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Using Standardized Patients to Teach Interprofessional Competencies to Dental Students
  • Interprofessional Education

Using Standardized Patients to Teach Interprofessional Competencies to Dental Students

  1. Nancy Campbell-Heider, BSN, MS, PhD
  1. Dr. Anders is Clinical Associate Professor, Oral Diagnostic Sciences, University at Buffalo School of Dental Medicine; Dr. Scherer is Associate Professor, University at Buffalo School of Nursing; Dr. Hatton is Clinical Associate Professor, Oral Diagnostic Sciences, University at Buffalo School of Dental Medicine; Dr. Antonson is Professor, Restorative Dentistry, University at Buffalo School of Dental Medicine; Dr. Austin-Ketch is Clinical Professor, University at Buffalo School of Nursing; and Dr. Campbell-Heider is Associate Professor, University at Buffalo School of Nursing.
  1. Direct correspondence to Dr. Patrick L. Anders, University at Buffalo School of Dental Medicine, 355 Squire Hall, Buffalo, NY 14214; 716-829-2241; planders{at}buffalo.edu.
  • Received March 24, 2015.
  • Accepted June 25, 2015.

Abstract

The aims of this study were to develop, implement, and evaluate a novel interprofessional standardized patient exercise (ISPE) with oral-systemic and interprofessional collaborative practice (IPCP) components. Dental students and doctor of nursing practice (DNP) students at one U.S. university participated in the simulation, which was primarily designed to test their teamwork skills. In spring 2014, DNP students worked in the dental clinics with dental students under the supervision of nursing and dental faculty members. To test the teamwork outcomes for both groups of students, a standardized patient (SP) scenario was designed to include multiple chronic medical diagnoses and an oral-systemic component. The exercise was filmed for later review. Outcomes measures included SP and student self-evaluations and faculty evaluation of student documentation. The primary outcome of interest from a dental standpoint was faculty evaluation of IPCP competencies derived from the Core Competencies of Interprofessional Collaborative Practice and were deemed to be observable by faculty when viewing the videotaped scenario. Eight teams of students participated with an SP trained in the scenario. Each team consisted of a DNP student, a fourth-year dental student, and a second-year dental student. All eligible students in the DNP class (n=20) and eight students from each dental class (approximately 110 each) participated. The results showed that the teams scored highest on the role/responsibilities subscale, indicating students were respectful of each other’s roles and expertise and effectively engaged each other to develop strategies to meet the patient’s needs. Scores on the three other subscales (values/ethics, interprofessional communication, and teams/teamwork) were also high. These findings appeared to support IPCP as a method to foster knowledge and respect for other roles and responsibilities, improve appreciation of teamwork, and encourage better communication among health care providers. The ISPE scenario provided an effective way to evaluate IPCP competencies.

Standardized patients (SPs) are trained actors who portray patients in realistic clinical interview and physical examination scenarios used in health professions education.1 Using SP interactions allows for a safe and controlled environment in which students can learn and practice clinical skills as well as receive feedback from both patients, who are trained for this purpose, and instructors.2 SPs have been used in dental education for a variety of purposes including training and evaluating students in geriatric dentistry,3 presentation of treatment plans,4 interviewing skills,5 tobacco cessation counseling,2 and medical emergencies.6 In each of these scenarios, the primary objective was to develop and evaluate clinical and communication skills exclusively for dentists at some level of training.

Standardized patients have also been used extensively in interprofessional education (IPE). The goal of IPE is to bring various health professions students together in an educational environment to promote collaborative practice.7 The overriding premise in IPE is that once health care professionals work together, the care they provide will become more patient-focused rather than discipline-specific as each group better understands the expertise of others, and therefore patient care will improve.8 Historically, most IPE collaboration has involved medical and nursing students.9,10 Until very recently, there has been minimal involvement of dental students in IPE.7,10 It has been noted that barriers to dental personnel on a health care team include limited experience of dentists on such teams and ignorance of other professionals about the significance of oral health to the overall health of the patient.11

However, dental involvement in IPE is increasing. The Affordable Care Act has placed more emphasis on teamwork to address needs of new patients entering the health care system.12 New accreditation standards in dental education include a mandate for IPE.7 A recent study found that 39 of the 51 U.S. and Canadian dental schools with a medical school on the same campus reported developing collaborative educational experiences with the medical school, and 29 dental schools reported having an interprofessional interaction with a school of nursing.13 Recent IPE initiatives have involved dental students with students from medicine, nursing, pharmacy, physical therapy and occupational therapy,1416 speech pathology,17 midwifery, social work, diagnostic imaging,8,15 and dental hygiene and physician assistant programs.18

The aims of this study were to develop, implement, and evaluate an interprofessional SP exercise (ISPE) involving dental and doctor of nursing practice (DNP) students at one academic institution. We will also discuss how our experience differed from those previously reported and present lessons learned that might be applicable to the development of similar exercises in the future.

Methods

This study was reviewed by the University at Buffalo Social and Behavioral Sciences Institutional Review Board and deemed exempt (Project Title: [551890-2] Evaluation of IPE/IPCP clinical experiences for DNP and dental students). The ISPE was a three-hour exercise held at the Clinical Competency Center (CCC), a University at Buffalo facility with 12 examination rooms and technology for observation and recording of student-SP interactions. The CCC is an established center that is used by multiple health science schools at this university. The SPs were experienced actors who are trained in the scenarios by the coordinator for training and evaluation.

A total of eight student teams participated with an SP trained in the scenario. Each team consisted of a DNP student, a fourth-year dental (D4) student, and a second-year dental (D2) student. The D2 students had had minimal patient contact at that point in their education, but they were included on the team because they were assigned to the same rotation as the D4 students and we wanted to maximize IPE interactions. The eight teams participated simultaneously.

Description of Exercise

The ISPE was developed as a component of a larger project on enhanced oral-systemic interprofessional education and practice.19 The specific purpose of this project was to enhance the oral-systemic health and interprofessional collaborative practice competencies of DNP students through development of innovative IPE experiences and interprofessional collaborative practice teams that include dental and DNP students and faculty. The development team for the ISPE included faculty from the School of Nursing and the School of Dental Medicine. A discussion of this ISPE from a nursing perspective is available elsewhere.20 Rather than creating a completely new scenario, we decided to adapt an existing scenario to include an oral-systemic component that would allow for IPE interactions.

The SP chosen was “Charlene Williams,” a 40-year-old female with Type II diabetes and hypertension. She presented to the DNP student with complaints of a persistent cough as well as pain and swelling related to a loose maxillary molar. The DNP student was given information including a list of medications, vital signs, A1C, and a clinical photograph and radiograph of periodontally involved maxillary molars. Initial interview and examination were performed by the DNP student, after which the dental students were called in as consultants. A “warm handoff” occurred, during which the DNP student introduced the dental students to the SP and relayed information based on his or her interview and exam. The D4 student interviewed and examined the SP while the D2 student either observed or participated, as directed by the D4 student. DNP and D4 students then discussed management issues in front of and with the patient. The students then entered progress notes into an electronic system.

The entire exercise was observed remotely by faculty members of both schools and was filmed for later review. The ISPE was preceded by a brief student orientation to the timing and logistics of the patient scenario and followed by a debriefing that included students and faculty from both schools. The debriefing was facilitated by a member of the nursing faculty with expertise in simulation. It included a discussion of clinical and interprofessional aspects of the exercise as well as initial student evaluations of the experience.

Outcome Measures

SP checklist

This checklist completed by the SPs included items relevant to the patient’s chief complaint, medical history, and laboratory results. The list was developed by faculty members from both schools with expertise in oral-systemic health and IP competencies. Students were evaluated on whether or not they addressed the items during history taking. For example, SPs were asked if the students asked about various aspects of their past medical history and current health problems. The SPs also rated aspects of the physical exam such as “the dentist looked at the back of my mouth using a tongue blade and light.” In addition, communication skills and perception of professional demeanor were evaluated using questions such as “the dentist listened carefully as I described my problems and did not interrupt me.” Each item was scored as yes (achieved) or no (not achieved). Additional representative items from the SP checklist appear in Table 1.

Table 1

Representative items from standardized patient checklist

Student self-evaluation

Students also completed a checklist consisting of items addressing history taking, physical examination, and communication. These items mirrored the items on the SP checklist such as “I listened carefully as the patient described her problems and did not interrupt.”

Student documentation

The students’ documentation of history, physical exam, differential diagnosis, and plan of care for the patient was assessed by faculty members. Data were obtained from the SP checklists. Student self-evaluation checklists and student documentation were entered into the software package B-line for calculation.

Interprofessional competence (IPEC) scale

This scale developed by the participating faculty was designed to reflect the Core Competencies for Interprofessional Collaborative Practice,21 which is the established source for identification of core competencies in IPE and was developed by an expert panel of health care disciplines including dentistry and nursing. The scale (Table 2) consisted of 16 items divided into four subscales: 1) values/ethics (five items) such as “respect and ability to work together are evident among team members”; 2) role/responsibilities (two items) such as “team members are respectful of each other’s roles and expertise”; 3) interprofessional communication (six items) such as “uses effective communication strategies to share patient treatment goals and outcomes of care”; and 4) teams and teamwork (three items) such as “engages other health professionals in shared patient-centered problem-solving.” The items selected were those that could be readily observed by faculty when viewing videotapes of the scenario. Each item was scored on a Likert scale that ranged from strongly disagree (1) to strongly agree (7). Three nursing and two dental faculty members independently scored the students’ performance while viewing the videotapes.

Table 2

Interprofessional competence scale

Results

Eight teams of students completed the exercise. Each team consisted of one DNP student, one D4 student, and one D2 student. All eligible students in the DNP class (n=20) and eight students from each dental class (approximately 110 each) participated. The DNP and D4 students were evaluated. Results of evaluation of the D4 students are reported.

Total scores for the SP checklists ranged from a high of 99.5% to a low of 67.7% with a mean (SD) of 82.8 (Table 3). Seven of the eight D4 students were above the cut-off of one standard deviation below the mean (74.6%). Total scores on the D4 students’ self-evaluation checklist ranged from a class high of 87.7% to a class low of 55.9% with a SD of 9.4% (Table 4). One student was below the cut-off of one standard deviation below the mean (67.4%).

Table 3

Standardized patients’ checklist checklist subscale scores of D4 students’ skills, expressed as percentages (n=8)

Table 4

D4 students’ self-evaluation subscale scores, expressed as percentages (n=8)

Pearson correlations were calculated to see if there was agreement between the SP and dental student self-assessments. Results ranged from 0.15 for perception to 0.79 for communication (Table 5). A correlation coefficient was not calculated for the recommend area since it was nonsensical to ask if students would recommend themselves to additional patients. However, all SPs said they would recommend their student dentists. Student documentation scores of history, physical exam, differential diagnosis, and plan of care for the patient ranged from a class high of 74.4% to a class low of 43.7%, with a class mean of 59.9% and a class cut-off of 51.6%. Two students were below the cut-off.

Table 5

Pearson correlations between standardized patient evaluations and dental student self-evaluations

Descriptive statistics were used to determine total and subscale means and SD on the IPEC scale. The total mean score on the IPEC scale was 5.80 with an SD of 1.65. The mean scores and SD for each of the subscales as well as the total score are shown in Table 6.

Table 6

Interprofessional collaborative practice scale total and subscale mean score and SD (n=8)

Discussion

The primary purpose of this ISPE from a dental standpoint was to evaluate D4 students’ ability to work collaboratively with DNP students in managing the care of a patient in a simulated clinical scenario. It is important to note that the dental students were volunteers and the ISPE was not associated with a course or a grade. While this exercise was an important first step in integrating IPE/IPCP into the dental curriculum, in the future it will be necessary to develop educational experiences that ensure all dental students receive exposure to IPE/IPCP competencies. Accreditation standards mandate that all dental graduates must “be competent in communicating and collaborating with other members of the health care team to facilitate the provision of health care.”22 The intent of this standard is that students receive clinical experiences that involve working with other health care students and practitioners. In the future, it will also be essential that IPE experiences are graded in a manner similar to other required courses. Otherwise, the relevance of the experiences will be questioned, and students’ motivation to learn could be diminished.23

Potential barriers to ISPE experiences include cost, cultural, and curricular barriers24 and, at our institution, unequal class sizes among the professions; however, some version of the model presented here would be desirable from an educational standpoint. In this case, cost was not an issue because the ISPE received grant support, but the actual cost of the exercise was in excess of $100 per student per scenario. IPE experiences are more effective when they represent realistic scenarios with students assuming their actual professional roles, and learners’ reactions are more favorable when they see a direct relevance between an educational experience and their future practice.23

The D4 students were evaluated in history taking, physical evaluation, care planning, and communication with patients. Mean scores on the SP evaluation of student performance indicated that the students demonstrated good communication skills, and a score of 100% on recommendation indicates that the SPs would choose to see the students again and recommend them to a friend or family member. The lower scores on history taking and physical evaluation can be at least partially attributed to some confusion about whether the D4 was supposed to complete a comprehensive history and physical exam or simply accept information that was provided during the handoff from DNP to D4. More explicit instructions prior to subsequent ISPEs are expected to enhance these scores.

Student self-evaluations correlated with SP evaluations. History, physical exam, and perception scores were lower than communication scores. The sample size was too small to determine statistical relationships between SP and self-evaluations, but the correlation coefficients indicated a trend toward self-awareness on the part of the students, at least in the area of communication. However, the weakest correlation was in the area of perception of professional demeanor. The SPs universally said they would recommend the student dentist to others, which could be seen as an endorsement of the students’ professionalism. The weak correlation might be a reflection of the dental students’ lack of comfort with the environment, which was a medical examination room. The fact that the ISPE included D2 students who had had minimal exposure to live patients prior to the ISPE and whose roles were not well defined could also have led to a disconnect with regard to perception of professional demeanor.

Core competencies of IPCP were evaluated by faculty members from both schools after reviewing videotapes of the scenario. Students were scored on a 1 to 7 Likert scale (with 7=strongly agree). Students scored highest on the role/responsibilities subscale (6.03, meaning mostly agreed), indicating that students were respectful of each other’s roles and expertise and effectively engaged each other to develop strategies to meet the patient’s needs. Scores on the three other subscales (values/ethics, interprofessional communication, and teams/teamwork) approached a mean score of 6. From a faculty standpoint, these findings supported exposure to IPCP teams as a method to foster knowledge and respect for other roles and responsibilities, appreciate teamwork, and encourage better communication among health care disciplines.

During the debriefing, all students reported that the experience allowed them to develop a better appreciation for each other’s roles as well as the importance of teamwork in providing patient-focused care. The dental students were particularly engaged. They were excited to share their impressions with the DNP students and faculty, and they enthusiastically endorsed the ISPE. This result could be attributed at least in part to the fact that the dental students had no previous experience with SPs, so the ISPE was seen to be novel and interesting. These faculty and student findings were consistent with previous studies examining the use of simulations in IPE.25,26

A small number of ISPEs involving dental students have been reported previously.13,2729 These scenarios involved interprofessional chronic disease management and included students from as many as seven disciplines. Our ISPE was distinctive in several ways. It included students from only two professions. Since the ISPE was related to a grant designed to enhance oral-systemic competencies in DNP students, the scenario was developed to include specific, acute signs and symptoms of an oral problem. The ideal management of the scenario required that all problems be addressed. Therefore, both the DNP and dental students had to address both the acute and chronic aspects of the SP’s medical history. That is, persistent cough related to antihypertensive medication, periodontal abscess, poorly controlled diabetes, and generalized advanced chronic periodontitis all needed to be addressed. This scope facilitated discussion of oral-systemic connections.

Another distinctive feature of this ISPE was that it was not designed as a stand-alone exercise but rather as the next in a series of encounters for the DNP students. The SP was Charlene Williams #3. The DNP students had met the character (although not necessarily portrayed by the same actor) on two previous occasions—first when she was young and healthy and next when she was diagnosed with diabetes. During this ISPE, the patient had advanced to poorly controlled disease, including an oral manifestation. This continuity of care provides context and integrates the oral issues into the systemic concerns in a way that would have been more difficult in a single scenario. While it is true that the dental students had only one encounter with the SP, future exercises might well involve a similar continuity of care.

The most important feature of our ISPE was that the simulation followed actual clinical collaboration involving live patients. The DNP students had previously completed a clinical rotation to the screening and urgent care clinics at the dental school, during which they interacted with certain dental students who were scheduled for these rotations and who became the pool from which the volunteer dental students were selected for this study. Therefore, all participants had at least some experience working in interprofessional teams prior to the ISPE. While the clinical experiences were of high value, they underscored the need for both groups to have more emphasis on IPCP concepts in their curricula. The students scored well on the IPCP subscales, but the interactions were intuitive and lacked a theoretical framework. It is clear that didactic instruction in the principles of IPE should be given prior to IPCP simulations.

The challenge will be to incorporate IPCP competencies into already packed curricula with disparate requirements, schedules, and resources. Some foundational training will necessarily be done online in an asynchronous manner. Development of true IPCP experiences will take a great deal of cooperation across the disciplines. Our institution is devoting considerable resources to development of IPE/IPCP experiences through establishment of the Office of Interprofessional Education and Collaborative Practice.

This study had some limitations. The small sample size and use of a convenience sample limit the generalizability of our findings. With only eight out of approximately 110 dental students from each class participating, not all dental students had the opportunity to work on IPCP clinical faculty teams, and only a small number could participate in the ISPE. Because of unequal class sizes in the dental and DNP programs, as well as the expense associated with the use of SPs, it is unlikely that large samples will be available in the future; therefore, statistical analyses will lack power. The fact that DNP students participated as part of a course but dental students participated as volunteers could have created a dynamic whereby unequal investment in the exercise impacted results. However, high scores on the IPCP competencies suggest that this was not a problem. Overall, despite these limitations, the faculty members and students alike found the ISPE to be a worthwhile experience.

Conclusion

This study of an ISPE involving dental and DNP students found that the SP scenario provided an effective way to evaluate IPCP competencies. The experience supports use of simulation to enhance learning and implementation of IPCP. A scenario involving oral manifestations as well as chronic medical conditions allows for increased understanding of oral-systemic connections. As the concepts of IPE and IPCP continue to evolve, the challenge will be to find ways of integrating the necessary competencies into existing curricula, with the ultimate goal of enhancing patient-centered care. ISPEs and other simulations will likely play an important role in the process.

Acknowledgments

This project was partially supported by a Department of Health and Human Services, Bureau of Health Professions, Health Resources and Services Administration, Advanced Nursing Education grant (#D09HP25931). The authors wish to thank Karen Zinnerstrom, PhD, Training Program Coordinator, Office of Medical Education, SUNY Buffalo, for her invaluable assistance with the development and implementation of the ISPE.

REFERENCES