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Assessment of Full-Time Dental Hygiene Faculty Participation in Clinical Practice

Key words: dental hygiene, dental education, professional practice

Submitted for publication 05/30/06; accepted 09/05/06

	Abstract

Top Abstract Methods and Materials Results Discussion Conclusion Appendix a. survey instrument References

 
The purpose of this research project was to determine how many U.S. dental hygiene (DH) programs had full-time (FT) faculty members who provided direct patient care unrelated to the curriculum. Questions in this project also assessed attitudes and opinions of DH directors regarding clinical practice and opportunities for salary supplementation. A questionnaire of twenty open-ended and closed-ended questions was designed on Survey Monkey, an online survey engine. After IRB approval and pilot testing, 278 U.S. DH program directors received two emails with the survey link requesting their participation. A response rate of 69.1 percent (n=192) was achieved. Results revealed that 14.2 percent of the programs required FT DH faculties to participate in clinical practice settings unrelated to the curriculum, while 67 percent of the programs had faculties who also participated in clinical practice. Eighty-three percent of respondents reported faculties who participated in clinical practice were financially compensated. The majority (95.4 percent) of directors indicated maintaining clinical skills was an advantage to clinical practice, while 48 percent of directors indicated participation takes time away from being an educator. Overall, the majority of DH programs did not require FT faculties to participate in clinical practice; however, respondents were generally in favor of allowing faculties the opportunity to practice and thought that it enhanced their competency as clinical instructors.

Several studies have been conducted on dental faculty practice plans (FPP) in the United States and Canada.^2–5 However, the studies did not include DH programs. Numerous studies have been conducted on FPP in health care programs, such as nursing, occupational therapy (OT), and medicine.^6–10

Various definitions of faculty practice have been proposed in the literature. McClure defines faculty practice as "doing what you teach others to do."¹¹ Millonig defines faculty practice "as an activity that is related to the care of patients, which is scholarly in nature." Millonig further explains that faculty practice does not include clinical teaching "because it has as its primary goal the education of the student."¹² Algase defines faculty practice as "advancement of the discipline of nursing."¹³ Wakefield-Fisher defines faculty practice as an expansion of teaching, which incorporates clinical practice.¹⁴ Collison and Parsons have two definitions for faculty practice. The first definition is a broad one, which includes the treatment of a patient by a faculty member during student clinics. The second definition is more restricted, in which faculty members are the only providers of treatment to patients.¹⁵ Kuhn’s definition of faculty practice does not entail teaching and supervising students in clinic.¹⁶ Kramer et al. define faculty practice as providing "service or care to patients/clients as their central focus" and do not include supervision or clinical teaching "because the central focus is education of the student."¹⁷ For the purpose of this article, clinical practice by faculty members is defined as direct patient care, in which the faculty member is the sole provider of treatment, unrelated to the curriculum. Clinical supervision of students is not included in the definition of direct patient care.

Numerous barriers and benefits of faculty practice have been cited in the dental and nursing literature. Barriers include available space, reimbursement issues, and time.^{4,6,12–14,18–23} Benefits to faculty practice include maintaining clinical skills, enriching the classroom environment, additional income, and developing research agendas.^{6,7,12,15,17–19,21,24,25}

What is currently not known is the extent to which DH faculties are participating in clinical practice outside of their academic responsibilities in order to stay current with their clinical skills. Therefore, the purpose of this study was to survey DH program directors regarding the involvement of their full-time (FT) faculty members in direct patient care, unrelated to the curriculum and, therefore, not including clinical supervision of students. Questions in this project also assessed attitudes and beliefs of DH directors regarding clinical practice among faculty members and opportunities for salary supplementation.

	Methods and Materials

Top Abstract Methods and Materials Results Discussion Conclusion Appendix a. survey instrument References

 
A twenty-question survey (Appendix A) was designed and subdivided into four sections: demographics, clinical practice patterns/settings, direct patient care settings, and attitudes and opinions. The survey contained Likert-scale questions along with open-ended and closed-ended questions. A survey specialist at the H.W. Odum Institute for Research in Social Science at the University of North Carolina (UNC) at Chapel Hill reviewed the survey. Corrections were made based on feedback.

The research project was submitted and approved by the Institutional Review Board (IRB) at UNC at Chapel Hill. The survey was pilot-tested by five DH program directors from different institutional settings. Minor corrections were made and resubmitted to the IRB for approval. Following final IRB approval of the survey, it was posted on Survey Monkey, an online survey website engine. Survey Monkey provided a Uniform Resource Locator (URL) for the survey.

A list of accredited U.S. DH programs was obtained from the American Dental Hygienists’ Association (ADHA) in July 2005. Program websites along with telephone calls were utilized to locate email addresses for DH program directors. A total of 278 program directors were identified and served as the study population. Two emails with the URL to the survey were sent three weeks apart to each program director, requesting his or her participation in the research study. Participants were informed that the survey was anonymous and that there were no incentives for providing responses.

The data was reported as percentages in Survey Monkey. Bivariate analyses were performed in order to acquire correlations using the chi square test when both compared variables were nominal. The Mantel-Haenszel row mean score test was used when nominal and ordinal variables were compared. Data were analyzed by SAS version 9.

	Results

Top Abstract Methods and Materials Results Discussion Conclusion Appendix a. survey instrument References

 
A total of 192 program directors responded to the online survey, achieving a response rate of 69.1 percent. For analysis purposes, technical/vocational colleges and community/junior colleges were combined. The majority (71 percent, n=137) of respondents were from technical/vocational colleges and community/junior colleges, followed by 16 percent (n=30) from a university/college without a dental school and 13 percent (n=25) from a university/college with a dental school. Almost half of the programs (49.5 percent) had one to five faculty members in a nine- or ten-month position, and 67 percent of programs had one to five faculty members in a twelve-month position.

Clinical Practice Patterns
When asked if the program requires FT faculty members to participate in direct patient care, 14 percent of programs indicated they do require participation. Fifty-nine percent of respondents whose program does not require participation in direct patient care indicated that faculty schedules and obligations do not permit time to participate. Thirty-three percent reported that the institution does not allow faculty members to provide direct patient care and that it is not part of faculty contracts.

When asked if the program elects to have FT faculty members participating in direct patient care, 67 percent of programs indicated faculties do participate. A majority (72.7 percent) of programs with faculties not participating in direct patient care indicated that faculty schedules and obligations do not permit time. Forty-five percent said there was no opportunity for the faculty members to participate, and 34.5 percent indicated that there is no setting available. Only 16 percent of respondents indicated that FT faculty members were not interested in providing direct patient care, and only 7 percent indicated state practice acts limited faculty members from participating.

Direct Patient Care Settings
DH directors reported a variety of patient care settings utilized by their faculties. The majority (90.3 percent) of respondents indicated faculties provided direct patient care in a private dental office. A quarter of respondents indicated faculties provided direct patient care in a setting associated with the institution, and 4 percent indicated an off-site clinic affiliated with the institution was available. Of the programs that have FT faculties participating in direct patient care, 60 percent indicated faculty members are on a <12 month contract and provide direct patient care during nonacademic periods.

Twenty percent of programs indicated that a set number of hours are allocated each week to be used at the discretion of the faculty for professional development, which may be used for clinical practice, research, or consulting. Only 11.7 percent of respondents indicated that a set number of hours are allocated each week specifically for clinical practice. Eighty-three percent of respondents reported faculties who participate in clinical practice are financially compensated, with the majority of these programs (95.1 percent) reporting compensation by an hourly, salary, or commission pay that is not part of the university base salary.

Attitudes and Beliefs Among DH Program Directors
One section of the survey focused on attitudes and opinions with specific questions about advantages and disadvantages of providing direct patient care (Table 1). Maintaining clinical skills and keeping current with clinical techniques were noted as advantages by 95 percent of respondents. Enhancing clinical instruction (75.6 percent), providing additional income (72 percent), and enriching the classroom environment (68.6 percent) were the next three most cited advantages. Over half (53.1 percent) of respondents indicated there are no disadvantages to providing direct patient care, and 48 percent indicated it takes time away from the primary role of serving as an educator.

Participants from programs requiring FT faculties to provide direct patient care were more in agreement with four of the five Likert scale questions in the attitudes and opinions section compared to those programs not requiring direct patient care. For example, 48.2 percent of participants requiring FT faculties to participate agreed DH faculties should be required to provide direct patient care while teaching in DH education (Table 3). Participants from programs with FT faculties participating in direct patient care, either through requirement or volunteering to do so, were more in agreement with three of the five Likert scale questions in the attitudes and opinions section compared to programs without faculties participating in care. For example, 79.5 percent of participants with FT faculties participating agreed that DH faculties should be given the opportunity to provide direct patient care while teaching in DH education (Table 4). Overall, respondents from programs that required faculties to practice and those with faculties volunteering to practice were always in more agreement with the Likert scale questions than other respondents.

Participants from programs that do not have FT faculties participating in direct patient care were more likely not to choose the following advantages of providing care from a list of nine: additional income (45.2 percent, p-value=0.01); maintaining clinical skills/keeping current with clinical techniques (19.4 percent, p-value=0.0132); and greater respect by students and faculties for their clinical application of knowledge (46.8 percent, p-value=0.0487). Additionally, participants from programs with FT faculties providing direct patient care were more likely to report that there are no disadvantages to providing care (53.6 percent). Respondents from programs without faculties providing direct patient care were more likely to report there are disadvantages to providing care (62.9 percent, p-value=0.0335).

	Discussion

Top Abstract Methods and Materials Results Discussion Conclusion Appendix a. survey instrument References

 
This study confirmed that the majority of DH programs in the United States do not require participation in direct patient care, but over half of the programs have faculty members participating, either during nonacademic periods or during times the institution sets aside each week to be used at the faculty members’ discretion. Only 29 percent of programs indicated that faculty members participate in direct patient care at a location associated with the institution. This number is less than reported in the 1996 Almog et al. study in which it was found that 96 percent of dental schools had FPP associated with the institution.⁵ However, compared with Barger’s findings of nursing programs (15 percent of nursing programs had nursing centers for faculty practice), DH programs had a higher percentage of practice locations associated with the institution.^7,8 A future research study could explore if more DH programs would encourage or require their faculty members to provide direct patient care if more institutions had a faculty practice or if a dental hygiene faculty practice could serve as a mechanism to increase income for the institution. In addition, faculty practice could be used as a center to provide care for those with little access to dental care.

DH program directors indicated numerous advantages to direct patient care that have been cited previously in the literature, such as additional income,^{12,15,18,19,24} opportunity for promotion and tenure,^6,7,15 maintaining clinical skills,^{12,17–19,21,24,25} and enriching the classroom environment.^{6,12,15,17,18,21,24,25} Respondents also indicated numerous disadvantages to direct patient care that have been reported, such as encouraging individuals to leave the academic world to pursue clinical work and taking time away from the primary role of being an educator.^12,18–20 Forty-eight percent of respondents in the current study indicated participating in direct patient care takes time away from being an educator. This percent is less than reported by Scoggin et al. who found that, among OT programs, 59 percent of respondents indicated clinical practice takes time away from the educator role.⁹ Scoggin et al. also found OT faculties (32 percent) participated in clinical practice less than DH faculties (67 percent). Faculty shortages could be a reason for these findings because FT faculties have to increase their workload at programs with faculty shortages.

A limitation to this study is that DH program directors and not FT DH faculty members completed the questionnaire. Therefore, the program directors were reporting what they believe are issues related to direct patient care, which may not necessarily be the opinions of the individual faculty members. Another limitation is not all program directors from accredited DH programs in the United States responded to the questionnaire, possibly due to Internet connection problems and time limitations. The emails were sent to program directors in August 2005, the beginning of a new semester and a busy time of year. Other respondents were confused about the definition used in the study to describe direct patient care, even though it was defined in the emails, and others indicated they did not respond because they did not have any faculty members who participated in direct patient care.

This study did not assess the number of years of clinical experience among DH faculty members, which may be an indication of why not all faculty members are required or participate in direct patient care while being employed as educators. A future study could assess clinical experience along with participation in clinical practice of FT DH educators.

Overall, the data revealed that over half of the respondents have FT faculty members participating in direct patient care. This study provides needed information on opportunities for DH faculties to practice in a clinical setting as health care providers and may present essential data to programs that desire faculty members to participate in direct patient care.

	Conclusion

Top Abstract Methods and Materials Results Discussion Conclusion Appendix a. survey instrument References

 
Our research found that while the majority of DH programs participating in the research project do not require FT faculty members to participate in direct patient care, over half of the programs have FT faculty members who participate in the treatment of patients unrelated to the curriculum. The primary professional environment in which faculty members participate in direct patient care is in private dental offices, followed by affiliation with a dental team to provide comprehensive care within the institution and health departments/community clinics. Dental hygiene program directors are generally in favor of allowing faculty members the opportunity to practice and think that it enhances their competency as clinical instructors.

	APPENDIX A. Survey Instrument

Top Abstract Methods and Materials Results Discussion Conclusion Appendix a. survey instrument References

 
Assessment of Full-Time Dental Hygiene Faculty Participation in Direct Patient Care
Instructions: Please complete the questionnaire below within two weeks. Answer questions according to dental hygiene faculty members’ involvement in direct patient care, which does not include clinical teaching and clinical supervision.

1. Demographics

   1. Please indicate the institutional setting of your dental hygiene program.

   Technical/Vocational Institute
   

   Community/Junior College
   

   College/University with a Dental School
   

   College/University without a Dental School
   

   Other (Specify)____________________________
   

   
   

   2. Please indicate the number of full-time faculty members in your dental hygiene program.

   1–3
   

   4–6
   

   7+
   

   
   

   3. Please provide the following information for full-time dental hygiene faculty members.

   ____ # of faculty in 9 or 10 month positions
   

   ____ # of faculty in 12 month positions
   

   
   

   
   
2. Clinical Practice Patterns

   4. Does your program require dental hygiene faculty members to provide direct patient care?

   Yes
   

   No
   

   
   

   5. If answered no to question #4, please answer.

   Why are dental hygiene faculty members not required to provide direct patient care? Check all that apply.
   

   The institution does not allow faculty members to provide direct patient care.
   

   Faculty schedules and obligations do not permit time to provide direct patient care.
   

   Faculty members are not interested in providing direct patient care.
   

   A setting is not available to provide direct patient care.
   

   There is no opportunity for the faculty members to provide direct patient care.
   

   State practice acts limitations.
   

   Other (Specify)_________________________________
   

   
   

   6. Do any of the dental hygiene faculty members at your program provide direct patient care?

   Yes
   

   No
   

   
   

   7. If answered no to question #6, please answer.

   Why don’t dental hygiene faculty members provide direct patient care? Check all that apply.
   

   The institution does not allow faculty members to provide direct patient care.
   

   Faculty schedules and obligations do not permit time to provide direct patient care.
   

   Faculty members are not interested in providing direct patient care.
   

   A setting is not available to provide direct patient care.
   

   There is no opportunity for the faculty members to provide direct patient care.
   

   State practice acts limitations.
   

   Other (Specify)_________________________________
   

   Skip to question #13 if answered question #7.
   

   
   

   8. Please indicate how dental hygiene faculty members are allocated time to provide direct patient care. Check all that apply.

   A set number of hours are allocated each week for clinical practice.
   

   A set number of hours are allocated each week to be used at faculty discretion for professional development (clinical practice, research, consulting, etc.).
   

   Faculty members are on a less than 12-month contract and provide direct patient care during nonacademic periods.
   

   Other (Specify)___________________________________
   

   
   

   9. For those faculty members who provide direct patient care, on average how many hours per week do they devote to this activity.

   1–4 hours
   

   5–8 hours
   

   9–12 hours
   

   13+ hours
   

   
   

   
   
3. Direct Patient Care Settings

   10. Please indicate all the settings in which your faculty members provide direct patient care. Check all that apply.

   Affiliated with a dental team, including dentists, to provide comprehensive care within the institution.
   

   A unit in the faculty practice (i.e., on a referral basis) within the institution.
   

   A dental hygiene practice where only dental hygiene procedures are performed within the institution.
   

   An off-site clinic affiliated with the institution.
   

   A private dental office.
   

   Health departments.
   

   Hospitals/Veteran Administration (VA).
   

   Public/private school systems.
   

   Extended care facilities/nursing homes.
   

   Other (Specify)________________________________
   

   
   

   11. Are the faculty members financially compensated for the care they provide?

   Yes
   

   No
   

   
   

   12. If answered yes to question 11, how are faculty members financially compensated? Check all that apply.

   Hourly/salary/commission (not part of university base salary).
   

   As a portion of their university base salary.
   

   Salary supplement.
   

   Placed in a compensation fund to be used for professional development.
   

   Other (Specify) ______________________________
   

   
   

   
   
4. Attitudes and Opinions

   13 What do you believe to be some of the advantages to providing direct patient care while being a dental hygiene educator? Check all that apply.

   Additional income.
   

   Fulfill partial requirements for promotion and tenure.
   

   Maintaining clinical skills/keeping current with clinical techniques.
   

   Enhanced clinical instruction.
   

   Enriching the classroom environment.
   

   Development of research agendas.
   

   Professional development.
   

   Respected more by students and faculty members for their clinical application of knowledge.
   

   Other (Specify)____________________________________
   

   
   

   14. What do you believe to be some of the disadvantages to providing direct patient care while being a dental hygiene educator? Check all that apply.

   Provides little or no additional financial incentive for the time it takes.
   

   Taking time away from the primary role of being an educator.
   

   Taking time away from research opportunities.
   

   May encourage individuals to leave the academic world and work in private practice.
   

   There are no disadvantages to providing direct patient care.
   

   Other (Specify) ________________________________
   

   
   

   
   How much do you agree or disagree with the following statements (#15–#18):

   15. Dental hygiene faculty members should be required to provide direct patient care while teaching in dental hygiene education.

   Strongly Agree
   

   Agree
   

   Neither Agree nor Disagree
   

   Disagree
   

   Strongly Disagree
   

   
   

   16. Dental hygiene faculty members should be given the opportunity to provide direct patient care while teaching in dental hygiene education.

   Strongly Agree
   

   Agree
   

   Neither Agree nor Disagree
   

   Disagree
   

   Strongly Disagree
   

   
   

   17. Dental hygiene faculty members who provide direct patient care enhance their competency as clinical instructors.

   Strongly Agree
   

   Agree
   

   Neither Agree nor Disagree
   

   Disagree
   

   Strongly Disagree
   

   
   

   18. Dental hygiene clinical instructors should be required to provide direct patient care.

   Strongly Agree
   

   Agree
   

   Neither Agree nor Disagree
   

   Disagree
   

   Strongly Disagree
   

   
   

   19. For dental hygiene faculty members who are involved in direct patient care, what do you consider their overall level of satisfaction?

   Very Satisfied
   

   Satisfied
   

   Neither Satisfied nor Dissatisfied
   

   Dissatisfied
   

   Very Dissatisfied
   

   Not applicable/faculty members are not involved in direct patient care
   

   
   

   20. We would appreciate any additional information you would like to share regarding dental hygiene faculty involvement in direct patient care.

   ________________________________________________________________________
   

   ________________________________________________________________________
   

   ________________________________________________________________________
   

   
   

   
   

Thank you for your time in completing the survey!!!

	Footnotes

 
Ms. Kiser is a dental hygiene instructor, Cape Fear Community College, Wilmington, NC; Ms. Wilder is Associate Professor and Director of the Graduate Dental Hygiene Program, Department of Dental Ecology, University of North Carolina at Chapel Hill; Ms. Fleming is a former Clinical Assistant Professor, Department of Dental Ecology, University of North Carolina at Chapel Hill; and Ms. George is Associate Professor, Department of Dental Ecology, University of North Carolina at Chapel Hill. Ms. Kiser conducted this project in partial fulfillment for the Master of Science Degree in Dental Hygiene Education at the University of North Carolina at Chapel Hill School of Dentistry. Direct correspondence and requests for reprints to Jessica Kiser, Cape Fear Community College, Allied Health Department-Dental Hygiene, 411 North Front Street, Wilmington, NC 28401; 910-362-7417 phone; 910-362-7418 fax; jkiser{at}cfcc.edu.

	REFERENCES

Top Abstract Methods and Materials Results Discussion Conclusion Appendix a. survey instrument References

 

1. Commission on Dental Accreditation, American Dental Association. Accreditation standards for dental hygiene education programs. Chicago: American Dental Association, 1998.
2. Gordon J. Intramural dental practices in dental schools. J Dent Educ 1972; 36(5):24–6.[Medline]
3. Speed EM, Wolff A, Barr JH, Bomba JL, Rule RW. A survey of intramural dental practices in United States dental schools. J Dent Educ 1973; 37(1):26–9.[Medline]
4. Shnorhokian HI, Zullo TG. A survey of faculty practice plans in United States and Canadian dental schools. J Dent Educ 1993; 57(4):318–20.[Medline]
5. Almog DM, Handelman SL, Black PM, Van Dyke TE. A survey of faculty practices in U.S. dental schools. N Y State Dent J 1996; 62(10):25–9.[Medline]
6. Bellinger K, Sanders DH. Faculty practice policy. J Nurs Educ 1985; 24(5):214–6.[Medline]
7. Barger SE. Personnel issues in academic nurse-managed centers: the pitfalls and the potential. Nurs Educator 1986; 11(3):29–33.
8. Barger SE. Academic nursing centers: a demographic profile. J Prof Nurs 1986; 2(4):246–51.[Medline]
9. Scoggin AE, Gibson RW, Hanson C. Perspectives on faculty clinical practice: views of occupational therapy curriculum chairpersons and faculty members. Am J Occup Ther 2000; 54(5):533–40.[Medline]
10. Bentley JD, Chusid J, D’Antuono GR, Kelly JV, Tower DB. Faculty practice plans: the organization and characteristics of academic medical practice. Acad Med 1991; 66(8): 433–9.[Medline]
11. McClure ML. Faculty practice: new definitions, new opportunities. Nurs Outlook 1987; 35(4):162–6.[Medline]
12. Millonig VL. Faculty practice: a view of its development, current benefits, and barriers. J Prof Nurs 1986; 2(3): 166–72.[Medline]
13. Algase DL. Faculty practice: a means to advance the discipline of nursing. J Nurs Educ 1986; 25(2):74–6.[Medline]
14. Wakefield-Fisher M. The issue: faculty practice. J Nurs Educ 1983; 22(5):207–10.[Medline]
15. Collison CR, Parsons MA. Is practice a viable faculty role? Nurs Outlook 1980; 28:677–9.[Medline]
16. Kuhn J. An experience with a joint appointment. Am J Nurs 1982; 82:1570–1.[Medline]
17. Kramer M, Polifroni EC, Organek N. Effects of faculty practice in student learning outcomes. J Prof Nurs 1986; 2(5):289–301.[Medline]
18. Cameron CA, Brattebo Yamagata PA, Olswang SG. Mandatory clinical practice for dental and dental hygiene faculty. J Dent Educ 1982; 46(3):153–7.[Medline]
19. Klooster J. Faculty practice: advantages and disadvantages. J Dent Educ 1978; 42(10):576–8.[Abstract]
20. Van Stewart A. Attitudes towards intramural-practice programs in American dental schools. J Dent Educ 1975; 39(10):687–90.[Medline]
21. Lambert CE, Lambert VA. Faculty practice: unifier of nursing education and nursing service? J Prof Nurs 1988; 4(5):345–55.[Medline]
22. Smith GR. Compensating faculty for their clinical practice. Nurs Outlook 1980; 28(11):673–6.[Medline]
23. Mauksch IG. Faculty practice: a professional imperative. Nurs Educ 1980; 5(3):21–4.
24. Anderson ER, Pierson P. An exploratory study of faculty practice: views of those faculty engaged in practice who teach in an NLN-accredited baccalaureate program. West J Nurs Res 1983; 5(2):129–43.[Free Full Text]
25. Barger SE. Academic nurse–managed centers: issues of implementation. Fam Comm Health 1986; 9:12–22.

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