Alphabet Soup

by Kelli Swanson Jaecks, RDH, BS

A push for a new career alternative for dental hygienists warrants a closer look at the similarities to nurse practitioners.

We all remember learning our ABC’s, painstakingly printing each letter, singing the song, and learning the different sound for each letter. We remember the joy we felt when we could first read a word or page. It was work to sound out the letters and put them together. It was much more fun to see the letters floating in a bowl of soup, trying to make sense of them and spelling out words.

Sometimes, with all the acronyms surrounding our profession, it takes some learning to make sense of it all. For instance, the new ADHP coming from ADHA. At the annual convention of the American Dental Hygienists’ Association in Dallas in June 2004, history was made as the House of Delegates overwhelmingly voted for adoption of a new resolution. This resolution has the potential to affect every hygienist, every dental hygiene school, every state practice act and, indeed, every American due to the changes in the delivery of oral health care. The concept of the Advanced Dental Hygiene Practitioner was born.

Access declared, “The ADHP will provide diagnostic, preventive, restorative, and therapeutic services directly to the public.”1

The wording of this definition was enthusiastically debated on the House of Delegates floor, and was carefully crafted after much debate. As you can imagine, the word “restorative” caused some concern. Would this new entity of hygienist with restorative abilities create conflict within states that already have more progressive practice acts? Would this be seen by some as counterintuitive to the manner in which state work is already being done? Would adding the word restorative invite intense opposition from the ADA and its state entities? Indeed, including the word restorative in the definition was a bold step, but the consensus was that bold is what we need.

“Directly to the public,” meaning independent service without direct or indirect supervision by a dentist, was another phrase that raised eyebrows and brought smiles and enthusiastic shouts! When considering the education and training of a dental hygienist, it is the contention of ADHA that dental hygiene services can be safely, competently, and skillfully performed in any and all practice settings. This phrase also raises some questions. How much opposition will we encounter from organized dentistry? What kind of work will be needed to change existing practice acts and allow for this type of practice? Will the public be our advocate and help shift current treatment paradigms?

Excitement filled the air as obvious strides were made to advance the profession of dental hygiene, while clearly striving to meet the unmet needs of millions of Americans who have little or no access to oral health care.

The need for the ADHP evolved from many round table discussions at the national level with organizations concerned with access to care issues. The U.S. Department of Health and Human Services designates there are 31 million Americans living in “dental health professional shortage areas.” This shortage is partially created by the fact that fewer dentists per capita are graduating from accredited dental schools, and fewer dentists are willing to live and provide care in rural areas. Conversely, dental hygiene is projected as one of the top five fastest growing professions of this decade, and therefore is better situated to meet the needs of the public by sheer numbers alone.1 An ADHP would be able to provide preventive, therapeutic, and basic restorative care (basic is a key word here because we are not talking about third molar extractions and root canal therapy) in a more cost effective manner. The goal is easy-to-access primary care to underserved populations. This new position creates many questions, and the ADHA provides answers through its Web site at www.ADHA.org.

The formation of the ADHP is an ongoing project and the outcome won’t be clear for some time. Currently, standards for curriculum, education, quality of care, and licensure are being developed.

The creation of the ADHP is being modeled after the profession of nurse practitioner (NP), another allied health profession that has made incredible strides in gaining autonomy in the medical world. It would be of interest then to take a closer look at that profession and glean what wisdom we can from their inception, challenges and journey to independent status.

According to www.nurse.org, “A nurse practitioner is a registered nurse with advanced academic and clinical experience, which enables him or her to diagnose and manage most common and many chronic illnesses, either independently or as part of a health-care team. A nurse practitioner provides some care previously offered only by physicians and, in most states, has the ability to prescribe medications. Working in collaboration with a physician, a nurse practitioner provides high quality, cost effective and individualized care for the lifespan of patients’ special needs.”2

Switch out the words nurse practitioner and physician, and replace them with dental hygienist and dentist, and you have a very exciting definition of what the future could be.

Most NPs hold a master’s degree in nursing and/or advanced certification. They have advanced training in diagnosis and treating illness as a general practitioner, as well as in their specialty. The beauty of NPs is that they focus on wellness, health maintenance, disease prevention, and education. The NP is concerned with the individual and providing holistic, all-encompassing care. An NP doesn’t want to simply treat the symptoms, but help patients find causes for the symptoms and ways to eliminate disease. The successful NP also values life-long learning and professional development.

This sounds a lot like the role of the dental hygienist in the dental care model - someone who focuses on prevention and education, cares for the medical, physical and emotional health of the patient, and treats the whole patient while focusing on his or her dental disease and health.

How did the nurse practitioner come into being and why? The nursing profession moved toward the creation of an advanced level nurse precisely for the same reasons the ADHA is moving forward with the ADHP - in recognition of huge unmet public health needs coupled with the desire to do something about it. Since the first NP education program in 1965, the profession has grown to include many specialties such as acute care, neo-natal care, nurse-midwifery, family and adult health, women’s health, geriatrics, and home care.

The curriculum in NP Masters or certificate programs is designed to prepare graduates for certification in any of these specialties. They also receive advanced training in research and management issues along with preparation for educators, mentors, advocates, and counselors within their profession.

A large part of the growth of the NP profession was working with the federal government toward becoming recognized as independent health-care providers. They needed provider status in order to assign and receive payment for specific services. The NP movement engaged in grass-roots activism and an aggressive lobbying campaign in Washington, D.C. In order to unite the profession and move the campaign forward, the American College of Nurse Practitioners was formed in 1993.

In 1997, the Balanced Budget Act granted NPs their coveted provider status. This authorized them to bill Medicare directly for services provided in any setting.3 These victories were part of the larger whole in the 1990s, when the federal government legislated expanded scope of practice for many non-physician clinicians. The promotion of alternative clinicians was part of a strategy for containing health-care costs, while meeting the needs of the public.4 Today, NPs open up private practices or are employed by hospitals, physician groups, or corporations. They have become an integral part of the medical care system around the world.

In a recent study reported in the British Medical Journal, the question was asked, “Do nurse practitioners provide equivalent care to doctors in a primary care setting?” The data concluded that patients are more satisfied with care from an NP than with a medical doctor, with no difference in health outcomes. Also, nurse practitioners provide longer consultations and carry out more investigations than doctors.5

Remember, NP’s are committed to treating the whole patient, not just their symptoms. In fact, other medical specialists often refer patients to nurse practitioners.

We can conclude that NP’s are a successful, respected addition to the medical community who meet the needs of the public with excellent care and cost effectiveness. Their profession has advanced with forward thinking and hard work. These are examples and lessons worth examining as the profession of dental hygiene moves forward, particularly with the development of the ADHP. Hopefully the ADHP will be as successful in the realm of oral health care as the nurse practitioner has been in the medical world.

As the ADHA House of Delegates convenes again this June in Las Vegas, more will be revealed regarding the future of the ADHP. It is expected that the Council on Education will share their work on competency development and educational standards, and provide a framework for the next layer of action.

Let us be willing to look closely at the future of dental hygiene with determination to work towards the goals of our organization. There is still much work to be done, debate to be had, and decisions to be made concerning the ADHP. Only time will tell if this “alphabet soup” goes down “Mmm ... mmm, good”!

Similarities of NP and ADHP

• Developed out of public health/access to care issues
• Focus on wellness, prevention, and education
• Scope of practice varies depending on state practice acts

Projected similarities

• Requires advanced education/certification
• Able to diagnose and treat independent of MD or DMD
• Increased job satisfaction
• Increased health care to the public

Key strategies behind NP independent practice

• Gaining recognition that nursing had the potential to increase its role
• Documenting nurse practitioners’ value
•Establishing standards in education and credentialing
• Using professional organizations to empower individuals
• Being willing to accept small, incremental gains over time
O’Brien JM. How Nurse Practitioners obtained provider status: lessons for pharmacists. Am J Health Syst Pharm. 2003 Nov 15;60(22):2301-7.

Kelli Swanson Jaecks, RDH, BS, practices in a general dental office and holds a LAP permit. Kelli was a 2003 winner of Butler/RDH Healthy Gums Healthy Life Award of Distinction. She is active on both the component and state level of Oregon Dental Hygienists’ Association, serving as president to her component and on the government relations council. You can reach her at [email protected].