The emerging dental workforce: why dentistry? A quantitative study of final year dental students' views on their professional career

Challenges facing health professions

Societal, political and economic change impacts on the healthcare workforce, which is recognised as 'critical' for health systems. [1, 2] Furthermore, the skills, motivation and commitment of the health workforce in general are increasingly recognised as being intimately linked with the performance of health systems, and thus important areas for research. [3] Sociologists' suggest that professionals are motivated by status in the financial and social orders, [4, 5] and that professional groups are facing challenges in their relationships with governments across Europe, [6] and the breaking down of traditional demarcations between professional groups. [7] In addition, there is some evidence of a generational effect in the workplace, with the suggestion that the emerging workforce has very different professional expectations than those in positions of authority and leadership, who are generally several decades older. [8, 9] Johnson et al., [6] suggest that the reaction and ability to address these challenges, which often emanate from forces outside of the immediate professional field, is critical to the future nature of professions. Research into the motivation and professional expectations of the emerging workforce is therefore vital to provide evidence to inform professional leadership and policy decisions. Within dentistry, such research is recognised to be especially important given the length and cost of training; [10] however, research in this field is limited and may not take account of the contemporary student intake. [11]

Dental workforce facing change

New graduates from UK dental schools are emerging into a profession facing a time of unprecedented change, both general as outlined above, and specific to the profession. [12] Fundamental changes to state funded dental care, include the introduction of a new dental contract for National Health Service [NHS] dentistry in England and Wales, with limits to the volume of state care that may be provided, [13–15] a significant shift of dental care to the private sector, [16] pressure on jobs from international graduates, [17] increased emphasis on skill-mix development within the dental team; [18] professionalisation of dental care professionals [DCPs]; [19] and continual innovation in dental techniques, products and materials [20]. New graduates face a professional career, which will be characterised by change in the 21^st century. [21]

Changing nature of the profession

As with entrants to university in general and other professions, such as medicine, admissions to dentistry include an increasing proportion of females and ethnic diversity. [22–25] Dentistry has been particularly effective in attracting minority ethnic groups during the 1990's as demonstrated by Bedi and Gilthorpe; [22] and evidenced by UCAS admissions statistics. [24] As with medicine, [26–29] there are concerns that the feminisation of the profession will result in greater workforce challenges and this is reflected in recent workforce modelling exercises in England and Wales [30] and Scotland, [31] together with recommendations for systems reform to facilitate their contribution to the professional workforce. [32] Recent concerns over workforce shortages in certain parts of the country have led to formal recruitment exercises in England, both international and nationally. [17, 33] Together with natural workforce immigration, this has resulted in more dentists from abroad joining the Dentists Register in 2005 than home students, [19] and more of the new NHS recruits coming from outside the UK. [34] In addition to the above, recent expansion of dental student numbers from September 2005 onwards announced by the Secretary of State for Health, [35] has provided additional opportunities for more young people, including increasing numbers of graduates, to pursue a career in dentistry. [24]

Educational changes

Changes in education policy have resulted in students emerging with significant levels of student debt. [36] New entrants will now face the additional challenge of top-up-fees; [37] these are likely to impact on admissions and result in financially driven long term professional decisions. It has been suggested that dental students are more likely to be affected as they have a longer academic career and shorter holidays than other students, with the result that their may be implications for their future location and system of working, even to the extent that new graduates may be less likely to wish to work amongst the more disadvantaged sections of our community. [38] Nonetheless applications for graduate entry programmes in dentistry are heavily oversubscribed.

What is known already about choice of dentistry as a career?

The motivation for studying dentistry has come under scrutiny amongst applicants to, and students of various schools across the UK, [10, 39–41] and beyond. [42–48] This has included comparisons with medical counterparts. [40] Past studies within King's College London Dental Institute have revealed that applicants appear to have a more idealised view of the profession than final year students; [10] however, both cohorts were largely concerned by professional and personal matters. Comparison of medical and dental students across six dimensions of interest (status and security, nature of the occupation, career opportunities, patient care/working with people, use of personal skills and interest in science) by Crossley and Mubarik, [40] suggested that dental students were significantly more likely to be motivated by 'status and security', 'high income' and the 'nature of the occupation', when compared with their medical counterparts; whereas medical students were significantly more likely to be motivated by 'altruism' than dental students. However, the lack of altruism identified in their sample of students is not supported by other studies, [10, 41, 48, 49] and researchers in the field. [50] None of the above studies has examined motivation in relation to all three demographic variables of sex, ethnicity and admission type, which given the changing nature of the profession is an important area for research.

King's College London Dental Institute (KCLDI)

KCLDI is the largest dental school in the UK and amongst the largest in Europe. The Institute contributes up to 25% of the home trained dentists to the profession in England, thus the views of its students, although not necessarily representative of the national picture, have a significant impact on the profession. UCAS data for 2003 and 2004 suggest that the dental school has a high proportion of students from ethnic groups relative to other schools, including medicine, within King's College London, [51, 52] and that the College as a whole has a higher intake of minority ethnic groups than nationally. [24] As the majority of the schools' undergraduate students are female and from minority ethnic groups, researchers at KCLDI are therefore well placed to examine the motivation and views of new entrants to the profession.

Programme of research

The findings presented in this paper represent part of a larger programme of research the aim of which is to investigate the views of final year dental students', and recent graduates, on their future professional careers and explore how they consider their working lives may be enhanced. Both qualitative and quantitative methodological approaches have been utilised, with the qualitative data informing the development of a questionnaire instrument for the quantitative research as well as providing the theory underpinning student views derived from qualitative analysis.

This paper reports the reasons that final year students at the end of their course perceive have influenced their choice of dentistry as a professional career and relates them to the current educational and health policy. Subsequent papers will report on students short- and long-term future plans in more detail and the theory emerging from the qualitative data.

The objective of the research presented in this paper was to investigate final year dental students' perceived motivation for their choice of dentistry as a professional career in relation to sex, ethnicity and type of entry to dental school.

Response

Of the 140 questionnaires distributed to the Year 5 dental students, 126 were completed and returned giving an overall response rate of 90%. The age of respondents ranged from 22–33 years, with a mode of 23 years (59%). Thirteen respondents (10.5%) were mature students, aged 26 years and over.

The majority of students (76%) identified that they had debts, 45% of whom had debts of £21,000 or more. Students reporting debt did not differ markedly from the overall profile of respondents in terms of age, sex or ethnicity.

Influences on choice of dentistry as a professional career: univariate analysis

Important influences: multiple response

Students were asked to score their level of support for a wide range of influences according to the level of importance they perceived the factor had in their choice of a professional career in dentistry (Figure 1). Eighty per cent identified 11 or more influences as being 'important' or 'very important' with over half the students indicating that 17 or more influences were 'important' or 'very important' in their choice of dentistry as a professional career. Combining 'important' and 'very important' influences, the top five were: 'regular working hours' (91%), 'degree leading to recognised job' (90%), 'job security' (90%), 'academic knowledge' (90%), and 'scientific knowledge' (88%). In contrast, 'careers advice' and the influence of 'family' and 'friends' were the least commonly acknowledged influences on respondents' choice of dentistry.

There was variation by age, sex and maturity on entry, in relation to the influences ranked as important, with three of the top five influences in common (Figures 2, 3).

'Job security' was the top influence of importance for males (91%), followed by 'regular working hours' (90%), whereas for females 'degree leading to recognised job' (95%) and a 'desire to work with people' (93%) were most important (Figure 2). Significantly more males (69%) than females (55%) perceived that being able to 'run a business' (p = 0.03) was important in influencing their choice of dentistry, whereas a 'desire to work with people' (p = 0.03) was a significantly higher influence on career choice for females.

Asian students identified ' academic knowledge' (93%), 'work experience' (91%) and 'regular working hours' (91%) most frequently as influences of importance, whereas white students identified 'degree leading to recognised job' (93%) and 'regular working hours' (93%) (Figure 3). Significantly more Asian than white students reported having 'tried an alternative career/course' (p = 0.004), a 'wish to provide public service' (p = 0.005), the 'influence of friends' (p = 0.007), a 'desire to work in healthcare' (p = 0.03) and 'work experience' (p = 0.04) as being of importance.

Direct entrants were significantly more likely to perceive 'work experience' (p = 0.027) as important in choosing dentistry, than mature students (88% cf 77%).

Major influence on choice of dentistry as a professional career: univariate analysis

Major influence: single response

Having identified to what degree the full range of influences had influenced their choice of dentistry, students were asked to specifically identify the single major influence on their career of choice. Only 17 of the same 23 listed options were utilised by respondents (Figure 4). Overall the single major influence was identified as a 'desire to work with people' (16%), followed by 'work experience' (10%), 'job security' (10%), 'independence' (8%), 'influence of family' (7%) and 'professional status of dentistry' (6%). The small group of respondents (7%) who identified 'family influence' as the major influence was almost exclusively female (90%) and from minority ethnic groups (90%).

The single major influence of the majority of male respondents was 'professional status of dentistry' (19%, n = 6) (Figure 5). 'Significantly more males than females identified that their choice of career was influenced by the 'professional status of dentistry' (p = 0.05). Among the 73 female respondents, the single major influence in choosing dentistry was a 'desire to work with people' (19%) and they were significantly more likely than males to express desire to work with people as the major influence (p = 0.03).

The major influence reported by Asian students was also 'desire to work with people' (18%). Asian students were significantly more likely than white students to consider 'desire to work with people' (p = 0.03) as their major influence in choosing their professional career. In contrast, white respondents considered 'practical/artistic skills' (18%) as their major influence.

The major influence for mature students was 'practical/artistic skills' (23%, n = 3); however, significantly more direct entrants than mature students considered a 'desire to work with people' (p = 0.03) as the major influence on career choice.

Influences on choice of dentistry as a professional career: multivariate analysis

Career choices and careers advice

As preliminary qualitative research identified that medicine had been an alternative career choice considered by many of the students, all students were asked whether they had considered choosing medicine as opposed to dentistry as their career of choice, together with reasons for not pursuing a career in medicine. Almost half of the respondents (n = 61; 48.5%) and 55% of males had considered medicine as an alternative career. There was no difference between the two main ethnic groups.

Medicine was actively rejected as a career option by dental students, for a range of reasons reported in open response (Figure 7). These included: 'longer working hours' (18%); 'stressful life' (18%); 'less hands-on' approach to care (16%), 'lengthy undergraduate period' (12%) and 'longer and difficult career pathway' (12%).

Introduction

This section considers the contribution of the findings to the existing literature, examines the influences that have motivated students to choose dentistry as their professional career and the implications for health and education policy, professional action and future research.

Contribution to the literature

This study contributes to the literature on dental workforce in three main areas. First, it examines the motives of final year students as they prepare to leave dental school, in contrast to the majority of published studies, which have focused on admissions or new entrants to dental school. [23, 41, 44–46, 54] It could be argued that it is rather late in their studentship to explore this issue; however, there is evidence from two studies that the reported motivations of students were not significant across the academic years. [49] Furthermore, within the overall aim of the research programme, it provides the opportunity to relate these views to future career plans. Second, development of the research instrument was informed by qualitative research, which will be published separately, and thus it quantifies contemporary issues for the current profile of students. Most other studies have used instruments constructed for medical counterparts or based on existing literature. Third, it provides both univariate and multivariate analysis of the data from this population survey in relation to sex, ethnicity and type of entrant (direct vs mature), which makes an important contribution to any consideration of the changing demography of the dental student intake and therefore the future workforce.

The response rate amongst students was high (90%), thus providing support to generalise the findings to the final year population under study, particularly as non-respondents did not differ in terms of their demographic profile. Although the findings cannot be considered to be representative of dental students in general in the UK, the views of this group of students, given their demographic profile and the trends in admission to dental school, are nonetheless important to inform workforce planning and policy.

KCLDI has a profile that is skewed towards Asian students. [51, 52] The majority are home students and will tend to be second or third generation in the UK, an issue which might be explored in future research. There is evidence from one UK dental school that Asian students are significantly more likely than their counterparts to have siblings or relatives (other than parents) in dentistry. [23] Dentistry's success in attracting Asian students is noteworthy; however, the fact that this is not matched across other ethnic groups within London is an area for further research, and action, as recommended by Stewart et al., [23] particularly given concerns that ethnicity of dentists may be related to the uptake of care by certain groups.

Motivation

Building on the qualitative components of this research programme, this quantitative study has confirmed the wide range of influences on students' choice of career, lending support to the range of influences raised in similar studies of applicants to or students of dentistry. [10, 23, 40, 44, 50] Multivariate analysis provided additional insight into the basic dimensions or clusters of motives. There are some parallels in the groupings identified in the US study of first year dental students by Scarbecz and Ross, [44] those utilised by Crossley and Mubarik in the north of England, [40] Bernabe et al. in Peru, [45] and Vigild and Schwarz in Denmark. [48] Factor analysis was undertaken on the data from US and Danish students. Scarbecz and Ross identified eight factors, which accounted for 59% of the variability in first year students; [44] whilst Vigild and Schwarz identified eight factors representing 65% of variability in first year students. [48] In this UK study of final year students, just five factors provided for 61% of the variability. Whereas 'money' was highlighted as the prime factor in the US, followed by 'people', and then various features of the professional job, Danish students showed some variance over time with the most recent study in 1994 identifying 'people', followed by 'convenience/esteem' and 'work conditions' as the main factors. Amongst KCLDI students the professional job factor was dominant followed by healthcare-people. Although the individual influence of 'high income' was an important influence for 78% of KCLDI students, it was not prominent in the factor analysis, when compared with US students, [44] and therefore similar to Danish students. [48] However, 'people' factors were secondary when compared with Danish students. [48] Each of the five clusters of motives from this study is examined in turn, starting with the leading factor.

Implications: summary

This study has highlighted the underlying factors, which determine students' choice of dentistry as a professional career. The balance between professional and people-healthcare factors appears to differ across published research; however, in this group of students, professional job related factors are dominant. In considering the wider context of health and health services, it appears that elements of three factors, which together describe 50% of the underlying motivation, are under particular challenge: features of the professional job, healthcare-people, and academic-scientific factors. The findings raise important issues about health professionals' motivation and highlighted the need for entrants to the healthcare workforce to understand the dynamic nature of professions and the pace of change, along with the need for mentoring support in relation to career development. Longitudinal research into the workforce expectations and subsequent career decisions and pathways could contribute to professional debate and inform policy planning, as with our medical counterparts. [72, 73] Given the rate and nature of change within health services, and the current emphasis on reshaping of the workforce, these are issues for healthcare in general.