Behind the screens: care staff observations on delivery of oral health care in nursing homes

Objective: To identify qualitatively carer staff attitudes, practices and clinical comments related to oral health care of functionally dependent nursing home clients. Design: Open-ended questions included in a longer quantitative questionnaire. Setting: 22 randomly selected nursing homes in the Bristol area. Subjects: 416 carers employed in these homes. Results: The majority of carers thought that clients had a right to good oral health, accepted the carers' role in helping clients with oral and denture hygiene, but recognised that oral health care provision was deficient. However, some carers believed oral health care to be solely the clients' responsibility despite high disability levels. Main barriers to providing oral health care were low prioritisation of oral health by nursing management, lack of co-operation from cognitively impaired clients, and lack of training. Carers were critical of homes' lack of arrangements for routine professional dental cheeks, lack of commitment to staff training, low standards of oral health care by colleagues, and lack of provision of oral hygiene aids and cleansing materials for clients. Many responses indicated ways in which nursing home oral health care could be improved. Carers reported contrasting experiences of dental treatment, and deplored recent decreased availability of subsidised dental care. Conclusions: Carers' generally positive attitudes towards clients' oral health care should encourage health educators. Insights gained from qualitative data can help to identify the less obvious causes for poor oral care delivery, which can then be addressed in education and training initiatives in nursing home settings.     

Development of an index to measure oral health care priority among nursing staff

Objective: To develop an index to measure oral health care priority among nursing staff. Background: Nursing staff, working on hospital wards, at nursing homes and at other facilities, have to deal with oral health care and there are many reports about the low priority that is given to oral health care by nursing staff. It is difficult to measure oral health care priority among nursing staff. A Dental Coping Beliefs Scale (DCBS) index was used in an intervention study and was found to be easy to handle but did not have the ability to reveal significant differences in small study samples. A development process consisting of added items and item numbering by chance was carried out. During this process, different nursing staff test groups were used. The aim was to develop an oral health care priority index that can be used both on hospital wards and at special facilities to measure oral health care priority among nursing staff over time and between groups. Material and methods: Nursing staff at both special facilities and hospital wards and nursing students. Results: It was found that the index, the nursing DCBS, was more stable compared with the version that was used in the initial intervention study. It was also noted that its ability to discriminate between the items was improved. Conclusion: The nursing DCBS index is a suitable tool for use in further studies where the aim is to measure how different nursing staff groups give priority to and allocate responsibility for oral health care, even where study samples are small.     

Health care professionals' perspectives on oral care for long-term care residents: nursing staff, speech-language pathologists and dental hygienists

doi: 10.1111/j.1741‐2358.2011.00513.x Health care professionals’ perspectives on oral care for long‐term care residents: Nursing staff, speech–language pathologists and dental hygienists Background: Oral health has been identified as a key factor in general health and systemic disease in long‐term care populations. To optimise oral health of this population, it is important to understand the oral care perspectives held by health care professionals involved in oral care provision. Objectives: To explore perspectives regarding oral care held by nursing staff, speech–language pathologists (SLPs) and dental hygienists (DHs) in long‐term care institutions and to understand how their perspectives impact activities and processes involved in the delivery of oral care. Methods: A focus group methodology was utilised. Separate focus groups for each targeted profession were held. Transcribed data were analysed using constant comparative analysis. Results: Daily oral health maintenance and monitoring was considered a role of nursing staff. SLPs and DHs have roles focusing on advocacy, education and supplemental care. Social factors motivate nursing staff to provide oral care, whereas factors related to the general health consequences of poor oral health underlined the motivations of SLPs and DHs. Conclusions: Education and training initiatives incorporating social aspects of oral health may be more effective for motivating nursing staff than approaches emphasising physical risk factors. Organisations can foster environments that support collaboration and communication amongst the members of multidisciplinary teams in order to promote oral health as a priority.     

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 invoked 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.     

The dental awareness of nursing home staff in Singapore - a pilot study

Objective: The aim of this pilot study was to assess the oral health knowledge among staff working in a local nursing home managed by a voluntary welfare organisation. Method: A self‐administered questionnaire was completed by 53 nursing staff working in a home with 270 residents. The questionnaire was structured to assess the staff's knowledge of dental caries, periodontal disease and the care and use of dentures. Results: 99.6% of the respondents felt that oral health care of the elderly was very important. However, only 45.3% of them attributed the cause of dental caries to the frequent intake of sugar. Bacteria in dental plaque was identified by 88.7% of them as the main cause of periodontal disease while 96.2% of them indicated that dentures should be cleaned at least once a day and rinsed after every meal. Conclusion: The staff of this nursing home demonstrated positive knowledge of periodontal disease and denture care. However, their knowledge of dental caries revealed substantial room for improvement. This could signal an area for future staff training and development. Such efforts would help establish a team of caregivers who can improve the oral health and quality of life for residents in the nursing home.     

Oral health care issues in aged care facilities in Western Australia: resident and family caregiver views

Objective: To investigate resident and family perceptions and attitudes towards oral health care and access to dental services for aged care facility residents. Method: Focus groups and individual interviews with residents and family caregivers were conducted at aged care facilities in the Perth Metropolitan Area, Western Australia. Results: There were 30 participants from twelve aged care facilities (21 residents and nine family caregivers). Five focus groups comprising both residents and family caregivers were conducted in addition to three face‐to‐face interviews with residents. Both groups considered oral health very important to overall health and quality of life. Family caregivers noted a lack of dental check‐ups and specialised professional oral care, particularly in high‐care facilities. Low care residents were more likely to have regular dental check‐ups or dental treatment and off‐site dental visits were straightforward due to their mobility and family member assistance. Family caregivers noted time limitations and lack of expertise in oral health care amongst staff in high‐care facilities, and the challenges of maintaining oral care for residents with poor mobility or cognitive impairment. It was considered important that staff and management liaise with family caregivers and family members in provision of oral care. Conclusion: Regular oral care, assessment and treatment were considered limited, particularly for residents in high care. There is a need for comprehensive, ongoing oral health programmes involving appropriately trained and empathetic dental health professionals and staff to improve oral health care in Perth’s aged care facilities.     

Treatment of residents in 74 nursing homes: the opinion of caregivers

This study is based on the outcomes of the program "Privacy In Nursing Homes" that has been initiated by the Dutch Department of Health in the late 90's. In this study, personnel of 74 nursing homes were asked to reflect on the way they treat residents. The attitudes of personnel were measured with a questionnaire that contains 80 propositions about their behaviour towards residents. The propositions can be reduced to five factors: kindness, structural environment, control, freedom to choose, and respect. First, we give the general results on these five factors. After that we give insight in the correlations between the five different aspects of treatment and the results of regression analysis. The general conclusion is that the behaviour towards residents in nursing homes at the beginning of the 21st Century is far from optimal. Residents most notably lack personal freedom and control over their received care and their way of living. This result is especially worrying because client conformed care has been an important point of attention for some time now. Another important conclusion is that the care for residents has a positive relation with the mangement policy of an organization and so, it is possible to improve the care.     

The perceived importance of appearance and oral function,comfort and health for severely demented persons rated by relatives,nursing staff and hospital dentists

Dental health is an aspect of the quality of life. Oral treatment goals for, the severely demented and the benefits of oral treatment are complex issues. Severely demented people can neither express their wishes nor make rational decisions about oral care. Acting “in the best interests” of a demented person who refuses or does not understand the purpose of treatment depends on what perspective and treatment priorities the advocate has. For oral treatment of a demented person the advocate may be a relative, a member of the ward staff or a hospital dentist. In a structured interview, the relatives of demented patients in a Stockholm hospital and members of the nursing staff were asked to rate the importance of goals for dental care. These ratings were also recorded for hospital dentists. In this study there was agreement on the importance of freedom from oral pain and fear of aspiration. Nursing personnel gave priority to aspects of good care such as being able to chew and enjoy eating. Relatives were also concerned with social behaviour and communication such as fresh breath, normal speech, and normal appearance. The ratings by the hospital dentists were generally lower which might reflect professional awareness of the limitations of treatment success implied by cognitive impairment.     

Attitudes to and knowledge about oral health care among nursing home personnel--an area in need of improvement

doi: 10.1111/j.1741‐2358.2011.00562.x
Attitudes to and knowledge about oral health care among nursing home personnel – an area in need of improvement Background: In 1999, a dental reform became law in Sweden that regulated both dental care to dependent individuals and training in oral health care for nursing home personnel. Substantial resources have been channelled into these efforts, but the outcome of these efforts has not been evaluated. The aim of this study was to explore attitudes to and knowledge about oral health care among nursing home personnel more than 5 years after the law was adopted, that being 2005. Methods: A total of 454 individuals employed at nursing homes answered a questionnaire of 16 multiple‐choice items concerning attitudes to and knowledge about oral health care. Results: Eighty‐nine per cent considered oral health care to be an important part of good nursing. The answers indicated problems, however, when it came to its implementation and knowledge, and 35% stated that they had had no formal education in oral health care. Conclusions: Despite generally positive oral health care attitudes, it is important that oral health care education is available to and made of interest for all nursing home personnel, especially in light of the increase in number of natural teeth and frequency of crowns and bridges among dependent elderly.     

Aged care staff perspectives on oral care for residents: Western Australia

Objective: To determine manager and staff perceptions of oral health and dental service issues for residents in aged care facilities in the Perth Metropolitan Area, Western Australia. Design: Focus groups and face‐to‐face semi‐structured interviews with aged care facility managers and staff. Setting and subjects: Personnel at 12 facilities (high‐level and low‐level care) located in the Perth Metropolitan Area participated in the study. Interviews were conducted with 14 facility managers. Focus groups and face‐to‐face interviews were conducted with 40 facility staff. Results: Managers and staff had similar views regarding most issues. While resident oral health was considered important, regular oral care programmes were limited or lacking. In general, high care facility residents did not have regular dental checkups, while those in low‐level care facilities usually visited their own dentist for checkups or treatment. Barriers to maintaining regular oral care included: resident non‐compliance; financial concerns; lack of co‐operation from family; mobility issues; and lack of interest from dental professionals. Suggested improvements to current services included regular on‐site visits, staff education and specialised dental professionals. Conclusion: Residents face many barriers to maintenance of adequate oral health care, particularly those who are functionally dependent and cognitively impaired. There is an urgent need for appropriate oral care programmes for aged care residents, which include dentists with aged care experience and continuing education for facility staff. Any major programmes should be evaluated carefully.     

Oral healthcare issues in rural residential aged care services in Victoria,Australia

doi: 10.1111/j.1741‐2358.2012.00652.x Oral healthcare issues in rural residential aged care services in Victoria, Australia Objectives: To identify major issues in providing and accessing oral health care in Victorian rural residential aged care services from the perspectives of dentists, aged care staff and residents. Methods: Structured interviews were conducted with five dentists, nine aged care staff and six residents. Three focus groups were conducted with aged care staff. These data were thematically analysed independently by two researchers. Results: The challenges reported by dentists included complexity of care, infrastructure needs and need for skill development. Aged care staff reported lack of skills and confidence in providing oral hygiene care, especially in residents with natural teeth, and an increasing burden on their daily workload. Residents reported concern and shame regarding their declining oral health status and increased challenges accessing appropriate oral health care. Conclusion: These findings indicate the need to build and sustain aged care ‘oral health teams’ who are able to provide daily oral hygiene care for residents and mentor other staff. Rural dentists need access to gerodontic training, portable equipment and appropriate workspaces in aged care services. Aged care and oral health services need to establish clear referral and communication pathways.     

A Systematic Review of Interventions to Change Staff Care Practices in Order to Improve Resident Outcomes in Nursing Homes

Background

We systematically reviewed interventions that attempted to change staff practice to improve long-term care resident outcomes.

Methods

Studies met criteria if they used a control group, included 6 or more nursing home units and quantitatively assessed staff behavior or resident outcomes. Intervention components were coded as including education material, training, audit and feedback, monitoring, champions, team meetings, policy or procedures and organizational restructure.

Results

Sixty-three unique studies were broadly grouped according to clinical domain—oral health (3 studies), hygiene and infection control (3 studies), nutrition (2 studies), nursing home acquired pneumonia (2 studies), depression (2 studies) appropriate prescribing (7 studies), reduction of physical restraints (3 studies), management of behavioral and psychological symptoms of dementia (6 studies), falls reduction and prevention (11 studies), quality improvement (9 studies), philosophy of care (10 studies) and other (5 studies). No single intervention component, combination of, or increased number of components was associated with greater likelihood of positive outcomes. Studies with positive outcomes for residents also tended to change staff behavior, however changing staff behavior did not necessarily improve resident outcomes. Studies targeting specific care tasks (e.g. oral care, physical restraints) were more likely to produce positive outcomes than those requiring global practice changes (e.g. care philosophy). Studies using intervention theories were more likely to be successful. Program logic was rarely articulated, so it was often unclear whether there was a coherent connection between the intervention components and measured outcomes. Many studies reported barriers relating to staff (e.g. turnover, high workload, attitudes) or organizational factors (e.g. funding, resources, logistics).

Conclusion

Changing staff practice in nursing homes is possible but complex. Interventionists should consider barriers and feasibility of program components to impact on each intended outcome.     

Oral health‐related quality of life in patients receiving home‐care nursing: associations with aspects of dental status and xerostomia

doi:10.1111/j.1741‐2358.2009.00344.x
Oral health‐related quality of life in patients receiving home‐care nursing: associations with aspects of dental status and xerostomia Objective: To explore the differences in oral status, dental attendance and dry mouth problems between patients with long‐term disease with high and low scores on Oral Health Impact Profile 14 (OHIP 14) and how patients cope with oral problems such as xerostomia and a reduced ability to brush their teeth. Background: There has been a lack of studies of oral health and oral health‐related quality of life in the frail elderly within the community services. Materials and methods: A cross‐sectional questionnaire study was conducted with 137 patients receiving home‐care nursing. Structured interviews were conducted by student nurses using OHIP‐14, items from the Xerostomia Inventory and questions concerning dental visit habits, brushing of teeth and data from medical records. Results: Eighty‐three per cent of patients had natural teeth and 60% had only natural teeth. ‘Natural teeth only’ indicated a low score on OHIP‐14. Problems with brushing and items concerning xerostomia indicated a high score on OHIP‐14. Contrasts in the assessments concerning brushing of teeth and xerostomia indicated low priority from the patients themselves and the nursing staff. Conclusion: Community health services should focus upon oral health. Both patients and nurses should assess the need for regular brushing of teeth carried out by home‐care nurses. Assessment and treatment of dry mouth problems should have higher priority.     

Are the barriers to good oral hygiene in nursing homes within the nurses or the patients?

doi: 10.1111/j.1741‐2358.2011.00554.x
Are the barriers to good oral hygiene in nursing homes within the nurses or the patients? Objective: To explore nursing home patients’ oral hygiene and their nurses’ assessments of barriers to improvement. Background: In nursing homes, nurses are responsible for patients’ oral hygiene. Materials and methods: This study assessed the oral hygiene of 358 patients in 11 Norwegian nursing homes. 494 nurses in the same nursing homes participated in a questionnaire study. Results: More than 40% of patients had unacceptable oral hygiene. ‘More than 10 teeth’ gave OR = 2, 1 (p = 0.013) and ‘resist being helped’ OR = 2.5 (p = 0.018) for unacceptable oral hygiene. Eighty percent of the nurses believed knowledge of oral health was important, and 9.1% often considered taking care of patients’ teeth unpleasant. Half of the nurses reported lack of time to give regular oral care, and 97% experienced resistant behaviour in patients. Resistant behaviour often left oral care undone. Twenty‐one percent of the nurses had considered making legal decisions about use of force or restraints to overcome resistance to teeth cleaning. Conclusion: Oral hygiene in the nursing homes needed to be improved. Resistant behaviour is a major barrier. To overcome this barrier nurses’ education, organisational strategies to provide more time for oral care, and coping with resistant behaviour in patients are important factors.     

Q Fever Knowledge,Attitudes and Vaccination Status of Australia’s Veterinary Workforce in 2014

Q fever, caused by Coxiella burnetii, is a serious zoonotic disease in humans with a worldwide distribution. Many species of animals are capable of transmitting C. burnetii, and consequently all veterinary workers are at risk for this disease. An effective Q fever vaccine has been readily available and used in Australia for many years in at-risk groups, and the European Centre for Disease Prevention and Control has recently also called for the use of this vaccine among at-risk groups in Europe. Little is known about attitudes towards this vaccine and vaccine uptake in veterinary workers. This study aimed to determine the Q fever vaccination status of veterinarians and veterinary nurses in Australia and to assess and compare the knowledge and attitudes towards Q fever disease and vaccination of each cohort. An online cross-sectional survey performed in 2014 targeted all veterinarians and veterinary nurses in Australia. Responses from 890 veterinarians and 852 veterinary nurses were obtained. Binary, ordinal and multinomial logistic regression were used to make comparisons between the two cohorts. The results showed that 74% of veterinarians had sought vaccination compared to only 29% of veterinary nurses. Barriers to vaccination among those not vaccinated did not differ between cohorts, and included a lack of perceived risk, financial expense, time constraints, and difficulty in finding a vaccine provider. Poor knowledge and awareness of Q fever disease and vaccination were additional and notable barriers for the veterinary nursing cohort, suggesting veterinary clinics and veterinarians may not be meeting their legal responsibility to educate staff about risks and risk prevention. Further evaluation is needed to identify the drivers behind seeking and recommending vaccination so that recommendations can be made to improve vaccine uptake.     

Challenges and barriers to quality oral care as perceived by caregivers in long-stay institutions in Brazil

doi: 10.1111/j.1741‐2358.2011.00475.x
Challenges and barriers to quality oral care as perceived by caregivers in long‐stay institutions in Brazil Objective: To describe how caregivers perceive the oral health status in the elderly they care for; the routines for oral hygiene in nursing homes; caregivers perceived barriers for quality oral care; and the caregivers competence and need for training in this area. Background: The phenomena surrounding ageing has been the subject of worldwide interest, particularly concerning issues related to institutionalised elderly, where several studies have shown the precarious oral health status of such individuals. Materials and methods: A qualitative interview study was held in a city in southern Brazil. Study participants were 26 caregivers of elderly people, belonging to seven institutions. Statements were collected through interviews, whose results were interpreted by phenomenological analysis. Results: Caregivers of institutionalised elderly reveal contradictions in knowledge and practices of oral health. Although it could be expected that the perception and attitudes of caregivers of their own oral health could influence the care they offer to the elderly, barriers to the implementation of such activities appear to refer to situations outside of their responsibility, especially in the absence of time and staff. Conclusions: The oral care of older people in geriatric institutions requires multidisciplinary and interinstitutional actions capable of reversing the continuing framework of neglect, requiring interventions for health promotion and disease prevention that can and should be implemented in institutions.