Swapping drills for dressings: redeployment of dentists to community nursing

In March 2020, NHS England instructed dentists to cease all routine dentistry in response to the COVID-19 pandemic (NHS England, 2020a). Most dental procedures (including scaling, restorations and surgical extractions) are aerosol-generating procedures (AGP) and, therefore, present a high risk of transmitting infectious agents. A remote triaging system was implemented until urgent dental centres (UDCs) were established to provide acute dental care (Public Health England (PHE), 2020).

A framework for the initial phase of voluntary redeployment among hospital-based dental teams was introduced in order to assist allied health professionals within the wider NHS (General Dental Council (GDC), 2020). Restricted to telephone triage, dentists within the hospital trust volunteered to provide their services in a variety of new settings, including community nursing and COVID-19 testing. A multitude of factors contributed to redeployment status, including clinical competency and individual risk assessments.

Predictions at the beginning of the COVID-19 pandemic suggested community nursing demands were going to exceed service capacity and reach an unprecedented high, due to a surge in the number and complexity of hospital discharge referrals, in addition to the continued care needed by existing community patients (Brennan, 2020). Alongside other adult nursing specialties whose services have temporarily ceased, dentists were identified as having transferable skills and experience that could aid service provision, and they were added to the community nursing workforce.

Dental training

Undergraduate dental training in the UK is a 5-year mixed academic and clinical medical programme, with dentists graduating with the principal skills required to be safe clinicians. Although the primary focus for dental professionals is the oral cavity, an overall understanding of the human body is paramount. To work within the NHS, new graduates are required to undertake a mandatory year of dental foundation training (Royal College of Surgeons of England (RCS England), 2019). As with other healthcare roles, dentists can practice dentistry within primary, secondary or tertiary care settings, including hospital, community and prison services.

While 85% of dentists are situated in general practice in primary care (NHS England, 2020b), a minority undertake focused training to lead to specialism within one of 13 dental specialties (RCS England, 2012).

The GDC plays a similar role to the Nursing and Midwifery Council (NMC) in regulating registrants. It is also responsible for ensuring lifelong learning through completion of continued professional development (CPD), alongside adherence to set standards of professionalism, confidentiality, communication, consent and working within the patient's best interests (GDC, 2013; NMC, 2018).

Transferable skills

As with all fields of healthcare, both dentistry and nursing require a set of specialist skills in order to provide a holistic approach to patient care. In response to the COVID-19 pandemic, NHS England has released guidance outlining transferable skills, alongside further training requirements deemed necessary prior to commencing redeployment roles (NHS England, 2020b). Suggestions for redeployment roles for dental professionals included emergency medicine, critical care, general medical practice, ambulance service, social care, NHS 111 and COVID-19 testing (NHS England, 2020b). While the role of community nursing is not directly listed, many of the tasks completed as part of a community nursing team are similar to those experienced in general medical practice or within a hospital environment.

On registration, dentists are considered to have achieved competencies in several skills that could be considered transferable to community nursing. One such skill is the safe administration of medicines and therapeutic agents, often via the delivery of technique-sensitive injections within the oral cavity (NHS England, 2020b). These skills can be honed and, with additional training and completion of competencies, applied to the safe administration of subcutaneous injections, including insulin and anticoagulants. For those with experience of providing intravenous sedation, the skills for phlebotomy and cannulation can also be used (NHS England, 2020b).

Nurses provide patient-centred, compassionate and sensitive care to vulnerable patients, often at difficult times in their lives (NMC, 2018). While dentists do not routinely deal with supportive or end-of-life care, the management of anxious patients is commonplace in the dental setting. The Adult Dental Health Survey 2009 identified 12.4% of the population as being dental phobic (Heidari et al, 2017). Routinely providing care for patients with dental anxieties might help support dentists in their new role to manage patients who may require emotional as well as physical care. Effective communication with both colleagues and patients is indispensable in order to collaborate and deliver personalised healthcare, regardless of the environment.

Similar to their nursing colleagues, dentists are also faced with the challenge of managing sensitive situations and recognising signs of abuse, neglect and non-accidental injury in vulnerable groups. On registration, dentists should be confident in the appropriate escalation and liaison with local safeguarding teams, which may be required as part of the delivery of care (NHS England, 2020b). With local induction and further training, dentists can expand their awareness of external services and their role in patient care, due to community nurses converging with these services more frequently.

Registered nurses play a key role in improving and maintaining the mental, physical and behavioural health and wellbeing of individuals, and they are actively involved in health promotion (NMC, 2018). Dentists have a detailed understanding of oral and general health promotion, with consultations regularly involving preventative advice, including alcohol and smoking cessation. The 5As (assess, advise, agree, assist and arrange) are behavioural change stages applied by dentists to help patients change harmful behaviours (Berwick, 2003). This behaviour-change model can also be applied when encouraging patients in the community to make positive lifestyle changes.

In accordance with CPD, all dental professionals are required to undertake basic life-support training annually, with some dentists choosing to further this skill by completing intermediate or advanced life support courses (GDC, 2018). As part of training, many dentists complete a post in oral and maxillofacial surgery within an acute hospital trust. Wound care, phlebotomy and recording; and identifying and assisting with the management of a deteriorating patient are also performed as part of this role, whereby dentists develop the basic skills needed when considering redeployment to a different area of healthcare.

The specialty of special care dentistry provides care for adults who have a physical, sensory, intellectual, mental, medical, emotional or social impairment (NHS England, 2015). This cohort of patients can receive treatment in general practice, community and hospital clinics, or within their own homes. Domiciliary care may be provided by general dental practitioners or as part of a specialist hospital or community service and can include provision of dentures, temporary filling placement and hand scaling. The delivery of dentistry within the home environment is difficult, but it provides an appreciation for the limitations that can arise when treating patients in their homes.

Role within redeployment

Both the GDC and NHS England recognise that, as part of redeployment, dentists may be asked to carry out roles that are not part of their remit (NHS England, 2020b). It was suggested that dentists complete tasks where low (minimum) or moderate (up to 3 days) training was needed in order to support their colleagues in their new roles. In community nursing, skills with low training requirements included talking to patients and relatives, history taking, patient hygiene and ‘buddying up’ with another member of the team to support visits. Roles with low training needs may also include basic wound care, blood glucose measurements and patient observations (NHS England, 2020b).

Working within a community trust, dentist volunteers were redeployed to community hospitals, COVID-19 swabbing and community nursing teams. Training within the trust included a training day of lectures delivered by specialist nurses (Table 1), which were made available, along with additional resources, on the trust's redeployment virtual campus for ongoing review. The redeployment virtual campus page also includes e-learning modules in medicine management and links to external online learning for registered national training in National Early Warning Score-2 (NEWS2), sepsis and diabetes management.

To ensure dentists felt confident in carrying out their new roles independently, competencies in line with a registered nurse's skillset were completed with a designated mentor. An induction and period of shadowing ensured that dentists were updated in local policy surrounding referrals, recording observations and clinical record-keeping.

In addition to the trust programme for redeployment, Health Education England (HEE) has developed training and induction modules to support those redeployed to various sectors across the NHS during the COVID-19 pandemic (NHS England, 2020b). These materials also include a self-assessment competency checklist, ensuring that redeployed staff feel competent in performing tasks that may be outside of their scope of practice.

Within the trust, most redeployed dentists have been given clinical responsibilities similar to those of a band 5 community nurse. It is important to note that, throughout redeployment, dentists have identified their limitations and have only carried out tasks following appropriate training and when they feel competent to do so (GDC, 2019).

Care activities

Diabetes affects 6.6% of the UK population, with this prevalence predicted to continue to increase (Guariguata et al, 2014). The monitoring of blood glucose and administration of insulin, which can occupy a substantial proportion of a community nurse's time, have been identified as transferable skills (NHS England, 2020b). With a well-founded understanding of diabetes, dentists already educate patients on the preventative management and treatment of diabetes-related oral complications. For the purpose of redeployment, online learning promoted familiarity with the use of safety needles and calibration of blood-glucose machines, in addition to building on existing knowledge on the management of medical emergencies, including hypoglycaemia. This theoretical knowledge was substantiated with clinical shadowing and achievement of competencies. Pre-existing knowledge of the micro- and macrovascular complications of diabetes can also be applied to wound assessments and management. The contribution of these skills has helped enable qualified nurses to focus on more complex tasks, which are beyond the remit of redeployed staff.

Xerostomia has been reported to affect up to 88% of patients with advanced cancer, and ulceration, oral thrush (Candida infection) and drooling are also known to adversely affect a patient's quality of life (Riley, 2018). Despite the presence of guidelines such as Oral health for adults in care homes (National Institute for Health and Care Excellence (NICE), 2016) and Palliative care-oral (NICE, 2018), the level of oral health training and confidence in community teams to manage and provide oral health advice is unclear (Binks, 2017). The experience of redeployment has allowed promotion of projects such as Mouth care matters (HEE, 2020) and provision of tailored oral health promotion to teams, patients and carers. Redeployed dentists have also been able to signpost patients to access dental care and are available as a continued point of contact for their nursing teams once their normal roles resume.

Patient response

As part of the COVID-19 healthcare response, patients have been informed that there may be other health professions temporarily assisting the community nursing team to deliver care. Understandably, this can be both confusing and daunting for many patients, who may not understand what transferable skills a dentist may possess. Despite this, the general patient response has been positive, although they have been surprised. The discussion of normal roles with patients while carrying out tasks such as wound dressing helps to prompt conversation and alleviate some of the health anxieties that are particularly common at this time. For some patients who are isolated from their families and friends, having a friendly face, irrespective of the normal role, is important to aid not only their physical health, but also mental wellbeing.

Some patients have expressed their feelings in other ways. Initial concerns surrounding the ability of dental professionals to carry out their redeployed roles has been expressed by only a minority of patients, but these concerns have generally been resolved following a simple conversation and through the provision of reassurance. Overall, most patients seem to be grateful for dentists who have volunteered to support their local nursing teams, and they have accepted that the NHS requires a united front from allied health professionals in order to manage healthcare during the COVID-19 pandemic.

What can dentists take back to dentistry?

Although dental professionals have an understanding of the physiology and pathology of comorbidities that can affect patients, for some, there is a lack of understanding of how individual care needs may change as a result of these conditions. For example, patients with diabetic complications may require additional care packages and alternate ways of accessing basic medical and dental needs, which dentists may not be overly familiar with.

Working within the community nursing team has strengthened comprehension of the services required (both internal and external to the NHS) in order to meet an individual's care needs. Public and private care agencies, pharmacies and social services all provide crucial elements of care and equipment to ensure that a patient's needs are met. Following the steep learning curve of redeployment, redeployed dentists feel they have a more comprehensive understanding of the impact of comorbidities and complex care needs on patients and their families. This understanding will help them with providing tailored oral and preventative care, in addition to the more practical side of delivering care, such as support with appointments, provision of domiciliary care or supporting carers and family members with dental advice and guidance.

Dentists who have worked within secondary care are familiar with the processes of handover and working within multidisciplinary teams to provide comprehensive care. Redeployment has helped to reinforce the importance of a multidisciplinary approach to care by enabling group discussions, improving awareness of patient circumstances and encouraging co-operative learning opportunities. The presence of redeployed nurses within the community nursing teams has also promoted further teaching and understanding surrounding other specialist services, including tissue viability and diabetes management.

In general, within the dental environment, there is limited exposure to managing unwell patients. The placement in community nursing has reinforced a familiarity with systems designed to recognise a deteriorating patient, alongside the practical skills needed to manage an acute situation. The exposure to palliative patients requiring end-of-life support has been challenging, but invaluable. It has helped provide some practical experience in supporting oncology patients, who may still present in a dental environment with complaints such as acute dental pain and xerostomia (Riley, 2018).

Lessons learnt

The prospect of being redeployed is incredibly daunting, particularly when redeployment roles involve reallocation to a different healthcare environment. Despite the redeployed dentists' apprehension, they have been made to feel exceptionally welcome by their new community nursing teams.

As with all novel settings, both challenges and opportunities have arisen and have been navigated with team support. The training coordinators had a momentous task in compiling and delivering an intense training package suitable for redeployed staff from a variety of different professional backgrounds, including dentistry and other specialties within the nursing profession. With such a diversity of skills, even among dentists, the training co-ordinators had a challenge in allocating redeployment roles. Completion of a skills self-assessment prior to induction may have helped community nursing teams identify individuals' learning needs and areas for further training and to support task allocation (NHS England, 2020b). However, the complexities in coordinating a training programme and redeployment process must be acknowledged. Irrespective of the challenges, the process of redeployment has provided a unique opportunity for learning, regardless of occupation and experience.

Conclusion

In a time of such uncertainty and adversity, there is a feeling of pride in the provision of support for NHS colleagues. Although redeployment has been met with mixed emotions, there is a resounding feeling of fondness and gratitude for the tireless work that nursing colleagues put into caring for patients in the community.

Key Points

• Dentists were identified as having transferable skills to be redeployed to provide support to community nursing teams during the pandemic
• Both dentistry and nursing require a set of specialist skills to provide holistic patient care
• Dentists redeployed to community nursing received practical and theoretical training. Following a period of shadowing, core competencies were completed in certain areas, prior to independent working
• Redeployment to community nursing teams enhanced dentists' knowledge of the impact of comorbidities on patients and families and the services required to meet an individual's care needs

CPD REFLECTIVE QUESTIONS

• How would you feel if faced with redeployment to an area of healthcare outside of nursing?
• Are there any other challenges, not mentioned in the paper, that you feel might arise during the redeployment process?
• Do you agree with the tasks being carried out by dentists in the community? What roles do you think are appropriate for dentists to do?
• If part of a community nursing team with a redeployed dentist, what steps would you take to ensure they were competent in their new role?
• What other health professionals could contribute to meeting the demand on community nursing services during the COVID-19 pandemic?