Clinical dental hygiene is a profession that involves responsibly providing education and care to fellow human beings, assisting others in discovering what is best for them, and reaching out through acts of service to care for the needs of the underserved. This profession requires compassion for self and others, self-awareness, self-regulation, self-forgiveness, self-care, and a deep and penetrating awareness of who we are and the role we play.
Dental hygiene is a people profession. Dental hygienists are called upon to comprehensively care for the oral health needs of people, employing skills of compassion, empathy, critical evaluation, and problem solving. Clinicians are asked to listen and discern values and desires of each patient and his or her individually unique situation, to establish trust and rapport in the midst of fears and uncertainty. Clinical practice requires entering an individual's intimate space. A lot of energy is exchanged within this space. From an emotional standpoint, how does one manage that?
Dental hygienists are asked to behave in compassionate, professional, and ethical ways, to reach out and serve the underserved, and to be advocates of health for their communities. These are the expectations, but out of 26 Educational Program Standards developed and regulated by the Commission on Dental Accreditation (CODA), only three (Standards 2-19, 2-22 and 2-23) address any of these "soft" skills of social-emotional learning. The curriculum requirements offer negligent formalized recommendations to empower the development of the emotional management of the self.
Students are asked, and often required, to reach out and compassionately serve the underserved. How can that be possible if they do not have the skills to be compassionate towards self or if they were raised in a less than compassionate environment? Are we asking of the student more than he or she is capable of delivering and more than we are currently offering?
The Medical Model
Over the past 20 years, medical education has been gradually transitioning some of its curricula to incorporate methods of teaching self-awareness and self-care. For example, meditation has been used at the Monash University Department of Community Medicine and General practice in Melbourne, Australia, by Dr. Craig Hassed as a way of cultivating objectivity, detached observation, enhanced autonomy, self-control, and effective action, and in developing self-knowledge.
In March 2008, at the 13th Ottawa International Conference on Clinical Competence, Dr. Craig Hassed and Dr. Ronald Epstein from the University of Rochester offered "Mindfulness Training: Student Self-care and Clinical Practice." The purpose was to explore the applications of mindfulness as a vehicle for self-care in medical curricula. Their focus was multifaceted. It included physiology and psychology of stress, mindfulness-based stress reduction, unexamined emotions, responding rather than reacting, and mindful practice in action.
The University of Rochester program further acknowledges the health care providers' need for maintaining sound clinical reasoning, strong patient-provider relationships, and excellent technical skills paired with the need for the provider's self-awareness and understanding of themselves, their thoughts, their feelings, and their own moment-to-moment level of attention. This is a model of mindfulness, self-awareness, and self-regulation in action.
Can we develop programs that go beyond intellect and clinical skills, that nurture, enhance, and sustain all human beings in the equation? If belief in the idea is present, it is possible. I believe the following concepts are necessary components of a Mindful Awareness vision connecting the inner and outer life of the dental hygiene student, the clinician, the faculty, and ultimately the patients who come to us for care. The concepts are mindfulness, self-awareness, self-regulation, and self-care.
What is mindfulness? Dr. Epstein describes it as "[m]oment to moment nonjudgmental awareness that includes the following features: 'clear,' nonconceptual, nondiscriminatory, flexibility, empirical, oriented to the present moment and stability."
A more complete description offered by Dr. Jon Kabat-Zinn is that "mindfulness can be thought of as moment-to-moment, non-judgmental awareness, cultivated by paying attention in a specific way, that is, in the present moment, and as non-reactively, as non-judgmentally, and as openheartedly as possible."
Self-awareness is another area to explore, as it relates to creating a well-rounded curriculum that addresses the inner dynamics of dental hygiene students. It requires not looking outward but inward. By learning how to become self-aware, we learn to be other-aware. Other-aware is the root of empathic behavior. Carl Rogers defined empathy as the ability to sense the private world of another as if it were your own. That requires the skillful means of self-awareness, the capability of knowing who we are, what we are feeling and sensing, and simultaneously generate an empathetic awareness of the person in our care.
The area of self-regulation is multifaceted. There is one piece of self-regulation that is directly related to the health and well-being of the person, in this case the student. Then there is a second aspect as it relates to outward behavioral expressions and reactions that a student exhibits based on stimuli. I see them as connected and similar, yet different.
Some students take antidepressants or anti-anxiety medication. Students are often challenged to manage the stress that comes with a dental hygiene education and believe that an increase in their medications is in order. Self-regulation skills allow a student to observe and reflect on the why's of their reactions, to see the story lines that lead them through their experiences.
The aspect of self-care is also important. The dental hygiene curriculum is demanding of time, energy, and physical, mental, and emotional reserves. We are very good at helping others, but in that equation we often forget ourselves.
Some dental hygiene students put on extra pounds as they progress through the program. Some even cut out exercise and sleep to carve out more study time. The parents in the group struggle with continuing uninterrupted parenting tasks, keeping up as they always have in spite of the fact that events and circumstances have changed. Something has to give, and much of the time it is the student. Change is necessary, but change is hard. Things cannot and do not stay the same in the midst of change. An awareness of the need for - followed with the implementation of - self-care practices is essential for the overall well-being of dental hygiene students. Students are taught how to care for their patients, but how to care for themselves is rarely adequately addressed. The demands of academic, clinical, and personal schedules sometimes take their toll.
Dr. Shauna Shapiro shares a metaphor offered by one of her clinical supervisors illustrating the need for self-care: "The heart pumps blood first to itself, before pumping blood to the rest of the body. If it didn't, it would die, and then the rest of the body would die. The art of caring for others is learning how to first care for yourself."
So can these concepts be taught in dentistry?
Dalhousie University School of Dentistry and Dental Hygiene in Halifax, Nova Scotia, instituted a Mindfulness curriculum in September 2008. I had an opportunity to interview some of Dalhousie's students. The benefits of mindfulness, they discovered, were intriguing:
- "Created better sleep and a calmer testing approach."
- "Made me aware of my mental attitudes. Physically I am fit and in shape; mentally I'm overweight, my mind needs to lose 60 pounds; my mind is heavy."
- "Mindfulness has decreased my comparison to others and has increased my own sense of self-worth. I have gotten away from allowing the 'mark' to identify me."
- "It helps me refrain from judgment, I stay open to more possibilities."
- "I am more aware and a better observer."
I have spent two years incorporating small mindful awareness practices in every class I teach. At first students see the activities as kooky and pointless, but they soon discover they learn a lot about themselves, their thought patterns, their reactivity levels, and their unchecked habits. Once made aware, change can happen.
I would like to see this topic further discussed, developed, and incorporated into our dental programs. If we desire compassionate service toward others from our students, let us offer ways in which they can discover and blossom their own innate compassion through mindfulness.
Prof. Deborah Holexa is a full-time dental hygiene educator at Mesa Community College in Mesa, Arizona. She teaches first-year dental hygiene students in radiography, head and neck anatomy, dental materials, dental hygiene theory, and preclinical and clinical courses. She has a Master of Arts degree in contemplative education from Naropa University in Boulder, Colorado.