Objective To describe the expectations of walk-in patients seeking emergency dental care out-of-hours.
Basic design Consecutive patients attending two emergency dental clinics at weekends were interviewed prior to seeing the dentist. The audio-recorded interview transcripts were analysed using the 'framework' method of applied qualitative data analysis.
Subjects and setting Forty-four walk-in emergency dental patients at a community-based dental clinic and a dental hospital emergency clinic at the weekend.
Results In addition to symptom relief, the main desired outcome for emergency dental patients may be informational and psychological — especially reassurance that the problem is not serious, and reduced uncertainty about the cause of the pain. In general, patients' stated expectations for specific treatments (such as antibiotics, or tooth extraction) were not absolute: rather, they implied these expectations were conditional upon the dentist deciding they were necessary.
Conclusions Emergency dental services, some of which are still dominantly treatment-focused, should reflect that many emergency dental attenders want advice and reassurance as much as relief from symptoms. This reinforces the importance of effective and sympathetic dentist-patient communication within emergency or out-of-hours consultations. It also implies that dentists' skills in listening, explaining and reassuring should be captured in any patient satisfaction or outcome measure designed for this patient group.
No previous studies have investigated what patients expect from out-of-hours or emergency dental services.
Although most of these patients primarily sought relief from pain, many also wanted reassurance that the problem was not serious, and greater certainty about the cause of their pain. Effective and sensitive dentist–patient communication may be more important in out-of-hours and emergency consultations than in other clinical situations.
Patients generally accepted that treatment would be partial or temporary, and expectations for specific treatments were mostly expressed conditionally, ie if the dentist thinks it is necessary.
Telephone-accessible out-of-hours dental services, and helplines like NHS Direct, could play a role in fostering realistic out-of-hours service expectations.
During the 1990s the perceived problem of emergency dental care, and out-of-hours services in particular, led to a considerable number of studies of emergency and out-of-hours dental services.1,2,3,4,5,6 Unfortunately none of these studies produced information about patients' expectations of the services or their satisfaction with the quality of the care provided. Yet evidence suggests that emergency dental care arrangements can be a major determinant of consumer satisfaction with dental services7 and also an important consideration when choosing a practice.8
Although the 'disconfirmation of expectations' comprises one of the main theoretical models of consumer satisfaction,9 empirical studies show that the relationship between satisfaction and expectations in healthcare is far from simple.10,11,12 However, surveys of primary care walk-in patients13 and of out-of-hours primary care patients14,15 have shown that, in these patient groups, decreased satisfaction with the consultation is associated with unmet expectations. A recent qualitative study of dental patients has also reasserted the importance of expectations in determining satisfaction with dental care.16
Whatever the exact role of expectations in patients' judgements of satisfaction or the quality of care, dentists might be interested in patients' specific expectations for emergency dental care. Moreover, the government's current plans for reforming emergency care incorporate the principle that they can only be effective if designed from the patients' perspective.17
Currently available evidence suggests mainly that the public expects that emergency dental services should exist, and that they should be accessible.8,18 Surveys revealing emergency dental service unavailability,19,20 evidence of multiple attempts before obtaining emergency dental care,1,4,21,22 as well as evidence of delayed care-seeking due to the belief that 'dentists don't work at weekends'23 all suggest that even these basic expectations of availability and accessibility in an emergency are still not met for a considerable proportion of patients.
In this paper I describe patients' reported expectations of their encounter with a dentist, shortly after their arrival at an emergency dental clinic. The broader, initial aim of the study was to inform the choice of outcome measures, including patient satisfaction, for an evaluation of alternative out-of-hours dental service arrangements.24 Analysis of the types of dental problems presented, how they were affecting people, and the overall process by which people sought dental care out-of-hours has been reported elsewhere.23
Semi-structured face-to-face interviews were conducted with 44 consecutive patients at two weekend emergency dental clinics, during three weekends in mid-1999: 25 attending the Cardiff dental hospital emergency clinic (Saturday mornings), and 19 attending the emergency dental clinic at Pontypridd health centre (Sunday mornings). Both services were walk-in treatment services, intended primarily for unregistered patients. All interviews were conducted by the author, and were audio-recorded with the permission of the interviewees. They were conducted after the patients had been booked in by reception staff, but before being seen by the dentist, and were either carried out in the waiting area, out of ear-shot of other patients (dental hospital), or in an adjacent spare room (at the community-based dental clinic). I introduced myself as 'a researcher based at the dental school at Cardiff'.
Information was prompted on six issues, including the patient's expectation of the visit by asking: 'What are you hoping that the dentist will be able to do for you today?' (The other five issues were: the problem description; 'trigger' for seeking formal care; quality of life effects; prior care; and self-care — the responses to those topics have been analysed in another paper on the care-seeking process.)23 Although the whole interview transcripts were analysed by the author using the 'framework' approach to analysing qualitative data,25,26 the sub-analysis of the interview data presented here did not allow as much abstraction of concepts as that method should involve. Instead, analysis of the data on patient expectations was more akin to a simple content analysis.27 (The anonymised interview transcripts, data 'index' and 'charts' are available from the author on request.)
Patients' quotations below are verbatim responses to the standard question stated above, unless beginning with '...', in which case expectations were expressed as part of their overall account of care-seeking.
Of the 44 interviews, 42 were with the patient, 1 was with the mother of a 6-year-old patient and one was with the girlfriend of a 21-year-old patient (both had difficulty speaking because of their dental problems). Only four did not describe their problem as toothache or some sort of oral pain. Although the study did not aim for a representative sample, the demographic characteristics of the sample are comparable with those in larger studies of out-of-hours emergency dental services (59% were male; median age 33, mean age 35, std. dev. 16). Seventeen mentioned their regular or usual dentist, and 11 implied that they were irregular dental attenders.
Patients expected or wanted one or both of two things:
Relief from symptoms, and
Greater certainty regarding the cause of their problem
The primary expectation for most was relief from symptoms: 'get rid of/stop the pain' or 'fix it/sort it out'. That is, in the patients' accounts, relief from pain was most often mentioned first, emphasised more strongly, repeated more often or was the only stated expectation. For some this desire was accompanied by or expressed through an expectation or desire for a specific physical treatment (eg for temporary fillings, for caps to be re-affixed, or for teeth to be extracted). However, usually the expectation or desire for a particular treatment appeared to be secondary to the fundamental desire to be free from pain.
'Well, stop the pain, which I think is going to involve filling it.' (P32: female, age 43)
'... I don't know whether you know what toothache's like but when you're in that much pain, it drives you mad in the end, you get nasty, irritable, and you just want to have the tooth out, or whatever they can do to it just to stop the pain.' (P31: male, age 31)
Two patients expressed that the need to be free from pain was in order to regain normal functioning (sleep or work routines).
'... so basically I haven't had any sleep. And I'm coming here, possibly see if they can refill it and kill the pain so I can go back to sleep. That's basically the problem.' (P41: male, age 21)
'Find out what the problem is, and hopefully sort it out today ... So I can get on with things, I mean I'm doing my exams at the moment so I want to get rid of the pain before I get back into them.' (P39: male, age 16)
Despite the finality implied in some of these expressions, many acknowledged that the care provided might be partial or temporary (ie would provide short-term relief from the immediate symptoms, but would not completely solve the problem):
'... so long as she can do something to stop the pain until my next appointment really'. (P28: female, age 38)
'... I thought well I'll nip round here and see if I can get any emergency treatment, temporary filling and then go to my own dentist.' (P40: male, age 57)
'Sort the pain out, and then it depends what needs to be done to it.' (P20, female, age 18)
'... A filling or even a temporary filling just to buy some time, just get the pain out of the way for now.' (P41: male, age 21)
Amongst those who knew, or suspected, that their problem was related to a lost restoration (filling or cap) expectations were often physically specific: 'block up the hole', 'refill it', 'get crown back on', 'put it back'. The other commonly expressed specific expectation for treatment (12 patients) was for the extraction of a problem tooth.
'Fix my tooth. Pull it out hopefully, if possible.' (P23: male, age 23)
'Either rip the nerve out or take the tooth out.' (P37: male, age 22)
'I don't care what they do as long as they get rid of it. If it means pulling my tooth, then so be it.' (P30: male, age 20)
Patients' accounts implied that the desire to, expectation of or stated willingness to have a tooth extracted was related to the location or visibility of the tooth (typically at the back) together with preconceived notions that certain teeth are 'not needed' or often extracted without loss of function (eg wisdom teeth), or a belief that it is only 'half a tooth' or beyond restoration in some other way.
Encouragingly, a desire or specific expectation for antibiotics was rarely mentioned. For the three patients who did mention them, the perceived need for antibiotics was uncertain and tentative:
'Yeah stop the pain I think. Yeah, I don't know if I need any antibiotics .. or not but er .. it's an abscess or something I'm not sure.' (P7: male, age 25)
'Hmm, prescribe me some antibiotics or something to take it away.' (P12: male, age 19)
Although relief from pain, and specific treatments expected to obtain it, dominate patient expectations, their wants and expectations were not solely based on symptoms and treatments. For a considerable number of patients ending uncertainty about the cause of their problem was at least as important as relief from immediate symptoms. As one patient, who had never had toothache before, expressed:
'I don't know .. I really don't know ... Even if it's a case of being able to tell me ... well if they can just locate the source of the possible problem, I mean, that is a start, effectively, you know. If it's an old filling that needs something doing with it or is there anything worse .. um .. in the jaw itself?. An abscess or anything like that. That's half the solution and it does ease the situation.' (P15: female, age 48)
Others echoed this desire to find out 'what is wrong', 'what's going on', or 'why this is so painful'. The desire for reassurance and information about the likely cause of the problem was sometimes fuelled by concerns about the recurrence of serious problems or feared links with general health problems:
'Then about a month ago I started to get pain again in the extraction site, and there's a huge lump on the side of it so I'm hoping it's not what happened before to my bottom jaw ['what happened before' was a jaw swelling which had resulted in emergency admission to hospital, followed by several operations.]. That it's simple maybe.' (P42: female, age 48)
and from a patient who had recently been hospitalised with septicaemia:
Researcher: 'So, if you could express what you want out of today's visit what would it be?'
'Well for them to check it and tell me what it is ... If the teeth were causing me to have blood poisoning then consequently take 'em out. You know ... I can't go on being ill.' (P2: male, age 55)
Even for patients whose primary presenting complaint is pain, the main desired outcome may be informational and psychological; reassurance that the problem is not serious, and reduced uncertainty about the cause of the pain. This echoes the findings of a similar study of how dental patients evaluate dentists,16 and a conjoint analysis of patients' preferences for different models of out-of-hours care (in which 'whether the doctor seemed to listen' was the most important service attribute identified).28 It no doubt also reflects that many of these patients sought emergency care in response to uncertainty about what the symptoms meant — rather than their symptoms per se.23 Moreover, reassurance may increase people's ability to cope with their pain on their own: several patients expressed that they could have coped with the pain for longer if they were reassured that the problem was nothing serious, and that it was not likely to worsen before an in-hours appointment could be made.
Encouragingly, there did not seem to be any widespread or unconditional expectation to be prescribed antibiotics. With the exception of those patients who said they wanted a tooth extracted, patients also generally expected that any treatment received would be partial or temporary. It is unclear how much such attitudes might be due to patients wanting to see their own dentist for full treatment, or awareness that dentists working out-of-hours cannot perform all dental procedures. Where patients stated desires for particular treatments these statements were rarely absolute.
For dentists, these findings are mostly encouraging and probably in line with clinical experiences. However, the prominence of patient expectations for reassurance and information about the possible cause of their problem re-asserts the importance of dentist—patient communication in out-of-hours consultations.
For planners of dental services there are other implications. There is a continued need to improve the public's understanding of what out-of-hours dental services are for (eg patients cannot expect all treatments to be available; cannot expect dentists to re-open their surgeries at any hour of the night; should expect dentists to only extract teeth as a very last resort). Services like NHS Direct go some way to raise such basic awareness. Dentists also have a role in keeping patients' service expectations realistic, but alongside efforts to increase awareness about the existence and contact arrangements for emergency dental services. Ultimately however, there is a limit to what people should be expected to know about out-of-hours dental care or what constitutes a dental emergency.23
With walk-in services even patients who are not in much pain, and who know that they probably do not need urgent treatment, will have to travel and visit a clinic in order to simply get professional reassurance that the problem is not serious. A follow-up questionnaire survey of emergency dental patients has shown that almost half (45% = 42/92) of emergency dental attenders (at the two walk-in services studied) said that they would have been happy with advice plus a reliable appointment when surgeries re-opened.24 In contrast, at the two services where telephone advice was available before attendance, only 13% (34/259) of attenders agreed afterwards that they would have been happy with advice only plus a reliable appointment in normal surgery hours. There is therefore an efficiency argument to supplement all 'walk-in' emergency dental clinics with some form of telephone access and consultation prior to attendance.
The study has several limitations. By using a small convenience sample it is not possible to make conclusive generalisations about the balance of patients' expectations in other emergency dental services. Rather it illustrates the range of expectations of probable importance. The study concerns expectations of a particular encounter with a dentist, immediately before the encounter, and in response to the patient's perceived urgent need for dental care. The findings should therefore be expected to differ from studies of expectations of routine dental care appointments, emergency dental services or dental professionals in general. The interviews were relatively short (lasting from 2 to 5 minutes) and information on some interesting issues, such as how much pain relief was expected, or how quickly they expected to feel better, was not specifically sought.
It should be noted that for some, the stated desire to 'have the tooth out' could be a symbolic statement — a figure of speech to convey the level of pain, and to show that they are prepared for the dentist to do anything (ie even take a tooth out) in order to get rid of the pain. Also, by using the question 'What are you hoping the dentist will do for you today?', respondents may have expressed more of their 'ideal expectations' (what they want to happen) than their 'practical expectations' (what they anticipate will happen).29 This question would also not elicit expectations concerning the accessibility of the service.
The study might seem premature, in the sense that the more basic expectations of emergency dental service availability and accessibility are clearly not met for many patients in some areas. The need for advice and reassurance as much as relief from symptoms must be better recognised in service design, care protocols and professional development. As in other studies of perceptions and expectations of dental care, this study shows the importance of effective and sympathetic dentist—patient communication within emergency or out-of-hours consultations.30,31,32 It also implies that the quality of dentists' communication — whether at the chair-side or over the telephone — should be a key dimension in any evaluation of the effectiveness of such services. Since many emergency dental patients suspect that they may not need urgent treatment (but are nevertheless worried that they might), it further raises doubts about both the efficiency and equity of emergency dental services which do not allow for telephone advice prior to seeking care. Although telephone advice risks dissatisfaction for those who wanted to be seen,15,33 as a standard component of out-of-hours care it allows a negotiation of the urgency of the problem and the opportunity for self-care, both of which are also important to many patients.17
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The author gratefully acknowledges the generosity and understanding of the patients who allowed him to interview them, and the staff and managers of the two services. The author also thanks Dr Kate Robson, Dr David Thomas, Dr Ceri Phillips and three anonymous referees for their many useful comments. At the time the work was conducted the author was jointly funded by the Medical Research Council and the Wales Office for Research and Development in Health and Social Care.
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