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The Dental Foundation Interview Guide with Situational Judgement Tests The Dental Foundation Interview Guide with Situational Judgement Tests Zahid Siddique Shivana Anand Helena Lewis-Greene Developing Young Dentists This edition ﬁrst published 2017 © 2017 by John Wiley & Sons, Ltd Registered ofﬁce: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial ofﬁces: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 1606 Golden Aspen Drive, Suites 103 and 104, Ames, Iowa 50010, USA For details of our global editorial ofﬁces, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identiﬁed as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. 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No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data Names: Siddique, Zahid, 1985- , author. | Anand, Shivana, 1990- , author. | Lewis-Greene, Helena, 1954- , author. Title: Situational judgment tests for dentists : the DF1 guidebook / Dr. Zahid Siddique, Dr. Shivana Anand, Dr. Helena Lewis-Greene. Description: Chichester, West Sussex ; Hoboken, NJ : John Wiley & Sons Inc., 2016. | Includes bibliographical references and index. Identiﬁers: LCCN 2015043956 | ISBN 9781119109143 (pbk.) Subjects: | MESH: Education, Dental, Graduate–Great Britain. | Dentists–psychology–Great Britain. | Educational Measurement–Great Britain. | Employment–Great Britain. | Judgment–Great Britain. Classiﬁcation: LCC RK76 | NLM WU 20 | DDC 617.60071/141–dc23 LC record available at http://lccn.loc.gov/2015043956 A catalogue record for this book is available from the British Library. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Cover image: © Getty/Westend61 Set in 9/12pt, MeridienLTStd by SPi Global, Chennai, India. 1 2017 Contents Preface, vii Acknowledgements, ix 1 What is dental foundation training?, 1 2 The application process, 3 DF1 recruitment process, 3 How to apply, 4 Key dates, 5 DF1 schemes – where to work, 5 DF1 interview – format, 9 Scotland applications, 11 3 The SJT exam, 13 What is an SJT?, 13 Format of the exam, 13 Marking format of the exam, 14 4 Deﬁnitions and legalities, 15 Deﬁnitions, 15 Legislation for the dental team, 17 Clinical governance, 19 5 Important notes for revision, 25 Standards for the dental team, 25 Consent, 26 Conﬁdentiality, 29 Complaints, 31 Scope of practice, 32 Continued professional development (CPD), 33 Raising concerns, 34 Child protection and vulnerable adults, 35 A checklist of sources to consult during revision, 37 6 Practice scenarios, 39 Introduction, 39 Professionalism, leadership and management scenarios, 40 Patient communication scenarios, 54 7 Situational judgement test practice questions, 57 Introduction, 57 v vi Contents Ranking-based SJTs: Questions, 58 Ranking-based SJTs: Answers, 86 ‘Best of three’ SJTs: Questions, 111 ‘Best-of-three’ SJTs: Answers, 144 8 How to write a dental CV, 165 Introduction, 165 Format, 166 Some dos and don’ts, 168 The meet and greet, 168 Some useful questions to ask, 168 Index, 171 Preface There are several books available on medical situational judgement tests (SJTs) but none for dentistry. Situational judgement test questions were introduced as part of the DFT application interview process in 2013. A relatively new concept in dentistry, SJTs have been widely used in industry as part of the selection criteria for professionals. We wanted to provide students with a selection of subject-speciﬁc SJT questions to help with their DFT preparations. Guidance for preparation has been put together by recently qualiﬁed dentists who understand the pressures that undergraduate study can impose. We hope that this book will be useful in helping all students gain experience with SJTs, leadership and management as well as clinical scenarios. The DFT application process is highly competitive. Simply put, the higher the ranking the better the chance of getting your ﬁrst choice placement. We hope that this book gives you all the information that you need in order to achieve this goal. The SJTs in this book were veriﬁed and standardized by a group of dentists and are answered in accordance to their opinion and expertise. vii Acknowledgements Thank you to Mr Raj Rattan for his continued support and mentorship throughout this process. Thank you to Professor Dunne our Professor in Primary Dental Care at King’s College London Dental Institute for his support and guidance from the beginning. A huge thank you to some of the panel members who include: Dr Razaullah Ahmed BDS Dr Keshvi Patel BDS MJDF RCS(Lon) Dr Nirupy Shanmugathas BDS MJDF RCS(Lon) Dr Simrun Chowdhary BDS MJDF RCS(Lon) ix CHAPTER 1 What is dental foundation training? Dental foundation training is a year when dental graduates across the United Kingdom embark on a period of relevant employment general dental practitioners under a contract of service by approved educational supervisors to provide a wide range of dental care and treatment. The successful completion of the DF1 year is mandatory for those who want to work in the NHS as part of their future dental career. Dental foundation training (DF1) introduces new graduates to general practice and gives them a protected environment in which to work and enhance the basic dental skills achieved through their BDS degree under the supervision of a educational supervisor practitioner. The educational supervisor’s role is to help and support the dental foundation trainee in all aspects of employment and provide continuous academic development through tutorials. The DF1 trainees also attend weekly study days outside of their general practice with the aim and objective of enhancing clinical and administrative competence and promoting high standards through relevant postgraduate training. The following competencies are included within the DFT curricula: to enable the dental practitioner to practise and improve dental practitioner’s skills; to introduce the dental practitioner to all aspects of dental practice in primary care; to identify the dental practitioner’s personal strengths and weaknesses and balance them through a planned programme of training; to promote oral health and the quality of dental care for patients; to develop and implement peer- and self-review and promote awareness of the need for professional education, training and audit as a continuing process; to demonstrate that the dental practitioner is working within the General Dental Council’s (GDC’s) standard guidelines. Excerpts from the National Health Service (Performers Lists) (England) Regu- lations 2013, found at http://www.legislation.gov.uk/uksi/2013/335/pdfs/uksi_ 20130335_en.pdf (accessed 24 February 2016). The Dental Foundation Interview Guide: with Situational Judgement Tests, First Edition. Zahid Siddique, Shivana Anand and Helena Lewis-Greene. © 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd. 1 CHAPTER 2 The application process CHAPTER MENU DF1 recruitment process, 3 How to apply, 4 Key dates, 5 DF1 schemes – where to work, 5 DF1 interview – format, 9 Scotland applications, 11 DF1 recruitment process All DF1 training vacancies are allocated through a centralized process for England, Northern Ireland and Wales. The online application process usually opens in the month of September for all UK-based year 5 dental students and EU graduates or overseas dentists. The recruitment process is split in two stages: First stage – trainees are ﬁrst allocated a particular DFT (dental foundation training) scheme. This is based on their DFT interview score ranking. The higher the candidates’ ranking scores, the greater is the likelihood of them obtaining their ﬁrst scheme preference and so forth. Second stage – trainees are allocated a particular practice in spring / summer of the following year. The individual practices are allocated through the DFT interview ranking scores, so those with the highest scores will receive their ﬁrst preference practice and so forth. Some schemes carry out second-round interviews, where an algorithm is used to pair up trainee preferences with edu- cational supervisor preferences. The Dental Foundation Interview Guide: with Situational Judgement Tests, First Edition. Zahid Siddique, Shivana Anand and Helena Lewis-Greene. © 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd. 3 4 The dental foundation interview guide Table 2.1 data collected for the application years 2011/12 and 2012/13 from COPDEND. Numbers 2011/12 EEA United ROW 2012/13 EEA United ROW England Kingdom England Kingdom and and Wales Wales Places Total 927 978 Applicants Total 1190 101 1044 45 1172 110 1031 31 Applicants eligible 1145 97 1042 6 1153 109 1027 17 and short listed Applicants 1110 86 1018 6 1138 104 1021 13 interviewed Applicants offered 940 47 889 4 1040 77 953 10 place Applicants 928 42 882 4 978 58 914 6 accepted offer Applicants not 12 5 7 0 18 13 3 2 accepted offer Applicants not 48 13 35 0 55 11 41 3 offered a place Notes: *EEA – European Economic Area; ROW – Rest of the World It is important to understand that the DFT application process is competitive. The number of DFT training places is generally linked to the number of ﬁnal-year stu- dents but places cannot be guaranteed for all UK graduates and it is therefore of utmost importance that all students give themselves the best opportunity to secure a place. Over the past few years the number of candidates applying has exceeded the number of DF1 positions available with EU and oversees dental applicants also applying. Table 2.1 shows the data collected for the application years 2011/12 and 2012/13 from the Committee of Postgraduate Dental Deans and Directors (COPDEND). How to apply London application process The London deanery and COPDEND change the application process on a yearly basis. It is always beneﬁcial to look at the guidance notes released by COPDEND on the London deanery web site beforehand at http://www.lpmde.ac.uk/ (accessed 22 November 2015). The application process 5 Scotland application process See below. Key dates COPDEND has the right to change the recruitment process on a yearly basis. Table 2.2 is a proposed timeline for recruitment with guideline months. Table 2.3 gives the selection centre interview venues across the United Kingdom. DF1 schemes – where to work A component of the DF1 application process involves choosing DF1 scheme area preferences around the United Kingdom. In 2014, applicants were asked to rank Table 2.2 Proposed recruitment timetable. Applications open 25 August 2015 Applications close 22 September 2015 Interview window 16 – 20 November 2015 Preferencing of schemes opens 8 December 2015 Preferencing of schemes closes 15 December 2015 Initial offers out by 06 January 2016 2nd round offers 06 July 2016 Placements commence March 2016 and September 2016 Table 2.3 Selection centre interview venues. Centre Venue Dental schools covered London London Recruitment Events Centre King’s College London Queen Mary University of London Bristol Bristol Marriott Hotel, City Centre Bristol University Cardiff University Peninsula College of Dentistry Manchester Reebok Stadium, Bolton University of Central Lancaster University of Liverpool University of Manchester Birmingham West Bromwich Albion University of Birmingham University of Shefﬁeld Belfast Ramada Hotel, Shaw’s Bridge, Belfast Queen’s University, Belfast Newcastle Newcastle United Football Club Newcastle University University of Leeds 6 The dental foundation interview guide their scheme preferences via the UK Offers System, which was done separately from the submission of their online application form for their original DF1 appli- cation. Candidates will be emailed with information regarding their interview date (which they must conﬁrm within 48 hours) and full instructions on how to com- plete scheme preferences, including use of the UK offers system. This involves logging into the system approximately 3 weeks after the interview and submitting their scheme area preference. The submission for schemes is open for 7 days – after this period submissions cannot be made. The London Deanery usually produces an information sheet about the avail- able schemes for that year. It is of utmost importance that candidates take time to consider all the schemes and their locations. Due to the competitive nature of the application process it is imperative that the candidates give themselves the best possible opportunity to obtain a DF1 job offer. These opportunities can decrease if candidates limit the number of schemes they are willing to work in. If they do not rank one of the schemes they will automatically forfeit their place, even if a position is available. However, it should also be noted that there is no point in can- didates ranking a scheme if they are absolutely certain that they are not willing to work in that region. The rationale for this is that if they do rank such a region and are offered a place within it, they will not be offered an alternative, or be given an opportunity to swap, if they decline the offer. We therefore advise candidates to try to be as ﬂexible as possible when ranking schemes to give themselves the best opportunity to secure a DF1 job. It is also important to note that, at this stage of the application process, candidates will only be given information regarding their scheme locations and not the locations of the actual training practices as they are not approved until spring / summer and can change on an annual basis. Some schemes cover a large geographical area and the distance between practices within a scheme can take over an hour to commute. The deanery will only provide detailed information about practices once they have all been approved; however, it might be possible to see the previous year’s information regarding individual practices on its web site. Once candidates have accepted their scheme in the beginning of January, they will have an option to ‘upgrade’ or ‘accept’ the offer. If they choose to accept, their deanery will be notiﬁed of their acceptance and their place for the DF1 year will be conﬁrmed. If they choose to ‘upgrade’, then on the last day of January their scheme will either be upgraded to a higher choice or the candidate will stay in the same scheme. Here are some useful points to consider when choosing where to work: 1 Travelling to work ∘ How far are you willing to travel to work? ∘ Do you drive? Will it be feasible to drive to work – Congestion charge? Parking? The application process 7 ∘ If you don’t drive will you need to relocate close to a train / tube station? Will you need to relocate to make your commute to work easier? 2 Finance ∘ How expensive will your living accommodation be in certain regions? ∘ Will living at home be more suitable? ∘ How expensive will your commute be? ∘ Do you have any family commitments or are supporting any children? If so, consider childcare and school arrangements. 3 Social life ∘ It is important that the location and environment you choose to work in provide a suitable social lifestyle outside of work, which caters for your individual needs. 4 It is only for one year ∘ Always take into consideration all factors. However, this is your opportunity to shine, build your CV, gain extra experience and make mistakes from which you will learn. ∘ Chose an environment in which you will feel comfortable to grow profes- sionally and personally. Flexibility is key and it is only for one year. 5 Location ∘ It is important to consider the region you want to work in. ∘ Do you want to be living at home? Do you want to stay in the same city as your university? Do you need to support a family? Are you someone who enjoys living in rural versus coastal areas? ∘ Speak to family and friends to aid and advise you. ∘ Speak to older dental colleagues to give you further information about regions within the United Kingdom. The list below gives the schemes that are available for DF1 applications. They may be subject to change in the forthcoming year. The HE region or deanery is displayed in bold and scheme names are displayed below them. A virtual map of DF1 schemes in the United Kingdom may be found at https://maps.google.co.uk/maps/ms?msid=209915530480942479969.0004c3c6972fd1afc3248&msa=0 (accessed 13 November 2015). HE East Midlands Chesterﬁeld Scheme Leicester Scheme Lincoln Scheme Loughborough Scheme Northampton Scheme Nottingham Scheme HE East of England Basildon Scheme 8 The dental foundation interview guide Bedford Scheme Essex Coast Scheme Ipswich Scheme Norwich Scheme Peterborough Scheme Welwyn Garden City Scheme HE Kent, Surrey and Sussex Central Scheme Coastal Scheme East Scheme South Scheme West Scheme HE North East GPT Scheme North 1 Scheme North 2 Scheme South 1 Scheme South 2 Scheme West Scheme HE North West Blackburn Scheme Lancaster Scheme North Manchester Scheme Pennine Scheme Wythenshawe Scheme HE North West (Mersey) Aintree Scheme Chester Scheme Clatterbridge Scheme Speke Scheme HE South West Bath Scheme Bristol Scheme Exeter Scheme Plymouth Scheme Salisbury Scheme Taunton Scheme Truro Scheme HE Thames Valley / HE Wessex Berkshire Scheme Buckinghamshire / Milton Keynes Scheme The application process 9 Oxfordshire Scheme Portsmouth Scheme Winchester Scheme HE West Midlands City Scheme Coventry Scheme Russells Hall Scheme (March only) Solihull Scheme Stafford Scheme Telford Scheme Worcester Scheme HE Yorkshire and the Humber East Yorkshire / North Lincolnshire Scheme GPT Scheme Harrogate Scheme Shefﬁeld and Doncaster Scheme Wakeﬁeld and Dewsbury Scheme York Scheme London Shared Services Northwick Park (March only) Northwick Park QMUL – Bart’s Scheme South East London Scheme South West London Scheme UCL– Eastman Scheme Northern Ireland Deanery Northern Ireland Scheme (August only) Wales Deanery East Wales Scheme Glamorgan Scheme North Wales Scheme South Wales Scheme South West Wales Scheme Port Talbot Scheme DF1 interview – format Assessments are scheduled to take place in late November in six centres across the United Kingdom. 10 The dental foundation interview guide ✓ Read all emails sent by the examining body prior to the interview date thoroughly and clearly, as they outline the majority of what is needed on the day, where the interview is and so forth. Do not discard them. ✓ Print out all relevant documents received. ✓ Compile all relevant documents and extras needed for the day – for example, bank state- ment, passport pictures. ✓ Work out the most efﬁcient route to your interview. ✓ Top up Oyster cards or ﬁll up with petrol beforehand. ✓ Dress smartly – boys: simple suit; girls: simple suit, long dresses or skirts and blouses. ✓ Girls – keep makeup simple. ✓ Keep a clear mind – do not plan other errands or have your mind elsewhere. ✓ Be conﬁdent! ✓ Speak clearly, comprehensively and steadily. ✓ Do not guess or make up answers; it is better to state ‘I do not know’. ✓ Once it is over do not dwell! The assessment process consists of: 1 Professional, leadership and management skills – objective structured clinical examination (OSCE) station. (10 minutes) 2 Clinical communication skills – OSCE station with real actors. (10 minutes) 3 Situational judgment test (SJT) – 56 SJT questions comprising both ranking-based SJTs and ‘best of three’ SJTs (105 minutes, discussed further in Chapter 3). Professionalism, management and leadership skills station This station is more like a mini viva station with the candidate discussing the scenario with two assessors. The candidate will be given a mark by both assessors, who will then collate their marks to calculate an average score for the student. Candidates will have 5 minutes to prepare in advance and 10 minutes for the actual station. (See mark scheme template in Chapter 3.) Clinical communication skills station This station will consist of a typical patient-dentist role-play scenario where an actor will be posing as the patient with a clinical problem. There will also be an assessor in the room, although he will have no involvement in the role play. The candidate will be marked by both the assessor and the actor in the role play (see mark scheme template in Chapter 3). Candidates will have 5 minutes to prepare for the station by reading and familiarizing themselves with the scenario and then 10 minutes for the actual station. The application process 11 Scotland applications Scotland has its own application process for which all year-ﬁve students can apply. The application for Scotland closes in early January and is done by emailing [email protected]. There is an application form to complete and to send to dental recruitment for Scotland. Supporting documentation is needed, such as proof of identity – one copy of photographic ID and two copies of conﬁrmation of address. CHAPTER 3 The SJT exam CHAPTER MENU What is an SJT?, 13 Format of the exam, 13 Marking format of the exam, 14 What is an SJT? The situational judgement test exam is designed to assess nonacademic skills and ethical values rather than clinical skills. Situational judgement tests are a measure- ment method designed to assess an individual’s judgement regarding situations in day-to-day working practice. These questions provide an effective method of assessing the key attributes required in dentistry: professional qualities; coping with pressure; communicating effectively; teamwork; putting patients’ interests ﬁrst. Format of the exam The exam consists of 56 SJT questions comprising both ranking-based SJTs and ‘best of three’ SJTs. Six of the SJT questions will be used for evaluation purposes. The candidate will have 105 minutes for the exam, which is machine marked. The Dental Foundation Interview Guide: with Situational Judgement Tests, First Edition. Zahid Siddique, Shivana Anand and Helena Lewis-Greene. © 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd. 13 14 The dental foundation interview guide Ranking-based SJTs Candidates will be given a question with ﬁve possible responses to speciﬁc situa- tions. They will then need to rank the ﬁve options from the most to least appro- priate usually from A to E. ‘Best of three’ SJTs The candidate will be presented with a situation question in which there will be eight possible answers. The candidate will then need to choose the three most appropriate answers when all of the answers are considered together. Marking format of the exam Ranking-based SJTs As explained above, the candidate is asked to rank ﬁve possible answers from the most appropriate to the least appropriate. The table below demonstrates how the candidate can score the maximum mark of 20 points for each question. For example, if the answer to a question is ACBDE, with A being the most appro- priate and E being the least appropriate, your score will be calculated according to a matrix which can look like the one in Table 3.1. Ranking the options correctly scores the candidate 20 marks. Best of three SJTs In this format the candidate must choose the three most suitable options when all the options are considered together. Each option scores four marks and therefore a maximum of 12 marks can be scored for each question. For example, if the correct three options are BCD the candidate will score 12 marks for choosing BCD, eight marks for only choosing two correct options, for example BCA, and four marks if the candidate only chose one correct option, for example BAE. Table 3.1 Mark scheme for ranking-based SJTs. Correct If you ranked If you ranked If you ranked If you ranked If you ranked ranking it ﬁrst it second it third it fourth it ﬁfth A 4 3 2 1 0 C 3 4 3 2 1 B 2 3 4 3 2 D 1 2 3 4 3 E 0 1 2 3 4 CHAPTER 4 Deﬁnitions and legalities CHAPTER MENU Deﬁnitions, 15 Legislation for the dental team, 17 Clinical governance, 19 Deﬁnitions General Dental Council The GDC is the primary regulator of dental professionals, with a principal role in ensuring patient safety. There are 12 members on the GDC; six are dentists and six are lay people. The functions of the GDC are to maintain the dental register, to ensure quality, to supervise dental education and to administer any disciplinary action required against its members where appropriate. Section 38 of the Dentists Act states that it is illegal to practise without being placed on the GDC register. Care Quality Commission (CQC) The CQC has been checking that healthcare service providers are meeting national standards for safe, effective, compassionate and high-quality care since 1 April 2009. It encourages all healthcare employers to always make continual improve- ments. The CQC hold inspections with all practices that should be registered with the CQC. Faculty of General Dental Practitioners (FGDP) Formed in 1992 as the academic home for general dental practitioners (GDPs). The FGDP(UK) is based at the Royal College of Surgeons of England (RCSEng) and aims to improve the standard of care delivered to patients through standard setting, publications, postgraduate training and assessment, continuing profes- sional development, education and research. The Dental Foundation Interview Guide: with Situational Judgement Tests, First Edition. Zahid Siddique, Shivana Anand and Helena Lewis-Greene. © 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd. 15 16 The dental foundation interview guide Clinical commissioning groups These are overseen by NHS England and are grouped in geographical areas by commissioning healthcare services including general practitioners, hospitals, den- tal services, pharmacists and specialist services. Local authority teams Local authority teams deal with practical, operational and administrative matters in communities. They report back to the NHS commissioning board. They have replaced primary care trusts (PCTs) but work with a central policy and consistent guidelines. Clinical governance Clinical governance is a systematic approach to maintaining and improving the quality of patient care within a health system such as the NHS. NHS organiza- tions have a duty to seek quality improvement, maintain quality healthcare and minimize risks. The practice framework is subdivided into 12 distinct areas. Indemnity provider This is an organization to support and provide impartial conﬁdential advice to den- tal professionals. The majority of indemnity providers are nonproﬁt organizations. It is a legal requirement for dentists to have in place arrangements for compensa- tion to be arranged if they cause harm. A sum is paid on behalf of the dentists for the loss experienced by patients. National Institute for Health and Care Excellence (NICE) The NICE publishes guidelines in: health technology within the NHS; clinical practice; public health sector workers in healthcare. Examples of clinical practice include: Prescription of antibiotics. The guidelines changed in 2008, so no prophylaxis against infective endocarditis is given. Advise patients against cover and liaise with their cardiologist for further assistance if needed. Extraction of wisdom teeth: ∘ unrestorable caries; ∘ no treatment of pulpal and PA pathology are available; ∘ cellulitis; ∘ abscess; ∘ osteomyelitis; ∘ internal and external resorption on wisdom teeth or the adjacent tooth; Deﬁnitions and legalities 17 ∘ fracture; ∘ disease of follicle – cyst/tumour; ∘ reconstructive surgery; ∘ in ﬁeld of tumour resection; ∘ pericoronitis for more than 2 years, one severe. Bisphosphonates – can cause bisphosphonate related osteonecrosis of the jaw (BRONJ). If a patient is on IV or oral bisphosphonates for more than 2 years, this may be a contraindication for extractions. Legislation for the dental team The law related to conﬁdentiality Data Protection Act 1998: ∘ data should be processed lawfully and fairly; ∘ data should be processed for speciﬁc purposes; ∘ adequate, relevant but not excessive note keeping; ∘ accurate, up-to-date records – for example, medical histories; ∘ medical records not kept longer than necessary – 11 years or 25 years if the patient is under 18 years old; ∘ data should be processed in line with subject rights; ∘ security: passwords and locked, encrypted USB safe sticks; ∘ data should not be transferred to countries outside EEA without adequate protection. Freedom of Information Act 2000: ∘ the patient has a right to access notes and records; ∘ the dentist has to give copy within 40 days of receipt of request; ∘ radiographs are the dentist’s property; ∘ patients have the right to correct factual errors in their medical notes; ∘ dentists may charge a fee for radiographs: £50 for a hard copy, £10 for a digital copy. Legislation relevant to raising concerns Public Interest Disclosure Act (PIDA) 1998: ∘ A healthcare professional can break conﬁdentiality and raise a concern if it is in the interest of the public. Qualiﬁed disclosure can occur when the law has been broken. ∘ Conﬁdentiality can be broken when there is a miscarriage of justice, environ- mental harm, when a crime has been committed, or when there is a serious health and safety issue. ∘ The breach in conﬁdentiality must be raised in good faith and undertaken using the correct process. 18 The dental foundation interview guide The law relevant to putting the patient’s best interest ﬁrst Ionising Radiation Regulations (IRR) Ionising Radiation (Medical Exposure) Regulations (IRMER) Health Technical Memorandum HTM01-05 Publications of the Health and Safety Executive (HSE) Disposal of Hazardous Waste/COSHH Human Rights Act 1998 The law relevant to consent Fraser guidelines ∘ Gillick competency and Fraser guidelines refer to the competence of a child under the age of 16 to consent to his or her own medical care. The Fraser guidelines require healthcare professionals to assume that everyone has the capacity to consent until proven otherwise. A child is someone under the age of 18 years old. Persons who usually consent for those under 18 years of age are their mother and father (as named on the child’s birth certiﬁcate) if the time of birth was after 2003, or the father at time of birth if this occurred before 2003. Therefore healthcare professionals can deem people under 18 years Fraser competent until otherwise proven. ‘Capacity’ is assessed by giving patients information and ensuring they are able to understand, retain, weigh up the options and communicate back a decision. Legislation relevant to consent Mental Capacity Act 2005 ∘ This enables those who are over 16 and lack capacity to be protected and empowered to make their own decisions. People who may lack capacity include those who have dementia, strokes, mental health issues, or learning disabilities. Healthcare professionals must assume that all have capacity until proven otherwise. They should help individuals make informed decisions themselves, assess periods of capacity versus no capacity and, if someone lacks capacity, help a decision to be made in that person’s best interest. ∘ Decisions made should be least restrictive of the affected person’s basic rights. ∘ The Mental Capacity Act allows for an ‘independent advocate’ or person pro- vided to support decision making especially if it may signiﬁcantly restrict the affected person’s wellbeing. ∘ How should professionals assess capacity? Does the person have a severe impairment? Does the impairment cause signiﬁcant issues in speciﬁc decision making? ∘ Capacity must be rechecked each time as there may be periods of lack of capacity interspersed with periods of capacity. ∘ How should professionals test for capacity? Understand the information relevant to the decision. Retain the information. Use and weigh up the information. Communicate that decision back. Deﬁnitions and legalities 19 Healthcare professionals must support decision making by thinking about the following: ∘ Has all relevant information been given? ∘ Could information be presented more easily? ∘ Have all alternatives been considered? ∘ Can others help with communication? ∘ Can the decision be delayed? ∘ Can decisions be made at better times during the day or in better environ- ments? ∘ Have other methods of communication been explored? Those who can help with decision making include: ∘ guardians; ∘ those previous named by the patient; ∘ those who take an interest in their welfare; ∘ those granted lasting power of attorney; ∘ those granted enduring power of attorney; ∘ a deputy appointed by Court of Protection. Those granted a lasting power of attorney or an enduring power of attorney must make sure that the Mental Capacity Act statutory principles are followed if the patient does not have the capacity to make decisions. Enduring power of attorneys are valid from before date when the Mental Capacity Act came into force (1 October 2007). All members registered with the GDC must have training in the Mental Capac- ity Act. Clinical governance NHS organizations have a duty to seek quality improvements, maintain quality healthcare and minimize risks. Clinical governance has seven pillars: 1 Clinical effectiveness 2 Audit and peer review 3 Risk management 4 Education 5 Patient information and safety 6 Using information and IT 7 Staff training. Risk factors may be minimized by: 1 Identifying the risk 2 Assessing the risk 3 Removing the risk factors 4 Reducing the risk factors 5 Weighing up the outcome 20 The dental foundation interview guide 6 Sending adverse incident reports and signiﬁcant event auditing to the National Patient Safety Agency (NPSA). The clinical governance framework is subdivided into 12 distinct areas, which are listed below. Infection control Supporting document HTM 01-05 – Decontamination in Primary-Care Dental Practices: this is an essential requirement for best practice; it requires involvement of the whole dental team: adequate staff training needed for CPD; every practice should have written infection control policy which should be followed; procedures should be regularly monitored during clinical sessions and routinely audited; all members of the dental team should understand and practise procedures: reg- ular discussions at team meetings are recommended; employers have responsibility to provide safe and hygienic environment for employees and patients. Child protection and safeguarding Supporting document: Children and Vulnerable Adults: dentists have a wider responsibility for the welfare of patients, which is not just limited to clinical care; all members of the dental team have a responsibility to protect patients from harm and should understand what actions need to be taken if they have any concerns; they should be able to recognize signs of abuse or neglect and ﬁnd out about local procedures and follow them – raising concerns appropriately; induction and training may be needed; all staff need enhanced criminal record bureau (CRB) or now known as disclo- sure and barring service (DBS) checks; patient safety: all staff should be open and honest about any incidents, practice policy should be followed on what to do, there should be contemporaneous record keeping, investigations should be followed, action should be taken where appropriate, lessons should be learned and there should be reﬂection at a staff meetings. Staff should: listen and observe the child; seek an explanation from both child and parent or carer; retain contemporaneous records of everything seen or discussed; consider whether they suspect maltreatment or not; record all actions taken, including their professional conclusion; discuss concerns with colleagues, senior staff members and safeguarding lead; note that informal advice can be taken from local social services anonymously. Deﬁnitions and legalities 21 Radiography Supporting documents: Ionising Radiation (Medical Exposure) Regulations 2000; Health and Safety at Work Act 1974: dental radiographs are taken very frequently – although the dose is small each time, professionals should always consider the collective effect; a radiation protection adviser and supervisor must be allocated to each practice; training records should be kept for all staff; staff should consider the justiﬁcation for and authorization of radiography; they should consider equipment: keep maintenance records; quality assurance – there should be a radiography maintenance plan; aim for 70% grade 1 and 20% not more than grade 2. Staff, patient, public and environmental safety Supporting documents: Health and Safety at Work Act 1974, Reporting of Injuries, Dis- eases and Dangerous Occurrences Regulations (RIDDOR) 2005. This section outlines all duties that employers have to their employees and the public, plus duties employees have to themselves and one another. Some of these include: providing necessary instruction, training and supervision and implementing health and safety practice policy; reporting injuries, diseases, dangerous occurrences; analysing procedures and initiating changes as a result; ensuring that all potentially harmful substances are handled and stored safely; providing a safe work environment; dealing appropriately with hazardous waste; disposing of mercury and amalgam correctly; dealing appropriately with asbestos; handling anaesthetic gases; ensuring electrical safety; taking ﬁre precautions; handling infection control correctly; taking appropriate precautions regarding radiation; noting the dates of medicines and clinical products; handling storage correctly; keeping adequate records. Evidence-based practice and research Supporting documents: NICE guidelines, Faculty of Dental Surgeons guidance: follow relevant NICE guidelines – for example, with regard to recall intervals and wisdom-tooth removal; evidence-based practice should be reﬂected in treatment plans, delivering better oral health; this should be evident in advice given regarding caries, toothbrush use, ﬂuoride, healthy eating, periodontal matters, smoking cessation, alcohol misuse, tooth 22 The dental foundation interview guide erosion, and crowns/cuspal coverage for endodontically treated molars; there should be compliance with referral protocols, for example the Index of Orthodontic Treatment Need (IOTN); continuing professional development (CPD) should be evidence based. Prevention and public health Supporting document: Delivering Better Oral Health (DBOH) 2014: evidence-based prevention policy for all oral diseases and conditions; delivering better oral health – smoking cessation, alcohol consumption, diet, ﬂuoride, toothbrushing, caries, periodontal, erosion. Clinical records, patient privacy and conﬁdentiality Supporting documents: Data Protection Act 1998, Caldicott Guidelines 1997, GDC Stan- dards: Section 4: clinical records should be securely stored: locked/password protected; there should be compliance with relevant legislation; conﬁdentiality should be maintained in all practice settings by all practice staff; clinical audit reports should be kept. Staff involvement and development Staff recruitment: relevant qualiﬁcations, experience, skills, abilities – scope of practice. Pre-employment checks: immunization, Disclosure and Barring Service (DBS), registration, indemnity. Discrimination policy: written procedure manual including employment poli- cies, for example regarding bullying, harassment, sickness, absence. Appropriate staff training: dealing with complaints, appointing someone as a main point of contact and for basic life support. Maintenance and CPD: CPD is a mandatory requirement and employers should ensure that staff undergo this. Clinical governance: quality assurance should be monitored via clinical audit and peer review. Meetings should be well attended by all staff and contributions should be made via staff feedback and surveys. There should be a conﬁdential process to allow staff to raise concerns: a practice policy should be in place with an identiﬁed lead and with links to practitioners’ advice and support schemes (PASS). Clinical staff requirements and records Supporting documents: GDC Standards – Section 7: all staff should be appropriately trained, registered and indemniﬁed; staff should have up-to-date CPD; Deﬁnitions and legalities 23 all staff should know and follow policies and protocol for raising concerns and handling complaints; staff should be aware of changes implemented as a result of any concern and investigations. Patient information and involvement Supporting documents: GDC Standards – Section 1: Communicating effectively: encourage questions and ensure understanding. Patient leaﬂets should be available in a variety of languages used locally. Patient feedback – surveys and suggestion boxes. Treatment plans: written and signed – there should be valid consent. Clear and effective complaints procedure: written, readily available and can easily lead to changes being made. Fair and accessible care Access to interpreters. Disability adjustments: ramps, hearing loops – reasonable efforts made to accom- modate disabilities. Emergency appointments available during the day – open-access appointments. All patients treated fairly. Audits and reports; changes made where necessary. Clinical audit and peer review All staff involved in choosing audit subjects and procedure and in peer review. Learning outcomes, changes communicated to all staff and local primary care trust. All staff attend meetings and contribute. CHAPTER 5 Important notes for revision CHAPTER MENU Standards for the dental team, 25 Consent, 26 Conﬁdentiality, 29 Complaints, 31 Scope of practice, 32 Continued professional development (CPD), 33 Raising concerns, 34 Child protection and vulnerable adults, 35 A checklist of sources to consult during revision, 37 Standards for the dental team These standards are from the GDC, used with permission. The information is correct at the time of going to press. Please visit the GDC website to check for any changes since publication: http://www.gdc-uk.org/Dentalprofessionals/ Standards/Documents/Standards%20for%20the%20Dental%20Team.pdf (accessed 10 November 2015). There are nine principles that registered dental professionals must keep to at all times. As a GDC registrant you must: 1 Put patients’ interests ﬁrst. 2 Communicate effectively with patients. 3 Obtain valid consent. 4 Maintain and protect patients’ information. 5 Have a clear and effective complaints procedure. 6 Work with colleagues in a way that is in patients’ best interests. 7 Maintain, develop and work within your professional knowledge and skills. The Dental Foundation Interview Guide: with Situational Judgement Tests, First Edition. Zahid Siddique, Shivana Anand and Helena Lewis-Greene. © 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd. 25 26 The dental foundation interview guide 8 Raise concerns if patients are at risk. 9 Make sure your personal behaviour maintains patients’ conﬁdence in you and the dental profession. Standards for the dental team apply to: ✓ dentists; ✓ dental nurses; ✓ dental hygienists; ✓ dental therapists; ✓ orthodontic therapists; ✓ dental technicians; ✓ clinical dental technicians. The principles are all equally important and are not listed in order of priority. They are supplemented by additional guidance documents which can be found at www.gdc-uk.org (accessed 10 November 2015) and which you must also follow. You have an individual responsibility to behave professionally and follow these principles at all times. The standards set out what you must do. If you do not meet these standards, you may be removed from the GDC register and will not be able to work as a dental professional. The guidance is there to help you to meet the standards. You are expected to follow the guidance, to use your professional judgment, demonstrate insight at all times and be able to justify any decision that is not in line with the guidance. Serious or persistent failure to follow the guidance could see you removed from our register and not able to work as a dental professional. Consent Consent is ‘permission or agreement for an action to occur’. Training must be undertaken by all dentists in order for them to take valid and comprehensive consent from individual patients. It is important to see the difference between competence and capacity. General Dental Council standards state that professionals should: Obtain valid consent before starting treatment, explaining all the relevant options and the possible costs. Make sure that patients (or their representatives) understand the decisions they are being asked to make. Make sure that the patient’s consent remains valid at each stage of investigation or treatment. Important notes for revision 27 Competence This is a key point to consider when dealing with consent. For patients to give valid consent they must be deemed to be ‘competent’. This requires them to understand fully all the information provided to them regarding their treatment and care. Based on this information they should then have the capability to make a rational decision. Competence is a legal judgement. Capacity Capacity to consent is a medical judgement. Capacity is assessed formally and has to be judged by healthcare professionals in order to conclude that patients are able to understand their management, comprehend the risks and beneﬁts, retain the information and make a decision based on all the information. Competence and capacity have similar connotations. It is important, however, that both are assessed at the time in conjunction with the proposed care plan and each stage must state whether the patient was capable of consenting. Professionals must comply fully with the Mental Capacity Act 2005 in all circumstances and a patient’s capacity must be assessed before consent can be obtained. The four areas considered are: the patient must understand all information given; the patient must be able to retain the information; the patient must be able to use and weigh up the risks and beneﬁts of the information; the patient must be able to communicate back a decision based on a balanced rationale. All adults are assumed to have capacity to consent until otherwise proven. This is to ensure patients have autonomy and full control on their decisions regard- ing their care. Patients may refuse treatment against your advice but this does not mean that they lack capacity. Those with mental illnesses, those who can- not communicate as easily, are young or have a different belief set should not be presumed to lack capacity. Senior colleagues should always be consulted if the healthcare professional is unsure as to whether a patient lacks capacity to consent. If a patient is deemed to lack capacity then the dentist should always act in the best interest of that patient without discrimination and try to involve the patient wher- ever possible. It is also good practice to involve more senior experienced colleagues to provide advice on how best to treat the patient. Seeking consent from a competent patient There are many types of consent but, within dentistry, we are mainly concerned with three types of consent. These are: 1 Voluntary ∘ Patient decides without consultation. ∘ No pressure is imposed. 28 The dental foundation interview guide ∘ The patient can refuse treatment or withdraw at any time. ∘ An example is the patient opening his or her mouth for an examination. 2 Verbal ∘ The patient states verbally that he or she is happy with the procedure. ∘ There is discussion regarding the risks and beneﬁts of a proposed treatment. ∘ There is continuous discussion aided by information over a period of time. 3 Informed ∘ There is discussion regarding the risks and beneﬁts of a proposed treatment. ∘ There is continuous discussion aided by information over a period of time. ∘ There is clear agreement on contract and charges with any amendments reconsented. ∘ Example: treatment planning form FP17 – all treatment to be carried out is written on this form in language understandable to the patient. The form outlines all risks/beneﬁts of treatment and includes both NHS and private cost of treatment. Patients keep a signed copy for themselves and the dentist keeps a signed copy in the patient’s notes. Verbal versus written consent Contemporaneous notekeeping is of the utmost importance within dentistry. Records are taken as part of the process outlining what both parties agreed upon, including a shared vision of outcomes of treatment including risks and beneﬁts proposed. An example of this is the ofﬁcial NHS FP17 treatment planning form. Voluntary and verbal consent may be sufﬁcient in most cases, for example when a special investigation is to be taken such as a ‘tender to percussion’ test or general examination. In these cases, patients must understand what the procedure is and how it will be of beneﬁt to them. If they agree to minor procedures, verbal consent may be enough in their clinical notes. Written consent is needed for any operative dental treatment and larger proce- dures. Some examples are as followed: complex procedures, such as surgical extractions; general anaesthetic; IV or nasal sedation the majority of paediatric procedures; when clinical care is not primarily the purpose of the procedure, for example aesthetic treatments; when treatment is for research; when clinical photography is to be taken. Competence and capacity in children See the section on children and vulnerable adults in this chapter, below. Important notes for revision 29 Conﬁdentiality General Dental Council Standard 4: maintain and protect patients’ information: Make and keep contemporaneous, complete and accurate patient records. Protect the conﬁdentiality of patients’ information and only use it for the pur- pose for which it was given. Only release patients’ information without their permission in exceptional cir- cumstances. Ensure that patients can have access to their records. Keep patients’ information secure at all times, whether your records are held on paper or electronically. ‘Maintain and protect patients’ information’ is one of the core ethical prin- ciples for dentists set by the GDC. The right to conﬁdentiality is paramount in the dentist-patient relationship. This protection of information creates trust and provides the right environment and culture for patients to feel safe during their interaction with the dentist and the wider dental team. As a dentist you have both an ethical and legal duty to keep patient information conﬁdential and patients reserve the right to keep information about them conﬁdential under the Data Pro- tection Act 1998. The GDC sets standards for all dentists to enable them to achieve and maintain patient conﬁdentiality where possible. It must be noted there may be some circumstances where conﬁdentiality may be breached and this will be discussed further below. A breach of patient conﬁdentiality contrary to the GDCs standards by dentists or the wider dental team could result in the dentists’ ﬁtness to practise being found impaired, leaving them liable to action being taken upon their registration. Key facts and information regarding conﬁdentiality There are circumstances when patient conﬁdentiality needs to be breached. This could be to help the patient, for example by sharing information with other health- care professionals regarding treatment, or it may be to protect a member of the public involved with the patient. The following situations are examples of when conﬁdentiality can be breached: 1 Disclosing information to other healthcare professionals or carers involved in the patients overall care. This could be, for example, something as simple as asking a dental colleague for a second opinion or writing a referral letter to another dentist or hospital department regarding the patient’s care, or liaising with the patient’s GP in providing a more holistic care approach for the patient. Breaches such as these occur routinely in practice and are accepted by patients as long as diligence is taken with the information provided, ensuring that it is limited to necessary information only. Patients are deemed to have provided implied consent and must be made fully aware each time any information is passed on to another healthcare professional. If the patient has any objections 30 The dental foundation interview guide to this, it is the professional’s obligation to respect the patient’s choice and try to seek the help needed for the patient without breaching conﬁdentiality. 2 Divulging information as required by law. Information may be disclosed through a court order even if it is against the patient’s wishes. If a court order has been presented then it is the professional’s legal duty to comply and provide the information required. 3 Releasing information for the sake of public interest and public safety, protect- ing the patient or others who are at risk of harm or death in not doing so. There are some situations where professionals will need to release conﬁdential information to protect the patient and others, where they feel the beneﬁt to society outweighs the duty of conﬁdentiality to the patient. Example scenarios of such situations could include treating a neglected child or vulnerable adult. If a female patient being treated for trauma injuries reveals, during her appointment, that she is being physically abused by her partner but does not want you to inform anyone, you might feel that the patient is at serious risk of harm from her partner and feel it is in her best interest to inform other authorities such as the social services or police without gaining valid consent from the patient. It is important to consider who else may be affected by this situation, assessing the wider picture. Does the patient have any children? Could they also be victims of abuse? Is their safety and wellbeing at risk? Considering factors like these will make it easier for you to decide if patient conﬁdentiality must be breached in order to have a greater beneﬁt to the patient and others involved, be it family members or society generally. Another common case is child abuse. If you deem that it is in the best interest of the patient to share information with a third party who can help with the patient’s circumstances, be it a trusted family member or social service, it is important you do so promptly. It is important to remember, with cases such as child abuse, that there is a duty upon you to share information with other agencies such as social services or the police. If for any reason you decide not to report, you should be able to justify your decision fully. If you suspect a child is being abused in any way and you decide to share information with other agencies, you must still tell the child’s parent or legal guardian you are doing so, unless you feel that this may put the patient at further risk of harm. Complicated cases such as these should always be dealt with delicately, espe- cially if you lack experience in dealing with them. In such a case it is important you seek impartial conﬁdential advice from senior colleagues or your indemnity provider who will be able to assist and guide you. Keeping the patient informed In any situation where you need to breach conﬁdentiality it is essential that you discuss it with the patient ﬁrst, gaining consent and informing the patient of your reasons for disclosure. This may prove to be a difﬁcult conversation; however, reas- suring the patient you are doing it in his or her interest or for a greater beneﬁt will make it easier for the patient to understand. If a situation arises where you breach conﬁdentiality without notifying the patient because you feel that by informing Important notes for revision 31 the patient of the breach it may cause further harm and risk to the either the patient or someone else, it is important that you gain advice from your union and other senior colleagues who may be able to help before disclosing any information. Complaints A complaint is any expression of dissatisfaction by a patient or a patient’s rep- resentative about a dental service or treatment, whether justiﬁed or not. Most complaints arise after a series of smaller events are experienced, which leave the patient feeling disappointed. A triggering factor can lead to a complaint. Most com- plaints arise primarily because a patient’s expectation are not met or accounted for. GDC Standard 5 – ‘Have a clear and effective complaints procedure’ The complaint may be justiﬁed or not, spoken or written and about any part of the service delivered. Handling the complaints well maintains and improves the rapport and relationship with your patient, hopefully preventing more complaints. Most complaints are about communication, so handling the complaint clearly and effectively aids ease of outcome. All practices must have a complaints-handling procedure for patients and staff members to follow: ✓ it must be visible; ✓ it should allow complaints to be addressed speedily; ✓ it should allow complaints to be investigated fully and fairly; ✓ it should respect conﬁdentiality; ✓ it should be clearly written; ✓ there should be no dental jargon; ✓ it should clearly explain outcomes; ✓ it should lead to improved service. Setting the framework Patients should know who to contact. Practice employees should familiarize themselves with complaints procedures. Practice employees should have appropriate training. The complaints procedure 1 Acknowledge the complaint and provide the patient with the practice com- plaint procedure. 32 The dental foundation interview guide 2 Inform the dental defence organization if you require advice. 3 Inform the patients of timescales and stages involved. 4 Acknowledge the complaint in writing, by email or by telephone as soon as you receive it – 3 working days maximum but ideally within 24 hours. 5 Respond to the complaint within 10 days – if circumstances arise that prevent this, ensure that the patient is aware of different timescales ensuring you reg- ularly update him or her (at least every 10 working days). 6 Hold a staff meeting for peer review, audit and feedback on the outcome of the complaint. Dealing with the complaints Do not be defensive – use the REACH approach (see box). Deal with all complaints and offer appropriate solutions within an accepted timeframe. Offer an apology – saying sorry shows concern, understanding and empathy, it does not mean you are admitting any responsibility. If justiﬁed, offer compensation. After investigation: send a letter – detailing what has been decided, practical solutions, compensation (if justiﬁed). If the patient is still not satisﬁed, forward the patient’s complaint to NHS Com- plaints Procedure Services (CPS), the Dental Complaints Service (DCS) (for pri- vate practices) or the Patient Advice Liaison Services (PALS) (hospitals). An Ombudsman can be asked to investigate a complaint by a patient formally at any time. R – Recognition E – Empathise A – Apologize C – Compensation H – Honesty Scope of practice General Dental Council registered dental care professionals are: 1 Dentists. 2 Dental nurses. 3 Dental hygienists. 4 Dental therapists. 5 Dental technicians. Important notes for revision 33 6 Clinical dental technicians. 7 Orthodontic therapists. ‘Scope of practice’ guidelines from the GDC give a comprehensive list of what each DCP (dental care professional) can and cannot do. The standards set by the GDC state that all DCPs must: work effectively; have appropriate support – especially in medical emergencies; delegate and refer patients when not competent and only accept patients if competent; communicate clearly; manage and lead the team using everyone’s skill set. When referring patients: clearly request all appropriate information; gain valid consent; if consent is received – be clear and competent and share information; know when to refer; explain the process to the patient; clear contemporaneous record keeping. Continued professional development (CPD) General Dental Council standard 7: ‘maintain, develop and work within your professional knowledge and skills’ All members of the dental team must comply in carrying out veriﬁable and nonver- iﬁable CPD on a 5-year rota. All members must work within their scope, develop their professional evidence-based practice and comply with the guidance from authorities such as NICE, FGDP. Continued professional development upholds the GDC standard of maintaining, developing and working within your professional knowledge and skills. Foundation dentist trainees have their CPD cycle start in the January of their foundation year. It is important to keep a log of CPD, electronic personal develop- ment plans (ePDPs) and any additional courses attended for their CPD log. Dentist = 250 hours total CPD, of which veriﬁable CPD = 75 hours. ✓ Medical emergencies = 10 hours. ✓ Infection control = 5 hours. ✓ Radiography and radiation protection =5 hours. Nurse = 150 hours total CPD of which veriﬁable CPD = 50 hours. ✓ Medical emergencies = 10 hours. ✓ Infection control = 5 hours. ✓ Radiography and radiation protection = 5 hours. 34 The dental foundation interview guide Other CPD themes include: legal considerations and ethics; dental materials – technicians can use this instead of ‘radiography and radiation protection’ as veriﬁable continuing professional development (vCPD); photography; business; complaints handling; techniques; oral medicine; periodontology. Online personal development plan (ePDP) An ePDP is an online log-in book of reﬂection and analysis on your dental expe- riences. Audit Local teams have a list of possible audit projects. Practices can also choose a project or reaudit to compare and contrast results over a period of time. Audit can be accepted as vCPD. It should include: aims and objectives; a summary of methodology; a timetable; detailed educational source material. Peer review Four to eight dentists discuss clinical governance, safeguarding and best practice, which includes clinical and administrative matters. The organizer must dictate fre- quency of meetings, venue and proposed review titles and can submit these to the local scheme. Raising concerns GDC standard 8: ‘raise concerns if patients are at risk’ Raising concerns is different from making a complaint. A complaint must prove a case with appropriate evidence. When raising a concern you should not be expected to prove the malpractice but you are opening a discussion with the aim of acting in the patient’s best interest. All practices should have a policy about raising concerns, with which all staff members should familiarize themselves. A concern must be raised if the patient might be at risk due to: The health, behaviour or professional performance of a colleague – unprofessional behaviour is unacceptable and should be acted upon. Any aspect of the environment where treatment is provided. Important notes for revision 35 Someone asking you to do something that you think conﬂicts with your duties to put patients’ interests ﬁrst and/or to act to protect them. Concerns may be raised with: senior colleagues; the lead person for raising concerns; employers; dental defence organization; professional associations; Public Concern at Work; Care Quality Commission; General Dental Council. There should be an open policy for raising concerns. Staff should feel encour- aged and conﬁdent in doing this, there should be a clear and efﬁcient system in place for it and staff should feel supported after raising a concern. If further guid- ance is needed this can be taken from the Public Disclosure Act 1998 (PIDA), which protects employees who raise genuine concerns in the NHS and privately. The process for raising concerns 1 Keep a log book of the series of events including email threads, time and dates of events and any colleagues’ opinions on the matter. 2 Familiarize yourself with the practice policy for raising concerns. 3 You can take informal advice from your defence organization at any point throughout the raising concerns journey. 4 Approach the raising concerns lead, practice manager or employer regarding your concern. 5 Try to solve the concern within the practice. If this is not applicable then approach your local primary care organization or NHS hospital trust. 6 Refer the matter to the GDC if: ∘ it is not practical to raise a concern at the local level; ∘ the local level has failed; ∘ serious problems have occurred: indecency, violence, crime, illegal practice, victimization or a cover up. Child protection and vulnerable adults All GDC registrants must raise concerns about the possible abuse of children or vulnerable adults. The standards for the dental team state: … You must raise any concerns you may have about the possible abuse or neglect of chil- dren or vulnerable adults. You must know who to contact for further advice and how to refer concerns to an appropriate authority such as your local social services department. 36 The dental foundation interview guide … You must ﬁnd out about local procedures for the protection of children and vulnerable adults. You must follow these procedures if you suspect that a child or vulnerable adult might be at risk because of abuse or neglect. In the United Kingdom, a child is anyone under the age of 18. Once children reach the age of 16 they are presumed by law to be competent and their con- ﬁdentiality must be respected as if they were adults. With regard to healthcare, children aged 16–17 cannot refuse treatment that is in their best interest if it has been agreed by a person with parental responsibility or by a court order. Con- versely, parents or legal guardians cannot overrule the decision of a competent child aged 16–17 when what the parents/guardian want is not in the best interest of the child. In practice, however, at times it can be very difﬁcult to start/complete a treatment that has been consented by a parent if the child in the chair is not willing to cooperate. In such cases it is important to not force the treatment on the child as this may make the experience worse for the child. The professional should think of alternative routes for treatment such as secondary care referrals. Children under 16 are not to be assumed to have the capacity to consent; hence, a parent (named on the child’s birth certiﬁcate) must be present to advocate any dental treatment required. Children under the age of 16 are allowed to give valid consent only if they are deemed Gillick or Fraser competent. Gillick or Fraser com- petency applies to children who have a sufﬁcient understanding and maturity to enable them to understand fully what treatment is proposed including weighing up all risks and beneﬁts of treatment and communicating back decisions based on all the information provided to them. A ‘vulnerable adult’ is ‘a person above the age of 18 years who is or may be in need of community care services (including healthcare) by reason of mental or other disability, age or illness; and who is unable to take care of him or herself, or unable to protect him or herself against signiﬁcant harm or exploitation.’ Spotting the ﬁrst signs of abuse A dental professional is likely to notice injuries to the head and neck region and also to the teeth in conjunction with welfare concerns. Signs and symptoms may include: bruising; burns; lip grazes; bite marks; eye injuries. Most of these injuries may not be coincident with the tooth injury and fall into the ‘zone of protection’ The triangle of safety must be carefully assessed, clinical considerations made, expert guidance taken and all factors must be taken into consideration. There are four types of abuse: 1 Sexual. Important notes for revision 37 2 Mental. 3 Physical. 4 Neglect. Neglect includes frequent caries, plaque stagnation and unclean clothing, which are all aspects that professionals can very easily assess in the dental room. If you make a professional judgement and decide not to share your concern with the appropriate authority, you must be able to justify how you came to this decision. You should contact your defence organization for advice. For more information on child protection and health, see the following web site: http://www.cpdt.org.uk/data/ﬁles/Resources/Childprotectionandthedentalteam_ v1_4_Nov09.pdf (accessed 10 November 2015). A checklist of sources to consult during revision ◻ GDC Standards for the Dental Team ◻ Raising Concerns ◻ Dental Team Working ◻ Scope of Practice ◻ Direct Access ◻ Consent ◻ Complaints ◻ Conﬁdentiality ◻ NICE Guidelines ◻ Steroid Cover ◻ Extraction of 8s ◻ Antibiotic Prophylaxis ◻ Bisphisphonates ◻ Conscious Sedation ◻ General Anaesthetic ◻ Delivering Better Oral Health ◻ Pilot Schemes and Clinical Care Pathway ◻ Whitening Legislation and Bleaching ◻ CQC, COSHH ◻ Clinical Governance ◻ Patient Information and Involvement ◻ Safeguarding Children and Vulnerable Adults ◻ Infection Control ◻ Dental Radiography ◻ Staff, Patient, Public, Environmental Safety ◻ Evidence Based Practice and Research ◻ Prevention and Public Health ◻ Clinical Records, Patient Privacy and Conﬁdentiality ◻ Staff Involvement and Development 38 The dental foundation interview guide ◻ Clinical Staff Requirements and Development ◻ Fair and Accessible Care ◻ Clinical Audit and Peer Review ◻ Quality Assurance ◻ Medical Emergency and Resus Guidelines ◻ Articles ◻ Breaking bad news ◻ Developing the dental team ◻ The ﬁrst ﬁve years ◻ Drug prescriptions ◻ SJT ◻ Social media and the GDC ◻ Reporting criminal convictions and the GDC ◻ Dental protection: ethics ◻ Acts and regulations ◻ Data Protection Act 1998 ◻ Employment Act 2008 ◻ Human Rights Act 1998 ◻ Equality Act 2010 ◻ Public Interest Disclosure Act 1998 ◻ Mental Capacity 2005 ◻ Ionising Radiations Regulations (IRR) 1999 ◻ Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000 ◻ Dental Organizations and Bodies ◻ General Dental Council (GDC) ◻ Faculty of General Dental Practice (FGDP) ◻ British Dental Association (BDA) ◻ Care Quality Commission (CQC) ◻ Dental Protection/Dental Defence Union (DDU) CHAPTER 6 Practice scenarios CHAPTER MENU Introduction, 39 Professionalism, leadership and management scenarios, 40 Patient communication scenarios, 54 Introduction These are scenarios. Information was correct at the time of going to press. Please visit the GDC web site to check for any changes since publication: www.gdc-uk.org (accessed 10 November 2015). The SJTs in this book were veriﬁed and standardized by a group of dentists. Each scenario within general practice, hospital, in a dental foundation year or any other ﬁeld, will be extremely speciﬁc to the individual case. It is important to follow all necessary guidelines, referring to documents, acting logically and methodically and speaking to relevant bodies or team members throughout. The following scenarios relate to each one of the GDC guidelines. Each scenario should be used as guidance only in understanding the basis of answering professionalism, management and leadership questions. There are guidance notes attached for all scenarios to give you a basic understanding of how to manage the scenario as a whole. The Dental Foundation Interview Guide: with Situational Judgement Tests, First Edition. Zahid Siddique, Shivana Anand and Helena Lewis-Greene. © 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd. 39 40 The dental foundation interview guide Professionalism, leadership and management scenarios GDC Standard: 1. Put patients’ interests ﬁrst Scenario: You see an 8-year-old boy for a new patient examination. He attends with his mother who seems uninterested. The patient looks unkempt, withdrawn and, on investigation, has multiple carious lesions and abscesses. After delivering oral-health instruction and trying to explain the plan to both mother and patient, the mother shouts aggressively at the child exclaiming this is his entire fault. You are concerned and worried about the wellbeing of this child. What are the clinical governance issues? How would you manage this scenario? How can you and the team learn from this? What are the clinical governance issues? Dento-legal issues: ∘ putting patients’ interests ﬁrst; ∘ communication; ∘ consent; ∘ conﬁdentiality; ∘ teamwork; ∘ core professional development; ∘ raising concerns; ∘ personal behaviour control. Other clinical governance issues: ∘ health and safety; ∘ record keeping; ∘ child and vulnerable adult protection; ∘ evidence-based practice; ∘ prevention; ∘ staff training and involvement; ∘ clinical effectiveness; ∘ patient information and involvement; ∘ quality assurance and self-assessment (audit, peer review). What would you do at this appointment? Firstly, ensure the patient’s best interest is put ﬁrst. Even though the patient is a minor, all considerations need to be made to ensure complete safety for the patient. Communicate effectively with the wider team. In practice there will always be someone to go to but the ﬁrst port of call will be to raise concerns with the practice safeguarding lead. You have a professional duty to explain all outcomes of the dental assessment to the patient and mother: Practice scenarios 41 explain all caries tooth by tooth; explain aetiology of the caries – poor diet, poor oral hygiene, neglect; explain the abscesses – show them to the mother in the child’s mouth and on the radiographs; write down all the risks and beneﬁts of treatment options; explain treatment options. Try to diffuse the situation by explaining that this is now a health-and-safety issue. Explain to the mother what steps you will take – for example, that you will be speaking to the practice safeguarding lead and introduce any senior members of clinical staff, starting with your educational supervisor, to gain a second opinion. Even though the patient is at risk, these matters must be dealt with profession- ally and you should try to follow consent and conﬁdentiality procedures here. Take a multidisciplinary approach including involving your educational super- visor or senior dentist in the practice, the patient’s GP, social services and any other healthcare providers – working as a team is imperative. Once the meeting is over and any social workers have attended, make contem- poraneous notes, explicitly noting all discussions, conversations, witnesses and outcomes – all notes should be dated, timed and signed. How can you and the team learn from this? The health-and-safety issues raised here need to be highlighted – all practices should have a protocol for health and safety, safeguarding, child protection and team work and these should be maintained and updated regularly. Staff training and involvement should be maintained with regular CPD in all aspects of raising a concern and child protection. Information leaﬂets should be left in the practice for all patients to be aware of issues. In this instance, an incident report form should be completed regarding the appointment and all the events that followed. The notes need to be contempora- neous and up to date on the computer system. There should be a practice incident book or folder in which the report form should be stored – a copy of this can also be attached to the patient’s ﬁle. Moving forward, regular audits should be encouraged – compare, contrast safeguarding issues, audit the practice procedure sheet, the child protection lead should be audited for consistency and outcomes should be monitored. At the next staff meeting a peer review on the management of the appointment and any future outcomes should be discussed and noted. This allows the team to address and learn from the situation and seek further training. GDC Standard: 2. Communicate effectively with patients Scenario: A colleague’s patient comes to practice complaining of pain for LL6. The colleague had performed endodontic treatment on this tooth. A postoperative radiograph shows a broken ﬁle in one of the canals. This has not been documented 42 The dental foundation interview guide in the radiographic report and the patient was unaware of this. How would you deal with this situation? What are the clinical governance issues here? How would you manage this situation? What future plans could be made to minimize risk? What are the clinical governance issues here? Dento-legal issues: ∘ acting in the patient’s best interest; ∘ communication; ∘ consent; ∘ raising concerns; ∘ complaints. Other clinical governance issues: ∘ evidence-based practice; ∘ staff training and involvement; ∘ clinical effectiveness; ∘ record keeping; ∘ health and safety; ∘ CPD, audit, peer review. How would you manage this situation? Your duty of care is to the patient, not the colleague. You must explain your ﬁndings to the patient. An apology will do much to alleviate the concern of the patient. Inform the patient that you will discuss the situation with the colleague who treated her initially. If you do not feel comfortable approaching the colleague directly then discuss the issue with the practice manager, a senior member of staff or the practice principal. A follow-up letter to the patient reassuring them that the practice will do every- thing possible to resolve the situation would be advisable. Offer a consultation to a specialist endodontist (to be paid for by the prac- tice / treating colleague). Medico legally, if the risks of ﬁle separation have not been documented, the full cost of the endodontic treatment should be paid for by the practice / treating colleague otherwise there may be other serious implications. If the patient wants to complain, ensure you direct her to the complaints pro- cedure. The patient can contact NHS complaints or Ombudsman if this complaint cannot be rectiﬁed locally. All complaints should be rectiﬁed locally before going to the primary care trust or General Dental Council. Contact your indemnity provider for advice. Practice scenarios 43 What future plans could be made to minimize risk? Quality assurance needs to be reassessed. Ensure all Care Quality Commission (CQC) outcomes have policies within the practice. The CQC is responsible for ensuring that all healthcare providers are of a gold standard. They will want to see policies that address any adverse incident that might occur, who the leaders for safeguarding and raising concern are within the practice and what standard protocols are in place to deal with the day-to-day running of the practice – for example, complaints, infection control, disposal of materials, staff CPD. All staff should have appropriate training when it comes to communication, raising concerns and complaint handling. There should be a risk assessment of the practice. Are ﬁles being used appro- priately? Are clinicians having proper training in endodontics and keeping CPD relevant? Is there a proper consent protocol? Have notes been made sufﬁciently, including all risks of treatment for all patients? Patient leaﬂets could be made to help patients to understand difﬁcult treatments. There should be self-assessment – audit, peer review, reaudit and comparing to other clinicians, reﬂection in ePDP (an online professional development plan where professionals are able to reﬂect, compare, contrast and state how they will better their learning). Raise the concern with the treating colleague – follow the raising concerns guideline, speak to the raising concerns lead in the practice. GDC Standard: 3. Obtain valid consent Scenario: Mrs Jones attends your surgery and after assessment you decide she needs several of her teeth extracted. She suffers from Alzheimer’s disease and has attended with her carer and friend. What are the issues here and what would you do next? What are the clinical governance issues here? How would you manage this situation? What are the future implications for managing risk? What are the clinical governance issues here? Dento-legal issues: ∘ consent; ∘ putting patients’ interests ﬁrst; ∘ communication; ∘ conﬁdentiality; ∘ teamwork. Other clinical governance issues: ∘ record keeping; ∘ child and vulnerable adult protection; 44 The dental foundation interview guide ∘ evidence-based practice; ∘ prevention; ∘ staff training and involvement; ∘ clinical effectiveness; ∘ patient information and involvement; ∘ accessibility; ∘ quality assurance and self-assessment (audit, peer review, patient feedback). How would you manage this scenario? First and foremost you must assess that Mrs Jones has capacity to make valid consent. Ensure that all options have been given to the patient to make a valid decision – leaﬂets, information videos, several appointments, times. Assessing a patient’s capacity includes giving the patient information, allow- ing the patient to retain the information, weighing up decisions and relaying the information back. The principles of the Mental Capacity Act 2005 are: 1 A person must be assumed to have capacity unless it is established that he lacks capacity. 2 A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success. 3 A person is not to be treated as unable to make a decision merely because he makes an unwise decision. 4 An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests. 5 Before the act is done, or the decision made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action. If Mrs Jones does not have capacity to make an informed decision it is advisable that two healthcare professionals agree on this before continuing treatment. If she has been deemed unable to consent then it is important to ﬁnd out who has power of attorney, and if a legal guardian or an appointed member has been allowed to make the decisions on her behalf. If there is no kin, attorney and so forth, does she need an independent mental capacity advocate (IMCA) before treatment may be carried out?. All decisions need to be made in the patient’s best interest with all beneﬁts out- weighing the risks in order to treat. Treatment must be the least restrictive – the option that is least likely to impair function for the patient and should include full patient cooperation and appropri- ate maintenance. The full team is expected to be a part of treatment, with a multidisciplinary approach with neighbouring specialities, for example special care and sedation units. General practitioners will provide an updated medical history and any changes to dental treatment can be advised accordingly by GPs. Practice scenarios 45 Clinical effectiveness is vital, especially as long duration of appointments or appointments scheduled at inappropriate timings may affect the patients coop- eration and the extent to which she can be assessed. Towards the end of the day the patient’s memory may deteriorate or cooperation may be reduced. Evidence-based practice must be carried out at all times ensuring all relevant guidelines are met and any medications the patient may be taking are documented. All records of options given, opinions and treatments not done must be jus- tiﬁed in contemporaneous notes. Any letters between GPs, surgeons or anyone else involved in the care of the patient must be kept with records. If at any point treatment becomes out of your scope, the relevant person is to be contacted. What are the future implications for managing risk? Quality assurance needs to be reassessed. Ensure all CQC outcomes have policies within the practice. Ensure all staff have appropriate training when it comes to communication, raising concerns and updating their knowledge on capacity assessment and consent. All professionals should be aware of the relevant legislation. There should be risk assessment of the practice to ensure appropriate accessi- bility. Are patient leaﬂets available? Are clinicians having proper training in treat- ment of vulnerable adults and keeping CPD relevant? Is there a proper consent protocol? Have notes been made sufﬁciently and including proper documentation of all risks of treatment for all patients? There should also be self-assessment – audit, peer review, reaudit, comparison to other clinicians, and reﬂection in the ePDP. Raise the concern with the treating colleague – follow the raising concerns guideline, speak to the raising concerns lead in the practice. Patient feedback will always aid in future treatment planning. GDC Standard: 4. Maintain and protect patients’ information Scenario: You have referred an elderly patient to hospital with a persistent mouth ulcer. You suspect oral cancer. The family asks you not to inform the patient if the results of any investigations conﬁrm diagnosis of cancer. What are the clinical governance issues here? How would you handle this scenario? What are the future implications for managing risk? What are the clinical governance issues? Dento-legal issues: ∘ putting patients interest ﬁrst; ∘ communication; ∘ consent; ∘ conﬁdentiality; ∘ complaints; 46 The dental foundation interview guide ∘ teamwork; ∘ core professional development. Other clinical governance issues: record keeping; child and vulnerable adult protection; prevention; staff training and involvement; clinical effectiveness; patient information and involvement; quality assurance and self-assessment (audit, peer review). How would you handle this scenario? Putting the patient’s best interest ﬁrst is the biggest factor here. Your ﬁrst duty is to the patient, not the family. Keeping the patient’s records conﬁdential if he has capacity to consent is vital. The results will be conﬁdential to the patient and must be discussed only with him unless he gives his permission for the information to be disclosed to the family. Protecting elderly relatives is a natural response to potentially bad news. How- ever, the patient’s interests are best served by the protection of his information. Protecting elderly patients is akin to protecting vulnerable adults and, in any case, no health professionals should break their oath by releasing patient infor- mation. The only circumstances are if information proves harmful to society or the patient. In these cases a court order needs to be presented. This scenario needs to be treated delicately. Involvement of the wider dental team is advised and all staff should have appropriate training in handling breaking bad news. The patient’s family needs to be educated in the policy on conﬁdentiality and it should be explained that results will be given to the patient ﬁrst unless otherwise stated. Your duty of care lies with the patient and records of any conversations, letters or demands need to be thoroughly documented in the notes to protect from any dento-legalities. What are the future implications for managing risk? Quality assurance needs to be reassessed. All CQC outcomes should have poli- cies within the practice. All staff should have appropriate training when it comes to conﬁdentiality, breaking bad news and communication, including complaints handling There should be risk assessment of the practice to ensure appropriate informa- tion storage – locked cupboards, electronic backups, hard drives. All staff should have proper training in conﬁdentiality and communication and in keeping CPD relevant, ensuring that all notes were adequate and that documentation included all conversations with the patient’s family. Practice scenarios 47 There should also be self-assessment – audit, peer review, reaudit, comparison to other clinicians, and reﬂection. Patient feedback will always aid in future com- munication. GDC Standard: 5. Have a clear and effective complaints procedure Scenario: A patient wants to complain with regards to how she was treated at the reception desk. She feels that the practice has failed, on numerous occasions, to meet her expectations. She asks you to direct her to the practice complaints pro- cedure. You look in the policy folder and see that there is no complaints procedure document and a lot of the policies are out of date. What are the clinical governance issues here? How would you handle this scenario? What are the future implications for managing risk? What are the clinical governance issues here? Dento-legal issues: ∘ putting patients’ interests ﬁrst; ∘ communication; ∘ consent; ∘ complaints; ∘ teamwork; ∘ core professional development; ∘ raising concerns. Other clinical governance issues: ∘ record keeping; ∘ evidence-based practice; ∘ staff training and involvement; ∘ clinical effectiveness; ∘ patient information and involvement; ∘ quality assurance and self-assessment (audit, peer review). How would you handle this scenario? Immediately reassure the patient. Explain that you will take her details and send a copy as soon as possible. Try to resolve any matters there and then. Involve the wider team – the practice manager, the practice principal, your educational supervisor. After the event, get a complaints procedure set up! The GDC clearly states that all practices must have ‘a clear and effective complaints procedure’. A CQC inspection is also likely to want to see documentation of the practice complaints procedure when carrying out a practice inspection. In this case, the person to approach will be the practice manager, who has the responsibility to ensure that current policies on all governance aspects of the practice are documented. Explain to the patient that you will look into supplying the complain

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