Lea Ladegaard Groenkjaer, MSN, RN
Oral Care in Hepatology Nursing Nurses’ Knowledge and Education
ABSTRACT This study aimed, for the first time, to explore hepatology nurses’ knowledge and education in the oral care and oral health assessments of patients with liver cirrhosis. Liver cirrhosis can be associated with lifestyles and behaviors that contribute to oral neglect and untreated oral inflammation. This inflammation can represent foci for systemic infections, with increases in morbidity and mortality rates. A questionnaire consisting of 26 closed- and open-ended questions was used to determine among heptalogy nurses the extent of knowledge, education, and current practices in oral healthcare among hepatology nurses. The study involved a sample of 94 nurses employed in different gastroenterology and hepatology units, with a response rate of 73%. The results indicated that respondents lacked substantial oral care education, both in connection with their initial training and after qualifying as nurses. The respondents had inadequate knowledge of basic oral health, the equipment used for oral care, and medications’ adverse effects on oral health. These results indicate a need for educational updates in cooperation with dentists and for the promotion of specific oral assessment guides in patients with liver cirrhosis.
T
he connection between oral and systemic health is becoming clearer every day. Oral health is necessary to maintain overall health, especially for individuals who have been hospitalized (Adams, 1996). Oral inflammation, such as gingival inflammation, periodontitis, and candidiasis, can exacerbate cirrhosis patients’ medical status, as cirrhosis is associated with several abnormalities of the body’s defense mechanisms (Arvaniti et al., 2010). With oral inflammation, a systemic infection response syndrome can occur, resulting in spontaneous bacterial peritonitis, urinary tract infections, respiratory infections, sepsis, encephalopathy, and death (Arvaniti et al., 2010; Gomez, Ruiz, & Schreider, 1994).
Unfortunately, patients with liver cirrhosis and their healthcare providers are often unaware of the oral complications that can occur and the multiple systems that can be affected. The complexity of care for patients with cirrhosis reinforces the need for knowledge of and education in oral care for nurses. However, research has indicated that nurses do not receive much education in oral care and might not consistently provide adequate oral care for their patients (Adams, 1996; Boyle, 1992; Ohrn, Wahlin, & Sjoden, 2000). Because it is not known whether nurses are providing oral care and whether they have sufficient knowledge to do so, the question is whether this basic need is being met in hospitals.
Background Received January 24, 2013; accepted June 26, 2013. About the author: Lea Ladegaard Groenkjaer, MSN, RN, is PhD Student at Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, Denmark. The author declares no funding or conflict of interest. Correspondence to: Lea Ladegaard Groenkjaer, MSN, RN, Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, Noerrebrogade 44, 8000 Aarhus C, Denmark ([email protected]). DOI: 10.1097/SGA.0000000000000086
The prevention of oral complications and the providing of thorough oral care can prevent life-threatening infections and provide greater comfort for patients (Coleman, 1995). Patients with liver cirrhosis, particularly those with hepatitis C or alcoholic cirrhosis, have been shown to display a loss of self-esteem and difficulties with their diets due to poor oral health (Coates et al., 2000; Guggenheimer, Eghtesad, & Close, 2007). In light of these findings, cirrhotic patients require nurses who have adequate knowledge of and education
22 Copyright © 2015 Society of Gastroenterology Nurses and Associates
Gastroenterology Nursing
Copyright © 2015 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
GNJ-D-13-00013.indd 22
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Oral Care in Hepatology Nursing
in oral health assessment and care. However, education and knowledge related to oral health among nurses working in hepatology settings have received little attention, and very little is known about how nurses manage oral care for their patients with cirrhosis. As a result, there is a need for a study to describe nurses’ knowledge of and education in oral health assessment and care for patients with liver cirrhosis.
Oral Complications Liver cirrhosis can be associated with lifestyles and behaviors that contribute to oral neglect and untreated oral disease, resulting in extracted teeth, caries, lesions, and plaque (DiMartini et al., 2004). Dirt and food debris can cause inflammation of the mucosa. Plaque is the main cause of gingival inflammation and can lead to periodontitis, with loss of tooth support (Van Dyke, Offenbacher, Philstrom, Putt, & Trummel, 1999). Three-quarters of all patients with cirrhosis admitted to hospitals are malnourished as a result of inadequate food intake and increased protein needs (Sargent, 2006). Reduced intake decreases the stimulation of salivary and enzymatic production, which ordinarily help protect the oral cavity from infections (Squier & Kremer, 2001). Systemic conditions, together with medications such as diuretics, steroids, antihypertensives, and antidepressants, affect the salivary rate, which decreases when the daily number of drugs used increases (Närhi, Meurman, & Ainamo, 1999). Hyposalivation and xerostomia affect a patient’s susceptibility to oral diseases. Cirrhotic patients have an increased risk of infection, as they are immunocompromised (Gomezet al., 1994). Therefore, local oral diseases can become systemic and life-threatening. In this context, many cirrhotic patients receive antibiotic treatment. The overgrowth of fungi, particularly candidiasis, is often observed in relation to treatment with broad-spectrum antibiotics. Similarly, oxygen therapy and suctioning devices contribute to oral mucosa injury. The drying effect of oxygen and the lesions associated with the removal of secretions and debris create a desiccated environment that is ideal for bacterial growth (McNeill, 2000). Finally, cirrhotic patients experience vitamin deficiencies, which can result in oral-related problems including pain, blisters, halitosis, and oral lesions. In addition, oral lesions can leave ulcerations which can result in infections, diffuse bleeding, and delayed wound healing due to cirrhosis patients’ coagulation abnormalities (Amitrano, Guardascione, Brancaccio, & Balzano, 2002). Liver cirrhosis can thus have harmful effects on oral health. This fact indicates that cirrhosis patients have special oral health needs. The performance of oral care by nurses during hospitalization and the use of specific oral assessment guides could help prevent oral complications (Lins et al., 2011). VOLUME 38 | NUMBER 1 | JANUARY/FEBRUARY 2015
Nurses’ Knowledge of Oral Care Clinical studies about oral care for several patient populations, including hepatology patients, have been lacking. Oral care is a basic nursing task that receives low priority (Paulsson, Anderson, Wårdg, & Öhrn, 2008; White, 2000). Therefore, oral care is often the last task to be performed in the personal care of patients, and oral care is the first item to be omitted when time is limited (Berry, Davidson, Masters, & Rolls, 2007). Several studies have suggested that oral health’s low priority is due to nurses’ lack of knowledge about oral health and practices (Adams, 1996; Daniel, Damato, & Johnson, 2004). Similarly, Wren, Martin, Yoon, and Bech (2010) suggested that nurses lack knowledge of the means and tools for mouth care, the indicators of a healthy mouth, and medications’ influences on oral conditions. A survey by Hatton-Smith (1994) found that oral care was administered in a routine manner, without reference to patients’ individual needs; in another study, nurses described oral care as an unpleasant task (Paulsson, Anderson, Wårgd, & Öhrn, 2008). Most oral care is delegated to nursing students, who report performing care without adequate knowledge (Peate, 1993). One reason for these practices could be that no guidance is provided regarding how to examine the mouth systematically or how to perform oral care (Evans, 2001). A number of oral assessment guides have been developed to assess patients’ oral status and to identify the need for oral care (Andersson, Hallberg, & Renvert 2002; Rattenburry, Moone, & Bowen 1999; Xavier, 2000); however, none of the oral assessment guides make intervention proposals or recommend courses of action for systematic intervention regarding the provision of oral care. In addition, there is doubt regarding how many nurses actually use these oral assessment guides. Ganley (1996) investigated nurses’ management of oral care and oral assessments of patients receiving head and neck radiation in an oncology setting. The results demonstrated that 24% of the nurses used an oral assessment guide and assessed oral status prior to the onset of complications. However, 76% did not use an oral assessment guide and assessed the oral cavity only after problems developed. A study describing the oral health profiles of cirrhotic patients awaiting liver transplantation emphasized the need to establish multidisciplinary protocols to manage oral disorders in patients with liver disease to improve their oral health (Lins et al., 2011). Another reason for the lack of focus on oral care could be nurses’ attitudes toward oral care. Andersson, Nordenram, Wårdh, and Berlund (2007) found that, although nurses were aware of the impact of oral health, their attitude was that oral health is a matter for dentists. This study highlighted the need for education and 23
Copyright © 2015 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
GNJ-D-13-00013.indd 23
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J
Oral Care in Hepatology Nursing
collaboration between nurses and dentists. Studies have shown that focused and systematic training programs improve knowledge and attitudes in the area of oral health (Petteri, Vehkalahti, & Simoila, 2007; Wårdh, Berggren, Andersson, & Sörensen, 2002). An oral health education program for nurses increased their knowledge and self-confidence with regard to administering quality oral care (Kullberg, Forsell, & Wedel, 2009).
Nurses’ Education in Oral Care Education in oral care appears insufficient, and a need for continuing education in oral care has been identified (Ohrnet al., 2000). McAuliffe (2007) found that 76% of nursing students had only 2–3 hours of oral health education. In addition, nursing students were often advised to use books that contained insufficient information to gain insight into oral care or mouth disease (Longhurst, 1998). Nurses consider the performance of oral care to be one of their competencies, but in a study by Danielsen, Dillenberg, and Bay (2006), fewer than half of the nurse respondents felt confident in their skills in this area. Boyle (1992) identified gaps in knowledge in specific areas, particularly concerning the effects of systemic disease and medications. A study by Adams (1996) investigated nursing practices in oral care for patients on medical wards. A total of 85.3% of the nurses had not received any oral care education since their qualifying examinations, and 14.7% had never received any oral care education. Similarly, Pettit, McCann, Schneiderman, Farren, and Cambell (2012) also identified that nurses, when describing their focus on oral care, had not received up-to-date educations since their initial training. The nurses reported that their nursing educations did not prepare them for oral care management. However, they felt that oral care was important and felt responsible for the oral care and oral cavity assessment of their patients. It is unclear what factors influence hepatology nurses’ oral care practices since there are few published studies in this area. The available literature suggests that oral care provision is less than optimal. As a result, this study was conducted to assess nurses’ knowledge of and education in oral care, identify the use of assessment tools in practice, identify how nurses on gastroenterology and hepatology nursing units practice oral care, and identify the barriers to oral care provision.
Methods Because no literature was found describing nurses’ knowledge of and education about oral health assessment and care in patients with liver cirrhosis, a descriptive design was undertaken that was the most appropriate and practical for addressing the research aims.
Instrument Development A self-administered questionnaire was developed from a review of the relevant research literature. The questionnaire consisted of 26 closed- and open-ended questions. The questionnaire was prepared to collect information on knowledge, education, and practice related to oral care and oral assessment. The questionnaire started with four demographic questions to assess education, the number of years practicing, and workplace setting. Next, there were four questions about the importance of performing oral care in patients with liver cirrhosis, three questions about oral assessment guides, 10 knowledge questions, and five questions about nurses’ education in oral health.
Pilot Study The questionnaire was pilot tested with 10 nurses from the gastroenterology and hepatology wards of a university hospital, including the head nurse and a clinical nurse specialist. One of the functions of the pilot study was to ensure that the wording in the questionnaire was clear, as it was necessary to gain an idea of how the nurses in the main study would interpret the questions. The pilot participants found the language and questions understandable and thus had no objections to the questionnaire. Data from the pilot study were not included in the final analysis and report.
Participants A convenience sample was recruited from attendees at an educational seminar for nurses working with patients with liver diseases, titled “Network and Knowledge-Sharing Meeting,” held at the University Hospital in Aarhus, Denmark. The aim was to include all nurses who met the eligibility criteria. The eligibility criteria included: (a) the participants must be registered nurses or student nurses, (b) they must be working on gastroenterology and hepatology wards (nursing units), and (c) they must be caring for adult (18 years of age or older) patients with liver cirrhosis. A total of 94 nurses met the eligibility criteria, and 69 nurses returned completed questionnaires, yielding a response rate of 73.4%. The respondents came from 12 different gastroenterology and hepatology wards in Denmark. Sixty-three (91.3%) of the 69 respondents were registered nurses, and 6 (8.7%) were enrolled (student) nurses. A total of 68.1% (n = 47) worked in university hospitals, and 31.9% (n = 22) worked in regional hospitals. A majority of the respondents (n = 47; 68.1%) were working full-time. The largest group of respondents had practiced for more than 6 years (n = 29; 42%), followed by those who had practiced 4–6 years (n = 18; 26.1%), 1–3 years (n = 18; 26.1%),
24 Copyright © 2015 Society of Gastroenterology Nurses and Associates
Gastroenterology Nursing
Copyright © 2015 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
GNJ-D-13-00013.indd 24
21/01/15 9:55 PM
Oral Care in Hepatology Nursing
TABLE 1. Demographic Characteristics of Participants Respondents
%
69
100
63
91.3
6
8.7
69
100
University hospital
47
68.1
Regional hospital
22
31.9
Working hours
69
100
Full-time
47
68.1
Part-time
22
31.9
69
100
< 1 year
4
5.8
1–3 years
18
26.1
4–6 years
18
26.1
> 6 years
29
42
Occupation Registered nurse Student nurse Workplace
Nursing experience
and less than 1 year (n = 4; 5.8%). The demographic characteristics of the participants are presented in Table 1.
Ethical Considerations The study was approved by the ward managers. The participants received an explanation of the questionnaire and assurance of anonymity and confidentiality. Each nurse was informed of the study’s purpose and that his or her consent to participate was voluntary. Return of a completed questionnaire was considered consent to participate.
Data Analyses Stata software, version 12.0 (StataCorp, 2011), was used for statistical analysis. Descriptive statistics were used to identify the oral care knowledge, education, and practices of the nurses. The closed-ended answers are expressed as numbers and percentages and are presented in Tables 1 to 4. The open-ended questions were analyzed using content analysis, in which similar responses were grouped into categories, and their frequencies were counted. Fisher’s exact test was used for the statistical analysis of the findings. A p value of
Oral Care in Hepatology Nursing Nurses’ Knowledge and Education
ABSTRACT This study aimed, for the first time, to explore hepatology nurses’ knowledge and education in the oral care and oral health assessments of patients with liver cirrhosis. Liver cirrhosis can be associated with lifestyles and behaviors that contribute to oral neglect and untreated oral inflammation. This inflammation can represent foci for systemic infections, with increases in morbidity and mortality rates. A questionnaire consisting of 26 closed- and open-ended questions was used to determine among heptalogy nurses the extent of knowledge, education, and current practices in oral healthcare among hepatology nurses. The study involved a sample of 94 nurses employed in different gastroenterology and hepatology units, with a response rate of 73%. The results indicated that respondents lacked substantial oral care education, both in connection with their initial training and after qualifying as nurses. The respondents had inadequate knowledge of basic oral health, the equipment used for oral care, and medications’ adverse effects on oral health. These results indicate a need for educational updates in cooperation with dentists and for the promotion of specific oral assessment guides in patients with liver cirrhosis.
T
he connection between oral and systemic health is becoming clearer every day. Oral health is necessary to maintain overall health, especially for individuals who have been hospitalized (Adams, 1996). Oral inflammation, such as gingival inflammation, periodontitis, and candidiasis, can exacerbate cirrhosis patients’ medical status, as cirrhosis is associated with several abnormalities of the body’s defense mechanisms (Arvaniti et al., 2010). With oral inflammation, a systemic infection response syndrome can occur, resulting in spontaneous bacterial peritonitis, urinary tract infections, respiratory infections, sepsis, encephalopathy, and death (Arvaniti et al., 2010; Gomez, Ruiz, & Schreider, 1994).
Unfortunately, patients with liver cirrhosis and their healthcare providers are often unaware of the oral complications that can occur and the multiple systems that can be affected. The complexity of care for patients with cirrhosis reinforces the need for knowledge of and education in oral care for nurses. However, research has indicated that nurses do not receive much education in oral care and might not consistently provide adequate oral care for their patients (Adams, 1996; Boyle, 1992; Ohrn, Wahlin, & Sjoden, 2000). Because it is not known whether nurses are providing oral care and whether they have sufficient knowledge to do so, the question is whether this basic need is being met in hospitals.
Background Received January 24, 2013; accepted June 26, 2013. About the author: Lea Ladegaard Groenkjaer, MSN, RN, is PhD Student at Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, Denmark. The author declares no funding or conflict of interest. Correspondence to: Lea Ladegaard Groenkjaer, MSN, RN, Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, Noerrebrogade 44, 8000 Aarhus C, Denmark ([email protected]). DOI: 10.1097/SGA.0000000000000086
The prevention of oral complications and the providing of thorough oral care can prevent life-threatening infections and provide greater comfort for patients (Coleman, 1995). Patients with liver cirrhosis, particularly those with hepatitis C or alcoholic cirrhosis, have been shown to display a loss of self-esteem and difficulties with their diets due to poor oral health (Coates et al., 2000; Guggenheimer, Eghtesad, & Close, 2007). In light of these findings, cirrhotic patients require nurses who have adequate knowledge of and education
22 Copyright © 2015 Society of Gastroenterology Nurses and Associates
Gastroenterology Nursing
Copyright © 2015 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
GNJ-D-13-00013.indd 22
21/01/15 9:55 PM
Oral Care in Hepatology Nursing
in oral health assessment and care. However, education and knowledge related to oral health among nurses working in hepatology settings have received little attention, and very little is known about how nurses manage oral care for their patients with cirrhosis. As a result, there is a need for a study to describe nurses’ knowledge of and education in oral health assessment and care for patients with liver cirrhosis.
Oral Complications Liver cirrhosis can be associated with lifestyles and behaviors that contribute to oral neglect and untreated oral disease, resulting in extracted teeth, caries, lesions, and plaque (DiMartini et al., 2004). Dirt and food debris can cause inflammation of the mucosa. Plaque is the main cause of gingival inflammation and can lead to periodontitis, with loss of tooth support (Van Dyke, Offenbacher, Philstrom, Putt, & Trummel, 1999). Three-quarters of all patients with cirrhosis admitted to hospitals are malnourished as a result of inadequate food intake and increased protein needs (Sargent, 2006). Reduced intake decreases the stimulation of salivary and enzymatic production, which ordinarily help protect the oral cavity from infections (Squier & Kremer, 2001). Systemic conditions, together with medications such as diuretics, steroids, antihypertensives, and antidepressants, affect the salivary rate, which decreases when the daily number of drugs used increases (Närhi, Meurman, & Ainamo, 1999). Hyposalivation and xerostomia affect a patient’s susceptibility to oral diseases. Cirrhotic patients have an increased risk of infection, as they are immunocompromised (Gomezet al., 1994). Therefore, local oral diseases can become systemic and life-threatening. In this context, many cirrhotic patients receive antibiotic treatment. The overgrowth of fungi, particularly candidiasis, is often observed in relation to treatment with broad-spectrum antibiotics. Similarly, oxygen therapy and suctioning devices contribute to oral mucosa injury. The drying effect of oxygen and the lesions associated with the removal of secretions and debris create a desiccated environment that is ideal for bacterial growth (McNeill, 2000). Finally, cirrhotic patients experience vitamin deficiencies, which can result in oral-related problems including pain, blisters, halitosis, and oral lesions. In addition, oral lesions can leave ulcerations which can result in infections, diffuse bleeding, and delayed wound healing due to cirrhosis patients’ coagulation abnormalities (Amitrano, Guardascione, Brancaccio, & Balzano, 2002). Liver cirrhosis can thus have harmful effects on oral health. This fact indicates that cirrhosis patients have special oral health needs. The performance of oral care by nurses during hospitalization and the use of specific oral assessment guides could help prevent oral complications (Lins et al., 2011). VOLUME 38 | NUMBER 1 | JANUARY/FEBRUARY 2015
Nurses’ Knowledge of Oral Care Clinical studies about oral care for several patient populations, including hepatology patients, have been lacking. Oral care is a basic nursing task that receives low priority (Paulsson, Anderson, Wårdg, & Öhrn, 2008; White, 2000). Therefore, oral care is often the last task to be performed in the personal care of patients, and oral care is the first item to be omitted when time is limited (Berry, Davidson, Masters, & Rolls, 2007). Several studies have suggested that oral health’s low priority is due to nurses’ lack of knowledge about oral health and practices (Adams, 1996; Daniel, Damato, & Johnson, 2004). Similarly, Wren, Martin, Yoon, and Bech (2010) suggested that nurses lack knowledge of the means and tools for mouth care, the indicators of a healthy mouth, and medications’ influences on oral conditions. A survey by Hatton-Smith (1994) found that oral care was administered in a routine manner, without reference to patients’ individual needs; in another study, nurses described oral care as an unpleasant task (Paulsson, Anderson, Wårgd, & Öhrn, 2008). Most oral care is delegated to nursing students, who report performing care without adequate knowledge (Peate, 1993). One reason for these practices could be that no guidance is provided regarding how to examine the mouth systematically or how to perform oral care (Evans, 2001). A number of oral assessment guides have been developed to assess patients’ oral status and to identify the need for oral care (Andersson, Hallberg, & Renvert 2002; Rattenburry, Moone, & Bowen 1999; Xavier, 2000); however, none of the oral assessment guides make intervention proposals or recommend courses of action for systematic intervention regarding the provision of oral care. In addition, there is doubt regarding how many nurses actually use these oral assessment guides. Ganley (1996) investigated nurses’ management of oral care and oral assessments of patients receiving head and neck radiation in an oncology setting. The results demonstrated that 24% of the nurses used an oral assessment guide and assessed oral status prior to the onset of complications. However, 76% did not use an oral assessment guide and assessed the oral cavity only after problems developed. A study describing the oral health profiles of cirrhotic patients awaiting liver transplantation emphasized the need to establish multidisciplinary protocols to manage oral disorders in patients with liver disease to improve their oral health (Lins et al., 2011). Another reason for the lack of focus on oral care could be nurses’ attitudes toward oral care. Andersson, Nordenram, Wårdh, and Berlund (2007) found that, although nurses were aware of the impact of oral health, their attitude was that oral health is a matter for dentists. This study highlighted the need for education and 23
Copyright © 2015 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
GNJ-D-13-00013.indd 23
21/01/15 9:55 PM
J
Oral Care in Hepatology Nursing
collaboration between nurses and dentists. Studies have shown that focused and systematic training programs improve knowledge and attitudes in the area of oral health (Petteri, Vehkalahti, & Simoila, 2007; Wårdh, Berggren, Andersson, & Sörensen, 2002). An oral health education program for nurses increased their knowledge and self-confidence with regard to administering quality oral care (Kullberg, Forsell, & Wedel, 2009).
Nurses’ Education in Oral Care Education in oral care appears insufficient, and a need for continuing education in oral care has been identified (Ohrnet al., 2000). McAuliffe (2007) found that 76% of nursing students had only 2–3 hours of oral health education. In addition, nursing students were often advised to use books that contained insufficient information to gain insight into oral care or mouth disease (Longhurst, 1998). Nurses consider the performance of oral care to be one of their competencies, but in a study by Danielsen, Dillenberg, and Bay (2006), fewer than half of the nurse respondents felt confident in their skills in this area. Boyle (1992) identified gaps in knowledge in specific areas, particularly concerning the effects of systemic disease and medications. A study by Adams (1996) investigated nursing practices in oral care for patients on medical wards. A total of 85.3% of the nurses had not received any oral care education since their qualifying examinations, and 14.7% had never received any oral care education. Similarly, Pettit, McCann, Schneiderman, Farren, and Cambell (2012) also identified that nurses, when describing their focus on oral care, had not received up-to-date educations since their initial training. The nurses reported that their nursing educations did not prepare them for oral care management. However, they felt that oral care was important and felt responsible for the oral care and oral cavity assessment of their patients. It is unclear what factors influence hepatology nurses’ oral care practices since there are few published studies in this area. The available literature suggests that oral care provision is less than optimal. As a result, this study was conducted to assess nurses’ knowledge of and education in oral care, identify the use of assessment tools in practice, identify how nurses on gastroenterology and hepatology nursing units practice oral care, and identify the barriers to oral care provision.
Methods Because no literature was found describing nurses’ knowledge of and education about oral health assessment and care in patients with liver cirrhosis, a descriptive design was undertaken that was the most appropriate and practical for addressing the research aims.
Instrument Development A self-administered questionnaire was developed from a review of the relevant research literature. The questionnaire consisted of 26 closed- and open-ended questions. The questionnaire was prepared to collect information on knowledge, education, and practice related to oral care and oral assessment. The questionnaire started with four demographic questions to assess education, the number of years practicing, and workplace setting. Next, there were four questions about the importance of performing oral care in patients with liver cirrhosis, three questions about oral assessment guides, 10 knowledge questions, and five questions about nurses’ education in oral health.
Pilot Study The questionnaire was pilot tested with 10 nurses from the gastroenterology and hepatology wards of a university hospital, including the head nurse and a clinical nurse specialist. One of the functions of the pilot study was to ensure that the wording in the questionnaire was clear, as it was necessary to gain an idea of how the nurses in the main study would interpret the questions. The pilot participants found the language and questions understandable and thus had no objections to the questionnaire. Data from the pilot study were not included in the final analysis and report.
Participants A convenience sample was recruited from attendees at an educational seminar for nurses working with patients with liver diseases, titled “Network and Knowledge-Sharing Meeting,” held at the University Hospital in Aarhus, Denmark. The aim was to include all nurses who met the eligibility criteria. The eligibility criteria included: (a) the participants must be registered nurses or student nurses, (b) they must be working on gastroenterology and hepatology wards (nursing units), and (c) they must be caring for adult (18 years of age or older) patients with liver cirrhosis. A total of 94 nurses met the eligibility criteria, and 69 nurses returned completed questionnaires, yielding a response rate of 73.4%. The respondents came from 12 different gastroenterology and hepatology wards in Denmark. Sixty-three (91.3%) of the 69 respondents were registered nurses, and 6 (8.7%) were enrolled (student) nurses. A total of 68.1% (n = 47) worked in university hospitals, and 31.9% (n = 22) worked in regional hospitals. A majority of the respondents (n = 47; 68.1%) were working full-time. The largest group of respondents had practiced for more than 6 years (n = 29; 42%), followed by those who had practiced 4–6 years (n = 18; 26.1%), 1–3 years (n = 18; 26.1%),
24 Copyright © 2015 Society of Gastroenterology Nurses and Associates
Gastroenterology Nursing
Copyright © 2015 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
GNJ-D-13-00013.indd 24
21/01/15 9:55 PM
Oral Care in Hepatology Nursing
TABLE 1. Demographic Characteristics of Participants Respondents
%
69
100
63
91.3
6
8.7
69
100
University hospital
47
68.1
Regional hospital
22
31.9
Working hours
69
100
Full-time
47
68.1
Part-time
22
31.9
69
100
< 1 year
4
5.8
1–3 years
18
26.1
4–6 years
18
26.1
> 6 years
29
42
Occupation Registered nurse Student nurse Workplace
Nursing experience
and less than 1 year (n = 4; 5.8%). The demographic characteristics of the participants are presented in Table 1.
Ethical Considerations The study was approved by the ward managers. The participants received an explanation of the questionnaire and assurance of anonymity and confidentiality. Each nurse was informed of the study’s purpose and that his or her consent to participate was voluntary. Return of a completed questionnaire was considered consent to participate.
Data Analyses Stata software, version 12.0 (StataCorp, 2011), was used for statistical analysis. Descriptive statistics were used to identify the oral care knowledge, education, and practices of the nurses. The closed-ended answers are expressed as numbers and percentages and are presented in Tables 1 to 4. The open-ended questions were analyzed using content analysis, in which similar responses were grouped into categories, and their frequencies were counted. Fisher’s exact test was used for the statistical analysis of the findings. A p value of
