matter of telling patients what a dentist believes patients should know. Bombarding patients with information in the forlorn hope they might remember it is unlikely to contribute to a collaborative consultation. Research has shown us that most patients quickly forget the vast majority of what HCPs tell them (e.g. Kessels, 2003). So, for information provision to be effective, it should be tailored to the specific patient’s needs and wishes for information.
There are generally four stages that are involved in the process of giving information. Showing empathy/understanding is the first stage. Normally, people quickly dismiss information they are given unless the source of the information is one they trust, like and feel confident about. Showing empathy and understanding is likely to put the dentist in a situation where their patient is more likely to want to listen to what they have to say rather than if they perceive the dentist as an indifferent professional with no time for them.
The second stage of the process involves finding out what the patient already knows. Research into human memory tells us that people are more likely to remember information if (i) it makes sense to them and (ii) it fits in with what they already know. Finding out what patients already know is thus helpful in that it helps HCPs ‘pitch’ the new information at an appropriate level. A second obvious advantage is that it helps HCPs to avoid telling patients things they already know (hence wasting both the patient’s and their own time). A third positive outcome of checking how much patients know first is that it gives dentists the chance to correct any misconceptions patients may have by establishing whether what they know already is accurate or not.
Giving information in a few small chunks is another useful skill. It is generally advisable to break down the information that needs to be delivered whilst at the same time telling the patient that this is what the dentist is doing. Long narratives and explanations are generally not helpful when giving information. Categorising the information about to be given and signposting on the other hand (‘there are three important things I would like to tell you. Firstly…’) build on the well‐researched and evidenced principle that people find it easier to remember a limited number (normally no more than five) of information chunks at any one time. Chunking is thus likely to help patients recall the information later. Although chunking is a useful strategy, it must be stressed that an important aspect of information provision is to ensure that the information delivered matches the needs for information of each patient. Clearly, a highly educated, professional adult will have different information expectations and needs to a toddler; as such, chunking techniques will need to be adapted to one’s audience.
The final stage of the information giving sequence is to check patient understanding. This sounds easier than it actually is in practice; essentially, the dentist’s task is to test the patient’s understanding which, in some cases (e.g. where the patient has fully understood), can appear to be quite patronising. This is one of those skills where the more one practises the better one is likely to become at it. A technique that is often used is to ask patients to re‐state in their own words the information they have been given, as if they were telling a friend. This will again need to be adapted, to match the intellectual level of the patient the dentist is working with and their respective information needs.
The final category of verbal communication that this chapter will consider has to do with ways in which dentists can aid both their own and their patient’s understanding. There are two ways in which the understanding of what is being said can be enhanced.
Paraphrasing is a useful technique often used to clarify or interpret what patients say. The way that this is accomplished is by simply using slightly different words to reiterate what has been said already, to check that what has been conveyed is actually true. For example, where a patient might complain ‘I know I should brush but I don’t because brushing makes my gums bleed’ the dentist might paraphrase this with ‘You are having trouble brushing because when you do, you find that your gums bleed and this worries you’. Where this paraphrasing takes place on the part of the dentist, what is conveyed is that (i) the dentist understands that the patient’s gums bleed when they brush, that (ii) this is the main reason why they do not brush, and (iii) that the patient is worried about it. By paraphrasing, not only is the dentist conveying to the patient that they have indeed listened and understood, but they are also giving them another chance to comment more fully (and thus disclose more, possibly helpful, information) on what they have said.
A second way to aid understanding is by offering patients a summary of what has been discussed in the consultation. Good summaries are selective; the point is not to objectively sum up everything that has been said, but to put together a few important signposts regarding those points of the consultation that the dentist would like the patient to take away from their verbal exchange.
This section has outlined some of the basic principles of effective verbal communication. It is not meant to be prescriptive or exhaustive but hopefully it should have alerted the reader to some of the ways in which verbal communication with patients can be enhanced.
Paralinguistic and Non‐Verbal Communication
This section outlines some of those communication behaviours that supplement verbal communication and can either aid or hinder a collaborative or consultative style of communication. Things like the dentist’s vocal cues (e.g. tone, pitch, rate, volume, silence, effect and responsiveness) and confirmatory noises (e.g. ‘hmmm’, ‘aha’) convey to patients important information about the type of communication episode between them and the dentist. The dentist’s posture (e.g. whether they speak to their patient while they are lying flat on a chair while the dentist is standing), the dentist’s facial expression (e.g. raised eyebrows, smiles, frowns), the amount of eye contact, the amount of physical space between them and the patient, as well as environmental features such as furniture placement, lighting and so on, will all give patients ideas about the sort of dentist one might be as well as what the dentist’s expectations are about the way patients behave in their surgery.
It is long established that patients make judgements on the technical ability of dentists based on the appearance of the dental surgery. In an experimental study, respondents were more likely to rate as clinically competent a dentist whose surgery appeared modern and clean. This effect interacted with age where it was particularly strong if the dentist was young. Older dentists were assumed to have experience, which made up for their inadequate facilities, but a young dentist in an old‐fashioned surgery was viewed as most incompetent.
It would appear that patients not only read a lot into what dentists tell them, but also into how and where they convey the information.
Special Issues in Communication: Giving Bad News
It might be the case that on some occasions during their professional career, dentists will be faced with a situation where they have to give their patients bad news. What patients interpret as bad news is likely to vary between patients, but generally things such as telling them they are going to lose one or more of their teeth, or that they require surgery to remove a lesion, or that the dentist has discovered symptoms that are suggestive of some systemic condition, for example oral cancer, are some of the instances that might reasonably be classified as ‘bad news’. How patients take the bad news will, obviously, depend very much on the patient’s predisposition. However, the way the news is communicated by the dentist is also likely to be extremely important in terms of the impact it will have.
Five key communication tasks, which might involve giving patients potentially ‘bad news’, are as follows:
- Screening for disease and communicating risk.
- Communicating a negative diagnosis.
- Providing information about treatment and pretreatment.
- Communicating following treatment and dealing with fear of recurrence.
- Discussing the end of life in diseases such as head and neck cancer.
In performing these specific communication tasks, the HCP draws upon a range of key communication skills common to all situations, using their expertise and experience to blend those skills in order to address the needs of the patient. The next section provides a brief overview of each communication situation, with specific reference to head and neck cancer.
Key Communication Skills
As the chapter has highlighted already, it is important to emphasise that effective healthcare communication incorporates not only medical information but also discussion of the patient’s emotional and social wellbeing. As has also been discussed, it is important that the information provided is tailored to the patient’s ability to understand; this element includes the issue of cultural sensitivity. For each patient, a key worker can be identified who they can contact for further information. This key worker can also act as a patient advocate, for example noting important choices and decisions the patient makes, and recalling them on behalf of the patient during the treatment process, since some patients may find it difficult to assert themselves in clinical encounters.
Screening for Disease and Communicating Risk
Individuals at high risk of developing oral disease require not only to be encouraged to change their behaviour, but also to have explained to them the purpose and possible outcomes of screening and the necessity to maintain vigilance (Kiviniemi et al., 2009). In the case of screening for oral cancer, HCPs appear to be reluctant to inform patients that they are screening for cancer, and are reticent about discussing this possibility with patients (Scott et al., 2009). There is a need for the healthcare team to develop specific skills and willingness to engage in such discussions. The use of oral cancer leaflets has been found to be useful in this regard, as a facilitator of discussion (Humphris et al., 1999). Informing patients of their risk is complicated by the difficulty many people experience in understanding the mathematical concept of risk (Calman, 1996). Recently there has been much interest in designing more effective ways of presenting risk to patients, and a systematic review of this evidence suggests that personalised communications are more effective in promoting uptake of screening than generalised communications (Edwards et al., 2006). Healthcare professionals should be encouraged to address the issue of screening for oral cancer, and their patients’ risk of developing head and neck cancer. Messages which are personalised to each patient and which are supported by written and visual materials appear to be of greater value than unsupported general information.
Communicating a Difficult Diagnosis
Giving bad news, while it may not be unexpected to the patient, will inevitably be distressing. The key principles of breaking bad news have been summarised as follows (McLauchlan, 1990; Newton and Fiske, 1999):
- Preparation. Ensure that there is sufficient time and privacy for the communication.
- Communicating the bad news.
- State the news.
- Elicit the response of the patient or carer or family member.
- Deal with emotional response.
- Ensure follow‐up.
- Arrange to meet with the patient or carer or family member.
- Discuss and review the situation both in terms of impact on the team and whether the communication could have been handled differently. What went well, what could be changed?
As noted earlier, patients are likely to recall only a small amount of the information that they are told at the initial diagnosis, and so a first consultation should focus on stating the news and dealing with that initial emotional response, while arranging a follow‐up meeting or discussion by telephone within 1 or 2 days. Breaking bad news is difficult both for patient and HCP. Faulkner (1998) outlines a range of specific techniques to ensure that breaking bad news is done sensitively, and provides guidance on addressing the emotional response of patients and their carers as well as the healthcare team.
Individuals who have been given bad news are likely to need information in three main domains: the medical, the psychological and the social. Medical information will include the discussion of prognosis and treatment options. Marked emotional responses are possible and may be enduring. A simple technique to improve the identification of psychological distress would be to incorporate standardised psychological measures into the assessment of patients – typically either pencil and paper or computerised questionnaires (De Boer et al., 1999; Verdonck‐de Leeuw et al., 2009). It is of course essential to discuss the findings of these with the patients. Where psychological distress is found, a stepped model of care is appropriate, with the most severe cases being referred for intensive psychological therapy (Pilling et al., 2009).
Providing Information about Treatment and Pretreatment
Evidence suggests that while patients are generally satisfied with the information they receive, communication in some areas could be improved. More specifically, this would appear to be the emotional and social domains.(Llewellyn, McGurk and Weinman, 2006; Chen et al., 2009).For example, Llewellyn and her colleagues (2006) suggest the need for tailored information for individuals with head and neck cancer concerning support groups, financial advice and the impact of treatment on ability to work, physical functioning and quality of life. Again, this may be facilitated by the use of structured assessment tools (Rogers, El‐Sheika and Lowe, 2009).
Communicating Following Treatment and Dealing with Fear of Recurrence
For patients who have been diagnosed with head and neck cancer, there is a call for an active process of discussing and planning for the transition from patient to ‘survivor’ (Houlihan, 2009). Healthcare professionals can assist this by providing a detailed plan of follow‐up. Fear of recurrence is common and distressing, and interventions aimed at using cognitive techniques to prevent patients from ruminating on the risks of recurrence have been shown to be effective, when coupled with provision of specific strategies to identify triggers for seeking help and support from the healthcare team (Hodges and Humphris, 2009; Humphris and Ozakinci, 2006).
Discussing End of Life
In discussing end of life options, it is of course important to assess the patient’s level of knowledge and desired knowledge, both about the disease process in general and specifically the expected time to death. Jacobsen and Jackson (2009) provide a framework for understanding this process and examples of discussing these difficult topics. The components of a ‘good death’ have been suggested to be (Sciubba, 2009):
- Management of pain.
- Clear decision‐making/reduction of the fear of pain.
- Preparation for death (funeral arrangements. wills, etc.).
- Completion or spirituality considerations.
- Contributing to others.
- Affirmation of the whole person.
Once the desires of the patient are known, these should be communicated with family, carers and other members of the healthcare team.
Special Issues in Communication: Motivating Behavioural Change
Often, dentists may find themselves talking to patients about oral health behaviours, or changes in their habitual, everyday behaviour such as snacking, with the ultimate aim to bring about change. In other words, dentists might often be engaged in giving people advice about changing their behaviour from one that is currently compromising their oral health, to one that, in their view, is going be beneficial for the patient’s health. In this context, there is more to the communication episode than just giving information. What the dentist is probably also hoping is that patients will listen to, understand, remember and take away advice from the surgery and, ultimately, adhere to it.
Research in medical settings tells us that most patients visit their HCPs, listen to what they have to tell them and then walk away, not adhering to any of the advice they have received. Researchers in the field call this the problem of ‘non‐adherence’. A review of adherence studies published in the last 50 years (Di Matteo, 2004) estimated that of the approximate 760 million visits to healthcare providers that took place in the USA in 2000, around 200 million resulted in patients not following the advice they were given. On a wider societal level, patients who do not adhere to treatment and preventive regimens use up scarce health resources and deny others the opportunity to benefit from healthcare.
Non‐adherence to health advice could be the result of several processes. The first one is motivation to adhere.
The following section will explore two aspects of motivation: first, changing the patient’s beliefs and attitudes towards oral health and oral health related behaviour, and second, providing incentives for the patient to turn their positive beliefs and attitudes into action. The structure for this article will draw upon the work of Philip Ley, who outlined a model of the relationship between various psychological constructs and health‐related behaviours. This model is shown in Figure 4.1.
This model proposes that the likelihood of an individual engaging in any particular healthy behaviour is related to three things: the patient’s memory for the information, their understanding of the information, and their satisfaction with the interaction they have had with their healthcare staff. The rest of this section considers each of these three areas in turn. For each of these three broad areas some practical recommendations about how the dental team can improve patients’ motivation will be made.
Improving Patients’ Understanding of Healthy Behaviour
In order to follow advice given by healthcare staff, patients must first understand the information given. Patients often do not understand the meaning of words used by clinicians. Furthermore, patients may have their own ideas about illnesses and these may differ from the accepted orthodox ideas of HCPs. Where patients’ ideas about illness differ from those of clinicians, patients will use their own framework of understanding to interpret the messages given. Thus it is important for the dental HCP to ascertain the patient’s view of their illness and to correct any misconceptions which may be hampering the patient’s motivation. For example, a patient may avoid brushing their teeth because when they do, their gums bleed. The patient interprets the bleeding as a bad sign. The dental practitioner, hygienist or other member of the dental team who understands the patient’s misconception can help the patient to correct their understanding. The positive aspects of the patient’s view of illness can be built upon, so they do not feel they have been doing everything incorrectly, and create an impression where they feel that what they are doing is pretty good and just needs some tweaking here and there to be really effective.
When information is given to patients, misunderstandings may occur for two main reasons. The first is if it contains a lot of jargon which patients do not comprehend or there is excessive complexity and depth. Do patients really need to know the anatomy of the periodontium in order to improve their tooth brushing skills? Second, the general language and sentence structures used may not be understandable to patients.
Every profession has its own particular set of jargon and dentistry is no exception. There are several words and phrases which those of us who work in dentistry take for granted but which may not be understood by patients, for example:
- Periodontal disease.
- Dental caries.
What proportion of the general population understands these terms? Some data collected among the patients at Guy’s Hospital illustrate this. In Figure 4.2 it is shown that only a small proportion of patients understood these common terms.
Such confusions can occur even with such seemingly simple instructions as those given for taking medications. The dental HCP who is giving information should consider the best form of words to make the message understandable, and to consider simple ways of explaining jargon terms. Use the terms the patient uses to describe their oral conditions: gum disease, pyorrhoea, tooth decay, rotting teeth.
Aside from jargon, more generally the words and sentence structures used by HCPs may be more or less understandable. Short sentences containing words with few syllables are more understandable than sentences containing many polysyllabic words. In order to make our message clearer we need to make the sentences we use more understandable. This can be done in several ways:
- Use personal statements, for example ‘I believe…’ ‘I think…’
- Avoid the passive voice.
- Keep sentences short.
- Avoid sub‐clauses in sentences.
The content of the advice that is offered is also important. The public are becoming increasingly sceptical of advice health experts give because so much of it is conflicting or it changes. It is important that content is kept simple, scientifically sound, relevant and appropriate to the particular patient’s oral health problem and concerns. The Scientific Basis of Oral Health Education (Levine, 2004) recommends the following key messages:
- Reduce the frequency and quantity of consumption of food and drink containing sugars.
- Clean your teeth twice a day with fluoride toothpaste.
- Visit a dentist once a year.
- Request your local water company to fluoridate the water supply to between 0.7 and 1 ppm.
- Refrain from smoking.
Health education is a skill that requires as much learning and practice as any other activity in the dental surgery. Some dental HCPs are better at it than others and it is possible to improve one’s skill. Good quality dental health education requires time and an appropriate environment. When the health education is provided is also important. Most dentists take the opportunity to provide health education during a treatment appointment, but it might not always be the best atmosphere for the patient to be receptive to such advice. They may be anxious about the item of treatment they are going to receive, smells and clinical sounds.
Providing written information is one way in which to support the advice given to patients, and to ensure that they have understood it. In designing written materials it is important to note the following considerations:
- The readability of the materials designed for patients is immensely important. It is not hard to design materials that are easily readable – the readability of text can be checked in most word processing packages. To ensure that one’s materials are widely accessible, it may be important that a low rather than a high level of readability is aimed at.
- The use of jargon should be considered carefully and complex detail should be avoided.
- Font size is another important aspect that will define how accessible one’s reading materials are. The Royal National Institute for the Blind (RNIB) recommends 12‐point text as a minimum for all written materials. Proportional spacing and non‐justified text are features that will make the text physically easier to read. These issues are particularly important where many patients may be older adults who have difficulty reading small print.
- Quality of production (colour, use of photographs and illustrations). If the information given is produced in a high‐quality format, it attracts the reader’s attention and, as a result, can be more memorable.
- Quality of reproduction. Once a high quality of product has been prepared, it is important that the quality is maintained for all copies.
- It is important that key points are emphasised.
- It is suggested that involving patients and relatives in the design of leaflets might be a helpful activity. Patients and relatives are an invaluable resource for designing information because they will know what information they want to glean, and what is important to them. When patient materials are designed, it is important that some thought is given to the cultural and ethnic diversity of the reader. At all times, the materials need to be scientifically sound and age/condition‐specific.
Improving Patients’ Memory for Health Information
Once patients have been given information about the particular health behaviour(s) that the dental HCPs wish them to follow, it is important that the patients remember that information. As stated earlier, patients often forget much of what they are told. Surprisingly there is little relationship between the time that has elapsed from the giving of the information and its recall and how much information is recalled. That is to say, patients tend to remember what they are going to remember regardless of how long it is before they are asked to remember the information. Patients seem to remember best that information which they are told first and the information which they believe is the most important.
The next section offers several practical tips to improve patients’ memory for healthcare advice:
- Tell the patient the important points first. Patients remember best what they are told first. This is known as the primacy effect. It has been shown that using the primacy effect can increase recall of health information by up to 36%.
- Let the patient know the most important points. Emphasise to the patient that information which is most important (this may increase recall by 13%).
- Remember to make the message understandable. Making the message more understandable using the techniques outlined above can improve recall by 13%.
- Categorise the information in an explicit manner to help the patient recall. Techniques which can be used include complex forms of categorisation, for example spider diagrams or other diagrammatic summaries; alternatively you could provide patients with mnemonic devices such as acronyms to help them recall particular points. Even simple categorisation can help to improve recall. For example, ‘There are three points for you to remember… ’.
- Repeat important information.
- Use specific statements rather than general statements. Making a message specific rather than general can improve recall of the message by up to 35%. For example, ‘I would like you to keep your teeth cleaner’ is general and provides the patient with only limited information about how they should go about changing their behaviour. This statement can be made more specific by stating more exactly what it is that the dentist would like the patient to do. For example, ‘I would like you to do three things to help keep your mouth cleaner. First I want you to brush your teeth twice a day using the technique I showed you. Clean them for about 2 minutes each time. Try cleaning each section, bottom right, bottom left and so on for about 30 seconds each. Second I would like you to floss the gaps between your teeth twice a week, say once on Sunday and once on Wednesday. Third I would like you to rinse round your mouth with a mouthwash once a day in the morning after you have cleaned your teeth’.
- Send out reminders. Telephone and email reminders for appointments may improve attendance by up to 17%. A phone call to let the patient know that they are expected the next day can reduce unexpected non‐attendance and so decrease lost time and associated costs.
Improving Patients’ Satisfaction with their Interactions with Healthcare Professionals
The key to improving patients’ satisfaction with their HCP team lies in the interaction between the patient and the dental team. In the previous sections the importance of identifying the patient’s understanding of their health and healthcare, and using specific communication techniques to improve patients’ memory for healthcare information has been highlighted. In this section more general skills which have been demonstrated to be related to a good dentist–patient interaction are described.
A body of literature has identified the aspects of medical and dental consultations associated with the best outcome. These are summarised as follows:
- Positive aspects.
- Active listening.
- Appropriate use of open questions.
- Frequent summaries.
- Negotiation of treatment plans.
- Clear explanations.
- Checking patient’s understanding.
- Checking patient’s compliance with treatment.
- Negative aspects.
- Inappropriate use of closed questions.
- Premature advice/reassurance.
The positive aspects are associated with a good outcome from the dentist–patient interaction – they are generally associated with patients feeling satisfied with their interactions with dental healthcare staff. The negative aspects are associated with dissatisfaction.
Although people generally believe that they are listening to somebody, it has been shown that generally we recall less than 25% of the information that we have been told. Active listening refers to a process where the individual listens and, at the same time, attempts to discern, interpret and summarise what the speaker is saying. This necessarily requires a great deal of attention on the part of the listener. This attention will be reflected in the body language and non‐verbal communication of the listener. Active listening involves trying to understand a speaker’s viewpoint and requires a degree of empathy on the part of the listener. Both active listening skills and empathy are related to patient satisfaction with the interview.
Empathy refers to the feeling that the listener is making an effort to understand the situation from the speaker’s point of view. Empathy may be conveyed in body language and tone of voice, and also in the way that the dental HCP talks about the patient’s problems. A simple technique is to try to use the same phrases and words as the patient to describe the problem or difficulty they are facing. For example, if a patient talks about the difficulty of finding time to carry out oral hygiene routines, it is suggested that that framework is used to explore how they might improve their health related behaviour.
Often dental healthcare staff assume that patients are following the oral health advice that has been given to them. It is a good idea to check the patient’s progress in changing their behaviour. This should be done in a supportive environment which allows the patient to identify any problems they may have had. In this case, it is important that non‐judgmental phrases such as ‘How did you get on with…’ or ‘Did you find any particular problems with…’ are used.
When patients are not following the advice they have been given, dentists can sometimes assume that they are not ‘motivated’. It is important that one steps beyond this simple explanation and looks at the factors which might be causing the apparent non‐compliance. There are two broad categories of reasons why patients may not follow health related advice: skills deficits and management deficits.
‘Skills deficits’ refers to those situations where a patient wants to follow the health related advice they have been given but simply lacks the knowledge or skill to perform the behaviour. In order to rectify such deficits the dental team should provide information and instruction to perfect the skill component. Techniques of observation and feedback are very effective in providing instruction. Written materials can support learning.
Management deficits are more complex. Here the patient understands what is required of them and has the requisite skills. However the patient finds it difficult to incorporate the behaviour change into their lifestyle, or difficult to maintain the behaviour change. It is akin to New Year resolutions. We have all made them, generally we know what to do to make the changes we have resolved to make, but it is difficult to maintain them. For management deficits the dental healthcare team need to adopt a different approach; this requires using the power of the environment to shape behaviour change.
Using the Power of the Environment
Much of our discussion to this point has focussed on changing patients’ knowledge of and attitudes towards oral health related behaviours. The aim of this was to provide patients with information to encourage them to engage in these behaviours. This is an important component of motivation, what is generally described as the ‘cognitive’ or ‘thought’ component of motivation. A second component refers to providing incentives for the individual to put these thoughts into action. We do this by producing an environment which is conducive to making the behavioural change. It is suggested that dental HCPs work with patients to plan how they will implement their behaviour changes. The plan should include the following:
- A specification of the goals that the patient and the dentist wish to achieve.
- A plan for the behaviour change.
- When to start.
- Opportunities to practise the new behaviour and perfect technique, e.g. tooth brushing or reading food and drink contents labels.
- A process of advising those close to the patient about the proposed change and a clear plan of how they will seek their support.
- A detailed plan of when and how the change will occur.
- A series of incentives for change.
- A plan to review progress and rectify problems.
The first step in planning any change in behaviour should be to specify goals. Working with patients to set goals, it is advisable that the set goals are:
- Short term.
- Regularly reviewed.
- Valued by patients and important to them.
- Designed to address their concerns and needs.
Motivation is difficult to maintain, so it is better to set a target for a few weeks rather than a year, and to review progress regularly. In advising a patient to cut down on smoking it is more effective to set a target to cut down a little for a month, then to review, rather than to set a target to stop completely over the next year.
Goals should be realistic. Patients are unlikely to use floss every day, but setting a target of using floss once a week is achievable and an improvement if the patient has not been using floss at all before.
By successively modifying goals over time, the dental HCP can gradually build towards a significant goal.
Plan the Behaviour Change
Careful planning of any behaviour change will pay dividends, particularly if the behaviour change is likely to be significant not only for the individual patient but also their family and friends. For example, a patient who decides to quit smoking will require the support of family and friends.
Picking a significant date on which to start any behaviour change helps to highlight the importance of the change and will motivate the patient. It is important that dentists plan with the patient how the patient will carry out the details of the behaviour change. For example, if the dentist would like the patient to floss their teeth twice a week, it would help if the dentist thought through with the patient when the patient will have the time to do it. It is often a good idea to build in a reminder to prompt the patient, for example writing in their diary, or putting a chart in the bathroom cabinet.
Rewards or other tangible incentives can help support behaviour change, even if these are devised by the patient themselves. The advantages of changing health related behaviours are in general remote. If the patient cleans their teeth well they are likely to benefit over a period of years rather than weeks. By building more short‐term incentives for behaviour change the dental team can help to motivate patients. This is particularly easy with child patients, where dentists are already accustomed to providing incentives with stickers and so on. However for adults it is probably best to let them decide on their own incentives.
Review Progress and Rectify Problems
Regular reviews of progress can themselves provide an incentive for change because patients are reminded of the changes they are supposed to be making. Reviews also provide the opportunity for identifying and rectifying problems. The common problems that occur in behaviour change are:
- Skills deficits.
- The goal is too difficult.
- The consequences of the behaviour are too far removed.
Skills deficits are easily rectified through education and instruction. A common problem is to expect too great a behaviour change in a short time. The dental practitioner or other member of the dental team may negotiate behaviour change with their patient and then discover that the change did not occur. This may lead them to reject the notion of behaviour change and to describe the patient as ‘lacking motivation’. But the problem may be that the change required was too big, and too difficult for the patient to make. When faced with a ‘failure’ at behaviour change, it is advisable to try breaking the behaviour change down into smaller steps. If the patient is finding it difficult to floss all their teeth then the dentist could ask them to floss only one or two for a few weeks, then once they have acquired the skill and incorporated flossing into their routine, to gradually increase the number of teeth they are required to floss. It is important to note that the size of change that an individual can manage will show variation between people. It is suggested that dentists ought to tailor their approach to the particular patient and what he or she can manage.
For children in particular, the consequences or rewards for oral health related behaviours such as cleaning their teeth are too far removed to be realistic. Oral health behaviours are often ignored in favour of more immediately rewarding activities. Parents can be encouraged to make the consequences more immediate, for example making more favoured activities contingent on the less favoured activity(e.g. the child must clean their teeth before they are allowed to watch TV or have their bedtime story).
Much of people’s behaviour is said to be driven by stimuli, sights and sounds, which tell people what actions to perform. Often people do o notice them. A common stimulus to human behaviour is time – it tells people when to get up, when to eat, when to go to work and so on. Forgetting to carry out an oral health related behaviour may result from the behaviour not being incorporated into the routine. It is important that dentists work with their patients to decide on a time and place when they will carry out the change. The power of environmental cues can be helpful in this case, to drive the behaviour change. This might also include introducing new stimuli to prompt. For example, wall charts or sticker charts can be provided for children.
We can motivate patients by providing them with knowledge and skills to carry out oral health related behaviours. This on its own is insufficient. We also need to create the conditions which make it easier for the patient to follow this advice. This can be achieved by encouraging patients to plan their behaviour change, through providing prompts or reminders which cue patients to engage in oral health related behaviours, and by providing tangible incentives for changing behaviour.