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The Journey Continues

The path to gaining expanded levels of practice may not be linear, but it is moving forward.

My first grandson came into this world with care provided by advanced practice nurses. He was delivered by a nurse midwife and the anesthesia was provided by a nurse anesthetist. My second grandson will be born soon, and I asked my daughter who would be delivering the baby. She replied, “The nurse midwife, I hope. She spends more time with me and focuses on the quality of the experience.” My daughter is a physician. She understands and appreciates the roles of various care providers, including those deemed midlevel practitioners.

Nurse practitioners first began practicing in the United States in the 1960s.1 The concept of a nurse practitioner was not immediately and universally endorsed. It met with resistance from both physicians and nurses. There were fears that the nursing profession would be destroyed. There were claims that the care would be “bad doctoring.” The nursing profession responded with studies demonstrating quality of care, cost effectiveness, and management competence (see page 48 for more on the evolution of the nurse practitioner model).

It is easy to minimize the journey that has been traveled by the nursing profession over the past 60 years. Nurses worked to gain the necessary recognition so they could help meet the need for care. This was followed by studies documenting the quality and effectiveness of the care they provided.2 Educational and credentialing standards were established. Advocacy for change came from nurses and nursing organizations, as well as other allies.1 It was not a linear process. There are definite parallels in the journey of the dental hygiene profession. Dental care has been identified as the greatest unmet health care need for children.3,4 The Health Resources and Services Administration notes that more than 49 million Americans are living in regions identified as dental care provider shortage areas. Policymakers and health advocates are looking for solutions.5

Alaska and Minnesota were leaders in developing midlevel practitioners to address the needs of their populations. A recent report to the Minnesota State Legislature concluded that clinics employing dental therapists reported improved quality and high patient satisfaction with dental therapist services.6 Further, the clinics employing dental therapists were seeing more new patients who were predominantly low-income, uninsured, and underserved. As of 2016, several states have some type of midlevel practitioner under consideration.7 In 2015, the Commission on Dental Accreditation (CODA) voted to adopt accreditation standards for dental therapy programs.

The journey toward the widespread implementation of the midlevel practitioner has begun. The pathway will not be linear, but it is moving forward.


From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental HygieneOctober 2016;3(10):50.

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