Communication
Aim: To outline two techniques of communication and their application to practice.
Learning outcomes: Following the completion of this CPD article the participant will
be able to demonstrate, through the completion of a questionnaire, the ability to:
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Identify the importance of communication skills from a medico-legal
perspective.
Identify an early model of communication and its theory.
Identify the ego states of Transactional Analysis.
Identify which ego state should be aimed for during communication with
patients.
Identify how to apply the methods and theories of neuro-linguistic
programming to practice.
Introduction
Good communication and influencing skills are important competencies for dental
nurses to have when dealing with patients in the surgery environment, and when
influencing the patient to make positive changes to their oral health. In addition, the
General Dental Council acknowledge, that a source of a patient complaint is not
necessarily about technical skills or the quality of care that the patient receives.
Complaints are often due to the patient’s expectations not being met, which is often
the result of a failure to communicate.1
The Dental Care Professional needs to consider that advanced communication skills
are necessary during consultations if patients are to feel at ease, and feel they are
working collaboratively with the health care professionals to improve their health.2
This article will outline some of the theories of communication and how to apply them
to practice in order to assist you in improving your communication skills with your
patients.
Early Models of Communication
Early models of communication such as the Linear model of communication
described by Shannon and Weaver (1949)3 described communication as a process
consisting simply of a sender, messenger and receiver with the aim being that by
transmitting a message, the sender will bring about a desired action from the
receiver (Figure 1).
4
Figure 1 Shannon and Weaver’s Linear communication theory
The message is received and interpreted in the way it was intended by the sender.
Such models may now be considered to be too simplistic when more contemporary
theories of communication and behaviour change are considered5.
Transactional Analysis
Berne’s theory of Transactional Analysis (1958)6 is described as a method through
which most forms of transaction can be analysed. An individual can adopt a Parent,
Adult or Child ego state and the state adopted can influence the ego state of the
other individuals involved in the communication process7.
The Child ego state may be divided into the Free Child and the Adaptive Child, and
the Parent ego state may divided into the Critical Parent and Nurturing Parent.8 At
any moment each individual in a social situation will exhibit a Parental, Adult or Child
ego state.9
In addition, individuals can shift with varying degrees of readiness from one ego
state to another. Transactional Analysis involves being aware of the ego state of the
person initiating the transaction and responding in a complimentary ego state in
order to minimise misunderstandings.10 It is suggested that dental professionals try
to aim for Adult to Adult ego state transactions7 (Figure 2).
Figure 211
Neuro-Linguistic Programming
In the 1970’s, Richard Bandler and John Grinder developed the theory of NeuroLinguistic Programming (NLP) which aims to enhance the effectiveness of
communication.12 NLP refers to the connections between the neurological
processes, linguistics and internal programming which leads to the actions and
behaviour of the individual.12
The NLP model of communication implies that once an external event occurs the
information is filtered by the individual’s values, beliefs, perceptions, experience,
memories and attitudes which results in the deletion, distortion or generalisation of
the intended message2 (Figure 3).
Figure 3
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Internal representation of an event
Applying the NLP method of communication to practice means that you may treat
two patients in exactly the same way but their individual experiences, attitudes and
beliefs may alter how their dental experience is perceived. The individual’s differing
interpretation of events could lead to a breakdown in communication.
Building Rapport
Establishing rapport is probably the single most important skill that you can learn as
a dental professional in order to gain trust and build rapport with your patients.2 NLP
involves listening to the patient and being aware of how an individual may interpret a
message.
1) Listen to the patient
A skilled healthcare professional needs to listen to all three aspects of
communication:
1) Linguistic
Listen to what the patient is saying. Egan (1990)14 proposes that the acronym
S.O.L.E.R is used in order to remember the skills that convey interest and effective
listening during communication. In the dental setting this involves;
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Sitting Squarely to the patient
Maintaining an Open position
Leaning towards the patient
Maintaining Eye contact
Relaxing
ii) Para linguistic
Listen to the message beyond the spoken word. Listen to the volume (loud or soft),
pitch (high or low) and speed (fast or slow) of the voice. In order to calm down a
patient who may be angry you can initially match the speed, tone and pitch of their
voice and then gradually calm them down by reducing the intensity of your own
voice.15 Alternatively, if someone needs cheering up, you may match a calm voice
before bringing them up to where you want them to be.15
iii) Non-verbal
A study conducted by Mehrabian (1981)2 found that 93% of communication skills are
through non-verbal communication and only 7% through actual words spoken. Nonverbal communication such as mirroring actions is a large part of NLP.16 Therefore,
to facilitate communication and rapport with your patients, you may choose to mirror
some of their actions and body language where appropriate. This may allow the
patient to feel confident in conveying some of their attitudes, values and beliefs and
allow the dental team to adapt the treatment for the patient accordingly.
2) Be aware of an individual’s learning style
The NLP model of communication observes that individuals have different
representational systems.2 Individuals may have a preferred learning style of being
visual, auditory, read/write or kinaesthetic (VARK) which can affect the interpretation
of information.7 For example a patient with a visual orientation to learning may wish
to be shown dental models and pictures; a patient with an auditory orientation to
learning may wish to simply listen to information; a patient with a read/write
orientation to learning may wish to take written instructions home, and a patient with
a kinaesthetic orientation to learning may wish to hold the dental models and get a
‘feel’ for things.
The language a patient uses may provide a clue as to what their orientation to
learning is. A patient may say “I see what you’re saying” if they are a visual learner
or “I hear what you’re saying” if they are an auditory learner.
In addition, the NLP model of communication suggests that when you are engaging
in communication you can take clues as to the individual’s orientation to learning by
watching the movement of the eyes. The diagram below outlines the different eye
positions. Taking note of eye positions may give you clues as to the correct language
to use for the individual’s learning styles and therefore may facilitate you in building
rapport with your patient. It also suggests that when the eyes move up and to the left
the individual may be constructing an answer rather than remembering an answer!
(Figure 4).
17
Figure 4
3) Perceptual Positioning
The NLP theory of perceptual positioning is a key skill in understanding other people,
and is an important part of the communication process.18 Perceptual positioning
allows you to step back and view a situation from three angles: your view, the other
person’s view and finally from an objective viewer’s perspective.
Applying the techniques to practice
As an example, imagine you have a patient you view as rude and uncooperative.
You apply perceptual positioning to the situation. When you consider the patient’s
view they are actually nervous from a previous difficult dental experience and this is
manifesting itself in an aggressive form.
Viewing the situation from an objective point of view you realise that you need to
build rapport and reassure this patient. To do this you listen to the patient’s concerns
regarding treatment by listening to the linguistic, para-linguistic and non-verbal
methods of communication. You listen to the patient’s previous dental experience,
matching tone, pitch and speed of the voice whilst gradually calming the patient
down. You match body language whilst maintaining eye contact. You establish that
the patient is a visual learner and alert the other dental professionals responsible for
the patient’s care that the patient may benefit from having treatment explained using
visual prompts such as diagrams.
The application of these techniques should then improve the dental experience for
your patient and hopefully start to alter the patient’s internal representation of a
dental experience from a negative to a positive one. The patient leaves the practice
satisfied with the treatment he or she has received.
Conclusion
Early models of communication which suggest that by transmitting a message the
receiver understands the message may now be considered too simplistic. The dental
care professional needs to understand more complex methods of communication to
improve the care that can be given to patients. Being aware of the techniques of
Transactional Analysis and Neuro-linguistic programming should assist in improving
relationships with the patient and help to ensure that the patient’s visit to the dental
practice is a positive experience.
Portfolio Tip
Further reading on Neuro-linguistic programming and Transactional Analysis is
available from the non-verifiable CPD section of the website. In addition, case
studies are available which demonstrate the application of the techniques to
practice.
The non-verifiable section of the website will also take you to an on-line quiz that
you can take to identify your preferred learning style.
Don’t forget to update your non-verifiable CPD log.
© 2012 Nicky Gough and Sue Bagnall
References
1 General Dental Council Standards Guidance (2006) The Principles of Complaints Handling. GDC: London.
2 Henwood, S. and Lister J. (2007) NLP and coaching for healthcare professionals. Developing expert practice. Chichester:
John Wiley and Sons.
3 McCabe, C. and Timmins, F. (2006) Communication Skills for Nursing Practice. China: Palgrave MacMillan.
4 Communication image (2011) Available at: http://en.wikipedia.org/wiki/Communication (accessed July 2nd 2011).
5 Humphris, G. and Ling, M.S. (2000) Behavioural Sciences in Dentistry. China: Churchill Livingstone.
6 Berry, D. (2007) Health Communication Theory and Practice. Berkshire: Open University Press.
7 Kay, E.J. and Tinsley, S.R. (2004) Communication and the Dental Team. London: Stephen Hancocks Limited.
8 Holmes, A. (2005) Transactional Analysis and Communication. Available at: Andrew Holmes CLLApril
2005G:\UCPD\Communication Skills\TRANSACTIONAL ANALYSIS.rtf. (Accessed 16th October 2009).
9 Berne, E. (1978) The Games People Play. The Psychology of Human Relationships. Available at:
http://www.geocities.com/ripxburn/ericberne-gamespeopleplay.pdf. (Accessed 19th October 2009).
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=gc4yfsRWsE&sig=5MqMB-bbedjBFZDRqJKdx8BxwV0#v=onepage&q=eric%20berne%20transactional%20analysis&f=false
(Accessed 17th October 2009).
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(accessed 18th July 2011).
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http://www.infed.org/biblio/nlp_and_education.htm (accessed 11th October 2009).
13 Individual interpretation image (2011) Available at: http://www.denisfleming.com/eft-nlp.html (accessed 14th July 2011).
14 Palmer, S. and Wolfe, R. (2000) Integrative and Eclectic Counselling and Psychotherapy. London: Sage Publications Ltd.
15 Personal Empowerment Coaching (2011) The secret science of self-empowerment. Available at:
http://www.pecoaching.com/HTML/Ezine/09061.html (accessed 14th July 2011).
16 Ribbens, G. and Whitear, G. (2007) Body Language. Oxon: Hoddler Arnold.
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18 Hoag, J. (2009) Perceptual Positions. Available at: http://www.nlpls.com/articles/perceptualPositions.php (Accessed 16th
Octobber 2009).