What’s Happening Current Trends in History Taking and Physical Examination: Teaching Dentists Physical Assessment
F o r the past four years, the University of WisconsinMilwaukee School of Nursing has provided physical assessment courses for dentists in a residency program from a local Veterans Administration hospital. These courses have been developed, coordinated, and taught by a nurse practitioner (NP) faculty member from the School of Nursing. In 1988, frustrated with his inability to obtain appropriate resources to meet the Medical Risk Assessment (MRA)guidelines for general practice dental residency programs (GPR), the dental resident program director contacted the University Nursing Center for help. An NP educator subsequently designed a 30-hour physical assessment course in concert with the University of Wisconsin-Milwaukee Nursing Center and Dental Residency program. This course was designed to meet the curricular guidelines of the commission on dental accreditation of the American Dental Association (ADA).It focused on the recognition of normal findings through physical assessment, health promotion, and disease prevention. Nursing students and clients from the community were used to facilitate the development of assessment skills among dental residents in the program. Physical assessment is currently considered to be a necessary component of a dental curriculum for two reasons: (a) The dentist must be able to understand how systemic diseases and their associated medications affect dental care; and (b) the dentist needs to understand the effect dental treatment can have on systemic well-being. According to the ADA Curriculum Guidelines for Physical Evaluation (1984), the dentist may be the first health care provider to encounter an undiagnosed systemic disease. To date, most dental students do not receive physical assessment in their dental curriculum. To obtain these
skills, a dental school graduate must apply to a postgraduate educational program (GPR) for dentists. These programs are designed primarily to provide dental school graduates with extended didactic and clinical training in most clinical specialty areas in preparation for general practice. The dental resident training in physical assessment or evaluation’ is called Medical Risk Assessment ( M U ) (Handelman, Blandford, & Balzer, 1983). Institutions offering GPR programs frequently differ in levels and types of available resources for conducting such programs. “It is common to hear of significant concerns expressed among program directors that this resource variability frequently causes difficulty in providing appropriate MRA training to general practice residents, especially in the area of physical examination” (Napholz & Kelly, in press, p. 4). Historically, the teaching hospital setting has been the site for teaching physical assessment and providing the essential environment, including patients, personnel, and equipment for the program (Woodworth, 1970). Unfortunately, rotations of dental residents with their medical colleagues have been largely unsuccessful (Wasserman, 1977). Part of the problem is related to the limited medical background of dental residents. In addition, the medical faculty and dental students are not always fully aware of the importance of medical training for dentists, and therefore not willing to invest the effort necessary for a successful learning experience (Stearns, Schwartz, Halazonetis, & Murnane, 1985). Since 1985, there have been reports of nursing instructors successfully teaching these skills in the clinical and didactic components of physical assessment training. (Napholz & Kelly, in press; Stearns et al., 1985).However, few programs have actually used this resource for teaching MRA.
‘The term “physical evaluation” for the MRA guidelines is limited to that area of dentistry that includes “obtaining and evaluating a
patient history (including medical, social, family, and psychological); performingappropriateaspects of a physical examination; and, when warranted by signs and symptoms, ordering and interpreting results of laboratory tests and radiologic studies to obtain sufficient data for planning and instituting dental therapy or for referral to the appropriate health care provider when a systemic disease is identified. It is not synonymous with, but does include, aspects of physical examination and physical diagnosis” (Curriculum Guidelines for Physical Evaluation, 1984, p. 339).
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DESCRIPTION OF THE PROGRAM The goals of this programmatic interface between nursing and dentistry have been twofold: The first has been to provide dental residents with sufficient knowledge, judgment, and skill to permit them to recognize normal physical findings as well as significant pathologic deviations. This enables the resident to
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
modify or defer dental treatment, if indicated, or to refer clients to appropriate health care personnel for evaluation. The second has been to provide the dental resident with practical experience in taking complete histories and performing appropriate aspects of physical examinations to aid in the development of an individualized comprehensive diagnosis and treatment plan for each client. The program includes didactic and clinical experience interpreting client histories, conducting appropriate physical examinations, interpreting findings of an examination, and communicating those findings to other health professionals. In the “hands-on” clinical component, psychomotor skills are practiced on peers, nursing students, and clients from the community who utilize the services of the nursing center. A concurrent, clinical component is provided at the hospital under the dental program director’s supervision to enhance learning and retention of appropriate dental pathology. The development of this program allows the NP educator to combine teaching with role modeling for nursing students and interdisciplinary research. It also provides a site for nursing students to act as teachers and learners in the capacity of role model and client. After completing an undergraduate physical assessment course, nursing students assist dental residents to understand various components of physical assessment by taking the role of the client in a clinical practice session with the dental residents. In this capacity, the nursing students guide and instruct the residents in appropriate technique and process for conducting an appropriate assessment of a client. Other incentives to become involved in the development of the program included the “close proximity to teaching sites, work load credit for clinical practice, additional financial remuneration, access to populations for scholarly research activities, and opportunity to work directly with students in a clinical capacity” (Lundeen, 1990, p. 308). 1. Meet with the GPR director. 2. Review ADA accreditation standards to develop guidelines for the program. 3. Review literature to become familiar with the application of physical assessment in dentistry. 4. Review literature and develop bibliography to supplement class readings. 5. Select an appropriate text. 6. Develop a course syllabus. 7. Generate a list and obtain audiovisual and physical assessment equipment to conduct the course. 8. Conduct the course. 9. Evaluate the course. FIGURE 1. Steps to develop a GPR program,
VOLUME 4, NUMBER 3.JULY-SEPTEMBER, 1992
Services provided by the NP educator are reimbursed through dental student fees for the physical assessment program. These fees cover the complete cost for running the program, including administrative fees, audiovisual materials, simulated models, and physical assessment equipment. In addition, organizational support is made available by the School of Nursing to develop and run the program. Figure 1 outlines the steps taken to develop the program at the University of Wisconsin.
POSITIVE ASPECTS Positive aspects of involvement by NPs in physical assessment instruction for dental residents include: 1. Dental residents were exposed to the role of NPs and nurses to the expanded role of dentistry. 2. Interface with nursing students and NP faculty provided a nursing role model for the dental residents. 3. The program was able to be structured to meet the special needs of dental residents. 4. Nurse practitioner faculty were highly effective because they had experience in the educational process as well as skills in physical assessment. 5. Because the program was developed by NPs, health promotion and prevention were emphasized. 6. Nurse practitioner faculty were able to provide dental residents with an opportunity to work with a healthy population from the community. These clients differ in health care needs from the patients seen by the residents in the hospital setting.
ISSUES AND PROBLEMS Some of the issues and problems to consider when offering a physical assessment program to dental residents include: 1. Program costs are high because the program is individualized for dental residents and not interchangeable with programs for other disciplines. 2. Nurse practitioner faculty need to spend time learning about the specific needs, terminology, and conceptualizations of another discipline. 3. There is a potential for resistance to learning by some dental residents who do not believe they will use the skills in their practices. 4. Some professional groups do not support dentists acquiring physical assessment skills.
NURSE PRACTITIONERS AS TEACHERS OF DENTISTS With the success of this program, one wonders why NPs have not been more involved with the instruction of dental students in the area of physical assessment. Until recently, no research had been conducted to determine 127
how programs organized their curricula to achieve physical assessment accreditation guidelines, how these programs were undertaken, and who was involved in teaching. A nationwide survey of GPR programs was conducted in 1992 to find the answers to some of these questions. Surveys were sent to dental residency programs across the nation. The findings were based on responses from 191 GPR program directors. Results showed that institutions offering GPR programs frequently differed in the levels and types of available resources necessary to implement this training. Dental residency program directors reported that this training is difficult to provide, especially in the area of physical examination. Acceptable levels of achievement were reportedly attained in most areas of basic- and intermediate-levelphysical assessment skills. However, approximately one third to one half of GPR directors reported that they were not achieving the standard for some intermediate or advanced physical assessment skills (Kelly & Napholz, in press; Napholz & Kelly, in press). Interestingly, only 1% (n = 2) of the programs identified nurses or NPs as the professionals responsible for teaching the didactic component. For most programs, physical assessment was team taught. However, only 2.5% (n = 8) of the respondents involved nurses or NPs in team teaching. Speculation regarding the underuse of NPs leads one to note that NPs tend to be based in community settings, where participants in dental programs have limited exposure to NPs and their skills. Conversely, many NPs may not be aware that dentists are learning physical
assessment skills. Perhaps dentists not familiar with advances in nursing practice that make NPs skilled in the area of physical assessment have not thought to utilize those resources.
CONCLUSION This joint venture has provided the dental residents with a consistent, personalized, high-quality physical assessment program. In fact, some of the dentists commented that they had a new understanding and respect for nursing as a result of this program. The success of this project has been largely based on cooperative efforts between the nursing center and the dental residency director for the past 4 years. The course has been modified to its present format through extensive feedback from the dental residents and the program director. Through dissemination of information regarding this successful venture between nursing and dentistry, i t is hoped that more dental residency program directors will employ NPs to teach their dental residents physical assessment and that NPs will realize that this is an area that is open and available for them to pursue.
Linda Napholz, PhD, RN University of Wisconsin-Milwaukee School of Nursing, Wisconsin
References Curriculum guidelines for physical evaluation (1984). Journal of Dental €ducation, 48(4), 219-222. Handelman, S. L., Blandford, D. H., & Baker, J. (1983). Impact of general practice residency training on dentists and dental practice. Journal of Dental €ducation, 47(9), 61 5-622. Kelly, W. H., & Napholz, L. (in press). A national survey of medical risk assessment instruction in general practice residency programs: Part I/. Special Care in Dentistry. Ludeen, S. P. (1990). Nursing centers models for automous nursing practice. In McCloskey, J. C., & Grace, H. K. (Eds.), Current issues in nursing (pp. 304-309). St. Louis: C. V. Mosby.
128
Napholz, L., & Kelly, W. H. (in press). A national survey of medical risk assessment instruction in general practice residency programs: Part I. Stearns, N. S., Schwartz, S. M., Halazonetis, T. D.,& Murnane, T. W. (1985). Clinical medicine for dental students. Journal of Dental Education, 54(6), 339-341. Wasserman, B. S. (1977). Teaching physical evaluation and physical diagnosis in a hospital setting. Journal of the American Dental Association, 95(1), 103-1 05. Woodworth, J. V. (1970). Medicine and the dental student. Journal of Dental €ducation, 34(2), 168-170).
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
F o r the past four years, the University of WisconsinMilwaukee School of Nursing has provided physical assessment courses for dentists in a residency program from a local Veterans Administration hospital. These courses have been developed, coordinated, and taught by a nurse practitioner (NP) faculty member from the School of Nursing. In 1988, frustrated with his inability to obtain appropriate resources to meet the Medical Risk Assessment (MRA)guidelines for general practice dental residency programs (GPR), the dental resident program director contacted the University Nursing Center for help. An NP educator subsequently designed a 30-hour physical assessment course in concert with the University of Wisconsin-Milwaukee Nursing Center and Dental Residency program. This course was designed to meet the curricular guidelines of the commission on dental accreditation of the American Dental Association (ADA).It focused on the recognition of normal findings through physical assessment, health promotion, and disease prevention. Nursing students and clients from the community were used to facilitate the development of assessment skills among dental residents in the program. Physical assessment is currently considered to be a necessary component of a dental curriculum for two reasons: (a) The dentist must be able to understand how systemic diseases and their associated medications affect dental care; and (b) the dentist needs to understand the effect dental treatment can have on systemic well-being. According to the ADA Curriculum Guidelines for Physical Evaluation (1984), the dentist may be the first health care provider to encounter an undiagnosed systemic disease. To date, most dental students do not receive physical assessment in their dental curriculum. To obtain these
skills, a dental school graduate must apply to a postgraduate educational program (GPR) for dentists. These programs are designed primarily to provide dental school graduates with extended didactic and clinical training in most clinical specialty areas in preparation for general practice. The dental resident training in physical assessment or evaluation’ is called Medical Risk Assessment ( M U ) (Handelman, Blandford, & Balzer, 1983). Institutions offering GPR programs frequently differ in levels and types of available resources for conducting such programs. “It is common to hear of significant concerns expressed among program directors that this resource variability frequently causes difficulty in providing appropriate MRA training to general practice residents, especially in the area of physical examination” (Napholz & Kelly, in press, p. 4). Historically, the teaching hospital setting has been the site for teaching physical assessment and providing the essential environment, including patients, personnel, and equipment for the program (Woodworth, 1970). Unfortunately, rotations of dental residents with their medical colleagues have been largely unsuccessful (Wasserman, 1977). Part of the problem is related to the limited medical background of dental residents. In addition, the medical faculty and dental students are not always fully aware of the importance of medical training for dentists, and therefore not willing to invest the effort necessary for a successful learning experience (Stearns, Schwartz, Halazonetis, & Murnane, 1985). Since 1985, there have been reports of nursing instructors successfully teaching these skills in the clinical and didactic components of physical assessment training. (Napholz & Kelly, in press; Stearns et al., 1985).However, few programs have actually used this resource for teaching MRA.
‘The term “physical evaluation” for the MRA guidelines is limited to that area of dentistry that includes “obtaining and evaluating a
patient history (including medical, social, family, and psychological); performingappropriateaspects of a physical examination; and, when warranted by signs and symptoms, ordering and interpreting results of laboratory tests and radiologic studies to obtain sufficient data for planning and instituting dental therapy or for referral to the appropriate health care provider when a systemic disease is identified. It is not synonymous with, but does include, aspects of physical examination and physical diagnosis” (Curriculum Guidelines for Physical Evaluation, 1984, p. 339).
126
DESCRIPTION OF THE PROGRAM The goals of this programmatic interface between nursing and dentistry have been twofold: The first has been to provide dental residents with sufficient knowledge, judgment, and skill to permit them to recognize normal physical findings as well as significant pathologic deviations. This enables the resident to
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
modify or defer dental treatment, if indicated, or to refer clients to appropriate health care personnel for evaluation. The second has been to provide the dental resident with practical experience in taking complete histories and performing appropriate aspects of physical examinations to aid in the development of an individualized comprehensive diagnosis and treatment plan for each client. The program includes didactic and clinical experience interpreting client histories, conducting appropriate physical examinations, interpreting findings of an examination, and communicating those findings to other health professionals. In the “hands-on” clinical component, psychomotor skills are practiced on peers, nursing students, and clients from the community who utilize the services of the nursing center. A concurrent, clinical component is provided at the hospital under the dental program director’s supervision to enhance learning and retention of appropriate dental pathology. The development of this program allows the NP educator to combine teaching with role modeling for nursing students and interdisciplinary research. It also provides a site for nursing students to act as teachers and learners in the capacity of role model and client. After completing an undergraduate physical assessment course, nursing students assist dental residents to understand various components of physical assessment by taking the role of the client in a clinical practice session with the dental residents. In this capacity, the nursing students guide and instruct the residents in appropriate technique and process for conducting an appropriate assessment of a client. Other incentives to become involved in the development of the program included the “close proximity to teaching sites, work load credit for clinical practice, additional financial remuneration, access to populations for scholarly research activities, and opportunity to work directly with students in a clinical capacity” (Lundeen, 1990, p. 308). 1. Meet with the GPR director. 2. Review ADA accreditation standards to develop guidelines for the program. 3. Review literature to become familiar with the application of physical assessment in dentistry. 4. Review literature and develop bibliography to supplement class readings. 5. Select an appropriate text. 6. Develop a course syllabus. 7. Generate a list and obtain audiovisual and physical assessment equipment to conduct the course. 8. Conduct the course. 9. Evaluate the course. FIGURE 1. Steps to develop a GPR program,
VOLUME 4, NUMBER 3.JULY-SEPTEMBER, 1992
Services provided by the NP educator are reimbursed through dental student fees for the physical assessment program. These fees cover the complete cost for running the program, including administrative fees, audiovisual materials, simulated models, and physical assessment equipment. In addition, organizational support is made available by the School of Nursing to develop and run the program. Figure 1 outlines the steps taken to develop the program at the University of Wisconsin.
POSITIVE ASPECTS Positive aspects of involvement by NPs in physical assessment instruction for dental residents include: 1. Dental residents were exposed to the role of NPs and nurses to the expanded role of dentistry. 2. Interface with nursing students and NP faculty provided a nursing role model for the dental residents. 3. The program was able to be structured to meet the special needs of dental residents. 4. Nurse practitioner faculty were highly effective because they had experience in the educational process as well as skills in physical assessment. 5. Because the program was developed by NPs, health promotion and prevention were emphasized. 6. Nurse practitioner faculty were able to provide dental residents with an opportunity to work with a healthy population from the community. These clients differ in health care needs from the patients seen by the residents in the hospital setting.
ISSUES AND PROBLEMS Some of the issues and problems to consider when offering a physical assessment program to dental residents include: 1. Program costs are high because the program is individualized for dental residents and not interchangeable with programs for other disciplines. 2. Nurse practitioner faculty need to spend time learning about the specific needs, terminology, and conceptualizations of another discipline. 3. There is a potential for resistance to learning by some dental residents who do not believe they will use the skills in their practices. 4. Some professional groups do not support dentists acquiring physical assessment skills.
NURSE PRACTITIONERS AS TEACHERS OF DENTISTS With the success of this program, one wonders why NPs have not been more involved with the instruction of dental students in the area of physical assessment. Until recently, no research had been conducted to determine 127
how programs organized their curricula to achieve physical assessment accreditation guidelines, how these programs were undertaken, and who was involved in teaching. A nationwide survey of GPR programs was conducted in 1992 to find the answers to some of these questions. Surveys were sent to dental residency programs across the nation. The findings were based on responses from 191 GPR program directors. Results showed that institutions offering GPR programs frequently differed in the levels and types of available resources necessary to implement this training. Dental residency program directors reported that this training is difficult to provide, especially in the area of physical examination. Acceptable levels of achievement were reportedly attained in most areas of basic- and intermediate-levelphysical assessment skills. However, approximately one third to one half of GPR directors reported that they were not achieving the standard for some intermediate or advanced physical assessment skills (Kelly & Napholz, in press; Napholz & Kelly, in press). Interestingly, only 1% (n = 2) of the programs identified nurses or NPs as the professionals responsible for teaching the didactic component. For most programs, physical assessment was team taught. However, only 2.5% (n = 8) of the respondents involved nurses or NPs in team teaching. Speculation regarding the underuse of NPs leads one to note that NPs tend to be based in community settings, where participants in dental programs have limited exposure to NPs and their skills. Conversely, many NPs may not be aware that dentists are learning physical
assessment skills. Perhaps dentists not familiar with advances in nursing practice that make NPs skilled in the area of physical assessment have not thought to utilize those resources.
CONCLUSION This joint venture has provided the dental residents with a consistent, personalized, high-quality physical assessment program. In fact, some of the dentists commented that they had a new understanding and respect for nursing as a result of this program. The success of this project has been largely based on cooperative efforts between the nursing center and the dental residency director for the past 4 years. The course has been modified to its present format through extensive feedback from the dental residents and the program director. Through dissemination of information regarding this successful venture between nursing and dentistry, i t is hoped that more dental residency program directors will employ NPs to teach their dental residents physical assessment and that NPs will realize that this is an area that is open and available for them to pursue.
Linda Napholz, PhD, RN University of Wisconsin-Milwaukee School of Nursing, Wisconsin
References Curriculum guidelines for physical evaluation (1984). Journal of Dental €ducation, 48(4), 219-222. Handelman, S. L., Blandford, D. H., & Baker, J. (1983). Impact of general practice residency training on dentists and dental practice. Journal of Dental €ducation, 47(9), 61 5-622. Kelly, W. H., & Napholz, L. (in press). A national survey of medical risk assessment instruction in general practice residency programs: Part I/. Special Care in Dentistry. Ludeen, S. P. (1990). Nursing centers models for automous nursing practice. In McCloskey, J. C., & Grace, H. K. (Eds.), Current issues in nursing (pp. 304-309). St. Louis: C. V. Mosby.
128
Napholz, L., & Kelly, W. H. (in press). A national survey of medical risk assessment instruction in general practice residency programs: Part I. Stearns, N. S., Schwartz, S. M., Halazonetis, T. D.,& Murnane, T. W. (1985). Clinical medicine for dental students. Journal of Dental Education, 54(6), 339-341. Wasserman, B. S. (1977). Teaching physical evaluation and physical diagnosis in a hospital setting. Journal of the American Dental Association, 95(1), 103-1 05. Woodworth, J. V. (1970). Medicine and the dental student. Journal of Dental €ducation, 34(2), 168-170).
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
