Validation of the inventory of ethical problems for oral health

Gomes, Doris; Zoboli, Elma; Finkler, Mirelle

doi:10.1590/1983-80422020284437

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Research • Rev. Bioét. 28 (4) • Oct-Dec 2020 • https://doi.org/10.1590/1983-80422020284437 copy

Validation of the inventory of ethical problems for oral health

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This is a methodological research to validate the Inventory of Ethical Problems in Primary Health Care for Oral Health using the Delphi technique, searching for a consensus among 23 dental surgeons. A comparative analysis between the reference instrument and the Inventory for Oral Health was requested, questioning their compatibility and adequacy, including ethical problems specific to the studied area. The professionals proposed rewriting and altering several items. A second round was conducted to seek consensus on issues not exhausted in the previous stage. The Delphi technique was essential to obtain more understandable and adequate items, enhancing the use of the inventory by oral health workers and public health managers, the ethical reflection on the problems experienced, and the construction of collective deliberation processes.

Keywords:
Ethics; Bioethics; Primary health care; Oral health; Validation study

Reference IEP-PHC item	IEP-PHC-OH Writing after 1st round	IEP-PHC-OH Writing after 2nd round
1. Difficulty in establishing the limits of the professional-user relationship.	1. Difficulty in establishing the limits of the professional-user relationship.
2. Prejudgment of service users by the teams.	2. Oral health professionals or UBS workers pre-judge and disrespect users and family members based on prejudice and stigmas.	2. Disrespect for users or family members by ESB professionals or UBS workers, based on prejudice and stigmas.
3. The professional disrespects the user.
4. Inadequate clinical indications.	4. Inadequate clinical indications.	4. Inadequate clinical indications of treatments or procedures by oral health professionals.
5. Prescription of a medicine that the user cannot afford.	5. The professionals prescribe specialized treatments or procedures that the user cannot afford, when these treatments/procedures are not offered by SUS.	5. Prescription of treatment or indication of procedure that the user cannot afford.
7. The user asks the doctor and nurse for the procedures they want.	7. The user asks the dentist for the procedures they want.	7. User ask the dentist for the procedures they want, following a coercive consumption pattern or traditional invasive cure.
8. How to convince the user to continue the treatment.	8. Oral health professionals feel powerless to convince the user to continue the treatment, especially without the educational and promotional work strengthened by the team, more specifically the TSB.	8. How to convince or motivate the user to continue the treatment, especially without the TSB's health promotion clinical work.	8. Difficulty in convincing or motivating the user to continue the treatment, especially without the TSB's clinical-educational work.
14. Lack of commitment and involvement of some professionals who work in the PSF.	14. Lack of commitment and involvement of some professionals who work in oral health and EqSF.	14. Lack of commitment and involvement of some ESB professionals related to their duties.
15. EqSF do not collaborate with each other.	15. ESB and EqSF do not collaborate with each other, have low strategic planning level and few joint actions.	15. EqSF and ESB do not collaborate with each other, resulting in few inter-professional actions.
16. Lack of respect among team members.	16. There is a lack of respect among the ESB members, especially with regard to valuing the auxiliary service and teamwork.	16. Lack of respect among the ESB members, especially with regard to valuing the auxiliary service and teamwork.
18. It is difficult to limit the role and responsibilities of each professional.
17. Lack of preparation of professionals to work in the PSF.	17. Lack of preparation/training (profile) of professionals to work in the PSF.	17. Inadequate training of oral health professionals to perform their duties in PHC.
19. Omission by professionals when the prescription is inadequate or wrong.	19. Omission by professionals when an improper or wrong clinical procedure is performed.	19. Omission by oral health professionals in face of inadequate clinical procedures or prescriptions.
21. Difficult in preserving privacy due to problems in the physical structure and routine of the USF.	21. Difficult in preserving privacy due to problems in the physical structure and routine of the USF.	21. Difficult in preserving user's privacy due to problems in the physical structure and routine of the ESB and UBS.
22. Lack of support with intersectoral actions to discuss and resolve ethical problems.	22. Oral health and EqSF professionals lack support from intersectoral actions, which depend on the system organization and management, to discuss and resolve ethical problems they encounter in their practice.	22. Lack of institutional support with intersectoral actions to discuss and resolve ethical problems.
23. Lack of transparency of the UBS management in solving problems with the professionals.	23. Lack of transparency of the UBS management in solving problems with the professionals.	23. Lack of transparency of the UBS coordination in solving problems involving professionals.
24. Excess of families assigned to each team.	24. Excess of families assigned to each team of the ESF and ESB.	24. Excess of families assigned to each ESB.
26. Devaluation of referrals made by PSF doctors.	26. Devaluation of referrals made by public service dentists.	26. Devaluation of the quality of care provided by public service dentists by other professionals, especially from the private sector.
27. Difficulties and lack of reference to carry out complementary examinations.	27. There is difficulty related to the referral and counter-referral system for radiographic examinations, in addition to lack of service agility and efficiency.	27. Difficulty in the reference system to carry out complementary examinations, especially radiographic ones.
32. Users who refuse to follow medical instructions or undergo examinations.	32. Users who refuse to follow the indications of preventive oral care actions, without changing their individual health management.	32. Users who do not follow professional guidelines in caring for their own health.
35. USF workers question the medical prescription.	35. ESB professionals question the dentists’ conduct.	35. Difficulty in preserve user's privacy due to problems in the physical structure and routine of the ESB and UBS.
38. Lack of structure at the USF to carry out home visits.	38. Home visits are hampered by issues related to commuting, especially the Odontomóvel, reducing the dentist's clinical practice power.	38. Lack of conditions for ESB professionals to carry out home visits.
39. Lack of conditions at the USF for emergency care.	39. UBS does not handle all dental emergency care, besides operational problems.	39. Lack of conditions or installed capacity for the ESB to meet all urgent needs.

Ethical problems in oral health	Writing after 1st round	Writing after 2nd round
2. The reception of users who seek dental care does not follow what is recommended by the ESF.	2. Disagreement between the reception of users in oral health and that recommended by the ESF.
6. Absence or insufficiency of ASB to develop preventive and clinical activities.	6. Absence or insufficiency of ASB to assist in clinical and collective work.
7. Difficulty in carrying out preventive actions due to problems in health-education intersectoral relations.	7. Difficulties in carrying out educational-preventive actions due to problems in health-education intersectoral relations.
10. Violence experienced at work.	10. Violence experienced at work involving several actors.
12. ESB professionals witness discrimination between users.	12. Discrimination of users against other users, related to social stigmas.	12. Discrimination between health system users, related to social stigmas.
13. Oral health professionals understand that users have cognitive problems related to social vulnerability.	13. Some oral healthcare users have cognitive problems related to socioeconomic conditions that generate social vulnerability.
15. The dental office structure makes teamwork difficult and facilitates auxiliary team's occupational illnesses.	15. Difficulty in developing clinical teamwork and illnesses at work due to problems in the dental office physical structure.
18. Decrease or lack of UPA emergency dental care.
20. Precarious working conditions.	20. Precarious working conditions in oral health.
22. Structural problems about properly allocating professionals to the CEO.	22. Inadequate or insufficient allocation of professionals to the CEO.
24. Lack of transparency in the waiting list for oral health medium complexity services.
26. Underestimation and deviation of function from TSB to ASB.
27. Engagement of professionals in the ESF is related to specific training for the area.	27. Lack of engagement by professionals, related to insufficient training for the ESF.	27. Lack of engagement by professionals, related to insufficient training to work in PHC/ESF.
29. Lack of unity of workers for a greater appreciation of PHC and oral health work.	29. Lack of ESB unity for a greater appreciation of PHC work.
30. Incomprehension of the dentist's performance beyond curative action and as part of the ESF.	30. Incomprehension of the dentist's performance as part of the ESF and beyond curative action.

Inventory of Ethical Problems in Primary Health Care for Oral Health (IEP-PHC-OH)
1. Difficulty in convincing or motivating the user to continue the treatment, especially without the TSB's clinical-educational work.
2. Excess of families assigned to each ESB.
3. Lack of conditions or installed capacity for the ESB to meet all urgent needs.
4. Lack of conditions for ESB professionals to carry out home visits.
5. EqSF and ESB do not collaborate with each other, resulting in few inter-professional actions.
6. Disrespect for users or family members by ESB professionals or UBS workers, based on prejudice and stigmas.
7. Prescription of treatment or indication of procedure that the user cannot afford.
8. Lack of commitment and involvement of some ESB professionals related to their duties.
9. Inadequate training of oral health professionals to perform their duties in PHC.
10. Inadequate clinical indications of treatments or procedures by oral health professionals.
11. Omission by oral health professionals in face of inadequate clinical procedures or prescriptions.
12. Devaluation of the quality of care provided by public service dentist by other professionals, especially from the private sector.
13. Difficulty in the reference system to carry out complementary examinations, especially radiographic ones.
14. Lack of respect among the ESB member, especially with regard to valuing the auxiliary service and teamwork.
15. Questioning about the dentists’ clinical conduct by other oral health professionals, including auxiliary professionals.
16. Lack of institutional support with intersectoral actions to discuss and resolve ethical problems
17. Difficulty in establishing the limits of the professional-user relationship.
18. The user asks the dentist for the procedures he wants, following a coercive consumption pattern or traditional invasive cure.
19. Difficulty in preserve user's privacy due to problems in the physical structure and routine of the ESB and UBS.
20. Lack of transparency of the UBS coordination in solving problems involving professionals.
21. Users who do not follow professional guidelines in caring for their own health.
22. Disagreement between the reception of users in oral health and that recommended by the ESF.
23. Absence or insufficiency of ASB to assist in clinical and collective work.
24. Difficulties in carrying out educational-preventive actions due to problems in health-education intersectoral relations.
25. Violence experienced at work involving several actors.
26. Discrimination between health system users, related to social stigmas.
27. Some oral health care users have cognitive problems related to socioeconomic conditions that generate social vulnerability.
28. Difficulty in developing clinical teamwork and illnesses at work due to problems in the dental office physical structure.
29. Decrease or lack of UPA emergency dental care.
30. Precarious working conditions in oral health.
31. Inadequate or insufficient allocation of professionals to the CEO.
32. Lack of transparency in the waiting list for oral health medium complexity services.
33. Underestimation and deviation of function from TSB to ASB.
34. Lack of engagement by professionals, related to insufficient training to work in PHC/ESF.
35. Lack of ESB unity for a greater appreciation of PHC work.
36. Incomprehension of the dentist's performance as part of the ESF and beyond curative action.

Inventário de Problemas Éticos na Atenção Primária à Saúde para Saúde Bucal (IPE-APS-SB)
1. Dificuldade em convencer ou motivar o usuário a dar continuidade ao tratamento, especialmente sem o trabalho clínico-educativo do TSB.
2. Excesso de famílias adscritas para cada ESB.
3. Falta de condições ou capacidade instalada para as ESB atenderem a todas as urgências.
4. Falta de condições para a realização de visitas domiciliares pelos profissionais da ESB.
5. As EqSF e ESB não colaboram umas com as outras, resultando em poucas ações interprofissionais.
6. Desrespeito aos usuários ou familiares por parte dos profissionais da ESB ou trabalhadores da UBS, com base em preconceitos e estigmas.
7. Prescrição de tratamento ou indicação de procedimento que o usuário não poderá pagar.
8. Falta de compromisso e envolvimento de alguns profissionais que atuam na ESB no desempenho de suas atribuições.
9. Inadequada formação dos profissionais da saúde bucal para o desempenho de suas atribuições na APS.
10. Inadequadas indicações clínicas de tratamentos ou procedimentos pelos profissionais da saúde bucal.
11. Omissão dos profissionais da saúde bucal diante de procedimento clínico ou prescrição inadequados.
12. Demérito da qualidade assistencial do cirurgião-dentista do serviço público por outros profissionais, em especial da iniciativa privada.
13. Dificuldade no sistema de referência para realização de exames complementares, especialmente os radiográficos.
14. Falta de respeito entre os membros da ESB, em especial na valorização do serviço auxiliar e do trabalho em equipe.
15. Questionamento sobre a conduta clínica dos(as) cirurgiões(ãs)-dentistas por outros profissionais da saúde bucal, inclusive pelos profissionais auxiliares.
16. Falta de apoio institucional com ações intersetoriais para discutir e resolver problemas éticos.
17. Dificuldade de estabelecer os limites da relação profissional-usuário.
18. O usuário solicita ao cirurgião-dentista os procedimentos que deseja, seguindo um padrão coercitivo de consumo ou tradicional de cura invasiva.
19. Dificuldade para preservar a privacidade do usuário por problemas na estrutura física e rotina da ESB e da UBS.
20. Falta de transparência da coordenação da UBS na resolução de problemas que envolvem os profissionais.
21. Usuários que não seguem as orientações profissionais no cuidado com sua própria saúde.
22. Desacordo entre o acolhimento aos usuários na saúde bucal e o preconizado pela ESF.
23. Ausência ou insuficiência de ASB para auxiliar no trabalho clínico e coletivo.
24. Dificuldades na realização das ações educativo-preventivas devido a problemas nas relações intersetoriais saúde-educação.
25. Violência vivenciada no trabalho envolvendo diversos atores.
26. Discriminação entre usuários do sistema de saúde, relacionada a estigmas sociais.
27. Alguns usuários da saúde bucal apresentam problemas cognitivos relacionados a condições socioeconômicas geradoras de vulneração social.
28. Dificuldade para desenvolver o trabalho clínico em equipe e ocorrência de doenças no trabalho devido a problemas na estrutura física do consultório odontológico.
29. Diminuição ou ausência de atendimento odontológico de urgência nas UPA.
30. Precarização das condições de trabalho na saúde bucal.
31. Inadequada ou insuficiente alocação de profissionais no CEO.
32. Falta de transparência na fila de espera pelos serviços de média complexidade em saúde bucal.
33. Subestimação e desvio de função de TSB para ASB.
34. Falta de engajamento dos profissionais, relacionada a formação insuficiente para atuar na APS/ESF.
35. Falta de união da ESB para maior valorização do trabalho na APS.
36. Incompreensão sobre a atuação do cirurgião-dentista como parte da ESF e para além da ação curativa.

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E-mail: bioetica@portalmedico.org.br

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[1] Correspondence Doris Gomes – Rua Rafael da Rocha Pires, 3.913, Sambaqui CEP 88051-001. Florianópolis/SC, Brasil.