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.
Professional job factor
Professional job factors explained 31% of the variation with 'independence', 'being able to run a business', 'regular working hours' and job security' associated with the professional job related factor. It is important to note that other aspects, close to being included were also job related: 'high income', and 'flexible working hours'. Aspects of the professional job have scored highly in other studies amongst admitted and final year students at the same school, [10] and beyond. [40, 44, 48, 49] The primary reasons for choosing dentistry amongst Irish students were related to features of the professional job, [49] and dental students in Manchester reported being motivated by dimensions of 'status and security' followed by the 'nature of the occupation'; [40] which together also relate to aspects of the professional job.
Multivariate analysis suggested that students attaching high importance to this factor also attached importance to future living standards and were more likely to be male. This supports sociologists perspectives on professions that their members are motivated by status in the social and economic orders, [4, 5] and past surveys of applicants to, and students of, dentistry. Comparing the factor analysis with the univariate analysis of the data, the findings suggest that different aspects of the professional job may be important to sub-groups with males showing significantly more interested in 'professional status' and 'business', whereas females were more interested in 'independence' and 'flexibility of working hours', as demonstrated in past research. [23, 40, 48, 49] However, past sociological views of professions will have been informed by male-dominated professions, which may explain why professional status was significantly more likely to be identified by males as the single major motivating factor in choosing dentistry, when compared with females. Given the changing demography of the student population, this may alter over time. There appears to be less interest amongst KCLDI students in the business aspects of dentistry than US counterparts. [44]
Work experience, which provides insight into features of the professional job, was reported as an important influence for 87% of students. Looking to the future, it is clear that the features of the professional role of dentists and their day-to-day job are likely to change significantly to the extent that it will be rather different to that encountered by current cohorts on work experience. There is anticipated to be much greater emphasis on 'team-working' rather than 'independence', [18] and increased freedom for corporate bodies in the running of primary dental care, [55] both of which are likely to lead to larger practices, with a resultant reduction in the volume of business opportunities than in the past. There is also the need to better facilitate career satisfaction within the dental team. [56] Patient demands for longer opening hours in primary care may challenge the 'regular working hours' of traditional dental practices. [57] There are now more entrants to the professional register from abroad, [58] and more dentists in training. [35] Traditional job security appears to be threatened by these new ways of working, together with pressure on limited NHS resources. [59] Furthermore, there is some concern that the ability of females to work flexibly may be limited by the current contracting requirements of the new dental contract. [60]
If the influences that attracted dental students to their chosen professional career are being, or will be, challenged over the forthcoming decades, it is important that as a dental profession we provide a realistic view to those who seek work experience and apply to dental school. Skelly and Flemming have already stressed the importance that those advising and recruiting people into the profession should ascertain whether applicants have a realistic idea of what lies ahead. [10] Potential applicants need to be aware of how dentistry as a professional career may change over time in relation to skill-mix, team-working, techniques and materials, highlighting that the ability to respond flexibly and to address the various challenges can result in a stimulating career. Along with effective mentoring, identified by Moats-Kennedy as particularly appropriate for this generational cohort, [8, 61] this will be important to minimise disillusionment with professional life and facilitate a positive approach to change. [8, 61, 62] However, professional and policy leaders also have a responsibility to recognise and minimise barriers that will negatively and inappropriately influence the ability of young dentists to contribute to the workforce.
Healthcare-people factor
People and healthcare issues were the second underlying factor, suggesting an element of altruism but not as strong as with Danish students in 1972 and 1994. [48] Whereas there was no age, sex or ethnic association with the factor as a whole, these variables were associated with individual components of the factor. A 'desire to work with people' was the second 'very important' factor in the choice of dentistry amongst all students (50%) and the most important for females (53%). This desire to work with or help people is reflected in the findings of most equivalent studies either as a primary or secondary influence, [23, 44, 45, 48, 49] and there is a growing body of evidence that suggests it is more common in females, [44, 45] and that altruistic motivations may be secondary to positive perception of working conditions. [49] The finding that the odds of Indian students choosing a 'desire to work with people' being more than double that for white or other ethnic groups is an important finding and one which should be explored in future research.
The other aspect of this factor, 'a desire to work in healthcare' was the second very important influence for females (52%) and Asians (53%). Factor analysis suggested that the healthcare-people factor was significantly related to 'family commitments' and this has implications for policy makers, managers and business owners as it will be important to facilitate commitment to family for these people-orientated dentists who can make an important contribution to professional care in terms of valuing patient contact and form a significant proportion of the profession. In addition to the professional job changing, the systems of providing healthcare are changing with increasing privatisation of dental care, [16, 63] and possibly over time greater emphasis on the use of state resources for priority groups. This is altering the nature of public service provided by dentists as it moves from being equivalent to medicine towards other professions such as law within the UK and dentistry.
Academic-scientific factor
Dentistry provides a clear avenue for pupils from a scientific background wishing to pursue an academic career. Other studies have identified a recurring 'interest in sciences' and the 'scientific nature of dentistry'. [23, 48] Both these factors are generic to healthcare professions and will equally apply to medicine as to dentistry, with students being drawn from the same pool. Univariate analysis suggested that the academic nature of dentistry was one of the top important influences on the choice of dentistry by Asians, who clearly value this aspect of the profession. Although medicine has been recognised as one of the most popular alternatives for dental students, [23, 44, 48, 49] and in the past some students have entered dentistry because they did not achieve the grades for medicine, the situation appears to be changing. The entry grades for dentistry are now as high, and in some institutions, including KCLDI, higher than medicine. That being the case, there is theoretically a higher academic status associated with entering dentistry. The declining volume of students studying scientific subjects in secondary school is a matter of public concern and therefore dentistry may be competing with other medical courses for a reducing pool of students in future.
Careers-advising factor
Faced with an ever expanding range of programmes available for study at university, assistance with choice becomes ever more important. In this technological age, computer-based advice through decision aid programmes was important for just over one quarter of students, with personal advice still more important for almost half of the total. Evidence from the multivariate analysis that those who report careers advice influenced their choice of dentistry are more likely to be influenced by the range of career opportunities in dentistry is important to note. Whether this relates to the quality of careers advice or the personality of the student seeking career advice, to inform a rational approach to decision making, is unknown; however these students' tended to be older and therefore perhaps especially anxious to have clear career plans. There are now more graduate entry students who will be older on exit from dental school; therefore these findings suggest that there may be more demands for careers advice within dentistry from this group. Moreover, in this time of change in modernising dental careers, [64] changing entrance criteria to specialisation, [65] possible innovative new tiers of care, [66–71] it becomes more important to provide contemporary advice and support to students and new dentists on the future nature of dentistry, modes of working and the range of career options.
Family-friends factor
This factor involved only 6% of the variation and interestingly was not associated with age, sex or ethnicity. However, univariate analysis would suggest that 'family' were the important single major influence for a small group of individuals, who tended to be female and come from minority ethnic groups. These individuals only represent a minority of students and the data do not support generalisation to the study population.
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.