Introduction

Law and ethics is a fundamental part of everyday life in dental practice and although the subject is included within the undergraduate curriculum for dental students, those who are interested in the topic at a postgraduate level were always left to pursue solely medical law and ethics courses to fulfil their interest in the subject. This started the discussion about designing a bespoke postgraduate course that was intended especially for dental practitioners who were not seeking to be lawyers, but would value the study of dental law and ethics to benefit their patients, their community and the wider profession. On the fifth anniversary of this unique course, the authors are presenting a reflection on how the course has evolved over the last few years and how they see it impacting and shaping the next generation of dental practitioners.

October 2012 saw the start of the first cohort of Dental Law & Ethics PgCert at the University of Bedfordshire and following on from the success of the PgCert, the MA course approval followed in 2015 with nearly 100 students completing the PgCert.

At the heart of this development was a desire to design a course that is relevant to dental practitioners and their teams, a course that relates to day-to-day dental practice whether it is private or NHS, based in hospital or community, and whether clinicians are single handed or working within a large team. The aim was also to place patients at the centre of the curriculum with real examples from practice as well as relevant links to current regulations and recommendations and in line with the GDC standards.1 The challenge was how to make this course distinct from studying medical law and ethics despite the shared concepts and values between medicine and dentistry. Another challenge was how to make the course relevant to all practitioners who come from different backgrounds with different levels of experience. All that needed to be combined with an academic level of study that is expected to include writing reflectively, critically analysing situations and linking theories, and what the literature says regarding day-to-day practice.

To achieve these aims, we embarked on a journey of collaboration with colleagues, stakeholders, and practitioners with different backgrounds and expertise. With these aims in mind, we developed a curriculum and an assessment strategy that emphasised students' freedom to address assessments by ways of linking them to their own individual practice, for example, selecting law cases that are relevant to their own practice, crafting and developing their own ideas, and designing artefacts that relate to their work environment. This approach enriched the students' experience and allowed each student to apply what they have learned into their own practice. For example, a review about informed consent is approached differently by a clinician with a background in orthodontics compared to another who is working mainly with elderly and special needs patients or within the prison services.

Teaching dental law and ethics

Teaching and assessing ethical dental practice is a challenge and students find that ethics is more challenging as a topic compared to studying dental law. Research showed that postgraduate (PG) dental students find studying ethics challenging,2,3 since studying a multifaceted subject like ethics requires a great deal of thinking and reflection. Dentists with an empirical science background come to the social science of ethics, with its own distinctive language, traditions and apparent imprecisions, with a mixture of unease, excitement and some confusion. By contrast the semester on legal aspects is infinitely more approachable and accessible but by the end of the semester on ethics, many of the students have found this to be the most rewarding and intellectually stimulating module. Ethics also requires posing and questioning established practice and culture, which can be unsettling. Education is more than imparting knowledge and ethics education speaks to individuals at a personal level.4

Through the course of this programme, the delivery of the ethics topics has been structured to progress slowly into addressing difficult and challenging ethical issues (for example, culture, safeguarding, whistleblowing, etc) especially since ethics in general sits within a paradigm that is open for debates and multiple realities (in comparison to the very specific rights and wrongs in diagnosis/treatment plans/doses of anaesthetics, etc). Additionally, teaching ethical practice presented the challenge of how to create a safe space for students to share their views openly without the fear of criticism or judgement. In a profession where clinicians take pride in their expertise and high achievement, it is invaluable to be able to share ideas, philosophies, values and personal experiences, rather than simply sharing only knowledge, to enhance personal development.

As the course developed, we were able to allow more thinking and preparation time for students to consider difficult topics and giving a voice to those who may be reluctant to participate in a big group. Feedback from different students' cohorts showed comments on the 'protected learning time' during teaching days and how this allowed them an opportunity to consider and question different legal and ethical aspects of practice that are usually taken for granted. Roper5 considered the impact of the taught subjects on students as individuals. This is crucial when it comes to teaching a topic like ethics where personal views and principles are challenged.3 Listening to different students' opinions and ideas creates a safe environment for teaching and learning, which is an important teaching standard. This is in line with Holley and Steiner's work6 about perception of 'safe space' for learning where opinions and views could be shared with ease. They argued that students need to be in an environment where they can challenge their own understandings and views without feeling at risk of being judged or belittled.6,7Safe space for learning also gives students at this level some useful tools needed in their future practice when facing some similar ethical challenges.

More emphasis was given on establishing classroom 'ground rules' of respecting one another and asking questions without fear or anxiety to support an open learning opportunity where students are allowed to think for themselves rather than being given ready-made answers. This is perhaps a different approach to other clinical based courses that are available for PG dental students. In the first instance, this may seem as a small detail to note; however, it is surprising how debates can get heated with strong opinions from experienced practitioners, for example in discussing the ethical dimensions of charging for emergency dental treatment which engage multiple issues of morality, professionalism and legal and contractual obligations.

Why is all this so relevant?

At a time where there is such a fear about litigation in clinical practice that inhibits clinicians from doing the very best they can, especially when they are involved in complaints or regulatory investigations,8 it is important that dentists are able to articulate the laws, understand the ethical principles, and provide themselves the reassurance that knowledge and perspective brings in their daily practice. When you understand exactly what clinical negligence is, what a duty of care amounts to and what the essential components of consent are, you become more not less empowered to be confident in your communications with patients.

Personal comments

Looking back, the authors can see the impact this programme has had, not only on our students, but also on the authors themselves. From an educational view-point, seeing individual students' journeys is immensely rewarding, as our students bring in their professional experiences, ideas, research and passion about dental practice into the classroom and they challenge some of the current thinking and ideas using structured arguments and the disciplines of critical thinking. Students are considered as partners in our own development as educators. This is in line with one of the main central themes of the higher education academy: 'students as partners'. Respecting students and working with them as partners increase engagement and success and enhance the teaching and learning process.9 It also makes teaching more stimulating and rewarding as every group of students brings some unique dynamics even within the generally similar learning outcomes and content outlines.

Throughout the 5-year development of this programme, we adopted more inclusive teaching and learning approaches with a mixture of facilitated sessions, flipped classroom, group work, and student-led presentations and activities. For example, students at the diploma stage took part in debating the effectiveness of regulatory bodies for dental practitioners and they commented on how they have changed their views in support of the role of regulatory bodies in regulating the profession. Group work has been fundamental in all classroom activities, looking at the ethics of dental treatment holidays, culture impact on ethical practice, and safeguarding, among other issues.

Students comment on how they think more about their decision-making, their note-keeping and their ethical and professional approach to using social media. They also comment on how they have developed a more holistic approach to treating their patients, seeing them within the wider context of community and their own personal role in wider healthcare delivery. Students became more aware of the issues of law and ethics and could see it virtually every day in the news headlines. This always provided a great teaching and learning opportunity for the authors when headlines impacted on healthcare issues, as they became the subject of debate on the face to face teaching days.

When important judgements10 were handed down from the courts, their significance to dentistry was eagerly extrapolated. Students also contributed to debates in peer-reviewed journals.11 The course has been a starting point not only for further study at the University of Bedfordshire and other institutions, but also new career opportunities with defence organisations, the GDC, CQC and as expert witnesses.

Looking forward, we are working with our MA students to strengthen their research focus through their independent research projects. This year, our students focused their dissertations on a wide range of topics related to dental law and ethics including professionalism and social media, the use of cosmetic fillers in dental practice, and ethical safeguarding. We are supporting our MA students to explore different ethical issues affecting patients' care, engagement with regulatory bodies, and cultural changes within the provision of dental care in the UK.