Main

Dental nurses are one of the most important groups within the dental team. They assist the dentist throughout the day and may act as advocates for the patient, as well as being an integral part of the dentist's clinical regime. It would seem that the work of dental nurses is essential for a successful general practice.

It seems somewhat curious that when asked about their employment as dental nurses these women admitted to experiencing dissatisfaction with work.1,2,3 Dissatisfaction was related to lack of control, being undervalued by the dentist and feeling stressed. However, what seemed to be central to the nurses' perceptions was a feeling of being taken for granted.1,2,3

The above research findings help in understanding the dental nurses' concerns about their work environment but do they provide reasons for their job dissatisfaction? Specifically, what is it about being a dental nurse which leads to perceptions of low professional self-esteem, dissatisfaction and so forth? The pilot work presented here attempts to provide answers to these questions. It introduces and uses the qualitative research methodology of grounded theory to discover possible reasons as to why dental nurses, essential dental health professionals, should experience feelings of job dissatisfaction and low professional self-esteem.

Introducing grounded theory and the concept of dental nursing

Grounded theory provides a qualitative research methodology by which complex social interactions may be studied.4 It allows the complex processes by which dental nurses understand and interpret their working environment in general dental practice to be explored in detail. In order to do so, a series of in-depth interviews were conducted. Twenty dental nurses working in general practice with many years' experience were invited to take part; none refused to participate. Appointments were made and each woman was interviewed away from the dental surgeries. They were encouraged to speak freely and openly about their life and working experiences as dental nurses.

Identifying the basic social process of dental nursing4,5,6 (fig. 1)

Figure 1
figure 1

The concept of dental nursing

Full size image

The qualitative data obtained from the interviews was analysed using the research methodology of grounded theory.4 The idea behind grounded theory is that the data speaks for itself. The researcher examines the data looking for a behaviour (the basic social process) that explains the dental nurses' perceptions of their role and purpose as being primarily concerned with providing assistance to the dentist in the dental practice. In order to do this the transcribed interviews and observational notes are closely examined.

The researcher summarises each line of the interviews and notes with a category or word which best describes what is happening (incident) during his interviews and observations. As the analysis continues more than one occurrence of a particular incidence will be noted and coded as before with a category. This new category will be compared with the previous one and the differences between them will start to generate a hypothesis about how the categories interact with one another.

Gradually as no new categories are found in the data it becomes apparent that one overall concept will group and organise the categories together. This overall concept is termed the core category.5,6 The core category, which groups and organises the categories in this study, is dental nursing.

For the dental nurses interviewed the core category of dental nursing explain-ed the process of being a dental nurse in general dental practice. Nursing in the surgery seemed to parallel work at home. Whether in the surgery or at home these women stated that they answered the telephone, paid the bills, took money, etc.

Examining the categories4,5,6

The next stage is to examine the elements or categories that illuminate the social process of being a dental nurse. There were four categories which characterise dental nursing. These were being taken-for-granted, four-handedness, economic dependence and surgery working (fig. 1).

Category 1: taken-for-grantedness

Taken-for-grantedness is the perception of how the dental nurses feel their work was rated by the dentists with whom they worked. Taken-for-grantedness is the category which describes the dental nurses' feelings when their clinical work is perceived as unimportant. The following example is illustrative:

A younger dental nurse talked of her experience with a dentist with whom she had worked for some time. During a treatment session she had placed materials and instruments onto the treatment tray. She knew his style of working and which instruments he would require next. He acted as if she did not exist. He only spoke to make requests, for instance to ask for a periodontal probe which was already on the tray. Later when he asked for a pair of scissors and she was busy, he remarked on her slowness.

Category 2: four-handedness

Within the surgery the dental nurse has shared responsibility with her dentistry for the surgery environment. In this way she and her dentist work together in their joint venture. Thinking in this way allows the dental nurse's clinical work with the dentist to be thought of as a joint venture with shared responsibilities for patient care. This may be represented by the concept of 'four- handedness'. This is the greatest point of contact between the dentist, the dental nurse and the patient. She acts as an extra pair of hands, so to speak, and in this way becomes an integral part of the dentist's daily, clinical regime. Within this shared clinical experience the dental nurses' clinical actions and responses are dependent upon the dentist's work and the patient's treatment needs.

For some women in this study clinical work was the most rewarding aspect of being a dental nurse. Clinical work increased their feelings of self-esteem while reducing their feelings of isolation and disillusionment. The following comments by a dental nurse show how clinical work was highly valued:

'I find [clinical work] the most rewarding aspect of my work ... of course some patients are difficult, but you don't get many of those here. I find that when I meet the patients I don't feel as lonely'.

Nevertheless even clinical work could also become worthlessness when the dental nurses became disillusioned with work. One dental nurse commented:

'I don't like dealing with the patients anymore, they just get in the way. I just can't be bothered with it anymore. It's not like it's appreciated. Most days I want to get home as quick as possible and get on with my own life'.

Category 3: economic dependence

When a person's livelihood is dependent upon the income of another he or she is economically dependent upon that person. When a dental nurse has no other visible means of income then he or she is economically dependent upon the earning power of the dentist for economic well-being and financial viability. Although an analgous situation may exist for the female secretary who works in a small business, differences do exist. In the dental practice it is the dentist's own presence and physical worth which determines the income level of the practice. In the small business, income can increase irrespective of the owner's physical presence or absence.

Many women talked about the economic position of being a dental nurse. Some talked about differences between hospital service and general practice:

'In general dental practice you have no-one to turn to — if you don't like it — you have to leave. And then where's the money to live on? You have to keep in with them, do as they say ... you've no choice ... whatever way you look at it you're dependent on them'.

Category 4: surgery working

Surgery working may be thought of as paralleling work in the home; it may be menial and routine. The dental nurse's daily routines are determined by the needs of others. By keeping the dental surgery running smoothly he or she enables the dentist to provide efficient and effective care for patients.7

Surgery working is determined by the dental treatment provided and the throughput of patients. These factors may influence the degree to which the dental nurse perceives his or her work as being important. Increased throughput of patients, for instance may reduce job satisfaction:

'After the dentist finishes with a patient I am the one who does the clearing away, wiping down the surfaces and putting the instruments in the sink. Then it's changing your gloves and putting a fresh tray on the bracket table — it's non-stop. The only variation is the treatment the patient requires. These days I don't [even] have time to say hello'.

Implications and ideas for future work

The work presented here attempted to explore the reasons why dental nurses have low job satisfaction. Grounded theory provided a useful framework for understanding the complex processes which are involved in dental nurses' working experiences. It was proposed that dental nurses' work in general practice could be explained as a process of dental nursing — which is characterised by feelings of taken-for-granted, economic dependence, four-handedness and surgery working.8

Nurses looked after the surgery for the dentist to enable the smooth running of the practice. Surgery working in this capacity, although 'unseen', could result in professional self-esteem.7 Nevertheless the meniality of surgery working (taken for granted) could also contribute to low job satisfaction. Similarly with clinical work, if taken for granted and/or perceived as being unimportant, the dental nurses reported low job satisfaction whereas if the nurse was encouraged to take an active and shared role in patient care (four-handedness) they felt content with their work situation. These findings suggest that a play-off may exist between the elements which characterise dental nursing. Depending on how their work is valued and appreciated (or taken for granted) the result will be either job dissatisfaction or feelings of contentment and professional self-esteem.

Thinking in this way provides some explanation as to why dental nurses have low job satisfaction. It may be proposed that dental nursing which is composed of surgery working and characterised by feelings of being taken for granted and economic dependence can result in low job satisfaction. Dental nursing, however, which is characterised by active patient care (four-handedness) and the smooth running of the surgery (surgery working) can be associated with contentment and professional self-esteem.7 In the former, the dental nurses experience their work as being undervalued whereas in the latter, they feel an important member of the dental team.1,2,3

Reasons for dental nurses' job dissatisfaction may be thought of as a dynamic interplay between these various categories or elements which explain the process of dental nursing. The work reported here is a pilot study. The interviews and observations gathered allowed the exploration of elements which seem to suggest reasons for the dental nurses' job dissatisfaction.

We believe that there is a need to develop research using qualitative research methodologies to investigate the complexities of job satisfaction in general dental practice.