One can argue that, for dentistry, this is the. Dentistry, Nursing, and Medicine: A Comparison of Core Competencies. Educational Methodologies

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1 Educational Methodologies Dentistry, Nursing, and Medicine: A Comparison of Core Competencies Andrew I. Spielman, D.M.D., Ph.D.; Terry Fulmer, R.N., Ph.D.; Elise S. Eisenberg, D.D.S., M.A.; Michael C. Alfano, D.M.D., Ph.D. Abstract: Health care, including oral health care and oral health education, is under great stress in the United States. The cost of and access to care, the cost of dental education, and a shortage of educators have led leaders in dental education, organized dentistry, and the public sector to underscore the problem. One of the proposed solutions is to find synergies and new health care and education models by building bridges among the health professions. One potential solution is being implemented at the NYU College of Dentistry (NYUCD). Dentistry and nursing are seemingly unrelated professions, and they are rarely if ever modeled together. That is about to change with the joining together of NYUCD and the Division of Nursing of the NYU Steinhardt School of Education in creating a College of Nursing within the College of Dentistry. This process has not been without controversy. Following the Division of Nursing s request to join NYUCD, and the subsequent announcement of the proposed combination by NYU in December 2004, some members of the dental profession responded by questioning the appropriateness of the merger and the similarity of the two programs. Nevertheless, substantial parallels exist in the education and practice of dentists and nurse practitioners (NP) including basic, social, and some clinical science education, practice models, research synergies, and community service. However, similarities in the core competencies of these professions have not been analyzed formally and in detail. Accordingly, the purpose of this study was to compare the core competencies of nurse practitioner and dental education programs. The results show a surprising overlap of the core competencies of the dental and nursing professions (38 percent partial or total overlap). A similar overlap with medicine also exists, albeit lower (25.4 percent). These results are notable because they demonstrate that the three health professions, independently of one another, developed very similar basic competencies and learning objectives. These data should encourage other health professions programs to seek new collaborative models for education, beyond the current silos of training, and new health care delivery systems as has been strongly recommended by the Institute of Medicine. Such collaborative education redirects health care toward providing truly interdisciplinary comprehensive primary care for patients. Dr. Spielman is Professor of Basic Science and Associate Dean for Academic Affairs, College of Dentistry; Dr. Fulmer is the Erline Perkins McGriff Professor and Dean, College of Nursing, College of Dentistry; Dr. Eisenberg is Director of Informatics, College of Dentistry; and Dr. Alfano is Professor of Basic Science and Periodontics and Dean, College of Dentistry all at New York University. Direct correspondence and reprint requests to Dr. Andrew I. Spielman, Professor of Basic Science and Associate Dean for Academic Affairs, College of Dentistry, New York University, 345 E. 24 th Street, New York, NY 10010; phone; fax; andrew.spielman@nyu.edu. Key words: dental education, nursing education, core competencies Submitted for publication 2/14/05; accepted 7/25/05 One can argue that, for dentistry, this is the best of times and the worst of times. Dentistry has never had it so good. The profession is robust, with a substantial increase in the number of applicants to dental schools in recent years. This year alone there is a 15.4 percent increase in the national applicant pool. 1 Thanks to new technologies, more and more people have bright and healthy-looking teeth and smiles, giving dentistry added appeal as a profession. Furthermore, the earning potential of a general dentist has significantly increased. Between 1986 and 2001, the net income of a general dentist has increased by 247 percent. 2 Yet, for dentistry, it is also the worst of times. Demographic changes resulting from an aging population, changes in the distribution pattern of oral diseases, and changing patient demands may all contribute to potentially difficult times ahead. The two main oral diseases that affect patients today dental caries and periodontal disease are in decline in the Western world, primarily among the population who can afford dental care. We now live in a society in which esthetics can affect one s professional success; consequently, patients are seeking dentists more frequently for elective, cosmetic procedures, rather than for primary care. This trend can affect the public s November 2005 Journal of Dental Education 1257

2 perception of dentistry as part of primary health care and may reduce dental insurance coverage in the future as employers, looking for ways to cut costs, may target dental insurance if it is no longer seen as covering essential health care, but rather is reserved for elective cosmetic care. Such a shift from primary health care to elective procedures may also put health education loans at risk, eventually affecting the pool of students entering the field. While the two main oral diseases, caries and periodontal disease, are in decline for most of the population, there is a growing segment of our society with reduced or no access to oral care. This is due to the demographic patterns of these diseases, as well as to problems in access to care and an escalation in the cost of care. Regarding access, even though for 2005 the United States was estimated to have fifty-eight dentists per 100,000 patients, 3 the number of dentists delivering care and the population in need of care are not evenly distributed. Many remote or underserved areas have far fewer dentists delivering care. There are as many as 25 million individuals in the United States who live in geographically inaccessible areas as defined by the Health Professional Shortage Area (HPSA) Act. 4 Moreover, 100 million Americans do not have access to fluoridated water. Another problem that is fueling an oral health crisis is the cost of care. There is a disproportionate burden of oral diseases among those with low income, the uninsured, and children. Children of less affluent and poor families are twice as likely to have oral disease as their more affluent counterparts. As many as 108 million children and adults, close to one-third of the population, do not have dental insurance. There are three times more adults without dental insurance than those without medical insurance. Furthermore, uninsured children are 2.5 times less likely to receive dental treatment than insured children. Additionally, as more and more dentists of the baby boom generation retire and fewer new dentists are educated to replace them, there will be a further decline in the dentist-to-patient ratio, potentially resulting in a dental workforce that is not able to meet the needs of the population. 4 In response to this impending crisis, the U.S. Surgeon General has issued a Call to Action to address the oral health care needs of the U.S. population. 5 It is clear that the current public health infrastructure is insufficient to address the needs of the entire population. To compound the crisis in health care and access to dental care, there is the ever increasing cost of dental education and the increasing rise in student debt. 6,7 This, in turn, affects the number of potential candidates who pursue dentistry as a profession. If we factor in that there are fewer dental schools than a decade ago and that there is a decline in the total number of graduates, we can anticipate a drop in the ratio of dental professionals to population in the next decade. Nevertheless, the 2001 ADA Future of Dentistry Report 3 does not call for increasing enrollment of dental students because of expected increases in productivity and the elasticity of the dental workforce. In response to the looming crisis in oral health care, certain state legislatures and the Indian Health Service have moved to institute solutions without waiting for the profession to address it first. In Alaska, where there is a particularly severe shortage of oral health care professionals, a program involving dental health therapists has been established. Dental health therapists in Alaska have been given permission to deliver a limited number of dental procedures, including extractions. In Minnesota, pediatricians are allowed to place dental sealants as a preventive measure. Such a procedure helps children who would normally see a physician but not a dentist. Both of these steps taken by state legislatures are attempts to address the oral health care needs of a neglected population or one lacking access to care. Furthermore, in 2001 the U.S. Department of Health and Human Services, Health Resources and Services Administration, Division of Medicine and Dentistry awarded eight center grants (currently only seven are active) to increase access to oral health services for children up to five years of age by training pediatric and family medicine residents to provide oral health assessments and apply fluoride gel. 8 In addition, California has created multiple pathways to dental licensure in an effort to increase the number of dentists. The American Dental Education Association (ADEA) has also responded to the crisis in oral health care and education. In its influential 2003 report, 9 ADEA outlines the responsibilities of the professions and institutions of higher education. First, academic institutions have a mission and obligation to seek out new health care solutions for the greater good of society. Second, they need to remove perceived or existing barriers to care and improve the oral health of the population in general and of those at risk, including children, in particular. One of the recommendations (number 2.1) of the ADEA report is to seek out nontraditional health 1258 Journal of Dental Education Volume 69, Number 11

3 care providers and to develop and support new models of oral health care that will provide care within an integrated health care system. New models should involve other health professionals, including family physicians, pediatricians, geriatricians, and other primary care providers as team members. The latter would include nurse practitioners registered nurses who have completed a graduate degree in a specialty area. (Nurse practitioners receive additional state licensure and can sit for a certification examination, which allows them to be reimbursed by Medicare and Medicaid. They practice either independently or in collaboration with physicians based on state law and have prescriptive authority in most states.) While the cost of oral health escalates quietly, the parallel increase in the cost of general health care makes headlines. Over 40 million Americans are uninsured. The cost of health care in the United States in 2001 reached 13.9 percent of GDP, 10 the highest in the Western world. Furthermore, the cost of medical education is escalating. 11 The cost of prescription medication, the rising cost of medical malpractice insurance, and the need for tort reform were all hot issues during the last presidential election. There is clearly a national shortage of health care professionals, including nurses. The Department of Labor projects a shortage of 810,000 nurses by In New York State alone, there is already a shortage of 17,000 nurses. 13 The shortage of nurses parallels a crisis in nursing education. There is a need to increase funding for nursing education and to replace aging faculty. With funds being cut primarily in state-supported nursing education, finding educational efficiencies at a time of increasing demand for nurses becomes a priority for many health education institutions, including NYU. In response to a general and oral health care and educational stress, and in line with the mandates of the surgeon general and ADEA leadership, NYU College of Dentistry and the Division of Nursing, NYU Steinhardt School of Education, have sought to merge into one institution in order to seek out educational synergies and efficiencies and to design health care delivery models that can provide better access to financially and geographically disadvantaged populations. After many months of deliberations, the initiative was announced by the leadership of New York University in an open letter seeking input on the proposed merger. The letter requested the opinion of a broad constituency of faculty, students, and alumni. The reaction was an outpouring of emotions for and against such a merger. Many of the responses were supportive, including those of the leadership of the two programs, most faculty and students, and other individuals who understood the nature of the health care and education crisis and the potential synergies that such a once-in-a-lifetime opportunity could yield. Many of the negative comments came from members of the profession who did not see these synergies. They asked, Why join two seemingly different health professions as dentistry and nursing? How are they related? To answer such questions, we first compared the core competencies of the nursing and dental programs at NYU. Second, we compared the published core competencies of the nation s dental and nursing programs. Finally, we placed these data in the context of health professions in general, by comparing the competencies and learning objectives of dentistry, nursing, and medicine. The results of this comparison show a remarkable closeness of the competencies and demonstrate a natural alliance between dentistry and nursing. Methods Several documents on the core competencies of dentistry, nursing, and medicine were used in this analysis. The sixty-three core competencies for the new dentist developed in 1997 by the American Dental Education Association 14 are numbered in sequence and shown in Table 1. The national core competencies for the nurse practitioner, 15 divided into seven domains, were also numbered consecutively to make comparison easier (Table 2). Finally, the source document for thirty national medical school competencies was the definition of predoctoral learning objectives put forth by the American Association of Medical Colleges 16 (Table 3). The following sets of comparisons of competencies/educational outcomes were made: 1) dentistry to nursing and medicine, 2) nursing to dentistry and medicine, and 3) medicine to dentistry and nursing. Two of the authors, independently of each other, looked at the list of dental, nursing, and medical competencies and compared them to each other. If there was a disagreement among the two reviewers, the competency overlap was not considered. Only competency overlaps identified by both reviewers were included in the results. Overlap of competencies was expressed as a percentage of the total number of competencies in each list. November 2005 Journal of Dental Education 1259

4 Total overlap (T) was assigned if the statement was seeking the same goal or competency even if the exact wording of the competency or learning objective from the respective disciplines was not identical. For example, the following competencies/ objectives from dentistry, nursing, and medicine were considered to represent total conceptual overlap even though the wording differed: dental The student will apply ethical principles to professional practice ; nursing acts ethically to meet the needs of the patient ; medical [the physician should have] knowledge of the theories and principles that govern ethical decision making. If the goal or competency had a partial overlap, a (P) was assigned. The following is an example of partial overlap: a dental competency indicating Table 1. Competencies for the new dentist General Skills 1 Apply ethical principles to professional practice. 2 Provide empathetic care for all patients, including members of diverse and vulnerable populations. 3 Apply the principles of jurisprudence to the practice of dentistry. 4 Continuously analyze the outcomes of patient treatment to improve that treatment. 5 Evaluate scientific literature and other sources of information to make decisions about dental treatment. 6 Manage oral health based on an application of scientific principles. 7 Participate in professional organizations. Information Management Currency of Skills 8 Assess his or her level of skills and knowledge and take steps to improve areas of deficiency. 9 Evaluate social and economic trends and their impact on oral health care. Practice Management 10 Evaluate career options, practice location, and reimbursement mechanisms. 11 Educate staff in professional, governmental, legal, and office policies and professional responsibilities. 12 Coordinate and supervise the activity of allied dental health personnel. 13 Maintain patient records. 14 Use business systems in dental practice settings for scheduling, record-keeping, reimbursement, and financial arrangements. 15 Implement and monitor infection control and environmental safety programs according to current standards. 16 Practice within the scope of one s competence and make referrals to professional colleagues. 17 Use information technology and information management systems for patient care, practice management, and professional development. Communication 18 Assess patient goals, values, and concerns to establish rapport and guide patient care. 19 Communicate orally and in writing with peers, other professionals, staff, patients or guardians, and the public at large. Community Resources 20 Participate in improving the oral health of individuals, families, and groups in the community through diagnosis, treatment, and education. Debt Management 21 Use professional debt management and financial planning skills. PATIENT CARE COMPETENCIES Diagnosis 22 Establish rapport and identify patients general needs and expectations. 23 Identify patients chief complaints. 24 Obtain medical, dental, psychosocial, and behavioral histories. 25 Perform head and neck and intraoral examinations. 26 Select, obtain, and interpret clinical, radiographic, and other diagnostic information and procedures. 27 Obtain medical and dental consultations when appropriate. 28 Recognize signs of abuse or neglect and report and refer as necessary. 29 Recognize predisposing and etiologic factors that require intervention to prevent disease. 30 Use clinical and epidemiological data to diagnose and establish prognosis for dental abnormalities and pathology Journal of Dental Education Volume 69, Number 11

5 the dental student should be competent in prescribing pharmacological agents for the treatment of dental patients, and a corresponding nurse practitioner competency indicating that NPs should be competent in prescribing medications in general. Where there was a disagreement among the two reviewers if it was a partial or total overlap between competencies, the lesser (partial) was considered. Results When the sixty-three national dental competencies were compared to the list of 124 national nurse practitioner competencies, we found 38 percent with partial or total overlap (Table 4). The same list of national dental competencies was matched against a list of thirty national medical learning ob- Table 1. Competencies for the new dentist (continued) 31 Recognize the normal range of clinical findings and significant deviations that require monitoring, treatment, or management. 32 Monitor therapeutic outcomes and re-evaluate and modify initial diagnoses or therapy. 33 Develop treatment alternatives based on clinical and supporting data. Treatment Planning 34 Integrate multiple disciplines into an individual, comprehensive, sequenced treatment plan using diagnostic and prognostic information. 35 Discuss etiologies, treatment alternatives, and prognoses with patients and educate them so they can participate in the management of their own care. 36 Develop and implement a sequenced treatment plan that incorporates patients goals, values, and concerns. 37 Obtain informed consent from patient, parent, or guardian. Treatment 38 Anticipate, diagnose, and provide initial treatment and follow-up management for medical emergencies that may occur during dental treatment. 39 Perform basic cardiac life support. 40 Recognize and manage acute pain, hemorrhage, trauma, and infection of the orofacial complex. 41 Manage patient with pain and anxiety by the use of nonpharmacological methods. 42 Select and administer or prescribe pharmacological agents in the treatment of dental patients. 43 Anticipate, prevent, and manage complications arising from the use of the therapeutic and pharmacological agents employed in patient care. 44 Provide patient education to maximize oral health. 45 Manage preventive oral health procedures. 46 Perform therapies to eliminate local etiologic factors to control caries, periodontal disease, and other oral diseases. 47 Manage patients with advanced periodontal diseases and conditions. 48 Manage patients with pulpal and periradicular diseases. 49 Perform uncomplicated endodontics procedures. 50 Perform uncomplicated oral surgical procedures. 51 Manage patients who have complicated oral surgical problems. 52 Manage patients requiring modification of oral tissues to optimize restoration of form, function, and esthetics. 53 Manage patients with occlusal and temporomandibular disorders. 54 Manage dental care for disabled and special care patients. 55 Manage patients in the hospital setting. 56 Manage a comprehensive maintenance plan following the active phase of periodontal treatment. 57 Manage patients requiring minor tooth movement or space maintenance. 58 Manage patients who have complex orthodontic problems. 59 Restore single defective teeth. 60 Restore partial or complete edentulism with uncomplicated fixed or removable prosthetic restorations. 61 Manage the restoration of partial or complete edentulism using implant procedures. 62 Manage patients with oral esthetic needs. 63 Communicate case design with laboratory technicians and evaluate the resultant prosthesis. Source: American Association of Dental Schools (now American Dental Education Association). Competencies for the new dentist. Proceedings of the 1997 AADS House of Delegates, Appendix 2. J Dent Educ 1997;71: November 2005 Journal of Dental Education 1261

6 Table 2. Domains and core competencies of nurse practitioner practice Domain 1: Management of Patient Health/Illness Status All nurse practitioners should be able to demonstrate competence in the domain of management of patient health/illness status when she or he performs the following behaviors in the following areas: A. Health Promotion/Health Protection and Disease Prevention Our Original numbering numbering 1 1 Differentiates between normal, variations of normal, and abnormal findings. 2 2 Provides health promotion and disease prevention services to patients who are healthy or have acute and chronic conditions, based on age, developmental stage, family history, and ethnicity. 3 3 Provides anticipatory guidance and counseling to promote health, reduce risk factors, and prevent disease and disability, based on age, development stage, family history, and ethnicity. 4 4 Develops or uses a follow-up system within the practice to ensure that patients receive appropriate services. 5 5 Recognizes environmental health problems affecting patients and provides health protection interventions that promote healthy environments for individuals, families, and communities. B. Management of Patient Illness 6 1 Analyzes and interprets history, including presenting symptoms, physical findings, and diagnostic information to develop appropriate differential diagnoses. 7 2 Diagnoses and manages acute and chronic conditions while attending to the patient s response to the illness experience. 8 3 Prioritizes health problems and intervenes appropriately including initiation of effective emergency care. 9 4 Employs appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, simplicity, acceptability, adherence, and efficacy Formulates an action plan based on scientific rationale, evidence-based standards of care, and practice guidelines Provides guidance and counseling regarding management of the health/illness condition Initiates appropriate and timely consultation and/or referral when the problem exceeds the nurse practitioner s scope of practice and/or expertise Assesses and intervenes to assist the patient in complex, urgent, or emergency situations. a. Assesses rapidly the patient s unstable and complex health care problems through synthesis and prioritization of historical and immediately derived data. b. Diagnoses unstable and complex health care problems utilizing collaboration and consultation with the multidisciplinary health care team as indicated by setting, specialty, and individual knowledge and experience, such as patient and family risk for violence, abuse, and addictive behaviors. c. Plans and implements diagnostic strategies and therapeutic interventions to help patients with unstable and complex health care problems regain stability and restore health in collaboration with the patient and multidisciplinary health care team. d. Rapidly and continuously evaluates the patient s changing condition and response to therapeutic interventions and modifies the plan of care for optimal patient outcomes. Appropriate to Both Subdomains 14 1 Demonstrates critical thinking and diagnostic reasoning skills in clinical decision making Obtains a comprehensive and problem-focused health history from the patient Performs a comprehensive and problem-focused physical examination Analyzes the data collected to determine health status Formulates a problem list Assesses, diagnoses, monitors, coordinates, and manages the health/illness status of patients over time and supports the patient through the dying process Demonstrates knowledge of the pathophysiology of acute and chronic diseases or conditions commonly seen in practice Communicates the patient s health status using appropriate terminology, format, and technology Applies principles of epidemiology and demography in clinical practice by recognizing populations at risk, patterns of disease, and effectiveness of prevention and intervention Uses community/public health assessment information in evaluating patient needs, initiating referrals, coordinating care, and program planning Applies theories to guide practice Applies/conducts research studies pertinent to area of practice. (Table 2 continued on next page) 1262 Journal of Dental Education Volume 69, Number 11

7 Table 2. Domains and core competencies of nurse practitioner practice (continued) Prescribes medications based on efficacy, safety, and cost as legally authorized and counsels concerning drug regimens, drug side effects, and interactions with food supplements and other drugs Integrates knowledge of pharmacokinetic processes of absorption, distribution, metabolism, and excretion, and factors that alter pharmacokinetics in drug dosage and route selection Selects/prescribes correct dosages, routes, and frequencies of medications based on relevant individual patient characteristics, e.g., illness, age, culture, gender, and illness Detects and minimizes adverse drug reactions with knowledge of pharmacokinetics and dynamics with special attention to vulnerable populations such as infants, children, pregnant and lactating women, and older adults Evaluates and counsels the patient on the use of complementary/alternative therapies for safety and potential interactions Integrates appropriate nonpharmacologic treatment modalities into a plan of management Orders, may perform, and interprets common screening and diagnostic tests Evaluates results of interventions using accepted outcome criteria, revises the plan accordingly, and consults/refers when needed Collaborates with other health professionals and agencies as appropriate Schedules follow-up visits to appropriately monitor patients and evaluate health/illness care. Domain 2. The Nurse Practitioner-Patient Relationship The nurse practitioner demonstrates competence in the domain of the nurse practitioner-patient relationship when s/he: 36 1 Creates a climate of mutual trust and establishes partnerships with patients Validates and verifies findings with patients Creates a relationship with patients that acknowledges their strengths and assists patients in addressing their needs Communicates a sense of being present with the patient and provides comfort and emotional support Evaluates the impact of life transitions on the health/illness status of patients and the impact of health and illness on patients (individuals, families, and communities) Applies principles of self-efficacy/empowerment in promoting behavior change Preserves the patient s control over decision making, assesses the patient s commitment to the jointly determined, mutually acceptable plan of care, and fosters patient s personal responsibility for health Maintains confidentiality while communicating data, plans, and results in a manner that preserves the dignity and privacy of the patient and provides a legal record of care Monitors and reflects on own emotional response to interaction with patients and uses this knowledge to further therapeutic interaction Considers the patient s needs when termination of the nurse-practitioner-patient relationship is necessary and provides for a safe transition to another care provider Evaluates patient s and/or caregiver s support systems Assists the patient and/or caregiver to access the resources necessary for care. Domain 3. The Teaching-Coaching Function The nurse practitioner demonstrates competence in the domain of the teaching-coaching function when s/he: Timing 48 1 Assesses the patient s ongoing and changing needs for teaching based on a) needs for anticipatory guidance associated with growth and developmental stage, b) care management that requires specific information or skills, and c) patient s understanding of his/her health condition Assesses patient s motivation for learning and maintenance of health-related activities using principles of change and stages of behavior change Creates an environment in which effective learning can take place. Eliciting 51 1 Elicits information about the patient s interpretation of health conditions as a part of the routine health assessment Elicits information about the patient s perceived barriers and supports to learning when preparing for patient s education Elicits from the patient the characteristics of his/her learning style from which to plan and implement the teaching Elicits information about cultural influences that may affect the patient s learning experience. (Table 2 continued on next page) November 2005 Journal of Dental Education 1263

8 Table 2. Domains and core competencies of nurse practitioner practice (continued) Assisting 55 1 Incorporates psychosocial principles into teaching that reflect a sensitivity to the effort and emotions associated with learning about how to care for one s health conditions Assists patients in learning specific information or skills by designing a learning plan that is comprised of sequential, cumulative steps and that acknowledges relapse and the need for practice, reinforcement, support, and re-teaching when necessary Assists patients to use community resources when needed Educates patients about self-management of acute/chronic illness with sensitivity to the patient s learning ability and cultural/ethnic background. Providing 59 1 Communicates health advice, instruction, and counseling appropriately using evidence-based rationale. Negotiating 60 1 Negotiates a mutually acceptable plan of care based on continual assessment of the patient s readiness and motivation, resetting of goals, and optimal outcomes Monitors the patient s behaviors and specific outcomes as a useful guide to evaluating the effectiveness and need to change or maintain teaching strategies, such as weight-loss, smoking cessation, and alcohol consumption. Coaching 62 1 Coaches the patient throughout the teaching processes by reminding, supporting, encouraging, and the use of empathy. Domain 4. Professional Role The nurse practitioner demonstrates competence in the domain of professional role when she or he: Develops and Implements Role 63 1 Uses scientific theories and research to implement the nurse practitioner role Functions in a variety of role dimensions: health care provider, coordinator, consultant, educator, coach, advocate, administrator, researcher, and leader Interprets and markets the nurse practitioner role to the public, legislators, policymakers, and other health care professions Advocates for the role of the advanced practice nurse in the health care system. Directs Care 67 1 Prioritizes, coordinates, and meets multiple needs and requests of culturally diverse patients Uses sound judgment in assessing conflicting priorities and needs Builds and maintains a therapeutic team to provide optimum therapy Obtains specialist and referral care for patients while remaining the primary care provider Advocates for the patient to ensure health needs are met Consults with other health care providers and private/public agencies Incorporates current technology appropriately in care delivery Uses information systems to support decision making and to improve care. Provides Leadership 75 1 Recognizes the importance of participating in professional organizations Evaluates implications of contemporary health policy on health care providers and consumers Participates in legislative and policymaking activities that influence advanced nursing practice and the health of communities Advocates for access to quality, cost-effective health care Evaluates the relationship between community/public health issues and social problems (poverty, literacy, violence, etc.) as they impact the health care of patients. Domain 5. Managing and Negotiating Health Care Delivery Systems The nurse practitioner demonstrates competency in the domain of managing and negotiating health care delivery systems when she or he: Managing 80 1 Demonstrates knowledge about the role of the nurse practitioner in case management Provides care for individuals, families, and communities within integrated health care services Considers access, cost, efficacy, and quality when making care decisions. (Table 2 continued on next page) 1264 Journal of Dental Education Volume 69, Number 11

9 Table 2. Domains and core competencies of nurse practitioner practice (continued) 83 4 Maintains current knowledge of the organization and financing of the health care system as it affects delivery of care Participates in organizational decision making, interprets variations in outcomes, and uses data from information systems to improve practice Manages organizational functions and resources within the scope of responsibilities as defined in a position description Uses business and management strategies for the provision of quality care and efficient use of resources Demonstrates knowledge of business principles that affect long-term financial viability of a practice, the efficient use of resources, and quality of care Demonstrates knowledge of relevant legal regulations for nurse practitioner practice including reimbursement of services. Negotiating 89 1 Collaboratively assesses, plans, implements, and evaluates primary care with other health care professionals using approaches that recognize each one s expertise to meet the comprehensive needs of patients Participates as a key member of an interdisciplinary team through the development of collaborative and innovative practices Participates in the planning, development, and implementation of public and community health programs Participates in legislative and policymaking activities that influence health services/practice Advocates for policies that reduce environmental health risks Advocates for policies that are culturally sensitive Advocates for increasing assess to health care for all. Domain 6. Monitoring and Ensuring the Quality of Health Care Practice The nurse practitioner demonstrates competence in the domain of monitoring and ensuring quality health care practice when she or he: Ensuring Quality 96 1 Interprets own professional strengths, role, and scope of ability to peers, patients, and colleagues Incorporates professional/legal standards into practice Acts ethically to meet the needs of patients Assumes accountability for practice and strives to attain the highest standards of practice Engages in self-evaluation concerning practice and uses evaluative information, including peer review, to improve care and practice Collaborates and/or consults with members of the health care team about variations in health outcomes Uses an evidence-based approach to patient management that critically evaluates and applies research findings pertinent to patient care management and outcomes Evaluates the patient s response to the health care provided and the effectiveness of the care Uses the outcomes of care to revise care delivery strategies and improve the quality of care Accepts personal responsibility for professional development and the maintenance of professional competence and credentials Considers ethical implications of scientific advances and practices accordingly. Monitoring Quality Monitors quality of own practice and participants in continuous quality improvement based on professional practice standards and relevant statutes and regulations Evaluates patient follow-up and outcomes including consultation and referral Monitors research in order to improve quality care. Domain 7. Cultural Competence The nurse practitioner demonstrates cultural competence when she or he: Shows respect for the inherent dignity of every human being, whatever their age, gender, religion, socioeconomic class, sexual orientation, or ethnicity Accepts the rights of individuals to choose their care provider, participate in care, and refuse care Acknowledges personal biases and prevents these from interfering with the delivery of quality care to persons of differing beliefs and lifestyles Recognizes cultural issues and interacts with patients from other cultures in culturally sensitive ways. (Table 2 continued on next page) November 2005 Journal of Dental Education 1265

10 Table 2. Domains and core competencies of nurse practitioner practice (continued) Incorporates cultural preferences, health beliefs and behaviors, and traditional practices into the management plan Develops patient-appropriate educational materials that address the language and cultural beliefs of the patient Accesses culturally appropriate resources to deliver care to patients from other cultures Assists patient to access quality care within a dominant culture Develops and applies a process for assessing differing beliefs and preferences and takes this diversity into account when planning and delivering care. Spiritual Competencies Respects the inherent worth and dignity of each person and the right to express spiritual beliefs as part of his/her humanity Assists patients and families to meet their spiritual needs in the context of health and illness experiences, including referral for pastoral services Assesses the influence of patient s spiritually on his/her health care behaviors and practices Incorporates patient s spiritual beliefs in the plan of care appropriately Provides appropriate information and opportunity for patients and families to discuss their wishes for end of life decision making and care Respects wishes of patients and families regarding expression of spiritual beliefs. Source: National Organization of Nurse Practitioner Faculties (NONPF). Domains and core competencies of nurse practitioner practice. At: Accessed: February jectives. There is a 25.4 percent partial or total overlap between the sixty-three dental competencies and thirty medical learning objectives. A comparison of the 124 nursing competencies was also extended to dentistry and medicine and found a partial or total overlap of 23.4 percent and 18.6 percent, respectively. Finally, we compared the thirty national medical school learning objectives to the sixty-three national dental competencies and the 124 national nurse practitioner competencies. There was 50 percent and 46.7 percent partial or total sharing of competencies, respectively. There was a difference in the percentage of overlap among sets of competencies when they were compared from the perspective of either one set or another. For instance, when competencies in dentistry were compared to competencies in nursing, the overlap was 38 percent. However, when competencies in nursing were compared to those in dentistry, it was 23.4 percent. The discrepancy between the two comparisons stems from the fact that there are more nursing competencies to start with and a single dental competency is listed in multiple nursing competencies. The same explanation is true for all other sets of comparisons. This is inevitable because nursing has 124, dentistry sixty-three, and medicine thirty competencies and learning objectives, respectively. To indicate where these overlaps specifically correspond, we listed the overlapping dental and nursing competencies and medical learning objectives, respectively, in Table 5. Dental competencies #1, 2, 3, 4, 5, 7, 8, 9, 13, 14, 16, 17, 18, 19, 21, 24, 25, 26, 27, 29, 30, 31, 32, 34, 38, 42, and 43 are shared with either the nursing and/or medical school learning objectives. Furthermore, dental competencies #1, 2, 3, 5, 8, 9, 16, 17, 24, 25, 26, 30, 34, and 38 appear in all three lists of competencies and learning objectives, a 22 percent overlap. A summary of the broad topics that are shared by all three areas is shown in Table 6. These competencies relate to the major issues of health care professional practice and interactions with patients. They include ethical behavior, empathetic care, application of the principles of jurisprudence, and the use of the scientific literature and lifelong learning for critical thinking and managing patients. Discussion This study compared, in detail for the first time, competencies across three major health professions including dentistry and nursing. A more general comparison of the general competency areas in dentistry, medicine, nursing, pharmacy, and occupational therapy was recently completed 17 but not as detailed as the current one. The results of the present study were unexpected, but not surprising Journal of Dental Education Volume 69, Number 11

11 Competencies may vary from school to school, and the results of this study may not be readily generalized to all schools. Nevertheless, comparing the nationally accepted core competencies for dentistry, nursing, and medicine, the source of most if not all individual institutional competencies, is a good approximation for competency overlap. We have used competencies for the dental and nursing programs but learning objectives for the medical profession. Unlike dentistry and nursing, where the graduate has to be competent by graduation to be licensed, the Accreditation Council for Graduate Medical Education (ACGME) 18 has designated competencies for the obligatory residency program that follows graduation from medical school. Therefore, to match the graduate level expectation of the dental and nursing competencies, we used the predoctoral medical school learning objectives developed by the Association of American Medical Colleges (AAMC) instead of medical residency competencies developed by the ACGME. The medical learning objectives are broader in scope and fewer in number (thirty) than the dental (sixty-three) and nurse practitioner (124) competencies. This may explain why the medical school learning objective overlap with nursing is 46.7 percent and 50 percent with dentistry, compared to a lower percentage of overlap between the more defined and more specific dental and nursing competencies. The data in this study clearly demonstrate that nursing, medicine, and dentistry have a great deal in common. In fact, it is reassuring to learn that the three health professions, independently of one another, developed basic competencies and learning objectives that exhibit great similarities. Table 3. Learning objectives for medical student education: guidelines for medical schools Altruism For its part the medical school must ensure that before graduation a student will have demonstrated, to the satisfaction of the faculty, the following: Our Original numbering numbering 1 1 Knowledge of the theories and principles that govern ethical decision making and of the major ethical dilemmas in medicine, particularly those that arise at the beginning and end of life and those that arise from the rapid expansion of knowledge of genetics. 2 2 Compassionate treatment of patients and respect for their privacy and dignity. 3 3 Honesty and integrity in all interactions with patients families, colleagues, and others with whom physicians must interact in their professional lives. 4 4 An understanding of, and respect for, the roles of other health care professionals and of the need to collaborate with others in caring for individual patients and in promoting the health of defined populations. 5 5 A commitment to advocate at all times the interests of one s patients over one s own interests. 6 6 An understanding of the threats to medical professionalism posed by the conflicts of interest inherent in various financial and organizational arrangements for the practice of medicine. 7 7 The capacity to recognize and accept limitations in one s knowledge and clinical skills and a commitment to continuously improve one s knowledge and ability. Knowledge For its part the medical school must ensure that before graduation a student will have demonstrated, to the satisfaction of the faculty, the following: 8 1 Knowledge of normal structure and function of the body (as an intact organism) and of each of its major organ systems. 9 2 Knowledge of the molecular, biochemical, and cellular mechanisms that are important in maintaining the body s homeostasis Knowledge of the various causes (genetic, developmental, metabolic, toxic, microbiologic, autoimmune, neoplastic, degenerative, and traumatic) of maladies and the ways in which they operate on the body (pathogenesis) Knowledge of the altered structure and function (pathology and pathophysiology) of the body and its major organ systems that are seen in various diseases and conditions An understanding of the power of the scientific method in establishing the causation of disease and efficacy of traditional and nontraditional therapies An understanding of the need to engage in lifelong learning to stay abreast of relevant scientific advances, especially in the discipline of genetics and molecular biology. (Table 3 continued on next page) November 2005 Journal of Dental Education 1267

12 In light of the results of this study, the joining of the NYU College of Dentistry and the Division of Nursing should be welcome news rather than cause for alarm. No change in health care alliances comes with easy acceptance. In the early twentieth century when dental hygiene was created, many members of the dental profession were adamantly opposed to it. They felt that such a change would undermine the profession and drive down revenue. A century later, no one questions the wisdom of such a move. As outlined in many influential studies, 6,8,9,19 academic institutions must lead in health care reforms, educate the profession, the public, and legislators and help them understand why the current move, although bold and unusual, is good for education, society, and the profession. Why is it good for education? Although both dental and nursing education programs must maintain all of their independent competencies and accreditation standards, a professional school with both programs can make dental and nursing education more efficient through judicious deployment of faculty in classrooms and clinics. Although there is a shortage of both dental and nursing educators, there should be synergies by which individual educators can be deployed in ways that utilize their specific skills more Table 3. Learning objectives for medical student education: guidelines for medical schools (continued) Skills For its part the medical school must ensure that before graduation a student will have demonstrated, to the satisfaction of the faculty, the following: 14 1 The ability to obtain an accurate medical history that covers all essential aspects of the history, including issues related to age, gender, and socioeconomic status The ability to perform both a complete and an organ system-specific examination, including a mental status examination The ability to perform routine technical procedures including at a minimum venipuncture, inserting an intravenous catheter, arterial puncture, thoracentesis, lumbar puncture, inserting a nasograstric tube, inserting a Foley catheter, and suturing lacerations The ability to interpret the results of commonly used diagnostic procedures Knowledge of the most frequent clinical, laboratory, roentgenologic, and pathologic manifestations of common maladies The ability to reason deductively in solving clinical problems The ability to construct appropriate management strategies (both diagnostic and therapeutic) for patients with common conditions, both acute and chronic, including medical, psychiatric, and surgical conditions, and those requiring short- and long-term rehabilitation The ability to recognize patients with immediate life-threatening cardiac, pulmonary, or neurological conditions regardless of etiology and to institute appropriate initial therapy The ability to recognize and outline an initial course of management for patients with serious conditions requiring critical care Knowledge about relieving pain and ameliorating the suffering of patients The ability to communicate effectively, both orally and in writing, with patients, patients families, colleagues, and others with whom physicians must exchange information in carrying out their responsibilities. Duty For its part the medical school must ensure that before graduation a student will have demonstrated, to the satisfaction of the faculty, the following: 25 1 Knowledge of the important nonbiological determinants of poor health and of the economic, psychological, social, and cultural factors that contribute to the development and/or continuation of maladies Knowledge of the epidemiology of common maladies within a defined population and the systematic approaches useful in reducing the incidence and prevalence of those maladies The ability to identify factors that place individuals at risk for disease or injury, to select appropriate tests for detecting patients at risk for specific diseases or in the early stage of disease, and to determine strategies for responding appropriately The ability to retrieve (from electronic databases and other resources), manage, and utilize biomedical information for solving problems and making decisions that are relevant to the care of individuals and populations Knowledge of various approaches to the organization, financing, and delivery of health care A commitment to provide care to patients who are unable to pay and to advocate for access to health care for members of traditionally underserved populations. Source: Association of American Medical Colleges. Learning objectives for the medical student education. Report I for the Medical School Objectives Project. Washington, DC: Association of American Medical Colleges, Journal of Dental Education Volume 69, Number 11

13 efficiently. For example, a geriatric nurse practitioner can add a richness to a dental program on geriatrics that is otherwise unattainable. In addition, a hybrid school might educate and test new models of health care delivery systems and ultimately provide better and more medically relevant education to both nursing and dental students. It could also create additional research synergies between the two programs. Some of the dental specialties, such as pediatric, commu- Table 4. Comparison of percent overlaps of core competencies/learning objectives among dentistry, nursing, and medicine % dental competencies in nursing 38.0 medicine 25.4 % nursing competencies in dentistry 23.4 medicine 18.6 % medical competencies in dentistry 50.0 nursing 46.7 Table 5. Comparison of dental and nursing competencies and medical school learning objectives Dental Competencies* Nursing Competencies** Medical Learning Objectives*** 1 98T****, 106T 1T 2 36T, 38P, 39T, 62T, 110T 2T 3 88P, 97P, 107P 3P 4 33T, 103T, 104T, 108P 5 59P, 63T, 100P, 102P, 109P 28P 6 63P 12P 7 75T 8 96T, 100T 13T 9 23P, 79P 25P 11 64P 13 43P 14 86P, 87T 16 12T, 34P, 70P, 72P, 96T 4P, 7T 17 73T, 74T, 84P 28T 18 36T, 38P 19 21T 24T 20 91P 21 86P, 87P 22 36T, 38P 24 6P, 15P 14T 25 16P 15P 26 6P, 17P, 32T 17T 27 12P, 34T, 70P, 72T, 89P 7P 29 2P, 3P 27T 30 22P, 109P 26P 31 1T 8P 32 33P, 103T, 104T, 108P 20P 33 10P 20P 34 30P 36 60P 38 8P, 13P 21P 39 8P, 13P 21P 40 23P 41 23T 42 26P, 28P 43 29T 44 2P, 3P, 11T *Numbers correspond to those listed in the first column of Table 1. **Numbers correspond to those listed in the first column ( our numbering ) Table 2. ***Numbers correspond to those listed in the first column ( our numbering ) Table 3. ****T stands for total, P for partial overlap The left column contains dental competencies, as they are numbered in the original list. Only competencies that are shared with either nursing or medicine are listed. The second column contains nursing core competencies that are shared with dentistry. The numbers correspond to those in the first column of Table 2. At the end of each nursing competency or medical learning objectives, it is indicated if there is a total (T) or partial (P) overlap between the dentistry and the respective competency or learning objective, respectively. An empty box next to a dental competency in either the nursing or medical column indicates the absence of a corresponding competency in the respective column. November 2005 Journal of Dental Education 1269

14 Table 6. Major areas of overlap between dental core competencies, nurse practitioner core competencies, and medical learning objectives 1. Apply ethical principles in interactions with patients. 2. Empathetic and compassionate care for patients. 3. Apply principles of jurisprudence. 4. Critical thinking and lifelong learning, use of evidence-based literature. 5. Use of referral for the benefit of patients. 6. Uses information systems to improve oneself, practice, and patient care. 7. Obtain accurate information from patients to formulate diagnosis and treatment. 8. Perform good physical examination. 9. Obtain and interpret diagnostic information. 10. Use scientific data from the literature for risk assessment. 11. Recognize normal and abnormal variations of clinical findings. 12. Develop treatment alternatives and strategies. 13. Recognize and provide initial treatment for emergencies and systemic complications. nity, and geriatric dentistry and oral surgery, are already naturally allied with nursing. Other joint programs will have to be developed and tested. Society would also greatly benefit from the alliance of dentistry and nursing. For instance, an adult nurse practitioner could provide regular screening and case management for individuals in need of chronic disease management. Patients with diabetes, coronary artery disease, hyperlipidemia, hypertension, or glaucoma, for example, might benefit from a nurse practitioner in proximity to a dental office. Nurse practitioners work independently in twentysix states, with collaborative agreements with M.D.s in fourteen states and supervision by M.D.s in six states. Only five states continue to have restricted practice. 20 Nurse anesthetists could manage dental anesthesia. Advanced practice nurses would be a valuable asset in terms of patient education and could provide onsite management of unanticipated medical emergences while awaiting transport. Routine health promotion actions such as flu shots, medication management and refills, smoking cessation education and follow-up, and nutrition and exercise counseling programs could be instituted and followed at annual dental visits. Functional assessment and quality of life assessments could be instituted for older adults. All of this could be accomplished during a routine visit to the dental office. The nurses might be paid by direct billing, third party reimbursement, or office salary depending on the state. Furthermore, an NP practicing in a dental office can solidify the role of the dental office as part of a strategic health care network necessary during a bioterrorist attack. Finally, dentists could enroll and graduate from nurse practitioner programs and have their own nurse practitioner practice, combined with their dental practice. The latter example could be analogous to individuals who have both M.D. and J.D. degrees. The combination will be good for the professions. Such an alliance with nursing can reengage dentistry with the primary health care arena, a move that would reconfirm the fact that dentistry provides must have health care services, not simply nice to have cosmetic services, and could determine the cost and shape of the future of dental insurance. Similarly, nurses educated in a curriculum with some unique dental interface would be much better educated to help address the abysmal oral health care that exists in so many hospitals and nursing homes. Conclusion At this point in time when the patient population is aging and is more medically compromised, deploying nurse practitioners in a dental setting, working alongside or in joint offices with dentists, provides a good business model and more income potential for both nurses and dentists. In the process, we can save on the cost of health care. The new model at NYU, which fosters collaboration and integration of the two health programs, based on an analysis of competencies at NYU and in the professions in general, is a natural alliance. This should lead to better models and efficiencies in education and health care delivery systems and should be cheered not just by academia but by legislators, the professions, and the public at large Journal of Dental Education Volume 69, Number 11

15 Acknowledgments We would like to thank Elyse Bloom and Gretchen North for reviewing and Janice Telford for her administrative help in preparing this manuscript. REFERENCES application cycle. AADSAS Newsletter, April At: Accessed: April Dental buying guide: dental practice income and expenses. At: income.asp. Accessed: April Future of dentistry. Chicago: American Dental Association, Health Policy Resources Center, Oral health in America: a report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, A national call to action to promote oral health: a publicprivate partnership under the leadership of the office of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2003: Institute of Medicine. Dental education at the crossroads: challenges and changes. Field MJ, ed. Washington, DC: National Academy Press, Primary care and oral health: an interdisciplinary educational approach to meeting the oral health needs of highrisk young children. At: bhpr.hrsa.gov/medicine-dentistry/ oralhealth.htm. Accessed: April DePaola DP, Slavkin H. Reforming dental health professions education: a white paper. J Dent Educ 2004; 68(11): Haden NK, Catalanotto FA, Charles AJ, Bailit H, Battrell A, Broussard J Jr, et al. Improving the oral health status of all Americans: roles and responsibilities of academic institutions. A Report of the ADEA President s Commission. Washington, DC: American Dental Education Association, 2003: Huber M, Orosz E. Health expenditure trends in OECD countries, Health Care Financing Rev 2003; 25(1): Morrison G. Becoming a physician: mortgaging our future, the cost of medical education. New Engl J Med 2005; 352(2): Flynn D. Blakeney takes on tough nursing issues. The Medical Herald, 2004;10: The nursing shortage. New York State Department of Education Office of Professions, April At: Accessed: April American Association of Dental Schools. Competencies for the new dentist. Proceedings of the 1997 AADS House of Delegates, Appendix 2. J Dent Educ 1997;71: National Organization of Nurse Practitioner Faculties (NONPF). Domains and core competencies of nurse practitioner practice. At: Accessed: April Association of American Medical Colleges. Learning objectives for the medical student education. Report I for the Medical School Objectives Project. Washington, DC: Association of American Medical Colleges, Geheb MA, Dickey J, Gordon G, Beemsterboer P, Flaherty-Robb M. Looking towards a model of organizational performance: can health systems professionalism and competence be defined? ACGME Bulletin, August 2004: Outcome project: accreditation council for graduate medical education. At: compfull.asp. Accessed: April Greiner AC, Knebel, E, eds. Health professions education: a bridge to quality. Washington, DC: Institute of Medicine of the National Academies, Pearson L. Sixteenth annual legislative update. Nurse Pract 2004;29(1): November 2005 Journal of Dental Education 1271