Parallels between the Development of the Nurse Practitioner and the Advancement of the Dental Hygienist

Public Health Issues

Nurse practitioners were introduced into the U.S. health system in the 1960s in response to the public's concern over physician shortages as well as the demand for affordable primary health care services to underserved populations and groups.^1-4 At the time, the number of primary care providers was insufficient to support the demand and need for medical care. Physician specialization contributed to a decrease in the number of primary care providers.² Vulnerable populations, including rural and poor urban populations, women, children, and the elderly had the greatest difficulty accessing medical care.² A real public health need for a new workforce model emerged as a result of access issues. The evolution of the independent nurse practitioner from existing nursing educational models was the result.¹

Just as in the 1960s when medical care concerns focused on physician shortage and rising costs, dentistry faces similar issues. According to the U.S. Department of Health and Human Services, the number of traditional dental health professional shortage areas has tripled in the last 25 years.⁵ Currently, about 5,000 areas in the U.S. are designated as dental health professional shortage areas (a ratio of 5,000 or more people to 1 dentist in the area). Reportedly, it would require roughly 7,300 more dentists to eliminate the designation of these shortage areas.⁶ Approximately 5,200 students graduated from dental schools across the U.S. in 2013, but 3,500 dentists retired last year and that number is expected to rise with the aging workforce population.^7,8 The Health Resources and Services Administration (HRSA) released a report in February of 2015 concluding that all 50 states in the U.S. will experience a shortage of dentists by 2025.⁹ The shortage of primary dental care providers is clearly evident in epidemiologic data.^5-9

Dental health shortage areas typically are populated by some of the most vulnerable populations.⁶ Disproportionately distributed dentists, coupled with the low numbers of dentists who participate in Medicaid, equates to millions of low-income children with inadequate dental care.¹⁰ The PEW Charitable Trusts reported that in 2011, less than half of the Medicaid-enrolled children received dental care in 22 states.¹⁰ These facts are significant since lower income children are twice as likely to develop cavities as their affluent counterparts.¹⁰ Low provider numbers and unmet needs of the underserved are 2 substantial parallels between the development of nurse practitioners and the future expansion of the dental hygienist's roles.^1-6,9 Low numbers of direct access dental care providers and underserved populations are now also prompting discussions about expanding roles for dental hygienists, educating more mid-level providers and making legislative changes to treat underserved populations.⁹

Rising dental costs also parallel the rising health care costs that occurred during the introduction of the nurse practitioner.^11-13 During World War II, health care expenditures accounted for 0.38% of the nation's Gross Domestic Product (GDP).¹¹ By 1961, it had risen to 1%, and resulted in concern over the lack of affordable care for the elderly, children and women.¹¹ This encouraged the development of a different workforce model in primary care, the nurse practitioner.¹¹ Economic costs are significantly higher today. In 2012, health care expenditures accounted for 17.2% of the GDP, meaning that, on average $8,915 is spent per person for health care.¹² Cost of dental services reached $110.9 billion in 2012 and continues to increase.¹³ Ultimately much like the introduction of the nurse practitioner, the introduction of new dental hygiene-based workforce models across the nation are being driven by similar public health issues (e.g., insufficient dental care providers, lack of dental care for vulnerable populations and rising dental care costs).^9,10,13

Constructs of Education

Registered nurses must obtain a master's or doctoral degree and then seek additional licensure in order to become a nurse practitioner.¹⁴ Today, there are over 350 academic nurse practitioner programs in the U.S.¹⁵ These programs started when nursing pioneers Loretta Ford and Henry Silver responded to demands for more health care access.² Ford and Silver recognized the need for nurses to have additional education and training to allow for more patient responsibility in expanded roles of care.² The new program would prepare nurses to assume more responsibility in treating underserved populations.^2,3 To fulfill such roles, these pioneers understood that education of the nurse practitioner needed to go beyond a bachelor's degree.¹⁶

State licensing boards for nurses recognize both the associate and baccalaureate entry points.¹ The same is true of dental hygiene, thus adding to educational inconsistency among practicing professionals. Such inconsistency can adversely influence graduate education for advanced-practice dental hygienists because there can be “no expectations for a student's consistent knowledge and skill level on admission or after program completion.”¹ The American Dental Education Association (ADEA) recognized the implications of varying entry-level programs in dental hygiene back in 2011. A brief entitled Bracing for The Future: Opening Up Pathways to the Bachelor's Degree for Dental Hygienists stressed the value of a bachelor's degree so that dental hygienists could enter master's-level programs to ensure safe provision of services in expanded roles.¹⁷

Economically, it is most feasible to train mid-level or advanced providers by supplementing the education of licensed dental hygienists just as nurses did with the nurse practitioner model. Advanced dental hygiene roles would require more education, and consequently the American Dental Hygiene Association (ADHA) and dental hygiene educators are establishing accreditation standards for advanced practice dental hygiene educational programs and new workforce models. The Commission on Dental Accreditation (CODA) assigned a task force to recommend standards for educating dental therapists, that is, mid-level providers. Initially, however, it did not seem that the standards recommended by the task force in December of 2013 were inclusive of dental hygiene-track advanced providers. The response, which was provided by the dental community, ADHA and the Federal Trade Commission, encouraged revisions to these recommendations.¹⁸ As of February 2015, CODA approved standards that allow for accreditation of dental hygiene-track advanced providers.¹⁹ Just like pioneers in nursing responded in 1965 with the introduction of the nurse practitioner model, so too today, ADHA and dental hygiene educators are supporting new workforce models and accreditation standards addressing the shortage of dental providers and concerns over rising dental care costs.^4,16,20 With expanded roles for dental hygienists, educational paths and specialized graduate degree programs must be established.¹⁶

Social and Political Environments

The introduction of the new nurse practitioner workforce model to primary medical care did not come without substantial battles. As the profession grew, nurse practitioners faced restrictions on practice, resources and reimbursement.^1,14 These legal and political barriers were often driven by physicians' territorialism, needs for status and culture.^1,2 Organized medicine viewed this new type of workforce model with suspicion, and expressed concerns about nurses practicing without direct supervision of a physician.²

Despite opposition, nurse practitioners documented expertise in disease prevention, public health promotion, the ability to increase access to care and patient satisfaction.¹ Substantial literature exists documenting that primary care outcomes do not differ between the delivery of care offered by a nurse practitioner and a physician.^21-25 Despite this, nurse practitioners are hindered by “inconsistent state laws, insurance reimbursement practices and a medical community that clings to outmoded notions of a physician-nurse hierarchy.”¹⁴ Continued research in areas of patient satisfaction and care documenting further beneficial outcomes may assist nurses to move forward in practice and acceptance.²

Similar to the nurse practitioner, the expansion of roles and education for dental hygienists has received resistance. Since regulations and scope of practice definitions fall under state laws, there are a variety of differences regarding how dental hygienists can practice within each state.²⁶ For instance, in Colorado dental hygienists are legally able to perform several dental preventive procedures independently, without the supervision of a dentist.²⁷ These procedures include dental prophylaxis, exposure of radiographs, topical anesthesia, fluoride application, sealants, and dental hygiene diagnosis and treatment planning. In contrast, Indiana is a state where dental hygienists cannot perform a simple non-invasive procedure such as placing a caries-preventive sealant on a patient's tooth without the direct supervision or written authorization of a dentist.^26,28 Despite the evidence of patient safety and satisfaction with direct access dental hygiene care, there are many states with restrictive practice acts.^29-32

As the profession of dental hygiene advances into the future, research will be needed to document quality care and satisfaction achieved under new dental hygiene workforce models. Such data could validate the continued development of new oral health care delivery models. Just as equivalency of many outcomes has been documented between nurse practitioners and physicians, outcome assessments will compare the care provided by dentists and dental hygienists.