Main

Scope of practice

An article published in the BDJ in 1999 entitled The role of the dental nurse in general dental practice1 suggested that dental nurses report 'dissatisfaction with their work associated with feelings of lack of control and being undervalued'. The paper also suggested that dental nurses felt their work was taken for granted and that because they were economically dependent on the dentist this added to their feelings of dissatisfaction. Of course this article was pre-registration and the change in the General Dental Council's (GDC's) Scope of practice2 allowing dental nurses to perform extended duties.

Dental nurses have long been able to take additional qualifications through the NEBDN (National Examining Board for Dental Nurses) such as certificates in dental radiography, oral health education, orthodontics and dental sedation. The new guidelines suggested that if trained, confident and competent to do so, qualified dental nurses could amongst other duties (see Scope of practice2 for full list) take impressions, apply rubber dam isolation, disclose and record plaque using indices, apply topical anaesthetic, apply topical fluoride varnish, take shades, and carry out intra-oral photography, thereby offering a more team centred approach to patient care and giving dental nurses more of a 'hands-on' role with patients.

Since July 2008 dental nurses have been required to be registered with the GDC. It is illegal to work and use the title 'dental nurse' unless qualified and registered.

Dental nurses: VIPs

I first started teaching extended duties to qualified dental nurses in November 2009. The legislation that added these duties to the Scope of practice occurred in April 2009.2

The role of the dental nurse is far more involved now than it has ever been ... I wanted to know whether job satisfaction had increased...

In my opinion, dental nurses are the most important group of professionals within the dental team. They assist the dentist, dental therapist and dental hygienist at the chairside, providing an extra pair of hands and eyes, support the patient emotionally as well as physically, act as advocate, and are responsible for cross infection control and quality assurance. Dental nurses are expected to know as much as other dental professionals with regard to CPR, manual lifting and handling, safeguarding children and adults, clinical governance, information governance and equality and diversity. The role of the dental nurse is far more involved now than it has ever been. They prepare the clinical environment, monitor sterilisers, mix dental materials, carry out audit and assist with reception and administration. Yet remuneration has not reflected the additional responsibilities that dental nurses are required to have.

I wanted to know, following registration and professional recognition, if job satisfaction had increased amongst dental nurses, and if this had led to them now feeling more valued and appreciated. I was also interested to find out whether undertaking extended duties has helped them feel more fulfilled.

The questionnaire

While I was lecturing at dental nurse symposia for the East of England Deanery I seized the opportunity to circulate a questionnaire to all dental nurses who attended, as well as to other dental nurses I came into contact with through work or other courses. One hundred and twenty-one completed questionnaires were returned to me. Eventually I collated the results and will share them with you in this article.

History of extended duties

Extended duties came to the fore for dental therapists and dental hygienists back in 1996 following the Nuffield Report (1993).3 Dental therapists had long awaited the go-ahead to train to give the inferior dental block (IDB), which for many was the most important extended duty. Dentists no longer had to have their work disrupted to go to another surgery to administer an IDB for the dental therapist or dental hygienist. Legislation permitting dental therapists to work in general dental services changed at the same time. Unfortunately, thinking only in monetary terms perhaps, many dentists employ dental therapists predominantly to undertake hygiene work, resulting in frustration for the therapist, feelings of being undervalued, then losing confidence and ultimately becoming de-skilled. If dental nurses are to embrace the full scope of extended duties I wonder if these extended duties will be fully utilised in the dental practice.

Of the extended duties I undertook – pulpotomies, pre-formed metal crowns (PMC), ID blocks and taking impressions, it is the ID block that has made the biggest difference to my clinical practice. Occasionally I perform a pulpotomy but I cannot remember the last time I was asked to do a PMC or take impressions.

Results

Desirable training

Despite my experience, according to my survey impression taking seems to be the extended duty most in demand by dental nurses at 57% (Fig. 1). Maybe it is because dental nurses are already in the surgery when the dentist decides s/he needs impressions taking and the dental nurse is going to mix the material anyway.

Figure 1
figure 1

What courses would you like to do?

Full size image

Of other extended duties (Fig. 1) 39% wanted to undertake smoking cessation, 38% fluoride varnish application, 38% topical anaesthetic application, 22% rubber dam application yet only 4% wished for training in radiography. This may have had something to do with the fact that 18% already had a radiography qualification. Eleven percent already had qualifications in conscious sedation, 7% were working as practice managers, and taking impressions was the next highest at 6%. Four percent had qualifications in oral health education (OHE) and 4% in implant nursing. Three percent were already involved in smoking cessation and one dental nurse was removing sutures.

Of the 121 questionnaires returned, the average number of years since qualification was 13, suggesting that dental nurses did consider nursing their career. For verification of this, I looked at responses to the following question: 'Do you consider dental nursing your career?' A staggering 102 respondents said 'yes'; this correlates to 84.5%. Of the rest, 14 said 'no' and five did not answer.

Career

The following question: 'What do you see yourself doing in five years' time?' gave me a clue as to why 15.5% either didn't answer or had other career ideas. In fact, the five respondents that didn't answer the previous question didn't answer this one either. Of the 14 dental nurses who said 'No, dental nursing is not my career', seven wanted to train in dental hygiene or dental therapy, two - already working as practice managers - had ideas of developing in that role, and one even suggested that she would like to manage the PCT! One dental nurse saw herself training in midwifery or as a paramedic; one wanted to do orthodontic therapy; one wanted to retire; and sadly one dental nurse who did not see dental nursing as her career, thought she would be doing 'much the same'.

When asked to rate job fulfilment and job satisfaction on a 0-10 scale (0 = no fulfilment/appreciation and 10 = extremely fulfilled/appreciated) the following results appeared (Fig. 2).

Figure 2
figure 2

Fulfilment and appreciation scores of dental nurses

Full size image

Fulfilment

When asked about fulfilment (Fig. 2), 4% of respondents did not reply. Of the remaining 96%, 65% scored 6 and above (7% scored a 10, 7% scored a 9, 26% scored an 8, 24% scored a 7, and 0.8% scored a 6) and 31% scored five or lower.

Appreciation

When asked about feeling appreciated (Fig. 2), 5% did not answer this section. Fifty-six percent scored a 6 or above (15% felt extremely appreciated answering a 10, 17% answered an 8, 14% chose a 7, and 10% chose a 6). Thirty-nine percent chose a 5 or below.

This clearly demonstrates that these dental nurses not only saw dental nursing as their career but were also proactive in their own career development.

Five dental nurses scored 10s for fulfilment and appreciation. I looked further to see why. Were their feelings of fulfilment and appreciation due to where they worked? Of these five dental nurses, four were employed in mixed NHS/private practices and one employed in private practice, three worked full time and two part time. There was also a mixture of work carried out but none of these dental nurses were non-clinical. All felt dental nursing was their career. Two of these dental nurses were qualified in dental radiography and all expressed an interest in doing further courses and undertaking extended duties in order to advance their career. When asked who decided what courses to take and who subsequently paid for the course, all except one answered 'me'. The remaining dental nurse said her 'boss'. None of these dental nurses were at the time offered any 'in-house' training. This clearly demonstrates that these dental nurses not only saw dental nursing as their career but were also proactive in their own career development.

Highly fulfilled and appreciated

Of the respondents who scored 6 or more in both categories (77 respondents), 69.5% worked in GDS/mixed practices, 12% in CDS and 18.5% in private practice. The majority worked part time (54%) and 34% worked full time. Twelve percent did not say.

68.5% were involved in extended duties of some kind, 20% taking radiographs, 9% taking impressions, 9% with sedation training, 9% working as practice managers, 6% with a certificate in implantology, 5% orthodontics, 4% OHE, 4% smoking cessation, 1% applying rubber dam, 1% removing sutures, and 1% working as an NVQ assessor. My statistics showed that 50% had no additional extended duties at all, yet 10.5% had achieved more than one.

Low scores for fulfilment and appreciation

Seventeen percent of all respondents scored a five or less for both job fulfilment and appreciation. Of these 80% worked in GDP/mixed practices with an equal amount working full time or part time. Twenty-eight percent were already using some additional qualifications – either radiography or sedation. Seventy-one percent expressed an interest in undertaking extended duties with 28% desiring three or more courses. None of these dental nurses wished to become practice managers and only one expressed an interest in dental hygiene or dental therapy.

Where respondents had not scored a 10 for fulfilment or appreciation, the next question invited the dental nurses to state what would improve their levels of fulfilment and appreciation – 'If not a 10 what would make it a 10?' There were no prompts at all. The nurses were free to comment. The results of this in relation to fulfilment and appreciation can be seen in Figures 3 and 4.

Figure 3
figure 3

What would improve your level of fulfilment

Full size image
Figure 4
figure 4

What would make you feel more appreciated?

Full size image

What would you change?

It is clear from the analysis that dental nurses would like more responsibility and involvement with patients, along with more respect, recognition (pay) and gratitude from employers.

I also asked what, if anything, the dental nurses would change about their job (Fig. 4). Again the results are in chart form, but it is interesting to see that 'more training/hands-on/more courses/more involvement with patients' and 'more responsibility' turned up in all three categories. It is clear from the analysis that dental nurses would like more responsibility and involvement with patients, along with more respect, recognition (pay) and gratitude from their employers.

When asking the high scoring group about further courses, 59% would like to take impressions, 46% would like to apply topical anaesthetic, 46% topical fluoride varnish, 22.5% would like to apply rubber dam isolation and 4% sedation, 3% radiography, 2.5% suture removal, 1% sedation, 1% OHE, and 1% implants. Only 10% did not express an interest in further training. Of this group 6.5% either did not answer or did not express an interest in further training as well as not declaring any additional skills or existing extended duties (Fig. 5).

Figure 5
figure 5

What would you change about your job?

Full size image

I have always been an advocate for dental nurses developing their skills and fully support a team approach to patient care. As a dental nurse in the WRNS (Women's Royal Naval Service) we were expected to be on-call for emergencies, place temporary dressings, remove sutures, treat dry sockets, and only call the dentist out in a real emergency. If the patient presented with an abscess we were expected to take the patient to sick bay where the Senior Medical Assistant would administer a shot of penicillin, issue a course of tablets and advise them to make an appointment with the dentist as soon as possible!

Dental nurse pay

NHS Pay Scales – Hospitals and Salaried Services

Taken from NHS Agenda for Change as from 1 April 2013:4 Band 4 Dental Nurse: £18,838-£22,016; Band 5 Dental Nurse Team Leader: £21,388-£27,901.

General Dental Service

Salaries are variable, but spotted in July 2013 – 'wanted in London: a full time dental nurse working 40 hours per week £8.00-£9.00 per hour' (Source Medicruit accessed 22/07/2013).

According to an article published in Dentistry dated 13 September 2010, New guidance on dental nurse salaries, the British Association of Dental Nurses (BADN) offered guidelines on dental nurse salaries.5 They issued the minimum salaries they considered to be acceptable, saying:

'The salaries shown below are per annum, for a 37-hour week. Overtime should be paid at 1.5 the normal rate, and double for Sundays or public holidays. Time off in lieu may be given instead of overtime payments, if this is acceptable to both employer and employee.

'Other factors, such as specific job role and duties, local conditions (i.e. what other, not necessarily dental, employers pay), etc should also be taken into consideration.

'The BADN considers that dental nurses paid according to, or in excess of, this salary scale should be responsible for payment of their own GDC registration and BADN membership fees, and claim the appropriate tax allowances from HM Revenue & Customs.

'In the event that these fees are paid by the employer, a dispensation should be obtained from HMRC by the employer as the HMRC regard this as a benefit in kind. There is no HMRC tax allowance for CPD costs if paid by the employee; however, tax allowances may be available to employers paying training costs, including CPD costs.'

The minimum salaries recommended by the BADN in this article were: registered dental nurse £20,000; registered dental nurse – extended duties £24,000; and senior dental nurse £28,000.

These 'minimum salaries' suggested by the BADN back in 2010 are higher than those recommended by Agenda for Change 2013. However, it is worth noting that hospital and salaried jobs within the NHS are subject to many benefits such as sick pay that are not offered in the private sector.

HM Forces

Dental nurse training is now undertaken by a joint forces centre based in Aldershot. Salaries are based on rank. When I qualified as a dental nurse I was still an 'Ordinary WRN' but because of good exam results I was awarded three months' accelerated advancement, which meant I would be promoted to 'Able WRN' after nine months instead of a year. A dental hygienist once qualified would be a 'Leading WRN'. For a dental nurse to become a leading 'wren' you had to have served a certain amount of time as an able wren and selected to go for advancement. A leading wren would usually be the nurse who did the ordering and rotas etc. Trainee salaries start from £14,145; Able Rating £17,767 to £29,357; Leading Rating £26,786 to £33,661; and Petty Officer £30,446 to £37,462.

Analysis

My survey represents a small collection of dental nurses in the East of England. These dental nurses had given up a Saturday to attend symposia organised by the East of England Deanery. This suggests my sample were career minded and highly motivated. This could mean that the dental nurses in my survey were more interested or involved in extended duties than a nationwide survey of all dental nurses may have discovered.

In their article in the BDJ Gibson et al.1 concluded that feelings of contentment and professional self-esteem improved with dental nurses' involvement 'in patient care (four handedness)'.

From my survey I can see that of those nurses claiming fulfilment and appreciation, over two thirds were involved in extended duties.

Conclusion

Most of the dental nurses taking part in this survey viewed dental nursing as their career (over 85%) and 79% thought they would still be dental nursing in five years' time. Thirty-seven percent expressed the need to 'do more'. It is clear that a vast proportion of dental nurses, whilst reasonably happy with their career, are looking for extra responsibility and involvement in patient care.

When looking at courses dental nurses would like to do (Fig. 5) it is interesting to see that most of them are patient-centred, indicating that dental nurses actually want 'hands-on' involvement with patients.

Unfortunately I did not look in depth at how training had been funded and how many practices were offering 'in-house' training. I would like to re-survey the dental nurses to find out if having undertaken extended duties they are actually using them in their practices and being remunerated for them.

I have trained many dental nurses in Northamptonshire, Leicestershire and South East London in fluoride varnish application, thanks to the changes in the scope of practice, and guidelines in Delivering better oral health: an evidence based toolkit for prevention.6 Recently I have begun training dental nurses to disclose and measure plaque and to apply rubber dam isolation, and look forward to training many more dental nurses in the future. I hope to see a time when dental nurses have patients booked in with them for dental health education. Imagine this scenario ... after a check-up appointment and assessment by the dentist, each patient receives bespoke one-to-one care with an extended duties dental nurse who carries out a disclosed plaque score, gives toothbrushing instruction and advice on interdental cleaning, carries out dietary advice, and topical fluoride application, takes radiographs and impressions if needed – all before the patient visits the hygienist for scaling, or the therapist for restorations; only referring back to the dentist for 'high end' dentistry – crowns, bridges, endodontics, permanent extractions, dentures and implants...