Consolidating core communication skills and specific communication challenges Flashcards
Why are communication skills important?
GDC identified dental team-patient communication as one of the core competencies required for good dental practice
-one of four domains for registration
The Calgary-Cambridge Framework
Patient-Centred clinical approach -initiating the session -gathering information -physical examination -explanation and planning -closing the session All the while providing structure and building the relationship
Types of communication skills
Content: what dentists communicate
Process: how dentists communicate
–> combining content and process
Patient-centred approach
Dentist tries to enter the patient’s world to
see the [illness/symptoms/condition] through the patient’s eyes
You are the expert on clinical dentistry, but your patients are the experts on their
own decisions and how they impact on them
Initiating the session
Preparation
Establishing initial rapport
Identifying the reason for the consultation
Gathering information
Exploration of the patient’s problems to discover
- biomedical perspective
- patient’s perspective
- background info - context
Providing structure
Making organisation overt
Attending to flow
Explanation and planning
Providing correct amoung and type of info
Aiding accurate recall and understanding
Achieving shared understanding: incorporating pt’s illness framework
Planning: shared decision making
Closing the session
Ensuring appropriate point of closure
Forward planning
Building the relationship
Using appropriate non-verbal behaviour
Developing rapport
Involving the pt
Specific challenges
- culture and social diversity
- dealing with emotions
- age related issues – the elderly, children
- the three way interview
- breaking bad news
- low literacy patients
- sensory impaired patients
- complaints
- ethics
- health promotion and prevention
What is dental anxiety?
General state of apprehension, prepared for
something negative to happen
What is dental phobia?
Severe anxiety which results in avoidance or
endurance of situation with significant discomfort
Dental anxiety and phobia stats
• 36% moderate dental anxiety; 12% extreme dental
anxiety (UK Adult Dental Health Survey, 2009)
• 45% named fear of the dentist as the barrier to dental
care
• 10-12 million Americans estimated to be Dental
Phobic, 35 million experience excessive anxiety
• Having a tooth drilled would make them very or
extremely anxious (30%) and having a local
anaesthetic injection (28%)
Dental fear pie chart
30% no fear
40% occasional or moderate fear
20% strong fear
10% dental phobia
Dental anxiety scale and pt behaviours
No fear: cognitively aware. Relaxed head, neck, and jaw for optimal access and visibility. Pro-active, prompt, trusting. Excellent referral source
Low: Easier to treat, more compliant, pro-active, and open to tx plans. Tongue battles, gagging and tense jaw. Fair referral source.
Moderate (typical): not pro-active in dental health, requires more time, talk through procedures, resists recommended tx plans. Low referrals
Extreme: frequently cancels or shows up late. Resists treatment. High stress for pt and team. Virtually no referrals.
The impact of dental anxiety on the patient
No dental care
Delayed treatment
More restorative treatment
–>reduced oral and general health, lowered quality of life
The impact of dental anxiety on the dental team
Missed apts
Higher levels of stress
–>admin and financial problems; lowered satisfaction and, over long-term, health and well-being
Causes of dental anxiety
Learning
-traumatic/ negative experiences (classical conditioning)
-friends, family, media (observational/ vicarious)
Uncertainty - ‘the fear of the unknown’
-unpredictability, lack of control, inadequate information, pain
Personality
-patient: neuroticism, generalised anxiety
-dentist: negative attributes - ‘impersonal’, ‘uncaring’, ‘disinterested’, ‘cold’, and poor communication skills
Dental pain stats
Up to 77% pts report some pain
11.6% LAs fail
76% highly anxious pts state fear of pain is all or part of their fear
-fear of pain –> anxiety –> avoidance/ non-attendance
Expected pain; perceived pain; actual pain
Dental pain
Pain is not just a response to a stimulus (e.g. cracked tooth) Pain involves an active interpretation of sensation Individual is active not passive Pain has multiple influencers • Expectations; Age; Gender • Socio-cultural factors • Personality; Emotional state
Three As of anxiety
Ask how anxious they are
Acknowledge what you have heard
Address the fears by offering solutions
Cognitive behavioural management techniques
- Reduce uncertainty
- Providing information about techniques and equipment prior to and during treatment - Enhance control
- Stop signals (Button or hand) - Distract
- Music; TV; Video-game;
headphones; eye-mask
CBT for dental anxiety
1) Evidence for effectiveness of self-help CBT for young people with general anxiety
2) Experience from use of CBT for dental anxiety in adults including CBT delivered by dental nurses in Sheffield
3) Recent RCT of guided online CBT reduced dental anxiety in Swedish children
- ->Sufficient evidence to suggest that a self-help CBT resource for young people with dental anxiety could be effective at reducing dental anxiety
Key features of anxiety guides
1) Challenge unhelpful thoughts • Normalises dental anxiety • Provides information 2) Enhance control • Message to the Dentist • Stop signal contract 3) Reflect and plan reward
Why is it difficult to give bad news?
Not knowing how best to do it
Fear of upsetting the patient’s existing life
Not knowing the patient; their resources and limitations
Fear of the implications for the patient e.g. pain, social and financial loss, disfigurement
Fear of the patient’s emotional reaction
Uncertainty as to what will happen next; not having answers to questions
The DCP may feel responsible and fears being blamed
Steps of giving bad news
Preparation –> discussing the news –> reviewing the situation
Preparation for giving bad news
Consider:
- the information to be given
- the setting of the interaction
- time considerations
Process of giving bad news
Give information
Check the patient’s understanding of the information
Identify the patient’s main concerns
Elicit the patient’s personal resources and decide on
way forward
Empathy definition
Empathy is the experience of understanding another person’s condition from
their perspective. You place yourself in their position
Dealing with emotion
Crying, anger, silence
• Empathic response = identify the emotion, the
cause, show connection has been made
• ‘This must be a shock to you…’
•‘I can see you are very upset. I am sorry to give you
this bad news.’
• Avoid platitudes ‘It happens to the best of us’ and false sympathy ‘I know what it’s
Shared decision making
- Shares own thinking as appropriate: ideas, dilemmas
- Involves patient; offers suggestions and choices rather than directives
- Explores management options
- Ascertains level of involvement patient wishes in making decision(s)
- Negotiates a mutually acceptable plan; signposts own preference on available options, determines patient’s
preferences - Checks with patient: if accepts plan and concerns have been addressed
Prevalence of disruptive and uncooperative behaviour
Most children are good
20-25% of children exhibit disruptive problems (Brill, 2000)
Strongly correlated with age and type of procedure
-younger pre-school children
-invasive procedure.
Is fear a normal reaction to restorative work in children?
The child must lie on their back, open their mouth, and have someone wearing a mask and gloves insert
sometimes multiple instruments that make
unusual noises, create unfamiliar sensations,
and sometimes inflict discomfort or pain.
So yes?
Verbal distress can be shown as
Crying
Moaning
Complaining
Screaming
Behavioural distress can be shown as
Flinching
Blocking
Thrashing
Turning away
Natural response to unpleasant situation (real or perceived)
Escape
Verbal distress
Behavioural distress
Contributors to children’s fear at dentist
Natural reaction Early experiences -negative (aka classical conditioning) -role models (aka observational learning from parents, peers, siblings, media) Pain experience -sensitivity/ thresholds -ineffective LA (11.6%)
Implications of dental anxiety and children
Distressing for child, parent and dental team
Oral health - children with dental anxiety 3x more
likely to have caries experience at 5 yrs
Need for dental tx is most common reason for
a child to have a GA in the UK
• 46,500 children and young people under 19 were admitted to
hospital for a primary diagnosis of dental caries in 2013–14
• These numbers were highest in the 5-9 year age group, which
showed a 14 per cent increase between 2010–11 and 2013–14
In Sheffield we undertake 2,000 dental GAs each year
In very deprived areas, 13% of under 5-year-olds have had a GA for dental extractions
Task with anxious children as DCPs
To reduce unpleasantness of the dental experience and increase its pleasantness
What is behaviour management in a dental setting?
The means by which the dental health team effectively and efficiently
performs dental treatment and thereby instils a positive dental attitude
Positive approaches to behaviour management for all children
Effective communication skills -language should be simple and concrete -easily understood words -children learn through experience (tell-show-do) Tell-Show-Do Distraction Behaviour shaping and positive reinforcement Hand signals: stop signals Written information PHARMACOLOGICAL: pain-control methods
Stage of child development
Six key age groups/ ranges Normative development -physical -sensory -cognition and language -emotional and social Implications for dental practitioners
Stage 1 of child development
BABIES (6 months)
Physical
• Lift head and chest, when held sit back straight, move head to follow movement, reach and grab
Sensory
• Prefer moving objects, interest in face, able to focus eyes, distressed by sudden noises
Cognition and language
• Laugh and vocalise, cry loudly, understand cause and effect, smile in response to speech, start to understand objects
Emotional and social development
• Respond with obvious pleasure to loving attention, show enjoyment at caring routines, increasingly wary of strangers
Implications of first stage of children’s development
• Respond to the baby’s needs
• Allow baby to touch objects – learn through touch
• Allow baby to hold/play with an object (e.g. rattle)
• Face to face communication (eye-contact) with baby
• Beginning to understand cause and effect – no
negative associations vital
• Introduce slowly and demonstrate all objects that
make noises
Stage 2 of children’s development
BABIES (AT 12 MONTHS)
Physical
• Rise to sitting position, crawl, point to objects interest, pick up small objects
Sensory
• See almost as well as adult, visual memory very good, know and respond to own name
Cognition and language
• Speak two to six recognisable words, understand very simple instructions
Emotional and social
• Fluctuating moods, shy of strangers, dependent on
reassurance, comforted by familiar objects
Implications of stage 2 of children’s development
- Provide interesting varied environment
- Use the baby’s name
- Talk to baby about everyday activities
- Provide simple instructions (e.g. look at …..)
- Encourage role play ‘lets pretend’ (e.g. ‘roar like a lion’)
- Plenty of reassurance – remember they’re shy of you
- Use of familiar comforting items (e.g. teddy)
Stage 3 of children’s development
TODDLER (AT 2 YEARS)
Physical
• More able bodied: Run, throw, push, pull, pick up tiny objects
Sensory
• Listen to general conversation with interest
Cognition and language
• Speak over 200 words - understand more
Emotional and social
• Express how feel, curious about environment, sometimes clingy sometimes independent
Implications of stage 3 of children’s development
- Provide simple instructions (e.g. open your mouth as wide as possible)
- Use toys, picture books, glove puppets to gain interest and help explain what you’re doing
- Play simple games ‘lets pretend’
- Encourage child to express feelings
Stage 4 of children’s development
PRE-SCHOOL CHILD (5 YEARS OLD)
Physical
• Good balance, increased agility, good co-ordination, may have started to brush own teeth
Sensory
• Increased attention span - listen to long stories/instruction
Cognition and language
• Fluent in speech, enjoy jokes, can provide full name, age etc.
Emotional and social
• Likes and dislikes, like to be independent
Implications of stage 4 of children’s development
- Encourage to do simple tasks (e.g. brushing teeth) with parent(s)
- Involve children in what you are doing
- Explain everything, encourage to ask questions
- May not be socialised to ask questions and be assertive so may need to increase confidence
- Try to engage through use of humour, interest in activities
- Will respond to praise & rewards
Stage 5 of children’s development
CHILD (8 TO 12 YEARS) Physical • Period of rapid growth and devlopment Cognition and language • Increased ability to remember, think and reason, understand complex sentences, deal with abstract ideas Emotional and social • Sensitive to criticism, more independent but still like adults to be present to help them, defined personality, increasingly self-conscious, increased ability to understand needs and opinions of others
Implications of stage 5 of children’s development
Encourage talk about feelings
Provide a good level of information so child/parent can make
informed choices
Shared decision making
• Not full decision making capacity but still able to
participate in medical decision making
• 75% 8 to 13-year-olds felt old enough to understand
treatment and believed their views should be heard
Stage 6 of children’s development
Physical
• Puberty, rapid growth spurts; restlessness
Cognition and language
• Able to think about possibilities, able to plan
ahead
Emotional and Social
• May feel self-conscious, anxious about appearance,
misunderstood, emotional swings, socially skilled
Implications of stage 6 of children’s development
• Avoid comments that could be interpreted as criticism
• More detailed explanations of procedures/options
• Importance of information provision
• Approaching age where they can give informed consent
• 14 years-old do not appear to be any less competent in
making treatment decisions than their adult counterparts
How to gain positive first impressions from children
Acknowledge the child! Use play and the environment • Meet with child in waiting room • Toys, bricks, balls etc. • Introduce yourself by first name • Position yourself on same level • Be encouraging • Ask about favourite foods, activities, friends etc.
The role of the patient
Present or absent?
Active or passive?
1. gain the child’s attention and improve compliance;
2. avert escape or avoidant behaviours;
3. enhance effective communication among the
dentist, child, and parent;
4. minimise anxiety and achieve a positive dental
experience
“Childrenese” terms for dental equipment
buzzy bee - slow handpiece
whizzy brush or Mr whistle - airotor
magic wind - triplespray/ inhalation sedation
jungle juice or sleepy juice - local anaesthetic
spray your teeth off to sleep - giving a local anaesthetic
rubber raincoat - rubber dam
clip or button - rubber dam clamp
tooth paint - fissure sealant
hoover suction -
silver star amalgam
Tell-Show-Do
• (TELL) describe to the child
• (SHOW) demonstration for the patient of
different aspects of the procedure in a nonthreatening setting
• (DO) then proceed to compete the procedure
Why are developmental milestones for children important?
Represent what an average child can do at particular age
*****
Behaviour shaping
• Reinforcement is the strengthening of a pattern
of behaviour, increasing the probability of that
behaviour being displayed again in the future
• Anything that the child finds pleasant or gratifying
can act as a positive reinforcer (verbal praise,
facial expression, positive voice modulation,
parental approval, rewards, treats)
• Modelling: live model, video
Pain control methods: pharmacological
• Topical applications • Local anaesthesia • Conscious sedation • General anaethesia All children should be able to expect painless, high quality dental care
Sedation
• ‘A technique in which the use of a drug or drugs
produce a state of depression of the central nervous
system enabling treatment to be carried out, but
during which verbal contact with the patient is
maintained throughout the period of sedation’
• Coupled with local anaesthesia when required
• Informed consent from parent required
Sedation guidelines
- UK Clinical Guidelines
- Scottish Intercollectigate Guidelines Network
- NICE Sedation in Children and Young People
What is general anaesthesia
Any technique using equipment or drugs which produces a loss
of consciousness in specific situations associated with medical or surgical interventions
General Anaesthesia: ‘a conscious decision’
- Fatalities - 2 deaths per year minor dental procedures
- Cessation of G.A in primary care setting - Dec 2001
- Decrease in the administering of G.A.s
Are sedation and GA effective for anxiety?
- Traditionally, dental anxiety in children has been managed using pharmacological techniques including inhalational sedation and general anaesthesia
- Evidence is such approaches DO NOT reduce children’s dental anxiety
- Cost per case for inhalational sedation or GA for dental treatment estimated at £273 and £720 respectively
Limitations of pharmacological approaches
‘Pharmacological agents are not substitutes for
effective communication and the persuasive ability of
the operator’
Expensive equipment/ staffing
Training required
Vicious cycle which maintains anxiety/fear
Manages anxiety rather than reducing fear level
Dependence - ‘I can only cope if I am sedated’
Short term management / long term difficulties
What are physical interventions
Protective stabilization is defined as “any manual method, physical or mechanical device, material, or equipment that
immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.”
Active immobilization involves restraint by another
person, such as the parent, dentist, or dental auxiliary;
passive immobilization utilizes a restraining device.
Active immobilization includes head holding, hand
guarding, and therapeutic holding.
Are physical interventions used?
No
“The inappropriate use of restrictive physical intervention may give rise
to criminal charges, action under civil law or prosecution under
health and safety legislation. As a general rule, restrictive physical
interventions should only be used when other strategies (which do
not employ force) have been tried and found to be unsuccessful or, in
an emergency, when the risks of not employing a restrictive
intervention are outweighed by the risks of using force”.
Language barriers apply to
Children
Elderly
Disabilities
Non-native English speakers
What is ‘cuture’?
An integrated pattern of learned beliefs and
behaviors that can be shared among groups and
include thoughts, styles of communicating, ways of
interacting, views of roles and relationships, values,
practices, and customs. Culture explains how we
explain and value our world, and provides us with
the lens through which we find meaning. We are all
influenced by and belong to, multiple cultures that
include, but go beyond, race and ethnicity.
What is cultural competence?
• Acknowledgement of the importance of culture in people’s lives • Respect for cultural differences • Minimisation of any negative consequences of cultural differences
Cultural competence and oral health care
Culture is fundamental to the development and management of disease in every population
• Disease is a process; illness is what pt experiences
• Culture influences beliefs about cause of
disease, how illness is experienced, what
txs are appropriate, how txs
should be provided, who should provide
tx, etc.
Not taking culture into account in pt/ dentist interaction can result in significant miscommunication
Miscommunication can result in under/ nonutilisation of care, poor compliance, > OH disparities, poor QOL, poor tx and health outcomes
The individual vs culture - the conundrum
Culture is not “all defining”
• Variations on cultural themes exist within subgroups as well as among individuals
• Individuals are unique and each develops his or her
own interpretations of cultural “guidelines.”
• Seeing individuals only as members of their “culture”
stereotypes them
• Ideal - treat pts as individuals; maintain
constant awareness of potential impact of culture
• In reality, all patient-dentist interactions are crosscultural in some sense.
• The interaction between patient and dentist is not
about group differences; it is about individual
preferences
• Therefore, all dentists should develop, refine, and
enhance their cultural competence across their
professional lifetimes.
Systematic desensitisation
Exposure to heirarchy of fear producing stimuli
7 steps
**
Effective communication skills in relation to language and cultural barriers
Eliciting, understanding and responding to the patient’s perspective • Information gathering • Explanation and planning Building the relationship
Cultural beliefs and oral health care
• Interpretation of symptoms
• Beliefs about causation
• Attitudes toward illness and disease
• Use of and beliefs about efficacy of complementary or
alternative sources of healthcare
• Gender and age expectations about roles and relationships
• Role of dentist and social interactions related to power and
ways of showing respect
• Psychosocial issues (diversity in family/community supports)
% of population over 60 by 2030
35%
Questions you should ask
yourself when working with
the elderly
- Are there special physical problems related to ageing
in this person? - Have hearing loss or neurological problems comprised this person’s ability to communicate?
- Are there limitations to the clinical management and
treatment of this person? - Are relatives or friends assisting this person? Do they need to be involved?
Dealing with difficult patients
- Take control of the situation. Once you have heard the
patient’s side of the story, take the appropriate action to resolve the problem. - Ask the patient what they want. You may be surprised to find that the patient’s solution to the problem is both fair and simple.
- Once you have established a plan of action, sell it. Explain to your patient how the plan will solve the problem.
- Ensure that the plan has been carried out and the results are acceptable to your patient – follow-up to ensure your patient is happy with the way you have handled the problem.
What makes the perfect dentist?
- Confident: The dentist’s confidence gives me confidence.
- Empathetic: The dentist tries to understand what I am
experiencing, and communicates that understanding to me. - Humane: The dentist is caring, compassionate and kind.
- Personal: The dentist is interested in me, interacts with
me, and remembers me as an individual. - Frank: The dentist tells me what I need to know in plain
language and in a forthright manner. - Respectful: The dentist takes my input seriously and
works with me. - Thorough: The dentist is conscientious and persistent.
