The Professional Practice Environment of Dental Hygienists in the Fifty States and the District of Columbia, 2001

April 2004

Chapter 3. The Dental Hygiene Professional Practice Index

This chapter summarizes the professional practice indices for DHs for the 50 States and the District of Columbia. It includes the following subsections:

• Introduction
• Description of the Scoring Instrument
• A Summary of the DHPPI Scores
• The details of the scoring of the DHPPI for each State can be found in Appendix C.

Introduction

The Index

The index that quantifies the practice environment for dental hygienists across States is built on a number of conditions for practice that are perceived to enable provision of care to patients without traditional access to oral health services and especially without access to preventive oral health services. The items on this index were chosen after consultation with hygiene professionals, discussion with the project advisory committee, and considerable research by project staff about the legal requirements for provision of hygiene services across States.

The index is composed of a number of individual items that carry a designated score. A score totaling from 0 to 100 is theoretically possible. The optimal score of 100 would indicate an actualized practice environment that would maximize access for the patient by enabling a hygienist to provide services within the scope of training unencumbered by unnecessary restraints of supervision and setting that distract from the provision of appropriate levels of care. This is a theoretical index built on several premises including recognition that care must be provided within parameters of education, training, and skill, that patient safety is of prime importance, and that appropriate oral health care should be available to the patient, enabled to the professional, and facilitated rather than discouraged by regulation. 

Certain procedural standards were adopted in creating and scoring the index:

• Legislation and/or regulation that was passed or enacted by December 31, 2001 was scored on the instrument. If a law was passed in a State but the regulation not yet promulgated the new legislated standard was scored. However, if legislation was pending on December 31, 2001, no credit was given for expansion of practice. In cases where change has occurred subsequent to December 31, 2001, those changes are footnoted as completely as possible. Those changes would elevate the score in the affected State in any future index.
• Explicit legislative or regulatory provisions guided the scoring on the instrument. Although actual practice conditions may differ from the legal standards in a State, the scoring instrument reflects, as accurately as possible, the legal conditions that enable practice. If, for instance, practice in an alternative setting is permitted in legislation but does not actually occur in a State due to other limitations, a score was still awarded. Although it is understood that actual practice may differ from that enabled in law and regulation, an objective standard is necessary to establish a level of confidence in the measures provided by the index.  It is also surmised that when actual practice differs from the legal standard, it occurs within the parameters of the standard but may not be as expansive as the law permits. 
• In certain situations, scoring was implicit. If, for example, a statute has no stated limitations on settings in which hygienists may practice then the supposition was made that no legal limitations on practice settings apply.
• The standard of unsupervised practice for hygienists in the provision of preventive oral health services was adopted as the theoretically optimal configuration for practice. This benchmark is based on the assumption that a licensed and regulated health professional who meets educational and certification standards can provide services within the scope of his/her clinical training with autonomy without endangering public safety or public health. This seems a fair assumption considering the legal and regulatory safeguards that establish parameters for practice of health professionals across States. Also worthy of consideration is the constraint and good judgment that is engendered in the education and training process of clinicians. Standards of prudent care are also part of the credentialing and certification process for clinical professions. Each of these processes, education, certification and licensure, provide inherent safeguards that foster clinical practice standards with a primary goal of doing no harm to patients. These extrinsic professional standards create implicit controls for professionals that probably do not need to be so explicitly legislated.

The Scoring Instrument

A scoring instrument was designed by researchers to quantify particular aspects of the legal practice environments for dental hygienists. The component items within the index selected for scoring were intended to capture characteristics of professional practice for dental hygienists in the 50 States and the District of Columbia that enabled hygienists to provide oral health services. An optimal environment was hypothesized to be one in which a professional hygienist had sufficient autonomy to provide preventive and prophylactic services to patients within a scope of practice that is consistent with the education and training of professional hygienists.

Emphasis within the instrument was placed on enabling features within practice acts and board regulations that permit greater access to hygiene services particularly for underserved populations. The individual items on the instrument were selected based on conditions that are perceived to affect access in a variety of practice environments. Weighted scores were applied depending on the perceived importance to achieving access.

Points (totaling 100) were assigned to the various items. A composite score for each State was achieved by summing the scores for each item within the instrument. A score of 0 would indicate a restrictive environment that did not favor access while a score of 100 would suggest an optimal environment for access to hygiene services. Scores in the range reflect more or less favorable practice environments.

The construction of the instrument was also guided by the dental hygiene profession and its perception of an ideal legal practice environment that would encourage optimal use of the skills and competencies of the trained professional.

The following suppositions guided the construction of the index:

• Professionals must be legally enabled to perform their work;
• Professionals must be allowed to work under circumstances that permit them some autonomy within their scope of practice;
• The tasks permitted must be within their professional education and training;
• Professionals must be paid for the services that they provide.

The instrument is designed under four major groupings that were selected to identify environmental considerations that affect practice by the profession:

• Legal and regulatory environment. Various factors in the legal and regulatory environment were addressed including governance of the profession, the composition of the State regulatory boards, the conditions for licensure in the State, and any required relationship between patient and dentist that might affect provision of hygiene services.
• Supervision in different practice settings. The supervision section of the document scored dental supervision requirements across a range of health settings including private dental practice and other non-traditional settings such as schools, nursing homes, long term care facilities, and correctional institutions.
• Tasks permitted under varying levels of supervision. In the section of the instrument addressing tasks allowed in legislation, services that are fundamental to hygienists such as prophylaxis were considered as well as the ability to provide expanded functions such as local anesthetics or placement of amalgam restorations.
• Reimbursement. The final category examined the reimbursement environment in the State and the manner in which payment to hygienists is addressed.

A continuum of practice conditions applies. For example, a dental hygienist may be permitted to provide oral hygiene education without direct involvement of a dentist. However, the administration of nitrous oxide would generally require more immediate involvement or availability of a dentist. This index is designed to accommodate that continuum.

A more lengthy explanation with State specific examples to illustrate the importance of the items chosen for the index is included in this report in Appendix C.

Center for Health Workforce Studies, University at Albany, 6/2003

[D]

Summary

The scores compiled on the index provide a statistical comparison of State practice environments for dental hygienists across the fifty States and the District of Columbia.

The scores should be viewed as a reference to evaluate conditions of practice in a State in comparison to practice in other States at a particular point in time. The individual components of the score provide insight to areas where change might better enable access to hygiene services or improve the availability of preventive oral health services in alternative settings. Caution is suggested when evaluating small variations of a point or two between States that are relatively insignificant. Overall, however, the wide variation in the range of scores is of note.

This range in scores from 10 to 97 suggests that the dental hygiene profession is unlike similarly positioned medical professionals. Index scores recently established for “mid-level” medical providers in a related scope of practice study indicate that nurse practitioners, physician assistants, and certified nurse midwives are experiencing standardization across States in their conditions for practice. These scopes of practice were scored based on legal recognition, prescriptive authority, and direct reimbursement indicators. The range of scores in the indices for these medical professions is much smaller suggesting more homogeneous models for practice across States. Their medical and nursing scopes of practice incorporate both permissive and restrictive characteristics especially with regard to supervision and collaboration with physicians, achieving a more equal tension than is afforded to dental hygiene. These legal conditions enable effective practice for the medical and nursing professionals while still providing safeguards to the public.

The broad range of scores for dental hygiene scope of practice across States is suggestive of a less progressed environment for practice. There does not appear to be the same standardization presently occurring for the hygiene profession across States as has occurred for medical professionals. Whereas some tension between permissive and restrictive features of professional practice seems to be desirable for any profession, the hygienists’ scope of practice in most States appears still to be much more restrictive than permissive in legislation and in regulation. The benchmarks for the professional regulation of hygienists are the States with the higher scores that have enabled practice for the profession and access for underserved population while still ensuring public safety and providing appropriate professional oversight.

Standardization of the professional norms across States will require legislative and regulatory change. It may also require a change in governance for the profession. Self-regulation may need to occur before practice conditions can be changed to further enable access. Some change in the present paradigm for provision of oral health services may also be indicated. This statistical index of professional scope of practice for dental hygienists supports the fact that significant disparity in professional regulation of hygienists exists. The index provides a graphical illustration of this variation across States and suggests there is opportunity for change to occur which might increase access while still providing appropriate inherent safeguards to the public.