By Anastasios Plessas, Robert Witton, Martha Paisi, Fiona Ellwood and Ewen McColl

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©DrAfter123/DigitalVision Vectors/Getty Images Plus

Introduction

Dentistry is recognised as a stressful profession and dentists perceive their profession to be more stressful than other healthcare professions.1 An alarming upwards trend in deterioration of mental health and wellbeing in the profession has been observed in recent years, with up to 87% of UK general dental practitioners reporting symptoms indicative of burnout.2

The COVID-19 pandemic has further heightened anxiety levels in all members of the dental team and especially in frontline dental nurses.3,4,5 In a study conducted at the dental department within Guy's Hospital in London at the beginning of the pandemic, nearly a quarter of dental nurses displayed severe symptoms of generalised anxiety.3 So far, the evidence around mental health and wellbeing of dental care professionals other than dentists is limited.6

The COVID-19 pandemic has brought into sharp focus the importance of looking after our own mental health wellness and looking out for each other. Work-related stress, as well as life experiences, may expose dental team members to feelings of anxiety, worry, and stress which if not addressed may lead to more serious issues such as burnout and depression. Evidence from the wider psychological literature suggests that stress negatively affects teams' dynamics, behaviours and overall performance,7 whilst healthcare teams are more prone to errors when under immense stress.8 In dentistry, and healthcare in general, teamwork is essential and patient care cannot be delivered effectively if all team members are not fully engaged and empowered. With patient safety in mind, it is only logical that protecting your team's mental wellness will have a positive impact on team morale and in turn improve patient experience and safety.

When it comes to preventing mental health and wellbeing issues in the workplace, three levels of intervention can be employed: primary prevention (ie system level interventions), secondary prevention (ie psychoeducational interventions) and tertiary prevention (ie counselling).5 These interventions can be delivered in turn at individual, practice or organisational and national level. Another paper in this issue of BDJ Team looks at individual level interventions to improve mental wellness, with emphasis given to early recognition of signs of poor mental health and early intervention. The current article aims to provide tips for dental teams to bring mental health wellness into the heart of their professional practice. The recommendations made in this paper are based on the Mental Health Wellness framework developed by the Dental Professional Alliance which can be accessed at: https://mhwd.org/download/mental-health-wellness-in-dentistry-framework/. We encourage readers to refer and consider implementing the framework into their practice and/or organisation.

First step: Risk assessment

A risk assessment can be conducted by the practice lead/owner, practice manager or even better by a mental health wellness lead which in ideal circumstances should be a member of the team but can also be provided by an external person. The role of the mental health wellness lead will be explained later in the paper.

It can be helpful to establish baseline mental health and wellness in the team. This can be achieved using a short anonymous survey using both closed and open-ended questions. This will help to identify the needs of the team, to inform action plans and the urgency of implementing change. Respecting confidentiality is paramount although in a small practice this can be challenging and a different (individual) approach may be required.

With patient safety in mind, it is only logical that protecting your team's mental wellness will have a positive impact on team morale and in turn improve patient experience and safety.

As part of the risk assessment the work environment, its systems and processes and the organisation of the practice should be looked at, ascertaining to what extent they may negatively influence the mental health wellness of the team. It is sometimes surprising how on reflection, simple changes can positively influence team wellbeing and workplace culture. A participatory approach where the views of all members of the team are taken into consideration is essential for this exercise to be worthwhile. Areas to be assessed can include:

  • Demands: Assess the individual team member's workload and work patterns. How do they cope? Is the workplace environment harmonious or chaotic?

  • Control: Assess the degree to which team members have control over their work

  • Support: Assess to what extent team members receive the necessary support or resources to achieve their potential. When it comes to mental health wellness assess what support and resources are available to the team. Are team members aware of the support available and how to access the resources?

  • Relationships: Identify poor working relationships and the presence of micro aggression between or among team members

  • Role: Assess whether all team members understand their role and their remit. Assess whether there is any conflict between team member roles

  • Change: Assess how change is communicated to and among team members. Assess how change is perceived and managed within the team.

Second Stage Action Plan and implementation

Once the necessary information has been gathered a SMART action plan can be created. Involving the whole team in the creation and decision making process can get you a long way down the path towards recognising the benefits. Creating a culture of trust and shared purpose will empower team members to engage with the process and become their best self at work.

A. The role of a mental health wellness lead

We actively encourage every dental workplace to adopt the Mental Health Wellness Framework, and appoint a Mental Health Lead. This should be a team member with good communication skills, whi has an interest in wellbeing and is approachable and respected by the whole team. The person should receive appropriate training and be supported to carry out their role effectively including dedicated time. The Lead's role is to promote openness about the subject, challenge stigma, promote a work environment conducive to positive mental health and signpost, where appropriate, to relevant resources and services. The Lead does not have to be an expert in mental health and they and the team should recognise the purpose of the role.

B. Demand and sense of control

Things to consider:

  • Review any workload challenges and make appropriate adjustments. Ensure that appropriate numbers of staff are available and there is an effective process to manage work absenteeism. Consider flexible working patterns and shift schedules where appropriate

  • Recognise the harmful effects of extreme time pressure review diary management to ensure that short breaks are incorporated into the working day and the team is not put under unreasonable pressure. For example, ensure that emergency slots are of an appropriate length, are available daily and discourage double bookings. Providing clinicians with control of the appointment length can better align the time required for the patient to diary planning.

C. Effective communication and regular meetings

Lack of clear and effective communication undoubtedly creates a chaotic working environment and increases the probability of administrative and clinical errors occurring which can lead to patient safety issues, reputational risks to the practice and regulatory fall out. Ensuring that processes and protocols are in place to facilitate clear communications within the team is a fundamental leadership requirement of any dental setting. Ensuring that each member's role is well defined and communicated minimises conflicts between roles and promotes team culture and trust.

A team is only as good as the sum of its parts and everyone has a role to support each other and provide help and signposting to colleagues who feel they need further help.

It is important to manage poor working relationships and micro aggressions using a conciliatory and impartial approach that avoids escalation or punitive actions. Encourage dental team members to discuss issues early and informally to address misunderstandings and ensure the practice or organisation‘s values are understood by all members of the team. Having a behaviour policy can help to set out what the practice or organisation expects from its employees. Undertaking regular equality, diversity and unconscious bias training can support positive behaviours and culture in the team.

Regular practice meetings are an excellent way to discuss issues and collectively problem solve. Encourage all team members to participate and speak up regardless of their role; reducing or removing hierarchies can improve understanding of a problem and often leads to a better or more long-term solution.

Communicate what has been discussed and agreed by distributing a copy of the meeting notes to the whole team. Incorporate morning and evening huddles in the daily schedule. These short meetings can be invaluable. Team members can use this as an opportunity to openly, and in a safe space, confess what their ‘stress bucket' is like on the day, check on each other and at an operational level, it facilitates preparation for the day ahead and important patient considerations. It cannot be emphasised enough the importance of compassionate leadership to achieve these open and honest conversations.

Discussion

It is widely acknowledged that recruitment and retention in the dental profession is challenging and as employers and members of the dental profession we all must do what we can to look after our teams' mental health and wellbeing. A team is only as good as the sum of its parts and everyone has a role to support each other and provide help and signposting to colleagues who feel they need further help.

We would advise all dental settings to adopt the Mental Health Wellness Framework, and embed policies and processes in practice that recognise and support mental health and wellbeing.

There is clear evidence from many sectors that positive mental health and wellbeing is associated with higher levels of job satisfaction which in turn leads to positive employee engagement, employee retention and resulting personal and organisational success. However, we acknowledge that it is not possible to control every aspect of dental practice, and many factors in the working environment are directed by national policies and regulatory frameworks. Where this is the case, we urge national leaders and policy makers to design a system that supports a sustainable workforce for the dental profession and removes unreasonable pressures from dental teams.