National competencies for dental hygiene entry-to-practice.

ABSTRACT

Objective: While the dental hygiene profession has several national documents pertaining to entry-to-practice issues, it lacks a common national standard. The need for such a standard is becoming increasingly important with the divergence of entry-to-practice educational models across Canada, programs being implemented in new jurisdictions, and the entrance of multiple post-secondary organizations into the educational sector. The objective of the study was to articulate the first draft of entry-to-practice competencies that would be used to support dental hygiene education, accreditation, examination and regulation. What are the essential national competencies for entry-to-practice into the Canadian dental hygiene profession? Methods: A 3-day workshop was held in February of 2007 with twenty-two key dental hygiene informants from across Canada. The initial product from the workshop was then refined and shaped through two feedback loops with the participants. Results: The group developed a new framework for dental hygiene competencies based on the literature in interprofessional education. The core abilities focus on dental hygienists as professionals, communicators and collaborators, advocates and managers. The competencies related to the specialized client services focus on dental hygienists as clinical therapists, oral health educators and health promoters. Conclusion: This draft competency profile better aligns the dental hygiene profession within the context of other health professions. However, it is still in an embryonic stage and needs to be validated with a larger group of dental hygienists. It has the potential to be a positive force to support greater consistency of educational, and possibly regulatory, standards across Canada.

RESUME

Objectifs: Bien qu'elle ait a l'echelle nationale plusieurs documents traitant des titres de competence pour l'acces a la profession, la profession des hygienistes dentaires n'a pas encore de normes communes pour l'ensemble du pays. Le besoin d'un tel document prend de plus en plus d'importance, vu la divergence des modeles de developpement des competences a travers le Canada, la mise en place de programmes sous de nouvelles juridictions et la multiplication des organisations post-secondaires dans le secteur de l'education. Cette etude a donc pour objet d'elaborer une premiere ebauche articulee des competences requises pour acceder a la profession et susceptibles de sous-tendre la formation, l'examen, l'agrement et la reglementation en matiere d'hygiene dentaire. Bref, quelles devraient etre les competences essentielles requises a l'echelle nationale pour acceder a la profession d'hygieniste dentaire au Canada? Methodes: Un atelier de trois jours a ete tenu en fevrier 2007, reunissant vingt-deux informatrices de toutes les regions du pays. Il en est ressorti un premier jet qui a ete peaufine par deux boucles de controle effectuees aupres des participantes. Resultats: Le groupe a elabore un nouveau cadre de competences en hygiene dentaire, base sur la litterature en matiere de formation interprofessionnelle. On a souligne que les aptitudes principales de l'hygieniste dentaire devraient porter sur la profession, la communication, la collaboration, la representation et l'administration. Les competences de l'hygieniste dentaire en matiere de services specialises aupres de la clientele portent sur la therapie clinique, l'education en sante dentaire et la promotion de la sante. Conclusion: L'ebauche du profil des competences situe mieux la profession d'hygieniste dentaire dans le contexte des autres professions de la sante. Toutefois, elle en est encore a l'etape embryonnaire et a besoin d'etre validee par un groupe plus important d'hygienistes dentaires. Elle a le potentiel de devenir une force positive pour appuyer une plus grande cohesion de la formation, sur le plan des normes, et peut-etre de la reglementation, a travers le pays.

Key words: dental hygiene, competencies, national standard

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Over the years different national dental hygiene organizations have established educational standards to support their work. These are found in various forms such as the requirements for accreditation, (1) the competency statements for the national examination, (2) a framework for education and practice standards articulated by our professional association, (3,4,5) and the learning outcomes developed by the educators' organization. (6) These documents express the concept of entry-to-practice in different ways. The dental hygiene profession does not have a common national standard associated with entry-to-practice for the profession. While the various dental hygiene regulatory authorities are responsible for developing their own standards of practice, a common core national standard is considered preferable for mobility purposes.

The need for such a standard is becoming increasingly important with the divergence of entry-to-practice educational models across Canada, programs being implemented in new jurisdictions (e.g. New Brunswick), and the entrance of multiple post-secondary organizations into the educational sector. Post-secondary organizations now include private and public organizations as well as colleges and technical institutes, university-colleges and universities. Entry-to-practice programs also vary in length ranging from 2-3-year diploma programs as well as one 4-year baccalaureate program.

National competency documents exist in many health professions; however, their integration across national organizations varies. Many tend to be organization specific documents as has been the case in dental hygiene. (2,6) Dentistry has developed a national standard regarding entry-to-practice for general practitioners and this is used by dentistry's national organizations. (7,8,9) It provides a foundation for national accreditation, education and examination as well as provincial regulation. Given the diversity of dental hygiene education and regulation in Canada, a similar standard for the profession is seen as integral to the work of national and provincial organizations in these times of rapid flux and transformation.

National dental hygiene organizations identified the need to articulate the knowledge, skills, attitudes and judgments required for entry-to-practice to the profession. The competency approach provides a vehicle through which to articulate this entry-to-practice standard (10,11,12,13) which can then be used to develop curriculum, assess programs, examine graduates and develop provincial regulatory standards as well as continuing competency programs. (14) The articulation of core competencies is also expected to lead to an understanding of the competencies shared by all health professionals. (15,16) It is expected to support interprofessional education initiatives given that a major barrier to such education is the lack of understanding of shared competencies. (17,18,19) Ultimately the core competency profile is designed to help build the capacity of dental hygienists to support the oral health needs of the Canadian public. (20,21)

COMPETENCIES

Why competencies?

The ability movement arose from a meshing of several related but unique discussions in the field of education. It was shaped from discussions surrounding outcomes based education (OBE), competency based education (CBE), learning outcomes and authentic assessments. (22-24)

OBE was developed in response to the mandate of secondary education to create "good citizens" and "good employees." (25,26) The OBE movement arose from concerns that American high school graduates did not posses the skills and knowledge to integrate into economic and community life. In this literature, learning outcomes are described as "high-quality, culminating demonstrations of significant learning in context." (25) This definition places an emphasis on the proof of outcomes, and on demonstrations of learning. It also identifies that these demonstrations focus on "significant" graduate outcomes and must reflect a notion of "quality" in an authentic practice environment. The learning outcomes are defined in broad, general terms so as to reflect cumulative learning upon graduation from an educational program, learning which is reflective of life in "real world".

This fuelled discussions about authentic assessments found in evaluation literature. Educators identified the need to focus on coherence of the educational experience and suggested that this could be achieved by focusing on the connections between learning and assessments. (27) Abilities-based education was viewed to challenge educators to reassess existing assessment strategies. (28,29) Current approaches to the evaluation of learning were not seen as meaningful when the aims of education were intellectual, moral and personal development. (30) From this perspective an abilities approach promoted a realignment of the curriculum, implementation and assessment strategies to harmonize these elements.

During the 1970s CBE was introduced into many vocational and occupational programs in postsecondary education. The CBE movement was intended to make education more relevant to the practice world of business and the trades. (28) It was strongly influenced by the behaviourist approach to learning with its emphasis on process guidelines. Proponents of CBE suggested that all learning could be broken down to discrete tasks which could be described in measurable, behavioural steps. (31,32) Initially CBE was criticized for its reductionist and behaviourist approach. (33) However, as educators worked with the competency framework, it evolved from descriptions of discrete technical tasks to explanations of complex exit skills for graduates of professional programs. Reynolds and Salters (34) suggest that several competency models have emerged, with the first ones focusing on behaviour at the cost of knowledge and understanding. Further models adopted a more holistic approach to include additional elements affecting performance such as understanding, knowledge and values. (14,35,36)

In Canada the first dental hygiene competencies were developed at the national level in the 1980s and they focused largely on the technical aspects related to clinical services. Dentistry also followed that route in the 1990s although their competency model reflected a shift on the continuum from competencies to learning outcomes; their model articulated more general outcomes. (13,14) The movement of the competency approach from discrete skills to program exit skills made the differentiation between learning outcomes and competencies fuzzy.

In the 1990s the concept of learning outcomes which emerged from the OBE movement was introduced into Canadian post secondary education in many provinces in association with discussions about quality and accountability. (37-45) Learning outcomes were viewed as a strategy for educational reform. (24,33,38,40) They were described as the core of a reform approach which included prior learning assessment strategies and a seamless educational system. (37,42,44) They were perceived as a vehicle to provide relevant and meaningful programs centred on learners' needs. (29,39,46,47) The language of a learning outcomes approach was believed to align more readily with academic programs although many in the academic areas resisted this approach for fear that it represented an economic, work-based approach rather than a liberal, arts approach. (48-52) Learning outcomes were perceived as an approach to "dumb down" and control curriculum by government policy makers.

During this time the dental hygiene educators in Ontario and British Columbia shifted to a learning outcomes approach as the model decreased the emphasis on the small technical skills, and more clearly articulated and emphasized the cognitive abilities associated with the profession. (53) Part of this shift also related to strategic issues; funds were available for the articulation of learning outcomes and this allowed for discussions about dental hygiene education. At the national level the discussions continued to revolve around competency statements through the examination organizations and the Commission on Dental Accreditation of Canada (CDAC). In the 2001 revision of the CDAC dental hygiene requirements, the concept of learning outcomes was included as a synonym with competencies. (1) At that time the competency statements developed through a collaborative approach by dentistry were also embedded in the CDAC requirements.

Defining the outcomes of dental hygiene education was also a national priority through the Association of Canadian Faculties of Dentistry (ACFD), Canadian Dental Hygienists Association (CDHA) and Dental Hygiene Educators Canada (DHEC). ACFD initiated work in this area through the implementation of a strategic planning session directed towards the development of educational standards for dental hygiene and dental assisting education in Canada. (54) The recommendations from this workshop encouraged national dental hygiene organizations to take further action to support the work of Canadian dental hygiene educators. CDHA revised its practice standards (5) and developed a Policy Framework for Dental Hygiene Education in 1998. (2) This was followed by the establishment of a Task Force on Dental Hygiene Education (55) whose members articulated learning outcomes for dental hygiene education at the diploma, baccalaureate, masters, and doctorate levels. DHEC became involved in validating the CDHA draft learning outcomes by conducting a study directed towards the articulation of learning outcomes for Canadian dental hygiene education at the diploma and baccalaureate level. (6) The work of both CDHA and DHEC used the learning outcomes language.

Language is used to shape discussions and the dental hygiene profession is ultimately striving to be more fully recognized by other professions and disciplines. Using the learning outcomes language may help communicate more effectively with many of the disciplines whose members often pale when "competencies" are mentioned. On the other hand, the various concepts surrounding the outcomes of education have merged over time as they have been shaped by different professions. This can also lead to communication challenges between dentistry and dental hygiene in Canada given that dentistry adopted competencies at a time when dental hygiene was moving away from this concept; the international discussions about dental hygiene abilities also frame them in terms of competencies. (56,57) However, communication challenges surrounding these terms are not unique to the dental hygiene profession. To better facilitate communication, many educators now use the term "abilities" and avoid the diverse terms used to describe "outcomes" of learning.

Currently there appears to be an increasing focus on the concept of "competencies" through the federal and provincial ministries, particularly those associated with health care. For example, the Public Health Agency of Canada is currently developing Pan Canadian Core Competencies for Public health, and encouraging all the professions in public health to develop disciplinary competencies to complement these core competencies (http://www.phac-aspc.gc.ca/php-psp/core_competencies_for_ph_index_e.html). It appears that health professions in Canada are adopting the competency language, and the language of learning outcomes may be waning perhaps because of its association with accountability movements. The discourse has now shifted to the development of capacity of people working in the health sector and this appears to have been influenced by the Severe Acute Respiratory Syndrome (SARS) issue as well as other global health safety concerns. People are looking at the commonalities among health professions with regard to abilities while acknowledging that each profession has some unique clinical abilities to bring to client care.

Ultimately the workshop participants were looking at expressing a national standard through the articulation of ability statements. The label selected for these statements was a political rather than a pedagogical decision. While it is important to have a context for understanding ability statements, the actual content of the ability statements involve more challenging issues and questions.

What competencies?

Regardless of the term applied, discussions about the outcomes of learning focus on what learners "know," "value" and are "able to do." The outcomes are described in terms of complex abilities that are multidimensional as opposed to simple, unitary constructs. (23,39) A main theme in debates about curriculum is the idea of bringing coherence and structure to education. (24,58-60) This discussion rests on the premise that traditional disciplinary approaches have tended to fragment curricula in ways that may no longer be relevant to our knowledge society. An abilities perspective is viewed as providing a way of realigning the curriculum, implementation and assessment strategies to harmonize these elements. (27)

The word "competency" or "outcome" places emphasis not so much on the intentions of education, but on the results of the learning experiences. (61) This is not a trivial distinction but a challenging one. This distinction is critical to the understanding of the competency profile arising from this current study. These statements do not reflect the intentions and hopes of educators; they are intended to be entry-to-practice competencies which graduates of dental hygiene programs must reliably demonstrate.

Although consensus has not been achieved regarding the specific terminology to be used, analysis of literature indicates there is some agreement about the general abilities required to live and work in a world of constant change. The most broadly stated abilities are articulated in the UNESCO document Learning, The Treasure Within. (62) Four pillars are described as the foundations for education: learning to know, learning to do, learning to be, and learning to live together. Other literature tends to focus on more specific abilities but generally the abilities reported in the Canadian literature (44,63,64), are similar to ones recorded in international documents from the United Kingdom, (65) Australia, (66) New Zealand, (67) the United States (68-73) and Europe. (36) An analysis of these documents suggests that they have the following abilities in common:

** Communication (oral, written, technology).

** Interpersonal abilities (working with others).

** Critical thinking and problem solving.

** Managing self (responsibility, ethical approach, flexibility, adaptability).

** Ability to learn independently (accessing information, numeric literacy, computer use, reading and writing).

There appears to be general agreement that these abilities are integral aspects of post secondary education ranging from diploma to graduate programs. It is only logical that these abilities also form the foundation for dental hygiene education.

The American literature in health care also provides insights into the abilities that would support graduates to meet the needs of our diverse communities. (74,75) This was supported by further discussions in the American, (57,76) as well as the Canadian dental hygiene literature. (53,55,77) These documents emphasize that health care professionals will be providing care for clients who are culturally diverse and who will present with complex health conditions and needs. They also highlight the need for evidence-based and interprofessional approaches to providing care.

There is an increased emphasis in ability statements with regard to informatics and how to manage the large volume of information available to professionals and the public. (71,78) Professionals are described as having an increasing role to assist clients in the interpretation of information. There is also an increased focus on issues such as leadership (79-82) and entrepreneurship. (83) Overall there is substantial literature in the field of ability based education to support the development of national dental hygiene competencies. The challenge is to create a profile that will support the work of diverse national and provincial dental hygiene organizations.

The overall project and this study

The initial idea for this project and this study came from the Board of DHEC. The members of the board were developing a plan to review and revise the learning outcomes which had been developed for diploma and baccalaureate dental hygiene programs. (6) During discussions with an educational consultant it was decided to broaden the scope of the project and use a collaborative approach to the articulation of these ability profiles. In June 2006, a meeting of national organizations was scheduled in conjunction with the CDHA national conference. Based on the interest expressed at that session, CDHA funded a further meeting of these interest groups in September 2006, in Ottawa.

The Project Planning Committee (PPC) which was established through these two meetings included representatives from the following organizations:

** Canadian Dental Hygienists Association (CDHA),

** Commission on Dental Accreditation of Canada (CDAC),

** Dental Hygiene Educators Canada (DHEC),

** Federation of Dental Hygiene Regulatory Authorities (FDHRA), and

** National Dental Hygiene Certification Board (NDHCB).

This is a collaborative project involving all interest groups as equal partners, and it represents the first such collaboration in Canadian dental hygiene profession. The public also has input through their membership on the various organizations supporting the project. The PPC was involved in designing the project, supported by an educational consultant who was hired to manage the implementation phase. All PPC members have contributed to the funding of the project and additional funding has been accessed through the Dentistry Canada Fund and the Canadian Foundation for Dental Hygiene Research and Education.

This article presents the findings from the first phase of the collaborative project which was implemented as an action research study. The focus of the study was directed to the articulation of a national entry-to-practice standard for the dental hygiene profession, one that will then be used to develop curriculum, assess programs, examine graduates and develop provincial regulatory standards as well as continuing competency programs.

METHODS

The objective of the study, as well as the overall project, is to articulate entry-to-practice competencies to support dental hygiene education, accreditation, examination and regulation. The study was guided by the following questions:

** What are the essential national abilities for entry-to-practice into the dental hygiene profession in Canada?

** What do new graduates need to know and be able to do to provide appropriate dental hygiene services for the Canadian public?

The development of the competency profile consists of three phases including the following:

Phase 1: workshop. This involved a 3-day workshop in February 2007 with 22 key informants from the dental hygiene profession, described in more detail below.

Phase 2: web-based survey. Phase 2 included a web survey based on a purposeful sampling approach (n=707). Study participants were selected on the recommendations of the national dental hygiene organizations involved in the project. The sample calculation was based on the assumption of an 90 per cent power level to detect a 1.5 difference on a 10-point scale and a 5 per cent alpha.

Phase 3: focus groups. The third phase will involve 3 focus groups (2 for anglophones and 1 for francophones) conducted by teleconferences to assess the data from the survey and finalize the ability statements.

Given the need for the development of a national consensus about these competencies, it was important to include several phases to allow for diverse input. McDougal et al. (84) found a combination of approaches to be effective in defining health outcomes; participants in the McDougal study expressed a high rate of satisfaction with the outcomes and the process. Others suggest that focus groups are effective in triangulating results from qualitative approaches, (85) and providing a check in long studies to ensure that the meaning of questions has not changed over time. (86)

The three phases complement each other and are expected to provide diverse and rich data to support the development of the competency profile into a product that will support the work of our national dental hygiene organizations.

This current article is directed to Phase 1 of the project which involved a 3-day workshop directed to the development of the draft profile. The PPC members were asked to submit recommendations for workshop participants focused on the following characteristics:

** Geographic location.

** Type of practice experience.

** Years since graduation.

** Educational profile.

** Knowledge of the profession based on involvement in professional activities.

Once the data had been compiled, the PCC selected and organized the participants into working groups of three people with one group having four members. This task was accomplished through a PCC teleconference. Each working group included a person with a history of the profession and a person who would bring new ideas and a fresh perspective to the discussions. While each participant did not represent a specific organization, the general profile of the participants was such that our national dental hygiene organizations felt their views were heard. Table 1 gives information about the general profile of participants.

The 2002 framework of the CDHA Dental Hygiene Definition and Scope (5) document was used as the basis for the workshop. The participants were organized into small working groups based on the CDHA defined areas of responsibility including: general professional abilities, clinical therapy, health promotion, education, change agent, research and administration. Workshop participants were assigned to a working group based on their practice experience and knowledge.

The CDHA framework was used to stimulate discussions about entry-to-practice dental hygiene abilities, but participants were encouraged not to be limited by the framework and to shape the profile as needed. Literature was made available to the participants prior to the meeting; workshop participants were assigned to read specific documents and articles to ensure that all the literature had been read by one member of each small working group. Participants were also encouraged to bring their own resources to the workshop.

The workshop commenced with an orientation during which the workshop participants discussed the background of abilities based statements, identified the values that underpin entry-to-practice abilities and brainstormed issues relevant to the development of the profile. It was important for all participants to clearly understand the parameters of the overall project and their role in Phase 1.

This was followed by small group work in the afternoon in the specific CDHA areas of responsibility. The groups were each assigned a room for their work and laptop computers were available for documentation. Two workshop facilitators circulated among the groups.

The files from each working group were collected at the end of the session, analyzed by the workshop facilitators and compiled for the participants to review the next morning. The facilitators identified themes and patterns from each day's work, and proposed a variety of ideas and questions for consideration by the workshop participants. The same schedule applied to the following two days.

Through these discussions emerged a draft profile and a definition of the dental hygiene profession. The final afternoon session included a brainstorming session of ongoing issues that needed to be addressed and the development of a plan to further refine the document. Following the workshop two further feedback loops were implemented with the workshop participants through email. Fourteen participants responded to the first round, and 11 responded to the second round. The resulting draft #5 formed the basis for the Phase 2 web-based survey implemented in the fall of 2007.

Lewin is often cited as the originator of action research more than 50 years ago. (87-91) His writings included the ideas of "action research", "research in action" and "cooperative research." (88) His work and the work of others suggest that action research includes a cyclical process directed towards a change intervention. It is often also described as a spiral process of fact finding, conceptualization, planning, action and evaluation of results. (87,88,91) The activities through the PPC meetings and ongoing emails, and the workshop reflect such iterations, and these are expected to continue in the next phases of the project. The February workshop can be considered the first cycle of an action research project.

Discussions about action research involve interventions and these interventions take many shapes. Acts of communication may take the form of reconceptualising an existing situation or articulating a desired future. (91) The draft competency profile represents such a reconceptualization. However, Susman and Evered (91) also identify how these very communications also limit other possibilities. The decision to focus on entry-to-practice directed attention to dental hygiene curriculum at the foundational level and limited discussions about baccalaureate and graduate dental hygiene curricula; a deliberate decision was made to avoid discussions of credentials and program length in an effort to establish foundational competencies.

The collaborative characteristic involved in action research is often identified as a feature which differentiates it from other applied research approaches. (88,90,92) This is reflected by the notion of doing research "with people" in contrast to doing research "on them." (93) However, the extent of the participants' involvement can vary tremendously. (87) Sanders and Waterman (92) talk about the responsive and flexible characteristics of the process. The plan for this project was shaped by the PPC and the workshop participants as Phase 1 was being implemented; as well workshop participants provided input to the other elements of the project. They made their own choices with regard to the extent of their involvement as evidenced by the data related to the feedback loops. While the facilitators were not members of a small working group, they participated in the discussions of the small groups as well as the overall group. This article is evidence of the ongoing collaboration between the project coordinator or researcher, the PPC members, the workshop facilitator and the participants.

Like other types of research, the goal of action research is to create new knowledge (88,92) with an emphasis on understanding and learning. (94) Action research has been identified as a valuable methodology for redesigning curriculum. (95) The workshop participants were engaged in a melding of knowledge from the literature and their diverse practice experiences similar to the project implemented by Booth (96) for the development of gerontology clinical guidelines in nursing. Booth describes the mix of nurses from diverse practice context as being a major strength of the study's methodology. The PPC strove to achieve such diversity by including people from clinical practice, public health, hospital settings as well as from educational and academic contexts.

Overall the project involves longitudinal knowledge construction with its emphasis on gradual learning. (87) Action research provides a way of developing new knowledge which is situational and futuristic; (91) hence it is well adapted to the goal of this project.

RESULTS

The product of this study is the draft competency profile which emerged from the workshop discussions. Having a clear definition of the dental hygiene profession was an integral component of this project. The following definition emerged:

Dental hygienists "are primary oral health care providers guided by the principles of social justice who specialize in services related to:

** clinical therapy,

** oral health education, and

** health promotion.

Dental hygienists provide culturally sensitive oral health services for diverse clients throughout their life cycle. They work collaboratively with clients, guardians and other professionals to enhance the quality of life of their clients and the public."

Participants developed the entry-to-practice competencies by clustering ability statements under domain headings. Together the domains and their associated abilities form the entry-to-practice profile. The domains were divided into core abilities and abilities related to the client services provided by dental hygienists. The core category includes abilities which are common to the provision of all dental hygiene services and which are shared by other oral health and health care professions. The description of these core abilities is then followed by the client service abilities which articulate the specialized services provided by dental hygienists, shown in Table 2.

During the course of the Phase 1 workshop participants shifted away from the CDHA areas of responsibility and explored domain headings used in a variety of the reference documents. Four domain headings in the core abilities were shaped to better align with the literature in the health professions. Table 2 shows a comparison between the study domains, the CDHA's areas of responsibility and the harmonizing model (19) which was developed from the analysis of ability statements in several Canadian health professions. There were seven small working groups and eight domains articulated.

Each of the domains includes 14-15 ability statements to support the domain role. The inclusion of all the ability statements is beyond the scope of this article. However, Table 3 provides an example related to the role of communicator and collaborator, a role which received more emphasis than in previous Canadian dental hygiene documents.

The draft competency profile is currently nine pages long, with an introductory page supported by eight domains, each one page in length. This draft formed the basis for the questions in the Phase 2 web-based survey implemented in the fall of 2007.

DISCUSSION

During the PPC meetings the focus of the initial project shifted from the revision of diploma and baccalaureate abilities, to the articulation of entry-to-practice abilities without reference to a particular Canadian educational model. What do new graduates need to know and be able to do to provide appropriate dental hygiene services for the Canadian public? This parameter was frequently reinforced and discussed during the workshop; it made the work more challenging as every item needed to be oriented to this entry-to-practice criterion. Participants wanted to create a meaningful profile, one that was relevant to current dental hygiene practice and would be useful for a variety of purposes.

The facilitators were mindful that it was important to provide some structure to the activities associated with the workshop. However, the participants were frequently reminded not to let the structure dominate their vision and their work. During the course of three days, participants gradually moved away from the CDHA framework identified in the Dental Hygiene Definition and Scope (5) document and integrated elements of the harmonizing model developed by Verma et al. (19) This harmonizing model was developed through an analysis of ability statements in medicine, nursing, occupational therapy and physiotherapy in Ontario. This work is now being continued with other health professionals such as pharmacy, dentistry and social work with the objective of identifying shared abilities to support interprofessional education (email communication with Dr. Verma, January 12, 2007). Some of the domains of the harmonizing model appeared to align well with the ability statements created during the workshop but a plethora of other documents were also referenced. The domain themes found in health professional literature were viewed as being more appropriate for the articulation of entry-to-practice abilities than some of the currently identified CDHA areas of responsibility.

The alignment of language to the competency model and the integration of aspects of the harmonizing model (19) were also viewed as prudent political decisions to better position the dental hygiene profession in the context of other health professions in Canada. The dental hygiene profession needs to identify the shared abilities we have with other professions. As with many other health care professionals, dental hygiene education often occurs in isolation with a subsequent expectation that all professionals will then work collaboratively in various settings. As Carlisle et al. (17) questioned in their article title: Do none of you talk to each other? A document to support discussions about shared competencies was deemed to be important for furthering intra- and inter-professional educational opportunities for dental hygiene students. It also appears prudent to align ourselves with other health care professionals so that we can encourage greater understanding of the respective profession roles, and ultimately provide comprehensive client care.

The group developed a new domain framework for dental hygiene competencies based on the literature in interprofessional education. The core abilities reflect the shared abilities dental hygienists have with other health professionals but they are fleshed out within a dental hygiene context. Verma (19) et al. suggest that shared abilities identify the elements of the social contract between the public and self regulating professionals. This is supported by Codes of Ethics at the provincial, national and international level which highlight dental hygiene responsibilities. These documents address issues of professionalism, accountability, advocacy and general beneficence at the individual and community level. (97,98)

The description of these core abilities is then followed by the client service abilities which articulate the specialized services provided by dental hygienists. These roles come more directly from the CDHA framework. (5) However, they have also been modified to a degree. The education focus was directed to "oral health" to better reflect our content expertise. The health promoter role was shaped more broadly to reflect our focus on oral and general health promotion. This then highlights the reality that dental hygienists perform a supporting role for the health promotion initiatives of other professionals.

As with any typology there are overlapping areas and limitations: the domains do not reflect discrete roles. In essence our entire scope of practice could be articulated within the context of professionalism. That is what happened during the workshop. The professional domain became so large that the small working group clustered abilities into themes within this domain. The size of this domain made it challenging to understand. Hence elements were shifted among the various domains and the domain itself was subdivided as well. The current document still includes many areas of overlap and perhaps redundancies. However, it was recognized that further validation activities would involve a larger group who could shed light on these issues and further shape the competency profile.

The areas of communication and collaboration were extracted from the professional domain. The preference was for a one-theme domain, but it presented challenges as the participants could not decide which of the roles to emphasize--the role of communicator or collaborator. Communication is a broad ability extending beyond the notion of collaboration. However, the group also wanted to clearly emphasize the collaborator role. Adding another domain to the competency profile was rejected given that it enlarged the overall profile. The best solution was to use both terms in one domain, placing the larger ability first.

The development of a domain in the area of leadership was also explored. While the participants recognized that leadership could take many forms, both formal and informal, they were also concerned with authentic measurement issues within the context of the entry-to-practice level. The solution was to embed this role within the context of advocacy in particular but other domains as well. While this role is present, its emphasis as a domain was considered to be unrealistic at an entry-to-practice level.

The workshop participants shifted their thought patterns towards the themes in the health professions' literature as they believed these themes more accurately reflected entry-to-practice, domains. The CDHA areas of "research and administration" were perceived to be more reflective of career paths for dental hygienists rather than entry-to-practice level abilities. The decisions in these domains were probably the most controversial and challenging as they moved the focus away from the CDHA framework (5) in a substantive manner. The move from "change agent" to "advocate" was more of an operational shift to support clarity. However, the combination of shifts does represent an important change in the way Canadian dental hygienists articulate their roles.

The initial competency profile developed in the 1980s was focused on discrete clinical skills such as instrumentation and fluoride application. The shift to learning outcomes resulted in the creation of broader ability statements (6,55) with more emphasis on the critical thinking processes that were not as readily evident in the initial national competency document. This current competency profile reflects a shift towards more detail, but not the same type of detail as in the initial competency document. It reflects a balance among the previous national documents.

CONCLUSION

This study was the first step in creating overarching ability statements that reflect a national standard for entry-to-practice into the dental hygiene profession. The product created aligns with current literature in the health professions with a particular emphasis on the articulation of shared abilities. The profile is, of course, in an embryonic phase and requires further validation by a larger group of dental hygienists.

If validated, the competency profile does represent a substantive shift away from the CDHA areas of responsibility so it has the potential of creating a ripple effect of change in many organizations, particularly educational organizations which often rely heavily on the CDHA framework. The competency profile is anticipated to support the work of various provincial and national organizations. These organizations will need to further shape the profile given that each organization may require a different level of specificity for its work. The profile has the potential to be a positive force to support greater consistency of educational, and possibly regulatory, standards across Canada.

Acknowledgement: We would like to acknowledge the members of the PPC including Dianne Gallagher (DHEC), Linda Jamieson (DHEC), Doris Lavoie (NDHCB), Susan Matheson (CDAC), Laura Myers (CDHA), Fran Richardson (FDHRA), Brenda Walker (FDHRA), Susan Ziebarth (CDHA), and the members of the Phase 1 workshop (Bonnie Blank, Laureen Best, Arlynn Brodie, Joanne Clovis, Sandy Cobban, Ann Comeau, Sharon Compton, Patricia Covington, Shafik Dharamsi, Laura Dempster, Linda Jamieson, Salme Lavigne, Sandra Lawlor, Sue McIntosh, Brenda Maclssac, Linda McKeown, Heather Murray, Fran Richardson, Louise Robichaud, Brenda Udahl, Mickey Wener, Ann MacDonald Wright) for their efforts in moving this project forward.

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Susanne Sunell*, EDD, RDH; Fran Richardson ([double dagger]), BSCD, MED, MTS, RDH; Brenda Udahl ([section]), BV/TED, MHRD, SDT, RDH; Linda Jamieson ([dagger]), MHS, BA, RDH; Dianne Landry ([nabla]), BED, RDH

* University of British Columbia, Vancouver and Omni Educational Group, Ltd.; ([double dagger]) Canadian Dental Hygienists of Ontario, Toronto; ([section]) SIAST, Wascana Campus, Regina, Saskatchewan; ([dagger]) Dental Hygiene Program, Georgian College, Orillia, Ontario and the Council for CDHO; ([nabla]) consultant CDHA, DHEC, CDHO, NBDHA and NSDHA. Submitted 30 Sept. 2007; Revised 19 Nov. 2007; Accepted 22 Nov. 2007

Correspondence to: S. Sunell, University of British Columbia, 2329 West Mall, Vancouver, BC V6T 1Z4; [e-mail]

Interest group      Numbers

FDHRA                4
CDAC                 2
NDHCB                2
CDHA                 2
DHEC / Educators
  Nova Scotia        1
  Quebec             2
  Ontario            4
  Manitoba           1
  Saskatchewan       1
  Alberta            1
  British Columbia   2
Total               22

Table 1: General profile of workshop participants

CDHA areas of
responsibility (5)  Study domains     Harmonizing model1 (9)

                    Core abilities

Professional        Professional      --
--                  Communicator and  Communication Collaborative
                      collaborator      practice
Research            Critical thinker  --
Change agent        Advocate          Consultation Cooperation
Administration      Manager           Coordination

                Dental hygiene services

Clinical therapy    Clinical          --
                      therapist
Education           Oral health       --
                      educator
Health promotion    Health promoter   --

Table 2: Comparison of domain frameworks

Study domain: the dental hygienist as a communicator and collaborator

The entry-level dental hygienist has reliably demonstrated the ability
to:
 1. Use effective verbal, non-verbal, visual, written, and electronic
    communication.
 2. Demonstrate active listening and empathy to support client services.
 3. Select communication approaches based on clients' characteristics,
    needs, and linguistic and health literacy levels.
 4. Consider the views of clients about their values, health and
    decision-making.
 5. Facilitate confidentiality and informed decision-making in
    accordance with applicable legislation.
 6. Use computer technology to access electronic resources, and enhance
    communication.
 7. Investigate the role of governments and community partners in
    promoting oral health.
 8. Inform other professionals about dental hygienists' scope of
    practice.
 9. Respect others' scope of practice in relationship to that of dental
    hygienists.
10. Work with others to assess, plan, implement, and evaluate services
    for clients.
11. Foster team relationships to support client services.
12. Function effectively within oral health and interprofessional teams
    and settings.
13. Apply knowledge of common risks to inform public policy and educate
    practitioners and the public.
14. Act as a knowledge source for clients, professionals and the public
    to gain knowledge about oral health and access to oral health care.

Table 3: Example of abilities to support the domain role of communicator
and collaborator