Dental informations for dentistry
“study, training, courses, seminars, reading and other activities undertaken by a dentist or dental professional, which could reasonably be expected to advance their professional development, as a dentist or dental professional” (GDC 2011).
Outcomes
The review of literature on CPD, for both dental and other healthcare professions, produced few robust evidence-based answers to the seven questions posed by the GDC. This was 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 was 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?
No studies of high quality (Grade 1 – systematic review(s) or Grade 2 – Randomised Controlled Trials (RCTs) )existed 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 including sustained, repeated, or longer term CPD activities, involving an interactive method of delivery utilising multimedia, or combining techniques, for example, interactive education were found to be effective. The importance of planning, self directed learning and reflective
6
practice for effective CPD was highlighted in the literature, as were the perceived benefits of personal learning plans and reflection to help clinicians to identify and take part in 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). It has been suggested that hours accumulated from activities involving active and targeted participation, which have been shown to be more effective than passive learning, should attract more credits (Bloom 2005). However, both Schostak (2010) and Grant (2011) have described the weakness of using inputs, such as hours of CPD completed to measure CPD. Freidman and Woodhead (2008) have suggested that an output approach that attempts “to measure what CPD is intended to achieve directly” and enables individual professionals to monitor their own progress may be better. However, 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. At present it is not possible to draw firm generalisable conclusions to answer question 2.
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. These encompass assuring activity levels and competency, satisfying public expectations, keeping abreast of advances in patient care and as a registration instrument. The literature did not reveal any studies that demonstrated benefits relating to regulatory purposes of CPD participation in terms of improved quality of care delivered, performance, professional standards, competence, public satisfaction or safety.
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. They include: helping to improve the safety and quality of care provided for patients and the public, maintaining skills and knowledge and reflecting on the standards of practice.
7
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?
Factors motivating practitioners to undertake CPD and barriers to CPD appeared 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. Cost, ease of access, and perceived relevance are all related to the ability to engage with CPD.
CPD and performance
Question 6.
Is CPD participation a valid indicator of professional competence or performance? Based on what criteria?
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 research 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 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.
8
2. Introduction Introduction Introduction Introduction Introduction Introduction Introduction Introduction Introduction Introduction Introduction
The General Dental Council (GDC) is the regulator of dental professionals in the United Kingdom. All dentists and Dental Care Professionals (DCPs): dental nurses, dental technicians, clinical dental technicians, dental hygienists, dental therapists and orthodontic therapists, must be registered with the GDC to practise in the UK.
The GDC has recently embarked upon a review of mandatory Continuing Professional Development (CPD) requirements in order to:
Evaluate the strengths and weaknesses of the current CPD model
Understand alternative approaches to CPD
Analyse the benefits of alternative approaches
Model operational processes in support of preferred approach
Make a recommendation to Council for a preferred ‘revalidation-ready’ model of CPD
Prepare a public consultation based on the Council’s preferred model
The GDC commissioned this literature review to investigate the impact of CPD activity on individual practice and competence assurance of all the professions it regulates.
The purpose of the literature review is to contribute to an evidence base to support the GDC in its undertaking of a review of the statutory requirements of CPD for dentists and dental care professionals. The findings of this study will be used by the GDC as part of evidence gathering for its review of CPD and may also help to inform the development of revalidation.
The contract for the review was with the Faculty of General Dental Practice (UK). The team that conducted the literature review was Professor Kenneth Eaton (academic leader), Dr Janine Brooks, Reena Patel and Farzeela Merali, with oversight from the FGDP (UK) by Dr Paul Batchelor and Amrita Narain.
Prior to the literature review, it was believed that very little high quality evidence on CPD in dentistry had been published.
The literature review set out to identify studies that addressed the seven research questions posed by the GDC and to assess the quality of these studies. It sought to review the literature comprehensively, and to identify studies from which conclusions could be drawn. It was a comprehensive review of the dental literature on CPD supplemented by a review of the literature on CPD for other healthcare professions. Because there were very few systematic reviews or Randomised Controlled Trials (RCTs) on dental CPD, the search strategy was designed to identify all relevant studies, the majority of which would not be included in a systematic review. Therefore, this review should be considered as using the methodology of a systematic review of literature rather than a systematic review as such.
The definition of CPD that has been adopted in this report is that used in the CPD guidance issued by the GDC, namely “study, training, courses, seminars, reading and other activities undertaken by a dentist or dental professional, which could reasonably be expected to advance their professional development, as a dentist or dental professional” (GDC 2011).
Nevertheless, there are other definitions and interpretations of CPD. In particular, the terms Continuing Professional Development, Continuing Medical Education (CME) and Continuing Education (CE) can be, and are frequently, used interchangeably. Furthermore, some countries, including the USA, still refer to CME rather than to CDP.
9
In this review the terms CPD, CME and CE are used as they appear in the reviewed literature. For example, when analysing American papers the term CME, rather than CPD, is used.
Aims
The overall aim of the literature review was to establish whether or not there is evidence that can be used to effectively demonstrate the range of likely positive and optimum impact of CPD upon the practice of dental professionals.
Within this overall aim the literature review addresses the seven questions posed by the GDC under the four themes of: models of CPD; regulatory purposes of CPD; CPD participation and CPD and performance. The questions were:
Models of CPD
1. What are the least and most effective modes of CPD for the healthcare professions, and in particular dentistry?
2. What are the least and most effective qualitative and quantitative measures of CPD activity for the healthcare professions, and in particular dentistry?
Regulatory purposes of CPD
3. What are the regulatory benefits of CPD participation in dentistry?
4. What are the regulatory purposes of making CPD a mandatory requirement in healthcare professional regulation?
CPD participation
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?
CPD and performance
6. Is CPD participation a valid indicator of professional competence or performance? Based on what criteria?
7. Is there a link between participation in CPD activity and performance enhancement in the healthcare professions including dentistry, and how is that formed?
10
3. Research mesearch m esearch m esearch mesearch mesearch m ethods ethodsethodsethods
The methods involved identifying the key search terms for the seven research questions, performing a comprehensive literature search within dentistry and other healthcare professions, contacting Subject Matter Experts (SMEs) to identify unpublished grey literature, summarising the literature, synthesising the evidence, and submitting an interim and a final report for review by the GDC.
These activities commenced on 15 August 2011, an interim report was submitted to the GDC on 22 September a draft final report was submitted on 17 October 2011 and the final report was submitted on 24 October 2011. Weekly telephone or face-to-face progress and review meetings were held throughout the review between the GDC and the research team.
3.1 Dental literature
Search Strategy
The search strategy was designed to be comprehensive and to allow for the selection of the most relevant primary studies and review papers. The search plan utilised electronic searching. The following databases: MEDLINE®, EMBASE® and the Cochrane Database of Systematic Reviews were searched to identify literature on the research questions. A more detailed explanation of the search strategy is provided in Appendix A. A systematic approach for searching the dental literature was used, with specific exclusion criteria designed to minimise the risk of bias in selecting papers for inclusion in the review. The exclusion criteria were:
1. Contained no human data
2. Was a meeting abstract, opinion piece, editorial, commentary, or letter
3. Did not include dentists/ dental care professionals
4. Did not include dental training or education
5. Did not evaluate an educational activity
6. Published prior to 1981
7. Did not apply to GDC key research questions
8. Did not include at least 15 fully trained dentists/ dental care professionals
9. Involved quality improvement without an educational activity
10. Not written in English
A standardised form (data template) was used for data extraction from the full versions of the papers. A full explanation of the data extraction process is detailed in Appendix B.
Quality Assessment: Rating the Body of Evidence
The quality of the resulting evidence was graded to address the research questions. The methodological characteristics of a study’s qualities were assessed by identifying if the papers involved:
Randomised or convenience samples
Interview-based questionnaires
11
Self-completed questionnaires
Focus groups
Qualitative interviews
Other techniques
The strength of the study design used in each paper was assessed using the grades of evidence listed
in Table 1. The five levels of evidence are those adopted by the National Health Service Research and
Development Centre for Evidence-Based Medicine (Evidence Based On-Call database 2002).
Table 1: Grades of evidence
The grades of
evidence
Strength of evidence
Grade
I
Strong evidence from at least one systematic review of multiple, well-designed,
randomised control trial/s.
Grade
II
Outcomes
The review of literature on CPD, for both dental and other healthcare professions, produced few robust evidence-based answers to the seven questions posed by the GDC. This was 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 was 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?
No studies of high quality (Grade 1 – systematic review(s) or Grade 2 – Randomised Controlled Trials (RCTs) )existed 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 including sustained, repeated, or longer term CPD activities, involving an interactive method of delivery utilising multimedia, or combining techniques, for example, interactive education were found to be effective. The importance of planning, self directed learning and reflective
6
practice for effective CPD was highlighted in the literature, as were the perceived benefits of personal learning plans and reflection to help clinicians to identify and take part in 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). It has been suggested that hours accumulated from activities involving active and targeted participation, which have been shown to be more effective than passive learning, should attract more credits (Bloom 2005). However, both Schostak (2010) and Grant (2011) have described the weakness of using inputs, such as hours of CPD completed to measure CPD. Freidman and Woodhead (2008) have suggested that an output approach that attempts “to measure what CPD is intended to achieve directly” and enables individual professionals to monitor their own progress may be better. However, 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. At present it is not possible to draw firm generalisable conclusions to answer question 2.
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. These encompass assuring activity levels and competency, satisfying public expectations, keeping abreast of advances in patient care and as a registration instrument. The literature did not reveal any studies that demonstrated benefits relating to regulatory purposes of CPD participation in terms of improved quality of care delivered, performance, professional standards, competence, public satisfaction or safety.
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. They include: helping to improve the safety and quality of care provided for patients and the public, maintaining skills and knowledge and reflecting on the standards of practice.
7
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?
Factors motivating practitioners to undertake CPD and barriers to CPD appeared 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. Cost, ease of access, and perceived relevance are all related to the ability to engage with CPD.
CPD and performance
Question 6.
Is CPD participation a valid indicator of professional competence or performance? Based on what criteria?
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 research 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 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.
8
2. Introduction Introduction Introduction Introduction Introduction Introduction Introduction Introduction Introduction Introduction Introduction
The General Dental Council (GDC) is the regulator of dental professionals in the United Kingdom. All dentists and Dental Care Professionals (DCPs): dental nurses, dental technicians, clinical dental technicians, dental hygienists, dental therapists and orthodontic therapists, must be registered with the GDC to practise in the UK.
The GDC has recently embarked upon a review of mandatory Continuing Professional Development (CPD) requirements in order to:
Evaluate the strengths and weaknesses of the current CPD model
Understand alternative approaches to CPD
Analyse the benefits of alternative approaches
Model operational processes in support of preferred approach
Make a recommendation to Council for a preferred ‘revalidation-ready’ model of CPD
Prepare a public consultation based on the Council’s preferred model
The GDC commissioned this literature review to investigate the impact of CPD activity on individual practice and competence assurance of all the professions it regulates.
The purpose of the literature review is to contribute to an evidence base to support the GDC in its undertaking of a review of the statutory requirements of CPD for dentists and dental care professionals. The findings of this study will be used by the GDC as part of evidence gathering for its review of CPD and may also help to inform the development of revalidation.
The contract for the review was with the Faculty of General Dental Practice (UK). The team that conducted the literature review was Professor Kenneth Eaton (academic leader), Dr Janine Brooks, Reena Patel and Farzeela Merali, with oversight from the FGDP (UK) by Dr Paul Batchelor and Amrita Narain.
Prior to the literature review, it was believed that very little high quality evidence on CPD in dentistry had been published.
The literature review set out to identify studies that addressed the seven research questions posed by the GDC and to assess the quality of these studies. It sought to review the literature comprehensively, and to identify studies from which conclusions could be drawn. It was a comprehensive review of the dental literature on CPD supplemented by a review of the literature on CPD for other healthcare professions. Because there were very few systematic reviews or Randomised Controlled Trials (RCTs) on dental CPD, the search strategy was designed to identify all relevant studies, the majority of which would not be included in a systematic review. Therefore, this review should be considered as using the methodology of a systematic review of literature rather than a systematic review as such.
The definition of CPD that has been adopted in this report is that used in the CPD guidance issued by the GDC, namely “study, training, courses, seminars, reading and other activities undertaken by a dentist or dental professional, which could reasonably be expected to advance their professional development, as a dentist or dental professional” (GDC 2011).
Nevertheless, there are other definitions and interpretations of CPD. In particular, the terms Continuing Professional Development, Continuing Medical Education (CME) and Continuing Education (CE) can be, and are frequently, used interchangeably. Furthermore, some countries, including the USA, still refer to CME rather than to CDP.
9
In this review the terms CPD, CME and CE are used as they appear in the reviewed literature. For example, when analysing American papers the term CME, rather than CPD, is used.
Aims
The overall aim of the literature review was to establish whether or not there is evidence that can be used to effectively demonstrate the range of likely positive and optimum impact of CPD upon the practice of dental professionals.
Within this overall aim the literature review addresses the seven questions posed by the GDC under the four themes of: models of CPD; regulatory purposes of CPD; CPD participation and CPD and performance. The questions were:
Models of CPD
1. What are the least and most effective modes of CPD for the healthcare professions, and in particular dentistry?
2. What are the least and most effective qualitative and quantitative measures of CPD activity for the healthcare professions, and in particular dentistry?
Regulatory purposes of CPD
3. What are the regulatory benefits of CPD participation in dentistry?
4. What are the regulatory purposes of making CPD a mandatory requirement in healthcare professional regulation?
CPD participation
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?
CPD and performance
6. Is CPD participation a valid indicator of professional competence or performance? Based on what criteria?
7. Is there a link between participation in CPD activity and performance enhancement in the healthcare professions including dentistry, and how is that formed?
10
3. Research mesearch m esearch m esearch mesearch mesearch m ethods ethodsethodsethods
The methods involved identifying the key search terms for the seven research questions, performing a comprehensive literature search within dentistry and other healthcare professions, contacting Subject Matter Experts (SMEs) to identify unpublished grey literature, summarising the literature, synthesising the evidence, and submitting an interim and a final report for review by the GDC.
These activities commenced on 15 August 2011, an interim report was submitted to the GDC on 22 September a draft final report was submitted on 17 October 2011 and the final report was submitted on 24 October 2011. Weekly telephone or face-to-face progress and review meetings were held throughout the review between the GDC and the research team.
3.1 Dental literature
Search Strategy
The search strategy was designed to be comprehensive and to allow for the selection of the most relevant primary studies and review papers. The search plan utilised electronic searching. The following databases: MEDLINE®, EMBASE® and the Cochrane Database of Systematic Reviews were searched to identify literature on the research questions. A more detailed explanation of the search strategy is provided in Appendix A. A systematic approach for searching the dental literature was used, with specific exclusion criteria designed to minimise the risk of bias in selecting papers for inclusion in the review. The exclusion criteria were:
1. Contained no human data
2. Was a meeting abstract, opinion piece, editorial, commentary, or letter
3. Did not include dentists/ dental care professionals
4. Did not include dental training or education
5. Did not evaluate an educational activity
6. Published prior to 1981
7. Did not apply to GDC key research questions
8. Did not include at least 15 fully trained dentists/ dental care professionals
9. Involved quality improvement without an educational activity
10. Not written in English
A standardised form (data template) was used for data extraction from the full versions of the papers. A full explanation of the data extraction process is detailed in Appendix B.
Quality Assessment: Rating the Body of Evidence
The quality of the resulting evidence was graded to address the research questions. The methodological characteristics of a study’s qualities were assessed by identifying if the papers involved:
Randomised or convenience samples
Interview-based questionnaires
11
Self-completed questionnaires
Focus groups
Qualitative interviews
Other techniques
The strength of the study design used in each paper was assessed using the grades of evidence listed
in Table 1. The five levels of evidence are those adopted by the National Health Service Research and
Development Centre for Evidence-Based Medicine (Evidence Based On-Call database 2002).
Table 1: Grades of evidence
The grades of
evidence
Strength of evidence
Grade
I
Strong evidence from at least one systematic review of multiple, well-designed,
randomised control trial/s.
Grade
II
Dental informations for dentistry
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