Effect of a person-centered mouth care intervention on care processes and outcomes in three nursing homes

Aspiration pneumonia in nursing literature-a mapping review

Introduction

Aspiration pneumonia (AP) is an infection of the lungs caused by inhalation of material. The reported incidences vary across literature and clinical populations and is associated with high morbidity and mortality. Management of AP is best carried out by a multidisciplinary team.

Methods

This aim of this review was to collate and describe the available evidence on AP to develop a greater understanding of the concept of AP as it is represented in the nursing literature. As a collaborative team, we undertook the six stages of a systematic mapping review. We searched for the term aspiration pneumonia in 200 peer reviewed nursing journals across 10 databases, over a ten-year period (2013-2023).

Results

In this review, 293 papers were coded. Dysphagia, oral health and tube feeding emerged as the most frequent risk factors for AP, and the most reported factors for preventing this condition. Mortality was the most commonly described consequence of AP, followed by hospitalisations and morbidity. Multiple management approaches were reported including dysphagia assessment, risk evaluation, oral care and texture modification of food and fluids. The role of nurses and interprofessional collaborations were described.

Discussion

Despite limited evidence related to the topic of AP in the nursing literature, the complexity of the causes, prevention, management and consequences of AP emerged. Certain factors, such as dysphagia, oral health, and tube feeding, were described under prevention, cause and management of AP. The importance of multidisciplinary approach in the management and prevention of AP was presented.

The Dutch version of the Oral Health Assessment Tool: Translation and inter-rater reliability among community nurses

OBJECTIVES

Translating the Oral Health Assessment Tool (OHAT) into Dutch and assessing the inter-rater reliability among community nurses.

METHODS

The original version of the OHAT was translated following the five stages of the 'Guidelines for the Process of Cross-Cultural Adaptation'. After a forward and backward translation, consensus on the pre-final version was obtained in an expert panel discussion. This version was pre-tested on its comprehensibility among 31 nurses and hereafter finalized. Then, inter-rater reliability of the OHAT-NL was determined by two trained nurses during oral assessments of 37 care-dependent community-dwelling older people. Intraclass correlation coefficient (ICC) and the Cohen's kappa statistic for individual items were estimated.

RESULTS

Feedback from nurses in the pre-test did lead to minor changes of the OHAT-NL. Inter-rater reliability was good (ICC 0.79; 95% CI 0.63-0.89) on the total score. Agreement on item level ranged from fair to very good, the kappa ranged from 0.36-0.89.

CONCLUSIONS

OHAT is now available in Dutch having good inter-rater reliability among trained community nurses. Future research can further validate the OHAT-NL and develop intervention according to total OHAT-NL scores.

Denture Plaque Biofilm Visual Assessment Methods: A Systematic Review

Denture plaque, a biofilm that develops on denture surfaces, could contribute to many oral and systemic afflictions. Hence, a quantitative assessment of denture plaque is important to evaluate the denture hygiene of denture wearers, particularly to prevent plaque biofilm-associated diseases. The aim of this systematic review, therefore, was to review and summarize the visual denture hygiene assessment methods using denture plaque indices and with planimetries published in the literature. English language studies published up to March 2022 in four electronic databases, PubMed, Medline, Embase, and Cochrane Library, were searched, followed by a manual search of Google Scholar by two assessors. The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) whenever possible. Details of the visual assessment methods, including the types of denture assessed, its materials and its surfaces, as well as the use of a disclosing agent, were the main outcomes. Of 492 screened studies, 74 were included per the inclusion and exclusion criteria. Of these, 60 studies utilized various denture plaque indices while 18 used planimetries. 43 out of 60 studies with indices and 17 out of 18 studies with planimetries used disclosing agents for visual evaluation of plaque. A total of 21 indices were described in the included studies, of which seven graded a divided denture surface, while the remainder graded entire denture surface. Of the 18 planimetric assessments, one study quantified squares of the disclosed plaques on denture images, 16 studies quantified such pixels with computer programs, and a single study quantified points, pixels, and contour of plaque areas. In summary, denture plaque indices appear to be popular in denture plaque assessment due to their simplicity. Computerized planimetric assessment, though more time-consuming, provides a more accurate assessment of plaque load as it is less prone to subjectivity and assessor errors.

Nurses' Awareness of and Current Approaches to Oral Care in a Community Hospital in Japan: A Longitudinal Study of Dental Specialists' Interventions

Objective: This study aimed to increase nurses' interest and priority in oral care by implementing educational interventions, such as teaching oral care methods suitable for each patient in clinical settings, over a period of one year. Materials and Methods: This study included all 150 nurses working in Unnan City Hospital in Japan who answered a questionnaire comprising 19 questions regarding awareness, actual implementation status of oral care provided, burden, and involvement with oral and maxillofacial surgery department of the hospital, along with participants' characteristics. The rate of interest in learning, need for oral care, time spent in oral care, and oral health-related caregiver burden index (OHBI) score were compared between pre- and post-intervention groups. Results: The number and rate of valid questionnaires were 136 and 90.7%, respectively. The mean years of clinical experience were 19.3 ± 12.5 years; 93.4% of the nurses were women. After the interventions by dental specialists, the nurses' level of interest in and priority to oral care were significantly higher than those before the interventions (p < 0.001), regardless of nurses' background, such as age, gender, or years of experience. However, the "burden" did not statistically decrease. Conclusions: This study shows that dental specialists succeeded in significantly increasing nurses' interest in and priority to oral care by intervening in clinical practice but failed in decreasing nurses' burden of oral care. In the future, we would like to investigate the problems that hinder the reduction of the sense of burden, reduce the burden of nurses' oral care, and improve oral care.

The Impact of Dental Care Programs on Individuals and Their Families: A Scoping Review

BACKGROUND

Despite significant global improvements in oral health, inequities persist. Targeted dental care programs are perceived as a viable approach to both improving oral health and to address inequities. However, the impacts of dental care programs on individual and family oral health outcomes remain unclear.

OBJECTIVES

The purpose of this scoping review is to map the evidence on impacts of existing dental programs, specifically on individual and family level outcomes.

METHODS

We systematically searched four scientific databases, MEDLINE, EMBASE, CINAHL, and Sociological Abstracts for studies published in the English language between December 1999 and November 2021. Search terms were kept broad to capture a range of programs. Four reviewers (AG, VD, AE, and KKP) independently screened the abstracts and reviewed full-text articles and extracted the data. Cohen's kappa inter-rater reliability score was 0.875, indicating excellent agreement between the reviewers. Data were summarized according to the PRISMA statement.

RESULTS

The search yielded 65,887 studies, of which 76 were included in the data synthesis. All but one study assessed various individual-level outcomes (n = 75) and only five investigated family outcomes. The most common program interventions are diagnostic and preventive (n = 35, 46%) care, targeted children (n = 42, 55%), and delivered in school-based settings (n = 28, 37%). The majority of studies (n = 43, 57%) reported a significant improvement in one or more of their reported outcomes; the most assessed outcome was change in dental decay (n = 35).

CONCLUSIONS

Dental care programs demonstrated effectiveness in addressing individual oral health outcomes. However, evidence to show the impact on family-related outcomes remains limited and requires attention in future research.

Effects of oral health intervention strategies on cognition and microbiota alterations in patients with mild Alzheimer's disease: A randomized controlled trial

We explored the effects of an oral health intervention on the oral microbiome and cognitive function of patients with mild Alzheimer's disease (AD) and determined the influence on disease progression. Sixty-six patients with mild AD were randomly assigned to intervention or control groups and received a 24-week oral health intervention and routine care, respectively. Data were collected at baseline and week 24. 16 S rRNA sequencing was used to analyze oral microbiota. After 24 weeks of oral health intervention, Kayser-Jones Brief Oral Health Status Examination (BOHSE), Mini-Mental State Examination (MMSE), Neuropsychiatric Inventory (NPI), Nursing Home Adjustment Scale (NHAS), and Alzheimer's Disease Cooperative Study-ADL (ADCS-ADL) scores were different between groups (p < 0.05). Subgingival plaque in patients with AD showed significant differences in the diversity and abundance of oral microbiomes, with a higher abundance of normal oral flora in the intervention group. We found oral health intervention strategies are effective in modifying subgingival microbiota differences and slowing cognitive decline in mild AD patients.

Oral Care Awareness and Factors Related to the Burden of Nurses at a Community Hospital in Japan

Objective: This cross-sectional study investigated the oral care knowledge, awareness, and challenges of 159 nurses and identified the factors related to the burden of oral care in Unnan City Hospital, Japan. Materials and Methods: This study included outpatient, ward, and operating room nurses who answered a questionnaire comprising 19 questions regarding awareness, actual implementation status of oral care provided, burden and learning experiences of oral care, and participants’ characteristics. A univariate regression model was used to assess whether catheterization was associated with the independent variables. Results: The number and rate of valid questionnaires were 134 and 87.6%, respectively. The mean years of clinical experience were 18.71 ± 12.02 years; 95.5% of the nurses were women. There were significant differences in the Oral Health-related Caregiver Burden Index among “interest in oral care” (p = 0.006), “priority of oral care” (p = 0.005), and “burden of oral care”. Conclusions: This study shows that nurses who are highly interested in oral care, prioritize oral care, and do not perceive oral care as a burden. Educational interventions, such as training sessions and direct guidance to solve challenges, are needed and can lead to improvements in the quality of life and advancement of health.

Oral health is Essential to the Well-Being of Older People

Although the highest attainable standard of health is a fundamental human right, oral health is often not considered an important component of overall health. Older people experience poorer quality of life due to discomfort and uncleanliness of their mouth and there continue to be barriers within health systems that contribute to this poor oral health. This paper advocates for oral health to be considered part of the basic human right to good health care and discusses how stakeholders can collaborate and work together to begin to meet the needs of this population, proposing solutions and recommendations to bring about change.

Continuing education interventions about person-centered care targeted for nurses in older people long-term care: a systematic review

BACKGROUND

Person-Centered Care is often seen as an indicator of quality of care. However, it is not known whether and to what extent person-centered care can be enhanced by continuing education interventions in older people's long-term care settings. This systematic review aimed to analyze and synthesize the existing research literature about person-centered care-based continuing educational interventions for nurses working in long-term care settings for older people.

METHODS

Five databases were searched 6/2019 and updated 7/2020; PubMed (Medline), CINAHL, PsycINFO, Cochrane and Eric using the keywords person-centered car* OR person-centred car * OR patient-centered car* OR client-centered car* OR tailored car* OR resident-centered car* OR individualized car* AND older* OR elder* OR old person* AND Long-Term Care OR Nursing home OR 24-h treatment OR long-term treatment. Twenty-seven full texts from 2587 initially retrieved citations were included.

RESULTS

The continuing educational interventions found were divided into five themes: person-centered interventions focusing on medication; interaction and caring culture; nurses' job satisfaction; nursing activities; and older people's quality of life. The perspective of older people and their next of kin about the influence of continuing education interventions were largely absent. The background theories about interventions, the measurements taken, and the clarity around the building blocks of the continuing-care interventions need further empirical verification. The pedagogical methods used were mainly quite behavioristic mostly lectures and seminars.

CONCLUSION

Most of person-centered care continuing education interventions are effective. Still more empirical research-based continuing education interventions are needed that include learner-centered pedagogical methods, with measurable outcomes that consider the opinions of older people and their next of kin. Continuing educational interventions for nurses need to be further developed to strengthen nurse's competence in person-centered care, job satisfaction and for better quality of care.

Home care aides' attitudes to training on oral health care

This study investigated home care aides' (HCAs) oral health care experience, knowledge, and their intention to receive professional training, to explain and predict factors of their intention to receive such training. This cross-sectional study collected data through a structured questionnaire. HCAs affiliated with home care agencies in Taichung, Taiwan were recruited through purposive sampling. A total of 487 questionnaires were distributed from September to December 2015 with 280 valid responses collected (57.4%).This study predicted the factors of HCAs' intention to receive oral health care training through a decision tree analysis. The decision tree model classified the respondents with an accuracy of 77.5%. The optimal predictor variable was oral health care knowledge (χ2 = 66.662, p < 0.0001). Among the low-scoring respondents on oral health care knowledge, 76.4% were classified in the "uninterested" group, whereas 84.8% of the high scorers were classified in the "interested" group. The second best predictor variable was whether oral health care is part of the job responsibility (χ2 = 7.979, p = 0.007). Among those who answered Yes, 92.9% were in the interested group, as were 76.5% of those who answered No. It is recommended to add "disease and oral care-related content" and "safety protection, assessment, and usage of oral care tools during practical oral care process" to the oral healthcare training course content for HCAs in order to improve HCAs' oral healthcare knowledge and oral care skills. These research findings are valuable and may be taken into account in the future development of the in-service educational training of oral healthcare for HCAs.

Oral Health in Adult Patients Receiving Palliative Care: A Mixed Method Study

BACKGROUND

Oral disease is highly prevalent in persons receiving palliative care (PRPC). Yet, little is known about how PRPC perceive their oral health status and related treatment needs.

METHODS

This mixed-method study included 49 English-speaking PRPC (age≥18) recruited from the University of Iowa Palliative Care Clinic. Participants first completed a structured review of oral symptoms, followed by an oral exam. A nested sample of 11 participants also completed a semi-structured, in-depth interview querying their perceived oral health concerns and related treatment needs. Quantitative and qualitative data was analyzed and integrated for interpretation.

RESULTS

Participants averaged 58.4 years. Nearly 70% had terminal cancer and 25% had advanced organ failure. Eighty-six percent of participants reported at least one oral symptom, including dry mouth (83.7%), a pain-related symptom (40.8%), or oral function difficulties (51.0%). Among the 31 dentate participants, 52% had untreated decayed/broken teeth and 33.3% had oral soft tissue lesions. Ill-fitting dentures and denture sores were common among denture users. About 40% of participants reported compromised health and/or quality of life due to oral conditions; however, the perceived impacts were modest. With the exception of painful conditions, oral treatment was not a priority for most of the participants.

CONCLUSION

Oral disease was highly prevalent in PRPC, yet its overall impact was modest. In the absence of painful symptoms, most participants reported limited desire to seek treatment for oral health conditions. However, given the serious impacts of untreated oral diseases, oral healthcare decision should not be based solely on self-reported symptoms or distress.

Cluster randomized control trial of nursing home residents' oral hygiene following the Mouth Care Matters education program for certified nursing assistants

Aims

The purpose of this study was to determine if the number of certified nursing assistants (CNAs) trained with the Mouth Care Matters (MCM) oral health educational program had an impact on nursing facility (NF) resident oral health.

Materials and methods

Three NFs participated in a cluster randomized control trial. In NF‐A: all CNAs were offered the MCM program, NF‐B: 3 CNAs were offered the MCM program, and NF‐C: Control (no CNAs were offered the MCM program). Demographic information, systemic health data, and oral health data at baseline, 3‐month, and 6‐month intervals were collected and analyzed using Kruskal‐Wallis, Wilcoxon signed‐rank and Wilcoxon rank‐sum tests. A total of 24 dentate residents participated in this study. Plaque control record scores for NF‐A were significantly reduced compared to NF‐B and NF‐C (P < .001 and P = .002 respectively) and gingival bleeding index for NF‐A were significantly reduced compared to NF‐B and NF‐C (P = .002 and P < .001 respectively).

Conclusion

Increasing the number of CNA's trained in the Mouth Care Matters educational program positively impacted NF residents’ oral hygiene.

Effects of a Caregiver Training Program on Oral Hygiene of Alzheimer's Patients in Institutional Care

OBJECTIVES

To investigate the effects of a caregiver training program on the oral hygiene of caregivers and patients with Alzheimer's disease (AD) and to identify program components and parameters for accurate assessment of outcomes.

DESIGN

Single-blinded prospective cohort study.

SETTING AND PARTICIPANTS

Patients with AD and caregivers in nursing homes in the Greater Zhengzhou Area, China.

METHODS

Initially 168 AD patient/caregiver pairs were recruited and randomly assigned to control, limited training, and comprehensive training groups. The mini-mental state examination, global deterioration scale, and Katz activities of daily living scale were conducted for patients with AD. Information on participants' oral hygiene habits and general oral health was collected. The modified Quigley-Hein Plaque Index (PI) and Gingival Index (GI) were used to assess oral hygiene and gingival health. Intervention included (1) an educational video showing the role of dental plaque and the modified Bass technique; and (2) caregivers practicing toothbrushing on themselves and patients with AD under professional guidance. Changes in oral hygiene and correlations between patient PI/GI and caregiver PI/GI were analyzed.

RESULTS

After 6 weeks, complete data for 146 AD patient/caregiver pairs were collected. Before enrollment, most patients with AD had very poor oral hygiene. Compared with controls and limited training, only comprehensive training was able to achieve steady reduction in PI and GI scores in patients with AD, which still fell short of desirable levels (PI: 2.46 ± 0.52, GI: 1.24 ± 0.24, week 6). PI and GI scores in caregivers saw steady improvement only through comprehensive training (PI: 1.41 ± 0.38, GI: 0.88 ± 0.19, week 6). Number of training sessions had the greatest influence on both patient PI and GI scores.

CONCLUSIONS AND IMPLICATIONS

Comprehensive caregiver training on toothbrushing skills is effective in improving the oral hygiene of caregivers and patients with AD in nursing homes. Additional evidence is needed to establish the optimal program structure.

Implementation and evaluation of an oral health education programme for caregivers in nursing homes

AIM

The aim was the design, implementation, and evaluation of an oral health education program for nursing home caregivers.

METHODS AND RESULTS

Fifty-five formal caregivers working in the three units of a nursing home were allocated to either a control (n = 27) or an intervention group (n = 28). A knowledge and attitudes questionnaire about oral health was developed and completed by the caregivers. Then, an education program about oral heath in older people was applied to the intervention group, and the completion of the questionnaire was repeated by both the intervention and control groups. Two months after the intervention, the questionnaire was completed again by the intervention group. Within groups analyses revealed a statistically significant increase in knowledge and attitudes only in the intervention group after the implementation of the education program (P < .001). Between-group analyses showed that the total knowledge and attitudes score in the intervention group were statistically significantly higher than in the control group (P < .001 and P = .02, respectively). In the intervention group, knowledge and attitudes were maintained in the measurement recorded 2 months later (P = .11 and P = .21, respectively).

CONCLUSION

The education program was effective in improving the caregivers' knowledge and attitudes toward nursing home residents' oral health and maintaining them 2 months after implementation.

Current Status and Challenges of Community-Based Elderly Care Centers in Chongqing, China: A Cross-Sectional Study

PURPOSE

China is facing various societal pressures owing to its rapidly aging population. In order to provide evidence-based suggestions to promote elderly care, this study investigated the community-based elderly care centres (CBECCs) in Chongqing of China, focusing on the site selections, physical environment, facilities, and operation.

METHODS

All CBECCs in a district of Chongqing were analysed via a single-stage cluster sampling survey design. Descriptive statistics were used to analyse the data.

RESULTS

A total of 69 CBECCs (60 government-run and 9 collective-run centres) were identified and analysed. Most site selections were reasonable. CBECCs that were located inside of apartment complexes with entrance guards, not located on main roads, and near a market were more popular. Only 4 (13.3%) CBECCs that were not located on the ground floor were equipped with elevators. A small number of CBECCs were near a noise pollution (10.1%) or far from a medical institution (11.6%). Nearly half (42.7%) of CBECCs only had an indoor area of <200 m2. Nearly all CBECCs had sufficient ventilation, natural lighting, and sufficient floor-to-floor height. 51.5% and 88.4% of the CBECCs fully met the criteria of 'four rooms and one canteen' and 'eight functional zones', but no significant difference was found in terms of the number of people served per month between the CBECCs that met the criteria and those that did not. A quarter of the CBECCs were operated by part-time staff. Only half provided home services (54.5%). The median of average number of people they served every month was 100 (interquartile range = 10-300).

CONCLUSION

Certain problems existed in the current CBECCs. Better elderly care especially calls for adequate elevator establishment, sufficient indoor and outdoor space, appropriate facilities and service, qualified managers and caregivers. A feasible and evidence-based plan to optimize the physical environment and facilities, functional layout and service provision is crucial to improve the CBECC service.

How accurate is the assessment of certified nursing assistants on resident's oral self-care function in three North Carolina assisted-living facilities?

AIMS

To examine the association between the assessments of certified nursing assistants (CNAs) on resident's oral self-care function and resident's oral hygiene outcomes in three North Carolina assisted-living (AL) facilities.

METHODS AND RESULTS

Sixty-five dentate AL residents were included in this secondary analysis. CNAs were asked to rate the AL residents' overall oral self-care function using a 6-point Likert scale. Their assessments were then compared with the objective, performance-based Dental Activities Test and the oral hygiene and gingival health measures. The analysis showed that nearly 90% of the participants presented with at least one untreated decayed or broken tooth. On average, nearly two-thirds of the surfaces were covered by soft deposits (Debris Index = 1.83, SD = 0.60). Generalized mild to moderate inflammation (Gingival Index = 1.51, SD = 0.53) commonly presented on residents' gingiva. CNAs were able to accurately identify the residents with substantial impairment in oral self-care function, yet they tended to overestimate the oral self-care function of residents with mild to moderate impairment. CNAs assessments were also not significantly correlated with residents' oral hygiene measures.

CONCLUSION

CNAs failed to identify and provide assistance to AL residents with impaired oral self-care function, contributing to poor oral oral hygiene in these vulnerable individuals.

Fidelity and sustainability of Mouth Care Without a Battle and lessons for other innovations in care

There are countless efficacious interventions that improve outcomes when conducted in controlled situations. Many fewer are effective when implemented in real-world situations, largely because they are not implemented with fidelity. Still fewer are sustained over time, for reasons including lack of institutional support and fit with existing values, among others. It is especially important to examine fidelity and sustainability when efficacious interventions are being implemented, because these interventions are the ones that hold the most promise. This project examined the fidelity and sustainability of Mouth Care Without a Battle (MCWB), an evidence-based program conducted in a two-year cluster randomized trial in 14 nursing homes. Results that triangulated two sources of data indicated that fidelity decreased after the first year; they provide guidance to promote fidelity and sustainability of this and other new care practices in nursing homes, including ongoing education, coaching, evaluation, feedback, and sufficient resources.

Evaluation of an Oral Hygiene Education Program for Staff Providing Long-Term Care Services: A Mixed Methods Study

Background: Oral hygiene is often neglected in clients receiving long-term care, suggesting that long-term care workers require formal oral hygiene education. Thus, the aim of this study was to investigate the effects of oral hygiene education on long-term care workers. Methods: This study utilized a mixed methods design. Eighty long-term care workers were recruited for participation in the oral hygiene education program, which employed three teaching methods: narration with multimedia presentation, demonstration, and teach-back. The effect of the education program on the participants’ level of oral hygiene knowledge, attitudes, and skills was measured using a structured questionnaire that was administered both pre- and post-delivery of the education program. Three months later, all participants submitted a self-report of their oral hygiene skills, and six participants completed a telephone interview. Quantitative data were analyzed using paired t-tests, and qualitative data were manually analyzed and coded. Results: Scores of oral hygiene knowledge (p < 0.001), attitudes (p = 0.001), and oral cleaning daily frequency for clients (p < 0.001), were significantly higher three months after undertaking the educational program. Conclusions: This preliminary study suggests that oral hygiene education may be effective in improving oral hygiene knowledge, attitudes, and skills among long-term care staff.

Effectiveness of a Mouth Care Program Provided by Nursing Home Staff vs Standard Care on Reducing Pneumonia Incidence: A Cluster Randomized Trial

Importance

Pneumonia affects more than 250 000 nursing home (NH) residents annually. A strategy to reduce pneumonia is to provide daily mouth care, especially to residents with dementia.

Objective

To evaluate the effectiveness of Mouth Care Without a Battle, a program that increases staff knowledge and attitudes regarding oral hygiene, changes mouth care, and improves oral hygiene, in reducing the incidence of pneumonia among NH residents.

Design, Setting, and Participants

This pragmatic cluster randomized trial observing 2152 NH residents for up to 2 years was conducted from September 2014 to May 2017. Data collectors were masked to study group. The study included 14 NHs from regions of North Carolina that evidenced proportionately high rehospitalization rates for pneumonia and long-term care residents. Nursing homes were pair matched and randomly assigned to intervention or control groups.

Intervention

Mouth Care Without a Battle is a standardized program that teaches that mouth care is health care, provides instruction on individualized techniques and products for mouth care, and trains caregivers to provide care to residents who are resistant and in special situations. The control condition was standard mouth care.

Main Outcomes and Measures

Pneumonia incidence (primary) and hospitalization and mortality (secondary), obtained from medical records.

Results

Overall, the study enrolled 2152 residents (mean [SD] age, 79.4 [12.4] years; 1281 [66.2%] women; 1180 [62.2%] white residents). Participants included 1219 residents (56.6%) in 7 intervention NHs and 933 residents (43.4%) in 7 control NHs. During the 2-year study period, the incidence rate of pneumonia per 1000 resident-days was 0.67 and 0.72 in the intervention and control NHs, respectively. Neither the primary (unadjusted) nor secondary (covariate-adjusted) analyses found a significant reduction in pneumonia due to Mouth Care Without a Battle during 2 years (unadjusted incidence rate ratio, 0.90; upper bound of 1-sided 95% CI, 1.24; P = .27; adjusted incidence rate ratio, 0.92; upper bound of 1-sided 95% CI, 1.27; P = .30). In the second year, the rate of pneumonia was nonsignificantly higher in intervention NHs. Adjusted post hoc analyses limited to the first year found a significant reduction in pneumonia incidence in intervention NHs (IRR, 0.69; upper bound of 1-sided 95% CI, 0.94; P = .03).

Conclusions and Relevance

This matched-pairs cluster randomized trial of a mouth care program compared with standard care was not effective in reducing pneumonia incidence at 2 years, although reduction was found during the first year. The lack of significant results in the second year may be associated with sustainability. Improving mouth care in US NHs may require the presence and support of dedicated oral care aides.

Trial Registration

ClinicalTrials.gov Identifier: NCT03817450.

Oral health-related quality of life and associated factors among older people in short-term care

OBJECTIVES

It is well known that oral health status is associated with oral health-related quality of life (OHRQoL) in the general population. The aim of this study was to describe and analyse OHRQoL among older people in short-term care and its associated factors.

MATERIALS AND METHODS

This cross-sectional study included 391 older people in 36 short-term care units. Data were collected via clinical oral assessments, questions about self-perceived oral and general health, Katz Index of Activities of Daily Living (Katz-ADL) and the Revised Oral Assessment Guide (ROAG). OHRQoL was measured using the Oral Health Impact Profile (OHIP-14). Multivariate logistic regression models were applied in the analysis.

RESULTS

Poor OHRQoL was reported by 34% of the older people. Associated factors were swallowing problems according to ROAG; quite poor/poor self-perceived physical, psychological and oral health; and being a woman.

CONCLUSIONS

There is an association between OHRQoL and older people's self-perceived health according to the OHIP-14. This indicates the importance of early detection of oral health problems in frail older people and to assess both oral health and swallowing problems among older people in short-term care.

Implementation of an Evidence-Based Oral Care Protocol to Improve the Delivery of Mouth Care in Nursing Home Residents

The current project assessed the oral health of residents in a long-term care (LTC) facility, implemented a new evidence-based oral care protocol, and trained nursing staff about oral hygiene for older adults. A pre-/post-intervention design was used to measure knowledge, skills, and attitudes among 29 staff members. The oral health outcomes of 10 LTC residents without dysphagia were assessed after 14 days of protocol use. Knowledge improved from a mean total pre-test score of 88.8 to a mean total post-test score of 97.7 (Z = -2.308, p = 0.021). The Oral Health Assessment Tool measured oral health outcomes at three time points in 10 older adults, and statistically significant improvement in oral health was identified (p = 0.001). Nursing home staff play an important role in improving oral hygiene of older adults in LTC facilities by routinely using an easy to follow oral health protocol twice daily. [Journal of Gerontological Nursing, 46(5), 33-39.].

Measuring Self-Efficacy and Attitudes for Providing Mouth Care in Nursing Homes

OBJECTIVES

Mouth care is increasingly recognized as an important component of care in nursing homes (NHs), yet is known to be deficient. To promote quality improvement and inform research efforts, it is necessary to have valid measures of staff self-efficacy and attitudes to provide mouth care.

DESIGN

A self-administered questionnaire completed by NH staff, information about the NH obtained from the administrator, and oral hygiene assessments of NH residents.

SETTING AND PARTICIPANTS

A total of 434 staff in 14 NHs in North Carolina who were participating in a cluster randomized pragmatic trial of Mouth Care Without a Battle (MCWB).

METHODS

Staff in MCWB homes completed the questionnaire at baseline; staff in control homes completed it at 2-year follow-up. The 35-item questionnaire used new items and those from previous measures, many of which were modified for the NH setting. Factorial, construct, and criterion validity were assessed.

RESULTS

Exploratory factor analysis identified a 3-factor 11-item self-efficacy scale (promoting oral hygiene, providing mouth care, obtaining cooperation) named "Self-Efficacy for Providing Mouth Care" (SE-PMC), and a 2-factor 11-item attitudes scale (care of residents' teeth, care of own teeth), named Attitudes for Providing Mouth Care (A-PMC). Scores varied significantly across NHs and differentiated them based on profit status, age, and, for the A-PMC, NH size. Scores also differentiated among staff based on age and, for the SE-PMC, years of experience. In NHs where staff scored more highly, residents featured better oral hygiene (P < .001).

CONCLUSIONS AND IMPLICATIONS

The SE-PMC and A-PMC are valid, parsimonious, and useful measures for quality improvement and research to improve mouth care in NHs that can be used jointly or individually. Preliminary evidence suggests that these scales may be associated with resident-level plaque and gingival hygiene, making them useful tools to assess promotion of mouth care.

A context analysis on how oral care is delivered in hospitalised patients: A mixed-methods study

AIMS AND OBJECTIVES

To analyse oral care delivery in one hospital through exploring experiences from both nurses' and patients' perspectives and examining patients' oral health.

BACKGROUND

Oral health problems are associated with undernutrition and other general health outcomes. Although oral care belongs to the essentials of nursing, it is often neglected. Improving oral health may require behaviour change of both nurses and patients. Defining tailored strategies need a clear view on the context.

DESIGN

A context analysis in one hospital using a convergent parallel mixed-methods design was reported following the EQUATOR guidelines using two checklists: COnsolidated criteria for REporting Qualitative research (qualitative research) and STROBE (observational research).

METHODS

Semi-structured interviews were conducted with 19 nurses and 11 patients. The topic list was based on the Integrated Change Model. Prospective oral examination was performed among 91 surgical patients using the Oral Health Assessment Tool (OHAT).

RESULTS

Nurses acknowledged that they did not prioritise oral care in daily practice. Furthermore, they lacked knowledge and skills to identify and provide care for oral problems. Nurses mentioned helpful resources to perform oral care, like standardised language and instruments. However, they had no access to or were unaware of them. Patients admitted that they did not prioritise oral care due to their sickness during hospitalisation, were unaware of the importance of oral care, but felt responsible for their oral care. The most prominent oral problems identified with the OHAT were unclean mouths (n = 75, 82%), unhealthy gum and tissues (n = 55, 60%) and dry mouth (n = 42, 46%).

CONCLUSIONS

This context analysis identified inadequate oral care due to lack of positive attitude and knowledge in both nurses and patients, skills for nurses, and resources.

RELEVANCE TO CLINICAL PRACTICE

The behavioural factors indicate strategies for development of a multicomponent intervention to improve oral care in this hospital, nutritional status and general health outcomes.

If we cannot measure it, we cannot improve it: Understanding measurement problems in routine oral/dental assessments in Canadian nursing homes-Part I

OBJECTIVE

To compare Resident Assessment Instrument-Minimum Data Set 2.0 (RAI) oral/dental items collected by nursing home (NH) care staff to (a) assessments collected by trained research assistants (RAs) and (b) "gold standard" clinical assessments by dental hygienists (DHs).

BACKGROUND

Routine collection of RAI oral/dental items is mandatory in most Canadian NHs. However, the performance of these items is less than optimal and oral/dental problems are severely under-reported. Accurate assessment is a prerequisite for preventing, detecting and treating oral health problems. Not knowing the reasons for performance problems is a barrier to improving performance of the RAI oral/dental items.

MATERIALS AND METHODS

We included 103 NH residents from 4 NHs in Edmonton, Alberta, Canada. Using Kappa statistics, we compared the agreement of residents' last (no older than 90 days) RAI assessment with RAI assessments completed by trained RAs and "gold standard" clinical assessments by DHs. We also assessed the inter-rater reliability (IRR) of RA and DH assessments.

RESULTS

Care staff assessments had poor agreement with RA and DH assessments (Kappa < 0.2 for most items). RAs and DHs identified more oral/dental problems than care staff. However, IRR of RA assessments was low (Kappa < 0.7 for 7/9 items). IRR of DH assessments was acceptable (Kappa > 0.7) for most items.

CONCLUSIONS

The quality of RAI oral/dental assessments can be improved by better training care staff and ensuring appropriate time to do the assessments. However, remaining problems-even with trained RAs-suggest that rewording some of the items or supplementing them by more robust tools may be required.

The Resident VIEW in Nursing Homes

This article presents the Resident VIEW (Voicing Importance, Experience, and Well-Being), a measure designed to learn directly from long-term care residents the extent to which they experience support that matters most to them. The Resident VIEW contains 63 items across eight domains developed through cognitive interviews with residents in different types of residential settings (e.g., nursing homes, assisted living, and adult foster care). Residents rate items on both importance and their experience. In total, 258 nursing home residents living in 32 Oregon nursing homes were selected through a two-stage random sampling design and participated in the study. Results demonstrate that what matters most to residents varies, emphasizing the value of asking residents directly about their preferences. The relationship between importance and experience differed by item. Residents who experienced support rated very important within some domains, reported better quality of life and reported lower levels of depressive symptoms than those who did not experience these things. The interaction between importance and experience, however, did not reach statistical significance, suggesting that positive experiences may provide benefit even in some areas that are not perceived as important by residents. Results underscore the value of incorporating the resident perspective into measure development in long-term care.

The Quality of Caregivers for the Elderly in Long-Term Care Institutions in Zhejiang Province, China

China is facing challenges in caring for older adults. This paper aimed to understand knowledge, attitude, and practice (KAP) regarding the quality of caregivers for the elderly in long-term care institutions in Zhejiang Province, and also to find related factors to improve the quality of caregivers. A cross-sectional survey was conducted from April to June 2016 in Zhejiang Province. In total, 84 caregivers were interviewed face-to-face with questionnaires on KAP towards elderly care. Multiple linear regression was used to find the related factors to KAP. A conceptual model was made to process path analysis among KAP and influencing factors using structural equation modeling. The study found that most caregivers in Zhejiang Province were middle-aged, female, and with a diploma below middle school. Many caregivers had not received any pre-employment training. Their salary was low although they undertook high-intensity work. Education and working years had a positive effect on knowledge and practice scores, and pre-employment training had a positive effect on knowledge and attitude scores. Knowledge and attitude regarding elderly care could positively affect elderly care practices. The quality of caregivers in Zhejiang Province was at a low level compared to developed countries. Continuous and regular elderly care training should be provided for caregivers to improve their elderly care knowledge and hence the quality of elderly care.

Can oral healthcare for older people be embedded into routine community aged care practice? A realist evaluation using normalisation process theory

BACKGROUND

An intervention 'Better Oral Health in Home Care' was introduced (2012-2014) to improve the oral health of older people receiving community aged care services. Implementation of the intervention was theoretically framed by the Promoting Action on Research Implementation in Health Services framework. Process outcomes demonstrated significant improvements in older people's oral health.

OBJECTIVE

To evaluate the extent to which the intervention has been embedded and sustained into routine community aged care practice 3 years after the initial implementation project.

DESIGN

A Realist Evaluation applying Normalisation Process Theory within a single case study setting.

SETTING

Community aged care (home care) provider in South Australia, Australia.

PARTICIPANTS

Purposeful sampling was undertaken. Twelve staff members were recruited from corporate, management and direct care positions. Two consumers representing high and low care recipients also participated.

METHODS

Qualitative methods were applied in two subcases, reflecting different contextual settings. Data were collected via semi-structured interviews and analysed deductively by applying the Normalisation Process Theory core constructs (with the recommended phases of the Realist Evaluation cycle). Retrospective and prospective analytic methods investigated how the intervention has been operationalised by comparing two timeframes: Time 1 (Implementation June 2012-December 2014) and Time 2 (Post-implementation July 2017-July 2018).

RESULTS

At Time 1, the initial program theory proposed that multi-level facilitation contributed to a favourable context that triggered positive mechanisms supportive of building organisational and workforce oral healthcare capacity. At Time 2, an alternative program theory of how the intervention has unfolded in practice described a changed context following the withdrawal of the project facilitation processes with the triggering of alternative mechanisms that have made it difficult for staff to embed sustainable practice.

CONCLUSION

Findings concur with the literature that successful implementation outcomes do not necessarily guarantee sustainability. The study has provided a deeper explanation of how contextual characteristics have contributed to the conceptualisation of oral healthcare as a low priority, basic work-ready personal care task and how this, in turn, hindered the embedding of sustainable oral healthcare into routine community aged care practice. This understanding can be used to better inform the development of strategies, such as multi-level facilitation, needed to navigate contextual barriers so that sustainable practice can be achieved.

Improving Nursing Home Residents' Oral Hygiene: Results of a Cluster Randomized Intervention Trial

OBJECTIVE

A 2-year cluster randomized trial of Mouth Care Without a Battle (MCWB) was conducted in nursing homes (NHs) to determine if recommended mouth care practices provided by NH staff could improve residents' oral hygiene and denture outcomes.

DESIGN

Cluster randomized trial of NHs.

SETTING AND PARTICIPANTS

Seven MCWB NHs and 6 control NHs. A total of 219 NH residents completed baseline and 24-month oral examinations and, if applicable, denture assessments (control = 98, intervention = 121).

INTERVENTION

The intervention consisted of training NH staff in the MCWB protocol, and providing support in its use for 2 years.

MEASURES

Descriptive data from the Minimum Data Set and clinical oral health assessments: the Plaque Index for Long-Term Care (range 0‒3), the Gingival Index for Long-Term Care (range 0‒4), and the Denture Plaque Index (range 0‒4), with lower scores indicating better oral health.

RESULTS

There were no significant demographic or health differences between groups at baseline. Residents' mean age (standard deviation) was 77.8 years (13.5), 71% were female, and 49% had cognitive impairment. At 24 months, there were significant improvements in oral and denture hygiene in the intervention group compared with control (all P < .05) with mean changes in indices that were 0.44 (Plaque Index for Long-Term Care), 0.55 (Gingival Index for Long-Term Care), and 0.67 (Denture Plaque Index) points lower in intervention NHs than control NHs.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Training NH staff to attend to residents' oral hygiene and denture care had a sustained, favorable impact on residents' oral and denture hygiene after 24 months compared with usual care. The protocol, MCWB, can be used by direct caregivers to improve the oral hygiene and denture care of NH residents.

Dentistry and nursing working together to improve oral health care in a long-term care facility

Inadequate oral care in long-term care (LTC) facilities compromises the quality of life of residents. This study assessed oral care knowledge of, and challenges experienced by, nurses and allied nursing staff (ANS) in a LTC facility in Canada. Dentists and nursing staff used the findings to implement strategies for improved care. Using a sequential mixed method design, data on oral care knowledge and practices were collected using self-administered questionnaires (n = 114) and focused groups (n = 39). Data were analyzed using descriptive statistics and thematic analysis. While participants (>80%) felt knowledgeable and confident in providing oral care, they desired improved skills to overcome resistive behavior, communication, and wanted adapted oral care materials. Implemented strategies included skills-acquisition workshop, oral care posters, and oral health champion. Overall, our interprofessional collaboration increased awareness of the need for oral care training, and implemented strategies to help nursing staff overcome barriers in providing care.

Iowa nursing facility oral hygiene (INFOH) intervention: A clinical and microbiological pilot randomized trial

PURPOSE/AIM

The aim of this pilot study was to evaluate feasibility and gather initial data for a definitive study to test the clinical and microbiological effectiveness of a nursing facility (NF) customized oral hygiene protocol, intended to be delivered by dental hygienists and NF personnel.

MATERIALS AND METHODS

A convenience sample of 8 Eastern Iowa NFs was recruited, and each NF was assigned to one of three intervention groups: (1) control (current oral hygiene practice), (2) educational program only, and (3) educational program plus 1% chlorhexidine varnish monthly application. Demographic information, systemic health data, patient centered data, oral health data, and microbiology samples were collected at baseline and after 6 months.

RESULTS

Recruitment response rates were 21% for NFs and 23% for residents. A total of 81 residents were examined at baseline and of those, 49 were examined at 6 months (39.5% attrition). There were no statistically or clinically significant differences among the intervention groups at 6 months for any of the recorded clinical or microbiological outcomes.

CONCLUSIONS

Recruitment and retention posed a significant challenge to this trial, even with a relatively short observation period. Results from this pilot study did not encourage further investigation of this customized oral hygiene protocol.

Randomised clinical trial: Efficacy of strategies to provide oral hygiene activities to nursing home residents with dementia who resist mouth care

OBJECTIVES

The purpose of this study was to test the efficacy of MOUTh (Managing Oral Hygiene Using Threat Reduction), a nonpharmacologic, relationship-based intervention vs. control on 2 primary outcomes for nursing home (NH) residents with dementia who resisted mouth care: (i) reduction in the occurrence and intensity of care-resistant behaviours (CRBs) and (ii) improvement in oral health. Two secondary outcomes were also examined: (i) the duration of mouth care and (ii) the completion of oral hygiene activities.

BACKGROUND

Persons with dementia who exhibit CRBs are at risk for inadequate mouth care and subsequent systemic illnesses.

MATERIALS AND METHODS

The study used a randomised repeated measures design. Recruitment occurred in 9 nursing homes that varied in size, ownership, reimbursement patterns and location. One hundred and one nursing home residents with dementia were randomised at the individual level to experimental (n = 55) or control groups (n = 46). One hundred participants provided data for the analyses.

RESULTS

Compared to the control group, persons in the experimental group had twice the odds of allowing mouth care and completing oral hygiene activities; they also allowed longer duration of mouth care (d = 0.56), but showed only small reductions in the intensity of CRBs (d = 0.16) and small differential improvements in oral health (d = 0.18).

CONCLUSION

The data suggest that this intervention facilitates mouth care among persons with dementia. The management of refusal behaviour may be a clinically more realistic approach than reducing or eradicating refusals.

Using an Interactive Video Simulator to Improve Certified Nursing Assistants' Dressing Assistance and Nursing Home Residents' Dressing Performance: A Pilot Study

This pilot study examined the initial effects and estimated effect size of a computer-based simulation education program on certified nursing assistants' level of assistance when dressing nursing home residents with dementia and on residents' dressing performance. Nine dyads, assigned to either the experimental or control group, completed the study. Both groups received a traditional 1-hour education module delivered by a research assistant. The experimental group was then instructed to undertake an additional 2-hour intervention using a video simulator that enabled nursing assistants to practice level of assistance skills. The appropriateness of dressing assistance from nursing assistants and residents' dressing performance was measured before and 6 weeks after the intervention. The results showed that the two groups did not significantly differ in either appropriate levels of dressing assistance (P = .42) or residents' dressing performance (P = .38). A lack of effort by some assistants to properly assist residents and low statistical power may explain the lack of significance. The effect sizes of the experimental intervention on appropriate levels of dressing assistance and resident dressing performance were 0.69 and 0.89, respectively. Incorporating a strategy to improve motivation should be considered in future studies.

Improving Oral Hygiene for Veterans With Dementia in Residential Long-term Care

Oral hygiene care is neglected in long-term care (LTC) due to patient-, staff-, and systems-level barriers. A dementia-specific oral hygiene program, implemented and evaluated in a Department of Veterans Affairs LTC unit, addressed barriers to oral care at multiple levels. Improved staff competency, access to oral care supplies, and standardized documentation systems were accompanied by reduced oral plaque and gingivitis, demonstrating the feasibility and benefits of direct care staff providing improved oral hygiene in LTC.

Evaluating student learning outcomes in oral health knowledge and skills

AIMS AND OBJECTIVES

To evaluate whether a set of oral health resources designed for workforce training was relevant for students undertaking an entry-level nursing or aged care qualification.

BACKGROUND

Oral health is one of the most neglected aspects of nursing care experienced by older people. Despite efforts to improve aged care worker oral health knowledge and skills, one-off training and rapid staff turnover have hindered the success of workplace programmes. Inadequate oral health content in entry-level nursing and aged care qualifications has perpetuated this.

DESIGN

Kirkpatrick's training and evaluation model was used to evaluate the resources developed by a project called Building Better Oral Health Communities. Students used them as prescribed study materials and completed pre- and postintervention questionnaires. Educators were interviewed to obtain their feedback. Quantitative data were analysed using descriptive and inferential statistics. Qualitative data were collated according to relevance to learning, presentation style and interest.

RESULTS

Evaluation showed high levels of student and educator satisfaction. Student learning outcomes demonstrated consistently positive attitudes and significant self-reported improvements in oral health knowledge and skills. Irrespective of course type, students gained similar levels of oral health knowledge and skills following use of the resources.

CONCLUSION

Nurses and care workers must be able to provide consistent standards of oral health care as a fundamental part of caring for patients. Validated as an effective learning and teaching package, it is recommended that these resources be used to strengthen the oral health content of entry-level nursing and aged care qualifications.

RELEVANCE TO CLINICAL PRACTICE

Building the oral health capacity of nurses and care workers is one way of reversing oral health neglect and improving the quality of care provided to older people.

Readily Identifiable Risk Factors of Nursing Home Residents' Oral Hygiene: Dementia, Hospice, and Length of Stay

BACKGROUND/OBJECTIVES

The poor oral hygiene of nursing home (NH) residents is a matter of increasing concern, especially because of its relationship with pneumonia and other health events. Because details and related risk factors in this area are scant and providers need to be able to easily identify those residents at most risk, this study comprehensively examined the plaque, gingival, and denture status of NH residents, as well as readily available correlates of those indicators of oral hygiene, including items from the Minimum Data Set (MDS).

DESIGN

Oral hygiene assessment and chart abstract conducted on a cross-section of NH residents.

SETTING

NHs in North Carolina (N = 14).

PARTICIPANTS

NH residents (N = 506).

MEASUREMENTS

Descriptive data from the MDS and assessments using three standardized measures: the Plaque Index for Long-Term Care (PI-LTC), the Gingival Index for Long-Term Care (GI-LTC), and the Denture Plaque Index (DPI).

RESULTS

Oral hygiene scores averaged 1.7 (of 3) for the PI-LTC, 1.5 (of 4) for the GI-LTC, and 2.2 (of 4) for the DPI. Factors most strongly associated with poor oral hygiene scores included having dementia, being on hospice care, and longer stay. MDS ratings of gingivitis differed significantly from oral hygiene assessments.

CONCLUSIONS

The findings identify resident subgroups at especially high risk of poor oral health who can be targeted in quality improvement efforts related to oral hygiene; they also indicate need to improve the accuracy of how MDS items are completed.

Administrators' Perceptions of Oral Health Care and Cancer Screening in Long-Term Care Nursing Facilities

An estimated 1.7 million adults in the United States more than the age of 65 reside in long-term care nursing facilities (LTCNFs), and only 17% of them receive dental care. More than 83% of LTCNF residents require assistance with oral care. Adequate dental care is a preventative behavior for oral cancer. Adults more than age 65 will account for 60% of oral cancer-related deaths, despite an 80% cure rate for early diagnosis. This study sought to expand knowledge of the perceived benefits, barriers, and ability to perform or provide for oral health care and oral cancer screening as reported by Administrators and Directors of Nursing in LTCNFs. Findings indicate that competing demands for resources make oral health a low priority issue and low knowledge about oral cancer risk among nursing home residents, family members, and staff is a barrier. Potential interventions suggested by participants are discussed.

Effective strategies to motivate nursing home residents in oral care and to prevent or reduce responsive behaviors to oral care: A systematic review

BACKGROUND

Poor oral health has been a persistent problem in nursing home residents for decades, with severe consequences for residents and the health care system. Two major barriers to providing appropriate oral care are residents' responsive behaviors to oral care and residents' lack of ability or motivation to perform oral care on their own.

OBJECTIVES

To evaluate the effectiveness of strategies that nursing home care providers can apply to either prevent/overcome residents' responsive behaviors to oral care, or enable/motivate residents to perform their own oral care.

MATERIALS AND METHODS

We searched the databases Medline, EMBASE, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science for intervention studies assessing the effectiveness of eligible strategies. Two reviewers independently (a) screened titles, abstracts and retrieved full-texts; (b) searched key journal contents, key author publications, and reference lists of all included studies; and (c) assessed methodological quality of included studies. Discrepancies at any stage were resolved by consensus. We conducted a narrative synthesis of study results.

RESULTS

We included three one-group pre-test, post-test studies, and one cross-sectional study. Methodological quality was low (n = 3) and low moderate (n = 1). Two studies assessed strategies to enable/motivate nursing home residents to perform their own oral care, and to studies assessed strategies to prevent or overcome responsive behaviors to oral care. All studies reported improvements of at least some of the outcomes measured, but interpretation is limited due to methodological problems.

CONCLUSIONS

Potentially promising strategies are available that nursing home care providers can apply to prevent/overcome residents' responsive behaviors to oral care or to enable/motivate residents to perform their own oral care. However, studies assessing these strategies have a high risk for bias. To overcome oral health problems in nursing homes, care providers will need practical strategies whose effectiveness was assessed in robust studies.

Barriers and facilitators in providing oral care to nursing home residents, from the perspective of care aides: A systematic review and meta-analysis

BACKGROUND

Oral health of nursing home residents is generally poor, with severe consequences for residents' general health and quality of life and for the health care system. Care aides in nursing homes provide up to 80% of direct care (including oral care) to residents, but providing oral care is often challenging. Interventions to improve oral care must tailor to identified barriers and facilitators to be effective. This review identifies and synthesizes the evidence on barriers and facilitators care aides perceive in providing oral care to nursing home residents.

METHODS

We systematically searched the databases MEDLINE, Embase, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. We also searched by hand the contents of key journals, publications of key authors, and reference lists of all studies included. We included qualitative and quantitative research studies that assess barriers and facilitators, as perceived by care aides, to providing oral care to nursing home residents. We conducted a thematic analysis of barriers and facilitators, extracted prevalence of care aides reporting certain barriers and facilitators from studies reporting quantitative data, and conducted random-effects meta-analyses of prevalence.

RESULTS

We included 45 references that represent 41 unique studies: 15 cross-sectional studies, 13 qualitative studies, 7 mixed methods studies, 3 one-group pre-post studies, and 3 randomized controlled trials. Methodological quality was generally weak. We identified barriers and facilitators related to residents, their family members, care providers, organization of care services, and social interactions. Pooled estimates (95% confidence intervals) of barriers were: residents resisting care=45% (15%-77%); care providers' lack of knowledge, education or training in providing oral care=24% (7%-47%); general difficulties in providing oral care=26% (19%-33%); lack of time=31% (17%-47%); general dislike of oral care=19% (8%-33%); and lack of staff=22% (13%-31%).

CONCLUSIONS

We found a lack of robust evidence on barriers and facilitators that care aides perceive in providing oral care to nursing home residents, suggesting a need for robust research studies in this area. Effective strategies to overcome barriers and to increase facilitators in providing oral care are one of the most critical research gaps in the area of improving oral care for nursing home residents. Strategies to prevent or manage residents' responsive behaviors and to improve care aides' oral care knowledge are especially needed.

A person-centred and thriving-promoting intervention in nursing homes - study protocol for the U-Age nursing home multi-centre, non-equivalent controlled group before-after trial

BACKGROUND

The literature suggests that person-centred care can contribute to quality of life and wellbeing of nursing home residents, relatives and staff. However, there is sparse research evidence on how person-centred care can be operationalised and implemented in practice, and the extent to which it may promote wellbeing and satisfaction. Therefore, the U-Age nursing home study was initiated to deepen the understanding of how to integrate person-centred care into daily practice and to explore the effects and meanings of this.

METHODS

The study aims to evaluate effects and meanings of a person-centred and thriving-promoting intervention in nursing homes through a multi-centre, non-equivalent controlled group before-after trial design. Three nursing homes across three international sites have been allocated to a person-centred and thriving-promoting intervention group, and three nursing homes have been allocated to an inert control group. Staff at intervention sites will participate in a 12-month interactive educational programme that operationalises thriving-promoting and person-centred care three dimensions: 1) Doing a little extra, 2) Developing a caring environment, and 3) Assessing and meeting highly prioritised psychosocial needs. A pedagogical framework will guide the intervention. The primary study endpoints are; residents' thriving, relatives' satisfaction with care and staff job satisfaction. Secondary endpoints are; resident, relative and staff experiences of the caring environment, relatives' experience of visiting their relative and the nursing home, as well as staff stress of conscience and perceived person-centredness of care. Data on study endpoints will be collected pre-intervention, post-intervention, and at a six-month follow up. Interviews will be conducted with relatives and staff to explore experiences and meanings of the intervention.

DISCUSSION

The study is expected to provide evidence that can inform further research, policy and practice development on if and how person-centred care may improve wellbeing, thriving and satisfaction for people who reside in, visit or work in nursing homes. The combination of quantitative and qualitative data will illuminate the operationalisation, effects and meaning of person-centred and thriving-promoting care.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov March 19, 2016, identifier NCT02714452 .

Interventions to Improve the Oral Health of People with Dementia or Cognitive Impairment: A Review of the Literature

OBJECTIVE

Oral diseases and conditions are prevalent among older people with dementia and cognitive impairment. While many interventions have been advocated for use in this population, evidence for their effectiveness is unclear. Our objective was to review systematically the content and effectiveness of interventions and implementation strategies used to improve or maintain the oral health of people with dementia or cognitive impairment.

METHODS

Original studies published in English at any time until January 2015 were identified through electronic searches of the Medline, Embase, CINAHL, Scopus and Cochrane databases and hand searches of eligible studies and relevant reviews. Two investigators independently abstracted study characteristics and assessed the methodological quality of eligible studies. Results were presented as a narrative review because significant heterogeneity among included studies precluded a meta-analysis.

RESULTS

The 18 included studies varied considerably in terms of size, scope and focus. Only two studies were identified that had been designed specifically for and examined exclusively in people with dementia or cognitive impairment. All studies were in residential care; none was population-based. While several studies reported positive effects, a number of methodological weaknesses were identified and the overall quality of included studies was poor. The specific outcomes targeted varied across studies but most studies focused almost exclusively on proximal clinical oral health outcomes such as levels of dental or denture plaque. Attempts to measure intervention integrity were limited and there was usually little or no effort to evaluate intervention effects over a sustained period.

CONCLUSION

There is a lack of high quality evidence to support the effectiveness of oral health interventions and implementation strategies for older people with dementia or cognitive impairment. More rigorous, large scale research is needed in this area. Recommendations are provided to improve the overall quality of evaluation in this area. Emphasis must be placed on developing evidence-based, achievable and sustainable oral health strategies if the needs of people with dementia and cognitive impairment are to be met into the future.

Oral hygiene of hospitalised older patients with lower limb fracture

INTRODUCTION

good oral hygiene is important for eating, talking and improved quality of life, and is part of basic patient care, but there are few observational studies in hospitalised older patients. The aim of this study is to investigate dental plaque load in older patients over time in hospital.

METHODS

we examined the mouths of 93 patients with lower limb fracture prospectively at day 1, 7 and 14 after admission in a Newcastle upon Tyne Hospital. We assessed dental and denture plaque load, dry mouth symptoms and tooth number, along with demographic and frailty variables. We used univariate generalised linear modelling and mixed effects models to investigate associations between increased plaque and patient characteristics.

RESULTS

in dentate patients, plaque score increased with time in hospital (P = 0.007, odds ratio (OR): 1.02; 95% confidence of interval (CI): 1.01-1.04). Frailty (P = 0.015, OR: 1.19; 95% CI: 1.04-1.37), dementia (P < 0.001, OR: 4.30; 95% CI: 2.03-9.12), residence in an institution (P < 0.001, OR: 4.61; 95% CI: 2.18-9.74), decreased mobility (P = 0.013, OR: 0.97; 95% CI: 0.96-0.99), but not Charlson comorbidity index (P = 0.102, OR: 1.08; 95% CI: 0.99-1.19), were associated with increased plaque scores at every time point.

CONCLUSIONS

oral hygiene deteriorated in dentate patients in hospital. Plaque scores were significantly higher in patients who were more likely to be dependent on others for their oral hygiene.

Barriers and facilitators in providing oral health care to nursing home residents, from the perspective of care aides-a systematic review protocol

BACKGROUND

Unregulated care aides provide up to 80 % of direct resident care in nursing homes. They have little formal training, manage high workloads, frequently experience responsive behaviours from residents, and are at high risk for burnout. This affects quality of resident care, including quality of oral health care. Poor quality of oral health care in nursing homes has severe consequences for residents and the health care system. Improving quality of oral health care requires tailoring interventions to identified barriers and facilitators if these interventions are to be effective. Identifying barriers and facilitators from the care aide's perspective is crucial.

METHODS

We will systematically search the databases MEDLINE, Embase, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. We will include qualitative and quantitative research studies and systematic reviews published in English that assess barriers and facilitators, as perceived by care aides, to providing oral health care to nursing home residents. Two reviewers will independently screen studies for eligibility. We will also search by hand the contents of key journals, publications of key authors, and reference lists of all the studies included. Two reviewers will independently assess the methodological quality of the studies included using four validated checklists appropriate for different research designs. Discrepancies at any stage of review will be resolved by consensus. We will conduct a thematic analysis of barriers and facilitators using all studies included. If quantitative studies are sufficiently homogeneous, we will conduct random-effects meta-analyses of the associations of barriers and facilitators with each other, with care aide practices in resident oral health care, and with residents' oral health. If quantitative study results cannot be pooled, we will present a narrative synthesis of the results. Finally, we will compare quantitative findings to qualitative studies to identify hypothesized associations or effects not yet tested quantitatively.

DISCUSSION

This review will advance the development of effective strategies for improving quality of oral health care and highlight gaps in research on barriers and facilitators to providing oral health care to nursing home residents, as perceived by care aides.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015032454.

Effective strategies to motivate nursing home residents in oral healthcare and to prevent or reduce responsive behaviours to oral healthcare: a systematic review protocol

INTRODUCTION

Oral healthcare in nursing homes is less than optimal, with severe consequences for residents' health and quality of life. To provide the best possible oral healthcare to nursing home residents, care providers need strategies that have been proven to be effective. Strategies can either encourage and motivate residents to perform oral healthcare themselves or can prevent or overcome responsive behaviours from residents when care providers assist with oral healthcare. This systematic review aims to identify studies that evaluate the effectiveness of such strategies and to synthesise their evidence.

METHODS AND ANALYSIS

We will conduct a comprehensive search in the databases MEDLINE, EMBASE, Evidence Based Reviews--Cochrane Central Register of Controlled Trials, CINAHL and Web of Science for quantitative intervention studies that assess the effectiveness of eligible strategies. 2 reviewers will independently screen titles, abstracts and retrieved full texts for eligibility. In addition, contents of key journals, publications of key authors and reference lists of all studies included will be searched by hand and screened by 2 reviewers. Discrepancies at any stage of the review process will be resolved by consensus. Data extraction will be performed by 1 research team member and checked by a second team member. 2 reviewers will independently assess methodological quality of studies included using 3 validated checklists appropriate for different research designs. We will present a narrative synthesis of study results.

ETHICS AND DISSEMINATION

We did not seek ethics approval for this study, as we will not collect primary data and data from studies included cannot be linked to individuals or organisations. We will publish findings of this review in a peer-reviewed paper and present them at an international peer-reviewed conference.

TRIAL REGISTRATION NUMBER

CRD42015026439.