Original article

Provision of dental care in aged care facilities NSW AustraliaPart 2 as perceived by the carers (care providers) Bettine C Webb1, Terry Whittle1 and Eli Schwarz2 1

Faculty of Dentistry, The University of Sydney, Westmead, NSW, Australia; 2School of Dentistry, Oregon Health & Science University, Portland, OR, USA

doi: 10.1111/ger.12103 Provision of dental care in aged care facilities NSW Australia- Part 2 as perceived by the carers (care providers) Objectives: To investigate carers’ perception of the provision of dental care in aged care facilities (ACFs) New South Wales (NSW), Australia. Background: Carers are responsible for ‘hands-on, day-to-day’ care of residents, including dental care, yet there were no specific figures available concerning their role in NSW ACFs. Materials and Methods: Questionnaires were mailed to 406 NSW directors of nursing (DONs) requesting completion by a carer who was proficient in English and without the influence of the DON. The 23item questionnaire was presented in 4 sections, and the data qualitatively analysed. Results: 211 questionnaires were completed and returned, giving a response rate of 52%. Carers were mostly female (91.9%) in the 40–50 and >50 age groups. Oral health training had been received by 66.7% of carers, and although 73.2% thought that their training was adequate, carers in general requested further training. Long waiting periods for government dental services (69.4%) and resident unable to communicate oral health problems (69.2%) were seen as the most frequent barriers to dental care. Almost all carers reported the availability of electric tooth brushes, fluoride gel, disclosing tablets/ gel, interdental brushes and the use of a foam mouth prop, while few reported the use of other dental care products. Conclusion: As carers provided almost all of oral health care for residents, emphasis should be placed on training in geriatric dental care techniques and use of dental products. Keywords: dental care, nursing homes, dental hygiene, geriatric dentistry. Accepted 30 October 2013

Aim

Introduction

The aim of this study was to investigate carers’ perception of the provision of dental care in New South Wales (NSW) aged care facilities (ACFs) and to determine carer characteristics, carer knowledge of dental/oral health techniques and the use of dental/oral health products. Barriers to carers’ delivery of optimal dental care and their desire for further dental education were studied. This project was the second in an innovative approach of collecting data at three different levels in ACFs – Part 1, Directors of Nursing (DONs) (care providers at managerial level); Part 2, carers (day-to-day care providers); and Part 3, residents (care receivers, the end users).

In NSW, Australia, as globally, there is an increase in the number of natural teeth in the ageing population, which is also showing a trend to increase. As a result, there is an increase in the number of teeth requiring treatment1. In our previous research (2005), which involved the mailing of questionnaires to all DONs in NSW ACFs, the DONs reported that 41% of residents still retained their natural teeth. Fewer residents are edentulous due to high-quality dental care2, and according to Sanders et al.3, the proportion of people aged 65 years and over living in residential care is projected to remain at around 7% over the period 1996–2021.

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© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2015; 32: 254–259

Dental care in NSW aged care facilities

In Denmark, Vigild4 showed that untrained carers were often responsible for oral hygiene procedures for the elderly in long-term care facilities. In 1988, Vigild suggested that instructions in oral hygiene procedures should be given to carers who rarely have sufficient knowledge and skill in these procedures5. To meet this situation a Swedish study has developed a Dental Coping Beliefs Scale (DCBS) index to measure oral health priority among nursing staff including those who work in ACFs. The authors concluded that the index was a useful tool to measure how nursing staff gave priority to and allocated responsibility for oral health care in different ways6. In the United Kingdom, Frenkel et al.7 in their study of oral health standards of elderly nursing, home residents found that staff did not effectively perform oral health care appropriate to residents’ needs. They recommended practical training for care assistants in basic oral health care in nursing homes. Frenkel et al. in another study, conducted a trial to assess whether oral healthcare education for nursing home carers would result in an improvement in residents’ oral health. Their study clearly showed that oral health education for carers resulted in improved oral hygiene for elderly, functionally dependent residents8. In the United States, an assessment of carers’ oral health attitudes and knowledge was undertaken by Reed et al.9, and although carers’ oral health knowledge improved following a geriatric service programme, they identified specific barriers to their provision of oral hygiene care to the residents. The carers reported that these barriers included physical limitations, fear of getting bitten and time constraints. Vigild10 in her study of oral mucosal lesions among the institutionalised elderly in Denmark emphasised that the necessary instructions should not only be given to the elderly but also to the nursing home staff who should be trained in the procedures required. Chalmers et al.11 investigated nurses’ aides’ selfreported oral care activities in facilities in Central and Eastern Iowa (USA), and they found that the oral hygiene in ACF residents was poor, and therefore, there was a need for further investigation and assessment of the aides’ training courses and continuing oral health education. In Australia, Chalmers12 in her study of geriatric health found that the carers of older adults did not have access to practical education about dental care. She stated that geriatric dental education did not have a high profile in Australian schools for dental professionals.

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In Western Australia, Paley et al.13 in their study of ACFs found that there was a need for continuing dental health education for staff, and their later investigation14 of resident and family perceptions of oral health care of residents in ACFs found that there was a need for staff education from oral health specialists. In NSW, according to Australian Bureau of Statistics (ABS), the number of people aged 65 years and over is projected to increase from 13% of the population in 2004 to between 26% and 28% of the population in 2051. Also, by then, the number of people aged 85 years and over is projected to increase even more dramatically. By 2051, this group will make up 6–8% of the population compared with 2% in 200415. In 2006, approximately 5.5% of the NSW population aged 65 years and over were residents of ACFs16, and carers were responsible for the ‘hands-on, day-to-day’ care of these residents including oral care, yet there were no specific figures available for the role of carers in NSW ACFs.

Materials and Methods A questionnaire, a reply-paid envelope and a letter of permission were mailed to the DONs at 406 NSW ACFs (refer to http://sydney.edu.au/ dentistry/research/article.php for copy of questionnaire and letters). Non-responders received a second posting after 4 weeks. Once permission was granted, the DON was requested to select a carer who could read and write English to complete the de-identified questionnaire without the influence of the DON. A letter describing the study purpose, confidentiality and avenues of complaint was included for the carer. The protocol of this study was approved by the University of Sydney Human Research Ethics Committee. The 23-item questionnaire was developed from other researchers’ published studies13,17,22 (Q 11, 18, 20) and new questions added that were specific to observed carer activity. It was divided into four sections: carer demographics (Q1–7), oral care in the ACF (Q8–12), resident’s oral care (Q13–17) and factors that influence oral care (Q18–22). Carer demographics included age, gender, ethnicity, education level, oral health training and percentage of dependent residents in their care. Oral care in the ACF covered carer duties, number of residents per carer and medical requirements of residents. Oral care of the residents enquired about resources available to the carer and techniques used to maintain oral health. Factors that may influence oral care of the

© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2015; 32: 254–259

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residents covered nutrition and future training opportunities. The method of sending questionnaires by mail to collect data was chosen for reasons given in previous article18 for example in large geographically dispersed populations it is often the only viable option. The data were qualitatively analysed19 The questionnaire was validated by reviewing it to determine whether the questionnaire measured what it was designed to measure, for example dental/oral care as perceived by the carers in NSW ACFs. In this case, the researchers found the questionnaire to be valid20.

Results Of the 406 questionnaires posted, 211 (121 in first post and 90 in second post) were returned, which gave a response rate of 52%.

100

Percentage

80

Male Female Total

60 40 20 0

20–30 years 30–40 years 40–50 years

50+ years

Age group

Figure 1 Graph to show carer characteristics.

The demographical questions showed that the carers were mainly female and in the 40- to 50year-age group (Fig. 1) The carers’ country of origin was mainly Australia (62.2%), with other countries such as the Philippines, Fiji, New Zealand, England and Ireland represented. The level of oral health training was considered adequate by 73.2% of carers, although only 66.7% had undertaken formal training of which 50.1% was in-house. Oral care questions found that carers’ duties consisted of cleaning dentures (97.6%), brushing teeth (96.7%), inserting dentures (93.8%), rinsing the mouth (89.1%) and flossing the teeth (11.4%). Carers used different techniques to care for residents’ dentures (Fig. 2), with only 19% of carers using the method of cleaning dentures with unscented soap and water. Greater than 90% of carers reported assisting residents in all aspects of cleaning and maintaining teeth/dentures, with 25.7% of the respondents stating that they were not given enough time for these duties. Dentures were cleaned with denture cleaner by 72% of carers, and a denture brush was used by 72.5% of carers, while a tongue cleaner and a mouth rinse were used by 29.9% and 19.4% of carers, respectively. Carers showed a limited knowledge of dental products (Fig. 3) When questioned about factors that influence oral care in their ACF, carers chose ‘Long waiting periods for Government dental services/domiciliary dental care’ (69.4%) and ‘Residents unable to communicate oral health problems’ (69.2%) as the two most important. Similarly, the two most chosen comments regarding concerns with resi-

100

Percentage

80

60

40

20

0

Rinsing w/water

Soaking - cleaner

Soaking - sterilizer

Brushing w/soap

Figure 2 Graph to show carers’ different methods of cleaning residents’ dentures. © 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2015; 32: 254–259

Dental care in NSW aged care facilities

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Disclosing tablets Dry mouth relief Other products Denture container Electric toothbrush Fluoride gel Biteblock/mouthprop Gum Tx Interdental brush 0

20

40

60

80

100

Percentage Figure 3 Percentage of carers who use different dental products.

dent’s ability to eat were ‘Poor mental health, for example dementia’ (85.2%) and ‘Poor oral health where residents cannot chew the food’ (59.8%). Carers (70.6%) considered it ‘important that the resident be able to chew the food’. The carers were eager to receive further training and identified six areas: effect of medication on oral health; oral management of cognitively impaired residents; recognition of ‘gum’ diseases; recognition of oral diseases; detection of oral cancer; and recognition of tooth ‘decay’.

Discussion The questionnaire instrument in research is inherently imprecise and will always only reflect the subjective response of the respondents. Respondents may try to give a normative answer or they may give an inaccurate answer. Rowntree explains that with questionnaires, there are many reasons why people may give false information. He states that perfect accuracy in statistical data cannot be expected21. Carers agreed with the DONs that residents did not have the ability to communicate their dental problems to staff and that there was a lack of government services available for older people. Carers considered that resident non-compliance prevented them from providing good oral health to residents in their care, whereas the DONs were concerned with mobility issues in obtaining dental services. This was a reflection of the difficulties experienced by carers in providing good oral health to residents. Yet, when answering ques-

tions taken from Vigild’s22 research concerning dental/oral health in ACFs, only 52.6% of carers wanted specialised oral care staff in ACFs. However, less than three-quarters of carers agreed that it was important for residents to be able to chew facility food, and this was reinforced by 59.2% of carers. In the same research, 60.7% of carers agreed that it takes considerable time and patience to deliver good oral care to residents. Over half of carers agreed that the appearance of natural teeth or dentures meant a lot to residents, and less than half considered that oral care for residents should be a public obligation. A very small percentage of carers agreed that oral care for residents should be the responsibility of the residents or their families (Table 1). This study provided key information about the carers’ perception of the delivery of dental care, resident dental health needs, the importance of dental care and the problems experienced by carers in providing adequate dental hygiene in ACFs. A flow-on from this research is the expected development of improved guidelines and training regimes involving a holistic approach to oral health delivery that could be adopted by ACFs, nursing and dental schools. In line with the NSW Government’s initiative to improve dental services in the State, the data from this, and our previous study involving the perceptions of the DONs of NSW ACFs, could be used to lobby for better state provision/support of dental/oral health care for our ageing population. These data could also be provided to State and Federal Branches of the Australian Dental Associa-

© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2015; 32: 254–259

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Table 1 Percentage of carers who rated the statements in relation to caring for oral health.

Statements It is of importance for the resident to be able to chew the food The appearance of teeth or dentures mean a lot to the residents It takes considerable time and patience to care for oral or denture problems in aged residents. Oral care for elderly residents should be a public obligation Oral care or denture care should be the responsibility of the residents themselves or their families. It would be a good idea to have specific oral care staff (dentists/hygienists/technicians) attached to the residential care.

Totally agree

Agree somewhat

Disagree somewhat

Totally disagree

70.62

20.85

3.79

0.95

3.79

56.40

30.81

8.06

1.42

3.32

60.66

30.81

6.16

1.42

0.95

42.65 8.06

27.96 22.27

9.00 34.60

4.27 29.86

16.11 5.21

52.61

26.54

8.06

5.69

7.11

Don’t know

Source: Vigild M. Oral health in institutionalised elderly. Tandlaegebladet 1990 Mar; 94(5):169–194.

tion (ADA) and to dental societies interested in geriatric care, such as the Australian Society for Special Care in Dentistry (ASSCID) and the International Association for Disability and Oral Health (iADH). The results have shown an urgent need for training of carers in geriatric dental care techniques and the use of dental products. These facts agree with the findings of King, Sanders et al., Vigild, Frenkel et al. and Reed et al. mentioned earlier. The carers in the current research were interested in receiving further training in the six areas previously mentioned as well as care of natural teeth, care of dentures, recognition of plaque/calculus and recognition of dry mouth. A limitation to this study was that the researchers could not contact the carers directly as protocol demanded that all correspondence be mailed to the DONs. This limitation was beyond our control,

References 1. King PL. Oral Health Needs of the Elderly. NSW Public Health Bull 1999; 10: 96–7. 2. King PL. New teeth for old. Bite 2007; 1a, 15–8. 3. Sanders AE, Slade GD, Carter KD, Stewart JF. Trends in prevalence of complete tooth loss among Australians, 1979–2002. Aust N Z J Public Health 2004; 28: 549–54. 4. Vigild M. National survey of oral health care in Danish nursing homes. Gerodontics 1986; 2: 186–9. 5. Vigild M. Oral hygiene and periodontal conditions among 201 dentate institutionalized elderly. Gerodontics 1988; 4: 140–5. 6. Wardh I, Sorensen S. Development of an index to measure oral health care priority among nurs-

however, a response rate of 52% was considered adequate for the study. Future research will include an investigation into the residents’ perception of dental care as compared to the observations of a clinician during a basic dental examination.

Acknowledgements This project was supported by the Australian Dental Research Foundation Inc. and the Australian Prosthodontic Society NSW and approved by The University of Sydney Human Research Ethics Committee. Thanks are due to all the aged care facility carers and Directors of Nursing who participated in this study and to Dr A Lee for reading the manuscript and offering helpful advice.

ing staff. Gerodontology 2005; 22: 84– 90. 7. Frenkel H, Harvey I, Newcombe RG. Oral health care among nursing home residents in Avon. Gerodontology 2000; 17: 33–8. 8. Frenkel HF, Harvey I, Newcombe RG. Improving oral health in institutionalised elderly people by educating caregivers: a randomised controlled trial. Community Dent Oral Epidemiol 2001; 29: 289–97. 9. Reed R, Broder HL, Jenkins G, Spivack E, Janal MN. Oral health promotion among older persons and their care providers in a nursing home facility. Gerodontology 2006; 23: 73–8. 10. Vigild M. Oral mucosal lesions among institutionalized elderly in Denmark. Commun Dent Oral Epidemiol 1987; 15: 309–13.

11. Chalmers JM, Levy SM, Buckwalter KC, Ettinger RL, Kambhu PP. Factors influencing nurses’ aides’ provision of oral care for nursing facility residents. Spec Care Dentist 1996; 16: 71–9. 12. Chalmers JM. Geriatric oral health issues in Australia. Int Dent J 2001; 51: 188–99. 13. Paley GA, Slack-Smith LM, O’Grady MJ. Aged care staff perspectives on oral care for residents: Western Australia. Gerodontology 2004; 21: 146–54. 14. Paley GA, Slack-Smith LM, O’Grady MJ. Oral health issues in aged care facilities in Western Australia: resident and family caregiver views. Gerodontology 2009; 26: 97–104. 15. Australian Bureau of Statistics. Source: Population Projections, Australia, 2006 to 2101 (3222.0) 57

© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2015; 32: 254–259

Dental care in NSW aged care facilities 16. Australian Bureau of Statistics. Australian Demographic Statistics Dec. 2006 3101.0 17. Chalmers JM, Carter KD, Spencer AJ. Caries incidence and increments in Adelaide nursing home residents. Spec Care Dentist 2005; 25: 96–105. 18. Edwards P, Roberts I, Clarke M, Diguiseppi C, Pratap S, Wentz R et al. Methods to increase response rates to postal questionnaires. Cochrane Database Syst Rev 2007; (2). 19. Hayllar B, Veal T. Pathways to Research. In: Hammat M ed. Chapter

6: Asking People: Questionnaire Surveys. Port Melbourne, Victoria, Australia: Rigby Heinemann, 1996: 63–4. 20. http://www.ehow.com/info_ 8421878_questionnaire-validationmethods.html 21. Rowntree D. Statistics without Tears. In: Chapter 2: Describing our Sample. London: Penguin Books, 1991: 34–5. 22. Vigild M. Oral health in institutionalized elderly. Tandlaegebladet 1990; 94: 169–94.

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Correspondence to: Dr BC Webb, Honorary Senior Lecturer, Jaw Function and Orofacial Pain Research Unit, Level 2, Westmead Centre for Oral Health, Darcy Road, Westmead 2145 NSW Australia. Tel.: +612 9845 7734 Fax: +612 9633 2893 E-mail: bettine.webb@sydney. edu.au

© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2015; 32: 254–259

Provision of dental care in aged care facilities NSW Australia- Part 2 as perceived by the carers (care providers).

To investigate carers' perception of the provision of dental care in aged care facilities (ACFs) New South Wales (NSW), Australia...
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