Background
Despite recent changes for the better, improving the oral health of children living in Scotland is a challenge with wide inequalities persisting. Although approximately 67% of Primary 1 (5 year old) children in Scotland have no obvious tooth decay, there is a strong socio-economic gradient with 49.5% of those living in the most deprived geographical areas having observable caries by the time they go to school [
1]. Moreover, dental registration rates are relatively low for very young children with only 47.2% of 0–2 year olds currently registered [
2] and limited preventive dental care being delivered to children registered with a National Health Service (NHS) dentist [
3]. To address these issues, in 2005, a national oral health programme for children living in Scotland (Childsmile) was funded by the Scottish Executive [
4]. Childsmile aims to improve the oral health of Scotland’s children through a comprehensive, longitudinal, pathway of care delivered in clinical and community settings [
5].
‘Childsmile Practice’, a key component of the Childsmile programme, promotes a shift from ‘reactive management’ to ‘anticipatory care’ [
5]. Parents are encouraged to register their child with a dentist from six months of age. Once registered with a general dental practice, Childsmile advocates that families receive tailored preventive care comprising tailored dietary advice (DA), oral hygiene advice (OHA), and the clinical intervention of fluoride varnish application (FVA). Childsmile’s recommendations are in keeping with recent clinical guidelines stating that all children (irrespective of caries risk status) should receive, OHA at least once per year (with hands-on toothbrushing instruction in the early stages of providing care), DA at least once per year and if aged over two years (and not contra-indicated) fluoride varnish (FV) applied to their teeth at least twice a year in practice [
6,
7].
In 2005, consultation during early programme development between Childsmile’s executive planning committee, public and oral health specialists (including NHS consultants in dental public health) and the General Dental Council, raised the concern that general dental practitioners’ (GDPs) capacity could potentially act as a barrier to the delivery of preventive care as recommended by the programme. This recognition led to Childsmile being instrumental in extending dental nurses’ roles and promoting a skill-mix approach within general dental practice [
8].
Skill-mix can be defined as the mix of skills and staff required to deliver a service. This can be achieved by enhancing the role or skills of a particular staff group, substituting one staff member for another, delegating tasks previously performed by one staff group to another or introducing new types of staff [
9]. Skill mix can be categorised into ‘role supplementation’ where less qualified staff members provide services that complement the activity of more qualified health-care workers and ‘role substitution’ where they replace the role of their senior colleagues [
10,
11]. Brocklehurst and Tickle [
12] explain that the latter can only occur and be cost-effective, if the more qualified colleague ceases to undertake the delegated tasks [
12]. As Childsmile utilises the whole dental team, extended duty dental nurses (EDDNs) are trained to supplement the activity of more highly skilled (and costly) GDPs.
The use of skill-mix in the UK was first implemented within general medicine in the 1970’s [
13,
14], although its uptake in dentistry has been relatively slow [
15‐
17]. Factors affecting the broader use of the whole dental team include: the extent of clinical activity that is permitted by the dental regulator, financial incentives within the payment system, availability of appropriate training for dental care professionals (DCPs), lack of clarity over the roles that DCPs can perform and the perceived threat to the dentists’ autonomy [
12,
15,
16,
18].
While EDDNs now operate throughout the NHS in the UK, when it was implemented in 2006, Childsmile was ground-breaking in its development of accredited training for EDDNs, enabling FVA under clinical supervision for the first time, an activity traditionally undertaken by the GDP. This training built on the changes that had been made by the dental regulator in 2002, which extended the range of duties which could be undertaken by DCPs [
17,
19]. Childsmile’s extended training for dental nurses was developed in partnership with and is delivered by NHS Education Scotland.
The literature suggests that skill-mix can have the potential to improve patient access and patient and professional satisfaction [
20‐
22]. However, for such benefits to be realised, barriers to implementation must be overcome: ensuring an education and training programme that is ‘fit for purpose’ [
14,
21], increasing the supervision of staff [
20,
21] and ensuring good human resource management to avoid unintended consequences such as increased occupational stress and lowered morale [
9,
14,
23]. These findings, coupled with the scale and innovative nature of the roll out of a new approach that embraces skill-mix within general dental practice across Scotland, pointed to the need for formal evaluation of the EDDN role.
This paper explores the extent to which EDDNs are contributing to skill-mix within dental practice across Scotland through supplementation of GDPs’ roles. Key research questions are whether EDDNs are satisfied with their role, whether they feel adequately equipped by the training they receive and to what extent they are delivering preventive care (DA, OHA and FVA) to their child patients. Potential barriers and facilitators to EDDNs’ delivery of preventive care to children in Scottish dental practices are investigated. Learning about nurses’ experiences of applying new skills within practice, and the factors which facilitate or hinder their use, is a necessary step to ensuring that nurses’ potential is reached and that children receive preventive care in line with clinical guidance in a cost-effective way.
Discussion
This study investigated the contribution of role supplementation by EDDNs, to skill mix in general dental practice across Scotland, by investigating: EDDNs’ satisfaction with their extended role, their views on the extended duty training they received and their experiences of delivering preventive care to children and their families.
On the whole, role supplementation was found to operate well, with EDDNs reporting frequent utilisation of their new skills in terms of delivering preventive care. This is in keeping with a growing body of literature suggesting that skill-mix, through extended roles, can make a positive contribution to the delivery of health-service provision [
10,
11,
20‐
22,
26,
27]. Galloway et al. [
22] found that dental care professionals (DCPs), including EDDNs, with appropriate training, can, extend into roles traditionally undertaken by the dentist, conduct oral health promotion and enhance productivity in a dental practice [
26]. While this study of Childsmile’s EDDNs did not specifically measure the impact of their utilisation on productivity in general dental practice, a gap that has recently been acknowledged in the research literature [
28], it concurs that with appropriate training EDDNs can deliver health promoting aspects of a dentist’s role in Scottish general dental practice.
EDDNs’ high role satisfaction, the positive association between frequency of delivering FV and role satisfaction and free text responses suggesting that attainment and delivery of new skills increased nurses’ job satisfaction are also in keeping with several studies reporting high employee satisfaction with extended roles [
29‐
32].
Nonetheless, it is notable that FV was reported to be delivered less frequently than DA or OHA. This is perhaps unsurprising in light of recent research suggesting that FV is not being applied to children’s teeth in general dental practice in Scotland as often as current clinical guidelines would advocate [
3,
33]. The Translational Research in a Dental Setting (TRiaDS) programme reported that a significant gap exists between optimal and actual practice for the prevention of child caries in Scotland with only 10% of GDPs surveyed reporting ‘always’ applying FV to their child patients’ teeth [
3]. A much lower proportion, than the percentage of EDDNs who reported ‘always’ applying varnish in this Childsmile study. There are a several possible explanations for the high levels of preventive delivery reported in this study.
First, when interpreting the findings of the Childsmile study, it must be borne in mind that those practices sampled, had chosen to sign up to Childsmile. It is plausible that staff working in these ‘early adopting’ practices hold more favourable views of the operation of skill-mix in general dental practice than those employed in practices which did not ‘opt in’ to the programme. Now that Childsmile has been mainstreamed as the national NHS dental service for all children in Scotland, all practices are expected to deliver preventive care to child patients in line with Childsmile principles, not just those that sign up to the programme. A survey of EDDNs working in all GDP practices in Scotland may yield different results.
Second, within Scotland, at the time of this study, Childsmile practices were being paid a fee for preventive care, including FVA. Since October 2011 this financial incentive has been extended to all practices in Scotland through the Statement of Dental Remuneration. Payment may in part explain the high rates of preventive delivery reported in this study, although it does not explain why FVA is delivered less often than DA or OHA.
Third, in contrast to studies which have reported that lack of resources can act as a barrier to the use of skill mix [
34,
35], the finding that resources, including time, staff capacity and equipment, were not associated with frequency of preventive delivery, may be a contributor to the high levels of preventive delivery reported in this study. The higher proportion of respondents who listed ‘resources’ as a factor which facilitated delivery of their EDDN role, than the proportion who listed ‘resources’ as a barrier, suggests that resources did not constrain delivery for the majority of EDDNs who responded. Carter et al. [
36] also found that the majority of nurses attending a FV training scheme in England, had adequate access to resources and a large proportion reported no barriers to utilising their skills [
36].
Despite high rates of preventive delivery, this study found that not all nurses are equally amenable to adopting and implementing new skills. Several factors were associated with the frequency of EDDNs’ preventive delivery. Nurses who had been practising longer, and to a lesser extent those who were older, were less likely to deliver FV as frequently as their colleagues. While research suggests that age is not a factor for resistance to change in skills or working practices, long-tenured staff may find it more difficult to adopt and implement new skills as they have invested more in their traditional role and working practices [
37,
38].
EDDNs working in practices with a larger number of practising GDPs were also less likely to apply FV. This could perhaps reflect GDPs’ influence within the practice; in single-dentist or small practices it may be more likely that all dentists were signed up to Childsmile, with more variability in attitudes in a larger practice, where signing up to the programme was made by a lead dentist or a majority decision. Collegiate support for preventive delivery was associated with frequency of FVA and listed by respondents as both a barrier and enabler to their role. Since nurses are employed by GDPs, their employers’ attitudes towards role-supplementation will influence the extent to which dental nurses can implement their extended role. Interpretation of these findings requires further investigation.
EDDNs’ motivation to deliver preventive care (including the perceived importance of delivery) was consistently the most strongly associated potential mediator of frequency of delivery for all preventive behaviours investigated. Candell and Engstrom [
39] found that motivating factors for dental hygienists included increased demand from patients and receiving recognition from patients of successful treatments, whilst barriers included patients cancelling appointments [
39]. Similarly, this study found that cooperative parents and increased patient numbers were described as facilitators to the EDDN role and, uncooperative parents and families failing to attend appointments as barriers.
Finally, the perceived difficulty of delivering preventive care was also independently associated with frequency of delivery. The harder nurses perceived the task to be, the less likely they were to apply FV to their child patients’ teeth or to provide OHA, including demonstration of toothbrushing. That there was no significant association with frequency of delivering DA may reflect the differing task requirements; DA relies solely on verbal communication in contrast to the physical action required to demonstrate toothbrushing or apply FV. Additionally both toothbrushing demonstration and FVA require the nurse to physically interact with their child patient - a role they would not previously have undertaken.
Since role-supplementation requires the attainment of new knowledge and skills, it is unsurprising that our findings support Jacob et al.’s conclusion that as skill-mix increases there is a need to address how education affects competency and skill in the workforce [
23]. While this study, like Carter et al. [
36], found that training can prepare EDDNs for their new role, the most frequently suggested modifications to training are illuminating. Similarly to Hatim & Kendall, in their study of FV training for dental nurses [
18], we found that suggestions point to more practical ‘hands-on’ experience as being beneficial. This was despite a formal requirement for Childsmile dental practices to provide EDDNs with an in-house mentor and for EDDNs to observe five FVAs administered by their mentor, complete ten FVAs and have their practice observed by their mentor prior to being certified as an EDDN [
40].
That those nurses who found the training most useful were more likely to apply FV, and that nurses’ knowledge and confidence were related to frequency of FVA, further underscores the importance of fit for purpose training and skills attainment. Communications training aimed at increasing nurses’ confidence and skills in patient interaction may be helpful.
This study was a preliminary investigation of the contribution to skill-mix in general dental practice by a previously under-studied population (EDDNs). It provides insight into the working practices of a relatively new group of professionals and to the factors which influence key aspects of preventive oral health care delivery for children living in Scotland. To date, published papers focussing on the EDDN role have been entirely descriptive [
18,
41]. However, Brocklehurst et al. have recently published a study protocol which aims to investigate the barriers and facilitators to role-substitution of DCPs in dental practices and to determine the most efficient model of role-substitution [
28]. The authors point to the increased potential for use of skill mix in dental practice, in the future, explaining that projected improvement in the population’s oral health, suggests that if skill-mix does not become more widespread in dental practice that NHS resources will be unnecessarily “devoted to the use of highly skilled and paid workers to perform relatively simple tasks on an increasingly healthy practice population which less costly staff are competent to carry out” [
28]. The most thorough published study of implementation of the EDDN role, undertaken by Carter et al. [
36] formally investigated a FV training scheme for nurses within a single training centre in London, England. 36 nurses responded to an electronic survey which included questions about skills use following training. This study adds to current knowledge by uniquely exploring potential barriers and facilitators to preventive delivery by EDDNs both uni-variately and multi-variately and by focussing on the Scottish context. It also affords interpretation of findings based on a much larger sample size than previous studies of the EDDN population [
18,
36,
41,
42] by sampling all practices in Scotland with the potential to employ a trained EDDN.
However, our inability to obtain an individual level sampling frame of all EDDNs delivering in dental practice in Scotland at the time of study and therefore to ascertain what percentage of those nurses responded may be considered a limitation. Although the practice-based response rate achieved is higher than the average for professional surveys of this type [
32,
43,
44], those nurses who responded may have been more motivated and active than those who declined to respond. Nonetheless, responding and non-responding practices did not differ significantly in terms of demographic characteristics which may have suggested response bias.
Another potential limitation is the self-reported nature of the preventive delivery measures used in the study. No objective measure of EDDN’s delivery was available at the time of study.
Additionally, when interpreting the potential mediators of nurses’ delivery of preventive care it is important to bear the level of variance in terms of frequency of delivery in mind. For example, the stronger associations found between potential mediators and FVA as opposed to DA and OHA may be, at least partially, explained by the greater variance exhibited by this delivery outcome. Additionally, skills and motivation may have been more strongly associated with preventive outcomes than other potential behavioural mediators as they were measured specifically for each outcome, rather than in relation to delivery of the Childsmile role more generally, as was the case for the other behavioural mediators.
Nonetheless, this study has provided evidence as to the extent to which: the role supplementation approach, widely applied in the general medical context, has been successfully translated to the field of general dental practice (EDDNs are delivering important clinical prevention to Scottish children in line with national guidance), and provided insight into barriers and facilitators to this delivery. Further research could usefully seek deeper understanding of the factors influencing EDDNs’ ability to fully embrace an extended duty skill-mix role. A potentially productive direction may be to compare experiences of those EDDNs working in practices where preventive delivery is meeting national guidelines with those who are working in practices where guidance is less well implemented (although the extent to which practices implement these guidelines is not necessarily related to extent of delivery by EDDNs).
Qualitative methods could be employed to gain further understanding (from EDDNs and other members of the dental team) of the complex range of factors (and their interactions) which are likely to influence EDDNs’ ability to deliver preventive care, particularly FVA. Such a study may benefit from utilising an existing behavioural framework (e.g. Michie et al.’s Theoretical Domains Framework [
45]) to ensure that all potential influences on behaviour are comprehensively covered and that findings can be translated into action to improve delivery of care in line with guidance. The theoretical domains framework consolidates existing psychological and organisational theory relevant to health practitioner clinical behaviour change [
46,
47] and has been used previously within dentistry [
48]. Since family factors were perceived to act as both barriers and enablers to extended duty delivery by dental nurses in this study, further research should also explore views on delivery of preventive care from the families’ perspective.
It is also acknowledged that investigating frequency of delivery, does not inform of the quality of that delivery, further evaluation is required to assess the quality of preventive delivery being delivered (by EDDNs and other dental team members) to children living in Scotland.
The lessons learned from this and proposed future studies would in addition to adding to the wider body of literature evaluating the translation of skill-mix policies (and their underlying theory into practice), provide a theoretical basis for intervening to improve operationalisation of the EDDN role, with a view to ultimately improving the oral health care that Scottish children receive from their dental team.