The Canadian view of self-regulation

Experience how Canada believes dental hygienists should govern themselves.

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by Fran Richardson, RDH, BScD, MEd

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Self-regulation is regulation, governance, or licensure by one's own peers in the public interest. There is only one reason for a professional to be regulated — to protect the public.

Professionals are self-regulated. They are not regulated by another profession, especially one that is also their primary employer. Regulation is for the public's benefit, as there is a risk of harm in the procedures performed. Self-regulation indicates a profession's maturity and the ability to govern its members (registrants) in the public's, rather than the profession's, interest. An excellent article by Lois Chandler-Cousins was published in the July 1996 issue of RDH, and it stated, "Self-regulation is not unique, not radical, not impractical — it's what professions do."

Regulation usually includes "title protection." Consequently, dental hygienists in Canada are mindful that the protected and legislated title is "dental hygienist" and they do not use the term "hygienist" in written form. Self-regulation also means using appropriate professional language.

How does self-regulation work in Canada?

Jurisdictionally, Canada is divided into ten (10) provinces and three (3) territories. Health is a provincial/territorial affair, so regulations and terminology vary from jurisdiction to jurisdiction. Dental hygienists in Quebec were granted self-regulation in 1975, followed by Alberta in November 1990 and Ontario in December 1993. British Columbia granted it in March 1995, and self-regulation occurred in Saskatchewan in March 1998.

Dental hygienists in the provinces of Manitoba, Nova Scotia, New Brunswick, and Prince Edward Island are actively pursuing self-regulation.

Dental hygiene boards or councils now govern 92 percent of the dental hygienists in Canada. The governing agencies are composed of dental hygienists elected by their peers and by a prescribed number of public members appointed by the respective provincial government. The boards/councils range in size from nine members in Saskatchewan to 20 in Ontario. A registrar oversees the administrative functions of the organization.

In three of the five self-regulating provinces, the registrars are dental hygienists. Quebec's registrar has a comprehensive business background rather than an oral health background, while British Columbia's registrar has a background in public policy.

To discuss issues of common interest, the registrars formed the Federation of Dental Hygiene Regulatory Authorities (FDHRA) in 1995. The FDHRA has representation on the Commission on Dental Accreditation of Canada (CDAC) and on the Board of the Canadian Dental Hygienists Association (CDHA).

A major contribution to the mobility of dental hygienists across Canada came with the signing of a mutual recognition agreement (MRA) under the country's internal trade. As of January 1, dental hygienists in Canada who are registered/licensed in one jurisdiction can move to another jurisdiction without facing artificial barriers. The most common registration requirements are graduation from an accredited school of dental hygiene, and a certificate from the National Dental Hygiene Certification Board (NDHCB). Certain jurisdictions require additional competencies such as restorative or pain management. However, under the MRA, applicants may obtain a temporary or limited certificate while they attain the additional education.

Why continue the pursuit of self-regulation?

Self-regulation is a privilege and must not be taken lightly. There are many obligations and decisions that must be made in the public interest. When a complaint is made against a dental hygienist, dental hygienists on the panel must hear the case and make a decision on the merits of the evidence.

On occasion, the matter could be referred to a discipline committee. If the dental hygienist is found guilty of professional misconduct, he or she could have their license suspended or revoked. The concept is one of being judged by one's peers.

But dental hygiene self-regulation is not all doom and gloom. It is a step towards full recognition as a complete and distinct profession apart from dentistry. Other steps towards complete professionalism may be a baccalaureate degree entry-to-practice, the advent of doctoral degrees in dental hygiene, an increased body of knowledge unique to dental hygiene, and unimpeded direct access to dental hygiene services by the public.

Dental hygienists in Canada have worked long and hard to achieve self-regulation because they believe that the public is the main beneficiary in such a system. The struggle continues in the other Canadian jurisdictions that have not yet achieved this goal. But we all support one another, and, collectively, we are happy to support our colleagues in the United States who are working toward self-regulation in their particular states. We are happy to share our experiences and assist where we can.

Governments have recognized that dental hygiene is a profession capable of self-regulation. That fact has already become apparent in Canada.

Fran Richardson, RDH, BScD, MEd, is the registrar and chief administrative officer of the College of Dental Hygienists of Ontario (www.cdho.org), which regulates the 7,500 dental hygienists in Ontario. She is also chair of the FDHRA, past president of the Canadian Dental Hygienists Association, and a frequent speaker on self-regulation.


What are the issues related to dental hygiene self-regulation?

Self-regulation has solved many problems for dental hygiene in Canada, but it certainly has not been the "be all and end all" that many dental hygienists expected. Among the issues that need to be considered when pursuing self-regulation:

• Self-regulation is expensive.

Dental hygienists pay for the administration of the regulatory authority through their registration/ licensing fees.

• Dental hygienists are responsible for their own actions.

When a patient files a complaint, the dental hygienist cannot say, "The dentist made me do it." Self-regulation means that dental hygienists are responsible to the public first through their regulatory council and to their employer second. The dental hygienist may have to make a choice between losing his/her job and possibly losing the right to practice. Of course, dentists, who are also regulated health-care professionals, should not be placing dental hygienists in unethical situations.

• Self-regulation does not necessarily mean an increased scope of practice.

While there may be opportunities to modify scope of practice, this often depends on jurisdictional laws and the ease of change in legislation. In many cases, organized dentistry has succeeded in stalling dental hygiene initiatives due to their sophisticated lobbying activities, financial resources, and perceived prestige.

On the other hand, self-regulation means that dental hygienists are seen as equals within the health-care system (at least on paper), and their regulatory authority has as much right to be heard in government corridors as do the more senior professions such as medicine and nursing.

• Self-regulation and independent practice are not the same thing.

Dental hygienists recognize this fact, but organized dentistry brings out this very tired argument every time organized dental hygiene approaches a government for self-regulation. The term "independent dental hygiene practice" is a term that was created by organized dentistry, not dental hygiene. Dental hygienists have always wanted unsupervised practice as befits their education and licensure.

Dental hygienists also continue to fight for the right to access those members of our communities who are unable to access traditional dental practices. Direct access to the oral health professional of their choice is a basic right of the consumer. In other words, dental hygienists want the option to go to the client who needs or wants them.

There is no such thing as "independent practice" as all health practices are integrated in one form or another. A dental hygienist who practices directly with clients will always require a referral system to a dentist, physician, nurse practitioner, or other health-care practitioner. That is the nature of comprehensive, preventive health care.

• Self-regulation may mean the end of supervision but not always.

The concept of supervision has many meanings. In Canada, the five self-regulating jurisdictions all have some ties with dentistry, but only Quebec has direct supervision. In British Columbia, the client must have seen a dentist within the past 365 days and the dentist must be on-site when the dental hygienist administers local anesthesia. There is currently a general supervision requirement in Alberta, but new legislation due to be enacted in 2004 will permit unsupervised practice.

In Saskatchewan, there is no supervision, but there is an expectation of an employment relationship with either an institution that also employs dentists or with a dentist in private practice. In Ontario, an "order" is required for the controlled act of "scaling and root planing including the curetting of the surrounding tissue."

Each dental hygiene jurisdiction is attempting to make changes to the current legislation but is experiencing strong resistance from organized dentistry.

• Organized dentistry will recognize dental hygiene as a separate and distinct profession.

The reality is that it will take several generations of both dental hygienists and dentists to fully recognize each other as true professionals.

Unfortunately, there are dental hygienists who continue to see themselves as appendages or "auxiliaries" to the dental profession. As dental hygienists accept the responsibilities of being a professional, other members of the health care system will mirror that respect. There are still dental hygienists who refer to themselves as "girls," and there are dentists who still see dental hygienists as "cash cows" for their practices.

Fortunately, there are also many individual dentists and dental hygienists who have tremendous respect for each other's roles and work collaboratively with one another.

• Dental hygiene can control its own educational destiny.

The advantage of self-regulation is that dental hygienists are able to set entry-to-practice requirements within their own jurisdiction. The downside is that any change is a lengthy government process and must be seen to be in the "public interest."

The Canadian Dental Hygienists Association (CDHA) has released a policy stating that dental hygiene educational institutions in Canada should work towards a baccalaureate entry-to-practice by the year 2005. As education is within the provincial jurisdiction, no definitive decisions have yet been made by the dental hygiene regulatory agencies.

• Dental hygiene will be consulted fully regarding human resource considerations.

Remembering that a full 92 percent of dental hygienists in Canada are self-regulated, one would believe that dental hygiene would be consulted regarding any perceived dental hygiene shortage in the country. Unfortunately, organized dentistry has decided on their own that there is a shortage of dental hygienists to meet their practice needs.

A meeting was held in January 2003, and the topic was the perceived shortage of dental hygienists in Canada.

Representatives from each of the dental associations across the country attended; however, not one dental hygiene representative was invited. Following the dentists' meeting, unsubstantiated information regarding a dental hygiene shortage was released to the public.

Organized dental hygiene is in the process of securing accurate, defendable statistics and has made it clear to organized dentistry and government that as a profession, dental hygiene is the one to speak regarding human resource needs.

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