A New Hope? Re-Registration for Dental Professionals in New Zealand. A Whole Dental Health Perspective, Appraisal and Reflection.
“A competent Dental Hygienist understands current biological, physical, cultural, social, and psychological factors involved in dental and oral disease, and in attaining and maintaining oral health”. NZDC, Scope of Practice for Dental Hygienists
Dental Hygienists are called, under a set of professional guiding standards, by the New Zealand Dental Council (NZDC) in their daily clinical and professional practice approach. They include putting our patients’ interests first, ensuring safe practice, communicating effectively, providing good care and maintaining public trust and confidence in the dental profession.
The NZDC also provides a legal Scope of Practice (SOP) document for Dental Hygienists in New Zealand, that compliments the Standards by guiding the practitioner to the boundaries of clinical activities pertinent to their specific qualifications. This demonstrates what is determined as “Best Practice” by understanding current scientific knowledge and skills, attitudes, communication, judgement, and demonstrate a commitment to real health promotion.
“Enable patients to maintain and enhance their individual well-being by increasing their awareness and understanding of “health matters”. NZDC Standards Framework Document section 22.
The Dental Hygienist has a legal commitment to follow the NZDC’s continuing professional development (CPD) 2-year recertification cycle presently by being able to demonstrate compliance through a portfolio of evidence if required. The Framework Document and Scope of Practice aligns the clinician with what is deemed necessary to do to achieve future recertification, as well as, of course, paying a practice certificate fee. The cost of that to a New Zealand Dental Hygienist is not unsubstantial, in fact far cheaper than that of a UK Hygienist, and very near to want a practising general Dentist has to pay. 1.
The recertification process has recently come under scrutiny by the NZDC. In February of this year, a summary of the critical features of a final design for their new recertification programme was published and disseminated to the registered body. It has been the subject of focus group attention for several weeks before the approval of its principles. We await the final draft details, but in the meantime, we can posset its incarnation and comparison with the same outcomes that Dental Professionals adopted in the UK in 2018. I find it interesting that the NZDC derives their inspiration for such change from the UK and Europe, once again. Interestingly though it appears they have done things a little differently and, it seems to me, slightly better. Perhaps this alludes to the historical and cultural differences between practice cultures in New Zealand and the UK, as well as the size of the professional populations of both countries.
“Will attending the course change the way you think, or carry out your role in your practice?” Postgraduate Medical and Dental Education for Wales, UK
The key features of the new design include the creation of a Professional Dental Plan (PDP), Professional Dental Activities (PDA’s) replacing the present learning title of CPD, annual online self-declaration to the effect of completion or attendance, a Professional Peer Relationship (PPR) and written reflective practice. These are radical departures from what is presently the norm, and they will come into effect, it is reported, from the 1st April 2021. All the above components are found at the General Dental Council (GDC) of the UK with minor nuanced changes from 2018. 2.
The roots of changes in the UK stem from the need to identify and develop personal, professional skills, in line with your present skill set and workplace environment. The PDP allows you to track and achieve those goals. A degree of flexibility and review of your learning journey is set into the PDP criteria. It is further boosted by the critical and supportive input of a skilled and qualified mentor, in the UK case and, here in New Zealand, a Professional Peer (PP). The PP “must be able to provide knowledge and credible feedback relevant to the practitioners’ professional development”. The New Zealand method is more personal, it can be one on one, via teleconferences or by email. The responsibility of the clinician/professional peer relationship is further emphasised by official confirmation that. “Before a practitioner applies for an Annual Practising Certificate (APC) each year, the PP will need to provide confirmation online that the practitioner has interacted with them during the year, has a PDP, participated in PDA’s and has reflected in writing”. The PP can also assist in developing and reviewing PDP’s and assist in PDA developmental choices.
“Fail to plan, and you plan to fail”. Benjamin Franklin
Primarily though, it allows the clinician learner the ability, responsibility and accountability of self-directing their own knowledge creation. There are a variety of sources to effect meaningful learning. Traditionally we as a professional body have leaned heavily upon the local professional study groups and associated learning events. The annual professional body seminars, Dental Trade Industry (DTI) sponsored events and roadshows are traditionally well-trodden sources of knowledge. There is a cost element attached to belonging to associations and paying for events, mollified by the DTI to some extent, more so in recent years. This brings into focus the issue of PDA’s being overtly linked to commercial interest, in part, where the Industry is in direct contact and potentially influencing the decision making of professionals. Historically the DTI has been on the fringes of conferences and meetings but now appear to be more directly involved in providing CPD. This is effectively brought to the attention of the discerning clinician by Gillis and McNally (2010) who state “University-industry relationships are becoming increasingly common in academe. While these relationships facilitate curriculum relevance, they also expose students to external market forces”. They continue, “Industry’s presence in academe is a concern. Dental educators (and dental health professionals from 2021 – author’s note), as stewards of the profession, must be nimble in brokering Industry’s presence without compromising the integrity of both the educational program and the teaching industry as a whole”. It appears that the NZDC’s move to create a new recertification process has considered this as well. Allowing self-directed study, independent research and authentic learning negate this influence, in part. 3.
“Before you decide to attend a course or an educational event, you need to question the relevance to you of the subject being covered”. Postgraduate Medical and Dental Education for Wales, UK
Additionally, in what I feel is a further bold move, there will be “No mandatory requirement to meet a quota of PDA hours.” There will also be no requirement for PDA’s to be verifiable and will be linked to “Any activity relevant to maintaining and building a practitioners competence in their SOP. PDA activities need to be aligned with “Specific developmental outcomes”. Think about your workplace, your roles within in it, clinically or non-clinically, the nature of the practice and its clients. For example, I work in a general and modern orthodontic practice, I treat both disciplines from a dental hygiene perspective, the parents of the younger orthodontic cases tend to be very involved with their children’s care, they are included too. I work collaboratively with orthodontic auxiliaries, dental assistants, dentists and reception and office staff and managers too, as a team. Planning meaningful and practical PDA may see learning in non-dental related subjects such as leadership, communication or team building.
Writing a PDP begins with an honest appraisal of where you are now professionally, your workspace, where you feel you need to go by identifying your specific career goals and learning needs to ultimately accomplish them. Consider your timeline, the NZDC are preparing a move from it being 2 to 3 years, whereas the GDC, UK have structured 5 into theirs. I’m not sure how I feel about this, the longer would be preferable as learning can be more open-ended and reviewing your PDP might lead to more changes as a consequence, as well as workplace changes leading to modifying learning goals. A 3-year cycle might be justified initially as trialling the new regime, but alterations to future timelines might require adjustment from feedback and experience. The templates for PDPs will be necessary too, created individually or by supportive professionally bodies or the DTI.
“You may wish to reflect after every activity, or at intervals during the year, reflect with your employer, or a peer or mentor”. Postgraduate Medical and Dental Education for Wales, UK
Reflection may be the most significant educational challenge that Dental Professionals face as part of this educational development change process. I had the opportunity to be exposed to reflection during a degree programme at the University of Kent several years ago. Initially, the process was very confusing, understanding the methodology, learning to write and express the sentiment of something you do mentally, every day in many clinical and ordinary experiences. Consider cooking a new recipe, you taste it and realise it may need seasoning or more of something and less of the other to enhance it, the next time you repeat it you alter your process again. This reflective critical self-appraisal doesn’t have to be a novel or a work of literal art but just an honest and revealing attempt to describe a situation in your professional environmental. We need to demonstrate learning that has occurred, what we alluded from it, or not, what would we do differently as a consequence of it. Eventually, it leads onto planning improved practise, and what future developmental directions do you think you need to go.
“Self-reflection is a humbling process. It’s essential to find out why you think, say, and do certain things – then better yourself”. Sonya Teclai
I can remember re-registering with the NZDC in 2013, returning to New Zealand from the UK with a portfolio of evidence of learning, with a PDP, PDA log and reflections linked to education. I was advised that at that time that there were gaps in my portfolio, and I needed to catch up with CPD hours to comply. I was horrified to think that what I had learned from a UK university while doing a dental education degree wasn’t deemed enough. Ironically now, it seems that the NZDC is adopting those things I presented way back then. I will fall back on what I originally learned and prepare a PDP, construct PDA’s and continue to reflect upon my processes. I will find a PP and form a relationship which will help me evolve my practice further. Also, as part 2 of this piece, I will delve further into self-directed learning methods that can help the independently minded critical thinker/learner/researcher to move forward in this COVID19, post COVID19 clinical environment “Brave New World”.
Annual renewal and fees, GDC, UK.
Gillis, MR & McNally ME (2010). The influence of Industry on dental education. https://www.ncbi.nlm.nih.gov/pubmed/20930240
A Personal and Professional Reflective Journey into an unknown and uncertain future. Whole Dental Health, A Brave New World.
Reflection will soon become a requirement of recertification as a Dental Hygienist in New Zealand. I’m not sure how many within the profession have written reflectively but what you find below is a quick example of reflective practice about my recent and ongoing experiences regarding the COVID 19 pandemic as a Dental Hygienist. It is both personal and professional, it could be written in a variety of ways, using different approaches of reflection from Kolb, Gibbs or Schon as examples but I’ve decided to use a What, So What, Now What pathway for its ease of use. For more information and examples, please use the referenced links at the end of the piece. Good luck and remember how beneficial it is they think about what you’ve experienced, how it has affected you and the changes you may consider making as a consequence of them.
“Necessity is the mother of all invention”. Old Proverb
Just three months ago I was looking forward to March, especially the 17th, when I was completing a six-month locum stint in practice in Blenheim, Marlborough. I had work organised in Nelson to replace what I was leaving behind and my professional life, for once, looked peachy. Little did I know that by that date, I had reappraised and adapted my clinical approach to dental hygiene treatment. At the same time, I was feeling underwhelmed by the lack of concern and fragility of fellow professionals being displayed in the clinical environment and in online professional chatline on social media. COVID 19 was a “Clear and present danger” to me and those I respected and cared for both personally and professionally. I had started giving it consideration by about mid-January when the news was slowly filtering from Wuhan via the media that a novel virus was causing lockdowns, infections and, the start of what was to be, many deaths being reported. The concerns of a rising epidemic becoming very real.
After listening to RNZ, I began to think about how I’d respond if it came to New Zealand. I could potentially be seeing asymptomatic, pre viral or even viral cases not far off in the distance. Ironically the first thing I did was to pick up a few masks and brought them home, we had a few boxes of gloves in the house from my Wife’s old locum midwifery practice. She had given me the “are you a conspiracy theorist” look initially but found a quiet place for them, just in case. My children and their respective partners had recently been to Europe on holiday, and all but 1 had experienced colds and fevers either during or on their return. I kept my distance from them and as the epidemic continued the realisation of it going pandemic grew. I started to consider how I was going to modify how I worked, my concerns being the safety of my clients and myself. About this time, a rush on not only toilet roll but hand sanitiser saw both items being panic bought and dental supply companies running out of stock rapidly overnight.
We had intended to have a practice meeting, scheduled on the 25th February, and I was going to present on a “Sustainable Approach to Dental Health”. This I withdrew from and advised the Practice Owner and Manager to consider the meeting’s topic changed to what might potentially happen over the next few days and weeks regarding COVID 19 and how protected and safe our clients and ourselves would be. It felt like we were transitioning to a weird kind of war footing (I had experienced this during Gulf War 1 in 1991) and felt some of our colleagues weren’t as aware of all the facts and even concerned as much as they should be. I’m glad we had the meeting as it began the process of mental adjustment for all and adapting to the threat of COVID. We placed information notices on doors, put out hand sanitisers for clients to use and took stock of the supplies we had and began to order more, especially hand gel, masks and gloves. The unknown became very real when on 28th February when” case of COVID 19 in New Zealand was announced.
One of my Wife’s friends is an Emergency Department Nurse who lives in Canada. Her Son, a young, healthy man in his early Thirties was one the first to die of COVID in his country. We heard this sad news about mid-March, Toni was devasted. She and I began to make the growing COVID risk more apparent to all our friends and family. Some found it too extreme, others were still unconcerned, but very soon the reality was setting in that things were not going to stay the same for much longer. The March Fest in Nelson, a Beer Festival, on the 14th, March was the last event I was to attend with my Sons for some time to come. New phrases like “Physical distancing” and “Flattening the curve” began to become accepted norms, similar as our forefathers call to action with phrases such as “Dig for Victory” and “Careless talk costs lives”. Regular visits to the shops to quietly stock up on food and groceries gathered a pace and our cupboards, once empty began to fill to support our “Bubble” isolation for the weeks to come.
The government initiated a COVID 19 strategy of “Going hard and fast” on protecting the population, stepping up testing and self-isolation for those returning to New Zealand after the 25th March. That week, a rapidly created Alert state had been implemented, we were at level 3 by the 23rd and total lockdown, Level 4, by the 25th, March. My routine and regular practice, something very familiar to me in various clinic guises for some 30 years, ceased that Monday and we held a final impromptu “socially distanced “practice meeting. The future and our careers seemed very uncertain, all of a sudden.
Way before the end of March, I started to reduce and then cease all my aerosol producing clinical activity, despite others continuing it. In particular, I hung up my ultrasonic and airflow systems and began making sure that I displayed to my clients super visual hand washing techniques as reassurance. However, I did continue to use slow handpieces continued, which do create a droplet field. My dilemma was genuine that clients were paying and expected to feel that their teeth were effectively cleaned. Aspiration was the best barrier to reducing its potential contamination. Cleaning down after treatment and set up processes for the next client were more deliberate and measured. I work without chairside support. This will need to change.
The New Zealand Dental Council with the Ministry of Health directed all unnecessary treatment cease from the 23rd, March as previously stated. They drew up unambiguous guidance on what is deemed an emergency and what is not. It was crushing to think that everything I did was effectively non-essential and that would remain true until we drop back to Level 2 from 4. The initial 4-week lockdown could be extended, if required, and no suggestion of when Level 2 is on the horizon as yet. However, the Prime Minister is now asking businesses to plan and consider how they restart or reset when that time approaches. What does this mean to me? I’m using the time to catch up on many things, educational I’m writing the blog, and this is fifth so far. I’ve a plan, set out last year and every excuse under the sun has held me back completing it. Not now. Additionally, and perhaps more importantly, I need to familiarise myself with all the recent updates and mentally preparing myself for an alternative, uncertain professional future.
I am also a little uncertain of this new clinical reality, one which will mean the wearing of Personal Protective Equipment beyond my previous norm in the course of routine dental hygiene treatment. One very visual video I saw on YouTube by the Auckland DHB demonstrated how to dress with PPE, hand sanitisation four times for one process of gown, gloves, masks and protective eyewear being put on and taken off. How many would our practice need and wherein these times of shortages of such items would we get them from? How much would they cost and would our clients accept the changes and additional fees is added to the treatment costs? These decisions I, fortunately, don’t have to make but how I approach my clinical practice, beyond the PPE debate, is evident to me.
PPE will need to be updated with visor and if required gowns. A few trial runs getting to know how to put it on, that’ll be interesting.
So, as per NZDA guidance, all my cases will be categorised as Low-Risk Care, not positive for COVID 19 or any associated exhibiting symptoms, or in close contact with those who do. The international travel aspect will shortly not apply for sure, for some time. No aerosol-generating equipment, all appropriate PPE equipment required, including gowns and our routine surgery use.
I wonder how many of the profession think everything will return to normal rapidly? Some, like myself, may align to that notion only when vaccination is developed and tested, produced in the numbers required to globally distribute and facilitate it. Essential healthcare and general workers, those at risk, the immunocompromised and the elderly will undoubtedly and rightfully be first in the queue. This will take time, and until then I will subscribe to the immortal words of the great Clint Eastwood, “Improvise, Adapt and Overcome” because “Tomorrow is promised to no one”. However, the lingering thought is this, how much will it ultimately cost the profession, additionally the client and will they return in the numbers they used too?
1. Ministry of Health, Dental Council and Professional Associations’ joint statement: COVID-19 update*
2. What is a Critical Reflection? Introducing the “What, So What, Now What” Model – Use the Course environment as your workplace and learning environments
3. Reflecting on a Personal Experience Using the “What, So What, Now What” Model https://youtu.be/_mQ_zDUX9nE
4. Sample Reflection: Reflecting on a Course Activity
Developing my PDA’s and PDP in the light of future changes to recertification. Redesigning from 2019 to 2022. Whole Dental Health – A Brave New World.
From April 2021, to gain recertification as a Dental Hygienist, I am required to create a Professional Developmental Plan (PDP) that lays out my learning and developmental aims and goals for my regulatory board. The New Zealand Dental Council (NZDC) has changed the criteria for Dental Healthcare Professionals (DHP). This is in line with many other regulatory organisations to add depth and quality to continuing professional development (CPD), involve the learner in educational attainment work directed towards their workplace culture and environment. In addition to these, a Professional Peer (PP) will be required to act as a mentor, advocate and overseer of this process combined with a personal written reflective practice of Professional Development Activities (PDA). The method that is demonstrated in figure 1.
Fig 1. GDC UK reflective cycle for PDA’s
In this account, I wish to look back on the previous year, starting April 2019, as the beginning of the new cycle, as the initiation of my PDP. Then account for the learning undertake from then to the present and consider the current situation with COVID 19 disrupting clinical practice for non-essential care. This is also, paradoxically, an excellent opportunity to find where you presently are professionally and where you feel you want or need to go in planning your learning journey. Historically I had created a PDP and record on it my PDA when I was studying at The University of Kent several years ago. It is something I lost touch with coming to New Zealand in 2013 but having prior knowledge of it has led me back to my archives to dust off the means of recreating them.
When choosing goals, I look at the NZDC standards framework guidance, feedback from clients and colleagues, appraisals from employers and management. Give consideration to non-clinical aspects of practice too, leadership, communication, research and teaching skills may form ideas for learning objectives. Prioritise, if possible, your goals in order of importance or in a timeline (authors note). The various methods of achieving learning objectives include conferences be they regional, national or international, the setting whether online learning or workplace training or shadowing. You could also create your own learning journey, focused on your needs where they can’t be met more formally. Authentic learning and action research, similar to inquiry learning, can offer self-directed alternative approaches to new claims to knowledge and more meaningful first personal development in addition to convention education.
Fig 2. PDP log
My practice culture and status over the last year has changed, from a general dental practice setting to a mixed but mainly orthotropic – arch expansion – orthodontic setting with 3 orthodontic auxiliaries, 1 dentist, 3 Dental Assistants, a Manager and Receptionist. The COVID crisis has seen the practice shed a dentist and Dental Assistant. The move from Blenheim to Nelson has seen a role shift into a new dimension of dental hygiene with a greater onus on a strict regime of infection control, being less liberal than the previous practice by some margin. My learning goal became one of catching up. Before starting work in my present location, as can be in figure 1, I was engaged in an epic 9-week overseas sabbatical, see “experimental Learning 19” menu and reflections related to it.
I constructed a way to present it through a website portal. I used WordPress to create a website that could additionally support the goal-setting, evidence gathering and writing. Getting the right themes and menus has been a challenge, the intricacies of knowing how to create pages and posts, how to tag and edit, insert pictures and keep up with new ideas and technical difficulties has been rewarding and, at times, a little stressful. Potentially It could be a useful device for colleagues to adopt if so inclined as a simple way to demonstrate compliance, development and transparency. Below are two links, created by the same person on how to go about creating one.
How To Make a WordPress Website – For Beginners https://youtu.be/8AZ8GqW5iak
How To Make a WordPress Website – In 24 Easy Steps https://youtu.be/2cbvZf1jIJM
It was my intention to develop my role in my current practice by travelling to Melbourne to complete a course in Oral Myofacial Function so I could evolve my practice and create my clinical time. This was cancelled due to the COVID 19 crisis, and there appears to be little prospect of undertaking it in the foreseeable future and, in effect, it is on hold. I am presently considering how I move forward with my PDA goals and have come to the conclusion that writing about topics that interest me, that are linked to my workplace and the future recertification process can take precedence for now. My colleagues have advised me on CPD topics related to orthotropics and oral myofacial function. Still, I’ve decided to engage those when the current Alert state reduces, and I have the inevitable clinical white space at work. The opportunity to focus on professional writing has been scarce until now. Below are two links to those subjects which will be added to the PDP shortly with a duel reflection and discussion with my professional peer.
Growing Your Face by Dr Mike Mew
A Speech Therapist’s Approach to Myofunctional Therapy
During my first few months in Nelson, I began to realise, very quickly, that many of my clients were somewhat “alternative” and investigative in their approach to subjects like fluoride and nutrition. There was also a cohort of clients interested in environmental issues and sustainability. This made me consider my approach to that, as well. In comparison to Blenheim cliental, where I continued to work as a locum for two days of the week, this posed a paradoxical living challenge. The contrast between the two client bases was stark both in terms of their dental knowledge and expectations of the nature of my delivery of care which makes me reflect. One I was cosy with, having worked there for several years and the other new. I had to move deeper into researching and investigating their positions on it. I was curious and willing to listen, to understand without judgement and I was careful to recognise and affirm other people’s opinions, and offer tailored alternative advice or options, especially regarding topics like nutrition and fluoride.
Moving forward, we still await the proposed changes to recertification to be officially confirmed. The NZDC response to the COVID crisis has allowed the professional to breathe a sigh of relief regarding compliance with the strict verifiable CPD hours. This allows an opportunity for all to reflect on the PDA and future educational goals with the time created by the lockdown. This is precisely what I’m doing, I have a project, begun last year to complete, I can continue on the theme of changing practices and direction within the new one, displayed via a website online for the sake of transparency. It also demonstrates my learning journey for others to view and to comment on and promotes my passion for self-directed, appropriate and authentic learning as a juxta-position to the norm.
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