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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 19  |  Issue : 1  |  Page : 16-21

Assessment of health-care ethical challenges in a dental hospital: A patient's perspective


1 Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India
2 Department of Public Health Dentistry, College of Dental Sciences, Davangere, Karnataka, India
3 Department of Implantology, College of Dental Sciences, Davangere, Karnataka, India

Date of Submission24-Feb-2020
Date of Decision30-Jan-2021
Date of Acceptance26-Feb-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Ashok Ranjit Chakrapani
Room No. 4, Department of Periodontics, College of Dental Sciences, Davangere - 577 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_8_20

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  Abstract 


Introduction: Ethical practice in health care is defined as consisting of informed consent, respect for integrity, and patient's autonomy. In the past few years, there has been an increase in the number of disputes ranging from inadequate and inappropriate treatments to serious problems of medical malpractice and negligence. There is thus a growing need to identify whether or not patients are satisfied with services provided and which ethical challenges, if any, patients value most in a health-care setting. This is not only to elevate the quality of treatment but also to potentially avoid unnecessary legal complications. Aim: The aim of this study was to evaluate the opinion of patients at a dental hospital about some commonly encountered ethical challenges and to investigate the ethical challenges which patients feel most important to them. Materials and Methods: One hundred and two participants were recruited for this cross-sectional study among patients who have visited the dental hospital more than twice. Each participant completed a self-administered questionnaire on some common ethical challenges. A three-point Likert scale was used. Data were entered in Microsoft Excel 2016 spreadsheet (Microsoft, USA), and Chi-square test was performed using SPSS (IBM) software (version 23.0). The results were considered as statistically significant when P < 0.05. Results: Seventy percent of the participants felt that doctors were competent in completing procedure in the time frame, and 82% felt that doctors followed the personal hygiene protocol. Only 47% of the participants felt that doctors accommodated missed appointments/lateness. Category E (infection control) was the category most commonly selected as the most important ethical challenge to patients with 36% of the participants. Conclusion: Participants were satisfied with a majority of the clinical services provided. The majority of the patients considered doctor competence and infection control as important issues. There is, however, a general lack of awareness regarding ethical issues in the dental field.

Keywords: Dental, dental care, dental survey, ethics, patient satisfaction


How to cite this article:
Chakrapani AR, Babitha G A, Prakash S, Prashanth G M, Sushanth V H, Kumari N. Assessment of health-care ethical challenges in a dental hospital: A patient's perspective. J Indian Assoc Public Health Dent 2021;19:16-21

How to cite this URL:
Chakrapani AR, Babitha G A, Prakash S, Prashanth G M, Sushanth V H, Kumari N. Assessment of health-care ethical challenges in a dental hospital: A patient's perspective. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2021 Apr 17];19:16-21. Available from: https://www.jiaphd.org/text.asp?2021/19/1/16/312649




  Introduction Top


The ultimate motto or supreme goal of any profession is to provide quality and standard services to people; these professions are governed by a set of rules and ethical principles designed to achieve this goal. Ethics is the science of the human character and behavior in situations where distinctions must be made between the right and the wrong, duty must be followed, and good interpersonal relations maintained.[1] Ethical practice in health care is defined as consisting of informed consent, respect for integrity, and patient's autonomy.[2]

The ethical standards of the dental profession are undergoing a steady decline, an increasingly market-driven system pushing away the altruistic concepts of the early teachers of the art.[3] There has been an increase in the number of patients challenging the dentist's authority over treatment planning and consent issues in the past few years.[4] Disputes range from inadequate and inappropriate treatments to serious problems of medical malpractice and negligence. As a result of this, the relevancy of ethical aspects of dentistry is increasing now more than ever before, thus exposing the dental practitioners to ethical issues or dilemmas in everyday practice. In the dental field, patient satisfaction can help locating the strength and weakness aspects, assist in elevating the quality of treatment planning, and potentially help avoid unnecessary legal complications.

Taking in the opinions and views of patients is regarded as an essential component of the quality of health care. It helps in locating the strength and weakness aspects, elevating the quality of treatment planning, and thus also potentially avoiding unnecessary legal complications.[5] As a result, this study aimed to evaluate the opinion of patients at a dental hospital about some commonly encountered ethical challenges and to investigate the ethical challenge considered most important by patients.


  Materials and Methods Top


Study design, area, and population

A cross-sectional study was performed with patients from the outpatient department of a dental hospital in Davangere, Karnataka.

Sampling methodology

One dental hospital (College of Dental Sciences) was selected. Outpatients reporting to the dental hospital during the month of September 2018 who had visited at least twice in total (including the visit at the time of questionnaire presentation) constituted the study population.

Sample size calculation

The prevalence of patients who have visited the dental hospital a total minimum number of two times was estimated to be 40%, and the sample size was calculated using the formula:

N = Zα2 pq/L2

where

p = Prevalence of patients who have visited twice minimum = 40% (data calculated over 6 months).

q = 100-P = 100-40 = 60%

Zα = Confidence factor for type I error α = 5% = 1.96

L = Allowable error, that is, 10%

N = (1.96)2 × 40 × 60/(10)2

= 92.3

Inclusion criteria

All the outpatients reporting for treatment at a dental hospital who had visited a total minimum number of twice were included till the sample size is achieved.

Exclusion criteria

  • Patients who are not willing to participate in the study
  • Patients unable to give informed consent.


Ethical clearance

Ethical approval was obtained from the Institutional Review Board of College of Dental Sciences, Davangere (Ref. No. CODS/1781/2018-19).

Survey instrument

Kemparaj et al. had earlier employed the use of open in-depth interviews and focus group discussions with a team of dental professionals and subject experts to assess the health-care ethical challenges in dental practice in the Indian scenario.[2] Based on the data gathered, broad themes/categories were constructed which were later ranked by subject experts in order of severity and magnitude of ethical issues occurring in the Indian context. To our knowledge, this is the only study which ranked ethical challenges faced in a dental setup, by a panel of dentists, and hence, we decided to include these categories in the present study.

A self-administered questionnaire was used to measure the patient satisfaction with the dental services provided by a dental hospital. A total of 25 closed-ended questions were used in the regional language. Questions were categorized into one of seven aforementioned categories. They are A (competence among doctors), B (consensus about treatment procedures among dentists), C (disagreement with treatment modalities between patient and doctor), D (knowledge and attitude of doctors toward ethics and law), E (infection control), F (informed consent), and G (medical record maintenance). Questions about each patient's demographic data such as age and sex were included. A reminder to answer as honestly as possible was included. The questionnaire was face validated by a group of researchers. Reliability test was performed, and reliability coefficient calculated was 0.76.

Survey methodology

After a brief introduction on the purpose and intent of the study, informed consent was obtained from the participants and questionnaires were distributed to the patients and filled questionnaires were collected. The questionnaire used a three-point Likert scale, ranging from “agree” to “disagree.” If participants were unsure, unaware, or had never experienced any of the questions, they were encouraged to select “neither.” Any confusion regarding any of the questions was clarified by personnel fluent in the regional language. Only completely filled questionnaires were considered for analysis.

Statistical analysis

Data were entered in Microsoft Excel 2016 spreadsheet (Microsoft, USA), and Chi-square test was performed using SPSS (IBM, New York, USA) software (version 23.0), to see if any correlation existed between age, sex, and education and the responses to questions. The results were considered as statistically significant at P < 0.05.


  Results Top


Among the 102 patients taken up for the study, 54 were male and 48 were female. The distribution of sex, age, and education level of the participants is tabulated in [Table 1].
Table 1: Distribution of study participants according to age, sex, and education

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In Category A, 70% of the patients felt that doctors were competent in completing a given procedure within the specified time, were committed to being on time, and encouraged asking questions/doubts. Sixty percent of the patients felt that doctors were easily available in case of postvisit doubts and that emergencies were handled promptly and effectively. Eighty-four percent of the patients felt that doctors give adequate posttreatment instructions. Interestingly, only 58% of the patients felt that doctors use modern instruments/devices which an even lesser proportion of 51% felt that it was not difficult to attain an appointment. Finally, only 47% of the participants felt that doctors accommodated lateness/missed appointments. An average of 22.809% in total responded with “neither” indicated a lack of sureness/awareness [Figure 1].
Figure 1: Assessment of responses regarding Category A questions

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Category B describes patient opinion about consensus about treatment procedures among dentists, and this category consisted of only one question. Only 54% of the patients felt that they were given a treatment change which does not change. Here also, relatively high proportions responded with “neither” (24%) and “disagree” (22%) [Figure 2].
Figure 2: Assessment of responses regarding Category B questions

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Among Category C questions, 60% agreed that the importance of following the prescribed treatment plan is explained in case of disagreement between doctor and patient. Similarly, 66% felt that alternatives are offered in case of such disagreement. The trend of unawareness continued with an average of 28% marking the “neither” option [Figure 3].
Figure 3: Assessment of responses regarding Category C questions

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Category D contained questions about “knowledge and attitude of doctors toward ethics and law.” Sixty-six percent of the participants felt that doctors act in accordance with the law whereas only 55% felt that doctors are truthful in case of any untoward incident. The average percentage of participants who responded with “neither” for category D questions was 30.3%. This marked the highest average among all categories. Interestingly, 15% of the patients felt that doctors do not take steps to rectify mistakes, if any [Figure 4].
Figure 4: Assessment of responses regarding Category D questions

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In Category E, a proportion of 82% of the participants found doctors' personal hygiene satisfactory, and 70% were satisfied with the cleanliness of the dental setup. Contrastingly, only 51% expressed satisfaction with patient protections such as gowns and laser protection goggles, with 27% not satisfied with this particular facility [Figure 5].
Figure 5: Assessment of responses regarding Category E questions

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In Category F, 82% of the patients felt that doctors take informed consent before a procedure and 71% felt that doctors adequately explain a procedure before performing [Figure 6].
Figure 6: Assessment of responses regarding Category F questions

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Curiously, among questions belonging to Category G, 18% felt that doctors do not maintain a record of treatments, investigations, etc., and 24% were unsure/unaware if payment history is well recorded [Figure 7].
Figure 7: Assessment of responses regarding Category G questions

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The patients expressed satisfaction with most of the categories to the tune of 60%–80%. Categories B and D in particular stood out both with sub-60 satisfaction ratios (54% and 59.39%, respectively). It has to be noted that Category B consisted of only one question and hence had the maximum number of “disagree” answers with 22%. The “neither” respondents were maximum for Categories C and D (28% and 30.3%, respectively) [Figure 8].
Figure 8: Summary of responses across all categories

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Of the 100 participants, only 49 submitted answers on their personal most important category. Here, 33% and 26% of the participants chose Categories E and A, respectively. Surprisingly, Categories F and G, both important issues in today's dental scene, were represented with only 11% and 4%, respectively. Questions 1, 15, 19, and 23 happened to be selected more often than any other indicating their relative importance [Figure 9].
Figure 9: Most important category according to patients

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Chi-square test analysis revealed a statistically significant relation at 10% between sex and question 23 (doctors adequately explain the procedure they are about to perform) (P = 0.050). It was seen that males were more likely to select “neither” whereas most females selected “agree.” Similarly, a statistically significant relation was seen between age and questions 15 (doctors are truthful in case of any untoward incident) and 23 (P = 0.001). It was observed that the age group 21–30 in particular was more likely to mark “neither” than the other age groups.

In our study, participants on completion were made to encircle the question/category which they identified as being most important to them. The results are displayed in [Table 2]. The ranking according to patients' opinion was E, A, D, F, B, C, and G, with the last 3 having equal number of responses.
Table 2: Ranking of categories according to participant responses

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[TAG:2]Discussion [/TAG:2]

Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine.[1] This study was conducted with the aim of gauging patient's opinions regarding various ethical issues in a dental hospital. There were multiple themes which were explored in this questionnaire. The ethical issue/category of primary importance to each participant was also noted. Self-administered questionnaire was used to collect said information.

When we adjust for the number of patients selecting “neither,” in many of the questions which were similar, the patient satisfaction levels were comparable to that found by Nagappan and John in a study conducted in Chennai in 2014.[6] For example, a similar proportion of patients found the doctors polite and courteous and encouraging of asking questions.

One of the most interesting observations was the large proportion of participants selecting “neither,” averaging 22.61% across all categories. This was highest in Categories C and D, with 28% and 30.303%, respectively. Since patients were told to select “neither” if none of the questions applied to them, an increased proportion of such responses in Category C may be partially justified. Even for certain questions in Category D such as “doctors are truthful in case of any untoward incident” and “doctors take the effort to rectify mistakes, if any,” the use of “neither” option can certainly be vindicated. However, the significantly high proportion of such responses coupled with the fact that student dentists, albeit under supervision, also provide treatment in the said dental hospital indicates some degree of unawareness among the participants. An average of 12.47% across all categories were not satisfied. This average is slightly skewed by the fact that Category B with only one question had 22% “disagree” responses, and the average of the remaining categories is 10.9%.

In the study conducted by Kemparaj et al., the various “themes” which were formed were subsequently ranked using the Delphi method. They were ranked in descending order as E, D, A, F, B, C, and G. This is almost the same as that obtained in our study. This indicates that the issues of primary concern are that of doctor competence and infection control. The individual question most selected was “doctors are truthful in case of any untoward incident.” The fact that “informed consent” and “medical record maintenance” ranked second last and last, respectively, indicates the lack of knowledge and awareness of one's own rights in the medical field in general in India.

The Chi-square analysis revealed that female patients are more likely to be satisfied with the explanation of the procedure given by the treating dentist. Newsome and Wright suggested that this finding might be because of females' greater exposure to dental services, likely moderating their expectations.[7] It was also found that the age group 21–30 was more likely to mark “neither” for questions 15 and 23. This age group corresponds to the most educated one in this study. This finding could possibly be explained by the fact that people in this age group are more likely to analyze the question and select “neither” if unsure, as a pose to blindly selecting “agree.”

One of the limitations of the present study was the relatively small sample size. In addition, since the questionnaire was only written in the regional language, those unable to comprehend the questions sufficiently were aided by an assistant well versed in both English and the regional language. Although efforts were taken to avoid inadvertent mistranslation and misinterpretation, the potential for human error cannot be completely overlooked. Hence, this represents another limitation of our study. To build on our findings, further multicenter studies with better representation from different strata of society are required in the future.


  Conclusion Top


The results of this survey questionnaire indicated that the majority of the patients were satisfied with the majority of the clinical services received at the dental hospital. The majority of the patients considered doctor competence and infection control as important issues. It was seen that females are more likely to be satisfied with the explanations given about the procedure by the doctor to the patient. There is, however, a general lack of awareness regarding ethical issues in the medical field, which can only be alleviated by proper education and development.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dunning JM. Principles of Dental Public Health. 4th ed. Cambridge, Massachusetts: Harvard University Press; 1986. p. 10-11.  Back to cited text no. 1
    
2.
Kemparaj VM, Panchmal GS, Kadalur UG. The top 10 ethical challenges in dental practice in Indian scenario: Dentist perspective. Contemp Clin Dent 2018;9:97-104.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Bhadauria US, Dasar PL, Sandesh N, Mishra P, Godha S. Medico-legal aspect of dental practice. Clujul Med 2018;91:255-8.  Back to cited text no. 3
    
4.
Vashist A, Parhar S, Gambhir RS, Sohi RK, Talwar PP. Legal modalities in dental patient management and professional misconduct. SRM J Res Dent Sci 2014;5:91.  Back to cited text no. 4
  [Full text]  
5.
Ali DA. Patient satisfaction in dental healthcare centers. Eur J Dent 2016;10:309-14.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Nagappan N, John J. Patient satisfaction with the dental services offered by a dental Hospital in India. J Indian Assoc Public Health Dent 2014;12:297.  Back to cited text no. 6
  [Full text]  
7.
Reifel NM, Rana H, Marcus M. Consumer satisfaction. Adv Dent Res 1997;11:281-90.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2]



 

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