Continually improve your skills in collecting information about patients.
Donna M. D`Anton, RDH, BS, MED
The traditional emphasis in dental-hygiene education has been focused on what data to obtain, not on how to obtain it. However, practicing hygienists are interested in what data to get, how to get it, and how to synthesize this data into an understanding of the patient`s total situation. Interviewing is the principal tool used by the dental hygienist to accomplish this, and it is, therefore, a skill which the effective dental hygienist must master.
Every interview has the function of collecting information that ultimately leads to a decision. The decision may be simply to do nothing because more information is needed. Or it may be highly complex, involving the initiation of a course of therapy. Clinical decision-making rarely is an isolated event. Decision-making is continuous. This is well known to physicians, dentists, and other health professionals who are experienced in continuing medical and dental care.
Hygienists tend to be less aware of this and tend to think of a given interview as a complete, self-limiting interaction after which a clinical decision must be made. The fact is, a tentative or preliminary decision is made, but it is subject to revision with each subsequent interview or appointment. Each subsequent interview will add increments of data that will increase the size of the "data bank" about the patient.
If the first interview is carried out in such a way as to increase the patient`s trust and confidence as well as his feeling of participation, the hygienist probably will obtain data with greater ease in subsequent encounters with the patient. Attitudes and expectations learned in each encounter have a significant influence on the patient`s response to the hygienist in the interviews and appointments that will follow.
Do not impose your standards on patients. They may never be able to meet your expectations and will sense your disapproval or rejection. Attempt to know the patients, their life-styles, their concerns, and their needs. Appreciate their roles as they seek care or assistance to achieve dental health.
Dental hygienists who bias a patient`s records in the first appointment will find that bias clouding their subsequent data and complicating the task of other clinicians who may take part in the patient`s dental care.
An effective hygienist-patient relationship ideally is characterized by trust and confidence in the hygienist; a feeling of appropriate participation on the part of the patient; and reasonable expectations on the part of both the hygienist and the patient. Patients come to the dental hygienist with a characteristic mixture of hope and fear. They hope that the hygienist will perform a thorough prophylaxis. At the same time, they fear that the hygienist may possibly cause pain. This fear may be compounded by apprehension over the cost of care.
The interview model
What kind of interview is most likely to produce a relationship characterized by trust and confidence, an appropriate degree of patient participation, and reasonable expectations on the part of the patient? It is my view that an open-ended interviewing style is most likely to produce the desired type of clinical relationship, and to be both effective and efficient in the task of data collection.
Before describing this open-ended model, let me examine two alternative approaches to interviewing. My five-year observations of dental-hygiene students led me to conclude that the average hygienist is likely to seek information in the most direct manner possible - by asking a great many questions. This style of interviewing might be called directive or interrogative. It often is referred to as history-taking. The dentist has a long list of items in mind about which he wishes to have information. Each bit of information given by the patient is followed by several specific questions elucidating details. In a number of observed situations, the patient has a tendency to become quite passive. Often, the patient makes some early efforts to bring in personal concerns, then ceases the efforts and limits his communication to supplying the information that is being sought. The relationship between interviewer and patient has rarely deepened by the conclusion of the interview.
In the mental-health care disciplines by contrast, there is very little emphasis on fact-finding through an inquisitory technique. Much attention is paid to the empathetic responses of the interviewer - and to the facilitation of communication. Facts are not actively sought; they are permitted to emerge.
The open-ended interview
The open-ended interview is a derivative of the interview styles that have emerged in the mental-health professions. It has been modified by Enelow and Adler to fit the health-care setting. "It combines the goals of the fact-finding type of interview with the concern for rapport and the emphasis on emergence of information, rather than the extraction of facts. The guiding principle of the open-ended interview is that the clinician should exert the least amount of authority necessary to obtain the information being sought within the time allotted for the interview or appointment."
There are four general characteristics of this style of interviewing. First, the interview should be carried out in an atmosphere that encourages spontaneous behavior on the part of the patient. Second, the interviewer`s behavior should encourage communication. Third, the interviewer should give attention to the patient`s nonverbal behavior as well as his story. Fourth, the interviewer`s specific information-seeking actions should be those that exercise the least control first, and the highest degree of control as late in the interview as possible."
An atmosphere that encourages spontaneous behavior has both physical and emotional attributes. Comfort and privacy should be provided whenever possible. The hygienist should arrange for the fewest possible interruptions. They hygienist should communicate by her manner that the patient can respond freely. It is especially important to keep the patient talking in the earlier part of the interview. Nonverbal communication often is more indicative of a patient`s state than a verbal account. Information not contained in words may be clearly expressed in behavior, manner, and appearance.
The interview is opened with a broad open-ended question such as "What kind of difficulties are you having?" as the patient answers, the hygienist should encourage spontaneous elaboration though facilitating remarks and gestures. Spontaneous reporting tends to produce the broadest range of information, most of which is likely to be relevant. If the hygienist observes that the patient is encountering difficulty in describing his discomfort, she should point it out to the patient. If there is incongruity between the patient`s behavior and his or her story, the patient`s attention should be drawn to the observed behavior. Lastly, if these methods have not yielded specific items of needed information, or if there is a point in the interview where specific details are needed to fill in the story, the hygienist should use direct questions.
Before embarking on a line of direct, specific questioning, the hygienist should try less-controlling actions. These are facilitation, support, and reassurance.
Encouraging communication by manner, gesture or words that do not specify the kind of information sought is called facilitation. Any interested, attentive manner is, of course, facilitating. Any change of facial expression or posture displaying greater interest for attention is a facilitation. A common mode of facilitation is the nod of the head, conveying, "I`m listening" or "Go on." The hygienist also may be facilitative by interjecting short words or phrases such as "yes" or "I see" without interrupting the flow of the patient`s narrative.
The hygienist`s ability to be appropriately supportive and reassuring helps create an atmosphere in which the patient is encouraged to communicate. Examples of supportive statements are: "I understand" and "That must have been very upsetting." A summary of what the patient has just said that conveys an empathetic comprehension is supportive. It must be clearly understood that supportive words without a supportive attitude on the part of the hygienist will sound hollow and will fail to accomplish their intended purpose. Without a genuine interest in the patient, a feeling of friendliness, and a desire to be helpful, supportive words are simply not supportive.
When a patient presents with a fear or phobia, the hygienist should determine exactly what fear is. Once the patient describes his fear or concern, the hygienist should make every effort to allay the patient`s concern with facts and evidence based in reality. For example, if the patient fears an intraoral injection, the hygienist can assure him or her that the "scaling procedure requires only a topical anesthetic, not an injection." Reassurance includes words or acts that tend to restore the patient`s sense of well-being and confidence. When patients are very frightened, a reassuring remark such as, "You may be overly concerned; it may not be as bad as you think," may have a remarkably helpful effect. To say, "There is nothing to fear," is a poor use of reassurance unless evidence clearly supports such a statement.
At what points in the interview is it wise to use direct questions? The first is when the hygienist cannot elicit needed information with facilitation and support. The second is when the broad outlines of the story have emerged and specific information about details is needed. Questions which seek clarification of topics the patient has just volunteered, such as the precise time-sequence of events, the exact location of a described phenomenon, the exact amount of a drug taken, and similar questions, usually will be tolerated during a patient`s spontaneous account if they are introduced at an appropriate pause.
Regardless of the time or reason for introducing direct questions, a good interviewing technique requires that direct inquiry be conducted in a manner that does not bias the resulting communication. Accuracy in communication is facilitated when the hygienist does not suggest responses she expects by the wording of her questions or by her demeanor, tone of voice, or other nonverbal communication. Facial expressions or gestures which express moral approval or disapproval or surprise will influence what the patient tells or does not tell.
In general, the more open-ended the question, the more likely the answer will be accurate. The hygienist should avoid suggesting an expected answer and permit the patient to formulate his own reply. Rather than "Does the pain occur right after meals?" ask "When does the pain occur?"
Questions should be framed for the specific patient being interviewed, taking into account his or her language skills, social and cultural background, and style of communication. With all patients, the hygienist should use simple, concise, nontechnical language.
When the hygienist decides to seek specific information, it is best obtained by gradually restricting the open-endedness of a series of questions presented to the patient. This is done by beginning with a general and exploratory question. An appropriate sequence of questions might be:
(1) "How is your new filling?"
(2) (If symptoms are mentioned) "Could you please describe the discomfort (or pain)?"
(3) "Where is the pain?" or "Could you please show me where the pain is?"
(4) "Is the pain always the same or does it change?"
(5) (If it changes) "What kind of things affect the pain?"
(6) (If hot liquids are not mentioned) "Does drinking hot liquids affect it at all?"
Each symptom or oral discomfort, whether reported by the patient spontaneously or elicited by the hygienist, requires specific qualifying information in order to be evaluated. Any necessary information that is not supplied by the patient during the open-ended phase of the interview should be sought during the stage of the interview in which direct questions are being asked. The qualifying information needed includes the following:
> Location. Where is it experienced? If pain, does it radiate? If so, Where? Under what circumstances does it do so?
> Quality. What does it feel like? Is it dull or sharp, aching, throbbing, or grinding? If the discomfort is a limitation of function, as difficulty in eating, a similar description of the character of the difficult experiences is needed.
> Intensity. Though the description will range from mild to very severe or even unbearable, it should be evaluated in terms of the patient`s personality or temperament. One man`s severe pain is another`s mild pain.
> Quantitative aspects. How many? How often? How much? Each of these may be applicable, depending on the type of discomfort or symptom reported.
> Time of onset, duration, and frequency. If several symptoms are reported, what is their chronological relationship to each other, if any?
> Setting. Under what circumstances does the symptom occur? Can it be related to the patient`s location, physical environment, or social environment?
> Aggravation and alleviation. Does anything make it worse or better?
> Are there clearly related symptoms or limitations of function, such as sensations of heat or cold, anxiety, or activity?
> Has the patient taken medication or made other attempts to modify the symptoms chemically or physically?
Having reconstructed the patient?s clinical problems and current symptoms beginning with their onset and having identified the course of the present problem, the hygienist should turn to the medical history. Once again, the preferred approach is to begin with an open-ended inquiry. OHow has your dental health been before this difficulty began?O is a good opening question. If the patient says something like, OPretty good,O the hygienist should be facilitative. OPretty good?O as a response will usually elicit qualifying data. Ongoing problems, such as chronic gingivitis, may call for a specific inquiry.
Hygienists may be OstudentsO of interviewing skills throughout their professional lives. Dental-health professionals should be concerned with improving their communicating skills with their patients to obtain valid, precise, and reliable data with high information content from patients. It is written from the point of view of the hygienist seeking medical- and dental-health history data. However, the principles of questioning described here usefully are applied in plaque control and nutritional counseling.
Donna M. D?Anton, RDH, BS, MED, is a dental marketing consultant and a member of the ADHA. She is based in Mahwah, NJ.
* O?Brien, M. Communications and Relationships in Nursing, second edition St. Louis: The C. V. Modby Company, 1978, p.113.
* Enelow, A. and Swisher, S. Interviewing and Patient Care. New York: Oxford University Press, 1972, p.29, 34.
* Benjamin, A. The Helping Interview, third edition. Boston: Houghton-Mifflin Company, 1981, p.73.
* Rogers, C. On Becoming a Person. Boston: Houghton-Mifflin Company, 1961, p.53.
* Enelow, A. and Wexler, M. Psychiatry in the Practice of Medicine. New York: Oxford University Press, 1966, p.57.
* Froelich, R. and Bishop, F. and Dworkin, S. Communication in the Dental Office. St. Louis: The C.V. Mosby Company, 1976, p.53,137.