Continuing Dental education
Other DCPs
Perceptions, attitudes and opinions of dental nurses to CPD (Mercer et al. 2007) Grade 4
Educational needs and employment status of dental nurses in Scotland (Ross and Ibbetson 2006) Grade 5
Views of dental therapists on the potential use at work of a progress file (Davenport et al. 2003) Grade 5
Determining dental therapists’ views on the development and implementation of a Progress File (Pee et al. 2000) Grade 4
Attitudes towards an online programme for dental hygienists (Fehrenbach et al. 2001) Grade 5
Dental hygienists' information seeking and computer application behaviour (Gravois et al. 1995) Grade 4
Hygienist’s participation, attitudes and perceptions of CPD (Ross et al. 2005) Grade 5
Participation and perception of dental hygienists in oral cancer CE programmes (Ashe et al. 2006) Grade 4
Participation rates and attitudes of dental technicians towards CPD (Ross and Ibbetson 2005) Grade 5
Participation rates of dental technicians in the United Kingdom. (Bower et al. 2004) Grade 5
Continuing professional development needs of dental technicians in the North of England (Reeson and Jepson 2007) Grade 4
Due to differences in employment status and working environments of dental nurses, dental hygienists, dental therapists, and dental technicians, the key findings for each of these professional groups are considered individually under separate headings set out below. These studies described how these DCPs currently engage with, perceive and benefit from CPD.
Dental Nurses
A study undertaken by the Yorkshire Deanery involved a postal survey of randomly selected GDPs, dental nurses and hygienists to report on attitudes to CPD (Mercer et al., 2007). Overall, the survey findings demonstrate that there is a requirement to promote a culture of lifelong learning within the practice-setting for the whole dental team. In particular, the study highlighted a number of issues that are summarised below:
30
Significant differences between GDPs and dental nurses’ perceptions of dental nurses needs and preferences for continuing education
A distinct lack of a culture of continuing professional development for DCPs within practices despite the fairly high percentage of qualified or qualifying dental nurses
A lack of activities that would encourage dental nurse education, for example the use of appraisals to assess needs, having formal training plans in situ, the use of computers for computer assisted learning, and involvement in quality assurance tools e.g. clinical audit
A lack of knowledge on the part of the majority of dental nurses about what type of further education was available to them and what their educational needs were. However, the vast majority of dental nurses felt they would benefit from continuing education with most preferring a hands-on training format with training taking place in the practice setting.
Lack of time was the greatest barrier to CPD for DCPs. Most dental nurses believed that dental nurses were entitled to protected time for training purposes.
Similar findings were reported in a national study in Scotland (Ross and Ibbetson, 2006), undertaken between 2003-2004 prior to mandatory CPD for DCPs, where dental nurses were surveyed to investigate perceived educational needs. Key findings are summarised below:
Attendance at educational events was low - only 21% of nurses attended scientific meetings or courses on a regular basis, and 51% stated they had attended between 1-4 events in the preceding 12 month period.
Funding for CPD courses was an issue - of the 75% who responded to this question, only 50% received financial assistance. Of those who responded to a question on the source of funding, 78% stated it had been received from their employer.
Problems in accessing continuing education included funding issues; travel; geographical location and a lack of opportunity.
CPD subjects that dental nurses felt would be of benefit to them included (in order of preference): information technology; infection control; oral surgery; health and safety; restorative techniques; periodontology; orthodontics and confidentiality and record keeping.
Dental Therapists
The studies on dental therapists identified in the search of the dental literature, explored their perceptions and experiences of the progress file (Pee at al. 2000, Davenport et al. 2003).
A progress file can be described as a tool to record learning, as a means of recording achievement. It also typically contains an element of reflection (Pee et al. 2000). In this study, participants viewed the tool positively and were able to identify many uses for the Progress File both within, and beyond their courses. However, they also expressed concerns regarding the effectiveness and feasibility of Progress File learning within present educational environments. In particular, they doubted the ability of reflection to enhance learning, and whether the progress file could be integrated with other course activities due to the subsequent increased administrative workloads.
A later study explored the dental therapists’ participation in CPD, and their views on the potential use at work of a progress file (Davenport et al. 2003). This study was undertaken prior to the
31
implementation of mandatory CPD requirements. Results demonstrated how therapists undertook a variety of CPD activities, ranging from formal courses and conferences to in-surgery training and private study, but not all CPD activities were evaluated or recorded. Most therapists felt they would benefit from more CPD and from a formal system or framework for managing it. Regarding the progress file, most therapists were positive about such a programme, but considered its success conditional upon factors such as input from the team leader. Overall, evaluation of the progress file was mainly positive: most therapists felt they would benefit from being more reflective.
Dental Hygienists
In a national survey of all registered dental hygienists with postal addresses in Scotland (Ross et al. 2005) reported on dental hygienists’ involvement in and attitudes towards CPD. The results highlighted a number of issues. Although hygienists’ involvement in CPD was good, results indicated that despite commitment to their profession, respondents felt that they did not always have support for CPD activities. Absence of funding for CPD was raised repeatedly, with only 41% reporting a degree of financial assistance. A total of 182 (65%) respondents reported that it was difficult to access continuing education and only 96 (35%) maintained that access was not a problem. A number of reasons were offered as to why access proved difficult, but ‘funding issues’, and ‘family commitments’ were most commonly cited. Geographical location was reported to be a barrier to education by 79 (28%), and 57 (21%) individuals highlighted ‘travel’ and ‘lack of opportunity’ as reasons for non-attendance. The demand for distance learning was investigated and, of those who replied (270; 93%), the majority (198; 73%) reported that this would be a desirable alternative mode of educational delivery, particularly in remote and rural settings.
A few international studies reported on information seeking behaviour, and attitudes towards online CPD, and individual programmes. In a questionnaire study of 197 registered dental hygienists residing in Alaska, Delaware, and Idaho, it was found that the most common sources used for professional development and information retrieval were continuing education courses, discussions with colleagues, and journals (Gravois et al. 1995). The respondents' own experience, credibility of the journal, and discussions with colleagues were the most frequent methods used to evaluate professional information. The hygienists tended to use continuing education courses, discussions with colleagues and journal literature as primary sources of information. They limited their use of the library and computers to obtain information pertinent to practice and professional development.
In a study originating from Marquette University, Wisconsin in the USA, dental hygienists’ attitudes towards an online programme were sought (Fehrenbach et al. 2001). The program followed a case-based educational model, and also included recent developments in dental theory and practice, with links to other Internet sites. An online feedback form was used. More than 77% of the participants felt that overall, the program met its objectives on an excellent to near excellent level. 81% felt the organisation, material presented, appropriateness of material and satisfaction of individual course objectives were met to an excellent or near excellent level.
Another international study related to participation levels and perception of dental hygienists in oral cancer CE (OCCE) programmes (Ashe et al. 2006). In a random sample of 651 dental hygienists practicing in North Carolina, authors reported that only 21% had attended an OCCE course within the past year. A total of 47% indicated having attended a course within the past 2 to 5 years, and 15% indicated that it had been more than 5 years since they last attended an OCCE course. Almost 10% indicated having never attended a course regarding oral cancer, although 96% indicated interest in attending such a course.
32
Dental Technicians
The dental literature search identified three studies investigating dental technicians participation in CPD in the UK, attitudes towards these programmes, and barriers to uptake.
In a survey of 250 dental technicians with postal addresses in Scotland, conducted prior to mandatory CPD, only 47% had attended an educational event within the preceding year, and of those who had not done this, a period of between two and 32 years had elapsed since any CPD involvement (Ross and Ibbetson 2005. A cross-sectional postal questionnaire survey of 1,650 dental technicians registered with the Dental Technicians Association in the UK revealed similar findings, where almost two thirds of the respondents had undertaken no verifiable CPD in the previous year.
Reeson and Jepson (2007) surveyed 39 commercial laboratories with postal addresses in the North of England, and 32 dental technicians working within NHS hospitals, community dental laboratories and a university dental school. Results demonstrated that the majority of technicians kept up to date with changing practice by reading journals, such as the Dental Technician (n = 34). Other methods were through contact with the Dental Laboratories Association (DLA), and the Dental Technicians Association (DTA). Universities and Colleges were also referred to along with conferences and exhibitions. Use of the internet and dialogue with colleagues were also mentioned.
In considering perceptions of CPD, Ross and Ibbetson (2005) found that 64% of the respondents felt they were out-of-date with professional education. A lack of educational structure was identified, as was poor remuneration and an absence of opportunity for career progression.
Regarding the introduction of mandatory CPD, Reeson and Jepson (2007) demonstrated that most technicians were prepared to record their CPD activity each year. However, willingness to do so was not as strong amongst those employed in commercial laboratories (n = 12 of 17 responses) as it was for NHS/University employed technicians who all answered yes. Popular topics for CPD were shown to be implantology and precision attachments.
In analysing barriers to CPD, although the prospect of CPD appeared to be desirable to many dental technicians, constraints around cost, time and access were highlighted (Reeson and Jepson). Specifically, Ross and Ibbetson (2005) demonstrated how many respondents reported that they would be penalised financially for undertaking CPD. Of these respondents, only 34% stated that any financial assistance had been available for educational purposes. There were also conflicting views as to who should meet the costs of such training. Those working in commercial laboratories felt it was up to the individual where as those in the NHS/University felt it was the responsibility of the employer (Reeson and Jepson 2007).
CPD was often dependent on the co-operation of the employer, and in certain cases access to this was denied. Other employment difficulties were highlighted where it was reported that staff shortages restricted the opportunity to undertake CPD and that long hours and poor wages in some commercial laboratories, removed the possibility of undertaking further education programmes (Ross and Ibbetson 2005). The survey also suggested that the main challenge facing laboratories is the meeting of production deadlines, particularly in the NHS sector, which together with long working hours means that CPD may be given a lower priority (Bower et al. 2004).
33
Other healthcare professional groups
The literature for other healthcare professional groups demonstrated a wide range of factors that can motivate practitioners to undertake CPD, as well as highlighting barriers to CPD.
From her recent literature review, Grant (2011) has produced a comprehensive list of factors that motivate or facilitate participation in CPD by doctors (Table 11).
Table 11: Factors that motivate or facilitate participation in CPD Authors and Dates Motivating/Facilitating Factors
Cividin and Ottoson (1997)
Perceived need to conform or alter current practices
The chance to network with others
Byers et al. (1996)
Satisfaction with previous courses/programmes attended
Gear et al. (1994)
The presence of a climate conducive to learning
Department of Health (1995)
A need to keep up to date
A career change (specialty)
Vaughan (1991)
To become/stay up-to-date
To train for new, additional roles
To increase job satisfaction and personal effectiveness
Woolf (1990)
Interest in the topics covered
Fox et al. (1989)
A desire for competence
Pressure to change arising from the clinical
environment
Financial incentives
Wood and Byrne (1980)
A desire among GPs to escape from problems associated with their practices
A desire to communicate with other GPs and health professionals
A hope for intellectual stimulation
A general desire to keep up-to-date
A need to refresh the memory and increase confidence
Barham and Benseman (1984) and Gross (1976)
Working in group settings
Grant et al. (1998)
Need identified from practice e.g. management training
Peer contact
Keeping up to date
General interest This table appears in the Good CPD Guide (Grant 2011) and is reproduced with the kind permission of Professor Janet Grant.
34
The ICPD has highlighted the problems of resources and the reliance ultimately on the co-operation, goodwill and responsibility of individual professionals to undertake appropriate CPD. It suggests that encouraging and rewarding voluntary CPD activity, over and above any necessary and existing level of compulsion, is the most effective means of propagating good practice (ICPD 2006). Friedman and Phillips (2001) considered barriers to professionals in CPD and cited time, cost and access as the most frequent. They pointed out that professionals are not homogenous and a range of factors – such as differences in career stage, preferred learning style(s) and individual ambition – affect the likelihood of taking part in CPD (Freidman & Phillips, 2001). They also drew attention to the fact that employers are in a strong position to influence participation in CPD. From their review of the literature on pharmacists’ CPD, Donayi et al. (2010) concluded that the barriers to engagement were: financial costs and resources issues, understanding of (the purposes of) CPD, facilitation and support, motivation and interest, attitudes towards compulsory CPD, system constraints and technical problems. Grant (2011) cited Cerverro (1988) and Langster (1994) and concluded that there was evidence that the following factors deterred doctors from engaging with CPD:
The costs involved in terms of money and time.
Dissatisfaction with the quality of the programmes on offer and a lack of personal benefit from participation.
General apathy with respect to education
A preference for self-directed learning
In conclusion, factors motivating practitioners to undertake CPD, and barriers to CPD appear to be influenced by work-related factors such as work environment, working patterns and employment status, which are all specific to each healthcare professional group, as well as individual perceptions of CPD. Cost, ease of access and perceived relevance which can influence engagement with CPD.
5.4 CPD and performance
Is CPD participation a valid indicator of professional competence or performance? Based on what criteria?
It was not possible to answer this question from the literature reviewed. Grant (2011) suggested that this is because there has never been a satisfactory approach to the outcome of CPD. Griscini and Jacano (2006) observed that: “The effectiveness and impact of continuing education remains unexplored and that continuing education is intended to ensure healthcare practitioners’ knowledge is current but it is difficult to determine if those who attend these courses are implementing what they have learnt”.
Grant (2011) cited Branthwaite et al. (1988) who found that GPs who were regular attenders at CPD meetings were more progressive in their work than those who did not attend regularly, more concerned about developing their skills and about having time and scope to practise effectively and more conscientious with respect to developing and improving their work. However, Gray (1998) questioned whether this was due to CPD participation or because the GPs who attended CPD courses regularly innately possessed the characteristics found by Branthwaite et al. (1988). In conclusion, both the dental and non-dental literature did not provide any information to demonstrate if CPD participation is a valid indicator of professional competence or performance. This is principally due to the challenges of assessing outcomes of CPD in terms of effectiveness and
35
impact. Is there a link between participation in CPD activity and performance enhancement in the healthcare professions including dentistry, and how is that formed?
No dental literature was identified that helped to provide an answer to this question. The medical literature demonstrated a wide range of studies which develop an association between performance enhancement in specific areas, after undertaking CPD activities.
In her recent literature review, Grant (2011) identified 13 studies that indicated that the doctors concerned enhanced their performance in specific areas after CPD activities. This suggests that for doctors there is a link between participation in CPD activities and performance enhancement. Two of the 13 studies raised issues about the differences in outcomes between the participating doctors and highlighted the need for contextual factors to be considered in connection with outcomes. Although it involved only six doctors, one of the studies followed the outcomes closely. It was based on a qualitative case study approach and followed their practice for a period of six months after they had attended a conference on cardiac arrhythmias (Crandall 1990). The differences between the participants, in terms of both decisions to change practice and actual changes made prompted Crandall to state that “CME does make a difference, but program planers must pay attention to the circumstances under which it does.” This conclusion suggests that targeting and management of CPD are important if performance is to be enhanced, and that individual clinicians may be more likely to achieve performance enhancement after CPD if they plan their CPD and its effects are appraised and validated independently. Personal development plans and annual appraisals are tools which seek to promote performance enhancement and are incorporated in the CPD systems advocated by the AMRC and the PSI (AMRC 2010, PSI 2010).
In conclusion, the dental literature did not address either of the two parts of this question. However, the medical literature suggested an association between undertaking CPD activities and enhancing performance. The benefits of targeting and management of CPD were highlighted, especially through the use of personal development plans and annual appraisals.
36
6. 6. Conclusions onclusions onclusions onclusions onclusions onclusions
The review of the literature on CPD, both dental and from other healthcare professions, has produced few robust evidence-based answers to the seven questions posed by the GDC. This is perhaps unsurprising as numerous authors have commented on the difficulties of conducting robust research into educational outcomes (Bloom 2005, Marinopoulos et al. 2007, Schostak et al. 2010, Grant 2011). It is not the purpose of this review to analyse these difficulties. However, they should be borne in mind when considering the conclusions, set out below, which address each of the seven questions posed by the GDC.
Models of CPD
Question 1. What are the least and most effective modes of CPD for the healthcare professions, and in particular dentistry?
It is evident from the literature that no studies of high quality exist to demonstrate the effectiveness of CPD, in terms of quality of care delivered, performance, professional standards, competence, public satisfaction or safety, or their longer-term effects on knowledge retention and application. However, particular elements of individual CPD programmes were deemed to be effective. These include the benefits of sustained, repeated, or longer term CPD activities, involving an interactive method of delivery utilising multimedia, or combining techniques, for example, interactive education and academic detailing. The importance of planning, self directed learning and reflective practice was highlighted in the literature. As were the perceived benefits of personal learning plans, in a process through which clinicians can be supported in the identification of their learning needs, to focus their selection of appropriate CPD.
Question 2. What are the least and most effective qualitative and quantitative measures of CPD activity for the healthcare professions, and in particular dentistry?
The Pharmaceutical Society of Ireland (PSI) highlighted the benefits of blended learning using a mixture of online and face-to-face activities and an online portfolio to allow a flexible approach that focuses on outcomes relevant to an individual practitioner’s practice (PSI 2010). The clearest advice with regard to qualitative and quantitative measures of CPD came from this report, where authors suggested that all Irish Pharmacists should be required to record a balance of different CPD activities in a portfolio accompanied by a robust external competency assessment which should be developed by peers and recreate “patient facing scenarios” (PSI 2010).
Overall, both the dental and non-dental literature demonstrated the difficulties in developing effective and evidence-based recommendations for quantitative or qualitative measures of CPD. PARN has suggested that output measures may be more effective than input at measures as a means to assess the effectiveness of CPD. A number of regulatory bodies and professional associations are adopting this approach. However, as yet there have been no studies on this topic specifically related to dentistry.
Regulatory purposes of CPD
Question 3. What are the regulatory benefits of CPD participation in dentistry?
The literature identified a range of potential regulatory benefits of participation in CPD, but did not demonstrate any direct associations with quality of care delivered, performance, professional standards, competence, public satisfaction or safety.
37
Question 4. What are the regulatory purposes of making CPD a mandatory requirement in healthcare professional regulation?
The peer reviewed dental literature did not reveal any studies that demonstrated the regulatory purposes of making CPD a mandatory requirement in healthcare professional regulation. However, the GDC website (GDC 2011) reminds registrants that: “Patients are right to expect that all members of the dental team are keeping their skills and knowledge up to date throughout their careers. We ensure that this is happening by making CPD a requirement for all dental professionals registered with us.” Information from other healthcare sectors focussed on the role of CPD in maintaining and demonstrating professional standards and competency to the public.
CPD participation
Question 5. How do healthcare professionals, and in particular dental professionals, currently engage with, perceive and benefit from CPD; and does CPD have particular consequences for different groups and forms of practice in dentistry?
The concept of self-directed assessment of CPD needs, and reflection of any subsequent improvement or achievements, has been highlighted in a range of healthcare professional groups. For dentists especially, the benefits of the personal development plan have been highlighted. Factors motivating practitioners to undertake CPD, and barriers to CPD appear to be influenced by work related factors such as environment, working patterns and employment status, which are all specific to each healthcare professional group, as well as individual perceptions of CPD.
CPD and performance
Question 6. Is CPD participation a valid indicator of professional competence or performance? Based on what criteria?
Both the dental and non-dental literature did not provide any information to demonstrate if CPD participation is a valid indicator of professional competence or performance. This is principally due to the challenges of assessing outcomes of CPD in terms of effectiveness and impact.
Question 7. Is there a link between participation in CPD activity and performance enhancement in the healthcare professions including dentistry, and how is that formed?
The dental literature did not address either of the two parts of this question. However, the medical literature appeared to suggest an association between undertaking CPD activities and enhancing performance. The benefits of targeting and management of CPD were highlighted, especially through the use of personal development plans and annual appraisals.
38
6. Glossary of terms lossary of terms lossary of terms lossary of terms lossary of terms lossary of terms Term Definition
Activity
An educational event for professionals which is based upon identified needs (a needs assessment), has specified educational objectives and is evaluated to demonstrate that the needs have been met.
Appraisal
An ongoing, two-way process involving reflection on an individual's performance, identification of education needs, and planning for personal development. The focus is on the appraised and his or her professional development needs.
Audit (clinical)
A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.
Cochrane Collaboration
This is an international not-for-profit organisation preparing, maintaining and promoting the accessibility of systematic reviews of the effects of health care.
Competence
This term is used to encompass knowledge, skills, attitudes, behaviours and performance. The effectiveness of a CPD activity may be evaluated by documenting a change in one or more competencies. However, this is not the only way of evaluating effectiveness.
Convenience sample
A convenience sample is a type of non-probability sampling which involves the sample being drawn from that part of the population which is close to hand. That is, a sample population selected because it is readily available and convenient. Generalisations about the total population could not be made from this sample because it would not be representative.
Continuing Dental Education
The terms Continuing Professional Development and Continuing Dental Education can be, and are frequently used interchangeably. This is in spite of the fact that Continuing Education (CE), be it Continuing Dental Education (CME), differs from CPD in that it may not include the element of planned development of an individual.
Continuing Medical Education
The terms Continuing Professional Development and Continuing Medical Education can be, and are frequently used interchangeably. This is in spite of the fact that Continuing Education (CE), be it Continuing Medical Education (CME), differs from CPD in that it may not include the element of planned development of an individual. Furthermore, some countries, including the USA, still refer to CME rather than to CDP.
CPD Activity
An educational event or product (activity) for professionals, which is based upon identified needs, has an educational purpose or objectives, and is evaluated to ensure that defined educational or professional development needs are met.
Distance learning
The provision of education through print or electronic communications media to professionals engaged in learning at a time and place of their own choosing and at a distance from a presenter, facilitator or tutor. The education may be web-based or fixed-format (e.g. CD-ROM).
Evaluation form
A form given by event providers to event participants in order for the participant to communicate, and the provider to determine, the relevance, quality and
effectiveness of an activity.
Perceptions, attitudes and opinions of dental nurses to CPD (Mercer et al. 2007) Grade 4
Educational needs and employment status of dental nurses in Scotland (Ross and Ibbetson 2006) Grade 5
Views of dental therapists on the potential use at work of a progress file (Davenport et al. 2003) Grade 5
Determining dental therapists’ views on the development and implementation of a Progress File (Pee et al. 2000) Grade 4
Attitudes towards an online programme for dental hygienists (Fehrenbach et al. 2001) Grade 5
Dental hygienists' information seeking and computer application behaviour (Gravois et al. 1995) Grade 4
Hygienist’s participation, attitudes and perceptions of CPD (Ross et al. 2005) Grade 5
Participation and perception of dental hygienists in oral cancer CE programmes (Ashe et al. 2006) Grade 4
Participation rates and attitudes of dental technicians towards CPD (Ross and Ibbetson 2005) Grade 5
Participation rates of dental technicians in the United Kingdom. (Bower et al. 2004) Grade 5
Continuing professional development needs of dental technicians in the North of England (Reeson and Jepson 2007) Grade 4
Due to differences in employment status and working environments of dental nurses, dental hygienists, dental therapists, and dental technicians, the key findings for each of these professional groups are considered individually under separate headings set out below. These studies described how these DCPs currently engage with, perceive and benefit from CPD.
Dental Nurses
A study undertaken by the Yorkshire Deanery involved a postal survey of randomly selected GDPs, dental nurses and hygienists to report on attitudes to CPD (Mercer et al., 2007). Overall, the survey findings demonstrate that there is a requirement to promote a culture of lifelong learning within the practice-setting for the whole dental team. In particular, the study highlighted a number of issues that are summarised below:
30
Significant differences between GDPs and dental nurses’ perceptions of dental nurses needs and preferences for continuing education
A distinct lack of a culture of continuing professional development for DCPs within practices despite the fairly high percentage of qualified or qualifying dental nurses
A lack of activities that would encourage dental nurse education, for example the use of appraisals to assess needs, having formal training plans in situ, the use of computers for computer assisted learning, and involvement in quality assurance tools e.g. clinical audit
A lack of knowledge on the part of the majority of dental nurses about what type of further education was available to them and what their educational needs were. However, the vast majority of dental nurses felt they would benefit from continuing education with most preferring a hands-on training format with training taking place in the practice setting.
Lack of time was the greatest barrier to CPD for DCPs. Most dental nurses believed that dental nurses were entitled to protected time for training purposes.
Similar findings were reported in a national study in Scotland (Ross and Ibbetson, 2006), undertaken between 2003-2004 prior to mandatory CPD for DCPs, where dental nurses were surveyed to investigate perceived educational needs. Key findings are summarised below:
Attendance at educational events was low - only 21% of nurses attended scientific meetings or courses on a regular basis, and 51% stated they had attended between 1-4 events in the preceding 12 month period.
Funding for CPD courses was an issue - of the 75% who responded to this question, only 50% received financial assistance. Of those who responded to a question on the source of funding, 78% stated it had been received from their employer.
Problems in accessing continuing education included funding issues; travel; geographical location and a lack of opportunity.
CPD subjects that dental nurses felt would be of benefit to them included (in order of preference): information technology; infection control; oral surgery; health and safety; restorative techniques; periodontology; orthodontics and confidentiality and record keeping.
Dental Therapists
The studies on dental therapists identified in the search of the dental literature, explored their perceptions and experiences of the progress file (Pee at al. 2000, Davenport et al. 2003).
A progress file can be described as a tool to record learning, as a means of recording achievement. It also typically contains an element of reflection (Pee et al. 2000). In this study, participants viewed the tool positively and were able to identify many uses for the Progress File both within, and beyond their courses. However, they also expressed concerns regarding the effectiveness and feasibility of Progress File learning within present educational environments. In particular, they doubted the ability of reflection to enhance learning, and whether the progress file could be integrated with other course activities due to the subsequent increased administrative workloads.
A later study explored the dental therapists’ participation in CPD, and their views on the potential use at work of a progress file (Davenport et al. 2003). This study was undertaken prior to the
31
implementation of mandatory CPD requirements. Results demonstrated how therapists undertook a variety of CPD activities, ranging from formal courses and conferences to in-surgery training and private study, but not all CPD activities were evaluated or recorded. Most therapists felt they would benefit from more CPD and from a formal system or framework for managing it. Regarding the progress file, most therapists were positive about such a programme, but considered its success conditional upon factors such as input from the team leader. Overall, evaluation of the progress file was mainly positive: most therapists felt they would benefit from being more reflective.
Dental Hygienists
In a national survey of all registered dental hygienists with postal addresses in Scotland (Ross et al. 2005) reported on dental hygienists’ involvement in and attitudes towards CPD. The results highlighted a number of issues. Although hygienists’ involvement in CPD was good, results indicated that despite commitment to their profession, respondents felt that they did not always have support for CPD activities. Absence of funding for CPD was raised repeatedly, with only 41% reporting a degree of financial assistance. A total of 182 (65%) respondents reported that it was difficult to access continuing education and only 96 (35%) maintained that access was not a problem. A number of reasons were offered as to why access proved difficult, but ‘funding issues’, and ‘family commitments’ were most commonly cited. Geographical location was reported to be a barrier to education by 79 (28%), and 57 (21%) individuals highlighted ‘travel’ and ‘lack of opportunity’ as reasons for non-attendance. The demand for distance learning was investigated and, of those who replied (270; 93%), the majority (198; 73%) reported that this would be a desirable alternative mode of educational delivery, particularly in remote and rural settings.
A few international studies reported on information seeking behaviour, and attitudes towards online CPD, and individual programmes. In a questionnaire study of 197 registered dental hygienists residing in Alaska, Delaware, and Idaho, it was found that the most common sources used for professional development and information retrieval were continuing education courses, discussions with colleagues, and journals (Gravois et al. 1995). The respondents' own experience, credibility of the journal, and discussions with colleagues were the most frequent methods used to evaluate professional information. The hygienists tended to use continuing education courses, discussions with colleagues and journal literature as primary sources of information. They limited their use of the library and computers to obtain information pertinent to practice and professional development.
In a study originating from Marquette University, Wisconsin in the USA, dental hygienists’ attitudes towards an online programme were sought (Fehrenbach et al. 2001). The program followed a case-based educational model, and also included recent developments in dental theory and practice, with links to other Internet sites. An online feedback form was used. More than 77% of the participants felt that overall, the program met its objectives on an excellent to near excellent level. 81% felt the organisation, material presented, appropriateness of material and satisfaction of individual course objectives were met to an excellent or near excellent level.
Another international study related to participation levels and perception of dental hygienists in oral cancer CE (OCCE) programmes (Ashe et al. 2006). In a random sample of 651 dental hygienists practicing in North Carolina, authors reported that only 21% had attended an OCCE course within the past year. A total of 47% indicated having attended a course within the past 2 to 5 years, and 15% indicated that it had been more than 5 years since they last attended an OCCE course. Almost 10% indicated having never attended a course regarding oral cancer, although 96% indicated interest in attending such a course.
32
Dental Technicians
The dental literature search identified three studies investigating dental technicians participation in CPD in the UK, attitudes towards these programmes, and barriers to uptake.
In a survey of 250 dental technicians with postal addresses in Scotland, conducted prior to mandatory CPD, only 47% had attended an educational event within the preceding year, and of those who had not done this, a period of between two and 32 years had elapsed since any CPD involvement (Ross and Ibbetson 2005. A cross-sectional postal questionnaire survey of 1,650 dental technicians registered with the Dental Technicians Association in the UK revealed similar findings, where almost two thirds of the respondents had undertaken no verifiable CPD in the previous year.
Reeson and Jepson (2007) surveyed 39 commercial laboratories with postal addresses in the North of England, and 32 dental technicians working within NHS hospitals, community dental laboratories and a university dental school. Results demonstrated that the majority of technicians kept up to date with changing practice by reading journals, such as the Dental Technician (n = 34). Other methods were through contact with the Dental Laboratories Association (DLA), and the Dental Technicians Association (DTA). Universities and Colleges were also referred to along with conferences and exhibitions. Use of the internet and dialogue with colleagues were also mentioned.
In considering perceptions of CPD, Ross and Ibbetson (2005) found that 64% of the respondents felt they were out-of-date with professional education. A lack of educational structure was identified, as was poor remuneration and an absence of opportunity for career progression.
Regarding the introduction of mandatory CPD, Reeson and Jepson (2007) demonstrated that most technicians were prepared to record their CPD activity each year. However, willingness to do so was not as strong amongst those employed in commercial laboratories (n = 12 of 17 responses) as it was for NHS/University employed technicians who all answered yes. Popular topics for CPD were shown to be implantology and precision attachments.
In analysing barriers to CPD, although the prospect of CPD appeared to be desirable to many dental technicians, constraints around cost, time and access were highlighted (Reeson and Jepson). Specifically, Ross and Ibbetson (2005) demonstrated how many respondents reported that they would be penalised financially for undertaking CPD. Of these respondents, only 34% stated that any financial assistance had been available for educational purposes. There were also conflicting views as to who should meet the costs of such training. Those working in commercial laboratories felt it was up to the individual where as those in the NHS/University felt it was the responsibility of the employer (Reeson and Jepson 2007).
CPD was often dependent on the co-operation of the employer, and in certain cases access to this was denied. Other employment difficulties were highlighted where it was reported that staff shortages restricted the opportunity to undertake CPD and that long hours and poor wages in some commercial laboratories, removed the possibility of undertaking further education programmes (Ross and Ibbetson 2005). The survey also suggested that the main challenge facing laboratories is the meeting of production deadlines, particularly in the NHS sector, which together with long working hours means that CPD may be given a lower priority (Bower et al. 2004).
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Other healthcare professional groups
The literature for other healthcare professional groups demonstrated a wide range of factors that can motivate practitioners to undertake CPD, as well as highlighting barriers to CPD.
From her recent literature review, Grant (2011) has produced a comprehensive list of factors that motivate or facilitate participation in CPD by doctors (Table 11).
Table 11: Factors that motivate or facilitate participation in CPD Authors and Dates Motivating/Facilitating Factors
Cividin and Ottoson (1997)
Perceived need to conform or alter current practices
The chance to network with others
Byers et al. (1996)
Satisfaction with previous courses/programmes attended
Gear et al. (1994)
The presence of a climate conducive to learning
Department of Health (1995)
A need to keep up to date
A career change (specialty)
Vaughan (1991)
To become/stay up-to-date
To train for new, additional roles
To increase job satisfaction and personal effectiveness
Woolf (1990)
Interest in the topics covered
Fox et al. (1989)
A desire for competence
Pressure to change arising from the clinical
environment
Financial incentives
Wood and Byrne (1980)
A desire among GPs to escape from problems associated with their practices
A desire to communicate with other GPs and health professionals
A hope for intellectual stimulation
A general desire to keep up-to-date
A need to refresh the memory and increase confidence
Barham and Benseman (1984) and Gross (1976)
Working in group settings
Grant et al. (1998)
Need identified from practice e.g. management training
Peer contact
Keeping up to date
General interest This table appears in the Good CPD Guide (Grant 2011) and is reproduced with the kind permission of Professor Janet Grant.
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The ICPD has highlighted the problems of resources and the reliance ultimately on the co-operation, goodwill and responsibility of individual professionals to undertake appropriate CPD. It suggests that encouraging and rewarding voluntary CPD activity, over and above any necessary and existing level of compulsion, is the most effective means of propagating good practice (ICPD 2006). Friedman and Phillips (2001) considered barriers to professionals in CPD and cited time, cost and access as the most frequent. They pointed out that professionals are not homogenous and a range of factors – such as differences in career stage, preferred learning style(s) and individual ambition – affect the likelihood of taking part in CPD (Freidman & Phillips, 2001). They also drew attention to the fact that employers are in a strong position to influence participation in CPD. From their review of the literature on pharmacists’ CPD, Donayi et al. (2010) concluded that the barriers to engagement were: financial costs and resources issues, understanding of (the purposes of) CPD, facilitation and support, motivation and interest, attitudes towards compulsory CPD, system constraints and technical problems. Grant (2011) cited Cerverro (1988) and Langster (1994) and concluded that there was evidence that the following factors deterred doctors from engaging with CPD:
The costs involved in terms of money and time.
Dissatisfaction with the quality of the programmes on offer and a lack of personal benefit from participation.
General apathy with respect to education
A preference for self-directed learning
In conclusion, factors motivating practitioners to undertake CPD, and barriers to CPD appear to be influenced by work-related factors such as work environment, working patterns and employment status, which are all specific to each healthcare professional group, as well as individual perceptions of CPD. Cost, ease of access and perceived relevance which can influence engagement with CPD.
5.4 CPD and performance
Is CPD participation a valid indicator of professional competence or performance? Based on what criteria?
It was not possible to answer this question from the literature reviewed. Grant (2011) suggested that this is because there has never been a satisfactory approach to the outcome of CPD. Griscini and Jacano (2006) observed that: “The effectiveness and impact of continuing education remains unexplored and that continuing education is intended to ensure healthcare practitioners’ knowledge is current but it is difficult to determine if those who attend these courses are implementing what they have learnt”.
Grant (2011) cited Branthwaite et al. (1988) who found that GPs who were regular attenders at CPD meetings were more progressive in their work than those who did not attend regularly, more concerned about developing their skills and about having time and scope to practise effectively and more conscientious with respect to developing and improving their work. However, Gray (1998) questioned whether this was due to CPD participation or because the GPs who attended CPD courses regularly innately possessed the characteristics found by Branthwaite et al. (1988). In conclusion, both the dental and non-dental literature did not provide any information to demonstrate if CPD participation is a valid indicator of professional competence or performance. This is principally due to the challenges of assessing outcomes of CPD in terms of effectiveness and
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impact. Is there a link between participation in CPD activity and performance enhancement in the healthcare professions including dentistry, and how is that formed?
No dental literature was identified that helped to provide an answer to this question. The medical literature demonstrated a wide range of studies which develop an association between performance enhancement in specific areas, after undertaking CPD activities.
In her recent literature review, Grant (2011) identified 13 studies that indicated that the doctors concerned enhanced their performance in specific areas after CPD activities. This suggests that for doctors there is a link between participation in CPD activities and performance enhancement. Two of the 13 studies raised issues about the differences in outcomes between the participating doctors and highlighted the need for contextual factors to be considered in connection with outcomes. Although it involved only six doctors, one of the studies followed the outcomes closely. It was based on a qualitative case study approach and followed their practice for a period of six months after they had attended a conference on cardiac arrhythmias (Crandall 1990). The differences between the participants, in terms of both decisions to change practice and actual changes made prompted Crandall to state that “CME does make a difference, but program planers must pay attention to the circumstances under which it does.” This conclusion suggests that targeting and management of CPD are important if performance is to be enhanced, and that individual clinicians may be more likely to achieve performance enhancement after CPD if they plan their CPD and its effects are appraised and validated independently. Personal development plans and annual appraisals are tools which seek to promote performance enhancement and are incorporated in the CPD systems advocated by the AMRC and the PSI (AMRC 2010, PSI 2010).
In conclusion, the dental literature did not address either of the two parts of this question. However, the medical literature suggested an association between undertaking CPD activities and enhancing performance. The benefits of targeting and management of CPD were highlighted, especially through the use of personal development plans and annual appraisals.
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6. 6. Conclusions onclusions onclusions onclusions onclusions onclusions
The review of the literature on CPD, both dental and from other healthcare professions, has produced few robust evidence-based answers to the seven questions posed by the GDC. This is perhaps unsurprising as numerous authors have commented on the difficulties of conducting robust research into educational outcomes (Bloom 2005, Marinopoulos et al. 2007, Schostak et al. 2010, Grant 2011). It is not the purpose of this review to analyse these difficulties. However, they should be borne in mind when considering the conclusions, set out below, which address each of the seven questions posed by the GDC.
Models of CPD
Question 1. What are the least and most effective modes of CPD for the healthcare professions, and in particular dentistry?
It is evident from the literature that no studies of high quality exist to demonstrate the effectiveness of CPD, in terms of quality of care delivered, performance, professional standards, competence, public satisfaction or safety, or their longer-term effects on knowledge retention and application. However, particular elements of individual CPD programmes were deemed to be effective. These include the benefits of sustained, repeated, or longer term CPD activities, involving an interactive method of delivery utilising multimedia, or combining techniques, for example, interactive education and academic detailing. The importance of planning, self directed learning and reflective practice was highlighted in the literature. As were the perceived benefits of personal learning plans, in a process through which clinicians can be supported in the identification of their learning needs, to focus their selection of appropriate CPD.
Question 2. What are the least and most effective qualitative and quantitative measures of CPD activity for the healthcare professions, and in particular dentistry?
The Pharmaceutical Society of Ireland (PSI) highlighted the benefits of blended learning using a mixture of online and face-to-face activities and an online portfolio to allow a flexible approach that focuses on outcomes relevant to an individual practitioner’s practice (PSI 2010). The clearest advice with regard to qualitative and quantitative measures of CPD came from this report, where authors suggested that all Irish Pharmacists should be required to record a balance of different CPD activities in a portfolio accompanied by a robust external competency assessment which should be developed by peers and recreate “patient facing scenarios” (PSI 2010).
Overall, both the dental and non-dental literature demonstrated the difficulties in developing effective and evidence-based recommendations for quantitative or qualitative measures of CPD. PARN has suggested that output measures may be more effective than input at measures as a means to assess the effectiveness of CPD. A number of regulatory bodies and professional associations are adopting this approach. However, as yet there have been no studies on this topic specifically related to dentistry.
Regulatory purposes of CPD
Question 3. What are the regulatory benefits of CPD participation in dentistry?
The literature identified a range of potential regulatory benefits of participation in CPD, but did not demonstrate any direct associations with quality of care delivered, performance, professional standards, competence, public satisfaction or safety.
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Question 4. What are the regulatory purposes of making CPD a mandatory requirement in healthcare professional regulation?
The peer reviewed dental literature did not reveal any studies that demonstrated the regulatory purposes of making CPD a mandatory requirement in healthcare professional regulation. However, the GDC website (GDC 2011) reminds registrants that: “Patients are right to expect that all members of the dental team are keeping their skills and knowledge up to date throughout their careers. We ensure that this is happening by making CPD a requirement for all dental professionals registered with us.” Information from other healthcare sectors focussed on the role of CPD in maintaining and demonstrating professional standards and competency to the public.
CPD participation
Question 5. How do healthcare professionals, and in particular dental professionals, currently engage with, perceive and benefit from CPD; and does CPD have particular consequences for different groups and forms of practice in dentistry?
The concept of self-directed assessment of CPD needs, and reflection of any subsequent improvement or achievements, has been highlighted in a range of healthcare professional groups. For dentists especially, the benefits of the personal development plan have been highlighted. Factors motivating practitioners to undertake CPD, and barriers to CPD appear to be influenced by work related factors such as environment, working patterns and employment status, which are all specific to each healthcare professional group, as well as individual perceptions of CPD.
CPD and performance
Question 6. Is CPD participation a valid indicator of professional competence or performance? Based on what criteria?
Both the dental and non-dental literature did not provide any information to demonstrate if CPD participation is a valid indicator of professional competence or performance. This is principally due to the challenges of assessing outcomes of CPD in terms of effectiveness and impact.
Question 7. Is there a link between participation in CPD activity and performance enhancement in the healthcare professions including dentistry, and how is that formed?
The dental literature did not address either of the two parts of this question. However, the medical literature appeared to suggest an association between undertaking CPD activities and enhancing performance. The benefits of targeting and management of CPD were highlighted, especially through the use of personal development plans and annual appraisals.
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6. Glossary of terms lossary of terms lossary of terms lossary of terms lossary of terms lossary of terms Term Definition
Activity
An educational event for professionals which is based upon identified needs (a needs assessment), has specified educational objectives and is evaluated to demonstrate that the needs have been met.
Appraisal
An ongoing, two-way process involving reflection on an individual's performance, identification of education needs, and planning for personal development. The focus is on the appraised and his or her professional development needs.
Audit (clinical)
A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.
Cochrane Collaboration
This is an international not-for-profit organisation preparing, maintaining and promoting the accessibility of systematic reviews of the effects of health care.
Competence
This term is used to encompass knowledge, skills, attitudes, behaviours and performance. The effectiveness of a CPD activity may be evaluated by documenting a change in one or more competencies. However, this is not the only way of evaluating effectiveness.
Convenience sample
A convenience sample is a type of non-probability sampling which involves the sample being drawn from that part of the population which is close to hand. That is, a sample population selected because it is readily available and convenient. Generalisations about the total population could not be made from this sample because it would not be representative.
Continuing Dental Education
The terms Continuing Professional Development and Continuing Dental Education can be, and are frequently used interchangeably. This is in spite of the fact that Continuing Education (CE), be it Continuing Dental Education (CME), differs from CPD in that it may not include the element of planned development of an individual.
Continuing Medical Education
The terms Continuing Professional Development and Continuing Medical Education can be, and are frequently used interchangeably. This is in spite of the fact that Continuing Education (CE), be it Continuing Medical Education (CME), differs from CPD in that it may not include the element of planned development of an individual. Furthermore, some countries, including the USA, still refer to CME rather than to CDP.
CPD Activity
An educational event or product (activity) for professionals, which is based upon identified needs, has an educational purpose or objectives, and is evaluated to ensure that defined educational or professional development needs are met.
Distance learning
The provision of education through print or electronic communications media to professionals engaged in learning at a time and place of their own choosing and at a distance from a presenter, facilitator or tutor. The education may be web-based or fixed-format (e.g. CD-ROM).
Evaluation form
A form given by event providers to event participants in order for the participant to communicate, and the provider to determine, the relevance, quality and
effectiveness of an activity.
Continuing Dental education
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