3M Dental is proud to sponsor the Dental Economics year-long "Mastering the Art of Communication" series.
Ron Pitts, the two o`clock patient, is right on time. As the hygienist escorts him to her operatory, he holds up his hands and says, "Don`t yell at me, Susan. I haven`t been flossing." Instantly, a dark cloud passes overhead.
This is definitely not the way to begin an appointment. Susan is now faced with a major dilemma. What should she say? Her response may be the most important decision she makes all day. If she demands, "Why not?" then Ron will likely become even more defensive. If she responds by saying, "Look Ron, I`ve got two teenage boys at home to nag. I don`t have any nags left for the office," she is essentially disconnecting from her patient as a means to deflect his attempts to shift responsibility for the problem. And finally, if she launches into a lecture about the importance of flossing, she is implicitly dismissing what her patient was attempting to communicate.
Most hygienists see themselves as health educators, as well as clinicians, and thus focus a substantial amount of time and energy on patient education. Unfortunately, "Educating Your Patients 101" is not included in the curriculum of most hygiene schools. Hygienists learn content - plenty of it - but receive virtually no training in educational principles and technique.
It is no wonder, then, that many hygienists believe they should be telling, lecturing, and regularly reinforcing previously conveyed information. But educational psychologists have long known that information alone does not change behavior. If it did, everyone would wear seat belts, no one would smoke, and there would be no drunk drivers. When people want their lives to be different in some meaningful way, they will seek information; they will also be more likely to apply that information by changing their behavior. If there is no personal investment in changing, however, people will not seek out information; furthermore, they will reject it if it is forced upon them. Because a change in behavior is the most important indicator that learning has occurred, it is easy to see why so many hygienists feel ineffective in their role as educator.
So, what is Susan`s alternative response? "Well, Ron. That`s an interesting way to begin our time together. Tell me about it." This response does several things. First, it acknowledges that Ron has something to say that Susan wants to hear and understand. It also shows that Susan has not assumed anything about what Ron actually meant by his opening salvo. Moreover, it permits Susan to stay focused on Ron and his issues rather than shifting to self-protection. And finally, it honors boundaries - the distinction between the patient and the provider.
As we shall see, an understanding of boundaries is essential in helping hygienists (and all members of the team) become better communicators and educators. Many hygienists are attracted to dentistry because they are highly motivated to help people. And, of course, that motivation is very important. Yet, when there is not a good understanding of boundaries and personal differentiation, "help" can be interpreted as doing some highly inappropriate things or avoiding things that are painful, but necessary.
When a baby is born, that child is totally dependent on its parents to fulfill every need and ensure survival. Unlike baby turtles or tadpoles, the infant human being has no ability to care for itself. This dependency is so profound that the child cannot even recognize that it is separate and apart from the parent. Mother and child are a single entity. There is no boundary distinction. But as the child begins to mature, it develops a sense of differentiation: "I am a separate being from my mother." When this happens, the child can begin to exercise control over its environment. Eventually, the child can be quite insistent about doing things independently. Many a three year-old has emerged from the bedroom dressed in striped leggings, a polka-dotted top and combat boots with lace-trimmed socks, proudly exclaiming, "I did it all by myself, mommy!"
This developmental process of differentiation is what begins to form the concept of boundary. Boundary is that place where one person`s area of responsibility or control ends and another`s begins. When boundaries are fully developed and healthy, a person knows clearly what part of a situation or problem is hers and what part belongs to others. When boundaries are poorly defined, however, people trespass into areas that are the responsibility of others. If a relationship is healthy, the boundaries are clear. Each person understands what part he or she plays in making things work. When Ron says, "Don`t yell at me, Susan. I haven`t been flossing," he is attempting to either deny his responsibility or transfer it to Susan. Susan is now faced with several options: does she ignore the comments, allow the transfer to take place, or pass the problem back to Ron? Because the patient must own his problem, her response must not in any way violate this boundary. And because the hygienist owns a responsibility as a clinical adviser, she must likewise choose a response which does not deny that role.
Susan`s first response could be, "Well, let`s see what else will work for you. How about these Stimudents?" She then has crossed his boundary, picked up his problem, and manufactured a solution. In essence, she took away his responsibility to deal with the problem in his own way, or not at all.
It is important to separate the issues. Who owns the problem of Ron`s dental condition? Not Susan. Not the dentist. Only Ron. Of course, Susan cares about Ron`s dental condition. But she cannot do for him what he cannot or will not do for himself. Thus, Susan`s job is more facilitator than educator. This distinction means that she must focus on helping people own their problems and support them in finding workable solutions.
The boundaries would be distinctly different had Susan or her dentist failed to bring Ron`s condition to his attention in the past, or provided an inappropriate service with negative results. Under those circumstances, Susan and her dentist would own a portion of the problem and would therefore have a different set of responsibilities. However, the problems most patients have are not caused by you and thus are not your problems to own. Most patient problems are due to many factors that are out of your control. Perhaps the patient is unaware of the importance of how to care for himself properly. Perhaps the patient was aware, but chose not to act. Or perhaps the patient has in the past chosen a less than optimal or desirable procedure or material because of the cost or amount of time involved. No matter what the cause (other than negligence on your part), you can care about the patient`s problem without accepting responsibility for it.
Once you clearly understand the notion of boundaries, you can begin sorting out who owns what part of what problem and do one of three things:
(1) Take responsibility - If you contributed in any way to a problem, you own a bit of it and must accept responsibility for creating and completing the solution.
(2) Facilitate - It`s your responsibility to help your patient clarify and evaluate options and choices - but only when the patient allows it. This is the primary form of communication for the dental hygienist who, in most cases, does not own the problem, but has professional expertise and the authorization to facilitate.
Clearly, dental disease and dental problems belong to the patient. But the hygienist has implicit permission to facilitate because it is the exact nature of her job - she has expertise the patient lacks.
In fact, hygienists who do not view themselves as facilitators are missing the boat. The good news is that almost everyone can master the skills of facilitation. It does require some time and special training, but the rewards are well worth the minor costs. (If you would like to learn more about those skills and how to develop them, simply send an e-mail to s[email protected]. Be sure to include your name and address.)
- Disengage ? When you do not own the problem or any portion of it, or when you do not have authorization to facilitate, you have no option but to disengage. Hygienists cross boundary lines frequently by offering suggestions to patients who have not yet accepted responsibility for their own problems. Frustrated, hygienists often offer an endless array of suggestions about how to incorporate flossing into a daily routine, despite the fact that the patient hasn?t accepted or is resistant to the importance of home care. This type of response is called Orescuing.O I first heard that term used by a friend who is a marriage and family counselor. She suggested that rescuers have a difficult time helping because they get into the problem rather than remaining separate from it. OOnce you?re in it,O she states, O... you lose perspective and the ability to help people.O
Professional therapists understand that they must remain outside the boundary of their clients? problems. You must maintain a healthy distance from your patients? problems. If the patient does not participate in problem solving, you must shift your discussion to more basic questions: What does the patient see as your role? What is the patient asking you to help him accomplish? Does the patient look to you for expertise and guidance? If the answer is yes, you can become a facilitator. If the answer is no, you must disengage.
Robert F. Barkley, DDS, once said that ODental health is peculiar. The rich cannot buy it and the poor cannot have it given to them. I can make people more comfortable, more functional, and more attractive. But I cannot make them healthy. I can teach them how to become healthy, but whether they remain that way will be up to them.O
The patient must want to be healthy. The patient must own the problem. The patient must want your help. It is as simple as that. No amount of education will change anything if the person does not want to change.
Behavioral contracts refer to a different level of understanding, not a written document.They are very simple and can be applied to almost every patient relationship, especially hygiene relationships.
The behavioral contract between the hygienist and her patient is based on the following questions:
- What do you (the patient) want? This is a question we explored in the August installment of OMastering the Art of Communication.O First, you must recognize that some patients know a great deal about what they want and others know very little. Even when they do know what they want, they may have difficulty expressing it.
- How can we help you get what you want? This part of the contract requires a discussion where the hygienist introduces clinical options.
- What are your expectations about your role and responsibility? Our role and responsibility?
This step requires a concerted effort. Helping a patient become clear about his/her expectations is a great service, because patients often harbor unexpressed expectations. If you are able to help a patient identify her own areas of responsibility, you will have properly established boundaries.
How will we check out how we are doing together? A behavioral contract without checkpoints will not be effective. Periodically revisiting your contract (perhaps at each visit) will ensure that both parties are clear and in agreement about the relationship that exists.