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Keywords:

  • education;
  • nursing homes;
  • oral care

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

doi: 10.1111/j.1741-2358.2011.00562.x Attitudes to and knowledge about oral health care among nursing home personnel – an area in need of improvement

Background:  In 1999, a dental reform became law in Sweden that regulated both dental care to dependent individuals and training in oral health care for nursing home personnel. Substantial resources have been channelled into these efforts, but the outcome of these efforts has not been evaluated. The aim of this study was to explore attitudes to and knowledge about oral health care among nursing home personnel more than 5 years after the law was adopted, that being 2005.

Methods:  A total of 454 individuals employed at nursing homes answered a questionnaire of 16 multiple-choice items concerning attitudes to and knowledge about oral health care.

Results:  Eighty-nine per cent considered oral health care to be an important part of good nursing. The answers indicated problems, however, when it came to its implementation and knowledge, and 35% stated that they had had no formal education in oral health care.

Conclusions:  Despite generally positive oral health care attitudes, it is important that oral health care education is available to and made of interest for all nursing home personnel, especially in light of the increase in number of natural teeth and frequency of crowns and bridges among dependent elderly.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

The proportion of elderly people in the population is increasing rapidly. By 2000, there were 69 million people over the age of 80 in the world, and there are estimated to be 377 million by 2050.1 The proportion still having their natural teeth in their old age is also increasing. Hugoson et al.2 showed that the proportion of edentulous 80-year-olds had decreased from 56% in 1983 to 3% in 2003 in the Swedish county of Jönköping. In a Norwegian study3 on oral health status of elderly residents living in nursing homes, the frequency of edentulous participants decreased from 71% in 1988 to 43% in 2004. In the dentate residents, the number of natural teeth and the frequency of crowns and bridges had increased. A recent study in Sweden revealed that the edentulous rate among dependent home-dwelling elderly was 32%, about 8% of whom had osseointegrated implant bridges.4 This development is undoubtedly positive, but it also constitutes a challenge to the nursing home personnel when the elderly residents are in need of support with their daily oral health care.

Today, it is known that poor oral health conditions have a negative impact on general health and quality of life in older adults.5 One of the WHO priority action areas is, therefore, oral health improvement amongst the elderly.6

In 1999, dental remuneration was regulated by law in Sweden, and the legislation also regulated dental care for dependent elderly individuals. It stated that these patient groups should have access to:

  •  an oral health care assessment in their home/residence, free of charge,
  •  basic dental care at subsidised rates and
  •  nursing home personnel who are trained in oral health care.

Usually, a dental hygienist performs the oral health care assessment. Basic dental care can include scaling, extractions, fillings and adjustment of dentures,7,8 scaling and plaque removal. The nursing home personnel should be offered training in both theoretical and practical oral health care once a year. This training is also usually given by a dental hygienist.

Substantial financial resources have been channelled into these efforts since the law was implemented, but the outcome of the efforts has not been evaluated. The aim of this study was to explore the attitudes to and knowledge about oral health care among nursing home staff more than 5 years after the law was adopted – 2005. It was part of a quality insurance project for nursing home work.

Material and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

The personnel at 12 nursing homes in the county of Jönköping and the city of Göteborg, who had had access to the oral health training programme for nursing home personnel included in the Swedish dental reform, were invited to participate in the study. A total of 630 nursing home employees, working at the nursing homes on a daytime schedule, were invited to participate. The nursing homes were selected as representing different geographical areas, community sizes and types of facility. The number of beds at the nursing homes varied between 25 and 90. In Sweden today, many nursing home residents have dementia or another serious illness, because the official policy is that when elderly nursing home residents deteriorate, they are not to be moved to other housing. Most nursing homes have special units for residents with dementia.

The questionnaire used in the study included questions on gender, working experience, profession and earlier oral health care training, as well as 16 multiple-choice questions on attitudes to and knowledge about oral health care. The questionnaire concluded with one open item for free comments about oral health care work. The questions were selected from two previously validated questionnaires.9,10 The selection process included a discussion how to choose the most valuable questions concerning attitudes to and knowledge about oral health care among nursing home staff. The discussions were held with a reference group, consisting of five nursing home employees who were not participating in the main study, led by author MJ. The nursing home personnel were informed about the study, both verbally and in writing, before inclusion. The local handling of the questionnaires was left to the nursing home managers.

Data analysis

The quantitative data were presented in total numbers or frequencies. The qualitative data were content analysed11 by reading the written comments and seeking meaning units (a group of words or statements that bear the same central meaning). These meaning units were then sorted into categories, which represent a group of contents that shared a common denominator. The categories were founded in the data by a selection of descriptive text quotations.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

A total of 454 nursing home personnel (72%) agreed to participate in the study. Six were registered nurses. Thirty-two per cent had been working for more than 20 years in nursing and 5% for 2 years or less. Sixty-five per cent of the nursing home personnel answered that they had received formal training in oral health care as part of their basic education and/or during their employment. Eighty-eight per cent had an appointment for a check up at a dental clinic themselves once a year.

Almost all the respondents stated that they gave oral health care to one or more of their residents every day, and 89% considered oral health care as an important part of good nursing. Seventy-seven per cent of the respondents were of the opinion that the residents would tell them when they were in need of help with their oral health care management.

Tooth brushing was considered by 60% to be a troublesome activity in nursing home care (Fig. 1), and close to 80% answered that the greatest obstacle to overseeing oral health care was that the residents were not cooperative (Fig. 2). More than half of the participants were of the opinion that a person’s teeth will fall out in old age whether or not they are well taken care of (Fig. 3).

image

Figure 1.  The participants were asked which of the four alternatives: hair washing, feeding, changing diapers and tooth brushing was, in their experience, the most troublesome to help a patient/resident with. The results are given in per cent of all answers. N = 413.

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image

Figure 2.  The participants were asked which of the four alternatives, don’t want to do it, don’t have enough time, the residents manage by themselves, the residents don’t cooperate, was the greatest obstacle to giving help with oral health care. The results are given in per cent of all answers. N = 444.

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image

Figure 3.  The participants were asked to give one of the three alternative answers: doubtful, don’t agree and agree, to the statement: ‘Even if you take good care of your teeth, they will fall out when you get older.’ The results are given in per cent of all answers. N = 454.

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With regard to questions related to oral health care, the majority, 94% of the respondents, answered that fluorides strengthen the teeth; 70% were aware that dental plaque, in combination with sugar consumption, was a reason for the development of caries. The most common reason for gingivitis seemed to be less well known. Forty-seven per cent answered that they brushed more cautiously when the residents’ gums were bleeding. Thirty-six per cent were of the opinion that a dental prosthesis could be left in the oral cavity during the night if the residents so wished.

The question about what type of education or help from the dental team that would best contribute to improving the residents’ oral health care had an internal drop out of 16%. Of those who answered the question, 40% thought that more time would be the most important factor. Twenty-five per cent considered help from the municipal dental team preferable, 21% practical oral health care training and 13% favoured theoretical training. Sixteen per cent of the participants, or 75 participants, gave free comments on oral health care work. The qualitative content analysis showed that the oral health care work included some common dimensions, or categories, although we did not rank them.

The first category was Uncooperative residents:

The most difficult are persons that refuse to open their mouth for their carers, and do not want help or think it is unnecessary.

The second category was Need of oral health care education:

Even the nursing staff notices bad oral health care work. I think it is good that they (the dental hygienists) come and teach us how to do this because there are those who do not know anything about what to do.

The third category was A good reform:

The elderly have much better teeth due to the education about how important it is to care for their teeth, even if there are things to be improved. There is lack of time but the reform is a fantastic advantage for the elderly.

The fourth category was Need of improved nursing home personnel cooperation:

The nursing staff ought to be present when the oral health care assessments are performed on the elderly.

The fifth category was Lack of nursing home personnel empathy:

It’s pure laziness from the staff not to brush the teeth of the elderly, and when there isn’t time. Imagine not to have your teeth brushed! You will always start with yourself.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Many efforts have been made worldwide to improve oral health care in nursing.12 The Swedish dental remuneration reform is one such effort, but its effects have not been evaluated. One of the aims of the Swedish dental reform was to support the nursing home personnel with knowledge and motivation to perform oral health care to improve the quality of life and nutrition of the elderly. This is secured through both theoretical and practical training. The training sessions are offered free of charge to the nursing home personnel by a dental team paid by the local government, but it is the responsibility of the nursing home managers to arrange for their staff to attend.

As regards the dropout rate, other studies in similar contexts have shown a response rate somewhere between 2513 and 75%14 of the sample. The dropout rate in the present study was 28%. It may be difficult to obtain a higher rate, because of staff turnover, sick leave and working schedules. There are probably also individuals who decline to participate in ways that might skew the result in a somewhat more positive direction. Free comments, given by only 16% of the participants, were probably also made by those with the greatest interest in oral health care.

Although 95% of the respondents had worked at nursing homes for more than 2 years, more than one-third had not received any oral health care training. Studies from other countries have shown that between 39 and 45.3%15,16 of nursing home personnel have been trained to perform oral health care on their patients. Despite the system of offering oral health care training to all nursing home personnel, the responsibility for ensuring that they attend is still with the nursing home managers. Often, temporary staff members are not allowed to attend the training sessions, and disturbances in the daily working plan is another reason for not allowing participation. One explanation for this could be high workloads.10

There were only a few registered nurses participating in the present study. Although there are not many registered nurses in Swedish elderly care, their participation is very important as they are responsible for the nursing work, despite the fact that they are seldom involved in the practical handling of the tasks,10 and they serve as managers for the other nursing home personnel. It has been reported that the registered nurses sometimes consider oral health care as the responsibility of the dental profession,17 but the present study does not support such findings. We were unable to draw conclusions about this owing to the small number of participating registered nurses.

Although nursing home personnel consider oral health care to be a part of good nursing, as supported in other studies,16,18 it has low priority in the daily work.10 The majority of the nursing home personnel in this study regarded tooth brushing as the most troublesome nursing activity and stated that the greatest obstacle to not giving oral health care was that the elderly residents were not cooperative, which has been highlighted many times before.9,18,19 Thus, although so many of the staff members found tooth brushing difficult, only 25% thought that help from the dental team would improve the oral health care. Perhaps, the nursing home personnel did not have confidence in the ability of the dental staff to handle uncooperative residents or perhaps, they were aware of their own professional nursing responsibility for the daily care. Many were of the opinion that the elderly themselves spoke up when they needed help with their oral health care. Could this be an excuse for not performing oral health care for uncooperative elderly residents? Dental fear among the nursing home personnel may be another reason.9

The nursing home personnel’s view of oral health care has been described as influential both in terms of the value set on oral health and the performance of oral health care at a nursing home.20 Oral health care education has been shown to improve both the nursing home personnel’s attitudes towards and knowledge of oral health care.21–23 Training may, thus, lead to improved performance, but there is very little research discussing the effects of such training.21 Paulsson et al.24 showed that 3 months after oral health care training, the nursing home personnel’s self-reported skills in performing oral health care on their patients had improved, but studies have failed to show any effect on the patients’ oral health/oral hygiene.25

What kind of oral health training is of interest to the nursing home personnel and will result in better oral health care for dependent individuals? Some authors have pointed out the value of continuous support and supervision in oral health care, especially when dealing with elderly individuals with dementia,26 but the present study did not give much support to practical oral health care training as the best way of improving oral health care. Although many of the respondents in the present study had regular dental care themselves, many were also of the opinion that a person’s teeth will fall out as they become older. It may be difficult for people to push for oral health care, if they think it is meaningless in the long run. Other studies also show that about 50% of nursing home personnel had the misconception that tooth loss is a natural process.16,21 What effects does this opinion have on oral health? Is there a need of supplementary assistance, for instance from municipal dental hygienists?

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

The results of the study indicate that the nursing home personnel have a generally positive attitude towards oral health care, but when it comes to implementation and knowledge, there are needs for improvements.

It is important that oral health care education is available to and made of interest for all nursing home staff. In addition, it is possible that in the nursing home context for the elderly of today, nursing home personnel cannot handle the daily oral health care alone, but need assistance from, for example, municipal dental hygienists.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

We thank all the nursing home personnel who enabled us to complete this project and dental hygienists Fayezeh Shams Nejad and Linda Stenström as well as language reviewer Linda Schenck. The study was financially supported by the Jönköping County Council.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Material and methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References
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