by Anne Nugent Guignon, RDH, MPH
Driving a car is a fact of life for most of us. It can be fun, a chore, hectic, nerve-wracking, dangerous, or even relaxing. It's a skill that requires practice, alertness, good judgment, and a license. The negative consequences of ignoring safe driving rules range from getting a ticket to risking injury, property damage, or even death. The more one drives, the greater the probability of a problem, especially if one takes risks. Even if you follow the rules, other drivers can create mayhem on the road.
Practicing dental hygiene is a lot like driving. Each time we open a patient record, do an assessment, instrument a tooth, interact with a patient or a colleague in any way, there is a potential for an ethical dilemma. It would be easy if all ethical dilemmas were black-and-white situations that could be readily answered with a simple yes or no, but in reality most are composed of many shades of gray.
Ethical dilemmas are a basic fact of professional life. According to research, it is not uncommon for health-care professionals to encounter situations that pose one or more ethical dilemmas.1 Moral distress, a byproduct of being confronted with an ethical dilemma, is defined as the physical and emotional distress a person experiences when prevented from following a course of action that he or she believes is right. Nurses often have more responsibility than authority, lacking the autonomy to do what they feel should be done.2 Dental hygienists often have the same type of experience.
Ethical conflicts are a source of job related stress and anxiety.2-5 Issues that cause moral distress are often ignored in the workplace, leading to feelings of isolation, loneliness, uncertainty, feeling threatened, frustration, worries about becoming a scapegoat, and avoiding making difficult decisions.6 Interestingly, women physicians have more difficulties in solving ethical dilemmas than their male colleagues,4 while older doctors find it easier to resolve these issues.4,7
Career satisfaction and quality of patient care are both adversely affected by situations that cause moral distress.8,9 Moral distress leads to emotional distress and physical symptoms.10 Healthcare workers often label these feelings as stress, burnout, emotional exhaustion, and job dissatisfaction.2 As the frequency and intensity of situations that cause moral distress increase and professional conflicts remain unresolved, health-care workers resort to a variety of actions to reduce or alter their situations, which include changing workplace locations or leaving a profession entirely.11,12
The health of an organization needs to be based on a positive ethical climate where open communication is used to identify and address issues that create moral distress.2,13 Ethical climates benefit both health-care workers and patients. Healthy organizations have a higher worker retention rate, and workers have increased levels of job satisfaction.11-13
Regardless of the health-care setting, patient care is complex and involves critical thinking and problem-solving skills.14 While most dental hygienists do not practice in environments that have the same level of stress as experienced by nurses in critical care units, most have strong feelings about quality of care and what it takes to perform optimal dental hygiene services. It is common for dental hygienists to bring ethical dilemmas forward on web-based forums and in continuing education seminars.
Just like nurses, most dental hygienists are employees, subject to how the dentist employer or supervising dentist chooses to run the organization. Today's job market is tight. As a result, many hygienists now face ethical dilemmas that were unheard of decades ago. We are often expected to perform more billable procedures in a shorter time frame. In many practices, the primary focus is on what the insurance will cover, not necessarily what a patient actually needs.
Without a doubt, most of us have been faced with some ethical dilemmas during our careers. How we respond to these situations ultimately impacts on how we feel about ourselves as dental professionals. An ethical problem can arise with the requirement of every patient having radiographs at every dental hygiene appointment. A dilemma can surface when only extra coarse prophy paste is available. A dental hygienist may be expected to perform a quadrant of definitive periodontal therapy in 15 minutes.
How do you feel about those who use fear to motivate a patient to accept treatment? What are your thoughts about business office personnel changing procedural codes to a more expensive treatment? Does it make your stomach turn when a dental assistant scales teeth in a state that does not allow them to perform this service? How would you handle knowing a married employer was having an intimate relationship with a fellow coworker?
We need to reach deep into our inner selves and decide where to draw the ethical line and what it will take for us to practice without moral distress. Pick your battles. Figure out if there is a reasonable way to resolve the conflict. Some have voluntarily left positions when they believe there is no chance to resolve ethical issues. Others have lost their jobs when they have spoken out or gone against the organization's culture.
An increasing number of dental hygiene professionals resolve ethical conflict by purchasing their own equipment and supplies. They believe their choices will improve the quality of their services when they perceive the practice has a substandard workstation.
Just like driving, practicing dental hygiene is complex, and the mix of challenges is always changing. Each of us must protect our license to practice and do what it takes to work with high ethical standards, which provides the ultimate comfort zone.
Anne Nugent Guignon, RDH, MPH, provides popular programs, including topics on biofilms, power driven scaling, ergonomics, hypersensitivity, and remineralization. Recipient of the 2004 Mentor of the Year Award and the 2009 ADHA Irene Newman Award, Anne has practiced clinical dental hygiene in Houston since 1971.
- Zydziunaite V, Suominen T, et al. Ethical dilemmas concerning decision-making within health care leadership: a systematic literature review. Medicina (Kaunas). 2010;46(9):595-603.
- Pendry PS. Moral distress: recognizing it to retain nurses. Nurs Econ. 2007 Jul-Aug;25(4):217-21.
- Grönlund CE, Dahlqvist V, Söderberg AI. Feeling trapped and being torn: Physicians' narratives about ethical dilemmas in hemodialysis care that evoke a troubled conscience. BMC Med Ethics. 2011 May 11;12:8.
- Klemenc-Ketis Z, Kersnik J, Ojstersek J. Perceived difficulties in managing ethical problems in family practice in Slovenia: cross-sectional study. Croat Med J. 2008 Dec;49(6):799-806.
- Bégat I, Ellefsen B, Severinsson E. Nurses' satisfaction with their work environment and the outcomes of clinical nursing supervision on nurses' experiences of well-being – a Norwegian study. J Nurs Manag. 2005 May;13(3):221-30.
- Mamhidir AG, Kihlgren M, Sorlie V. Ethical challenges related to elder care. High level decision-makers' experiences. BMC Med Ethics. 2007 Apr 10;8:3.
- Peisah C, Latif E, et al. Secrets to psychological success: why older doctors might have lower psychological distress and burnout than younger doctors. Aging Ment Health. 2009 Mar;13(2):300-7.
- Pauly B, Varcoe C, et al. Registered nurses' perceptions of moral distress and ethical climate. Nurs Ethics. 2009 Sep;16(5):561-73.
- Rushton CH. Defining and addressing moral distress: tools for critical care nursing leaders. AACN Adv Crit Care. 2006 Apr-Jun;17(2):161-8.
- McNeely E. The consequences of job stress for nurses' health: time for a check-up. Nurs Outlook. 2005 Nov-Dec;53(6):291-9.
- Corley MC, Minick P, et al. Nurse moral distress and ethical work environment. Nurs Ethics. 2005 Jul;12(4):381-90.
- Hart SE. Hospital ethical climates and registered nurses' turnover intentions. J Nurs Scholarsh. 2005;37(2):173-7.
- Bell J, Breslin JM. Healthcare provider moral distress as a leadership challenge. JONA's Healthcare Law Ethics Regul. 2008 Oct-Dec;10(4):94-7.
- Sullivan DL, Chumbley C. Critical thinking a new approach to patient care. JEMS. 2010 Apr;35(4):48-53.
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