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Introduction
In recent years, rapid social change and the development of science and technology have had a great impact on people’s values in life as well as their personal and professional beliefs. This situation is changing human values such as human dignity and individual characteristics and bringing about many changes in ethical values1). Oral health is also changing and developing rapidly.
As the social awareness and role of dental professionals are expanding, the role of dental hygienists is also growing2). The American Dental Hygienists Association (ADHA) defines a dental hygienist as a specialist who prevents and treats oral diseases to improve the overall health of patients3). The Korean Dental Hygienists Association (KDHA) defines a dental hygienist as a professional who plays a role in improving the oral health of people by providing oral health education, preventive dental treatment, dental treatment cooperation, and business management to local residents and people with dental diseases4).
In this way, this group of professionals can not only cultivate knowledge and technical skills but also have integrated and comprehensive problem recognition. This enables professional decision-making behavior based on problem-solving ability and an ethical attitude5). Dental hygienists often face situations that require ethical judgment during the dental hygiene management process in dental offices, including cases in which decisions must be made to determine legal and ethical responsibilities6,7).
Dental hygienists’ ethical attitudes and values can affect dental hygiene behavior and treatment results. Incorrect judgment can have a great impact on patient safety, trust, and society as a whole, so the evaluation of dental hygienists’ ethics is necessary8). An awareness survey targeting dental hygiene department students clearly revealed the need for education to improve patients’ oral health.
However, awareness of ethical issues such as inappropriate infection control, violation of the scope of care, and misdiagnosis is low9). Dental hygiene education should cultivate ethical awareness and judgment for dental hygienists in various treatment environments based on their expertise. To do so, specific education based on various practical cases should be provided10).
Dental hygiene education in Korea currently focuses on preparation for the national examination, so education on ethics is not systematically implemented in dental hygiene education11). Even current courses are still dominated by theoretical lectures12). This lecture-based education does not help dental hygiene students develop the ability to recognize, judge and solve problems independently when treating patients in clinical practice after graduation13). Although there is a difference between theory and application and a difference between education and clinical practice, it is important to devise and derive an effective method of teaching dental hygiene ethics within university education.
As this awareness has recently increased, dental hygiene ethics has been included in the national dental hygienist examination, and ethics education has become mandatory in continuing education and public hearings to improve the ethical awareness of dental hygienists. Accordingly, the Department of Dental Hygiene needs to implement a curriculum in which ethical conflicts in the dental field can be addressed in advance and judgments and actions can be taken14). Problem-solving classes including role-playing, debates, small group discussions, problem-based learning (PBL), team-based learning (TBL) and discussion-based learning (DBL) are already used in ethics education in medical and nursing schools15-18).
The discussion and debate class is a teaching method that is designed to actively involve students19). By giving students the opportunity to interact with others, this approach creates a learner-centered learning environment. It is also effective in developing students’ problem-solving, creativity and critical thinking skills20). The dilemma discussion, one of the discussion and debate teaching methods, has been gradually expanded and applied after being used in medical ethics education in medical schools21-23), and various studies on the class effect have been reported24,25).
In this study, the dilemma discussion was used in a dental hygiene ethics class to assess changes in students’ moral sensitivity and moral judgment and to examine the implications.
Materials and Methods
1. Study subjects
This study was approved by the Research Ethics Review Committee of Sunmoon University (SM-202109-064-1). Forty-six students who fully understood the purpose of this study and agreed to participate were selected from second-year dental hygiene students who attended a dental hygiene ethics class in 2021. The subjects of this study had no previous experience with DBL-based education and dental hygiene ethics classes. To assess the degree of change in their moral perception before and after the dilemma discussion class, a predesigned questionnaire was administered twice, once in the first week and once in the 15th week of the class. Of the questionnaires distributed, a total of 44 copies were retrieved excluding omissions, for a response rate of 95.7%.
2. Running a dental hygiene ethics class based on DBL
Dental hygiene ethics education should cultivate professional ethics and correct ethical judgment when dental hygienists are faced with situations that require ethical judgment. Therefore, the dilemma discussion method was used in the DBL-based dental hygiene ethics curriculum of the ADDIE model26). During the course orientation, detailed instructions on how to conduct the class were provided. The class was conducted according to the procedure shown in Fig. 1.
3. Progress of the DBL-based dilemma discussion class
Dental hygiene ethics is a crucial class for students to acquire and internalize dental hygiene-related ethics and solve various ethical problems that may be encountered in the clinic when students are dental hygienists. Since ethics can be cultivated through specific educational methods based on practical cases rather than a one-sided theoretical lecture method, the curriculum was based on the model of DBL-based classes as discussed by Choi and Kim26). The classes were conducted as shown in Fig. 2.
4. Summary of DBL-based dilemma discussion class
In the discussion and debate class, various dilemma topics were selected for each team to engage in pro and con discussions (Table 1). The selected topics were as follows: illegal medical practices in dental clinics run by non-dentists, ethical issues surrounding surrogacy, management of infected patients in the consultation room, false medical advertising practices, ethical dilemmas in dental hygiene treatment for patients lacking motivation for oral care, suspected child abuse cases among patients, and delegated medical practices.
The debates were conducted with the presentation teams and opposing teams presenting their opinions on each topic, followed by pro and con discussions on key issues. Students not in the presentation or opposing teams asked questions related to the topics and made decisions regarding their stance.
Subsequently, the professor gathered the opinions from both sides, presenting various perspectives on the dilemmas discussed. Finally, the results of the entire discussion were summarized, and all important points and decisions were reiterated and communicated to the students, bringing the session to a close.
5. Self-report survey tool for measuring moral sensitivity and moral judgment
Dental hygienists face various ethical issues in the clinical field. To make ethical decisions with the correct ethical values and attitudes, they must sensitively recognize the issues and make judgments based on moral principles. Therefore, this study used a self-administered questionnaire that consisted of moral sensitivity questions and moral judgment questions. It was restructured and developed based on previous literature by two researchers who had experience using questionnaires as teaching strategies. Moral sensitivity was measured with the Moral Sensitivity Questionnaire (MSQ) developed by Lützén et al27). The MSQ translated into Korean was restructured and used for measurement in the field of dental hygiene ethics28). The higher the MSQ score, the higher the respondent’s moral sensitivity. Moral judgment is an essential part of morality and is the ability to judge social problems with moral principles.
Moral judgment was measured with the Defining Issue Test (DIT) developed by Rest based on the theory of stages of moral development29). In this study, the Korean Defining Issues Test (KDIT), which was adapted and restructured in Korean, was used to measure dental hygiene ethics30).
5.1. Assessment of moral sensitivity
Moral sensitivity consisted of 4 questions on ‘responsibility for patients’, 5 questions on ‘honesty in treatment’, and 4 questions on ‘respect for patients’. Each question was evaluated before and after class using an 11-point Likert scale.
5.2. Assessment of moral judgment
For the moral judgment items, two ethical dilemmas related to medical practice among the six dilemma cases of the DIT, ‘husband’s worries’ and ‘patient’s plea’, were used. ‘Husband’s worries’ is about whether a poor husband should steal medicine to save his wife, who is dying from a strange disease. ‘Patient’s plea’ is about whether to prescribe painkillers with a high risk of death to a woman who is terminally ill due to painful cancer. To evaluate changes in the moral judgment and social and individual ethical consciousness of students, the same questionnaire was used before and after the class for repeated evaluation.
6. Reliability measurement and guidance
Cronbach’s alpha coefficients for moral sensitivity and the two moral judgment items were 0.766, 0.629, and 0.608, respectively, satisfying internal consistency. Students were instructed to answer freely and honestly about their individual moral competence. A response time of 30 minutes was provided so that the questionnaire items could be sufficiently reviewed.
7. Statistical analysis
Questionnaires were collected from 46 students who took dental hygiene ethics courses from September to December 2021. The survey results of 44 students, excluding nonresponse data, were used for analysis. To confirm moral sensitivity and moral judgment, frequency analysis was conducted to calculate the frequency and percentage and the mean and standard deviation. To confirm the normality of the data, the Kolmogorov-Smirnov test was performed, and nonparametric tests were performed for items with nonnormality. To confirm the difference in changes in moral sensitivity before and after the dental hygiene ethics class, the Wilcoxon signed-rank test was conducted after calculating the average score. In addition, to confirm the difference in changes in social ethics and individual ethics, a new variable was created by summing the total scores of each subquestion, and the difference before and after was confirmed through the Wilcoxon signed-rank test. All analyses were performed using SPSS (Statistical Packages for Social Science 26.0. SPSS Inc., USA), and the statistical significance was set at a=0.05.
Results
1. Moral sensitivity measurement results in the dental hygiene area
Table 2 shows the results of confirming moral sensitivity before and after the dental hygiene ethics class. For the ‘Responsibility for the patient’ question, the response to ‘If the condition of the patients I manage does not improve, my work will feel meaningless’ significantly increased, with an average of 6.73 (1.91) points before class and 7.36 (2.20) points after class (P<0.05). For the ‘Honesty in treatment’ question, the response to ‘I often contemplate my own values and norms that can affect my behavior’ significantly increased, with an average of 7.30 (1.80) points before class and 8.02 (1.44) points after class (P<0.05). In addition, the item ‘It is important that I have rules to follow when patients refuse treatment’ averaged 6.95 (1.71) points before class and 7.55 (1.848) points after class, which was a significant increase (P<0.05).
For the ‘Patient respect’ question, the response to ‘I believe that good dental hygiene interventions should include respecting the patient’s right to self-determination’ significantly increased, with an average score of 8.34 (1.45) before class and 9.05 (1.31) after class (P<0.05). In addition, the item ‘I think it’s a good dental hygiene intervention to include patients in decision-making’ significantly increased, with an average score of 7.95 (1.36) before class and 8.43 (1.34) after class (P<0.05).
2. Results of measuring moral judgment based on social and individual ethical consciousness
To confirm the change in moral judgment due to the dental hygiene ethics class before and after the class, the scores for each item were added and the difference before and after the class was confirmed. The results are shown in Table 3. First, in Case 1, social ethical consciousness averaged 15.79 (2.79) before class and 15.50 (2.91) after class, showing no change in moral judgment. In the case of individual ethical consciousness, it decreased to an average of 19.43 (3.49) points before class and 18.50 (2.78) points after class, which was statistically significant (P=0.029).
Second, in Case 2, social ethical consciousness increased from an average of 17.55 (3.66) points before class to 18.43 (3.03) points after class, but it was not statistically significant (P>0.05). Social ethical consciousness also increased from an average of 15.70 (2.58) points before class to 16.15 (2.65) points after class, but it was not statistically significant.
3. Changes in moral behavioral choice according to dental hygiene ethics classes
Table 4 shows the results of measuring the degree of change in moral judgment before and after class. In Case 1, there were 11 students (25.0%) who showed a change in behavior selection before and after class and 9 students (20.5%) who showed non-selection of the behavior with ‘I don’t know’. Twenty-four students (54.5%) showed no change in behavioral choices before and after class. In Case 2, there were 10 students (22.7%) who showed a change in behavior selection before and after class and 12 students (27.3%) showed nonselection of the behavior with ‘I don’t know’. Twenty-two students (50.0%) showed no change in behavioral choices before and after class.
Discussion
Dental hygienists encounter various ethical issues in their clinical practice31,32). To make ethical decisions with the right ethical values and attitudes, it is important to recognize moral conflicts sensitively and judge the problems that occur based on moral principles. Therefore, it is essential to operate a curriculum that exposes and judges ethical conflict situations encountered in the dental care field so that students can become ethical and professional dental hygienists.
This study aimed to help second-year dental hygiene students at a four-year university acquire problem-solving, creativity, critical thinking, social attitude, and discussion skills through DBL dilemma discussions on dental ethics education and to examine the implications by assessing changes in moral sensitivity and moral judgment skills before and after the class.
First, we measured students’ change in moral sensitivity before and after the dental ethics class and found significant differences in patient responsibility, honesty in practice, and respect for patients. Moral sensitivity is a factor that precedes moral judgment in the process of manifesting moral behavior33). Even if a person has excellent moral judgment, if he or she cannot recognize that a particular issue is an ethical issue, moral behavior will not be manifested14). In fact, research has shown that high moral sensitivity plays an important role in ethical decision-making in the clinical setting (Table 2)34). Therefore, the increase in moral sensitivity after the dental hygiene ethics course indicates that students were able to recognize issues and identify the ethical elements inherent in them, which may help them to establish sound ethical values when they are faced with various health care issues as dental hygienists.
Second, the change in moral judgment before and after the dental hygiene ethics class showed a significant decrease in individual conscientious judgment in the case of “A worried husband” (Table 3). However, judgment based on social norms was not significant. Ethical issues can be perceived differently depending on the laws and ethical norms set by society. Therefore, it is essential to consider social norms when recognizing and judging issues, as various problems may arise when an issue is considered only through individual judgment35). In particular, it is essential for dental hygienists to internalize a professional ethic of concern, commitment, and constant self-checking for the health and social well-being of patients. This is linked to professionalism, which is the pursuit of social and public benefits beyond individual judgment36). Therefore, dental hygiene ethics classes should not be one-time classes but should be repeated so that in-depth learning can take place within the university course. In this way, changes in judgment according to social norms are also expected.
Third, assessing changes in moral judgment before and after the dental ethics course revealed that, in both scenarios presented in Table 4, over 20% of participants chose actions contrary to their previous responses, while another 20% selected “no change”. Interpreting “no change” as reflecting difficulty in judging the ethical dilemmas suggests participants recognized the complexity of the ethical issues. While these findings indicate notable changes in moral judgment for some students, the overall impact of the course on moral judgment appears limited, given that over 50% of participants showed no change. Although a significant increase in moral sensitivity scores (P<0.05) and the increased percentage of students exhibiting behavioral changes suggest a positive influence of the education on students’ moral reasoning, a lack of comparable research on the effects of dental hygiene ethics education on similar changes in moral judgment prevents a precise comparison. Therefore, while the findings suggest a positive impact, the limited sample size and research design necessitate caution regarding generalizations. Future research employing more rigorous designs and larger samples is needed to validate these findings.
The limitations are as follows. First, one of the limitations of this study is the insufficient consideration of various social and cultural factors that may influence dental hygiene students’ moral sensitivity and moral judgment. Students live in social relationships with friends, family, and their environment, and these factors may impact the results of the study. In particular, the ethical values and personal experiences that students already possess may lead to differences in their judgments about specific ethical issues, and these factors were not investigated in advance. Therefore, future studies should conduct a comprehensive analysis that takes these variables into account to determine their ultimate impact on moral judgment.
Second, the results of this study were based on second-year dental hygiene students at a single university, making it difficult to generalize the findings. It is necessary to expand the sample size and repeat the study to support the results.
Third, the dilemma cases used in this study are suitable for medical environments but may not be directly applicable to dental health care settings. To address this, it is essential to develop and apply dilemma cases optimized for the dental health care field and conduct more sophisticated research.
Finally, the reality of university education in Korea is that the majority of subjects are still based on memorization rather than in-depth study, making it difficult to cultivate ethical thinking. Therefore, it is crucial to provide students with continuous education across various subjects rather than focusing solely on one subject, such as dental hygiene ethics, to foster correct moral reasoning. Additionally, the dental hygiene curriculum should transform to emphasize ethical thinking, enabling students to develop into dental health care professionals with sound ethical judgment.
Conclusions
Students’ moral sensitivity and moral judgment are important factors that influence good ethical thinking. The results of this study showed an increase in moral sensitivity after the dental hygiene ethics course, suggesting that students were able to recognize issues and identify the inherent ethical elements within them. Although there was no significant change in moral judgment, it is clear that there was a shift in thinking to deeper consideration of students’ judgments. Continuous education within the curriculum is necessary to ensure that this shift in thinking is not a one-time occurrence and that it can help in the development of dental hygienists who think ethically. In conclusion, dental hygiene departments should consider various teaching designs and activities to foster these competencies. We hope that this study can be used as an effective way to improve dental hygienists’ ethical thinking skills.
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