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Apr 23, 2024

Assignment Task

Introduction

This paper will reflect on an ethical dilemma that took place in my profession as a general practitioner dentist. The aim will be to describe and critically analyse this dilemma, using the Rolfe et al. (2001) reflective model, ‘what? ‘So what?’ and ‘Now what?’ This model was chosen as it structures the process, ensuring that an outline, analytical discussion and an action plan for professional development are provided. Reflexivity is a key introspective process in the dentistry profession, with an examination of one’s judgements, practices and beliefs (Cousin, 2014). [The link between these two sentences is not clear.] It focuses on change and changing one’s professional practice (Cousin, 2014). This is important within healthcare as Social Identity theory outlines that how an individual feels and thinks about self stems in part from their group memberships (Pratt et al., 2006). It is important to integrate with other professional groups, overcome hierarchy and interpret multiple logics within the relationship in accordance with the Bourdieusian theory of professionalism [You would need to say more about this.] (Noordegraaf and Schinkel, 2011). The following paragraphs would outline the care scenario, referring to the patient as Patient X to ensure the ethical right to confidentiality in accordance with the General Dental Council (2013) guidelines.

‘What’

I cared for Patient X, a 75-year-old woman with mild dementia who had intermittent capacity and the inability at times to accept dental treatment. This was a complex ethical situation, with the need to communicate with the patient’s daughter and to obtain advice from the dementia nurse who had called prior to the appointment. The patient became quite distressed and therefore I adapted my communication skills, using short sentences, maintaining eye contact and avoiding the use of jargon or abbreviated terms. I also used therapeutic touch to alleviate her distress, using clinical judgement to determine if she would benefit from this method. I ensured that I communicated with the rest of the team, whilst adhering to the Mental Capacity Act (2005) legislation. I recognise the need to act in line with the patient’s best interest, assuming that they have the capacity to form decisions unless it is found to be lacking.[ You need to be clearer about the legislation, in this regard] Patient X had the capacity to accept her dental care; however, when we were about to start the procedure, she got distressed. I delegated to the dental nurse, asking her to hold the patient’s hand. The patient’s daughter held her other hand and she was able to continue, providing consent. We recognised that her capacity may come and go and therefore this was checked throughout her care. This scenario was noted as an ethical dilemma in lieu of my professional knowledge base [Not really clear what you mean here]and values and other professionals as it was related to the ethical principles of autonomy, beneficence, non-maleficence, and justice as discussed by Beauchamp and Childress (2019). I was able to focus on ethics and the patient’s biopsychosocial needs; however, my confidence levels may have negatively influenced the care process.[ It is not clear why your confidence levels were affected]From a positive perspective, I was able to use transformational leadership skills in order to gain the compliance and motivation of the team to provide high-quality, compassionate dental care. I cared for a relative who had dementia, which influenced my moral standing, ethical stance and how I handled the ethical dilemma. I had provided care for her for a number of years informally, which was shaped by my view of older patients, possibly with a degree of stigmatisation upon reflection. [Again, it is not clear what you mean here]This will be expanded upon in the next sections, focusing on reflexivity and professional development.

‘So What?’

Over the past number of years, healthcare has moved from a paternalistic approach to a focus on autonomy and informed decision-making (Schaper et al., 2021). Paternalistic care is the historically traditional method of dentistry, focusing on professional hierarchy, rather than the tailored needs of the patient (Schaper et al., 2021). In healthcare, the view used to be that the professional knew more than the patient, with a sole focus on beneficence whilst overlooking autonomy and justice (Barker, 2012). The Hippocratic Oath emphasises the need for doctors to do everything to save an individual’s life; however, this is no longer appropriate [Is it not still a principle of medicine?/ Now adapted - might be good though to explain a bit more - your audience is multi-professional not just health profession ]with an autonomous patient-centered focus (Barker, 2012). Within dentistry and ethics, it is vital to uphold respect for human integrity as a key aspect of care, especially when caring for those with dementia (GDC, 2013). Patient X provided her consent prior to the treatment; however, it was lacking when the treatment was about to be initiated and therefore the team paused and waited to move forward in the patient’s best interests. This is in line with the Mental Capacity Act (2005) which notes that every adult has the right to make their own decisions and should receive support to do so.

The Mental Capacity Act (2005) has five main principles, to ensure that every adult has the right to form their own decisions, assuming that they have the capacity unless it is proved otherwise. An individual such as Patient X should be provided with all of the support possible prior to treatment to provide consent and form decisions. In addition, personal values, beliefs and preferences must be considered, noting that unwise decisions can be made by the patient and any decisions made for them must be in their best interests. [A person should not to be treated as unable to make a decision just because they have made an unwise decision]Lastly, any interventions should be balanced with specific circumstances in the case, in the provision of ethically sound support (Mental Capacity Act, 2005).[ least restrictive] My knowledge of this legislation helped to shape my morals, beliefs and competency, ensuring that I considered the patient’s autonomy prior to treatment. Autonomy is the belief that every patient should have the ability to make decisions and control their actions and behaviours (Beauchamp and Childress, 2019). Everyone can be motivated by internal forces such as reflection, in contrast with external aspects[such as?] (Butts and Rich, 2015). From an ethical perspective, autonomy upholds the patient’s rights and freedom of choice; however, conflicts arise between respecting autonomy, paternalistic protection, the viewpoint of family and other confounding factors (Banks and Gallagher, 2009). I was aware that Patient X might not have had an understanding of her situation and therefore I considered my values from a Kantian perspective, focusing on the truth regardless of the situation[what truth??] (Buka, 2014). I discussed the patient’s care with her, noting that she was receiving a dental clean and polish, whilst evidence argues that information should be tailored to each patient and from a need-to-know perspective[not clear] (Carvalho, 2019).

I also considered my morals and the morals of the team, which are my personal beliefs, behaviours and standards in regard to what is and what is not appropriate to do (Mastroianni et al., 2019). This is shaped by one’s home life, school, religion, and societal for example. In comparison, values are the beliefs shared by a culture on what is undesirable, desirable, good or bad [they can also be individual ](Mastroianni et al., 2019). Individuals with dementia lose their values and morals [This is somewhat loaded - we cannot assume this as the condition progresses differently for different people]as their condition progresses and therefore, I considered this in reflection of my own (Barker, 2012). Dementia patients such as Patient X may no longer recollect their moral standing, resulting in moral relativism based on capacity and impaired memory (Barker, 2012). Bilbeny created a morality paper, noting that patients with dementia would gradually lose their ability to communicate and a sense of identity which influences their values (Banks and Gallagher, 2009). When reflecting upon Patient X’s care it was essential to consider the ethical theories of utilitarianism and consequentialism (Goldberg, 2017). I recognise the need to consider proxy values and how they influence my moral standing and my morality influences, especially when conflicts arise (Jonsen et al., 1982). Utilitarianism discusses the greatest good for the greatest number of individuals (Barrett et al., 2016). In regard to the greater good, there should be a positive outcome whereas, consequentialism notes that morality is dependent on the outcome (Barrett et al., 2016). If the outcome is good then the actions will be good, benefiting the individual, the dentistry team and family members (Carvalho, 2019). However, utilitarianism and consequentialism are considered to be effective if prima facie objectives[such as? ]are not in conflict (Carvalho, 2019). I considered the ethical responsibility that I had upon each individual, prioritising whose morality[needs?] should be recognised initially. The patient’s daughter wanted her to receive treatment to prevent her dental health from deteriorating. Patient X also wanted to receive treatment until she lost capacity temporarily in distress. The team wanted to complete the treatment to also prevent deteriorating dental health, noting the risk of tooth decay, gum disease and the negative impact that this would have upon her holistic health (nutrition, pain levels) (Barker, 2012).

The team and I focused on effective teamwork, adhering to the virtues of fairness, judgement, kindness, leadership and honesty (Buka, 2014). I utilised transformational leadership, distributed leadership and noted the influence of ethics in my early childhood. [What was the influence?]Evidence has recommended the need to introduce moral education to create a good moral standing and the ability for healthcare professionals to provide ethically sound care (Pratt et al., 2006). Distributed leadership is a type of leadership in which power and facilities can be shared to utilise resources, decision-making and goal setting from an organisational viewpoint (Barker, 2012). Distributed leadership was chosen when caring for Patient X as the regional health authority (DHA) notes it as a key aspect of policy; however, there has been uncertainty and confusion in relation to its use to clinical and non-clinical staff (Martin et al., 2015). Martin et al. (2015) examined distributed leadership in the NHS by utilising information from three different healthcare units that used it as part of their strategy. Qualitative insight was beneficial, gaining insight from the viewpoint of the individuals, rather than focusing on statistical, quantitative data that would not have provided humanistic knowledge (Butts and Rich, 2015). The authors note that theorising views distributed leadership as a hybrid, with a focus on dispersed leadership; however, Martin et al. (2015) identify this as a challenge for leaders and managers who are implementing this approach as a policy. Martin et al. (2015) revealed that there are three forms of disconnect and that they negatively influence distributed leadership. [This is interesting but is more a discussion on leadership than on ethical tensions.]Therefore, they argue that rather than the disconnect that posed a substantial issue for the discourse of leadership, they provided an imagined leadership that supported the discourse (Martin et al., 2015). I utilised distributed leadership by including leaders at all levels of the organisation to create the capacity for improvement when caring for dementia patients. I used effective communication skills and transformational leadership to inform the team, ensuring that they were aware of Patient X’s tailored needs; however, there are conflicts that can arise between professionals and managers, as discussed by Noordegraaf and Schinkel (2011).

Noordegraaf and Schinkel (2011) discuss a Bourdieusian analysis of conflicts between managers and professionals, noting that although Bourdieu did not focus on professionalism, his social theory supports an understanding of the growth of professional work. [The relevance of this to your ethical dilemma is not clear.]Professionalism is a number of symbolic aspects that produce occupational pathways, often favouring skills and expertise (Cocquyt et al., 2017). Within neo-liberal countries, this is contested, and professional powers are considered conservative and closed-off (Noordegraaf and Schinkel, 2011). Noordegraaf and Schinkel (2011) conclusively argue that professional capital is acquired by managers to differentiate new from old professional work in greater economised areas of power. When caring for Patient X, conflict was avoided between management, [what management?]leaders and the wider team by adopting a positive organisational approach, focusing on family-centred care and transparency (Goldberg, 2017). As a leader, I delegated tasks to others, asking my team member to hold Patient X’s hand, having identified that this alleviated her distress. My practical, intellectual skills and attributes supported compassionate care and effective leadership, using emotional intelligence and communication to overcome the ethical dilemma of Patient X’s care. I used a family-centred approach, actively listening to the patient’s daughter’s perspective and my own professional identity [which is?], reflecting on how this would influence the situation. A family-centred approach was vital, as evidence has found that it overcomes ethical concerns, ensuring that family members feel involved and respected (Barker, 2012).

I considered the ethical principles of beneficence and nonmaleficence when caring for Patient X, providing effective leadership and considering my professional identity in relation to others and the patient’s care. I recognised how my professional identity would influence the care provided, as a multifactorial phenomenon that is characterised by clinical and non-clinical factors like, environmental factors, my experiences and expectations (Petriglieri, 2011). Sarraf-Yazdi et al. (2021) outlines the link between professional identity, self-identity and personhood; [not clear] [Yes. What are these links?]however, evidence has found that these are often inadequately defined. It is therefore difficult for dentistry educators to support the formation of professional identity. The authors,[??] therefore, ,[ Why?] aimed to determine how professional identity formation influences medical students through the perspective of the ring theory of personhood[What is this?] and how to find ways to support this development. A systematic review was conducted by the authors,[ ??] which is considered to be the gold standard of methodologies (Buka, 2014). There were 76 articles included in the study,[ This is very unclear. What study?] suggesting quite high levels of external validity (Buka, 2014). Ultimately, the formation of professional identity involves deconstruction, inculcation and the iterative construction of professional beliefs, behaviours and values (Sarraf-Yazdi et al., 2021). Longitudinal monitoring and mentoring have been identified as key aspects of balancing personal and professional identities throughout one’s career (Sarraf-Yazdi et al., 2021). I, therefore considered this when caring for Patient X, recognising the need to mentor my team members and to listen to my manager. I had cared for a relative who had dementia, which would have influenced the care that I provided when overcoming the ethical dilemma of capacity and treatment. This experience was positive, with utmost care and compassion, in addition to the dementia-specific communication skills that I had gained, outlining how personal identity and experience can impact professional identity (Ashforth and Mael, 1989). However, I was aware that others in the cohort may have lost a loved one with dementia, or may have had a negative care experience that influenced their ability to care for Patient X. This highlights the different factors that lead to professional identity development. Evidence notes five main factors[Again, not sure of the relevance of this here] that enable this development: professional socialisation, goal orientation, self-efficacy, mentoring, critical thinking and reflection (Finlay et al., 2003).

Beneficence is defined as an act of kindness, with a focus on doing good as a moral right (Beauchamp and Childress, 2019). Evidence notes that all healthcare professionals have the moral foundation of doing right (Goldberg, 2017). The ethical principle of non-maleficence was also important when caring for Patient X and the ethical dilemma of capacity and informed consent. This refers to inflicting the least harm on the individual whilst obtaining a positive outcome (Goldberg, 2017). Issues can arise due to different professional value systems when morals and opinions do not align with one another and the patient or family member for example (Schaper et al., 2021). When caring for Patient X, the manager wanted to proceed with the care, rather than waiting to alleviate her anxiety. I had to articulate why this was not an effective approach, ensuring that we considered Patient X’s ethical right to autonomy in line with the Mental Capacity Act 2005 legislation. Evidence notes that patients must be provided with the ability to make decisions when they have the capacity to do so, even if the decision seems unwise (Mental Capacity Act, 2005). As a younger professional, I sometimes experience a lack of confidence and consider how that influences the care that I provide. Evidence has identified a lack of confidence with impaired trust between the professional and the patient and therefore I am aware of this when reflecting upon the care that I provide (Makarem et al., 2019). Furthermore, as a younger professional, it is important to recognise how I view older patients, as evidence suggests that older individuals are often perceived in a negative manner than the general population (Crutzen et al., 2022). Crutzen et al. (2022) noted that healthcare professionals were at risk of developing a negative view of older people. This is due to an accumulation of biomedical education on ageing and often caring for vulnerable and dependent older individuals such as Patient X; however, stigmatisation negatively impacts the provision of a tailored care approach (Makarem et al., 2019). Crutzen et al. (2022) therefore aimed to differentiate the view of older people among health care professionals, with an epistemological assumption using a cross-sectional study approach. In both the healthcare professional and the general population group, negative adjectives were used to describe older individuals. Healthcare professionals were more likely to stigmatise older individuals, highlighting the need to adhere to a holistic view of ageing to avoid ageism as an axiological assumption about what is valuable in the study (Crutzen et al., 2022).

Brown (2015) notes that subjectively constructed identities are the meanings that individuals link reflexively to themselves when responding to questions about what they want to be in the future and who they are (an ontological assumption about the nature of reality). This is based on self-narratives, interactions with others and complexities that progress through internal monologue (Brown, 2015). Furthermore, narrative identity stems from individuals and groups, with opportunities that are available locally and with ongoing repair and maintenance. I am aware that professional identities can be under threat by conflict, ethical issues such as the care of Patient X and different viewpoints, whilst self-doubt and a lack of confidence can also result in identity instability (Buka, 2014). Brown (2015) outlines that reflexivity, and the narrative of identity are fragile and insecure, whilst Buka (2014) suggest that these are aspects of humanity, to live precariously. When caring for Patient X, I had to communicate with other members of the team, delegate tasks and discuss aspects with the manager. I acted as a hybrid, with Croft et al. (2015) outlining that hybrids are situated between professional and managerial groups, supporting their ability to move between different organisations such as the dementia team or nursing homes. Hybrids often experience identity transition to address any conflicts that arise when communicating in different organisation settings (Croft et al., 2015). However, how these are managed is not clear and therefore Croft et al. (2015) investigated this area, considering concepts of liminality. A positive liminal space has been outlined as an essential aspect; however, Croft et al. (2015) note that hybrid professionals have a perverse liminal area, with perpetuated identity conflict and impaired identity transition that influences their effectiveness. The authors, therefore, question the reliance on professional hybrids, suggesting that organisational reform is required (Croft et al., 2015).

I experienced lower levels of confidence when I began caring for Patient X, recognising that I would have to consider legislation and the most ethically sound care methods. I was also concerned in relation to communicating with different professionals and managers whilst upholding effective leadership. I view myself as a confident person; however, at times this does not transfer to my professional life, an issue that has been outlined in evidence (Barrett et al. 2016). Patient X required confident care in order to trust the team; however, as stated, I was nervous. Dening (2023) notes that patients with dementia have comorbidities and required quite complex, ethical care, becoming highly dependent on health and social care services. Therefore, the health and social care sector needs to have the skills and knowledge required to be confident in meeting the complex needs of patients with dementia patients (Dening,2023). The Dementia Training Standards Framework was made to support the knowledge and competency levels within the health and social care sector. This framework outlines a three-step approach to dementia training, with 14 subject topics. Targets were outlined for the number of staff who had to receive this training; however, there is a lack of progress in terms of accreditation, accountability and regulation (Dening, 2023). Dening (2023) also argues that a one-size-fits-all training approach cannot meet the complex and diverse needs of different health and social care settings, with different education, exposure and proficiency. I did not care for a dementia patient within my professional setting prior to Patient X, which would have influenced the care that I provided as I did not have a past negative or positive experience.

When caring for Patient X, conflict was avoided and her ethical right to autonomy was upheld, using a compassionate approach, with emotional intelligence, active listening and effective communication. Patient X received her treatment, upholding her ethical right to justice (Beauchamp and Childress, 2019). Aristotle discussed justice, noting that individuals should be treated as equals (Buka, 2014). Justice outlines that there should be equality in all healthcare decision making, considering resources, treatments, legislation, burdens and benefits (Beauchamp and Childress, 2019). Her care was in line with the Equality Act 2010, which has shaped my professional identity and the decision-making process. The Equality Act 2010 highlights that patients must not be discriminated against predetermined perceptions such as age.

Conclusion

To conclude, this reflection has critically appraised my professional identity in terms of others in my practice.[ Is your PI different from others you were working with?] I have negotiated and articulated complex ethical situations in the context of different professional value viewpoints, using my practical and intellectual skills to reflect on Patient X’s care. This included a critical appraisal of my identity and the ability to consider this in accordance with professional practice. I believe that I have demonstrated transferable employability and enterprise skills,[ But this is not the thrust of this assignment] with the ability to utilise legislation and the ethical care of Patient X, with autonomy and person-centred care. This reflection has enabled me to become reflexively aware of personal assumptions and how my past experiences and interactions have shaped my professional and personal identities with a clear overlap. [You need to develop this further]The following section will provide an action plan for the future in support of my professional development.

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