The team at #TalkingTeeth in April are raising the issues of registration and health care workers. Dental assistants are the largest group of people working in dental practice. They undertake parts of the care pathway that are critical to the health and welfare of the public.
Despite their importance, they are not required to have any formal education, and remain outside the registration process. The team compare this to parts of Canada and the UK where dental assistants are integral registered members of team based care.
The #TalkingTeeth Team is Alexander Holden, Research Scholar, Gillian Jean, Research Scholar, Professor Estie Kruger, Professor Marc Tennant and Professor Heiko Spallek.
The #TalkingTeeth team write:
Dental assistants have never been professionally registered or formally regulated in Australia, so why the call for change?
Dental assistants play a substantial role in the oral health workforce.
In Australia, there are over 18,000 dental assistants; more than any registered division of dental practitioner and almost as many as the number of dentists, dental hygienists, dental therapists, oral health therapists and prosthetists put together.
The National Registration and Accreditation Scheme
The National Law was an attempt to deliver uniform regulation by creating the National Registration and Accreditation Scheme (NRAS), which came into effect in 2010. Dental assistants are not included in the NRAS, despite being engaged in sensitive aspects of clinical care and practice management.
Dental assistants are frequently responsible for accessing and recording information within electronic health records, submitting insurance claims and significantly, often they are the members of the dental team actively conducting cross-infection control procedures. The nation has seen effective infection control mechanism as a weak-point in the health system over the last few years.
The current legal framework places dental assistants in a position of equivalency with members of the public with regards to their professional regulatory status. To be a dental assistant requires no mandatory qualifications (although many dental assistants do gain qualifications on a voluntary basis) or assessment of fitness to practice such as health or criminal conviction declarations nor any of the reporting requirement around safe practice that cover other health professionals such as Nurses, Aboriginal Health Care workers or Doctors.
Role of dental assistants
Dental assistants are not passive members of the dental team; they are often able to be the first to recognise when a patient may be anxious or unwell and in need of further care. The lack of a requirement for formal training means that many dental assistants may never fully develop these skills in a safe and supportive environment, instead, relying upon unstructured, experiential learning.
The lack of formal regulation of dental assistants creates doubt about their legal standing relating to scope of practice. The National Law defines restricted dental acts that may only be carried out by a registered medical or dental practitioner. One of the challenges that un-registered status creates for dental assistants is the uncertainty around what these members of the dental team may carry out as part of their legitimate and legal practise. The restricted acts do not allow any procedure that is part of creating a dental device (such as a crown, denture, occlusal splint or bridge to name several examples) to be carried out by a non-registered individual.
This conflicts with the expansion of the scope of how the skills of dental assistants are utilised; for example, training courses are offered in Australia to teach dental assistants the skills of impression taking. Similar uncertainty exists as to whether dental assistants would be permitted by the legislative framework to place rubber dam or matrix bands to assist in a clinical procedure.
The National Code of Conduct for health care workers
The National Code of Conduct for health care workers has been developed to strengthen procedures for investigating complaints brought against health care workers not registered with the NRAS. The Code has yet to be ratified in every state and territory, but health ministers have reached agreement on the need to introduce the code Australia wide.
Dental assistants are named as a group targeted by the Code, and although to date there have not been any documented instances of investigations or disciplinary proceedings involving dental assistants, there is a likelihood of there being greater interest in the role of dental assistants in matters affecting public safety in the future.
What the code fails to do is support health care workers to understand the level of knowledge and training required to competently perform their duties. This puts vulnerable members of the dental team in a precarious position. How can dental assistants know what they don’t know? As previously mentioned, many dental assistants do complete formal training and qualifications, but there is no legal requirement to do so.
Safety and quality issues
Unqualified dental assistants still account for a significant proportion of the workforce. There is a potential for these untrained dental assistants to be perhaps unfairly held accountable for significant harm to members of the public because as a profession we have failed to recognise the implications of not mandating training to an accredited standard.
The only regulatory mechanism that can protect dental assistants from disciplinary action, stemming from inadequate training, is through inclusion of dental assistants in the NRAS. Alternatives such as self-regulation or negative licencing do not provide sufficient safeguards to guarantee that dental assistants have the level of knowledge required to practise safely. Although the purpose of the NRAS is to protect the public, it can only do so by taking responsibility for making sure the health workforce is appropriately trained.
Arguments about the lack of significant risk and potential costs of administration to warrant the inclusion of dental assistants, can be countered by reference to the potential enormity of the consequences of poor levels of training. If the NRAS wants to protect the public it should also protect its workforce.
The UK, South Africa, and a number of Canadian provinces have introduced formal regulation for dental assistants. In each instance there has been vocal resistance from professional organisations representing dentists. In South Africa, Dr Kgose Letlape, President of the Health Professions Council of South Africa, stated his lack of understanding at the resistance encountered; “why dentists would obstruct having their assistants being professionalised, so that they can get capable people, but meet a standard. But also so these people can have the pride of having this profession”.
We strongly agree with these sentiments; if the dental profession fails to recognise the value of investing in workforce development and ensuring public safety, it risks eroding public trust as well as raising questions of self-interest and of the nature of professionalism itself.
Alexander Holden and Heiko Spallek are from the Faculty of Dentistry, University of Sydney. Gillian Jean, Estie Kruger and Marc Tennant are from International Research Collaborative Oral Health and Equity, School of Human Sciences, The University of Western Australia.