A Maryland Perspective on Expanding Scope of Practice

As the landscape of medicine and dentistry evolves, the roles of health care professionals are expanding to include interprofessional practice, which will hopefully lead to improved access to care. Dental hygienists must be strategic in their advocacy efforts in order to expand their scope of practice. Legislative change occurs when dental hygienists—who are committed to reforming oral health care or the rules and regulations governing the profession—advocate for change.¹ Advocacy drives change and effects policy and scope of practice, and, ultimately, leads to better oral health care for patients. The American Dental Hygienists’ Association (ADHA) Bylaws and Code of Ethics state that advocacy is necessary for the promotion and improvement in patient health.² Thus, advocacy is an integral component of our organization and profession.³

Prior to 2009, Maryland dental hygienists were unable to provide direct access care to patients and restricted from administering local anesthesia and nitrous oxide. Educator involvement, a perceptive lobbyist, and a well-run and supported Maryland Dental Hygienists’ Association (MDHA) legislative committee proved instrumental in effecting change. The identification of legislative champions in the Maryland House and Senate would eventually lead to the successful passage of laws expanding dental hygiene scope and practice settings. As educators and former presidents and legislative chairs of MDHA, we’d like to share our legislative journey and provide insights for colleagues seeking change in scope of practice and furthering access to care.

EDUCATOR INVOLVEMENT

As most states already permit the administration of local anesthesia and nitrous oxide—including the neighboring District of Columbia—the University of Maryland, School of Dentistry (UMSOD) dental hygiene faculty decided it was necessary to prepare students with the skills needed to work in other states. Some faculty members traveled out of state to take certification courses, successfully passed the appropriate regional examinations, and created curriculum years prior to seeking legislative change. The courses were presented to the Maryland State Board of Dental Examiners. Once approved by the board, all dental hygiene faculty members received didactic and clinical education, and began teaching these courses to entry-level students. Dental colleagues supervised the new clinical sessions. Fortunately, these supportive dentist colleagues—active in their professional associations and state board—became advocates when they saw firsthand the value and quality of the education provided. With our colleagues, we began the long and arduous process of assembling a broad-based coalition to support bills that included pain management by dental hygienists in Maryland.

BILL DRAFTING

Sandy Schrader, former MDHA lobbyist, clearly understood who we were, as well as our concerns and needs. As a former state senator, she helped us navigate the legislative bodies and identified key legislators who ultimately became champions for our cause. The lobbyist, sponsor, bill drafter, and legislative committee should collaborate to develop a bill prior to the legislative session. Bill drafting is not the time to compromise. You will likely compromise later or walk away empty handed. Scope of practice changes, such as local anesthesia or nitrous oxide administration, have been widely accepted across the nation. In some states, dental hygienists have been administering local anesthesia since the early 1970s. There is no valid reason why any state should be different. Our ultimate goal was the administration of local anesthesia and nitrous oxide, but change in Maryland was incremental. For example, MDHA first passed monitoring of nitrous oxide, and then administration. At the last minute, organized dentistry requested a sunset report to ensure the public was safe, which required an additional legislative session. It ultimately took three successful sessions to reach our goal. Careful wordsmithing of bill language and keeping it as simple and clean as possible were key. More words often make a bill more restrictive. Defining a population is a common roadblock used by the opposition to restrict scope. Be extremely cautious if a bill defines a population. For example, organized dentistry asserted that dental hygienists should only administer local anesthesia to “dental hygiene” patients. After we gained grassroots support from dentists, we were able to strike “hygiene” allowing dental hygienists to administer anesthesia to all “dental patients.”

CREATING MOMENTUM

Dental hygienists must understand the integral role they play in driving legislative initiatives. MDHA created a new website that encouraged all grassroots dental hygienists to join the mailing list by simply entering their email address. We sent mass emails via this database to announce legislative initiatives. Communication was timely and created an environment of inclusion (members and potential members). Blast emails included template letters to legislators and other interested parties encouraging them to support adding local anesthesia, then nitrous oxide to the scope of practice (Figure 1). A list of legislators/districts with email links was also included, making it seamless to contact legislators.

Once a bill drops, the dance begins. Create a simple and memorable mantra, for example, “Dental hygienists are licensed and credentialed oral health care providers who advocate for quality and affordable oral health care for all.” The ADHA provides a wealth of knowledge by tracking state initiatives, including the history and educational requirements for various scopes of practice initiatives in map and table format.⁴ Create a single page of talking points that is visually attractive (including the constituent logo) that summarizes the bill (see the web version of this article at dimensionsofdentalhygiene.com for an example). It should include bulleted points reviewing the upcoming legislation, House and Senate bill numbers, and contact information. Avoid technical language, keep the message simple and easy to understand, and ensure it is not self-serving. Offer additional current information, articles, research, course syllabi, textbook examples, etc, if needed to help educate legislators. When you are discussing your bill and lobbying legislators, solicit additional sponsors. A good bill quickly grabs the attention of legislators who will want to sign on as sponsors. When legislators are not available, discuss your bill with their aides by reviewing the talking points. If you make a connection with the legislative aide, your message is more likely to reach the legislator. A good legislator-sponsor is like a good pitcher. He or she is highly credible, can work both sides of the aisle, and is respected by his/her peers. A champion sponsor will pitch your bill, set the tone in the hearing room, help you dodge opposition, ask questions of your opposition, and serve as a mediator if needed.

Consider scheduling an advocacy day during the legislative session. This provides a platform to talk up your bill and solicit sponsorship. On any given day, multiple groups are lobbying during session. To be successful, your event requires significant planning. Consider a Monday through Thursday, as many legislators return home for the weekend. Encourage attendance by including school and student involvement. Future professionals need to understand the legislative process. Students should feel a sense of inclusion and ownership of their profession before they graduate. Organize groups by county or legislative districts, and assign a seasoned member of the association to lead the group. Legislators enjoy talking with their constituents and appreciate the perspectives of future and seasoned professionals.

Creating a large unified front helps legislators see that you are organized. Armed with talking points and educational information, advocacy groups visit their legislators’ offices. In Maryland, we also give a preventive oral health gift bag. Gift bags can be given to all legislators and aides, just legislators, or only committee members. The event may culminate with a lunch or dinner. Special consideration to time and location are necessary, as the legislators are in session. In Maryland, we hosted a lunch in the Senate ballroom, catered by a renowned local restaurant. A looped PowerPoint presentation can provide bill information and showcase dental hygienists volunteering at state events. The magnitude of the event is determined by funding availability. If your association is hosting a lunch or dinner, like any special event, invitation, location, time, and food quality are considerations.

PROVIDE WRITTEN AND VERBAL TESTIMONY

There is a saying in politics, “You either have a seat at the table or you’re on the menu!” Any bill directly related to the practice of dental hygiene/dentistry requires representation by your association. Thoughtfully written and verbal testimony provided by the constituent president, legislative chair, lobbyist, and/or someone influential, such as an expert witness is necessary. Solicit additional testimony from other interested parties, such as consumers, advocacy groups, and like-minded professionals. Legislators are generally happy to support initiatives improving access to care; for example, direct access for nursing home patients. They are less likely, however, to take a stand for a scope of practice issue, such as local anesthesia or nitrous oxide. Legislators generally do not want to get involved in a perceived turf battle. Consider framing all testimony as a positive for state constituents. For example, when we were seeking administration of local anesthesia, we were providing patients with needed pain management that respected the patient’s time, as well as the supervising dentist’s time. We wanted legislators to understand that dental hygienists were team members, and dental offices would run more efficiently while providing patients with needed pain management. As educators and content experts, we were able to provide testimony concerning course content and curriculum.

Patient testimony can be a very powerful resource. Consider giving first person accounts describing why change is needed, or telling stories or providing a second-person account from a patient’s perspective. Stories can be relatable and memorable. Lastly, testimony provided by an alliance may provide a neutral perspective. The message from a third party can hold more influence, especially when the dental hygiene profession is on board with providing the workforce to offer a solution.

If your legislative committee decides to oppose or testify against a bill or amendment, explain why in a rational and respective manner, and provide friendly amendments or alternative solutions. When amendments are offered to a bill, show legislators you are willing to come to the table, offer solutions, and compromise. Legislators respect honest, intelligent, and meaningful testimony presented in a logical and respectful manner. Ultimately, an association builds integrity and creates meaningful relationships.

EXPECT OPPOSITION

When presenting testimony, be prepared for opposition from other entities. Surprisingly, one of the opponents of our local anesthesia and nitrous-oxide bills was a representative of the state anesthesiologist association, who testified that dental hygienists were going to kill patients by administering the inferior alveolar nerve block or nitrous oxide gas. While verbal communication is limited in a hearing room, text messaging is permitted. When unforeseen opposing testimony occurs, a champion legislator can ask questions and help refute unfounded testimony.

Generally, the initiator of legislation and others supporting the proposed legislation will present verbal testimony first, followed by opposing testimony. There is generally no rebuttal in the process, so you must think ahead. In your testimony, address adversarial and/or potential false claims. If false testimony is not refuted during a hearing talk to committee members individually armed with the facts based on peer-reviewed research.

CONCLUSION

Change is never easy. While it required several years of persistence, the Maryland practice act today allows dental hygienists to provide direct-access care to patients in nursing homes or long-term care facilities, and includes the administration of local anesthesia (including mandibular block) and nitrous oxide. A hardworking team and legislative champions committed to improving oral health care led to the successful passage of numerous laws influencing dental hygiene practice. Well-trained faculty, a supportive dental board and educational institutions, a cohesive legislative committee, and the influence of legislative champions and coalitions all contributed to our success. The legislative process requires time, energy, organization, resources, commitment, and passion. For change to occur, you must align and commit to your cause. Who better to drive the wave of change? Dental hygienists are savvy professionals. When armed with the right tools, we can lead the way to successful legislative changes impacting not only the profession but the patients we serve.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2017;4(10):34-38.