HygienistsPrécis: Dental hygienists are not given the opportunity to use all of their skills, are enthusiastic about the future, and most would like to continue working in a team setting.

Abstract:
Background: Dental hygienists (DHs) in Ireland have a choice regarding undertaking further training to update their skills to the current scope of practice. No data exists in relation to how many DHs have updated their skills, how often they use these new skills and how confident they are in using them.
Purpose of the study: To identify the percentage of DHs who have the full range of skills currently included in the scope of practice for DHs, and  how regularly and confidently they are using these skills. It was opportune to also ascertain if DHs have encountered any barriers to using these skills, and their work practice aspirations for the future.
Materials and methods: An online survey was offered to all members of the Irish Dental Hygienists Association in August 2014 (n=189). The survey, which was piloted and revised, contained 13 questions relating to the profile, current work practices and future aspirations of the DHs.
Results: There was a 52% response rate. Most DHs were confident in their ability to carry out their skills. Some 22% had not updated their skills to include block local anaesthesia (LA). A high percentage of DHs reported never or hardly ever using the skills of block LA (40%), dental radiography (62%), placing temporary dressings (73%), or re-fitting crowns (82%). Reasons for not using these skills were provided by the DHs.
Conclusions: DHs rarely use some of their current skills; however, they are still interested in adding more skills to their scope of practice.

Introduction
In 1992, as a consequence of the establishment of a register for dental hygienists (DHs) by the Dental Council in Ireland, the first training programmes for DHs were established in the Cork and Dublin Dental University Hospitals. The scope of practice of the DH has expanded to include a number of additional skills since then. These are infiltration anaesthesia (1997), dental radiography (2001) and, most recently, block anaesthesia, placing temporary dressings and re-fitting crowns temporarily (2007). Training courses are provided by the training schools to allow DHs to acquire these new skills.
In Ireland, a DH must be registered with the Dental Council and dental hygiene treatment may only be carried out under the supervision of a registered dentist who has first examined the patient and who has indicated to the DH the course of treatment to be provided. The term “supervision” means that the dentist ultimately retains clinical responsibility for the patient and has a responsibility to ensure that the DH is competent to carry out the treatment indicated in an efficient manner. Direct supervision is required when local anaesthesia is used, or when a patient is being treated under sedation or general anaesthesia. The term “direct supervision” means that the supervising dentist must be on the premises in these circumstances.
Subject to these conditions, the current scope of practice of a DH as stated by the Dental Council is as follows:

  1. Confirm medical and dental histories.
  2. Record the soft tissue and periodontal status.
  3. Clean and polish teeth.
  4. Provide supra- and subgingival scaling, including comprehensive root surface debridement, and apply medicaments when indicated.
  5. Apply appropriate prophylactic materials, including solutions, gels and sealants, to the teeth and/or gums.
  6. Give advice in relation to oral health, including the planning and implementation of oral health promotion programmes, smoking cessation and diet analysis in relation to the prevention of dental caries and personalised plaque control programmes.
  7. Re-fit crowns with temporary cement and place temporary dressings when crowns or fillings become dislodged in the course of treatment by a DH.
  8. Take and process dental radiographs to the prescription of a dentist (having completed a Dental Council-approved course in dental radiography).
  9. Administer local infiltration and block anaesthesia to patients they are treating, to the prescription of a dentist (having completed a Dental Council-approved course in local infiltration and block anaesthesia).1

The current guidelines on professional behaviour from the Dental Council state that all dentists have an obligation to maintain and update their knowledge and skills through continuing professional development (CPD). There is currently a voluntary scheme for dentists to monitor their CPD while waiting for legislation to make this scheme mandatory.2 The Irish Dental Hygienists Association encourages DHs to follow the CPD guidelines provided for dentists by the Dental Council. While anecdotal evidence suggests that DHs are extremely motivated to maintain and update their knowledge, they ultimately have a choice regarding attending further training.
A public consultation process was undertaken by the Department of Health in 2013 in relation to new legislation to replace the Dentists Act (1985) and discussions continue to this day.3 The new Dental Act may introduce some changes to the scope of practice of DHs. Other countries have expanded the role of the DH and introduced independent practice. No research has been carried out in relation to the extent to which DHs in Ireland use their current scope of practice, how many DHs have updated their skills to include the new skills, and if they would like to see more skills added to their scope of practice.
The objectives of this study were:

  1. To assess the extent to which DHs in Ireland use the skills in their scope of practice, with particular emphasis on the new skills added.
  2. To assess their confidence levels using these skills.
  3. To identify any barriers experienced in using these skills.
  4. To identify any difficulties in accessing training courses for new skills.
  5. To determine if DHs would like additional skills added to their scope of practice.
  6. To determine if DHs’ work practice might change if given the option to practice independently.

Methods
This study was carried out as a summer research project by a student DH (Bairbre Pigott-Glynn) from Dublin Dental University Hospital, and was supported by a GlaxoSmithKline scholarship. The research proposal was written by the then dental hygiene programme director (Catherine Waldron). The timeframe to complete the project was three months. The study was a quantitative and qualitative cross-sectional study of a convenient sample – DHs who were current members of the Irish Dental Hygienists Association (IDHA) (n=189) – using a web-based online questionnaire. This was judged to be a timely and cost-effective means of accessing a sample of the full register of DHs in Ireland, which numbered approximately 420 at that time.
The survey questionnaire had 13 questions, which included questions in relation to the profile of the DHs, the skills included in their original qualification, additional skills obtained, confidence levels, barriers and future aspirations (Table 1). Given the lack of data on the thoughts of DHs in Ireland in relation to their work practice, comments were encouraged by the addition of free text comment boxes throughout the questionnaire to provide a small qualitative element to the study. The IDHA facilitated the use of its Survey Monkey account for one month. In this time the questionnaire was piloted to a small group of DHs, amendments based on feedback from this pilot were made, and the final survey link was emailed to the current membership and posted on the members’ section of the IDHA’s website in August 2014 for a period of three weeks. The IDHA was very supportive of the initiative, encouraging members to complete the survey via texts and Facebook posts. The survey was open for three weeks, and a reminder email was sent one week before the closing date.

Table 1

Results
The response rate was 52% (n=99), with 45% (n=85) answering all questions. Question 5, which related to how often they used particular skills, was skipped by 7% of respondents. A possible explanation for skipping this question was that there was no option provided to answer: “I do not have this skill”. Other questions skipped were more complex and required more thought; it is possible that respondents found the questionnaire too long. Research carried out on response rates to electronic surveys determined the mean response rate to be 39.6% (SD = 19.6%), with this dropping to 34.6% (SD = 15.7%) when all questions were answered.4 Based on this information, the response rate for this survey was considered to be good.

Profile
The number of years since qualification was spread evenly over the respondents and ranged from less than one year to 16 years or more. The majority of DHs (47.5%) work three to four days per week, 30% work five days per week, and 6% stated that they were not currently working.

Updating of skills
Of the skills not included in the original 1992 scheme for DHs in Ireland, 75% of the respondents had infiltration LA and 76% had dental radiography included in their undergraduate qualification. Dental radiography training can be undertaken by dental nurses, some of whom subsequently become DHs, which might explain why the percentage of those with this skill is greater despite it being added to the scope of practice more recently than infiltration LA. Only 31% of respondents had block LA included in their undergraduate qualification (Table 2).
The skill most commonly updated by DHs is CPR (70%). Some 46.6% had undertaken update training in block LA, and 20% had not undertaken update training in any of the skills listed (Table 3). Given the relatively recent addition of the DH to the dental team in Ireland (23 years), and the multiple changes that have taken place to the scope of practice over these years, it is worth noting that all DHs are not the same. Dentists should make themselves aware of the actual skills of the DHs they employ.
Other training and continuing professional development (CPD) undertaken by DHs included the Specialist Certificate in Oral Health, the Diploma in Health Promotion, business management, air polishing, impression taking, tooth whitening, periodontal root surface debridement, implant maintenance and oral cancer screening.

Dentalhygienists-Table2 JIDA_Feb_March_2016.qxp_JIDA

Use of skills
Of the skills added to the scope of practice, the most commonly used skill was infiltration LA, with 36.5% using this skill several times a day, and another 18% using it several times a week. The least used skills were re-fitting crowns temporarily (82% never or hardly ever used), placing temporary dressings (73% never or hardly ever used) and dental radiography (62% never or hardly ever used) (Table 4). The skill of applying fissure sealant was included in the list of skills as a comparison, as it is a skill that was included in the original scheme but is used to varying degrees by DHs depending on the type of practice/clinic they are working in.
The reasons given in the free text comments section for not using the skills included: working in a paedodontic practice/clinic so not requiring the full range of skills, especially LA; the opportunity not arising; and, the skill being performed by other team members (dental radiography). The issue of maintaining competence in little used but necessary skills is relevant in many professions, including dentistry. The identification of CPD core topics for DHs, which would include these skills, might help DHs in retaining their competence.

Dentalhygienists-Table4

Confidence levels
Levels of confidence appear to be linked to how often the DHs use their skills. There were moderate levels of confidence reported for the lesser-used skills, with only 60%, 66%, 67% and 75% saying that they were fairly confident, confident or very confident performing block LA, re-fitting crowns, placing temporary dressings or taking dental radiographs, respectively. This is compared with 93% being fairly confident, confident or very confident placing fissure sealants (Table 5). These findings highlight the need for CPD to retain competence in the lesser-used skills.

Dentalhygienists-Table5

Difficulties or barriers
When asked if they had encountered difficulties or barriers using their skills in practice, 68% responded “no”, 26% said “yes, sometimes”, 4% said “yes, regularly” and 2% said “yes, all the time”. Details to explain a positive response given in the free text comments included not being referred patients with a need for the skills, lack of opportunity to use the skills, losing skill and confidence due to lack of opportunity to use the skill, appointment times too short (for block LA, dental radiography), other team members performing the skill (taking dental radiographs, fissure sealants, severe periodontitis cases), the need for a prescription for some skills (LA/dental radiographs), and the need to have a dentist on the premises when using LA.
The DHs were asked if they had ever been asked to carry out duties that are outside their scope of practice and, if so, to give details. They were instructed to include duties that they are permitted to carry out but only under particular conditions, for example re-fitting temporary crowns for patients other than when dislodged during their treatment, or administering LA when there is no dentist on the premises. A total of 30% of respondents indicated that they had been asked to carry out duties beyond their scope of practice. Details of the types of duties asked of them were provided in the free text comments section and included: impression taking; tooth whitening; suture removal; administration of LA without a dentist on the premises; de-bonding orthodontic brackets; placing temporary dressings not dislodged during their treatment; delivering, fitting and instruction regarding bleaching trays; determining their own treatment plan; treating a patient without a referral; and, treating a patient under oral sedation without direct supervision. Those providing details of these duties were asked if they thought these duties should be included in their scope of practice, and all but one DH answered in the affirmative.

Access to CPD
Access to courses to update skills was generally good, with only 37% finding it somewhat difficult and 12% finding it very difficult to access training. Comments in relation to the difficulties accessing CPD focused on the range and type of courses available in Ireland, the distance to travel and costs.

Extending the scope of practice
A list of skills based on the 2013 IDHA submission to the Department of Health as part of the public and key stakeholders’ consultation process in relation to new legislation to replace the Dentists Act 1985 was provided. The respondents were asked to indicate if they would use these skills if they were included in their scope of practice and training was provided.
The list was made up of skills already permitted for DHs in other countries and was as follows: suture removal; impression taking; tooth whitening; removing overhanging margins on restorations; diagnosing dental caries; diagnosing periodontal disease; prescribing dental radiographs within your scope of practice; treatment planning within your scope of practice; treating patients directly, i.e., without a referral from a dentist, within your scope of practice (direct access); prescribing and administration of LA without direct supervision of a dentist, within your scope of practice; prescribing medications within your scope of practice, i.e., fluoride solutions, antibiotic cover; and, treating patients in institutional settings (i.e., nursing homes) without referral from a dentist and within your scope of practice (limited direct access).5
There was general interest in the list of skills. The highest level of interest was for taking impressions (92%) and the lowest level of interest was for treating patients directly, i.e., without a referral from a dentist, within your scope of practice (direct access) (68%) (Table 6).

Dentalhygienists-Table6

Work practice of the future
The respondents were asked how they see their work practice changing in the future. In order to give clarity to the range of terms in use to describe work practice options, the following was given to explain the meaning of the terms being used:
“The terms ‘direct access’, ‘independent practice’ and ‘self-employed’ have different meanings in different countries. In this instance the term ‘direct access’ means that a patient can attend you for treatment without first being examined by a dentist and without a referral from a dentist. The term ‘self-employed’ means that you would still work under the supervision of, and take referrals from, a dentist but have a contract of service with the dentist, i.e., pay your own taxes, etc.”

The type of work practice most likely to be chosen by DHs given the choice was “I would work in a practice with a dentist with both referrals and direct access” (48%). The least likely choice was “I would work under the supervision of a dentist in a practice but be self-employed” (6%). Some 16% were unsure (Table 7). These findings are interesting; similar to countries where direct access is permitted, most DHs in Ireland would not choose to set up their own independent practice. However, only 9% would choose to be an employee, which is the only option available to most DHs in Ireland at the moment, and only 6% would choose to be self-employed, which up until recently was the only other choice available to DHs. It appears that DHs are not happy with their current work practice options.
The final question asked if there were any other duties, not already mentioned, that they would like to be able to perform. A small number of respondents (7%) added some duties. Being able to carry out domiciliary visits without a prescription, and the duties of dental therapists and orthodontic therapists, were the most common suggestions.

Dentalhygienists-Table7

Conclusions
Despite the limited guidelines in relation to CPD for DHs, this survey shows that most of the respondents are motivated and proactive in relation to maintaining and updating their knowledge and skills, and are following the guidelines on professional behaviour suggested to dentists by the Dental Council. However, almost one-quarter of DHs (22%) are not trained to deliver block LA to their patients more than seven years after it was added to their scope of practice. Some 10% of DHs are not trained to take dental radiographs, 12 years after this skill was added. There does not appear to be any major issue with access to training for updating these skills.
DHs report that they are only moderately confident performing ID block LA, dental radiography, placing temporary dressings and re-fitting crowns. The most likely reason to explain this lack of confidence is the limited opportunities that arise to allow them to use these skills on a regular basis.
The issue of retaining competence in skills that are not used regularly is common in many professions, including dentistry. The availability of CPD to update knowledge or retrain in these skills would be helpful. However, dentists may play a role in providing the opportunity for DHs to use their full scope of practice by making themselves aware of the skills the DHs in their employment have and using these skills to the full by, for example, referring patients with prescriptions for dental radiographs and LA if needed, and widening the range of patients referred to DHs to more regularly include patients with moderate and severe periodontitis who may require treatment under LA.
It is worth noting that 30% of DHs in the survey reported that they had been asked to carry out skills outside their current scope of practice by their supervising dentists. Does this indicate that some dentists are unclear about the exact scope of practice of DHs, or could it be that dentists are as impatient and ready for new skills to be added as DHs are?
The long-awaited new legislation may add to the scope of practice of DHs. The aim is to improve both the access to and standard of oral care provided to the public.
It is not surprising to find that DHs in Ireland would most like to continue to work as part of an oral healthcare team should direct access be introduced. This follows similar trends around the world, where only approximately 6-7% of DHs opt to set up practice independently where direct access has been introduced.6,7 Limitations to this study include the time available to carry out the study and the population studied. However, it might be assumed that DHs who are members of their professional association are more likely to undertake CPD, and in fact the percentage of DHs without these skills might be even higher in the entire population of DHs in Ireland.
This survey highlights a number of interesting issues regarding the range of skills, confidence levels and work practice aspirations of DHs in Ireland. They are a skilled and enthusiastic workforce, and it is important that their skills are fully used in the best interests of the public.

References

  1. Dental Council of Ireland. Scope of Practice, 2014 – http://dentalcouncil.ie/ files/Scope%20of%20Practice%20-%20Guidance%20(approved)%20-%2020 141203.pdf (accessed April 25, 2015).
  2. Dental Council of Ireland. Code of Practice relating to: Professional Behaviour and Ethical Conduct, 2012 – http://dentalcouncil.ie/files/Professional%20Behaviour%20 and%20Ethical%20Conduct%20-%20final%20-%20%2020120116.pdf (accessed April 25, 2015).
  3. Department of Health. Report of the Consultation Process on new legislation to replace the Dentists Act, 1985, 2014 – http://health.gov.ie/blog/publications/ report-of-the-consultation-process-on-new-legislation-to-replace-the-dentists-act-1985/ (accessed August 31, 2015).
  4. Cook, C., Heath, F., Thompson, R.L. A meta-analysis of response rates in web- or internet-based surveys. Educational and Psychological Measurement 2000; 60 (6): 821-836 – http://epm.sagepub.com/content/60/6/821.full.pdf+html.
  5. Johnson, P. International profiles of dental hygiene 1987-2006: a 21-nation comparative study. International Dental Journal 2009; 59 (2): 63-77 – http:// www.ifdh.org/dt/IDJ-Apr-09-2076-Johnson-pp63-771.pdf.
  6. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, 2014-15 Edition, Dental Hygienists – http://www.bls.gov/ooh/ healthcare/dental-hygienists.htm (accessed April 25, 2015).
  7. Swedish Dental Association (2003). Dentistry in Sweden – https://www.mah.se/ upload/FAKULTETER/OD/Avdelningar/who/EURO/Sweden/dentistry_03.pdf (accessed April 24, 2015).

 

catherine waldron

Catherine Waldron RDH MSc MA (Health Promotion)

Bairbre Pigott-Glynn, student dental hygienist

Corresponding author:
Catherine Waldron
Dublin Dental University Hospital, Lincoln Place, Dublin 2
E: waldrocg@tcd.ie