There is an increasing emphasis on enhancing dental student learning through various pedagogical approaches, such as incorporating virtual reality [20] and problem-based learning [21]. However, of equal importance, students’ clinical awareness and confidence in raising clinical concern have not been explored as thoroughly. Existing data on healthcare undergraduate students’ confidence and attitude towards raising concerns are scarce and primarily focused on medical and nursing students [15–17]. This study is among the few to investigate the level of self-reported confidence and the barriers to raising concerns from the perspective of undergraduate dental students during their clinical education.
Like other healthcare settings, malpractice and wrongdoing in dentistry should be actively monitored [8, 22]. Issues related to patient safety issues and other malpractice may be more common in training environments, making it crucial for students to feel empowered, confident and well supported to raise concerns [17]. The attitudes and practices students develop during their training will likely influence their behavior and approach after graduation. However, implementing stringent procedures to address fraud in undergraduate settings has been reported as inadequate [11].
The overall results of this study indicate that, undergraduate dental students are marginally confident in raising concerns, with self-reported confidence levels varying depending on the nature of the issue. The data revealed that students undergoing clinical training exhibit a higher level of self-reported confidence in addressing concerns related to patient safety. However, self-reported confidence levels were notably lower when it came to issues involving the attitude and conduct of clinical staff or fellow students. These findings align with a previous study conducted at Queen Mary University of London, which also found that medical students were most confident when reporting patient safety issues [17]. In descending order, lower confidence levels were observed in reporting issues related to probity, staff and student conduct, the attitude of staff toward patients, and interactions between colleagues [17]. Additionally, a study involving medical students and surgical staff at a public hospital in South Africa found that just over half of the participants felt confident in reporting adverse events, while others expressed uncertainty or reluctance to report [15].
In the current study, participants’ confidence in raising concerns varied not only by context but also by the type of person students felt comfortable approaching. Higher self-reported confidence levels were noted when students raised concerns with fellow students or their direct clinical supervisor. In contrast, students were less confident when addressing concerns to other staff members, such as the clinical course director or the clinical manager. This pattern aligns with findings from a previous study, which showed that students were more confident discussing issues with peers or junior doctors but less so when engaging with formal authority figures [17]. This may be partly due to students often discussing their concerns with peers or junior staff first to gauge the validity and shared nature of their concerns before proceeding to formal reporting. A cross-sectional qualitative study exploring professionalism dilemmas among dental, nursing, pharmacy, and physiotherapy students identified common issues such as student mistreatment, patient safety breaches, and whistleblowing. The study also concluded that students from different disciplines express emotions differently and suggested that sharing these experiences and practicing ideal responses can strengthen their commitment to professional values [23].
Although in the current study, 45% of the participants reported observing inappropriate practices at least once during their clinical training, the data also revealed 29% of the participants were unsure whether they had encountered situations that warranted raising a concern. This uncertainty may point to a need for further support in helping students identify and evaluate what constitutes a legitimate concern. Previous research indicates that students sometimes find it challenging to differentiate between minor issues and more significant ethical concerns and merely suspecting wrongdoing does not necessarily lead to whistle-blowing or raising concerns [24, 25]. Further research should focus on understanding the level of students’ knowledge and awareness regarding malpractice and ethical violations and how this affects their likelihood of raising concerns.
The current study also explored the barriers to raising concerns. The three most frequently mentioned barriers by the students were fear of causing trouble, fear of being unsupported, and fear of being ignored. Students often perceive the risk of raising concerns as too high, especially when they believe that their actions will lead to no meaningful change and may even expose them to potential punishment [18]. Another contributing factor to this reluctance could be the inefficacy of addressing concerns primarily with fellow students or junior staff members, who may lack the necessary knowledge or authority to resolve the issue [17]. Consistent with the findings of this study, research conducted among physicians in the USA identified similar reasons for the lack of reporting, including the belief that someone else will address the problem, fear of retaliation, lack of confidence that appropriate action will be taken, and a sense of loyalty or duty to colleagues [13]. A recent integrative review of 82 studies concluded that whistleblowing in clinical services can lead to positive outcomes, such as enhanced patient safety and favorable resolutions in employment disputes, legal settlements, and court rulings. However, whistle-blowers frequently face negative consequences, including occupational, legal, financial, and socioemotional challenges. Despite the presence of protective policies in most healthcare organizations, whistle-blowers frequently suffer adverse repercussions [26]. To address these issues, future whistle-blowing policies should focus on minimizing the negative impact on whistle-blowers while simultaneously improving patient safety and the quality of care provided [26].
Considering the issues highlighted above, it is essential for institutions to adopt a proactive and transparent approach in addressing concerns to ensure that students feel their opinions are valued and acted upon without fear of retribution. Establishing an ethically safe and supportive workplace culture is crucial. A previous study emphasized that encouraging the reporting of such incidents is more complex than it appears [19]. The study suggested additional measures to promote reporting, such as fostering team trust, providing training sessions, and ensuring the timely reporting of incidents [19]. In the current study, confidence in raising concerns was found to be influenced by gender and year of study. Encouragingly, confidence increased with the year of study, correlating with greater clinical experience. However, due to limited data from similar studies conducted on undergraduate students, direct comparisons with previous research are challenging.
The authors acknowledge limitations in this study. Notably, only 33% of the potential participants completed the survey and were included in the analysis. Given the sensitive nature of the topic and participants' concerns about potential retaliation or punishment, it is possible that individuals who were even more apprehensive chose not to participate, potentially leading to overly optimistic results. Despite these limitations, this study is significant as it represents the first attempt to gather data at a national level from the only two public dental schools in Jordan, currently involving students at the clinical training level. Other recently established Dental schools currently have students at the preclinical level which are not eligible to participate in this study. This contributes valuable insights to the limited evidence available on dental students in this context. However, generalizing these findings to other dental schools in different countries may be challenging due to cultural and environmental differences. To address this, an international comparative study could be beneficial. Additionally, incorporating data from official incident reporting data extracted from the healthcare systems and qualitative methods such as focus groups would provide a more comprehensive understanding of the actual barriers and facilitators directly related to raising concerns.
The results of the current study aim to improve the ethical quality and safety of clinical environments in dental educational institutes. Key steps include developing comprehensive ethical curricula, promoting ethical discussions, implementing supportive practices to reduce wrongdoing, increasing students' confidence in raising concerns, and alleviate the negative consequences associated with reporting issues. It is clear that there is scope for more improvement in this area.