An inquiry into the culture and conditions of the dental assisting profession – An experiential examination for cultivating trust: An annotated bibliography

EDUC 823
Simon Fraser University – Faculty of Education
Curriculum & Instruction in an Individual Teaching Specialty
MEd Post-Secondary, VCC Cohort
Professor: Dr. Michael Ling
Student: Kathryn Truant
April 5, 2020

A Brief Introduction:
“Guess there are times when we all need to share a little pain
And ironing out the rough spots
Is the hardest part when memories remain”[1]

Perhaps I should start at the beginning of my own cautionary tale. I believe the sole purpose of our existence is to help each another. I help people, and not only for intrinsic rewards; I help people because it is the right and decent thing to do. This is the reason I became a Certified Dental Assistant (CDA), and why I was devastated when I was bullied within my professional domain (Government of BC, n.d.). I will not go into detail because it is not helpful at this stage. I do have questions though.

Why was I targeted? Why didn’t my employers help me? This was the beginning of my downfall (and painful demise) at my dream job. I loved my job; it was ‘the big show’[2] for me as a dental assistant. I am still trying to move forward, and I have a lot of unanswered questions. Specifically: What can be done to improve workplace conditions for certified dental assistants?

Sadly, my case is not isolated. In the Spring of 2019, when I decided to pursue an MEd, my goal (when I wrote my letter of intent) was to address the critical shortage of dental assistants in the province, by exploring effective ways of expanding dental assisting programs. I have since been afforded the opportunity to reflect on my own perceptions, particularly to confirm a qualitative and trustworthy study. My approach within my vocational and educational domains has shifted (or evolved) to address the culture and conditions that are contributing to the shortage. A strong case in point is that our license to practice is not regulated by our own professional association[3].

CDAs are regulated by the College of Dental Surgeons of British Columbia[4]. A conflict of interest occurs when employers regulate their employee’s professional body. Is this the reason that CDAs are not consistently finding meaning in their work, and many are not continuing in the profession (CDABC, 2018)? It is well-documented that there is a critical shortage of dental assistants in British Columbia (Gould, 2017). Dentistry cannot happen without dental assistants. Why are dental assistants not being given the safe and respectful work environments that they deserve? What can we do differently? I do not have the answer(s), yet. And, more questions arise with perspective.

This annotated bibliography is unorthodox, in that the resources are not itemized alphabetically. Rather, they are organized by the context of the stages of grief (Gregory, 2019) over my former (dream) job, and generated by the conditions that continue to be accepted (or ignored) in dental offices. The literature in this annotated bibliography is the foundation of resources that will help to support my research (I discover new ones daily). Further, my plan is to interview colleagues and document their experiences. I am on a personal and professional mission to carry forward a legacy of positive change for myself, my colleagues (dentists and CDAs alike), and especially my dental assisting students. I still love being a CDA. Thank you, Sir Elton, for inspiring me to ‘iron out the rough spots.’

Resources (to date):

Section One – A ‘Brief’ introduction

CDABC. (n.d.). Certified Dental Assistants of British Columbia 2018 Employment Survey. Retrieved from https://www.cdabc.org/media/30196/2018-employment-survey-cdabc.pdf

This employment survey, generated by the Certified Dental Assistants of British Columbia (CDABC), is distributed to dental assistants every two to three years. This is the most current survey report. Completion of the survey is voluntary. The response rate in 2016 was 28% and increased to 44% in 2018 (p. 2): I believe that this statistic alone signifies a change in attitude within my profession. It is a lengthy and extremely comprehensive survey that also includes many  experiential comments from participants.

Gould, C. (2017). CDA shortage – Could the shortage of CDAs have anything to do with dentists? The Bridge (Spring 2017), pp. 9-10.

This journal article, that appeared in the British Columbia Dental Association (BCDA) Spring 2017 edition of The Bridge, was intended for dentist’s only. There have been several journal articles posted and published by the BCDA on the dental assistant shortage, but the publication is distributed to members only (and I am not a dentist). I emailed the BCDA and requested access to these articles; they kindly sent me this one. I am pleased that the BCDA is addressing the shortage, although I do not agree with the measures they are taking to rectify it, specifically, hiring non-certified (un-trained) staff to fill the role, and training them on-the-job without critical theory or background knowledge (e.g. the important role of asepsis in dentistry).

Government of BC. (n.d.). Address Bullying. Retrieved from https://www2.gov.bc.ca/gov/content/careers-myhr/all-employees/working-with-others/address-issue/address-bullying

This web page on the Government of BC website defines and identifies what bullying in the workplace is, in its subtleties and obvious presentations. I had to ask myself during my experience: ‘Am I being bullied?’. It is not often apparent or observable, and the key to identifying bullying is to document a pattern of behaviour. The article also outlines how to prevent and address bullying in the workplace, and links for further resources are highlighted.

Gregory, C. (2019, April 11). The five stages of grief – An examination of the Kübler-Ross model. Psycom. Retrieved from https://www.psycom.net/depression.central.grief.html

This journal article from the website Psycom, explains that grief and the emotions associated with it are not always related to death. “Grief can be cause by situations, [and] relationships” (para. 1). The author, Dr. Christina Gregory, talks about the widely accepted Kübler-Ross Model[5] and its five stages of grieving: Denial (This cannot be happening!), Anger (How did this happen?), Bargaining (How can I make sense of what is happening?), Depression (How could I have   let this happen?), and Acceptance (What can I do to flourish again?). Dr. Gregory argues that if a person suffering loss identifies and understands their emotions, they will be able to experience healing. Most importantly (my own assertion), the grief model allows us to discover that there is the potential to envision a different future or course of action following a life-changing loss or situation.

Section Two – Denial

Tolstoy, L., Pevear, R., & Volokhonsky, L. (2007). War and Peace. London: Vintage.

I took solace in Russian literature[6] in the denial phase of my grief. What better way to avoid the painful confusion of being bullied than to identify with the rich characterization of people facing insurmountable odds. Even though Tolstoy’s novel is a work of fiction, it helped me identify what I was feeling. One of main characters, is Pierre Bezukhov. Pierre is deceived by a loved one, and feels betrayed by his countrymen. He becomes depressed and confused, which prompts a spiritual journey that spans the novel. The passage that I identify with is Pierre’s desire to be rid of the ‘complicated tangle of life’s demands.’ He is seeking a rest from life’s anxieties. He seeks calm, peace and serenity. During   this reflective pause, Pierre finds the inner strength to fight for what he believes is right (pp. 1025-1027). War and Peace, gave me two perspectives – First,   sometimes good people do bad things. And secondly, it is important to take the opportunity to reflect upon those things.

Mitchell, S. (1988). Tao Te Ching. New York: Harper Collins.

Lao-tzu was a Chinese philosopher. He wrote the Tao Te Ching (also known as Book of the Way) sometime between the fourth and sixth centuries (the exact dates of his existence are not known). The book consists of eighty-one short verses that explore “the basic predicament of being alive and gives advice that imparts balance and perspective, a serene and generous spirit” (back cover). A common theme in the literature being examined in this section is perspective, and a quest for serenity.

Cain, S. (2012). Quiet: The power of introverts in a world that can’t stop talking. New York: Random House.

Amidst my feelings of denial, and the shock of what I had experienced, I needed to switch my focus from escape mechanisms (reading long novels, and seeking answers in eastern philosophy) to face what was happening. How had I become an easy target? People who are bullied tend to internalize responsibility. In Quiet, author Susan Cain explores the personality traits of introverts. I identify as an introvert. Cain discusses “firsthand how difficult it is for introverts to take stock of their own talents” (p. 7). This passivity can be a breeding ground for workplace bullying. Cain also mentions Tolstoy and Lao-tzu in her index which I find interesting and worth exploring the connection. Cain argues that our culture values extroverts, and shares the accounts of successful introverts who are often seen as being submissive.

Crowne, D. P. (2009). Personality theory (2nd ed.). Don Mills: Oxford University Press.

Psychology Professor at the University of Waterloo, Douglas Crowne, provides scientific research and (for me), a deeper understanding of the dynamics of introversion and extroversion; I am tempted to use the term ‘versus’ when identifying their differences and how these two personality traits can become at odds in the workplace, but Dr. Crowne explains, through the research of Dr. Hans Eysenck,[7] that psychosis can occur in the introversion-extraversion spectrum, and only negatively characterizes people at the extremes (pp. 307-313). I caution myself not to delve too intensely into the science of personality traits; I simply need a better understanding of what was happening to me. It is important to advance through stages of grief and get mad (a defence mechanism).

Section Three – Anger

Reina, D., & Reina, M. (2015). Trust and betrayal in the workplace – Building effective relations in your organization (3rd ed.). Oakland: Berrett-Koehler Publishers.

This book certainly resonates with me; I haven’t read it yet. I stumbled upon it while researching titles on workplace bullying. The authors, Dr. Dennis Reina, and Dr. Michelle Reina, operate ‘Reina, A Trust Building Consultancy.’ The fact that their work exists means that I am not alone. Subjects in the index include: opportunity and betrayal, and breakdowns of trust. I have a feeling that I will be referring to this book throughout the stages of my research because I also see a progression of ideas in the index as well: validation, acknowledgement, and regaining trust. It is the lack of acknowledgement of the conditions that occur in the workplace that cause me the most anger. And, it is very difficult for a dental assistant, one who has chosen a profession of service to others, to get angry. Our culture requires us to assist and serve our patients and our dentists.

Byrne, E. (2017). Swearing is good for you – The amazing science of bad language. Norton: New York.

Dr. Emma Byrne is a research scientist specializing in robotics (of all things) at Queen Mary University in London, who has had a lifelong fascination in the use of profanity! Again, I discovered this book when researching workplace bullying. The title intrigues me. Chapter Two introduces the reader to Mr. Phineas Gage. In 1848, Mr. Gage, a railroad contractor, who by his employer’s accounts was an efficient and capable man, was grotesquely injured when a six-foot rod of iron blasted through his skull. He survived the accident, but it changed him. He started using a profound and uncharacteristic amount of profanity following his accident (pp. 21-27). I suppose I am, in some way, comparing myself to Phineas Gage. My theory is that he was angry about what happened on-the-job, compounded by the fact that his employers refused to hire him back (as opposed to the theory at the time that the accident changed the physiological makeup of his brain which affected his personality). I’m not saying that Mr. Gage’s physiological make up was not affected; I am simply suggesting that the incident changed his perceptions of his employers. He was angry, considering the documented quality of his work ethic prior to the accident, which, in turn changed the way he conducted himself, on a physical and mental level. Perhaps my anger at work (that I thought was justified) was making me a pariah as well.

Mill, J. S., & Ryan, A. (2007). On liberty and the subjection of women. Penguin Classics. New York: Penguin Group.

Nineteenth century philosopher, John Stuart Mill, wrote The Subjection of Women in 1869. His elegant prose does not disguise his contempt for “the principle which regulates the existing social relations between the two sexes – the legal subordination of one sex to the other” (p. 133). Of course, it is no longer legal to regulate oneself over another based-on gender. However, this stage of my research teeters on genderizing the issue of workplace bullying in the dental office. Perhaps the reason that dental assistants are struggling to find sufficient meaning in their work is because they have been de-valued by “deeply rooted . . . old institutions and customs” (p. 134). The ‘glass ceiling’[8] has been broken in many previously male dominated professions over the past 150 years. For example, female dentists, while not the majority, have become the norm. But, dental assisting remains a female dominated profession. I am not entirely sure where I am going with this line of thought, I do however find it significant, and worthy of further exploration. Many thanks to John Stuart Mill for so eloquently illuminating the oppression of women. What is the connection to my research? I mentioned that I do not know where I am going with this particular line of inquiry, and no longer want to dwell in a form of unarticulated outrage. It is time to find meaning.

Section Four – Bargaining

Jarvis, P. (2018). Chapter Two Learning to be a person in society – Learning to be me. In K. Illeris (Ed.), Contemporary theories of learning: Learning theorists … In their own words (2nd ed.) New York: Routledge.

When an individual seeks meaning in their chosen vocation, it can cause self-doubt. And, an important question to consider is: do I exist as a person outside of my professional domain? In Chapter Two of Illeris’ collection of influential learning theorists, Peter Jarvis presents his understanding of learning from an existential perspective. “We can describe this process as that of the human essence emerging from the human existent, a process that continues throughout the whole of life, and that essence is moulded through interaction with the world” (p. 24). Jarvis continues by arguing that the fundamental process of learning is the “understanding of the whole person in the social situation – it is a philosophical anthropology but also a sociology and psychology” (p. 24). An individual becomes who they are through the process of lifelong learning (interaction and experiences), and adjustments can be made along the way. Jarvis gives me a lot to reflect on in the sense that ‘I am not done yet, physically and mentally.’ His theories encourage me to strive to ‘mould’ a positive interaction with my students.

Freire, P. (1970). Pedagogy of the oppressed. Toronto: Penguin Books.

Paulo Freire was a philosopher of education. I am not sure how this differs from a learning theorist (e.g. Jarvis); a philosopher of education sounds favourably more honourable (I digress). Freire wrote Pedagogy of the Oppressed during a six-year exile. To oversimplify, his views on the oppressive nature of education (he felt that education should be a right for all and not just the elite classes) outraged political leaders in his home country of Brazil. His work is important to my research because Freire articulates the “culture of silence” (p. 15) that exists in organizations, like professional domains, to maintain traditional hierarchy, much like Mills argued in 1869. I agree with Freire that oppressed people cannot expect generosity in the form of change from their oppressors. Dental assistants need to work with dentists; one cannot exist without the other. This was another turning point in my process of finding meaning. “And this fight, because of the purpose given it by the oppressed, will actually constitute an act of love opposing the lovelessness which lies at the heart of the oppressors’ violence, lovelessness even when clothed in false generosity” (p. 27). Freire suggests that people who perceive themselves as being oppressed need to oversee their own liberation. Liberation on this level is a mutual process.

Section Five – Depression

Pressman, T. E. (2019). Deconstructing anxiety – The journey from fear to fulfillment. Lanham: Rowman & Littlefield.

This book was recommended by a colleague. I haven’t read it yet. The author, Todd Pressman, is a clinical psychologist who has dedicated his research to bridging eastern and holistic philosophies to contemporary strategies of well-being. The index is loaded with subjects such as avoidance (I’m good at that!), goals (as a form of defense), meaning, and most poignant in my research to date: resistance. “It is important to emphasize that only resistance is suffering. There is no other source or experience of suffering to consider. We never suffer because of the ‘thing’ we are upset about. It is only our reaction to that thing – our resistance, born of our defenses – that needs to be addressed” (p. 125). On this note, it is my assertion that the suffering caused by effects of a toxic workplace, arises from resistance (or fear) to change, and I believe it ties in with Freire’s assertion that resistance will lead to liberation.

Brookfield, S. (2015). The skillful teacher – On technique, trust, and responsiveness in the classroom (3rd ed.). San Francisco: Jossey-Bass.

“Change entails moving into the unknown” (p. 219). I was encouraged by a colleague, who was witnessing the deterioration of my livelihood, to become a teacher; not as an alternative, but as an extension of what I had built in my professional domain as a CDA. I was resistant, at first, but followed her suggestion to enrol in the Provincial Instructor Diploma Program (PIDP). This is when I was introduced to Stephen Brookfield. Brookfield is an esteemed ‘scholar in adult education’[9] known for the value he places on critical reflection as   practitioners, and as learners. His prose is conversational; this is the first thing that struck me. The second thing I noticed about the book is Brookfield’s humble and honest struggle to use critical reflection for professional growth. He candidly talks about imposter syndrome: “We wear an external mask of control but beneath it we know that really we are frail figures, struggling not to appear totally incompetent to those around us” (p. 58). This is how I feel, and I am not sure if it is from the effects of being bullied for many years, but his admission gives me a feeling of solidarity, hope, and a motivation to change because someone like Brookfield feels the same way that I do.

Section Six – Acceptance

Pink, D. H. (2009). Drive – The surprising truth about what motivates us. New York: Penguin Group.

“The secret to performance and satisfaction – at work, school, and at home – is the deeply human need to direct our own lives, to learn and create new things, and to do better by ourselves and our world” (back cover). The acceptance stage in the Kübler-Ross grief cycle is terrifying, and at the same time, potentially promising. I believe that it is very difficult to put a plan of change (a new direction) into action (regardless of whether you are running away from something or running toward something). Referring to Brookfield, what if my perception is not accurate? What if I am making a big mistake? What if people laugh at my ideas? Pink’s book was recommended by a colleague who was also struggling with a managerial situation in her professional practice. I found this book to be transformational because it illuminates a new perspective. Pink asserts that the key to motivation is threefold: autonomy, mastery (the opportunity for), and purpose. The book outlines experiential accounts and offers methodologies to put theory into practice. It is helping me with my own renaissance, and I will continue to refer to it in my domain as an educator to motivate and empower my students.

Biesta, G. J. J. (2013). The beautiful risk of education. New York: Routledge.

“This book is not an unbridled celebration of all things weak, but an attempt to show, on the one hand, that education only works through weak connections of communication and interpretation, of interruption and response, and, on the other hand, that this weakness matters if our educational endeavors are informed by a concern for those we educate to be subjects of their own actions – which is as much about being the author and originator of one’s actions as it is about being responsible for what one’s actions bring about” (p. 4). I am new to Dr. Gert Biesta and somewhat obsessed with his controversial theories on education, and what constitutes actual learning. Biesta is a Professor of Public Education (his title as per his website), and a prolific researcher, writer and philosopher of education. His views are controversial (and empowering to me) because he looks at education as something ‘being taught,’ where a student is open to an interruption, a change, a gift, as opposed to ‘learning from,’ as something that the student takes as a resource from the teacher (p. 57). I can certainly be a resource, but I also want to create a positive change or ‘interruption.’

Rogers, C. R. (1969). Freedom to learnA view of what education might become. Columbus: C. E. Merrill.

Carl Rogers (1902-1987) wrote Freedom to Learn over fifty years ago. Rogers was a psychologist and an educator whose research focused on the self-actualization of an individual. His philosophy of fostering lifelong learning remains contemporary. Rogers believed that a student-centred approach to instruction, where learners become involved in the process, is the key. I was introduced to Rogers in the PIDP, and this book has become my handbook for sustenance and advice throughout the process of building/rebuilding trust with myself, and my profession(s). Roger’s generously shares his own accounts in the classroom, his successes and failures as well the accounts of colleagues, much like I want to do in my course of research. Subjects in the index include acceptance, change, and   trust. “If I distrust the human being then I must cram him[10] with information of my own choosing, lest he go his own mistaken way. But if I trust the capacity of the human individual for developing his own potentiality, then I can provide him with many opportunities and permit him to choose his own way and his own direction in his learning” (p. 114).

Appendix (to date):

Key Terms and Contemplations
Value of Experiential Accounts
Existential Meaning and Identity
Reflection and Pause (the importance of)
Resistance (fear) and Change
Trust

Questions that Arise
What does lifelong learning look like for my students?
Will my continuous/ongoing mentorship be enough to sustain them?
Will this query constitute meaning for my students?
What does a safe space within my domain(s) look like for me? For my students?
How does one teach empowerment?
Is this a dentistry specific issue?
Is this a gender issue?


Footnotes:

[1] These lyrics are the first three lines of Elton John’s Sad Songs from the album Breaking Hearts (1984).

[2] The Big Show was originally coined as a baseball term measuring one’s rise from the minor leagues to the major leagues. It is a phrase that articulates when an individual has succeeded at the top of their chosen professional domain.

[3] Certified Dental Assistants of British Columbia (CDABC) is a non-regulatory organization that provides guidance to dental assistants. Membership is voluntary.

[4] College of Dental Surgeons of British Columbia (CDABC): the dentists.

[5] Psychiatrist Elizabeth Kübler-Ross introduced the grief model to identify the five stages of grief in her publication, “On Death and Dying” (1969). The stages of grief commonly known are denial, anger, bargaining, depression, and acceptance. Grieving is a discrete process.

[6] Russian Literature: The common theme (especially in Tolstoy’s works) is suffering, often accompanied by redemption.

[7] Hans Eysenck (1916-1997) was a psychologist and professor at King’s College London. He was a controversial and prolific researcher of personality.

[8] The glass ceiling is an unofficially acknowledged barrier to advancement in a profession, especially affecting women. In 2019, as per the American Dental Association (ADA), 33.4% of dentists are female (I couldn’t find Canadian statistics). In 2020, as per Canadian statistics, 99% of dental assistants are female. Interestingly, I have never met a male dental assistant, but I know they exist; I hope to interview a male (non-female) CDA for my research to see if barriers persist.

[9] ‘Scholar in adult education’ is how Wikipedia describes Brookfield: another excellent scholastic title (I further digress)

[10] Rogers’ use of the pronouns he/him cannot be interpreted as gender specific considering the year (context and conditions) it was written.

Resources Alphabetized:
Biesta, G. J. J.
Brookfield, S.
Byrne, E.
Cain, S.
CDABC
Crowne, D. P.
Freire, P.
Gould, C.
Government of BC
Gregory, C.
Jarvis, P.
Mill, J. S., & Ryan, A.
Mitchell, S.
Pink, D. H.
Pressman, T. E.
Reina, D., & Reina, M.
Rogers, C. R.
Tolstoy, L., Pevear, R., & Volokhonsky, L.