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Turkish Nurses’ Attitudes and Practices Regarding Oral Care Hüsna Özveren, PhD, MSc, and Dilek Özden, PhD, MSc Hüsna Özveren, PhD, MSc, is an Assistant Professor at the Nursing Department, Faculty of Health Sciences, Kirikkale University, Kirikkale, Turkey, and Dilek Özden, PhD, MSc, is an Assistant Professor at the Nursing Department, Faculty of Health Sciences, Dokuz Eylül University, Izmir, Turkey.
Search terms: Nurse, oral care, professional practice Author contact: [email protected], with a copy to the Editor: [email protected]
PURPOSE: This study was conducted to determine the attitudes and practices of nurses working in intensive care units of four different hospitals regarding oral care. METHODS: One hundred eighty-five nurses who worked in adult intensive care units comprised the sample of this cross-sectional descriptive study. CONCLUSION: It can be said that intensive care nurses perform oral care without an oral care protocol and assessment guideline, and that the methods and frequency of oral care and solutions and tools used for oral care differ from one institution to another. IMPLICATIONS FOR NURSING PRACTICE: The results emphasized the need for continuing training in this area. AMAÇ: Bu aras¸tırma, dört farklı hastanede yog ˘ un bakım ünitelerinde çalıs¸an hems¸irelerin ag ˘ ız bakımına ilis¸kin tutum ve uygulamalarını saptamak amacıyla yapılmıs¸tır. YÖNTEM: Kesitsel tanımlayıcı tipteki bu çalıs¸manın örneklemini yetis¸kin yog ˘ un bakım ünitelerinde çalıs¸an 185 hems¸ire olus¸turmus¸tur. Verilerin deg ˘ erlendirilmesinde yüzdelik dag ˘ ılım ve ki-kare testi kullanılmıs¸tır. SONUÇ: Yog ˘ un bakım hems¸irelerinin deg ˘ erlendirme rehberi ve protokolü olmadan ag ˘ ız bakımı yaptıg ˘ ı, ag ˘ ız bakım yöntem, sıklık, solüsyon ve araçlarının kurumlara göre farklılık gösterdig ˘ i söylenebilir. HEMS ¸˙I RELI˙ K UYGULAMALARI ˙I ÇI˙ N ÖNERI˙ LER: Sonuçlar bu alanda sürekli eg ˘ itime ihtiyaç oldug ˘ unu vurgulamaktadır.
Oral care is an essential and integral part of the nursing care provided to ensure cleanliness and moisture of the oral mucosa (Abidia, 2007; Chan & Ng, 2012; Costello & Coyne, 2008; Cutler & Davis, 2005; Yeung & Chui, 2010). Patients staying in intensive care units (ICUs) are exposed to oral health problems more than patients staying in other clinics due to reasons such as immune suppression, intubation, high-dose drug and oxygen therapy, not being able to take liquid or food orally, reduction in saliva secretion, and not being able to perform oral care themselves (Chan & Ng, 2012; Cutler & Davis, 2005; Kozier, Berman, Snyder, & Erb, 2008; McNeill, 2000; Türk, Güler, Eser, & Khorshid, 2012). In addition, due to the presence of the endotracheal tube, patients’ mouths remain open permanently; thus, bacteria can easily enter the airways, and the impaired cough reflex and mucociliary activity may lead to an increase in secretion. In this case, Gram-positive bacteria forming the normal flora of the oral mucosa are replaced by Gram-negative bacteria, which leads to plaque formation on the tooth surface and changes in the oral flora (Augustyn, 2007; © 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 26, No. 4, October 2015
Berry, Davidson, Rolls, & Masters, 2007; Harris & Miller, 2000; Munro & Grap, 2004). Changes in the oral flora increase the risk of developing ventilator-associated pneumonia (VAP) in patients staying in ICUs (Chan & Ng, 2012; Yeung & Chui, 2010). In the literature, it has been reported that 22.8% of patients receiving mechanical ventilation developed VAP and that the mortality rate was between 24.0% and 50.0%. The development of VAP increases the duration of mechanical ventilation 10 more days and the length of stay in the ICU 6.5 more days (Augustyn, 2007; Munro & Grap, 2004; Safdar, Dezfulian, Collard, & Saint, 2005). Therefore, it is extremely important for nurses to provide and maintain oral care for patients staying in ICUs in order to prevent oral health problems and VAP (Lin, Chang, Chang, & Lou, 2011; Soh, Soh, Japar, Raman, & Davidson, 2012). Poor oral care can deteriorate the integrity of oral tissue and lead to halitosis, dryness of the mouth, an increased risk of bacteremia, and respiratory tract infections, all of which ultimately cause pain and discomfort to the person (Chan & Ng, 2012; McNeill, 2000; 163
Turkish Nurses’ Attitudes and Practices Regarding Oral Care O’Reilly, 2003; Türk et al., 2012). The development of these problems extends the length of stay in ICUs, and thus may lead to increased cost and mortality rate (Cutler & Davis, 2005). Hence, nurses working in ICUs can reduce the risk of complications and the development of VAP by conducting regular oral assessment and implementing evidence-based oral care (Abidia, 2007; Cutler & Davis, 2005; Feider, Mitchell, & Bridges, 2010; Ganz et al., 2009; Katherason et al., 2009; Rello et al., 2007).
Literature Review Several studies reported that materials and solutions used in oral care differ from one clinic to another (Binkley, Furr, Carrico, & McCurren, 2004; Rello et al., 2007; Türk et al., 2012), that nurses do not implement oral care in accordance with recommendations based on the results of the latest research (Ganz et al., 2009; Grap, Munro, Ashtiani, & Bryant, 2003; Johnstone, Spence, & McClain, 2010; Stout, Goulding, & Powell, 2009), and that they lack knowledge to assess oral care (Johnstone et al., 2010; Stout et al., 2009; Thurgood, 1994; White, 2000). In the international literature, there are a lot of studies conducted to determine intensive care nurses’ knowledge, attitude, and practices regarding oral care (Chan & Ng, 2012; Costello & Coyne, 2008; Ganz et al., 2009; Grap et al., 2003; Johnstone et al., 2010; Stout et al., 2009; Yeung & Chui, 2010). On the other hand, in our country, there has been only one study conducted to determine intensive care nurses’ practices regarding oral care (Türk et al., 2012). In Türk et al.’s study (2012), the methods and frequency of oral care implemented by intensive care nurses differed from one nurse to another, and that oral care was not performed in accordance with recommendations based on the results of the latest research. However, they did not give any information about nurses’ attitudes toward oral care. Thus, in our country, there is a need for studies investigating oral care practices and attitudes of nurses working in ICUs in different hospitals. This study was conducted to determine the attitudes and practices of nurses working in ICUs of four different hospitals regarding oral care.
Method Setting and Sample The study was carried out in the adult ICUs of four training and university hospitals located in four provinces of Turkey. The population of this study consisted of 230 nurses working in the adult ICUs of four training and university hospitals that are located in four provinces in the Central Anatolia region of Turkey between April 20, 2012 and June 20, 2012. Of these 230 nurses, 185 who agreed to participate in the study comprised the study sample. The participation rate was 80.43%. 164
H. Özveren and D. Özden
Instrument The study is a cross-sectional descriptive study. The data were collected through a questionnaire prepared by the researchers based on the literature (Binkley et al., 2004; Grap et al., 2003; McNeill, 2000; Munro & Grap, 2004; O’Reilly, 2003; Rello et al., 2007; Soh et al., 2012). The questionnaire consists of three sections: The first section includes 11 questions to determine nurses’ age, gender, marital status, educational level, total length of service, the clinic they are working in, the number of patients nurses provide care for, and the method that nurses use at work. The second section comprises 12 questions that determine the most frequent nursing care practices performed in ICUs, daily evaluation of oral care, performing oral care regularly, implementing oral assessment guidelines and standards, methods, frequency, tools, and solutions regarding oral care. The third section comprises 10 questions to determine the attitudes of nurses, with the following possible responses: I agree, I disagree, or I am undecided. Data Collection After the questionnaire was prepared, it was given to 10 nurses who were not included in the study between December 15, 2012 and December 21, 2012. Questions considered incomprehensible, unclear, or badly prepared were revised, and then the study was conducted. Each nurse was instructed how to respond to the questions in the questionnaire and then asked to fill in the questionnaire in their clinical environment. It took approximately 20 min to fill in the questionnaire. The participating nurses completed the questionnaire between April 20, 2012 and June 20, 2012. Ethical Considerations Before the study was carried out, the written permissions of the hospitals where the study was to be conducted and the approval of the ethics committee (Decision No: 2012-01/13) were obtained. The nurses were first told that it was entirely their own decision whether to participate in the study, that they should not write their names on the questionnaire, that the data gathered in this study would only be used within the scope of the study, and that confidentiality was definitely ensured, and then their verbal informed consents were obtained. Data Analysis The data were evaluated with the SPSS 18.00 computer program (SPSS Inc., Chicago, IL, USA), the percentage distribution, and the chi-square test.
H. Özveren and D. Özden
Turkish Nurses’ Attitudes and Practices Regarding Oral Care
Table 1. Distribution of How Intensive Care Nurses Perform Oral Care and How They Implement Oral Assessment Guidelines and Protocol (n = 185) Hospital A (n = 70)
Hospital B (n = 58)
Hospital C (n = 21)
Hospital D (n = 36)
Total (n = 185)
Statistical evaluationa
n
n
%
n
%
n
%
n
%
χ2; p
57.1 42.9
58 0
100 .0
21 0
100 .0
25 11
69.4 30.6
144 41
77.8 22.2
χ2 = 41.342; p = .001
.0 100
1 57
1.7 98.3
0 21
.0 100
1 35
2.8 97.2
2 183
1.1 98.9
χ2 = 2.188; p = .534
74.3 12.9 12.9
19 39 0
32.8 67.7 .0
3 18 0
14.3 85.7 .0
25 11 0
69.4 30.6 .0
99 77 9
53.5 41.6 4.9
χ2 = 66.775; p = .001
51.4 48.6
58 0
100.0 .0
20 1
95.2 4.8
25 11
69.4 30.6
139 46
75.1 24.9
χ2 = 45.418; p = .001
%
Oral assessment Was done 40 Was not done 30 Oral assessment guidelines Used 0 Not used 70 Oral care protocol Not present 52 Present and used 9 Present but not used 9 Regularly oral care Was performed 36 Was not performed 34 a
The chi-square test was performed.
All of the nurses working in the ICUs of hospital B (Erciyes University Hospital) and hospital C (Gaziosmanpas¸a University Hospital), 57.1% of the nurses working in hospital A (Cumhuriyet University Hospital), and 69.4% of the nurses working in hospital D (Ankara Dıs¸kapı Teaching Hospital) said that they performed oral assessment. Almost all of the nurses (98.9%) working in the intensive care clinics in all of the four hospitals reported that they did not use oral assessment guidelines (Table 1). Of the nurses, 53.5% said that their clinics did not have a standard oral care protocol, 41.6% said that their clinics had an oral care protocol and they implemented it, and 4.9% reported that although there was an oral care protocol in their clinics they did not implement it. The statistical evaluation revealed a statistically significant difference between the hospitals in terms of performing oral care, oral assessment regularly, and the implementation of oral care protocol (p = .001) (Table 1).
86.1% of the nurses in hospital D said that they used solution for oral care, and more than half of the nurses (55.2%) in hospital B reported that they used the toothbrushing method. When the frequency of oral care provided by hospitals was evaluated, it was found that 71.4% of the nurses in hospital A performed oral care when necessary, 76.2% of the nurses in hospital C three times a day, half of the nurses (50.0%) in hospital B every 6 hr, and 38.9% of the nurses in hospital D twice a day. The statistical evaluation revealed a statistically significant difference between the hospitals in terms of the methods used for oral care and of the frequency of providing oral care (p = .001) (Table 2). More than half of the nurses in all of the four hospitals used a depressor wrapped in gauze for oral care, whereas 69.0% of the nurses in hospital B and 85.7% of the nurses in hospital C used a sponge stick. Very few nurses said that they used suction foam swabs for oral care (11.9%). There was a statistically significant difference between the hospitals in terms of using foam swabs, suction toothbrushes, mouthwash, toothpaste and brushes, and suction foam swabs for oral care (p = .001); however, the difference was not statistically significant in terms of using a depressor wrapped in gauze (p = .192). Most of the nurses in all of the four hospitals used sodium bicarbonate solution for oral care, whereas 72.4% of the nurses in hospital B and 71.4% of the nurses in hospital C used chlorhexidine solution. The statistical evaluation revealed that there was a significant difference between the hospitals in terms of the types of solutions (sodium bicarbonate, chlorhexidine, distilled water, lip moisturizer) used for oral care (p < .05) (Table 2).
Oral-Care Related Practices by Nurses
Nurses’ Perception of Oral Care
All the nurses in hospital C (100.0%), 92.9% of the nurses in hospital A, 44.8% of the nurses in hospital B, and
When the nurses’ responses regarding oral care given in Table 3 were evaluated, it was determined that 76.2% of
Results The nurses’ mean age was X = 29.42 ± 6.06 years. Of the nurses, 83.2% were female, 65.4% had undergraduate education, 74.0% had a length of service ranging between 1 and 10 years, 33.7% worked in the ICU of an internal diseases department, 18.4% worked in the ICU of a general surgery department, and 78.9% had training on oral hygiene. Nurses stated that they carried out mostly oral care (30.8%) after intravenous catheter care (33.0%) in the ICU. Nurses’ Knowledge and Attitudes Toward Oral Care
165
Turkish Nurses’ Attitudes and Practices Regarding Oral Care
H. Özveren and D. Özden
Table 2. Practices Regarding Nurses’ Oral Care
Oral care Methodsa Wiping with solution Brushing teeth Just rinsing Frequency When necessary Three times a day Two times a day Once a day Every 6 hr Toolsa A depressor wrapped in gauze Foam swab Suction toothbrush Mouthwash Toothpaste and brush Suction foam swab Solutionsa Sodium bicarbonate Chlorhexidine Moisturizing agents Saline Hydrogen peroxide a
Hospital A (n = 70)
Hospital B (n = 58)
Hospital C (n = 21)
Hospital D (n = 36)
Total (n = 185)
Statistical evaluationb
n
%
n
%
n
%
n
n
%
χ2; p
65 2 3
92.9 2.9 4.3
26 32 0
44.8 55.2 .0
21 0 0
100.0 .0 .0
31 2 3
86.1 5.6 8.3
171 40 15
92.4 21.6 8.1
χ2 = 73.131; p = .001
50 2 6 12 0
71.4 2.9 8.6 17.1 .0
8 7 11 3 29
13.8 12.1 19.0 5.2 50.0
4 16 1 0 0
19.0 76.2 4.8 .0 .0
8 9 14 2 3
22.2 25.0 38.9 5.6 8.3
70 34 32 17 32
37.8 18.4 17.3 9.2 17.3
χ2 = 159.840; p = .001
42
60.0
35
60.3
8
38.1
24
66.7
109
58.9
χ2 = 4.737; p = .192
14 6 4 8 9
20.0 8.6 5.7 11.4 12.9
40 30 19 14 21
69.0 51.7 32.8 24.1 36.2
18 0 5 1 3
85.7 .0 23.8 4.8 14.3
22 0 3 3 6
61.1 .0 8.3 11.4 16.7
94 36 31 26 39
50.8 19.5 16.8 14.1 21.0
χ2 χ2 χ2 χ2 χ2
= = = = =
46.000; p = .001 57.591; p = .001 19.346; p = .001 7.759; p = .001 11.826; p = .008
52 3 4 5 2
74.3 4.3 5.7 7.1 2.9
31 42 32 4 4
53.4 72.4 55.2 6.9 6.9
13 15 10 2 0
61.9 71.4 47.6 9.5 .0
32 11 15 9 5
88.9 30.6 41.7 25.0 13.9
128 71 61 20 11
69.2 38.4 33 10.8 5.9
χ2 χ2 χ2 χ2 χ2
= = = = =
14.671; p = .002 73.44; p = .001 39.737; p = .001 9.451; p = .024 6.67; p = .083
%
More than one answer was marked. The chi-square test was performed.
b
the nurses agreed with the statement “Oral care should certainly be performed in intensive care units strictly.” Of the nurses, 93.0% agreed with the statement “Oral care should take precedence for patients in intensive care units”; 88.6% agreed with the statement “Standard oral care protocols should be implemented to patients staying in intensive care units”; 73.5% agreed with the statement “Oral problems and mechanical ventilator-associated pneumonia (VAP) can be prevented when patients in intensive care units are given oral care”; and 68.1% agreed with the statement “Cleaning oral cavities is an unpleasant task” (Table 3). Discussion Oral assessment is the most important step in planning effective oral care. Good oral care starts with an appropriate assessment (Binkley et al., 2004; White, 2000). In this study, it was found that the majority of nurses (77.8%) evaluated patients’ mouths in their clinics daily, but that approximately half of the nurses working in ICUs of two hospitals (A and D) did not perform oral assessment and that the difference between the hospitals was statistically significant (Table 1). This finding is important since it indicates that there is a significant difference between the hospitals in performing oral assessment. It is striking that while some of the nurses stated that they evaluated 166
patients’ mouths in their clinics daily, almost all of them (98.9%) said that they did not use oral assessment guidelines (Table 1). Several studies in the literature also report that nurses do not use oral assessment guidelines for oral assessment (Berry et al., 2007; Jones, Newton, & Bower, 2004; Yeung & Chui, 2010). This was due to the fact that nurses lacked knowledge and time regarding oral assessment tools, and that it was not easy to use these oral assessment tools (Adams, 1996; Furr, Binkley, McCurren, & Carrico, 2004). It is important to use a standard oral care protocol in ICUs developed by institutions themselves. When these protocols are implemented, not only are patients given regular and proper oral care, but also the incidence of oral problems and VAP is minimized, differences between nurses regarding oral care practice are eliminated, and the quality of nursing care is improved because implementation of the protocols prevents nurses from spending unnecessary time and energy (Özveren, 2010; Soh et al., 2012). Schleder, Stott, and Lloyd (2002) stated that the use of protocol, including toothbrushing, increased nurses’ compliance with oral care, and thus reduced the incidence of VAP. A large number of the nurses (88.6%) who participated in our study noted that intensive care clinics should have an oral care protocol (Table 3). A great number of nurses working in ICUs of hospitals B and C stated that there was an
H. Özveren and D. Özden
Turkish Nurses’ Attitudes and Practices Regarding Oral Care
Table 3. Nurses’ Statements on the Implementation of Oral Care (n = 185) I agree
Oral care should certainly be performed in intensive care units. Oral care should take high priority for patients in intensive care units. Standard oral care protocols should be implemented to patients staying in intensive care units. Oral cavities are difficult to clean. Cleaning oral cavities is an unpleasant task. Oral care is not my job to do. I did not do enough training to make oral care. The mouths of most mechanical ventilated patients get worse no matter what I do. A dentist can perform oral care instead of me. Oral problems and mechanical ventilator-associated pneumonia (VAP) can be prevented when patients in intensive care units are given oral care.
oral care protocol in their hospitals and they implemented it, whereas the nurses working in ICUs of hospitals A and D stated that their hospitals lacked an oral care protocol. The difference between the hospitals was found to be significant (Table 1). In line with these findings, it can be said that while some of the hospitals have oral care protocols, others do not have one and that these protocols are not implemented in ICUs by nurses. However, studies indicate that solutions, tools, and methods used for oral care by nurses differ from one nurse to another due to lack of evidence-based oral care protocols in hospitals (Fitch, Munro, Glass, & Pellegrini, 1999; Grap et al., 2003; Soh et al., 2012). Our study demonstrated that the methods used by nurses in oral care were not based on the latest research evidence, that a great number of nurses (92.4%) performed oral care by cleansing the mouth with solution, and half of the nurses (58.9%) achieved this cleansing with a depressor wrapped in gauze and the other half (50.8%) with a foam swab, and that there was not a significant difference between hospitals (Table 2). Although there is evidence in the literature that toothbrushing is the best method to remove dental plaque in ICU patients (Abidia, 2007; Berry et al., 2007; Chan & Ng, 2012; McNeill, 2000; Pearson & Hutton, 2002), in our study it was observed that this method was not used much (21.6%). Performing oral care with a depressor wrapped in gauze is a traditional method used in clinics. In their study, Türk et al. (2012) reported that, of the intensive care nurses, 49.5% performed oral care with a depressor wrapped in gauze and 82.2% with foam swabs, which is in line with our findings. In their studies, Grap et al. (2003), Binkley et al. (2004), and Chan and Ng (2012) reported that foam swabs were widely used for oral care in ICUs. The reason why nurses prefer foam swabs for oral care in ICUs might be due to the fact that foam swabs are easy to use and cheap. However, several studies report that although foam swabs are effective for the stimulation of mucosal tissue in the mouth, they are ineffective in removing dental plaque (Abidia, 2007; Pearson & Hutton, 2002; Soh et al., 2012).
I disagree
I am undecided
n
n
%
n
%
%
141 172 164
76.2 93.0 88.6
5 2 12
2.7 1.1 6.5
39 11 9
21.1 5.9 4.9
132 126 53 76 90
71.4 68.1 28.6 41.1 48.6
39 41 117 97 68
21.1 22.2 63.2 52.4 36.8
14 18 15 12 27
7.6 9.7 8.1 6.5 14.6
61 136
33.0 73.5
99 18
53.5 9.7
25 31
13.5 16.8
Although there are several recommendations related to the use of oral care tools and solutions in the literature, in the hospitals and ICUs where we conducted our study, traditional methods were still in use and there were differences between these hospitals regarding oral care practices. In this study, nurses mostly used sodium bicarbonate solution (69.2%) for oral care, followed by chlorhexidine solution (38.4%) (Table 2). Several other studies report that sodium bicarbonate is an oral rinse product frequently used in clinics (Binkley et al., 2004; Chan & Ng, 2012; Miller & Kearney, 2001; Türk et al., 2012). These results support the results of our study. In a study by Türk et al. (2012), using sodium bicarbonate solution was the most common way to provide oral care (79.2%), followed by chlorhexidine gel use (9.9%). On the other hand, in Ganz et al.’s study (2009), it was reported that 75.0% nurses used chlorhexidine for oral care. In their study, Rello et al. (2007) found that 61.0% of the healthcare workers performed oral care with chlorhexidine solution. It can be said that factors such as lack of material, the availability of solutions, the hospital’s policy, and nurses’ knowledge and preferences play a role when a nurse decides what kind of solution should be used for oral care. How often oral care should be performed in patients in ICUs is controversial (Abidia, 2007; Çelik, 2006; Cutler & Davis, 2005; Jones et al., 2004; Türk et al., 2012). In some studies (Cutler & Davis, 2005; McNeill, 2000), it is stated that oral care should be performed in patients connected to a mechanical ventilator every 2–4 hr or when necessary. However, according to some other studies (Çelik, 2006; Cutler & Davis, 2005), oral care should be performed every 4–8 hr or 12 hr. In our study too, in line with the literature, nurses’ responses on how often oral care should be performed varied from one nurse to another. While a vast majority of nurses in hospital A said that they performed oral care when necessary, the nurses in hospital C said that they performed it three times a day, and there were differences between the hospitals in terms of the frequency of performing oral care (Table 2). This might be due to the fact 167
Turkish Nurses’ Attitudes and Practices Regarding Oral Care that the hospitals where the study was conducted did not implement oral care assessment guidelines or oral care protocols and that information on the frequency of oral care in the literature is not clear enough or is not based on the results of randomized trials. Costello and Coyne (2008) reported that of the nurses, 21.0% provided oral care every 4 hr, 24.0% twice a day, and 24.0% when necessary. This finding is similar to ours. Türk et al. (2012) reported that 44.5% of the nurses in ICUs provided oral care fewer than four times a day. Nurses’ attitudes toward oral care affect oral care (Yeung & Chui, 2010). In this study, the fact that the majority of nurses (76.2%) stated that oral care should definitely be provided in the clinics (Table 3) is of importance because it indicates that nurses believed in the necessity of oral care and thus performed it. The vast majority of the nurses in our study (75.1%) stated that they provided oral care regularly (Table 1), which supports this finding of ours. This is striking because it indicates that nurses’ positive attitudes toward oral care affect their oral care practices positively. In addition, the fact that the vast majority of the nurses (73.5%) stated that regular oral care can prevent oral problems and VAP is something desired. In their study, Yeung and Chui (2010) found that one of the purposes of the nurses in providing oral care was to prevent VAP. Almost all of the nurses in this study pointed out that oral care should be provided for patients in ICUs in the first place (Table 3), but it was found that it took the second place in conducting nursing care practices. A study performed in Hong Kong and Singapore on nurses’ oral care practices reported that the nurses provided oral care after fulfilling other tasks (Chan & Ng, 2012; Yeung & Chui, 2010). While several studies in the literature (Binkley et al., 2004; Chan & Ng, 2012; Fitch et al., 1999; Grap et al., 2003; Kite & Pearson, 1995; Rello et al., 2007) state that oral care is often neglected, some other studies (Ganz et al., 2009; Grap et al., 2003; Jones et al., 2004) report that providing oral care has a priority. In a study conducted in Turkey, it was stated that 61.3% of ICU nurses performed oral care in the first place (Türk et al., 2012). However, the nurses in our study did not put oral care in the first place, which might be due to the fact that they considered cleaning the inside of the mouth to be a difficult and unpleasant task. Soh et al. (2012) reported that 40.2% of the nurses considered cleaning the oral cavity to be a difficult task. When compared with our results, it is quite noteworthy that the majority of nurses in our study (68.1%) considered oral care to be an unpleasant task and that 71.4% of them thought it was difficult to clean the inside of the mouth. Moreover, almost a similar proportion of nurses both in Soh et al.’s (2012) study and in our study (46.2% and 48.6%, respectively) reported that the mouth worsened in patients connected to the mechanical ventilator no matter what they did for oral care (Table 3). This finding is very important since it indicates that almost half of the nurses (48.6%) did not believe in the effectiveness of oral care. 168
H. Özveren and D. Özden Conclusion
This study demonstrated that ICU nurses performed oral care without oral care assessment guidelines or an oral care protocol, that the frequency of oral care, methods, and solutions used for oral care varied from one hospital to another, and that they did not use evidence-based guidelines. “Patients in intensive care units have the priority to receive oral care,” “standard oral care protocols should be implemented to patients staying in intensive care units,” and “if patients in intensive care units receive oral care, oral problems and mechanical ventilator associated pneumonia decrease.” It is determined that nurses agreed with these statements in a high rate. In line with our study findings, it can be proposed that in our country, education programs should be provided for nurses to improve their knowledge, attitudes, and practices regarding oral care, that oral care guidelines should be prepared, used, and periodically evaluated, and that observation studies should be performed in different populations. References Abidia, R. (2007). Oral care in the intensive care unit: A review. Journal of Contemporary Dental Practice, 8, 1–8. Adams, R. (1996). Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. Journal of Advanced Nursing, 24, 552–560. Augustyn, B. (2007). Ventilator-associated pneumonia. Critical Care Nurse, 4, 32–39. Berry, A., Davidson, P., Rolls, K., & Masters, J. (2007). Systematic literature review of oral hygiene practices for intensive care patients receiving mechanical ventilation. American Journal of Critical Care, 16, 552–562. Binkley, C., Furr, E., Carrico, R., & McCurren, C. (2004). Survey of oral care practices in us intensive care units. American Journal of Infection Control, 32, 161–169. Çelik, S. (2006). Mechanical ventilation of the patient care. Journal of Intensive Care Nursing, 10, 19–25. Chan, E. Y., & Ng, H. L. I. (2012). Oral care practices among critical care nurses in Singapore: A questionnaire survey. Applied Nursing Research, 25, 197–204. Costello, T., & Coyne, I. (2008). Nurses’ knowledge of mouth care practices. British Journal of Nursing, 17, 264–268. Cutler, C., & Davis, N. (2005). Improving oral care in patients receiving mechanical ventilation. American Journal of Critical Care, 14, 389–394. Feider, L. L., Mitchell, P., & Bridges, E. (2010). Oral care practices for orally intubated critically ill adults. American Journal of Critical Care, 19, 175– 183. Fitch, J., Munro, C., Glass, C., & Pellegrini, J. (1999). Oral care in the adult intensive care unit. American Journal of Critical Care, 8, 314–318. Furr, L. A., Binkley, C. J., McCurren, C., & Carrico, R. (2004). Factors affecting quality of oral care in intensive care units. Journal of Advanced Nursing, 48, 454–462. Ganz, F. D., Fink, N. F., Raanan, O., Asher, M., Bruttin, M., & Benbinishty, J. (2009). ICU nurses’ oral-care practices and current best evidence. Journal of Nursing Scholarship, 41, 132–138. Grap, M., Munro, C., Ashtiani, B., & Bryant, S. (2003). Oral care interventions in critical care: Frequency and documentation. American Journal of Nursing, 12, 113–119. Harris, J., & Miller, T. (2000). Preventing nosocomial pneumonia: Evidencebased practice. Critical Care Nurse, 20, 51–66. Johnstone, L., Spence, D., & McClain, J. K. (2010). Oral hygiene care in the pediatric intensive care unit: Practice recommendations. Pediatric Nursing, 36, 85–97. Jones, H., Newton, J. T., & Bower, E. J. (2004). A survey of the oral care practices of intensive care nurses. Intensive and Critical Care Nursing, 20, 69–76.
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Katherason, S. G., Naing, L., Jaalam, K., Musa, K. I., Nik Abdullah, N. M., Aiyar, S., . . . Ismail, A. (2009). Ventilator associated nosocomial pneumonia in intensive care units in Malaysia. Journal of Infection in Developing Countries, 3, 704–710. Kite, K., & Pearson, L. (1995). A rationale for mouth care: The integration of theory with practice. Intensive and Critical Care Nursing, 11, 71–76. Kozier, B., Berman, A., Snyder, S., & Erb, G. (2008). Fundamentals of nursing concepts, process and practice (8th ed.). Upper Saddle River, NJ: Prentice Hall. Lin, Y. S., Chang, J. C., Chang, T. H., & Lou, M. F. (2011). Critical care nurses’ knowledge, attitudes and practices of oral care for patients with oral endotracheal intubation: A questionnaire survey. Journal of Clinical Nursing, 20, 3204–3214. McNeill, H. (2000). Biting back of poor oral hygiene. Intensive and Critical Care Nursing, 16, 362–367. Miller, M., & Kearney, N. (2001). Oral care for patients with cancer: A review of the literature. Cancer Nursing, 24, 241–254. Munro, C. L., & Grap, M. J. (2004). Oral health and care in the intensive care unit: State of science. American Journal of Critical Care, 13, 25–33. O’Reilly, M. (2003). Oral care of the critically ill: A review of the literature and guidelines for practice. Australian Critical Care, 16, 101–110. Özveren, H. (2010). Oral care in patients receiving mechanical ventilator. Hacettepe University Faculty of Health Sciences Nursing Journal, 17, 92–99. Pearson, L., & Hutton, J. (2002). A controlled trial to compare the ability of foam swabs and toothbrushes to remove dental plaque. Journal of Advanced Nursing, 39, 480–489.
Rello, J., Koulenti, D., Blot, S., Sierra, R., Diaz, E., Waela, J., . . . Rodriguez, A. (2007). Oral care practices in intensive care units: A survey of 59 European ICUs. Intensive Care Medicine, 33, 1066–1070. Safdar, N., Dezfulian, C., Collard, H., & Saint, S. (2005). Clinical and economic consequences of ventilator-associated pneumonia: A systematic review. Critical Care Medicine, 33, 2184–2193. Schleder, B., Stott, K., & Lloyd, R. C. (2002). The effect of a comprehensive oral care protocol on patients at risk for ventilators-associated pneumonia. Journal of Advocate Health Care, 4, 27–30. Soh, K. L., Soh, K. G., Japar, S., Raman, R. A., & Davidson, P. M. (2012). A cross-sectional study on nurses’ oral care practice for mechanically ventilated patients in Malaysia. Journal of Clinical Nursing, 20, 733–742. Stout, M., Goulding, O., & Powell, A. (2009). Developing and implementing an oral care policy and assessment tool. Nursing Standard, 23, 42–48. Thurgood, G. (1994). Nurse maintenance of oral hygiene. British Journal of Nursing, 3, 332–334. Türk, G., Güler, K. E., Eser, I., & Khorshid, L. (2012). Oral care practices of intensive care nurses: A descriptive study. International Journal of Nursing Practice, 18, 347–353. White, R. (2000). Nurse assessment of oral health: A review of practice and education. British Journal of Nursing, 9, 260–266. Yeung, K. Y., & Chui, Y. Y. (2010). An exploration of factors affecting Hong Kong ICU nurses in providing oral care. Journal of Clinical Nursing, 19, 3063–3072.
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Turkish Nurses’ Attitudes and Practices Regarding Oral Care Hüsna Özveren, PhD, MSc, and Dilek Özden, PhD, MSc Hüsna Özveren, PhD, MSc, is an Assistant Professor at the Nursing Department, Faculty of Health Sciences, Kirikkale University, Kirikkale, Turkey, and Dilek Özden, PhD, MSc, is an Assistant Professor at the Nursing Department, Faculty of Health Sciences, Dokuz Eylül University, Izmir, Turkey.
Search terms: Nurse, oral care, professional practice Author contact: [email protected], with a copy to the Editor: [email protected]
PURPOSE: This study was conducted to determine the attitudes and practices of nurses working in intensive care units of four different hospitals regarding oral care. METHODS: One hundred eighty-five nurses who worked in adult intensive care units comprised the sample of this cross-sectional descriptive study. CONCLUSION: It can be said that intensive care nurses perform oral care without an oral care protocol and assessment guideline, and that the methods and frequency of oral care and solutions and tools used for oral care differ from one institution to another. IMPLICATIONS FOR NURSING PRACTICE: The results emphasized the need for continuing training in this area. AMAÇ: Bu aras¸tırma, dört farklı hastanede yog ˘ un bakım ünitelerinde çalıs¸an hems¸irelerin ag ˘ ız bakımına ilis¸kin tutum ve uygulamalarını saptamak amacıyla yapılmıs¸tır. YÖNTEM: Kesitsel tanımlayıcı tipteki bu çalıs¸manın örneklemini yetis¸kin yog ˘ un bakım ünitelerinde çalıs¸an 185 hems¸ire olus¸turmus¸tur. Verilerin deg ˘ erlendirilmesinde yüzdelik dag ˘ ılım ve ki-kare testi kullanılmıs¸tır. SONUÇ: Yog ˘ un bakım hems¸irelerinin deg ˘ erlendirme rehberi ve protokolü olmadan ag ˘ ız bakımı yaptıg ˘ ı, ag ˘ ız bakım yöntem, sıklık, solüsyon ve araçlarının kurumlara göre farklılık gösterdig ˘ i söylenebilir. HEMS ¸˙I RELI˙ K UYGULAMALARI ˙I ÇI˙ N ÖNERI˙ LER: Sonuçlar bu alanda sürekli eg ˘ itime ihtiyaç oldug ˘ unu vurgulamaktadır.
Oral care is an essential and integral part of the nursing care provided to ensure cleanliness and moisture of the oral mucosa (Abidia, 2007; Chan & Ng, 2012; Costello & Coyne, 2008; Cutler & Davis, 2005; Yeung & Chui, 2010). Patients staying in intensive care units (ICUs) are exposed to oral health problems more than patients staying in other clinics due to reasons such as immune suppression, intubation, high-dose drug and oxygen therapy, not being able to take liquid or food orally, reduction in saliva secretion, and not being able to perform oral care themselves (Chan & Ng, 2012; Cutler & Davis, 2005; Kozier, Berman, Snyder, & Erb, 2008; McNeill, 2000; Türk, Güler, Eser, & Khorshid, 2012). In addition, due to the presence of the endotracheal tube, patients’ mouths remain open permanently; thus, bacteria can easily enter the airways, and the impaired cough reflex and mucociliary activity may lead to an increase in secretion. In this case, Gram-positive bacteria forming the normal flora of the oral mucosa are replaced by Gram-negative bacteria, which leads to plaque formation on the tooth surface and changes in the oral flora (Augustyn, 2007; © 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 26, No. 4, October 2015
Berry, Davidson, Rolls, & Masters, 2007; Harris & Miller, 2000; Munro & Grap, 2004). Changes in the oral flora increase the risk of developing ventilator-associated pneumonia (VAP) in patients staying in ICUs (Chan & Ng, 2012; Yeung & Chui, 2010). In the literature, it has been reported that 22.8% of patients receiving mechanical ventilation developed VAP and that the mortality rate was between 24.0% and 50.0%. The development of VAP increases the duration of mechanical ventilation 10 more days and the length of stay in the ICU 6.5 more days (Augustyn, 2007; Munro & Grap, 2004; Safdar, Dezfulian, Collard, & Saint, 2005). Therefore, it is extremely important for nurses to provide and maintain oral care for patients staying in ICUs in order to prevent oral health problems and VAP (Lin, Chang, Chang, & Lou, 2011; Soh, Soh, Japar, Raman, & Davidson, 2012). Poor oral care can deteriorate the integrity of oral tissue and lead to halitosis, dryness of the mouth, an increased risk of bacteremia, and respiratory tract infections, all of which ultimately cause pain and discomfort to the person (Chan & Ng, 2012; McNeill, 2000; 163
Turkish Nurses’ Attitudes and Practices Regarding Oral Care O’Reilly, 2003; Türk et al., 2012). The development of these problems extends the length of stay in ICUs, and thus may lead to increased cost and mortality rate (Cutler & Davis, 2005). Hence, nurses working in ICUs can reduce the risk of complications and the development of VAP by conducting regular oral assessment and implementing evidence-based oral care (Abidia, 2007; Cutler & Davis, 2005; Feider, Mitchell, & Bridges, 2010; Ganz et al., 2009; Katherason et al., 2009; Rello et al., 2007).
Literature Review Several studies reported that materials and solutions used in oral care differ from one clinic to another (Binkley, Furr, Carrico, & McCurren, 2004; Rello et al., 2007; Türk et al., 2012), that nurses do not implement oral care in accordance with recommendations based on the results of the latest research (Ganz et al., 2009; Grap, Munro, Ashtiani, & Bryant, 2003; Johnstone, Spence, & McClain, 2010; Stout, Goulding, & Powell, 2009), and that they lack knowledge to assess oral care (Johnstone et al., 2010; Stout et al., 2009; Thurgood, 1994; White, 2000). In the international literature, there are a lot of studies conducted to determine intensive care nurses’ knowledge, attitude, and practices regarding oral care (Chan & Ng, 2012; Costello & Coyne, 2008; Ganz et al., 2009; Grap et al., 2003; Johnstone et al., 2010; Stout et al., 2009; Yeung & Chui, 2010). On the other hand, in our country, there has been only one study conducted to determine intensive care nurses’ practices regarding oral care (Türk et al., 2012). In Türk et al.’s study (2012), the methods and frequency of oral care implemented by intensive care nurses differed from one nurse to another, and that oral care was not performed in accordance with recommendations based on the results of the latest research. However, they did not give any information about nurses’ attitudes toward oral care. Thus, in our country, there is a need for studies investigating oral care practices and attitudes of nurses working in ICUs in different hospitals. This study was conducted to determine the attitudes and practices of nurses working in ICUs of four different hospitals regarding oral care.
Method Setting and Sample The study was carried out in the adult ICUs of four training and university hospitals located in four provinces of Turkey. The population of this study consisted of 230 nurses working in the adult ICUs of four training and university hospitals that are located in four provinces in the Central Anatolia region of Turkey between April 20, 2012 and June 20, 2012. Of these 230 nurses, 185 who agreed to participate in the study comprised the study sample. The participation rate was 80.43%. 164
H. Özveren and D. Özden
Instrument The study is a cross-sectional descriptive study. The data were collected through a questionnaire prepared by the researchers based on the literature (Binkley et al., 2004; Grap et al., 2003; McNeill, 2000; Munro & Grap, 2004; O’Reilly, 2003; Rello et al., 2007; Soh et al., 2012). The questionnaire consists of three sections: The first section includes 11 questions to determine nurses’ age, gender, marital status, educational level, total length of service, the clinic they are working in, the number of patients nurses provide care for, and the method that nurses use at work. The second section comprises 12 questions that determine the most frequent nursing care practices performed in ICUs, daily evaluation of oral care, performing oral care regularly, implementing oral assessment guidelines and standards, methods, frequency, tools, and solutions regarding oral care. The third section comprises 10 questions to determine the attitudes of nurses, with the following possible responses: I agree, I disagree, or I am undecided. Data Collection After the questionnaire was prepared, it was given to 10 nurses who were not included in the study between December 15, 2012 and December 21, 2012. Questions considered incomprehensible, unclear, or badly prepared were revised, and then the study was conducted. Each nurse was instructed how to respond to the questions in the questionnaire and then asked to fill in the questionnaire in their clinical environment. It took approximately 20 min to fill in the questionnaire. The participating nurses completed the questionnaire between April 20, 2012 and June 20, 2012. Ethical Considerations Before the study was carried out, the written permissions of the hospitals where the study was to be conducted and the approval of the ethics committee (Decision No: 2012-01/13) were obtained. The nurses were first told that it was entirely their own decision whether to participate in the study, that they should not write their names on the questionnaire, that the data gathered in this study would only be used within the scope of the study, and that confidentiality was definitely ensured, and then their verbal informed consents were obtained. Data Analysis The data were evaluated with the SPSS 18.00 computer program (SPSS Inc., Chicago, IL, USA), the percentage distribution, and the chi-square test.
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Turkish Nurses’ Attitudes and Practices Regarding Oral Care
Table 1. Distribution of How Intensive Care Nurses Perform Oral Care and How They Implement Oral Assessment Guidelines and Protocol (n = 185) Hospital A (n = 70)
Hospital B (n = 58)
Hospital C (n = 21)
Hospital D (n = 36)
Total (n = 185)
Statistical evaluationa
n
n
%
n
%
n
%
n
%
χ2; p
57.1 42.9
58 0
100 .0
21 0
100 .0
25 11
69.4 30.6
144 41
77.8 22.2
χ2 = 41.342; p = .001
.0 100
1 57
1.7 98.3
0 21
.0 100
1 35
2.8 97.2
2 183
1.1 98.9
χ2 = 2.188; p = .534
74.3 12.9 12.9
19 39 0
32.8 67.7 .0
3 18 0
14.3 85.7 .0
25 11 0
69.4 30.6 .0
99 77 9
53.5 41.6 4.9
χ2 = 66.775; p = .001
51.4 48.6
58 0
100.0 .0
20 1
95.2 4.8
25 11
69.4 30.6
139 46
75.1 24.9
χ2 = 45.418; p = .001
%
Oral assessment Was done 40 Was not done 30 Oral assessment guidelines Used 0 Not used 70 Oral care protocol Not present 52 Present and used 9 Present but not used 9 Regularly oral care Was performed 36 Was not performed 34 a
The chi-square test was performed.
All of the nurses working in the ICUs of hospital B (Erciyes University Hospital) and hospital C (Gaziosmanpas¸a University Hospital), 57.1% of the nurses working in hospital A (Cumhuriyet University Hospital), and 69.4% of the nurses working in hospital D (Ankara Dıs¸kapı Teaching Hospital) said that they performed oral assessment. Almost all of the nurses (98.9%) working in the intensive care clinics in all of the four hospitals reported that they did not use oral assessment guidelines (Table 1). Of the nurses, 53.5% said that their clinics did not have a standard oral care protocol, 41.6% said that their clinics had an oral care protocol and they implemented it, and 4.9% reported that although there was an oral care protocol in their clinics they did not implement it. The statistical evaluation revealed a statistically significant difference between the hospitals in terms of performing oral care, oral assessment regularly, and the implementation of oral care protocol (p = .001) (Table 1).
86.1% of the nurses in hospital D said that they used solution for oral care, and more than half of the nurses (55.2%) in hospital B reported that they used the toothbrushing method. When the frequency of oral care provided by hospitals was evaluated, it was found that 71.4% of the nurses in hospital A performed oral care when necessary, 76.2% of the nurses in hospital C three times a day, half of the nurses (50.0%) in hospital B every 6 hr, and 38.9% of the nurses in hospital D twice a day. The statistical evaluation revealed a statistically significant difference between the hospitals in terms of the methods used for oral care and of the frequency of providing oral care (p = .001) (Table 2). More than half of the nurses in all of the four hospitals used a depressor wrapped in gauze for oral care, whereas 69.0% of the nurses in hospital B and 85.7% of the nurses in hospital C used a sponge stick. Very few nurses said that they used suction foam swabs for oral care (11.9%). There was a statistically significant difference between the hospitals in terms of using foam swabs, suction toothbrushes, mouthwash, toothpaste and brushes, and suction foam swabs for oral care (p = .001); however, the difference was not statistically significant in terms of using a depressor wrapped in gauze (p = .192). Most of the nurses in all of the four hospitals used sodium bicarbonate solution for oral care, whereas 72.4% of the nurses in hospital B and 71.4% of the nurses in hospital C used chlorhexidine solution. The statistical evaluation revealed that there was a significant difference between the hospitals in terms of the types of solutions (sodium bicarbonate, chlorhexidine, distilled water, lip moisturizer) used for oral care (p < .05) (Table 2).
Oral-Care Related Practices by Nurses
Nurses’ Perception of Oral Care
All the nurses in hospital C (100.0%), 92.9% of the nurses in hospital A, 44.8% of the nurses in hospital B, and
When the nurses’ responses regarding oral care given in Table 3 were evaluated, it was determined that 76.2% of
Results The nurses’ mean age was X = 29.42 ± 6.06 years. Of the nurses, 83.2% were female, 65.4% had undergraduate education, 74.0% had a length of service ranging between 1 and 10 years, 33.7% worked in the ICU of an internal diseases department, 18.4% worked in the ICU of a general surgery department, and 78.9% had training on oral hygiene. Nurses stated that they carried out mostly oral care (30.8%) after intravenous catheter care (33.0%) in the ICU. Nurses’ Knowledge and Attitudes Toward Oral Care
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Turkish Nurses’ Attitudes and Practices Regarding Oral Care
H. Özveren and D. Özden
Table 2. Practices Regarding Nurses’ Oral Care
Oral care Methodsa Wiping with solution Brushing teeth Just rinsing Frequency When necessary Three times a day Two times a day Once a day Every 6 hr Toolsa A depressor wrapped in gauze Foam swab Suction toothbrush Mouthwash Toothpaste and brush Suction foam swab Solutionsa Sodium bicarbonate Chlorhexidine Moisturizing agents Saline Hydrogen peroxide a
Hospital A (n = 70)
Hospital B (n = 58)
Hospital C (n = 21)
Hospital D (n = 36)
Total (n = 185)
Statistical evaluationb
n
%
n
%
n
%
n
n
%
χ2; p
65 2 3
92.9 2.9 4.3
26 32 0
44.8 55.2 .0
21 0 0
100.0 .0 .0
31 2 3
86.1 5.6 8.3
171 40 15
92.4 21.6 8.1
χ2 = 73.131; p = .001
50 2 6 12 0
71.4 2.9 8.6 17.1 .0
8 7 11 3 29
13.8 12.1 19.0 5.2 50.0
4 16 1 0 0
19.0 76.2 4.8 .0 .0
8 9 14 2 3
22.2 25.0 38.9 5.6 8.3
70 34 32 17 32
37.8 18.4 17.3 9.2 17.3
χ2 = 159.840; p = .001
42
60.0
35
60.3
8
38.1
24
66.7
109
58.9
χ2 = 4.737; p = .192
14 6 4 8 9
20.0 8.6 5.7 11.4 12.9
40 30 19 14 21
69.0 51.7 32.8 24.1 36.2
18 0 5 1 3
85.7 .0 23.8 4.8 14.3
22 0 3 3 6
61.1 .0 8.3 11.4 16.7
94 36 31 26 39
50.8 19.5 16.8 14.1 21.0
χ2 χ2 χ2 χ2 χ2
= = = = =
46.000; p = .001 57.591; p = .001 19.346; p = .001 7.759; p = .001 11.826; p = .008
52 3 4 5 2
74.3 4.3 5.7 7.1 2.9
31 42 32 4 4
53.4 72.4 55.2 6.9 6.9
13 15 10 2 0
61.9 71.4 47.6 9.5 .0
32 11 15 9 5
88.9 30.6 41.7 25.0 13.9
128 71 61 20 11
69.2 38.4 33 10.8 5.9
χ2 χ2 χ2 χ2 χ2
= = = = =
14.671; p = .002 73.44; p = .001 39.737; p = .001 9.451; p = .024 6.67; p = .083
%
More than one answer was marked. The chi-square test was performed.
b
the nurses agreed with the statement “Oral care should certainly be performed in intensive care units strictly.” Of the nurses, 93.0% agreed with the statement “Oral care should take precedence for patients in intensive care units”; 88.6% agreed with the statement “Standard oral care protocols should be implemented to patients staying in intensive care units”; 73.5% agreed with the statement “Oral problems and mechanical ventilator-associated pneumonia (VAP) can be prevented when patients in intensive care units are given oral care”; and 68.1% agreed with the statement “Cleaning oral cavities is an unpleasant task” (Table 3). Discussion Oral assessment is the most important step in planning effective oral care. Good oral care starts with an appropriate assessment (Binkley et al., 2004; White, 2000). In this study, it was found that the majority of nurses (77.8%) evaluated patients’ mouths in their clinics daily, but that approximately half of the nurses working in ICUs of two hospitals (A and D) did not perform oral assessment and that the difference between the hospitals was statistically significant (Table 1). This finding is important since it indicates that there is a significant difference between the hospitals in performing oral assessment. It is striking that while some of the nurses stated that they evaluated 166
patients’ mouths in their clinics daily, almost all of them (98.9%) said that they did not use oral assessment guidelines (Table 1). Several studies in the literature also report that nurses do not use oral assessment guidelines for oral assessment (Berry et al., 2007; Jones, Newton, & Bower, 2004; Yeung & Chui, 2010). This was due to the fact that nurses lacked knowledge and time regarding oral assessment tools, and that it was not easy to use these oral assessment tools (Adams, 1996; Furr, Binkley, McCurren, & Carrico, 2004). It is important to use a standard oral care protocol in ICUs developed by institutions themselves. When these protocols are implemented, not only are patients given regular and proper oral care, but also the incidence of oral problems and VAP is minimized, differences between nurses regarding oral care practice are eliminated, and the quality of nursing care is improved because implementation of the protocols prevents nurses from spending unnecessary time and energy (Özveren, 2010; Soh et al., 2012). Schleder, Stott, and Lloyd (2002) stated that the use of protocol, including toothbrushing, increased nurses’ compliance with oral care, and thus reduced the incidence of VAP. A large number of the nurses (88.6%) who participated in our study noted that intensive care clinics should have an oral care protocol (Table 3). A great number of nurses working in ICUs of hospitals B and C stated that there was an
H. Özveren and D. Özden
Turkish Nurses’ Attitudes and Practices Regarding Oral Care
Table 3. Nurses’ Statements on the Implementation of Oral Care (n = 185) I agree
Oral care should certainly be performed in intensive care units. Oral care should take high priority for patients in intensive care units. Standard oral care protocols should be implemented to patients staying in intensive care units. Oral cavities are difficult to clean. Cleaning oral cavities is an unpleasant task. Oral care is not my job to do. I did not do enough training to make oral care. The mouths of most mechanical ventilated patients get worse no matter what I do. A dentist can perform oral care instead of me. Oral problems and mechanical ventilator-associated pneumonia (VAP) can be prevented when patients in intensive care units are given oral care.
oral care protocol in their hospitals and they implemented it, whereas the nurses working in ICUs of hospitals A and D stated that their hospitals lacked an oral care protocol. The difference between the hospitals was found to be significant (Table 1). In line with these findings, it can be said that while some of the hospitals have oral care protocols, others do not have one and that these protocols are not implemented in ICUs by nurses. However, studies indicate that solutions, tools, and methods used for oral care by nurses differ from one nurse to another due to lack of evidence-based oral care protocols in hospitals (Fitch, Munro, Glass, & Pellegrini, 1999; Grap et al., 2003; Soh et al., 2012). Our study demonstrated that the methods used by nurses in oral care were not based on the latest research evidence, that a great number of nurses (92.4%) performed oral care by cleansing the mouth with solution, and half of the nurses (58.9%) achieved this cleansing with a depressor wrapped in gauze and the other half (50.8%) with a foam swab, and that there was not a significant difference between hospitals (Table 2). Although there is evidence in the literature that toothbrushing is the best method to remove dental plaque in ICU patients (Abidia, 2007; Berry et al., 2007; Chan & Ng, 2012; McNeill, 2000; Pearson & Hutton, 2002), in our study it was observed that this method was not used much (21.6%). Performing oral care with a depressor wrapped in gauze is a traditional method used in clinics. In their study, Türk et al. (2012) reported that, of the intensive care nurses, 49.5% performed oral care with a depressor wrapped in gauze and 82.2% with foam swabs, which is in line with our findings. In their studies, Grap et al. (2003), Binkley et al. (2004), and Chan and Ng (2012) reported that foam swabs were widely used for oral care in ICUs. The reason why nurses prefer foam swabs for oral care in ICUs might be due to the fact that foam swabs are easy to use and cheap. However, several studies report that although foam swabs are effective for the stimulation of mucosal tissue in the mouth, they are ineffective in removing dental plaque (Abidia, 2007; Pearson & Hutton, 2002; Soh et al., 2012).
I disagree
I am undecided
n
n
%
n
%
%
141 172 164
76.2 93.0 88.6
5 2 12
2.7 1.1 6.5
39 11 9
21.1 5.9 4.9
132 126 53 76 90
71.4 68.1 28.6 41.1 48.6
39 41 117 97 68
21.1 22.2 63.2 52.4 36.8
14 18 15 12 27
7.6 9.7 8.1 6.5 14.6
61 136
33.0 73.5
99 18
53.5 9.7
25 31
13.5 16.8
Although there are several recommendations related to the use of oral care tools and solutions in the literature, in the hospitals and ICUs where we conducted our study, traditional methods were still in use and there were differences between these hospitals regarding oral care practices. In this study, nurses mostly used sodium bicarbonate solution (69.2%) for oral care, followed by chlorhexidine solution (38.4%) (Table 2). Several other studies report that sodium bicarbonate is an oral rinse product frequently used in clinics (Binkley et al., 2004; Chan & Ng, 2012; Miller & Kearney, 2001; Türk et al., 2012). These results support the results of our study. In a study by Türk et al. (2012), using sodium bicarbonate solution was the most common way to provide oral care (79.2%), followed by chlorhexidine gel use (9.9%). On the other hand, in Ganz et al.’s study (2009), it was reported that 75.0% nurses used chlorhexidine for oral care. In their study, Rello et al. (2007) found that 61.0% of the healthcare workers performed oral care with chlorhexidine solution. It can be said that factors such as lack of material, the availability of solutions, the hospital’s policy, and nurses’ knowledge and preferences play a role when a nurse decides what kind of solution should be used for oral care. How often oral care should be performed in patients in ICUs is controversial (Abidia, 2007; Çelik, 2006; Cutler & Davis, 2005; Jones et al., 2004; Türk et al., 2012). In some studies (Cutler & Davis, 2005; McNeill, 2000), it is stated that oral care should be performed in patients connected to a mechanical ventilator every 2–4 hr or when necessary. However, according to some other studies (Çelik, 2006; Cutler & Davis, 2005), oral care should be performed every 4–8 hr or 12 hr. In our study too, in line with the literature, nurses’ responses on how often oral care should be performed varied from one nurse to another. While a vast majority of nurses in hospital A said that they performed oral care when necessary, the nurses in hospital C said that they performed it three times a day, and there were differences between the hospitals in terms of the frequency of performing oral care (Table 2). This might be due to the fact 167
Turkish Nurses’ Attitudes and Practices Regarding Oral Care that the hospitals where the study was conducted did not implement oral care assessment guidelines or oral care protocols and that information on the frequency of oral care in the literature is not clear enough or is not based on the results of randomized trials. Costello and Coyne (2008) reported that of the nurses, 21.0% provided oral care every 4 hr, 24.0% twice a day, and 24.0% when necessary. This finding is similar to ours. Türk et al. (2012) reported that 44.5% of the nurses in ICUs provided oral care fewer than four times a day. Nurses’ attitudes toward oral care affect oral care (Yeung & Chui, 2010). In this study, the fact that the majority of nurses (76.2%) stated that oral care should definitely be provided in the clinics (Table 3) is of importance because it indicates that nurses believed in the necessity of oral care and thus performed it. The vast majority of the nurses in our study (75.1%) stated that they provided oral care regularly (Table 1), which supports this finding of ours. This is striking because it indicates that nurses’ positive attitudes toward oral care affect their oral care practices positively. In addition, the fact that the vast majority of the nurses (73.5%) stated that regular oral care can prevent oral problems and VAP is something desired. In their study, Yeung and Chui (2010) found that one of the purposes of the nurses in providing oral care was to prevent VAP. Almost all of the nurses in this study pointed out that oral care should be provided for patients in ICUs in the first place (Table 3), but it was found that it took the second place in conducting nursing care practices. A study performed in Hong Kong and Singapore on nurses’ oral care practices reported that the nurses provided oral care after fulfilling other tasks (Chan & Ng, 2012; Yeung & Chui, 2010). While several studies in the literature (Binkley et al., 2004; Chan & Ng, 2012; Fitch et al., 1999; Grap et al., 2003; Kite & Pearson, 1995; Rello et al., 2007) state that oral care is often neglected, some other studies (Ganz et al., 2009; Grap et al., 2003; Jones et al., 2004) report that providing oral care has a priority. In a study conducted in Turkey, it was stated that 61.3% of ICU nurses performed oral care in the first place (Türk et al., 2012). However, the nurses in our study did not put oral care in the first place, which might be due to the fact that they considered cleaning the inside of the mouth to be a difficult and unpleasant task. Soh et al. (2012) reported that 40.2% of the nurses considered cleaning the oral cavity to be a difficult task. When compared with our results, it is quite noteworthy that the majority of nurses in our study (68.1%) considered oral care to be an unpleasant task and that 71.4% of them thought it was difficult to clean the inside of the mouth. Moreover, almost a similar proportion of nurses both in Soh et al.’s (2012) study and in our study (46.2% and 48.6%, respectively) reported that the mouth worsened in patients connected to the mechanical ventilator no matter what they did for oral care (Table 3). This finding is very important since it indicates that almost half of the nurses (48.6%) did not believe in the effectiveness of oral care. 168
H. Özveren and D. Özden Conclusion
This study demonstrated that ICU nurses performed oral care without oral care assessment guidelines or an oral care protocol, that the frequency of oral care, methods, and solutions used for oral care varied from one hospital to another, and that they did not use evidence-based guidelines. “Patients in intensive care units have the priority to receive oral care,” “standard oral care protocols should be implemented to patients staying in intensive care units,” and “if patients in intensive care units receive oral care, oral problems and mechanical ventilator associated pneumonia decrease.” It is determined that nurses agreed with these statements in a high rate. In line with our study findings, it can be proposed that in our country, education programs should be provided for nurses to improve their knowledge, attitudes, and practices regarding oral care, that oral care guidelines should be prepared, used, and periodically evaluated, and that observation studies should be performed in different populations. References Abidia, R. (2007). Oral care in the intensive care unit: A review. Journal of Contemporary Dental Practice, 8, 1–8. Adams, R. (1996). Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. Journal of Advanced Nursing, 24, 552–560. Augustyn, B. (2007). Ventilator-associated pneumonia. Critical Care Nurse, 4, 32–39. Berry, A., Davidson, P., Rolls, K., & Masters, J. (2007). Systematic literature review of oral hygiene practices for intensive care patients receiving mechanical ventilation. American Journal of Critical Care, 16, 552–562. Binkley, C., Furr, E., Carrico, R., & McCurren, C. (2004). Survey of oral care practices in us intensive care units. American Journal of Infection Control, 32, 161–169. Çelik, S. (2006). Mechanical ventilation of the patient care. Journal of Intensive Care Nursing, 10, 19–25. Chan, E. Y., & Ng, H. L. I. (2012). Oral care practices among critical care nurses in Singapore: A questionnaire survey. Applied Nursing Research, 25, 197–204. Costello, T., & Coyne, I. (2008). Nurses’ knowledge of mouth care practices. British Journal of Nursing, 17, 264–268. Cutler, C., & Davis, N. (2005). Improving oral care in patients receiving mechanical ventilation. American Journal of Critical Care, 14, 389–394. Feider, L. L., Mitchell, P., & Bridges, E. (2010). Oral care practices for orally intubated critically ill adults. American Journal of Critical Care, 19, 175– 183. Fitch, J., Munro, C., Glass, C., & Pellegrini, J. (1999). Oral care in the adult intensive care unit. American Journal of Critical Care, 8, 314–318. Furr, L. A., Binkley, C. J., McCurren, C., & Carrico, R. (2004). Factors affecting quality of oral care in intensive care units. Journal of Advanced Nursing, 48, 454–462. Ganz, F. D., Fink, N. F., Raanan, O., Asher, M., Bruttin, M., & Benbinishty, J. (2009). ICU nurses’ oral-care practices and current best evidence. Journal of Nursing Scholarship, 41, 132–138. Grap, M., Munro, C., Ashtiani, B., & Bryant, S. (2003). Oral care interventions in critical care: Frequency and documentation. American Journal of Nursing, 12, 113–119. Harris, J., & Miller, T. (2000). Preventing nosocomial pneumonia: Evidencebased practice. Critical Care Nurse, 20, 51–66. Johnstone, L., Spence, D., & McClain, J. K. (2010). Oral hygiene care in the pediatric intensive care unit: Practice recommendations. Pediatric Nursing, 36, 85–97. Jones, H., Newton, J. T., & Bower, E. J. (2004). A survey of the oral care practices of intensive care nurses. Intensive and Critical Care Nursing, 20, 69–76.
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