Key determinants of health and wellbeing of dental nurses: a rapid review of over two decades of research

Characteristics of included studies

The electronic database search yielded 4450 citations with 4004 remaining after the removal of duplicates. Forty-four papers were included for full-text screening and 37 studies met the inclusion criteria and were included in this review. A detailed presentation of the process of identifying the studies is shown in the PRISMA flow chart presented in Fig. 1 [27].

There were 34 quantitative (mostly cross-sectional surveys (n = 31)), three qualitative, two longitudinal and one mixed-method study included in this review.

Four of the studies were identified as high quality, 13 moderate-high, 14 moderate-low and six low-quality studies using the MMAT quality tool as presented in Table 1 in the Supplementary Material.

Twenty-four (88%) of the included studies were published within the last 10 years with almost 30% of them related to the effect of the COVID-19 pandemic on dental professionals. Eighteen of the studies were conducted in Europe with eight from the United Kingdom [13, 37,38,39,40,41,42,43] and three from Germany [15, 44, 45]. The other European studies were from Finland [46, 47], Norway [48, 49], Sweden [50] and Slovenia [51]. There were four studies from Saudi Arabia [52,53,54,55], two each from China [18, 56], Thailand [57, 58] and Jordan [59, 60], one each from Iran [61], Turkey [62], Israel [63], the United States of America [64], Malaysia [65], Japan [66], Trinidad and Tobago [67] and Nigeria [68]. One final study provided comparative evidence of the dental workforce within the UK, New Zealand and Trinidad and Tobago [69].

Overall, the studies had clear research questions and appropriate data collection methods. All the studies used a questionnaire as part of the data collection procedure with varied methods of administration such as postal surveys [15, 38, 48, 66, 67, 69], online self-administered [37, 39, 44, 45, 55], a combination of methods [40, 43, 63], printed questionnaires [52, 57, 59, 68], via interviews, either in person, focus groups or online [41, 42, 61, 62] and computer-assisted telephone interviews [46, 47].

To augment data collected in questionnaires, studies utilised physical examinations [46, 59], photographs [64] and direct observation [65]. The findings on the current health and well-being of dental nurses (Table 1) the quality assessment scores and the key determinants of well-being of dental nurses (Table 2) of the included studies can be seen in the Supplementary Material.

Measuring dental nurses’ health and well-being

To measure the health and well-being of dental nurses, studies examined one or more of the following areas: health (physical, emotional, psychological) (n = 19), job well-being (job satisfaction, hazards, burnout, work-life balance) (n = 15) and individual (anxiety, wellness) (n = 3). There were some similarities with the instruments used in the different studies with most using a combination of questionnaires. Two studies used the 22-item Impact of Event Scale-Revised and depressive symptomatology using the Patient Health Questionnaire-2 [37, 39], variations of the Generalized Anxiety Disorder Questionnaire (GAD-2, GAD-7) [40, 44], Posture Assessment Instrument [64, 65], Work Stress Inventory for dental assistants (WSI) [60, 63] and the Warr–Cook–Wall instruments [15, 43]. The Depression Anxiety Stress Scale (DASS-21) was used by four studies [45, 53, 55, 66], as was the Maslach Burnout Inventory [18, 52, 63, 70]. 78% (n = 29) of studies used pre-existing or validated measures, with the majority of the studies using a combination of questionnaires.

Sample characteristics

There was evidence of research across a range of dental settings, with over 25% of the included studies conducted in university or tertiary hospitals [13, 18, 40, 52, 56, 57, 59, 62, 64, 68]. Six studies involved the use of professional/association lists [43, 45, 47, 66, 67, 69]. Six studies were conducted in a mixture of public and private settings [41, 48, 49, 53, 55, 63], four were in public facilities [42, 50, 54, 65] and primary care [37, 38, 58] and six studies had unclear settings [15, 39, 44, 46, 61, 70]. Only one study was conducted in private practice [60]. Sixteen studies focussed exclusively on dental nurses [15, 38, 53, 55, 56, 58, 60, 63, 67, 70] while the other 21 studies included other dental care professionals.

Dental nurse’s general health and well-being

The findings of the studies on the key determinants of dental nurses’ general health, and personal and job well-being following the work of Salazar [23] are presented in Table 2 in the Supplementary Material and in three levels, namely, macro, meso and micro-level factors. Regarding the studies related to the COVID-19 pandemic, there appeared to be a worsening of the well-being of dental nurses, as evidenced by the reported increased stress and anxiety, depression and social isolation [13, 40, 45, 61, 62].

Determinants of health and well-being among dental nurses

Findings on key determinants of the health and well-being of dental nurses, namely, macro- (Dental healthcare system, regulation and profession), meso- (job specification and workplace characteristics) and micro- (personal factors, professional and social relationships, career level)-level factors, are presented in the diagram (Fig. 2) from the model by Gallagher and Colonio-Salazer [21,22,23].

Micro-level determinants

Personal factors—(general factors)

Age

Increasing age was associated with upper extremity disorders, psychological distress (dental nurses > 35 years) and higher work engagement in dental nurses [18, 50, 56]. However, younger age [19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37] was associated with a higher prevalence of hand eczema among dental team members in clinics in Japan and younger workers with atopic dermatitis had a higher risk of developing hand eczema [66].

Sex

Although not statistically significant, it was found that more women experienced musculoskeletal pain than men (82.8% compared with 68.4%) in Slovenia whereas in Saudi Arabia, most female dental nurses were happier with their salary than their male counterparts (p < 0.05) [51, 53].

Family factors

In a Chinese study, dental nurses over 46 years faced pressures from their children going to college and elderly parents leading to lower work engagement compared with those aged 40–45 years who had children who could care for themselves (p = 0.001) [56].

Personal factors (pandemic-associated factors)

Age and sex

In a German study by Dreher et al. [44], dental nurses in the oldest age group (>41 years) health and well-being were significantly associated with an increased perceived risk of COVID-19 infection (OR 1.64 (95% CI 1.13–2.39)) whereas, in Norway, women reported being significantly more concerned about contracting the COVID-19 virus than their male counterparts [49].

Health-related behaviours

Dental nurses in Germany and the UK who had a higher self-rating of their health were significantly more likely to feel sufficiently prepared for dealing with patients with COVID-19 however, there were high levels of anxiety around personal protection and health (1.54 (95% CI 1.12–2.12)) [41, 44]. Dental nurses in China who regularly exercised were found to have statistically significant higher work engagement [56].

Family factors

In an Iranian study, staff with relatives who died from COVID-19 were 2.47 times more likely to have anxiety than those who did not [61].

Professional career level (general factors)

In China, the more advanced in their careers dental nurses were, the higher work engagement they had due to more experience and stable family life; however, in Saudi Arabia, when compared to other dental professionals, dental assistants (dental nurses) had the lowest level of personal accomplishments in terms of their self-assessment of their proficiency and productivity (p = 0.048) [52, 56].

Years working as a dental nurse

Dental assistants (dental nurses) in Norway with more work experience had a statistically significant increased prevalence of symptoms consistent with cognitive malfunction like memory and psychosomatic symptoms [48].

Extended duties/additional skills

Within the UK, most dental nurses (87%) agreed that continuous professional development courses had improved their skills and expanded their scope of practice (e.g. taking impressions, radiographs and applying fluoride varnish) [43]. In Scotland, extended-duty dental nurses were completely (28.2%) or very (39.7%) satisfied with their role and listed ‘resources’ and ‘supportive colleagues’ as facilitators to their success [38].

Professional and social relationships (general factors)

Dental nurses felt overworked and were unsatisfied with their relationships in Thailand, with a Saudi study echoing this and reporting that only 31.9% of dental nurses were satisfied with their professional and personal lives [53, 58].

Professional and social relationships (pandemic-associated factors)

At the height of the COVID-19 pandemic in the UK, self-isolation and social distancing put further strain on these relationships [13, 40]. Nevertheless, in one qualitative study of staff working in Urgent Dental Care Centres (UDCs) in England, dental nurses felt that their professional relationships were strengthened and they learned from and appreciated each other [41].

Meso-level determinants

Job specification (general factors)

Dental nurses in Thailand with numerous and non-specific roles reported more internal conflict which increased their stress and reduced their effectiveness [58].

Working hours

Dental nurses who worked fewer hours (<20 h/week) reported being more satisfied with their work (and income) compared to those working longer hours [15]. There was a similar finding in Saudi where male dental nurses working >8 h per day were less satisfied than those working less than 8 h (p = 0.01) [53].

Job specification (pandemic-associated factors)

During the pandemic, only 49.6% of dental assistants felt well-informed about interacting with patients with the virus with 87.6% unsure of the proper course of action to take and those that were redeployed and working in UDCs were concerned about working outside of their field of expertise, being assigned to a setting with higher risk (wards with patients positive for COVID), worries about the scarcity of Personal Protective Equipment (PPE) and feeling vulnerable to litigation [40, 41, 44].

Working hours

Working two back-to-back shifts daily was significantly associated with moderate levels of Post Traumatic Stress Disorder symptoms [61].

Workplace characteristics (general factors)

Private/Public sector

Dental nurses working in the private sector in Saudi Arabia were more satisfied than those employed in the public sector [53].

Work environment

Dental nurses reported being somewhat satisfied with their jobs in Jordan (53.5%) [60] which contrasted with the findings by Naidu [67] in Trinidad, where unsatisfactory working conditions for dental nurses were reported. Additionally, studies in Israel and China reported that there was psychological distress in dental nurses which was linked to lower pay, longer workweeks, burnout, high job stress, lower job satisfaction, regret over career choice and violent events in the hospital [18, 63].

Occupational hazards

In a Finnish study, 25% of dental nurses reported work-related dermatoses on their hands, forearms or face [46] while in Jordan, compared to controls (third-year dental students- preclinical), they had poorer hearing in the left ear which was statistically significant at the higher frequencies but not at lower frequencies [59]. Additional occupational hazards include musculoskeletal pain (46.8% of Thai dental nurses), daily use of methacrylates which was related to a significantly increased risk of adult-onset asthma (adjusted OR 2.65, 95%; CI 1.14–7.24), nasal symptoms (dose-response) (1.37, 1.02–1.84) and work-related cough or phlegm (1.69, 1.08–2.71) [44, 47, 57].

Workplace traits (factors related to the pandemic)

Concerning work during the pandemic, there was significant anxiety among dental staff in Norway, Turkey and the United Kingdom about restarting aerosol-producing procedures. Additionally, the constantly changing guidelines and increased patient demands in the UK and a higher risk of contracting COVID-19 in Germany were factors that negatively impacted the well-being of dental nurses [13, 41, 44, 49, 62].

Macro-level determinants

Dental healthcare systems (general factors)

Regulation

While dental nurses in Trinidad and Tobago were confused about the legislation regarding private practice, in the UK, dental nurses were unhappy about the cost of registration, with 74% finding the charge too expensive even though they agreed with completing Continuing Professional Development (CPD) and compulsory registration [43, 67].

Dental healthcare systems (pandemic-associated factors)

Profession

There was dissatisfaction with communication from the health system in England at the start of the pandemic [41]. Additionally, dental nurses in the UK report difficulty in paying for CPD with some opting to attend only free courses [43]. Dental nurses in Germany and Saudi Arabia were dissatisfied with their income and were uncertain about their financial situation during the pandemic [44, 53].

Comparing the pre-pandemic and para-pandemic well-being of dental nurses, the pandemic increased stress, anxiety and redeployment, causing a decline in the health, especially mental health, and well-being of dental nurses [13, 40, 41, 61].