A lifetime of ‘leaning in'

As we continue to celebrate our profession's centennial milestone, it is appropriate to remember one leader in particular who has made some of the most significant contributions to the dental hygiene profession.

Jul 10th, 2013
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by Lynne Slim, RDH, BSDH, MSDH

As we continue to celebrate our profession's centennial milestone, it is appropriate to remember one leader in particular who has made some of the most significant contributions to the dental hygiene profession. Michele L. Darby, RDH, MS, Eminent Scholar, University Professor, Chair, Gene W. Hirschfeld School of Dental Hygiene, Old Dominion University, is a giant in the profession.

Michele L. Darby

In discussing Professor Darby's star performance, I will occasionally reference another shining star in the business world, Facebook COO Sheryl Sandberg. Sheryl and Professor Darby both display powerful leadership and mentoring skills, and each one took risks, chose growth in their respective professions, and challenged themselves in managing their careers.

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It was hot and humid when I walked into the Health Sciences Building on the campus of Old Dominion University (ODU) in the late 1970s. It was my first day in Professor Darby's research methodology class, and I had recently enrolled in the BSDH degree completion program. She greeted us with the enthusiasm of a child who is given cotton candy for the first time. Professor Darby was charismatic, driven, and a visionary. In short, she changed my career from that of a clinician in private practice going through the motions, in a manner of speaking, to a thought leader. Therefore, I owe her a huge debt of gratitude. Professor Darby is the reason I am devoted to evidence-based dental hygiene, and she will forever be in my thoughts.

As she reviewed the course syllabus, I knew I would be challenged. But her joie de vivre and passion for the subject made me drool with anticipation of what was to come. We were expected to write a scientific research proposal, and she demanded nothing but the best. I chose to compare circumferential probing to mesial probing in the clinical detection of periodontal pockets, using a convenient sample of patients, and it ended up becoming my master's degree thesis.

Professor Darby, and her co-author, Denise Bowen, RDH, MS, were the first to author a research methods textbook for oral health professionals. This was about 20 years before evidence-based teaching was introduced in U.S. dental hygiene curricula.1,2 Never before had I been exposed to topics such as searching the dental literature, writing hypotheses, creating a research proposal step-by-step, and critiquing research findings. Professor Darby purposely but gently drummed into us steps of the scientific method, leading us to challenge the common assumptions clinicians make in everyday practice. Her students already knew that their clinical decisions had important implications for patient outcomes but she taught us not to accept the status quo.

Recently, I talked to Professor Bowen about Professor Darby's contributions to the profession, and we focused mostly on her impact on research and theory development. Professor Darby was instrumental in moving dental hygiene from an occupation towards full professional status. She was always ahead of her time. Many years ago, a Canadian article about dental hygiene as a female dominated semi-profession fascinated me.3 According to the author, dental hygiene at that time (1979) was considered a new occupation in Canada and received little attention by researchers despite its unique character. The article reviewed established professions and revealed seven features that make them unique, including a systematic body of theory and mastery/application of this body of knowledge.

In the mid-1970s, Professors Darby and Bowen travelled to North Carolina from Virginia to host the first meetings of the ADHA Research Committee. At that time, it was an unfunded committee. The ADHA House of Delegates gave them permission to form the committee but would not give them any money to support their efforts. Early discussion in their small committee focused on how to heighten interest among practitioners on the importance of research to clinical decision-making. One of the articles that was written by Darby/Bowen and published in Educational Directions (no longer published by ADHA) was on demystifying research. Eventually, Professor Darby chaired the first ADHA committee that wrote policies on research and its importance to practice, and she became chair of the ADHA's Research Council. She co-wrote the first grant guidelines for the ADHA Foundation to provide seed money for dental hygienists in practice to initiate research projects.

Early in Professor Darby's career, she challenged the assumptions about gender in dental hygiene and acknowledged the existence of sexism in dentistry and dental hygiene.4 In her 1977 article titled "Status of Dental Auxiliaries: An Issue of Gender," co-written by Susan Schwartz, RDH, MS, the authors challenged the assumption that women are less dedicated to their profession than men. They discussed the frequent charges against the feminist movement, especially accusations that women want to be "like" men. They emphasized that women want to be themselves, however they define it, and they make career decisions based on whatever works for them in achieving their personal and professional goals.

Here's one powerful observation by Darby/Schwartz regarding the status of dental assistants and registered dental hygienists that still falls on deaf ears: "Women's role in dentistry is changing and can be further facilitated by challenging the current perspective of the auxiliary role as a subjugated one rather than as a complementary one." Darby and Schwartz weighed in on gender stereotyping, just as Sandberg does in her popular book, "Lean In."

As Sandberg continued to climb in the corporate executive world, she mentions that men in the professional world are rarely seen through the same gender lens as a female. Darby/Schwartz realized this, too, and wrote about it because it was, and continues to be a thorn in the side of many practicing dental hygienists. As the tide turns and more female dentists enter leadership positions, new turf battles are emerging because women sometimes engage in "queen bee" behavior, and they use their elevated positions to put down "worker bees." Sandberg discusses this issue in her book at length.

Professor Darby spent her entire career in dental hygiene "leaning in." She had the intelligence and unrelenting will to lead, the commitment to grow the dental hygiene profession, and a strong work ethic, with opportunities for all, regardless of gender, provided only that they were dedicated to the profession. Sandberg points out that many women avoid challenging assignments that make them stretch and provide new challenges because they worry too much about whether they have the skills needed for a new role. She believes that women need to shift their thinking from "I'm not ready to do that" to "I want to do that, and I'll learn by doing it."

I recently spoke to two of Professor Darby's colleagues about her 39- year career at ODU. S. Lynn Tolle, BSDH, MS, is professor and clinic director, and Gayle B. McCombs, BSDH, MS, is professor, graduate program director and director of the Dental Hygiene Research Center. Professors Tolle and Darby taught together for 30 years, and Tolle wants readers to know that Professor Darby inspired and excelled at mentoring hundreds of individuals at ODU during her teaching career. She pointed out that Professor Darby has received every award every university has to offer and every professional award dental hygiene has to offer. She describes Professor Darby as a premier educator, scholar and widely sought-after international speaker who has been invited to serve on many major decision-making committees within the profession in the United States and abroad. Tolle honored her work in this special way: "Working with her for 30 years, she has inspired me daily with her dedication, hard work, vision, kindness, intellect, and enthusiasm."

In my conversation with Tolle, we focused on one of Professor Darby's greatest visionary achievements: the development of the Dental Hygiene Dental Needs Conceptual Model. The first edition of Dental Hygiene Theory and Practice by Professors Darby and Margaret Walsh was guided by this model, and it enabled dental hygiene clinicians to diagnose and solve problems within the scope of dental hygiene practice. Again, this was an understated but powerful achievement in dental hygiene's growth as a profession because it provided a framework for decision making, problem solving and predicting outcomes.

Professor McCombs used an acronym (see below) to describe Professor Darby's leadership and professional achievements. In McCombs' words, Professor Darby always put others first, hence the reference to "you" below. She gave Professor Darby so many accolades during our conversation that I couldn't absorb them all. One quote she gave me says it all: "As a director of a premier dental hygiene program, educator, and leader, she is second to none." According to Professor McCombs, when you think of ODU, you think of Michele Darby.

McCombs' adjectives to describe Darby play on an acronym of her last name: Dental hygiene, Advocate, Role model, Bold, and You.

I cannot praise too highly Professor Darby's accomplishments; the list is almost endless. She touched the lives of so many dental hygienists in the United States and around the globe, and she is one of dental hygiene's greatest leaders. I read in Sandberg's book that great leaders make others better as a result of their presence, and this impact lasts even in their absence. Professor Darby is one of those leaders whose formidable presence will never be forgotten. She is now retired, but this is not the end of her contributions. Stay tuned for her next chapter! RDH

References

1. Darby ML, Bowen DM. Research methods for oral health professionals. C.V. Mosby Company, St. Louis, 1980.
2. Chichester SR, et al. Utilization of evidence-based teaching in U.S. dental hygiene curricula. J Dent Hyg 2001 Spring; 75(2): 156-64.
3. Jones L. Dental hygiene as a female dominated semi-profession. Can J Dent Hyg 1979; 13(3): 62-66.
4. Darby ML, Schwartz S. Status of dental auxiliaries: an issue of gender? J Dent Hyg 1977; 51: 271-275.


In April 2013, I asked Professor Darby some questions about important issues in dental hygiene. Here are the answers she provided, in her own words:

Slim: Professional dental hygiene holds a unique place in the U.S. health-care system. We work in diverse settings but primarily in private dental practices. In light of the economic downturn, many dental hygienists are being paid less and oftentimes they are working without benefits. Is there hope for dental hygiene and how can we "lean in" and ensure a more secure future?

Darby: When families and individuals experience tough financial circumstances, preventive oral care, unfortunately, is often viewed as a luxury. This lapse frequently results in poor oral and other health outcomes, including pain and the need for more expensive care later on. In addition to diminished health-seeking behavior, reduced funding on the policy and private practice levels can lead to cutbacks experienced by dental hygiene practitioners.

However, where there is a challenge, there is also an opportunity.

Dental hygienists are ideally suited to bridge budget gaps, as our evidence-based interventions can be seen as both promoting health and saving costs.

Dental hygiene can become a strategy for rectifying some of the problems in our health-care system such as health-care costs, access to care, and health inequalities. The profession must cultivate effective leadership and renewed energy around these issues. Stingy oral health budgets and cost cutting also create opportunities for dental hygiene practitioners to find more creative solutions to fill gaps in our dental health-care system. Examples include nontraditional delivery of oral care, optimal incorporation of technology, and partnerships with organizations to address oral care challenges from the community to the policy level.

In today's dynamic health-care system, dental hygiene practitioners cannot be content to stagnate. Instead, we need to innovate, problem-solve, and add value to any practice, organization, or institution of which we are a part. We should ask ourselves, "How can I make this better? How can I be a leader and positive advocate for change?" Even more, we should aim to constantly perform at the peak of our training and educational level. Only by pushing the field further will we achieve the recognition and security that the profession deserves. We need to think big, we need to think differently, and we need to think about solutions that are mutually beneficial to our patients and our inter-professional colleagues. Working in isolation is not an option.

Slim: Do you consider dental hygiene to be a full profession, or are we still stuck as a semi-profession, and what do you think we need to focus on to continue our professional advancement?

Darby: Dental hygiene is most definitely a profession in transition; we have several challenges that undermine our effectiveness and status as a full profession. Fortunately, we are conducting our own research to support practice and decision-making, but this needs to be expanded and funded at a higher level. Although our Clinical Practice Standards and Code of Ethics demonstrate our commitment to society, and our recent development of the advanced dental hygiene practitioner adds legitimacy, we need to achieve self-regulation so that we can be at the policy-making table when health care reform is being planned.

Our colleagues to the north, the Canadian dental hygienists, are outstanding examples of how achieving self-regulation has affected their ability to advance. There are already various avenues for professional development in disciplines such as nursing, occupational therapy, and physical therapy, as evidenced by the prevalence of advanced-level degree opportunities. More of our dental hygienists need to have advanced degrees, and it is time that we developed doctoral-level degree programs for dental hygienists. Lastly but not least, we should always seize opportunities for professional contributions to the health and quality of life of all people and professional advancement for dental hygienists. By contributing to and improving society in a greater sense, we become true professionals.

Slim: Are you optimistic about a widespread implementation of legislation to allow additional clinical skills as an advanced dental hygiene practitioner?

Darby: I am very optimistic about initiatives such as the advanced dental hygiene practitioner model. Historically in the U.S., dental health-care access has been limited by lack of dentists practicing in rural or inter-city areas. Patients also experience barriers due to limited education, economic resources, cultural beliefs, and health status disadvantages. Because of these barriers, some people suffer in pain or delay preventive care and treatment until the oral condition is severe and expensive to correct. When dental problems reach a crisis, some people seek dental care from hospital emergency rooms where health-care providers may temporarily alleviate pain but are not able to treat dental disease.

Following the Surgeon General's National Oral Health Call to Acton report, the American Dental Hygienists' Association developed a plan, model, and competencies for a new mid-level practitioner called the advanced dental hygiene practitioner (ADHP).

The main role of this new mid-level practitioner is to increase societal access to primary oral healthcare in a cost effective manner via assessment, evaluation, and provision of preventive, restorative, and therapeutic services. Unlike the dental hygienist who works primarily in private practice settings where people have a dental home, ADHPs work outside of the traditional private practice setting to provide services in nursing homes, schools, and community clinics, thus closing the dental care gap for vulnerable populations. With advanced dental hygiene practitioners, more oral health care can be provided to underserved populations where they live, work, or play, resulting in improved oral health of the population at less cost. The concept is similar to other mid-level providers, and just like other mid-level providers such as the advanced nurse practitioner, it requires graduate-level education. The Pew Center on the States reports that by 2014, with health care reform and the provision of dental insurance to millions of U.S. children, the demand for oral health care services will increase.

Another challenge is that a significant number of dentists are expected to retire from practice just as the need for dental care is expected to escalate. Given Pew's prediction, the ADHP will close the disparity gap between the number of people who need care and the number of providers able to meet the need.

The groundbreaking master of science in advanced dental therapy program in Minnesota is the first to graduate dental hygienists as mid-level practitioners to work in collaboration with an authorizing dentist within the legal scope of practice. Some services include nonsurgical extractions of periodontally diseased permanent teeth with tooth mobility, prescribing analgesics, anti-inflammatory drugs and antibiotics, atraumatic restorative therapy, pulpotomies on primary teeth, cavity preparation and restoration of primary and permanent teeth, extraction of primary teeth, and preparation and placement of preformed crowns. Dental hygienists prepared as mid-level providers will help the professions of medicine, dentistry and dental hygiene meet the oral health care needs of the community. The development of ADHPs will also result in cost-effective, quality, primary dental care and healthier citizens in the U.S.

Slim: What can we learn from the nursing profession that will help us as we continue to grow our profession?

Darby: The nursing profession has done a truly excellent job in advocating for their autonomy and unique expertise in medical clinical practice. In the United States, nurse practitioners have positioned themselves to play a major role in the delivery of care, especially as healthcare reform under the Affordable Care Act is scheduled to unfold. As the cost of care continues to climb, mid-level providers such as nurses, physicians assistants, and dental hygienists can seize the moment to solidify our place in cost-containment and quality improvement. The dental hygiene profession can use nursing as a model for expanding our own independence and interdependence on the health care team and developing more innovative models of high-value care delivery.

Slim: In looking back over your teaching career, what have been the most gratifying experiences for you?

Darby: I think the relationships that I've made -- with students and colleagues inside and outside of academia -- have been the most rewarding part of my University career. Because I was fortunate enough to have excellent mentors during my own dental hygiene education, I've enjoyed the chance to "pay it forward" by serving as a role model and mentor to the next generation. I've loved being a teacher-scholar at Old Dominion University, and I feel especially fortunate to have served in an environment in which I also get to learn every day in order to convey the most current knowledge and skills to my students and colleagues. I think being a teacher is one of the most significant contributions you can make, whether it is educating your patient about oral health behaviors, counseling and coaching students and peers, or making a career in advancing the profession.

Slim: In reviewing the history of dental hygiene, where do you see the future of dental hygiene at our bicentennial?

Darby: As a profession, our responsibility is to create opportunities for those that we work with -- for example, collaborating with patients/clients so they may achieve optimal health, advance student and colleague careers so they may contribute to the profession and society, expand dental hygiene research/scholarship that raises the standards of education and ethical, evidence-based clinical decision making of dental hygienists, and participate in the formation of public policies that facilitate access to dental hygiene care and quality of life of all people.

To serve the international society, sustainable partnerships with people from diverse backgrounds and cross-cultural settings, like my collaborations with colleagues at Jordan University of Science and Technology, are necessary to create such opportunities. Because healthcare is a worldwide human need, our profession promotes quality formal education globally that will increase access to sustained, cost-effective dental hygiene care to prevent and control dental disease, and reinforce trust so that new health goals can be identified and achieved together, regardless of the location of the global community. Carrying out these responsibilities requires a steadfast commitment to these partnerships. Hopefully, more of our accredited dental hygiene programs will embrace this responsibility and involve students in global health."


LYNNE SLIM, RDH, BSDH, MSDH, is an awardwinning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at periocdent@mindspring.com or www.periocdent.com.

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