Health Education England (HEE) London developed an innovative 2-year pilot educational and training initiative for enhancing skills in periodontology for dentists and dental hygienists/therapists in 2011. This study explores the perceptions and experiences of those involved in initiating, designing, delivering and participating in this interprofessional approach to training.
MATERIALS AND METHODS:
Semi-structured qualitative interviews were conducted with a purposive sample of key stakeholders including course participants (dentists and dental hygienists and/or therapists), education and training commissioners, and providers towards the end of the 2-year programme. Interviews, based on a topic guide informed by health services and policy literature, were audio-recorded and transcribed verbatim. Data were analysed based on framework methodology, using QSR NVivo 9 software to manage the data.
Twenty-two people were interviewed. Although certain challenges were identified in designing, and teaching, a course bringing together different professional backgrounds and level of skills, the experiences of all key stakeholders were overwhelmingly positive relating to the concept. There was evidence of ‘creative interprofessional learning’, which led to ‘enhancing team working’, ‘enabling role recognition’ and ‘equipping participants for delivery of new models of care’. Recommendations emerged with regard to future training and wider health policy, and systems that will enable participants on future enhanced skills courses in periodontology to apply these skills in clinical practice.
The interprofessional approach to enhanced skills training in periodontology represents an important creative innovation to build capacity within the oral health workforce. This qualitative study has provided a useful insight into the benefits and tensions of an interprofessional model of training from the perspectives of different groups of key stakeholders and suggests its application to other areas of dentistry.
Health Education England (HEE) London has led the way nationally in developing training for dentists, hygienists and/or therapists to provide ‘enhanced skills’ in Periodontology through a 2-year pilot programme established in 2011 at King’s College Hospital. This initiative was developed based on the concept of ‘Dentists with Special Interests’, initiated in 2004, which aimed to train practitioners working in primary care to provide supplementary services in addition to their generalist role and, therefore, addressing the ‘gap’ between primary and tertiary care levels.1 Guidance on implementing this concept,2,
With professionals now needing to work majorly in a team setting, sentience and interaction between the professionals has become vital for delivering quality patient care,9,
Training dually qualified dental hygienist/therapists is increasingly common across the United Kingdom.18,19 Their roles, whether singly or dually qualified, are equivalent to mid-level dental providers, delivering basic evaluative, preventive and/or minor surgical dental care at primary care level; and are believed to have great potential to address issues of access to dental care.18,20 This potential received a further boost in May 2013, when General Dental Council professional policy in the United Kingdom, enabled patients to have ‘direct access’ to dental hygienists and therapists.
Improvements in oral health, with falling levels of dental caries and increasing retention of teeth which are therefore at risk of other diseases, has prompted developments in the oral healthcare systems in relation to skill mix and innovative care pathways.21 Epidemiological surveys highlight the prevalence of periodontal disease in the adult population, which increases with age.22,23 Health policy in England advocates the provision of services in a primary healthcare setting and maximising the full scope of skill mix in the dental team. Therefore, there is scope for encouraging prevention and utilising mid-level providers such as dental hygienists/therapists,24 and growing interest in exploring whether employing an interprofessional (skill mix) model contributes to improved patient, personnel and organisational outcomes.25
Considering the above policy frameworks, HEE London devised an innovative pilot skill mix, interprofessional, initiative to provide education and training for dental hygienists/therapists along with dentists. The aim was to train both the skill sets together and enable the delivery of a standard of periodontal treatment in primary dental care that is recognised by the National Health Service (NHS) commissioners/planners, teaching and regulatory organisations.26 Another subsidiary aim of the course was to test an interprofessional model of education for dentists and dental hygienists/therapists together. They trained together 1 day per fortnight over a 2-year period in the dental hospital.
Previously, similar schemes for Dentists with Special Interests in Periodontics and minor oral surgery have been evaluated through exploring the views of general dental practitioners and patients;27,28 however, there is only one study exploring the views of key stakeholders involved in development and management of such innovative programs.8 Therefore, the aim of this qualitative study was to explore the perceptions and experiences of all the key stakeholders regarding an interprofessional approach to training dentists and hygienists/therapists on this course.
MATERIALS AND METHODS
Semi-structured qualitative interviews were conducted with dentists, dental hygienists and/or therapists participating on the course and other stakeholders associated directly, or indirectly, with the training initiative. Collectively, these participants will be referred to as ‘key stakeholders’. This study was approved by National Research Ethics Committee (13/NS/0102) and King’s College Hospital NHS R&D committee (King’s College Hospital 13-143). It was part of a wider mixed methods study, the overview of which is being reported as a separate paper. All of the 19 participants on the course (10 dentists and 9 with hygienist and/or therapist qualifications; the latter will collectively be referred to as hygienists/therapists hereafter) were invited to take part in an interview. Other stakeholders were purposively sampled,29,30 based on their role in commissioning, initiating, developing, delivering or participating in the training to ensure representation across key areas. Key stakeholders were approached by means of a letter of invitation, supported by an information sheet and consent form regarding the study, either in person or by post. Potential participants were followed up after a week either by email or phone to enquire about their decision to participate and were given an opportunity to ask questions about the study. Written consent was obtained, prior to conducting a one-to-one interview in person or over the telephone in a private office setting by one of three of the co-authors from public health backgrounds (SG, JG and VH). To ensure consistency between interviewers, a structured topic guide was used, informed by the literature. Participation was voluntary and participants were assured that all data would be anonymised. The interviews were conducted over a 6-month period (Oct 2013 to March 2014) in line with the availability of the stakeholders and course participants; interviews ranged from 30 to 60 min in duration.
Interviews were audio-recorded and transcribed verbatim. Data were analysed based on framework methodology,31 using QSR NVivo 9 software (supplied by QSR International Pty Ltd., Melbourne, VIC, Australia) to manage the data. The transcripts were read and re-read to enable familiarisation with the data and a coding frame was developed by one of the authors (ER) based on the initial themes and sub-themes emerging, together with the wider literature. The transcripts were coded by ER, a qualitative researcher with a background in social science, then crosschecked and verified with two other authors (JG and SG), discussing any areas of difference to ensure a consistent approach. An overarching conceptual framework was then refined to enable the data to be synthesised to examine relationships between themes and develop explanatory accounts for the data.31 This involved continually referring back to the original transcripts to ensure findings accurately reflected key stakeholders’ perceptions and experiences. Methods and results have been presented with reference to a comprehensive checklist for reporting qualitative research.32
A total of 22 key stakeholders participated in interviews. Out of the 19 participants on the course invited to take part in an interview, 12 agreed to participate, comprising 4 dentists and 8 hygienists/therapists. No response was obtained from the remaining seven course participants. Out of the 27 other stakeholders invited to participate, 10 agreed. This included representatives from HEE, involved with initiating and commissioning the training course, one representative from Dental Public Health, six course educators and training providers, and one practice principal. NHS Commissioners of the training course, although invited, did not respond.
The interprofessional aspect of the training was a very prominent theme in the data. Results are presented and discussed on the main themes identified by the key stakeholders. Challenges of the interprofessional aspect of the pilot training will then be presented and discussed. Based on the results, recommendations are discussed in relation to future training, health policy and the wider health system. Throughout this paper, results are supported by quotes from the original transcripts. Figure 1 provides a summary of the key findings and recommendations.
Creative interprofessional learning
There was evidence of creative interprofessional learning, formal and informal, among both the dentists and DCPs. One of the visions of the course, identified by the training initiators and the educators, was to test a model of interprofessional training for qualified dentists and hygienists/therapists, as can be seen in the following quote. This model of training was regarded as innovative and therefore identified as not having been previously evaluated.
Interprofessional training was considered by trainers as particularly important in the field of periodontology, as hygienists/therapists are very involved in this aspect of dental care, as the quote below demonstrates.
Training initiators talked about a vision of hygienists/therapists and dentists sharing responsibility for patient care, as shown in the quote below.
All participants reported that both groups of dentists and hygienists/therapists had benefited from the experience of interprofessional learning, describing this as ‘a two-way learning curve’ (D 206). Specifically, hygienists/therapists and dentists both reported that dentists gained skills from the hygienists/therapists on instrumentation and communication skills with patients. Hygienists/therapists and dentists both reported that hygienists/therapists gained skills from dentists on diagnosis and treatment planning. This is illustrated in the two quotes below from a hygienist/therapist and dentist.
The quote below illustrates the view that the course provided a valuable opportunity for dentists and hygienists/therapists to learn from each other, which did not routinely happen in dental practice due to time constraints. The setting of a dental hospital where facilities are open plan rather than closed dental surgeries may have further facilitated informal learning.
Educators supported these findings, stating that professional relationships developed between hygienists/therapists and dentists, and both groups benefited from shared learning.
Educators were also learning through their role in the training, as demonstrated by the following quotation, and thus it was a ‘creative’ process for them too.
Enhancing team working
Another reported vision for the course was to enhance team working and communication skills to improve quality of care. Linked with this, recognising and understanding dental team member’s roles was identified as another aim of the course, as illustrated in the two quotes below.
All participants spoke very positively about how well hygienists/therapists and dentists had worked together during the course. Hygienists/therapists and dentists had worked together in pairs in clinics, assisting one another reciprocally and all participants discussed how this had facilitated good team working and the development of good professional relationships. The quote below from a hygienist/therapist illustrates the way in which participants felt that professional barriers were being broken down, leading to improved teamwork that would lead to better patient care.
Educators’ accounts also supported participants’ reports of improved team working.
Facilitating role recognition
Both hygienists/therapists and dentists discussed the ways in which the interprofessional approach to training had increased role recognition across the dental team and changed their wider working relationships in practice. Dentists reported that they now had much more of an understanding and appreciation of the role of hygienists/therapists after training together and the hygienists/therapists also agreed that dentists had more of an appreciation of their role and described feeling ‘valued’ (H/T 204) and given ‘respect’ (H/T 214). This point is illustrated below in quotes from a dentist and hygienists/therapist.
This increased role recognition had implications for practice as some of the dentists felt their dental practice would benefit from a hygienist joining their team as they had not previously worked with one. In some cases practices were planning to employ a hygienist shortly and one had employed a hygienist already as a direct result of a dentist attending the training course, as shown in the quote below.
These findings were supported by interview data from educators who also felt that role recognition had been an important aspect of the course for participants, as shown in the following quote.
Participants also discussed skill recognition as another outcome of the interprofessional training, which enabled them to understand their own skills and capabilities as well as those of others. This increased an understanding of skills and boundaries within the wider context of patient care, as illustrated in the quote below.
Equipping participants for delivery of new models of care
One vision of the interprofessional model discussed by the educators and training initiators was to prepare for the introduction of ‘direct acccess’, whereby patients may now be treated by dental hygienists without the supervision of a dentist, by enhancing the skills of hygienists/therapists. The concept of patients having ‘direct access’ to dental hygienist/therapists moved to a reality during this 2-year course with the support of the General Dental Council. This aim was supported by some of the hygienists/therapists who discussed preparing for ‘direct access’ as one of the reasons for enrolling on the course, as demonstrated in the quote below.
It is currently too early to assess any impact the enhanced skills training course in periodontology may have had in relation to this particular change in the dental care system.
Another wider vision of the course identified by the public health consultant, training initiators and educators, related to cost-savings on the basis that it would cost the NHS less to employ hygienists/therapists to carry out routine periodontal work compared to general dental practitioners. The quote below from a training initiator frames this in terms of providing value for money for the public.
The above was not a view shared by dental practitioners. Furthermore, the NHS does not currently provide remuneration to dentists and hygienists/therapists for applying their enhanced skills within primary care; therefore, at present, it is too early to assess any potential cost-savings. This issue will be discussed further in the recommendations section.
Challenges of an interprofessional model of training
Training initiators and educators discussed the challenges in relation to designing and teaching a course bringing together hygienists/therapists and dentists with different professional backgrounds and approaches. Training initiators identified some potential issues, acknowledging that dentists and hygienists/therapists have different professional backgrounds and level of skills and felt it was important that course educators take this into account, as seen in the following quote.
The public health consultant also acknowledged that it is important that the course material is appropriate for both dentists and hygienists/therapists, as seen below.
In support of these potential issues identified, educators reported experiencing some challenges in teaching hygienists/therapists and dentists together.
First, challenges were identified in terms of initially designing the course for hygienists/therapists and dentists, as each group had different expectations and outcomes. From the education perspective, the overall outcome of the course for dentists was to develop skills to become dentists with enhanced skills based on the competencies for dentists with a special interest in periodontology, but the outcome for hygienists/therapists was less clear as the nature of the hygienists’ role meant they already focused in this field. However, with direct access having been recently introduced after the course began, preparing for this was highlighted as one aim for hygienists/therapists taking the course.
Second, educators suggested there were challenges teaching hygienists/therapists and dentists together because they felt the two groups had different professional knowledge and responsibilities. Three of the six educators interviewed reported experiencing specific difficulties teaching dentists and hygienists/therapists together as a group and suggested that it may have been more beneficial to separate them at certain points during the course, as can be seen in the quotes below.
In support of the data from the educators, some participants recognised that educators experienced some challenges in providing training to an interprofessional group due to the different approaches, expectations and learning needs of the dentists and hygienists/therapists. A small number of dentists also suggested it may be beneficial to separate hygienists/therapists and dentists at some points during the course, as seen in the two quotes below. However, this was not suggested by any hygienists/therapists, who were very much in favour of being trained together with dentists. This was the only issue where the two groups of dentists and hygienists/therapists indicated differing views.
However, the majority of participants felt that an interprofessional approach was appropriate for an enhanced skills course in periodontology and reported very positive experiences of the teaching, as demonstrated by the following quotes.
The findings therefore suggest that the concerns raised by educators were not reflected among the course participants.
This pilot study demonstrates the potential for future training programmes which, as with any new initiative, should incorporate the learning from this evaluation. It is important that the professional status of any interprofessional training course is clear and a qualification should be offered in line with competencies currently being developed for dentists with enhanced skills. This needs to be in line with NHS service requirements for periodontal care. It is recommended that a set of competencies is also developed for hygienists/therapists that will enable the outcome of interprofessional training to be clear for both dentists and hygienists/therapists.
For future training initiatives, separating hygienists/therapists and dentists for some aspects of the training may possibly be beneficial for the following indications:
Educators found it difficult to pitch lectures at right levels to benefit both groups for topics such as gingival/periodontal surgery especially for dental hygienists/therapists.
Dental hygienists/therapists were well versed with instrumentation regarding scaling and polishing; however, dentists felt the need of additional training.
Treatment planning for dentists involved other restorative aspects, whereas for dental hygienists/therapists treatment planning was different with respect to their scope of practice.
Given that the surgical module is only within the remit of dentists, that portion of the course time could have been used more helpfully for dental hygienists/therapists.
There was support from the stakeholders for the course running under one umbrella programme, whereby both groups have a mixture of common and separate learning. This recommendation is based on the interview findings from educators who experienced some challenges in training hygienists/therapists and dentists together and a small number of dentists who also felt that some separate teaching maybe beneficial in addressing the different aims and approaches of the two professional groups, as discussed.
For future interprofessional training, having hygienists/therapists and dentists from the same practice training together on a course may facilitate application of skills within a practice setting, as it may make it easier in terms of team working and implementing necessary changes. This point is illustrated by a training initiator below.
Dentists and the practice principal discussed the gap in interprofessional training in undergraduate training in general and the practice principal also felt there was a clear lack of training for dentists in managing a multidisciplinary team. Therefore, applying an interprofessional model of training in other areas of dentistry such as Paediatric dentistry maybe one way to address these gaps. It is recommended that further training courses are developed and tested based on an interprofessional model, perhaps involving staff from the same practice who can contribute to any future managed networks of clinical care.
Health policy and systems
It was strongly recommended that funding systems are put in place to enable participants on future interprofessional training courses in enhanced skills in periodontology to apply these skills in a practice setting. There is a need for enhanced skills contracts for both dentists and dental hygienists/therapists to be established.33,
The quote below from the public health consultant highlights the need for elements of the healthcare system to be reformed in order to support the application of enhanced skills in practice to improve patient care. It also highlights the need for a continuous programme of training to be established rather than a one-off course.
Linked with the establishing of funding systems to support the use of enhanced skills in primary care, it is also recommended that dentists and hygienists/therapists with enhanced skills are recognised in the care pathways that are currently being developed,38,
The interprofessional model of enhanced skills training in periodontology is the first course of its kind, and thus was conducted as a pilot within London. It is particularly relevant given the level of need for periodontal care in our ageing dentate population.22,23 Certain challenges were identified in designing and teaching a course bringing together hygienists/therapists and dentists with different professional backgrounds and level of skills; however, the findings suggest that this aspect of the programme was not an issue for participants. Nonetheless, the concept and experiences reported in relation to the interprofessional aspect of training were overwhelmingly positive by all groups of key stakeholders, particularly course participants. This is despite evidence suggesting that attitudinal factors among healthcare students are the most challenging barriers to successful interprofessional education.43 This shift towards interprofessional education is being seen globally through the World Health Organization,44 and the International Dental Federation.45
In relation to the limitations of the study, the sample may not fully represent opinions and experiences of all key stakeholders as the health service (NHS) commissioners invited to participate did not respond and not all clinicians were willing to participate. However, the sample included key stakeholders from a range of professional backgrounds, delivering both NHS and private care, from both sexes and a range of ages and ethnic backgrounds. It could be argued that interview stakeholders had a vested interest in the course and were therefore more likely to give positive feedback, particularly those who chose to participate; however, there was a range of opinions represented and the data were detailed and rich. The participants in particular were positive about the concept and principles of the scheme but were willing to provide challenge and constructive feedback about how the course should be developed and run in future.
One of the main visions of the skill mix pilot training identified by training initiators and educators was to enhance team working that was reported as a main outcome by both educators and participants. Other learning outcomes reported were interprofessional learning involving mutual role recognition, boundary setting and skill recognition that are recognised aspects of contemporary healthcare education in support of team working.12,46,
Another vision for the pilot training identified by training initiators and educators, and a small number of hygienists/therapists, was to ‘equip participants for delivery of new models of care’, prepare for the introduction of regulatory changes that would enable patients to be treated directly by hygienists/therapists, without working under the supervision of a dentist. As the course began, the concept of ‘direct access’, for patients to dental hygienists and dental therapists, has been approved by the General Dental Council.50,51 As its practical implementation to healthcare has been slow, it is currently too early to assess any impact the enhanced skills training course in periodontology may have had in relation to this change in the dental care system, particularly with regard to the NHS. In the state system, additional policies need to be modified to facilitate direct access for patients, whereas private providers may begin to implement change more readily. It was clear from these findings that having a qualification would underpin the delivery of care directly by dental hygienist/therapists. Furthermore, as care pathways evolve within the NHS, harnessing the skills of practitioners with additional training will become very important to serve the population effectively,39,52,53 providing level 2 care, between that of a regular dentist and specialist. There is no reason why dental hygienist and/or therapists cannot form part of a delivery team within a managed care network led by one or more consultants in restorative dentistry or the mono-specialty of periodontology.
One vision for the pilot training identified by the public health consultant, training initiators and educators was potential cost-savings for the NHS; however, the NHS does not currently provide remuneration to dentists and hygienists/therapists for applying enhanced skills in periodontology within primary care. Before any future interprofessional training in enhanced skills in periodontology takes place it is strongly recommended that funding systems are reformed to enable participants to apply their skills in an NHS practice setting, including enhanced skills contracts for both dentists and hygienists/therapists. There is a need for dental contracts that recognise the role that dental professionals can play in addressing periodontal disease, and move toward rewarding outcomes in terms of a diminution in treatment need, rather than one based on the number of interventions,54 subject to contemporary understanding of periodontal diseases.
Although this study did not set out to test the principles of interprofessional education,55,
This model of training should possibly be piloted for other aspects of dental care such as paediatric dentistry where dental hygiene/therapists may play a significant role.15,21,58 In initiating other similar training courses, it will be important to take on board the learning from this initiative. The interprofessional approach to enhanced skills training in periodontology is a creative innovation. This qualitative study has provided useful insight into the benefits and tensions of an interprofessional model of training from the perspectives of different groups of key stakeholders. The training model tested demonstrates potential and the findings from this study can enhance future programmes which should be developed to include a qualification in line with the original guidelines,59 and may also prove beneficial in other areas of dentistry. It is recommended that evaluation processes should be built into future training to enable longitudinal evaluation from inception to end.
We thank all stakeholders who participated in the interviews conducted during this study and HEE North West London that funded this research. We would like to pay tribute to our co-investigator Vicki Harrison, a specialist in both Periodontology and Dental Public Health, who passed away after a long illness in 2015.
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