Challenging patient behaviors: Strategies for listening to difficult patients

Editor’s note: This is part four of a four-part series. Part one examined early maladaptive schemas and how they influence irrational thinking and problem behaviors in dental patients. Part two examined personality disorders and how to deal with red-flag patients. Part three examined strategies for effective reasoning with unreasonable patients.

High-quality care and patient satisfaction requires effective provider-patient communication. Miscommunication between providers and patients decreases trust, heightens tensions, and can lead to patients’ aggressive behaviors.¹ All patients want to feel heard and understood during the process of their care. As part of overall communication, listening to patients is an essential skill that increases trust, decreases dental anxiety, and helps prevent patients from experiencing anger and aggression toward the provider and staff.^1-4 Effective listening skills can help de-escalate many situations, from dealing with a patient with a negative attitude to serious incidents of patient aggression and violence.^4,5

Cultivating a comfortable environment for patients

According to Jenstad et al.,⁶ up to 80% of health-care lawsuits are directly related to poor provider-patient communication. Patients need to feel safe with their provider to communicate honestly about their anxieties and expectations. Feeling understood increases this trust and allows patients to openly express their negative experiences and feelings, and accurately convey medical health information they feel may not be pertinent to dental treatment but that is actually crucial to treatment planning.^6,7

What makes patients feel like they aren’t heard?

When patients don’t believe they are heard, tense situations, anger, and aggressive behaviors can result. Many factors can lead to patients feeling like their dental provider has not listened to them:^2,7-9

Negative past experiences
Dental anxiety
Current expectations about what is possible with treatment
Personality disorders or mental health status
Emotional feelings of being rushed or not being included in their treatment planning
Physical pain
Lack of consistent messaging from dental staff

As dental care providers, it is never our intention to leave patients feeling as though we didn’t listen to them or didn’t adequately include them in treatment decisions. However, these elements of a dental office’s daily operations can add to these feelings in our patients:^4,6-8

Increased administrative tasks or treatment documentation and coding completed in the operatory
Overworked staff and the pressure to see more patients for decreased insurance reimbursement rates
Stress related to being short-staffed
Lack of communication among team members
Lack of empathy for patients’ situations
Mental health and stress levels of the provider and other staff members

What can we gain from active listening?

When dental providers actively listen to patients, it motivates patients to provide all the information the provider needs to make an appropriate diagnosis and develop the best treatment plan options based on the individual patient’s needs. Listening establishes a comfortable, trusting environment for patients to share details about any negative experiences they’ve have, what is causing their significant dental anxiety, or why they have neglected their oral health for so long. This openness on the part of patients helps dental providers fully understand the depth of their situation and needs. Excellent listening skills help facilitate proper referrals to medical providers and other dental specialists, and patients are more receptive to those referrals. Explain referrals like this: “I want to help you, but I think there is an individual who is much better positioned to do that. I want to help you get connected with that specialist.”^8-10

Implement effective listening

Studies show that health-care providers can build their listening skills through time and practice.^5,8 The patient-centered interview is the best practice to implement effective listening, gather the appropriate information in the shortest time frame, and keep the patient’s needs at the focus of the appointment.^3,8,10

Steps to conduct a patient-centered interview

First, face the patient at eye level.
Sit down and pull the operator’s chair beside the patient’s chair.
Stay away from the computer screen and avoid entering information into the electronic health record while the patient is talking.
Look directly at the patient and be cognizant of your own body language. Strive to exhibit a body language that is inviting and open. Soften your facial expression, don’t cross your arms, and greet your patient with a smile and handshake.^2-4,10
Thank the patient for their time and for coming to the appointment. If you are running behind schedule, instead of apologizing for being late, thank the patient for their patience and acknowledge that their time is valuable.⁵

How to help an anxious patient

The longer waiting time may have raised the anxiety level in an already nervous patient. Pain can further exacerbate this anxiety. Demonstrate empathy for the patient’s discomfort or situation. Use phrases such as, “I can see that you are in pain today; tell me what’s going on,” or “I can understand how frustrating this must be for you.”

Allow the patient to finish speaking. Don’t interrupt or you’ll cause the patient to feel rushed and make them think you aren’t listening to them. If the patient is giving you information that’s not helpful, wait for them to pause before speaking, and then redirect an open-ended question to get the information you need for diagnosis.^2-4,9,10

Listen to their words for meaning and any possible schemas the patient may be expressing in their dialogue. Ask open-ended questions to clarify and understand. For example: “You said that your teeth are sensitive. Can you tell me if it’s all the teeth or just one? Can you tell me what makes them sensitive?”

Open-ended questions take more time than typical yes-no questions, but they will significantly build trust with the patient. This trust encourages patients to be more honest and open with their provider, so we can listen for meaning in their words and determine any schemas or underlying personality disorders or mental health concerns that might be at play and could potentially elicit aggressive behaviors. Listening for the patient’s emotional concern and acknowledging that concern may be the single most effective tool in preventing patient aggression.^2-4,6,10

Steps dental professionals can take to be effective listeners

Based on research studies, there are 15 steps that health-care providers can take to be effective, active listeners:^2-4,9

Face the patient, not the computer.
Maintain eye contact; don’t lose yourself in taking notes.
Always remain relaxed and calm, even if the patient is frustrated.
Be attentive and listen carefully. Listen for the emotions in what the patient is saying.
Be open-minded and flexible. You don’t know what other providers may have said or done to cause the patient’s frustrations.
Listen to the patient’s words for meaning. What are they trying to communicate to you?
Summarize it back to the patient so they know you’ve listened. For example, “What I hear you saying is …”
Watch the patient’s body language for clues. Are they gripping the chair arms tightly? Do you need to try a different approach to calm them?
Be aware of your own body language. What does it convey to the patient?
Don’t interrupt; let the patient finish speaking.
If you need to get the conversation back on track, wait for the patient to pause before speaking.
Ask open-ended questions to clarify.
Don’t judge the patient; only judge their symptoms to determine a diagnosis.
Try to understand what the patient feels and validate those feelings. For example, “I can see you are angry, and I understand why you would be.”
Only say that you understand how the patient feels if you actually do. Validate their feelings by imagining yourself in that same situation and thinking about how you would feel. For example, “I imagine that it’s very difficult and frustrating to quit smoking. I admire you for sticking to your goal of quitting. Let’s see if I can connect you to some resources that you may find helpful.”

Editor’s note: This article first appeared in Clinical Insights newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe.

References

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Drossman DA, Ruddy J. Improving patient-provider relationships to improve health care. Clin Gastroenterol Hepatol. 2020;18(7):1417-1426. doi:10.1016/j.cgh.2019.12.007
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Kimberly A. Erdman, MSDH, RDH, FAADH, FADHA. is a practicing dental hygienist and public health dental hygiene practitioner. She was a civilian-dental hygienist for the U.S. Navy and spent nine years as a forensic dental technician. She has a decade of experience in higher education and administration. Kimberly has been awarded a fellowship with the American Academy of Dental Hygiene and the American Dental Hygienists’ Association.