In the present descriptive qualitative study, an inductive content analysis approach [20] was used to explore dentists’ perspectives on the role orientation, duty tasks and developing situation of dental hygienists. We used the Consolidated Criteria for Reporting Qualitative research (COREQ) as a guideline [21]. The Theory of Planned Behaviour (TPB) formed the theoretical foundation for the study [22]. The sample size was not fixed or predetermined, but was based on the principle of “information saturation” [23]. When the information collected during the interview is repeated, in order to determine whether the information is truly saturated, researchers will select new participants for the interview to ensure that there are no additional insights or variations in the data emerged.

Participants and settings

Purposive sampling was used to identify potential participants. Purposive sampling was chosen because it made it possible to select most appropriate participants for the study who had fund of knowledge about dental hygienists and could provide rich information on the matter [24]. All participants met the following inclusion criteria: (1) Voluntary participation in the research of this project and be able to continue participating in this research; (2) Dentists with 10 years or more dental clinical experience; (3) Intermediate or above professional title; (4) Participated in research work for dental hygienists; (5) Member of the CSA. The exclusion criteria of the study were ignorance of dental hygienists and refusal to participate in interviews.

The participants were recruited between February and March 2023 through managers and personal contacts at both the tertiary general and stomatological hospitals. The potential participants were contacted by the first author and provided with a brief verbal description of the study and its aims, as well as a written participant information sheet. If individuals were interested in participating, a mutually convenient time was arranged for the interview and written informed consent was received before the interview was conducted. A total of 13 dentists ( 4 women and 9 men; age 33–59 years; work experience 12–40 years) from four general tertiary hospitals and one stomatological hospital in Shandong, Hebei, Xi ‘an and Beijing participated in this study. 12 participants have had the experience of working with dental hygienists in overseas dental clinics for further education.

Data collection

Between April 2023 and June 2023, individual, semi-structured in-depth interviews were conducted by the first author. After obtaining institutional permission, conversations between the research team and the dentists were conducted via telephone or WeChat (a popular Chinese social media application) or in person [25]. Subsequently, dentists were provided with a comprehensive overview of the study’s aims, importance, and confidentiality, along with the option to withdraw from participation at any point. An interview guide was initially designed by the first author and there after developed in consultation with all authors. Examples of questions included “Can you tell me about any research on dental hygienists both domestically and internationally?” and “What is the scope of practice for foreign dental hygienists?”. The participants were also encouraged to make suggestions that could change the situation in our country. Then, based on the participants’ answers, clarifying and exploratory questions such as: “Please tell me elaborate” and “How did it feel?” were asked. These interviews ranged from 30 to 60 min and were recorded digitally and transcribed by an online service. A demographic data questionnaire and a semi-structured interview schedule in Table 1 were used to collect data.

Table 1 Semi-structured interview scheduleData analysis

The transcribed data were organized and processed in MAXQDA10 software, and analysed using an inductive approach to qualitative content analysis, as described by Graneheim and Lundman (2004) [20]. The method is well suited to analysing the sensitive phenomena specific to nursing [26] and is often used in health science research [27].

First, the transcripts were read through several times to obtain a sense of the whole and to identify the meaning units dealing with the dentists’ views on the role orientation, duty division and development situation of dental hygienists. A unit of meaning consists of several words, sentences or paragraphs that are related by content and context [20]. Next, each meaning unit was condensed to preserve its essential content and subsequently assigned a code. These codes were then analysed for differences and similarities. Codes with analogous content were systematically organized into categories and subcategories. Thereafter, the categories were then evaluated and analyzed to form a theme, which is the underlying main meaning of the study or the latent content at an interpretive level [20]. Throughout the analysis process, categories, subcategories and themes were initially identified by the first author, and thereafter discussed by all authors until consensus was achieved. Also, two professionals who were experienced in qualitative research and nursing education, reviewed the analysis process.

Rigour and trustworthiness

The rigor and trustworthiness of the study was assessed using Lincoln and Guba’s criteria, including credibility, dependability, confirmability and transferability [28]. (1) Each participant voluntarily participated in the study; the interviewer emphasized that there was no right or wrong answer to each question and encouraged participants to be outspoken. This ensures the credibility of the interviews. (2) The dependability of the findings was determined through the use of audio-recorded and transcribed interviews. The coding of the interviews and data analysis was assessed by all authors. In addition, two professionals reviewed the analysis process and approved the quality of coding. (3) To ensure confirmability, the data were meticulously documented in a manner that would permit external observers to evaluate them and gain a clear understanding of the research process. (4) Transferability was achieved by providing thick, rich descriptions of the research context, setting and participants. While this study is unique to the Chinese context, key findings may be transferable widely.

Findings

A total of 13 participants were interviewed for this study. To preserve the identity of participants, aggregated, rather than individualised demographic characteristics are presented in Table 2.

Table 2 Demographic characteristics of participants

Three themes were extracted, based on the analysis of the data, including national condition determined comprehensive paraprofessionals, multi-skilled preventive health care professionals, and opportunities and challenges coexist in Fig. 1.

Fig. 1

An overview of the themes and related sub-themes of the role orientation of dental hygienists in China by dentists

Theme 1: National condition determined comprehensive paraprofessionalsUnique allocation of dental human resources

The dental workforce in China are mainly composed of four categories: dentists, dental assistants, dental technicians and dental nurses. Dentists and dental assistants constitute the primary workforce, dental nurses are the main auxiliaries who usually perform plenty of auxiliary work to assist dentists in performing diagnostic and treatment operations, as well as part of dental technicians and interns (fifth year students majoring in stomatology). However, there are great differences in the qualifications, role orientation, and functions of various types of auxiliary staff, which makes it difficult to guarantee the quality and effectiveness of oral care and treatment.

About dental nurses, participants stated that the dental nurses mainly performed auxiliary dental treatment and had a relatively limited scope of practice. They play a vital role in front desk triage, equipment management, disinfection, and other aspects, while their collaboration and communication skills related to profession are weak. “The nursing personnel in our department is actually mixing the materials, in addition to having a prescription priced and charge etc., and the competence of four-handed operation is relatively weak” (Participant 3).

The participants perceived that due to the lack of specialized functional training and professional qualification certification of dental nurses by relevant institutions, the quality of work is uneven and lacks legal qualifications, resulting in various hidden dangers. Such as participant 8 said: “Scaling is not within the scope of the work of dental nurses, but there are still many nurses in oral diagnosis and treatment institutions performing this operation”.

Participants expressed that dental technicians are not qualified to diagnosis and treatment and are not permitted them to have access to patients. They should work in processing plants in technical areas such as prosthetics and orthotics. However, “Now the technicians in our department are trained from the processing plants, but in reality, they usually conduct cleaning teeth, caring and cooperating with dentists” (Participant 11). Additionally: “In some tertiary hospital and stomatological hospitals as well as private dental clinics, dental technicians with higher qualifications usually take up the duties of dentists, while some less experienced technicians act as dental nurses to perform marginal work” (Participant 4).

According to the participants, the interns may not have a comprehensive knowledge and expertise of stomatology when they first enter the dental department, “This means that only after they have mastered the basic operation skills can be reluctantly used as assistants, which requires a long process” (Participant 7).

Some participants stated that because dental nurse in China can only provide auxiliary services for oral diagnosis and treatment, and dental technicians are supposed to work in processing plants, in addition to accomplishing the diagnosis and treatment of oral diseases, dentists must carry out a large number of oral primary preventive health care tasks, such as tooth cleaning, pit and fissure sealing, and fluoride application. This is not only causes great waste of advanced dental human resources, but also exacerbates the contradiction between the supply and demand of oral healthcare.

Auxiliary personnel of multi-professional integration

Due to the lack of dental human resources in China, especially the dental auxiliary personnel, the participants unanimously recommended that dental hygienists be positioned as dental auxiliaries. It is worth noting that dental hygienists would integrate the professional knowledge and skills of dentists, dental nurses, and dental assistants, and are comprehensive talents that integrate service, communication, and technology. At the same time, attention should be paid to the unique function of dental hygienists in preventive health care, primary diagnosis and treatment of services, as well as the maintenance and promotion of health for all, which is an enhancement and expansion of the connotation of dental nursing services.

Regarding the definition of dental hygienist role, participant 13 said: “The dental hygienist is a dental medical profession with social public value that is urgently needed by oral public health in China, which is extremely different from dental nurses. For example, scaling can only be done by dentists and dental hygienists, and other personnel are not qualified to implement, including application of fluoride, pit and fissure sealing, and some oral healthcare” (Participant 6). Another participant stated: “The duties of dental nurses are clearly defined as nursing, not just nursing, they have a large amount of work, including management (management of the clinic), prevention and control of nosocomial infection, and even have to know some dental equipment (disinfection).” (Participant 1).

“In China, dental assistants are not a separate profession who belong to the category of dentists, they are not qualified to work independently in medical institutions at the county level or above. Instead, they need to be directed by a dentist to carry out treatment” (Participant 12). In this regard, dental hygienists are the same as dental assistants; they likewise have no authority to practice independently.

One participant pointed out that dental hygienists are allowed direct access to patients in the United States. However, due to the fact that China is still in the early stage of development of dental hygienists, it is not appropriate for dental hygienists to perform overly complex tasks independently. According to some participants:

“It is a great necessity of dental hygienists to be able to accomplish the initial classification of patients, conduct health examinations and education, and in addition, the preventive treatment of various diseases” (Participant 2). “The dental hygienists should be engaged in routine education and oral healthcare work. For instance, routine fluoride application and pit and fissure sealing for children, and fluoride application and regular checkups for adults. Sometimes a detailed program can also be developed after a comprehensive examination. Periodontal maintenance therapy can also be done” (Participant 10).

Therefore, combined with our national conditions, in general, dental hygienists refer to professional medical occupations that assist dentists or independently carries out related dental duties with the authorization of dentists, they need to have the following competencies: (1) high-quality services and cooperation level in oral specialty nursing (four handed operation, etc.), (2) favourable communication ability of dental professional knowledge and patient comfort, routine health education, detailed plan formulation and referral, (3) Expertise in basic oral treatment (taking an x-ray, pit and fissure sealing and simple caries filling treatment, etc.) and preventive treatment (application of fluoride, plaque display, sandblasting and scaling, etc.).

Theme 2: Multi-skilled preventive health care professionals

Participants emphasised that preventive health care is the unique professional characteristics of the dental hygienist. Their duties are to prevent or reduce the incidence of oral diseases through oral and various preventive measures under the guidance of a dentist, thereby ensuring the oral and overall health of the public; to improve the quality and cultivation of the public’s oral health through oral hygiene instruction; and to comprehensively improve and enhance the oral hygiene and health level of the public through full life-cycle oral care.

According to the participants, the emergence of dental hygienists would solve most of the oral health problems and achieve early prevention and treatment of oral diseases. Participant 9 said: “Most oral diseases are preventable, and appropriate preventive measures can reduce the incidence of oral diseases, and dental hygienists are experts in this field.”

Several participants mentioned that there are still many erroneous traditional concepts in China. For example, there is an old saying in China that teeth cannot be brushed during the puerperal period, otherwise you will get toothache and even cause teeth to fall out. Participant 11 said: “I’ve seen numerous outpatients who neglect dental hygiene during the puerperium, with some not brushing since pregnancy. Surprisingly, many still hold this deep-rooted and unscientific concept. Even with bleeding and swollen gums, they avoid brushing, resulting in tooth loss from worsening periodontitis.” (Participant 8). Poor oral hygiene can lead to gingival bleeding and periodontitis during pregnancy and at various stages of the postpartum period, but these specialized knowledge and concepts require guidance by professional oral health personnel.

In addition, mouth-to-mouth feeding still exists in China, such as participant 4 said, “Some elderly people pre-chew food and feed it mouth-to-mouth to their young children, believing it aids digestion and absorption. They consider themselves healthy and have no infectious diseases, expressing love through this practice, which is more common before children’s teeth are fully developed.”

Teaching dental cleaning methods with a focus on brushing is an important endeavor. One participant said: “Most of us usually brush our teeth twice a day, once in the morning and once in the evening, but I recommend brushing five times a day. For myself, I brush my teeth in the morning, before and after meals, and before going to bed” (Participant 7). “Dental hygienists need to instruct the public to master the correct oral hygiene methods, especially tooth brushing and the use of flossing, such as teaching children and parents how to brush their teeth and teaching the elderly how to use dental floss, and also guiding them on how to choose appropriate oral cleaning tools” (Participant 3).

In conclusion, many participants pointed out that oral prevention and health care education and science popularization are important tasks of dental hygienists, such as correcting and instructing for the misconceptions about oral problems that currently exist among the Chinese public. The oral hygiene instruction related duties provided by dental hygienists are supposed to focusing on dietary advice for caries prevention, oral health guidance before pregnancy, oral care during pregnancy, oral care for infants and the elderly and so on.

Theme 3: Opportunities and challenges coexistDifficulties and barriers to the development of dental hygienists

Currently, the position of dental hygienist has not been established and the scope of practice has not been clearly defined; at the same time, there are no specialized dental colleges or institutions to train dental hygienists. The position establishment, role orientation, task division, professional ability and qualification certification of hygienists are still in the exploratory stage, and may face a variety of unknown difficulties.

In the first place, many participants emphasised the definition of the name is a major issue. Although our country wants to introduce the internationally relative mature role of the dental hygienist, some participants perceived that the role should be called dental therapist. One participant explained: “This leads to confusion with the treatment of the dentist” (Participant 13). Participant 8 said: “The difference of the name determines the great differences in the role and scope of practice, which is the most fundamental problem and is the main confusion and controversy at the moment, which has largely hampered the development of researches on dental hygienists.”

Secondly, it is initially proposed that the excellent trained dental nurses as practitioners of dental hygienists in China. However, a problem with this is that it will attract a large number of nurses to sign up for training, which may have a huge impact on the whole nursing team and cause disruption in the nursing workforce. “This program in the actual implementation of the process may have some contradictions with our physician law and the competition between industries” (Participant 13).

The dental nurses have received specialist training in outpatient dentistry relevant practicing certificates, which makes it difficult to set salaries for the positions of dental hygienists. A salary that is too low could easily lead to the return of these personnel to their previous positions, while a salary that is too high could significantly increase the cost of health care. Participant 4 “As far as the current situation is analyzed, the feasibility of the whole hospital is not very high in terms of manpower cost and posting considerations.” “If he (the dental hygienist) feels there is no future in this department, no avenue for advancement, (he) will would like to go back to the dental nurse team” (Participant 6). The participants mentioned that training dental nurses to transform them into dental hygienists cannot solve the essential problem. Therefore, whether we consider to choose the academic education may be more suitable for China’s national conditions, this issue is also being discussed and explored at the national level.

Finally, according to the participants’ statements, the generation of a profession is very complex, which needs to match the legal and industry standards and the most important point is to have vitality. At present, the career development plan for dental hygienists in China is not yet clear, and there are many barriers, including our country has not established this occupation owing to the existing personnel management system and some provisions of physician laws.

“The current personnel structure in China restricts the development of the dental field. If the country cultivates talents like dental hygienists, but they do not engage in their own job like dental technicians, many turn to clinical roles, nursing or hospital administration. This shift contradicts the state’s educational goals and is a typical example of failure” (Participant 5). In the long run, it is worth pondering how to establish the dental hygienist as a promising and gradually developing profession, and how to better play their unique functions and values in public oral health prevention.

Development advantages and prospects of dental hygienists

The development of dental hygienists in China has certain advantages and broad prospects. In the context of the population ageing and national strategy to promote oral health for all, the public’s awareness of oral healthcare has gradually increased, oral diseases have gradually shifted from a treatment-oriented to a prevention-oriented approach. “The aging society has brought about a large number of patients who require long-term oral management, which brings great opportunities for the development of the industry, and can also solve the employment problem to a certain extent” (Participant 12).

From the perspective of domestic academic research, domestic scholars paid more attention to dental hygienists, frequent academic exchanges, and increased close contact with advanced foreign theories and knowledge. Furthermore, the government’s support for colleges and universities has gradually increased, and students’ willingness to learn has also increased, both the CSA and the Chinese Nursing Association (CNA) are actively working to establish this profession.

Regarding the development of dental hygienists, the participants recommended that a vocational college training system be established first; followed by an undergraduate vocational training system; at the same time, a public health education system for oral health be established in general colleges and universities, with the long-term goal of establishing a system of postgraduate training. “The goal is to comprehensively construct China’s oral healthcare system, establish and improve China’s oral public health system, cultivate qualified oral healthcare professionals for the country, improve the oral health and even overall health of the whole population, and enhance the quality of life of the public” (Participant 13).

In the longer term, the participants suggested that dental hygienists, dentists, dental assistants, dental nurses, and dental technicians should be identified as the five core segments of dental occupational development. Their respective functional characteristics, interrelationships and social attributes should be studied together, so as to comprehensively demonstrate the scope of dental medicine occupation and to build a occupational system of dental medicine with Chinese characteristics.

Additionally, with the development of community oral health and the injection of private capital, domestic high-end private dental hospitals or clinics to learn the foreign model, began to configure a specialized consulting staff, which makes the actual work of doctors relatively simple, and the propaganda and education role of dental hygienists in grass-roots units become more obvious, and the promotion role of private clinics is very strong, thereby offering a broader space for the development of dental hygienists. As participant 5 said: “As far as I know, there are great differences between private stomatological hospitals or clinics and public hospitals. Nowadays, high-end private dental hospitals or clinics have specialized consultants, and the dentists actually have a very simple job, which is to do a good job in their occupation and look after the patients.”