Moral competence of dental students: an explanatory mixed-methods study
The adherence to moral principles in dentistry was recognized as a core competency . Moral and communication skills in the dental profession are effective in building patients’ trust and increasing patients’ cooperation . Moral in dentistry is defined as dentists’ commitment to ethical responsibilities towards their patients, colleagues, and society . Acquiring these moral skills assists dentists in making the best decisions when facing difficult clinical challenges and ethical dilemmas . The American Dental Association announced that the biggest issue of dental education is the challenges of ethical and moral behavior of dental students . Due to the spread of ethical dilemmas in care processes, the need for healthcare providers’ support in ethical decisions has increased . Guidelines for professional ethics in dentistry based on the model of ethical reasoning of Rest were prepared by committees consisting of the Council of Dental Education (CDE), the American College of Dentists (ACD), and the American Association of Dental Schools (AADS) . This guideline classified moral skills into four domains: moral sensitivity, moral judgment, moral motivation, and moral courage . The moral skills describe four processes, each of which independently affects ethical behavior. Moral sensitivity means awareness of the moral aspects of a situation and ethical behavior in any situation. Moral reasoning refers to a state in which a person recognizes the moral challenge and chooses the best possible solution by considering their moral aspects. Moral motivation is related to a person’s inherent desire to perform ethical actions and prioritize professional values. Moral courage is attained when a person controls his/her behavior in different moral situations. A person should have enough perseverance, emotional strength, and executive skills to conduct moral behavior. According to the Rest model, in order for someone to “behave morally” in a certain situation, the person must have applied at least the four basic processes [ – ]. Chambers  stated that four components of moral skills are interrelated. Therefore, he designed a questionnaire called “Moral Skills in Inventory” that scored the four domains of Rest’s model in the form of self-evaluation . According to previous studies, a growing body of research has been conducted in the medical field; however, ethical issues require more investigation in dentistry. Evaluating students in the four components can clearly define the level of individuals’ moral skills. Targeted planning for developing moral behaviors among dental students requires more inquiry in determining the level of the mentioned domains. Moreover, a main concern of educational systems is the declining trend of moral reasoning and students' adherence to ethical principles in academic years . Thus, assessment of the moral skills of the students in different academic years may be useful in addressing the concern. Therefore, the present study aimed to 1) investigate the level of four domains of moral sensitivity, moral reasoning, moral motivation, and moral courage among dental students and 2) explore the factors affecting the engagement of students in moral behavior. 

Study design This study is an explanatory mixed-method study conducted in two quantitative–qualitative phases. In the first phase, a descriptive study was conducted, and in the qualitative phase, the participants’ experiences were explained concerning the factors affecting their engagement in moral behavior. In the quantitative phase, participants included undergraduate students in clerkship courses in dentistry school. Participants Quantitative phase The inclusion criterion was the students who are studying in clerkship courses (the fourth, fifth, and sixth years of education), and the exclusion criterion was students’ unwillingness to participate. The sample size was calculated to be 139 participants, which considering z = 1.96, σ 2 = 36, d 2 = 1, and added a 30% increase, it was estimated to be 180. Qualitative phase Participant recruitment was guided by the principle of data saturation , a widely accepted approach in qualitative inquiry. Sampling continued until data saturation was achieved, indicating that no new themes or codes emerged from the data, and existing codes were fully explored and refined. In the qualitative phase, the participants were selected using maximum variation sampling. According to the sampling, the participants who scored the highest ( n = 8) and lowest ( n = 9) in the quantitative phase were included in this phase ( n = 15). 

This study is an explanatory mixed-method study conducted in two quantitative–qualitative phases. In the first phase, a descriptive study was conducted, and in the qualitative phase, the participants’ experiences were explained concerning the factors affecting their engagement in moral behavior. In the quantitative phase, participants included undergraduate students in clerkship courses in dentistry school. 

Quantitative phase The inclusion criterion was the students who are studying in clerkship courses (the fourth, fifth, and sixth years of education), and the exclusion criterion was students’ unwillingness to participate. The sample size was calculated to be 139 participants, which considering z = 1.96, σ 2 = 36, d 2 = 1, and added a 30% increase, it was estimated to be 180. Qualitative phase Participant recruitment was guided by the principle of data saturation , a widely accepted approach in qualitative inquiry. Sampling continued until data saturation was achieved, indicating that no new themes or codes emerged from the data, and existing codes were fully explored and refined. In the qualitative phase, the participants were selected using maximum variation sampling. According to the sampling, the participants who scored the highest ( n = 8) and lowest ( n = 9) in the quantitative phase were included in this phase ( n = 15). 

The inclusion criterion was the students who are studying in clerkship courses (the fourth, fifth, and sixth years of education), and the exclusion criterion was students’ unwillingness to participate. The sample size was calculated to be 139 participants, which considering z = 1.96, σ 2 = 36, d 2 = 1, and added a 30% increase, it was estimated to be 180. 

Participant recruitment was guided by the principle of data saturation , a widely accepted approach in qualitative inquiry. Sampling continued until data saturation was achieved, indicating that no new themes or codes emerged from the data, and existing codes were fully explored and refined. In the qualitative phase, the participants were selected using maximum variation sampling. According to the sampling, the participants who scored the highest ( n = 8) and lowest ( n = 9) in the quantitative phase were included in this phase ( n = 15). 

Quantitative data collection The Moral Skill Inventory was used in this phase. This questionnaire was designed by Chambers in 2011 based on Rest’s four-component model of moral behavior . The validity of the questionnaire was confirmed in the context (Cronbach’s alpha = 0.8) . This questionnaire consists of four domains, each of which has ten questions (40 questions in total). Each question is scored between 0–2. The highest score is 80, and the lowest score that people can get is considered zero . Students completed the questions as a self-administrated. In order to collect data, written informed consent was obtained from students for participating in this research while stating the objectives of the research. Then, the students were asked to fill out the questionnaire. Quantitative data analysis The data were summarized using mean, standard deviation, and frequency (percentage). One sample t-test, independent t-test, one-way analysis of variance (ANOVA), and a post hoc Bonferroni test were used to analyze the data. SPSS version 22 software was used, and the significance level of 0.05 was considered. Qualitative data collection In this phase, the experiences of the students are explored through semi-structured interviews. The semi-structured interview guide was developed through a systematic process, informed by established protocols for designing and refining qualitative interview instruments . The development process commenced with a critical evaluation of the study's purpose and research questions to ensure the suitability of the semi-structured interview method. Subsequently, a review of the literature was conducted to retrieve and synthesize prior knowledge relevant to the study. A preliminary version of the semi-structured interview guide was then formulated, wherein the retrieved knowledge was operationalized into a structured, logical, and coherent framework. To validate the guide, a pilot study was conducted with three student participants, and their feedback and suggestions were incorporated into the final version of the interview guide. In this phase, a trained interviewer conducted a semi-structured interview. The interviews were conducted during the academic semester in a quiet place. There was no interaction between the participants and the interviewer. The interviews were initiated based on the interview guide with the question, “What is the state of adherence to moral principles in the clinic? What factors make you engage in moral behavior? What factors prevent the occurrence of moral behavior among you and your peers? Why do such behaviors happen in the environment of clinical training?” (Appendix 1). The interview was continued with probing questions to explain the participants’ experiences. The interview sessions were recorded. While conducting the interview, the interviewer took notes of the interviewees' key statements. Each interview lasted about 45 min. Data collection continued until data saturation was achieved , which occurred when no new codes were being generated, and existing codes were not being further elaborated or refined. This milestone marked the point at which the data collection process was deemed complete, as further data collection was unlikely to contribute new insights or themes to the study. Qualitative data analysis Data were analyzed using conventional qualitative content analysis, which Graneheim and Lundman introduced. Based on the content analysis, data coding starts with open codes, and by combining them, categories and themes emerge . All interviews were typed word by word. In order to get to data immersion, the researcher listened to the interviews several times and reviewed their typed text many times. In order to analyze the data, meaningful units were obtained from the participants’ statements that express their experiences. Subsequently, meaningful words and short sentences were specified to extract the codes. Then, to extract the codes, the data were read word by word, the highlighted words were identified, and coding was extracted by taking notes in the margin of the text. Next, the codes were merged and placed in categories based on semantic affinity. After the organization, categories were formed based on the relationship between them. The themes were then compared, and the theme emerged. Trustworthiness In this study, the criteria of Guba and Lincoln , including credibility, transferability, dependability, and conformability, were used. Various methods were used to attain the credibility criteria, including reflection on the purpose of the study and the main research question, using the in-depth interview to collect data, reflection on the semantic units for analysis, and long-term involvement with the data and spending enough time to collect and analyze data. This qualitative content analysis may influence researchers’ positions and biases, which inherently shape the interpretation of the data . As researchers situated within the context of health professions education and dental education, our experiential knowledge and preconceptions have informed our approach to data collection and analysis. Specifically, our backgrounds as health professions educators have instilled in us a particular understanding of the research topic, which may have influenced our coding and theme exploration. To mitigate the potential for confirmation bias and increase the transparency and trustworthiness of the findings, the researchers engaged in regular reflexive practice throughout the research process. It involved documenting our thoughts and assumptions, soliciting feedback from colleagues and peers to challenge our interpretations, and critically examining our position and its potential impact on the research. This study employed reflexivity strategies to ensure the credibility of the research findings . The participants were asked to review the explored results to ensure the findings matched their experience. (Member-checking). In addition, peer debriefing was used to ensure the credibility of research . Peer debriefing was performed by two qualified peer researchers who conducted a comprehensive review and evaluation of the study's transcripts, categories, and final themes or findings. This process was designed to ensure the accuracy, and integrity of the research, and to scrutinize the researcher's work for any errors or oversights. Team reflexive dialogue and reflexive writing (memo and field note) were used to facilitate critical self-reflection and examination of the research process. Bracketing was employed to suspend the researchers' perspectives and gain a deeper understanding of the research participants' experiences. Reflexive journaling was also used to track the researchers' own biases, assumptions, and emotional responses to the data and to identify potential areas of influence on the research findings. By incorporating these reflexivity strategies, the researchers were able to critically evaluate their research practices and enhance the reliability of the research findings. Continuous comparisons between the content of categories and themes were used to monitor semantic and structural coherence. In the present study, all the stages of the research, especially the stages of data analysis, were recorded in detail to achieve the transferability criteria. Also, to facilitate the transferability of the findings, a clear description of the context, the selection method, and the characteristics of the participants, the data collection process, and the data analysis process was provided. The mapping of quantitative and qualitative results within the moral competence in dental education was developed and validated by five experts in the field of dental education. Ethical consideration The present study was approved by the ethics committee of the National Agency Strategic Research in Medical Education, Tehran, Iran (ID: IR.NASRME.REC.1400.460). This research adhered to the principles of information confidentiality. The informed consent for participating in the research was obtained. The right to withdraw from the study at any stage of the study and to record the interviews was explained to the participants. 

The Moral Skill Inventory was used in this phase. This questionnaire was designed by Chambers in 2011 based on Rest’s four-component model of moral behavior . The validity of the questionnaire was confirmed in the context (Cronbach’s alpha = 0.8) . This questionnaire consists of four domains, each of which has ten questions (40 questions in total). Each question is scored between 0–2. The highest score is 80, and the lowest score that people can get is considered zero . Students completed the questions as a self-administrated. In order to collect data, written informed consent was obtained from students for participating in this research while stating the objectives of the research. Then, the students were asked to fill out the questionnaire. 

The data were summarized using mean, standard deviation, and frequency (percentage). One sample t-test, independent t-test, one-way analysis of variance (ANOVA), and a post hoc Bonferroni test were used to analyze the data. SPSS version 22 software was used, and the significance level of 0.05 was considered. 

In this phase, the experiences of the students are explored through semi-structured interviews. The semi-structured interview guide was developed through a systematic process, informed by established protocols for designing and refining qualitative interview instruments . The development process commenced with a critical evaluation of the study's purpose and research questions to ensure the suitability of the semi-structured interview method. Subsequently, a review of the literature was conducted to retrieve and synthesize prior knowledge relevant to the study. A preliminary version of the semi-structured interview guide was then formulated, wherein the retrieved knowledge was operationalized into a structured, logical, and coherent framework. To validate the guide, a pilot study was conducted with three student participants, and their feedback and suggestions were incorporated into the final version of the interview guide. In this phase, a trained interviewer conducted a semi-structured interview. The interviews were conducted during the academic semester in a quiet place. There was no interaction between the participants and the interviewer. The interviews were initiated based on the interview guide with the question, “What is the state of adherence to moral principles in the clinic? What factors make you engage in moral behavior? What factors prevent the occurrence of moral behavior among you and your peers? Why do such behaviors happen in the environment of clinical training?” (Appendix 1). The interview was continued with probing questions to explain the participants’ experiences. The interview sessions were recorded. While conducting the interview, the interviewer took notes of the interviewees' key statements. Each interview lasted about 45 min. Data collection continued until data saturation was achieved , which occurred when no new codes were being generated, and existing codes were not being further elaborated or refined. This milestone marked the point at which the data collection process was deemed complete, as further data collection was unlikely to contribute new insights or themes to the study. 

Data were analyzed using conventional qualitative content analysis, which Graneheim and Lundman introduced. Based on the content analysis, data coding starts with open codes, and by combining them, categories and themes emerge . All interviews were typed word by word. In order to get to data immersion, the researcher listened to the interviews several times and reviewed their typed text many times. In order to analyze the data, meaningful units were obtained from the participants’ statements that express their experiences. Subsequently, meaningful words and short sentences were specified to extract the codes. Then, to extract the codes, the data were read word by word, the highlighted words were identified, and coding was extracted by taking notes in the margin of the text. Next, the codes were merged and placed in categories based on semantic affinity. After the organization, categories were formed based on the relationship between them. The themes were then compared, and the theme emerged. Trustworthiness In this study, the criteria of Guba and Lincoln , including credibility, transferability, dependability, and conformability, were used. Various methods were used to attain the credibility criteria, including reflection on the purpose of the study and the main research question, using the in-depth interview to collect data, reflection on the semantic units for analysis, and long-term involvement with the data and spending enough time to collect and analyze data. This qualitative content analysis may influence researchers’ positions and biases, which inherently shape the interpretation of the data . As researchers situated within the context of health professions education and dental education, our experiential knowledge and preconceptions have informed our approach to data collection and analysis. Specifically, our backgrounds as health professions educators have instilled in us a particular understanding of the research topic, which may have influenced our coding and theme exploration. To mitigate the potential for confirmation bias and increase the transparency and trustworthiness of the findings, the researchers engaged in regular reflexive practice throughout the research process. It involved documenting our thoughts and assumptions, soliciting feedback from colleagues and peers to challenge our interpretations, and critically examining our position and its potential impact on the research. This study employed reflexivity strategies to ensure the credibility of the research findings . The participants were asked to review the explored results to ensure the findings matched their experience. (Member-checking). In addition, peer debriefing was used to ensure the credibility of research . Peer debriefing was performed by two qualified peer researchers who conducted a comprehensive review and evaluation of the study's transcripts, categories, and final themes or findings. This process was designed to ensure the accuracy, and integrity of the research, and to scrutinize the researcher's work for any errors or oversights. Team reflexive dialogue and reflexive writing (memo and field note) were used to facilitate critical self-reflection and examination of the research process. Bracketing was employed to suspend the researchers' perspectives and gain a deeper understanding of the research participants' experiences. Reflexive journaling was also used to track the researchers' own biases, assumptions, and emotional responses to the data and to identify potential areas of influence on the research findings. By incorporating these reflexivity strategies, the researchers were able to critically evaluate their research practices and enhance the reliability of the research findings. Continuous comparisons between the content of categories and themes were used to monitor semantic and structural coherence. In the present study, all the stages of the research, especially the stages of data analysis, were recorded in detail to achieve the transferability criteria. Also, to facilitate the transferability of the findings, a clear description of the context, the selection method, and the characteristics of the participants, the data collection process, and the data analysis process was provided. The mapping of quantitative and qualitative results within the moral competence in dental education was developed and validated by five experts in the field of dental education. 

In this study, the criteria of Guba and Lincoln , including credibility, transferability, dependability, and conformability, were used. Various methods were used to attain the credibility criteria, including reflection on the purpose of the study and the main research question, using the in-depth interview to collect data, reflection on the semantic units for analysis, and long-term involvement with the data and spending enough time to collect and analyze data. This qualitative content analysis may influence researchers’ positions and biases, which inherently shape the interpretation of the data . As researchers situated within the context of health professions education and dental education, our experiential knowledge and preconceptions have informed our approach to data collection and analysis. Specifically, our backgrounds as health professions educators have instilled in us a particular understanding of the research topic, which may have influenced our coding and theme exploration. To mitigate the potential for confirmation bias and increase the transparency and trustworthiness of the findings, the researchers engaged in regular reflexive practice throughout the research process. It involved documenting our thoughts and assumptions, soliciting feedback from colleagues and peers to challenge our interpretations, and critically examining our position and its potential impact on the research. This study employed reflexivity strategies to ensure the credibility of the research findings . The participants were asked to review the explored results to ensure the findings matched their experience. (Member-checking). In addition, peer debriefing was used to ensure the credibility of research . Peer debriefing was performed by two qualified peer researchers who conducted a comprehensive review and evaluation of the study's transcripts, categories, and final themes or findings. This process was designed to ensure the accuracy, and integrity of the research, and to scrutinize the researcher's work for any errors or oversights. Team reflexive dialogue and reflexive writing (memo and field note) were used to facilitate critical self-reflection and examination of the research process. Bracketing was employed to suspend the researchers' perspectives and gain a deeper understanding of the research participants' experiences. Reflexive journaling was also used to track the researchers' own biases, assumptions, and emotional responses to the data and to identify potential areas of influence on the research findings. By incorporating these reflexivity strategies, the researchers were able to critically evaluate their research practices and enhance the reliability of the research findings. Continuous comparisons between the content of categories and themes were used to monitor semantic and structural coherence. In the present study, all the stages of the research, especially the stages of data analysis, were recorded in detail to achieve the transferability criteria. Also, to facilitate the transferability of the findings, a clear description of the context, the selection method, and the characteristics of the participants, the data collection process, and the data analysis process was provided. The mapping of quantitative and qualitative results within the moral competence in dental education was developed and validated by five experts in the field of dental education. 

The present study was approved by the ethics committee of the National Agency Strategic Research in Medical Education, Tehran, Iran (ID: IR.NASRME.REC.1400.460). This research adhered to the principles of information confidentiality. The informed consent for participating in the research was obtained. The right to withdraw from the study at any stage of the study and to record the interviews was explained to the participants. 

One hundred eighty dental students participated in this study. The demographic characteristic of the participants is also shown in Table . The moral skill scores of the dental student in different domains are showed in Table . The mean students’ scores of moral skills by academic years of education are shown in Table . The difference in students’ moral skills scores in different years was significant (Table and Fig. ). A significant difference in students’ scores in the domains of moral sensitivity and courage during the academic years was reported ( p -value < 0.05). The post hoc test showed that the scores in the domains of moral sensitivity and reasoning of the 4th-year students were significantly lower compared to other academic years. The results showed no significant difference between students’ moral skill scores in genders ( P = 0.66). The student’s scores were related to their age ( P = 0.002). The moral skill scores of the students had a significant negative relationship with taking the ethics course in the formal curriculum (r = 0.16 and P = 0.02). The relationship between moral skills scores and participation in forensic dentistry workshops was not significant ( P = 0.22). The mean score of students, which is 43.61 (6.25), is higher than the theoretical mean (mean score of the scale, which is equal to 40) ( P = 0.0001). Qualitative results The participants’ experiences were explained under the theme “Morality as a neglected element in dentistry.” This theme includes two categories “Disregarding professionalism as a professional responsibility” and “unsupportive behaviors of clinical teachers in a moral dilemma.” (Table ). A- Disregarding professional responsibility This category addressed the challenges of moral behavior among students, which included three subcategories: “negligence in commitment to professional values,” “indifference towards unprofessional behaviors,” and “conflict of values and interests.” A1- Negligence in commitment to professional values This category discussed the negligence of dental students in professional principles and insensitivity to unprofessional behavior by others. A student stated: I took a part of the suction that didn’t have a cover; for a moment, I thought of changing the gloves, but then, I told myself, “Let it go”. It was the restorative department, and I didn’t have much time. I had to finish the job in this meeting. (Female, semester 8, 22 years old). Some classmates did not obey the professional principles. The patient was not so important to them, and conducting complete treatment was not so important to them. So, they did not want to take care of hygiene, and they didn’t have the patience to completely cover everywhere or even completely wash all the equipment and then sterilize it in the autoclave (Female, semester 11, 23 years old). In the clinic, I wanted to conduct the procedures quickly; for example, I didn’t fix caries or fill the teeth with amalgam with some problems, but it didn't matter because the side effects occurred when I wasn’t working in that clinic for long. (Male, 23 years old, semester 11). Suppose you fix the patient’s problem in two hours instead of one. The patient thinks you don’t know her job, so you are prolonging the process. You will lose the patient’s trust right away. (Female, 23 years old, semester 11). A2- Indifference toward unprofessional behaviors The second category discussed students' indifference towards peers and clinical teachers' unprofessional behavior. The students believed that they did not recognize error disclosure and that correcting and reporting a peer’s error was a professional responsibility. They considered not reacting to the observed peers’ errors the best way to protect themselves from adverse consequences. My friend took an x-ray of the patient’s teeth several times. I understood that the patient was exposed to too much radiation, but I thought it had nothing to do with me (Female, semester 9, 23 years old). One of my friends took the wrong tooth out. Honestly, I didn’t do anything because if that person has a conscience, he will follow up and explain. If I want to say something, I will get in trouble. Everyone should be responsible for their work, even if it goes wrong. (Female, semester 9, 23 years old). Everyone is responsible for what they do, and I cannot tell that person or anyone else because I am a student and cannot give others feedback. (male, 23 years old, semester 11) . If I understand a classmate's mistake, it depends on his personality whether I give him/her feedback or not. I won’t say anything if he/she is proud and self-righteous because I don’t like his/her reaction. He/she might frown or say something that will upset me. People’s reactions are important to me and depend on that person’s conscience, not mine (male, 24 years old, semester 11). A3- Conflict of values and interests The challenge of students' interest in the decision-making of ethical dilemmas was discussed in the category. The students believed personal interests, such as getting good scores and popularity, were more important than adherence to professional principles. In this regard, a participant stated: Grades are even more important to me than everything. Grades are important to me so that I can raise my achievement and stay the top student (female, 22 years old, and semester 9) . My classmates and I make mistakes to do the job faster. For us, the patient is like a customer, so I only want to get the grade (Female, 24 years old, semester 9). I could not wear the crown of the patient’s teeth, so I had to fix it so that the error would not be visible. Otherwise, I had to do it again. If I repeated it, I would have to pay for the laboratory myself. I was not willing to repeat the same procedure. For me, both my prestige and financial issues were important (male, 23 years old, semester 11) . In the restoration department, I only want to finish the task soon and complete the number of requisitions. I don’t want to learn (male, 23 years old, semester 11). I’m alone in the clinic, so no matter what I do. Since there is a financial issue here, I didn’t involve myself much in principles. I like to finish the patients’ care quickly and see the next patient, even if it leads to making a mistake (male, 23 years old, and semester 11). My classmate used dental burs several times and touched different places with his/her gloves, and then he/she put it in the patient’s mouth because he/she wanted to finish the job faster and get a grade from the clinical teacher. There is no benefit or harm for them, so they will do it again (female, 23 years old, semester 11). B- Unsupportive behaviors of clinical teachers in moral dilemmas In this category, systemic challenges were discussed. The unsupportive behaviors of clinical teachers in the moral dilemmas were explained as a key element of the educational system in two subcategories: “concern about negative feedback from clinical teachers” and “irresponsible behaviors of clinical teachers.” B1- Worrying about negative feedback from clinical teachers Students believed that when they encounter moral and professional problems and challenges, they should hide them to avoid negative reactions from clinical teachers. In this regard, a participant stated: In the department of diagnosing oral diseases, they behave in such a way that the student is humiliated. So, fear makes you hide things if something goes wrong. I know I made a mistake, but I’m not going to say it because I’m afraid of clinical teachers. (Female, semester 9, 23 years old). I made a mistake and did not disclose my error because no one would help me. Instead of finding a solution, the clinical teacher would get angry at me and scold me in the future (male, semester 11, and 23 years old). When I make a mistake, I take an x-ray so that it looks good because I am afraid of the teachers’ bad behavior. I try to hide it (female, semester 11, and 23 years old). B2- Irresponsible behaviors of clinical teachers The non-commitment of the clinical teachers to the principles of professionalism was explained in this category. The participants believed that clinical teachers do not follow professionalism principles. In this regard, a participant stated: In the prosthetic department, my clinical teacher works without gloves. He takes the turbine without gloves and works in the patient’s mouth; his phone rings, and he answers the phone and returns to work with that hand. The clinical teacher understands and knows, but he is tired and does not care. I do not do anything for him. (Female, semester 9, 23 years old). A clinical teacher who puts his hands in the patient’s mouth without gloves does not care. They surely do not do such a thing in their office because they lose the patient’s trust there. However, it doesn’t matter to them in the university clinic because the patients would come here anyway (female, 24 years old, and semester 11). Figure illustrates the mapping of the quantitative and qualitative results within the domain of moral competence in dental education. 

The participants’ experiences were explained under the theme “Morality as a neglected element in dentistry.” This theme includes two categories “Disregarding professionalism as a professional responsibility” and “unsupportive behaviors of clinical teachers in a moral dilemma.” (Table ). A- Disregarding professional responsibility This category addressed the challenges of moral behavior among students, which included three subcategories: “negligence in commitment to professional values,” “indifference towards unprofessional behaviors,” and “conflict of values and interests.” A1- Negligence in commitment to professional values This category discussed the negligence of dental students in professional principles and insensitivity to unprofessional behavior by others. A student stated: I took a part of the suction that didn’t have a cover; for a moment, I thought of changing the gloves, but then, I told myself, “Let it go”. It was the restorative department, and I didn’t have much time. I had to finish the job in this meeting. (Female, semester 8, 22 years old). Some classmates did not obey the professional principles. The patient was not so important to them, and conducting complete treatment was not so important to them. So, they did not want to take care of hygiene, and they didn’t have the patience to completely cover everywhere or even completely wash all the equipment and then sterilize it in the autoclave (Female, semester 11, 23 years old). In the clinic, I wanted to conduct the procedures quickly; for example, I didn’t fix caries or fill the teeth with amalgam with some problems, but it didn't matter because the side effects occurred when I wasn’t working in that clinic for long. (Male, 23 years old, semester 11). Suppose you fix the patient’s problem in two hours instead of one. The patient thinks you don’t know her job, so you are prolonging the process. You will lose the patient’s trust right away. (Female, 23 years old, semester 11). A2- Indifference toward unprofessional behaviors The second category discussed students' indifference towards peers and clinical teachers' unprofessional behavior. The students believed that they did not recognize error disclosure and that correcting and reporting a peer’s error was a professional responsibility. They considered not reacting to the observed peers’ errors the best way to protect themselves from adverse consequences. My friend took an x-ray of the patient’s teeth several times. I understood that the patient was exposed to too much radiation, but I thought it had nothing to do with me (Female, semester 9, 23 years old). One of my friends took the wrong tooth out. Honestly, I didn’t do anything because if that person has a conscience, he will follow up and explain. If I want to say something, I will get in trouble. Everyone should be responsible for their work, even if it goes wrong. (Female, semester 9, 23 years old). Everyone is responsible for what they do, and I cannot tell that person or anyone else because I am a student and cannot give others feedback. (male, 23 years old, semester 11) . If I understand a classmate's mistake, it depends on his personality whether I give him/her feedback or not. I won’t say anything if he/she is proud and self-righteous because I don’t like his/her reaction. He/she might frown or say something that will upset me. People’s reactions are important to me and depend on that person’s conscience, not mine (male, 24 years old, semester 11). A3- Conflict of values and interests The challenge of students' interest in the decision-making of ethical dilemmas was discussed in the category. The students believed personal interests, such as getting good scores and popularity, were more important than adherence to professional principles. In this regard, a participant stated: Grades are even more important to me than everything. Grades are important to me so that I can raise my achievement and stay the top student (female, 22 years old, and semester 9) . My classmates and I make mistakes to do the job faster. For us, the patient is like a customer, so I only want to get the grade (Female, 24 years old, semester 9). I could not wear the crown of the patient’s teeth, so I had to fix it so that the error would not be visible. Otherwise, I had to do it again. If I repeated it, I would have to pay for the laboratory myself. I was not willing to repeat the same procedure. For me, both my prestige and financial issues were important (male, 23 years old, semester 11) . In the restoration department, I only want to finish the task soon and complete the number of requisitions. I don’t want to learn (male, 23 years old, semester 11). I’m alone in the clinic, so no matter what I do. Since there is a financial issue here, I didn’t involve myself much in principles. I like to finish the patients’ care quickly and see the next patient, even if it leads to making a mistake (male, 23 years old, and semester 11). My classmate used dental burs several times and touched different places with his/her gloves, and then he/she put it in the patient’s mouth because he/she wanted to finish the job faster and get a grade from the clinical teacher. There is no benefit or harm for them, so they will do it again (female, 23 years old, semester 11). B- Unsupportive behaviors of clinical teachers in moral dilemmas In this category, systemic challenges were discussed. The unsupportive behaviors of clinical teachers in the moral dilemmas were explained as a key element of the educational system in two subcategories: “concern about negative feedback from clinical teachers” and “irresponsible behaviors of clinical teachers.” B1- Worrying about negative feedback from clinical teachers Students believed that when they encounter moral and professional problems and challenges, they should hide them to avoid negative reactions from clinical teachers. In this regard, a participant stated: In the department of diagnosing oral diseases, they behave in such a way that the student is humiliated. So, fear makes you hide things if something goes wrong. I know I made a mistake, but I’m not going to say it because I’m afraid of clinical teachers. (Female, semester 9, 23 years old). I made a mistake and did not disclose my error because no one would help me. Instead of finding a solution, the clinical teacher would get angry at me and scold me in the future (male, semester 11, and 23 years old). When I make a mistake, I take an x-ray so that it looks good because I am afraid of the teachers’ bad behavior. I try to hide it (female, semester 11, and 23 years old). B2- Irresponsible behaviors of clinical teachers The non-commitment of the clinical teachers to the principles of professionalism was explained in this category. The participants believed that clinical teachers do not follow professionalism principles. In this regard, a participant stated: In the prosthetic department, my clinical teacher works without gloves. He takes the turbine without gloves and works in the patient’s mouth; his phone rings, and he answers the phone and returns to work with that hand. The clinical teacher understands and knows, but he is tired and does not care. I do not do anything for him. (Female, semester 9, 23 years old). A clinical teacher who puts his hands in the patient’s mouth without gloves does not care. They surely do not do such a thing in their office because they lose the patient’s trust there. However, it doesn’t matter to them in the university clinic because the patients would come here anyway (female, 24 years old, and semester 11). Figure illustrates the mapping of the quantitative and qualitative results within the domain of moral competence in dental education. 

This category addressed the challenges of moral behavior among students, which included three subcategories: “negligence in commitment to professional values,” “indifference towards unprofessional behaviors,” and “conflict of values and interests.” 

This category discussed the negligence of dental students in professional principles and insensitivity to unprofessional behavior by others. A student stated: I took a part of the suction that didn’t have a cover; for a moment, I thought of changing the gloves, but then, I told myself, “Let it go”. It was the restorative department, and I didn’t have much time. I had to finish the job in this meeting. (Female, semester 8, 22 years old). Some classmates did not obey the professional principles. The patient was not so important to them, and conducting complete treatment was not so important to them. So, they did not want to take care of hygiene, and they didn’t have the patience to completely cover everywhere or even completely wash all the equipment and then sterilize it in the autoclave (Female, semester 11, 23 years old). In the clinic, I wanted to conduct the procedures quickly; for example, I didn’t fix caries or fill the teeth with amalgam with some problems, but it didn't matter because the side effects occurred when I wasn’t working in that clinic for long. (Male, 23 years old, semester 11). Suppose you fix the patient’s problem in two hours instead of one. The patient thinks you don’t know her job, so you are prolonging the process. You will lose the patient’s trust right away. (Female, 23 years old, semester 11). 

The second category discussed students' indifference towards peers and clinical teachers' unprofessional behavior. The students believed that they did not recognize error disclosure and that correcting and reporting a peer’s error was a professional responsibility. They considered not reacting to the observed peers’ errors the best way to protect themselves from adverse consequences. My friend took an x-ray of the patient’s teeth several times. I understood that the patient was exposed to too much radiation, but I thought it had nothing to do with me (Female, semester 9, 23 years old). One of my friends took the wrong tooth out. Honestly, I didn’t do anything because if that person has a conscience, he will follow up and explain. If I want to say something, I will get in trouble. Everyone should be responsible for their work, even if it goes wrong. (Female, semester 9, 23 years old). Everyone is responsible for what they do, and I cannot tell that person or anyone else because I am a student and cannot give others feedback. (male, 23 years old, semester 11) . If I understand a classmate's mistake, it depends on his personality whether I give him/her feedback or not. I won’t say anything if he/she is proud and self-righteous because I don’t like his/her reaction. He/she might frown or say something that will upset me. People’s reactions are important to me and depend on that person’s conscience, not mine (male, 24 years old, semester 11). 

The challenge of students' interest in the decision-making of ethical dilemmas was discussed in the category. The students believed personal interests, such as getting good scores and popularity, were more important than adherence to professional principles. In this regard, a participant stated: Grades are even more important to me than everything. Grades are important to me so that I can raise my achievement and stay the top student (female, 22 years old, and semester 9) . My classmates and I make mistakes to do the job faster. For us, the patient is like a customer, so I only want to get the grade (Female, 24 years old, semester 9). I could not wear the crown of the patient’s teeth, so I had to fix it so that the error would not be visible. Otherwise, I had to do it again. If I repeated it, I would have to pay for the laboratory myself. I was not willing to repeat the same procedure. For me, both my prestige and financial issues were important (male, 23 years old, semester 11) . In the restoration department, I only want to finish the task soon and complete the number of requisitions. I don’t want to learn (male, 23 years old, semester 11). I’m alone in the clinic, so no matter what I do. Since there is a financial issue here, I didn’t involve myself much in principles. I like to finish the patients’ care quickly and see the next patient, even if it leads to making a mistake (male, 23 years old, and semester 11). My classmate used dental burs several times and touched different places with his/her gloves, and then he/she put it in the patient’s mouth because he/she wanted to finish the job faster and get a grade from the clinical teacher. There is no benefit or harm for them, so they will do it again (female, 23 years old, semester 11). 

In this category, systemic challenges were discussed. The unsupportive behaviors of clinical teachers in the moral dilemmas were explained as a key element of the educational system in two subcategories: “concern about negative feedback from clinical teachers” and “irresponsible behaviors of clinical teachers.” 

Students believed that when they encounter moral and professional problems and challenges, they should hide them to avoid negative reactions from clinical teachers. In this regard, a participant stated: In the department of diagnosing oral diseases, they behave in such a way that the student is humiliated. So, fear makes you hide things if something goes wrong. I know I made a mistake, but I’m not going to say it because I’m afraid of clinical teachers. (Female, semester 9, 23 years old). I made a mistake and did not disclose my error because no one would help me. Instead of finding a solution, the clinical teacher would get angry at me and scold me in the future (male, semester 11, and 23 years old). When I make a mistake, I take an x-ray so that it looks good because I am afraid of the teachers’ bad behavior. I try to hide it (female, semester 11, and 23 years old). 

The non-commitment of the clinical teachers to the principles of professionalism was explained in this category. The participants believed that clinical teachers do not follow professionalism principles. In this regard, a participant stated: In the prosthetic department, my clinical teacher works without gloves. He takes the turbine without gloves and works in the patient’s mouth; his phone rings, and he answers the phone and returns to work with that hand. The clinical teacher understands and knows, but he is tired and does not care. I do not do anything for him. (Female, semester 9, 23 years old). A clinical teacher who puts his hands in the patient’s mouth without gloves does not care. They surely do not do such a thing in their office because they lose the patient’s trust there. However, it doesn’t matter to them in the university clinic because the patients would come here anyway (female, 24 years old, and semester 11). Figure illustrates the mapping of the quantitative and qualitative results within the domain of moral competence in dental education. 

The status of the four components was investigated in dental students at a medium level. The moral reasoning and motivation domains were reported to have the highest and the lowest scores, respectively. The participants’ experiences were explained under the theme “morality as a neglected element in dentistry.” This theme includes two categories: “disregarding professionalism as a professional responsibility” and “unsupportive behaviors of clinical teachers in a moral dilemma.” These findings not only provide insight into the status of moral skills among dental students but also address the second research purpose—identifying factors influencing these skills. The qualitative data revealed specific challenges, which play a critical role in shaping students’ moral behaviors. The development of moral behaviors in the health profession is required to enhance four domains of moral skills. The current results indicated that the moral skills of dental students in different academic years were at a medium level. The scores of senior students were higher than medium, and junior students’ scores were lower than medium. Similar to the present study, the results of the Vardian-Tehrani study, showed that the scores of moral skills of both dentists and dental students were at the mean level. However, the score of moral skills in students was reported to be higher than that of dentists . In line with our results, the results of Yazdani’s study showed that the moral skill of 384 general dentists was reported at a medium level . The similarity of the results conducted in the investigated context can be due to the weakness of the formal and informal curriculum and the challenges of the hidden curriculum. The present findings showed that students’ moral skills scores had a significant inverse relationship with attending the ethics course, indicating the lack of effectiveness of formal ethics training in the dental education program. This result suggests that the current ethics curriculum may be overly theoretical, lacking integration with the practical challenges students face in clinical environments. A case-based and reflective approach to ethics education suggests assisting students in developing the moral motivation to prioritize professional values over personal interests. Our study showed a significant negative correlation between participation in ethics courses and moral skill scores, while there was no significant association with participation in forensic workshops. This outcome suggests potential inadequacies in the structure and delivery of ethics education in the current dental curriculum. Ethics courses are largely conducted through traditional lectures, which lack interactive components such as case-based discussions or small-group dilemmas that are crucial for enhancing moral reasoning and ethical decision-making . As a result, students may find these courses ineffective in preparing them for real-world ethical challenges, potentially contributing to the negative correlation. Conversely, forensic dentistry workshops, which primarily focus on technical skills rather than ethical or moral reasoning, likely have a limited impact on moral skill development. These findings highlight the importance of reforming the curriculum to include active learning approaches, such as discussions on moral dilemmas, moral case deliberation, and competence-oriented assessments, which have been shown to enhance moral reasoning and ethical competence in previous studies . Our results showed that the moral motivation domain had the lowest values compared with other domains of moral skills in dental students. In light of this, it is crucial to focus on strategies that can improve a stronger commitment to ethical behavior within educational settings, especially among dental students. Rest’s four-component model emphasizes that moral motivation involves prioritizing moral values over other considerations and taking responsibility for the moral outcomes of one’s actions . Enhancing moral motivation could be achieved by creating educational environments that actively engage students in moral dilemmas, such as through case studies or role-playing exercises. These activities provide students with a platform to navigate complex ethical issues, allowing them to integrate moral principles with decision-making processes. In addition, implementation of bioethics into the dental curriculum can help students identify ethical issues and develop strategies to address them effectively. Reflective discussions and analyses of common ethical challenges in dentistry, such as patient consent or addressing treatment anxieties, could encourage deeper ethical reasoning . Innovative teaching approaches, such as mentoring and collaborative learning, could reduce hierarchical barriers between educators and students, which empower students to take ethically sound actions . These strategies aim to bridge the gap between ethical awareness and the application of moral principles, particularly in the interpersonal aspects of dental practice. Failure to accept a commitment to moral principles as a professional responsibility among clinical teachers and students is a key factor affecting students’ scores. The qualitative results explained the challenges at both individual and systemic levels as obstacles to moral behavior. The category of disregarding professionalism as a professional responsibility describes individual challenges. The students believed that their main priority in decision-making was their interests. The students’ perception leads to neglecting professional principles. Another challenge was indifference to unprofessional behaviors among peers, which could spread indifference and negligence in moral behavior in the educational system. In addition to individual challenges, the results explored systemic problems that also affected the level of moral skills of the students. The students considered the unsupportive behaviors of clinical teachers in moral dilemma situations as one of the factors that caused their indifference to moral behavior. They believed that concerns about negative feedback from clinical teachers led them to choose their interests to avoid punishment in moral dilemmas. Moreover, the qualitative results highlighted how students focus on personal interests over professional principles due to a lack of internalization of moral values. This non-commitment reflects individual challenges but is also influenced by systemic issues, such as the absence of constructive feedback or ethical support in clinical settings. Also, the negative role model and irresponsible behaviors toward professional principles effectively normalized unprofessional behaviors among the students. Thus, when students encounter moral dilemmas, they act on what they have learned from negative experiences, focusing on their interests and ignoring professional principles so as not to be punished by their clinical teachers. The results showed that the student’s scores in the domain of moral motivation were the lowest compared to other domains. Moral motivation means prioritizing moral values over personal interests. Moral motivation is related to the organization of values in students in such a way that they consider moral values a priority. In other words, the internalization of moral principles is emphasized in this domain. Students should prioritize moral values to become the basis of their decision-making. The internalization of moral values is considered one of the issues in developing moral skills, which is influenced by individual and systemic factors. In the qualitative step, individual challenges related to non-commitment to professional principles in conflict with the personal interests of individuals and conflict between values and interests were explained in the category of “disregarding professionalism as a professional responsibility.” The qualitative results showed that when faced with moral dilemmas, students prioritized their interests as the basis for decision-making. These challenges were a key obstacle to the internalization and inherent desire to choose ethical behaviors among students. In addition, systemic challenges such as observing negative role models and the lack of commitment of clinical teachers to professional principles can also disrupt internalizing moral motivation among the students. The current study indicated that significant difference in students’ scores in their academic years. They also showed that scores in all domains were lower in junior students, and the moral sensitivity of senior students was higher than other students. Also, the scores of the 5th-year students, which was the first year of entering the clinical departments, were higher in the domains of moral reasoning and moral courage. The low scores of junior students can be due to their lack of experience and weak training manifested in the growth of the examined components. The decreased scores of students in 6th year may be caused by individual concerns due to the increase in their duties in clinical units and research work (doing thesis). The impact of negative role models related to non-commitment to professional principles in the clinical environment also affects the results. In line with the present results, Chambers’ study  showed that the scores of the ethical criteria and its four domains increased with the age of the participants. In Al Zain’s study, the scores of senior students were significantly higher than those of first-year students . Sajadi and colleagues showed that senior dental students scored higher in all domains of moral skills except moral motivation comparing first and third-year students . Inconsistent with the results of the present study, Yazdani’s study showed that the obtained scores in four moral domains were significantly higher in junior students . The study results showed that the 5th-year students who entered the clinical departments in the first year obtained higher scores in moral skills. Although a decrease in scores was also reported in 6th-year students, the difference was not significant. Therefore, longitudinal studies are required to follow the future moral skills trend in dental students. The analysis revealed that moral sensitivity and reasoning improved as students progressed in their academic years. However, there were notable challenges in moral motivation and courage. The qualitative data further emphasized that moral principles are often neglected due to pressures such as grades, time constraints, and peer influence. Many students reported prioritizing efficiency over adhering to professional standards, particularly when clinical teachers demonstrated unsupportive behaviors. These findings highlight the need for comprehensive changes in both curriculum and clinical training environments to foster an ethical mindset in dental students. Limitation The study provides valuable insights into the moral skills of dental students and their responses to ethical dilemmas, making an important contribution to understanding professional conduct within dental education. However, there are several limitations that should be taken into consideration for the interpretation of the results and designing future studies. First, the study sample was drawn from a single institution, which may limit the generalizability of the findings to dental students in other schools or regions. Future research could improve the diversity of the sample by including participants from multiple institutions and regions. Moreover, assessing variables such as student's academic performance and personality traits could provide a more nuanced understanding of the factors influencing moral behavior and ethical decision-making. Second, a notable methodological limitation of the study was the absence of clinical instructors' perspectives, which would have provided a more comprehensive understanding of the relationship between instructors' unsupportive actions and students' moral behaviors. Incorporating instructors’ viewpoints through interviews or surveys in future research could help identify gaps between their perceptions of ethical dilemmas and students’ experiences, providing valuable insights to bridge these gaps and enhance ethical education in clinical settings. Third, the study identified a significant inverse relationship between students’ moral skills and their formal ethics training, suggesting potential limitations in the current ethics curriculum. However, it did not evaluate the curriculum in detail to identify specific areas of weakness. Future studies should consider analyzing the structure and content of ethics education programs and their alignment with the practical needs of students. Recommendations such as incorporating case-based learning or revising the curriculum could better equip students to navigate ethical challenges in their professional practice. Fourth, the cross-sectional design of the study limits its ability to assess the evolution of moral skills over time. Longitudinal studies to track students in academic years would enable a comprehensive evaluation of how education influences long-term professional conduct. 

The study provides valuable insights into the moral skills of dental students and their responses to ethical dilemmas, making an important contribution to understanding professional conduct within dental education. However, there are several limitations that should be taken into consideration for the interpretation of the results and designing future studies. First, the study sample was drawn from a single institution, which may limit the generalizability of the findings to dental students in other schools or regions. Future research could improve the diversity of the sample by including participants from multiple institutions and regions. Moreover, assessing variables such as student's academic performance and personality traits could provide a more nuanced understanding of the factors influencing moral behavior and ethical decision-making. Second, a notable methodological limitation of the study was the absence of clinical instructors' perspectives, which would have provided a more comprehensive understanding of the relationship between instructors' unsupportive actions and students' moral behaviors. Incorporating instructors’ viewpoints through interviews or surveys in future research could help identify gaps between their perceptions of ethical dilemmas and students’ experiences, providing valuable insights to bridge these gaps and enhance ethical education in clinical settings. Third, the study identified a significant inverse relationship between students’ moral skills and their formal ethics training, suggesting potential limitations in the current ethics curriculum. However, it did not evaluate the curriculum in detail to identify specific areas of weakness. Future studies should consider analyzing the structure and content of ethics education programs and their alignment with the practical needs of students. Recommendations such as incorporating case-based learning or revising the curriculum could better equip students to navigate ethical challenges in their professional practice. Fourth, the cross-sectional design of the study limits its ability to assess the evolution of moral skills over time. Longitudinal studies to track students in academic years would enable a comprehensive evaluation of how education influences long-term professional conduct. 

The development of dental students’ moral skills is a complex phenomenon influenced by various factors. The results showed a gap between dental students’ current and desirable status of moral skills. The highest scores were reported in the domain of moral reasoning, and the lowest scores were reported in the domain of moral motivation. “Indifference to professional responsibility” as an individual factor and “unsupportive behaviors of clinical teachers in a moral dilemma” as a systemic factor were explained as obstacles to developing moral skills. The participants’ experiences were explained in the theme of “morality as a neglected element in dentistry.” Therefore, developing moral behaviors among dental students requires planning, monitoring, and providing feedback to students. It is also recommended to plan for the development of moral skills among clinical teachers as role models in the school of dentistry. Additionally, future research could explore the relative impact of individual versus systemic factors on students’ moral development. Identifying specific elements within the clinical environment or curriculum that hinder ethical behavior would provide actionable insights for designing more effective interventions. 

Supplementary Material 1. 

