Clinical leaders

May 1, 2012
Taking a leadership role in the clinical setting can improve the quality of care that dental hygienists provide.
The role of the hygienist as a leader

by Howard M. Notgarnie, RDH, EdD

Taking a leadership role in the clinical setting can improve the quality of care that dental hygienists provide. Bourgeault identified some weaknesses in the socially defined relationships among the various health professions, and between health professionals and their patients. The social mechanisms for educating health professionals have created a culture of narrowly defined roles. These roles include the privileged status of a small group of professions expected to exhibit expertise in all aspects of the health-care industry. That privileged role dominates a subservient role for other health professionals and a dependent role for patients.1

In contrast, Adams demonstrated that the dental hygiene profession has been growing in its leadership capacity by accentuating the unique character of dental hygienists’ scope, expertise, and interaction with patients.2 In particular, dental hygienists’ leadership should improve the health status of the community as the profession focuses on wellness, access to care3 and participation as specialists in multidisciplinary teams.4,5

Dental hygienists act as leaders when educating patients to take an active role in their own health,6 ensuring that those patients have adequate resources,7 as well as during the planning of treatment.3 These benefits of leadership are prominent in proposed doctoral curriculum (Boyd et al.) in dental hygiene.8 Thus, there is a growing emphasis on leadership in dental hygiene. While the profession emphasizes leadership at the social and political level, dental hygienists can demonstrate individual leadership through interactions with coworkers and clientele.

Co-diagnosis as leadership

One effective mechanism of leadership is helping followers understand the implications of data and respond effectively to those implications. Bettencourt et al. emphasized information services. People who manage information require individualized data sets to meet their clients’ needs. With that data, information managers educate and engage their clients to define problems and identify solutions.9

Dental hygienists function as information managers while carrying out the first half of the dental hygiene process of care:

  • Collecting individualized data constitutes an assessment
  • Defining a problem is dental hygiene diagnosis
  • Identifying solutions is the same as composing a treatment plan

Bettencourt et al. asserted that information managers should not define the tools to solve their clients’ problems unilaterally. Instead, optimal solutions arise through collaboration with each client. Leadership in this regard entails defining the client’s role and responsibility in achieving an outcome. The professional leads by clarifying the tasks for the client to perform, ensuring the client is capable of performing those tasks, and fostering the client’s motivation toward achieving the outcome.9

The role of dental hygienists as educators exemplifies the collaboration described by Bettencourt et al. Dental hygienists seek to understand the interests of new patients regarding improving health, appearance, and in decreasing risks of disease. Assessment of a patient’s comprehension of health concepts and dexterity signals the concepts that are likely to influence a patient’s attitudes and personal responsibility. A discussion then can lead to choices of effective home-care products for thorough plaque removal, for example.

At the following appointment, improvements in diagnostic data will demonstrate to a patient that the home-care activities are effective, thereby promoting internal motivation. Areas still needing improvement lead in to the educational tools that demonstrate where the patient needs to concentrate.

Choosing clients wisely

Bettencourt et al. also indicated that effective leadership demands choosing clients wisely; the clients’ philosophy and motivation should be compatible with the leader’s principles. Success depends upon the client’s dedication to the goals developed through collaboration. The importance of dedication becomes evident when the leader must suggest a change in strategy to continue progress toward the goals acknowledged by the client. Collaboration between the professional and the client increases in importance as the solution increases in complexity.9 This aspect of leadership as co-diagnosis reflects the role of patient commitment in achieving health goals.

As with any organization, the members of a health-care clinic would like to increase their market share. A mistake in pursuing that increase is to appeal to all consumers regardless of their disposition. Instead, accepting that some patients seek a type of care that is not consistent with your professional mission eases dismissal of a potential customer. That acceptance frees yourself for other clients who share your philosophy and frees the prospective client for colleagues whose philosophy is more amenable to that consumer’s wishes. Likewise, a similar approach toward employment has the potential to bring together dental hygienists and dentists who share a practice philosophy.

Instead of following theory from textbooks, Fullan recommended practitioners learn through practice in their profession and through interaction with others. Then practitioners can improve their performance by applying theory to their successes,10 reflecting the definition of evidence-based care by Chichester et al.: combining evidence with personal experience and client preferences.11

Leaders are resolute in their endeavor toward a goal; yet they maintain empathy toward those who express dissent. Identifying the underlying values of those who do not share a leader’s vision helps the leader find the path by which the dissenters will cooperate. People often feel threatened by change, but that threat disappears if they recognize there is a place for them in the vision. Being effective leaders thus becomes an intrinsic motivator to continue developing their role in that vision.10

Dental hygienists are in a well-suited position to express Fullan’s perspective of leadership when interacting with co-workers and patients. Earlier in my career, I joined an established office team whose previous dental hygienist, current dentist, and dental hygiene assistant were a little shy about addressing periodontal disease. A murky definition of periodontitis and a fear of losing clientele led to frequent delays of diagnosis and superficial scaling, even when a diagnosis of periodontitis had been made.

With passionate but respectful discussions that included citations of peer-reviewed research, I was able to convince my teammates to learn the language of early intervention, promote a higher level of health to our patients, convince most patients to embrace that vision, and accept that some patients are not interested in the level of health our vision featured.

Fullan explained that teams are synergistic because conflict within a friendly relationship results in sharing and building a knowledge base as participants collaborate and pick up one another’s styles. Leaders recognize they always have more to learn; yet they are confident they can apply what they already know to their circumstances. Leaders rely not merely on evidence but on recognizing which evidence is applicable to the situation. Finally, a leader can make the vision look simple from a holistic, broad perspective despite complexity at the practical level.10

Transactional leadership

A theory that helps explain motivation through leadership behavior balances transformational and transactional styles.12 Both transformational and transactional leadership styles can be effective for aspects of dental hygiene care.

Van Eeden et al. described transactional leadership as a leader satisfying a follower’s needs in return for the follower satisfying that leader’s needs. Transactional leadership includes rewards for effective results and punishments for ineffective results. Transactional leadership also includes management-by-exception. Active management-by-exception entails seeking and responding to deviations from standard expectations. Passive management-by-exception is a response to those deviations only when those deviations are brought to the leader’s attention.12

Transactional leadership fosters adherence to professional standards.13 Therefore, transactional leadership may play an important role in the professional development of dental hygienists who pursue excellence in their practice. Azman et al. found that transactional leadership correlates with perceptions of distributive justice. Followers perceive distributive justice when the compensation they receive is commensurate with their contributions, thereby providing a basis for trust in their leaders.14

Transactional leadership is relevant to supporting clients’ decision making. Administrative personnel express transactional leadership behavior when scheduling patients, particularly in explaining the importance of arriving on time and the charges patients incur for their treatment or when breaking an appointment. Transactional leadership is also evident in the informed consent process, where the dental hygienist reviews treatment options and likely outcomes of accepting or rejecting those options.

Transformational leadership

Transformational leaders exhibit four behavioral categories described by Van Eeden et al.: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration. Idealized influence consists of behaviors and dedication, implying the belief that expressed goals are achievable.

Followers emulate the influential leader. Inspirational motivation is a passion for the goals and vision of the organization. The motivation comes through a supportive role in followers’ achievement of their parts in the goals. A leader provides intellectual stimulation by encouraging followers to accept challenges that develop personal growth. Individualized consideration involves mentoring followers with personalized strategies to motivate performance.12 Followers of transformational leaders are motivated by intrinsic values; successful work experiences are rewarding without any benefit external to the person performing that work.13

For this reason, Eliyana noted, transformational leadership behavior results in improved organizational function through voluntary rather than mandated actions. These actions result in an organization that is highly responsive to the changing social environment in which it operates and that enjoys a positive public image. This responsiveness develops through the culture of the organization expressed by the leader, primarily through the organization’s vision and goals, leading to innovation and growth.13

According to Azman et al., transformational leadership correlates with perceptions among followers of procedural justice. In procedural justice, the mechanisms by which outcomes and decisions are perceived as fair, ethical, accurate, consistent, and without bias.14

Educating clients and evaluating outcomes of treatment are examples of transformational leadership behavior. Dental hygienists express a vision of wellness by connecting oral health to human needs.15 We support our patients in wellness by teaching a unique regimen applicable to each patient’s condition. We anticipate an improved state of health at subsequent appointments and review diagnostic data to determine if that regimen has resulted in the anticipated effect.

Dental hygienists are frequently the first clinicians to provide diagnostic and therapeutic services upon a patient’s visit to a dental office. This initial contact gives dental hygienists the opportunity to lead by setting the tone of wellness, beginning a change of attitude among many patients from reactive to preventive health care.

Setting this tone involves not only leading patients but also leading co-workers by fostering the development of a mutually supportive team, the language of prevention, and the intrinsic motivation that comes with success.

Dental hygienists can express leadership in the clinic through a variety of interaction mechanisms. Three of those mechanisms are co-diagnosis, transaction, and transformation.

Using interviews of nurses to collect data, Wallace showed that leadership is a process parallel to the decision-making process in health care. Leaders who openly communicate their values develop trust from their co-workers and clients, thereby fostering collaboration. Leaders support followers’ creative application of skills, resulting in a sense of responsibility and ownership of one’s work.

In the relationship between practitioner and client, leadership qualities emerge in the process of care, most notably as the “caring communication ... necessary to promote healing.”16 To begin or improve one’s experience as a leader, a dental hygienist can apply the process of care. First, observe data in the work setting and diagnose an interaction that could benefit from leadership behavior. Then devise and implement a leadership intervention through engaging in dialogue and being an example. Finally, evaluate the effect of that intervention, and document that effect, particularly by showing patients and co-workers the successes and improvements after a course of action.

Howard M. Notgarnie, RDH, EdD, practices dental hygiene in Colorado. He has eight years of experience in professional association leadership and five years of teaching experience.


1. Bourgeault IL. (2006). Sociological perspectives on health and health care. In D. Raphael, T. Bryant, & M. H. Rioux (eds.). Staying Alive: Critical Perspectives on Health, Illness, and Health Care (pp. 35-58). Toronto, Ontario, Canada: Canadian Scholars’ Press.
2. Adams TL. (2003). Professionalization, gender, and female-dominated professions: Dental hygiene in Ontario. Canadian Review of Sociology and Anthropology, 40(3), 267-289.
3. Cheng YA, Huang ST, Hsieh ST. (2007). A predictive study on the role and function of dental hygienists in Taiwan. International Journal of Dental Hygiene, 5(2), 103-108. doi: 10.1111/j.1601-5037.2007.00236.x
4. Darby ML. (2009). The Advanced Dental Hygiene Practitioner at the master’s degree level: Is it necessary? Journal of Dental Hygiene, 83(2), 92-95.
5. Jaecks KMS. (2009). Current perceptions of the role of dental hygienists in interdisciplinary collaboration. Journal of Dental Hygiene, 83(2), 84-91.
6. Johnson PM. (2008). Dental hygiene regulation: A global perspective. International Journal of Dental Hygiene, 6(3), 221-228. doi: 10.1111/j.1601-5037.2008.00317.x
7. Harris S, Hopson M. (2008). Using an equity audit investigation to prepare doctoral students for social justice leadership. Teacher Development, 12(4), 341-352. doi: 10.1080/13664530802579926
8. Boyd LD, Henson HA, Gurenlian JR. (2008). Vision for the dental hygiene doctoral curriculum. Access, 22(6), 16-19.
9. Bettencourt LA, Ostrom AL, Brown SW, Roundtree RI. (2002). Client co-production in knowledge-intensive business services. California Management Review, 44(4), 100-128.
10. Fullan M. (2011). Change leader: Learning to do what matters most. San Francisco: Jossey-Bass.
11. Chichester SR, Wilder RS, Mann GB, Neal E. (2002). Incorporation of evidence-based principles in baccalaureate and nonbaccalaureate degree dental hygiene programs. Journal of Dental Hygiene, 76(1), 60-66.
12. Van Eeden R, Cilliers F, van Deventer V. (2008). Leadership styles and associated personality traits: Support for the conceptualisation of transactional and transformational leadership. South African Journal of Psychology, 38(2), 253-267.
13. Eliyana A. (2010). Impacts of transactional and transformational leaderships upon organizational citizenship behavior. Journal of US-China Public Administration, 7(6), 24-30.
14. Azman I, Mohamad MH, Mohamed HA, Rafiuddin NM, Zhen KWP. (2010). Transformational and transactional leadership styles as a predictor of individual outcomes. Theoretical & Applied Economics, 17(6), 89-104.
15. Mueller-Joseph L, Peterson M. (1995). Dental hygiene process: Diagnosis and care planning. Albany, NY: Delmar.
16. Wallace J. (2001). Leadership as healing: Developing an innovative partnership model in healthcare education. Dissertation, University of Texas at Austin.

More RDH Articles
Past RDH Issues