In 2004 I was recruited as a Lay Member of the General Dental Council (GDC) Fitness to Practise Panel (FtPP). I'd spent most of my life to that point as an actor and musician and remarkably little of it in the dental surgery. Unlike those of you who work in a regulated, healthcare role, artists don't have to worry about patient safety or the reputation of an entire profession. In fact having a criminal record or indulging in wild behaviour has enhanced many an actor's career instead of ending it.
I had ten years of sitting on a huge variety of cases and watching the story behind each emerge. When the whole dental team became regulated in 2008, I noted a slow change in the type of cases we saw, as DCPs gradually started to appear before us. Before then, we rarely saw a DCP as a respondent – mostly, they were witnesses in cases of a dentist's alleged misconduct. I often thought how difficult it must be for a dental nurse to come and give evidence about a current or former employer and I greatly admired the courage that your colleagues showed in doing so.
Nowadays, more and more cases with a DCP as respondent are appearing before the FtPP. However the numbers are still very small, whatever way you look at it: only 14.5% of cases in 2014 featured DCPs. As the largest registrant group – there are 66,607 DCPs to 39,418 dentists – it looks like DCPs are pretty good at staying out of trouble.
Putting statistics aside for a moment, I will go back to my own, personal experience of DCP misconduct cases and see what common factors seemed to emerge. I am not a legal or dental expert, so my input comes from the perspective of a lay member, which means that I am a member of the public, put there to represent the public interest, protect patients and make sure that the process is as fair and open-minded as possible. I now work in the training world and have developed expertise in designing and delivering training events. This means that every day I explore motivation, behaviours and insight in all walks of the working life. My training company, Xperient, uses interactive techniques to explore issues around communication and so it was inevitable that my eye and mind would be most drawn to the issues in a case where communication was the common factor. Gradually I realised that almost every case had a communication (or miscommunication) issue at its heart, even when the allegations focussed on clinical treatment.
Apart from miscommunication, another common factor that I noticed was a lack of insight or self-awareness. These ‘blind spots’ would lead to unfortunate decisions being made where the patient was not being put first. You may have heard of ‘reflective practice’, which is how we all develop insight in the real world when mistakes inevitably do get made. And finally, in many of the cases involving DCPs, I noticed a naivety about professionalism and the responsibilities of being a regulated professional. This was reflected in personal behaviour in and out of the workplace that brought the profession into disrepute and seriously damaged public confidence.
Before 2008, my window into the world of the nurses, receptionists, practice managers, therapists, technicians and hygienists came through the evidence given by them as witnesses. After 2008 I was commissioned to create some training workshops for DCPs about the responsibilities of being a registrant. I spoke with many of your colleagues to discover what preoccupied them: some of you were deeply concerned about the responsibility to ‘whistle-blow’ as you didn't want to get the blame for something that wasn't your fault nor get sacked for being a troublemaker. It also brought up confusions and irritations about Professional Indemnity, CPD, the Annual Retention Fee and for some, fears of being expected to perform outside of your Scope of Practice. At this time, the profession lost many of its DCPs who did not want the added cost and responsibility.
I could see how many of you were struggling to ‘manage upwards’. In other words, struggling to say ‘no’ to your boss, or tell a senior colleague that you weren't happy with a decision they'd made or the way they had behaved. Many of you were uneasy about some of the standards under which you had to work or were uncomfortable with the culture and atmosphere of the workplace but you didn't feel empowered to do or say anything about it. Regulation brought this power to you all but it also brought other responsibilities and, critically, it brought accountability.
So what are the actual issues that bring a DCP in front of his or her regulator? Are there any patterns and are there any pitfalls to avoid? The best way to put your mind at rest is to inform yourself. Reading the summaries of cases on the GDC website is a useful education. When I looked today for recent DCP cases, I found one ‘theft by employee’ in a case where the DCP had a criminal conviction, another where the DCP had failed to declare a conviction on the GDC application form (which was found to be ‘dishonesty’) and another where a DCP registrant had a conviction for ‘actual bodily harm’. I then researched the bigger picture by looking at all the issues that led to 28 DCP cases in front of the Professional Conduct Committee in 2014. 17 of these respondents were nurses, ten were technicians and one was a hygienist. When I read through the summary of issues, some phrases leapt out at me, for example: ‘uncooperative and obstructive’, ‘gave no clear warning of risk’ and ‘had many opportunities to correct the situation, but did not do so’.
These were classic example of the insight and communication issues that I mentioned earlier.
With the seventeen nurses, the issues were as follows:
• Failure to disclose a criminal conviction or police caution (disorderly behaviour, criminal damage and a dangerous dog)
Inappropriately claiming sick leave
Creating a false patient record
Operating beyond scope of practice (in one case, re: tooth whitening)
Not obtaining patient consent
Embezzlement of over £19,000
Drink driving and cannabis conviction
Dishonesty about qualifications and
Convictions for Actual Bodily Harm, Harassment and Violence.
Amongst the ten technicians, I found the following:
Making inappropriate sexual comments
Police caution for possessing indecent pseudo-photographs of children
Allowing a dispute with a dentist to compromise quality of patient care
False statements in advertising and
8 of the 10 cases related to Exceeding scope of practice.
For the solitary hygienist, the case surrounded deficiencies relating to record keeping, communication and consent.
Very few of you reading this will ever be involved in a case that reaches that level of seriousness. You are still more likely to appear as a witness, if at all. So if we take these themes away from the court room, so to speak, what is there to be learned from the mistakes that others have made? What about all the small, apparently trivial incidents in your everyday working life that challenge your professionalism? What can you do to make your personal approach to your practice more patient-centred and more professional?
In an ideal world we would all like to work in a team where we were encouraged to take responsibility, show initiative, ask difficult questions, were able to admit when we were confused or had made an error. I hope that many of you enjoy that working environment. However through the cases I have sat on at the GDC, I have seen that in many workplaces your colleagues endure difficult and unrewarding work cultures. In an ‘ordinary’, non healthcare job many people ‘put up and shut up’. They can walk away from the job at day's end and forget all about it, just enjoying the pay packet. For members of a dental team, the issue of public safety and the reputation of your profession effects all the choices you make, in and out of work. It makes it so much harder to accede to a culture of carelessness, or ego-driven bad decisions. Yet many people do turn a blind eye to their own or others' behaviour. It was clear to me that some of the DCPs we saw giving evidence at a hearing had not realised that they could lose their right to practice and seemed to take no responsibility for patient safety. It was possible for a DCP to get all the way to a hearing without having taken any professional advice, perhaps because they didn't have indemnity to that level and sometimes because they didn't realise the potential seriousness of the outcomes.
I could see, as a case unfolded, that an uncomfortable working environment was often the catalyst. This has a cascade effect that compromises everyone in the end. It was rare to hear cases that had occurred at attractive and professional dental surgeries with a happy team and trusting patients. It's not that they don't make mistakes too. But it did make me wonder: Could it be that the problems were likely to be communicated more clearly and dealt with more effectively at a much earlier stage? Could it be that if people are able to admit to their mistakes, they can be constructively dealt with? And what about reflective practice? Having made a mistake, could it be that the happy, professional dental practice managed to deal with that mistake at grass roots level?
I realise that it is easy for me to say, ‘why didn't that DCP just speak up and say something’. I understand how difficult it might be to give feedback to an employer or your manager. I appreciate that it is very tempting to turn a blind eye and hope that someone else will deal with the situation, or have a good moan in the staff room and then just get on with the job and keep your head down. I have worked for 15 years on training events in private and public sector exploring how to manage upwards, deliver difficult messages and how to raise concerns. It is extremely human to dread and avoid such conversations. But the rewards are tremendous. Practising being a transparent, self-aware and insightful team member means that it gets easier every day and your behaviour will influence others and can change the culture of the workplace. Reflecting on your own choices and behaviours adds to your credibility daily with patients and colleagues. You may even want to keep a reflective log of the issues that most challenge you so that if, God forbid, trouble does strike, you know that you have documented, robust reasons for your decisions. And you will know that you are doing the best you can for yourself, the team, the profession and, most importantly, your patients.
Nicola Burnett Smith runs a series of national training workshops for the Dental Team entitled ‘Professionalism in Practice’. For more information, contact firstname.lastname@example.org.
(If you have serious concerns about public safety and conduct in your workplace and want some advice, contact Public Concerns at Work http://www.pcaw.org.uk)