Haley Williams Curriculum Issues: Integrating Ethics
Curriculum Issues in Dental Hygiene Education: Integrating Ethics
Haley Hays Williams, BS, RDH
Hays1@bcd.tamhsc.edu
Texas A&M Health Science Center: School of Graduate Studies
Words: 1,885
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Haley Williams Curriculum Issues: Integrating Ethics
Abstract
Ethical dilemmas are an everyday occurrence in the clinical practice of any registered
dental hygienist. These dilemmas are frustrating and confusing for the new graduate.
Research suggests that more should be done in didactic and clinical course work to better
prepare the dental hygiene graduate for ethical problems they may face. This paper
explores the research that is available to identify the need for ethics integration in dental
hygiene education and a possible solution for rectifying the problem of ethics integration.
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Haley Williams Curriculum Issues: Integrating Ethics
Issue Analysis
In a day and age where we hear and read more and more about insurance fraud and
unprofessional behavior surrounding dental practices it is imperative that allied health
personnel, specifically dental hygienists, are trained in professionalism and ethical
practices. It is becoming a more common and economical practice that the dental
hygienist’s scope of practice is increasing to include a larger role in ethical decision
making.1 Since the day I began working as a registered dental hygienist, I have very seldom
come across an issue in clinical skills. Instead, most of the problems I faced in the first year
of practice dealt with ethical dilemmas. The issues all center on the basic ethical principles
of nonmaleficence (do no harm), beneficence (do good), patient autonomy, veracity
(truthfulness) and justice (fairness).2 Some of the specific ethical dilemmas graduating
dental hygienists are facing include substandard care, overtreatment, scope of practice,
fraud, confidentiality and consent, impaired practitioners, sexual harassment, physical
abuse, and health status.1 Although accreditation standards require ethics to be taught in
dental hygiene curriculum there is little research on how ethics is currently being taught in
the dental hygiene curriculum.3
Duley et al conducted a survey in 2006 in which 1,165 students at 141 different
dental hygiene programs completed a written survey.1 The survey tested graduating dental
hygiene students’ attitudes toward the ethical dilemmas listed above. The findings indicate
that of the graduating dental hygiene students’ the majority of respondents indicated it was
their responsibility to report abuse, educate patients on health status, and report sexual
harassment.1 However, the students’ were not certain that it was their responsibility to
report unethical behaviors regarding fraud, infection control, practicing outside of a
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Haley Williams Curriculum Issues: Integrating Ethics
practitioner’s scope of practice, and failure to diagnose disease.1 These findings indicate
that there is a lack of clear understanding by graduating dental hygiene students in proper
ethical behavior and decision making.1
In another study, also conducted in 2006 a group of dental hygiene educators
surveyed other dental hygiene educators to determine how ethics is being taught to dental
hygiene students. Kacerik et al developed a survey to evaluate teaching methodologies in
dental hygiene curriculum and how many hours of instruction, clinical and didactic, were
included in instruction.2 The results showed that the majority of dental hygiene programs
that responded taught ethics in a separate course or that ethics was taught in several
dental hygiene courses.2 Of the respondents the majority stated that 10 or less clinical
hours were spent on ethics and that it was difficult to determine the true amount of hours
spent on ethical instruction clinically.2 They also found that many different methods are
used by the majority of dental hygiene programs including lecture, discussion, case studies,
role play and readings.2Evaluation methods for 89% of respondents included tests and
quizzes and 73% also use written assignments.2 Interestingly enough, this study did find a
difference in emphasis between pre-baccalaureate programs and baccalaureate programs.
The results from the survey found that on average pre-baccalaureate programs spent more
time on ethics instruction both clinically and in didactic courses than baccalaureate
programs.2
I can say that from my own personal academic experience in a baccalaureate
program with a dental school component, I do not recall a lot of time outside of our ethics
class where we discussed ethical principles as they applied to dental hygiene practice. Even
our ethics class was mixed with second year dental students. We were examined with
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Haley Williams Curriculum Issues: Integrating Ethics
weekly quizzes and written case studies. Many of our cases had to do with ethical dilemmas
from the dentist’s perspective. I believe that I left the class with a very basic understanding
of ethical principles but had little knowledge on how to apply them to dental hygiene
practice.
Everyday, the dental hygienist will encounter problems, they may not all be ethical
dilemmas, but the dental hygienist needs to know how to apply the basic principles of
ethics to any given scenario. Some examples include: a patient wants a regular cleaning
even though periodontal disease is present, a patient refuses radiographs for the fourth
year in a row, the dentist wants the hygienist to do a deep cleaning on a patient that does
not have active periodontal disease, the dentist or office manager wants the hygienist to do
a deep cleaning on a patient with severe active periodontal disease in forty-five minutes,
the dentist over diagnoses treatment, the assistant performs coronal polishing and places
sealants without proper certification, the list goes on and on. Ethics in dental hygiene
education is crucial because every decision that the practicing hygienist makes and every
decision the dental team makes can violate basic ethical principles and put the practicing
dentist and hygienist’s license on the line.1 Dental hygiene students work so hard to get
into a good dental hygiene program and then once they are there they work so hard to
prepare to be the best clinicians they can be and to pass every licensing exam and it is a
shame that not more time is spent on applying ethics to clinical cases that will be applicable
to the student once they have graduated and are practicing on their own. Once a practicing
dental hygienist is out of the academic environment and working on his or her own under
their own license sound ethical decisions have to be made to protect their license, their
patients, their doctor and the practice of dental hygiene.
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Haley Williams Curriculum Issues: Integrating Ethics
If this issue is rectified, then more graduating dental hygienists will be able to make
ethically sound decisions when it comes to ethical dilemmas. As stated earlier, the dental
hygienist’s scope of practice is changing and more decisions are being left to the hygienist
and he or she must not only know the principles but also apply them and adhere to them.4
If the issue is left as it is now, then more and more graduating dental hygiene students will
graduate and know the basic principles of ethics and will be able to pass their boards, but
the dental hygienist will not know how to think critically about ethics and apply ethical
principles to every day practice and this needs to begin with faculty demonstrating proper
ethics and facilitating critical thinking in this area.4,5
Solution
If dental hygiene faculty are going to properly train dental hygiene students in
ethical decision making then it must first start with the educators. I would require adjunct
and full time faculty to complete continuing education in ethics and professionalism and
would also implement annual faculty training and development in ethics and in facilitating
critical thinking.4 From my research, little is found on implementing ethics in dental
hygiene curriculum, but most research encourages guest lecturers, multiple evaluation
methods including case studies, role playing, and finally, stringent grading on clinical and
personal ethics throughout the dental hygiene curriculum. 1,3,4,5,6
I would base my solution off of the article by Drs. Brondani and Rossoff from the
University of British Columbia Dental School. Although this model was made for dental
students, I believe it would make a fantastic model for dental hygiene students as well. The
model that they have developed and implemented includes beginning ethics instruction
starting the very first week of dental curriculum. They do a three-day intensive study of
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Haley Williams Curriculum Issues: Integrating Ethics
ethics.6 The first day they spend in lecture where basic ethical principles and reasoning are
discussed.6 The next two days, the students are broken up into groups. An ethical dilemma
is presented and the lecturer spends ten to fifteen minutes discussing the case.6 The groups
must deconstruct the ethical dilemma that is presented in a case study and do a write up
discussing the core ethical principles and the course of action that should be taken.6 These
group sessions are moderated by a dental or dental hygiene faculty who can clear up any
confusion and impart wisdom from his or her own clinical and professional experiences.6
Following the deconstruction students pair up with another student and present their
course of action following a basic script to address the following questions:
What are the issues at stake?
Who should make the decision on what to do?
What are the consequences of acting or not acting?
Who else is affected?6
Next, each student has an opportunity to put his or her learning into action. They are put in
the “hot seat” where they are paired with a standardized patient (an actor) who role-plays
a certain ethical scenario. Each scenario lasts between eight and ten minutes, but students
are allowed a time out to discuss with his or her group recommendations for a course of
action.6 After this experience, the student writes a self-reflection paper to discuss what
they learned from the experience.6
I believe this model is a great way to encourage critical thinking and ethical decision
making starting very early in the dental hygiene curriculum. I do not believe that I would
start all of the role playing and presentations until after a little bit of clinical and didactic
learning has taken place but I think it could begin as early as the end of the first semester of
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dental hygiene curriculum or the beginning of the second semester. I would recruit dental
and dental hygiene faculty members to act as the standardized patients and would meet
with them prior to go over expectations and their script for the role playing. Just like Drs.
Brondani and Rossoff, I would have a round table with all faculty involved in this learning
experience to discuss possible scenarios and come up with new cases based on everyone’s
own personal experiences in practice.6 Higher levels of Bloom’s taxonomy must be used in
acting out different scenarios, learning and teaching your peers, and reflecting on your own
experiences. Evaluation of this very first introduction to ethics would be based on group
participation, critical thinking, and identification of important ethical issues, identification
of patient feelings and opinions, and use of ethical reasoning.6
I would also include ethical decision making scenarios throughout dental hygiene
curriculum as new clinical issues are taught. Not only would ethics be graded in the
classroom, but also in the clinic. Grading would be based on professionalism and decision
making skills.
Summary
As dental hygiene students graduate, many are faced with ethical decisions and
dilemmas that he or she was not exposed to in academia. Based on research, many dental
hygiene students who are about to graduate do not have a firm grasp on some of the
clinical ethical dilemmas they will encounter in private practice. Some of these dilemmas
include fraud, infection control, practicing outside of a practitioner’s scope of practice, and
failure to diagnose disease.1 Additionally, there is little research on instructional methods
for ethics in dental hygiene curriculum.3 There is evidence supporting the use of case
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Haley Williams Curriculum Issues: Integrating Ethics
studies and role playing to encourage higher levels of thinking and ethical decision making.
1,3,4,5,6
This paper reviewed and suggested a solution to the issue of integrating ethics by
encouraging ethics instruction from the beginning to the end of dental hygiene education
and by using a multifaceted approach as discussed by Drs. Brondani and Rossoff.6 Drs.
Brondani and Rossoff conclude that ethics instruction should not just be limited to a one
time or one year part of the curriculum but it should be reinforced and applied throughout
the entire curriculum.6
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Haley Williams Curriculum Issues: Integrating Ethics
References
1. Duley SI, Fitzpatrick PG, Zornosa X, Lambert CA, Mitchell A. Dental hygiene students’
attitudes toward ethical dilemmas in practice. J Dent Educ. 2009;73(3):345-352.
http://www.jdentaled.org.lib-ezproxy.tamu.edu:2048/content/73/3/345.full.pdf+html.
Accessed July 25, 2013.
2. Beemsterboer PL. Facing ethical dilemmas. Dimens Dent Hyg. 2009;7(12):44-47.
http://www.dimensionsofdentalhygiene.com/ddhright.aspx?id=6774. Accessed July 24,
2013.
3. Kacerik MG, Prajer RG, Conrad C. Ethics instruction in the dental hygiene curriculum. J
Dent Hyg. 2006;80(1):1-13. http://web.ebscohost.com.libezproxy.tamu.edu:2048/ehost/pdfviewer/pdfviewer?sid=e4be37da-1192-47b0-b3c141fb1adc267c%40sessionmgr4&vid=2&hid=21. Accessed July 29, 2013.
4. Majeski J. Ethical issues for the dental hygienist. Access. 2013;(4):16-20.
http://web.ebscohost.com.libezproxy.tamu.edu:2048/ehost/pdfviewer/pdfviewer?sid=191c9376-6602-4fce-a9e3ebfe53d26134%40sessionmgr15&vid=2&hid=21. Accessed July 25, 2013
5. Masella RS. Renewing professionalism in dental education: overcoming the market
environment. J Dent Educ. 2007;71(2):205-215. http://www.jdentaled.org.libezproxy.tamu.edu:2048/content/71/2/205.full.pdf+html. Accessed July 27, 2013.
6. Brondano MA, Rossoff LP. The “hot seat” experience: a multifaceted approach to the
teaching of ethics in a dental curriculum. J Dent Educ. 2010;74(11):1220-1229.
http://www.jdentaled.org/content/74/11/1220.full.pdf+html. Accessed July 28, 2013.
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Criteria
Possible SelfComments
points
Evaluation
50
44
Issue Analysis
I believe I clearly identified
the problem and how it
relates to the practicing
dental hygienist
Clarity & justification of
importance of issue/problem
statement
12
Elements/components of the
issue/problem
15
10
This was the most difficult
part of the paper for me. I
do not think that I
completely understood
what was being asked of
me and tried to describe all
of the elements and
components I could think
of and find research to
support.
Various viewpoints
Strengths and Weakness
15
15
I used examples and
viewpoints from faculty and
students’ perspectives
Consequences if not resolved
8
12
7
Solution
45
Description
Resources
Time
I hope that I made
consequences clear if not
resolved. If the issue is not
resolved we will continue
to see dental hygienists put
their professional ethics
and morals on the line to
keep a job and possibly at
the expense of their
license.
37
15
12
I do not think I adequately
covered the time
requirement. I discussed
where the teaching would
take place and that it would
occur throughout the
curriculum
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Haley Williams Curriculum Issues: Integrating Ethics
Process of implementation
20
15
This was also a difficult
part for me, I was not sure
that I discussed
implementation to the
degree that was wanted.
Discussed the need for
faculty continuing
education and getting
faculty involved in roleplaying scenarios.
Plan for evaluation
10
10
Discussed the need for
evaluation and grading
throughout. Discussed how
evaluation would be based
of multiple methods.
5
I reviewed the information
Summary paragraph
5
References
Total
100
86
12