Joumal of Advanced Nursmg, 1996,24,552-560

Qualified nurses lack adequate knowledgerelated to oral health, resulting in inadequateoral care of patients on medical wards

Rachel Adams RGN BScWard Sister, Demford Hospital, Plymouth, England

Accepted for publication 6 October 1995

ADAMS R (1996) Joumal of Advanced Nursing 24, 552-560Qualified nurses lack adequate knowledlge related to oral health, resultmg ininadequate oral care of patients on medical wardsThis study tested the theoretical proposition that qualified nurses lack adequateknowledge related to oral health, resulting in madequate oral care of patients onmedical wards The research was undertaken m a local district general hospitalduring January 1995 The project aimed to look at local practices of qualifiednurses related to oral care of patients hospitalized in medical wards Extent ofknowledge and cuiTent practice of care was exammed using a questionnaireOpen and closed style questions were used The sample compnsed nurses onone elderly care ward and three general medical wards and the sample size was34 The results revealed gaps m knowledge of oral care procedures Inparticular, a lack of assessment and documentation was highlighted However,the nurses mdicated a high level of interest at updating themselves m this areaof nursmg The limitations of this study are discussed

TxrTi»nnTTr"rTnw '® poor A healthy oral status is fundamental for the com-INTRODUCTION ^^^ ^ ^ general well-bemg of tbe pabentgTbe Umted Kingdom Central Council (UKCC) (1992) code Accordmg to Miller & Rubmstem (1987) bospitalizedof conduct for nurses states tbat the nurse sbould 'act pabents often suffer from inadequate or non-existentalways m sucb a manner as to promote and safeguard tbe moutb care and 'since only approximately 50 per cent ofwell-bemg of pabents' smd to ensure tbat no act or omis- tbe populabon receive regular dental care, many pabentssion witbm the nurse's sphere of responsibility is detn- enter tbe hospital with existing dental problems'mental to the condibon of pabents The code also states A pabent with a dry moutb may expenence difficultytbat nurses sbould respond to tbe individual's need for speakmg (Alderman 1988, Seymour 1994), and dry andcare cracked lips can be painful (Cbandler 1991, Seymour

In my climcal expenence, as a ward sister on an acute 1994) Oral problems may also lead to a reduced diet andmedical ward for elderly pabents, oral care is generally a fluid mtake (Hilton 1980, Alderman 1988, Meckstrothneglected area of nursing m terms of assessment and actual 1989, Peate 1993) due to pam (Hallet 1984, Seymour 1994),care given If this is mdeed tbe case, tben many nurses are reduced taste sensabon (Watson 1989, Cbandler 1991,guilty of misconduct accordmg to tbe UKCC document Heals 1993} and difficulty swallowing (Hallet 1984,quoted above Alderman 1988, Seymour 1994) In addibon to exacerbat-

Crosby (1989) believes that a pabent's oral status is a mg oral problems, a reduced diet and fluid intake can affectgood mdex of tbe general standard of care given, implying tbe overall bealtb of a pabent who may already bethat tbe standard of care is poor if tbe pabent's oral status nutribonally compromized as a result of his/her condibon

Tbe pnnciple objecbve of moutb care is 'to maintain tbemoutb m good oral condibon that is comfortable, clean.

Correspondence R Adams, 104 Old Laira Rood, Laim, Plymouth, Devon moiSt and free of lnfBCbon' States WatSOn (1989) In a SbldyPL3 BAB, England of 26 termmally ill pabents on a general medical ward,

552 ® 1996 Blackwell Science Ltd

Knowledge related to oral aire

Hallett (1984) noted tbat 21 of tbem bad badly coatedtongues Twelve of those 21 had obvious fui^al mfecbon,and only two of them were being treated with anbfungaltherapy Neglect in mouth care provision appears, there-fore, to be more tban a local problem Apart from tbeunpbcabons for the pabent in terms of discomfort andthe potenbaily delayed recovery time, tbe mcreasing mci-dence of hbgabon as a result of negligence of care, mterms of tbe UKCC (1992) code of conduct, sbould bebome in mind and act as a pertment reminder for nursesto carry out a tborougb assessment and carefuldocumentabon

Jenkms (1989) argues tbat oral care is one of the basichygiene needs in botb sick and well people He believesthat if oral care is seen by nursmg staff to be of value mpabent care tben accurate and conbnumg assessment isneeded

Tbis researcb pro)ect evolved from my belief tbat tbisassessment is not earned out m pracbce, and tbat oral carepracbce is madequate From my observations of oral carepracbce m tbe bospital envuromnent, pabents' mouthsoften become ulcerated, infected or dry before it is nobcedtbat problems are likely to occur Locally, in tbe medicaldirectorate, tbere does not seem to be any form of assessmgpabents wbo are at nsk of developmg oral problems TbereIS also a lack of provision related to tbe oral cavity on thenursmg admission documentabon used

The theorebcal proposibon formulated was qualifiednurses lack adequate knowledge related to oral health,resultmg m madequate oral care of pabents on medicalwards

LITERATURE REVIEW

In reviewmg the literature related to oral care, severalrecumng topics were noted The different types of equip-ment and solubons used for oral hygiene were, as onewould expect, widely covered m the literature The prac-bce and frequency of moutb care was discussed, emd theuse of oral assessment guides was explored The relevanceof drug therapy affecbng oral health was also covered

Equipment used in oral care

Crosby (1989), Hallett (1984) and Howarth (1977) allmvesbgated the use of hydrogen peroxide, sodium bicar-bonate, lemon and glycerme, cblorbexidme and softpareifBn m oral care Soft paraffin was shown to be effecbvem preventmg dry, cracked lips

Hydrogen peroxide and sodium bicarbonate were foundto be effecbve m removing debns but botb are unpleaseintto taste Turner (1994) pomts out tbat both need to bediluted carefully as superficial bums can result if strongsolubons are used

Even m 1977 lemon and glycerme was found to mibally

stimulate saliva producbon but tben cause reflex exbaus-bon (Howarth 1977), yet this is still commonly usedCrosby (1989) also points out tbat lemon is acidic, causingimtabon and decalaficabon of teeth

Most 'over-tbe-coimter' moutbwasbes contam alcoholand create drying of tbe moutb according to Damelson(1988) Cblorbexidme was found to be 'ideal' (Crosby1989) and 'strongly recommended by dentists' (Hallett1984)

Clarke (1993), Trenter Rotb & Creason (1986) and Goocb(1985) all advocate water as the best and safest moistuns-mg agent for oral care as it 'causes mimmal disnipbon totbe oral ecosystem'

Tbe value of foam sbck applicators m cleaning tbe oralcavity was quesboned by Watson (1989), but it was notedthat they proved to be popular with many nurses andpabents Shepherd et al (1987) and Goocb (1985) alsoclaimed cotton-wool, forceps and swabbed fillers to betmsuitable and meffecbve for cleamng teetb, but of somebenefit m cleamng tbe oral mucosa

Hams (1980) and Howartb (1977) found tbat tbere wasa reluctance amongst nurses to use a tootbbrusb for pabentmoutb care despite tbe demonstrable effecbveness of itsuse Sbepberd et al (1987), Goocb (1985) and Hallett(1984) all recommend a toothbrusb as tbe most effecbveimplement to remove debns

Practice of oral care

Tbe issue of wbo actually cames out tbe procedure willnow be addressed Peate (1993) concluded that most oralcare tasks were delegated to junior nurses

Anecdotal evidence from dentists that moutb care isdescnbed by nurses as an unpleasant task was noted byBoyle (1992) He found tbis to be true m bis own study,as well as a dislike by nurses of bandlmg dentures Oneproblem mentioned by Speedie (1983) was tbat reducedstaffimg levels affect oral care m tbat tbis area of care isgiven less pnonty tban 'tbe more obvious areas of wasbmg,dressmg, toilettmg and feeding'

According to Goocb (1985) debydrated pabents sbouldbave tbeir mouth moistened at least hourly witb water, iceor moutbwash Howartb (1977) states the aims of moutbcare to be mamtenance of comfort, cleanlmess, moisture,and prevention of mfecbon Howartb observed 50 pabentshaving 4-hourly mouth care and it was sbown to be inad-equate Crosby (1989) states that several studies which setout to compare different products used m oral care con-clude tbat tbe 'frequency and consistency in performingoral care' are the vital factors

Peate (1993) found tbat feedback from student nurs^returning to nursmg college after clmical placement sug-gests tbat despite tbe available hterature, mouth care wasperformed without the appbcabon of a knowledge baseAccordmg to Boyle (1992), knowledge and pracbce of

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R Adams

nursing staff is a relabvely unexamined area He identifiedbigb levels of knowledge m oral care from basic traimngbut 'gaps m knowledge in specific areas are evident, par-ticularly concenung the effects of systemic disease anddrugs'

Oral assessment guides

Many authors have argued the importance of lmbal oralassessment of pabents (Speedie 1983, Shepherd et al1987, Crosby 1989, Jenkins 1989, Bamett 1991, Holmes &Mountam 1993) Crosby (1989) states tbat many nursesonly assess the pabent's tongue and that the lack of a toolwith which to assess a pabent's oral status bas bmderedresearch in companng the effectiveness of different mouthcare procedures

Accordmg to Eilers et al (1988) 'numerous authors havedescnbed oral assessment tools witbout applymgreliability and validity data' Tbey looked at 10 differentoral assessment guides wbich were publisbed between1962 and 1983 All tbe assessment guides were found tobe madequate Eilers eta/ (1988) devised their own assess-ment guide Eigbt categones were given to assess voice,swallow, lips, tongue, saliva, mucous membranes, gmgivaand teetb/dentures A numencal score of 1 to 3 was givenfor eacb category, 1 being normal, 2 being mild abnor-mality, and 3 being very abnormal Descnpbons of eachcategory were given with each score The overall assess-ment score was the sum total of tbe eigbt subtotals

Twenty pabents undergomg bone marrow transplantwere used m a study to assess tbe guide (as oral compli-cations are a significant side effect of tbis procedure) Theoral assessment guide was a 'clinically useful tool toobtain, record, emd communicate oral cavity status and todetermme cbanges expected witb stomatotoxic treat-ments' However, no advice was given about likely highnsk scores, or advice about mouth care mtervenbonsNeither did the score take mto account other factors whichaffect oral health such as drug therapy, age and nutnbon

One ofthe earlier assessment gindes proposed by DeWaltm 1975 (cited by Speedie 1983) listed mne structures ofthe oral cavity to be assessed on a score of 1 to 3 'Normal'was scored at 3, and 'very abnormal' was scored at 1 Noguidelmes were given to suggest 'at nsk' scores No addedrisk factors, sucb as underljnng medical condibons, werefeatured m tbis guide

One of tbe more comprebensive assessment gmdes wascited by Hatton-Smitb (1994) tbe Jenkms oral calculatorfeatures a broad range of assessment categones andincludes otber nsk factors to be taken mto account A nskscore IS given witb suggested frequency of care to be givenTbe aims of oral care are also stated

Drug therapy

One important factor wbicb can affect tbe oral status is theuse of medicabons Parbcularly m hospital pracbce, thelikelibood of pabents needmg drugs is mcreased In medi-cal pabents, sucb as tbose on tbe wards studied in tbisresearcb, many lllnesses/condibons are cbromc or long-term, wbicb necessitates on-gomg drug treatment

Crosby (1989) cites one study wbicb found tbat 40% ofadults and 90% of children develop oral compbcabonswben treated with cytotoxic drugs This is not surpnsmgwhen one considers that the nature of drugs used in cancertreatments is to destroy rapidly dividing cells Bamett(1991) states tbat altbougb even careful attenbon to oralbygiene will not avoid stomabbs, it will belp to minimizetbe problem

Crosby (1989) further pomts out tbat in pabents wbo areimmunocompromized, local (oral) mfecbons can becomesystemic and life-tbreatening Steroids increase tbe sus-cepbbility to mfecbon and Watson (1989) notes tbe 'mbibi-tory effect of steroids on tbe bealmg process' in those withoral mfecbons Antibiobcs may reduce the microffora mtbe mouth, allowing harmful microbes access to grow (oneof tbe most common compbcabons bemg candidiasis)

Many drugs bave been found to cause xerostomia anti-depressants, diurebcs, anbconvulsants, narcobc anal-gesics, anbpsychobcs, anbhistemnnes, antibj^ertensivesand anbcholmergics (Bamett 1991) Crosby (1989) andDamelson (1988) both acknowledge tbe xerostomic effectsof oxygen tberapy and oral sucboning, resultmg indecreased salivation and mucosal drying and blistering Inpabents who are prevented from taking oral diet andfiuids, a more rapid development of plaque occurs as thenormal chewmg acbon (which mcreases saliva productionand inhibits plaque growtb) does not take place In viewof tbe potenbaily senous effect drugs have on oral statusthere is a surprising paucity of acknowledgment of this mtbe many joumal arbcles relating to oral care

METHOD

Tbe metbod used m this study was a survey conducted bymeans of a quesbonnaire Tbe target group was trainednurses working m acute elderly care and general medicalwards m a local distnct general bospital This consistedof three general medical wards and one elderly care wardOnly tramed nurses were used m this study as they arethe people responsible for the assessment of pabents,although untrained nurses may also carry out oral hygienefor pabents

Formulating the questionnaire

The quesbonnaire consisted of open questions allowingfr«e responses from respondents, and closed quesbons to

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Knowledge related to oral care

obtam fixed answers Tbe lmbal quesbonnaire consistedof 29 quesbons with room for the respondent to commentif necessary The quesbonnaire was devised to generateinformation in three broad areas personal data, extent ofknowledge and educabon, and current pracbcesQuesbons 1 to 4 asked for personal data qualificaboncategory, type of ward worked on, length of post-qualificabon expenence, and which dubes the nurseworked Quesbons 5 to 29 were designed to establisbmformabon about knowledge relabng to oral care, andcurrent pracbces

Tbe quesbonnaire was worded carefully For example,m asking if tbe nurse uses an assessment tool tbey maylist implements used rather tban a model of assessment

The pilot study

The pilot study was conducted on an acute medical wardfor the elderly and the questionnaires were handed to eachtrained nurse One of the funcbons of the pilot study wasto ensure clanty of wording in the quesbonnaire as it wasnecessary to gam an idea of how people would interpretthe quesbons m the mam study Although the responserate was high the consensus w£is that the quesbonnairewas too long, and the format of tbe questions was restruc-tured to reduce the length of the quesbonnaire The finalquesbonnaire consisted of 26 questions (Table 1)

The main study

The msun study was conducted on three general medicalwards and one elderly care ward The study took place atthe end of January 1995 and all trained nurses were invitedto participate With permission from tbe ward managers,the names of all trained nurses on each ward were takenfrom tbe duty roster so that tbe letters attacbed to tbe ques-tionnaires were addressed personally to each member ofstaff The letter explained wbo the researcher was, whythe study was bemg conducted, and confidenbahty andEinonymity were stressed The nurses were unsupervisedwhen completing tbe quesbonnaire A deadline data wasincluded in the letter, which allowed 2 weeks to completethe quesbonnaire

Thnty-five questionnaires were returned out of the 70issued One of these was mcomplete, therefore the samplesize was 34

RESULTS

Equipment and solutions

Two respondents hsted hydrogen peroxide as being usedand 12 respondents (35 3%) hsted sodium bicarbonate(Table 2) Tbese solubons were not favoured eis beingeqmpment of choice (Table 2) Twelve nurses hsted lano-

lm cream as being available, but only two nurses preferredto use It No otber creams were listed to prevent dry lipsLemon solubon was a popular cboice of equipmentTwenty-two respondents listed it as available and 10respondents listed it as being preferred

Equipments preferred by nurses were lemon solubon,moutbwasb tablets, and sponge swabs in moutbcare traysTen nurses m tbis study menboned tbe use of tootbbnishesand eight menboned toothpaste as equipment of cboice(29 4% and 23 5% respecbvely) Only tbree nurses in tbisstudy listed water as available and being equipment ofcboice

Finally, m lookmg at the overall percentages of tools ofchoice there was no overwhelming favourite — the greatestchoice (mouthwash tablets) was only favoured by 12respondents (35 3%)

Practice of oral care

Ten respondents agreed with the claim tbat untrainednurses carry out most moutb care and 10 disagreedHowever, tbe other 14 respondents stated tbat trained anduntrained nurses carry out oral care equally Altbougb itcannot be concluded tbat untrained nurses perform mostmouth care, it is clear that they do carry out a substanbalamount of oral care

The majority of nurses m this study work some mghtduties (23 out of 34) Sixteen ofthe total respondents statedthat mouth care frequency should vary None ofthe repliesstated oral care frequencies of less than 6-hourly However,this quesbon asked how often mouth care should be per-formed, not how often it is performed m pracbce, 82 4%of respondents believed that mouth care is not performedas often as it should be Nineteen nurses ldenbfied lack ofbme as a problem bindermg oral care, m addibon ninerespondents specifically menboned reduced staff levels(Table 3)

Oral assessment guides

Tbere are a number of oral assessment guides available,but currently none are used for patients m tbe medicalwards studied Most nurses (618%) felt that not allpabents should be assessed on admission to hospital Tbeother 38 2% of respondents felt tbat all pabents should beassessed

Two nurses stated that all pabents are assessed onadmission It should be noted tbat tbe quesbons were notdirected at tbe mdividual respondent unplymg tbat he/sbeshould carry out tbe assessment, but tbey aimed to estab-lisb wbat was generally occurrmg in pracbce and wbat tberespondents believed sbould occur

Table 4 sbows the types of pabents wbo bave oral assess-ment on adimssion, 23 5% of tbe respondents stated tbatno pabents are assessed on admission. Of tbe 10 different

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Tdtkl Research — ——questionnaire l Are you (a) RGN (b)EN

2 Do you work(a) Internal rotation (b) Night duty (c) Day duty

3 Do you work on (a) General medical ward (b) Elderly care ward4 How long bave you been qualified''

(a) up to 1 year (b) 1-3 years (c) 4-6 years (d) over 6 years5 Do you feel all patients should have assessment of their mouth on admission''

(a) yes (b)no Please comment if necessary

6 Are all patients mouths' assessed on admission'' (a) yes (b) no7 If any patients are assessed on admission please specify which ones

8 What factors do you look for to indicate a healthy mouth''

9 Do you use an assessment tool/guide for mouthcare'' (a) yes (b) no10 If you answered yes to question 9, please name assessment tool used11 Who IS the person tbat cames out most moutbcare on your ward (dependent patients)''

(a) trained nurse (b) untrained nurse12 How often should moutbcare be performed''13 Mouthcare is always done as often as it sbould be (please tick answer)

(a) agree (b) disagree14 Are there any problems which hinder you from performing mouthcare''

(a) yes (b) no15 If you answered yes to question 14, please list problems16 Are untrained nurses taught moutbcare'' (a) yes (b) no17 If you answered yes to question 16, wbo teaches them''18 Did you receive instruction about moutbcare dunng your training''

(a) yes (b) no (c) can't remember19 Have you received any mouthcare instruction since qualifying''

(a) yes (b) no (c) can't remember20 Do you believe tramed nurses need to receive updates on moutbcare''

(a) yes (b) no21 If you answered yes to question 20, how often should the updates be''22 Which pieces of equipment (including solutions) do you use for oral cleaning on your ward''

23 Which equipment and solutions do you prefer to use for oral cleaning''

24 Are you aware of any drugs which adversely afect moutb health''(a) yes (b) no

25 If you answered yes to question 24, please list drugs

26 Do you feel it would be useful to use an oral assessment guide''(a) yes (b) no

Please add any further comments you may wish to make, using tbe back of tbe page if necessaryThank you for your time

categones of pabents tbe respondents felt should be normal swallow, watery saliva, moist tongue, smootb lips,assessed, all but one of tbe nurses listed only three or less pink lips, moist lips, dentures fr«e of debns, and absenceof tbe categones (Figure 1) of candidiasis

In loolung at wbat nurses see as healthy mouth lndi- It is evident from some of the comments received thatcators (Table 5), 64 7% (22 nurses) listed moist mucosa, oral care is an important but neglected area of nursmg For58 8% (20 nurses) listed pmk mucosa, and 50% (17 nurses) example, one nurse stated tbat the use of an assessmentlisted clean teeth Less tban balf of tbe nurses in tbis study guide would make nurses more aware of oral bygiene, andlisted a pink tongue (44 1%), and only 8 8% menboned a anotber nurse felt tbat oral care is as important as pressuremoist tongue Tbe otber categones which are not sbown area careon tbe chart bad five or less responses They were voice. Figure 2 shows that apart from one respondent who

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Table 2 Equipment used on wards and respondents' pteferredchoice of equipment

Eqmpment named

Number of nursesciting equipmentused on wardsn %

ToothbrushToothpasteWaterSponge swabsHydrogen peroxideLemon solutionLemon swabsSodium bicarbonateMouthwash tabletsLanolin creamSpatulaMouthcare packArtificial salivaGauze and fingerGhlorbexidine moutbwashSuctionNo preference

1283

242

223

122512

814

5333

(35 3)(23 5)

(8 8)(70 6)

(5 9)(64 7)

(8 8)(35 3)(73 5)(35 3)(23 5)(412)(14 7)

(8 8)(8 8)(8 8)

Not applicable

Table 3 Reasons for lack of care

Reasons identified Nurses (n)

Lack of tuneUncooperative patientReduced staff levelsLack of equipmentLack of knowledge

1917952

Respondents'preferredchoice ofequipmentn %

1083

101

1022

1224514304

Type of patient Responses (n)

StirokeReduced bydrationMouth breathingTerminally illGonfused patientUnconsciousElderlySelf-neglectMalnourishedOral problemsNone

13 (38 2%)7 (20 6%)1 (2 9%)8 (23 5%)2 (5 9%)7 (20 6%)2 (5 9%)4 (11 8%)1 (2 9%)4(114%)8 (23 5%)

(29 4)(23 5)

(8 8)(29 4)

(2 9)(29 4)

(5 9)(5 9)

(35 3)(5 9)

(118)(14 7)

(2 9)(118)(8 8)

(118)

Table 4 Number of responses by type of patient assessed

'0 '2Responses (n)

•4

Figure 1 Number of responses by number of nurses (of the 32nurses wbo stated tbat not all patients are assessed onadmission)

Table 5 Number of responses by healthy mouth mdicator

Healthy mouth indicators

Moist mucosaPmk mucosaGlean teethPink tongueAbsence of halitosisAbsence of ulcersHealthy gingivaWell-fittmg dentures

Responses (n)

22 (64 7%)20 (58 8%)17 (50%)15 (44 1%)11 (32 4%)10 (29 4%)10(29 4%)

7 (20 6%)

'1 '2 '3 '4 '5 '6 '11

Figure 2 Number of responses of healthy mouth indicators bynumber of respondents

listed 11 factors to look for m a healthy mouth, tbe rest ofthe respondents were able to list only six or less factorsThe majonty of nurses were able to list only four or lessfactors

Drug therapy

A laj^e number of respondents were aware of drugeffects — 79 4% in total All of tbe nurses wbo stated tbattbey were aware of drugs affecting oral bealtb were ableto ldenbfy at least one drug However, the list of drugsobtamed bom respondents was not exbausbve (Table 6),and apart from 22 nurses (64 7%) wbo stated anbbiobcs

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Table 6 Number of responses accordmg to drug type or name

Drug type or name Nurses (n)

AntibioticsInhalersIronGytotoxicsSteroidsNarcoticsSyrupsDiureticsAntidepressantsAntihistammeHyoscmeAntiparkinsonPhenytoin

22 (64 7%)5 (14 7%)1 (2 9%)

12 (35 3%)1 (2 9%)1 (2 9%)3 (8 8%)1 (2 9%)1 (2 9%)1 (2 9%)4(118%)1 (2 9%)3 (8 8%)

as a drug type included in this category, tbere was a poorresponse rate to tbe rest of the drugs named

The lack of knowledge m this area may be deduced fromtbe fact that no respondents hsted more than four drugsaffecting mouth health (Figure 3)

DISCUSSION

From the results of this study, it appears that there is alack of general knowledge relabng to oral health whichone would expect qualified nurses to have Bamett (1991)and Miller & Rubmstem (1987) claimed tbat altbougbnurse training includes oral care, it is rarely taught bypeople with specialist knowledge in this field

This study asked the respondents if they had receivedoral care instrucbon m training and/or after qualifyingMost nurses m eacb category of years smce qualifying (28nurses) bad received instrucbon dunng tbeir training(Table 7) Twenty-nine nurses had not received instructionsince qualifying (Table 8), and none ofthe five nurses whohad not had mstrucbon during trammg had receivedinstrucbon after qualifying It should be noted, bowever,that quality and quantity of instrucbon was not identified

'0 •2 '3Responses (n)

Table 7 Number of respondents who had received instructiondunng training by length of time qualified

Gan'tInstructed Uninstructed remember Total

1107

1634

Table 8 Number of respondents wbo had received instructionsince qualifying by length of time qualified

Under 1 year1-3 years4—6 yearsOver 6 yearsTotal

174

1628

23

5

Under 1 year1—3 years4-6 yearsOver 6 yearsTotal

Instructed

224

Uninstructed

1

105

1329

Gan'tremember

11

Total

1

107

1634

Figure 3 Number of drug responses given by number ofrespondents

As 31 nurses (91 2%) claimed that trained nurses on tbewards teach untrained nurses mouth care procedures, thishas serious ramifications if the trained nurses lack loiowl-edge themselves

Tbe trainmg wbicb ENs received was different to RCNtraining, therefore a senes of comparisons was madethroughout the results secbon There was found to be nosignificant difference between RGN emd EN responses

Most nurses seemed to agree that they need to haveupdates m oral care (85 3% of respondents) Half of therespondents (50%) stated that updates should take placeevery 6 months to a year In view of the difficulty staffsometimes have in attending study days, and the turnoverof staff in health care, it would seem appropnate to runupdates annually Staff should also be encouraged to keepup to date with current researcb findings published mjournals

Scbon (1991) believes that reflecbng on one's own prac-tice IS one way of reducing the theory-pracbce gap, as thepracbtioner also expenences the research role in pracbceInterestingly, one of the nurses in this study believed thatupdates in oral care are not necessary 'if we quesbon andreflect on pracbce'

Addressmg the issue of oral care pracbce on the wards,more nurses menboned tbe use of tootbbrusbes and tootb-paste as equipment of cboice (29 4% and 23 5% resi)ect-lvely) than m a study conducted by Rak & Warren (1990)(12 5% and 10% respecbvely) It is interesbng to note thatalthough 35 3% of nurses stated that tootbbrusbes wereused on tbe wards, 5 9% of tbese nurses did not prefer touse a tootbbrusb m carrymg out oral care

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Clarke (1993) and Goocb (1985) recommend water as tbebest moistunzmg agent for oral care, yet tbis was onlymentioned by tbree nurses m tbis study

Peate (1993), Boyle (1992) and Bamett (1991) all claimedthat untramed nurses carry out most moutb care Altboughit cannot be concluded that untramed nurses perform mostmoutb care, it is clear tbat they do carry out a substanbalamount of oral care

Speedie (1983) noted that reduced staff levels meantthat otber areas of care had pnonty over oral care Lackof bme and low staffing levels were specifically hsted byrespondents as being problems m tbis study

McCord & Stalker (1988) believe that oral care sbouldvary according to mdividual needs Individual care cannotbe given unless mdividual needs are assessed properlyMany pabents on medical wards have chest problems andit IS surprising that these pabents did not feature m theresponses I believe that an oral assessment guide wouldbe a useful tool to assess individual needs of pabents andthe nsk of oral problems

Crosby (1989) claimed that most nurses only assesspabents' tongues, however, less than half of the respon-dents listed a pmk tongue on the assessment of oral cavityMoist and pmk mucosa were the two healthy mouth mdi-cators which were listed most commonly by respondents

From the literature reviewed, it can be seen that drugscan bave adverse effects on oral bealth, many of thesedrugs are frequently used None of the literature revieweddocumented any studies related to nurses' knowledge ofadverse drug reacbons affecting oral health

Surpnsingly no respondents menboned oxygen therapy,which IS frequently used on medical wards and has anobvious drying effect

Limitations

Firstly, as tbe sample size was small (34 valid responses),the 36 missing responses may have caused major alter-ations m the results either posibvely or negabvely, if thosenurses had parbcipated

Secondly, due to tbe limited bme m which the researchwas undertaken, a quesbonnaire was used to obtain thedata However, had the respondents been interviewed, itwould have been possible to ensure tbat the nurses under-stood the quesbons, and it would have been possible toclarify both the research quesbons if necessary, and thenurses' responses

Finally, this study was specific to elderly care andgeneral medical wards The general medical wards do nothave direct emergency admissions (although they do havepabents admitted from outpabent departments andbooked admissions) The emergency admission weirdswere not mvolved m this study as the pabents areintended to be tbere for only 24-48 hours before bemgtransferred to otber wards, and m my expenence most

moutb care problems eitber develop and/or are nobcedafter tbis bme However, tbis was not taken mto accountm the wording of the quesbons, and m retrospect itwould have been useful to mclude tbe admission wardsin tbe study

CONCLUSION

Oral care is pivotal to pabent well-bemg and comfort, tbeprevention of mfecbon, and maintenance of nutnbonalstatus

Tbe nurse bas a duty of care to pabents tbe UKCC codeof conduct (1992), and standards for record keepmg docu-ments (1993), pomt out the standards and responsibilitiesof the nurse In my expenence, the amount of documen-tation recorded does not reflect the significance of oralhealth problems

In view of tbe results of tbis study, it is my opinion tbatan oral assessment guide would improve awareness of tbeimportance of mouth health, and therefore more assess-ment would take place and the oral assessment guidewould provide a facility for documentation

It IS impossible to evaluate tbe actual quality of caregiven without observabon of practices However, nursesin this study generally felt that oral care is an importantarea of nursing, and a keen mterest to keep updated m thisarea of nursmg was noted

The results of this study support the theorebcal prop-osition that qualified nurses lack adequate knowledgerelated to oral health, resulting m madequate oral care ofpabents on the medical wards involved m this research

Acknowledgement

I would like to thank Linda Meddick, who was my researchsupervisor dunng this research

References

Alderman G (1988) Oral hygiene Nursing Standard July 9, 24Bamett J (1991) A reassessment of oral healthcare Professional

Nurse Sept, 703-708Boyle S (1992) Assessing moutb care Nursing Times 88(15),

44-46Ghandler J (1991) Tabbner's Nursing Care Theory and Practice

2nd edn Gburcbill Livingstone, LondonGlarke G (1993) Moutb care and tbe hospitalized patient Bntish

Joumal of Nursing 2(4), 225-227Grosby G (1989) Metbod m moutb care Nursmg Times 85(35),

38-41Damelson K (1988) Oral care and older adults Joumal of

Gerontological Nursing 14(11), 6-10Eilers J , Berger A & Petersen M (1988) Development, testing, and

application of the oral assessment guide Oncology NursingFomm 15(3), 325-330

Gooch J (1985) Mouth care Professional Nurse Dec, 77-78

© 1996 Blackwell Science Ltd, Journal of Advanced Nursing, 24, 552-560 559

R Adams

Hallett N (1964) Mouthcare Nu»ing A6m7rlS«(21), 31-33Hams M (1980) Tools for mouth care Nursmg Times Fab,

340-342Hatton-Smith G (1994) A last bastion of ntualised practice''

Professional Nurse Feb, 304-308Heals D (1993) A key to well-being oral bygiene in patients with

advanced cancer Professional Nurse March, 391-398Hilton D (1980) Oral bygiene and mfection Nursmg Times July

17, 1270-1272Holmes S & Mountain E (1993) Assessment of oral status evalu-

ation of three oral assessment guides Joumal of ClinicalNursing 2, 35-40

Howarth H (1977) Mouth care procedures for the very ill NursingTimes, March, 354-355

Jenkins D (1989) Oral care in tbe IGU an important nursing roleNursmg Standard 4(7), 24-28

McGord F & Stalker A (1988) Brusbmg up on oral care NursingTimes 84(13), 40-41

Meckstroth R (1989) Improving quality and efficiency m oralhygiene Joumal of Cerontological Nursmg 15(6), 38-42

Miller R & Rubmstem L (1987) Oral health care for hospitalizedpatients the nurse's role Joumal of Nursing Education 26(9),362-366

Peate I (1993) Nurse-admmistered oral hygioae m the hospi-talized patient Bntish Joumal of Nursing 2(9), 459-462

Rak O & Warren K (1990) An assessment of the level of dentaland mouthcare knowledge amongst nurses working with elderlypatients Community Dental Health 7, 295-301

Scbon D (1991) The Reflective Practitioner Avebury, HantsSeymour R (1994) Identifying and treatmg ADRs of the mouth

Prescnber Feb, 63—66Shepherd J , Page G & Sammon P (1987) Tbe mouth trap Nursing

Times 83(19), 25-27Speedie G (1983) Nursology of mouth care preventing, comfor-

ting and seekii^ activities related to moutb care Joumal ofAdvanced Nursmg 8, 33-40

Trenter Roth P & Graason N (1986) Nurse admimstered oralhygiene is tbere a scientific basis'' Joumal of Advanced Nursing11, 323-331

Turner G (1994) Oral care for patients wbo are termmally illNursing Standard 8(41), 49-54

UKGG (1992) Code of Professional Conduct 3rd edn UKGC,London

UKGG (1993) Standards for Records and Record KeepingUKGG, London

Watson R (1989) Gare of tbe moutb Nursing 3(44), 20-24

560 © 1996 Blackwell Science Ltd, Joumal of Advanced Nursing, 24, 552-560