Running Time: 45 min
Statistics on non-compliance behaviours Describe barriers to patient self-care Discuss the hygienists
Release Date: September 30, 2014Subtitle:
Welcome to the module on oral health counseling. I’m Karima Bapoo-Mohamed. I’m a dental hygienist with practice in Edmonton, Alberta for the last two decades, and I teach at the University of Alberta. Teaching and dental hygiene are so synonymous. This is what we do in our private practices day in, day out, in counseling our patients for self-care for optimum oral health. This module will go over some of the statistics of what are some of the non-compliace behaviors. We’re going to address some of the barriers for patients facing optimum self-care. And then, we’re going to switch over to, what is our role as dental hygienists in really helping patients achieve that optimum self-care. We’re going to switch over to some communication strategies and tools, that we can maybe refresh ourselves to get some heightened response from our patients. And then very briefly, we’re going to talk about a couple of theories on learning processes, in order to make ourselves more effective as communicators and in sharing our knowledge with our patients. We will end the presentation on just some differential instruction that we customized for our patients. So this module will carry us through, really, some self-based evidence that is used for communication. There’s a whole body of research that we will come through and share and talk about today, and then move on to how does this apply to us Monday morning in our dental clinic. So let’s talk about non-compliance. Compliance is really an indication of a positive behavior, in which the patient is actually self-motivated sufficiently that they will go and do the treatment or the prescription that you have recommended for them. Now, there’s a difference between compliance and adherence, where patients will adhere to something you’re telling them. For example, you might recommend the Sonicare toothbrush, or a certain kind of a medical device you want them to get. They may go out and actually fill out the prescription and get the device, and that’s just the adherence part of it. However, the compliance is the action of actually conducting the action of doing what you’re asking them to do. It’s interesting. The statistics on non-compliance actually is a problem in the health care system, because it’s costing the US economy anywhere from $100,000 to $300 billion annually, because patients are just not following up with the health care provided to them. And they’re ending up in hospitalizations or nursing home admissions, or actually sometimes premature death. So compliance is a good place to investigate and understand how can we get more compliance or higher levels of compliance from our patients. And of course, there’s two types of compliance. There is the intentional one and then the non-intentional one. And I think most of our patients are motivated enough. They have the intention, the human nature to have the intention and go out and do it. And then, we use that motivation somewhere along the line. So we’re going to talk about those factors. And what are some of the strategies we can then apply to sustain that motivation for our patients? Some of the factors that actually affect noncompliance– and this is fairly general, in that it relates to non-dental and the whole health care domain– relates to two key areas. One is the patient-centered. The other one is the therapy-centered. So in patient-centered, for example, demographics plays a huge role. And there’s statistics and studies done to show how, for example, female patients generally are more compliant than male patients. What are the psychological issues that the patient is dealing with? Does the patient have some beliefs or motivations– and sometimes they can be very religious-based beliefs that they feel would be the right thing to do. That may be an impediment to compliance of the counseling you’re providing. They may just have a negative attitude, period, about the therapy you’re trying to recommend for them. Health literacy is a huge area where patients really maybe don’t even understand completely what you’re trying to tell them or what you’re asking them to do. And we’re going to talk about strategies to help patients with that. Sometimes, patients just forget. Their personalities may be such that they are not very compliant, per se. They’ll do it for a while and then lose the momentum. Social factors, again, peer pressure, as well as peer support plays a huge role in how effectively the patient’s going to comply to the recommendations and the therapy we’re recommending. Therapy-related– this is more drugs or prescription-based. But really, they’re saying the factors that affect non-compliance for patients for therapeutic-related items are the type of drug that we’re administering, and how they have to take it. Do they have to take it systemically or otherwise? How complex is it to actually do the treatment that we’re asking them to do? How long does the treatment have to be? And we hear of patients that get the prescription. They fill it out, and then they’ll just do it for the first two or three days. And it’s a seven-day dosage, but they don’t actually stay with the sustained time period. So sometimes, they just don’t understand maybe, or they don’t think they have to finish all those pills. Are there any side effects of the things we’re telling them to do? And that actually has an effect on whether they’ll comply or to sustain compliance to the therapy, as well. What about the taste of the medication? It’s also a factor. And requirement for drug storage or shelf life of what we’re suggesting. So if there’s a mouthwash or something we’re giving them, is it easy to look after and sustain it there? We’ll talk about now some of the key factors. I rattled off a whole bunch of key factors. But some studies have shown if we have to narrow it down, yes, actually, it boils down to the patient’s general health belief, to their specific health belief. What are their preferences? And patient preferences play a huge role in how compliant they’re going to be. Their experiences– what have their past experiences been? And maybe they’ve had a past negative dental experience that just makes them shy away from this whole compliance of dental health. What’s their social interaction like, and do they actually understand and are conversant about what we’re telling them or asking them to do, or suggesting that we do? And sometimes, a socio demographic factor also is one of the key factors for non-compliance. I think, in my personal experience, the patient-practitioner relationship is really the trump card of it all. At the end of the day, if the patient likes you, connects with you, has trust in you, their chances of being compliant to your recommendation are a lot higher. And we’re going to talk about that piece a little bit later on. This is an interesting study, actually. It’s a non-dental study, and I’m curious to find out. Why do people leave the establishments where they’ve been doing business for a long time? And there’s a whole bunch of factors. Some of them actually just pass away. 3%, according to this study, say that they move away. 4% it says “naturally float,” whatever that means. They’re just floating out there. Some of them will change things actually based on their friends’ recommendations. We’ve heard that before. How about the shopper patients? They’ll go and find something cheaper somewhere, and now they’ve moved their businesses to another establishment. Some of them are just chronic complainers. Patients like to be heard and like to complain. They’ll go from one place to the other place and repeat their complaints. However, a large majority of this statistic shows 68% felt that the people they were dealing with were indifferent to their needs. And this is why they left the place of business. So really, that indifferent feeling. They just didn’t have that connection with anybody there, to feel they really don’t care about me. I don’t need to be here. So I think that’s a good context for where people’s mindset is. How do we improve compliance? Let’s move over to that segment of thinking. And before we even improve compliance, we’ve got to understand the cause of the non-compliance. Unless we have a grasp of why is the patient– what are their barriers for not complying to the intervention we’re suggesting, we won’t be very effective. Interventions also should combine actually three aspects that we teach at the university. And I apply it clinically to my practice on a daily basis, is really have the cognitive, behavioral, and affective components to what we’re suggesting in our intervention. And I’ll give you specific examples of that a little later on. And then, patients really have to have their participation, their voice in all of this, for them to actually be more compliant to the recommendation you’re making. And finally, of course, make it simple, so that there’s a benchmark that they can compare it to and then rely it to. And understand their progress along the way, as well. Those are really important parts for compliance issues. What about motivation? Now in dentistry, we don’t use the word “compliance.” So I felt this slide was necessary to talk about in dentistry, we use the word “motivation” to describe compliance. Compliance is a more health care domain issue, I guess. Patients compliant, not compliant. And motivation seems to refer really to anything that the patient has in the space between the ears, really. Their lack of understanding maybe, maybe their inability to listen and really grasp the knowledge you’re giving them. And really, what is their philosophy about their health? So a good way to actually get patients interested is understanding the listening skills. We’re going to spend some time on listening skills, and really understanding what are their desires and their wants to change, as well as our ability as clinicians to listen. So it’s one part to have the patients be a good listener. But we also need to be good listeners in turn, as well. Moving on then to, what is the hygienist’s role in oral health counseling? Well, we wear a lot of hats on a daily basis. We are the professional authority. And we have to be careful how we call this authority, because you don’t want to come across so autocratic that the patient feels demure and overpowered by what we’re saying. However, we are the content experts in what we can do, and knowledge that we can impart to our patients. So absolutely, we are that authority figure in that relationship. We’re an educator. We’re educating constantly, and really understanding where the knowledge deficits are for the patient, and how can we fill those gaps for that patient. I think hygienists are great motivators. We’re constantly trying to adopt and change and modify our recommendation, so that the patient has a sustained motivation in moving forward with the recommendation. We’re also great evaluators. We always have great benchmarks. And we’re evaluating up against how are things getting better or worse for us. And I feel another key role a hygienist plays is actually a facilitator. You are great in taking where the patient is in their needs and their desires, as well as their skill sets, and matching it to where you need it to be and have them meet in the middle somewhere. I think the end goal of any oral health counseling that we do as hygienists is really have the patient take ownership of their own health. And that, to me, is a key end goal that I’m always striving to achieve. And these are just some examples of what hygienists do do on a daily basis as examples of counseling. We’re always big on caries risk counseling and periodontal disease cessation. What about tobacco use, as well as nutritional deficit counseling? We’re great with also– patients have always questions about whitening treatment, for example. We’re always counseling whether they would be a good candidate or not. And as preventative measures go, we’re also giving sealant therapy. And we’re always constantly explaining the rationale for what we do, why we do, and how is it beneficial to the patient. Let’s talk about some of the communication strategies. And this, I think, is a key piece of our effectiveness as hygienists in really meeting the patient’s needs. I feel that first visit of that patient-hygienist interaction is really key, because aside from getting a comprehensive medical, dental history, you are taking time and really learning and understanding where that patient’s dental experiences have been. Have they had any dental phobias or fears from their past experiences? And there’s statistics that show that over half the American population suffers from dental phobias or related anxiety. So as soon as you say “dental,” people are associating that with a pain thing. And they have a phobia about it. So how can we help understand them and help them cross over to the other side? They’re also taking a great social history of these patients, and understanding any behavior issues that they have which may be contributing to their oral health demise. Age of the patient– absolutely there’s studies showing that elderly who have mobility issues, vision, hearing impairment, they have a lot of medical issues, too. It’s tough to get them really compliant. And you have to modify and constantly adjust your process as you go along. Children, of course, is the other cohort of the population that we want to significantly improve their oral hygiene performance. A patient’s socioeconomic status and culture background plays a key role, too. So really as hygienists, we’re assessing and gathering all this data as we move forward, before we even have asked them to comply to anything yet. Communication has four key elements to it. Of course, there is a sender and there is a receiver. Then, there’s the message itself. That’s including the body language. And then, there’s the whole context or the setting of this message. And so we’re finding that behaviors are reportedly correlated with low satisfaction rates, because a lot of the time, patients felt that the appointments were too rushed, that they didn’t take the time to really explain the process or the procedure to me, and really, there was a perceived lack of caring or compassion will also turn people off. So very important to pay attention to these four key elements of communication. When we look at communication, absolutely words is– when you think of communication, you think, oh, yeah. You’ve got to talk to them. So words are a big part of it. Actually your voice, how you’re projecting, is 38% of your communication. And the large part of your communication is actually your physiology, how you’re coming across. And we’re going to spend some time analyzing what that physiology looks like. I’m talking about body language and that “silent” communication that the patient’s picking up on. And sometimes, you meet somebody, and their attitude is just so loud, you’re not even hearing the words that are coming out of their mouth. And so that attitude can be positive or negative. And how can we use this to our advantage and make it positive? Nonverbal cues, again as I mentioned, is that silent communication. It’s happening constantly. For example, are you making eye contact with your patient? And it has to the right amount of eye contact. You don’t want to be so intense that they get overwhelmed or intimidated by you. What about your facial expressions? Cross-culturally, when I travel and present around the world, a smile is universal communication in all languages and cultures. So how is your facial expression? Maybe have somebody critique you sometimes to observe you, or videotape yourself to see how you’re actually coming across. There’s a big reality gap between what we think we’re doing and what we’re actually doing, and how the patient is perceiving that to be. The way you sit, the way you stand, the way you walk, the way you’re holding your head, your posture, all this– are you attentive when you’re talking and caring is something patients are picking up on. And they’re going to decide whether I’m connecting with this person or not. Your tone of voice– are you warm? Are you confident? Are you interested in them? What about your body? Are you relaxed or are you really tense all the time? And I know as hygienists, our backs and necks get really sore. But pay attention to how you’re presenting yourself to that. Your sound of voice has to show that caring. And really, touch has to be appropriate when needed, of course. And again, pay attention to any of the non-verbal cues that the patient is giving you. The important thing is English language– I did some research on this. Did you know the English language has twice as many negative words than it does positive words? So maybe we use the words in the wrong context. The other fact is psychologists have told us that we don’t think with an emotion in our head. We actually think by words. So when you think of a word, now the body reacts by giving you the biochemical reaction in your brain. And now, you feel that emotion. So an example would be instead of thinking, I am so angry or mad about this patient doing this or this person doing that, what if you use the word “I am curious. I wonder why that person did that.” A different psychological emotional reaction happens in your body. And remember that English language has twice as many negative words as it does positive words. So my message here is really watch the choice of words that you use on a daily basis. And really create that unhurried environment in the dental setting, because that does help reduce dental anxiety for the patient. Patient motivation– again, we talked about the differences between motivation or compliance to adherence. And how often do you have a patient in the chair and says, oh, yeah. Thank you for the reminder. The office called that I have an appointment in two days. So guess what? I started flossing yesterday. And the studies have actually shown that patients– that because we have a regularly scheduled recall appointment with our patients, that it actually helps with compliance of oral hygiene care. And so that’s called the “reactive effect of measurement,” or actually the “white-coat syndrome,” where patients will now actually start doing the care regiment, because they’ve got to come see you. All right. We’re going to move now into patients’ experiences of these learning processes. So we’ve talked about communication, and how do we then perceive it from the patient’s side? What are some of their barriers as they move forward on this? And really, they may not comply with the recommendations you’re giving them because they just don’t have enough time. Or maybe they don’t have the skills or the dexterity to do this complex C-shaped flossing that you want them to do once a day. Maybe their attitudes are a little different. They’re good for a while, and then it changes. And just tend to have a low self-efficacy– they’ll do it for a while, and then it changes. So as I tell my patients and my students and my kids is human beings were created. And it’s natural for us to have habits. So always putting good habits, or the bad habits will come in and take over. They’re going to do something, do it right anyway. And so again, creating that self-efficacy and good habits and good behaviors. Again, education and motivation is only possible if patients like you and they trust you and they have a rapport with you. There are five strategies in patient education that I use, and there’s research-based evidence on these. Let’s talk about each one of these individually, starting with giving information small amounts at a time. Interesting thing about communication, 50% of what’s communicated to the patient is not even relevant to them. It’s totally redundant. Add to that, people will only listen to 25% of the verbal communication. There’s studies and data that prove this. It’s pretty scary. 25% is all they’ll hear. And when you think about it, I’m guilty of this, too. If I’m going through some explanation in my head or somebody’s talking to me about something, my mind wanders. There’s this mind chatter. And you pick up one word here, and then your mind goes somewhere. Oh, groceries, don’t forget that. You come back to what this person’s telling you. So it’s possible that our patients are only gathering or being attentive to a small percentage of what we’re talking to them. 50%, according to this study, show that patients don’t even understand what you said. But they may be a little shy or feel embarrassed to maybe ask you that. They don’t have that comfort level to really be open of oh, what do you mean by that? Or I don’t get that. 50% of them, actually– half of them actually need help in making decisions. That seems a little high, but these are the stats that up to 50% can’t make that decision on their own. and if you give small amounts of information, maybe just repeat them throughout the appointment. And that seems to be very effective in compliant behavior. And too much information and too much instruction– if you just give it to them, it swamps the patient. And then, they don’t understand what’s important. What does she want me to do? Or was this supposed to be first? They’ll get really confused and not do anything. So there goes the compliance of it. So what’s the clinical significance of it? What I do a lot of times, I’ll pay attention to if the patient in the waiting area has arrived alone today or has a person with them. And I’ll invite, if they would like, the partner or the companion to come with them during the oral hygiene instruction component, or any part of the dental hygiene therapy appointment. And what happens is yes, the patient may just listen to 25%. But maybe the companion will listen to another 25%, or they have a support mechanism where they can talk about, oh, yeah, the pocket area here needs attention. And we need to work on A, B, C, D. So it’s a good strategy to have someone with them and invite them to the dental hygiene therapy appointment. The second part is let the patient set the pace of the conversation, and really them determine how fast or how slow they want to go. And sometimes, just leaving a quiet space, dead space, is a good thing. It does a few things actually. The patient then absorbs the information in that quiet space, but it’s also telling the patient what you’ve just shared with them is something very important, and that they need to pay attention to this. So it’s absolutely– I think it’s our human nature to be not having any quiet space. But really let the patient to be in control of that space. The third component is supervising the patient. What do we mean by that is not actually having a crack and a whip. It’s more like really encouraging them, and making them go in the direction of really proficient practice. So whatever skills they’re trying to master, what you want to do is encourage them and provide the supervision as far as adjustments go. So for example, if you’re teaching the Bass method of brushing and they haven’t quite understood what that 45-degree angle is that you’re talking about, you would help them get in there and actually adjust it for them. So that’s a very important piece of that component of education. Give them feedback. Research shows actually that if between the action and the knowledge and the shortest time in which them the feedback, guess what? The behavior is anchored for a longer time, and compliance is increased. So these are all the behaviorism principles we learned in psychology. And tell the patients to actually self-evaluate. Again, my end goal I mentioned earlier is to give the patient that power and autonomy to be in control of their own health. So a lot of times, I’ll tell the patient and send them home with some disclosing tablets, for example. And they can do their plaque scores on a daily basis or a frequent basis at home. Having a good post program– when am I going to see you next? Let’s set up that appointment. I would say 95% of my patients advance-book their next hygiene appointment at the time they’re leaving today’s appointment. And things adjust. They have to change or I have to change. But they’re committed to it, and it’s already in our system in the computer. So that goes a long way in motivating and getting compliant behavior. And really, a long-term goal also should be developed to see, this is a step in direction A, B or C. And why are we doing what we need to do, and why this is so important to go there. And really, the last strategy is that positive reinforcement. We touched on it a little bit earlier. But as we were saying, praising the patient and rewarding the patient and really giving them accolades– that’s awesome! Your plaque score went from you were only 35% effective last time to 68% effective today. That’s phenomenal! And these are great mile markers for the patient also to know, OK. I can do this. This is manageable for me. I’m going in the right direction. And really, the remarks I think were all very good and tactful with that. But always, the remarks should really relate to the behavior and not the person. And really keeping that negative feedback to a minimum or a zero is really the way to go for motivation. Listening– I call it the forgotten skill. And reflecting on this, when you think about the formal training we get on all these communication skills, I figure we spend about 12 years of our early life learning how to write and read and to speak. Speaking starts as early as year one and two. But there is no formal training for listening. And yet listening is such an important part of communication. And that’s different from hearing. Hearing is just a physical process of actually your ear canal grabbing the vibrations, and the brain deciphering the words to say this is what you’re hearing. Listening is actually taking what you hear, digesting it, reflecting it, understanding it, and then putting it in the context. That’s a tough skill, and there is really no formal training for it. I do some practice management for dentists across North America. And I remember going in a dental office. And I asked the dentist, so who does the talking when you have a new patient consult in the chair, and what happens? And he said, I do the talking, because I have the knowledge. And they’re here to learn from me. And they’re paying me for my knowledge, so I have to tell them everything I know. And really, think of all those five principles. You’re giving them too much information. You’re coming across too authoritative. And really, maybe there’s a different way of switching that around. I feel my dad said it great. He said, “God gave us two ears and one mouth. We should be listening twice as more as we speak.” So with that, I leave that “listening– the forgotten skill” idea with you. Let’s move on to the next objective now. And this is really based on what are some of the models and evidence-based theories out there that we can use in our dental hygiene practice to help motivate and really anchor the patient’s learning, so that it stays sustained over time? There are very many. There is a human needs one, the human belief– the Health Belief Model. I will choose to actually speak about two today, motivational interviews that I think, inadvertently, we’re using it all the time. But I just want to talk about these theories. And the other one is the transtheoretical model of motivation. Motivational interview actually is a very patient-centered technique. And this is where you’re encouraging the patient to speak. And they are really doing a self-discovery in your presence, with you moderating that experience for them, to really help them identify what their oral health needs are. And your job as a health professional, I feel, is to be a catalyst. Give them that intervention as you need, but really let them speak and self-reflect to understand where they’re at and what they don’t like about their behavior. And what would they like to change, and where would they like to go and really assessing their conflict they may have. And within that interviewing process, you might even learn about some of their readiness to change. Maybe they’re not quite that ready to move forward. Motivational interviews is also a way of talking in a very caring, empathetic way to your patients to help them increase their health behaviors. And really if you’re sincere, it’s not that you want them to do it for you. This is I’m telling you this because I feel it will improve your health, and it’ll benefit you in the long term. And it is my professional obligation to share this knowledge with you. So really coming in from that, and where the patient is owning the changed behavior pattern. And really, the patient will come up with the solution. Oh, I think I can do this. Or maybe this is manageable. Maybe I’ll try this for a week. So they are the ones that come up with that solution, and you’re just supporting them. Something I– the acronym OARS actually fits really well, because it makes me remember how to conduct a motivational interview. I’d like to share with you is OARS, O-A-R-S. O stands for Open-ended question. So you always want to have questions where it’s not a yes/no answer. The patient has to stop, think, reflect, and then come up with a statement that resonates with what they’re thinking. Amazing strategy to understand where the patient’s head space is, and what are their experience levels at right now. You want to talk about affirmation, where you are really encouraging and building that rapport with the patient to reinforce the improvements for the health behavior that you’re wanting. Reflective listening actually is a very key skill. And that’s where you actually rephrase what the patient says. Say, “so I’m understanding you right,” and then go on and get the affirmation from the patient. And so it gives that power to the patient. Wow, this person really cares if she’s understanding, and took the time to tell me what they’re thinking or what they’re hearing me say. And then, the last thing I always try and do is create a little summary at the end. So if I understand you right, we talked about this and this. Today’s appointment entailed this and that, and the next steps are going to be so and so. That summation piece is so critical, because a patient is walking out with that last thought in their head. Oh, yeah. We talked this, and now I have to go and continue on with this thing. So that was a motivational interview component. Let’s talk about the transtheoretical model. We’ve all heard about these components, which is the precontemplation, contemplation, preparation, action, and then there’s a maintenance relapse phase. So precontemplation is now today’s maybe the first day the patient’s become aware that there is a need for them to change. And there’s something that they’re doing that’s damaging their health. So this is just a very preliminary stage of things. Contemplation is when the patient is thinking now about the pros and cons. Contemplation can happen beyond the dental office. So you’ve put a thought or planted the seed in their head. And now at some point, they’ll be thinking– maybe the next cigarette they’ll light up, they’re thinking of the pros and cons, based on what that precontemplation experience was for them. And sometimes, they can become stuck in this contemplation for a very long time. We’ve all got patients who’ve been trying to quit smoking for maybe years and years. So this can be a longer stage, and there’s no judgment being passed. It’s just highlighting in our heads which stage is the patient at. At some point, the patient will move from contemplation to preparation, where they now have a higher self-awareness. And this higher self-awareness will make them think about the pros more than the cons. So every time they’re looking in the mirror and they see their teeth, it’s like, I need to get my teeth whitening now. That’s it. It’s just not white enough for me. I’m just not happy with the way it is, whereas before they knew about it, but now they’re a little bit more aware of that need. And so that becomes that preparation stage to prepare them for what? For the action piece. So action is actually when they cross over from preparation to actually doing it, to conducting whatever it is that we were recommending that they do for that section. And this is just giving you a pictorial diagram of what that model looks like. The patient can start with the precontemplation, move to contemplation. Then, there’s preparation. They get into action. Action can be short-lived or long-lived. But guess what? Then, they can go into a maintenance phase where OK, they did it. They got it. They’re on top of it. They can manage this behavior. And again, once in a while, they will go through a relapse. And when you get the relapse mode, you go through that same cycle again of precontemplation and so on. So really assess where that patient’s readiness is. And sometimes, we’re documenting it, so you know and you’ve had this conversation, and understand how you can help them with that behavioral change. So some of the things, again, we do. I think tobacco cessation is huge. Nutritional counseling, as well, I think for hygienists, is relating to caries risk and periodontal diseases is huge, as well. Health beliefs– what is the patient’s? That’s very difficult to really elicit the patient to say what is that health belief. Sometimes patients, as I mentioned, they don’t want to look like they’re ignorant, or they get embarrassed about not having the knowledge base or the information. They may be even reluctant, especially the older-generation patient. They just don’t want to waste the doctor’s time, as they’ll call it. And it’s more because I should be able to manage this. I shouldn’t talk about it. I shouldn’t go out and get the help, because I don’t want to waste your time. So what is that belief? Where is that patient’s belief based at? And a lot of times– and this takes time and effort. And I don’t profess to say I’m perfect at it. I am work-in-progress all the time. So instead of asking a direct question like, “what do you think will happen if we take your blood pressure today?” maybe an indirect question may be helpful in saying “what is going on through your mind right now?” Very open-ended, very gentle, and very kind almost. And it doesn’t matter. There’s no right or wrong in this case. Or “what does your wife or partner think about this?” Because we know 50% of decisions need that support from the other component of the relationship. So really to summarize this whole piece, we want to really make sure that we understand and have an opportunity for the patient to explain what their health belief is, and really reinforcing that positive attitude to health. You want to really counter the myths or negative attitudes. Recently, I had a patient saying, yeah, I don’t want x-rays, because x-rays are bad. And there’s too much radiation in this world, anyways. I don’t want any x-rays. And really my response– not exactly, but something along the line was– that’s fine. But will you allow me to explain to you the type of technology we use here in our office? So again, very permission-asking. The patient is in control. And of course at the end of that explanation, the patient did go ahead and get the CBCT scan done as required. So once the patient understands that they can put their guards down and really trust you, the attitude will change. Next thing is really coming up with an appropriate course of action. You really want to make sure that the patient is aware of the next step of what we’re going to go and do. So in conclusion really, as people grow intellectually, there is this mature thought process that is replaced by their old belief or a flawed model that they were maybe caring carrying forever. And you have helped to explain those processes like oral diseases, and what are some of the valid models that support the current evidence that you’re talking about. I think having evidence-based practice is really the key to helping patients understand the reason or need to possibly change their behaviour to a positive one. Dental hygienists foster this mature response with health care issues by really giving that effective interaction in a very professional role, and being educators for our patients in the expertise of oral and systemic health. So really, this mature response gives the patient then an opportunity to actually go through their learning continuum and replace that old model. So the key takeaway from the oral health counseling model, really, we want to really understand that social data that the patient has, their perception of what their health belief is. You want to address it and embrace it, and come up with a plan that’s going to really help them. And also, recognizing that there is a treatment plan that we’re going to– we can help you with this. This is something we can work towards and change it. Patient’s perception is huge. Life is all about perception. There is no reality, and reality’s a perception of reality. So what is that patient’s reality in understanding their ability to cope with that health deficit that you have just identified for this patient? And then, really what you want to do is reduce that anxiety and the stress level that leads to patients actually being more compliant with your recommendation. So we started the module with actually understanding what do we mean by non-compliant behavior, or what we call motivation in dentistry. What are some of the statistics, and actually the impact and negative effects of non-compliant behavior? Then, we talked about what are the patients’ barriers for self-care. And why do they not do what they’re supposed to do, or what we recommend them to do? And then, we talked about what is our key role as hygienists in really helping our patients meet that health deficit need. And we discussed the communication strategies. And there’s five key elements that we talked about that how do we communicate to our patients will really help them actually grasp the knowledge, and then implement it in a positive way. We talked about putting the foot on the other shoe now. And how does the patient see us and view us? And how can we help that learning process? We discussed the two theories of motivational interviews, as well as transtheoretical model, and how we can use those principles in sustaining patients’ learning needs. And we ended up with creating an individualized, customized patient care model for our patients. I will end today’s module with the power of questions. You’ve all heard the story about this wife preparing dinner. And it was a beautiful lamb dinner. And the husband’s sitting there watching the wife prepare dinner. And what the wife was doing was actually taking the ends of the ham and chucking them in the garbage, and putting the ham in the oven. So the husband says, “hey, why did you cut the ends of the ham out?” And the wife says, “I don’t know. I guess mom did it.” So they phone mom. “Mom, you know when you make ham and you cut the ends of the ham out and put it in the oven? Why’d you do that?” Mom says, “oh, I don’t know. Because grandma did it. Let’s phone grandma.” They phone grandma. Grandma says, “oh, you mean the ends of the ham?” Because she can’t hear too well. She says, “yeah.” She says, “oh, I just did it to make it fit in the pot.” So sometimes, we continue doing things on a daily basis because that’s what we did yesterday, or that’s how the office is set up. Or that’s how we always do. But be bold to think of some of those brave questions. And questions are very powerful, because they’ll actually break your habitual thinking. And ask yourself– I know my dad used to do that. Five kids around the kitchen table, and he would always ask us a question. “What did you learn in school today?” And we literally had to come up with an answer of what did I learn. And usually, it was nothing for me. But I’d go to a dictionary, look up a word before dinner. And then, I would have something to tell my dad that I learned the word, whatever it was. Power of questions. It’ll break your thinking. It’ll stop you in your tracks and what you’re doing every day, and do something different. It gets us curious, doesn’t it? You do this with your patients, with your kids, with the people in your life. “I’m wondering.” “What about?” “What if?” Ask those kinds of questions. And it creates a different awareness of our current reality. So maybe we are doing what we’re doing, but now, we have it in our conscious mind of what we’re doing. It’s that awareness piece. And that awareness piece actually brings validation to our actions. It’ll actually say, yeah, I’m doing this because of this. And this makes sense, so I’m going to continue doing it. I’m not saying you’ve got to change everything in your dental office after you listen to this module. But you can actually validate what you’re doing, as well. And of course, it takes the whole practice, the whole environment to a higher sense of awareness and a higher level of efficiency. So Absolutely we need to ask the questions. And really re-examine it, so that we can innovate and be better, so we can give better service and better therapeutic care to our patients. Thank you for joining us for the oral health counseling module. Good bye.