Introduction

Dental nurses are registered dental professionals who provide clinical and other support to dentists and their patients;1 they are the largest group, representing approximately 47.3% (n = 63,876) of the total United Kingdom (UK) dental registrant workforce (October 2024).2

The route to becoming a dental nurse has become more formalised over the past 15 years, from apprenticeships3,4 to mandatory registration in the UK from 2008,5 with the requirement to engage in continuing professional development to maintain their registration with the General Dental Council (GDC).

Dental nurses are essential members of the oral healthcare team and it is important to understand their motivation and career expectations; previous studies suggest that dental nurses were primarily motivated to pursue a career in dentistry because of the ‘features of the job', such as job security and regular working hours.6,7 Awojobi et al.8 explored the career aspirations of trainee dental nurses trained through a pilot scheme and reported that, as they progressed in their training, they became more certain of their overall career plans. When dental nurses apply their full range of clinical skills within their areas of competence and scope of practice, they feel valued, increasing job satisfaction and playing a significant role in their retention within the NHS workforce.9

Studies have shown dental nurses expressed dissatisfaction with their remuneration.8,10 According to Dingle and Balmer,11 COVID-19 resulted in increased challenges for dental nurses, with many considering leaving the profession due to factors including stress and poor remuneration, in addition to the cost of the GDC annual registration fee.

The Scope of practice by the GDC outlines dental nurses' core duties and the additional skills which may be developed during their career.1 These additional skills allow them to undertake more responsibilities and contribute to the diverse skill mix of the dental workforce. For example, trained dental nurses can apply fluoride varnish either on a prescription from a dentist or directly as part of a structured dental health programme.1,12,13 Dental nurses can also pursue additional qualifications through recognised bodies, such as the National Examining Board for Dental Nurses, including specialities like oral health education, dental radiography, sedation nursing, special care dental nursing and orthodontic dental nursing. Durkan et al.14 reported that conscious sedation was the most frequently acquired and used additional skill among qualified dental nurses at one London dental hospital and, despite being well-trained, skills like impression-taking and suture removal were used less often.

The appropriate use of skill mix within the dental team can result in a greater utilisation of clinical resources and provision of a more efficient service.15 Dental nurses with additional skills can perform various additional dental procedures. However, there is no evidence of the time spent on performing these procedures compared with dentists, dental hygienists and therapists.15,16

The Delivering better oral health toolkit (contemporary evidence-based guidelines in England) recommend the application of fluoride varnish twice or more a year for children over three years old and twice annually for adults at high risk of caries;17 delegating this procedure to dental nurses presents a promising revenue-generating opportunity.16,18 Exploring how dental nurses with additional duties may allow dental practices to ensure efficient use of limited staff and facilities during the current access crisis is increasingly important and in line with delivering better oral health.17

Aim of the study

This study aims, first, to explore the motivation, job satisfaction, training status and the use of additional skills by qualified dental nurses working at one NHS Foundation Trust, their perception of departmental support for using these skills, and the career aspirations that may facilitate their retention within the profession. And second, to determine the time taken to perform key dental procedures by dental nurses with additional duties and the perceived factors that affect these timings.

Material and methods

Study population

All 80 qualified dental nurses at one NHS Foundation Trust, along with its community dental clinics, were invited to participate in this cross-sectional survey as part of an exploratory service evaluation in South East London.

Survey tool

A structured questionnaire was developed and delivered to invited participants in electronic and paper formats, featuring open- and closed-ended questions from validated instruments.

Demographic data were collected in line with the National Office of Statistics guidelines19 and educational background adopted from previous surveys.14 Career motivation was assessed using the Gallagher Motivation Index20 and job satisfaction questions were adapted from the Warr-Cook-Wall scale.21

Questions regarding training and skills utilisation were based on the GDC Scope of practice,1 drawing on the work of Durkan et al.14 Career aspirations were explored using questions from the NHS 2010 staff survey22 and previous surveys on dental nurses.10 Timings for performing key duties and influencing factors were adopted from the British Dental Association's Heathrow timings inquiry,23 the GDC Scope of practice1 and a survey on dental procedure timings for dentists, dental hygienists and therapists.15

Participants were asked to provide information on the time taken to perform duties in both clinical settings and non-clinical settings, which refer to outreach activities conducted outside of dental clinics or hospitals, in settings like schools or care homes, where dental care is provided in a non-clinical environment.

Six factors influencing treatment time were considered: patient factors; quality of care; clinical setting; equipment care; personal skills/experience; and payment system, with an open option for participants to identify additional relevant factors.15 Open-ended questions explored perceived barriers and facilitators to skill use, suggestions for better skill utilisation, and career plans for the next five years. A pilot study was conducted among nursing leads to assess the readability, applicability and length of time required to complete the questionnaire.

Data collection

Data were collected over nine weeks from July to September 2023, as per the Dillman et al. approach.24 The dental nurse leads circulated information sheets and invitation letters to participants via email. The letter included an anonymous link and QR code for survey access via Qualtrics software. Two reminder emails were sent after two weeks, with a one-week interval. For paper surveys, envelopes with information sheets and questionnaires were distributed to qualified dental nurses, who returned completed forms to a secure, designated box in the nursing lead's office for daily collection. All responses from the questionnaire were anonymous and confidential and the participants gave consent to participate before completing the survey questionnaire.

Ethical approval

Ethical approval was not required for this survey because it was conducted as a service evaluation within the trust. This survey was registered as an audit and evaluation and supported by the audit department of the dental clinical care group, as indicated by the reference number (DENT-M-03-23).

Data analysis

This study used quantitative descriptive analysis and qualitative content analysis. Descriptive analysis with the Statistical Package for the Social Sciences (SPSS) version 25.0 explored the sample characteristics, providing frequencies and percentages for categorical variables and mean, mode and range for numerical data, such as dental procedure timings. Inductive content analysis explored responses and themes to open-ended questions.25

Results

Descriptive and associated content analyses

Characteristics of the respondents

The demographic characteristics of the survey respondents are shown in Table 1. A total of 49 qualified dental nurses responded to the questionnaire. However, ten responses were excluded as they only answered the education section. Of the remaining 39 respondents, four work in community dental clinics and the remainder work in the hospital. All respondents qualified in the UK, with NVQ Level 3 in dental nursing being the most common qualification. On average, participants had 12.9 years of experience; one-third (n = 14) had obtained qualifications in the past five years (2017-2023), and the majority (n = 30) within the past ten years (2012-2023). Additionally, 17 identified themselves as dental nurses with additional duties.

Table 1 Characteristics of the participants (n = 39)
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Motivation for a career in dental nursing

A ‘desire to work with people' was the main reason for choosing a career in dental nursing, followed by ‘job security', ‘desire to work in healthcare' and ‘regular working hours' (Table 2). When participants were asked to select one major motivating factor, the following factors were reported equally: ‘job security'; ‘influence of friends'; ‘desire to work with people'; ‘personal experience of dental care'; and ‘high income'. Only one participant identified ‘needing a job' as an additional factor.

Table 2 Motivating factors influencing the career choice of dental nursing (n = 39)
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Job satisfaction

Almost half of the participants (48.7%) reported their overall job experience as ‘very satisfied' or ‘extremely satisfied'. The most influential factors in promoting job satisfaction were ‘colleagues and fellow workers', ‘hours of work' and ‘amount of responsibility you are given'. The primary sources of dissatisfaction were ‘remuneration', ‘physical working conditions' and ‘recognition for good work' (Table 3).

Table 3 Levels of job satisfaction (n = 39)
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Training status and utilisation of additional skills

Conscious sedation, radiography, intra-oral photography and impression-taking were the most acquired and used skills. Fluoride varnish application was the least used skill, as out of the four dental nurses who received training, only one respondent reported using this skill (Table 4). Skills that participants most expressed interest in receiving training for were ‘removing sutures', ‘radiography', ‘conscious sedation' and ‘applying fluoride varnish'.

Table 4 Training status with respect to additional skills from the GDC scope of practice for dental nurses (n = 39)
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Department support in using additional skills

Qualitative findings on participants' perceptions about enhancing additional skills utilisation in their departments showed three key themes: 1) ‘resource constraints (physical/human)'; 2) ‘service/specialisation availability'; and 3) ‘involvement'.

Participants' suggestions for better utilisation of their skills

The key suggestions for enhancing service in the South East area by greater utilisation of the participants' skills included: 1) ‘improve clinical opportunities'; 2) ‘allocating dental nurses strategically to departments that match their additional skills'; 3) ‘reducing administrative responsibilities'; 4) ‘increasing the awareness of clinicians about the scope of practice of trained dental nurses'; 5) ‘value and support'; 6) ‘salary banding alignment'; and 7) ‘community specialised units/nurse-led clinics'.

Career aspiration and future plans

Most participants intended to pursue further qualifications (56%; n = 22), with many receiving support for field developments (46%; n = 18). However, 48.7% (n = 19) reported a lack of career progression opportunities. Qualitative findings on dental nurses' five-year career plans revealed four themes: 1) ‘transition to non-clinical roles'; 2) ‘further training and skills development'; 3) ‘progression to become orthodontic therapist, hygienist, or therapist'; and 4) ‘uncertainty/lack of specific career plan'.

Timings

Table 5 shows the estimated time for dental nurses with additional duties to complete six dental procedures: fluoride varnish application, oral health education and promotion, and health advice (diet, oral hygiene, tobacco cessation and minimising alcohol consumption). In non-clinical settings, the average time for fluoride varnish application was longer compared with clinic settings. Similarly, delivering diet advice in non-clinical settings took almost twice the time compared with clinics. Conversely, oral health education and promotion and smoking-cessation advice took slightly longer to deliver in clinics compared with the non-clinical settings.

Table 5 Duration of time to perform dental procedures by dental nurses with additional duties
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Influencing factors

Table 6 summarises the key themes and subthemes of the qualitative findings from participants' perceptions of factors affecting treatment timings, including patient factors, quality of care, clinic settings, equipment, personal skills and experience, and the payment system.

Table 6 Influencing factors and main themes
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For the ‘patient' factor, five themes were identified: 1) ‘type of patient' (age, mental capacity, confidence, and disability); 2) ‘patient cooperation'; 3) ‘anxiety'; 4) ‘communication'; and 5) ‘punctuality'.

In terms of ‘quality of care,' two themes were identified: 1) ‘quality standards'; and) ‘time management'.

For the ‘clinic setting' factor, key themes included: 1) ‘space and infrastructure constraints'; 2) ‘collaborative teamwork'; 3) ‘efficient pre-procedure setup'; 4) ‘well-organised and easily accessible instruments'; 5) ‘time for waste management'; and 6) ‘inadequate staffing'.

The main theme reported for ‘equipment' was ‘availability and accessibility'.

In terms of ‘personal skills and experience,' some of the main themes identified included: 1) ‘communication'; 2) ‘years of practice'; and 3) ‘knowledge and confidence in skills utilisation'.

According to the participants, the payment system does not affect the timing of treatment delivery. Although opportunity to include additional factors, if perceived as relevant, was provided, none were reported.

Discussion

Motivation

The majority of participants joined the dental profession motivated by their desire to work with people, work in healthcare, and factors related to job features, such as regular working hours and job security. These aspects provide stability and professional confidence and reassurance in their professional roles - motivating features which are shared by other dental professionals, such as dentists,26 dental students7 and orthodontic therapists.27 The average years in clinical practice (12.8 years) among nurses may influence their emphasis on job security. This shift in focus towards career longevity as dental nurses gain experience is observed by Awojobi et al.8 in trainee dental nurses' career progression.

Job satisfaction

A recurring issue for dental nurses remains dissatisfaction with their ‘remuneration,' aligning with prior research findings among trainee dental nurses.8 Dental nurses feel their financial compensation does not correspond adequately to their job responsibilities and skill level. Dissatisfaction with the remuneration is further aggravated for those with additional skills, as they undertake extra duties within their departments without receiving due compensation. Additionally, dissatisfaction with ‘recognition for good work' suggests a gap between the effort and dedication they invest and the acknowledgement of their contributions in their role. This dissatisfaction might stem from non-monetary recognition, such as feedback and career growth opportunities, or from monetary recognition, such as financial incentives. Insufficient acknowledgement and recognition could lead to demotivation, affecting commitment to roles and highlighting the need for improved workplace communication and appreciation mechanisms. Further investigation into the specific areas and forms of recognition required by dental nurses is recommended to address this concern effectively. Dissatisfaction with ‘physical working conditions' is also a factor that requires attention due to its potential impact on career retention decisions.10

Career aspirations

Most participants expressed their aspirations to enhance their qualifications and there was great interest in progressing into managerial roles. Participants were also interested in gaining additional skills, mainly in suture removal, radiography, fluoride varnish and conscious sedation. Despite challenges reported by the participants in finding relevant courses or funding, they remained eager to continue their professional development and take additional courses, indicating a strong commitment to their career growth and progression. As previous studies suggest,8 working in a hospital where dental nurses use additional skills widely could be a motivational factor for further skills development.

Additional skills utilisation

There were differences in the utilisation of additional skills, with some dental nurses effectively using their trained skills, while others found them superfluous in their specific departments. Participants faced limitations that hindered their contribution due to a range of factors, which included insufficient resources, such as dental chairs, time and staff shortages, in addition to restrictions imposed by clinicians, either because of awareness gaps about the extent of nurses' additional skills/duties they can perform, or due to limited resources, such as staff shortage, leading to missed opportunities for collaborative care. Overall, this results in a scenario where trained and capable dental nurses are prevented from contributing to their full potential, which might lead to deskilling, demotivation and a potential risk of loss of valuable workforce.28 The decentralised model suggested by the participants to establish specialised units in the community led by dental nurses may be worth further consideration to enhance access to specialised care while empowering dental nurses to take on more roles in alignment with the Scope of practice outlined by the GDC.

Timings and influencing factors

Oral health education, promotion and smoking cessation advice took more time in clinics than in non-clinical settings. This could be due to clinics often being larger with a more diverse patient cohort, which might necessitate extra time for personalised education and counselling. Application of fluoride varnish in clinics takes less time than in a non-clinical environment because clinics may have better access to necessary equipment and resources, streamlining the application process.

When comparing the average treatment timings for fluoride varnish application, oral health education and promotion, and health advice (related to diet, alcohol and smoking cessation) to the results of a previous inquiry, it was noted that dental nurses with additional duties took longer time in comparison to dentists and dental hygienist/therapists.15 A possible explanation could be that these preventive procedures are a significant part of the dental nurse's additional skills,1 and as some of the nurses in this survey reported that they perform oral health education and promotion daily, they might approach these procedures more comprehensively, involving detailed explanations, discussions and patient interactions. On the other hand, dentists and dental hygienists/therapists might prioritise streamlined procedures within their scope of practice.1

Patients with dental anxiety and those who need reassurance before undergoing dental treatment were identified as factors that contribute to longer treatment times. Participants also emphasised that a shortage of personnel extends the treatment period due to increased workload on available dental nurses, who cover multiple roles. In addition, working in an old building with infrastructure issues, such as inadequate heating or cooling and water leaks, amplified these challenges. On the other hand, the knowledge and confidence of dental nurses, longer years of practice, and their adept utilisation of skills, were reported as important in reducing the duration of dental treatments. Effective communication and clear instructions from clinicians were also vital in streamlining the treatment process.

Only eight out of the 16 dental nurses with additional duties completed the procedure timings section of the survey. Anecdotal evidence suggests that nurses faced difficulties completing this section due to a lack of clinical opportunities to apply their trained skills in fluoride varnish application. Furthermore, while a substantial proportion of the surveyed nurses (61.5%; n = 24) had received training in at least one additional skill, only 17 individuals (43.6%) self-identified as dental nurses with additional duties. One plausible explanation is that the existing work structure and task allocation within their roles do not align with their specialised training, leading to an underutilisation of their additional skills. It is also possible that some dental nurses were unaware that their post-registration qualifications qualified them to undertake additional duties. Further studies are recommended to explore the awareness of trained dental nurses regarding their scope of practice and how well they recognise their qualifications and the additional duties they are qualified to perform.

The study had limitations to consider. First, using a sample from one hospital trust resulted in a non-representative group of UK dental nurses. However, it included nurses from various clinical and non-clinical settings, providing valuable insights into their motivations and experiences. Second, the low response rate was affected by the challenging context of the study, including recent doctor and dentist strikes and financial constraints post COVID-19, which reduced dental nurses' willingness and availability to participate. A larger sample size would have allowed investigation of factors such as gender or geographical location. Lastly, the self-administered questionnaire may have been affected by social desirability bias.

While limitations exist, the study's implications align with NHS England's skill mix recommendations9 and show that there is a need for effective harnessing of qualified dental nurses' skills for enhanced patient care and job satisfaction. The results of this study can help inform health service planners and policymakers to allocate resources more effectively to enhance oral healthcare service provision and address demotivating factors to improve nurse retention within the dental profession.

Recommendations

This study recommends conducting larger national studies involving dental nurses from various hospital trusts and settings, including general dental practices, to further explore the generalisability of these findings and understand dental nurses' motivations and experiences across England. Further investigation could explore how specific dental departments, specialties and job assignments influence the identification and utilisation of extra skills among dental nursing staff. While this study has examined the use of additional skills, it is equally important to acknowledge that dental nurses may choose to enhance their careers through formal qualifications, which open opportunities for further specialisation and progression in their professional roles. Further research could explore how the utilisation of these qualifications impacts job satisfaction, professional development and the efficiency of dental services.

Conclusion

This study highlights that dental nurses were primarily motivated by the desire to work with people and in healthcare, and with job security. However, dissatisfaction with remuneration, physical working conditions and recognition persists. Despite challenges, dental nurses show a strong commitment to skill enhancement. Differences in skill utilisation exist, attributed to resource constraints as dental practices evolve to meet the demands of contemporary oral healthcare recommendation. Addressing these challenges ensures that qualified dental nurses are valued and effectively utilised for patient-centred care.

Comparisons with previous research indicates that dental nurses with additional duties report spending more time on certain procedures compared to other dental professionals.