Exploring the challenges which influence General Dental Practitioners’ participation as Educational Supervisors in Dental Foundation Training in the Southwest of England.

doi:10.21203/rs.3.rs-4308206/v1

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Exploring the challenges which influence General Dental Practitioners’ participation as Educational Supervisors in Dental Foundation Training in the Southwest of England.

https://doi.org/10.21203/rs.3.rs-4308206/v1

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Introduction

The NHS dental crisis is well documented and access to dental care continues to be a major issue for many patients. Recruitment and retention of dentists and the wider team have been identified as a key factor, particularly within rural and coastal communities. Availability and geographical location of Dental Foundation Training (DFT) placements is considered to be an important element in recruiting new dental graduates to poorly served areas. However, a recent decline in the number of dentists applying to act as Educational Supervisors (ES) for DFT has been observed, which has raised concerns over the impact this could have on recruitment and NHS dental access.

Aims

The study aimed to explore specific challenges faced by ESs that may act as influencing factors to participating in DFT in Southwest England.

Design

Cohort study of existing and previous ESs, using qualitative methodology.

Methods

ESs in the six schemes of the Southwest of England participated in semi structured one-to-one interviews to explore the challenges which they faced in their role as an ES for DFT. Data underwent inductive thematic analysis.

Results

Eighteen ESs were interviewed with the main challenges identified as increasing workload, financial, recruitment process, feeling valued and the ES application process.

Conclusion

An increasing number of challenges are undermining the positive benefits of being an ES. If these are not addressed this is likely to result in continuing difficulties in the recruitment and retention of ESs. Some of these challenges can be addressed at a regional or local level, but the factors related to funding, national recruitment and the increasing educational responsibility of the ES, need to be addressed at a national level.

Health sciences/Health care/Dentistry

Dental Foundation Training

Educational supervisor

Recruitment and retention

NHS Dental access

The NHS dental crisis is well documented and access to dental care continues to be a major issue for many patients⁽¹⁾. Rural and coastal communities are particularly affected⁽²⁾, and these problems appear to be closely linked to recruitment and retention (R&R) of the dental workforce⁽³⁾. Factors affecting R&R of dentists in rural and coastal areas have been reported to include geographical challenges, poor transport links, urban prominence of dental schools, and dentists preference to work within urban areas⁽⁴⁾. Additional factors such as delays in dental system reform, the COVID pandemic and BREXIT have also been reported to impact on R&R in rural areas⁽⁴⁾.

Undergraduate placement and postgraduate exposure have been recognised as influential factors in recruiting and retaining medics within rural areas ^{(2, 5-7)} demonstrating the importance of aligning postgraduate training opportunities with workforce needs. The majority of UK dental graduates undertake a one-year period of Dental Foundation Training (DFT) following graduation. This is based in primary care under the supervision of an Educational Supervisor (ES) and successful completion is mandatory for UK dentists who wish to gain an NHS ‘Performers Number’ and be included in the National Performers List. Long term career choices and dentists’ geographical location can be strongly influenced by the DFT placement experience⁽³⁾. The availability and location of DFT posts is likely therefore to influence the R&R of dentists.

The South West (SW) Postgraduate Dental Deanery has been aware of a decline in the number of dentists applying to act as an ES for DFT in recent years⁽⁸⁾. An internal survey of ESs, conducted by the SW Deanery suggested several factors affecting R&R within DFT practices⁽⁹⁾. The survey provided a scaffold on which to build this in-depth study to explore more deeply the factors which influence ESs to participate in DFT in the SW and was commissioned by the local NHS England Workforce, Training and Education (NHSEWTE, previously HEE) team.

Rationale

Table 1 shows data relating to applications for ES roles in the SW Deanery received between 2016 and 2022; including the number of new applications received, and numbers of ESs who had stepped down from their role. During this time, an 18% decrease in the overall number of ES applications was noted. In 2016, no ESs discontinued their role, whereas 19 out of 77 (25%) ESs resigned in 2022 (Table 1).

Table 1: ES Applications received, discontinued and renewed.

Year	Total number of applications received	Number of ESs discontinuing position	First-time ES applications
2016	87	0	15
2017	83	23	13
2018	85	10	17
2019	84	6	10
2020	70	11	13
2021	79	6	10
2022	71	19	13

The availability and quality of training practices is critical in providing new graduates with a supportive environment in which to develop their skills, knowledge and capabilities. Geographical distribution is also an important factor in terms of retaining the workforce and maintaining access to services for patients, particularly in rural areas. Figure 1 shows the locations of the ESs recruited for 2022, and which schemes they were recruited into. Access to a large pool of ESs is important in terms of geographical distribution, as well as being an important factor in maintaining standards. A surfeit of applications to positions available ensures the appointment of trainers is a competitive process with the most appropriate practices and trainers being selected.

This study aimed to explore the challenges faced by ESs in relation to the influencing factors of becoming or remaining an ES, and how this could impact on the long-term sustainability of DFT.

Design

In-depth semi-structured interviews were undertaken to explore participants’ views, thoughts and experiences of acting as an ES. Such methods that produce a rich qualitative dataset are particularly suitable when the research question aims to gain a deeper understanding or knowledge of a subject from an individual’s perspective⁽¹⁰⁾. Stewart et al. describe the use of qualitative methods in dentistry as being “ideally suited to research where little is already known or understood”⁽¹¹⁾

Sampling and recruitment

Educational Supervisors from the SW of England, past and present, were invited to participate. Recruitment was facilitated by the Postgraduate Deanery who contacted ESs across the six DFT schemes (Bath and West, Bristol and South Cotswold, Devon and Coastal, Dorset and Wiltshire, Somerset, and West Devon and Cornwall). Contact was initiated by email, including study details, a link to the participant information sheet (PIS), and an on-line consent form hosted by JISC (https://www.onlinesurveys.ac.uk/). Hard copies were available upon request. A snowballing technique was used to promote ongoing recruitment; heterogeneity was achieved through purposive sampling with consideration given to ES’s current recruitment status, level of experience and geographical location.

Data collection

Semi-structured interviews were conducted remotely, hosted on the Microsoft Teams© platform, each lasting 45-50 minutes. Interviews were directed by a previously developed topic guide developed from findings of the SW Postgraduate Deanery survey, published literature, and personal experience of DFT. The topic guide was refined following review by a Regional Training Programme Director and piloting with two ESs. The topic guide focussed on three key areas: specific factors that influenced an individual to apply to be an ES; positive aspects of being an ES; and current challenges of the role. Interviews were audio-recorded and transcribed verbatim. The transcripts were checked for accuracy by HM with data anonymised.

Data Analysis

Data collection and analysis took place concurrently as part of an iterative process, with recruitment continuing until theoretical data saturation⁽¹²⁾ was considered to have been achieved. Reflexive inductive thematic analysis was conducted, adhering to Braun and Clarke’s six recursive stages ⁽¹³⁾. NVivo^TM software was used to organise the data and facilitate mapping of codes to the a priori themes. The research team regularly reviewed transcripts, compared codes, considered divergent cases and agreed theme generation to ensure intercoder reliability.

Demographics

Eighteen interviews were conducted, with nine female and nine male ESs. Most of the participants were located in Devon (n=11). Other locations included Somerset (n=3), Dorset (n=1), Gloucestershire (n=1), Cornwall (n=1), and Wiltshire (n=1). Three ESs were new to the role (first time applicants), thirteen had over ten years of experience, and two had recently resigned.

Thematic Analysis

Data were guided by the three overarching a priori themes intrinsic to the research questions:

Motivating Factors ([inspiration] to become an ES),
Positive Aspects (of being an ES) and
Challenges (of being an ES).

Motivating Factors included three key themes: Career Progression, Business Continuity and “Giving Back” (See Figure 2)

Positive Aspects included three key themes: Personal and Professional Fulfilment, Service Delivery and Practice Benefits. (See Figure 3)

Challenges included five key themes: Workload, Financial, Recruitment Process, Feeling Valued and ES Application. (See Figure 4)

In the interests of brevity, and to highlight the area with the greatest scope for intervention, this paper focusses, this paper will focus on the challenges which Educational Supervisors reported to be a barrier to their potential continuation in the role.

Challenges

Participants were eager to share their growing frustration with the changing role of the ES over the last number of years (See Figure 4). The overarching complaint related to increasing workload and responsibility, with a decreasing remuneration.

“So we're getting less money, but they expect us to do more stuff” #4

Workload

One of the major frustrations was the level of workload and responsibility which was considered to have increased steadily over recent years. This was in part due to the administrative burden, but was also related to the level of support required by new FDs in terms of their clinical, professional and personal development.

Administration

Participants raised concerns over the increasing number of assessments and the level of administrative work relating to the e-portfolio.

“Staying on top of the portfolio, it's onerous in my opinion, too onerous…..the DOPS and the ADEPTS I mean I think a lot of those are unnecessary …. just seems that it's quite a lot of duplication.” #12

Participants did acknowledge the value of the assessments, particularly for FDs who needed more support, but felt there should be more flexibility in terms of the needs of the individual.

“I think a lot of the ESs find it quite tedious to fill in the portfolio….It does become a little bit repetitive….if there was some way of streamlining that so that if you know part way through the year the FD was sort of was doing well that you know you moved to a much lighter touch.” # 16

Foundation Dentist Support

A consistent view expressed by the ESs was that many Foundation Dentists (FDs) were not adequately prepared for practice and that there had been a decline in clinical experience, confidence and resilience of new graduates compared to previous years.

“They do seem to be a little less resilient; I do think it's a lot more training involved, especially when I've had a few years where I've had some challenging FDs to say the least, and it's been a lot more training.” #4

A common viewexpressed was the feeling that many new graduates had a significant lack of clinical experience, which placed a greater responsibility on the trainer in terms of educational support and direct supervision.

“I think the graduates coming through probably have less clinical experience. I think they're getting a lot less numbers through their hands than they should have done.” #8

It was also suggested that FDs were less confident carrying out certain clinical tasks and required significantly more guidance and support than was previously the case.

“They've become progressively less confident in their abilities when they get to us. And so as well as building on their clinical dentistry, you have to build on that confidence”. #1

The reported lack of experience and confidence of new graduates was considered to place greater pressure, stress and burden on the ES, directly impacting on the ability of the trainer to attend to their own patients, as well as the FD output being lower.

The level of support required was very much dependent on the individual, with a wide range of capability, experience, confidence and attitude observed across new graduates. This range of abilities could have a profound impact on the practice and the ES.

“But if you've got someone who's really bad, a year is endless because the amount of extra paperwork you have to do, the amount of excusing yourself from your patients to go up and dig them out of something that they shouldn't have got themselves into in the first place, you're having to do maybe an hour before they start and an hour at the end of the day, sort of a debrief finding out what they're doing.” #13

Funding

Inadequate funding for DFT was highlighted repeatedly and was seen by some as the main challenge to being an ES.

"They're adding more and more things, but the pay is less and less." #14

Educational Supervisor Funding

Several elements of the funding were highlighted and this tended to focus on the increasing level of responsibility without a commensurate increase in remuneration. The service cost element of funding was heavily criticised by several practice owners and was now considered to be inadequate in the face of rising costs.

“The service contract being so poor. And I think that is probably why most of the educational supervisors leave. When you look at our service contract, it hasn't really changed since 2008 or 9.” #13

Business Pressures

With increasing practice costs, participants expressed the view that DFT was no longer profitable, and without a significant increase in funding, continuing as an ES was unsustainable.

“The funding hasn't kept pace with inflation,……it hasn't kept pace with my practice expenses by any stretch of the imagination. So as a practice owner, as a business owner, you think actually could this surgery be better utilised.” #12

National Recruitment Process

A national recruitment process was introduced for England, Wales and Northern Ireland in 2011, which was a radical shift away from the previous model. The previous process operated at a practice level with students applying directly to join the practice. The process was considered unfair by some, with allegations of nepotism, leading to a desire to create an equitable and transparent process. The current process allocates students to a particular training scheme based on their national ranking assessed by a Situational Judgement Test. The applicants, in rank order, then select the practice which they wish to join, with the ES excluded from the decision-making process.

Lack of input

The national recruitment process was widely criticised and perceived as unfair to the practice, with the ES not involved in selection or allocation. Experienced ESs, familiar with the previous process, lamented the loss of control, and were highly critical of National Recruitment and the potential impact it could have on the practice, staff, patients and FD.

"The biggest thing that people worry about is who they're going to get and the fact that it is a bit of a bit of a lottery with the national recruitment…. you're getting no say in who you're getting, like, I think that's the biggest challenge." #8

The lack of influence, for both the ES and the FD, over practice allocation was seen as a potential issue in terms of the fit of the individual within the team. This was considered an important element in how well the FD integrated into the practice and the relationship with the ES was seen as key to the development and progress of the trainee.

“People's personalities matter in terms of like making sure it's a good fit. If you're gonna be having a supervisor and an FD relationship, I think it's important that there aren't any clashes there.” #17

Feeling valued

Several participants did not feel supported, or fully valued in their role as an ES, and considered a lack of communication to be a key factor.

“As a new or an existing ES, I don't think we get that much communication from the Associate Dean and the Dean. I don't think educational supervisors feel valued. And I think not feeling valued comes from a lack of communication.” # 1

Some changes which had been implemented without engagement with ESs had caused a degree of frustration and resentment. These included changes to the training day schedule, a shift towards on-line training, and cessation of the ES Study Days. Such actions were perceived as a lack of understanding by the Deanery, and made ESs feel undervalued.

“There is a definite lack of understanding from the post graduate department” #4

“You sometimes feel like you've been taken for granted which makes it very easy for people to walk away because they don't feel valued.” #13

Educational Supervisor Applications

Application process

Participants raised concerns around the ES application process, describing it as onerous and unnecessarily burdensome, particularly by those who had been trainers for several years. However, the recent simplification of the process by the deanery was appreciated by the ESs.

“It is a complete ball-ache and having to do it every year is incredibly tedious. I think it is a barrier to application to apply.” #3

Trainer eligibility

There has been a significant reduction in NHS provision across the UK, with many dentists reducing their commitment to the NHS. In England, ESs are required to have a minimum commitment to the NHS in terms of Units of Dental Activity (UDAs). The shift towards the private sector creates a potential barrier for some ESs to continue in their role.

“But I think an awful lot of practices are also giving up on the NHS, we have to do 1000 UDAs to be approved as an educational supervisor” #12

Dental Foundation Training was introduced in the UK as a mandatory requirement in 1993 for those wishing to work within NHS primary care. Satisfactory completion (or equivalence) is now a statutory requirement for inclusion on the NHS Performers List. The role and delivery of DFT has changed significantly over the last 30 years in response to the changing dental and healthcare environment, the needs of new graduates, and an improved understanding of dental pedagogy placing a greater responsibility on the ES.

At a time when there are growing concerns about access to NHS dentistry, workforce recruitment and retention, mental health and wellness, and the preparedness of graduates for practice, DFT plays a vital role in supporting students make the smooth transition from undergraduate to independent practitioner. In the wider study/dataset, the participants recognised the value which DFT provides for new graduates, as well as dentists, dental practices and patients, and identified positive elements that prompt dentists to act as ESs. However, they voiced concerns about some of the changes which have been introduced over recent years, which they believe are impacting negatively on ES experience and participation.

The main challenges identified are workload and funding, and there is clearly a growing frustration that the changing role and responsibilities of an ES do not appear to be recognised nor appreciated. Participants felt the challenges were getting greater, resulting in an increased workload and responsibility, but with no commensurate increase in remuneration. The DFT funding, most pointedly the ES trainers grant, was considered inadequate. Remuneration had not increased in line with inflation for over a decade⁽¹⁴⁾ and this was causing significant frustration and resentment, given the increased workload. The NHS service cost funding had also been neglected in real terms⁽¹⁴⁾ and this was particularly an issue for ESs who were also practice owners. Dental inflation has been running at high levels⁽¹⁵⁾ with costs of delivering care rising exponentially, and this was considered to make DFT increasingly unviable financially.

The administrative burden for ESs was deemed to have increased in volume and complexity, with more time required to support the FD and complete paperwork. The number and frequency of submissions on the e-portfolio was often referred to as “onerous” and “burdensome”, and was not tailored to the specific needs of the individual. The educational value of some of the assessments and reflective exercises were questioned, and participants felt that a review of the process was overdue.

The lack of preparedness for practice within recent FD cohorts was a consistent message, with many highlighting concerns around a declining level of clinical experience, confidence and resilience of students. This was acknowledged as variable across the cohort but was an important factor in terms of the level of support required. Greater levels of supervision adversely affected the ESs own clinical time, causing stress, pressure, additional workload and loss of income. Previous literature indicates that various opinions exist on how prepared new graduates are for practice, and what strengths and weaknesses may be present ^(16-18).

Most dental students are thought to graduate with an excellent level of theoretical knowledge, but some studies suggest they are less prepared for certain complex clinical procedures (minor oral surgery, molar endodontics and fixed prosthetics) and across some areas of ‘professionalism’, including attitude and motivation. ^(16-18). Educational Supervisors within this study reported trainees having “less clinical experience” but there was limited detail on which areas they were deemed to be lacking in; how they had reached this opinion; nor what the impact was. Many ESs equated having to spend more time in the surgery with an assumed lack of clinical experience, but there was little information to support this assumption. This is a topic of much interest within dental education, and although acquisition of clinical skills within dentistry is extremely important, it has been suggested that solely the number of procedures completed during undergraduate training is not a valid indicator to assess student competency and clinical experience⁽¹⁹⁾. ESs within this study expressed similar thoughts, and reported that some FDs with a self-reported lack of undergraduate clinical experience had high levels of competency, but lacked confidence. This is clearly an important distinction from an educational perspective, but ultimately may still have a profound bearing on the level of support required by the FD.

The national recruitment process was a concern for many ESs and was seen as a significant failing in the allocation of trainees. Recruitment of FDs is centralised, with places allocated according to a national ranking system based on an online Situational Judgement Test result. Neither the ES nor the practice have influence on allocation, which was considered unfair, particularly for rural practices which were often deemed less attractive for FDs in view of their remoteness and potential isolation. It was suggested that the current process did little to consider the importance of “fit” in terms of location, personality and shared interests, which could also impact on the mentor-mentee relationship. There was a strong sense that the process needed to be revisited and that ESs and practices should have some influence as to who joined their practice.

Workload, financial remuneration and national recruitment are primarily factors which are determined at a National level, and it is important that the concerns of ESs are listened to and acted upon to ensure the long-term sustainability of DFT. Failure to do so will undoubtedly see further erosion of DFT, at a time when it is desperately needed. Other factors can potentially be addressed at a local or regional level by changes to the application process, reductions in the NHS eligibility criteria, improving communication, simplifying the application process and providing support, training and networking opportunities for ESs.

NHS provision is declining across the UK, and in the SW of England only 70% of UDA activity was delivered for the 2022/23 year⁽²⁰⁾. Many practices and practitioners are actively reducing their commitment to the NHS, and this can have a direct impact on the eligibility of dentists to apply to be an ES. The loss of experienced ESs, due to a reduction in NHS commitment, is likely to have an impact on the quality and availability of trainers. This has been recognised by the SW Postgraduate Deanery, which has led them to adopt a more flexible approach, and introduce a number of progressive changes, including simplifying the application process: offering educational incentives: reducing the UDA threshold for eligibility: proactively recruiting practices / trainers: and facilitating new trainer workshops. This appeared to have a positive impact on recruitment in 2023/24, with 23 new ESs applying to participate in the SW schemes. Compared to the previous year, resignations decreased by 63.2% (n=7) which resulted in an overall 14% (n=81) increase in applications.

The geographical distribution of DFT practices was also considered important in terms of dental access and long-term recruitment. Practices within “dental deserts”⁽²¹⁾ were specifically targeted, and Cornwall saw a substantial increase in applications compared to previous years. (2022: n = 5 to 2023: n = 9) [Figure 5 (circled)]. Unfortunately, two of the Cornwall practices FD places were left unfilled following national recruitment, indicating the importance of promoting the benefits of training in rural areas to prospective FDs, and reviewing the national recruitment processes.

The NHS Long-Term Workforce Plan aims to deliver a significant increase in the number of dental students graduating in the UK in the future ⁽²³⁾. This will require a complimentary expansion in the number of DFT places and recruitment of additional ESs. Unless the issues highlighted within this paper are addressed, we will continue to lose ESs to the point where DFT may be seriously compromised. Recent announcements on a proposal to introduce Provisional Registration for International Graduates, will potentially place additional pressure on mentors and we must ensure that adequate training, funding and incentives are made available to resource this properly.

There are limitations to this study, in terms of the geographical homogeneity of the participant sample. Most participants were based in Devon, despite the best efforts of the research team to recruit from other areas of the SW. The findings may therefore be subject to selection bias.

This research identified motivational factors and benefits of DFT from an ESs perspective and details several challenges directly impacting the recruitment of trainers. Some of these factors can be addressed at a regional level to mitigate loss of experienced ESs. This has been demonstrated with the successful changes made by the SW Postgraduate Deanery. Other elements must be addressed on a national level. If issues, such as funding, national recruitment, dental system reform and changes to ES eligibility are not addressed, dental practitioners will continue to withdraw from DFT, irrespective of local changes. This will place additional pressure on the Postgraduate Deaneries and impact directly on the availability of DFT which will in turn affect NHS access for the most vulnerable.

Dental Foundation Training is a critical step in the transition from student to independent practitioner. New graduates are entering a challenging and demanding environment, where regulators and patients have increasingly high expectations. It is crucial that FDs are provided with high quality mentoring and support, to ensure a positive start to their dental career. Recruitment and retention of Educational Supervisors is key and current challenges must be responded to and addressed appropriately to ensure the sustainability of DFT. The availability and geographical distribution of Foundation Training practices is an important factor in terms of dentist recruitment within rural areas. Urgent changes to DFT are required to avoid a further decline in oral health provision, especially within dental deserts.

Conflict of Interest

This study was funded by NHS England (Formerly HEE). Authors wish to declare no conflict of interest.

Author Contributions Statement

Hesham Matabdin: questionnaire development, collection of data, quantitative and qualitative analysis including development of themes and preparation of draft manuscript.

Ian Mills: contributed to all aspects of the study, including questionnaire development, quantitative and qualitative analysis including development of themes and writing the final manuscript.

Amy Rathbone: qualitative analysis including development of themes, writing text and proof-reading manuscript.

Laura Clarry; qualitative analysis including development of themes, revising text and proof-reading manuscript.

Sally Hanks: oversight of project, qualitative analysis including development of themes, language editing and editing final manuscript.

Acknowledgements

The authors wish to acknowledge and thank all dental foundation training educational supervisors who agreed to take part in this study. The authors would also like to acknowledge the HEE SW Team, Jane Luker, David Lee, Katy Williams and Jennifer Albiston for their support throughout the study, and Dr Marie Bryce for reviewing the manuscript prior to submission.

Ethical approval

The study was approved by the Faculty of Health, Faculty Research Ethics and Integrity Committee (Project ID 3951, Dated: 24/03/2023).

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Exploring the challenges which influence General Dental Practitioners’ participation as Educational Supervisors in Dental Foundation Training in the Southwest of England.

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Abstract

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Introduction

Methods

Design

Sampling and recruitment

Data Analysis

Results

Demographics

Thematic Analysis

Funding

Feeling valued

Educational Supervisor Applications

Discussion

Conclusion

Declarations

Conflict of Interest

Author Contributions Statement

Acknowledgements

Ethical approval

References

Additional Declarations

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