An interprofessional education initiative between students of Dental Hygiene and Bachelor of Science in Nursing.
Introduction: Interprofessional education (IPE) is defined as occasions when two or more professions learn about, from, and with each other to improve collaboration and the quality of care. Nursing and dental hygiene students at George Brown College were brought together in an IPE initiative to learn about, from, and with each other in regards to the overlapping roles they share in oral health and blood pressure monitoring. The World Health Organization (WHO) has long advocated for "multiprofessional" education among undergraduate healthcare students to build "the skills necessary for solving the priority health problems of individuals and communities that are known to be particularly amenable to team-work". Discussion: The discussion will present developments the Ministry of Health and Long Term Care (MOHLTC) in Ontario, Health Force Ontario, the Registered Nurses Association of Ontario (RNAO) and the Office of the Chief Dental Officer (OCDO) are making to improve collaboration and quality of care within healthcare. The new National Competencies for Dental Hygiene also advocates such collaborative practices. Findings: There is evidence of the connection between oral health and systemic health, and the increased need for proper daily oral health assessment and care for populations within acute and long term care. At present, members of the nursing profession whose scope of practice includes providing oral assessment and daily oral care are the front line caregivers for these populations. The increase in high blood pressure within the general population is also a priority health problem. Dental hygienists are front line health professionals in oral assessment and oral care education whose scope of practice includes taking blood pressure and pulse. Conclusions: The results of the Canadian Health Measures Survey (CHMS) show that approximately 70 per cent of the population sees an oral health practitioner on an annual basis. Dental hygienists are in an ideal position to monitor and screen for high blood pressure. This paper reports the lessons learned from the IPE initiative, rationales for continuing this initiative, and the future directions of this initiative in fulfilling aspects of the proposal by George Brown College (GBC) to implement IPE initiatives.
Contexte: La formation interprofessionnelle (FIP) se definit comme etant une source d'occasions pour deux professions et plus de s'instruire et de se former mutuellement afin d'ameliorer la collaboration et la qualite des soins. Les etudiantes en soins infirmiers et en hygiene dentaire du College George Brown ont ete reunies dans une initiative de FIP pour s'instruire et se former reciproquement sur le partage des roles qui se recoupent dans les soins buccaux et le monitorage de la pression arterielle. L'Organisation mondiale de la sante (OMS) preconise depuis longtemps la formation * pluriprofessionnelle * des etudiantes en soins buccaux pour etablir * les competences necessaires visant a resoudre les problemes prioritaires de la sante des personnes et des collectivites qui se pretent particulierement au travail d'equipe * Discussion: La discussion presente les echanges entre le Ministere de la sante et des soins de longue duree (MSSLDO) d'Ontario, ProfessionsSanteOntario, l'Association des infirmieres et infirmiers autorises de I'Ontario (AIIAO) et le Bureau du dentiste en chef (BDC) visant a ameliorer la collaboration et la qualite des soins dans le cadre des soins de la sante. Les nouvelles Competences nationales en hygiene dentaire preconisent de telles pratiques de collaboration. Resultats: Les donnees temoignent du lien qu'il y a entre la sante buccale et la sante generate et du besoin de plus en plus grand d'evaluer correctement et quotidiennement la sante buccale des populations sous soins intensifs de longue duree. Actuellement, les membres de la profession des soins infirmiers dont le champ de pratique comprend l'evaluation buccale et les soins buccaux quotidiens sont en premiere ligne du personnel soignant de ces populations. L'augmentation de la tension arterielle de la population en general est aussi un probleme de sante prioritaire. Les hygienistes dentaires sont en premiere ligne des professionnelles de la sante concernant l'evaluation buccale et I'education des soins de sante dont le champ de pratique comprend la tension arterielle et le pouls. Conclusions: Les resultats de I'Enquete canadienne sur les mesures de la sante (ECMS) montrent qu'approximativement 70 pour cent de la population consulte annuellement la praticienne en sante buccale. Les hygienistes dentaires sont ainsi dans une position ideale pour surveiller et depister la haute tension arterielle. L'etude fait etat des lecons de 1'initiative de FIP, les raisons de poursuivre l'initiative et les orientations a lui donner pour realiser la proposition du College George Brown (GBC) sous ses divers aspects et mener a bien les initiatives de FIP.
Key words: interprofessional education, oral health, blood pressure, Dental Hygiene, Nursing
This paper describes an interprofessional education (IPE) initiative involving students of Dental Hygiene (DH) and Bachelor of Science in Nursing (BScN) at George Brown College (GBC) in Toronto, Ontario. It focuses on the development of an IPE initiative within the IPE curriculum at GBC. This initiative is comprised of two distinct components: i.) oral health assessment/daily oral care, and ii.) blood pressure/pulse. It utilizes the connection between oral and systemic health as an agent for an interprofessional collaboration between the dental hygiene and nursing professions. Summaries of the feedback given by the students from each of the components are provided as well as suggestions for expansion of this initiative.
The scientific community that informs both dental and non dental healthcare professions, recognizes an association between oral and systemic health. As well, healthcare experts have called for action for collaborative approaches to address the need for interventions to improve health outcomes and quality of life. As a result, educational institutions are focusing effort and attention on defining their role in preparing healthcare workers for collaborative practice.
Development of initiatives within the IPE curriculum at GBC
In 2005, proposals were requested by the Centre for Health Sciences at GBC to develop and implement interprofessional education (IPE) curriculum pilot initiatives that supported the College's new interprofessional education learning outcomes.' See also Figure 1.
[FIGURE 1 OMITTED]
1. Appraise the relationship between one's own profession and the background, roles and scopes of other healthcare professions.
2. Evaluate one's ability to work in a team.
3. Participate collaboratively as a health team member to support patients/clients' achievement of their expected health outcomes.
4. Assess the impact of the broader legislative and ethical framework on inter professional practice.
At that time, an initiative was proposed and developed between the collaborative BScN (George Brown site) and the Dental Hygiene (DH) programs. It reflected the Applied Interactive Activity involving two or more programs which was one of the six possibilities that were recommended in the call for proposals. This initiative included two interprofessional learning components:
The first utilized 2nd year DH students to guide 1st year BScN students in the practice of oral assessment and daily oral care appropriate for co operative long term care patients or clients.
The second involved 2nd and 3rd year students from the BScN program guiding 1st year DH students in the practice of taking a manual blood pressure and pulse.
Questionnaires were developed for students to complete anonymously at the end of each of the oral health and blood pressure sessions. The information gathered from the questionnaires has aided in the design and evaluation of both components of the IPE initiative for future iteration.
Design of the IPE initiative
1. Oral health component
This component consisted of eight 2nd year DH students, two DH faculty mentors, two hundred 1st year BScN students, and four BScN supervising faculty mentors. Over the course of four days in the simulation lab setting, dental hygiene student "teachers" facilitated the nursing student "learners" practice of daily oral assessment and oral care appropriate for cooperative patients. Each day consisted of two, 2-hour sessions, which served approximately fifty BScN student "learners". DH student "teachers" presented a short demonstration session about oral assessment, daily oral healthcare procedures and care for various oral prostheses (e.g., dentures). Following the demonstrations, simulation exercises began with DH student "teachers" assigned to clinician-patient teams of BScN student "learners". Time was provided for each BScN student "learner" to switch roles in the practice session. See Figure 2. The DH faculty provided guidance to both student "learners" and student "teachers".
[FIGURE 2 OMITTED]
2. Blood pressure component
Approximately fifteen volunteer 2nd year BScN students and three of their faculty mentors met at the GBC Dental Clinic to work with DH students and their supervising faculty during one of the pre-clinical health assessment sessions. The session began with a BScN student "teacher" demonstrating the skills for taking a manual blood pressure and pulse to each of four pairs of DH student "learners". Once the demonstrations were completed, the BScN student "teacher" returned to each DH student "learner" pair and facilitated the practice of the skills as demonstrated. See Figure 3. The BScN faculty provided guidance to both the student "learners" and student "teachers".
[FIGURE 3 OMITTED]
Student feedback from both components of this IPE initiative
At the end of the blood pressure and oral health components of this IPE initiative, questionnaires were given to the student "learners" and the student "teachers" to answer anonymously for the purposes of program development. Table 1 shows the statements that both the student "learners" and student "teachers" were asked to evaluate. Students were asked to rate their answers on a five point Likert scale, ranging from '1' (strongly disagree) to '5' (strongly agree). Students from GBC's Health Information Management Program, also a part of the Centre for Health Sciences, entered and analyzed the data from the questionnaires using SPSS version 17.
Table 1. Statements from the student "learners" and student "teachers" questionnaires. Statements for the student Statements for the student "teachers" "learners" to evaluate to evaluate 1. The information demonstrated 1. I understood the information was accurate that I was to demonstrate 2. Explanation of the procedure 2. The students asked questions was easy to understand that I was able to answer 3. The students who were 3. The student learners had an teaching were able to answer adequate understanding of the questions appropriately theory prior tothe demonstration 4. I now feel comfortable to 4. The student learners were better practice on my partner in the able to practice once I had an pre-clinic lab opportunity to practice with them 5. I enjoyed working with 5. I enjoyed working with students in students in another another profession profession
In both components of the initiative, the data revealed that students agreed or strongly agreed with the statements regarding accuracy of information presented, ease of understanding and knowledge level of the "student teachers". See Table 2. In addition, most, if not all, student "teachers" felt able to answer questions they were asked by the student "learners" (Box 7 and 17 in Table 2); and the student "learners" liked practising the skills with their student "teachers" (Box 9 and 19 in Table 2). Both student "learners" and student "teachers" reported that they enjoyed working with students from another profession (Box 5, 10, 15 and 20 in Table 2). The BScN student "teachers" all felt they understood the information that they were to demonstrate to the DH students about taking a manual blood pressure (Box 6 in Table 2).
However, in two instances the data revealed that students disagreed or strongly disagreed. In the first instance, DH student "teachers" in the oral health component felt that the BScN students did not have adequate understanding of the theory of oral assessment or daily oral care prior to the demonstration (Box 18 in Table 2). In the second, DH student "learners" in the blood pressure component reported that they would not feel comfortable taking a manual blood pressure and pulse after this one teaching session (Box 4 in Table 2).
Analysis of the questionnaires has provided feedback that has been utilized to improve both the oral health and blood pressure components of this IPE initiative.
Call for collaboration from the scientific and healthcare community
The scientific community has indicated a low to moderate association between periodontal disease and heart disease, and a moderate association between periodontal disease and stroke. (2) Additionally, there is mounting evidence of a probable two way association between periodontal disease and diabetes. (2) Research is emerging regarding improved oral hygiene and the reduction in respiratory infections in long term care settings. (3) There is also growing recognition of the importance of oral health to quality of life. (3)
The World Health Organization's (WHO) 1948 definition of health (4) states, "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." With an ever increasing awareness of the connection between the health of the oral cavity and the health of the whole body, the American Surgeon General's (ASG) report (5), in 2000, focused on the relationship between oral health and overall good health throughout life. The report described the mouth as a "mirror for general health and well-being and the association between oral health problems and other health problems." (5) Lawrence and Leake (6) in their article Canadian Perspective of the US Surgeon General's report on Oral Health state that one of the calls to action within the report was to "educate non-dental health professionals about oral health and disease and their role in ensuring that patients receive good oral healthcare". They also indicate that more research is needed as in the US, and that Canada should apply interventions that demonstrate effectiveness in eliminating oral health disparities. (6) The philosophies of both the ASG and the WHO are increasingly recognized by governments, scientific communities, and members of the public. Additionally, in 2004, the Canadian government established the Office of the Chief Dental Officer (OCDO) to provide strategies to support the oral health of Canadians focused on increasing access to oral healthcare, and using a collaborative approach to health promotion. (7)
Oral health data from the Canadian Health Measures Survey (CHMS) were released in 2010. (8) The CHMS, supported by both Health Canada and Statistics Canada, was undertaken to collect key information relevant to the health of Canadians. It provides a national baseline level of the oral health of Canadians including decayed, missing, filled teeth scores (DMFT) for Canadians from 6 to 79 years of age. The 2010 results show that only 6% of adult Canadians are edentulous. While, in 1972 data indicated the edentulous rate was 24%. This represents a vast improvement in the number of people who retain their teeth. (8)
The Chief Dental Officer of Canada also reports findings of the CHMS that demonstrate oral health disparities exist for a number of population groups. Key to addressing these disparities is research that asks why and how disparities occur, who are the most vulnerable, and what can be done to improve oral health for all". (8) The Canadian Institutes of Health Research (CIHR) is currently investigating these issues. "This research is focused on finding ways to influence health and economic policies, education and dental services for the benefit of Canadians who have difficulty accessing oral healthcare". (8)
There is evidence from Statistics Canada that the number of seniors in the Canadian population is rising--7.7% (1966) to 13.7% (2006). (9) In the next twenty-five years it is projected that the population of seniors could nearly double. (10) Also, life expectancy of Canadians stands at 82.5 years for women and 77.7 years for men. (10) Eighty-seven per cent of older women and 92.7% of older men say they have one or more chronic health problems. (11)
Since Canadians are living longer and retaining their teeth there is a demonstrated need for health professionals to be experienced in oral assessment and daily oral care, particularly when working with vulnerable populations such as those in either acute or long term care. There is a growing consensus that health professionals working as partners, in a team approach, will produce better health outcomes, improved access to services, improved use of resources, and greater satisfaction for both patients and providers. Such teams are better positioned to focus on health promotion and to improve the management of chronic diseases. (12)
Health Force Ontario is a provincial government body that addresses Ontario's health human resource needs to ensure that Ontarians have access to the right number and mix of qualified healthcare providers, now and in the future. (13) Health Force Ontario has been engaging partners in education and healthcare to develop skilled, knowledgeable providers, and to create interprofessional healthcare delivery teams. The implementation of interprofessional care is to provide comprehensive health services to patients or clients by multiple health care givers, who work collaboratively to deliver quality care within and across healthcare settings. (14) Interprofessional care has the potential to provide the needed services to Ontarians. The education system needs to prepare current and future health professionals to work in multidisciplinary, collaborative, team based models. The BScN-DH initiative provides a partnership and collaboration to enhance the outcomes of improved oral assessment and daily oral care for the public.
Additionally, changing guidelines from the Ministry of Health and Long-Term Care regarding oral assessment and daily oral care for residents within long term care are becoming more precisely defined. Nurses are the front line delivery health professionals responsible for assessing oral health status and implementing daily oral care within acute or long term care settings. Dental hygienists can provide knowledge and expertise to nurses for outcomes required by government and nursing regulatory bodies. Dental hygienists are well positioned to work as integrated members of healthcare teams addressing oral health issues across a continuum of care in conjunction with physicians, radiation therapists, dentists, social workers, occupational therapists, registered dieticians and most importantly, patients or clients.
The recent Long Term Care Home Act (15) in Ontario places the care of the mouth for residents in long term care [LTC] under the skin and wound care program for LTC facilities. The Standards and Criteria for Resident Care and Services (16) implemented in 2006 by the Ontario Ministry of Health and Long Term Care (MOHLTC) indicated that each LTC home operator shall develop and follow policies on the management of skin care, including care of the skin, nails, feet and mouth. An interdisciplinary team shall coordinate the LTC home operator's program of skin care and wound management. This interdisciplinary team shall include a skin care coordinator and a regulated health professional who will coordinate the required expertise to educate and support the team on skin care and wound management, and knowledge of current "best practices". (16) In addition, the Registered Nurses Association of Ontario (RNAO) released Nursing Best Practice Guidelines on Oral Health: Nursing Assessment and Interventions. (17) The target users of the guidelines are nurses in various practice settings who work with vulnerable populations of those who need assistance to meet their oral hygiene needs. Nursing faculty in the collaborative Bachelor of Science in Nursing (BScN) program at the George Brown College site recognized the opportunity for improved education for nursing students related to oral health assessments and daily oral healthcare in acute and chronic care facilities.
Dental hygienists work with their clients to establish a dental hygiene treatment plan that includes disease prevention, therapeutic interventions, and appropriate referrals. Recent amendments to the Dental Hygiene Act (18) in Ontario allow the public increased access to dental hygiene services. This access creates the potential for more Ontarians to be assessed for oral health problems that may impact their overall health. Moreover, it provides an opportunity for dental hygienists to work with other health professionals in multiple practice settings to ensure that the oral health needs of Ontarians are addressed safely, effectively, and efficiently. (18) As a result, dental hygienists are now even better positioned to be part of the interdisciplinary team identified by the LTCHA required to educate and support staff on skin care and wound management, and knowledge of current best practices.
New National Dental Hygiene Competencies for Entry-to-Practice were developed and released in 2008. (19) One of the domains calls for dental hygienists to be communicators and collaborators. This is supported by competencies from the Public Health Agency of Canada (20) which states
"Communication involves an interchange of ideas opinions and information. This category addresses numerous dimensions of communication including internal and external exchanges; written verbal, non-verbal and listening skills; computer literacy; providing appropriate information to different audiences; working with the media and social marketing techniques. Collaboration captures the abilities required to influence and work with others to improve the health and well-being of the public through the pursuit of a common goal. Partnership and collaboration optimize performance through shared resources and responsibilities."
During the oral health component of the IPE initiative, both students and faculty had an opportunity to experience each other's professional language, and learned that this is a necessary step for improved communication between health professionals. By way of example the term calibration was used by nursing and dental hygiene faculty during the blood pressure component to mean distinctly different things. BScN faculty defined the term "calibration" as a "measurement for the blood pressure instrument", while the DH faculty use the term to refer to "consistency of knowledge and skill among clinical teaching faculty". It demonstrated the confusion that can result and the need for good communication skills when working in an interprofessional team.
Both components of this IPE initiative provided the opportunity for all participating students to observe and better understand the importance of communication professionals within the healthcare community. An improved understanding puts students closer to being "workplace ready"; a concern which is high on the list of priorities for employers. (21)
Lessons learned from this IPE initiative
There have been many lessons learned by both students and faculty over the multiple iterations of this initiative. The lessons students learned are summarized below.
1. Students report recognizing how much they have learned when given the opportunity to teach others outside their profession.
2. Students learned there are shared skill sets across the dental hygiene and nursing professions.
3. BScN student "learners" discovered that dental hygienists need to take a manual blood pressure and pulse.
4. DH student "learners" discovered that nurses are responsible for providing daily oral healthcare for clients in acute and LTC settings.
5. BScN student "learners" recognized that there are differences in the roles of a DH and a Dental Assistant (DA).
6. DH student "learners" gained insight into the various types of nursing professionals such as a BScN, a Registered Practical Nurse (RPN) and a Personal Support Worker (PSW).
7. BScN faculty recognized the need for additional Personal Protective Equipment (PPE) when providing oral care to patients (i.e., eye protection, masks and gloves).
8. DH faculty recognized the need for improved bedside ergonomics for providers of oral care to patients or clients.
The challenges and lessons learned by faculty members related to both components of this initiative are reported in the list below.
1. The first and most persistent challenge in this type of endeavor is scheduling:
i. There is a complexity about time tabling across two programs and two campuses that requires specific focused attention to lab availability, supplies, and time to coordinate the initiative.
ii. Scheduling issues create logistical challenges on other involved faculty members not directly involved in both programs related to pre-existing class times and clinics.
iii. Students who participated and then had to make up any missed regularly scheduled clinics or labs were also affected by this inititative's scheduling. Both programs continue to review strategies in future planning to consider ways in which more seamless scheduling can minimize or eliminate missed classes or clinic time.
2. Flexibility and a willingness to work together are essential to make a project of this nature work.
3. An overview of the principles and benefits of IPE for students and faculty is critical to the success of the project.
4. The feedback from the student "teachers" questionnaire regarding the need for better understanding of theory prior to the demonstration of the skill has resulted in provision of additional up to date resources related to the theory of oral assessment and daily oral care to the BScN faculty. (22) These up to date resources will now be available for nursing student "learners" by the nursing faculty in future iterations of this IPE initiative.
5. Feedback from DH student "learners" blood pressure and pulse questionnaires informed faculty of the need to implement additional practice sessions for DH students in the health promotion centre. Nursing students are onsite weekly to provide assistance to all health sciences students who are practising the skill of taking a manual blood pressure and pulse. This provided students with another interprofessional opportunity. It was determined that 3rd year BScN students were better suited to be student "teachers" due to the extra year of gained experience in their learning regarding vital signs.
6. This initiative allowed us to think more broadly about partnerships. Accordingly we connected with students from the Health Services Management program who entered and analyzed the data from the questionnaires. While they contributed to the project outcomes, they were not a part of the IPE education dynamic, as they did not learn about, from and with the BScN and DH students. Attention to this will be necessary in future endeavours to ensure that the most is made of the partnership.
7. The initiative allowed faculty who normally do not have an opportunity to work together to collaborate, and to realize that the IPE benefits extend beyond students and patients or clients to the faculty members themselves.
Recommendations for future IPE initiatives
Faculties are now focused on better defining learning outcomes specific to this initiative. In addition, work continues on how best to evaluate interprofessional experiential learning as a sustainable aspect of the curricula of both programs. Currently, all 1st year students in the BScN program participate in the oral health initiative. It is felt that students in the Registered Practical Nurse (RPN) and Personal Support Worker (PSW) programs should participate in an oral health IPE initiative as they are the health professionals most likely to be providing this care. It is suggested that all DH students would benefit from participation in this type of initiative to enhance communication and interprofessional collaboration as outlined in the new National Dental Hygiene Competencies for Entry-to-Practice. (18) As well, it is believed that all BScN students would benefit from participating in a manual blood pressure and pulse IPE initiative with other health science students who are in need of learning this skill. Furthermore, there is a need to establish academic credit for students participating in IPE initiatives to embed effectively interprofessional education within curriculums.
Efforts are underway to expand the oral health aspect of this project into settings where both DH and BScN students have clinical experiences within common long term care and rehabilitation centres. It is believed that collaborative problem solving between the two professional groups "in the field", regarding the oral care needs and challenges of selected clients, could result in improved quality of oral care for clients and expanded and improved skills amongst the students.
In addition to the lessons learned, we offer the following thoughts and recommendations for those considering an initiative of this nature:
1. Choose a primary skill or competency from your health profession that is also a skill or competency that can or is required to be performed by another health professional.
2. Be flexible in making arrangements and willing to think "outside the box".
3. Implement a pilot version first. Include an evaluation component to survey the student participants for their feedback from both the pilot and newly implemented activities.
4. Plan joint debriefing sessions for the faculty involved.
5. Plan debriefing sessions for the student "teachers" involved.
6. Schedule adequate planning time for each academic year.
7. Schedule voluntary focus groups for student "learners" for further feedback.
The scientific and healthcare communities indicate the need for collaborative interprofessional approaches to care that are initiated in the education of health professionals. Furthermore, evidence is clear that there is an association between the health of the oral cavity and the health of the whole body. (2), (3) Heart disease, strokes, diabetes, and respiratory disease are among the top chronic diseases afflicting the general population (11) which could potentially relate to increased costs to the healthcare system. Added to that are the ever increasing numbers of the population moving into their senior years who are expected to live longer and retain their dentitions. This IPE initiative is an effective vehicle to enable all BScN, RPN, PSW, and DH students to learn about, from and with each other, and this initiative lends itself to the development of interprofessional teams of students. Our hope is that TPE initiatives such as those we have described and experienced will be a model for others in establishing IPE learning opportunities for their students.
In closing, it is critically important to state that while it was beyond the scope of this initiative, it is recognized that properly designed research is required to better test the outcomes from an IPE initiative of this nature. Any future research should also include following graduates into their practice settings to determine the extent that these interprofessional learning experiences have informed their professional practice.
The authors would like to acknowledge the contributions made by the students, Gary Kapelus, Coordinator for Interprofessional Education; Connie Barbour, Nursing Professor, the accompanying part time nursing faculty, all faculty members in the dental hygiene program who have supported this initiative, and all from George Brown College's Centre for Health Sciences, Faculty of Community Services and Health Sciences.
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(11.) Novak M and Campbell L. Personal Health and Illness. In Veitch, Yarzab, DeRuiter, Kohmeier & Koch (eds.) Aging and society. p. 87. 2006. Toronto: Thomson-Nelson.
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(15.) Government of Ontario. Service Ontario e-Laws. Long-Term Care Homes Act 2007. S.O. 2007, CHAPTER 8. [Cited 14 Aug. 2010] Available from http://www.e-laws.gov.on.ca/html/statutes/eng-Iish/elaws_statutes_07108_e.htm
(16.) Ontario Ministry of Health and Long-Term Care. Homes Program Manual. Resident Care and Services Standards and Criteria. [Cited 14 Aug. 2010] Available from: http://www.health.gov.on.ca/english/providers/pub/manuals/ltc_homes/sub_secs/09_03.pdf
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(18.) Government of Ontario. Service Ontario e-Laws. Dental Hygiene Act 1991. S.O. 1991, Chapter 22. [Cited 14 Aug. 2010] Available from: http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_91d22_e.htm
(19.) College of Dental Hygienists of Ontario. National Dental Hygiene Competencies for Entry-to-Practice [monograph on Internet]. 2008. [Cited 14 Aug. 2010] Available from: http://www.cdho.org/Home/EntryToPractice.pdf
(20.) Public Health Agency of Canada. Core Competency Statements. [monograph on Internet]. [Cited 30 Dec. 2010] Available from: http://www.phac-aspc.gc.ca/ccph-cesp/stmts-enon-eng.php#4
(21.) Conference Board of Canada. Employability Skills, [monograph on Internet]. [Cited 5 Jan. 2011] Available from: http://calsca. com/conf erence_board.htm
(22.) University of Manitoba. Oral Health Promotion Fact Sheets & Video Clips for Mouth Care in Long Term Care [monograph on Internet]. [Cited 5 Jan. 2011] Available from: http://umanitoba.ca/faculties/dentistry/ccoh/ccoh_longTermCare.html
THIS IS A PEER REVIEWED MANUSCRIPT. Submitted 27 Aug. 2010; Revised 6 Jan. 2011; Accepted 10 Jan. 2011
[section] Faculty of Nursing, Community Services and Health Sciences, George Brown College
[DELTA]Faculty of Dental Hygiene, Community Services and Health Sciences, George Brown College
Correspondence to: Lynne Grant, Professor; email@example.com
Centre for Health Sciences, School of Dental Health, George Brown College, Toronto, Ontario
Lynne Grant[DELTA], RDH; Linda K, McKay[DELTA], RDH, BScD; Lisa G. Rogers[DELTA], RDH, BEd; Sandy Wiesenthal[section], RN, MN; Shari L. Cherneys [section], RN, MHSc; Lorraine A. Betts[section], RN, BSc, BScN
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|Title Annotation:||EVIDENCE FOR PRACTICE|
|Author:||Grant, Lynne; McKay, Linda K.; Rogers, Lisa G.; Wiesenthal, Sandy; Cherneys, Shari L.; Betts, Lorrai|
|Publication:||Canadian Journal of Dental Hygiene|
|Date:||Feb 1, 2011|
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