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Ethical Issues for the Dental HygienistBy Jean M ajeskiEthical Dilemmas in Practice

"There's not a whole lo t of literature about ethicaldilemmas that arise in the dental hygiene workplace,"said Phyllis Beemsterboer, RDH, MS, EdD, FACD. If you'reinterested in the topic, you probably recognize her name.Beemsterboer wrote the leading dental hygiene textbookon the subject. Ethics and La w for Dentai Hygienists.The book includes sample cases of ethical dilemmas thatBeemsterboer collected from dentai hygiene colleagueswho shared them with her."Often, the hygienist will feel without power in thesesituations. And they go to someone who is usually theirdental hygiene friend and colleague, who 'll say, 'Oh you

poor thing, you're being used and abused .'" But there aremore positive ways of dealing with ethical dilemmas, andas with many things, education is the first step.Frank A. Catalano tto, DMD, professor and chair, Depart-ment of Community Dentistry and Behavioral Science, Uni-versity of Florida College of Dentistry contributed a chapterto Ethics and La w for Dentai H ygienists."Dental hygienists, like any health care professional,should know basic ethical principles," he said. "The onetextbook on ethics for dental hygienists covers thoseprinciples, so there, to m e, is an outrigh t stateme nt that adental hygienist should know what those principles are."Shari G. Peterson, RDH, MEd, is the director of the as-sociate and baccalaureate dental hygiene programs atthe

"The first thing students a re taught are the

College of Southern Nevada. As a former member of thNevada State Board of Dental Examiners, ethics is a topin which she is well-versed."The first thing students are taught are the basic prciples of ethics," she said. "We do use Phyllis' book as atextbook, so they're taught what the ADHA Code of Ethis, and they're taught what the different concepts meanand how they are to be compliant with them and applythem every day in their practice of dental hygiene."Peterson explained that the programs' policy and prdures manual requires compliance with the ADHA CodeEthics for D ental Hygienists. Students who commit profsionalism infractions receive professional remediation tincludes counseling and review of the infraction. After asecond viola tion, a student is put on probation , and aftthird, the student is interviewed to determine if her or hpattern of behavior warrants dismissal from the progra"We let them know that from day one, when theygraduate, their ethics will be put to the test," Petersonsaid. "Because we know that they will have to cut downtheir t ime, we know that they may have to cut down onthe procedures that they do, that they're not going to bpracticing academic dental hygiene anymore."But it 's completely up to them how much of that acdemic deal hygiene they're going to carry over into thepractice. And I would love to say that all of my graduatare completely ethical. I think that they have good intetions, but I do think that the pressures from the increa

demands of the work environment are the things thatmake them compromise."So a graduate leaves the academic setting , ethical

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the same amount of t ime and the sameresources that had been available in school.In the eyes of that graduate, might the newcoworkers' day-to-day practice behaviorlook unethicai?"It might," Beemsterboer said. "I wasreviewing some ethics essays just yester-day. One of them was obviously from a hy-giene student, and she was writ ing that shesaw her instructor diagnosing caries, and

that was out of the scope of practice. Weii,in essence, most iikely what the instruc-tor was doing wasn't 'diagnosing,' it was'bringing attention to something she saw.' Ithink that more experienced hygienists andpractitioners kind of balance that lack ofsophistication and lack of experience [in thepractice setting].A common area where ethical issuesarise is scope of practice. Whether practi-t ioners take it upon themselves to performduties outside their scope, or if the dentistassigns the m, or if a coworker is performingthem, it's an ethicai issue."From what I hear from my graduates,the most common ethicai dilemma is theiremployers asking them to do things thatare not within the scope of practice fortheir state," Peterson said. "Our [Nevada's]practice act says that we have authorizedpractice, which means that the dentist hasto have done an exam and a treatment pianbefore the hygienist can see the patient.And in several of the offices, the front of-fice person is putting new patients on theschedule to see the hygienist f irst so the hy-gienist can get them cleaned up, and thenthey get put on the dentist 's schedule for an

exam and treatment plan, which is not legalin our state."Peterson explained that if the den talhygienist performed the treatment, and ifthe patient did not return for an examina-tion by the dentist but did seek treatmentelsewhere, claiming never to have beendiagnosed with periodontai disease theoffice would be liable for not following theprotocol outlined by law."It all comes back to whether or not thelicensees know their dental practice act,and whether they are willing to abide bythe practice act," Peterson said, adding that

100 percent of the fault does not necessar-ily lie with the de ntist. "Hygienists have aresponsibility to know their dental practiceact, as weli."Peterson said that in cases where hergraduates have questioned the appropriate-ness of the front office's scheduiing, theyare sometimes told "Well, this is the way wedo it here, and you're going to have to talkto the dentist.""And so when they talk to the dentist, sometimes the dentistwiil comply, sometimes they will not, and then the hygienist hasto make a choice. Either they make a choice to stay and try andchange the empioyer's work practices, or they choose to leave

the job."And so the ethical dilemma for them is 'What am I willing toput up with, and am I willing to put my license at risk over this?'

Box 1Ethical dilemmas related to issues of employment include

Unfair treatme nt of employees in terms of compen sation, assignment of workhours, benefits etc. (justice) Reimbursement related to salary versus hourly wages; unpaid overtime Unsafe work environment that does not meet specific standards putting staff(and in some instances, patients) at risk (beneficence, non-maleficence) Illegal activities with roots in violatio n of ethical principles; e.g. insurancefraud, which vioiates veracity; violating confidentiality, which also violatesHIPAA Failure to inform a patient of injury to a patient and failure to document theincident Disrespectful or inappropriate behavior in the office; e.g., extrama rital affairbetween coworkers Sexuai harassment; quid pro quo and hostiie work environm ent Excessive trea tme nt or inferior or inapp ropriate care Noncompliance: infection control; MSDS; office annual OSHA trainin g; nosigned abuse-reporting acknowledgment form; no informed consent Working with ou t a iicense Failure to repo rt wrong doing or illegal practices of other employees Employer's direction of prac titioner to work outside scope of practice

Ethical dilemmas related to interaction with patients include Providing unnecessary care to patients (veracity and justic e) Providing poor quality care with patients (harm) Failure to obtain informed consent, which violates the patient's autonomy aswell as the legal obligation to obtain consent Failure to refer, which may cause harm and violates a legal obligation Failure to provide sufficient time for the dental hygienist to meet the stan-dard of care for dental hygiene services, which may cause harm, is not fair tothe patient and may have iegal implications Being disrespectful to patients due to their status, mentally comprom ised,lower SES, limited heaith iiteracy, primary language not English (justice) Failure to report child or adu lt abuse, which continues the harm and has iegalimplications Con fidentiality issues; e.g., patien t informs practitione r of change in medlcaihistory, but doesn't want parent or partner to know; e.g., pregnancy, HIVstatus

Ethical dilemmas related to interaction with coworkers include Disrespectful treatm ent of employees, creating a hostile work environmentdue to gender, ethnic or religious background. This touches on the ethicalprincipies of justice, employee autonom y, etc. and also has legal implications. Knowledge that an employee or colleague is providing excessive, inferior,incompetent or inappropriate care Knowledge that a coworker is not knowledgeable or skilled to perform proce-dures he or she is performing Failure to report improper treatmen t by a coworker Instigating inappropriate conflicts among coworkers Knowledge tha t a cowo rker who claims to be licensed is unlicensed or has anexpired license Coworkers' stating and charting false information

Sources: Michelle Hurlbutt, R DH, MSDH an d Pamela Zarkowski, JD, MPH

"In Nevada, there are not very many jobs for a hygienist. Andso a lot of them end up compromising what they know they shouldbe doing, just to be able to keep their jobs."Of course, scope of practice is not the oniy ethicai issue. Box 1lists several other examples of the types of situations that arise inthe dental practice, such as the issue of the impaired practitioner."If a dental hygienist is in an office and knows that another

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another, there's an ethical principle, termed nonmaleficence, toavoid harm to patients," Catalanotto said. "That dental hygienistnow has an ethical problem, and that problem is that she or hehas to say something if there is potential for harm to a patient byanother dental professional in the office that is under the influenceof drugs and is performing procedures that could do harm to thatpatient."It 's one of the examples we use when we teach ethical di-lemma situations to our students. In the traditional example thatwe use, one of the assistants in the office may have a drug depen-

dency problem that is impairing performance, and what does thedentist do? The dentist has an obligation to remove that personfrom patient care. Again, that person may be an assistant that'snot licensed, and obviously there are those kinds of issues aboutlicensure and so forth that are the regulation end, but the guidingissue is the ethical principle. Well, the dental hygienist has thesame obligations, even if the individual doing the potential harm isthe dentist in the office."Patient well-being and satisfaction are central to the discussionof ethics in the den tal hygiene workp lace. Lynn Marsh, RDH, EdD,associate professor. Department of Dental Hygiene, FarmingdaleState College listed three aspects of the ethical responsibility topatients: the patient/provider relationship, confidentiality andautonomy.

"A sense of trust can facilitate a patient'sconnection with the dental hygienist andperhaps inspire greater patient satisfaction andincrease patient com pliance. "

"Trust is the foundation of a successful patient-provide r rela-tionship," Marsh said. "A sense of trust can facilitate a patient'sconnection with the dental hygienist and perhaps inspire greaterpatient satisfaction and increase patient compliance."According to Marsh, the relationship between dental hygien-ist and patient is based on confidentiality. "Patients have the rightto privacy, and it is vital that they give the dental hygienist acomplete medical history to ensure that any treatment is carriedout safely," she said. The patient is more likely to feel comfortableproviding a complete and honest response to medical history ques-tions when it is understood that any information revealed will notbe disclosed without the patient's consent.The ethical principle of autonomy includes the issue of informedconsent. "It is essential that the dental h ygienist educate thepatient regarding the treatment plan to the fullest extent of theirabilities," Marsh said. "This helps to ensure that the patient is mak-ing an educated decision concerning tre atme nt.""Patients should make their own decisions about their healthcare and what's done to them and done to their bodies," Catalanot-to added. "So there's an obligation for dental hygienists to makesure that the patient understands what the side effects of scalingand root planing might be, or if a patient does not want f luoride,adhering to that wish, trying to educate the patient about the ben-efits of f luoride. But if that patient doesn't want f luoride, and it 'sthe hygienist's usual custom to apply fluoride, the hygienist has anobligation to do what the patient wants, in that case."That's an ethical issue, not a legal issue. A good way to put itis what should be done, not necessarily wh at m ust be done. Andhopefully they coincide, but not always."Complicating the issue is the fact that patients have easy ac-cess to health information and take the init iative to do their ownresearch. "Patients are very oral health savvy nowadays," Peterson

said. "They will come in and tell the hygienist, 'I only want thisdone because my insurance will only pay for this.' Or they'll comein and they feel like they have enough knowledge to dictate the

those periodontal probings because it hurts. And I have said bacto them, 'If you're asking me to compromise the standard of cathen I may not be able to treat you today.'"If the patient is trying to dictate treatment that you feel isnot the standard of care, go to your dentist f irst, and inform himof the situa tion. I 've had very supportive de ntists that have comback to the patient and said, 'I 'm sorry, this is our recommendetreatment, and if you are not willing to follow this recommendetreatment, then I invite you to find another dentist that would bwilling to follow what your parameters are.'"

Ethical Problem-So lving R esources and Skills for DentalHygienistsDental hygienists seeking to solve ethical dilemmas have anumber of resources at their disposal. In addition to the ADHA

Code of Ethics for Dental Hygienists, the code of ethics of theAmerican Dental Association also contains valuable informationthat can be used as a resource when discussing an issue with aemployer or other staff member, said Pamela Zarkowski, JD , MPprovost and vice president for Academic Affairs at the UniversityDetroit Mercy."Determine if there is an office staff manual and what itincludes, what it does not include and what is should include,"Zarkowski suggested

"Seek a mentor or confidant," added Michelle Hurlbutt, RDHMSDH, associate professor. Loma Linda University DepartmentDental Hygiene and president of the Dental Hygiene CommitteeCalifornia. "Consult books and journal articles. You can find manresources with a quick Internet search."Look for continuing education in ethical issues, and learn ahow your state board of dentistry or dental hygiene works andwhat resources it offers. Find out what the peer evaluation procis and how to report incidents."Beemsterboer, Hurlbutt and Zarkowksi all advise use of an etcal decision making model such as the one outlined in Ethics anLaw for Dental Hygienists. Beemsterboer said she included it be-cause it drives people to approach their ethical situation analytic"And by writ ing it down," she said. "I think by writ ing it dowforces you to kind of look at more than just your view of the stoAccording to Beemsterboer, ethical analysis is commonly tauto dental hygiene students. "We can't foresee every problem ththey're going to come up against. But when you can analyze sothing, it'll assist you in the clarity."The reason that people have an ethical dilemma or an ethicproblem is because they're caught between competing obligatioso when they face the situa tion, they've g ot to carefully weighdifferent options. The ethical decision making model links the pciples to the options you create."The steps of the model include identifying the dilemma orproblem, collecting information, listing available options, applyithe ethical principles to the options and making and implementia decision.Hurlbutt identified evaluation as a critical to the process."Reflect on the outcome. Would you make the same decision if sented with the dilemma again? If not, what will you do differennext t ime and why?"

Reporting Ethical and Legal ViolationsIf a dental hygienist recognizes some thing wrong in the worplace and makes the decision to report it, they need to determito which entity the issue should be reported. Generally speakinstate boards of dentistry don't address ethical issues unless theare also legal issues. The fact-finding step of the ethical decisiomaking model can help distinguish ethical from legal issues,

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"Wha t does your state board say? You may think it says some-thing, but go back and look - state boards change all the time ,"she said."Once you've collected the information, and you've gone overthe various options and applied the principles to those options, thenyou make the decision, and if the decision is you need to report thisto the board because you think your employer has a drinking prob-lem or a gambling problem or whatever the issue, that takes somegumption and guts to follow through on it," Beemsterboer said."A state board can become involved if that state board has legal

jurisdiction through statute or regulations," explained Hurlbutt. "Ifthe state board has jurisdiction, potential outcomes of reporting aworkplace issue to the state board include disciplinary action. Allreports are investigated by the state board's enforcemen t staff.Actions a state board might take in the case of a iegai violationinclude discipline against a license such as citing and fining, proba-tion or revocation of the license. If legal action is taken, a reportwill be provided to the National Practitioners Data Bank."This is not to imply that ethical and iegal issues are mutuallyexclusive. "Many rules and regulations have an ethical foundation,"Zarkowski said. "A state board can become involved if an ethicalviolation has compromised the standards set forth by the stateboard."Peterson, who served on Nevada's state board of dental exam-

iners for five years, expiained the process in her state."If the board receives a verif ied com plaint, they have a disci-plinary screening coordinator that will look at the complaint anddetermine whether it 's an ethical issue or whether it 's a statuteviolation. And they have to look at the evidence that was providedin the statement and make a determination whether or not theboard can act on it."If the board determines that the complaint merits an investiga-t ion, they send a letter to the individual named, cit ing the com-plaint and giving the recipient 15 days to respond with evidenceregarding the complaint. If the person does not respond within 15days, or does respond but the response is inadequate, the boardsends out a disciplinary screening officer to investigate. If the per-son does respond w ithin 15 days and provides adequate explana-

t ion, the board keeps the complaint on file and remands it back tothe main coordinator indicating that no action is recommended."If the disciplinary screening officer goes out and finds thathere is an infraction or a violation, they are given within 30 to 45days to investigate," Peterson said. "That means they can go intoan office, and they can ask for records, they can ask for testimonyfrom patients, they can do any of those types of things."After the investigation, the disciplinary screening officer makesa report to the board of dental examiners, who will determine whataction needs to be taken against that individual, typically one ofthree options. The first is to remand the complaint, keeping it onfile without further action. The second is to suspend the prac-tit ioner's iicense for a period of t ime . The third is to revoke thepractit ioner's iicense."It 's very few times that they actually revoke," Peterson said.But one of the other things that we do here in Nevada that'spretty unique is many times the attorney wiii go to the individualand say, 'We don't w ant to suspend yo ur license will you agreeto go through some type of remediation training?' Or maybe '[Apatient] needs to be reimbursed because you said you did fourquads of scaling and root planing and in actuaiity what you did wasa cleaning.'"Nine times out of 10, they will actually enter into a stipulationagreement with the individual, and that individual wiii sign thattipulation rather than having their license suspended.""State boards vary in the penalties that they can impose,"arkowski agreed. "Often, decisions made by the board are printedin dental or den tal hygiene society n ewsletters or we bsites. Alicensee's status can also be checked through the state's websites."If it's clear that an issue is not appropriate to bring to the den-

Box 2Ethical versus Legal and Other Distinctions

Ethical: Pertaining to a standard of right and wrong. Ethi-cal codes are aspirational standards that are created toguide the provider.Legal: Legal issues may be determined by a law or statuteand have specific consequences outlined. Civil, criminal andadministrative laws are created to protect citizens and soci-ety. There are consequences for health care providers thatmay include fines, imprisonment, probation, suspension ortermination of a license to practice.Moral: Like ethics, morals are standards of right andwrong. Some definitions distinguish morals as personalto an individual whereas ethics can be uniform across themembers of a profession, for example.Beneficence: Beneficence protects and promotes thewell-being of others, such as the patients of health careproviders.Dilemma: A dilemma is a situation in which p otential reso-lutions are equally unacceptable.Justice: Justice requires the fair and equitable distributionof resources, such as health care services.Malpractice: In health care, malpractice is practice thatviolates the standard of care and causes injury to a patient.Tort: Tort is an area of law that deals with acts such asthose performed by health care providers that result ininjury to someone other than the person performing theact, such as patients.

"Depending on the ethical violation, there may be legal implica-tions, and it can be reported to the appropriate regulatory agency for examp le, the Equal Em ployment O pportunity O ffice, Officeof Civil Rights or the dental insurance provider," Hurlbutt said.Other alternatives include a iabor relations board, Medicaid dentalprogram, local law enforcement agency or peer review.In Nevada, as in many other states, the dental and dentaihygiene associations have peer-review committees created to ad -dress ethical issues, Peterson said."If the hygienist feels like it is a violation of the practice act,they will go to the Nevada State Board of Dentai Examiners. Butwith most of the peer reviews, it's reaily members of the profes-sional association that are wanting to be abie to work out an issuewith th at particular person." However, this option is available onlyto association members. In Nevada, complaints against nonmem-bers of the professional groups may be considered by the dentalboard whether it is a iegal issue or an ethical one.Peterson said that there are few peer review cases againstdental hygienists. "Most of the time, the hygienist will blame theirconduct or performance on the work practice or the demands thathave been placed on them. And the co mmittee really tries to w orkwith them to [help them] understand what the standard of careis. It's more like a counseling session. Then if there Is any furtherincidence, usually the person who made the original complaint willpursue the issue with the board of dental examiners."Having one's license suspended or revoked is a potential rami-fication for the dental hygienist who doesn't maintain standards ofpractice, but the person reporting the violation may face repercus-

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"Even in larger communities, people know; the dental world isnot that big," Beemsterboer said. "So yes, there can be reper-cussions. If you're in a small community, and you have causedproblems for Doctor A, no doubt Doctor B, C, D and E are going toknow about it."Take that a step further: if I'm a single mother with three chil-dren to support and there are no other jobs around, I have to takethat into consideration."Peterson agreed. "The biggest ethical dilemma is whether ornot to report. And I think that not even just my graduates, but

jus t from dental hygienists out there they do feel the pressureof having the concept of being blacklisted."We do have a statute that was put into play for all health careproviders, which is a whistleblower clause, that the individual whofiles a complaint cannot be fired from that practice based on theircomplaint against their employer. But in reality, the employer willfind another reason to let them go."Peterson said she believes that blacklisting of practitioners isless prevalent than the fear of it. "I don't necessarily think thereis a blacklist out there I think that dentists are too busy to takethe time to deal with blacklisting opportunities. They may, throughword-of-mouth, say, I don't have this person anymore, but that'sreally only going to travel within their circles and not necessarilyacross the whole entire association so that the individual doesn'tget hired. I don't know that someone would be barred from work-ing at somebody's practice just because of word-of-mouth. I've notpersonally seen it. But the concept's out there.""Independent practice is going to put morepressure on dental hygienists to follow theethical principles by knowing them rather thanby following them by implication when theyworked for a d entist. "Developing Issues

As society advances, the types of potential ethical concerns in-crease. This is the case with technology, in both the dental hygieneworkplace and in academia, especially in the area of social mediaand information sharing."Some ethical issues regarding social media and the dentalhygienist are discussing clinical issues," Marsh said. "Social mediamaterial available on the Internet frequently exists in the publicdomain; however, it is important that dental hygienists exercisecaution when discussing any details relating to specific patients ordental cases."Dental hygienists have a legal and ethical duty to protectpatient confidentiality. Disclosing any identifiable information about

patients without consent on any social media sites would consti-tute a breach of confidentiality and could result in complaints frompatients as well as litigation."Peterson related a similar event that was brought before herstate dental hygiene association. "Some issues were discussedabout dental hygienists on Facebook talking about the patients thatthey saw that day and divulging personal information. Somebodythat was friends with somebody that was friends with somebodyelse identified that the patient being discussed was them, eventhough that person was not named. And the patient was very up-set and complained to the dentist because their hygienist had puttheir personal scenario out on Facebook."I'm sure it goes on, and I'm sure that hygienists feel thatthey're probably safe if they don't name who it is, bu t they're be-

ing very descriptive about the situation."Peterson said that the College of Southern Nevada has asocial media policy for students recruiting patients. "We've had

Facebook and said 'I'm a dental hygiene student at this collegeand I need patients.'" The college has a dedicated staff person ocampus to watch Facebook postings that violate school policy."More of a concern to me are students that will post on craiglist for patients, and they just say 'dental hygiene student/ and'contact me,' and they have their personal phone number there.We're concerned about their safety not knowing who is goingbe contacting them ."Beemsterboer says she is not aware of problems with studenin social media. On the other hand, she offers a word of caution

regarding the type of information students should share, knowinthat they will soon be looking for a professional position."I'm sure that there are people checking social media whenthey're looking to hire hygienists and assistants. I think people a little too free with social media."It's not only technological progress that is creating new reasto keep ethics in mind. As the dental hygiene profession grows,do the areas where ethical mindedness is warranted."For the most part, in our system in this country, hygienists aremployed by dentists and therefore subject to the wishes of thedentist," Catalanotto said. "And so, traditionally ... it's not fair to sahygienists didn't have to worry about the ethical principles, but thassumption was that if the dentist was practicing ethically, the dewould not ask the hygienist to do anything against those principleHowever, as Catalanotto points out, dental hygienists are allowto do more without direct supervision, which puts pressure on tprofession to ensure that dental hygienists are aware ofthe ethprinciples of health care practice, and that they adhere to themall times ."Independent practice is going to put more pressure on denhygienists to follow the ethical principles by knowing them raththan by following them by implication when they worked for a dtist. So I think that's the big change that the profession is goingbe facing, because I think we're going to see more of this looseing up of what I call restrictive dental practice acts that don't aldental hygienists to do what they're trained and capable of doinAt the University of Florida, Catalanotto has a grant from theHealth Resources and Services Administration to provide facultydevelopment training."The primary target was our dental school faculty, but we haoffered this to some hygiene programs that we affiliate with, anwe're actually going to do it statewide now. The rationale for whdental hygienist faculty need more training in how to promotecritical thinking skills the rationale put toge ther by the dentahygienist educators that I consulted with is that dental hygieists are going to be more and more in practice settings withoutsupervision. They therefore need to make critical thinking deci-sions about what is the right thing to do in this particular situatwhereas in the previous practice model, they could rely on thedentist to make those critical decisions."So now, with all this independence, they need to think more

critically. That's not to say that they didn't think critically beforebut now there's really a responsibility on the part of hygieneprograms to have faculty that know how to teach students to thcritically and then how you assess that."

ConclusionCatalanotto summed up the issue of ethics for dental hygientoday as "knowing the principles, knowing how to use and applythem, in particular in settings where they are practicing more inpendently than they have traditionally in the past.""Hygienists ge t faced with a variety of ethical issues," Beemsterboer said. "Some of them will rise to the level of an ethical

dilemma, but sometimes they're just simple problems."Even if it's simple, writing it down helps with clarity. Havinganalyze it gives some clarity."

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