Reconciling duty: a theory and typology of professionalism

The paper addresses the question of what dental professionalism means in practice within the UK context. Professionalism is emphasized by the General Dental Council and is central to dental education outcomes. Historically, sociological approaches shifted from trait-based functionalism toward interactionist and critical analyses, recognizing that professionals operate within complex organizational and social systems. Organizational culture, regulation, and system constraints influence professional attitudes and behaviors. Recent calls advocate viewing professionalism as influenced by behavioral and systems factors and as a complex adaptive system. Prior work by the authors and the GDC highlighted the lack of a single agreed definition and the need to understand how professionalism manifests in everyday dental practice. This study seeks to elucidate how dentists make sense of professionalism in real-world contexts, why it matters, and how competing expectations are navigated.

The introduction and discussion situate the study within sociological and healthcare professionalism literature. Early functionalist definitions emphasized individual traits underpinning public trust (e.g., Royal College of Physicians), but critiques argue such views are insufficient. Interactionist and critical perspectives recognize contextual, organizational, and systemic influences. A systems/complexity lens conceptualizes professionalism as emergent from multiple interacting factors within healthcare environments. In dentistry, GDC standards and educational frameworks foreground professionalism, yet shared understanding remains contested. Prior studies addressed definitions, assessment, and student perspectives, with limited theory-building in dentistry and insufficient integration of sociological theory. This study responds by developing grounded theory to bridge practical dental contexts with broader social theory, engaging debates on patient-first imperatives, commercialism, and neoliberal influences in healthcare.

Design: Constructivist Grounded Theory (Charmaz) qualitative study conducted 2012–2017. Ethics: King’s College London Research Ethics Committee approvals BDM/11/12-27 and LRS-17/18-5297; informed written consent obtained. Sampling and participants: Purposive and theoretical sampling of dental professionals working in England (across NHS primary and secondary care and private practice), recruited via email from around London and the north of England. Participants (n=24) spanned early (n=9), mid (n=11), and late (n=4) career stages; most were dentists (n=22) with primary care settings common (n=20). Theoretical sampling phases targeted: (1) dentists and dental care professionals to compare perspectives; (2) private practitioners critical of NHS delivery; (3) dentists moving away from primary care to explore reasons (including one retraining to medicine). Data collection: Single interviewer (AT) conducted in-depth, semi-structured interviews using a piloted topic guide informed by the literature; interviews lasted ~45–80 minutes, were audio-recorded, transcribed verbatim; field notes taken. Data management: NVivo 10 and Word used for coding and organization. Analysis: Iterative, concurrent data collection and analysis using CGT with initial, focused, and theoretical coding; constant comparison across interviews; memo writing throughout; development and testing of emergent categories and a typology; theoretical saturation claimed for categories when new interviews no longer generated novel concepts. Quality: COREQ criteria guided reporting; reflexivity addressed through team discussion and avoidance of forcing preconceptions into analysis.

Sample: 24 participants, mostly dentists (n=22); settings primarily primary care (n=20); career stages early (n=9), mid (n=11), late (n=4). Core grounded theory: Reconciling Duty — a social process in which dental professionals harmonize multiple, sometimes conflicting duties owed to different parties (patients, self/family, colleagues/staff, business/practice, profession/society). Categories and properties: 1) Applying Order to the System: how participants define what professionalism ought to be through five properties — Conforming (appearance/attitudes in line with professional expectations), Relating to a team (hierarchy vs flat teamwork, leadership), Representing the profession (status, public trust), Being honest (integrity, transparency, admitting mistakes/limits), Giving good care (technical quality, materials, meeting patient needs). 2) Rationalising what is Fair: recognizing explicit duties to patients and to self/economic viability; adjudicating conflicts between duties to reach a personally justifiable distribution of value; dissonance arises when conflicts are hidden or unresolved. 3) Responding to the System: strategies to actualize fair outcomes within constraints of NHS/private systems and regulation, with properties — Accepting (recognizing imperfections; frustration vs proactive system-improvement stance), Balancing (restricting services or resources to align care with viability), Exclusivising (limiting patient groups or moving private to protect quality and income), Withdrawing (leaving primary care or retraining when reconciliation fails). Typology (archetypes): Type 1 — Patient focus, personal compromise: accepts reduced income, prioritizes patient needs; strength: patient-centeredness; challenges: sustainability, contractual and peer pressures. Type 2 — Access focus, patient compromise: balances care and business; limits on care scope or grade, rationing within NHS constraints; strength: maximizes access; challenges: business pressures, decisions on acceptable compromises. Type 3 — Standards focus, societal compromise: sets high fees, emphasizes technical excellence and outcomes; strength: high standards; challenges: exclusion based on ability to pay, limited societal benefit; justification sometimes includes giving back outside clinical work. Overall: Professionalism in practice is not a fixed trait list but an ongoing reconciliation of legitimate, competing duties; stable, coherent positions cluster into three archetypes.

Findings address the research question by grounding professionalism in dentists’ everyday decision-making under system constraints. Rather than a single normative definition, professionalism is the reconciliatory process of adjudicating duties to patients, self/family, colleagues, business, profession, and society, and implementing justifiable compromises. The theory maps a multi-dimensional possibility space, with three coherent archetypal regions reflecting different compromise strategies. This advances understanding beyond trait lists toward a systems-informed, behaviorally embedded view, aligning with calls to consider organizational and complexity perspectives. Implications include caution against one-size-fits-all definitions or assessments of professionalism; recognition that patient-first ideals are widely held but operationalized with qualifiers due to resource, contractual, and regulatory realities; and the need for regulatory and educational frameworks that support system-level conditions enabling desired professional behaviors. The typology highlights political-economic tensions (e.g., Type 3’s market logic versus equity concerns) and potential workforce impacts if certain archetypes are favored by system incentives.

Professionalism in dentistry can be conceptualized as an ongoing process of reconciling multiple, competing, legitimate duties within complex systems to reach fair, personally coherent decisions and actions. The grounded theory of Reconciling Duty, with its three categories and properties, and a three-archetype typology (patient/personal compromise; access/patient compromise; standards/societal compromise), offers a systems-oriented framework for understanding how dentists conceptualize and operationalize professionalism. The work informs regulators and educators by emphasizing that professional conduct emerges from personal codes interacting with systemic constraints and incentives. Future research should: (1) develop quantitative instruments based on this theory to examine prevalence of archetypes and outcomes; (2) test external validity across regions and specialties; (3) evaluate policy and organizational interventions that shift system conditions to better support patient-centered, sustainable, and equitable professional practice.

Qualitative study with small sample size (n=24) limits statistical generalizability. Potential selection and access biases: difficulty recruiting dentists from very high-end private practices and arranging interviews outside London; theoretical sampling risks misjudging views prior to interviews; social distance may have limited participation. While categories were theoretically saturated for this dataset, full saturation across all viewpoints is unlikely. Reflexivity and researcher–clinician insider status may introduce bias, mitigated through memoing, team dialogue, and delayed use of theoretical terms. External validity for quantitative generalization remains to be established; future survey-based studies may face selection bias challenges.