Are the barriers to good oral hygiene in nursing homes within the nurses or the patients?
Tiril Willumsen, Dental Health Services’ Competence Centre for Eastern Norway (TKØ), Hammersborg torg 3, 0179 Oslo, Norway.
Are the barriers to good oral hygiene in nursing homes within the nurses or the patients?
Objective: To explore nursing home patients’ oral hygiene and their nurses’ assessments of barriers to improvement.
Background: In nursing homes, nurses are responsible for patients’ oral hygiene.
Materials and methods: This study assessed the oral hygiene of 358 patients in 11 Norwegian nursing homes. 494 nurses in the same nursing homes participated in a questionnaire study.
Results: More than 40% of patients had unacceptable oral hygiene. ‘More than 10 teeth’ gave OR = 2, 1 (p = 0.013) and ‘resist being helped’ OR = 2.5 (p = 0.018) for unacceptable oral hygiene. Eighty percent of the nurses believed knowledge of oral health was important, and 9.1% often considered taking care of patients’ teeth unpleasant. Half of the nurses reported lack of time to give regular oral care, and 97% experienced resistant behaviour in patients. Resistant behaviour often left oral care undone. Twenty-one percent of the nurses had considered making legal decisions about use of force or restraints to overcome resistance to teeth cleaning.
Conclusion: Oral hygiene in the nursing homes needed to be improved. Resistant behaviour is a major barrier. To overcome this barrier nurses’ education, organisational strategies to provide more time for oral care, and coping with resistant behaviour in patients are important factors.
The number of dentate elderly people is increasing rapidly throughout the world1. In Norwegian nursing homes, the percentage of patients with 20 + natural teeth has been reported as high as 45%2, and the prevalence of edentulous patients is decreasing rapidly. In a national study from 20043, the county of Østfold had the highest prevalence of patients with natural teeth in nursing homes (80%).
The number of natural teeth an institutionalised older person retains has been found to correlate negatively with oral hygiene; i.e., the more natural teeth an older person retains, the poorer the oral hygiene2. Poor oral hygiene can lead to various kinds of oral infections such as gingivitis, marginal and apical periodontitis, candidosis or secondary infections of mucosal lesions. Several studies have found a relationship between oral infections and general health complications such as aspiration pneumonia4–6, general health, mortality and quality of life7–9. In a review from 2005, Jablonski et al.10 stated that, ‘poor oral health may exacerbate existing diseases, such as diabetes, while promoting the development of new ones, such as pneumonia’.
The keys to avoiding these oral infections are the proper removal of dental plaque and the regular cleaning of teeth and gums. The gold standard should be that 100% of all nursing home residents have acceptable oral hygiene, but there are several barriers in the process of reaching this standard. To explore these barriers, it is relevant to explore how nurses working in nursing homes assess the factors associated with barriers to proper oral hygiene.
The first factor may be within the patients. Institutionalised old people have poor general health, and in Norway most patients in nursing homes have cognitive impairment. Dementia and oral health are strongly connected. Studies have shown that dental pain is under-diagnosed by medical staff11. In a review paper from 2005, Chalmers et al.12 reported that older adults with dementia have problems such as reduced salivary flow, higher accumulation of dental plaque, gingival infection, dental caries and oral mucosal pathology.
One explanation for the greater accumulation of dental plaque in older people may be that many patients with dementia neglect their personal hygiene, including oral hygiene, and that they resist help with teeth cleaning from nurses. Marin et al.2 found that in a Norwegian nursing home, 25.1% of patients were unco-operative when receiving assistance with tooth cleaning. Resistant and aggressive behaviour seems to be an important barrier to oral care as well as to other aspects of care in nursing homes13–17. Marin et al.2 also reported that unco-operative patients have poorer oral hygiene than co-operative patients and patients who brush their teeth themselves. Any kind of restriction, for instance, holding the patient’s hands during brushing, is defined as restraint or force. This leads to a difficult ethical dilemma. To ensure that patients receive good preventive medical care, tooth cleaning is a simple and effective procedure. The question arises as to whether tooth cleaning should be neglected whenever the patient resists. That is, when is it legitimate to overcome this resistance by use of restraint or force, as in holding the patient’s hand during brushing? In Norway as in many other countries, laws regulate the use of force or restraints in medical care18. Before a health worker can give medical treatment to a patient who lacks the ability to give consent and who resists help, the carer is required by law to make a legal decision about the use of force or restraint. To make such a legal decision, three conditions must be fulfilled: (i) the medical care must be necessary, (ii) not to give the medical care can lead to serious illness, and (iii) the type of force used during the treatment must be in proportion to the outcome of the treatment18.
Considering the consequences of neglected oral hygiene, our first research question addressed whether legal decisions about the use of force or restraint to help patients with proper teeth cleaning are discussed and made regularly in nursing homes.
A second possible factor that affects oral hygiene in nursing homes is the nurses’ knowledge and attitudes. Several studies have shown positive effects of oral health care education for nurses19–22. Samson et al.23 showed that many nursing students received instruction in oral health as part of the curriculum. However, oral hygiene remains poor in many nursing homes13,22. In most nursing homes, the nurses have different educational backgrounds and some have no formal education. Our second research question concerned whether nurses with different levels of nursing education have different attitudes towards and knowledge of oral medicine and oral care.
A third possible factor may be the organisation of oral care in nursing homes. In clinical practice, many nurses report that they do not have the opportunity to implement good oral hygiene, and many report insufficient time or equipment for oral care. Our third research question addressed whether the organisation of routines and equipment in nursing homes is a challenge to providing good oral hygiene for patients.
The primary aim of this study was to explore whether patients’ oral hygiene was acceptable and explore clinical observations and nurses’ assessments concerning the need for improvements in patients’ oral hygiene.
Further we asked whether the barriers to improvement in oral hygiene are related to:
- • difficulties within the patient (resistance),
- • knowledge of and attitudes towards oral health care among nurses with different levels of health care education, or
- • organisation of oral health routines.
Materials and methods
Design and setting
This was a cross-sectional study including a questionnaire study among nurses and clinical examinations of their nursing home patients.
To ensure that the population of patients was representative of the county of Østfold, the nursing homes selected to be invited to join the study were required to meet the following criteria: (i) one nursing home in each of the 11 community dental hygiene districts and (ii) the first nursing home to be visited by the dental hygienist in March 2010. All 11 invited nursing homes accepted.
A dental hygienist performed a routine screening of oral hygiene. The patients in the nursing homes were asked for consent to use information from their dental records in the present study. The head nurse decided whether the patients were able to give informed consent. Relatives gave written consent for the patients who could not give consent themselves. At the same time as the routine screening of patients, all 674 nurses (registered nurses, auxiliary nurse and assistant nurses) who worked regularly in the selected nursing homes were invited to participate. To maintain anonymity, the questionnaires were numbered and given to the nurses by the head nurse of each nursing home. The participants completed the questionnaire, and all questionnaires were kept in a locked box in the nursing home. After one month, the boxes were collected, and the answers to all questionnaires were recorded in the Statistical Package for the Social Sciences (PASW) using the given identification number.
The Regional Committee for Medical and Health Research Ethics approved the study.
Patient variables. The data collected from the patients’ dental records included the background variables of sex and age and number of teeth. Oral hygiene was measured using the mucosal plaque index (MPS), a coarse oral hygiene index with a score of 2–824. This index is derived by adding the plaque score, rated from 1 (normal) to 4 (excessive amount of plaque), to the gingival score, rated from 1 (normal) to 4 (high degree of inflammation). All dental hygienists were trained clinically and taught to use a standardised method to obtain the scores. In addition, they had an instructional guide with pictures illustrating the different index scores. The index was dichotomised into an acceptable oral hygiene score <5 and an unacceptable oral hygiene score ≥5.
Information about the patient’s cognitive status was collected from the responsible nurse and was recorded as: (i) normal cognitive function, (ii) mild dementia and (iii) moderate/severe dementia. The frequency of assistance with tooth cleaning was recorded as (i) never (ii) sometimes and (iii) always. The frequency of resistant behaviour during nurse-assisted tooth cleaning was recorded as (i) never (ii) sometimes and (iii) always.
Questionnaire completed by the nurses. The background variables recorded were sex and age (≤29, 30–50 and ≥51 years). The nurses’ educational level was recorded as: (i) registered nurse (bachelors degree from a university college), (ii) auxiliary nurse, (health care studies in upper secondary school or junior college), and (iii) assistant nurse, (without any formal nursing education). Experience working in nursing homes was recorded as the number of years in nursing home duty. We discussed with the experienced nurses how to categorise a nurse as ‘experienced’, and we decided from these discussions that the definition would be >5 years experience in nursing home work.
The nurses’ evaluation of patients’ resistance to assistance with tooth cleaning was assessed by five questions constructed to explore the use of constraints, which were recorded as (i) ‘never’, (ii) ‘sometimes’ or (iii) ‘always’ (Table 1).
Table 1. The nurses’ evaluation of patients’ resistance during tooth cleaning
|How often do you encounter patients who need assistance with tooth cleaning but do not want help? n = 483||2||14||2.9||249||51.3||222||45.8|| |
|When the patient resists assistance, how often do you leave tooth cleaning undone? n = 457||2||22||4.8||305||66.6||131||28.6|| |
|When the patient resists assistance, how often do you perform inadequate tooth cleaning? n = 440||2||129||29.3||274||62.1||38||8.6||R vs. Au*|
Au vs. As*
|When the patient resists assistance, how often do you perform proper tooth cleaning? n = 415||1||275||66.1||127||30.5||14||3.4|| |
|When the patient resists assistance, how often do consider the possibility of deciding to use force to help the patient with tooth cleaning? n = 414||1||326||78.6||81||19.5||8||1.6|| |
Knowledge of and attitudes towards oral health care were measured using a previously-designed questionnaire that assesses the nurses’ (N) attitudes (A), implementation (I) and knowledge (K), called NAIK here. NAIK was developed by a Swedish team comprising a dentist, dental hygienist and registered nurse25,26. The NAIK has three topics: (A) four items about attitudes to oral health were assessed on a Likert scale from 1 (never) to 5 (always), (I) six items about implementation opportunities on a Likert scale from 1 (never) to 5 (always), and (K) six items about the importance of knowledge on a Likert scale from 1 (unimportant) to 5 (important).
Data were analysed using PASW edition 16.0 (PASW statistics, IBM Corporation, Armonk, NY, USA). Categorical data and skewed numerical data were compared using the chi-square test and Mann–Whitney test for between-group differences. Odds ratios from regression analyses were used to investigate the association between unacceptable oral hygiene and combinations of different patient characteristics.
Three hundred and fifty-three of the 527 patients who were examined by the dental hygienists gave consent to use data from their dental records (response rate 67.0%). The mean age was 84.5 ± 8.3 years (range, 46–104 years); 73.9% were women and 26.1% men.
Eighty-eight (25.1%) of the patients were edentulous, 85 (24, 6%) had 1–9 remaining teeth, 77 (22.0%) had 11–19 teeth and 99 (26.1%) had 20 teeth or more. Eighty-nine (23.8%) were recorded to have normal cognitive function, 133 (35.6%) mild dementia and 152 (40.6%) moderate/severe dementia. The majority (73.5%) received help with tooth cleaning (sometimes or always) and 45.3% resisted being helped (sometimes or always).
Twenty-two (24.7%) of the non-demented patients and 144 (52.4%) of the demented patients resisted assistance (p < 0.001).
One hundred and forty-six patients (41.4%) had an unacceptable MPS (MPS ≥5).
With regard to oral hygiene, no significant differences were found between patients who received help with tooth cleaning versus patients who brushed their teeth themselves or between nom-demented versus demented patients.
Logistic regression revealed two variables to predict unacceptable oral hygiene significantly; ‘more than 10 teeth’ gave OR = 2, 1 (p = 0.013) and ‘resist being helped’ OR = 2.5 (p = 0.018).
Questionnaire completed by the nurses
Four hundred and ninety-four nurses completed the questionnaire (response rate 73.3%). Only 19 (3.9%) were men. There were 114 registered nurses, 243 auxiliary nurses and 136 assistant nurses. Nearly half of the nurses (47.3%) were 30–50 years of age; 24.0% were younger than 30 years, and 28.7% older than 50 years. A chi-square test showed that the assistant nurses were younger than the other nurses.
The sample was experienced in nursing home work: 62.7% reported >5 years of practice. A Mann–Whitney test showed that the distribution of experienced nurses was not equal across training levels. Significantly more auxiliary nurses (82.2%) had >5 years experience than nurses in the other educational levels (p < 0.001). The percentage of nurses with >5 years experience was significantly higher for registered nurses (56.8%) than for assistant nurses (33.3%) (p = 0.002).
Resistance to tooth cleaning
Nurses in all educational levels reported that they evaluated patients who needed assistance with tooth cleaning but who did not want the assistance to be a considerable problem. Nearly all (96.9%) reported this to be a problem every day or sometimes. The answer to the research question concerning regularity of discussions about the use of force or restraint gave indications that this was not a commonly used assessment as only 21% had considered the opportunity of making legal decisions about use of restraints or force to help the reluctant patient with teeth cleaning. The only significant difference between nurses groups was that more registered nurses (78.8%, p = 0.004) and auxiliary nurses (73.1%, p = 0.006) than assistant nurses (61.9%) reported that inadequate tooth cleaning occurred when the patients resisted.
Results from NAIK questionnaire
A – Attitudes to oral health care. Few nurses considered taking care of other people’s teeth as unpleasant; 74.2% scored 1 or 2. Most nurses found it difficult in practical terms to provide oral care from time to time (62.3% scored 3–5).
Using pairwise comparisons, the Mann–Whitney test showed that registered nurses significantly more often considered oral hygiene to be included in their duties (96.4% scored 4 or 5) than did auxiliary nurses (88.2% scored 4 or 5) (p = 0.018) and assistant nurses (85.3% scored 4 or 5) (p = 0.003). No other significant differences were found between the different nurses’ education (see Table 2).
Table 2. Response to the NAIK questionnaire: A – attitudes to oral healthcare
|Taking care of other people’s teeth is unpleasant n = 488||2||230||47.1||134||27.1||79||16.2||35||7.1||10||2.0|| |
|Oral health is included in my duties n = 482||5||14||2.8||12||2.5||25||5.1||57||11.5||274||77.6||R vs. Au*|
R vs. As*
|Providing oral care is difficult in practical terms n = 490||3||56||11.3||126||25.5||220||44.5||73||14.8||15||3.0|| |
|Patients refuse to be helped n = 487||3||9||1.8||111||22.5||303||61.3||56||11.5||8||1.6|| |
I – Implementation opportunities. Implementation opportunities reflect the organisation of routines and equipment in nursing homes. When asked about implementation opportunities, 22.5% of the nurses could always take the time necessary for patients’ oral care, and 24.6% assessed their own knowledge to be sufficient in every oral care situation. Educational level was associated with knowledge (Table 3). Only 27.7% of auxiliary nurses, 22.8% of registered nurses, and 18.2% of assistant nurses assessed that they always had enough knowledge. Significantly fewer assistant nurses (56.4% scored 4 or 5) and auxiliary nurses (56.4% scored 4 or 5) than registered nurses (83.3% scored 4 or 5) assessed their knowledge to be sufficient (p = 0.003 and 0.012, respectively).
Table 3. Response to the NAIK questionnaire: I – implementation opportunities
|I can take the time necessary n = 489||3||11||2.2||66||13.4||169||34.2||133||27.2||110||22.5|| |
|I have sufficient knowledge n = 492||4||0||0||19||3.8||116||23.5||236||47.8||121||24.6||R vs. As*|
Au vs. As*
|I have the equipment that I need n = 493||4||1||0.2||23||4.7||111||22.5||185||37.5||173||35.0|| |
|I am familiar with the practical procedures n = 493||4||3||0.6||13||2.6||45||9.1||223||45.1||206||41.7|| |
|I am able to give advice to care receivers n = 490||4.0||2||0.4||17||3.4||95||19.2||198||40.1||177||35.8|| |
|I am able to influence reluctant care received n = 489||4.0||5||1.0||35||7.1||168||34.0||192||38.9||86||17.7|| |
K – Importance of knowledge. With regard to whether nurses with different levels of nursing education have different attitudes towards and knowledge of oral medicine and oral care, we found that nurses of all educational levels reported all aspects of knowledge to be important; the median score was 5, and 76.6–89.4% scored 4 or 5 for the questions about the importance of knowledge (Table 4). The groups differed significantly on two of the questions. A lower percentage of assistance nurses (76.1% scored 4 or 5) than registered nurses (90.3% scored 4 or 5) assessed knowledge about the physiological function of the oral cavity to be important (p = 0.016).
Table 4. Response to the NAIK questionnaire: K – importance of knowledge
|Equipment n = 484||5||0||0||6||1.2||43||8.7||95||19.2||340||70.2|| |
|Diseases of the oral cavity n = 483||5||2||0.4||15||3.0||58||11.7||92||18.6||316||65.4|| |
|Oral prosthetic restoration n = 485||5||3||0.6||10||2.0||57||11.5||99||20.0||316||64.0|| |
|Healthy oral cavity n = 482||5||3||0.6||8||1.6||48||9.7||100||20.2||323||65.4|| |
|Physiological function of the oral cavity n = 481||5||7||1.4||13||2.6||75||15.2||113||22.9||273||56.8||R vs. As*|
|Psychosocial function of the oral cavity n = 477||5||10||2.0||12||2.4||86||17.4||113||22.9||256||53.7||R vs. As*|
Nursing professionals have professional responsibility for patients’ daily oral care, and their reflections on the barriers to improving oral hygiene are important. The distribution of educational levels among the nurses who completed the questionnaire was comparable to the overall distribution in this region: the ratio of auxiliary nurses to registered nurses was 2.1 in our study and 1.9 in total community care in Østfold. We were unable to obtain reliable numbers for assistant nurses27.
The first aim of the study was to determine whether oral hygiene should be improved; we found that more than 40% of the nursing home patients had unacceptable oral hygiene, as assessed by the MPS. Considering the consequences of poor oral health on quality of life and associations with general health7–9, oral hygiene in our population needs to be improved. The finding that patients with more than 10 teeth doubled their risk of poor oral hygiene (OR = 2.0) supports earlier findings2 and with the increasing number of teeth in the ageing population, these findings highlights the need for working out ways to maintain good and improve poor oral hygiene in dentate medically compromised patients.
The risk of poor oral hygiene was more than doubled (OR = 2.5) in patients who resisted assistance with tooth cleaning. It is an interesting finding that dementia did not increase the risk of poor oral hygiene; neither did nurse assistance with tooth cleaning. This highlights the resistant behaviours as a major barrier for adequate oral hygiene in nursing home patients. This was supported by the nurses. Half of the nurses reported regular experiences with patients resisting being helped with oral hygiene, and they considered this a considerable problem (median score, 3).
Almost all (97%) of the nurses reported experiences with patients needing assistance with tooth cleaning but who resisted this help. It appears that these patients do not receive proper tooth cleaning because it is left undone. Only one-third of the nurses stated that they help patients with proper tooth cleaning when they resist sometimes or on a daily basis. Non-demented patients are usually able to give consent and autonomy is important. The result that about one-quarter of these patients resisted assistance when needed highlights a problem. To improve oral hygiene in these patients the nurses should focus upon motivational factors to overcome the patients’ barrier to receive assistance with tooth cleaning.
We found that more than half of the demented patients resisted help. Thus, our results support resistant behaviour to be an important factor contributing to the poor oral health status of patients with dementia12–15. Wårdh et al.28 wrote that, ‘concern about the client’s privacy and dignity has led nursing staff to be reluctant to undertake oral hygiene measures’ and that less-educated nursing personnel were more likely to have this concern. However, our results do not support this view because there were only minor differences in the level of concern expressed by nurses with different levels of education.
One major finding in our study is that only one-fifth of the nurses had ever considered the possibility of making legal decisions about using restraint or force to help patients out with tooth cleaning. This must be discussed in the perspective that almost half of the patients (45.3%) resisted being helped sometimes or always and the majority lacked ability to give consent. There are several possible reasons for this low percentage. The principle of autonomy is essential in all medical care, and acting against this principle requires the health professional to believe that such action is important to the patient’s health. Nursing staff may not consider tooth cleaning important enough to the patient’s health to fulfil the conditions for making a decision about the use of force. This might reflect differences in culture between dental and nursing staff, as described by Andersson et al.29 who concluded that both district nurses and GPs find oral care to be ‘a matter for dentistry’. It is possible that the dental professionals’ knowledge about the consequences of neglected oral care make them believe that oral care is a more important part of total care than do other health professionals. In addition, many nursing homes aim not to use force or restraint. The law says that before a legal decision about the use of force or restraint is made, trust-giving behaviour should be attempted. Examples of such behaviour include two nurses working together, communication strategies and use of sedatives. Our questionnaire did not collect information about the use of these behaviours. However, from a dental professional’s viewpoint, it seems clear that regardless of the strategies used by the nursing homes, too many patients had unacceptable oral hygiene.
Further research should focus upon procedures to improve oral hygiene in resistant patients, such as communication skills and use of antibacterial toothpastes. An interdisciplinary consensus about what is ‘good enough’ oral hygiene in nursing homes should be discussed among all actors involved in the daily care of geriatric nursing home residents, including physicians, registered and auxiliary nurses, patients, relatives, dentists and dental hygienists.
Many studies have shown that nursing education provides an effective tool for improving oral hygiene15,21,26. Our results show that nurses can benefit from more education about oral care. Most of the nurses considered knowledge of oral conditions important (median on these issues, 5), and few considered taking care of other people’s teeth as unpleasant (median 2.0). However only about one-quarter of the nurses assessed their own knowledge to be sufficient in every situation, and the majority found it difficult in practical terms to provide oral care from time to time (median 3.0).
Our results partly support that the educational level of the nurses would affect their knowledge and attitude about oral hygiene in the nursing home patients. Although there were no differences according to education level for many aspects of attitudes and knowledge, educated nurses (registered and auxiliary nurses) more often considered ‘oral care is a part of my responsibilities’, and registered nurses more often found knowledge of the physiological function of the oral cavity important.
Our results also partly support that the organisation of routines and equipment is a challenge to adequate oral care. The nurses considered the lack of time for oral care a regular problem (median, 3). Most likely this is a universal problem in nursing homes. The nurses in our study assessed quite similar with nurses from Sweden concerning the issue ‘I can take the time necessary’26.
Oral hygiene needs to be improved in the 11 Norwegian nursing homes as more than 40% of patients had unacceptable oral hygiene. Having more than 10 teeth predicted poor oral hygiene. Patients with dementia had the same oral hygiene as non-demented patients. However poor oral hygiene could be predicted 50% of demented patients and 25% of non-demented patients who showed resistant behaviour. Dealing with resistance brings up practical and ethical challenges. We need to focus on these challenges as the number of elderly and demented persons will dramatically increase in the years to come.
Improving oral hygiene in nursing homes requires increased education, organisational strategies to give more time for oral care, and improvements in methods and routines to cope with resistant behaviour in the patients.