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The Dental Nurse

History

Until 2008, any person wishing to work as a nurse or assistant in the dental surgery environment could do so without undertaking any form of training or passing any examination. Since 1943, the National Examining Board for Dental Nurses (NEBDN), previously called the National Examining Board for Dental Surgery Assistants, had been setting and running its voluntary examination for any persons working as nurses (assistants) in the dental workplace. Qualification in the National Certificate examination showed that successful candidates had achieved a set basic standard in dental nursing, were able to work unsupervised alongside the dentist and could call themselves a ‘dental nurse’ (previously a ‘dental surgery assistant’).

More recently, City & Guilds (C&G) introduced its Level 3 NVQ in Dental Nursing, as an alternative qualification for those students wishing to follow a vocational rather than a more academic career pathway to becoming a dental nurse. Both qualifications ran successfully alongside each other, and were open to any students wishing to take them. In Scotland, students were able to access a Scottish equivalent of the NVQ, as well as the National Certificate.

In the last 5 years, dental nurses, along with all other dental care professionals, have gradually been brought under the regulatory umbrella of the General Dental Council (GDC). Following a period of ‘grandparenting’, during which unqualified but well-experienced dental nurses were allowed to register with the GDC without prior qualification, compulsory training and qualification for all were introduced.

Registration

Since 2008, any person wishing to work as a dental nurse has had to undergo a period of ­supervised training, and then pass a formal examination before being allowed to register with the General Dental Council. All unqualified dental nurses must be supervised and ‘in training’ to be able to work directly with patients, and all qualified dental nurses must be registered on an annual basis with the GDC, to be able to continue to work with patients unsupervised.

As with the other dental care professionals (DCPs) listed in Chapter 1, the necessity of registration for dental nurses has raised their role to that of a professional in the eyes of both the public and other members of the dental team. In addition, it has brought all members of the dental team into line with other healthcare professionals in the United Kingdom, so that all are now ­accountable to a regulatory body.

In line with other regulators, the purpose of the GDC in its regulatory role is to maintain the list – or Register – of those persons deemed suitable to work as healthcare professionals at their level of qualification. This is correctly termed their ‘fitness to practise’.

As with all other GDC registrants, dental nurses are required to pay an annual retention fee to maintain their place on the Register, having behaved in a professional manner throughout the previous 12-month period. In other words, the GDC has to ensure not only that anyone joining the Register is fit to practise at the point of initial qualification but that they remain so throughout their career. Consequently, the GDC’s own aims are summarised throughout its publications as: ‘Protecting patients, regulating the dental team’.

Role of the General Dental Council in dental nurse training and qualification

To ensure that dental nurses are adequately trained and qualified to a suitable level in their chosen dental career, the GDC describes the learning outcomes that each student must be able to demonstrate by the end of their training, to be able to join the GDC Register. Originally, these outcomes were published in the GDC document Developing the Dental Team but they are now covered in the updated publication Preparing for Practice – Dental Team Learning Outcomes for Registration. This updated document has also superseded the equivalent publication for dental ­undergraduates, The First Five Years. All GDC publications can be viewed or downloaded by accessing its website at www.gdc-uk.org.

In summary, then, the GDC has a vital role to play in the regulation of the whole dental team, including dental nurses, from the time that they enter a formal course of training as a student, right through their professional career until they leave the GDC Register. The GDC’s functions as a regulatory body and the way that this affects the dental nurse are as follows.

• Set standards to be followed – in relation to behaviour, education (pre- and postregistration) and ethics.
• Handle fitness to practise issues – in relation to poor health, poor professional performance or professional misconduct.
• Remove individuals from the Register and prevent them from practising as dental ­professionals, if they are considered to be ‘unfit’.

In carrying out its role as a regulatory body for the dental profession, the GDC also promotes its own aims to.

• protect patients
• regulate the dental team
• promote public confidence in all dental professionals
• quality assure dental education for all dental professionals working in the UK
• ensure that all dental professionals maintain an up-to-date level of knowledge
• assist patients with serious complaints against dental professionals.

These fundamental aims of the GDC affect the working lives and careers of every dental professional on a day-to-day basis, and represent the standards that should be achieved by all. The GDC has conveniently published these principles and standards in booklet format, General Dental Council Standards Guidance, and made them available to all registrants. They are discussed in detail in Chapter 3. All student dental nurses are expected to be familiar with the detailed contents of these booklets by the time they sit their qualification examinations.

Learning outcomes and qualification

As mentioned previously, the GDC has set out the outcomes that dental nurses must be able to demonstrate by the end of their training period, in order to become a registrant and be deemed ‘fit to practise’. Within a training course, demonstration of these outcomes is met through ­education, training and assessment, and they are therefore referred to as ‘learning outcomes’. They are derived from the GDC’s own Standards for Dental Professionals document, and include the ­requirements set by the GDC for lifelong learning to be achieved. In the UK, student dental nurses can meet the training requirements by following an approved course and passing either the NEBDN National Diploma examination or the City & Guilds Level 3 Diploma in Dental Nursing examination.

The GDC learning outcomes have been developed so that a student who achieves them can be said to be competent – they can practise safely, effectively and professionally as a dental nurse. The vast majority of the learning outcomes are actually set, word for word, for each dental professional category, from the dentist through to the dental technician. Once achieved, they demonstrate that the student has the knowledge, skills, attitudes and behaviours required to become a GDC registrant.

To understand what is required from student dental nurses during their training, education and assessment, the following interpretations of these key terms may be useful.

• Knowledge – the underpinning, theoretical information gained from learning or experience, which gives the student understanding of a subject.
• Skills – the special abilities acquired by learning and practice to be able to complete a task, often manually or verbally.
• Attitudes and behaviours – the moral and ethical beliefs held by the student which ­demonstrate their values and priorities, and guide their actions.

Students must exhibit all of these attributes to be considered as professional dental nurses after qualification, and be entered onto the GDC Register. They must then maintain and improve upon these qualities throughout their working life, to stay on the Register.

The GDC learning outcomes are grouped into four domains for all registrants, and their specific relevance to the dental nurse is as follows.

• Clinical – described as the range of skills required to deliver direct care, where registrants interact with patients.
• Communication – described as the skills involved in effectively interacting with patients, their representatives, the public and colleagues, and recording appropriate information to inform patient care.
• Professionalism – described as the knowledge, skills and attitudes/behaviours required to practise in an ethical and appropriate way, putting patients’ needs first and promoting confidence in the dental team.
• Management and leadership – described as the skills and knowledge required to work effectively in a dental team, manage own time and resources, and contribute to professional practice.

The NEBDN National Diploma curriculum has been designed to follow these domains and learning outcomes very closely, with more detail given in many areas, as necessary. The glossary of terms has been reproduced in Appendix 1. Details of the qualification itself are given at the end of this chapter, together with information on the C&G Level 3 Diploma.

Student ‘fitness to practise’

The GDC’s role in regulating the dental profession begins when any student enrolls on a training course and is deemed to be ‘in training’. This is irrespective of the category of the future registrant (whether a dentist, dental nurse and so on), or whether the training is being delivered in a dental hospital, further education college or in the dental workplace. All healthcare regulators are required to ensure the safety of patients while being treated by healthcare students, and to ensure that they are fit to practise at the point of registration. While the student dental nurse would not be in a position to ‘treat’ a patient as such, certain standards of professionalism are quite rightly expected of them, as with any other healthcare student.

Some of the areas of concern that may draw the attention of the GDC to a particular ­student in relation to issues surrounding their fitness to practise may come as a surprise to some, ­especially when events have occurred outside the training course or the workplace. While those allegations or areas of concern involving the police (whether resulting in a conviction or a ­caution) are bound to be considered by the GDC in fitness to practise hearings, other circumstances (such as cheating in an examination or having a poor work attitude) may be erroneously considered to have little to do with the regulator. However, actions and behaviours such as these latter ­examples may give an overall impression of an unprofessional attitude by the student to the public, and are therefore of great concern to the GDC. Further examples of the types of allegations or ­convictions that may cause concern and bring into question a student’s fitness to practise are set out in Table 3.1 in Chapter 3.

The principles of professionalism that the student dental nurse must adhere to are clearly laid down in the GDC Standards for Dental Professionals document (see Chapter 3 for details), and fall into the following six categories.

The responsibility is on the education provider to inform students that unprofessional behaviour or serious health problems during their training may affect their ability to register with the GDC, if they are not considered to be ‘fit to practise’. The provider must have transparent processes and procedures in place to communicate and investigate concerns when they arise, and determine whether the student could possibly put patients and the public at risk by their actions.

Full details of the guidance available from the GDC in these matters, for both education ­providers and students, are available from the GDC website at www.gdc-uk.org.

To ensure that student dental nurses fully appreciate the levels of professionalism expected of them as members of the dental team, examples of some of the potential areas of concern that may result in a fitness to practise investigation are shown in Table 3.1. The topic of professionalism is discussed in detail in Chapter 3.

Dental nurses and the law

The ethical and legal issues that affect dental nurses in their workplace and day-to-day duties are covered in detail in Chapter 3, and those related to safe working practices in Chapter 4.

Overall, the two Acts of Parliament that govern the whole dental profession, including dental nurses, are:

• The Dentists’ Act 1984 (Amendment Order 2005)
• The Health and Social Care Act 2008.

The Amendment Order to the Dentists’ Act stipulates that only those persons registered with the GDC, following success in a register-able dental nursing qualification, can legally call themselves a ‘dental nurse’. This may seem a minor point but a breach of the Order is viewed as a serious legal matter involving an abuse of trust, as the person is seen to be misleading the public over their implied professional status. Qualified dental nurses who have failed to maintain their registration simply by not paying the GDC annual retention fee are therefore breaking the law, and can be ­prosecuted. Any other registrant (dentist or DCP) who employs such a person is also putting their own registration at risk.

The Health and Social Care Act was introduced in response to the apparent loss of trust in the healthcare professions (including the dental profession) by the public. This followed public inquiries into several notorious cases of serious harm being done to patients by their doctors, both in the hospital environment and out in the community. The most shocking of these was probably the case of Dr Harold Shipman, a GP in Manchester who was successfully convicted of murdering 15 of his patients. His actions were only uncovered after the solicitor daughter of one of his victims became suspicious of events surrounding the death of her mother, and contacted the police. The case highlighted just how uncontrolled and unaccountable a healthcare professional could be at the time, as Shipman is alleged to have killed over 200 of his patients over the years, without raising any suspicions until that point.

Finally, in addition to the above enactments, the same professional standards of behaviour listed previously for students also apply to those who are qualified, and must be adhered to throughout their working career. Now that all DCPs are individually registered with the GDC, the onus is on each team member to take full responsibility for their own actions and to act in a professional manner at all times. The issue of ‘vicarious liability’ no longer applies – the dentist is no longer ­personally responsible for the actions or omissions of other registered members of the dental team. However, they are still responsible for unregistered staff, including trainee dental nurses.

The practical application of the professional principles laid down in the GDC Standards for Dental Professionals document requires all members of the dental team to behave in the following manner, as professional individuals and on a day-to-day basis.

• Apply the principles in your work as a dental professional, whether or not you routinely treat patients.
• Understand that you are professionally responsible for your actions and must be able to account for them.
• Put patients’ interests before your own or those of your colleagues.
• Apply these principles when handling queries and complaints from patients and in all other aspects of non-clinical professional service.
• Maintain your GDC registration and work only within the limits of your knowledge, professional competence and physical capability.
• Take effective action to protect patients if you believe they are being put at risk by your health, behaviour or professional performance, or those of a colleague, or by any aspect of the ­practice clinical environment.
• If in doubt, obtain advice from senior staff, appropriate professional body or the GDC.
• Treat patients with respect, courtesy and awareness of their dignity and rights.
• Understand and promote patients’ responsibility for making decisions about their bodies, their priorities and their care, and obtain their consent before any treatment is undertaken.
• Provide all the information, including the risks, benefits, costs and alternative options, upon which they can make their decision.
• Ensure that there is no discrimination against patients regarding their race, ethnic origin, age, sex, disability, special needs, sexuality, lifestyle, beliefs or economic status.
• Treat all information about patients as confidential, and for use only for the purposes for which it was provided.
• Ensure that such material is kept securely to prevent any accidental or unauthorised access to it.

These points are discussed in detail in Chapter 3.

General Dental Council registration completes the first stage of the dental nurse’s professional career. From that point on

• compliance with your legal obligations, knowledge, skills and professional competence must be maintained and updated by verifiable continuing professional development
• justify your professional status, and the trust of your patients and colleagues, by honesty and fairness in all your professional and personal activities
• apply all these ethical principles to clinical and professional relationships, and to any commercial or business dealings in which you may be involved
• maintain proper standards of personal behaviour in all aspects of your life, and thereby ­promote patients’ confidence in you and public confidence in the dental profession.

Continuing professional development

Continuing professional development (CPD) and lifelong learning are now statutory requirements for the continuing registration of DCPs, and more recently the concept of becoming a ‘reflective practitioner’ has enabled dental professionals to understand how experiences in their daily working lives should guide their CPD achievements. Carrying out CPD activities should aim to guide an individual in updating their skills and education throughout their working lives, to ensure that they stay abreast of all the changes and updates involved in their chosen career. This should then ensure that they provide the best care and service possible to patients. A summary of information and knowledge is given here, but the subject is discussed in more detail in Chapter 3.

Continuing professional development is either verifiable or non-verifiable. Verifiable CPD is that offered formally, with specific learning outcomes given. Certificates of attendance and/or ­participation in verifiable CPD activities will be issued and must be kept as evidence of complying with the GDC’s requirements; they may even have to be produced as evidence of verifiable CPD activity. Examples of verifiable CPD are as follows.

• Attendance on postgraduate courses.
• Attendance at local meetings organised by postgraduate tutors or deaneries.
• Distance learning programmes with learning outcomes.
• Computer-aided learning programmes (CAL).
• Attendance at conferences with stated learning outcomes.
• Studying and taking formal examinations in dentally related subjects.
• Completing tests set on articles published in dental journals.

Some topics of coverage are considered to be essential to the safe delivery of dental care, and are therefore called ‘core subjects’. The GDC stipulates the amount of CPD that must be undertaken in these core subjects over a 5-year cycle, for each category of registrant. For dental nurses, the core subjects and the number of verifiable CPD hours for each are as follows.

• Medical emergencies – 10 h.
• Disinfection and decontamination – 5 h.
• Radiography and radiological protection – 5 h.
• Legal and ethical issues – if dealing with patients on a regular basis.
• Complaints handling – if dealing with patients on a regular basis.

Non-verifiable CPD is that done on an informal basis, often purely on a personal interest basis. Although new information may well be learned during these activities, it cannot be tested nor proved that specific learning outcomes have been achieved. Currently, the num/>

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