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Behavior Guidance for the Pediatric Dental Patient
SAMPLE COMMUNICATION TECHNIQUES FOR PATIENTS & PARENTS
When clinicians share information, they predominantly TELL information, often in too much detail, and in terms that sometimes alarm patients. Information sharing is most effective when it is sensitive to the emotional impact of the words used. By using a technique of ask-tell-ask, it is possible to improve the patients’ understanding and promote adherence. According to the adult learning theory, it is important to stay in dialogue (not monologue), begin with an assessment of the patient’s or parents’ needs, tell small chunks of information tailored to those needs, and check on the patient’s under- standing, emotional reactions, and concerns. This is summarized by the three step format Ask-Tell-Ask. ASK to assess patient’s emotional state and their desire for information. TELL small amounts of information in simple language, and ASK about the patient’s understanding, emotional reactions, and concerns. Many conversations between clinicians and parents sound like Tell-Tell-Tell, a process known as doctor babble, because clinicians seem to talk to themselves, rather than have a conversation with parents or patients.
The Ask-Tell-Ask format maintains dialogue with patients and their parents. The important areas for sharing include:
ASK to assess patient needs:
1. Make sure the setting is conducive.
2. Assess the patient’s physical and emotional state. If patients are upset or anxious, address their emotions and concerns before trying to share information. Sharing information when the patient is sleepy, sedated, in pain, or emotionally distraught is not respectful and the information won’t be remembered.
3. Assess the patient’s informational needs. Find out what information the patient wants, and in what format. Some patients want detailed information about their conditions, tests, and proposed treatments; recommendations for reading; websites; self-help groups and/or referrals to other consultants. Others want an overview and general understanding. Patients may want other family members to be present for support or to help them remember key points. Reaching agreement with the patient about what information to review may require negotiation if the clinician understands the issues, priorities, or goals differently than the patient. Also, some patients may need more time, and so it might be wise to discuss the key points, and plan to address others later, or refer them to other staff or health educators. Instead of asking, “Do you have any questions?” to which patients often reply, “No,” instead ask, “What questions or concerns do you have?” Be sure to ask, “Anything else?”
4. Assess the patient’s knowledge and understanding. Find out what previous knowledge or relevant experience patients have about a symptom or about a test or treatment.
5. Assess the patient’s attitudes and motivation. Patients will not be interested in hearing your health information if they are not motivated, or if they have negative attitudes about the outcomes of their efforts, so ask about this directly. Start by asking general questions about attitudes and motivation: “So – tell me how you feel about all of this?” “This is a complicated regimen. How do you think you will manage?” If patients are not motivated, ask why, and help the patient work through the issues.
TELL information:
1. Keep each bit of information brief. It is difficult to understand and retain large amounts of information, especially when one is physically ill, upset or fearful.
2. Use a systematic approach. For example, name the problem, the next step, what to expect, and what the patient can do.
3. Support the patient’s prior successes. Explicitly mention and appreciate patients’ previous efforts and accomplishments in coping with previous problems or illness.
4. Personalize the information. Personalize your information by referring to the patient’s personal and family history.
5. Use simple language; avoid jargon. Be mindful of how key points are framed.
6. Choose words that do not unnecessarily alarm. Words and phrases a practitioner takes for granted may be misinter- preted or alarm patients and families.
7. Use visual aids, and share supplemental resources. Find reliable resources and educational aids to meet the needs of your patients.
ASK: Continue to assess needs, comprehension and concerns.
After each bit of telling, stop and check in with patients. When finished with information sharing, make a final check. This step closes the feedback loop with patients, and helps the practitioner understand what patients hear, whether they are taking home the intended messages, and how they feel about the situation. The second ASK section consists of the following items:
1. Check for patients’ comprehension. ASK about the patients’ understanding. This ASK improves patient recall, satisfaction, and adherence.
2. Check for emotional responses and respond appropriately. Letting patients know their concerns and worries have been heard is compassionate, improves outcomes, and takes little time.
3. Check about barriers. Patients may face external obstacles as well as internal emotional responses that inhibit them from overcoming obstacles.
Teach Back A strategy called teach back is similar.
The dentist or dental staff asks the patient to teach back what he has learned. This may be especially effective for patients with low literacy who cannot rely on written reminders. It is important to present the process as part of the normal routine. This pertains to explanations or demonstrations: “I always check in with my patients to make sure that I’ve demonstrated things clearly. Can you show me how you’re going to floss your teeth?” If the patient’s demonstration is incorrect, the dentist may say, “I’m sorry, I guess I didn’t explain things all that well: let me try again.” Then go over the information again and ask the patient to teach it back to you again.
Motivational Interviewing
Motivational interviewing facilitates behavior change by helping patients or parents explore and resolve their ambivalence about change. It is done in a collaborative style, which supports the autonomy and self-efficacy of the patient and uses the patient’s own reasons for change. It increases the patient’s confidence and reduces defensiveness. Motivational interviewing keeps the responsibility to change with the patient and/or parent, which helps to decrease staff burnout. In dentistry, it is useful in counseling about brushing, flossing, fluoride varnish, reducing sugar sweetened beverages, and smoking cessation. Open-ended questions, affirmations, reflective listening, and summarizing (OARS) characterize the patient centered approach. It is especially helpful in higher levels of resistance, anger, or entrenched patterns. Motivational interviewing is empowering to both staff and patients, and by design is not adversarial or shaming.
Adapted from Goleman J. Cultural factors affecting behavior guidance and family compliance.
Pediatr Dent 2014;36(2):121-7. Copyright © 2014, American Academy of Pediatric Dentistry, www.aapd.org.