Australian Dental Journal
The official journal of the Australian Dental Association
Australian Dental Journal 2015; 60: 154–162 doi: 10.1111/adj.12317
Australian dentists: characteristics of those who employ or are willing to employ oral health therapists# C Kempster,* L Luzzi,† K Roberts-Thomson‡ *Lecturer, School of Dentistry, The University of Adelaide, South Australia. †Senior Research Fellow, Australian Research Centre for Population Oral Health; Director, Dental Statistics and Research Unit, Australian Institute of Health and Welfare; School of Dentistry, The University of Adelaide, South Australia. ‡Director, Australian Research Centre for Population Oral Health, School of Dentistry, The University of Adelaide, South Australia.
ABSTRACT Background: There has been an increase in the availability of oral health therapists (OHTs) in the oral health workforce in the last decade. The impact these clinicians will have on the oral health of the general public is dependent on access pathways and utilization. This study aimed to profile Australian dentists who employ or are willing to employ OHTs and to explore the degree of association between dentist characteristics and employment decisions. Methods: This cross-sectional study used a random sample of Australian dentists (n = 1169) from the Federal Australian Dental Association register in 2009. Participants were sent a postal questionnaire capturing dentist characteristics and oral health practitioner employment information. Results: An adjusted response rate of 55% was obtained. Dentists willing to employ OHTs included non-metropolitan dentists, dentists in multiple surgery practices and those considering practice expansion. Age, gender and sector of practice were not significantly associated with retrospective employment decisions or willingness to employ in the future. Conclusions: Certain characteristics of dentists or of their practice are associated with their history of employment and willingness to employ OHTs. Employment decisions are more commonly related to entrepreneurial aspirations (expressed as a willingness to expand), sector of practice, surgery capacity and regionality over gender and age. Understanding the factors that influence the employment of OHTs is important in enhancing access pathways to the services provided by OHTs. Keywords: Access, employment, oral health therapist, prevention, utilization, workforce. Abbreviations and acronyms: OHT = oral health therapist. (Accepted for publication 5 August 2014.)
INTRODUCTION Practitioners who have completed an Australian Dental Board approved and accredited bachelor programme of study in the ‘dual streams of dental therapy and dental hygiene’ can now register under the new national registration category of ‘oral health therapist’ (OHT).1 OHTs may provide clinical services in which they are competent to all members of the general public, under a collaborative and referral relationship with a dentist. The OHT works as part of a dental team but there is no longer a requirement for the dentist to be onsite.2 The OHT can make #An oral health therapist is an Australian oral health practitioner who has obtained a qualification at a Bachelor level and is registered with the Dental Board of Australia to practise within the traditional disciplines of dental therapy and dental hygiene. 154
autonomous decisions relating to patient care within their scope of practice. As all health care professionals are expected to operate in Australia, OHTs must only provide clinical services that fall within their educational, professional and ethical boundaries.2 OHTs are permitted to own a private dental practice; however, practice ownership to date has been relatively limited. Given that a large proportion of dentistry in Australia is undertaken in the private sector, it can be said that in part, the responsibility for the employment and geographic distribution of OHTs across the country now lies with private sector dentists. Therefore, it is timely to profile those dentists that have employed, or might be willing to employ OHTs and to examine the personal, demographic and practice characteristics that impact on their employment decisions. It is reasonable to question whether these characteristics and employment decisions ultimately © 2015 Australian Dental Association
Australian dentists who employ oral health therapists impact on general public access to preventive and primary care services that OHTs are specifically trained to provide. Anecdotally, it has been suggested that females may be more sympathetic toward the employment of an OHT, public sector dentists would be more likely to employ an OHT given their history working with dental therapists and older dentists would be less likely to employ an OHT given their tendency to hold sovereign views. Part A of the analysis aimed to test those suggestions and assess whether other characteristics such as practice location (metropolitan, rural, state/territory), region, type (general, specialist), number of surgeries and considered practice expansion were associated with dentists’ decisions to currently employ or consider future employment of OHTs. With very few training courses remaining around Australia that produce just dental therapists or dental hygienists as singular discipline operators, it is certain that there will be a greater number of graduates with a Bachelor of Oral Health or equivalent looking to enter the dental labour force in coming years. However, graduates may find it difficult to gain satisfying employment across Australia, employment that will allow the full utilization of their complete skill set, if barriers to employment exist within certain dentist subpopulations. This article explores factors in relation to OHT workforce employment and skill utilization, and its impact on public access to preventive and maintenance services in Australia. From these observations, educational or policy related interventions designed to encourage team service delivery, improved interprofessional understanding and greater allied oral health workforce utilization, can be better targeted. This study aimed to profile dentists across Australia who employ OHTs or are willing to employ an OHT and explore the degree of association between certain personal characteristics and employment decisions. MATERIALS AND METHODS Human research ethics approval was sought and granted by the University of Adelaide’s Office of Research Ethics, Compliance and Integrity (ORECI). A postal questionnaire was based on qualitative data collected from a focus group conducted at the Australian Research Centre for Population Oral Health (ARCPOH) in late 2008. For the focus group a simple random sample of 83 dentists on the South Australian Dental Board register were selected and invited to participate. Twelve dentists responded positively and nine attended. A grounded approach to questioning3 was used to capture dentists’ attitudes towards a range of issues including dental education, the value © 2015 Australian Dental Association
of an OHT, team work and service delivery to the general public. Qualitative analysis was performed to extract themes from the discussion which were then used as the basis for question formulation for the data instrument. A stratified systematic random sample of 1169 Australian dentists was selected from the Federal Australian Dental Association register in 2009. Selected dentists were sent a postal questionnaire. Sample size calculations were based on a two-sided significance level of 0.05 and 80% power in order to detect a 15% difference in the percentage who would consider employing an OHT in their practice. Dentists were categorized to capital city or rest of state strata based on their practice postcode using the Australian Bureau of Statistics (ABS) Statistical Division, Postcode Concordance File version 2006,4 obtained from the ABS website. The questionnaire comprised three parts. Part A asked dentists to provide demographic information as well as an indication as to whether they currently employed dental therapists, dental hygienists or OHTs. Dentists were also asked if they would consider employing only an OHT regardless of whether they were in a position to hire or not. Part B required participants to identify whether they thought certain clinical procedures could legally be performed by OHTs and was classified as ‘Yes’, ‘No’, ‘Don’t Know’. Part C explored dentists’ perceptions and attitudes using a five-point Likert scale for 15 statements (also themed using the focus group data). Dentists were also invited to provide open comment in relation to the role of the OHT at the end of the questionnaire. Only the results from the analysis of the data received in Part A are presented in this article. Following three mailings, based on the Dillman ‘Total Design Method’,5 an adjusted response rate of 55% (n = 565) was obtained. From the sample of 1169 participants, there was no response from 439 individuals, three were retired, three were no longer practising dentistry, seven refused to participate, one participant was deceased, 127 were returned to sender and 24 questionnaires were returned blank. The demographic characteristics of Australian dentists’ characteristics from this sample were compared to that of the Australian Institute of Health and Welfare Dental Labour Force data from 2006.6 Due to the differences between the sample and the national labour estimates, the data were weighted for age, sector of predominant practice, state and region (metropolitan versus rest of state). Cases with missing values were excluded from all analysis. Table 1 documents these results. Statistical analysis were conducted using PASW Statistics 18 to account for complex sampling design. 155
C Kempster et al. Table 1. Comparison of the unweighted frequencies of dentists’ characteristics with those reported in the AIHW Dental Labour Force 20065 Participant characteristics
Gender Male Female Age 20–29 30–39 40–49 50–59 60+ Sector of predominant practice Public Private Both State New South Wales Victoria Tasmania South Australia Western Australia Northern Territory Queensland Australian Capital Territory Practice location Metropolitan Rest of state Area of practice General Specialists Other University of graduation Australian o South Australian o NSW o VIC o QLD o WA Non-Australian
2006 Dental Labour Force Data %n
%n
70.3 376 29.7 159
71.0 7390 29.0 3014
14.3 19.1 21.4 27.4 17.7
12.3 23.7 27.0 24.1 12.9
81 108 121 155 100
1279 2461 2810 2505 1349
9.0 51 76.1 430 14.9 84
13.3 1386 78.1 8126 8.6 892
29.2 16.5 8.1 11.7 9.9 5.5 14.0 5.1
34.2 23.5 1.7 7.9 10.3 0.8 19.5 2.1
165 93 46 66 56 31 79 29
3562 2449 172 826 1071 78 2029 217
53.3 301 46.7 264
79.3 8250 20.7 2154
87.3 493 10.6 60 2.2 12
87.5 9158 12.0 1246 0.5 50
82.0 23.3 21.4 12.1 15.2 9.9 18.0
432 123 113 64 80 52 95
Not reported
Dependent variables were ‘dentists currently employing’ and dentists ‘willing to employ’ an OHT. Independent variables examined (or factors associated with dentists’ employment decisions) were dentist age, gender, practice location (metropolitan or rest of state), sector of predominant practice and Australian state or territory in which they practice. Other physical and economic employment barriers were examined such as clinic space and willingness to expand practice services. Non-parametric analyses were performed (Pearson’s chi-squared) to provide employment and willingness to employ estimates for the independent categorical variables and to test for predictor association. Multivariable logistic regression modelling and analysis was undertaken to confirm the strength of the range of factors associated with dentists OHT employment decisions. 156
RESULTS Current employment of dental therapists, dental hygienists and oral health therapists When asked to indicate current employment of an OHT, a dental hygienist or a dental therapist 31.5% (n = 178) of dentists employed at least one of the three oral health practitioners; 12.1% (n = 57) employed an OHT, 18.3% (n = 86) employed a dental hygienist and only 7.4% (n = 35) employed a dental therapist only, leaving 62.2% not employing any. To determine whether specific employment of OHTs was associated with dentist demographics and practice characteristics, bivariate analysis was conducted. Significant associations were found between dentists’ age, sector of practice, state in which dentists’ practice and the number of dental surgeries within the dental practice (Table 2). Dentists employed fewer OHTs as they aged beyond 50 years, if they worked solely in the public sector, if their practice was located in Tasmania, Western Australia, New South Wales or Victoria, or if their practices contained fewer surgeries. Estimates relating to the influence of sector though should be interpreted with caution as it is possible that some may have responded on behalf of the organization that they work for. Multivariable analysis was used to assess the impact of the dentist and practice characteristics on employment of OHTs (Table 3). This analysis assists understanding of the association while controlling for demographic factors. The dependent variable used here was a dichotomous ‘employs OHTs’ (Yes/No) in order to specifically explore the likelihood of dentists employing the OHT only. Analysis confirmed that after controlling for dentists’ age and regionality, dentists age and practising in multiple surgery practices were influential demographic variables amongst dentists that currently employ an OHT. Table 3 shows the odds ratios of dentists choosing to employ an OHT and confidence intervals for dentists in each category. The reference categories chosen for the age, sector and surgery number comparisons represents the category with the lowest value from the bivariate analysis. The state of Queensland was chosen as the reference category on this occasion as the University of Queensland was the first university to offer an undergraduate degree programme graduating OHTs and employed the highest number of OHTs across all states. As dentists aged, the likelihood of them employing an OHT declined. When compared to dentists aged 20–29 years, dentists aged 40 years plus were significantly less likely to currently employ an OHT (OR = 0.39, 95% CI 0.118–0.91). © 2015 Australian Dental Association
C Kempster et al. Table 3. Multivariable comparison of employment of OHT by dentist and practice characteristic Employing an OHT Age category 30–39 40–49 50–59 60+ years Sector Private Both State/Territory NSW VIC SA WA TAS NT ACT Number of surgeries 2 3 4 5
OR
95% CI – – – –
Reference category 20–29 year olds
0.42 0.33 0.22 0.23
0.14 0.12 0.08 0.08
1.24 0.92 0.59 0.68
2.78 4.94
0.56 – 13.95 0.82 – 29.57
0.50 0.37 1.24 1.44 1.27 1.96 0.86
0.24 0.14 0.48 0.48 0.48 0.53 0.27
– – – – – – –
1.06 0.99 3.27 4.37 3.37 7.30 2.81
1.12 2.11 3.30 4.33
0.18 0.68 1.07 1.50
– – – –
1.77 6.59 10.67 12.46
Public sector State of QLD
1 surgery
The reference category selected represents the lowest value for each factor taken from the bivariate analysis of those who currently employ an OHT (with the exception of Queensland who employed the highest number of OHTs across Australia).
A complex sample binary logistic regression model for ‘willingness to employ’ was constructed. The variables shown in Table 4 with significant bivariate association were included in the analysis along with age and sector. The dependent variable was a dichotomous ‘willingness to employ’ (Yes/No) and covariates were dentists’ age, sector of practice, region of practice and number of surgeries in the practice. Analysis confirmed that only region of practice (p = 0.001), number of surgeries in the practice (p = 0.01) and consideration of practice expansion (>p = 0.03) were significant factors in relation to dentists’ willingness to employ an OHT. Dentists age (p = 0.06) and sector of practice (p = 0.07) had a marginal association and were therefore included in the odds analysis. Table 5 shows the odds ratios of dentists willing to employ an OHT, confidence intervals and reference variable for dentists in each category who were willing to employ. The reference category chosen for each individual predictor represents the category with the lowest value of dentists reporting a willingness to employ an OHT in the bivariate analysis. Dentists who were not willing to employ because they currently employed an OHT already were removed from the multivariable analysis. Dentists aged 20–29 years reported higher odds of a willingness to employ an OHT compared with all other age categories, with the 50–59 years category being the least willing (Table 5). Although age category was not significant in the bivariate analysis, it is noted that the probability of them considering 158
employing an OHT reduced across age categories with dentists aged 50–59 years being significantly less willing to employ an OHT over a dentist aged in their twenties (OR = 4.61, 95% CI 1.70–12.50). Dentists were asked to consider their willingness to employ an OHT even if they ‘were not a principal dentist or practice owner’. Despite the slightly weaker statistically significant association, it was noted that those working in the public sector may be more willing to employ an OHT if they were in a position to do so (OR = 2.82, 95% CI 1.01–7.85), although working across both sectors did not make a significant difference (OR = 1.40, 95% CI 0.63–3.13). Those working in non-metropolitan areas were twice as likely to consider employing an OHT as their metropolitan colleagues (OR = 2.22, 95% CI 1.32–3.73). Similar trends were noted in relation to surgery numbers between willingness to employ an OHT and dentists who currently employ an OHT. Significant increases in likelihood started at those who worked in practices with three or more surgeries (OR = 3.14, 95% CI 1.25–5.11). Again, as surgery numbers within the practice increased so did the odds of dentists being willing to employ an OHT. Dentists who have considered practice expansion were nearly four times more likely to consider employing an OHT than those who had not (OR 3.96, 95% CI 2.02–7.75). DISCUSSION Australian dentists are largely responsible for the employment distribution and utilization of the dental hygienist, dental therapist and oral health therapist labour force. This study and analysis suggests that there are a number of both demographic and personal characteristics of dentists that influence decisions specifically around OHT employment. The age of the dentist and the number of surgeries available within the practice are two demographic factors that have been major influences over the OHT employment decisions of dentists to date. Although dentists’ age was significantly associated with past OHT employment decisions, it became less of an influencing factor in dentists deciding whether they would be willing to employ an OHT. That said there were significant differences between the 20–29 year old cohort and the 50–59 year old cohort that are worth noting. Dentists who are more likely to be willing to employ OHTs are those practising in non-metropolitan areas, who have public sector background, are in clinics with multiple surgeries and in practices where dentists have aspirations of practice expansion. These decisions seem to relate to economic or business related intentions and regionality over personal characteristics of dentists such as age and gender. © 2015 Australian Dental Association
C Kempster et al. Table 3. Multivariable comparison of employment of OHT by dentist and practice characteristic Employing an OHT Age category 30–39 40–49 50–59 60+ years Sector Private Both State/Territory NSW VIC SA WA TAS NT ACT Number of surgeries 2 3 4 5
OR
95% CI – – – –
Reference category 20–29 year olds
0.42 0.33 0.22 0.23
0.14 0.12 0.08 0.08
1.24 0.92 0.59 0.68
2.78 4.94
0.56 – 13.95 0.82 – 29.57
0.50 0.37 1.24 1.44 1.27 1.96 0.86
0.24 0.14 0.48 0.48 0.48 0.53 0.27
– – – – – – –
1.06 0.99 3.27 4.37 3.37 7.30 2.81
1.12 2.11 3.30 4.33
0.18 0.68 1.07 1.50
– – – –
1.77 6.59 10.67 12.46
Public sector State of QLD
1 surgery
The reference category selected represents the lowest value for each factor taken from the bivariate analysis of those who currently employ an OHT (with the exception of Queensland who employed the highest number of OHTs across Australia).
A complex sample binary logistic regression model for ‘willingness to employ’ was constructed. The variables shown in Table 4 with significant bivariate association were included in the analysis along with age and sector. The dependent variable was a dichotomous ‘willingness to employ’ (Yes/No) and covariates were dentists’ age, sector of practice, region of practice and number of surgeries in the practice. Analysis confirmed that only region of practice (p = 0.001), number of surgeries in the practice (p = 0.01) and consideration of practice expansion (>p = 0.03) were significant factors in relation to dentists’ willingness to employ an OHT. Dentists age (p = 0.06) and sector of practice (p = 0.07) had a marginal association and were therefore included in the odds analysis. Table 5 shows the odds ratios of dentists willing to employ an OHT, confidence intervals and reference variable for dentists in each category who were willing to employ. The reference category chosen for each individual predictor represents the category with the lowest value of dentists reporting a willingness to employ an OHT in the bivariate analysis. Dentists who were not willing to employ because they currently employed an OHT already were removed from the multivariable analysis. Dentists aged 20–29 years reported higher odds of a willingness to employ an OHT compared with all other age categories, with the 50–59 years category being the least willing (Table 5). Although age category was not significant in the bivariate analysis, it is noted that the probability of them considering 158
employing an OHT reduced across age categories with dentists aged 50–59 years being significantly less willing to employ an OHT over a dentist aged in their twenties (OR = 4.61, 95% CI 1.70–12.50). Dentists were asked to consider their willingness to employ an OHT even if they ‘were not a principal dentist or practice owner’. Despite the slightly weaker statistically significant association, it was noted that those working in the public sector may be more willing to employ an OHT if they were in a position to do so (OR = 2.82, 95% CI 1.01–7.85), although working across both sectors did not make a significant difference (OR = 1.40, 95% CI 0.63–3.13). Those working in non-metropolitan areas were twice as likely to consider employing an OHT as their metropolitan colleagues (OR = 2.22, 95% CI 1.32–3.73). Similar trends were noted in relation to surgery numbers between willingness to employ an OHT and dentists who currently employ an OHT. Significant increases in likelihood started at those who worked in practices with three or more surgeries (OR = 3.14, 95% CI 1.25–5.11). Again, as surgery numbers within the practice increased so did the odds of dentists being willing to employ an OHT. Dentists who have considered practice expansion were nearly four times more likely to consider employing an OHT than those who had not (OR 3.96, 95% CI 2.02–7.75). DISCUSSION Australian dentists are largely responsible for the employment distribution and utilization of the dental hygienist, dental therapist and oral health therapist labour force. This study and analysis suggests that there are a number of both demographic and personal characteristics of dentists that influence decisions specifically around OHT employment. The age of the dentist and the number of surgeries available within the practice are two demographic factors that have been major influences over the OHT employment decisions of dentists to date. Although dentists’ age was significantly associated with past OHT employment decisions, it became less of an influencing factor in dentists deciding whether they would be willing to employ an OHT. That said there were significant differences between the 20–29 year old cohort and the 50–59 year old cohort that are worth noting. Dentists who are more likely to be willing to employ OHTs are those practising in non-metropolitan areas, who have public sector background, are in clinics with multiple surgeries and in practices where dentists have aspirations of practice expansion. These decisions seem to relate to economic or business related intentions and regionality over personal characteristics of dentists such as age and gender. © 2015 Australian Dental Association
Australian dentists who employ oral health therapists Table 4. Characteristics of dentists willing to employ an OHT Percentage of dentists who would consider employing an OHT within each characteristic Dentist characteristic Gender Male Female Age 20–29 30–39 40–49 50–59 60+ Sector Public Private Both State NSW VIC QLD SA WA TAS NT ACT Region Metro Rest of state/territory Practice type General Specialists Other Number of surgeries 1 2 3 4 5+ Considered practice expansion Yes No
Yes %’s CI
No %’s CI
Undecided %’s CI
Total n
54.9 47.5 – 62.0 55.2 44.8 – 65.2
27.5 21.5 – 34.4 22.0 14.4 – 32.1
17.7 12.6 – 24.2 22.8 15.6 – 32.1
338 60
18.1 – 42.7 14.8 – 35.7 7.4 – 24.5 10.2 – 27.9 5.7 – 28.0
76 102 113 139 81
17.0 6.2 – 38.7 21.1 16.3 – 26.9 6.7 3.0 – 14.3
39 398 74
18.9 – 35.8 8.4 – 29.7 7.1 – 25.7 4.9 – 31.0 7.6 – 37.5 8.4 – 32.9 7.1 – 37.0 8.8 – 39.2
140 87 73 59 54 41 28 29
61.1 55.0 57.4 47.0 50.4
47.1 42.5 45.5 36.1 35.6
– – – – –
73.4 66.9 68.6 58.2 65.2
69.3 49.1 – 84.1 50.7 44.3 – 57.1 66.8 51.4 – 79.3 49.2 55.3 64.4 57.2 47.6 67.2 72.4 39.6
40.0 41.2 50.8 40.6 30.7 50.1 52.6 22.9
– – – – – – – –
58.5 68.7 76.1 72.4 65.1 80.7 86.1 59.0
10.0 21.3 28.7 35.7 36.3
4.6 – 20.6 12.6 – 33.7 19.3 – 40.5 25.4 – 47.5 23.7 – 51.0
13.7 5.7 – 29.1 28.2 22.6 – 34.5 26.4 14.9 – 42.5 24.3 28.3 21.6 29.5 34.2 15.4 10.1 40.5
17.3 – 32.9 17.4 – 42.5 12.2 – 35.2 17.2 – 45.8 19.6 – 52.5 6.5 – 32.0 3.2 – 27.7 22.8 – 61.1
28.9 23.7 13.8 17.3 13.3
26.5 16.4 14.0 13.3 18.2 17.5 17.5 20.0
0.47 0.06
0.07
0.47
0.001
51.4 44.0 – 58.1 67.5 60.3 – 73.9
28.7 22.8 – 35.4 17.1 12.2 – 23.5
20.2 15.2 – 26.5 15.4 10.9 – 21.4
274 237
53.4 47.1 – 59.5 55.1 37.3 – 71.7 100.0 100.0
25.6 20.6 – 31.4 34.9 20.0 – 53.4 0.00 0.00
21.0 16.3 – 26.6 10.0 3.7 – 24.4 0.00 0.00
453 50 7
10.6 – 32.2 15.5 – 33.6 11.9 – 32.6 13.1 – 40.3 2.3 – 12.9
85 150 103 71 97
20.6 13.9 – 29.5 18.4 13.4 – 24.7
201 310
35.3 48.8 56.5 64.3 76.3
23.1 38.2 43.6 48.4 64.1
– – – – –
49.7 59.4 68.5 77.6 85.3
61.6 52.0 – 70.4 49.6 42.2 – 57.0
45.5 27.9 23.2 11.5 18.2
32.1 – 59.6 19.4 – 38.3 13.8 – 36.3 5.0 – 24.5 10.3 – 30.2
17.8 11.4 – 26.7 32.1 25.6 – 39.3
19.2 23.3 20.3 24.2 5.6
Sig.
0.13
0.01
0.03
Note: Weighted %’s. Unweighted n’s. Statistical test was Pearson’s chi-square. Missing values were excluded. Fifty-one cases were also excluded from the analysis after ticking N/A for question 15 – would you consider employing.
Practising state Worth investigating further could be the influence of attraction and retention of dentists to certain states and territories and the possibility that therapists, hygienists and OHTs are employed as an intermediary. In the Northern Territory, 29% of dentists employed an OHT, where dentists practising rates were at their lowest.6 The Northern Territory saw the highest proportion of dentists employing dental therapists, dental hygienists and/or OHTs with more than half of the territory’s dentists employing at least one of these various oral health providers (54.8%, n = 25). Conversely, across the eight Australian states and territories, the lowest proportion of dentists employing a dental therapist, dental hygienist or OHT was in the two eastern seaboard states of Victoria (24.8%, n = 82) and New South Wales (26.7%, n = 128) where dentist practising rates are high.6 The © 2015 Australian Dental Association
difficulties associated with attracting dentists to certain states and territories could offer an explanation as to why some employers take on a complementary oral health practitioner but requires further investigation. When considering the type of oral health practitioner to employ, Queensland dentists categorically favoured OHTs (36.0%, n = 24), followed by dentists in the Northern Territory (29.0%, n = 8), then South Australian dentists and those in the Australian Capital Territory. The type of award course offered and graduates these courses train might provide explanation as to why dentists in some states hire one type of professional over another. For example, Queensland was the first state to graduate bachelor degree trained OHTs, offering an undergraduate Bachelor of Oral Health programme in 1998.6 Prior to that, dental hygiene courses were non-existent in Queensland 159
C Kempster et al. Table 5. Multivariable comparison of willingness to employ an OHT by dentist and practice characteristic Willing to employ an OHT Age category 20–29 30–39 40–49 60+ years Sector Public Both Region Rest of state Number of surgeries 2 3 4 5 Considered practice expansion Yes N/A
OR
95% CI
– – – –
4.61 1.96 1.52 1.05
1.70 0.85 0.71 0.46
2.82 1.40
1.01 – 7.86 0.63 – 3.13
2.22
1.32 – 3.73
2.25 3.14 7.19 5.41
1.00 1.25 2.30 2.14
3.96 5.03
2.02 – 7.75 2.28 – 11.09
– – – –
12.50 4.52 3.19 2.38
Reference category 50–59 year olds
Private Metropolitan 1 surgery
5.11 7.90 22.48 13.70 No
The reference category selected represents the lowest value for each factor taken from the bivariate analysis of those who were willing to employ an OHT.
which might also have had an effect on Queensland dentists’ knowledge of, understanding of and familiarity with this particular dental provider. The type of training course offered in each respective state or territory may also impact on the supply of the dental therapists, dental hygienists and OHTs within each state/territory. For example, the highest proportion of dental hygienists was in South Australia where TAFE SA Gilles Plains has had a long history of training dental hygienists (Table 2). Another important factor to consider is the transition to national registration in 2010. Prior to that, each state or territory operated under its own Dental Act where there was variation in the scope of practice, supervision and prescription of dental care between the states and territories.7 The influence that regulatory differences may have had over the variation of the employment of OHTs across Australia to date could be significant. Further investigation is needed to assess any differences amongst dentists across the eight states and territories which might account for the preferential selection and employment of supplementary oral health providers. Numbers of surgeries Perhaps not surprisingly, OHTs are more likely to be employed in larger scale dental practices with multiple surgeries. Results showed that the greater the number of surgeries available within individual practices, the greater the proportion of dentists who were currently employing OHTs. This is similar to Ross et al.7 findings in which the number of surgeries in the practice 160
was also found to be a significant factor in dentists’ clinical staff employment decisions. The highest proportion of dentists currently employing OHTs were in practices where there were four individual surgeries. What isn’t clear is whether the space had been created specifically to introduce or expand the OHT or traditional hygiene type services to complement or substitute for a dentist. What also remains unclear is the influence of the growing number of corporate or franchised dental practices has over considerations to employ OHTs. Further investigation into the policies and practices of such entities when it comes to workforce employment and utilization seems necessary. This study demonstrates that almost half (45.1% of respondents, CI 26.6% – 65.0%) employed an OHT for ‘predominantly hygiene services only’. Such an intention raises questions about the motive for OHT employment when only part of the OHTs skill set is being utilized given that OHTs are also trained in restorative dentistry for both the deciduous and permanent dentition. For example, is adding ‘hygiene’ service provision a good profit centre for the practice, or is the addition of hygiene services related to increased periodontal management capacity and preventive services for patients? Focus group and qualitative questionnaire data collected in the early stages of this project suggest that the attitudes of dentists towards the role of an OHT may be influencing how they are being utilized. This is in line with results published by Blue et al.8 who reported that attitudes as well as prior experience working with non-dentist practitioners (dental therapists and dental hygienists) were drivers of utilization. Further investigation will be required around the motivation for employment in larger scale practices and the potential under-utilization of oral health therapists in Australia. Willingness to employ a dental therapist, dental hygienist or oral health therapist Dentists’ age The fact that dentists aged 20–29 years are more willing to employ OHTs than their older colleagues is evidence of a changing team approach to service delivery. This study suggests that younger, more recently graduated dentists are more accepting or have a greater understanding of the role of OHTs. Further investigation is needed to explore the factors that influence the views of younger dentists. One suggestion is that integrated approaches to dental education in Australia are increasing interprofessional understanding and relationships. However, evidence in relation to the success of course integration and interdisciplinary learning in health seems at odds. Furze et al.9 showed that integrated educational © 2015 Australian Dental Association
Australian dentists who employ oral health therapists programmes can be effective at increasing interprofessional understanding and respect. However, Ross et al.10 observed that undergraduate dental students at the end of a five-year integrated dental science programme had sound knowledge of the OHT role, although their attitudes in relation to OHT clinical activity remained somewhat unfavourable. Sector of practice Respondents were asked to ignore their level of control or responsibility over employment decisions when considering their willingness to employ an OHT. To make a decision on this would then require some level of reflection on one’s knowledge, attitude and perception of the role and in turn what the OHT would bring to a practice. Public sector dentists would be almost three times more willing to employ an OHT if they were in the position to do so. This raises the question of whether experience working with dental therapists (who have been traditional partners in the provision of public sector school dental services in Australia) may influence the knowledge, attitudes and/ or perceptions of Australian dentists in relation to OHTs. Blue et al.8 found that experience working with expanded-function dental hygienists or assistants was the only factor significantly associated with American dentists’ opinion that ‘expanded-function personnel could have a positive impact on the quality of dental care’. They also noted that patient perception of the quality of services provided by the nondentist was similarly linked to dentists’ attitudes. Further sociological analysis in an Australian context is required to assess the differences between public and private sector dentists when considering employment and utilization of OHTs.
of dentists who were willing to employ were from practices that had multiple surgeries, with four out of five dentists (76.3%, n = 97) from large practices with five or more surgeries were willing to employ an OHT. This is a clear indication that physical space to accommodate an OHT plays a role. Furthermore, a degree of innovation or commercial entrepreneurialism of the employer are possible factors that might influence employment considerations of dentists. Consideration of practice expansion Dentists considering practice expansion were more open to the idea of employing OHTs. Nearly twothirds of the group indicated that they have considered practice expansion (62%). Of those, nearly half were willing to employ an OHT (45%). This further supports the view that commercial interest and innovation is a factor. Different models of team service delivery are a key element when practice expansion is considered. These dentists may consider the financial viability or the value an OHT can bring with them to the practice and to their patients. Again further investigation into the inspirations and visions of this group is necessary to tease out these attitudinal differences. Dentists’ attitudes
A greater proportion of dentists were willing to employ an OHT if their practice was situated in a non-metropolitan region (67.5%, n = 237). The employment considerations of regional dentists may be influenced by poor supply of, or problematic attraction and retention of new dentists, an increased confidence in the abilities of OHTs, a better knowledge of the full range of clinical capabilities of OHTs, or patient acceptance of complementary oral health providers. Further research into the attitudinal differences between metropolitan and regional dentists is required and should be of interest to regional workforce planners.
Literature on the characteristics of dentists and their attitudes towards OHTs, dental therapists and dental hygienists in Australia is scarce. Ross et al.11 in a survey of dentists in general dental practice in south-east Scotland identified some ‘predictors’ of dentists willingness to employ an OHT ranging from gender, to the number of dentists in the practice, to surgery availability and previous experience working with a complementary oral health provider. Attitudinal negativity amongst Scottish dentists toward the nature and clinical remit of OHTs was also identified as a factor having an influence over employment decisions and OHT utilization. They suggested that a lack of knowledge of the scope of practice and unfavourable attitudes impacted on dentists’ willingness to employ and appropriately utilize OHTs across the full scope of practice. Further analysis of the data collected from Parts B and C of the questionnaire used in this study needs to be conducted to test for the association between dentists’ attitudes and complementary oral health practitioner employment and utilization here in Australia.
Number of surgeries
CONCLUSIONS
Following similar trends as those who currently employ allied oral health providers, larger proportions
Certain characteristics of dentists have been shown to be associated with their history of employment and
Region of practice
© 2015 Australian Dental Association
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C Kempster et al. willingness to employ dental therapists, dental hygienists and OHTs. An understanding of the factors that influence their employment is important if access pathways for the general public in Australia to the services provided by these oral health professionals remain the same. This study demonstrates that to date employment decisions have been more commonly related to entrepreneurial aspirations (aspirations of practice expansion), surgery availability and the state in which a dental practice (or potential employing dentist) is situated. However, other factors such as age, employment sector and attitudes towards dental therapists, dental hygienists and OHTs may also play a part in influencing future employment considerations. With an increase in the availability of OHTs, there will be a wider degree of skill mix and provision of preventive and maintenance services available to the general public. That said, greater numbers of allied oral health providers and increased skill mix across the entire dental workforce alone may not be enough to respond to the current and projected future needs of the Australian population. Emphasis must be placed on the development of public and private sector workforce models designed to increase the employment and holistic utilization of the complete skill set of the OHT. It is timely for oral health workforce planners to review employment and utilization barriers facing OHTs. Dental educators must continue to develop initiatives that will foster a greater degree of understanding and appreciation of the roles of OHTs, together with more instruction on dental team leadership. REFERENCES 1. Dental Board of Australia. Oral Health Therapist Registration. AHPRA, 2011. URL: ‘http://www.dentalboard.gov.au/Registration/ Oral-Health-Therapist.aspx’. Accessed October 2011.
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2. Dental Board of Australia. Scope of Practice Registration Standard. AHPRA, 2011. URL: ‘http://www.dentalboard.gov.au/ Registration-Standards.aspx’. Accessed October 2011. 3. Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Sociology Press, Aldine: 1967. 4. Australian Bureau of Statistics. Statistical Division from Postal Area Concordance, 2006. URL: ‘http://www.abs.gov.au/AUS STATS/[email protected]/39433889d406eeb9ca2570610019e9a5/01b98 cd854335e99ca25730c0000a5ad!OpenDocument’. Accessed November 2009. 5. Dillman DA. Mail and telephone surveys: the total design method. NY: Wiley, 1978. 6. Balasubramanian M, Teusner DN. Dentists, specialists and allied practitioners: the Australian dental labour force 2006. Dental Statistics and Research Series No. 53. Cat. no. DEN 202. Canberra: Australian Institute of Health and Welfare, 2011. 7. Satur J. Australian dental policy reform and the use of dental therapists and hygienists. Geelong: Deakin University, 2002. PhD thesis. 8. Blue CM, Funkhouser DE, Riggs S, et al. Utilization of nondentist providers and attitudes toward new provider models: findings from the National Dental Practice-Based Research Network. J Public Health Dent 2013;73:237–244. 9. Furze J, Lohman H, Mu K. Impact of an interprofessional community-based educational experience on students’ perceptions of other health professions and older adults. J Allied Health 2008;37:71–77. 10. Ross M, Ibbetson R, Turner S. The impact of team-working on the knowledge and attitudes of final year dental students. Br Dent J 2007;206:163–167. 11. Ross M, Ibbetson R, Turner S. The acceptability of duallyqualified dental hygienists-therapists to general dental practitioners in South-East Scotland. Br Dent J 2007;202:E8.
Address for correspondence: Mr Clinton Kempster Lecturer Level 4, Room 4.04a, Oliphant Building School of Dentistry The University of Adelaide North Terrace Adelaide SA 5005 Email: [email protected]
© 2015 Australian Dental Association
The official journal of the Australian Dental Association
Australian Dental Journal 2015; 60: 154–162 doi: 10.1111/adj.12317
Australian dentists: characteristics of those who employ or are willing to employ oral health therapists# C Kempster,* L Luzzi,† K Roberts-Thomson‡ *Lecturer, School of Dentistry, The University of Adelaide, South Australia. †Senior Research Fellow, Australian Research Centre for Population Oral Health; Director, Dental Statistics and Research Unit, Australian Institute of Health and Welfare; School of Dentistry, The University of Adelaide, South Australia. ‡Director, Australian Research Centre for Population Oral Health, School of Dentistry, The University of Adelaide, South Australia.
ABSTRACT Background: There has been an increase in the availability of oral health therapists (OHTs) in the oral health workforce in the last decade. The impact these clinicians will have on the oral health of the general public is dependent on access pathways and utilization. This study aimed to profile Australian dentists who employ or are willing to employ OHTs and to explore the degree of association between dentist characteristics and employment decisions. Methods: This cross-sectional study used a random sample of Australian dentists (n = 1169) from the Federal Australian Dental Association register in 2009. Participants were sent a postal questionnaire capturing dentist characteristics and oral health practitioner employment information. Results: An adjusted response rate of 55% was obtained. Dentists willing to employ OHTs included non-metropolitan dentists, dentists in multiple surgery practices and those considering practice expansion. Age, gender and sector of practice were not significantly associated with retrospective employment decisions or willingness to employ in the future. Conclusions: Certain characteristics of dentists or of their practice are associated with their history of employment and willingness to employ OHTs. Employment decisions are more commonly related to entrepreneurial aspirations (expressed as a willingness to expand), sector of practice, surgery capacity and regionality over gender and age. Understanding the factors that influence the employment of OHTs is important in enhancing access pathways to the services provided by OHTs. Keywords: Access, employment, oral health therapist, prevention, utilization, workforce. Abbreviations and acronyms: OHT = oral health therapist. (Accepted for publication 5 August 2014.)
INTRODUCTION Practitioners who have completed an Australian Dental Board approved and accredited bachelor programme of study in the ‘dual streams of dental therapy and dental hygiene’ can now register under the new national registration category of ‘oral health therapist’ (OHT).1 OHTs may provide clinical services in which they are competent to all members of the general public, under a collaborative and referral relationship with a dentist. The OHT works as part of a dental team but there is no longer a requirement for the dentist to be onsite.2 The OHT can make #An oral health therapist is an Australian oral health practitioner who has obtained a qualification at a Bachelor level and is registered with the Dental Board of Australia to practise within the traditional disciplines of dental therapy and dental hygiene. 154
autonomous decisions relating to patient care within their scope of practice. As all health care professionals are expected to operate in Australia, OHTs must only provide clinical services that fall within their educational, professional and ethical boundaries.2 OHTs are permitted to own a private dental practice; however, practice ownership to date has been relatively limited. Given that a large proportion of dentistry in Australia is undertaken in the private sector, it can be said that in part, the responsibility for the employment and geographic distribution of OHTs across the country now lies with private sector dentists. Therefore, it is timely to profile those dentists that have employed, or might be willing to employ OHTs and to examine the personal, demographic and practice characteristics that impact on their employment decisions. It is reasonable to question whether these characteristics and employment decisions ultimately © 2015 Australian Dental Association
Australian dentists who employ oral health therapists impact on general public access to preventive and primary care services that OHTs are specifically trained to provide. Anecdotally, it has been suggested that females may be more sympathetic toward the employment of an OHT, public sector dentists would be more likely to employ an OHT given their history working with dental therapists and older dentists would be less likely to employ an OHT given their tendency to hold sovereign views. Part A of the analysis aimed to test those suggestions and assess whether other characteristics such as practice location (metropolitan, rural, state/territory), region, type (general, specialist), number of surgeries and considered practice expansion were associated with dentists’ decisions to currently employ or consider future employment of OHTs. With very few training courses remaining around Australia that produce just dental therapists or dental hygienists as singular discipline operators, it is certain that there will be a greater number of graduates with a Bachelor of Oral Health or equivalent looking to enter the dental labour force in coming years. However, graduates may find it difficult to gain satisfying employment across Australia, employment that will allow the full utilization of their complete skill set, if barriers to employment exist within certain dentist subpopulations. This article explores factors in relation to OHT workforce employment and skill utilization, and its impact on public access to preventive and maintenance services in Australia. From these observations, educational or policy related interventions designed to encourage team service delivery, improved interprofessional understanding and greater allied oral health workforce utilization, can be better targeted. This study aimed to profile dentists across Australia who employ OHTs or are willing to employ an OHT and explore the degree of association between certain personal characteristics and employment decisions. MATERIALS AND METHODS Human research ethics approval was sought and granted by the University of Adelaide’s Office of Research Ethics, Compliance and Integrity (ORECI). A postal questionnaire was based on qualitative data collected from a focus group conducted at the Australian Research Centre for Population Oral Health (ARCPOH) in late 2008. For the focus group a simple random sample of 83 dentists on the South Australian Dental Board register were selected and invited to participate. Twelve dentists responded positively and nine attended. A grounded approach to questioning3 was used to capture dentists’ attitudes towards a range of issues including dental education, the value © 2015 Australian Dental Association
of an OHT, team work and service delivery to the general public. Qualitative analysis was performed to extract themes from the discussion which were then used as the basis for question formulation for the data instrument. A stratified systematic random sample of 1169 Australian dentists was selected from the Federal Australian Dental Association register in 2009. Selected dentists were sent a postal questionnaire. Sample size calculations were based on a two-sided significance level of 0.05 and 80% power in order to detect a 15% difference in the percentage who would consider employing an OHT in their practice. Dentists were categorized to capital city or rest of state strata based on their practice postcode using the Australian Bureau of Statistics (ABS) Statistical Division, Postcode Concordance File version 2006,4 obtained from the ABS website. The questionnaire comprised three parts. Part A asked dentists to provide demographic information as well as an indication as to whether they currently employed dental therapists, dental hygienists or OHTs. Dentists were also asked if they would consider employing only an OHT regardless of whether they were in a position to hire or not. Part B required participants to identify whether they thought certain clinical procedures could legally be performed by OHTs and was classified as ‘Yes’, ‘No’, ‘Don’t Know’. Part C explored dentists’ perceptions and attitudes using a five-point Likert scale for 15 statements (also themed using the focus group data). Dentists were also invited to provide open comment in relation to the role of the OHT at the end of the questionnaire. Only the results from the analysis of the data received in Part A are presented in this article. Following three mailings, based on the Dillman ‘Total Design Method’,5 an adjusted response rate of 55% (n = 565) was obtained. From the sample of 1169 participants, there was no response from 439 individuals, three were retired, three were no longer practising dentistry, seven refused to participate, one participant was deceased, 127 were returned to sender and 24 questionnaires were returned blank. The demographic characteristics of Australian dentists’ characteristics from this sample were compared to that of the Australian Institute of Health and Welfare Dental Labour Force data from 2006.6 Due to the differences between the sample and the national labour estimates, the data were weighted for age, sector of predominant practice, state and region (metropolitan versus rest of state). Cases with missing values were excluded from all analysis. Table 1 documents these results. Statistical analysis were conducted using PASW Statistics 18 to account for complex sampling design. 155
C Kempster et al. Table 1. Comparison of the unweighted frequencies of dentists’ characteristics with those reported in the AIHW Dental Labour Force 20065 Participant characteristics
Gender Male Female Age 20–29 30–39 40–49 50–59 60+ Sector of predominant practice Public Private Both State New South Wales Victoria Tasmania South Australia Western Australia Northern Territory Queensland Australian Capital Territory Practice location Metropolitan Rest of state Area of practice General Specialists Other University of graduation Australian o South Australian o NSW o VIC o QLD o WA Non-Australian
2006 Dental Labour Force Data %n
%n
70.3 376 29.7 159
71.0 7390 29.0 3014
14.3 19.1 21.4 27.4 17.7
12.3 23.7 27.0 24.1 12.9
81 108 121 155 100
1279 2461 2810 2505 1349
9.0 51 76.1 430 14.9 84
13.3 1386 78.1 8126 8.6 892
29.2 16.5 8.1 11.7 9.9 5.5 14.0 5.1
34.2 23.5 1.7 7.9 10.3 0.8 19.5 2.1
165 93 46 66 56 31 79 29
3562 2449 172 826 1071 78 2029 217
53.3 301 46.7 264
79.3 8250 20.7 2154
87.3 493 10.6 60 2.2 12
87.5 9158 12.0 1246 0.5 50
82.0 23.3 21.4 12.1 15.2 9.9 18.0
432 123 113 64 80 52 95
Not reported
Dependent variables were ‘dentists currently employing’ and dentists ‘willing to employ’ an OHT. Independent variables examined (or factors associated with dentists’ employment decisions) were dentist age, gender, practice location (metropolitan or rest of state), sector of predominant practice and Australian state or territory in which they practice. Other physical and economic employment barriers were examined such as clinic space and willingness to expand practice services. Non-parametric analyses were performed (Pearson’s chi-squared) to provide employment and willingness to employ estimates for the independent categorical variables and to test for predictor association. Multivariable logistic regression modelling and analysis was undertaken to confirm the strength of the range of factors associated with dentists OHT employment decisions. 156
RESULTS Current employment of dental therapists, dental hygienists and oral health therapists When asked to indicate current employment of an OHT, a dental hygienist or a dental therapist 31.5% (n = 178) of dentists employed at least one of the three oral health practitioners; 12.1% (n = 57) employed an OHT, 18.3% (n = 86) employed a dental hygienist and only 7.4% (n = 35) employed a dental therapist only, leaving 62.2% not employing any. To determine whether specific employment of OHTs was associated with dentist demographics and practice characteristics, bivariate analysis was conducted. Significant associations were found between dentists’ age, sector of practice, state in which dentists’ practice and the number of dental surgeries within the dental practice (Table 2). Dentists employed fewer OHTs as they aged beyond 50 years, if they worked solely in the public sector, if their practice was located in Tasmania, Western Australia, New South Wales or Victoria, or if their practices contained fewer surgeries. Estimates relating to the influence of sector though should be interpreted with caution as it is possible that some may have responded on behalf of the organization that they work for. Multivariable analysis was used to assess the impact of the dentist and practice characteristics on employment of OHTs (Table 3). This analysis assists understanding of the association while controlling for demographic factors. The dependent variable used here was a dichotomous ‘employs OHTs’ (Yes/No) in order to specifically explore the likelihood of dentists employing the OHT only. Analysis confirmed that after controlling for dentists’ age and regionality, dentists age and practising in multiple surgery practices were influential demographic variables amongst dentists that currently employ an OHT. Table 3 shows the odds ratios of dentists choosing to employ an OHT and confidence intervals for dentists in each category. The reference categories chosen for the age, sector and surgery number comparisons represents the category with the lowest value from the bivariate analysis. The state of Queensland was chosen as the reference category on this occasion as the University of Queensland was the first university to offer an undergraduate degree programme graduating OHTs and employed the highest number of OHTs across all states. As dentists aged, the likelihood of them employing an OHT declined. When compared to dentists aged 20–29 years, dentists aged 40 years plus were significantly less likely to currently employ an OHT (OR = 0.39, 95% CI 0.118–0.91). © 2015 Australian Dental Association
C Kempster et al. Table 3. Multivariable comparison of employment of OHT by dentist and practice characteristic Employing an OHT Age category 30–39 40–49 50–59 60+ years Sector Private Both State/Territory NSW VIC SA WA TAS NT ACT Number of surgeries 2 3 4 5
OR
95% CI – – – –
Reference category 20–29 year olds
0.42 0.33 0.22 0.23
0.14 0.12 0.08 0.08
1.24 0.92 0.59 0.68
2.78 4.94
0.56 – 13.95 0.82 – 29.57
0.50 0.37 1.24 1.44 1.27 1.96 0.86
0.24 0.14 0.48 0.48 0.48 0.53 0.27
– – – – – – –
1.06 0.99 3.27 4.37 3.37 7.30 2.81
1.12 2.11 3.30 4.33
0.18 0.68 1.07 1.50
– – – –
1.77 6.59 10.67 12.46
Public sector State of QLD
1 surgery
The reference category selected represents the lowest value for each factor taken from the bivariate analysis of those who currently employ an OHT (with the exception of Queensland who employed the highest number of OHTs across Australia).
A complex sample binary logistic regression model for ‘willingness to employ’ was constructed. The variables shown in Table 4 with significant bivariate association were included in the analysis along with age and sector. The dependent variable was a dichotomous ‘willingness to employ’ (Yes/No) and covariates were dentists’ age, sector of practice, region of practice and number of surgeries in the practice. Analysis confirmed that only region of practice (p = 0.001), number of surgeries in the practice (p = 0.01) and consideration of practice expansion (>p = 0.03) were significant factors in relation to dentists’ willingness to employ an OHT. Dentists age (p = 0.06) and sector of practice (p = 0.07) had a marginal association and were therefore included in the odds analysis. Table 5 shows the odds ratios of dentists willing to employ an OHT, confidence intervals and reference variable for dentists in each category who were willing to employ. The reference category chosen for each individual predictor represents the category with the lowest value of dentists reporting a willingness to employ an OHT in the bivariate analysis. Dentists who were not willing to employ because they currently employed an OHT already were removed from the multivariable analysis. Dentists aged 20–29 years reported higher odds of a willingness to employ an OHT compared with all other age categories, with the 50–59 years category being the least willing (Table 5). Although age category was not significant in the bivariate analysis, it is noted that the probability of them considering 158
employing an OHT reduced across age categories with dentists aged 50–59 years being significantly less willing to employ an OHT over a dentist aged in their twenties (OR = 4.61, 95% CI 1.70–12.50). Dentists were asked to consider their willingness to employ an OHT even if they ‘were not a principal dentist or practice owner’. Despite the slightly weaker statistically significant association, it was noted that those working in the public sector may be more willing to employ an OHT if they were in a position to do so (OR = 2.82, 95% CI 1.01–7.85), although working across both sectors did not make a significant difference (OR = 1.40, 95% CI 0.63–3.13). Those working in non-metropolitan areas were twice as likely to consider employing an OHT as their metropolitan colleagues (OR = 2.22, 95% CI 1.32–3.73). Similar trends were noted in relation to surgery numbers between willingness to employ an OHT and dentists who currently employ an OHT. Significant increases in likelihood started at those who worked in practices with three or more surgeries (OR = 3.14, 95% CI 1.25–5.11). Again, as surgery numbers within the practice increased so did the odds of dentists being willing to employ an OHT. Dentists who have considered practice expansion were nearly four times more likely to consider employing an OHT than those who had not (OR 3.96, 95% CI 2.02–7.75). DISCUSSION Australian dentists are largely responsible for the employment distribution and utilization of the dental hygienist, dental therapist and oral health therapist labour force. This study and analysis suggests that there are a number of both demographic and personal characteristics of dentists that influence decisions specifically around OHT employment. The age of the dentist and the number of surgeries available within the practice are two demographic factors that have been major influences over the OHT employment decisions of dentists to date. Although dentists’ age was significantly associated with past OHT employment decisions, it became less of an influencing factor in dentists deciding whether they would be willing to employ an OHT. That said there were significant differences between the 20–29 year old cohort and the 50–59 year old cohort that are worth noting. Dentists who are more likely to be willing to employ OHTs are those practising in non-metropolitan areas, who have public sector background, are in clinics with multiple surgeries and in practices where dentists have aspirations of practice expansion. These decisions seem to relate to economic or business related intentions and regionality over personal characteristics of dentists such as age and gender. © 2015 Australian Dental Association
C Kempster et al. Table 3. Multivariable comparison of employment of OHT by dentist and practice characteristic Employing an OHT Age category 30–39 40–49 50–59 60+ years Sector Private Both State/Territory NSW VIC SA WA TAS NT ACT Number of surgeries 2 3 4 5
OR
95% CI – – – –
Reference category 20–29 year olds
0.42 0.33 0.22 0.23
0.14 0.12 0.08 0.08
1.24 0.92 0.59 0.68
2.78 4.94
0.56 – 13.95 0.82 – 29.57
0.50 0.37 1.24 1.44 1.27 1.96 0.86
0.24 0.14 0.48 0.48 0.48 0.53 0.27
– – – – – – –
1.06 0.99 3.27 4.37 3.37 7.30 2.81
1.12 2.11 3.30 4.33
0.18 0.68 1.07 1.50
– – – –
1.77 6.59 10.67 12.46
Public sector State of QLD
1 surgery
The reference category selected represents the lowest value for each factor taken from the bivariate analysis of those who currently employ an OHT (with the exception of Queensland who employed the highest number of OHTs across Australia).
A complex sample binary logistic regression model for ‘willingness to employ’ was constructed. The variables shown in Table 4 with significant bivariate association were included in the analysis along with age and sector. The dependent variable was a dichotomous ‘willingness to employ’ (Yes/No) and covariates were dentists’ age, sector of practice, region of practice and number of surgeries in the practice. Analysis confirmed that only region of practice (p = 0.001), number of surgeries in the practice (p = 0.01) and consideration of practice expansion (>p = 0.03) were significant factors in relation to dentists’ willingness to employ an OHT. Dentists age (p = 0.06) and sector of practice (p = 0.07) had a marginal association and were therefore included in the odds analysis. Table 5 shows the odds ratios of dentists willing to employ an OHT, confidence intervals and reference variable for dentists in each category who were willing to employ. The reference category chosen for each individual predictor represents the category with the lowest value of dentists reporting a willingness to employ an OHT in the bivariate analysis. Dentists who were not willing to employ because they currently employed an OHT already were removed from the multivariable analysis. Dentists aged 20–29 years reported higher odds of a willingness to employ an OHT compared with all other age categories, with the 50–59 years category being the least willing (Table 5). Although age category was not significant in the bivariate analysis, it is noted that the probability of them considering 158
employing an OHT reduced across age categories with dentists aged 50–59 years being significantly less willing to employ an OHT over a dentist aged in their twenties (OR = 4.61, 95% CI 1.70–12.50). Dentists were asked to consider their willingness to employ an OHT even if they ‘were not a principal dentist or practice owner’. Despite the slightly weaker statistically significant association, it was noted that those working in the public sector may be more willing to employ an OHT if they were in a position to do so (OR = 2.82, 95% CI 1.01–7.85), although working across both sectors did not make a significant difference (OR = 1.40, 95% CI 0.63–3.13). Those working in non-metropolitan areas were twice as likely to consider employing an OHT as their metropolitan colleagues (OR = 2.22, 95% CI 1.32–3.73). Similar trends were noted in relation to surgery numbers between willingness to employ an OHT and dentists who currently employ an OHT. Significant increases in likelihood started at those who worked in practices with three or more surgeries (OR = 3.14, 95% CI 1.25–5.11). Again, as surgery numbers within the practice increased so did the odds of dentists being willing to employ an OHT. Dentists who have considered practice expansion were nearly four times more likely to consider employing an OHT than those who had not (OR 3.96, 95% CI 2.02–7.75). DISCUSSION Australian dentists are largely responsible for the employment distribution and utilization of the dental hygienist, dental therapist and oral health therapist labour force. This study and analysis suggests that there are a number of both demographic and personal characteristics of dentists that influence decisions specifically around OHT employment. The age of the dentist and the number of surgeries available within the practice are two demographic factors that have been major influences over the OHT employment decisions of dentists to date. Although dentists’ age was significantly associated with past OHT employment decisions, it became less of an influencing factor in dentists deciding whether they would be willing to employ an OHT. That said there were significant differences between the 20–29 year old cohort and the 50–59 year old cohort that are worth noting. Dentists who are more likely to be willing to employ OHTs are those practising in non-metropolitan areas, who have public sector background, are in clinics with multiple surgeries and in practices where dentists have aspirations of practice expansion. These decisions seem to relate to economic or business related intentions and regionality over personal characteristics of dentists such as age and gender. © 2015 Australian Dental Association
Australian dentists who employ oral health therapists Table 4. Characteristics of dentists willing to employ an OHT Percentage of dentists who would consider employing an OHT within each characteristic Dentist characteristic Gender Male Female Age 20–29 30–39 40–49 50–59 60+ Sector Public Private Both State NSW VIC QLD SA WA TAS NT ACT Region Metro Rest of state/territory Practice type General Specialists Other Number of surgeries 1 2 3 4 5+ Considered practice expansion Yes No
Yes %’s CI
No %’s CI
Undecided %’s CI
Total n
54.9 47.5 – 62.0 55.2 44.8 – 65.2
27.5 21.5 – 34.4 22.0 14.4 – 32.1
17.7 12.6 – 24.2 22.8 15.6 – 32.1
338 60
18.1 – 42.7 14.8 – 35.7 7.4 – 24.5 10.2 – 27.9 5.7 – 28.0
76 102 113 139 81
17.0 6.2 – 38.7 21.1 16.3 – 26.9 6.7 3.0 – 14.3
39 398 74
18.9 – 35.8 8.4 – 29.7 7.1 – 25.7 4.9 – 31.0 7.6 – 37.5 8.4 – 32.9 7.1 – 37.0 8.8 – 39.2
140 87 73 59 54 41 28 29
61.1 55.0 57.4 47.0 50.4
47.1 42.5 45.5 36.1 35.6
– – – – –
73.4 66.9 68.6 58.2 65.2
69.3 49.1 – 84.1 50.7 44.3 – 57.1 66.8 51.4 – 79.3 49.2 55.3 64.4 57.2 47.6 67.2 72.4 39.6
40.0 41.2 50.8 40.6 30.7 50.1 52.6 22.9
– – – – – – – –
58.5 68.7 76.1 72.4 65.1 80.7 86.1 59.0
10.0 21.3 28.7 35.7 36.3
4.6 – 20.6 12.6 – 33.7 19.3 – 40.5 25.4 – 47.5 23.7 – 51.0
13.7 5.7 – 29.1 28.2 22.6 – 34.5 26.4 14.9 – 42.5 24.3 28.3 21.6 29.5 34.2 15.4 10.1 40.5
17.3 – 32.9 17.4 – 42.5 12.2 – 35.2 17.2 – 45.8 19.6 – 52.5 6.5 – 32.0 3.2 – 27.7 22.8 – 61.1
28.9 23.7 13.8 17.3 13.3
26.5 16.4 14.0 13.3 18.2 17.5 17.5 20.0
0.47 0.06
0.07
0.47
0.001
51.4 44.0 – 58.1 67.5 60.3 – 73.9
28.7 22.8 – 35.4 17.1 12.2 – 23.5
20.2 15.2 – 26.5 15.4 10.9 – 21.4
274 237
53.4 47.1 – 59.5 55.1 37.3 – 71.7 100.0 100.0
25.6 20.6 – 31.4 34.9 20.0 – 53.4 0.00 0.00
21.0 16.3 – 26.6 10.0 3.7 – 24.4 0.00 0.00
453 50 7
10.6 – 32.2 15.5 – 33.6 11.9 – 32.6 13.1 – 40.3 2.3 – 12.9
85 150 103 71 97
20.6 13.9 – 29.5 18.4 13.4 – 24.7
201 310
35.3 48.8 56.5 64.3 76.3
23.1 38.2 43.6 48.4 64.1
– – – – –
49.7 59.4 68.5 77.6 85.3
61.6 52.0 – 70.4 49.6 42.2 – 57.0
45.5 27.9 23.2 11.5 18.2
32.1 – 59.6 19.4 – 38.3 13.8 – 36.3 5.0 – 24.5 10.3 – 30.2
17.8 11.4 – 26.7 32.1 25.6 – 39.3
19.2 23.3 20.3 24.2 5.6
Sig.
0.13
0.01
0.03
Note: Weighted %’s. Unweighted n’s. Statistical test was Pearson’s chi-square. Missing values were excluded. Fifty-one cases were also excluded from the analysis after ticking N/A for question 15 – would you consider employing.
Practising state Worth investigating further could be the influence of attraction and retention of dentists to certain states and territories and the possibility that therapists, hygienists and OHTs are employed as an intermediary. In the Northern Territory, 29% of dentists employed an OHT, where dentists practising rates were at their lowest.6 The Northern Territory saw the highest proportion of dentists employing dental therapists, dental hygienists and/or OHTs with more than half of the territory’s dentists employing at least one of these various oral health providers (54.8%, n = 25). Conversely, across the eight Australian states and territories, the lowest proportion of dentists employing a dental therapist, dental hygienist or OHT was in the two eastern seaboard states of Victoria (24.8%, n = 82) and New South Wales (26.7%, n = 128) where dentist practising rates are high.6 The © 2015 Australian Dental Association
difficulties associated with attracting dentists to certain states and territories could offer an explanation as to why some employers take on a complementary oral health practitioner but requires further investigation. When considering the type of oral health practitioner to employ, Queensland dentists categorically favoured OHTs (36.0%, n = 24), followed by dentists in the Northern Territory (29.0%, n = 8), then South Australian dentists and those in the Australian Capital Territory. The type of award course offered and graduates these courses train might provide explanation as to why dentists in some states hire one type of professional over another. For example, Queensland was the first state to graduate bachelor degree trained OHTs, offering an undergraduate Bachelor of Oral Health programme in 1998.6 Prior to that, dental hygiene courses were non-existent in Queensland 159
C Kempster et al. Table 5. Multivariable comparison of willingness to employ an OHT by dentist and practice characteristic Willing to employ an OHT Age category 20–29 30–39 40–49 60+ years Sector Public Both Region Rest of state Number of surgeries 2 3 4 5 Considered practice expansion Yes N/A
OR
95% CI
– – – –
4.61 1.96 1.52 1.05
1.70 0.85 0.71 0.46
2.82 1.40
1.01 – 7.86 0.63 – 3.13
2.22
1.32 – 3.73
2.25 3.14 7.19 5.41
1.00 1.25 2.30 2.14
3.96 5.03
2.02 – 7.75 2.28 – 11.09
– – – –
12.50 4.52 3.19 2.38
Reference category 50–59 year olds
Private Metropolitan 1 surgery
5.11 7.90 22.48 13.70 No
The reference category selected represents the lowest value for each factor taken from the bivariate analysis of those who were willing to employ an OHT.
which might also have had an effect on Queensland dentists’ knowledge of, understanding of and familiarity with this particular dental provider. The type of training course offered in each respective state or territory may also impact on the supply of the dental therapists, dental hygienists and OHTs within each state/territory. For example, the highest proportion of dental hygienists was in South Australia where TAFE SA Gilles Plains has had a long history of training dental hygienists (Table 2). Another important factor to consider is the transition to national registration in 2010. Prior to that, each state or territory operated under its own Dental Act where there was variation in the scope of practice, supervision and prescription of dental care between the states and territories.7 The influence that regulatory differences may have had over the variation of the employment of OHTs across Australia to date could be significant. Further investigation is needed to assess any differences amongst dentists across the eight states and territories which might account for the preferential selection and employment of supplementary oral health providers. Numbers of surgeries Perhaps not surprisingly, OHTs are more likely to be employed in larger scale dental practices with multiple surgeries. Results showed that the greater the number of surgeries available within individual practices, the greater the proportion of dentists who were currently employing OHTs. This is similar to Ross et al.7 findings in which the number of surgeries in the practice 160
was also found to be a significant factor in dentists’ clinical staff employment decisions. The highest proportion of dentists currently employing OHTs were in practices where there were four individual surgeries. What isn’t clear is whether the space had been created specifically to introduce or expand the OHT or traditional hygiene type services to complement or substitute for a dentist. What also remains unclear is the influence of the growing number of corporate or franchised dental practices has over considerations to employ OHTs. Further investigation into the policies and practices of such entities when it comes to workforce employment and utilization seems necessary. This study demonstrates that almost half (45.1% of respondents, CI 26.6% – 65.0%) employed an OHT for ‘predominantly hygiene services only’. Such an intention raises questions about the motive for OHT employment when only part of the OHTs skill set is being utilized given that OHTs are also trained in restorative dentistry for both the deciduous and permanent dentition. For example, is adding ‘hygiene’ service provision a good profit centre for the practice, or is the addition of hygiene services related to increased periodontal management capacity and preventive services for patients? Focus group and qualitative questionnaire data collected in the early stages of this project suggest that the attitudes of dentists towards the role of an OHT may be influencing how they are being utilized. This is in line with results published by Blue et al.8 who reported that attitudes as well as prior experience working with non-dentist practitioners (dental therapists and dental hygienists) were drivers of utilization. Further investigation will be required around the motivation for employment in larger scale practices and the potential under-utilization of oral health therapists in Australia. Willingness to employ a dental therapist, dental hygienist or oral health therapist Dentists’ age The fact that dentists aged 20–29 years are more willing to employ OHTs than their older colleagues is evidence of a changing team approach to service delivery. This study suggests that younger, more recently graduated dentists are more accepting or have a greater understanding of the role of OHTs. Further investigation is needed to explore the factors that influence the views of younger dentists. One suggestion is that integrated approaches to dental education in Australia are increasing interprofessional understanding and relationships. However, evidence in relation to the success of course integration and interdisciplinary learning in health seems at odds. Furze et al.9 showed that integrated educational © 2015 Australian Dental Association
Australian dentists who employ oral health therapists programmes can be effective at increasing interprofessional understanding and respect. However, Ross et al.10 observed that undergraduate dental students at the end of a five-year integrated dental science programme had sound knowledge of the OHT role, although their attitudes in relation to OHT clinical activity remained somewhat unfavourable. Sector of practice Respondents were asked to ignore their level of control or responsibility over employment decisions when considering their willingness to employ an OHT. To make a decision on this would then require some level of reflection on one’s knowledge, attitude and perception of the role and in turn what the OHT would bring to a practice. Public sector dentists would be almost three times more willing to employ an OHT if they were in the position to do so. This raises the question of whether experience working with dental therapists (who have been traditional partners in the provision of public sector school dental services in Australia) may influence the knowledge, attitudes and/ or perceptions of Australian dentists in relation to OHTs. Blue et al.8 found that experience working with expanded-function dental hygienists or assistants was the only factor significantly associated with American dentists’ opinion that ‘expanded-function personnel could have a positive impact on the quality of dental care’. They also noted that patient perception of the quality of services provided by the nondentist was similarly linked to dentists’ attitudes. Further sociological analysis in an Australian context is required to assess the differences between public and private sector dentists when considering employment and utilization of OHTs.
of dentists who were willing to employ were from practices that had multiple surgeries, with four out of five dentists (76.3%, n = 97) from large practices with five or more surgeries were willing to employ an OHT. This is a clear indication that physical space to accommodate an OHT plays a role. Furthermore, a degree of innovation or commercial entrepreneurialism of the employer are possible factors that might influence employment considerations of dentists. Consideration of practice expansion Dentists considering practice expansion were more open to the idea of employing OHTs. Nearly twothirds of the group indicated that they have considered practice expansion (62%). Of those, nearly half were willing to employ an OHT (45%). This further supports the view that commercial interest and innovation is a factor. Different models of team service delivery are a key element when practice expansion is considered. These dentists may consider the financial viability or the value an OHT can bring with them to the practice and to their patients. Again further investigation into the inspirations and visions of this group is necessary to tease out these attitudinal differences. Dentists’ attitudes
A greater proportion of dentists were willing to employ an OHT if their practice was situated in a non-metropolitan region (67.5%, n = 237). The employment considerations of regional dentists may be influenced by poor supply of, or problematic attraction and retention of new dentists, an increased confidence in the abilities of OHTs, a better knowledge of the full range of clinical capabilities of OHTs, or patient acceptance of complementary oral health providers. Further research into the attitudinal differences between metropolitan and regional dentists is required and should be of interest to regional workforce planners.
Literature on the characteristics of dentists and their attitudes towards OHTs, dental therapists and dental hygienists in Australia is scarce. Ross et al.11 in a survey of dentists in general dental practice in south-east Scotland identified some ‘predictors’ of dentists willingness to employ an OHT ranging from gender, to the number of dentists in the practice, to surgery availability and previous experience working with a complementary oral health provider. Attitudinal negativity amongst Scottish dentists toward the nature and clinical remit of OHTs was also identified as a factor having an influence over employment decisions and OHT utilization. They suggested that a lack of knowledge of the scope of practice and unfavourable attitudes impacted on dentists’ willingness to employ and appropriately utilize OHTs across the full scope of practice. Further analysis of the data collected from Parts B and C of the questionnaire used in this study needs to be conducted to test for the association between dentists’ attitudes and complementary oral health practitioner employment and utilization here in Australia.
Number of surgeries
CONCLUSIONS
Following similar trends as those who currently employ allied oral health providers, larger proportions
Certain characteristics of dentists have been shown to be associated with their history of employment and
Region of practice
© 2015 Australian Dental Association
161
C Kempster et al. willingness to employ dental therapists, dental hygienists and OHTs. An understanding of the factors that influence their employment is important if access pathways for the general public in Australia to the services provided by these oral health professionals remain the same. This study demonstrates that to date employment decisions have been more commonly related to entrepreneurial aspirations (aspirations of practice expansion), surgery availability and the state in which a dental practice (or potential employing dentist) is situated. However, other factors such as age, employment sector and attitudes towards dental therapists, dental hygienists and OHTs may also play a part in influencing future employment considerations. With an increase in the availability of OHTs, there will be a wider degree of skill mix and provision of preventive and maintenance services available to the general public. That said, greater numbers of allied oral health providers and increased skill mix across the entire dental workforce alone may not be enough to respond to the current and projected future needs of the Australian population. Emphasis must be placed on the development of public and private sector workforce models designed to increase the employment and holistic utilization of the complete skill set of the OHT. It is timely for oral health workforce planners to review employment and utilization barriers facing OHTs. Dental educators must continue to develop initiatives that will foster a greater degree of understanding and appreciation of the roles of OHTs, together with more instruction on dental team leadership. REFERENCES 1. Dental Board of Australia. Oral Health Therapist Registration. AHPRA, 2011. URL: ‘http://www.dentalboard.gov.au/Registration/ Oral-Health-Therapist.aspx’. Accessed October 2011.
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2. Dental Board of Australia. Scope of Practice Registration Standard. AHPRA, 2011. URL: ‘http://www.dentalboard.gov.au/ Registration-Standards.aspx’. Accessed October 2011. 3. Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Sociology Press, Aldine: 1967. 4. Australian Bureau of Statistics. Statistical Division from Postal Area Concordance, 2006. URL: ‘http://www.abs.gov.au/AUS STATS/[email protected]/39433889d406eeb9ca2570610019e9a5/01b98 cd854335e99ca25730c0000a5ad!OpenDocument’. Accessed November 2009. 5. Dillman DA. Mail and telephone surveys: the total design method. NY: Wiley, 1978. 6. Balasubramanian M, Teusner DN. Dentists, specialists and allied practitioners: the Australian dental labour force 2006. Dental Statistics and Research Series No. 53. Cat. no. DEN 202. Canberra: Australian Institute of Health and Welfare, 2011. 7. Satur J. Australian dental policy reform and the use of dental therapists and hygienists. Geelong: Deakin University, 2002. PhD thesis. 8. Blue CM, Funkhouser DE, Riggs S, et al. Utilization of nondentist providers and attitudes toward new provider models: findings from the National Dental Practice-Based Research Network. J Public Health Dent 2013;73:237–244. 9. Furze J, Lohman H, Mu K. Impact of an interprofessional community-based educational experience on students’ perceptions of other health professions and older adults. J Allied Health 2008;37:71–77. 10. Ross M, Ibbetson R, Turner S. The impact of team-working on the knowledge and attitudes of final year dental students. Br Dent J 2007;206:163–167. 11. Ross M, Ibbetson R, Turner S. The acceptability of duallyqualified dental hygienists-therapists to general dental practitioners in South-East Scotland. Br Dent J 2007;202:E8.
Address for correspondence: Mr Clinton Kempster Lecturer Level 4, Room 4.04a, Oliphant Building School of Dentistry The University of Adelaide North Terrace Adelaide SA 5005 Email: [email protected]
© 2015 Australian Dental Association
