Introduction

Dental nurses are a vital part of the dental team. According to the General Dental Council (GDC), dental nurses are ‘registered dental professionals who provide clinical and other support to registrants and patients’.1

In past decades, dental nurses in the UK were generally school leavers with no previous work experience who trained within a dental surgery or hospital setting under supervision of the dentist or senior dental nurse;2 today, dental nurses are required to undertake standardised training and sit a recognised examination.3 Qualifications currently offered for dental nurses include the National Certificate in Dental Nursing awarded by the National Examining Board for Dental Nurses and the National Vocational Qualification Level 3 in Dental Nursing.4

Dental nurses can train in practice and study for a qualification on a part-time course in the evening or day release, or they can take a full-time course in a dental hospital. Apprenticeships for training offered by some NHS Trusts give the benefit of ‘earning while learning’ and they may be useful for those working and wanting to qualify further.5

After qualifying as a dental nurse, the majority work within general dental practice although theoretically there are opportunities to work in a wide range of dental services.4 Dental nurses also have to register with the GDC after they qualify and are required to undertake continuing professional development (CPD).6 Proponents of compulsory registration argue that it raises the profile for dental nursing across other health professions. Opponents feel it may have added to existing recruitment and attrition problems.7

The ‘scope of practice’ of dental nurses has evolved with continuous advancements in dentistry and has been formally identified by the GDC.8 Dental nurses do not diagnose disease or treatment plan. They can develop further skills during their career and undertake procedures under a dentist's prescription. This is known as ‘additional skills’ for dental nurses.1,9,10 Dental nurses may also obtain a number of post-qualification certificates, which offer opportunities for career progression,10 including conscious sedation nursing, dental radiography, special care dental nursing and oral health education; in addition to which, the Adult Teaching Certificate prepares dental nurses to become dental nursing tutors.10

Exploring the views of qualified nurses in one dental hospital by Durkan et al.11 revealed that their motivation to pursue a career involved ‘The opportunity to progress in the dental sector’ as most important, followed by ‘preference for healthcare’ and ‘job availability’. Personal satisfaction was the most important factor expressed by dental nurses as the reason for their desire to pursue further training, while increased chances of employability was the least important factor. More than half the respondents were having training in further skills; those who were not stated they would like to. Conscious sedation was the most common additional skill obtained, and radiography was the most desired skill to be learned. Extending their scope of practice was perceived as ‘adding variety to their role’, ‘being able to deliver better service’ to their teams and patients, ‘being more valued by their colleagues’, ‘career progression’, and ‘enjoyment of learning’, an ‘interest in the courses’ and ‘the potential to teach others’.11

Belsi et al.12 also explored the motivation to study dental professions in one London dental institute among dental students, dental hygienists/therapists and dental nurses. All three groups shared similar motivations. ‘Features of the job’ was the most important including job security, a wide range of careers within dentistry and a recognised job. This was followed by the ‘desire to work with people’, ‘a degree leading to a recognised job’, ‘a desire to work in healthcare’ and ‘academic knowledge’ respectively. Friends' influence and career advice were reported to be of least importance.

Rationale for the study

Recruitment challenges, together with losing dental nurses to dental hygiene and/or therapy, and from the profession overall, are significant and require investigation.13 Addressing the motivators for students to choose a programme is considered a useful tool to design effective recruiting strategies and help provide the future workforce with a complete picture of the different professions.12,14 There has been little research amongst trainee nurses from general dental practice settings who form the majority of trainees. In order to address this gap, there is a need to begin with qualitative research amongst current trainee dental nurses which includes those training from a dental practice setting.

Aim

To explore the motivation, career expectations and influences of dental nurses training in educational establishments in South London.

Methods and methodology

This qualitative study explored the motivation, career expectations and influences of trainee dental nurses in South London. Approval was obtained from King's College London Research Ethics Committee before the commencement of the study (reference number BDM/12/13-56).

The research was conducted by SS as part of an MSc in Dental Public Health in 2013. The research group has undertaken work on various dental team members and their roles, and this study contributes further to this field of research. The main training institutions serving practices in South London were identified via the Internet and tested with dental nurse leaders in London. Contact with all five institutions providing training for dental nurses in hospital or practice was made by letter and email, providing information about the study. After one week, contact was made by phone to follow up on the request.

When an institution agreed to support the study, information sheets were provided for the students in advance. The researcher (SS) met with the dental nursing students during a scheduled session to introduce the research and answer questions. Confidentiality was assured. Students were given the opportunity to consent to the study or withdraw from the focus group that was conducted and moderated by the researcher using a topic guide informed by the literature and past research.15,16,17 Students were asked to provide socio-demographic data to enable the researchers to provide an overview of the participants.

Two focus groups were conducted with ten participants in each group. Students were asked a series of open-ended questions to allow them to elaborate on their views without restriction. Focus groups were transcribed verbatim using an approved transcription firm with encrypted services and a confidentiality agreement in place.

Data analysis was approached using Framework Analysis18 involving five key stages: familiarisation, identification of a provisional thematic framework, indexing, charting and mapping and interpretation. It followed the approach used in parallel studies of dental students and new graduates.15,16,17

In line with Framework Analysis, the first stage of the analysis was familiarisation. Transcripts were examined to identify the main themes emerging from focus groups. A thematic framework was then developed to identify key issues withdrawn from respondents repeatedly, and those withdrawn from the literature and policy. Data were indexed by applying the thematic framework to transcripts. After this, charting - which is a two-way process - was carried out involving rearranging the data and extending the thematic framework in light of the application of the data. Finally, Mapping and interpretation of the information generated from indexing to define concepts, map the range and nature of phenomena, and find associations between themes is carried out with a view to providing explanations for the findings and generating theory. This process was influenced by the original research aim, as well as the emergent data.18,19

Results

Participants

Two educational establishments agreed to participate in the research during the time-frame for this study, providing a total of 20 dental nursing students. All focus group participants were female. Of the 17 who returned demographic information, 41% were aged 20-24 years, 23% 25-29 years and 17% within the age band of 30-34. Almost one quarter (23%) were over 35 years of age. Fifty-two percent of dental nurses held Diplomas, 35% of the respondents held GCSEs, and 11% held other qualifications. Respondents came from a wide range of ethnic groups; white participants were represented at the highest proportion (52%).

Fieldwork and presentation of findings

Whilst one group of dental nursing students participated actively, the other group, conducted at the end of an evening study session, was more passive. Only two establishments within the geographic limits of our study and the time frame proposed agreed to facilitate their students to participate.

Focus group discussions explored three main topics: motivations to pursue a career in dental nursing, career expectations including the ‘mode’ and ‘nature’ of work, and finally perceived influences on their professional careers, each of which will be presented in turn with illustrative quotes in italics. Each quotation is referenced back to the original text including the group, participant and line. Additional demographic details are presented where relevant.

Motivation

Findings included ‘features of the job’, ‘interest in the dental field’, ‘professional factors’, ‘healthcare’, ‘lifestyle’ and ‘experience’ in the dental field and the influence of ‘advisors’; the latter comprised family and friends. ‘Features of the job’ included availability of the job, reliability and flexibility and the financial security. ‘Professional’ factors included mainly the opportunity for future career progress, as many of the student nurses originally started dental nursing to gain the experience required to get into dental hygiene and therapy course. ‘Features of the job’ and ‘professional factors’ were suggested to be the strongest motivators. The above points are shown in Figure 1 and are illustrated by the following quotations:

Figure 1
figure 1

Motivation of dental nurses in training for a selection of careers in dentistry

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‘My mum was a dental nurse, so I've been seeing the experience through her eyes’ 1fg1-3

‘I think it's a good career for when you have children. I can have a family and a good job’ 4P2-9

‘Mine was maybe for the access for dental hygiene therapy, um, because I may want to do that someday. So as dental nursing is a way of getting in and it gives you a better insight to what it's actually like to get to work alongside a therapist’ 8fg1-26

‘Lifestyle factors’ motivated those who have families and need to work part-time.

‘I think it's a good career for when you have children. I can have a family and a good job’ 4p2-9

‘Experience’ of working in or around the dental field and ‘the ability to work with people in healthcare’ were additional motivators. There was evidence of having ‘rejected other careers’ such as waitressing because of dissatisfaction with them.

‘I was working as a waitress for nearly a year, I hated it, I can do it but it's not my dream you know, then I started looking for dental nursing courses’ 10P2-34, 35

Career expectations

There was a wide range of career expectations from routine dental nursing, developing extended duties, progressing to a career in dental hygiene/therapy, being uncertain, to changing career completely.

In relation to ‘settings’ there was interest in working across hospital and general dental practice settings, both NHS and private. There was a strong interest amongst the hospital trainee nurses to pursue a career in the hospital ‘setting’ in a full time ‘mode’ within the NHS ‘system’. Informants valued the hospital setting because of the better opportunities to progress and the ability to meet different people and undertake a variety of procedures. Figure 2 presents the points above, and they are illustrated by the following quotations:

Figure 2
figure 2

Career expectations of dental nurses in training

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‘I'd like to work full-time in a hospital, um, because I think you see more variety. You see a variety of different people different procedures going on here, compared to being in a practice, and you get to meet a lot more people. Whereas with private practice is just you and the dentist, then the patients come in and out. I'd like to see more variety.’ 10FG-178

Those who had families were planning to work part-time within the NHS.

‘I could work part-time around the family’ 5fg1-19

The other group were less vocal about their career expectations which included general dental practice, being uncertain and wanting to change career completely.

‘I think I will be working in NHS because it is a fixed job, full-time’ 10p2-108,109

‘I'd like to work full time in a private...(practice)’ 1p2-86

Many of the trainees expressed a desire to become dental hygienists or therapists as their future ‘role’ within the dental workforce.

‘After I am a dental nurse and have a spare time and the experience as well, I would like to go a level higher for a hygienist’ 1P2-87,88

A few preferred challenges outside of dental nursing because they considered it stressful and boring.

‘Actually, dental nursing is not interesting, I don't know why, it is really stressful.’ 11P2-54

Career influences

The trainee dental nurses perceived future influences to be most importantly ‘financial’. They perceived they were underpaid and that better remuneration would keep them in the profession. There was evidence of having selected dental nursing as a stepping stone, demonstrating that opportunity to undertake further courses would encourage them to stay in the career. This falls under the ‘Professional’ influence as the ‘opportunity of career development’ demonstrated by an earlier quote. Family responsibilities were perceived to be a ‘Personal’ influence. Key influences are presented in Figure 3, and are illustrated by the following quotations.

Figure 3
figure 3

Career influences perceived by trainee dental nurses

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‘Like after 10 years, I might want to be earning more money so I have to think about doing more training, getting additional skills and then may be trying a different job role like moving up from dental nursing to something else, so probably lifestyle factors will influence me, money's involved about what I've to think about’ 5FG1-226

‘If the money goes up...(stay in career)’ 3P2-118

Informants also suggested that they would be encouraged to take more courses and further their careers if courses were funded, made available, free or affordable.

‘I think more training, like to make it more available’ 8FG1-232,234

‘Not everyone can afford the training if you're paying for it by yourself, more accessible’ 3FG1-236

‘To some ... if you're in practice, you're going to pay for your own courses. But if you're in a hospital, the hospital might pay for you to do it’ 3FG1-239

Vision

Being on the course has changed student dental nurses' vision of the career of dental nursing. Most of them said they didn't know how much they could do within dentistry and how much further they can progress. They also felt confident and more important.

‘When I first got ... went to the course, I still didn't know that there were that many pathways that you can actually go through, that how good dental nursing actually is, and being on the course like widened my eyes’ 8FG1-108,110

Expanding the areas included in the basic training of dental nurses was suggested. There was a sense that dental nurses were undervalued and this was reflected in their prominence and salary.

‘Nurses don't get paid as much as they should for what they do’ 10FG1-46

‘Sometimes, I don't think we're valued enough in this job’ 4FG1-152

‘I guess it's maybe trying to make a nurse more of a forefront or bring them forward because they are more of a background figure’ 7FG1-435

Nonetheless informants suggested that there was a need to increase awareness of careers in dental nursing and ensure there is careers advice in schools.

‘Maybe they could promote it more when you're at school and you have careers advice’ 5FG1-474

Discussion

Motivation

The findings from our study suggest that trainee dental nurses share similar motivations for a career in dentistry to dentists,15 and dental students.17 Both perceived ‘features of the job’ to be the strongest motivator. Some of the common features were flexibility, availability of the job and security. Academic interest was not a motivator to dental nurses as it was for dentists.15 Whilst there is evidence that those pursuing a career in dentistry may have rejected medicine as an alternative to dentistry,15 dental nurses reported having rejected other service roles, outside of healthcare, such as waitressing. The framework for analysis within our study was developed on the basis of previous research by Gallagher et al.15 Dental students preferred ‘job security’ (57%); ‘degree leading to recognised job’ (49%); ‘independence’ (48%); ‘regular working hours’ (44%); and a desire to work with people (50%). The findings on the motivations of student dental nurses support the results from Belsi et al.12,20 on research also conducted in the London area. It is not surprising that ‘features of the job’ are common to dentists and dental nurses, given the nature of dentistry and close working between these two groups.

Career expectations

Dental nursing students, like dental students, perceived there were opportunities within the NHS as a system of work because of the better opportunity of future career development.17 Interestingly, although there was a spread of opinion, student dental nurses appeared to be interested in working full-time, whereas many entering dentistry are attracted by the potential for working less than full-time.15,16,17

The option of leaving dental nursing expressed by some of the nurses was motivated by low salaries and stress arising from the job. Stress is a problem of retention with many jobs.21 Low remuneration was also a problem among dental nurses in Scotland.22 Intention to leave dental nursing was also indirectly related to job beliefs; personal accomplishments and work engagement were the two most important factors determining intention to leave dental nursing.7

The NHS has introduced some strategies to improve nursing retention23,24 such as: helping nurses to buy or rent homes, the funding of additional nurse consulting posts, reforming the pay system and improving nurse management. Perhaps such initiatives could be applied to dental nurses to improve their recruitment and retention?

Influences on professional careers

Student dental nurses, like Foundation Dentists (formerly known as vocational dental practitioners - VDPs), were influenced by ‘financial’, ‘professional’ and ‘personal’ factors.15 The opportunity for future progress was a common ‘professional’ influence. ‘Financial’ influences were the most prominent in dental nurses. Together with VDPs and dental students they share a common vision for the need of better remuneration and funding support for further education courses.15 Dental nurses expressed a need for more training courses and raised concerns about the fees of these courses.11 Financial issues were seen to be an obstacle preventing dental nurses from undertaking training courses; this conforms to the results from the study on Scottish dental nurses.22 Balancing family responsibilities was rated an important influence by dental students and dental nurses.7,17Perhaps some of the strategies used for general nurses, outlined above, could be introduced by dental practices to assist with dental nurse retention? Given the options for career progression involving extended skills training and training as hygienists/therapists, there is now a range of possible options open to dental nurses – options that require support from employers.

Vision

The findings suggest that dental nursing students' vision of working life has changed in the short period in which they have been training. They didn't have knowledge of the variety of opportunities offered for career progression. This finding is similar to that of qualified hospital nurses;11 and for some ‘professional status’ was important as they wished to progress to train as a dental hygienist/therapist, unlike some Scottish dental nurses who were uncertain over career pathways.7

Limitations

The main challenge with the study was recruitment. The sampling frame was geographically defined and the study-period time limited. Given that the staff who run educational programmes in further education colleges are generally part-time, identifying and making contact with them proved a challenge. Furthermore, the study was conducted during the spring term when courses are concluding, and this may have impacted on the invitation to participate in the study. Although this research was conducted in South London, the findings are similar to other studies elsewhere in the UK,7,22 and given the paucity of literature provide an important base for further research. Future research, informed by this study, should focus on schemes within primary dental care to explore their views in greater detail and include research amongst dental nurses at various stages in their careers.

Conclusion

The findings suggest that student dental nurses' motivation, career expectations and influences are similar to other members of the dental team. ‘Features of the job’ play an important role and there is strong interest in professional development within dentistry including dental hygiene and therapy. Career intentions covered both NHS and private systems and hospital and practice settings. Remuneration and the opportunity for further training, particularly in dental hygiene/therapy, were perceived as predictors of future career retention.