Abstract
Purpose: Little is known regarding why prospective dental hygiene students select a four-year entry-to-practice baccalaureate degree rather than a diploma granting program in Canada. The purpose of this study was to explore motivating influences for selecting an entry-to-practice baccalaureate degree in dental hygiene from the perspective of former students.
Methods: This study employed a qualitative narrative inquiry consisting of 20 individual semi-structured interviews with 10 former first-year students of the University of British Columbia's Bachelor of Dental Science (dental hygiene) program. Analysis included deductive and inductive coding, member checking, and researcher memos that facilitated the development of emerging themes.
Results: Primary reasons for selecting a Bachelor of Dental Science degree included: expanding career opportunities, access to graduate education, prestige and status of the university, perceived credibility, in addition to family, cultural, and peer influences.
Conclusion: Findings reveal insights for educational institutions to better understand the possible factors attracting prospective students to a dental hygiene baccalaureate degree program. This information may also be useful for clinicians practicing with a diploma or associate degree who are considering additional education towards a baccalaureate degree.
Introduction
Dental hygienists in Canada are educated primarily through three-year diploma programs in approximately 33 post-secondary institutions across the country.1 Canada offers four dental hygiene degree-completion (DC) programs for dental hygienists who are practicing with a diploma. These DC opportunities are found at the University of British Columbia (UBC) (since 1992), the University of Alberta (since 2000), Dalhousie University (since 2008), and the University of Manitoba (since 2010). In addition to their DC pathways, UBC and the University of Alberta offer four-year, entry-to-practice (ETP) bachelor degrees in dental hygiene (since 2007 and 2017 respectively) for students with no prior dental hygiene education. According to the 2017 Canadian Dental Hygienists Association (CDHA) Job Market and Employment Survey, 21% of dental hygienists in Canada are practising with a bachelor's degree as their highest academic credential but only 6% hold a bachelor's degree specifically in dental hygiene.2
According to the American Dental Hygienists' Association (ADHA), there are 57 dental hygiene DC programs and 70 ETP bachelor degree programs in the United States.3 There has been a growing movement towards creating additional pathways aimed at advancing dental hygiene education over the past decade. The impetus for this movement stems primarily from a sense of responsibility to address the growing health complexities of the public through non-traditional and diverse practice settings, a demand for qualified dental hygiene educators, a need for dental hygiene research, and a desire to advance the profession by aligning with the educational models of other health professions.4,5
There is a high level of clinical skill development in dental hygiene diploma education; however, progress towards advanced theory is limited due to the length of diploma-level programs.4,5 This model of education, focusing on the development of clinical skills, provides limited opportunity to prepare dental hygienists for roles outside of private practice.4,5 The CDHA states that furthering one's education in dental hygiene depends on an individual's goals, aptitudes, and interests.6 Education beyond the diploma or associate degree level would be a natural next step for dental hygienists with a desire to enhance their professional expertise and academic qualifications, increase their knowledge and abilities, develop critical thinking and research skills, take a leadership role in the community, and explore varied career opportunities in non-traditional settings.6-8 The baccalaureate degree for entry into practice has been proposed in CDHA's 2009 Education Agenda4 as well as in a 2015 ADHA white paper on transforming the dental hygiene profession for the twenty-first century.9
Despite what is known about the outcomes of dental hygiene degree education, there is a limited body of research exploring the motivation for pursuing dental hygiene baccalaureate education from the student perspective. The few existing studies have focused on dental hygiene DC education and examined reasons why practicing dental hygienists holding diplomas or associate degrees returned to university to complete a bachelor's degree.10-12
Imai and Craig's mixed-methods survey on 27 dental hygienists who had graduated from UBC's dental hygiene DC program identified the following motivating reasons that diploma dental hygienists have for pursuing a degree: personal satisfaction (93%), increasing knowledge (85%), advancing career (56%), the status afforded by the degree (37%), and for graduate school entrance requirements (8%).10 Similarly, an older survey by Waring conducted on 189 dental hygienists in the United States also found that personal satisfaction (98%), increasing knowledge and skill (95%), career advancement (81%), and status of a degree (76%) were primary motivators for dental hygienists to complete their baccalaureate degree.11 A qualitative phenomenological study by Kanji et al. explored reasons why dental hygienists who first earned a diploma returned to university to earn their dental hygiene degree in Canada.12 Motivating influences shared by these participants included expanding career opportunities in dental hygiene, personal development and a desire for knowledge, remaining competitive, status and recognition, access to graduate education, and third-person influences involving instructors from dental hygiene diploma programs, family, and friends.12
Several North American studies that have investigated career outcomes of earning a dental hygiene degree clearly demonstrate that baccalaureate prepared dental hygienists have been more successful in securing employment outside of the clinical practice setting.13-15 From this research, such employment was found to include positions in education, public health, administration, research, and industry. Position papers and trends suggest that to work in more non-traditional practice settings and with patients exhibiting more complex chronic illness with comorbidities, dental hygienists should have a minimum of a baccalaureate degree to be prepared for expanded interprofessional roles and to deliver the comprehensive care needed for these diverse populations.4,16
There appears to be an absence of research which has investigated reasons for pursuing a four-year entry-to-practice dental hygiene degree. This gap in the literature informed a broad student retention study that explored former first-year students' experiences transitioning into a large university and throughout their first year of study at the UBC Bachelor of Dental Science (BDSc) program. Braxton and Hirschy's model of student departure informed this broader study's examination into factors influencing student persistence in higher education.17 Exploring student motivations for pursuing advanced dental hygiene education such as the BDSc degree is relevant as the student retention literature has associated students' educational motivations and career aspirations with their levels of engagement and persistence.17-20
Accessibility to the UBC BDSc program is comparable to the other dental hygiene diploma programs in British Columbia in regards to geographical location, the number of students admitted, and eligibility criteria for admissions (pre-requisite subjects and minimum grade point average); however, the financial commitment in the UBC program is higher due to its longer duration. Learning about what motivates students to select baccalaureate education, particularly when such a model is not required for licensure in dental hygiene in North America, can provide meaningful insights for educators, administrators, and professional stakeholders. The aim of this study was thus to explore reasons why students, with no prior dental hygiene education, selected a four-year Bachelor of Dental Science in Dental Hygiene (BDSc) degree at the University of British Columbia rather than a dental hygiene diploma program for entry into practice.
Methods
This qualitative narrative inquiry study examined former first year students' reasons for selecting a BDSc degree. This inquiry was part of a broader study on student retention that exploried students' experiences transitioning into a large university and throughout their first year of study in a BDSc program. Ethics approval was granted by UBC's Behavioural Research Ethics Board.
Since the researchers were interested in learning about the experiences of first year students in the BDSc program who did not progress to the second year of study, a purposeful sample of former first year students, who had been academically dismissed by UBC, was selected. A total of 30 BDSc students have been dismissed by the institution during their first year of study due to academic challenges since the program's inception in 2007 up to 2015. All 30 former students received an electronic letter of invitation sent by a third-party recruiter to participate; a follow-up invitation was sent two weeks later. Of the 30 prospective participants who met the inclusion criteria,10 former students volunteered to participate.
Clandinin defines narrative inquiry as the study of human lives to honor lived experiences that are storied into a narrative chronology.21 Twenty individual interviews were conducted on this sample of 10 former first year BDSc students. Participation was incentivized through an offering of a $50 gift card for each interview. Individual interviews were conducted at two separate times, approximately one week apart, with each former student. Both interviews were conducted by the same interviewer. Two interviews per participant facilitated the study of experience and the emergence of chronological and relational stories that are central to a narrative inquiry.21,22
Interviews were conducted in-person or through the telephone and ranged from 44 to 84 minutes each in length. The interview guide was semi-structured, and the questions were open-ended to ensure that space was provided to hear the voices of the participants and to facilitate storytelling.22 The interview questions were provided to the participants several days before the interview in order to reduce anxiety and to allow for some reflection time to provide more thoughtful responses.
With consent, interviews were audio-recorded and transcribed verbatim to facilitate the thematic coding of emergent themes. Narrative analysis involved an examination of former students' experiences related to temporality, place, and sociality.21 Participants' experiences were contextualized to time, physical environment, and their social interactions in their first year of study, and were accomplished through descriptive and in-vivo coding23 (deductive and inductive), member checking, and researcher memos. A codebook was developed outlining a protocol for which codes should be placed in the various thematic categories in order to ensure a consistent and rigorous approach.24 Transcribed interviews and subsequent interpretative summaries were given to the participants for review and to offer the opportunity to provide corrections and additional information. This process of soliciting participant feedback, termed member checking, serves as an important tool for minimizing the possibility of misinterpreting the meaning of what participants have said.22 Member checking and researcher memos also helped bracket researcher preconceptions, assumptions, and biases.22
Participant demographics (n=10).
Results
The participants varied in the cohort year in which they were enrolled as a first-year student at UBC, age at enrollment, prior education, parents' highest level of education, accommodation, employment status, financial aid required, and self-identified culture (Table I). Pseudonyms were created to protect participants' identities in their stories shared.
Five prevalent themes emerged from the narrative accounts regarding reasons for selecting the BDSc program at UBC: expanding career opportunities, access to graduate education, prestige and status of the university, perceived credibility, and family, cultural, and peer influences (Figure 1).
Emerging themes regarding motivating influences for selecting a baccalaureate degree dental hygiene program.
Career Opportunities
All participants expressed that they believed earning a BDSc degree would increase career opportunities outside of the traditional clinical practice setting. At the time of application to the BDSc program, participants seemed to have a strong conviction through their own readings and discussions with practicing dental hygienists that a bachelor's degree would be required to explore career paths outside of the private dental practice. Participants were fully informed that a dental hygiene diploma remained the credential for practicing dental hygiene in Canada but desired to invest additional time, energy, and finances into earning an advanced degree due to their career aspirations.
Although research, public health, and independent practice were mentioned as career options of interest, the strongest interest pertained to teaching. For example, Lindsay commented: “I wanted the degree in dental hygiene because it would lead to more career opportunities for me than a diploma.” Similarly, Ashley stated: “I found that with the degree program, you could move higher…. if I wanted to be a teacher, if I wanted to do something that's government related…” Likewise, Kristine expressed: “I wanted to pursue a degree because… I want to work in other areas other than a private practice…. like research and teaching. When I did some research, I learned that for other areas of dental hygiene… you need a degree so I think for myself having that opportunity and option to go higher was the reason I wanted to pursue a degree over a diploma.”
Access to Graduate Education
Strongly connected with career aspirations, a second theme to emerge was access to graduate education. Several participants had a strong interest in pursuing a graduate degree in the short-term future, and most participants wanted that option to be at least available to them. Participants shared the following desires: “A degree would lead to an easier transition to a masters or a PhD… I wanted to keep that door open” (Ashley), “I could pursue higher education if I wanted to in the future” (James), and “I knew that getting a bachelor's degree was a prerequisite for getting a graduate degree later on” (Jessica).
Prestige and Status
The prestige of attending UBC and earning a university degree was another prominent theme that the former students explicitly highlighted. Participants often used the following words to describe UBC: “top university,” “well known,” “reputable,” “recognizable,” and “highly ranked.” The prestige attached to earning a degree from a top-ranked well-known university was noted by all: “UBC is one of the top universities in Canada… and in the world… I wanted to be part of that community” (Natasha). “It is a well-known university, who wouldn't want to go there… being part of the name of UBC” (Shora). “Everyone wants to apply to UBC; everyone dreams about getting accepted… it's such a prestigious school” (Kristine).
Several participants also shared their belief that finding employment in any practice setting and networking among professionals would be easier for a graduate from a well-known university due to the institution's reputation. For example, Shora expressed: “… going to a known university… considering future prospects when you try to get a job, they [potential employers] would obviously see that ‘oh, she's from UBC’ and there's value in that.” Others similarly stated: “… the recruitment rate [from future employers] for people who have UBC on their resume is probably a lot higher than other schools” (Ashley) and “UBC also has a good reputation around the world so it would be easier to find a job” (Lindsay). The former students felt purpose in working hard investing additional years to earn a dental hygiene degree from a well-known prestigious university in order to realize the personal validation, societal acceptance, and career opportunities that they were seeking.
Perceived Credibility
A sense of pride and perceived credibility attached with earning a dental hygiene degree compared with a dental hygiene diploma also resonated among all 10 former students. The undertone that members of society and the profession view those with a higher credential in high esteem was prevalent. The former students were proud that they attended UBC and were motivated by the societal recognition and credibility that they perceived the status of a degree to offer ubiquitously. They felt society bestowed those who have earned a degree with additional merit. When describing why they selected the BDSc degree, many participants pointed to the perceived lack of credibility and recognition awarded to a dental hygiene diploma. Participants used words such as “settle,” “only,” and “just” to describe their feelings about earning a diploma. For example, Yoon stated: “Others will respect you more with a degree” and Aya expressed: “I felt like a degree defines a successful person I believe in education.” Jessica shared a similar sentiment: “If I'm capable of getting a degree, why would I settle for a diploma?” Kristine, whose parents had emigrated from Vietnam in order to provide their daughter with a better life, also shared: “When you're applying for a job, a degree counts more than a diploma… it [a degree] is given a higher preference in my opinion… compared with someone who says “oh I have a diploma,” people assume that you don't have as much knowledge… “
Family, Cultural, and Peer Influences
The extent to which participants' decisions to apply to UBC and pursue a BDSc degree was influenced by family and peers was considerable and reverberated throughout the narratives. Childhood stories about the importance of education featured prominently. All 10 participants recalled vivid childhood memories about the importance of valuing education to the extent where visualizing themselves as university graduates became part of their social norm in their households and part of their pre-written stories for their future selves. Three participants whose parents did not have post-secondary education recalled strong, consistent messages to strive higher, particularly for those families who immigrated to Canada who made significant sacrifices and desired a better future for their children. For example, Kristine shared the following story: “Both of my parents are Vietnamese immigrants…born in Vietnam into affluent families… once the Vietnam War broke out, both families lost everything… in Vietnam, my mother was able to teach elementary school kids… they immigrated to Vancouver… my Mom ended up working as a bottle sorter at a recycling company.”
The financial hardship that some parents experienced served as a strong impetus to pursue higher education to foster a different more lucrative lifestyle. Parents had reaffirmed throughout the primary and secondary school years that attending a well-known university would lead to more rewarding career opportunities. Yoon expressed: “From their [parents] eyes, graduates from UBC were retaining more career options than any other schools.” The influence of parents was also prevalent in a comment from Aya: “With pursuing this degree, I would be able to keep my parents happy too.” Career aspirations for Kristine also involved influences from her culture: “Growing up in an Asian household, they [parents] have pretty high standards for their kids. Coming from a family where my parents emigrated from Asia, they [parents] worked really hard to build a future for their kids that they might not have had.”
Similarly, Yoon, who identified as a Chinese-born Canadian, attributed pressure felt from her parents to attend a reputable university to her Asian culture: “My parents considered UBC to be the Harvard of British Columbia… I did not have much of a choice… there was always this huge pressure on me to do well.”
In thinking back to secondary school, participants recalled that many of their best friends from the same geographical area were applying to university and many were headed to UBC. There was a strong desire to maintain these friendships as well as some pressure to keep pace with expectations established in early childhood.
Other Motivating Influences
Other less prevalent reasons for applying to UBC's BDSc program that surfaced from some participants' stories included a desire for more knowledge and self-validation. Three participants were attracted to the four-year dental hygiene degree program because they desired the additional knowledge they expected to acquire in a program of longer duration. Finally, part of the motivating reasons for applying to UBC for Kristine and Jessica included a search for self-validation. Both expressed that they wanted to prove to themselves and to their families that they were capable of exceling in what was perceived to be a challenging top university. Kristine stated: “I wanted to prove that I can achieve higher learning and prove that I can get into one of the top 20 schools in the world.” Similarly, Jessica said: “I wanted to show that I was capable of achieving anything.”
Discussion
This study makes a novel contribution to the literature as it explores motivators for selecting a four-year ETP dental hygiene baccalaureate degree program intended for applicants with no prior dental hygiene education. Results from this study stem from a broader study on student retention focusing on their experiences throughout their first year of study in a dental hygiene baccalaureate program at a large university. The rationale for selecting former first-year students who did not progress in their dental hygiene studies due to academic dismissal was to provide program administrators with unique insights into the challenges experienced by BDSc students that can inform institutional policies and practices to better support entering students. The motivating reasons for selecting a dental hygiene degree from this population of former first-year students who were institutionally dismissed aligns closely with existing literature about motivators on students who have been successful in their dental hygiene degree-completion (DC) studies.17-20 Findings from the larger study of first-year BDSc student experiences will be discussed in a future paper.
All 10 participants in this study expressed a desire to earn a dental hygiene bachelor's degree to broaden their prospective career opportunities. Pursuing higher levels of dental hygiene education to expand career options outside of clinical practice has been a dominant theme across past research in which study participants have expressed interest in seeking employment in such areas as education, public/community health, residential care, administration, industry, and research.8,10-12 Several studies have investigated practice outcomes of earning a dental hygiene degree and have clearly demonstrated that dental hygienists with a baccalaureate degree are more likely to practice in educational institutions, government health authorities, professional associations, regulatory bodies, industry, and graduate degree studies.13-15 Most recently, Kanji and Laronde's 2018 study on career outcomes of dental hygiene baccalaureate education demonstrated that 45% of the respondents were employed in non-clinical practice settings.15 In addition, 35% of the respondents indicated that the bachelor's degree was required for employment, and 86% stated their degree was considered an asset.15
Participants in this study also expressed an interest in pursuing graduate studies and recognized that a bachelor's degree would serve as a bridge for master's and doctoral programs. Access to graduate education has been previously documented as a motivating influence in prior related research in which participants expressed interest in pursuing a master's degree to further broaden and deepen their knowledge base and open additional career opportunities.8,10,12 Kanji and Laronde found that over 25% of UBC BDSc graduates have pursued graduate education in the areas of adult education, business administration, dental and craniofacial sciences, and public health.15 Adopted from earlier student retention theorists, Braxton and Hirschy included several student entry characteristics to help predict student persistence in higher education and incorporated motivational attributes of individuals which can shape students' levels of commitment.17 They posited that students' commitment to a particular program or institution is influenced by their career and academic aspirations. A student who expects to pursue doctoral studies, for example, is more likely to complete an undergraduate degree.17
The prestige of attending UBC and the perceived social status and credibility awarded to earning a degree, particularly when compared to a dental hygiene diploma, emerged as a motivating influence for pursuing a BDSc degree. This finding has also been documented in Imai and Craig's study in which 37% of survey respondents cited the status of the degree as a very important motivator.10 Dental hygienists in Kanji et al.'s phenomenological study had also expressed frustration at the lack of recognition that other health professionals and the public bestow towards a dental hygiene diploma.12
Mirowsky and Ross state that education forms a unique and powerful dimension of social status.25 They assert that educational attainment marks social status at the beginning of adulthood, preceding and therefore influencing other acquired social statuses such as occupational status, personal and household income, and freedom from economic hardship. Education helps develop human capital which Mirowsky and Ross defined as the productive capacity developed and embodied within human beings.25 Similarly, Bourdieu's theory of social reproduction posits that societal structure determines an individual's place in society, asserting that education can be a successful mechanism to reproduce social inequalities.26 The structure and distribution of the different forms of capital can represent the structures of the social world and may manifest as educational achievements which can influence social status.26
Approaching status from a profession's lens, Clovis' foundational article discussing attribute theories and the professionalization of dental hygiene declares that the amount of education required and the extent of specialization are central to achieving professional status.27 Establishing baccalaureate dental hygiene programs in universities will further contribute to society's understanding that the degree of specialization in dental hygiene is high and will garner further recognition that dental hygiene remains the only health profession dedicated to the prevention of oral disease.4,27 Whether considering an individual's perceived credibility in society, the impact of education on human capital, or the professional status of an occupation, the level of educational attainment and its impact on status appears to be a powerful motivator for pursuing advanced education.
Family and peer influences emerged as significant motivators for selecting the BDSc degree at UBC. Messages stemming from participants' parents since childhood about the importance of education and the opportunities that advanced education would enable reverberated throughout the former students' narratives. Within the context of dental hygiene, the only other study that documented family and peer influence as a motivator for pursuing post-diploma DC education was Kanji et al. who noted that encouragement from instructors from dental hygiene diploma programs, parents, and close friends profoundly influenced decisions to apply for DC education.12 Whereas in some cases, participants in their study were motivated to earn a bachelor's degree because everyone else in their family had earned degrees, other participants desired to be the first in their family to achieve this educational milestone.12
Buddel's narrative inquiry on first-generation university student persistence also discussed how parents and grandparents storied the value of higher education and future roles as university students in the lives of their children, integrating a family narrative towards pursuing a university degree.28 Students were deeply affected by their families' financial struggle to survive which served as a powerful impetus to break free, be different, and want more through pursuing higher education.28
Pressure from parents to attend and excel in university felt particularly strong for three participants in this study who identified as Chinese or Vietnamese. They expressed that being raised in an Asian household, attending university was extremely important since their parents sacrificed so much in immigrating to Canada for a better life for their children. This message of sacrifice and the value of education permeated throughout their household habitus. These narratives closely correlate with other studies exploring Asian students' experiences in higher education which demonstrate that Asian students are feeling excessive pressure from parents and peers to excel academically.29-31 Research that has explored the Model Minority Stereotype (MMS), which labels Asian Americans as the model of success, speaks to the extent to which Asian Americans themselves may have internalized the MMS and its potential harm to their mental health demonstrating that the MMS and associated pressures to excel academically have been significant sources of chronic stress for students.29-32
Other less prevalent reasons for applying to the BDSc program included a desire for more knowledge. The desire for more knowledge acquired in a degree program of longer duration compared to a dental hygiene diploma is consistent with the findings in Imai and Craig's survey in which 85% of survey respondents noted to increase knowledge as a very important reason for pursuing a BDSc degree.10 Kanji et al. also reported that dental hygienists practising with a diploma returned to university to complete their bachelor's degree to deepen and broaden their knowledge within and outside of dental hygiene theory.8,12
In 2015, the CDHA published the Canadian Competencies for Baccalaureate Dental Hygiene Programs outlining the additional educational competencies that dental hygiene students are expected to demonstrate in a baccalaureate dental hygiene program as compared to a diploma program. These additional competencies include: research use, policy use, disease prevention (population level), and leadership.33 Studies that have investigated ability-based outcomes of earning a dental hygiene baccalaureate degree have reported that dental hygienists feel they have acquired additional knowledge and feel more competent in reading and appraising research, using research to inform practice decisions, academic writing and communication skills, and interprofessional collaboration as a result of their DC education.7,8 Existing research on motivators and outcomes of dental hygiene baccalaureate education should serve as impetus for further dialogue within educational institutions, professional associations, regulatory bodies, and government about offering additional opportunities for dental hygienists to advance their education.
Self-selection bias may have been a limitation in this study. Students with the greatest perceived resentment towards the program or university may have opted not to participate due to negative feelings of anger and embarrassment. This study also reports results from a single institution. Future research can integrate student motivators for selecting baccalaureate education across Canadian and American dental hygiene baccalaureate programs to collect more national data on rationale for selecting dental hygiene education programs beyond the entry-to-practice requirements. Investigating motivators for pursuing graduate level dental hygiene education and associated practice outcomes also warrant investigation. Conversely, barriers to pursuing advanced education in dental hygiene appear not to have been explored.
Conclusion
This study makes a novel contribution to the dental hygiene literature by exploring motivating influences for selecting a four-year entry-to-practice BDSc degree at a Canadian university from the perspective of former first-year BDSc students. Results from this qualitative narrative inquiry strengthen the understanding of reasons for advancing one's dental hygiene education: career opportunities outside of the clinical practice setting, access to graduate education, prestige/status of earning a degree, perceived credibility, and family, peer, and cultural influences. These findings provide insight for dental hygiene educational administrators to better understand what may motivate prospective students to their baccalaureate programs. This information may also prove useful for those dental hygienists practicing with a dental hygiene diploma or associate degree who are considering additional education.
Footnotes
Zul Kanji, EdD, RDH, is the Dental Hygiene Degree Program Director, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada.
Michelle Pidgeon, PhD, is an associate professor, Faculty of Education; Michelle Nilson, PhD, is an associate professor, Faculty of Education; both at Simon Fraser University, Burnaby, BC, Canada
This manuscript supports the NDHRA priority area: Professional development: Education (education models).
- Received September 27, 2018.
- Accepted March 24, 2019.
- Copyright © 2019 The American Dental Hygienists’ Association
