Values related to professionalism in dental education at the University of Chile: Student and faculty perceptions

Abstract Objective It is recognised that professionalism should play a central role in dental education. However, its implementation into the curricula of dental schools is still limited. Our objective was to identify the main values related to professionalism based on the perceptions of students and faculty members from the Faculty of Dentistry, University of Chile. Methods A Dental Values Survey was validated and culturally adapted in order to guarantee the greatest possible internal validity. The adapted survey was administered to students and faculty members (416 and 225, respectively). The final survey contained 64 items rated on a Likert scale of 1‐5. Each item was categorised according to five dimensions: Altruism, Consciousness, Personal Satisfaction, Quality of Life and Professional Status. The values were compared between faculty and students and among students at different courses. A values scale was constructed by selecting the five items with the highest average score for each dimension. Results Survey respondents composed 34.32% of the universe, of which 50.46% were faculty and 49.54% were students. Values associated with Altruism, Consciousness and Professional Status, were the highest rated by students and faculty. Values associated with Personal Satisfaction and Quality of Life received the lowest scores for both groups. Conclusions To provide the best possible attention to patients (Consciousness), and that patients have access to affordable dental care (Altruism), are the values at the top of our scale. On the other hand, to maintain financial stability and to be well paid (Quality of Life) were the less considered.

values and conducts that must be shown by a person in the specific context of a profession. 1,3 A number of professional associations, dental schools and researchers in dentistry consider training on professionalism of great relevance for the future of dentistry. Indeed, many hold the view that dental schools are responsible for developing academic lesson plans that incorporate both specific technical skills and transversal competencies to ensure the development of certain attitudes, values and ethical behaviours among students. 1,[4][5][6][7][8] Existing evidence in dental education suggests that the professional attitudes taught to students in dental programmes will greatly determine the attitudes with which students will finally exercise their profession as a dentist. 9 Therefore, early instruction on professional attitudes and on related educational values is of notable importance, where dental students, and future dentists, can effectively be taught the level of professionalism required to meet ethical standards in dentistry. Ultimately, the application of this approach will result in better dental care for patients. [10][11][12][13] In addition, the climates and educational contexts created within the faculties or schools of dentistry, derived from the challenge of patient clinical care, clinical programmes to be followed, and teaching performances, often promote individualism, competence and stress in the students, all factors to the detriment of learning the values of professionalism during dental training. 8,[14][15][16] Considering this, the efforts made by faculty members to create an academically inclusive and professional climate are also relevant for student education. Specifically, having an integrated learning environment constantly reinforces positive aspects from the first day of a student's education. Furthermore, having such a climate would leave no doubt for faculty members, administrative staff and students as to what constitutes acceptable and unacceptable behaviour, whether in clinical or academic environments. 17 In addition to specific professional competencies, efficient professional development of a dentist should contemplate transversal or generic competencies, which are mainly related to personal development, attitudes and professional behaviour. An important aspect regarding generic competences is that they involve ethics and values as part of a competent behaviour, and therefore, the acquisition and development of these competencies cannot be left to chance or in the hands of the student. Instead, it is the role of educational institutions to instil these values and ensure they are reflected by the attitudes and actions of the faculty. 18 It has been described that in order to properly integrate the values of professionalism during professional training, it is relevant, as a first step, to identify what the core values important to encourage for the institution are, being surveys useful tools that could help in this first step. 19 In a dental context, one of the few instruments that allows this first approach to the values of professionalism is the Dental Values Survey, developed and applied in Canada by Langille et al, 20 which helps to establish a Dental Values Scale. However, there is no Spanish version of this tool to apply in dental schools from Spanish speaking countries.
The objective of the present study was to identify the values closely related to professionalism from the standpoints of students and faculty members from the Faculty of Dentistry at University of Chile through a validated survey administered to dental students and faculty members of the institution.

| MATERIAL S AND ME THODS
The protocols for research and survey administration were evaluated and approved by the Scientific Ethical Committee of the Central Metropolitan Health Service of Chile's Ministry of Health (certificate number 23/15).

| Cultural adaptation and validation of a Dental Values Survey
The survey developed by Langille et al, 20 which created a values scale associated with professional conduct at a dental school in Canada, was culturally adapted and validated for use in the present study. Indeed, it has been demonstrated that preferences regarding professional values are strongly defined by social and cultural factors that are characteristic in a specific population. 21  Once the pilot study was ended, the survey results were statistically analysed to determine internal consistency. The survey was considered sufficiently reliable, returning a Cronbach's α of 0.94 for the entire survey. Each survey item was grouped according to the or programme year (students). An open space was also provided for additional comments.

| Procedure for administering the Dental Values Survey
To deliver the survey to the target population, the final adapted and culturally validated survey was sent by email to the faculty members and undergraduate students from the Faculty of Dentistry at the University of Chile (N = 641; 225 faculty and 416 students), through an online platform (Survey Monkey, San Mateo, CA, USA). For faculty members, the only exclusion criterion applied was to have a profession different from dentist (biochemist, biologist, speech therapist, etc). The emails invited faculty and student participation in the survey, explained the objectives of the survey, guaranteed confidentiality, clearly expressed that participation was voluntary, and that participants could terminate involvement at any moment during the survey. Before beginning the survey, each participant had to click to provide informed consent, and only then, the survey material was shown. The survey was open-access and available for four weeks, with two reminders sent to the target population during this period.

| Information analysis
Descriptive analyses were performed for the study group, specifically of frequencies and percentages in regards to sex and level of specialisation/programme year. The averages obtained per items within each dimension were compared between faculty and students and between students according to programme year. Significant differences were established by Student's t test when data were normally distributed and the Mann-Whitney U test for non-parametric data. Additionally, the opinions/comments of participants were assessed by inductive qualitative analysis using the N-Vivo program (QSR International, Melbourne, VIC, Australia).

| RE SULTS
Faculty and students (N = 220) from the Faculty of Dentistry at the University of Chile, representing 34.32% of the available universe, completed the survey. Of these respondents, 50.46% were faculty and 49.54% were students. Table 1 presents the general characteristics of participants: age, sex, number of students and faculty members, and level of training.
When comparing the average scores for items from each of the five survey dimensions, Quality of Life, which was primarily related to obtaining a good and comfortable life, as well as achieving financial stability and security, was one of the lowest rated dimensions and did not show significant differences between faculty and students (4.04 ± 0.3 vs 4.01 ± 0.36, respectively; P > 0.05; Table 2).
The dimension Personal Satisfaction, with items referring to having a harmonious and enjoyable life outside of work/study and to being happy, was the second lowest rated dimension in both groups and significantly lower for students (4.26 ± 0.22 vs 4.22 ± 0.39, respectively; P < 0.01; Table 2).
In contrast, Altruism, defined as behaving with compassion, demonstrating kindness and understanding others, did not present significant differences between instructors and students, in addition to being the highest rated of the evaluated professional dimensions (4.42 ± 0.27 vs 4.41 ± 0.13, respectively; P > 0.05; Table 2). Quality of Life 4.00 ± 0.29 vs 3.46 ± 0.26; Table 3).
The optional opinions of students and faculty, assessed via inductive qualitative analysis, were grouped into two categories: perception of the profession and aspects related to training. Subcategories were assigned to each of these two categories, which, in addition to all the responses, are summarised in Table 4.
The category perception of the profession is related to all the opinions, from students and faculty members, regarding their experiences when performing the profession. The comments in this category were related, on one hand, to the fact that they think that to study dentistry you need to have the real vocation to help others and, on the other hand, to the fact that when practising dentistry, it is difficult to reconcile your time with family life, and that there is work

| D ISCUSS I ON
The present study validated and administered a Dental Values Survey to faculty members and students from the Faculty of Dentistry at the University of Chile in order to identify the most important professionalism-associated values. Different works have demonstrated the relevance of this aspect in medical and dental education, describing that in order to introduce professionalisms into the curriculum, it is previously necessary to establish an own definition of professionalism and its values, reaching a consensus between students and faculty members' opinions (or even other members of the academic community). Once the relevant professional values for a specific institution and its context identified, their introduction into the curriculum through vertical integration in a spiral curriculum and using proper methodological and evaluative tools is mandatory. 19,22 In this study, the dimension Quality of Life was scored the lowest, without significant differences between faculty and students.
This could be principally due to the current market situation for the dental profession in Chile. Specifically, the lack of regulation Integrate multidisciplinary teams 2 The programme does not provide training for this aspect 3 Revalue undergraduate education, oriented to form good general and dentists with integrity 2

Stress
Emotionally draining and stressful degree programme 3 on the quantity of dental programmes being offered has resulted in high enrolments and an inflated number of dentistry graduates in recent years, and the labour market has not been able to absorb these numbers, creating a complex job market for dentists. 23 This situation has been mostly prevalent in the first generations of dentists that are unemployed or underemployed, principally by private clinics or "mega"-health providers. Many are paid a percentage of services rendered, which varies depending on the number of patients. This is in addition to forgoing many traditional benefits, such as a work contract, health insurance and workers' compensation. 24 Particularly in regard to students, other factors that may contribute to the perceived low quality of life include a demanding educational programme that leaves little free time and insecurity about real job prospects upon graduating, resulting in high degrees of frustration and anxiety according to student opinions (Box 1).
When we compare our results with those obtained by Langille et al, we observed that the dimensions Quality of Life and Personal Satisfaction were lower in our reality. This can be explained, at least in part, by the Chilean context and environment for dental professionals in comparison with the context in Canada. Currently, Chile has 34 dental schools with a total of 22 859 dentists 25 for a population of 17 million people, with a dentist to population ratio of 1:760.
In Canada, there are just 10 dental schools 26 for a country with 37 million people and with a dentist to population ratio of 1:1622. 27 Related to this, the recommended ratio from the Organisation for Economic Co-operation and Development (OECD) is 1:1785 which means that, in total, Chile has approximately a 230% oversupply of professionals. However, if we analyse the distribution of dentists between public and private sectors, public sector, with approximately 4500 dentists, 25 provides care to about 80% of the population (~13.6 million people) and, therefore, has an approximately 100% deficit of dentists with an important overload of work for these professionals.
On the other hand, if we consider that private sector gives dental treatment to the remaining 20% of the population (~3.4 million people), it has about a 1000% oversupply (1:185 dentist to population ratio), which means a highly competitive scenario, specially for future dentists. In this context, this situation is very likely to have a negative influence in students' and dentists' perception regarding their Quality of Life and Personal Satisfaction. Moreover, in Canada there is the National Dental Examining Board, which ensures a standard after graduation for all dentists in the country, and in Chile, just 16 out of 34 dental schools have a proper accreditation, which ensures some quality standard of their graduates. 28 This situation may reflect a more unstable situation for dentists in Chile than in Canada, which could be responsible for the lower score for these dimensions.
The second lowest rated dimension was Personal Satisfaction, with student ratings significantly lower than those of faculty. These students, which consumes most paid hours, but also implies unpaid overtime to complete tasks such as class and seminar preparation and grading quizzes/tests. This work situation undoubtedly contributes to a deteriorated perception of the work-life balance and little time for personal and family activities (Box 1).
In the dimension Consciousness, encompassing professional values of acting ethically and honestly, it was interesting to find that although it was the second highest rated dimension, indicating its value of importance, students rated this dimension significantly lower than faculty. This is in line with that previously reported by Langille et al 20 and might be explained, in part, by the dishonest actions that students have admitted to taking to prevent programme failure. 14,36,37 Moreover, it is probable that the high enrolment costs and debt associated with financing higher education in Chile further promote unethical behaviour. The present results could also be associated with previous studies, which indicate that existing environments in dentistry faculties favour individualistic and competitive behaviour over personal development. [37][38][39] Due to the variety of interactions that can occur when students are attending patients, it is reasonable to assume that the hidden curriculum (teachings transmitted to students that does not explicitly appear in the formal curriculum) becomes more active in a clinical context, where the supervising instructor should act as a model for students to follow in regard to attitude and behaviour. In this context, instructors should also act as moral models and receive training on the educational system. 12 The dimension Professional Status did not present significant differences between students and instructors, and this was similar to the previously reported in Canada. However, it is worth mentioning that the two most important items for both groups were continued professional development and that the profession is related to the medical environment. These aspects are fundamental in the educational environment of today. This is especially true in health professions given the paradigm shift in skill formation, where it is necessary to train dentists able to critically self-assess and continuously update their knowledge. 40 The values associated with Altruism obtained the highest averaged values, without significant differences between instructors and students. These results indicate that those who study dentistry at the University of Chile, in large part, do so as a vocation for helping people and that this premise is maintained not only while studying, but also after graduation. This result becomes relevant if institutions assume student education not only from a technical standpoint, which is undoubtedly the first moral responsibility, but also from a standpoint of training professionals that will contribute to a better, more humane and more just society. 41,42 In Canada, although the values for this dimension were also high, the highest dimension was Conscientiousness. In our opinion, this difference is due, at least in part, to social and health inequities, as well as to difficulties to access dental care for the most vulnerable population in Chile. In were consistently decreasing during the years, being specially lower in the last year when compared with the first one. They described that this situation may represent a "relaxation" effect in that senior students know the realistic amount of work needed to complete the programme and, therefore, they would need some reinforcement to prevent conscientiousness from slipping further and to give the fourth-year students a more realistic expectation of the level of conscientiousness needed for success in dental practice. 20 In the present study, fourth-year students must attend real patients for the first time, which could contribute to emotional burnout, pressure and stress, as previously analysed. In contrast, years one to three of the programme are focused on basic science and preclinical practices.
In the sixth year, students finalise their school-based training and enter residency programmes at hospitals and rural/urban primary care centres. While faced with new environments and challenges, during residencies, students are freed from the pressures of completing specific clinical modules and obtaining patients. It is also possible that by fully executing their profession, sixth-year students are "reenchanted" by their selected major, which continues to hold high social recognition. An additional limitation is related to the fact that the survey was applied in a faculty of dentistry. This was not only a methodological decision but also a conceptual one since we were mainly interested in identifying, from a critical social perspective of understanding education, our institutional situation regarding this topic, in order to further transform and enhance their development in our students.

| CON CLUS IONS
We also believe that our institution may reflect and influence an important part of the dental reality in our country. Indeed, the Faculty of Dentistry at the University of Chile is the oldest (with more than 100 years of history) and the most important in Chile, being the only Chilean dental school in the prestigious Academic Ranking of World Universities 2018 (ranked 101-150).

| PER S PEC TIVE S
Currently, the Faculty of Dentistry at the University of Chile is in the fifth year of innovating its curriculum, with specific initiatives to have students practice in integrated clinics, thus bringing the student closer to real clinical situations from earlier stages of training.
Gaining clinical competencies by providing comprehensive patient care and not by simply fulfilling individual tasks could be an opportunity to significantly decrease the stress of students, in addition to strengthening their sense of responsibility and empathy with patients. This, in turn, will prevent seeing the patient as an object or programme to complete, but rather as a person who needs help to resolve their oral health problems and recover their general wellbeing. This earlier in-clinic practice will also give students the opportunity to work the values of professionalism.
In relation to the dental profession, there is an exaggerated number of Dental Schools in Chile, many of which are of doubtful quality.
Due to this, we believe it is of vital importance to address and review the different existing programmes, with the obligatory accreditation of individual dentistry programmes being a fundamental and urgent basic requirement to ensure that graduates are properly trained.
Stricter institution and programme requirements will prevent high graduate numbers and, consequently, decrease the future unemployment or unstable employment of new professionals. In a later stage, specific and transversal competency levels could be required from graduates via a Standardized National Dentistry Exam, the application of which has an extensive track record worldwide. 46,47 Passing this exam should be an indispensable requirement for dentists in Chile, in both public and private sectors. These steps would grant greater confidence in the quality of dental programmes as well as for the graduates from these programmes, changes that would significantly improve the quality of life and oral health of the Chilean population.

ACK N OWLED G EM ENTS
We would like to acknowledge all the students and faculty members who participated in this study. We also thank Mr Juan Fernández and Ms Ashley VanCott for translational assistance during the preparation of this manuscript and with the linguistic validation of the survey.

CO N FLI C T O F I NTE R E S T
The authors declare that there is no conflict of interest regarding the publication of this article.