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Dentistry, Nursing, and Medicine: A Comparison of Core Competencies

Key words: dental education, nursing education, core competencies

Submitted for publication 02/14/05; accepted 07/25/05

	Abstract

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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.

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 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 Report³ 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 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 2020.¹² 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

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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 Association¹⁴ 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 1-124 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 Colleges¹⁶ (Table 3).

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 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

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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 objectives. 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.

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

Top Abstract Methods Results Discussion Conclusion References

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.

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 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, community, 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 twenty-six 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

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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.

	Acknowledgments

 
We would like to thank Elyse Bloom and Gretchen North for reviewing and Janice Telford for her administrative help in preparing this manuscript.

	Footnotes

 
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; 212-998-9916 phone; 212-995-4240 fax; andrew.spielman{at}nyu.edu.

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