M. Dingle and C. Balmer conducted a study of 1,006 dental nurses. Thirty-two percent reported difficulty paying their annual retention fee to the GDC and 65% have considered leaving dentistry.

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Abstract

Introduction The experiences of the dental nursing profession though the COVID-19 pandemic is not well publicised. Aims To highlight the impact that COVID-19 has had on our dental nursing colleagues. Design A 24-point anonymous online survey created using Microsoft Forms, collecting both quantitative and qualitative data. Setting A link to the survey was shared on five popular national UK dental nursing Facebook groups, the majority of which require a name and associated GDC number to become a member. Materials and method A link to the survey was shared on 21 September 2020 and was open for four weeks. Results: One thousand and six dental nurses completed the questionnaire by 22 October 2020. Eight hundred and eighty-eight respondents work in a dental practice, 65% NHS and 35% private. Seven percent of respondents have been redeployed whilst 48% report being furloughed. Forty-nine percent report COVID-19 has had a negative effect on their personal finances and 32% report financial difficulty paying their GDC registration. Sixty-five percent have considered leaving dentistry altogether. Discussion Nearly two-thirds of the respondents have considered leaving the profession, commonly stating stress, pay and the General Dental Council (GDC) annual retention fee (ARF) as determining factors. Conclusion Dental nurses are indispensable members of the dental team and it is worrying to see such high levels of dissatisfaction within their profession.

Introduction

It is clear that the COVID-19 pandemic has had a huge impact on dentistry in both the United Kingdom and further afield. In the UK, the dental profession has faced numerous challenges since the four Chief Dental Officers advised the cessation of all routine face-to-face dentistry on 25 March 2020.1 The negative effect COVID-19 has had on patients' ability to access urgent care has been well documented at national level, with emotive reports such as a patient extracting his own molar without local anaesthetic being published on the national BBC news website.2 The impact COVID-19 has had on dentists themselves has also been well publicised with the help of the British Dental Association (BDA), with numerous stories being published in the national press highlighting the financial hardship many dentists are having to endure.3

Within current publications there is an obvious deficit concerning the experiences of key members of the dental team, our dental nurse colleagues. Professor Phil Taylor, Dean of the Royal College of Surgeons of Edinburgh (RCSEd)'s Faculty of Dental Surgery has raised concerns about a potential wave of dental nurse jobs being put at risk due to the financial uncertainty the pandemic brings. Professor Taylor goes on to state that 'dental nurses play a vital role in the dental profession and are an essential part of the team. It is of utmost importance that they are supported during this period… they need better support from the UK Government as well as the NHS as they adjust to new regulations, PPE and AGP procedures'.4

Triggered by the COVID-19 pandemic, the British Association of Dental Nurses (BADN) are currently campaigning for recognition of dental nurses' contribution to dentistry and have produced a template letter for members to send to their local MPs.5 BADN President Jacqui Elsden explains the key issue this letter seeks to address: recognition of NHS employment status - with the associated benefits: access to NHS pension scheme, key worker status and salary banding - reflecting the financial outgoings such as registration fees, indemnity cover, training and CPD costs.

In addition, the BADN have also lobbied the GDC for a reduction in the annual retention fee (ARF) for dental nurses to help ease financial pressures, or at least to allow for payment in monthly instalments. However, it was confirmed at the GDC October Council meeting that the ARF is to be maintained at its current level for the coming year.6 The BADN President reports this refusal to recognise the dire financial plight of the largest registrant group, insisting on full payment of £114 by 31 July, has led to more than 3,500 dental nurses failing to re-register.5

Materials and methods:

A 24-point anonymous survey was created using Microsoft Forms. Questions 1-22 are closed questions allowing for quantitative data capture. Q23 - 'If you have considered leaving dentistry altogether, please explain why' and Q24 - 'Do you have any other comments regarding the impact of COVID-19 on the nursing profession?' gave the opportunity for participants to express their concerns in their own words, providing qualitative data for analysis. Q23 and Q24 were then subject to thematic analysis to identify key trends.

On 21 September 2020 a link to the online survey was shared on five popular national dental nurses Facebook groups: Advice for Dental Nurses, Dental Nurse Support, Dental Nurse (UK), Support for Dental Nurses (UK), Northwest Dental Nurse Forum. Most Facebook groups are closed groups, often requiring full name and GDC registration number for the administration staff to grant entry, although it is acknowledged there are a number of members who are non-GDC registered trainees. Permission to post the survey link to was granted by the group administrator on each occasion. The link was posted by a registered dental nurse colleague at Liverpool University Dental Hospital.

Results

A total of 1,006 dental nurses completed the survey by 22 October 2020. One thousand and two of these responses were recorded between 21 September - 1 October 2020.

Q1: Where do you work? Please tick all that apply.

The responses to Q1 are illustrated in Figure 1.

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Responses to Q1: Where do you work?

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Eighty-six percent of participants work in dental practice. Five percent work in the community dental service and 5% work in a hospital. Three percent work in 'other' which includes: MOD, HMP, Locum, 111, EDS.

Q2: If you work in a dental practice, is it predominantly NHS or private?

Of the 86% (888 participants), 65% work in an NHS dental practice and 35% work in private practice.

Q3: Have you worked in an Urgent Dental Centre (UDC) during the COVID-19 pandemic?

Eighty percent of respondents report they have not worked in an Urgent Dental Centre during the pandemic.

Q4: Have you been redeployed during the COVID-19 pandemic?

Ninety-three percent (931 participants) report that they have not been redeployed during the pandemic; 7% (75 participants) have been redeployed.

Q5: Are you undertaking Aerosol Generating Procedures (AGPs) at your place of work?

Ninety-four percent of participants are undertaking AGPs at their place of work; 6% (60 participants) are not undertaking AGPs.

Q6: Do you know what dental procedures are classed as AGPs?

Ninety-eight percent (985 participants) know what dental procedures are classed as AGPs.

Q7: To what extent has COVID-19 changed your working practice?

Ninety percent (906 participants) report COVID-19 has significantly changed their working practice. Nine percent report COVID-19 has slightly changed their working practice. Four participants reported their working practice has not changed at all.

Q8: To what extent are you confident following new COVID-19 Standard Operating Procedures (SOPs) in your workplace?

The responses to Q8 are illustrated in Figure 2.

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Responses to Q8: To what extent are you confident following new COVID-19 SOPs in your workplace?

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Twenty-five percent (255 participants) feel extremely confident following new COVID-19 Standard Operating Procedures (SOPs); 49% (493 participants) feel confident. Therefore, a total of 74% feel confident or extremely confident following new COVID-19 SOPs. Only 1% feel extremely unconfident and only 5% feel unconfident. Nineteen percent feel neither confident nor unconfident.

Q9: To what extent do you feel safe following the new COVID-19 Standard Operating Procedures (SOPs) in your workplace?

The responses to Q9 are illustrated in Figure 3.

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Responses to Q9: To what extent do you feel safe following the new COVID-19 SOPs in your workplace?

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Nineteen percent (196 participants) feel very safe following new COVID-19 SOPs. Forty-five percent (457 participants) feel safe. Therefore, 64% feel safe or very safe following new COVID-19 SOPs. Eight percent (78 participants) feel unsafe, and 2% (21 participants) feel very unsafe. Twenty-five percent (254 participants) feel neither safe nor unsafe.

Q10: I have received adequate training and support in implementing/undertaking these SOPs.

The responses to Q10 are illustrated in Figure 4.

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Responses to Q10: I have received adequate trainingsupport in implementing/undertaking these SOPs

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Twenty-one percent (209 participants) strongly agree that they have received adequate training and support implementing/undertaking these SOPs. Thirty-seven percent (375 participants) agree they have received adequate training. Therefore, a total of 58% of participants agree or strongly agree they have received adequate training. Twenty-six percent (264 participants) are neutral. Thirteen percent (126 participants) disagree and 3% (32 participants) strongly disagree.

Q11: I have been fit tested for an FFP2/FFP3 face mask to perform AGPs.

Eighty-nine percent (897 participants) have been fit tested for an FFP2/FFP3 mask to perform AGPs. Ten percent (104 participants) have not been fit tested and 1% (five participants) are not sure.

Q12: I am anxious about wearing enhanced PPE.

The responses to Q12 are illustrated in Figure 5.

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Responses to Q12: I am anxious about wearing enhanced PPE

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Eighteen percent (178 participants) strongly agree that they are anxious about wearing enhanced PPE. Thirty-three percent (330) agree that they are anxious about wearing enhanced PPE. Twenty-three percent (238 participants) are neutral, whilst 19% (187 participants) and 7% (73 participants) disagree and strongly disagree respectively that they are anxious wearing enhanced PPE.

Q13: I am comfortable being close to patients and staff provided I am wearing the appropriate PPE.

The responses to Q13 are illustrated in Figure 6.

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Responses to Q13: I am comfortable being close to patientsstaff provided I am wearing the appropriate PPE

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Twenty-three percent (235 participants) strongly agree they are comfortable being close to patients and staff provided they are wearing the appropriate PPE. Forty-five percent (455 participants) agree with this statement. Therefore, 68%, over two-thirds, of participants are comfortable being close to patients and staff provided they are wearing the appropriate PPE. Eighteen percent (178 participants) are neutral. Eleven percent (110 participants) disagree and 3% (28 participants) strongly disagree with this statement.

Q14: Have you been furloughed?

Fifty-two percent (518 participants) have not been furloughed, whilst 48% (483 participants) have been furloughed.

Q15: Have you worked weekends or late nights due to COVID-19?

The responses to Q15 are illustrated in Figure 7.

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Responses to Q15: Have you worked weekends or late nights due to COVID-19?

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Sixty-four percent (642 participants) reported working no additional late nights or weekend work due to COVID-19. Nine percent (95 participants) have worked additional weekends whilst 15% (148 participants) have worked late nights. 12% (121 participants) have worked both additional weekends and late nights as a result of COVID-19.

Q16: If your total number of hours per week has changed, have they increased or decreased?

Thirty-five percent (350 participants) report their total weekly hours have increased as a result of COVID-19, whilst 32% (326 participants) report a decrease in their total weekly hours as a result of the pandemic. Thirty-three percent (330 participants) did not answer.

Q17: Has COVID-19 had a negative impact on your personal finances?

Forty-nine percent (488 participants) report COVID-19 has had a negative effect on their personal finances, 46% (461 participants) state COVID-19 has not had a negative effect on their personal finances, whilst 5% (52 participants) are not sure.

Q18: As a result of COVID-19 have you encountered financial difficulty paying your GDC registration?

Thirty-two percent (322 participants) report they have encountered financial difficulty paying their GDC registration. Sixty-eight percent (675 participants) report they have not encountered financial difficulty paying their GDC registration.

Q19: I am happy with the support my employer has given me during the COVID pandemic.

The responses to Q19 are illustrated in Figure 8.

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Responses to Q19: I am happy with the support my employer has given me during the COVID-19 pandemic

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Twenty-one percent (208 participants) are extremely happy with the support their employer has given them during the pandemic. Thirty-two percent (323 participants) are happy whilst 28% (275 participants) are neither happy nor unhappy. Fourteen percent (140 participants) and 6% (60 participants) are unhappy and extremely unhappy respectively. Therefore, one in five participants are either unhappy or extremely unhappy with the support their employer has given them during the pandemic.

Q20: If applicable, has your employer been flexible regarding childcare during the COVID-19 pandemic?

The responses to Q20 are illustrated in Figure 9.

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Responses to Q20: If applicablehas your employer been flexible regarding childcare during the COVID-19 pandemic?

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Ninety-eight participants report their employer has been extremely flexible regarding childcare during the pandemic, whilst 155 participants report their employer has been flexible. Eighty-five participants are unsure. Sixty-three participants state their employer has been inflexible with regards to childcare whilst 32 participants state their employer has been very inflexible. This question was not applicable to 573 participants.

Q21: What effect has COVID-19 had on your mental health?

The responses to Q21 are illustrated in Figure 10.

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Responses to Q21: What effect has COVID-19 had on your mental health?

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Fifty-three percent (530 participants) report COVID-19 has had a negative impact on their mental health, whilst 13% (135 participants) report it has had an extremely negative effect. Therefore, two-thirds (66% of participants) report COVID-19 has had a negative or extremely negative impact on their mental health. Twenty-eight percent (282 participants) report COVID-19 has had no effect on their mental health. Three percent (31 participants) report the pandemic has had a positive effect on their mental health, whilst 0.9% (nine participants) report an extremely positive effect.

Q22: Has the COVID-19 pandemic made you consider leaving dentistry altogether?

Sixty-five percent (655 participants) report the COVID-19 pandemic has made them consider leaving dentistry altogether. Thirty-five percent (351 participants) report they have not considered leaving dentistry as a result of the pandemic.

Q23: If you have considered quitting, why?

Of the 655 participants who reported they have considered leaving the profession, thematic analysis highlights the reasons shown in Table 1.

Table 1
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Q24: Any other comments?

Thematic analysis of 'other comments' highlighted the themes shown in Table 2.

Table 2
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Discussion

It is clear that COVID-19 has had a significant impact on the dental profession in the UK. Dental nurses, regardless of their place of work, are on the front line and are essential to the delivery of COVID-19 safe dentistry. It is reassuring that only 3% of participants strongly disagree that they have received adequate training and support in implementing COVID-19 SOPs in their workplace, and only 1% of nurses felt extremely unconfident following these SOPs. One in five nurses are unhappy to some degree with the support their employer has given them during the pandemic. Whilst this is arguably high, it should be noted that four in five nurses are not unhappy with the employer support they have received. This suggests that COVID-19-specific clinical training and support by employers has generally been good.

Nearly 50% of participants have been furloughed at some point during the pandemic. With face-to-face dentistry ceasing for a significant period this is not unsurprising, given that as of 20 September 2020 approximately 9.6 million jobs from 1.2 million different employers were furloughed.7 Over one-third of participants (36%) have worked additional weekends, late-nights, or a combination of both due to COVID-19. In addition, 35% of participants report an increase in the total number of hours worked per week. This highlights the versatility, flexibility and commitment of our dental nurse colleagues. This is invaluable, as without their presence these additional clinics would not be appropriately staffed and may not be viable at all.

Two-thirds (66%) of participants report COVID-19 has had a negative or extremely negative effect on their mental health. This cannot be dismissed as a reason for dental nurses to seek change and leave the profession. The Society of British Dental Nurses (SBDN) are aware of the importance of mental health on their members and as such are part of the Mental Health and Wellbeing UK initiative.8 With such a high number of respondents reporting an adverse effect on their mental health, it is encouraging that the SBDN are aware of the issue and have resources in place to support their members.

It is clear that as a profession dental nurses are incredibly adaptable, resilient and selfless. The issues raised in this paper, such as mental health, pay, ARF and NHS worker status have been simmering along prior to COVID-19.

Sadly, nearly half of respondents (49%) report COVID-19 has had a negative effect on their personal finances and consequently, nearly one-third (32%) have encountered financial difficulty paying their GDC registration. Of the 652 participants that report considering quitting dental nursing, over one-third (36%) cite low pay/wages and the GDC's ARF as the cause. It is worth noting that the average hourly rate for a dental nurse in the UK is £9.03 per hour.9 The national living wage (NLW) as of April 2020 is £8.72 per hour.10 The difference of 31p per hour is almost negligible when considering the GDC's annual retention fee, which is set at £114. As an example, a full time (40h p/w) dental nurse on the national average £9.03p/h would have to work over nine full weeks just to offset the ARF and break even with someone on the (NLW) working equivalent hours (£114/31p = 368 hours. 368h/40h = 9.2 weeks).

Conclusion

This pandemic has been a catalyst for the BADN's campaign to recognise dental nurses' contribution to dentistry and highlights the issues within the profession. The long-standing matter of being recognised as an NHS member of staff has been thrown into stark relief by COVID-19. Dental nurses have been unable to access the benefits an NHS key worker brings, such as early morning supermarket shopping and countless discounts/offers for NHS staff. In spite of this, Jacqui Elsden reports that when the NHS called for volunteers to assist on the front line, dental nurses to her understanding, were the largest group to volunteer.5

It is clear that as a profession dental nurses are incredibly adaptable, resilient and selfless. The issues raised in this paper, such as mental health, pay, ARF and NHS worker status have been simmering along prior to COVID-19. The pandemic has brought them to the boil, and as a consequence two-thirds of nurses involved in this survey are considering quitting dentistry altogether. As of 31 December 2019, there were 58,898 registered dental nurses, making up 49% of all titles registered with the GDC.6 More than 3,500 have already failed to re-register and our research shows this may increase significantly by July 2021.