Dental nurses' perception of CPD in Wales

Introduction

Mandatory registration with the General Dental Council (GDC), introduced in July 2008, was intended to bring dental nurses (DNs) in line with other health personnel, increasing their standing and identifying them as a highly trained professional group.¹

Continuing professional development (CPD) for all staff members is considered vital to clinical competence, personal growth, a rewarding career and optimal care for patients² and is increasingly related to perceived fitness to practise and continued registration.³

Providing appropriate education and training opportunities for all members of the dental team is one of the duties of postgraduate dental deaneries,⁴ therefore it is important to determine what constitutes ‘appropriate’ CPD for dental nurses. A survey undertaken in 2010⁵ regarding the views of dental technicians in Wales yielded data that assisted with the development of CPD to meet the needs of this cohort. Lynch et al.⁶ found that 95% of the DNs surveyed were interested in attending CPD courses but little is known about dental nurses' perceptions of their own educational needs in general.⁷ Previous studies have explored the topic in England⁷ and Scotland⁸ but no survey of this type had previously been undertaken with DNs in Wales.

This paper explores dental nurses in Wales' views on CPD and GDC registration and seeks to identify perceived barriers that may impact on participation and engagement.

The survey

Letters were sent to all 2,138 dental nurses throughout Wales (1,986 from general practice and 152 from hospital and community dental services) on the mailing list held by the Wales Deanery, Dental section, Cardiff University inviting them to complete a paper questionnaire (returned via FREEPOST) or an online version.

Letters were sent in early January 2011. To encourage response, all early returns were entered into a prize draw to win one year's annual retention fee (ARF). Eighty-eight percent of all returned questionnaires met this deadline.

Results

Questionnaires were returned from 335 dental nurses and 334 valid questionnaires were analysed, giving a response rate of 16%. A full demographic breakdown can be seen in Table 1.

Table 1 Demographic information of respondents

The majority of respondents (50%) worked in dental surgeries that provided both private and NHS dental treatment; more than half the sample (51%) had worked as a dental nurse for at least 16 years; and 64% held a NEBDN certificate in dental nursing.

Continuing professional development

Respondents were asked to identify what format of (CPD) activities they had undertaken during the current cycle (ie since July 2008) and what format of activities they would prefer to take part in (Fig. 1).

Figure 1

Activities undertaken and preferences (selected all that applied % of 333)

Courses made up the top two responses for both the ‘undertaken’ and ‘preferred’ questions: lectures with 93% and 72% and small group seminars with 74% and 61% respectively. Most of the other options received similar scores in the undertaken and preferred questions apart from reading scientific journals or books (undertaken by 78%/preferred by 46%) and clinical audit/peer review (undertaken by 27%/preferred by 11%).

Views on preferred times to undertake CPD courses were sought (Table 2).

Table 2 When would be the most convenient time for CPD courses? (Selected all relevant)

The majority reported that weekdays (Monday to Friday) were the most convenient times to attend courses (68%). The ‘Other’ option included responses such as: it varied depending on work commitments; location of the course; all choices are inconvenient; that they should be given a day off work to attend courses (all received one response each).

The preferred time commitment for courses that take a number of days to complete was 1-2 days per month (76%). Ten percent selected the ‘Other’ option, which included comments such as 1-5 days per quarter or 1-2 days per year.

Forty-five percent reported that they would like to take part in CPD in DN-only groupings and 40% favoured in-practice team training. However, 28% selected ‘All DCP groups’ and 36% had no preference over groupings for CPD activities.

Respondents were asked to suggest topics or activities they would like in the future in free text (Fig. 2).

Figure 2

Topics interested in for CPD (identified all that applied, % of 333)

Seventy-three people suggested topics they would like to receive CPD in but there was little consensus within responses; there were 43 topics in the ‘Other’ category alone. Only topics with five or more responses were included in this table for brevity. The most frequently identified topic was forensic dentistry (30%) with oral health coming third, being identified by 16% of respondents. The second most identified category was a general ‘All topics/All topics relevant’ to DNs (18%).

Seventy-five percent of respondents were aware of CPD programmes arranged by the Deanery, 23% were unaware and 2% were unsure. The majority reported finding out about CPD courses from the Deanery's mailing list or flyers through the post (89%). Other methods included hearing about courses from work colleagues or via word of mouth (5%) and information from the Deanery's website or emails (3%).

Opinions on CPD and registration

The questionnaire included a list of statements about CPD and mandatory registration to which respondents were asked to indicate whether they agreed or disagreed. The results indicated generally positive views (Table 3).

Table 3 Views on CPD and registration

Eighty-seven percent agreed that CPD was valuable for a DN's career progression and 81% agreed that knowledge gained from CPD contributes to their day-to-day work.

Mandatory registration with the GDC was felt to be helpful in keeping up-to-date with current technology and practice (85%) and was welcomed by 73%. Sixty-nine percent agreed that the introduction of mandatory registration had raised the profile and status of dental nurses.

Ninety-one percent were confident that they would achieve the required 50 verifiable hours of CPD and 88% agreed they would achieve the required 100 non-verifiable hours. Ninety-five percent disagreed with the statement ‘I have not undertaken any verifiable CPD hours since I registered with the GDC’ indicating that the majority of respondents had completed some verifiable CPD hours. Respondents disagreed that they had difficulty keeping up-to-date with CPD (73%). Sixty-four percent disagreed with removing DNs from the DCP register if they did not meet the required CPD hours

Negative perceptions of CPD and registration were shown in only two statements. Seventy-four percent agreed with the statement that having to pay for CPD limited the amount of CPD they could undertake. The statement ‘geographical location makes it difficult to participate in verifiable CPD’ had the closest split in results with 57% agreeing.

Further educational qualifications

Thirty-four percent indicated they had attained at least one further educational qualification (Table 4). It is worth noting that 55 of the 218 respondents who had not achieved a further qualification were grandparented on to the register.

Table 4 Further educational qualifications

Just over half identified achieving more than one further educational qualification. Radiography was the most reported topic by 15% of the respondents. Non-clinical courses were also reported, eg practice management (7%), ‘management course’ (3%) and NVQ3 Customer Care (2%).

Seventy-seven respondents identified at least one further qualification they would be interested in studying. Table 4 identifies topics identified by five people or more. Radiography and oral health education were the most frequently specified courses by 66% and 47% respectively. Sedation (27%) and orthodontic therapy (21%) were also identified by more than 20% of the respondents.

The cost was identified as a factor that frequently prevented respondents from embarking on further qualification courses (74%). Nearly half identified a problem with taking study time off work (48%); lack of funding (38%) and the course venue (37%) were also considerations.

Just over half of the respondents thought DNs themselves should be responsible for financing their own further education (53%). A further quarter felt that the costs should be shared by the DN and their employers (26%). Only 15% felt that employers should be solely responsible for funding.

Other comments

Space was provided for additional comments and responses included the prohibitive cost of courses, mandatory registration fees and CPD hours, DN salaries, problems getting time off work to study, difficulty travelling to venues and the range of topics that are currently provided.

The cost of registration and attending courses was a common topic. Respondents talked of making considerable financial contributions but perceived little return in the form of increased salaries.

‘I feel that we are being forced to continually train to be on a registered list which we have to pay for the pleasure but our wages are still rubbish. Where is the sense in that!’

Others disputed that registration and the professionalism of their role has had any positive effect for them.

‘The fee for annual registration is too high for nurses and apart from taking money from me to allow me to continue working I don't know how it benefits me. It feels like we have to pay another form of tax just to continue doing our job.’

Some were so dissatisfied with the current requirements that they were considering leaving the profession completely:

‘I'm even considering leaving the profession and getting a job in the local supermarket as the pay is the same, less stress and responsibility, and no annual fees to pay!’

The compulsory CPD requirements for registration were a concern among respondents:

‘I feel that since professional registration and compulsory CPD has come into effect, it has limited the availability of courses to people who actually want to learn about these subjects rather than people attending them because they have to do this to keep their job.’

‘Dental nurses need a standardised structure of employment and pay regulations before they can be subjected to a standardised structure of registration requirements.’

While DNs are required to undertake CPD, employers may not be supportive or workplace commitments may prove problematic. Evening courses were also unpopular due to family commitments.

It was pointed out that dentists can claim travel costs back but dental nurses are unable to, even when participating on the same course

‘Employers need to honour courses. At the moment I have to use valuable holidays to attend courses.’

It was pointed out that dentists are able to claim travel costs back but DNs are not able to, even when both may be participating in the same course.

There was some criticism of the relevance of current CPD available. Current courses were felt to be tailored to dentists or dental hygienists' needs rather than those of DNs. Some respondents were keen to extend their knowledge, take on more responsibilities or use CPD to further their career but felt that this wasn't being encouraged within the current provision.

‘Always loads of courses for dentists but not many for nurses. Make our role more responsible and not just a “pretty dental nurse”.’

Discussion

One of the aims of this study was to explore what the CPD needs of dental nurses were in order to improve provision. Despite the poor response rate, the data provide valuable insights into the views of dental nurses on CPD. That such a low proportion of the dental nurses in Wales responded to the survey is a limitation. We compared the demographics of the sample with wider demographic data held on the Wales Deanery database on dental nurses in Wales. The survey results showed that 6% of respondents worked in private dental practices compared with 3.2% recorded on the Wales database. The percentage of returners with recognised qualifications on our survey was 83% and was 71% on the Deanery database. Such comparison gives us confidence that the sample returning the questionnaire was a fair representation of dental nurses in Wales.

The results indicate that respondents are interested in formally organised rather than self-directed learning methods, preferring courses, in-practice team delivery and seminars while distance learning packages, DVDs and case-based discussions were less popular. A similar pattern was found by Mercer et al.⁷ who reported that practice meetings (68%) were the most frequently used method but a preference was expressed for hands-on learning (77%) and lectures (17%). This may be linked to registration and having to pay to attend courses; dental nurses want to feel like they are receiving something for their money rather than something that they arrange and lead on themselves.

A wide range of potential CPD topics were identified: forensic dentistry, oral health, orthodontics and radiography were all suggested by at least 10% of respondents. Mercer et al.⁷ found that general refresher courses, new materials and product updates and cross infection and contamination were the most commonly requested topics while Ross and Ibbetson's⁸ top three topics were information technology, infection control and oral surgery. Although only 73 people answered this question there were 43 separate topics that were each suggested by only one person, suggesting that even within a small sample there are a wide variety of learning needs and interests. Mercer et al.⁷ found that only 41% of their respondents answered a similar question and responses also tended to be general updates or refresher courses. This finding led the authors to conclude that there was a general lack of understanding amongst the dental nurses they surveyed about their educational options and learning needs.

There is also a need to find a balance between topics that are of interest to dental nurses and those that address vital learning needs.

The list of courses identified reflects those that are currently available as opposed to new directions that DNs would like to take. The most frequently requested topic, forensic dentistry, is offered by the department but only accounts for 1% of all CPD hours delivered in the last five years. The most frequently taken courses over that period were medical emergencies (19%), cross infection and contamination (13%) and radiography and radiation protection (12%). Only three topics on the lists were GDC core topics (radiography, legal & ethical and cross infection & contamination) and the second most commonly requested topic was for any CPD topics relevant to dental nurses. These findings tie in with the open-ended comments which stated that courses tend to be directed at dentists and dental hygienists. The issue of having to take courses in topics that are irrelevant to them is possibly one area that could, if addressed, increase satisfaction with CPD. However, there is also a need to find a balance between topics that are of interest to dental nurses and those that address vital learning needs.

In 2002 John et al.¹ stated that mandatory registration would bring DNs in line with other health personnel, increase their standing and identify them as a highly trained professional group. Our respondents' views on CPD and registration were mixed. Although the majority of respondents in this study displayed positive attitudes in their response to the statements about registration, views expressed in the open comments were more negative, particularly around registration fees and professionalism. However, it is possible that this was a reflection of the time: this questionnaire was issued in January 2011 when the expected increase in fees in June was a topic of discussion. The survey provided an insight into the opinions of DNs in Wales with regards to CPD and registration and it is clear from the comments that there is strength of feeling regarding the ARF and the costs associated with CPD and registration.

There are challenges emerging for DNs as they continue to adjust to statutory registration and the responsibilities associated with this. As dental care professionals (DCPs) enter the 4^th year of the first five-year CPD cycle there is a need for the Deanery to ensure that the courses and training provided meet the needs of this cohort. This is particularly pertinent in the austere financial climate where living costs are escalating. CPD must remain affordable to this group.

The dental workforce must be trained to meet the needs of the population and the Deanery has a role to play in providing this training to ensure a workforce fit to meet the demands of the patients they serve. Postgraduate tutors must be aware that there is a need to encourage and nurture DNs to ensure that they fulfil their potential and provide the best level of care to their patients.

This survey has provided an initial view, albeit limited, of the perceptions and needs of DNs in Wales. It is planned to repeat this survey in the future and in the meantime continue to establish and provide quality CPD provision for dental nurses in Wales.