A pilot study on the feasibility of training nurses to formulate multicomponent oral health interventions in a residential aged care facility.

OBJECTIVES: This 10 weeks feasibility study investigated whether residential care nurses with 12 hours advanced oral health training in assessments and saliva testing could formulate, implement and monitor individualised oral care plans of early dementia residents. METHOD: Four trained lead advocate nurses using SXI-D, OHIP14, oral health assessment tool (OHAT) assessments and a modified saliva test formulated nurse scheduled comprehensive oral care plans (NSCOCPs) by selecting and scheduling preventive products and procedures multiple times throughout the day to alkalise the mouth of 8 residents as an adjunct to assisted brushing and high-fluoride toothpaste. RESULTS: Nurse assessments, saliva tests and care plans were validated against oral health therapist (OHT) findings. Care plan agreement between Nurse and OHT intervention selection and scheduling was high (75%-88%). Untrained nurse compliance was very high, 86%-99% for the 4930 scheduled interventions. Untrained nurses delivered multiple scheduled interventions by following NSCOCPs despite initially not understanding the reason for each of 9 interventions categories. NSCOCPs could track and monitor whether a recommended intervention had been completed by general nursing staff over 3 nursing shifts. CONCLUSION: The role of nurses may have to be expanded beyond traditional roles to meet the growth and changes in oral health needs in residential facilities. Intensive training of a few lead advocate nurses to assess risk and formulate individualised NSCOCPs provides a method to transfer knowledge to untrained staff and deliver multicomponent preventive interventions soon after entry into residential care where timely visits by dental professionals to examine residents and prescribe preventive interventions are infrequent or unlikely.

The integration of oral health care into day-to-day care in nursing homes: a qualitative study.

OBJECTIVE: This qualitative study explored barriers and enabling factors to the implementation of an oral hygiene protocol in nursing homes. BACKGROUND: Oral health care in nursing homes in Flanders (Belgium) is inadequate. MATERIALS AND METHODS: Qualitative data were obtained from nurses employed in 13 nursing homes involved in two randomised controlled trials in Flanders-Belgium. Data were collected by focus group and face-to-face interviews during April 2005 and December 2009. All transcripts were analysed with support of NVivo 8 (Version 2008). Transcripts were intuitively analysed in a two-step method. RESULTS: Most revealed barriers were consistent with previous findings in the literature. Newly reported barriers were respect for residents' self-determination, experience based oral health care by nurses, residents' oral health status and nurses' inability to notice residents' oral health status. Demand-driven oral health care was found to be a strong enabling factor. CONCLUSION: The integration of oral health care into day-to-day care seems to be a major problem due to a multitude of barriers. In future implementation innovations in oral health care an a priori assessment of influencing factors is recommended.

Provision of dental care in aged care facilities, NSW, Australia - part 1 as perceived by the directors of nursing (care providers).

OBJECTIVE: To ascertain the Directors of Nursing (DONs) perception of the provision of dental care and the difficulties in oral health maintenance for residents in New South Wales (NSW) aged care facilities (ACFs). BACKGROUND: There were no specific figures relating to DONs' perceptions of oral health needs and dental care nor obstructions to dental care of residents. MATERIALS AND METHODS: A total of 414 questionnaires, encoded for confidentiality, were posted to all DONs of ACFs in NSW and the data analysed. RESULTS: Questionnaires were returned from 255 ACFs (response rate 61.6%) representing 16 861 residents with a male-to-female ratio of 1:3.45. Of these residents, 48% had a dental assessment on admission by qualified dental staff. In 74.2% of facilities, no regular visits by dental staff took place, and 58.6% considered the perceived unwillingness of dental professionals to visit residents a barrier to good oral health. DONs reported that 53.6% of residents had dentures only, while 18.3% had natural teeth only. The most frequent difficulties reported by staff were residents' use of abusive language (78.2%) and residents refusing to open mouth (60.9%). CONCLUSION: Lack of involvement of dental professionals in admission assessment and in ongoing programmes was of concern to DONs in ACFs.

The district nurse's perceptions of elderly patients' oral health: a qualitative interview study.

OBJECTIVE: The aim of this qualitative study based on interviews was to explore the perceptions that district nurses have of the oral health of elderly patients. MATERIAL AND METHODS: The criterion for inclusion was being a district nurse working in a primary health-care centre in the County of Stockholm. The respondents were asked open-ended questions about their perceptions of oral health and about the impact of oral problems on the general health and well-being of elderly patients. The analyses started at the first interview and proceeded in parallel until no further relevant information could be obtained. Analysis of the open-ended questions was inspired by grounded theory methodology and comprised four stages: native reading, open coding, axial coding, and selective coding. RESULTS: The one core category identified, namely indistinct professional duties of the district nurse, formed the central meaning of the district nurse's perceptions of oral health in elderly patients. This related to two other categories labelled 'insights into the district nurse's professional role' and 'obstacles for the district nurse', with sub-categories. CONCLUSION: Although the district nurses in this study were aware of the impact of oral health in old age, their attitude was that this was a matter for dentistry.

Effects of 11-month interventions on oral cleanliness among the long-term hospitalised elderly.

OBJECTIVES: This trial studied the effects of interventions on the oral cleanliness of the long-term hospitalised elderly. BACKGROUND: Oral cleanliness is mostly poor in long-term facilities. While many agree on the importance of oral hygiene education for nursing personnel, little information and agreement exists on how to organise this education in geriatric institutions. MATERIALS AND METHODS: This is a longitudinal study with interventions. After a baseline clinical examination, the patient wards were divided into three groups (A, B and C) and the type of intervention was randomly assigned. In group A, dental hygienists provided oral hygiene measures for the subjects once every 3 weeks. In group B, the nursing staff first received hands-on instructions after which they assumed responsibility for the subjects' daily oral hygiene. Group C served as a control. Denture hygiene and dental hygiene were recorded at baseline and in the end of the 11-month study period. In total, 130 subjects completed the interventions; their mean age was 82.9 years. RESULTS: The best outcome in both denture and dental hygiene occurred when nursing staff at the wards took care of hygiene (group B). The increase in the proportion of those with good denture hygiene was the most prominent in group B (from 11% to 56%). The proportion of subjects with poor overall dental hygiene decreased from 61% at baseline to 57% in the end, for group B from 80% to 48%. CONCLUSIONS: Organised oral health education of the nursing staff should receive more attention.

Los cuidados de la higiene oral de los ancianos con demencia en las residencias / Oral hygiene care for adults with dementia in residential aged are facilities

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The effect of an oral health education program after three years.

Three years after providing an oral health education program (OHEP) to nursing personnel, the authors analyzed the effect of the program on knowledge of the importance of oral health and on perception among the nurses of the possibility to implement oral care in patient care. The study was based on a cross-sectional survey of all nursing personnel (N = 2,901) in five municipalities in the Southwestern Sweden, of whom 950 had attended four one-hour lessons during an OHEP in 1996. The response rate to the survey questionnaire was 67% (1,930 subjects). Statistical analysis was performed by means of descriptive and analytical statistics. The program was shown to have an independent effect on the dependent variables "knowledge of oral health" and "assessment of implementation possibilities," This study has given further evidence of the feasibility of an educational program to improve both knowledge and implementation of oral health care.

Nursing personnel's views on oral health from a health promotion perspective: a grounded theory analysis.

The aim of this study was to develop a model for how nursing personnel view oral health in general and the oral health of the care receivers in particular, applying a health promotion perspective and using grounded theory analysis. Data were collected through interviews with 17 nursing personnel, selected by strategic sampling. Analysis of the transcribed interviews showed that there were four strategies, related to staff education, hospital resources, and leadership motivation. The strategies were grounded in data and emerged from the interaction between the two main categories: 'the valuation of the importance of oral health' and 'the behavior towards oral health maintenance'. They were characterized as the routine, theoretical, practical, and flexible strategies, with the latter considered ideal. As increased knowledge is one important part in enhancing the nursing personnel's ability to perform oral hygiene procedures, there is a need for education among nursing personnel, primarily among those using a routine strategy.

Promoting oral health in institutionalised older adults: a nursing perspective.

Current demographic trends necessitate that increased attention be paid to problems arising in the older population. One such area relates to the oral cavity, which may be affected by both the effects of aging and the effects of disease and illness. Yet the evidence shows a significant lack of adequate oral care, which may create major problems for affected individuals, causing oral and dental problems that may, in turn, predispose to nutritional deficiencies, communication difficulties and devastating dental disease (Ogle, 1982). This paper reviews the literature pertaining to this complex subject, concluding that although nurses have an important role in providing effective oral care for the institutionalised patient, it is difficult to identify appropriate techniques, agents and tools with which to provide such care. Further research in this field is undoubtedly needed.

Evaluation of an oral health education program for nursing personnel in special housing facilities for the elderly.

The aim of this study was to evaluate the influence of an oral health education program (OHEP) on attitudes among the responsible nursing personnel toward performing oral health procedures for care receivers. A total of 2882 nursing personnel were offered participation in the OHEP, and the effect was evaluated by means of a questionnaire distributed pre-educationally as well as 1-2 months post-educationally. The nursing personnel were allocated, on the basis of nursing education, to either a "high level of health care education" group (HHCE), including registered and enrolled nurses, or a "low level of health care education" group (LHCE), including nursing assistants and home care aides. Statistical analysis was performed by means of descriptive and analytical statistics. After the OHEP, the nursing personnel estimated their ability to perform oral hygiene procedures for care receivers to be significantly increased. Post-educationally, a significant shift in importance was observed from knowledge regarding the diseased oral cavity to knowledge regarding the healthy oral cavity. It was also observed that, in the LHCE group, the OHEP favored practical procedures, while in the HHCE group, theoretical considerations were favored. This indicates that, when oral health education programs are designed, due attention should be paid to the nursing personnel's education level.

Staff attitudes to oral health care. A comparative study of registered nurses, nursing assistants and home care aides.

This study compares differences in attitude, of oral health care of nursing personnel working with dependent elderly and severely disabled patients. A questionnaire was administered to 398 personnel covering (1) personal oral health care habits, (2) experiences and attitudes in assisting oral care and (3) willingness to assist patients/residents with their daily oral hygiene. Three hundred and sixty-four persons answered the questionnaire, including 70 registered nurses, 148 nursing assistants and 146 home care aides. The study revealed that oral care assistance is viewed as more disagreeable than other nursing activities. Although registered nurses were found to have more positive attitudes toward oral care assistance than the other nursing groups, they were seldom involved in the daily practice of oral hygiene care. The results indicate a gap between knowledge and practice in nursing personnel's attitudes toward oral health care of dependent elderly and severely disabled patients.

Nurses' oral health assessments of nursing home residents pre- and post-training: a pilot study.

The purpose of this study was to determine if instruction in how to perform the MDS (Minimum Data Set) oral health assessment and RAP (Resident Assessment Protocol) Summary required by federal regulations will improve nurses' accuracy of the assessments. Fifty residents, admitted within 90 days before a training lecture, were assessed by 18 nurses. A 30-minute training session demonstrated how to perform an oral examination, including hands-on practice under a dentist's supervision. Seven to ten days after the lecture, the nurses re-examined the same residents. These assessments were compared with the admission assessments and a dentist's findings (reference). The results of this study indicate that a 30-minute training session made a significant difference in improving nurses' accuracy in completing the assessments with regard to oral health status and treatment need.

The effect of nurses' background on performance of nursing home resident oral health assessments pre- and post-training.

The purpose of this study was to determine the effect of nurses' background on their accuracy in determining oral health status and treatment need of newly admitted nursing home residents before and after tutoring. Eighteen nurses examined 50 nursing home residents before and after an In-service training lecture. Examinations performed by a dentist served as reference. Background items evaluated were: regularity of each nurse's own dental visits; years since graduation from nursing school; length of experience in an LTC facility; and training received in oral health care. At the second evaluation, nurses greatly improved the % agreement on all items. The results of this study indicate that, regardless of background characteristics, the combination of training, the presence of the dentist, and knowledge that they were in a study appeared to improve nurses' performance on the assessment. Before training, more experienced nurses were better able to determine hard tissue abnormalities than their less experienced counterparts; before training, neither group performed well in assessing soft tissue lesions. Therefore, improvements in basic nursing training in this area appear to be necessary.

Factors influencing nurses' aides' provision of oral care for nursing facility residents.

Nurses' aides provide the majority of direct care for nursing facility residents. This study investigated aides' self-reported oral care activities and personal, job, organizational, and resident factors associated with oral care. A 30-item questionnaire was completed by 488 aides, and interviews were conducted with 65 of these aides. Aides were performing oral care activities for residents. Associations between some of the four groups of factors proposed and aides' oral care provision were found. Aides' attitudes toward oral care, lack of time and staff to complete oral care, and behavioral and physical difficulties with residents may have affected the time spent by these aides in providing oral care. The study highlighted the need for further investigation and assessment of (1) aides' CNA training courses and (2) continuing oral health educational interventions in nursing facilities. Personal interview were found to be a useful qualitative instrument for conducting dental research in nursing facilities. Further investigation is needed of interviews and other methodologies, such as observation, to supplement self-report as a measure of aides' oral care activities.

Oral hygiene care levels in Iowa intermediate care facilities.

This study was undertaken to improve understanding of current oral hygiene care practices in intermediate care facilities. Questionnaires were sent to directors of nursing of all licensed intermediate care facilities in Iowa. Results show that an estimated 57% of residents needed direct oral hygiene assistance. In all intermediate care facilities, the majority of direct oral hygiene care was provided by aides. Oral hygiene care was often not provided at an optimal level, and the main reasons reported for this lack of care were uncooperative residents (82%), lack of perceived need by aides (68%), and inadequate time/personnel (49%). Development and promotion of oral hygiene care programs in intermediate care facilities must take into consideration the realities and problems involved. Otherwise, efforts to introduce or implement new or improved care programs will fail.