Bullying and Burnout in Dental Hygiene

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In early June, the American Dental Association published a news article on the difficulties dentists are facing in recruiting dental team members post COVID-19 now that dental offices have reopened to provide full services.¹

According to results from a 2020 survey published in the Journal of Dental Hygiene, 8% of dental hygienists left the workforce since the onset of the COVID-19 pandemic.² This article explores the many reasons dental hygienists have left or are leaving the profession and provides some suggestions for change.

In a 2019 survey of dental hygienists, 43% cited not feeling valued or respected as one of the primary reasons they would seek a new job within the next year. “Burnout” and feelings of frustration due to overly restrictive state practice acts were other reasons hygienists cited for deciding to leave the field.³ With the onset of COVID-19, dental hygienists across the country made a decision about if and how they wanted to work, and in many instances, they voted with their feet and walked away.

According to a September 24, 2020, article on Dentistry iQ, it is not clinical hygiene that hygienists are unhappy with, but rather their work environment that makes them cringe and dissatisfied overall. Hygienists expressed feelings of being “undervalued, underpaid, resentful, and completely exhausted.” Other issues included working in offices with outdated technology, employers with poor communication skills, and toxic coworkers.⁴

Most dental hygienists enter the profession because they want to make a difference in the oral health of patients by partnering with their dentist employer and coworkers. Unfortunately, all too often their dreams of working in a cohesive group of like-minded individuals fall short. This frequently occurs due to unrealistic expectations by either the hygienist or employer, a lack of communication, or a toxic work environment that may include bullying by coworkers or the dentist/employer.

Dental hygienists are highly educated, licensed oral health providers, but unfortunately over the years, they have sometimes been referred to in a negative context as prima donnas, implying they are difficult to work with or exclude themselves as part of a team. Name calling is abusive, derogatory, and a form of relational bullying and harassment.

According to study findings published in June in the International Journal of Dental Hygiene, dental hygienists experience a variety of inappropriate behaviors at work, including verbal attacks, sexual innuendos, and evaluation of their appearance. Among the study participants, 47.3% said they received rude signals from others, 17.9% said they were subjected to sexual evaluations regarding their appearance, and 29.4% said their abilities were ignored by patients and family members of patients.⁵

Patients frequently get their cues on how they act and behave by what is tolerated by the dentist-employer. Mutual respect in the workplace allows all employees to know that they are valued for their achievements, abilities, and qualities. Being valued and being treated respectfully helps promote a positive work culture in which employees are fulfilled, loyal, engaged, and motivated to perform at their very best.⁶

In a 2019 national survey of dental hygienists, more than 25% of respondents indicated they experienced workplace bullying, with the most frequent perpetrator equally distributed between the owner-dentist and receptionist/front-desk person.⁷ Workplace bullying has been associated with high turnover rates. An article by Investopedia suggests that up to 30% of bullied employees will resign from their jobs, and 20% of those who witness bullying will also leave the organization. Figures released by overcomebullying.com suggest that the number of employees who leave due to bullying could be much higher—perhaps as much as 70%.⁸

Each time an employee leaves the workplace, there are replacement costs associated with recruiting, hiring, and training new staff. Indirectly, workplace bullying also often brings a decline in morale, making the workplace even more susceptible to high turnover rates.⁸

To ameliorate these negative behaviors among colleagues and their superiors, a clear message of no tolerance for bullying in the workplace should be instituted. The importance of such a policy cannot be overemphasized, as bullying behaviors negate teamwork, hinder communication, delay implementation of new practices, and can be a threat to the patient and employee health and safety.⁷

With the onset of the COVID-19 pandemic, dental offices around the country closed, leaving a number of dental hygienists either furloughed or permanently let go from their positions. According to the 2020 study of employment patterns of dental hygienists in the US during the COVID-19 pandemic, of the unemployed respondents, more than 50% reported either receiving unemployment benefits and the other 50% stated they had applied for benefits but had not yet received any. Another 38.3% had not applied for unemployment benefits, and 1 in 10 reported their unemployment benefits application had been denied.²

During this time, threads on dental hygiene social media forums began popping up with hygienists questioning if now was a good time to look for employment outside of clinical dental hygiene. Dental hygienists demonstrate extreme attention to detail, have incredible time management skills, work independently, are self-starters, and have exceptional people skills. All of these skills can and are being put into new roles outside of the operatory.⁹

Frustrations of overly restrictive state practice acts and difficulty with licensure are 2 other areas hygienists have cited for moving on. Dental hygiene is traditionally a female-dominated profession. According to the American Dental Hygienists Association, approximately 98% of hygienists in the US are female.¹⁰ In the early years of the profession, most dental hygienists relied on their spouse’s income to run their household, but this is no longer true. As living and housing costs have risen exponentially, most homes require a 2-income family to cover basic living expenses. For dental hygienists who are single parents or unmarried, employment is a must.

America is a mobile society. Each year millions of Americans move. During the COVID-19 pandemic, which forced many Americans to stay home, more than 7 million households moved to a different county—nearly half a million more households than in 2019.¹¹ For dental hygienists moving across state lines, this frequently means having to apply for licensure from the state dental board or taking another clinical exam. Applying for licensure is not only costly and time-consuming but also very stressful.

­­­­­­Due to COVID-19, many regional dental hygiene board exams were canceled or pushed out for safety measures, leaving a “hole” for prospective employers that new clinicians entering the profession had previously filled.

To remedy this situation, in 2020, 21 dental boards across the country authorized dental hygienists to take the American Board of Dental Examiners (ADEX) manikin-based clinical exam while the country was in a state of emergency. Another 14 states authorized dental hygienists to take the Central Regional Dental Testing Service (CRDTS) manikin-based exam, with California, Alabama, Illinois, and South Carolina authorizing both.

As of January, 30 states had authorized dental hygienists to take the ADEX manikin-based clinical exam. Only Georgia, Nebraska, and Delaware do not authorize the ADEX exam as a pathway to initial licensure. At the June 2020 Georgia Board of Dentistry meeting, board members approved dentists to take the clinical ADEX exam as a pathway to licensure due to the hardship of not having a CRDTS testing site available in the state. When the Georgia Dental Hygienist’s Association requested the same consideration for dental hygienists during the July Georgia board meeting, board members denied the request, stating there were enough testing sites available.

Image courtesy of the Commission on Dental Competency Assessments.

By August 2020, Georgia had surpassed 200,000 COVID-19 cases (the fifth US state to do so), leaving recent dental hygiene graduates not only unable to find a CRDTS testing site in the state but also unable to find a patient willing to sit for the exam. Consequently, Georgia dentists are now experiencing a shortage of dental hygiene applicants.

With the onset of COVID-19, some dental hygienists moved from laggard states to more progressive states. The top states for inbound moves were Idaho, South Carolina, Oregon, South Dakota, and Arizona—all with inbound migration percentages higher than 60%.¹² And all with more autonomy and diverse dental hygiene practice acts than the laggard states they left.

These hygienists not only have to negotiate a pathway for licensure but must also take additional courses for certification to meet state practice acts considered an educational standard in the rest of the country.

Nancy Goodwin, MEd, CDA, RDH, program chair in the Department Dental Hygiene at Athens Technical College in Georgia, stated; “I have dozens of former students/graduates who moved away from Georgia to practice in Utah, Wyoming, Alaska, Missouri, South Carolina, Tennessee, Arkansas, etc, all of which authorize dental hygienists to administer local anesthesia. Unfortunately, since Georgia’s practice act does not permit hygienists to administer anesthesia, dental hygiene programs may only teach this skill to didactic (but not to clinical) competency. So, when these graduates leave Georgia, they must take additional coursework that includes clinical experience to obtain this certification in order to be employable in almost every other state in the US.”

To rationalize some of the reasons why 2021 is experiencing a dental hygiene workforce crisis, some dental forums are pointing the finger at “high-paying unemployment benefits and government stimulus money,” suggesting dental hygienists would rather sit home and do nothing. Other forum posters suggest dental hygienists are taking unfair advantage of the situation by demanding high pay and having unrealistic expectations. However, these posters do not acknowledge that when the shoe was on the other foot and dentist-employers received many applications for a single position, they took advantage of the situation to make the best deal possible at the lowest wage possible or let a long-term employee go to hire a new graduate for less money.

Other dentists have expressed their frustration and anger over the situation and suggest “payback” by recommending dentists do their own hygiene or hire an associate for the position until the dental hygiene market becomes flooded again and employees “come crawling back.”

These rationalizations completely miss the mark for the current situation many dental offices find themselves in. The COVID-19 pandemic didn’t create the dental employment issues we are now experiencing; it exposed the profound issues staff members experienced prior to the pandemic that required attention but were ignored.

Tonya Lanthier, RDH, founder and CEO of DentalPost, an online and mobile dental jobs board, recommended offices experiencing a workforce issue intentionally take steps to create a culture in which team members feel valued, appreciated, and respected and offer continuing education to keep team members inspired and challenged to do more. This effort also shows team members they are valued and worth the investment.¹³

Although employment once was viewed as a means to pay the bills, it’s now widely accepted that finding a fulfilling career is one of the keys to a happy life.¹⁴ The COVID-19 pandemic led many hygienists to examine their career choice and make decisions for the future. Whether dental hygienists choose to stay in clinical or move on to a new career path outside of operatory, at the end of the day, dental hygienists want what all professionals want—to be allowed to work at the top of their education and to be valued and respected for what they do. Workplace bullying and burnout need to be replaced by feeling valued at work. Higher levels of engagement, satisfaction, and motivation will follow in addition to better physical and mental health.

References

1. Versaci MB. Understaffed and ready to hire, dentists face applicant shortage as they emerge from COVID-19 pandemic. American Dental Association. June 9, 2021. Accessed June 15, 2021. https://www.ada.org/en/publications/ada-news/2021-archive/june/dentists-face-applicant-shortages-as-they-emerge-from-covid-19-pandemic?utm_source=DEC_DIQ+Morning+Briefing&utm_medium=email&utm_campaign=CPS210609055&o_eid=1540A5968523A2V&rdx.ident%5Bpull%5D=omeda%7C1540A5968523A2V

2.Gurenlian JR, Morrissey R, Estrich C, et al. Employment patterns of dental hygienists in the United States during the COVID-19 pandemic. J Dent Hyg. 2021;95(1):17-24. Accessed June 10, 2021. https://jdh.adha.org/content/jdenthyg/95/1/17.full.pdf

3. The state of the RDH career in 2021. RDH. February 1, 2021. Accessed June 10, 2021. https://www.rdhmag.com/career-profession/article/14190024/the-state-of-the-rdh-career-in-2021

4.Auger A. 4 mistakes every hygienist makes that lead to career disappointment. DentistryIQ. September 24, 2020. Accessed June 1, 2021. https://www.dentistryiq.com/dental-hygiene/career-development/article/14184036/4-mistakes-every-hygienist-makes-that-lead-to-career-disappointment

5. Won SE, Choi MI, Noh H, Han SY, Mun SJ. Measuring workplace violence for clinical dental hygienists. Int J Dent Hyg. Published June 6, 2021. doi:10.1111/idh.12527

6. How and why to demonstrate respect in the workplace. Syndeo. February 15, 2018. Accessed June 1, 2021. https://syndeohro.com/demonstrate-respect-workplace/
 

7. Sundburg SD. Workplace bullying: a national survey of dental hygienists. Old Dominion University. Fall 2019. Accessed June 5, 2021. https://digitalcommons.odu.edu/cgi/viewcontent.cgi?article=1016&context=dentalhygiene_etds

8. Fowler J. Financial impacts of workplace bullying. Investopedia. Updated May 1, 2021. Accessed June 4, 2021. https://www.investopedia.com/financial-edge/0712/financial-impacts-of-workplace-bullying.aspx

9. Brittain E. Career advice: making the jump out of clinical dental hygiene. Today’s RDH. May 9, 2020. Accessed June 10, 2021. https://www.todaysrdh.com/career-advice-making-the-jump-out-of-clinical-dental-hygiene/

10. Oral health fast facts. American Dental Hygienists’ Association. Accessed June 12, 2021. https://www.adha.org/resources-docs/72210_Oral_Health_Fast_Facts_&_Stats.pdf

11. Wu Y, Melgar L. Americans up and moved during the pandemic. Here’s where they went. The Wall Street Journal. Updated May 11, 2021. Accessed June 10, 2021. https://www.wsj.com/articles/americans-up-and-moved-during-the-pandemic-heres-where-they-went-11620734566

12. Davis E. Study: Americans moved West, South in 2020. US News & World Report. January 4, 2021. Accessed June 12, 2021. https://www.usnews.com/news/best-states/articles/2021-01-04/americans-moved-west-and-south-in-2020-amid-coronavirus-pandemic-study-finds

13. Lanthier T. Survey: COVID-19 compounds dental staffing challenges. Dental Economics. February 1, 2021. Accessed June 24, 2021. https://www.dentaleconomics.com/macro-op-ed/article/14198501/survey-covid19-compounds-dental-staffing-challenges

14. Kahn C. 5 reasons why it’s time to make a career change. CareerFoundry blog. Updated September 24, 2018. Accessed June 6, 2021. https://careerfoundry.com/en/blog/career-change/5-reasons-to-make-a-career-change/