Insights in interprofessional education: Dental hygiene students' suggestions for collaboration

Abstract

Background:

Interprofessional education (IPE) promotes team-based approaches to professional practice and lifelong collaboration. However, there is little consensus on its “best practice” in dentistry and dental hygiene curricula. This study aimed to explore dental hygiene students' perceptions and experiences of collaboration with dentistry students in an IPE program that authentically represents private practice settings and work processes. The intent was to identify what students thought would best help prepare them to work collaboratively in an oral health team once they graduated after participating in this experience.

Methods:

Data were collected from 40 dental hygiene student written reflections and 6 dental hygiene students through a focus group session that was audiorecorded and transcribed. Data were examined using thematic analysis.

Results:

Five interrelated themes emerged: 1) understanding of roles and responsibilities; 2) hierarchical perceptions and level of experience; 3) team dynamics; 4) instructor and staff involvement and support; and 5) timing and structure of IPE activities. The findings suggest that dental hygiene students need consistent and sustained access to realistic environments in which to practise team roles and work directly with dentistry students. Opportunities to build relationships with dentistry students before working together in professional roles appear to alleviate hierarchical concerns that impede teamwork.

Conclusion:

IPE should occur throughout students' education as hierarchical perceptions appear to influence collaboration. Informal and/or non-clinical IPE opportunities should be introduced early in students' education to develop a foundation for team dynamics in later formal and/or clinical IPE activities. Students should collaborate in ways that will be reflected in professional expectations after graduation; the environment in which they learn their team role should provide the opportunity to authentically practise it.

PRACTICAL IMPLICATIONS OF THIS RESEARCH.

• Interprofessional education appears to enhance collaboration and mutual respect among dental hygiene and dentistry students.

• Interprofessional activities should occur throughout students' education; informal, nonclinical opportunities should be introduced first to develop a team foundation for later formal and/or clinical activities.

• Instructors and staff play an important role in the delivery of interprofessional education; standardized training and outcomes should be developed and implemented.

INTRODUCTION

The professional relationship between dentists and dental hygienists in Canada is founded on a hierarchical legacy of domesticity ¹ but has evolved over time with legislative changes, which have enabled dental hygienists to obtain an extended scope and independent practice. ² However, polarized perspectives of professional identities and roles still exist between dentists and dental hygienists ^{3, 4} and may include hierarchical perceptual differences that can complicate collaboration. ² Research has found that dentistry (DDS) students tend to view the provision of oral care as dentist-centred, ² believe the main role of dental hygienists is to support the dentist, ³ and perceive dental hygienists as “the assistants of dentists” ^{2, p414}. Conversely, dental hygiene (DH) students generally view themselves as future independent practitioners. ^2,4,5 These diverging views may produce tension, hamper future collaboration within oral health teams, and negatively affect client care and practice efficiency. Consequently, there would seem to be a need for training DDS and DH students in a shared and interactive learning environment that promotes enhanced collaboration and client care. ³

The importance of instilling collaborative philosophies among future dentists and dental hygienists through education has long been recognized. ⁶ However, dentistry and dental hygiene curricula generally lack an emphasis on collaborative oral health professions' education, ^5,7 thereby inhibiting valuable opportunities for students to practise teamwork. ⁵ Although the American Dental Education Association (ADEA) defines intraprofessional education as “when students in two or more oral health professions learn, and provide client care together, in a fashion that promotes lifelong collaboration” ^{8, p2}, the wider literature defines intraprofessional education as “collaboration between two or more disciplines within the same profession” ⁹ . In contrast, interprofessional education is “collaboration between members of two or more health and/or social care professions to improve the delivery of care” ⁹ , and often refers to occasions when students from 2 or more health professions (e.g., medicine and nursing) learn with, from, and about each other to cultivate collaborative practice to improve client care quality. ^10-12 Intra- and interprofessional education share similar collaborative underpinnings, and each model has been highlighted in the literature as an effective means to enhance teamwork and communication, knowledge of roles and responsibilities, mutual respect, and improved client outcomes. ^{2,4,10,11,13,14} While the oral health literature often refers to the dentistry-dental hygiene relationship as intraprofessional (i.e., within the same profession), this study uses the term interprofessional (i.e., between professions) because dental hygiene is the sixth largest regulated health profession in Canada, ¹⁵ and is distinct from the profession of dentistry. Much has been explored in the literature on interprofessional education (IPE) between oral health professions and other health professions, but the information on dentistry and dental hygiene IPE remains sparse. ^8,10

Previous studies on dentistry and dental hygiene IPE curricula found lecture courses, clinical activities, volunteer activities, and community service or service-learning activities to be most common. ^6,10,16,17 However, as noted by Formicola et al. ¹⁰ there are few exemplar programs that highlight IPE's “best practice” in the oral health professions. Medicine and health care research suggests that simulation-enhanced interprofessional education may hold advantages over other educational techniques. ¹⁸ Simulation-enhanced education is characterized by generated situations or environments that allow individuals to experience a representation of a real event. ¹⁸ The ability to create learning environments that resemble realistic, authentic, and relevant clinical practice is integral to meaningful collaborative learning experiences. ^2,18-20 Thus, dentistry and dental hygiene IPE programs that are realistic, authentic, and convened in relevant environments should be further explored.

The University of Alberta's (UofA) dentistry and dental hygiene programs host an IPE experience called “the satellite rotation” that places students in a clinical office setting reflective of the environment in which they may find themselves working upon graduation. ²¹ This environment has DH students engage in their scope of practice with other members of the oral health team (e.g., DDS, registered dental assistants [RDAs], and front-end staff) within realistic time constraints and structures (e.g., 1- to 2-hour appointments involving both practitioners' care) to share client care and collaborate in clinical practice.

DH and DDS students are scheduled for a 2-week rotation together at a northern, rural satellite clinic during their final year of training. Two interprofessional groups of 4 students each (i.e., 2 DH and 2 DDS students) live together and engage as teams in different communities across Alberta. Supervision and instruction are provided either by assigned DDS instructors from within the department's clinic program or by experienced DDS practitioners from various parts of Alberta, ²¹ as well as by other satellite staff, such as RDAs and front-end personnel. The realistic and relevant representations of the private practice working environment in the satellite clinics provide a valuable opportunity to study DH students' collaborative learning experience in this context.

The purpose of this qualitative study was to explore DH students' perceptions and experiences of collaboration within the satellite rotation at UofA. The central research question of the study was “What do DH students think would best help prepare them to work efficiently in an oral health team?” This research aimed to use the insights generated to formulate suggestions that will help inform the development of IPE curricula that reflect professional needs in dentistry and dental hygiene.

METHODS

The study design was guided by qualitative description as it is a suitable method to provide a direct and rich description of student views and insights. ^{22, 23} A constructivist lens, which assumes that knowledge is constructed from varied and multiple subjective meanings that humans ascribe to their experiences, was used. ²⁴ The University of Calgary Conjoint Faculties Research Ethics Board and the University of Alberta Health Research Ethics Board approved this study (CFREB IRB: REB19-1723; REB IRB: Pro00097055).

Participants

Senior DH students who completed the satellite rotation in the 2018-2019 academic year participated in this study. This cohort had a unique experience because they participated in the rotation twice as the program underwent a transition from diploma-entry to degree-entry. Typically, DH students complete 1 rotation at a single location. By completing 2 rotations, this cohort of students gained a greater breadth of understanding, perspectives, and experience, enabling them to speak to comparative experiences across rotations unlike other student cohorts and share subjective perceptions of how best to plan future cohorts' rotations.

Data collection

Data were collected from students' satellite reflection papers and a focus group discussion.

Written reflections

Students were required to complete an individual reflection paper about their experience following their second rotation. Written prompts were provided as guides (e.g., describe your most rewarding experience, describe your most challenging experience). Within these prompts, students were specifically asked to elaborate on interprofessionalism (e.g., how did your experience on the satellite clinic enhance your interpersonal skills?). Students submitted reflections via an online submission link in a course website that was administered by the course coordinator. Reflections were directly exported and anonymized by the course coordinator and then relayed to the study team.

Focus group

Satellite rotation coordinators contacted students via email to provide study information and invite their participation in a focus group discussion. Students were instructed to contact a member of the research team who was arms-length to the DH program (MH) if they were interested. Focus groups were chosen for data collection to promote heterogeneity in the discourse arising from the diversity of comments related to perspectives and experiences of the group of participants. ^24-26 This opportunity was important because the students had different but similar experiences in their 2 separate rotations (locations) with different DDS students and instructors.

Consent for focus group participation and to be audio-recorded was obtained prior to the session. The 90-minute session was facilitated by a member of the research team (MH) using a semi-structured interview guide containing methodologically informed sequences and types of questions, and included broad, open-ended questions. ²⁷ The facilitator reflected on the content and conduct of the session immediately after its completion and reflexively documented the awareness of any feelings or perceptions that would impact interpretations of data. ²⁸

Students were asked about their collaboration expectations and experiences in the satellite rotations (e.g., What expectations, if any, did you have regarding working with the dentistry students? Tell me about your experience collaborating with the dentistry students. What did you like? What didn't you like?). Specific questions related to suggestions for collaboration (e.g., What do you think would best help prepare you to work in an oral health team? What do you think has already prepared you or has been the most helpful? What do you think would make interprofessional educational opportunities more rewarding or useful for your future practice?) aimed to elicit students' perceptions of factors that facilitated enhanced collaboration and their suggestions for IPE improvement.

Data analysis

Themes were inductively (i.e., without preconceived categories and conceptual frameworks) identified from the data using Yin's ²⁹ 5-phase cycle of thematic analysis (TA). TA involves transcribing audio data, assembling and gathering written data, disassembling compiled data through a manifest content coding process to reveal patterns, reassembling coded data into themes by identifying how categories are related, interpreting the reassembled data in a way that tells a story, and drawing conclusions. Throughout this process, reflective, critical, and diagrammatic memos were recorded alongside respective areas on the reflections and transcripts to identify specific text segments related to the research aims and existing themes in the literature.

To enhance methodological rigour, separate researchers (MH and MY) independently followed an analytical strategy and then discussed discrepancies to reach consensus. To enhance credibility, member check,s were employed to confirm that the researchers' interpretation of data was aligned with the participants' own meanings and perspectives. ³⁰ Participants were presented with a summary of the discussion and given the opportunity to review and engage with the researchers' interpretation immediately after the focus group in a post-session debriefing ²⁶ and then again via email once the data were further analysed. The themes identified depict the multiple perspectives and experiences of participants.

RESULTS

Forty DH student reflections were analysed, and 6 DH students participated in the focus group session. Five common and interrelated themes emerged across the data sets: 1) understanding of roles and responsibilities; 2) hierarchical perceptions and level of experience; 3) team dynamics; 4) instructor and staff involvement and support; and 5) timing and structure of IPE activities. Supporting quotations from the student reflections are presented in Appendix A (participants are identified starting with R), while supporting quotations from the focus group session are presented in Appendix B (participants are identified starting with FG).

Theme 1: Understanding of roles and responsibilities

DH students conveyed they had little prior knowledge of DDS roles and responsibilities. They expressed that working closely with the DDS students during the satellite rotations enhanced their confidence to interact and learn with them, which provided greater exposure to different procedures, perspectives, and expertise on the oral health team. They shared that this interaction deepened their knowledge and understanding of DDS roles and responsibilities, and further enhanced their oral health and dental hygiene knowledge repertoire. DH students also noted feeling that DDS students demonstrated appreciation for DH roles and responsibilities from their experiences working alongside one another.

DH students expressed that an enhanced understanding of both professions' roles and responsibilities led them to appreciate each profession's expertise. They emphasized that their experiences during the rotations allowed them to learn more about their roles and responsibilities as dental hygienists and increased their confidence. They also noted that the opportunity to practise their skills in a team setting and visualize how their role fit with others improved their understanding of how DH and DDS roles intersect and how they may collaborate in the future.

Theme 2: Hierarchical perceptions and level of experience

DH students expressed an awareness of hierarchical divisions between professions and communicated concerns about a lack of respect from DDS students due to perceived power imbalances. They also indicated this hierarchy was embedded in their interactions with the rotation's DDS instructor. For example, one focus group participant recounted feeling that the instructor's erroneous perception of the dental hygiene scope of practice led them to dismiss the DH student's knowledge and expertise, which made them “feel worthless” (FG5). However, DH students expressed optimism in the DDS students who shared in the satellite experience, which provided opportunities for them to encounter the full capacity of DHs at an early stage, therefore alleviating the potential for future dismissive behaviour.

In addition to the perceived imbalance in professional status and lack of respect, students also highlighted potential power dynamics after graduation from an employer-employee perspective within private practice clinics. Despite this recognition of workplace hierarchies, DH students expected to be treated as partners or equals in client care, recognizing that dental hygienists have their own expertise. DH students noted they felt more confident in sharing their expertise when they had more experience, both in general and in comparison to their DDS student counterparts. For example, one student expressed that this made them feel like they “had something to offer” (FG1). In both instances where DH students had a greater breadth of experience to draw from, they communicated feeling there was greater mutual respect and collaboration.

Theme 3: Team dynamics

DH students emphasized that the satellite rotations were beneficial for collaboration because their 2-week duration provided the opportunity to cultivate team dynamics with the other students and staff. Namely, they shared that the relationships and friendships built with the DDS students alleviated the preconceived hierarchy, notions, and anxiety they held and that this then facilitated their ability to work more effectively with the DDS students. DH students perceived that relationship building with the DDS students, instructors, and satellite staff helped to build trust and mutual respect, creating an environment in which they were confident in their participation and ready to learn, instead of being afraid to make mistakes in fear of judgement. They also shared that the social time they spent together outside of clinic helped to further build this foundation of trust and respect and decrease perceived barriers between the 2 professions. DH students felt that these connections resulted in enhanced collaboration in the clinic as they sensed camaraderie (R30) and unity (R17) as everyone endeavoured to help one another for the betterment of the team and clients. Students desired to continue these working relationships within the school clinic and to obtain similar, “genuine connections with [their] colleagues” (R8) in their future careers. To better facilitate relationship building and collaboration, they suggested having more “day-to-day” (FG6) opportunities to work with DDS students, attending didactic classes and working on case studies with them, and participating in team building activities together. They noted it may be beneficial for DH students to have prior interaction with DDS students with whom they will work clinically later.

Theme 4: Instructor and staff involvement and support

DH students conveyed that satellite instructors and staff played a large role in either creating or hindering a collaborative environment during IPE activities. Students expressed that this influence occurred in 2 main ways: 1) through their ability to outline clear expectations from the outset and provide guidance to students throughout IPE activities; and 2) through the precedent they set by their interactions with students and other staff. Students relayed that there were more opportunities for collaboration when instructors and staff outlined clear expectations and set the tone for collaboration. DH students elaborated that, when instructors and staff were “sitting back” (FG2) and did not provide clear expectations and role modelling for collaboration, the opposite occurred and they “felt very isolated” (FG3).

DH students perceived a difference in the collaborative atmosphere between their 2 satellite experiences, which they attributed to the different satellite instructors and staff who were present at each rotation's location. Although students felt the DDS instructors were helpful, they also indicated they would have appreciated having a DH instructor present to provide more directed guidance on their specific scope of practice, and as one focus group DH student noted, “to advocate for [them]” (FG5).

Theme 5: Timing and structure of IPE activities

DH students expressed that the satellite rotations were the most useful IPE experience for future collaborative practice and noted aspects of the structure and timing as strengths. Successful aspects of the structure were related to the rotations' interactive, relevant, and realistic environment. For example, students valued that the satellite clinics simulated private practice and provided an authentic experience (e.g., appointment lengths, routine, and close working proximity to DDS students). They felt that such an environment led to more natural and authentic collaboration than the universit,y-based clinic where students regularly practise, and they reported the satellite rotations helped to prepare them to work in the “real world” (R24). Further, students noted that the satellite rotation's assessment structure, which allowed for self-assessment and formal grading of the entire experience rather than grading of every component, promoted better collaboration than the university clinic, as students felt less stressed and less afraid to make mistakes.

DH students relayed that structuring the university-based clinics more like private practice would better prepare them to work collaboratively in oral health teams. They shared that having better access to the DDS students in their regular university clinics could help them collaborate in ways that would reflect future working relationships (e.g., a DDS student acting as the “recall [person]” [FG3] for the day). However, they also indicated that the scheduling of such clinical interactions would need to be purposeful to reflect when students would have sufficient clinical experience to participate effectively.

Regarding successful aspects of the timing of the satellite rotation, DH students highlighted that participating in the rotation twice gave them a greater variety of experiences to learn from, and the 2-week duration allowed for sustained, consistent learning and contact between DH and DDS students. DH students expressed that both these factors helped establish relationships and routines benefiting collaboration.

DISCUSSION

This study explored DH students' perceptions and experiences of collaboration with DDS students within the satellite rotation. Overall, DH students shared a range of positive and negative perceptions of their experiences. They expressed that consistent and sustained access to realistic environments in which to practise their team role and work directly with the DDS students would best prepare them to work in an oral health team upon graduation. The data gathered showed 4 key collaboration-centred student experiences: 1) understanding of roles and responsibilities; 2) hierarchical perceptions and level of experience; 3) team dynamics; and 4) instructor and staff involvement and support. These experiences influenced the students' perceptions of the ideal timing and structure of IPE as part of their program.

This study's findings reinforce the notion that IPE activities should not only occur throughout students' education, but also be aligned and relevant to students' level of experience and situated within their professional identity development. Students expressed that they felt more confident in collaborating once they fully understood their own professional role, which has been previously reported in the literature. ^14,31,32 Research also shows that DH students do not always perceive themselves as knowledgeable and confident members of collaborative health care teams ^33,34 and feel more respected and validated when other health professions hold a positive view of their role. ³⁵ Similarly, the current study's findings indicate that DH students' confidence to collaborate increased when they received validation from DDS students on their expertise, as well as when they felt more experienced than their DDS counterparts. These findings suggest that the value DH students ascribe to their contributions and expertise may stem from DDS perspectives of dental hygiene (i.e., external affirmations of their unique knowledge and skill) and further demonstrate that DH students may hold internalized hierarchical self-perceptions of their professional role and identity. Considering the history of domesticity between dentistry and dental hygiene, ¹ the students' comments might be understood through Paulo Freire's lens on the duality of the oppressed, who “are one and the same time themselves and the oppressor whose consciousness they have internalized” ^{36, p48}. Thus, these findings suggest DH students need to establish a foundational understanding of their value and worth as members of the oral care team so they can participate with confidence in clinical care. It may, therefore, be advantageous for dental hygiene programs to incorporate curricula aimed at improving internal perceptions of the profession and fostering students' self-confidence.

In relation to perceptions of professional roles, Colonio Salazar et al. ³ found that DDS students appear to have a higher preference for an exclusive professional identity (e.g., non-inclusive in terms of shared roles and care) and suggested this preference is due to preconceived stereotypes held by DDS students and their reinforcement by role models, such as instructors and staff, during their education. Since DH students in this study reported greater feelings of mutual respect from less-experienced DDS students, it might be inferred that DDS students should have early exposure to DH students to establish an understanding and respect for dental hygienists' expertise and value before the DDS sense of professional identity is solidified. This notion supports the argument that effective teamwork requires not only an understanding of the different roles and responsibilities of other team members, ⁴ but also a deeper conception of appropriate attitudes ³⁷ that reflect a more inclusive approach ⁴ since status and professional stereotyping are significant barriers to IPE. ^3-5,38

McComas et al. noted IPE “should be intentional and formally taught in the classroom setting and reinforced in the clinical setting” ^{6, p330}. In this study, the relevance of informal IPE opportunities was evident, suggesting that it may be advantageous to introduce informal and/or non-clinical IPE opportunities (e.g., team building) to students before they are expected to participate in more formal and/or clinical IPE opportunities (e.g., shared client care). Such an approach would allow students to first develop an understanding of their own role and how it fits within a team practice, and to build a foundation for team dynamics (i.e., rapport, mutual respect) prior to formal clinical interactions. The satellite rotation's 24/7 nature of interaction was highlighted as a catalyst for relationship development, which then translated into enhanced understanding and collaboration in clinic. Notably, McComas et al. ⁶ found that when DDS students and DH students share more classes, they spend more time in the clinic collaborating on client care. Similarly, the present study revealed that the more time students spent together in general (e.g., living together during the rotation), the more likely DH students were to translate that relationship into perceived enhanced clinical collaboration. To heighten the frequency of opportunities for relationship development and collaboration, students discussed having more “day-to-day” exposure to DDS students, such as increasing the number of shared classes where students may interact casually (e.g., radiology or oral pathology) or integrating team building activities into their education.

The relationship between collaboration and social factors, such as the amount of time students spend socializing, has not been well documented in dentistry and dental hygiene IPE literature. However, this relationship has been highlighted in nursing and education literature. Nursing literature reports that the development of long-term relationships fosters trust and mutual understanding, ²⁵ which may then work to better facilitate social interactions (i.e., getting to know someone both personally and professionally) and enhance collaboration. ³⁹ Between nurses and physicians specifically, social exchanges in the workplace (e.g., displaying humour with members of the interprofessional team) have been found to facilitate the development of trust, respect, and collaboration. ⁴⁰ Similarly, education research shows that daily social exchanges foster mutual trust and collaboration among colleagues in educational organizations. ^41,42 Of further interest, Moore et al. highli,ghted an increasing recognition that trust and collaboration within organizations and between people are dynamic and “influenced by prior and current experiences” ^{39, p1}.

This study's findings suggest that opportunities for DH students to establish relationships with DDS students as individuals first to develop a foundation for team dynamics (i.e., trust and respect) may aid in dismantling hierarchical perceptions and stereotypes, which may then translate into more effective collaboration in a clinical environment. This notion is significant because of the mismatched perceptions students may already have of their professional identities, roles, and responsibilities. ^{2,4 ,5} Importantly, a lack of trust has been highlighted as one of the main reasons that interdisciplinary projects are unsuccessful. ⁴³ When mutual respect and a sense of equality are lacking among team members, trust may be diminished, which may then lead to a lack of perceived safety and decreased group participation. ³² Therefore, it might be inferred that establishing trust ³² and creating the foundation for effective team dynamics are essential to successful IPE implementation. The essentiality of establishing a foundation for IPE was also echoed in Jackson et al.'s ⁴⁴ study, which identified that the majority (94.8%) of DDS and DH students believe that students need to trust and respect each other for shared learning to work.

Once students create a foundation for team dynamics and are confident in their own professional roles, responsibilities, and scopes (perhaps in the final years of training), IPE activities should expand to more formal and/or clinic scenarios. This could include dedicated sessions in which interprofessional student groups work on case studies together or collaborate during their regular clinics. In these later scenarios, it is important that these opportunities be presented in a realistic and relevant manner to students' professional practice. Evans et al. ⁴⁵ also alluded to this notion that students “need to experience the roles they will play when they enter the workplace so they can recognize its value” ^{45, pp243-44}. Comparably, this study's findings suggest students should collaborate in authentic ways that will be reflected in professional expectations after graduation. Dentists and dental hygienists work together, share clients and cases, and are in dialogue with each other every day ⁴⁶ ; the environment in which they learn their team roles should provide the opportunity to authentically practice it. ^19,20,45

This study's participants valued the satellite clinics' structure (i.e., how collaboration was facilitated and the authenticity of the experience) both in terms of assessment and environment. Students felt that less structured clinical assessments, such as self-assessment and formal grading of the entire experience rather than every component, allowed them to focus on the experience rather than the consequence of making a mistake. As students noted that less-structured assessments promoted more genuine collaboration, educators should consider assessment structure when planning meaningful IPE experiences. Further, students appreciated the “private practice” structure of their learning environment because they felt it was interactive, relevant, and realistic. This finding is well situated in the literature, as students have long valued authentic learning experiences relevant to their future practice. ^2,18-20 However, it is important to note that dental hygienists are increasingly practising in settings outside of private clinical practice (e.g., community-based and other non-traditional settings) due to evolving scopes of practice. ⁴⁷ Although many DH students anticipated working in traditional private practice settings upon graduation, curricula should also explore the use of IPE activities that simulate non-traditional settings so that students can experience working in realistic team roles within a variety of contexts. Such experiences may prevent DH students from feeling limited to a future career in private practice.

IPE plays both a critical and challenging role in preparing DH and DDS students for team practice. Well-designed and purposeful activities are a valuable way to facilitate group interaction. However, even the most rigorously designed IPE program would be ineffective without strong instructor and staff role modeling and leadership, in addition to institutional support. ³¹ Following Morison et al. ⁴⁸ since effective teamwork requires members to feel their roles are positively perceived, oral health team educators must acknowledge that perceptions of status may influence behaviour and interaction—including their own.

It is widely recognized that clinicians and educators are role models from whom students learn attitudes, values, and beliefs ^48-51 ; thus, ineffective leadership and role modelling may reinforce harmful, preconceived stereotypes that hamper effective collaboration. ^38,45,48 Instructors and staff should recognize the impact they have on student learning experiences and exemplify leadership in collaboration. ³¹ Moreover, Jones et al. ⁴⁹ cautioned that a lack of strong leadership by instructors in encouraging collaboration, may impair students' learning and experiences of teamwork as they are more likely to simply co-exist during IPE activities. The implications of DH instructors' absence during the satellite rotations were an important finding of the present study, as this absence resulted in a perceived lack of guidance on the specific roles and responsibilities of dental hygienists, which seemed to be interconnected with DH students' confidence to collaborate. Dentistry and dental hygiene programs should consider the impact instructors and staff have on IPE learning experiences and ensure that pointed and appropriate guidance on respective professional roles and responsibilities are available to each student group, and that standardized training and outcomes are developed and implemented by instructors and staff. ^31,50,52,53

The lack of understanding that, in almost all regions of Canada, dental hygienists do not require supervision from a dentist and are self-regulated primary health care professionals ⁵⁴ perpetuates hierarchical perceptions not only among the public, but also among students who enroll in DH programs with little understanding of the profession they are entering. This viewpoint is pervasive; a 2020 survey administered to the Canadian public revealed nearly half of respondents did not view dental hygienists as primary health care professionals, and only one-fourth of respondents were comfortable with the thought of visiting an independent dental hygienist. ⁵⁴ The discourse within the literature on collaborative learning opportunities between dentistry and dental hygiene largely situates dentistry and dental hygiene under a single umbrella of oral health professionals, ⁸ with these learning activities primarily referred to as intraprofessional. ^{2,5,6,10-12,55,56} However, the authors of this article challenge this notion of “intra-” professionality because it fails to recognize the distinct roles, responsibilities, and scopes of practice each profession contributes to the collaborative team in delivering optimal oral care. Based on this study's findings, hierarchical perceptions created by the notion of intraprofessionality itself may be reinforcing and systematically perpetuating the stereotype of domesticity of the profession of dental hygiene, among other distinct oral health professions, subsumed under the single category of dentistry.

Limitations

This qualitative study was limited to students in one dental hygiene cohort and was conducted at one university housing both dentistry and dental hygiene programs, thus reducing the generalizability of the findings. However, this research offers insights that may be transferable to new areas ⁵¹ in which concepts and practices of IPE may be further explored. This study was intended,as an initial inquiry into DH students' experiences with DDS students within authentic, relevant, and realistic IPE environments. The perceived benefits of IPE in this context were notable and deserve further attention, even though further studies with larger samples are needed to confirm DH students' perceptions and experiences of collaboration within these settings, as well as their curricular development suggestions. Moreover, future studies should explore DDS and other oral health professional students' perspectives. The relation between satellite rotation scheduling, DH and DDS professional identity, and their perceptions of one another should also be investigated.

CONCLUSION

This study identified DH students' perceptions and experiences of, and suggestions for, collaboration after participating in 2 satellite rotations. Interprofessional opportunities for DDS and DH students to interact regularly and repeatedly with one another, be exposed to working roles and responsibilities, and develop relationships appear beneficial for both professional development and collaboration. The findings suggest that the key areas in which future IPE curricula and activities involving DH students may be enhanced are the timing and structure of IPE activities, as well as instructor and staff support in creating positive learning environments. IPE development should not only focus on providing realistic, authentic, and relevant experiences for students, but also require thoughtful reflection on the systemic facets and discourse through which hierarchical perceptions may be perpetuated in institutional and interpersonal settings.

Appendices

Appendix A:

SAMPLE PASSAGES FROM STUDENT REFLECTIONS

Theme	Representative verbatim reflection quotations
Understanding of roles and responsibilities	R24: I did not realize how little I knew about dentistry until this rotation…Working so closely with the dental students increased my knowledge drastically and it was honestly one of my favorite parts about the rotation. R8: Working side by side with dentistry students made me more confident to interact with them and ask them questions about certain procedures that they were doing which was a great learning opportunity. R16: Getting to work alongside two dentists was such a wonderful experience and I loved getting the opportunity to see a different perspective in the dental world and to learn from them and their personal experiences. I found it so interesting to ask them questions and hear their opinions on different topics related to oral health and I feel like I grew a lot as a dental hygienist through this process. R25: Working alongside the dentistry students in this manner positively impacted my ability to read x-rays, notice intraoral findings and view caries. The dental students enhanced our clinical skills as dental hygienists as they were eager for us to present them with any intraoral findings and thoughts about the patient's treatment plans. R38: It gave the opportunity to understand how each member contributes and allowed for the expansion of perception of my own role and the roles of others. R35: I recognize just how interlinked the two professions are...Both professions have the same goal in mind for the patient, which is to help them achieve dental and oral health. R29: I learned a lot about the dental profession and how to encourage collaboration by offering insight and asking for advice...I would frequently ask questions about dental procedures the students were performing, and they would ask me for advice on how to communicate the importance of oral health to patients in a more effective manner.
Hierarchical perceptions and level of experience	R1: In society, we tend to put doctors and dentists on a pedestal and sometimes we forget about our mutual respect for each other. R26: At first, we noticed that dental hygiene was not as prioritized as dentistry, however dental hygiene should be prioritized… R41: The dental students and supervising dentist acted as partners while we treated patients…and that is the type of working relationship I want in the future. R40: At the start of my rotation, I was unsure of how the relationship between the two professions was to work, and spent most of the first week having the dentist let me know what they wanted done, and then I would just follow their recommendations. However, by the second week, due to conversations with my dentist, and overall practice throughout the week, I started to understand that that was not the way an actual practice operates, and was able to start making co-decisions with the dentist, or make my own decisions.
Team dynamics	R1: Getting to work and live alongside the dental students was very nerve-racking at first, until our first interaction with them when they explained that they were nervous as well. R18: Over the next two weeks we would become amazingly close with one another, sharing secrets, being ourselves and just having the best time we could in the confines of our northern home…This friendship extended well into the clinic setting every day, we worked as a team wherever we could. R6: By the end of the two weeks, we felt like a family; we lived and worked very well together. We made meals together, watched movies together, and went to the gym together. This allowed us to feel energized every day in clinic, which translated to our excellent patient care. R5: To work as a team in an interprofessional surrounding, it is important to help your co-workers as much as possible and to not be afraid to ask for help when I need it too. R30: I appreciated the comradery in the clinic, where everyone helped each other out and no one was left behind. R17: Everyone started the day together and everyone left the clinic together and through this a unity and bond was built interprofessionally. R3: The client's best care is the responsibility of everyone in the office and you cannot give best care without rapport and communication between professionals. R20: It is crucial to make sure you are working as a team and helping each other to then help the patients. R8: I think that getting to know the other students and being able to create genuine relationships in such a short period of time made the rotation not only survivable but also enjoyable...I will also take what I learned about building quality relationships with who I live and work with by working towards creating genuine connections with my colleagues in the future. R31: I am thankful for this incredible experience with the dental students and looking forward to continue working with them in [the university] clinic.
Instructor and staff involvement and support	R25: I would also like to say how amazing [the satellite staff] were throughout our rotation, they made me feel so confident each day and helped educate us on x-rays. R10: I did not have my [DH] clinic instructors to guide me, or my notes to review. I did feel overwhelmed. So at that moment I had to rely on my confidence and knowledge to deliver anaesthetic (thank god for [the DDS instructor] that stayed with me and supported me). R15: After talking to [the DDS instructor] about how to go about treatment, he was able to give me insight…which helped build my confidence and knowledge prior to the appointment.
Timing and structure of IPE activities	R35: I think [the satellite rotation is] as close as simulating private practice as it can get, and it's useful for me to have an idea of how it's like because I'd like to work at a private practice in the future. R41: Being able to work in close proximity with dental students, and our supervising dentist, gave good insight as to what private practice will be like. R36: In the university clinic we always discuss and practice interprofessional skills in a manner of diagnosis and treatment, but on satellite we helped each other more times than I could count. If someone didn't have a patient, they would develop your radiographs for you, help you clean your operatory or assist in treatment. R3: Many of the appointments I saw were people coming in for an exam and dental hygiene so I took lots of bitewing radiographs and had to work in a team with the dentist to examine them. R33: During my rotation, my operatory was in very close proximity to the dental students…I believe that I am better prepared for work after school, as I have a better understanding of what working with a dentist is going to be like. R24: This rotation was a steppingstone between our school clinic experiences and the world of private practice. I think this is exactly the rotation we need to become the best clinicians possible. It is a great way to prepare us for the real world and it gives us many hours of hands-on experience. R40: The routine and appointment lengths we experienced on rotation were more similar to how practices outside of school run, so having the confidence to excel in that type of environment will make it easier to adapt to being a dental hygienist after graduation.

Appendix B:

SAMPLE QUOTATIONS FROM THE FOCUS GROUP

Theme	Representative verbatim focus group comments
Understanding of roles and responsibilities	FG2: I did get a chance to kind of help out, assist, and I felt like it gave me a better understanding of what they actually do. FG3: …Because you don't really know what they're doing over there. Like you know they pull teeth, they do fillings, all that stuff, and I'm like, I don't know what it looks like or what materials you need… FG2: …I liked the learning experience of it…Just seeing what stuff they use. I really liked getting more dental knowledge…like a higher dental IQ basically, just knowing what are some things that they look for. They kind of gave good tips too when we were working together. Like, “Oh look at that,” “isn't that interesting,” and would point things out that your eye may not be able to catch. So that was interesting to me…it's stuff that you don't learn in school. FG1: One thing that kind of made me have that light bulb moment was [providing dental hygiene therapy to a DDS student during a cancellation]. So, I brought him over and I'm just working away, and he was like “wow, you guys really hold the tool proper…you really have a lot of control! I don't do that” …and…it was just kind of a moment like, so we are very much an expert on what we're doing, while you're very much an expert on what you're doing…They're just totally different kind of professions. FG5: You can't do one without the other.
Hierarchical perceptions and level of experience	FG5: The dentist that we went up north with, I don't think he actually knew that we can diagnose… FG4: Yeah, he didn't. They don't know our scope of practice… FG5: …He looked at my diagnosis and he crossed it out. He's like, “You didn't diagnose anything these whole two weeks,” and I was kind of like, “Excuse me? Like, everyone had perio, I diagnosed a lot.” He just put a line through it. I was like, this makes me feel worthless, almost, you know? FG3: …I think [with] experiences like the northern rotations…you get more of a respect. I think the dental students that will graduate, who have gone through and seen what a hygienist can do…they will be further prepared [to collaborate]. FG3: You don't know if [the DDS will] give you the amount of respect that you think you deserve as a hygienist, like that power kind of thing. FG2: ...I'm kind of nervous for entering private practice…one thing that's different from going up north is that they will be your boss...who should be held above you kind of, you know what I mean? That's kind of how it works… FG5: To build on that, obviously if a dentist hires you, they're your boss and there's a hierarchy in that way. But I guess I would hope that in terms of clinical care and patient-centred care that they would view me as an equal. FG6: ...I went to school. I know what's acceptable so I feel like I should be able to make that call. I don't want to be dictated on what I do for my patient's care.
Hierarchical perceptions and level of experience	Facilitator: For my understanding…you found that there was less collaboration when [the DDS student] had more experience? FG4: Yeah, you're not on the same level. FG3: It wasn't like asking questions about things together, like working through situations being like “oh I've never seen this before.” It's more like they're doing their thing, we're doing our thing, and it's kind of black and white. FG4: Whereas when the dental students are in the same year of learning as us, they don't know as much as we do so they're not, it was…more of a mutual respect, I think. FG1: It was like both students learning together. Facilitator: …So, on the flip side, if you were to have more experience…How do you think that exchange would go? FG1: …more confidence, less intimidation, maybe. FG4: I feel like…once you feel comfortable with hygiene, it's much easier to just be like, “Hey this is what I found” or ask, “Hey, is this a carious lesion?”… FG2: I do think it's super important to know your role so you can be confident in it…I find that I got more confident asking questions because I know now what I should and shouldn't know…that gave me more confidence and especially getting to know the mutual respect thing too, that you can just ask and not be judged. FG3: …[Also], if you ever get questioned you know where you stand. FG5: Yeah, like when that dentist said, “You guys don't diagnose” …I should have been like, “Are you kidding me?”
Team dynamics	FG1: Dental students kind of seem intimidating at first…but then once you actually get to know them, you are in the same kind of boat. FG3: …I was a little bit, not scared of [the DDS students], but just kind of timid to approach them at the beginning. Whereas, by the end of the two-weeks you've been living together, you really build a good relationship and I would be totally comfortable just walking up, whether they have a patient or not and be like, hey, when you get the time, come and do a recall exam for me. So…I think you build that trust over time. FG6: The more time you spend with them, the more comfortable you'd be. If we only had a couple days rotation with the dental students (FG2: so true), well, we wouldn't be opening up (FG1: absolutely not). But the two weeks, over that time we open up. FG1: And you're with each other 24/7, too. FG5: I find that, once that trust is kind of built we both were asking each other questions about each profession… FG2: …It's almost something your ego doesn't want you to ask, right? When you're not comfortable around someone. You just want to be like, ok, I'm going to pretend I know what that is because I'm not dumb. [laughter] FG3: But once they ask us stupid questions about hygiene, then I'll be able to ask you a stupid question about dentistry. FG1: Yeah, like breaking that barrier.
Instructor and staff involvement and support	FG5: I think [the satellite instructor and staff] really help…or hinder the collaboration between the students. FG2: True. They're kind of the framework, right? FG5: Because if they're saying, “Okay, this person has charting, let's help them with this”, it kind of shows this is the expectation in the team dynamic and it just sets the tone. FG3: …I found it was different the two different times. The first time I went, the supervising dentist was like, “Oh, I know that the dental students are done right now so I'm going to get them to come check, and then I'll come double check later” …but then the second time I went, I was in a secluded room and I never saw any of the other students, so it was just me and the dentist. FG2: …honestly, we didn't really collaborate a lot because we didn't even know that was a thing really because the supervising dentist was kind of sitting back. FG4: The assistants in [location 1] worked together so much better…[RDA1] would be like, “this is our amazing, beautiful, receptionist”…whatever [RDA1] actually thought of her, she showed us that you respect her…Whereas in [location 2] I found the team was more like…“Hey, you would never guess what [this staff member] did to me” and “this dental student's really pissing me off.” [agreement]. FG3: …In [location 1] they'd be like, “[FG3], I see you have two or three charts that you need to catch up on, let me wipe [your operatory]” to help out, collaborate…to get out of there together. Whereas [in location 2] I felt very isolated... FG2: I actually sometimes found that I wish that there's a hygiene instructor up north. FG5: to advocate for you? FG2: …Yeah, when you're booking someone back because they have severe perio, you're not getting questioned on why or something. [agreement]. FG4: …That communication was a little rough of what we needed because it was very focused on dental, so it was like hygiene, well you should know what you should be doing. Like the dentists going up are focused more on the dental aspect of it… FG3: I think because it's a dental supervisor, they were more like (FG2: on the same page [with the DDS students]), talking about very specific things [to the DDS students], like hey you need to work on this specifically, whereas when they came over to us, they [wouldn't provide] as direct guidance that we're used to in our clinic [by our DH instructors].
Timing and structure of IPE activities	FG5: I think it helps with the collaboration in the satellite versus [the university clinic]. In [the university clinic] we're all doing our own thing. You don't know what the dentists are doing. They don't know what you're doing. Whereas, when you're on satellite, you see the schedule, you see, oh, this dental student has a root canal, and after you could ask them how did that root canal go, or you can say, “Oh, can I see that x-ray, will you tell me about this?”…You know, you have a better idea of what everyone's doing and you're working more closely, side by side, rather than just on separate sides of clinic. FG1: …You're being graded on [everything] so you want to make sure it's perfect and good. Versus up north, you're being graded on the full two weeks in general, so you are not as afraid to make a mistake… FG2: It's so much easier to collaborate up north. FG3: [It is] more like private practice because you're not getting graded on everything it's more self-assessment. FG6: I think…making [the university clinic] seem more like a private practice. So even on our first appointments with patients when we're doing all the assessments, just have the dental students come in for like ten minutes to do that quick peek for their recall exam, so they get used to having to leave their patient to go check our patient, and then were getting used to sharing our patient with the dentists. FG3: …I think if we had better access to [the] dental students in our normal clinics…even if it's like a wandering student dentist, like your dental lead, who can just pop in, be the recall [person] for the day. Facilitator: What would help improve collaboration and help you get to know the DDS students? FG6: ...I think…being able to collaborate with the dental students throughout our whole education, not just on selected things like our northern rotation or screening diagnosis, PEDO…almost make it more of a day-to-day type thing. FG5: …I know we take the same, almost, oral pathology course and like a lot of similar things. They should try and combine those… FG2: …I really remember [the team building] from the first week, but it was tough because there's all the different professions there. FG6: It's not just hygiene and dentistry…I think it would be really cool if we did that at some point throughout the program…a bit later on too? FG4: But then it's like, go with the [DDS] year that you're going to [work in clinic] with…end up with [clinically]… FG5: ...Doing clinical case studies, and you could talk about…this is what I bring to the table, this is what I can say about it, and then they can say, and this is what I know…cause then you're able to role define, talk about scope of practice, learn things from each other…

CONFLICTS OF INTEREST

The authors have declared no conflicts of interest.