Gaps in oral care protocols and the complexity of nursing oral care

Several studies found that a lack of oral care guidelines and protocols hindered effective training and education for nurses and implementation of oral care in care homes (Jablonski et al 2018, Keboa et al 2019, Zimmerman et al 2020a, 2020b). Some high-income countries have developed oral care protocols to address this overlooked nursing intervention, however these protocols are not always used by healthcare professionals, often because of their lack of practicality, consistency and comprehensibility (Cadet et al 2016, Jablonski et al 2018).

It has been recognised in the literature that care home residents with dementia and/or dysphagia are particularly neglected, as they are less likely than other residents to receive oral care from nurses due to safety concerns such as risk of aspiration, lack of knowledge about oral care for older adults, time and resource constraints and lack of confidence in delivering oral care (Goh et al 2016, Jablonski et al 2018, Keboa et al 2019). Many studies have identified care-resistant behaviours among older adults with cognitive impairments and dysphagia as the most significant barrier to oral care delivery, and these issues are often not addressed in oral care protocols, policies and guidelines (Goh et al 2016, Jablonski et al 2018, Keboa et al 2019, Zimmerman et al 2020a, 2020b).

A crucial factor to facilitate daily oral care in care homes is the availability of clear and concise practice guidelines for nurses (Jablonski et al 2018, Krausch-Hofmann et al 2021). Oral care protocols need to be evidence-based and tailored to meet the needs of older adults, particularly those with physical and cognitive impairments, and should serve as a standard manual for education and training (Jablonski et al 2018, Krausch-Hofmann et al 2021).

Scientific evidence regarding the effectiveness of oral care devices and approaches for care-dependent adults is inadequate due to the complexity of this population’s health status and oral health needs (Jablonski et al 2018, Krausch-Hofmann et al 2021). There are differences in guidelines regarding some aspects of oral care, such as denture storage and care, whether to rinse the mouth with water after brushing or only to spit out toothpaste after brushing, and management of care-resistant behaviours (Krausch-Hofmann et al 2021). Although the aim of guidelines is to improve nurses’ knowledge and practice in relation to oral care, barriers such as training, time constraints and clarity in terms of their responsibilities adversely affect their ability to apply these guidelines in daily practice. Jablonski et al (2018) emphasised the importance of developing alternative approaches to oral care delivery, with a focus on gerodontology, to address the needs of care-dependent older adults and improve the quality of their oral care.

Several studies have found insufficient evidence for the effectiveness of carer education in improving oral health in care-dependent older adults (Goh et al 2016, Jablonski et al 2018, Zimmerman et al 2020b). Zimmerman et al (2020b) asserted that such education should include oral health assessments using evidence-based tools such as the Oral Health Assessment Tool (Chalmers et al 2005). There is also a need for high-quality studies that measure the effectiveness of nurses’ oral health education (Goh et al 2016, Aagaard et al 2020).

How interprofessional collaboration and education can improve oral care

Providing oral care to care-dependent older adults is complicated by the various physical and psychological issues that this population typically experiences, including comorbidities (Jablonski et al 2018). These complexities mean that oral care practice, including oral hygiene methods and assessment, cannot be addressed by one discipline, but requires interprofessional collaboration between nurses and dental hygienists to achieve individualised and sustainable changes and to prevent oral disease and aspiration pneumonia (Seleskog et al 2018, Niesten et al 2020).

The studies reviewed suggest that it is possible to implement shared oral care for most care home residents through interprofessional collaboration and education that enhances the competency of those providing such care (Aagaard et al 2020, Niesten et al 2020). Haresaku et al (2020) identified that tertiary education institutes and hospitals in Japan have started to develop interprofessional collaboration and education among medical, nursing and dentistry faculties to overcome the gaps and barriers to optimising older adults’ oral health.

Many nurses in the reviewed studies recognised the importance of broader collaboration and integration between healthcare professionals and academics to improve the delivery of effective oral care to older adults (Seleskog et al 2018, Keboa et al 2019). Johansson et al (2020) found that nurses often recognised limitations in their oral health assessment and practice and valued contact with dental services for on-site technical support with oral assessment, care delivery and referrals. Collaboration between nurses and dental professionals that incorporates methods for preventing and managing oral diseases in older adults can lead to effective oral care delivery that also addresses residents’ psychosocial issues and physical barriers, and can improve communication between stakeholders; that is, older adults, families, carers and healthcare professionals (Jablonski et al 2018, Keboa et al 2019). In addition, interprofessional collaboration and education on oral care for older adults with dementia can provide opportunities for other disciplines, such as speech and language therapists and dietitians, to learn from nurses (Keboa et al 2019), so may be beneficial in improving the delivery of oral care to care-dependent older adults.

Interprofessional research teams with broad competence in nursing care, oral health, psychology and gerodontology have been shown to support nurses to provide high-quality oral care to older adults (Johansson et al 2020). It has been found that nurses’ confidence in delivering oral care for residents who are resistant to care improves when they are supported by dental hygienists (Seleskog et al 2018).

Haresaku et al (2020) identified that providing a dentists’ oral health education course for nursing students increased their oral health knowledge and confidence regarding oral care practice, as well as their willingness to undertake oral health screening and counselling. Further, Johansson et al (2020) found that an oral health coaching programme resulted in nurses maintaining a high level of oral health with improved plaque control. Therefore, by promoting interprofessional relationships based on mutual respect and trust (Seleskog et al 2018, Aagaard et al 2020), interprofessional collaboration and education is a feasible way to address the complex challenges of older adults’ oral care by improving practice and assessment skills among nurses.

Limitations and unresolved issues in nurses’ oral care training

The attitude of healthcare professionals is a major factor in the effectiveness of oral care provision (Goh et al 2016, Janssens et al 2016, Wretman et al 2020). An important facilitator of positive changes in oral care practice is equipping healthcare professionals with the appropriate knowledge and attitudes for providing personalised care (Aagaard et al 2020, Niesten et al 2020). Healthcare professionals’ belief in the potential positive effects of care integration is a crucial element of effective interprofessional collaboration and education (Niesten et al 2020). Such positive attitudes can lead to shared norms, common goals and clear professional roles and responsibilities and are crucial to healthcare professionals’ commitment to providing integrated and collaborative oral care (Niesten et al 2020). Commitment is linked to people’s intentions and behaviours and as such is one of the main predictors of the effectiveness of integrated oral care (Niesten et al 2020). In particular, nurses’ attitudes towards oral care provision for care-dependent older adults in care homes require further exploration (Wretman et al 2020). Thus, oral health education may significantly influence healthcare professionals’ attitudes as they will have the opportunity to discuss how they feel about oral health.

One major issue identified is that it can be challenging to improve attitudes towards oral care delivery, despite advanced oral care education with interprofessional collaboration (Janssens et al 2016), and improvements may not be sustained after the completion of collaborative projects (Lewis et al 2019, Johansson et al 2020).

Several studies have investigated whether improved knowledge is associated with improved attitudes towards oral care among nurses. For example, a large-scale longitudinal study used an evidence-based programme to train care home nurses with two purposes: to improve nurses’ self-efficacy and attitudes in relation to delivering oral care for residents and to improve the oral health of residents (Volk et al 2020). The researchers found a significant improvement in nurses’ self-efficacy and knowledge after training. Another study found that training enhanced nurses’ awareness of the limitations of their oral care delivery and resulted in improved attitudes towards supporting residents who were resistant to oral care (Seleskog et al 2018).

In contrast, other studies found that oral care training increased nurses’ knowledge but did not improve their attitudes. For example, in a large-scale study, Johansson et al (2020) found significant increases in nursing knowledge, but the only improvement in attitude was residents’ ability to report oral care needs. Further, Janssens et al (2016) found that training based on an oral care protocol increased nurses’ knowledge in the intervention group compared with the control group, but attitudes were not significantly different between the groups. Similarly, Cadet et al (2016) and Red and O’Neal (2020) did not find significant improvements in self-efficacy and/or attitudes towards future training following oral care theory training, despite significant increases in nurses’ knowledge of oral health.

Several studies have found that healthcare assistants have positive attitudes towards oral care practice, even though they often have a lack of knowledge and a fear of undertaking oral care interventions (Goh et al 2016, Janssens et al 2016). Indeed, Janssens et al (2016) found that nurses demonstrated greater knowledge but a more negative attitude than healthcare assistants. Therefore, there is no clear evidence that knowledge and attitude regarding oral care provision are inextricably linked for nurses.

Several studies discussed the role that experience contributes to nurses’ attitudes to oral care. Some studies have found that older nurses have a better attitude than younger nurses (Janssens et al 2016, Ab Malik et al 2018). For example, Ab Malik et al (2018) identified that the length of time working as a nurse was significantly associated with a general intention to deliver oral care to patients. Moreover, Janssens et al (2016) found that the attitudes towards oral care delivery among nurses working on a psychogeriatric ward, where they were trained to cope with care-resistant behaviours, improved to a greater extent following training compared with nurses working on a somatic ward. In contrast, however, Wretman et al (2020) found that younger and new staff had significantly higher self-efficacy and attitude scores in relation to oral care delivery, as did staff working in non-profit and newer care homes. Thus, no clear pattern emerged from the literature regarding what governs nurses’ attitudes towards oral care delivery.

Implementing strategies that can improve nurses’ attitudes towards oral care delivery is important for theoretical and technical training, along with interprofessional collaboration and education, to succeed in supporting nurses to enhance their practice. This may be challenging because attitudes towards oral care are complex and influenced by multiple factors, such as age, education and skill levels, ward environments, personality traits and organisational level of commitment to performing oral care (Janssens et al 2016, Niesten et al 2020).

There is evidence to suggest that organisational commitment and support for oral care improvement projects can positively influence nurses’ self-efficacy and attitudes towards oral care practice. For example, Volk et al’s (2020) study indicated that the motivation of the participating care homes and the dedication of the dental hygienists who served as coaches were crucial factors for the success of an oral care project. Institutional support and commitment, where there is a clear strategy for oral health and accountable structures that include referral systems to medical or dental professionals, has been shown to encourage nurses to perform oral care (Goh et al 2016, Lewis et al 2019). The availability of oral care guidelines, equipment, training, a suitable working environment and longer work experience are also important factors to promote effective oral care practice (Ab Malik et al 2018). Therefore, attitudes towards oral healthcare are likely to improve with systematic approaches implemented by committed care home managers (Niesten et al 2020). To achieve attitude changes in oral care it is essential to explore ways to involve stakeholders systematically at individual, interpersonal, organisational and policymaking levels. Such consistent efforts and integration of oral care across levels could lead to positive changes in attitude among all stakeholders (Niesten et al 2020).

Limitations

One limitation is that this was a narrative review which is not as robust as a systematic or scoping review. Further, most studies reviewed were conducted in Western countries and all were written in English, so it could be beneficial to explore the subject of oral care in care homes in non-English speaking countries.