Abstract
Purpose: The impact of the COVID-19 pandemic on healthcare providers includes physical, psychological, financial, and childcare issues. The purpose of this qualitative study was to explore the experiences of dental hygienists returning to clinical practice after the March 2020 closure due to the COVID-19 pandemic.
Methods: A qualitative phenomenological research design was used with virtual focus groups. Clinical dental hygienists who had worked a minimum of 3 days a week prior to dental practice closures in March 2020 and had returned to work in May 2020 were invited to participate through purposive sampling on dental hygiene social media sites. Demographic data was collected prior to a one-hour focus group session. Two investigators independently analyzed and coded the data using a qualitative data analysis software program. The themes identified were used to generate a description of the major findings.
Results: Data saturation was achieved with (n=35) participants for a total of 13 focus groups. Most participants were female (89%), and the average age was 40 years. The following major themes were identified: physical issues; emotional; adherence to infection control protocols; fear of contracting/transmitting COVID-19; financial stress; our career was marginalized; and let’s get back and make money.
Conclusion: Dental hygienists experienced similar physical and mental health stressors as other health care professionals upon returning to work during the COVID-19 pandemic, however dental hygienists also reported feeling marginalized and undervalued. Results from this study suggest that dental hygienists need both personal and workplace support to manage the issues resulting from the COVID-19 pandemic in order to retain them in the workforce.
- COVID-19
- SARS-CoV-2
- dental hygienists
- dental hygiene workforce
- anxiety
- personal protective equipment
- career satisfaction
Introduction
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads primarily through droplets of saliva or discharge from the nose when an infected person coughs or sneezes.1 While most people infected with COVID-19 feel mild to moderate respiratory illness and recover without requiring special treatment, a small percentage will be hospitalized with severe symptoms.1 According to the World Health Organization (WHO), as of March 2022, there were over 6 million deaths worldwide, and 476 million cases of COVID-19.2 In comparison to the general public, healthcare workers (HCWs) interact directly with the patients who may be asymptomatic or in the 14-day incubation period before symptoms are manifested putting them at high risk for contracting COVID-19.3 Early in the pandemic, dental hygienists were identified as belonging to one of the highest risk non-hospital occupation groups.3 The Canadian Center for Occupational Health and Safety also classified dental hygienists as one of the highest risk occupations with a O*NET (Occupational Information Network) score of 100 based on frequency of exposure to disease/infection, physical proximity to other people, working indoors, and need for protective equipment.4
Research has shown that COVID-19 is associated with mental health challenges among HCWs.5–7 The prevalence of depression among health professionals ranged from 22.8% to 38% in meta-analyses of the research literature.5–7 Prevalence of anxiety has ranged from 23.2 to 33%, with stress measured to be high (45%) in healthcare providers.6 Healthcare workers reporting physical symptoms of COVID-19 have also reported high rates of PTSD (post-traumatic stress disorder), stress, anxiety, and depression.5–7 Healthcare teams recorded high depression and anxiety rates during the height of the pandemic as a result of working with infected individuals.5–7 Since HCWs are on the front lines and at high risk for COVID-19 infection, the impact of having a large percentage of HCWs experience mental disorders, burnout and desire to leave the health care profession affects society as a whole. In addition, the fear of infection among HCWs can lead to ineffective care, potentially lowering patient care outcomes.8 Other stressors have included fears of bringing the virus home and infecting their children.9
The physical health of HCWs has also been affected by COVID-19.9 A systematic review of the literature and meta-analysis published in 2021 showed that HCWs were at considerably higher risk for contracting SARS-CoV-2 than the general public, with nearly 52% testing positive.10 As members of the health care professions, dentists and dental hygienists are among the groups at risk of contracting COVID-19. However, in early 2021 the prevalence of testing positive or being diagnosed with COVID-19 was shown to be considerably lower than other HCWs with dentists reporting 6.4% and dental hygienists reporting 3.1%.11,12 Common COVID-19 symptoms identified amongst HCWs were fever, myalgia, and anosmia (loss of sense of smell),13 however 15% of HCWs reported severe complications with 1.5% dying from the disease.10 In addition, the PPE needed to mitigate risk of infection has resulted in physical adverse events such as headaches, chest discomfort, dyspnea, exhaustion, and cutaneous manifestations with skin damage, particularly on the bridge of the nose, ears, cheeks, and chin.14
Healthcare workers also experienced challenges in caring for their children due to closure of schools and difficulties in accessing child care.9 Child care shortages in turn strained the health care system due to increases in work absenteeism among HCWs15 with one study reporting that 50% of HCW households were unable to find child care.9 Issues related to childcare and at-home schooling resulted absenteeism among healthcare workers.9
Experiences of HCWS during the COVID-19 pandemic have been widespread and multifactorial in nature. In a study among dental hygienists in the United States (US), findings showed elevated symptoms of anxiety and depression.12 Dental hygiene requires a close distance between the patient and the clinician, elevating the risk for contracting COVID-19 and future emerging transmissible diseases.4 Understanding dental hygienists’ personal experiences are needed to identify the workplace support and policies needed for dental practices’ to retain dental hygienists in the workforce. There is currently limited information regarding the psychological, physical, and lived experiences of dental hygienists following the closure of dental practices in March 2020 and after returning to work in May 2020. The purpose of this study was to explore the experiences of dental hygienists returning to clinical practice during the COVID-19 pandemic.
Methods
A qualitative, phenomenological research design was used with a purposive sample of dental hygienists employed in clinical practice settings for this MCPHS Institutional Review Board exempt study (MCPHS IRB040721B). A purposive sample of dental hygienists was recruited to participate with a target of a minimum of 30 participants. Literature suggests data saturation is reached after 12 interviews; 30 participants set as the minimum sample size to ensure saturation.16 The inclusion criteria included clinical dental hygienists who have provided patient care for at least 3 days/week prior to the closure of dental practices in March 2020 and following the reopening in May 2020. Respondents who did not meet the criteria were excluded from participation.
Instrument
The data collection instruments included a demographic survey (11 items) to gather the characteristics of the participants and an interview guide. The interview guide consisted of one open-ended question, “Tell me about your experience in clinical practice since returning to work after the closure of dental office in the spring of 2020?” with prompts to encourage participants to expand on responses. The focus groups were held via a web-based videoconferencing platform, (Zoom; San Jose, CA, USA) and could be accessed from multiple devices including computers, tablets, and cell phones. The virtual format allowed for the recruitment of a national sample.
A pilot focus group was conducted with four dental hygienists to obtain feedback on the virtual process and clarity of the open-ended question. The researcher served as the facilitator of the focus group, which lasted approximately one hour. No revisions were made to the procedure or interview guide based on the pilot focus group.
Procedures
Participants were recruited via social media websites and dental hygiene groups and contacts. The interested participants who met the inclusion criteria provided their email to the principal investigator (PI) via an online survey platform (Qualtrics; Provo, UT, USA). Interested participants were polled regarding availability and were then sent log-in information for the assigned focus group. Invitation reminders were sent to the participants via email; participants were able to choose to opt-out of using their webcam and join the focus group with audio only. Participants could also choose a fictitious name when joining the focus group session to provide confidentiality.
At the beginning of the focus group session, participants received a link to obtain their consent to participate. Once consent was obtained, participants were taken to the short demographic survey. Verbal consent to participate was confirmed and each participant was given a number to maintain confidentiality. The moderator/PI reviewed the ground rules at the beginning of each focus group. The moderator asked one open-ended question, “Tell me about your experience in clinical practice since returning to work after the closure of dental office in the spring of 2020?” and ensured each participant had an opportunity to respond without interruption. Prompts were used to encourage participants to elaborate on their answers as needed. The focus groups were conducted in June 2021 and lasted approximately one hour and were audio recorded. No incentives were provided for participation. All audio recordings were transcribed within 48 hours. The data was prepared for analysis by initial transcription of the audio recorded sessions verbatim using a transcription software program (TranscribeMe; San Francisco, CA, USA) and was verified by the PI. Each recording was replayed multiple times to check for accuracy.
Analysis
An inductive approach to analysis was taken to allow themes to emerge from the data. The transcripts were read multiple times prior to initial coding. In vivo coding was utilized to focus on the participants’ words to minimize interpretation. The initial coding process identified common word(s) or short phrases. Patterns from the initial coding were used to create categories names and the coded segments were then grouped into themes.16 The themes were reviewed to merge similar ideas, remove those with limited data, and identify any sub-themes. The PI conducted the qualitative analysis process manually and a second investigator, who did not participate in conducting the focus groups, independently analyzed and coded the data using a qualitative data analysis software program (MAXQDA; Boston, MA, USA). Any discrepancies between investigators were reviewed, and agreement reached before finalizing the themes. The themes identified were used to generate a description of the major findings. Quotations from participants were used to strengthen and present the findings.
Results
Data saturation was achieved with (n=35) participants for a total of 13 focus groups. Focus group size varied from 2 to 5 participants as some who had confirmed attendance did not join as arranged. Most participants identified as female (89%) with the majority being from California (43%, n=15). The sample was ethnically diverse with 40% identifying as White, 31% Black or African American, 23% Hispanic, 3% Asian and 3% Native Hawaiian or Pacific Island. Settings. Sample demographics are shown in Table I.
Respondent demographics (n=35)
The qualitative data analysis generated themes related to the research question: “What are the experiences of dental hygienists in clinical practice due to COVID-19 since returning to work after the spring 2020 shutdown of dental offices?” Seven major themes emerged from the data: physical reaction; emotionally harmful; are we following some kind of protocol?; I didn’t want to bring it home; stressful financially; our career was marginalized; and let’s get back and make money.
Theme 1: Physical Issues
This was the theme identified most frequently in the participant responses. The range of physical issues included headache, exhaustion, breathing issues, overheating, light-headedness, neck pain, and skin issues. Quotes to illustrate this theme included:
“When I first started wearing the PPE, the N95s were just giving me a terrible headache. I would get out of work feeling exhausted.” (P26)
“…had a raw callus on my nose right here. My ears were sore. I did get those bands that kept it off my ears. That saved me. I ended up getting this little plastic mask that I wore under my mask that kept the mask off my face. It helped because I was jutting my jaw forward, which was then giving migraines every day.” (P13)
“…wearing more things on my head, I noticed that caused a lot more pain on my neck. So, wearing a shield and more material on my head and another mask, it exacerbated my rosacea, so my rosacea was just out of control. And my skin, it looks like I was going through puberty with so much acne.” (P26)
Theme 2: Emotional
Discussion of the emotional impact was also a prevalent theme in the data. Anxiety, nerve wracking, stressful, fear, scared, and emotionally harmful were all terms participants used to describe this theme. Sample quotes to illustrate this theme included:
“And we were relying on patients’ honesty if they’re not sick or not or if they caught something. So, it was very--psychologically, anxiety is really, really, up.” (P22)
In the quote that follows, the participant is quite emotional about not being prepared to go back to work and goes on to express her anxiety about returning to the workplace.
“Oh, God. I’m not mentally prepared for this. So, I don’t know. I had a lot of anxiety going back and even, in the beginning, working for the first few weeks, I had a lot of anxiety.” (P14)
“It was emotionally harmful, physically harmful. There were moments where I wanted to cry while working because I just felt ill-prepared. And no matter how many [inaudible] want to talk about it, emotionally, I wasn’t there.” (P12)
“..fear of the unknown at the very beginning was really, really tough.” P22)
Theme 3: “Are we following some kind of protocol?”
This theme encompassed ideas around access to personal protective equipment (PPE), safety, and following infection control protocols. The dimensions of the theme ranged from participants who reported adequate PPE and training on protocols following recognized guidelines to those who had to reuse PPE for days or even weeks and were not trained on protocols prior to or upon return to work. Examples of quotes that illustrated this theme included:
“Nobody really knew what we should be doing to prevent the transmission of the COVID-19. I would say that everybody had a different view of COVID-19, so that even made the office a little bit scarier to work in.” (P28)
“They just told me, “Oh, okay. One mask per day,” and then we started-- that just started getting real-- they wouldn’t let the gloves be in our room anymore and things like that because they wanted to just narrow the amount of things we were able to use per day.” (P29)
“So pretty much we just had the N95 masks, which we had to reuse throughout two weeks. And then we only had-- I only had two gowns to use in a span of two weeks, so I had to reuse the same gown.” (P10)
“I wanted to make sure I was safe [at?] the office. And I really didn’t feel as safe when we had the hygienist using the cavitron without any-- and I said, “It’s not just for us. It’s for the patient because if that patient has COVID and you use the cavitron, the next patient could potentially be at risk to catch the COVID-19.” And they were like, “Well, I still want to use it anyways.” (P28)
In addition to those who had issues with PPE and protocol, some participants reported offices providing training and being prepared. Here is one example of this perspective:
“My office did a phenomenal job. I walked in the door; every single PPE thing was available to me when I walked in the door on May 1. That was the only thing that made me feel a little better. They had everything ready. And all of the procedures that we were going to then start, ready to teach us and let’s go.” (P13)
Theme 4: Fear of contracting/transmitting COVID-19
Participants in the study shared their concerns about the fear of contracting COVID-19 and taking it home to their family and loved ones. These are some sample quotes from participants:
“I did experience some fear. That was my initial-- my initial reaction was fear of contracting COVID.” (P26)
“Am I going to put my family and friends at risk because I am seeing patients? We don’t even know if they have COVID. There is no testing that’s being done. They could be asymptomatic, and they can pass it on to me. I’ll pass it on to my friends and family.” (P10)
“I don’t want to bring this home to my family.” Like I said, my mom watches my daughter, but my mom also has cancer, so…” (P3)
“My husband is asthmatic, so I was like, “I can’t bring it home. I don’t want to bring it home.” (P27)
Theme 5: Financial stress
Some participants reported financial challenges with a few noting they were covered by unemployment and finances were not an issue. The following are sample quotes associated with the financial stresses:
“So the entire thing was very stressful, both emotionally and financially, and I have since not opened my business and it was a very disappointing experience for me.” (P15)
“I did not have any unemployment come in, so I was affected that way. But thankfully, I have a good support system.” (P16)
A sample of a quote from a participant who did not have financial challenges:
“My employer was really good about getting us onto unemployment, so I didn’t struggle financially” (P23)
Theme 6: Career was marginalized
Another theme that emerged was related to our profession and its value. Lack of being considered an essential worker creating feelings of being marginalized were shared. The following quotes illustrate some of the impressions shared by participants for this theme:
“I felt like our career was marginalized through all of this.” (P13)
“It also felt like we were very dispensable.” (P12)
“I think that our profession has been underappreciated, undervalued, and so hopefully, these dentists can see if a pandemic happens, we still need to treat the members of our team the same.” (P29)
“…we didn’t have a standard of care for ourselves. There was none. It was, “Well, are you going to do it?” Your dentist is saying, “Do it.” There was no outlined plan, really, for us. It is, “This is what this office is doing,” and so that’s why I feel like we just need more governing of ourselves so we can tell you what we’re going to do. I’m going to tell you what I’m going to do. I’m going to tell you my fee, and I’m going to tell you if I’m going to do that or not. Not you’re going to tell me because I’m the professional, right, of hygiene. So that’s where I feel COVID also exposed the lack of governance that we need over ourselves so we’re not put in these vulnerable positions where I’m getting exposed if I don’t want to be.” (P29)
Theme 7: Let’s get back and make money
The last theme related to dentists focusing on productivity upon re-opening of their dental practices. Examples of quotes relating to this theme included:
“I really feel that the end game for our entire field was, “Let’s get back and make money.” And that’s a terrible place to be.” (P13)
“It hurts my heart, it’s very disheartening because I’m all about bringing money to the practice. I want to make you money, but I want to do it the right way. And I don’t feel like we were given that choice.” (P13)
“You want to overexpose me and you don’t care. And they were getting loans to stay open, PPP loans, and charge this, charge that, and then they asked to dock our pay for six weeks.” [P29]
Additional sample quotes for each theme can be found in Table II.
Themes and sample quotes
Discussion
Dental hygienists returning to work after closure of dental practices in March 2020 during the COVID-19 pandemic shared a wide range of experiences. Many of the themes that emerged in the focus groups were similar to research with other HCWs, however there were also findings relatively unique to dental hygienists. The theme related to the physical effects of the return to work ranged from overheating due to the enhanced PPE, to headaches, trouble breathing, lightheadedness, fatigue, and skin damage. The physical effects among the participants in this study were consistent with the literature among HCWs, particularly in regard to body heat, headaches, dyspnea, and skin damage.8,14,17 Feelings of being lightheaded from wearing the PPE was not a finding reported in previous literature of HCWs. This may in part be because hospital workers such as nurses are more accustomed to wearing N-95 masks and enhanced PPE for patients with infectious disease in isolation or critical care units and most likely are not wearing magnification loupes and lights.
The second theme related to emotional impact in returning to work during the pandemic was similar to those reported in the literature on mental health among HCWs during the COVID-19 pandemic and included high anxiety, stress, depression.5–7,17,18 Reports from a nationwide survey of dental hygienists in the US conducted in 2020 found elevated stress and anxiety levels among practicing clinicians.12 However, the individual comments from the participants illustrated the lived experiences of dental hygienists in a way that statistics cannot convey.
Participants reported concerns about following appropriate infection control protocols and having access to adequate PPE. These findings mirrored the national survey of US dental hygienists where the majority (99.1%) reported that while enhanced infection prevention or control efforts due to the pandemic were in place, PPE use and the availability of supplies were a significant concern amongst clinicians.11 A similar national survey conducted among dentists in the US found that enhanced infection control procedures along with the optimal use of PPE decreased over the duration of the data collection in 202019 which may have contributed to some of the concerns expressed by the participants in the current study. Dental hygienists’ experiences seemed to be consistent with the significant shortages of PPE for HCWs with at least one piece of PPE being unavailable or single-use PPE being reused even in intensive care units.20 Literature focused on HCWs suggests that having adequate resources and up-to-date, accurate information for mitigation of COVID-19 was a protective factor for mental health amongst health care professionals.7 A similar approach should be taken in the dental community to better support and retain dental hygienists and other dental staff members in the workplace.
Fear of contracting and/or taking COVID-19 home to family members was a theme that emerged among the study participants. This concern has also been reported among HCWs in addition to an international sample of dentists and dental hygienists where it was shown to have an impact on psychological distress and anxiety levels.5,7,21,22 The range of mental health effects of the fear of contracting and transmitting COVID-19 among oral health care providers needs further investigation.
The theme related to financial concerns found amongst the study participants was less evident in most literature reporting on challenges HCWs faced during the pandemic. However, it is interesting to note that in the US Department of Labor’s employment report for April 2020 immediately following the suspension of non-essential health services, employment in health care declined by 1.4 million with the highest number of job losses reported in dental offices (503,000) followed by physician offices (234,000).23 Several participants in this study reported being unable to obtain to unemployment benefits and it is unknown how widespread this problem was among those who were laid off. The American Dental Association (ADA) reported the impact on dental practices was an average loss of 18% of net income from 2019 to 2020 due to practice closures and a reduction in the number of hours worked.24 The average amount dentists received in federal government relief was reported to be $95,000.24 In other health care professions affected by the discontinuation of elective procedures and preventive care during the closure, declines in revenue/income and challenges in financial recovery have been reported.25–28
The theme related to feeling one’s career (dental hygiene) was marginalized appears to be a new finding which needs further research. A survey of allied health professionals’ perceptions regarding whether their profession was essential showed audiologists gave the lowest ratings for their profession being essential followed by speech-language pathologists, physical therapists, and occupational therapists.28 The personal and professional impact of certain health care professions being designated as ‘non-essential’ during the pandemic will be important to investigate to understand how it may affect the professional identity, intent to stay in the profession, and may even affect those considering entering the profession.
The final theme focused around returning back to work following the dental office closures in March 2020 to “make money” has not been previously reported in the literature. This may be because dental practices are different than settings of many other health care providers. Many dental practices are still owned by individual dentists rather than large corporate entities. While data gathered by the American Dental Association showed only 30% collections in May 2020 as offices began to re-open after closure, the rebound was fairly rapid, returning to 65% in June 2020 and by October 2021 total collections were over 90% of pre-pandemic levels.29 A focus on productivity at a time of great anxiety and stress among dental hygienists and other staff resulted in a failure to provide the support needed to adapt to the major changes brought about by the pandemic. It was anticipated participants would report school closure and shortages in childcare, would result in increases in work absenteeism and inability to return to work among healthcare providers.9,15 However, this was mentioned by only three of the participants. This may be in part because only about one-third of participants were in a traditional childbearing age group.
Limitations in this study included purposive sampling which limits the ability to generalize the findings. However, the links found to the existing literature lend support to the qualitative findings. In addition, the sample was more diverse in terms of gender and ethnicity/race than the general population of dental hygienists. Although efforts were made to recruit a more balanced national sample, those self-selecting to participate were from a limited number of states. The timing of the study during the summer of 2021 and the options for focus group meetings times could also have limited participants’ availability.
Conclusion
This qualitative study allowed dental hygienists to provide in-depth descriptions of their experiences upon returning to clinical practice during the COVID-19 pandemic. While dental hygienists experienced similar physical and mental health stressors to other health care professionals, dental hygienists reported feeling marginalized and undervalued. Results from this study suggest that dental hygienists need both personal and workplace support to manage the issues resulting from the COVID-19 pandemic to retain them in the workforce.
Footnotes
This manuscript supports the NDHRA priority area, Professional development: Occupational health (career satisfaction and longevity).
- Received December 11, 2021.
- Accepted May 4, 2022.
- Copyright © 2022 The American Dental Hygienists’ Association
