Nursing and Geriatric Oral Care

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Nursing and Geriatric Oral Care

Summary

Nurses make up the largest workforce within healthcare around the world and are in a strong position to influence the oral health of older people. However, oral care for older people is poorly understood and often unrecognized as being an important component of care by many nurses despite the profession recognizing that oral care is often a nursing responsibility. Nurses themselves can underestimate the impact that their care has in transforming the lives of older people by reducing pain, assisting communication and socialization, improving appetite and the enjoyment of food and drink, enhancing self esteem, identifying and referring potential problems (Clay 1999).

The scope of nursing practice

A definition of nursing helps to outline the scope of influence that nurses could have in this important area of care:

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.

(International Council of Nurses www.icn.ch)

In ideal circumstances, nurses in all the areas of practice would have a working knowledge of the oral care problems commonly experienced, the skill to assist the promotion or maintenance of health and effective prevention of disease, and an attitude that fosters respectful partnerships with older people.

For example, nurses working in community settings providing supportive care in the homes of older people might find themselves teaching and demonstrating tooth brushing skills and denture care to carers, offering advice about the effects of disease processes and drug therapy on appetite and dryness in the mouth, discussing how changes in physical ability can be managed in order to facilitate oral health, helping clients to choose tooth brushing aids that help them to continue caring for their own oral health, providing verbal and written information about services and professionals that can contribute to their care, and collaborating with other health professionals associated with care delivery.

Nurses in hospital settings looking after older people who are not able to look after their own oral care needs, or whose oral care needs are complex as a result of underlying pathologies would use their knowledge and skills in a different way. Here the aims of oral care might be to keep the different surfaces of the mouth clean, moist, intact, and free of infection and pain, so that oral function is enhanced or maintained. This could involve nurses assessing and documenting the current state of the patients oral health, planning care to address the needs of each person, delivering whatever "mouth care" was required at specific time intervals, evaluating how effective the plan of care had been, and altering the plan of care accordingly.

Mouth care might involve brushing a person's teeth and dentures after every meal for a few days, and making sure that drinks are available and accessible to patients. It could involve care over lengthy periods while a person is rehabilitating after a stroke, in which case care plans at different times might involve the input of dieticians, speech therapists, occupational therapists, pharmacists, medical/dental colleagues, and the patient and their family/carers. One early set of priorities might be to ensure food debris and plaque are removed after each meal using a small headed tooth brush and a mouth wash, and that the lips and skin are protected from the effects of saliva escaping from the mouth by using a lip salve.

A challenge to nursing is that of equipping itself with the knowledge, skills and attitudes required to interact with older people in a way that promotes oral health within the context of contemporary health care environments. There are major barriers to achieving this, including those within nurse education and nursing practice.

Barriers within Nurse Education

Issues within nurse education include: the availability and accessibility of quality teaching resources and materials; teaching and practicing core skills; applying research-based care in practical areas.

For instance, there are only a few quality texts written for nurses, by nurses or dentists, that include material dedicated to this area of care. There are many references about oral care in nursing journals, many of which are relevant and applicable to the care of older people. However, most nurses find it difficult to access, read, understand, and apply findings from journal articles (Bryar et al 2003).

Two texts that come highly recommended by gerontological nurses and nurses with a passion about oral care in the United Kingdom (UK) are those by Clay (1999) and Mallett & Dougherty (2000). They contain 15 pages of text that cover: dental health, changes in the oral cavity during the ageing process, the common problems that older people might develop, the effect that these can have on nutrition and wellbeing (for example, xerostomia, dental caries, gingivitis, periodontitis, thrush, and oral cancers), problems with dentures, sores, and lesions. They also include an outline of the importance of assessing the oral cavity, together with the processes involved in performing tooth brushing, rinsing the mouth, cleaning and storing dentures, and caring for dry and cracked lips. The Mallett & Dougherty (2000) text, which is often found in practice settings, lists and describes the oral care agents that are used in The Royal Marsden Hospital for mouth care (i.e., chlorhexidine gluconate, fluconazole, sucralfate, nystatin, fluoride, and artificial saliva).

The information in these texts provides readers with an appreciation of what might be required in some situations but it falls far short of the type of information and practice required to begin to support the development of confident and competent practitioners.

For those who are passionate about improving oral care for older people through the education of nurses there are a number of organizational, managerial and attitudinal issues to negotiate. For example:

It might be difficult to convince course directors that oral care should be included within schedules that are already crowded
There may not be a staff or faculty member who feels confident enough to teach the subject
There may not be links with dental schools, community dental practitioners or dental hygienists to advise and assist in teaching
Class sizes may be too big to accommodate in one session
Teaching rooms may not have sink facilities
A budget may not be available for consumable equipment
There may not be support staff available to do repeat teaching sessions
Nurse educators in specialist fields may not feel confident to help students apply their learning to different client group needs

However, demonstrating and practicing the basic skills of recognizing, assessing and recording the needs of clients with a healthy mouth, together with plaque disclosure, effective tooth brushing, and how to care for dentures, can be done in less than ideal environments.

Students often appreciate the learning that takes place through practical-based teaching. Such sessions can prompt exciting discussions about real client needs and problem solving in practice. They also provide the opportunity for students and carers from diverse backgrounds and disciplines to explore and overcome their own barriers to assessing and performing oral care. For example, many nurses and carers are afraid of harming clients, and some are physically revolted by the thought of brushing the teeth of others, or of having their own teeth brushed by someone else.

In Hull, UK, I became a victim of my own success in relation to promoting oral health teaching, and was asked to speak to many groups of students about oral care. Eventually I sought sponsorship to produce a computer assisted learning package to cover core information (Pearson & Chin 1997). Students were asked to spend around 45 minutes to work through this package before teaching sessions with myself so that we could use our time together practicing the assessment, planning, delivery and evaluation of oral care. The impact of this type of teaching does need to be evaluated and consolidated in different practice areas if it is to become part of the repertoire of nurses.

Barriers within nursing practice

The implementation of research findings in nursing practice is no different than in other professions in that there is a considerable time lag between knowledge generation and implementation. In many hospital settings, it is difficult to deliver quality oral care to adults in general, and older people in particular (Pearson and Hutton 2002). Reasons for this include:

The culture of the organization may not promote change
Nurse leaders may not be aware of effective practice
Care may be based on tradition
The assessment of oral care needs may not occur
The documentation of oral care needs may not be documented
Tooth brushes, denture containers, etc. may not be supplied or available from relatives
Ineffective tools like foam swabs may be the only tools available
The time available for care within each shift may be short
Oral care needs may go unnoticed and unreported
Staff may not know how to assess, record, plan, deliver and evaluate care
The mix of staff (registered vs untrained) may be inadequate for teaching and practice development
Staff may be unaware of the risks of not providing effective care
Patients may be in hospital for short periods of time

Drivers of change

Within nursing, it is heartening to know that there are some strong initiatives to develop academics, practitioners and researchers who can enhance the care that older people receive. For example, in the United States of America (USA) the John A Hartford Foundation is supporting five new "centers of geriatric nursing excellence" that will receive about $1.3 each in the first 5 years of this millennium. In the UK, The Royal College of Nursing has developed a gerontological nursing program that integrates all of its work on policy, research, education and practice development initiatives that are important to working with older people.

Important drivers to the improvement of care in many practice settings include the valuing of research knowledge at organizational levels, more frequent interdisciplinary interaction, using a philosophy of care that values older people (Clarke, Hanson and Ross 2003), and the impact that complaints about oral care have on making this care visible to managers and policy makers.

The evidence-based practice movement drives and fuels many of the policies and financial decisions of health care systems in parts of our world. Some authors have prompted us to think more broadly when we look at the kind of evidence that we use when making decisions about care so that we aren't limited to only valuing Randomized Controlled Trials [RCTs] when seeking to develop practice.

Different research approaches contribute to different aspects of the development of oral care for older people in practice settings. For example, RCTs have generated knowledge about the effectiveness of treatments, tools (Pearson & Hutton 2002), and the effect of teaching programs on the oral health of older people. Action Research and Participative Research approaches have been used to identify processes and barriers to change in practice setting, and to empower staff to own and develop their own practice. Using biographical approaches to connect carers with the lives of older people can reorient care from being "a job to get done" to that which values and understands the needs of older people (Clarke, Hanson and Ross 2003).

Finally, changes in care are driven by policies that seek to challenge ageist practices in healthcare (Department of Health 2001a & b), and by the participation of users and user groups in developing services.

Summary

Caring for the oral health care needs of older people has the potential to improve the lives of a growing number of people in the world to a significant degree. There are many challenges to nurses making a valuable contribution to this area of care. Many of these challenges could be addressed more effectively if closer relationships between the nursing and dental professions were established and fostered.

A strategy for the future might include:

Identifying the oral health care needs of older people as perceived by older people themselves through the establishment of partnerships between users and specialist health practitioners
Capturing the nature and degree of improvements that interventions can bring to the lives of older people
Articulating the needs for, and benefits of, oral health care to policy makers, users, nurses and carers
Mapping the existence of, and potential for, dental/nursing partnerships
Identifying and disseminating current best practice
Capitalizing on new teaching technologies to support the education and practice of health professionals and carers by using practice-based, problem solving, person-centered approaches
Promoting the need for developing oral care through lobbying national and international leaders and organizations that are affiliated to the needs of older people
Supporting practice at local levels through understanding and supporting practitioners who are working under difficult circumstances
Establishing a multidisciplinary and user participatory web-based forum for disseminating information and practice development initiatives

References

Bryar R M, Closs, S J, Baum G, Cooke J, Griffiths J, Hostick T, Kelly S, Knight S, Marshall K, & Thompson D R (2003). The Yorkshire BARRIERS Project: diagnostic analysis of barriers to research utilisation International Journal of Nursing Studies 40, 73-84.
Clarke A, Hanson E J, & Ross H (2003). Seeing the person behind the patient: enhancing the care of older people using a biographical approach Journal of Clinical Nursing 12(5) 697-706.
Clay M (1999). Neglected areas: Dental health, foot care and skin care. Chapter 7 in Heath H & Schofield I (editors) (1999) Healthy Ageing Mosby London ISBN 0 7234 2952 9 This text is an adaptation of a US text: Ebersole P & Hess P 1994 Towards healthy aging: human needs and nursing response. Mosby 4th Edition.
Department of Health (2001a). National Framework for older people - modern standards and service models. London, Department of Health.
Department of Health (2001b). Caring for Older People: A Nursing Priority. Integrating knowledge, practice and values. Report by the Nursing and Midwifery Advisory Committee, London, Department of Health.
Mallett J & Dougherty L (editors) (2000). Mouth Care in The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Chapter 24 pp 360-367, 5th Edition, Blackwell Science, Oxford.
Pearson L S & Hutton J L (2002). A controlled trial to compare the ability of foam swabs and toothbrushes to remove dental plaque. Journal of Advanced Nursing. 39, (5), 480-489.

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