Survey of oral nursing care attitudes, knowledge and practices in a neurorehabilitation setting

'Why doesn't anyone ask me'? Patients' experiences of receiving, performing and practices of oral care in an acute Orthopaedic Department

AIMS AND OBJECTIVES

Oral care is an integrated part of everyday life. Within nursing, barriers related to providing oral care often lead to unmet caring needs. Poor oral care is associated with a risk of respiratory and cardiovascular complications during hospitalisation. Knowledge on patients' perspectives of maintaining or receiving oral care during admissions are limited. Following the Fundamentals of Care (FOC) framework, this study uses a person-centred approach to explore patients' perceptions and experiences of receiving or performing oral care, including the nursing staff's clinical practices.

METHODOLOGICAL DESIGN AND JUSTIFICATION

A focussed ethnographic approach was used to explore patients' perspectives and clinical practices during acute admissions in an Orthopaedic Department.

ETHICS ISSUES AND APPROVAL

The local Data Protection Agency and the Ethics Committee approved the study.

RESEARCH METHODS, RESULTS AND CONCLUSIONS

Data were collected in an Orthopaedic ward at a Copenhagen University hospital, Hvidovre, and consisted of 14 days of field observations of clinical practices and 15 patient interviews. Data were analysed inductively using qualitative content analysis. Two themes were identified. The first, 'The purpose of oral care is defined by the eye of the beholder', describes the social implications for the patients and how patients reject the assumption of oral care being a transgressive act. The second, 'The unspoken need', focus on the lack of dialogue, including the limited provision of oral care and how the nursing staff assesses patients' ability to perform oral care (in)dependently without including the patients.

CONCLUSION

Oral care is related to the patient's psychological and physical well-being and affects social appearance. When oral care is provided respectfully, patients do not experience oral care as a transgressive act. Nursing staff's self-assessments of the patients' (in)dependency to perform oral care risk leading to incorrect care. Developing and implementing interventions applicable to the clinical practice is needed.

The struggle is real-A mixed qualitative methods synthesis of challenges in nursing care in activities of daily living

INTRODUCTION

Supporting care receivers in Activities of Daily Living (ADL), irrespective of diagnosis, setting, or cultural background, lies at the heart of fundamental nursing care. The pursuit of quality ADL care becomes increasingly challenging with the changing complexity of care needs. ADL care delivery is often undervalued and is considered a low-status task despite its crucial importance to care receivers. This study aims to synthesize challenges in ADL care irrespective of the care setting.

METHODS

In the mixed qualitative methods study, we used expert panel consultations, world café sessions, and a rapid literature review. For data analysis, we simultaneously analyzed the three data sets using inductive and deductive inquiry.

RESULTS

We identified four challenges and their corresponding subthemes. They are (1) Undervalued common-sense work versus complex, high-skilled care provision; (2) Limitations in professional reflective clinical decision-making; (3) Missed opportunities for shared ADL decisions; and (4) Meeting ADL care needs in a high-throughput system.

CONCLUSION

These challenges reveal the complexity of ADL care and how its paradoxical narrative relates to the conditions in which nursing professionals struggle to create opportunities, for reflective clinical reasoning and shared ADL decisions, by facing organizational and environmental barriers.

CLINICAL RELEVANCE

This study is relevant to nursing professionals, care organizations, policymakers, and researchers aiming to improve ADL care and provide insights into challenges in ADL care. This study forms the starting point for a changing narrative on ADL nursing care and subsequent quality improvements in the form of, for example, guidelines for nursing professionals.

Provision of Oral Care in the Cardiothoracic Intensive Care Unit: Survey of Nursing Staff Training, Confidence, Methods, Attitudes, and Perceived Barriers

BACKGROUND

Poor oral health is associated with adverse outcomes in critical care settings. Although provision of oral care is a fundamental aspect of nursing practice, both formal training and practice among nursing staff remain unclear.

METHOD

Cardiothoracic intensive care unit nurses were recruited to complete a 16-item survey regarding training, confidence, methods, prioritization, and barriers to provision of oral care.

RESULTS

A total of 108 nurses participated (70% response rate). Formal training in oral care was reported by 38%, most frequently reported as less than 1 hour (53%) in duration. Of the respondents, 70% reported confidence in providing oral care. Nine methods and 16 products were identified, with variability in the frequency of provision. Prioritization of oral care was rated most frequently as moderate (53%), with 28% reporting barriers.

CONCLUSION

Despite limited formal training, surveyed nurses reported confidence in providing oral care. Methods, frequency, and prioritization were variable. Both development of formal curricula and evaluation of adherence to standardized protocols for oral care are warranted. [J Contin Educ Nurs. 2023;54(7):313-321.].

Patterns and predictors of dental hospitalizations in patients with acquired brain injury from pre-injury to acute and post-acute injury

BACKGROUND

Acquired brain injury (ABI) can cause long-term disability and functional impairment.

OBJECTIVE

This study aims to determine the prevalence of dental hospitalizations in an ABI cohort across different phases of injury and identify factors associated with such hospitalizations.

METHODS

The cohort comprises patients with ABI (n = 683), traumatic (n = 282) and non-traumatic (n = 401) who were admitted to a neurorehabilitation service in Western Australia between 1991 and 2016. De-identified patient data were linked to the Hospital Morbidity Data Collection. The incidence of dental hospitalizations was calculated per 1,000 person-years (PY), and associated factors were investigated using multilevel mixed-effects logistic regression.

RESULTS

Dental hospitalizations significantly increased from pre-injury (3.35/1,000PY) to acute injury (302.65, Δ+299.3) and remained elevated in the post-acute phase (23.98, Δ+20.63). Dental caries had the highest incidence rate among all diagnoses in the pre-injury and post-acute phases (0.68 and 8.93, respectively), followed by gingivitis and periodontal diseases (3.60) in the post-acute phase. Tooth extractions were performed more often than restorative and preventive treatment in the pre-and post-injury phase, p < 0.001. Dental hospitalizations were associated with the type of ABI, age at injury, remoteness, and history of pre-injury hospitalization.

CONCLUSION

Implementing comprehensive preventive dental care can reduce potentially preventable dental hospitalization among ABI patients.

Effectiveness of Standard Oral Care Plan During Hospital Stay in Individuals With Brain Injury

Objective: To investigate the effectiveness of an existing standard oral care program (SOCP) and factors associated with it during hospitalization in individuals with acquired brain injury (ABI).

Material and Methods: A total of 61 individuals underwent a SOCP for 4 weeks in a longitudinal observational study. Rapidly noticeable changes in oral health were evaluated by performing plaque, calculus, bleeding on probing (BOP) and bedside oral examination (BOE) at weeks 1 and 5. Individuals' brushing habits, eating difficulties, and the onset of pneumonia were retrieved from their medical records. Association between oral-health outcomes to systemic variables were investigated through multilevel regression models.

Results: Dental plaque (P = 0.01) and total BOE score (P &lt; 0.05) decreased over time but not the proportion of dental calculus (P = 0.30), BOP (P = 0.06), and tooth brushing frequency (P = 0.06). Reduction in plaque and BOE over time were negatively associated with higher periodontitis scores at baseline (coef. −6.8; −1.0), respectively, which in turn were associated with an increased proportion of BOP (coef. ≈ 15.0). An increased proportion of calculus was associated with eating difficulties (coef. 2.3) and the onset of pneumonia (coef. 6.2).

Conclusions: Nursing care has been fundamental in improving oral health, especially reducing dental plaque and BOE scores. However, our findings indicate a need for improving the existing SOCP through academic-clinical partnerships.

Clinical Relevance: Early introduction of oral care program to brain-injured individuals is beneficial in reducing plaque accumulation and improving oral health.

Internal structure and validity of the bedside oral examination tool in patients with brain injury at neurorehabilitation setting

OBJECTIVES

To assess the internal structure and validity of the 'bedside oral examination' (BOE) instrument in individuals with acquired brain injury (ABI).

METHODS

Ninety ABI individuals were examined using BOE in their first week of neurorehabilitation. BOE measures oral health within eight categories including: swallow, tongue, odour, teeth, lips, saliva, mucosa and gingiva. To assess the validity of BOE, full-mouth clinical examination (gold standard) was performed. The internal structure of BOE was assessed using exploratory and confirmatory factor analyses. To measure the validity, the BOE scores were dichotomised into excellent oral health and altered oral health. Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve of the six/eight BOE items were compared with their related clinical oral examination tool.

RESULTS

Overall, the patients had poor oral health irrespective of the oral examination tool used. Factor analyses indicated two factors within BOE: 'oral hygiene' (teeth, gingiva and mucosa) and 'orofacial health' (lips, swallow and saliva). BOE tongue and odour items loaded in neither factor. BOE items showed low validity since the highest area under the ROC curve was 0.60. Findings on the sensitivity value ranged from 35.0 to 74.2, while specificity from 44.4 to 83.3, depending on the item evaluated.

CONCLUSION

Bedside oral examination does not seem to be an ideal 'single' outcome tool in a neurorehabilitation setting as it lacks validity. BOE evaluates oral health as two independent but correlated components and treat them separately indicating precision treatment depending on their oral health dysfunction. It is advisable to use BOE as a screening tool. However, it should be complimented by proper clinical examination before establishing a treatment plan for oral health in patients with ABI.

Tongue cleaning in the elderly and its role in the respiratory and swallowing functions: Benefits and medical perspectives

Oral dysfunction, including oral uncleanness and decline in tongue motor function, tongue pressure and swallowing function, precedes frailty. The tongue's dorsum is a reservoir of oral microbiota, desquamated epithelial mucosa and leukocytes due to the multi-papillate anatomy, and leads to tongue coating. The tongue coating is frequently found in older adults because of hyposalivation, immunity's hypoactivity, diminished motor function and compromised tongue's pressure with age. Anaerobe-driven volatile sulphur compounds in tongue coating are a major cause of intra-oral malodor. Dysbiosis of the tongue-coating microbiome rather than the amount of microorganisms is associated with a risk of aspiration pneumonia. Daily tongue cleaning with a brush or scraper is an easy way to control tongue coating deposits and quality. Using mouth wash or rinse-containing germicides is also a way to control the microbiota of tongue coating. The tongue function is closely related to swallowing. Tongue and suprahyoid muscles are linked with respiratory muscles through the endothoracic fascia. The mechanical stimulation during the cleaning of the tongue may stimulate the respiratory muscles. An intervention trial revealed that tongue cleaning by mucosal brush improves tongue pressure, swallowing and respiratory function in old residents of nursing homes, suggesting a rehabilitative effect of tongue cleaning on the swallowing and respiratory functions, preventing aspiration pneumonia. This narrative review assesses the tongue-cleaning benefits for respiratory and swallowing functions and the possibility of preventing aspiration pneumonia.

Mouth care training and practice: a survey of nursing staff working in National Health Service hospitals in England

Background

This study investigated the training and mouth care practice of nursing staff in hospital Trusts across England. Oral health has been found to deteriorate during hospital admission, mouth care standards have been found to be poor.

Aims

The objectives of the study were to assess if and what the barriers are to supporting inpatients' mouth care, and to assess how confident nursing staff are in carrying out mouth care assessments and mouth care and see if this is related to previous training.

Methods

A cross-sectional descriptive survey was conducted in 33 Trusts in England with 1576 members of the nursing team including nurses and nursing assistants. Nursing staff were asked to complete a questionnaire on previous oral health training and their current practice.

Results

Nursing staff reported that they had limited training in mouth care. The main barriers to mouth care were time and patient compliance. Confidence in recognising oral cancer was low.

Conclusions

Nursing staff would benefit from mouth care training targeted at assessing the mouth and providing mouth care for all inpatients.

Changes in oral health related quality of life and its associated factors in individuals with brain injury

Purpose: To evaluate changes in oral health-related quality of life (OHRQoL) and associated factors in individuals with acquired brain injury (ABI) during hospitalization.Methods: Forty-six individuals with ABI were examined at week 1 and 5 of hospitalization. OHRQoL was recorded through Oral Health Impact Profile-14 (OHIP-14), clinical oral examinations were conducted, while orofacial health-related 'motor' and 'cognitive' scores were retrieved from patients' e-journal. Association between variables were investigated using factor analysis and multilevel regression modeling.Results: There were no significant differences in the OHIP-14 scores between week 1 and 5. Factors analysis revealed two OHIP-14 domains, 'psychosocial' and 'physica'. Individuals who improved their cognitive skills over study period and those with 'severe' periodontitis at baseline had increased scores of OHIP-14 'psychosocial' domain. Individuals who improved orofacial health-related 'motor' skills over study period had decreased 'physical' domain scores. Increased cognition over study period, current smoking and dental calculus were associated with increased 'physical' domain.Conclusions: The OHRQoL was poor both at week 1 and 5. Individual's cognitive and motor skills as well as their oral health status influenced their OHRQoL. Thus, individual's awareness and involvement in addition to oral care seem to be imperative in improving the OHRQoL in neurorehabilitation setting.

Mechanical tongue cleaning is a worthwhile procedure to improve the taste sensation

BACKGROUND

There are still only a few therapeutic strategies to improve taste sensation, which is part of oral health and quality of life.

OBJECTIVE

Therefore, here we aimed to investigate gustatory functions of healthy subjects performing mechanical tongue cleaning (MTC), an easy-to-perform oral hygiene procedure, to demonstrate taste changes and to describe possible negative side effects.

METHODS

Prior to and 14 days following MTC with an Orabrush^® , the following tests were conducted in 65 healthy participants including both non-smokers (n = 50, 76.9%) and smokers (n = 15, 23.1%): 'taste strips' test, the Winkel Tongue Coating Index (WTCI), and subjective self-assessment.

RESULTS

Among non-smokers, subjective self-assessments of gustatory function (P < .01), halitosis (P = .03) and tongue coating (P < .01) improved after 14 days of MTC; furthermore, they exhibited higher total taste (P < .01) and lower WTCI (P < .01) values. Their age and sex did not correlate with the differences between the pre- and post-MTC WTCI scores; however, differences between pre- and post-MTC total taste values were correlated with age. The total taste value improvements were greater in non-smokers aged 45-91 years than in those aged 20-44 years (P = .01). In smokers, total taste values (P < .01), as well as sweet (P = .03) and sour (P = .04) taste values, were significantly improved after 14 days of MTC.

CONCLUSION

Fourteen days of MTC using an Orabrush^® can improve gustatory functions in non-smokers and smokers. Therefore, MTC might be a useful, costless and easy option to improve taste and should be considered as a part of the daily oral care.

Factors associated with the number of microorganisms on the tongue surface in patients following acute stroke

BACKGROUND

Oral hygiene management of patients with acute stroke is important for preventing aspiration pneumonia and ensuring oral intake. The tongue coating score can be useful for evaluating the oral hygiene level since it reflects the microorganism number on the tongue surface in elderly patients. However, the relationship between the number of oral microorganisms and the tongue coating score in patients with acute stroke remains unclear.

OBJECTIVES

We aimed to investigate the relationships between the microorganism number on the tongue surface and oral factors, including tongue coating score, tongue surface moisture level and tongue function.

METHODS

This cross-sectional study enrolled 73 patients with acute stroke who were hospitalised at an acute care hospital and underwent dental intervention. Potential explanatory factors, including sex, age, Glasgow Coma Scale score, tongue coating score, tongue surface moisture level, nutrition intake method, number of functional teeth and tongue function, were evaluated. Logistic regression analysis determined their association with the microorganism number on the tongue surface.

RESULTS

The tongue coating score (odds ratio: 1.31) and tongue surface moisture level (odds ratio: 1.10) were significantly associated with increased microorganism numbers on the tongue surface.

CONCLUSION

The tongue coating score, which reflects the actual number of microorganisms on the tongue surface, could be an effective tool for evaluating oral hygiene level in patients with stroke. Moreover, reducing oral microorganisms in saliva through oral hygiene management, including removing the tongue coating, could contribute towards the prevention of aspiration pneumonia.

Guideline Recommendations for Oral Care After Acquired Brain Injury: Protocol for a Systematic Review

BACKGROUND

Oral care is important to prevent buccal and systemic infections after an acquired brain injury (ABI). Despite recent advancements in the development of ABI clinical practice guidelines, recommendations for specific clinical processes and actions to attain adequate oral care often lack information.

OBJECTIVE

This systematic review will (1) identify relevant ABI clinical practice guidelines and (2) appraise the oral care recommendations existing in the selected guidelines.

METHODS

A search strategy was developed based on a recent systematic review of clinical practice guidelines for ABI. The protocol includes a search of MEDLINE, EMBASE, and DynaMed Plus databases, as well as organizational and best-practice websites and reference lists of accepted guidelines. Search terms will include medical subject headings and user-defined terms. Guideline appraisal will involve the Appraisal of Guidelines for Research and Evaluation II ratings, followed by a descriptive synopsis for oral care recommendations according to the National Health and Medical Research Council evidence levels.

RESULTS

This project started in April 2019, when we developed the search strategy. The preliminary search of databases and websites yielded 863 and 787 citations, respectively, for a total of 1650 citations. Data collection will start in August 2020 and we expect to begin disseminating the results in May 2021.

CONCLUSIONS

Nursing staff may not have detailed recommendations on how to provide oral care for neurologically impaired patients. The findings of this review will explore the evidence for oral care in existing guidelines and improve outcomes for patients with ABI. We expect to provide adequate orientations to clinicians, inform policy and guidelines for best practices, and contribute to future directions for research in the ABI realm.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/17249.

Surgeon motivation, and obstacles to the implementation of minimally invasive spinal surgery techniques

Background

This study aimed to analyze the motivators and obstacles to the implementation of minimally invasive spinal surgery techniques (MISST) by spinal surgeons. Motivators and detractors may impact the availability of MISST to patients and drive spine surgeons' clinical decision-making in the treatment of common degenerative conditions of the lumbar spine.

Methods

The authors solicited responses to an online survey sent to spine surgeons by email, and chat groups in social media networks including Facebook, WeChat, WhatsApp, and Linkedin. Descriptive statistics were employed to count the responses and compared to the surgeon's training. Kappa statistics and linear regression analysis of agreement were performed.

Results

A total of 430 surgeons accessed the survey. The completion rate was 67.4%. A total of 292 surveys were submitted by 99 neurosurgeons (33.9%), 170 orthopaedic surgeons (58.2%), and 23 surgeons of other postgraduate training (7.9%). Personal interest (82.5%) and patient demand (48.6%) were the primary motivators for MISST implementation. High equipment (48.3%) and disposables (29.1%) cost were relevant obstacles to MISST implementation. Local workshops (47.6%) and meetings in small groups (31.8%) were listed as the primary knowledge sources. Only 12% of surgeons were fellowship trained, but 46.3% of surgeons employed MISST in over 25% of their cases.

Conclusions

The rate of implementation of MISST reported by spine surgeons was found to be high but impeded by the high cost of equipment and disposables. The primary motivators for spine surgeons' desire to implement were personal interest and patient demand.

Lumbar vacuum disc, vertical instability, standalone endoscopic interbody fusion, and other treatments: an opinion based survey among minimally invasive spinal surgeons

Background

A diseased lumbar intervertebral vacuum disc void of any structurally intact tissue may be vertically unstable. A primary standalone endoscopic decompression and interbody fusion surgery in the treatment of vertical instability in patients with a vacuum disc may be a more reliable treatment than decompression alone.

Methods

The authors solicited responses to an online survey sent to spine surgeons by email, and chat groups on social media networks, including Facebook, WeChat, WhatsApp, and Linkedin. Descriptive and correlative statistics were employed to count the responses and compare the surgeon's responses recorded on a Likert scale from 1 (disagree) to 10 (agree) or in multiple-choice questions. Surgeons were asked about their familiarity with the concept of vacuum disc and vertical instability and how they would treat such patients. Kappa statistics and linear regression analysis of agreement of incoming responses were performed.

Results

A total of 1,165 surgeons accessed the survey. The completion rate was 22.78. The majority surgeons were very familiar with the concept of a "vacuum disc" as a sign of end-stage lumbar degenerative disc disease and a collapsing lumbar motion segment (182/273; 66.7%; Likert score 6.53). The majority of surgeons also thought that vertical instability precedes anterolateral lumbar instability (187/273; 68.5%; Likert score 6.64) and that a vacuum disc may cause vertical instability with symptomatic dynamic foraminal & lateral recess stenosis (222/273; 81%; Likert score 7.48), mechanical back pain (201/273; 73.1%; Likert score 7.48), and may cause sciatica-type low back and leg pain (179/273; 66.3%; Likert score 6.59). The majority of surgeons indicated that vacuum phenomenon on radiographic studies is associated with vertical instability and collapse resulting in dynamic foraminal and lateral recess stenosis and should be treated surgically (199/266; 73.7%; 7 missing responses; Likert score 6.86). Preferred treatments were decompression alone without fusion (P<0.014). There was consensus in support of fusion by TLIF or PLIF with a Likert score of 6.68 (184/266; 69.2%; 7 missing responses). There was no consensus on standalone fusion.

Conclusions

Vacuum phenomenon on radiographic studies is associated with a vertical instability and collapse, resulting in dynamic foraminal and lateral recess stenosis that should be treated surgically. Preferred surgical treatments were decompression alone, decompression with interbody fusion using just bone graft, and fusion employing TLIF or PLIF. Further research into the clinical significance of lumbar vacuum disc, vertical instability and its most appropriate surgical treatments if any is necessary.

Is Asia truly a hotspot of contemporary minimally invasive and endoscopic spinal surgery?

Background

The purpose of this study was to analyze the training in relation to practice patterns of surgeons in Asia who perform lumbar endoscopic spinal surgery in comparison to surgeons the world over. The authors solicited responses to an online survey sent to spine surgeons.

Methods

Pearson Chi-Square measures, Kappa statistics, and linear regression analysis of agreement or disagreement were performed by analyzing the distribution of variances of responses in relation to surgeons' training using statistical package SPSS Version 25.0.

Results

A total of 430 surgeons accessed the survey. The completion rate was 67.4%. Analyzing the responses of 292 surveys submitted by 97 neurosurgeons (33.2%), 161 orthopaedic surgeons (55.1%), and 34 surgeons of other postgraduate training (11.6%) showed that only 14.0% (41/292) of surgeons had completed a fellowship. Ninety-one of the 292 respondents were from Asian countries/regions. A statistically significantly higher percentage of Asian surgeons (96.7%) compared to non-Asian surgeons (81.6%) indicated that they perform modern minimally invasive (MIS) and endoscopic spinal (ES) surgery (P=0.001). Spinal endoscopy was employed by 70.3% of Asian versus 55.2% of non-Asian surgeons (P=0.015). Endoscopic decompression techniques requiring advanced training was employed nearly twice as high by the Asian surgeons than by non-Asian.

Conclusions

Training requirements for MIS and ES surgery and implementation of privileges vary in different parts of the world. While industry-sponsored weekend cadaver workshops have remained the mainstay of training aspiring endoscopic spinal surgeons in North America and Europe leaving many of them to become autodidacts.