Are healthcare professionals sufficiently aware of dental ethics? Fields research in southeast Turkey

Abstract Developments in the field of health and the changing characteristics of society have revealed the concept of medical ethics, which ethically evaluates the studies dealing with human life and produces solutions. The aim of this study was to evaluate the awareness of healthcare personnel in the Faculty of Dentistry of Dicle University about ‘the legal responsibilities of dental practitioners’ and ‘rights of patients’. The study included 150 volunteers who were healthcare workers in the Faculty of Dentistry, Dicle University, between June and July 2019. The subjects were randomly selected from five different professional groups and data were collected using a single data collection form. All items on the form were graded using a 5-point Likert-type response. In the statistical analyses, Pearson’s Chi-square, Yates’ Chi-square and the Fisher Exact tests were used. The questionnaire responses showed that 61.3% of the study participants had received training on patients’ rights and 56.7% had information about the legal responsibilities of dentists. The rate of dentists who had received training was below average and 38.9% of the dentists reported not having any information about their own legal responsibilities. A positive response was given to the items on the questionnaire by 58% and a negative responseby 33%. The responses to some items were seen to have been affected by variables such as age, gender and professional group. Although some confusion was experienced by the healthcare personnel about patients’ rights and the legal responsibilities of dentists, the levels of awareness of medical ethics were evaluated as satisfactory.


Introduction
The concept of patients' rights can be defined as fulfilling the basic needs and expectations of the patient. These rights are based on showing respect, receiving the best service, being informed correctly, providing consent for interventional proceedures and confidentiality [1]. The first documentation related to rights of patients was the Lisbon Declaration published by the World Medical Association in 1981. This declaration includes headings such as confidentiality of information, the rights of the patient to select a physician, and accept or reject treatment. In Turkey, the 'Patients' Rights Guidelines' published by the Ministry of Health came into operation in 1998 [2,3,4].
The basic rules related to patients' rights-according to medical ethics-can be summarised as: necessary, the patient must be able to submit a complaint [5].
An increased work load and some economic, social and technological problems can cause problems in healthcare personnel-patient communication. It is a primary duty and responsibility of healthcare personnel to pay attention to patients' rights and to prevent neglect of these [6,7]. Patients should also have sufficient information and sensitivity about their own rights [8,9].
The most important criteria of high-quality healthcare service is sensitivity shown to meeting the needs and expectations of patients and patients' satisfaction [10,11]. This definition is the difference between the service imagined and perceived by the patient [12]. Factors affecting patients' satisfaction include the age, gender, education level and income level of the patient, and the educational level of the health care personnel [13,14].
In Turkey, a system protecting patients' rights and preventing medical mistakes has still not been fully implemented. Especially during dental services, the predominant view is that rights of patients are neglected. However, as a result of incorrect interventional procedures, there are criminal, compensation and administrative responsibilities. Criminal responsibility arises from carelessness and lack of precautions taken by the physician. Compensation responsibility corresponds to financial and emotional damage experienced by the patient and their family. Administrative responsibility is determined with a disciplinary investigation to be conducted by the dental association or institution where the dentist is employed [15].
For dentists to be able to be free of legal liability: 1. The diagnosis and treatment must be made only by the dentist, 2. Treatment applications must be based on medical, social or psychological indications, 3. Written informed consent must be obtained from the patient before interventional procedures, 4. Treatment procedures must be applied with care as required by the dental specialist area [5,15].
To improve the quality of the services provided, the patients' satisfaction should be periodically evaluated [16,17]. Questionnaire studies will contribute to healthcare planning [18]. In recent years, there have been several scientific studies and activities on the subject of patient rights in Turkey. A signficant proportion of these have measured the awareness of patients and physicians [4,16,19]. As patients have more communication with healthcare personnel other than physicians, and a significant amount of medical and administrative procedures are conducted by this personnel, it is necessary to evaluate their awareness [20].
In accordance with this understanding, the aim of this study was to evaluate the awareness of healthcare personnel working in the Dental Faculty of Dicle University about patients' rights and the legal responsibilities of dental practitioners.

Participants
The study was carried out with a total of 150 volunteers (dentist, nurse, Healthcare clerical worker, health technician, and other assistant health personnel) determined by using a random sampling method from five different groups employed at Dicle University Faculty of Dentistry in 2019, between June and July. The survey technique, which is one of the quantitative data collection techniques, was used to measure the level of knowledge of various levels of health professionals about patients' rights and the legal responsibilities of dentists. The questionnaire questions were determined by four academics competent in the field, and similar studies in the literature were reviewed and edited.

Ethics statement
Participants were informed about the purpose of the study and their consent was obtained by paying attention to the principle of volunteering. It was also ensured that the information about the participants would be kept confidential. Approval for the study was given by the Ethics Committee of Dicle University Faculty of Dentistry (decision no: 2019/3).

Evaluation of questionnaire
The responses given by the individuals were evaluated according to the regulations of the TDB (Turkish Dental Association) and the patient rights guide published by the Ministry of Health.
In the research, a data collection form compatible with the Ministry of Health Patient Rights Guidelines was used. The questionnaire consists of 25 items in 2 parts. The first part consists of five descriptive questions about healthcare professionals. They are shown in Table 1.
The second part consists of twenty questions aimed at determining the level of knowledge and attitude of healthcare personnel about the responsibilities of dentists and rights of patient. The answers were in the form of positive and negative statements as a 5-point Likert-type response: 1 ¼ Strongly agree, 2 ¼ Agree, Table 2).
Data obtained in the study were analysed statistically using R version 3.2.3 (2015-12-10), Copyright (C) 2015 The R Foundation for Statistical Computing free software. In the statistical evaluation of categorical variables (number, percentage), the Pearson Chi-square, Yates Chisquare and Fisher Exact tests were used. A confidence interval of 95% was applied. A value of p < 0.05 was accepted as statistically significant.

Results
Accoring to the results, it was determined that the professional distribution was not balanced, as dentists comprised 75% of the study sample and the majority of the participants were in the 26-35 years age group (Table 1), males and females were represented equally (Table 4).
Patients' rights training had been received by 61.3% of the participants and not received by 38.7%. Of all the respondents, 56.7% had information about the legal responsibilities of dentists, and 43.3% did not. The general findings of the responses given by the participants are shown in Table 2; information about their job title is given in Table 3, gender variables in Table 4, and educational level in Table 5.
The responses of 'Strongly agree' and 'Agree' were evaluated as positive and 'Disagree' and 'Strongly disagree' were evaluated as negative. The response of 'Undecided' was not taken into consideration. Accordingly, to the question 'have you received training about patients' rights?', 57.8% of the respondents in the 18-25 years age group gave a negative response, and as age increased, so did the rate of having received training. Of the nurses and clerical staff, 100% had received training, and the rate was observed to fall to 54.9% for dentists.
To the question, 'do you know about the legal responsibilities of dentists?', 56.6% of the respondents in the 18-25 years age group gave a negative response and as age increased, the awareness also increased. Of the dentist group, 61.1% stated a level of knowledge and this rate fell to 40% for nurses.
To the statement, 'The dentist should give information about complications to a patient who is receiving treatment for the first time', the respondents supported this view at approximately 98% and the opposing rate was 1.5%.
The statement, 'The dentist can refuse to see a patient for professional or personal reasons' was supported by approximately 75% and opposed by 11%. A positive view was given by 87% of the dentists, 54% of the dental technicians and 50% of the nurses. Males responded positively at a rate of 80% and females at 71%.
The statement, 'The dentist can leave a patient without finishing the treatment for professional or personal reasons' was supported by approximately 31% and opposed by 55%.
The statement, 'The dentist can prescribe drugs for patients with a green prescription' was supported by approximately 29% and opposed by 42%.
The statement, 'The dentist can perform treatments such as botox and dermal fillers without a specialist certificate' was supported by 40% of the male respondents and 24% of the female respondents.  The patient has the right to know the identity, position and title of the dentist and other personnel who will provide the healthcare and has the right to select and change the personnel who will provide the healthcare The statement, 'The dentist can write a sicknote for a patient without a specialist certificate' was supported by approximately 71% and opposed by23%.
The statement, 'The dentist can diagnose and prescribe drugs for a disease other than in his/her own field (diabetes, hypertension)' was supported by 9% and opposed by 81%.
The statement, 'Patients' consent must be obtained for every kind of medical intervention, and the patient must benefit from these' was supported by 93% and opposed by 4%. A positive response was given by 100% of the clerical staff, dental technicians and other personnel, by 92% of the dentist sand 80% of the nurses.
The statement, 'The patient has the right to know the identity, position and title of the dentist and other personnel who will provide the healthcare and has the right to select and change the personnel who will provide the healthcare' was supported by approximately 73% and opposed by 15%. A positive response was given by 80% of the auxiliary healthcare personnel, 75% of the dentists and 70% of the nurses.
The statement, 'There is a responsibility to give full and complete information related to the patient's health' was supported almost equally by males (93%) and females (92%).
The statement, 'Medical interventions can only be made without patients' consent because of medical necessity and when precautions must be taken in respect of public health' was supported by approximately 53% and opposedby 23%. A positive response was given by 67% of the health care clerical staff, by 58% of dentists and 50% of nurses.
The statement, 'The patient can request all kinds of information verbally and in writing related to their health status' was supported by approximately 90% and opposed by 5%.

Discussion
In Turkey, the awareness of patients about their own rights is not at the desired level, for reasons such as lack of information, hesitation by healthcare personnel, and the concern that nothing would change or the situation would become worse for them. In a 2007 study conducted in Denizli State Hospital, the results showed that 76.6% of patients had no information about patients' rights, 70.3% would not complain if Table 3. Opinions of the healthcare personnel according to professional group. Item 9 The dentist can refuse to see a patient for professional or personal reasons. The patient has the right to know the identity position and title of the dentist and other personnel who will provide the healthcare and has the right to select and change the personnel who will provide the healthcare. there were a problem, 81.6% did not know where they could make a complaint, and 29.4% thought that even if they made a complaint, nothing would change [21]. However, great progress has been made in recent years with mass communication and education. In a study by Zaybak et al. [6], those living in the city centre were seen to use patients' rights at a higher level than those in provincial centres or villages. Information about the subject for illiterate patients was determined to originate from the media.
Eksen et al emphasised that females were more sensitive to the subject of patients' rights than males [22]. However, another study conducted in Kayseri reported that males had a higher level of knowledge about patients' rights than females, and that the level of knowledge increased with a greater length of time as a physician [23]. Topbaş et al. [4] determined that approximately 60% of physicians in a Medical Faculty knew about patients' rights. In a study by Eşiyok et al. [24], 43.1% of dentists had received trainning on the subject of patients' rights. In a similar study, Teke et al. [10] reported that 55% of nurses had received training about patients' rights.
Previous studies have shown that information about rights of patients is generally acquired in training after graduation. Ozturk et al. [25] concluded that although physicians and nurses working in state hospitals and university hospitals had a high level of knowledge, these rights were not sufficiently respected in university hospitals. When evaluating the approach to patients' rights of personnel in first-level healthcare institutions, Ocaktan et al. [26] reported that 30.9% of personnel had acquired knowledge related to rights of patients with training before graduation, and 48.8% had received training after graduation.
In the results of the present study, approximately 61% of healthcare personnel had received training on patients' rights [100% of those aged 36 years and above, and 42% of those younger than 25 years]. The rate of dentists who had received training was observed to be below average. It was noteworthy that 38.9% of the dentists did not have knowledge about their own legal responsibilities. When the responses of the healthcare personnel to the questionnaire items were examined according to age, there was a statistically significant difference in the responses to items 4, 5, 9, 11, 17 and 25 (p < 0.05). When the responses were examined according to Professional group, there was a statistically significant difference in the responses to items 4, 7, 8, 20, 23 and 24 (p < 0.05). In the evaluation of the responses according to gender, the only item showing a statistically significant difference was item 20 (p < 0.05).
The results obtained indicated a need for the subjects of patients' rights and the legal responsibilites of physicians to be added to the curriculum in further education colleges and faculties training healthcare personnel. There is a significant requirement for in-service training after graduation to be repeated at certain intervals and for scientific activities to be organized. Increasing awareness on the subject of patients' rights will contribute to increasing patients' satisfaction and improving the quality of service. Patients' satisfaction questionnaires applied at certain intervals will be of guidance in taking the necessary precautions.
In the present study, the positive responses to the items in the questionnaire were at the rate of approximately 58% and the negative responses were at the level of 33%. The items with a high rate of positive response were item 8 (97.9%), item 19 (92.7%) and item 25 (90%). These rates provide information that the interventional healthcare services applied in our hospital are patient-centred. The items with a high rate of negative responses were item 18 (81.4%), item 16 (65.3%), item 15 (55.4%) and item 10 (54.6%). These results demonstrate that the healthcare Table 4. Opinions of the healthcare workers according to gender. Item 9 The dentist can refuse to see a patient for professional or personal reasons personnel who participated in the study act in accordance with the ethical rules, and the dentists showed sensitivity to remaining within their legal responsibilities.
The responses to some of the items were very interesting: The statement, 'The dentist can refuse to see a patient for professional or personal reasons' was supported by 87% of the dentists, and 50% of the nurses. Article 4 of the declaration published by the American Dental Association is about professional codes of conduct. According to this statement, 'While dentists have a reasonable discretion to select patients for their practice while serving the public, dentists should not refuse to provide this service because of patients' race, belief, color, gender, sexual orientation, gender identity, national origin or disability' [27]. It is extremely thought-provoking that 87% of the dentists participating in the study think that they may have the right to refuse to see the patient. According to Article 18 of the Medical Deontology Regulation, 'The physician and dental practitioner may refuse to look after the patient for professional or personal reasons, except for emergency aid, the performance of official or humanitarian duty'. Article 19 includes the statement 'The physician and dentist may leave the patient without finishing the treatment for professional or personal reasons' [28]. Unless the conditions in the articles are fulfilled, the physician cannot refuse her/ his patient. The reason why this question was answered 'yes' by some participants may be that these conditions may have occurred.
The statement, 'Patients' consent must be obtained for every kind of medical intervention, and the patient must benefit from these' was supported by 100% of the clerical staff and dental technicians and, although supported by 92% of the dentists and 80% of the nurses, these latter two groups were relatively more undecided. The responsibility for obtaining informed consent belongs to the healthcare professional administering the treatment. Physicians and nurses are the people who interact with the most patients in the healthcare team. However, nurses working in the clinic face many problems during the informed consent process. The biggest problems encountered are that nurses are inadequate in what they should do and how they should behave. In addition, it can be listed as they think they do not have any responsibilities or do not make any inquiries. Although nurses determine the needs of the patient and identify the problem related to informed consent, they hesitate so as not to risk acting in a wrong way, to go beyond their duties and responsibilities, to get reactions or to make an institutional wrong practice [29]. It is for these reasons that the nurses participating in our study are more hesitant about obtaining patients' consent for any medical treatment than dentists.
It was extremely interesting that the statement, 'The patient has the right to know the identity, position and title of the dentist and other personnel who will provide the healthcare and has the right to select and change the personnel who will provide the healthcare' was supported by almost three-quarters (73.4% of all the personnel). With regard to the right to choose a physician, it is possible to express that patients and their relatives choose and change the health worker, which is the most basic right of patients, and they play a participatory role in their diagnosis and treatment. In the Lisbon Declaration, there is a statement that 'the patient has the right to freely choose her/his doctor'. In the Amsterdam Declaration, there is a statement that 'patients have the right to choose and change their physician or other health personnel and health institutions in accordance with the functioning of the health system'. According to the Basic Document of the European Statute (Articles of Incorporation) on Patients' Rights, every individual with sufficient knowledge has the right to choose between different treatment procedures and people who will give the treatment. The patient has the right to decide which diagnosis and treatment method will be used and the choice of doctor, specialist or hospital [30]. It is seen as gratifying that the healthcare professionals participating in our study also attach importance to this right of the patients.
In recent studies, the importance of increasing the knowledge level of healthcare professionals and students on dental and medical ethics is emphasized. Jatana et al. [31] conducted a study to measure the knowledge and behavior level of medical students regarding medical ethics. It was reported that the rate of those who knew the basic principles of medical ethics was only 18.4%, and that the education in medical ethics should be strengthened with training and seminars.
Al-Rawee et al. [32] conducted a survey study on dentists, and reported that 77.91% of the participants had knowledge about ethics, and 84.16% acted according to dental ethics. In a similar study, Siddiqui et al. [33] analyzed the awareness of ethics among dental faculty graduates. They stated that there was a general lack of knowledge about ethics and efforts should be made to improve the situation. It was found that only 40.7% of the participants were aware of the international ethical rules and 30% did not learn dental ethics during the education process.
Demirtas [34] evaluated the perspectives of sixthgrade medical faculty students, assistants and academicians on medical ethics. In the study the majority agreed that medical ethics education is necessary (92.7%), and that ethical education should be given by experts.
Al-Shehri et al. [35] evaluated the knowledge attitudes and practices of assistant physicians on medical ethics in their study; 35.6% of the participants had insufficient knowledge and only 25.6% of the participants stated that they had never encountered unethical practices. This situation revealed the prevalence of unethical practices. The researchers emphasized the importance of strengthening the medical ethics education.
Salve et al. [36] examined the knowledge, attitudes and practices of dental staff and students on ethics in dental practice. Approximately 44.8% of the participants stated that they had insufficient knowledge about the ethical aspects of dentistry. They found that knowledge and awareness of existing ethical laws and governing bodies were not sufficient. The results of our study are also in agreement with the study of Salve et al. [36].
The results of this study are similar to previous findings in the literature. Despite some confusion about the subjects of patients' rights and the legal responsibilities of dentists, the levels of awareness were satisfactory.

Conclusions
The results of this study demonstrated that the healthcare personnel in the Dental Faculty of Dicle University were evaluated relatively positively in respect of their knowledge and attitudes toward rights of patients. As the level of training increased together with the time spent in the profession, there was a positive development in the behaviours related to patients' rights. Healthcare personnel should not forget that the patients are the reason that they are there, and policies should be followed that prioritise patients' rights and patients' satisfaction.