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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 4  |  Page : 319-325

Factors that influence the retention and turnover of dental professionals: Suggestion for Pacific nations


1 School of Public Health and Primary Care, Fiji National University (FNU), Suva, Fiji
2 Colonial War Memorial Hospital, Suva, Fiji
3 Rakiraki District Hospital, Rakiraki, Fiji

Date of Submission27-Nov-2020
Date of Decision05-Feb-2021
Date of Acceptance24-Feb-2021
Date of Web Publication19-Aug-2021

Correspondence Address:
Dr. Masoud Mohammadnezhad
School of Public Health and Primary Care, Fiji National University (FNU), Suva.
Fiji
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JIOH.JIOH_341_20

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  Abstract 

Aim: The aim of this article was to identify factors that influence the retention and turnover of dental professionals and to provide a suggestion for Pacific nations. Materials and Methods: A literature survey was conducted for the full-text English articles which looked at factors that influence the retention and turnover of dental professionals, from January 1, 2000 to October 31, 2020. Results: In total, 328 papers were retrieved, which reduced to 282 following removal of duplicates. The abstracts were screened using the eligibility criteria; 36 were found to match the criteria. After screening the full-text articles, 24 were excluded, resulting in a total of 12 articles. The significant findings and conclusions were extracted and grouped under themes. Conclusion: Factors that have been found to motivate and retain staff in the workforce include good patient relationship and opportunities for further studies and career advancements. In contrast, work stress, musculoskeletal disease, and fragile patient–dentist relationship were found to demotivate dental professionals. Furthermore, the results of such a research could be used to implement workforce policies and strategies, which will aid in the retention of dental staff and prevent brain drain. Ultimately, this would ensure that oral health status of the Pacific is not compromised.

Keywords: Dental Professionals, Dental Services, Oral Health, Pacific, Retention, Turnover


How to cite this article:
Nair RD, Gohil DA, Raman Reddy K V, Mohammadnezhad M. Factors that influence the retention and turnover of dental professionals: Suggestion for Pacific nations. J Int Oral Health 2021;13:319-25

How to cite this URL:
Nair RD, Gohil DA, Raman Reddy K V, Mohammadnezhad M. Factors that influence the retention and turnover of dental professionals: Suggestion for Pacific nations. J Int Oral Health [serial online] 2021 [cited 2021 Oct 26];13:319-25. Available from: https://www.jioh.org/text.asp?2021/13/4/319/324140




  Introduction Top


Oral diseases are the most prevalent non-communicable diseases (NCDs), affecting almost 4 billion people worldwide.[1] Oral health and general health have been found to be integral, and dentists aim to maintain and improve both of these, through their scope of training, experience, education, within the ethical boundaries pertaining to their profession.[2] In 2015, the World Health Organization (WHO) declared that the dental workforce globally involved 1.5 million personnel, of which 80% were dentists and the remainder included dental therapists, dental hygienists, and dental technicians.[3] Such a huge workforce is needed to provide dental services, as oral diseases have a vast impact on people’s daily lives and economic development, with the loss of millions of school and work hours yearly around the world.[4]

The Pacific region is no exception to this mounting issue, and the people of this area face oral health problems of varying magnitudes.[5] This is because industrialization and urbanization of Pacific island nations, in particular those which lie on trade routes, have brought a transformation in lifestyle, which encompasses a diet high in refined sugar, resulting in deterioration in oral health.[6] In order to address this growing issue, Pacific island nations introduced oral health programs, water fluoridation, and fissure sealants, and these initiatives resulted in a reduced caries experience.[7] However, these practices have been deemed insufficient in combatting the growing oral disease burden of the region. At the Pacific Oral Health Summit in 2001, regional oral health leaders were asked on what they perceived to be the major challenges they faced in the provision of oral healthcare; the factors identified were equipment, finance, lack of management, and manpower.[8] The issue of manpower and workforce planning for health workers is complicated by a multitude of factors.[5] In 2007, a survey conducted by the Commonwealth Dental Association[9] provided data on the Pacific islands. The report highlighted the variation in population-to-dentist ratio throughout the Pacific region, with some countries suffering from a clear shortage of oral health personnel. Countries such as Papua New Guinea (1: 283,527), Kiribati (1: 42,247), and Vanuatu (1: 34,812) were found to have the lowest dentist-to-population ratio in the world.[7],[8],[9] The problem of workforce planning and availability of manpower is compounded by the limited teaching institutions and training of new health workers.[5] The World Dental Federation lists the Fiji School of Medicine (now known as the College of Medicine, Nursing, and Health Sciences under the Fiji National University (FNU)) as the only teaching facility in the Pacific islands region involved in the training of dental therapists, hygienists, technicians, and dentists.[9],[10] In addition, the University of Papua New Guinea offers some oral health programs among its courses which include Bachelor of Oral Health, Diploma in Dental Technology, and Bachelor of Dental Surgery.[11] Thus, it could be said that the Pacific region lacks adequate teaching facilities and institutions for the training of oral health care workers, and this is evident by the unfavorable dentist-to-population ratio.

Moreover, the issue of unfavorable dentist-to-population ratio in the Pacific is further worsened by the migration of these skilled workers to higher-income countries. According to Balasubramanian et al.,[2] dentist migration is an emerging policy issue in the Asia-Pacific region. The reasons for dentist migration are multifactorial and include the lure of better remuneration, career growth, professional development, better living conditions, and working environment.[12] Australia and New Zealand, for instance, are the prime destinations for Pacific island dentists to migrate.[13] Research from developed countries has shown that migrant doctors report excessive workload, low-pay, discrimination at work, bad working conditions, and other issues that affect their satisfaction toward work, resulting in their decision to migrate.[14] While migration is a human right,[15] and considered essential for global development, it has led to “brain drain” in the Pacific region.[13] Another factor that is responsible for the unfavorable dentist-to-population ratio in the Pacific is the movement of dentists from public sector (government) to private sector. The Fiji Islands Health System review revealed that dentists are attracted to private practice due to a bottleneck regarding promotion within the public system. Furthermore, the report highlights that specialization in dentistry has not been developed, except for oral surgery,[16],[17] to allow for career advancement and improve retention of staff. Therefore, it could be said that movement of dentists to foreign countries or private sector is a major issue Pacific nation’s encounter, which can directly affect the delivery of service and implementation of oral health programs. Job satisfaction is an aspect that is now gaining attention in the world of human resource management. According to Locke,[18] job satisfaction can be described as a pleasurable or positive state of mind, resulting from the appraisal of an individual’s job or job-related experiences. Job satisfaction is linked with various aspects such as patient care, burnout, stress, turnover, teamwork, organizational functioning, and health system outcomes.[19] According to Luzzi et al.,[20] job satisfaction has been discussed in relation to issues such as potential loss of productivity, high turnover of dental staff, and even entirely moving away from the dental field. In fact, low job satisfaction has been linked to high turnover of dental auxiliaries and dentists, resulting in reduced quality of patient care and loss of productivity.[21] Based on this, it could be said that job satisfaction may be a significant factor influencing Pacific island dentists to move overseas or private sector.

In general, the movement of dentists to foreign countries or private sector is a major issue that Pacific island countries (PIC) face. The purpose of this narrative review is to identify factors that influence the retention or turnover of dental staff and to suggest Pacific nations on further research in this area.


  Materials and Methods Top


Search strategy

This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)[22] The research focussed question was identified with the aid of the PICO format: (P) is for the Participants, (I) for the Intervention, (C) for the Comparison, and (O) for the Outcome.[23] (P) were the studies that focussed on dental staff, and (I) were factors that influenced dental staff to become demotivated or move away from the profession. (C) were dental staff not exposed to factors that could demotivate or influence them to move away from the profession. (O) were the factors that affect the retention or turnover of dental staff from the profession.

Information sources

An electronic search was conducted in Medline, Embase, Scopus, and ProQuest databases. The keywords used included: (factors OR conditions OR component) AND (Dentist* OR “Oral health”) AND (“Dental staff” OR “Care giver”), AND (“Dental Services” OR “Oral Health”) AND (Retention OR Turnover). Narrative review was applied because the disparate themes and data were unsuited to systematic review or meta-analysis. The research was done to find answer to the question “what are factors that influence the retention or turnover of dental staff from the profession.” A survey of the literature was conducted for the full-text English articles from January 1, 2000 to October 31, 2020. This is because PIC are still developing and some of the issues that dental professionals in the region could possibly be experiencing may have already been studied and documented in the early 2000 s. Hence, published articles from 2000 were considered for this review.

Inclusion criteria were all studies that focussed on factors affecting retention or turnover of dental staff from the profession and the studies between 2000 and 2020. Exclusion criteria were conference abstracts, case reports, unpublished data, and studies conducted prior to year of 2000.


  Results Top


During the selection process, a total of 328 papers were retrieved, which reduced to 282 following removal of duplicates. The abstracts were screened using the eligibility criteria, 36 were found to match the criteria. After screening the full-text articles, 24 were excluded, resulting in a total of 12 articles [Figure 1]. These 12 articles were selected in the review; significant findings and conclusions were extracted and grouped, to formulate the themes made in this study. The included articles are summarized in [Table 1].
Figure 1: Flow chart for the search process indicating numbers (n) of included and excluded studies

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Table 1: Included articles

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  Discussion Top


This study found four themes that can influence dental staff retention and turnover. These include stress and burnout, musculoskeletal disorders (MSDs), dentist–patient relationship, dental education, and career advancements. These themes will be explained below in order.

Theme 1: Stress and burnout

Dentistry is seen as a difficult career, and dentists experience more occupational stress than other professions.[24] Types of stress for dentists are numerous, including financial issues, private practice problems, patients’ challenges, and feelings of time urgency and strain, which can be partly linked to career aspirations of dentists.[25] Furthermore, occupational stress among physicians not only affects patients adversely, but could also decrease the overall quality of healthcare service.[24],[25] Chronic stress (at the workplace) that has not been effectively tackled can lead to burnout, which is characterized by fatigue and dissociation (negativism) and is seen mainly in the healthcare and medical professions, including dentists.[26] Singh et al.[27] further elaborate that factors associated with an increase in the incidence of burnout among dental professionals include younger age, male gender, personality characteristics, clinical degree program graduates, high work-time training, and qualifications. In a retrospective cross-sectional study conducted by Anwar et al.[28] involving 124 dental practitioners of Karachi, Pakistan, the results revealed that 62% of the dental practitioners experienced burnout, and dental professionals who were in the practice for 5–10 years experienced more burnout than other groups. However, the burnout prevalence decreased for practitioners with more than 10 years of experience. According to the authors, this could be due to the fact that practitioners learn to cope with work stress and hence experience less burnout. Similarly, in a questionnaire survey conducted by Choy and Wong,[29] concerning 301 dentists of Hong Kong, 25.4% had a high level of emotional exhaustion, 17.2% had a high level of depersonalization, and 39.0% had a low level of personal accomplishment. However, only 7% of the respondents had a high level of overall burnout (high emotional exhaustion, high depersonalization, and low personal accomplishment). Khamisa et al.[30] elaborated in their study that stress and burnout could be major factors that have been found to be associated with job turnover, absenteeism, low morale, and personal dysfunction in nurses. Such similar sentiments may also be experienced by dentists.

Theme 2: Musculoskeletal disorders

MSDs are defined as a group of diseases and complaints that affect different structures of the musculoskeletal system. These include muscles, tendons, ligaments, bones, nerves, blood vessels, and supporting structures such as intervertebral discs.[31] Risk factors for the development of work-related MSDs in dental professionals are multifactorial, which include static or ineffective postures (specifically linked to both the neck and shoulders), repeated movements and the use of force (most frequently linked to the hand), lack of adequate lighting (including both brightness and location), inadequate patient positioning, and the individual characteristics.[32] In a self-reported questionnaire survey conducted by Leggat and Smith,[33] of 285 dentists of Queensland, Australia, it was found that 87.2% of the respondents reported having experienced at least one MSD symptom in the past 12 months; MSDs which interfered with daily activities during the previous 12 months were reported at the lower back (22.1%), shoulders (21.8%), and neck (24.6%). Over a third (37.5%) of the dentists had sought medical treatment or advice for an MSD during the previous 12-month period. Lastly, one in 10 dentists reported taking leave in the previous 12 months due to MSD. The authors concluded that MSD was shown to interfere with daily activities in some cases, whereas a significant proportion of dentists had also sought medical attention for their symptoms. Thus, it could be said that MSDs may have a huge impact on the career of a dental professional. Studies have shown that many dentists who suffer from MSDs seek medical treatment for their condition.[31],[33],[34] Furthermore, having such disabilities and illnesses at the workplace not only have direct costs in terms of obtaining medical care and compensation, but also indirect costs, such as productivity losses, lost earnings, and diminished quality of life.[33] Overall, it could be said MSDs may contribute in the movement of dentists away from the profession.

Theme 3: Dentist–patient relationship

Despite significant and dramatic changes in the medical systems and procedures, the clinical interaction between clinician and patient remains a central component of healthcare, with the development of a strong clinician–patient partnership at the center of real experiences essential to achieving patient-centered treatment.[35] In the last few years, patients have become critical consumers who search for better priced services, and their requirements and expectations from dentists are higher, resulting in greater levels of disappointment when treatment provided is not up to their expectations.[36] Such a scenario may arise, due to mistakes that may have been made, conduct of a dental staff, missed appointments, expectations of the treatment, or a difference of opinion on the size of the bill.[37] Dentists are typically perfectionists who get easily frustrated when not reaching the ideal therapeutic goal, and the burden to meet the patient’s high aesthetic demands and persistent desire for technical perfection contributes to overall stress level of the dentists.[38] In a study conducted in the UK, by Myers and Myers, on self-reported questionnaires of 2441 General Dental Practitioners (GDPs), stress was reported by GDPs in the following: coping with difficult, uncooperative patients (64.8%), dissatisfied patients (52.2%), and treating extremely nervous patients (47.4%). The authors further elaborate that fragility of patient–dentist relationship and scheduling pressures and time are work stressors that contribute to the overall stress in the GDPs life.[39]

Another important aspect of patient–dentist relationship is patient confidentiality and ethics. Professionalism includes many responsibilities, such as dedication to professional competence, patient sincerity, patient confidentiality, maintaining adequate rapport with individuals, and all of these affect the trust of the public in their dentists.[40] In all cultures and societies, medical and dental practitioners have been obliged to the patient throughout their existence to follow the principles governed by the medical and dental professional codes.[41] A cross-sectional study conducted by Garbin et al.[42] involved 100 Brazilian dentists who looked to identify and analyze the knowledge and attitude with respect to professional confidentiality in dental practice. It was found that dentists mentioned being mindful of professional confidentiality; however, they showed ignorance to ethical and legal aspects of the dental profession. Violation of professional confidentiality was clear as participants disclosed knowledge about clinical cases to colleagues, friends, and spouses. Any discrepancy in the patient–dentist relationship may result in medicolegal issues. According to Kumar et al.,[43] the spurt in litigation, concerning dental professional or establishment liability, claiming redressed for the suffering caused due to dental negligence, vitiated consent, and breach of confidentiality, is a matter of concern. Most dentists are not often aware of the possibility that they could become involved in a complaint procedure, and when it does happen, it may have a serious impact.[44]

Furthermore, several studies have reported that receiving a medical complaint has a significant negative impact on a doctor, ranging from stress, significant risks of moderate or severe depression, and adjustment disorder, to alcohol and drug abuse, physical illness, and anxiety.[45],[46] A survey conducted by Bruers et al.,[44] looking at 413 Dutch dentists and dental specialists, who were involved in a complaint that was being dealt by the Complaints Committee of the Royal Dutch Dental Association in the period of mid-2008 to mid-2013, revealed that after receiving a formal complaint, 71% experienced considerable impact in their professional practicing and 52% stated that it had seriously influenced their attitude toward colleagues and patients. Lastly, 60% mentioned the effects of a complaint to affect their mental and physical wellbeing. The authors elaborated that dentists feel that their good reputation is tarnished, experience the complaint as a personal let down, lose their self-confidence in contacts with colleagues, patients, and even staff, become mentally unbalanced (stress, insomnia, suspicious).[44] It is difficult to describe this in general, since personal characteristics also play a part. Thus, it could be said that patient–dentist relationship is a crucial factor that can make or break dentists.

Theme 4: Dental education and career advancements

Each dentist should be educated and interested in dentistry growth, analyze new research and the strongest scientific evidence available, apply reflective and critical thinking in ways that best integrate new techniques into practice, improve quality of care in accordance with modern ethical standards, and serve the community.[47] According to Price and Reichert,[48] training and education of staff across all career stages is imperative to increase staff recruitment, retention, and reduce turnover. Furthermore, in a study conducted by Cui et al.,[49] which looked at the satisfaction of 170 dentists in Beijing, China, it was found that factors such as patient relations and delivery of care were related to job satisfaction. The authors suggest that there is a need to offer more courses on patient management, preferably in dental schools as that is where dentists get their knowledge from and implement it in the workplace, and there is also a need to offer early and mid-career dentists, hospital managers, and policymakers courses about practice management to define the standard of dental care and other policies.[49] Furthermore, a cross-sectional study conducted by Chandrashekar Janakiram and Antony[50] looked at 179 Dental Public Health (DPH) specialists in India. The results revealed that nearly half of the respondents felt that they are yet to achieve the accomplishment from the present career as public health dentist. Only 46.9% felt that there is advancement in the profession as a career, 44.2% of DPH were willing to change their career given a choice, and 63% experienced lack of advancements in their DPH career. The authors elaborate that career advancement is one of the most important elements for employee satisfaction and retention, and when career paths are dim or non‑existent, individuals tend to be less focussed, less motivated, and more uncertain, which is seen among DPH specialists in India.[50] Therefore, it could be said that dental education and career advancements are important aspects for job satisfaction and retention of staff.

Application for Pacific nations

Based on these findings, it can be said that there are several factors that can influence the retention and turnover of dental professionals. Factors that have been found to retain dental staff in the workforce include: good dentist–patient relationship and opportunities for further dental education and career advancements. On the contrary, work stress, MSD, and poor patient–dentist relationship were found to demotivate dental professionals. Overall, the migration of Pacific island dental professionals from the public sector to foreign countries or private sector cannot be ignored. PICs must conduct surveys to ascertain the factors responsible for the brain drain of dental professionals. Such a survey if conducted will provide the ideal foundation from which workforce policies and strategies can be implemented and enforced. The ultimate goal is to prevent brain drain, ensuring that dental professionals are retained in the public sector. The goal is also to ensure that oral health services are delivered efficiently and oral status of the Pacific is not compromised.

Several limitations of this study need to be mentioned. Firstly, this literature review looked at studies conducted in countries outside the Pacific, since no data or studies were available for Pacific nations. As a result, the conclusions drawn from these studies may not necessarily be applicable to PIC. Furthermore, the general limitations of narrative review can be applied to this study as well, which includes subjective biasness in study selection and analysis and possibility of misleading conclusions being drawn. Therefore, there is a need for PIC to conduct research to accurately determine the factors involved in the retention and turnover of Pacific island dental professionals.


  Conclusion Top


Factors that have been found to motivate and retain staff in the workforce include good patient relationship and opportunities for further studies and career advancements. In contrast, work stress, MSD, and fragile patient–dentist relationship were found to demotivate dental professionals and in some cases lead to turnover. Thus, the aim of this literature review was to highlight this gray area of dental staff leaving the profession, which is prevalent in PIC. Furthermore, the results of such a research could be used to implement workforce policies and strategies, which will aid in the retention of dental staff and prevent brain drain. Ultimately, this would ensure that oral health status of the Pacific is not compromised.

Acknowledgements

Nil.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

Ethical policy and institutional review board statement

Not applicable.

Patient declaration of consent: (If in-vivo study/case reports)

Not applicable.

Data availability statement

The data set presented within this manuscript has been obtained from 10 original research articles and 2 systemic review articles. The data were readily available within the articles.



 
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