Oral Care for Neuroscience patients in New Zealand – A national survey

Oral care is a pertinent issue in neuroscience nursing as many patients are unable to maintain their oral hygiene due to reduced consciousness, cranial nerve palsies or limb weakness. Oral care practice is based on tradition or experience rather than evidence based (Cohn & Fulton, 2006; Coker et al., 2017). Thirteen studies on oral hygiene practice and experience in nursing were explored. Binkley et al (2004) developed a questionnaire tool which formed the basis of four surveys (Chan & Ng., 2012; Perrie & Scribante., 2011; Saddki et al., 2014; Soh et al., 2011).

Binkley et al. (2004) carried out a large quantitative survey (n = 556) which had face and content validity, was developed by a research team and conducted in 421 intensive care units in the United States.

Twenty-seven questions using the five-point likert scale examined attitudes, knowledge and belief, types and frequency of care provided, training and hospital provision within their questionnaire.

Three studies of neuroscience nurses were identified, from the Netherlands, USA and the United Kingdom (Cohn & Fulton, 2006; Hollaar et al., 2015; Horne et al., 2015). The USA study was small, for both nursing staff (38%, n=15) and unlicensed staff or health-care assistants (60%, n=15) (Cohn & Fulton, 2006). This was the only study to question health-care assistants as well as nursing staff. They used different questionnaires for the two groups and looked at attitudes, beliefs and preferences regarding oral care. This study recommended the use of open-ended questions to collect more information. Hollaar et al. (2015) used a questionnaire to examine the knowledge and skills of nursing staff in oral hygiene, and also educated staff using a guideline and then evaluated their knowledge by examination (n = 18). Both the above studies were small, carried out in a single hospital, so generalizability was limited. Horne et al. (2015), carried out a mixed-method survey using a combination of focus groups and telephone interviews with senior nurses on a stroke unit (n = 11). Common themes arose including oral care was a neglected area, stroke patients lacked awareness of the importance of oral hygiene and there was a lack of advice provided for them. Nurses were aware of the importance of effective oral care but lacked knowledge and education. Protocols and assessment tools were also unavailable.

There were no studies exploring oral care amongst neuroscience nurses in Australasia. Only three studies worldwide explored neuroscience nurses’ experiences and practice in oral care and most were conducted in intensive care. Therefore, a need existed to explore ward nurses’ experience and practice in oral care. Several common findings of the surveys regarding oral hygiene practice and experience in nursing existed which will be discussed.

This study aimed to explore the experience and knowledge of nurses, working on acute neuroscience wards providing oral care for their patients. The findings will aim to contribute to the development of evidence based oral hygiene education to guide and standardize practice in New Zealand.

This survey was designed as a cross sectional survey. Binkley et al (2004) permitted the use of their validated questionnaire and the original was provided. Some statements and questions were changed to reflect experiences of ward nurses providing oral care rather than critical care units and the language was also reviewed.

The survey was designed online using Survey Monkey with twenty five questions. Closed questions were used to reduce the time for completion; some contained the option ‘other’ so participants could make additional comments. A series of statements using the 5 point Likert scale were modified and included to reflect the ward setting. (See appendix 1).

The quantitative questions collected nominal and ordinal data. Qualitative questions were explored to gain more knowledge and scenario-based questions included as it was more realistic, allowed for deeper insight, and was suggested in a previous study (Chan & Ng, 2012). Content validity was ensured by consultation with a hospital dentist who reviewed the questionnaire. A focus group of five local neuroscience ward based nurses pre-tested the questionnaire. Telephone interviews were conducted with the educators or nurse managers who acted as gatekeepers to determine their oral care practice within their ward.

There were approximately 150 neuroscience nurses within five neuroscience wards in five hospitals in New Zealand. To maximize sample size and increase external validity, purposive sampling was used, targeting a group of people with specific characteristics or experiences. In this survey, one unit declined participation and the researchers own ward was excluded. Therefore three neuroscience wards in three tertiary hospitals in New Zealand participated. The inclusion criteria comprised neuroscience registered nurses and enrolled nurses working clinically on an acute ward. Nurses working in all ethnic groups, ages, levels of experience and genders were included. . The exclusion criteria included any health care professionals who were not nurses, any nurses working in critical care or nurses who were not working clinically.

Questionnaires were distributed via email to the gatekeepers who were nurse educators or ward managers to all three units using Survey Monkey. A reminder email was sent once a week for four weeks to ensure a maximum sample size. After 4 weeks, there were only 22 responses, so the survey period was extended by three weeks for a total of 7 weeks. This produced 34 responses.

The ethics application for this study was reviewed by a committee of experienced academic researchers and was judged to be low risk. The Massey University Code of Ethical Conduct, Teaching and Evaluations involving Human Subjects (2015) guided the research process.

Participants had the right to full disclosure of information. An information sheet was sent with the questionnaire to explain the rationale and ensure participants were fully informed about the research. Consent was implied when they chose to complete the survey. The information was kept securely in a password protected computer and the data was securely archived. The institutions and clinical leaders gave their consent for the research to be conducted and their research departments were fully informed.

The quantitative data was exported from Survey Monkey into an excel spreadsheet, further exported into the Statistical Package for Social Sciences (SPSS) and screened for incomplete information. Descriptive statistics and frequencies were used to analyze the results. This data was presented in tables and graphs. A content analysis was used to analyze the qualitative data from the questionnaire. In this study, the data from the open-ended questions were read and put into categories identifying key themes and then collated in a table with examples of common responses.

There were 94.1% (n=32) registered nurses, 5.9% (n=2) enrolled nurses in the sample and of these 91.2% (n=31) were female (Table 1). Some nurses had nursing experience over 40 years 5.9% (n=2) but the majority worked between 1-10 years (52.9 %, n=18). The mean nursing experience was 12 years.

The majority of these nurses (64.7%, n=22) recalled having oral hygiene education during their nursing training. Adequate training was reported by 55.9–88% of nurses in other studies (Binkley et al., 2004; Chan & Ng., 2012; Saddki et al., 2014; Soh et al., 2011). Some of these nurses believed their education was adequate (40.6%. n=13) with 25% (n=8) rating their oral hygiene training as inadequate. When starting on their current ward, 57.6% (n=19) of the nurses did not receive any oral hygiene education. A total of, 60.6% (n=20) of the nurses believed their oral hygiene knowledge was good. With 65–94.7% of nurses were keen for further training or guidelines.

Nurses were asked to comment on a series of statements using a 5 point Likert scale of strongly disagree, disagree, neutral, agree, and strongly agree. The majority of respondents agreed that oral hygiene was a high priority when caring for their patients (agreed 50%, n=17; strongly agreed 35.3%, n=12). This is comparable to the literature where over 89% of the nurses rated oral hygiene a high priority (Azodo et al., 2013; Binkley et al., 2004; Chan & Ng, 2012; Perrie & Scribante, 2011; Saddki et al., 2014; Soh et al., 2011). Almost all nurses believed that oral care significantly impacted on their patients’ clinical outcomes with 52.9% (n=18) agreeing and 26.5% (n=9) strongly agreeing. Most nurses were also satisfied with their own oral care provided to patients with 44.1% (n=15) agreeing and 26.5% (n=9) strongly agreeing. Although some nurses believed other procedures took priority over oral care (47.1%, n=16).

Nurses were asked to comment on several statements regarding oral hygiene education and educational requirements. The majority of respondents remained neutral on whether they required more information on evidence based oral care (41.2%, n=14) or an in-service session (47.1%, n=16) with a mode of 3 for each statement. In the survey, 85% (n=29) of the respondents did not have an oral assessment tool available for use on the ward. Some respondents agreed (47.1%, n=14), and 14.7% (n=9) strongly agreed that they assessed the oral health of their patients regularly, although 42.4% (n=13) agreed and 27.3% (n=8) strongly agreed they would like an oral assessment tool to help them assess the oral health of their patients.

Nearly half of the respondents said nurses were solely responsible for the oral care of patients (47%, n=16) although others 32% (n= 11) thought that nurses and health care assistants shared responsibility. With a lack of training and inability to use suction it would be inappropriate to delegate this task to a health care assistant, as it is beyond their scope of practice (Klein et al., 2017). Health-care assistants should be educated about the principles of oral care but, only nurses should provide oral care for patients with dysphagia. Neuroscience patients are a complex population with aphasia or dysphagia, an impaired ability to chew with reduced oral clearance increasing bacterial load and high risk of pneumonia and therefore should be cared for by nurses due to aspiration risk (Ajwani et al, 2017; Kwok et al 2015).

The majority of nurses were unsure if a dental team was available in the hospital (55.88% n=19). Nurses were asked to comment on when they would contact the dental team and three people mentioned for infections and two specified brain abscesses. Some mentioned broken, loose or rotten teeth. In a study of nurses and health-care assistants, Cohn and Fulton (2006) determined that 60% were aware of a lack of expert input, particularly surrounding guidelines, and recommended that such input is important to improve care. A qualitative question was asked about the complications caused by poor oral hygiene to assess nurses’ knowledge. Infection, although unspecified, was frequently mentioned (n=17) as well as thrush (n=16). Dry mouth, halitosis (bad breath) was mentioned infrequently. Poor oral hygiene leads to pneumonia, prolonged hospital stay and even death (Dietrich et al, 2017; Martino, 2005; Scannapieco & Shay 2014). There was no mention by respondents of a link with cardiovascular disease, stroke and a poorer prognosis of diabetes, as identified in the literature (Borgnakke et al., 2013; Dietrich et al, 2013).

A lack of co-operation was the biggest barrier to effective oral care in this study (see graph), with issues related to low levels of consciousness, lack of bite reflex and confusion identified. These conditions were also identified in other studies (Costello & Coyne, 2008; Hollaar et al., 2015; Chan & Ng, 2012). Nurses lacked the ability to access the mouth as patients often bite down, which was the second most common barrier reported. Dale et al. (2016) carried out an ethnographic study of intensive-care nurses and their experiences of oral care and determined that it is difficult to provide oral care when the patients bite down, making access difficult. Bite blocks or tools to open the mouth need to be explored. The third most common barrier was unstable or critically unwell patients also identified as a barrier by Chan and Ng (2012).

Time was a common barrier and could be related to the nurse–patient ratio, which is 1 nurse to 4–6 patients in neuroscience wards in New Zealand, compared to 1 nurse to 1–2 patients in critical care, as in the study by Chan and Ng (2012). Costello and Coyne (2008), in their survey of nurses in the United Kingdom, also reported time as a common barrier. This could be linked with inadequate staffing, which is widely reported in nursing (Twigg et al., 2015). Improved nurse–patient ratios contribute to improved outcomes (Aiken et al., 2011). When considering time as a factor, most respondents said that oral care would take between 5 and 10 minutes. The literature reported that a lack of time restricted the provision of effective oral care (Wårdh, Hallberg, Berggren, Andersson, & Sörensen, 2003; Costello & Coyne, 2008). When recommending products, time must be a consideration and ease of product use is fundamental.

Professional development regarding oral hygiene emerged as an important issue from the results of the questionnaire. Several studies have identified that oral hygiene education is lacking and created a barrier to effective oral care (Costello & Coyne, 2008; McGuire, 2003; Smith et al., 2016; Talbot et al., 2005).

To assess the nurse’s knowledge a series of scenarios were given to determine their choice of products and frequency of use. There were differences in timing for the use of products and this is well reported in the literature (Costello & Coyne, 2008; Horne et al., 2014). Oral care varies amongst nurses due to the large product range which is rarely evidence based (Cohn &Fulton, 2006; Coker et al., 2017). However toothbrushes and paste were commonly used throughout the scenarios, which is recommended twice daily and prevents plaque build-up, periodontitis and gingivitis (Chan & Ng, 2012; New Zealand Dental Association, 2010; Prendergast, Jakobsson, Renvert, & Hallberg, 2012; Prendergast et al., 2013).

Mouthwash featured highly in all three scenarios; 79.41% of respondents used this product for mouth care; although this is known to cause xerostomia (dry mouth) and should be avoided (Eilers, 2004; Shi et al., 2013). Foam swabs were also reported to be commonly used for mouth care (79.41%). Dale et al (2016) carried out an ethnographic study and reported the texture of these swabs are not popular and make oral care more difficult. Swabs are predominantly for comfort care and do not replace toothbrushes and are not effective for the removal of plaque or debris (Chan & Ng, 2012). In the UK mouth swabs have been removed from practice due to a patient death (Medicines and Healthcare Product Agency, 2012).

Nurses were asked if they would allow family members to carry out oral care of a patient with a poor swallow and inability to provide their own care. Surprisingly 48.48% (n=16) said they would allow them to provide care. Family members should not carry out this task for patients with poor swallow or cognition due to the risk of aspiration and pneumonia. Garrouste-Orgeas et al. (2010), carried out a study to investigate family participation in the intensive care unit and 97% (n=101) of families wanted to be involved in care. Oral care was thought to be one of the more appropriate tasks for families to provide by doctors, nurses and health care assistants. However, while 65.3% of nurses favoured family participation in oral care, some expressed concerns of adverse events during care.

In the second scenario a patient had a dry mouth and lips, and was unable to provide their own care, a common situation in neuroscience patients. Toothpaste and toothbrushes were used mostly 12 hourly. Mouthwash and swabs featured again in this scenario and, therefore, would add to the problem of dry mouth. Artificial saliva was used by a third of the respondents for dry mouth, but this can cause a coating to form on the tongue and patients find this unpleasant or perceive more difficulty with swallowing as a result (Furness et al., 2011). A dry-mouth toothpaste and gel, such as the Oral7® product neutralizes the mouth and prevents the build-up of plaque, which was considered locally and recommended by dentists. The gel acts as saliva in the mouth and can be used regularly with patients’ mouths easier to clean as a result.

A patient with a full set of dentures was mentioned in the last questionnaire scenario. One-third of the respondents mentioned the use of denture tablets once daily. This should occur at night time, when dentures are removed for soaking in a sealed container to prevent the occurrence of denture stomatitis and reduce the risk of pneumonia (Coker et al., 2017; Iinuma et al., 2015; Gendreau and Loewy, 2011). Coker et al. (2017) reported that patients refuse to have their dentures removed while in hospital mostly because they don’t want to be seen without them, and they did not find that these patients developed denture stomatitis. However, wearing dentures overnight doubles the risk of pneumonia according to Iinuma et al. (2015).

Availability of products was addressed by the questionnaire. Toothbrushes, toothpaste, foam swabs, mouthwash and artificial saliva were provided in all of the three hospitals. However, the availability of denture-cleaning tablets was low and needed to be addressed.

Thrush was the most commonly mentioned complication nurses encountered in practice, present in immunocompromised hospitalized patients, those with dysphagia, patients taking steroids or antibiotics, or patients with xerostomia (Kragelund et al., 2016). When asked about the oral complications that can occur in their patients, respondents commented about dry mouth and a dry or coated tongue. It is unclear whether this is attributed to the use of saliva substitutes.

One hospital used a universal guideline, not specific to their department or neuroscience, but the other two units did not. In the survey, most nurses agreed that they would like to have an oral assessment tool. No national guidelines were available to standardize care and thus variations occurred in oral care. Currently, oral assessment tools exist for oncology and neuroscience intensive care, but none are available for use with ward-based neuroscience patients (Eilers et al., 1988; Prendegast et al., 2013). There is also a lack of guidelines for oral care in neuroscience patients and there is a need for more research in this area (Hollaar et al., 2015). A nationally available assessment tool and guideline would be beneficial.

Generalizability was not possible, due to the small sample size (34%) The recruitment period had to be extended due to the poor uptake of the questionnaire from 4 weeks to 7 weeks. Bias has to be considered, as those nurses more interested in oral hygiene would have been more likely to participate. The individual wards were not identifiable.

The development of an easy to use and quick to complete oral assessment tool and guideline would standardize care. The main oral health problems are dry mouth, poor swallow, and dentures. The guideline needs to identify products useful for these conditions. Education should be provided regularly for all nurses and health care assistants in how best to provide oral care.

Since the completion of this study, the oral care online learning package has been developed for use for health care assistants, nurses and speech and language therapists. A guideline (see appendix 1) and flowchart has been implemented with a positive response. A standardized approach should be used to improve care with collaboration between hospitals.

“No conflict of interest has been declared by the author(s).”