Nurses' oral hygiene care practices with hospitalised older adults in postacute settings

Implementation of a nursing oral health care protocol in a university teaching hospital: A cluster-randomized stepped-wedge design

INTRODUCTION

Providing oral care is an essential part of basic nursing care but receives little priority in daily practice, with a risk of adverse events. Also, nurses report many barriers to adequate provision of oral care, such as time restraints, insufficient materials, fear of causing pain, lack of knowledge and a negative attitude towards providing oral care.

METHODS

We performed a cluster-randomized, stepped-wedge study to explore the effect of the the implementation of a new nursing evidence-based oral care protocol on nurses' knowledge, attitude and protocol adherence. The study population included both nursing students, graduated nurses and patients in selected wards. The implementation strategy included oral and written information, instruction videos and reminders. Nurses' knowledge and attitude towards oral care were assessed at baseline and after the implementation of the protocol with a validated 47-item questionnaire with a score range of 0-100. Secondarily, nurses' protocol adherence to teeth brushing, measured in Activities of Daily Living (ADL) dependent patients, was evaluated. The Standards for Reporting Implementation Studies (StaRI) Statement was used.

RESULTS

At baseline, the questionnaire was completed by 226 nurses; after implementation by 283. Knowledge had significantly improved from 68.8 to 72.3. Nurses' attitude improved not significantly. Protocol adherence was assessed in 73 ADL-dependent patients at baseline, in 51 after implementation. Adherence to teeth brushing significantly decreased in patients with permanent teeth. Also, adherence to both teeth brushing and usage of soap decreased in patients with (partial) dentures.

CONCLUSION

Nurses' knowledge and attitude of oral care increased somewhat after the implementation of a new nursing evidence-based protocol. After implementation, there was an unexplained decreased adherence to oral care in ADL-dependent patients.

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.

Oral care practices for patients in intensive care unit: A systematic review

OBJECTIVES

To critically analyse and discuss oral hygiene protocols in the hospital environment in patients admitted to the ICU, through a systematic review of the literature.

METHODS

The electronic search was performed on Pubmed, Cochrane, Web of Science and Google Scholar databases. The indexing keywords according to the PRISMA protocol were: 'hospital dentistry', 'oral health', 'oral care' and 'intensive care unit'.

RESULTS

The initial search resulted in a total of 2671 articles. Pre-selection based on titles led to the exclusion of 2510 articles and the remaining 36 were selected for abstract reading. After analysing the eligibility of the articles, eight studies were included in the review and submitted to qualitative analysis.

CONCLUSION

It can be concluded that cleaning with a soft bristle brush, use of chlorhexidine and lip moisturizing are methods commonly used in dental care actions in patients hospitalized in intensive care units.

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.

'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.

Missed nursing care: A cross-sectional and multi-centric study from Turkey

AIM

The aim of this study is to explore the extent of missed nursing care in Turkey and identify its predictors.

DESIGN

This was a descriptive, cross-sectional, multicentre study.

METHODS

A total of 477 nurses working in seven public hospitals participated in this study from March to July 2019. The survey included two components: a personal and professional characteristics data form and the MISSCARE survey.

RESULTS

The study revealed that emotional support, patient bathing and ambulation were the most frequently missed nursing care activities. An inadequate number of assistive personnel and staff, along with an unexpected increase in patient volume, were identified as the primary reasons for missed nursing care. Of the 21 missed nursing care activities, nine predictive models showed statistical significance (p < 0.05). Factors such as the type of unit, years of work experience, working hours, number of patients cared for in a shift and intention to leave the unit were found to be significant predictors of seven missed nursing care activities (p < 0.05).

CONCLUSION

This study found that numerous variables influence each care activity, which suggests the need to devise more targeted and specific strategies to minimize missed nursing care. Thorough investigation into the impact of these strategies on each care activity is essential.

A Dentist-Led Oral Care System Can Prevent Stroke-Associated Pneumonia: The Effects of Early Intervention by Dental Team

Background

Our facility's dental team consists of a full-time dentists and dental hygienists who work exclusively in the wards to implement best practices in oral healthcare. We executed the dental care system (DCS) that includes lectures and practical training for nurses conducted by dentists and dental hygienists, the introduction to oral assessment, standardization of oral care procedures, a process for nurses to request the dental team, and early bedside oral screening conducted by the dental team. This study investigated the DCS's effects on the incidence of stroke-associated pneumonia (SAP).

Methods

This single-center retrospective cohort study included 2,771 acute stroke patients who were newly hospitalized between April 1, 2012, and March 31, 2020. The 8-year period was divided into four phases at two-year intervals as follows: Pre (N=632), Post-1 (N=642), Post-2 (N=716), and Post-3 (N=781). Pre was prior to DCS practice. Post-1 was an early introduction to DCS. Post-2 simplified dental team requests from nurses, and Post-3 added bedside oral screening within 72 hours of admission by the dental team. Statistical analysis was performed using the Cochran-Armitage trend test, followed by multivariate logistic regression.

Results

A decrease in SAP rates was observed across the four groups (P<0.0001). Logistic regression analysis revealed a significant difference for respiratory disease (odds ratio 7.74, 95% confidence interval 5.49-10.90), hypertension (2.28, 1.39-3.73), cardiac failure (1.72, 1.04-2.85), and diabetes (1.59, 1.11-2.26), 3-digit code on the Japan coma scale (3.57, 2.53-5.05 [reference ≤2-digit code]), age ≥90 years (2.34, 1.15-4.77 [reference 18-59 years]), male (1.86, 1.31-2.67), and the Post-1 (0.49, 0.31-0.76 [reference Pre]), Post-2 (0.38, 0.25-0.61 [reference Pre]), and Post-3 (0.24, 0.15-0.40 [reference Pre]) periods.

Conclusion

The suppression of SAP is effectively achieved through early intervention and education of nurses by dental professionals.

Development and psychometric testing of the attitude and confidence with oral healthcare among nursing students (ACORN) scale

AIM

To develop and test the psychometric properties of the attitude and confidence with oral healthcare among nursing students (ACORN) scale.

BACKGROUND

Delivering oral healthcare is an essential component of care, which is often overlooked and omitted. A nurse's attitude or confidence may influence how oral healthcare is prioritised. To date, there are no scales that assess both attitude and confidence for nurses when undertaking oral healthcare and thus the ACORN scale was developed.

METHODS

The 24-item scale was developed following a three-stage process, which included concept identification and item construction, pilot testing, factorial and discriminant validity and reliability testing. The survey was distributed to nursing students to assess their attitude and confidence in providing oral healthcare. This study has been registered with the Registry of Efficacy and Effectiveness Studies (12940.1v1).

RESULTS

Using a before and after intervention survey design, the psychometric properties of the ACORN scale were examined with data collected from two student groups. Exploratory Factor Analysis yielded a two-factor structure, which was verified using Confirmatory Factor Analysis. Importantly, aggregated scale scores were able to detect differences in attitude and confidence following oral healthcare education (4.95 versus 5.66, p < 0.01). The Cronbach's alpha for the 24-item scale was 0.94.

CONCLUSION

The ACORN scale is a valid and reliable tool that can be used to assess differences in attitude and confidence of students following oral health education. Further research is recommended to test the utility of this scale using other educational interventions with different groups of healthcare providers.

Feasibility of a nursing guide for the oral management of outpatients with diabetes mellitus

Support for nurses is necessary to enable them to practice the oral management of patients with diabetes; however, no support for nurses in this context has been reported. The objective of this study was to verify the feasibility of a nursing guide for the oral management of outpatients with type 2 diabetes, aimed at giving nurses the ability to independently practice oral management for patients with diabetes in an outpatient department. Questionnaires were administered to 25 certified diabetes educator nurses from 54 medical facilities. The evaluation and degree of understanding of the guide were assessed using items in the nursing guide. In addition, opinions and impressions about the guide in the form of free responses were requested. Descriptive statistics were calculated for all measured variables, and data gathered from the free responses were divided into categories based on their similarities and differences. The feasibility of the nursing guide was confirmed, and nurses confidently provided education regarding oral management to patients with diabetes using the guide. These results suggest that a guide may improve nurses' knowledge, skills, and confidence in providing patient education and improve the overall practice of oral management. Further improvements based on the opinions of nurses, such as the expression of terms, implementation of checklists for oral assessment, and identification of devices that can be utilized in a shorter time, are needed to facilitate the implementation of the guide into practice by nurses.

Body care of older people in different institutionalized settings: A systematic mapping review of international nursing research from a Scandinavian perspective

Body care is considered a key aspect of nursing and imperative for the health, wellbeing, and dignity of older people. In Scandinavian countries, body care as a professional practice has undergone considerable changes, bringing new understandings, values, and dilemmas into nursing. A systematic mapping review was conducted with the aims of identifying and mapping international nursing research on body care of older people in different institutionalized settings in the healthcare system and to critically discuss the dominant assumptions within the research by adapting a problematization approach. Most identified papers reported on empirical research with a biomedical approach focusing on outcome and effectiveness. Conceptual papers, papers with a focus on the perspectives of the older people, or contextual and material aspects were lacking. The research field is dominated by four dominant assumptions: Body care as an evidence-based practice, body care as a relational ethical practice, the body as a body-object and a body-subject, the objects in the body care practices as nonrelational materialities. Given the complexities of professional body care practices, there is a need for other research designs and theoretical perspectives within nursing that expand our understanding of body care taking into consideration the multiple social and material realities.

The Need for Oral Hygiene Care and Periodontal Status among Hospitalized Gastric Cancer Patients

Poor oral hygiene leads to the accumulation of dental plaque, thus contributing to the initiation of periodontal disease (PD). Local infections can lead to systemic inflammatory responses, which are essential mediators for the evolution of systemic conditions or cancer tumorigenesis. Often, patients hospitalized with life-threatening and incapacitating disorders such as gastric cancer (GC) might lose interest in keeping their mouth healthy. This study evaluates oral hygiene, periodontal status, and the need for oral care and medical personnel to assist in achieving it in patients hospitalized with GC. This study was carried out on 25 patients with a diagnosis of GC, divided into two groups (GP-14 patients from the Gastroenterology Department, and SP-11 patients from the 1st Department of Surgery). Patients were examined on the day of admission (T0), the day of the medical procedure of endoscopy or surgery (T1), and the day of discharge (T2), recording the number of absent teeth, dental plaque (PI), bleeding on probing (BOP), probing depths (PPD), frequency of toothbrushing, and if the oral hygiene had been self-performed or assisted. Data were subjected to statistical analysis. Our results showed that, in both the GP and the SP group, there were strong and statistically significant correlations between PI and BOP measured on the last day of hospitalization and the period of hospitalization after the medical procedure. Longer hospital stays and the presence of surgery were risk factors for changing toothbrushing frequency. Results also highlight the need for a dentist to diagnose and eventually treat periodontal disease before and after hospitalization, and for a trained nurse who should help take care of the patient's oral hygiene during hospitalization.

Oral Health of Elderly People in Institutionalized Care and Three-Month Rehabilitation Programme in Southern Poland: A Case-Control Study

Demographic ageing is a global growing process and the quality of ageing is an important parameter in this process. The aim of the study was to analyse the distribution of remaining dentition in relation to oral hygiene indicators among elderly people remaining in institutional care and those who participated in a 3-month rehabilitation program, aimed at increasing time of independent functioning, in southern Poland. The patients underwent a questionnaire and clinical examination. An analysis of missing teeth was performed, plaque index, and gingival index were measured. Residents of the Municipal Health Centre for Older and Dependent People (n = 50) had a higher incidence of missing teeth in the maxilla (88.4%), mandible (77.6%), as well as in the maxilla and mandible combined (83%) than residents of the Daily Medical Care House (n = 30). The distribution of the remaining teeth, in both groups, corresponds to the outlets of the large salivary glands. The group of 53.8% of patients with dry mouth had PI scored 3. Residents with dry mouth were more likely to have plaque deposits and gingival inflammation. It is necessary to develop and implement an oral care program for patients with reduced saliva secretion, with a particular focus on dependents.

Good in Providing Oral Care, but we Could be Better-Nursing Staff Identification of Improvement Areas in Oral Care

Introduction

Oral care to older people in short-term care units is a complex and challenging everyday practice for nursing staff. Oral care research and knowledge about prerequisites and obstacles is extensive. However, there is a lack of knowledge about how nursing staff in short-term care units describe their satisfaction about provided oral care in order to maintain older people's oral health.

Objective

The purpose of this study was to describe how nursing staff perceive their satisfaction of oral care provided for older people in short-term care units and to identify oral care improvements.

Methods

This study reports on the results of two open-ended questions that were part of a larger study. Informants (n = 54) were nursing staff working in the involved short-term care units in municipalities from both densely and sparsely populated regions in central and northern Sweden. The answers to the open-ended questions were analyzed using content analysis.

Results

The analysis yielded one main category; “Working together to improve satisfaction with older people's oral care” and four subcategories: “Older people's oral health,” “Consideration and respect for the older person's autonomy,” “Having access to adequate products,” and “Working together in the same direction.”

Conclusion

Identification of older people's oral health problems together with adequate nursing intervention will increase older people's health outcomes and quality of life. However, regardless of work role, the nursing staff might have difficulty changing their behavior or transforming intentions into actions. Oral care is a complicated and proactive practice that requires nursing staff's attention as well as both educational and organizational initiatives. Working in a supportive and collaborative relationship provides prerequisites for optimal oral care in short-term care units.

Developing an Instrument to Measure Self-Efficacy, Challenges and Knowledge in Oral Care among Geriatric Home Care Nurses-A Pilot Study

The role of geriatric nurses is essential in preventing oral health problems of older people with impaired daily functioning. Nurses have reported low self-efficacy with regard to oral health care practices and wish to receive more information on the topic. The main aim of this pilot study was to develop an instrument to measure the self-efficacy beliefs, challenges and knowledge of geriatric home care nurses with regard to the oral health care of older. A questionnaire was developed to evaluate geriatric home care nurses' self-efficacy beliefs, challenges and knowledge regarding the oral health care of the older people. In this case, 18 nurses participated in a one-day intervention and filled in the questionnaire before and after the intervention. The comments and questions of the nurses were analysed utilising the principles of inductive content analysis. Cronbach's alpha for the scales varied between 0.69-0.79. The interactive intervention improved both nurses' self-efficacy beliefs and oral health-related knowledge, and most of the challenges faced by nurses in older people's oral health care were diminished. Financial resources and older people's self-determination were the most common limitations to oral care. In this pilot study, we developed an instrument to measure geriatric home care nurses' self-efficacy beliefs, challenges and knowledge regarding older people's oral health care. In the future, this instrument can be validated with a larger study population.

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.

Oral status of older people in medium to long-stay health and social care setting: a systematic review

Background

Older patients who spend long periods hospitalized or those who are in a situation of institutionalization represent a risk group in this regard, as many of them suffer a degree of dependence and need help to perform the basic tasks of personal care. It is therefore important to learn more of the oral health status of this group of patients in order to make a proper assessment of the situation and to develop protocols for its management. The purpose of the study was to conduct a systematic review to ascertain the oral health status of older people patients admitted to institutions or hospitalized for a long period of time.

Methods

a systematic review of the literature published in two different databases (PubMed, Embase and Cochrane Library) was carried out, with 12 different combinations of keywords based on the following selection criteria: studies published in the last 5 years, in English and/or Spanish and/or Portuguese, with samples of ≥30 patients, performed in patients older than 65 years, admitted to any type of institution and/or hospital center for at least 7 days and in which the state of hard and/or soft tissues of the oral cavity were evaluated in some way. The selected articles were subjected to a thorough analysis.

Results

The search strategy covered 1.014 articles: 689 from Pubmed and 325 from Cochrane Library. After applying the eligibility criteria, five articles were selected for our review. The level of evidence of the articles was, a sample of 773 patients most of them were women with an average age older than 70 years old.

Conclusions

The oral health of patients aged more than 65 is worse than that of the rest population. Long hospital stays or being institutionalized in a residence makes this group susceptible to a worsening of their oral health status. It is necessary to develop protocols for the oral health care of these patients, accompanied by training programs for the personnel responsible.

(Lack of) oral hygiene care for hospitalized elderly patients

OBJECTIVE

to analyze the oral hygiene care for hospitalized elderly patients provided by the nursing staff.

METHOD

this is a qualitative, exploratory-descriptive study carried out in a university hospital, with the participation of 35 professionals from the nursing staff. Data collection was carried out through semi-structured interviews, explored through thematic content analysis.

RESULTS

two categories emerged: The oral hygiene of hospitalized elderly patients as an extension of body care and Barriers in (lack of) care with the oral hygiene of hospitalized elderly patients, with two subcategories: The oral hygiene and dental prosthesis technique performed divergently; Care hampered by deficit of materials and human resources.

FINAL CONSIDERATIONS

this study showed weaknesses in the oral hygiene care of hospitalized elderly patients, promoting reflections on the practice informed in data and management actions, allowing recommendations of care standards for the nursing staff.

Technology for maintaining oral care after stroke: considerations for patient-centered practice

PURPOSE

Activities of daily living including oral care may be challenging after stroke. Some stroke survivors are not able to complete oral care independently and need assistance from healthcare professionals and care partners. Poor oral hygiene may impact stroke recovery and rehabilitation possibly incurring issues such as aspiration pneumonia, malnutrition, and social isolation. The objective of this paper is to outline practical ways to apply oral care technology in daily use for stroke survivors.

MATERIALS AND METHODS

We reviewed the literature on i) stroke-related impairments impacting oral care, ii) oral hygiene dental devices, and iii) technology for oral care education.

RESULTS

Oral care activities involve integrated skills in the areas of motivation, energy, planning, body movement and sensation, and mental acuity and health. Post-stroke impairments such as fatigue, hemiparesis, and mental impairments may impact oral care activities. Technology may help survivors and caregivers overcome some barriers. Three types of technologies are available for facilitating post-stroke oral care: i) non-powered tools and adaptations; ii) powered oral care tools, and; iii) electronic aids to guide oral care activities. Particular choices should maximise patient safety and autonomy while ensuring accessibility and comfort during oral care tasks.

CONCLUSION

The available device and technologies may help substantially with the accommodations needed for post-stroke oral care, improving the oral health of stroke survivors. Good oral health confers benefit to overall health and well-being and could enhance recovery and rehabilitation outcomes. Nonetheless, more research is necessary to demonstrate the feasibility and effectiveness of technology in stroke contexts.IMPLICATIONS FOR REHABILITATIONOral care may be challenging after stroke due to patient fatigue, hemiparesis, cognitive impairments, and other impaired body functions.Poor oral hygiene may impact stroke recovery and rehabilitation due to risk of aspiration pneumonia, malnutrition, and social isolation.Powered oral care tools, non-powered tools, and adaptations to non-powered tools are some of the technology available to help overcome post-stroke barriers for oral care.Computer programs and online resources for education and guidance for oral care activities may help improve recommendation uptake and compliance.

Relying on nursing staff for oral hygiene care: A qualitative interpretive description study

Nurses may not prompt or offer assistance with oral hygiene care activities to patients who do not ask for help because they appear independent in their ability to perform their oral hygiene care. That is, nurses may be inclined to preserve patient autonomy over ensuring adequate oral hygiene outcomes. The purpose of this qualitative Interpretive Description study was to explore, with older patients in post-acute settings, their perspectives and experiences with being autonomous or relying on nursing staff for oral hygiene care. Bedside interviews with 21 patients revealed that: (a) their oral hygiene had deteriorated since hospitalization; (b) nurses may not be aware of patients' oral health values or offer help unless asked; and (c) patients are generally open to being asked if they need help with oral care, being prompted to complete oral care, being asked if they have completed oral care, and having nurses ensure adequate oral care.

Improving oral care for hospitalised patients: choosing appropriate products

BACKGROUND

Oral care is a fundamental part of nursing but it is often performed as a routine task, often based on historic practice, and lacks an evidence base. A variety of oral care products are used in practice.

AIM

To discover evidence of effective oral care products for use in hospitalised patients.

DESIGN

A systematic literature review was undertaken.

METHODS

A review of articles was conducted using CINAHL, PubMed, the Cochrane Database and Google Scholar between 2007 and 2019. All articles were compared and contrasted and some excluded due to the quality of the evidence.

DISCUSSION

The literature review identified a number of oral care problems and investigated a range of products.

RESULTS

The main finding was that there is a need for a definitive, evidence-based oral care guideline on the products suitable for different oral care conditions, including dysphagia, xerostomia, mucositis, and for patients wearing dentures.

Oral care quality-Do humanity aspects matter? Nursing staff's and older people's perceptions

AIM

(a) To describe and compare perceptions of humanity aspects of oral care quality in relation to nursing staff in short-term care units and intensive care units and older people in short-term care units and their person-related conditions; and (b) to compare humanity aspects of oral care quality perceptions between nursing staff and older people in short-term care units.

DESIGN

Cross-sectional study. Self-reported questionnaire and clinical assessments.

METHODS

Nursing staff (N = 417) and older people (N = 74) completed the modified Quality of Care from a Patient Perspective instrument and person-related items. Older people's oral health status was clinically assessed using the Revised Oral Assessment Guide. Data were analysed using descriptive and analytic statistics. The data were collected from 2013-2016.

RESULTS

Nursing staff's perceptions of humanity aspects of oral care quality were related to gender, work role and care environment. Older people's perceptions of humanity aspects of oral care quality were related to self-reported physical health. Nursing staff in short-term care units perceived the subjective importance of humanity aspects of oral care quality higher compared with older people in short-term care units.

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.

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.

Relationship between anxiety/depression and oral health-related quality of life in inpatients of convalescent hospitals

The aim of this study is to examin the association between anxiety/depressive tendency and oral health-related quality of life in inpatients of convalescent wards. This cross-sectional study included inpatients of convalescent wards (age range 34-100 years). Data on age, sex, functional independence measure, number of teeth, odontotherapy status, and primary disease for which hospitalization was required were collected. The Hospital Anxiety and Depression Scale (HADS) was used to assess emotional distress. The oral health-related quality of life was evaluated by the Geriatric Oral Health Assessment Index (GOHAI). Oral hygiene level was assessed by the Oral Health Assessment Tool (OHAT). We performed a multiple regression analysis to assess relationships among HADS, GOHAI, and OHAT. Following the analysis, causal connections of these factors were evaluated with structural equations modeling. The scores of GOHAI and OHAT in the caseness cohort (HADS score > 11) were significantly worse than those in the non-caseness cohort (HADS score < 7). Multiple regression analysis revealed that GOHAI was a statistically significant predictor of HADS score (p = 0.012), and that HADS and OHAT scores were predictors of GOHAI (p = 0.012 and < 0.001, respectively), adjusted by sex and age. We found that a model connected from OHAT to HADS through GOHAI was a good fit for the data of inpatients. Oral health-related quality of life, affected by oral hygiene status, was strongly associated with emotional distress in inpatients of convalescent wards. Daily oral care and assessment by healthcare professionals can reduce the emotional distress of inpatients in convalescent wards.

Misperception of Oral Health among Adults in Rural Areas: A Fundamental but Neglected Issue in Primary Healthcare

Background: Poor oral hygiene is associated with metabolic syndrome, systemic diseases, mortality and many chronic diseases. Misperception means a wrong or incorrect understanding or interpretation. Few studies have examined the subjective perception and objective condition of oral health among community adults in rural areas. Methods: This was a cross-sectional, community-based study. Participants were recruited via convenience samples from December 2015 to July 2016. One thousand six (1006) community residents participated in the project, of which 973 fulfilled the inclusion criteria. The average age was 42.8 (SD = 12.3) years, range 20–64, selected from a collaboration local hospital. Results: Most of the participants reported brushing their teeth every day, however, 72% reported seldom brushing their teeth after meals, 54% seldom used dental floss, 64% seldom received dental scaling, 29.5% had experienced a toothache within 6 months, and 30.5% demonstrated significant tooth loss. However, most of them perceived their oral health as good. Misperception of oral health was common, 21.5% among whose number of remaining teeth <25 under-assess their actual oral health. The more number of remaining teeth (p < 0.001) and regular dental check-up (p < 0.01) were positively associated with feeling good about their oral health. After adjusting for potential confounders, clinically significant findings indicated that number of remaining teeth (OR = 3.03, p < 0.001), age (OR = 0.99, p < 0.001), regular dental check-ups/scaling (OR = 1.85, p < 0.001), education (OR = 1.45, p < 0.05), and water consumption (OR = 1.38, p < 0.05) were independently associated with good perceived oral health. Conclusions: The findings showed that subjective self-perception of oral health was not matched with their objective oral condition. Excluding the unmodifiable factors, the clinical implications indicated that oral health promotion programs, particularly for adopting regular dental check-up, healthy diet and oral hygiene habits are urgent in rural areas.

Healthcare providers' experiences of assessing and performing oral care in older adults

AIMS AND OBJECTIVES

The purpose of this study was to describe healthcare providers' experiences, knowledge and attitudes in relation to the assessment of oral health in older adults.

BACKGROUND

Oral health is an important element in the care of older adults. An increasing proportion of older people need the help and support of community-based healthcare services, which are responsible for providing oral health assessment for this group. Although oral care is an important part of nursing care, studies show that it is often an overlooked area in the care of older people.

DESIGN

An inductive qualitative description design was used.

METHODS

The participating healthcare providers were selected from a municipality in western Sweden. Purposeful sampling was employed and data were collected through focus-group interviews and were analysed with content analysis.

RESULTS

The analysis resulted in four categories: healthcare providers' knowledge and attitudes to oral health; routines affect flexibility; challenges in assessing and performing oral care and ethical dilemmas. The results showed that oral health was neglected because of several factors. Lack of knowledge, inadequate procedures and time constraints were most prominent. The healthcare providers' own attitudes affected the performing of oral health assessments. Ethical dilemmas related to the attitudes of those people in receipt of care and their relatives, and their integrity and autonomy, could be seen as complicating factors.

CONCLUSIONS

The healthcare providers expressed that they did not have the necessary knowledge of oral health that was required in their area of responsibility. In addition, they described their own attitudes as being important when attending to the patients' oral health.

IMPLICATIONS FOR PRACTICE

The healthcare providers themselves identified lack of knowledge and their own attitudes as being especially important factors in the oral care of older adults, and further research in this area is needed.

Oral hygiene and mouth care for older people in acute hospitals: part 1

The oral health of older people in acute hospitals has rarely been studied. Hospital admission provides a prime opportunity for identification and rectification of problems, and oral health promotion. This two-part article explores oral hygiene and mouth care provision for older adults in acute hospitals. The first article presents the findings of a literature review exploring oral and dental disease in older adults, the importance of good oral health and mouth care, and the current situation. Searches of electronic databases and the websites of relevant professional health service bodies in the UK were undertaken to identify articles and guidelines. The literature shows a high prevalence of oro-dental disease in this population, with many known detrimental effects, combined with suboptimal oral hygiene and mouth care provision in acute hospitals. Several guidelines exist, although the emphasis on oral health is weaker than other aspects of hospital care. Older adults admitted to acute hospitals have a high burden of oro-dental disease and oral and mouth care needs, but care provision tends to be suboptimal. The literature is growing, but this area is still relatively neglected. Great potential exists to develop oral and mouth care in this context. The second part of this article explores clinical recommendations.

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.