3

Legal and Ethical Issues

Until 2006, dentists were the only individuals who could carry on the business of dentistry, and although others (including dental nurses) were involved in the dental care of patients up to this point, the dentist was solely responsible for all acts and omissions on behalf of their staff. So, if anything was below standard or harmful to a patient, the dentist alone was held responsible.

The General Dental Council (GDC) is the regulatory body of the dental profession (see Chapter 1), and in 2006 it opened the Dental Care Professionals Register so that all other persons involved in the dental care of patients had to become registered with it. Dental nurses joined the register in 2008 and have become a profession in their own right, along with other registrants such as ­therapists, hygienists and dental technicians. However, with registration comes professional responsibility and compliance with professional standards – registrants are now responsible for their own acts and omissions in relation to patient care, unless it is proven that their employer knowingly prevented the member of staff from acting professionally.

To become a registrant, the dental nurse must first qualify by passing a recognised examination in dental nursing; currently these are the National Examining Board for Dental Nurses’ (NEBDN) Diploma or the City & Guilds Diploma in Dental Nursing. Until qualification, the staff member is a trainee dental nurse (but must be on an approved training course and studying towards qualification) and their employer is still responsible for them.

Once initially registered, the dental nurse must meet the following criteria to ensure their annual re-registration, and therefore be legally entitled to work as a dental nurse in the UK.

• Comply with all relevant legislation and regulations to ensure they act both ethically and legally at all times.
• Maintain a professional standard of behaviour at all times.
• Comply with continuing professional development (CPD) requirements in core topics and minimum hours over a 5-year cycle.
• Maintain indemnity insurance cover from one of the dental protection organisations.
• Pay the annual retention fee (ARF).

The relevant legislation and regulations are covered throughout this text, particularly in Chapter 4, and the text as a whole covers the full curriculum requirements for the NEBDN Diploma ­qualification. The City & Guilds Level 3 Diploma in Dental Nursing curriculum requirements are covered in the alternative textbook, due to be released in late 2013.

In addition, the GDC has published a set of Standards Guidance booklets for use by all registrants, and trainee dental nurses are expected to be familiar with their contents by the time they sit their final register-able qualification. Each booklet and its relevance to the trainee dental nurse will be discussed in detail here. Other useful GDC publications for consideration throughout the training course include:

• Preparing for Practice – formerly called Developing the Dental Team and giving details of the expected level of skills and knowledge of each registrant group upon qualification
• Scope of Practice – gives details of the additional skills, after qualification, that may be achieved by the various groups of registrants, following a period of suitable and recorded training, and forming the basis of the extended duties and postregistration qualifications available to registered dental nurses
• Fitness to Practise – gives details of the professional standards expected of all registrants, and the disciplinary procedures that should be followed when they are not upheld, some of which are also relevant to the trainee dental nurse.

Further details of all these publications can be found at www.gdc-uk.org.

In summary, the ethical and legal implications of the following topics will be discussed here, with those of particular relevance to the duties of the dental nurse being covered in greater detail.

• Duty of care and professional obligations – overview.
• Fitness to practise guidance.
• GDC Standards Guidance – overview and notes on its relevance in other sections.
• Impact of Care Quality Commission (CQC) registration on dental workplaces.
• Clinical governance.
• Record keeping:
  • confidentiality of patient records
  • information governance.
• Consent to treatment.
• Protection of children and vulnerable adults:
  • Criminal Records Bureau (CRB) checks.
• Complaints handling.
• Raising concerns.
• Continuing professional development, reflective practice and developing the dental team.

Duty of care and professional obligations

It is the responsibility of the employer to ensure that the dental workplace and its day-to-day running comply with all of the legislation and regulations pertinent to the practice of dentistry, but every registrant working in the premises also has a duty of care to their colleagues and the patients to work safely and responsibly at all times. This requirement comes under the Health and Safety at Work Act, and is covered in greater detail in Chapter 4.

In line with our medical colleagues whose professional responsibilities include the phrase ‘First, do no harm’, the dental professional’s first duty of care can be said to be ‘always act in the patient’s best interests’. This theme runs throughout the various sections of this chapter, and it will be seen that at all times, the guidance from the GDC with regard to the expected standards of dental ­professionals is to always put the patient’s interests first, and act to protect them. This is the duty of care that all registrants must uphold towards all patients.

The professional obligations of registrants are discussed in greater detail later, and can be ­summarised as the following.

• Maintain their professional registration.
• Ensure that all patients have equal rights.
• Work within their professional level of competence.
• Undertake lifelong learning in their areas of competence.
• Be able to demonstrate their fitness to practise.

Fitness to practise guidance

No one factor determines whether a registrant is ‘fit to practise’ or not – whether a dental nurse is suitable to work in the dental workplace is not solely based on their academic achievements. Their qualification indicates that they are competent to do so – they have demonstrated an adequate ability to carry out the duties of a dental nurse – but suppose they are consistently rude to staff and patients, or lazy and neglectful, or dishonest and untrustworthy? Are they still fit to practise simply because they have a qualification in the required subjects? Of course, the answer is ‘no’.

The qualities required to be fit to practise are to have good personal skills and acceptable ­attitudes and behaviour, as well as successful academic qualifications – together they produce the professional dental nurse.

One definition of the word ‘professional’ as a descriptive term for a person is ‘… characterised by or conforming to the technical and ethical standards of a profession’, so by becoming professional members of the healthcare team, all registrants are expected to behave in a suitable manner in public, whether working or not.

It may be surprising to some that registrants are expected to follow a high standard of behaviour not just in the workplace but while not at work too. So it is not acceptable to be seen as ‘pillars of society’ from 9am to 5pm, and then become drunk and disorderly or antisocial while out with friends in the evening, for example.

As a professional, the registrant’s conduct, behaviour and personal qualities are open to ­scrutiny by the public at all times, and the public quite rightly expects anyone who is regarded as a professional to behave correctly and to set an example of good behaviour and conduct that others aspire to achieve. Any registrant who falls short of these expectations may have their fitness to practise called into question – by the public, their colleagues, their employer and ultimately by their professional regulator – the General Dental Council.

If the registrant is called before the GDC to attend a conduct committee and is found to be unfit to practise, they may be suspended, or even erased, from the Register. It is then illegal for that registrant to work as a dental nurse again in the UK, until such time as the GDC allows them to ­re-register – and that may require further training and requalification in some cases. Effectively, to be erased from the Register, the registrant would be considered to have brought the profession into disrepute.

Table 3.1 shows a list of potential areas of concern that would highlight a registrant and their behaviour to others, including the GDC, and prompt an investigation into their fitness to practise. Examples of the types of allegations that fall into each area are given, but they must not be assumed to be exhaustive.

The second column of examples of allegations lists some of the types of poor behaviour or poor attitude that would draw attention to the registrant, or student, in the first instance. All examples given range from disappointingly unexpected and unacceptable behaviour by a so-called profe­s­sional (such as having an undeclared health issue that may affect their capability to deliver a good standard of care to patients) to actual criminal activity (such as abuse, fraud, drink driving).

The crux of the matter is that the public would not expect to see these types of attitude and behaviour in a professional person. Professionals are assumed to ‘set a standard’ of behaviour and attitude that others should aspire to, rather than be seen to be behaving in an irresponsible fashion.

While in training, and therefore before becoming a registrant under the regulation of the GDC, students may believe that their previous poor behaviour will go unnoticed. However, several sections of the registration documentation ask for declarations of good character and good health, to be signed by other professionals, and failing to declare any relevant details at the very start of the newly qualified dental nurse’s professional career would not be advisable.

General Dental Council Standards Guidance

The GDC has published a set of booklets that are available to all registered dental professionals, which set out the professional standards expected of every member of the dental team. As new team members train and become qualified, and are then entered onto the Register by the GDC, their own copy of the standards will be issued to them. However, all dental nurses are expected to be familiar with their content by the time of sitting their final qualifications (indeed, some examination questions will be based on their content) so students are advised to access them directly from the GDC website at www.gdc-uk.org.

The main booklet in the Standards series, shown in Figure 3.1, explains the six key principles of professionalism that every dental registrant should follow, and how they should be applied to their day-to-day working life. Some of these principles are then further clarified and discussed in greater detail in the accompanying GDC booklets of the series.

• Principles of Patient Confidentiality
• Principles of Dental Team Working
• Principles of Patient Consent
• Principles of Raising Concerns
• Principles of Complaints Handling

Table 3.1 Fitness to practise issues

These topics are discussed in greater detail later in this chapter. The one area that is deliberately not covered by the documentation is clinical standards.

The six key principles of the over-arching booklet should be considered and followed at all stages of the registrant’s education and practice, including their time leading up to registration as a dental professional. From that point on, they should be applied to every action they take as a dental professional, whether treating a patient or not. The GDC states that it is the responsibility of each dental professional to do the following.

• Be familiar with and understand:
  • current standards which affect your work
  • relevant guidelines issued by organisations other than the GDC
  • available sources of evidence that support current standards.
• Apply your up-to-date knowledge and skills ethically.

The importance of lifelong learning and participation in CPD activities becomes clear, as these are the methods used to ensure that updated information on relevant topics is made available to dental professionals. CPD is discussed later in this chapter.

The six key principles of practice in dentistry, which apply to all dental professionals, are listed below.

Depending on the level of qualification of the registrant, from dentist through all categories of dental care professionals (DCP) to trainee DCPs, the principles must be interpreted and followed accordingly – their application by a dentist will be different from that of a trainee dental nurse. Each registrant must use their own judgement to apply the principles to their daily work, and be prepared to justify their actions to the GDC if asked to do so. Failure to account for their behaviour satisfactorily is likely to result in their professional registration being at risk of suspension or even erasure.

The details and application of each key principle are further expanded in the Standards booklet, and the points raised are discussed below. Having a copy of the booklet to hand would be useful for this discussion. The following points are taken from Standards for Dental Professionals, © General Dental Council. Please visit the GDC website to check for any changes since publication: www.gdc-uk.org.

Put patients’ interests first and act to protect them

Respect patients’ dignity and choices

Protect the confidentiality of patients’ information

Co-operate with other team members and other healthcare colleagues in the interests of the patient

Maintain your professional knowledge and competence

Be trustworthy

The Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and adult social care services in England, and since the empowerment of the Health and Social Care Act of 2008 it has been the organisation responsible for ensuring adequate standards in premises such as hospitals, nursing homes for the elderly, and care homes for such as those with a wide range of special needs.

From 1st April 2011, its powers of regulation were extended to include all providers of primary dental care services in England that carry on ‘regulated activities’ (in this case dentistry and oral healthcare), and all providers, whether NHS or private, have had to become registered with them from this point on.

Registration with the CQC has involved every primary dental care provider, as an individual or as an organisation, showing evidence of their compliance with new essential standards of quality and safety in all regulated activities. However, it should be noted that CQC registration is relevant in England only, and not in Scotland, Wales or Northern Ireland. Other laws and regulators are likely to perform a similar role in the future throughout the UK.

The stated aim of the CQC is to ‘… make sure that people get better care’. It achieves this by:

• driving improvement across health and adult social care
• putting people first and championing their rights
• acting swiftly to remedy bad practice
• gathering and using knowledge and expertise, and working with others.

In the dental workplace, the relevance of CQC registration is that all primary care providers are expected to comply fully with the essential standards of quality and safety – the vast majority found that they already did so, but that they had little or no evidence in place to prove it, while others found that they did not fully comply. In other words, a standard had been set that every dental workplace must achieve as a minimum to ensure registration. Although initially the ­registration process was partially a ‘tick box’ exercise for the workplaces, the CQC are currently inspecting those providers who are now registered to ensure that there is indeed evidence of their full compliance in all of the essential standards.

The regulations are set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, and although the full content of the standards and outcomes is beyond the remit of the trainee dental nurse, further information is available for those who are interested at www.cqc.org.uk.

Areas of the essential standards of particular relevance to the trainee dental nurse are as follows.

• Those new procedures involved in infection control, such as the bagging and date stamping of all sterilised reuseable items (see Chapter 8).
• The necessity of resterilising unused bagged items within set time periods, to ensure their ­sterility at the time of use (see Chapter 8).
• The set-up and correct use of the decontamination area (see Chapter 8).
• The necessity of CRB checks for all staff – see later in this chapter.

Clinical governance

Clinical governance is the term used to refer to the NHS Framework for Quality Assurance that must be aspired to and followed by all those working in the delivery of NHS health and dental care. It defines the level of service quality that all NHS organisations (hospitals, clinics and practices) are expected to meet or be working towards, and those relevant specifically to dental services were set out in 2006. Although set out by the NHS and subject to compliance checks by primary care trusts (although these bodies will cease to exist from April 2013), it is good practice for private dental workplaces to follow the framework too.

The aim of the framework is not only to improve the quality of healthcare provided by standardising it, but also to make providers accountable for ensuring a consistency of care, thereby making the service they provide reliable for the patients.

As clinical governance has been around in dentistry for over 7 years now, it would be difficult to imagine that all workplaces do not already comply with its required standards, although many may not refer to it under this title. The 12 themes that are covered by the framework and examples of the key actions and policies necessary for compliance are listed in Table 3.2 and all trainee dental nurses should find equivalent examples of compliance in their own dental workplace.

The 12 themes in the first column indicate the clinical areas where the NHS expects every dental workplace to have evidence of how it ensures that the service provided is to a consistent standard for all patients. So with infection control as the example, there should be a written policy of how the workplace ensures that cross-infection does not occur – by stating the methods used for decontamination and sterilisation, that single-use disposables are used wherever possible, that staff and patients are provided with suitable personal protective equipment (PPE), and so on. All of these points should then tie in with the relevant sections of Health Technical Memorandum 01-05 (HTM 01-05 or equivalent) (see Chapter 8) and be shown to do so, and then further ­evidence such as staff immunisation records are also held by the workplace as further evidence of compliance. An inoculation injury policy will demonstrate that all staff members are aware and trained to deal with this eventuality in an approved manner, by having a written policy readily accessible to all. Some workplaces may have other evidence of compliance besides those given as examples in the second column too.

Table 3.2 Clinical governance themes and compliance

COSSH, Control of Substances Hazardous to Health; CPD, continuing professional development; CRB, Criminal Records Bureau; GDC, General Dental Council; IRR, Ionising Radiations Regulations; IR(ME)R, Ionising Radiations (Medical Exposure) Regulations; NICE, National Institute for Health and Clinical Excellence; QA, quality assurance; RIDDOR, Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995.

Many of the examples of actions listed above are discussed in more detail later in this chapter and elsewhere in the text. None of the entries in the second column should be unfamiliar to the dental nurse.

Record keeping

The purpose of dental records is to provide an up-to-date case history of each patient’s condition, and includes the examination findings and treatment given on each attendance at the surgery. By referring back to previous visits, the dentist can assess the results of earlier courses of treatment and thereby decide the best line of treatment on future occasions. Adequate records also facilitate the transfer of patients between dentists in the practice when absence or staff changes occur. When recorded correctly, another dentist should be able to determine all previous treatments for a patient and continue that care safely, without any risk of errors or omissions due to incomplete information.

In effect, the records are a communication tool which allows anyone reading them to determine what treatment was carried out, when and by whom, and how it was achieved. So the fullness and accuracy of the records are required for:

• patient safety
• evaluation of treatment
• basis for patient accounts
• monitoring of the provision of care
• probity enquiries.

Recording methods will be either manual or on computer, and the amount of detail recorded may vary considerably from practice to practice, but patients’ records consist basically of personal and clinical information. They should include all of the following.

• Patient name, address, date of birth and telephone numbers.
• Doctor’s details and contact information.
• Full medical history.
• Dental history.
• Contemporaneous clinical notes of each attendance (that is, written at the time or as soon as possible after, so that they are in date order).
• Tooth and periodontal chartings.
• Soft tissue assessments.
• Details of all appointments with other staff, such as the hygienist, therapist or oral health educator.
• All legally required NHS or private paperwork.
• Consent forms.
• Copies of all referral letters and response correspondence.
• Correctly identified and mounted radiographs.
• Photographs.
• Laboratory slips.
• Records of all payment transactions.
• Copies of all patient correspondence.
• Information on failed or cancelled appointments.

Where two or more patients exist with the same name or date of birth, the record should be clearly marked to alert all readers that a similar patient exists – otherwise there is a risk that one patient will receive treatment required by another.

For new patients, the personal details, reason for attendance, and medical and dental history are conveniently recorded by giving or sending a medical history form, such as the British Dental Association (BDA) Confidential Medical History Form, for home completion before their first visit. At that visit it would be assessed by the dentist, signed and dated, and placed in the patient’s file. Clinical details of the visit, and subsequent ones, are entered on a dental chart and kept in the file.

A separate record of all attendances and treatment each day is kept in the daybook, or its ­computerised equivalent, and forms a valuable cross-reference system with the charts.

Apart from clinical records, those relating to practice administration are just as important. Such records concern the supply and purchase of equipment, materials and drugs used for treatment, batch numbers of drugs and medicaments over a set time period (so that those used on a certain date can be traced back where necessary), details of despatch and receipt of work done by dental laboratories, and staff personnel records.

Most practices use computers for dealing with the following.

• Stock records.
• Accounts.
• Patient recall systems.
• Standardised patient correspondence, such as account letters or appointment cancellation and rearrangement letters.

Importance of records

Accurate dental records are essential to ensure that patients receive necessary, appropriate and safe treatment. Poor record keeping often forms the basis of patient complaints that cannot be defended, and the dentist is ultimately responsible for their errors and omissions unless the notes were written to record treatment provided by a dental care professional. Errors or omissions in recording information may result in incorrect treatment being carried out, or failure to provide necessary treatment to maintain oral health. The dental nurse must accurately record information given by the patient or dictated by the dentist, ensuring that records are filed properly, made ­available at each appointment, and signed as necessary by the patient and the dentist.

Dental records are also extremely valuable as a means of establishing identity. In fatal accidents where facial features are destroyed, the teeth are often unaffected and can be compared with dentists’ records to identify a victim.

Proper records allow correct treatment planning and provide a check on details of past treatment. They form the basis on which fees are calculated and accounts rendered to patients. Failed appointments and refusals of treatment are noted and the patient’s attitude to oral health, as well as any risks factors to good oral health, can be assessed. Appropriate recall arrangements can then be made for each patient, in line with National Institute for Health and Clinical Excellence (NICE) guidelines.

Adequate records allow the practice to run with the greatest efficiency for all concerned, and should be retained for at least 11 years after completion of treatment, or to the age of 25 years in the case of children’s records. Many difficulties concerning individual patients can be prevented altogether if complete records are available of all attendances at the practice, while no time is wasted in putting such information at the dentist’s disposal. Recording and filing systems may vary considerably in different practices but whichever method is used, records must always be accurate, legible, comprehensive and easily accessible.

Clinical records

Clinical records consist of the past and present appointment and daybooks, as well as records of each patient attending the practice, and contain the information specific to the delivery of oral healthcare to that patient. They include the medical history, dental history, present oral health status (including chartings), treatment received on each date, and then the required estimate, consent and account paperwork. The relevance of each area of information to be recorded is ­discussed below.

Medical history

The importance of a full medical history in successful treatment planning is discussed in detail in Chapter 12, and summarised here.

Full details of any past and present illnesses, and other medical issues must be regularly updated, ideally at every recall appointment as a thorough run-through and update of the medical history form itself, which is then signed and dated as being updated at that time. A verbal confirmation of no changes at each treatment appointment is then satisfactory. The assessment of any updated entries or declarations is solely the responsibility of the dentist, although the information can be collected by the dental nurse. Medical history forms vary considerably, but the basic areas of ­questioning should include the following.

• Currently receiving any medical treatment – full details must then be given.
• Any history of steroid use within the last 2 years.
• Details of any current medications, including non-prescription ones – any unfamiliar drugs can be checked in the British National Formulary.
• Any allergies, with details.
• Any reactions to local or general anaesthetics.
• Currently pregnant or a nursing mother.
• Human immunodeficiency virus (HIV)-positive status.
• History of rheumatic fever, liver or kidney disorders.
• History of any heart or circulatory disorders.
• History of any respiratory disorders.
• History of diabetes, epilepsy or arthritis.
• Details of any medical warning cards issued, especially the use of anticoagulants.
• Smoking, tobacco and alcohol history.

In order to ensure complete confidentiality, a medical history must be taken and discussed in private where it cannot be overheard. Patients cannot be expected />

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