Keywords: oral healthcare, interview, qualitative analysis, education, nursing.

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1 ORIGINAL ARTICLE Oral health education for nursing personnel; experiences among specially trained oral care aides: One-year follow-up interviews with oral care aides at a nursing facility Inger Wårdh 1 Dentist, PhD student, Lillemor R-M. Hallberg 2 RN, Psychologist, Professor, Ulf Berggren 3 Dentist, Professor, Lars Andersson 4 Dentist, Asst Professor and Stefan Sörensen 5 Sociologist, Asst Professor 1 Department of Oral and Maxillofacial Surgery, Central Hospital, Västerås, Sweden, 2 The Nordic School of Public Health, Göteborg, Sweden, 3 Department of Oral Diagnosis, Faculty of Odontology, Göteborg University, Göteborg, Sweden, 4 Kuwait University, Kuwait and 5 Centre of Clinical Research, Uppsala University, Central Hospital, Västerås, Sweden Scand J Caring Sci; 2003; 17: Oral health education for nursing personnel; experiences among specially trained oral care aides: One-year follow-up interviews with oral care aides at a nursing facility The improved dental health in most industrialized countries is not apparent among elderly and long-term care patients. Oral healthcare has been found to have low priority in nursing care. To create lasting positive effects in oral healthcare education, a new educational model was tested in an oral healthcare project. After approval from ethical committee, nursing assistant and nurses aides took part in a dental auscultation period at a dental clinic to serve as oral care aides additional to traditional oral healthcare education. Following this period, the aides were given responsibility for the oral healthcare at their ward. After serving as oral care aides for 1 year, interviews were made and analysed based on the Grounded Theory methodology. The aim was to investigate how the oral care aides had experienced their new duties regarding oral healthcare. The results indicated that, despite several environmental changes, reluctant residents and occasional lack of commitment from colleagues, the oral care aides felt responsible for the oral healthcare provision. The oral care aides expressed courage, the capacity to cope with reality, confirmation and empathy, characteristics that propelled them from novices to oral care aides with an expert competence. Keywords: oral healthcare, interview, qualitative analysis, education, nursing. Submitted 29 August 2001, Accepted 6 March 2002 Introduction Oral healthcare has been shown to have low priority in nursing, especially among nursing personnel with shorter education. Paradoxically, it is these nurses who perform most of the oral health provision at nursing facilities (1, 2). Poor oral hygiene, which may result in rapid loss of teeth, is likely to have serious negative effects on the already frail patient (3). Evidence suggests that impaired functional status is associated with untreated dental decay which can be modified by the dental care utilization of residents (4). It has also been concluded that only physically healthy and coherent elderly adults can effectively participate in oral educational programmes; on the other hand, elderly persons who are physically unhealthy and disoriented need regular professional support (5). Thus, functionally Correspondence to: Inger Wårdh, Department of Oral and Maxillofacial Surgery, Central Hospital, entrance 27, Västerås, Sweden. dependent elderly residents must rely on an already overburdened nursing staff (4). Dental health education has often shown only limited success in changing attitudes towards dental issues and short-term gains in knowledge. Consequently, a need for greater insight into the relationships among awareness, knowledge, attitudes and health behaviour is essential (6). In a recent study in Sweden, a 4-hour oral healthcare education session for nursing personnel had positive effects on oral knowledge (7). Nevertheless, although an oral training programme for nursing staff in England was well received and resulted in improved oral knowledge, barriers to practice of oral care by carers still remained (8). It is difficult to implement a new procedure. Any procedure at ward and hospital level will be adapted to meet not only the needs of the individual patients but also the local conditions and resources (9, p. 44). There is need for realistic and practical educational interventions at nursing facilities to improve oral care provision (10, 11). The problem is not so much a question of learning facts about oral health care, but to transmit the acquired knowledge to 250

2 Oral health education for nursing personnel 251 others in the nursing context (12). Follow-through to change requires commitment from leadership that quality improvement is important and encouragement for staff to participate in quality improvement activities (13). Identifying specific individuals who would be responsible for daily oral care within the long-term-care facility may provide a new perspective on the oral healthcare problem (14). It has been shown that teaching some of the nursing staff how to do an oral health assessment increased the awareness of all nursing staff of the importance of oral hygiene (15). Thus, as a part of an oral healthcare project, a traditional oral healthcare programme was complemented with specially trained oral care aides (16). The aim of the present study was to investigate how the oral care aides had experienced to perform their new duties regarding oral healthcare work at their nursing facility wards. Method Study population The respondents included two nursing assistants and two nursing aides who had been selected to work as oral care aides in two units at a nursing home. The present study was part of a larger project where this method was compared with a control group at another nursing home with a traditional oral healthcare system. Assessments were made with both nursing staff and residents (16). The oral care aides were experienced nursing personnel. They were chosen by the ward Director and head nurse and, at the time of selection, they had full daytime employment and worked on different work schedules. Procedure Approval from the local ethics committee had been received. All nursing staff members, the oral care aides included, had given their written consent to participate. They were informed that participation was voluntary and that all information about them was confidential. Each person on the nursing staff was offered a 3-hour oral healthcare education session. In addition, the oral care aides in the intervention group attended a dental clinic for auscultation training 1 day per week over a 4-week period. They returned to their nursing work with a written outline of their new duties as oral care aides. The specific structure of their work tasks was left to be solved locally, however. The residents dental care were subsidized by a new dental insurance system. Both the intervention and control groups had the possibility to have contact with the dental team. However, it was the nursing staff and not the dental team that informed the residents about these favourable circumstances. When the project had been running a year, the oral care aides attended one more auscultation day at the dental clinic as repetition. Interviews We used personal interviews as research method. Much of the challenge in healthcare has a social dimension to enhance ability of individuals to perform roles and activities while many research studies have mainly dealt with these complex socio-medical problems from purely medical or technical perspectives (17). This is even more obvious in the area of odontology, where clinical studies using sociological perspectives and methods are rare. However, personal interviews have been found to be useful qualitative instruments for dental research in nursing facilities (10). In conjunction with the auscultation repetition day, the first author (IW) carried out interviews with the oral care aides. This author had previously performed both individual interviews (2) and focus group interviews with the nursing staff (16). Because one of the co-authors (LH) had extensive experience in interviewing, she acted as consultant. The interviews, which took about 90 minutes, were tape-recorded and transcribed by a secretary. Each interview focused on the respondents own description of how they experienced their prospect of being responsible for oral healthcare provision at their ward. An outline of their function as oral healthcare aides, was used as a guideline during the interviews (Appendix 1). Analysis of data The analysis of the interviews was influenced by the methodology of Grounded theory (18). The aim of this method is to generate hypotheses, models or preliminary theories about what is revealed in a social situation. The content of the interviews was subsequently analysed sentence by sentence by the interviewer (IW). If anything seemed unclear, the interviewer contacted the respondents and asked for more information. When further information could not be obtained, the study was terminated. The analysis involved a three-step procedure. The first step consisted of open coding, by which concepts were developed. Similar concepts were grouped to form higherorder concepts, i.e. a more abstract level, termed categories. The next step, axial coding, developed main categories and their subcategories. The third step involved selective coding, which meant integrating the categories to form a theoretical framework. This procedure identified a story line that explained the central phenomenon and became the core category. The core category stands in relationship to all other categories, like the sun to its planets (18). Results One core category, expert competence, and four additional categories, labelled courage, coping with reality, confirmation and empathy, were anchored in the data. The oral care aides

3 252 I. Wårdh et al. experienced that they had become competent oral healthcare providers. They looked upon themselves as a special resource but they had to face both the reality of circumstances and reactions from colleagues (Fig. 1). In the beginning the oral work was a bit hard. But now I ve come more and more into it. Now the other staff members understand that I m a oral care aide. I even feel like a police, keeping the oral healthcare work at a high level. Sometimes I refer to myself as a dental nurse and it works when residents refuse to open their mouths. We are more familiar with the patients oral problems than the nurses. When we have to phone the dental clinic, I prefer to make the call myself, because I know how to describe the problem. Below, each additional category will be described and illustrated using comments from the respondents. Courage The oral care aides had to act with courage when they faced negative reactions from colleagues. These reactions were mainly of three types: lack of information, laissez faire and the law of Jante mentality. Lack of information. The oral care aides experienced some of their colleagues as being largely unaware of the oral healthcare provision on their ward. Similarly, when the oral care aides observed that their colleagues were either uninterested in the oral healthcare work or performed the work in the wrong way, the aides felt responsible to tell their colleagues this condition even if it was difficult. Documentation about the mouth is somewhat obscure. Oral reports from the hospital are lacking. It comes second to all medical things. It s even worse than for those who came directly from their homes. When an elderly wife or husband has more control over oral problems than hospital staff, then one can wonder. When you notice that a staff member does something wrong, you really must tell them directly, even Figure 1 Model of the oral care aides experiences of expert competence as responsible for oral healthcare work when facing reality of circumstances and reactions from colleagues. though it is difficult. And you have to do it at once: not at award meeting three weeks later. Laissez faire. This reaction by some of the nursing staff has been described earlier in the project (16). It expressed an attitude of I don t care, when the oral care aides tried to generate enthusiasm to their colleagues regarding oral healthcare provision. Some staff members you have to remind the whole time; otherwise, the oral work will be forgotten. They claim they know how to perform oral care, but it s obvious that they don t. Perhaps some of them really think that they know, but when they don t even brush the residents teeth at evenings. I think the problem has to do with the nature of one s personality. Some of the younger staff members only care about money and their spare time. I think of the day when I, too, will become old. How will it be? The law of Jante. It can be a difficult situation to be put into a work role that is not available for all. This situation created some talk behind the oral care aides back. The law of Jante is originated from the Norwegian author, Aksel Sandemose, and tells that you always should be loyal to the collective. The different, spontaneous and new is dangerous, and trying to be better than others is repressed and socially punished (19). We don t always talk with each other but we do talk behind each other s back. It s a lot of shit like, Have you seen how she works; she does it [oral care] the wrong way. Sometimes you really try to be kind, polite and I don t know what but it doesn t matter. You can say whatever you want to some staff members, but there are those that you can t get close to. It s a matter of bad talk and so on. Coping with reality Some of the circumstances (e.g. lack of personnel, financial restraints and high workload) of the nursing staff and oral care aides in the nursing environment could not be changed immediately for the nursing staff, including the oral care aides. Instead, to efficiently run the oral healthcare work the aides had to continuously come up with new strategies to manage these daily hassles. Lack of personnel. The oral care aides experienced an increasing workload in their nursing duties. This situation was largely due to frail and dependent caretakers but it was also because of a lack of personnel, especially registered nurses. In daytime, we should be eight personnel but now we are scheduled to be six: in reality we have been only four. You just run around the whole time. And it s not that easy to replace a vacancy either. Some nursing

4 Oral health education for nursing personnel 253 staff has gone to other employments when it s been bad times and now when we need them again they are gone. We tried to introduce a system in which nursing is done in pairs, with a registered nurse and a nursing assistant working together. But the nurses got ill and I had to work alone. It didn t work and we quickly abandoned the system. Financial restraints. The local government had placed a noticeable financial restraint on the nursing facilities. The financial restraints were in effect during the time of the current project time, which forced the oral care aides to deal with this situation in their daily work. The obligation to save money just arrived from heaven. Night staff personnel were told that they had to clean the wards and the residents would be given deserts only on weekends and holidays. Some of the residents will suffer: for example, those who only eat the deserts. I really don t know how they will manage. I had to leave a part of my employment that was on vacancy. In such a situation you still have to manage the oral care work. Perhaps it works because I ve a chance to influence my working schedule. The oral care work takes time. Otherwise, it doesn t work. Somebody else might help you with some of the other duties instead. High workload. The oral care aides acted on the resident s personal needs rather than merely performing their routine duties, adapted to working schedules. The recent time many new residents had arrived with diagnosis that the ward staff was not used to take care of. Because of the weak economy, we were not allowed to have empty beds. We have very demanding residents that come here. The more active ones go to other places. The workload has been much higher than it was earlier. We have small baskets with oral tools for residents that need additional oral care in the residents rooms. This way staff members don t have to waste time looking for the tools. Oral care usually is done in the late afternoons but some of the residents want to stay up longer in the evenings where it is likely that they will want something to eat. In this case, oral care has to be carried out latter in the evening, even if the staff is reduced in the evenings. Confirmation It was important for the oral care aides to feel reassured that they were performing their duties effectively, especially the assurance that came from the nurses and the dental team. When colleagues showed commitment, nurses placed confidence in them and dentistry became integrated in the oral care aides work, they felt confirmed. Commitment. This position of commitment by the nursing staff has been described earlier (16). It expressed a behaviour when the oral healthcare provision was well functioning at the ward. We took the idea of commitment very seriously: in fact, more than many others and started quickly with the oral care work. We give information about our oral care work to new residents. The first things to ask about are teeth and incontinency. Starting about 6 months ago, the other staff members came to us with problems regarding oral care. They probably came to us because they understand that we will deal effectively with problems on oral care. Even the night staff has been participating in the oral education. It s good because some of them work on the day schedule when there is generally a lack of staff. Confidence. The oral care aides shared in the responsibilities of the oral healthcare work with the nurses and sometimes the aides felt more competent in decisions about what kind of treatment was suitable or when a dental contact was necessary. It is often the older relatives that contact the nurses. When somebody phones the nurses about oral matters, the nurses often come to us and discuss actual oral problems. They also remind us about new residents with oral care needs. When we need oral care tools from the Pharmacy, the nurses order it and it usually comes the same day. The head nurse concerns very much about our function as oral care aides. Integration. The dental team, and especially the dental hygienist contacts, became a natural part of the oral healthcare work. The dental visits have increased appreciably since the project s start. The oral care plan cards are very good. They are visibly placed in each resident s room. When an oral problem occurs the staff first look at the oral care plans and we discuss the case at a report time. Based on the information provided at these meetings, we decide if the dental clinic has to be contacted. The greatest problem is the residents who refuse to open their mouth. When the dental hygienist comes, then suddenly the residents comply with our request that they open their mouth. Empathy The oral care aides felt empathy for the dependent elderly residents and thus sided with the residents so they could

5 254 I. Wårdh et al. benefit from the oral healthcare provision. The aides learned to understand the resident s doubtfulness and acted due to advocacy. Doubtfulness. Some residents were unable to decide quickly or firmly when informed about the new oral healthcare activities at the wards. This behaviour was sometimes even relevant for the resident s relatives. The most interesting factor seemed to be the price. A special problem was refugees who didn t understand the language and were familiar with other dental care procedures. Acting with uncertainty was also visible when oral healthcare was performed. It can be a good thing to wait a bit with the oral information. If they are demented and come as new residents, then all things had to settle down before taking up issues regarding oral care. Often some relative are present when I come into their room. It s usually easier with the residents children. Sometimes they phone afterwards and ask for more information. Residents from abroad are special because the relatives are not good in communicating in Swedish. It often leads to misunderstandings. When it comes to brushing, the residents can be reluctant. You have to be persistent and wait until you succeed. Advocacy. The oral care aides felt it important to inform the residents and their relatives in an effort to enhance their dental care interest. They also looked upon different circumstances from the resident s point of view. The residents may talk about their former dentist but then suddenly a relative informs us, Yes, You should have been there, but you know that it won t be so. They don t ask for oral care; we have to encourage them to take an interest in oral hygiene.. A wife told me about her own expensive dental visit. I reminded her about the dental reform. Although this woman had written her name on the information paper, she nevertheless didn t know her husband s rights. He wanted new dentures. As a caregiver, one must consider that many elderly patients have relatives that are also old. In the beginning, I thought that the oral work was unpleasant. Now, my main concern is about the residents, especially the patients who still have their own teeth. You could imagine how it would be if you were in their shoes. Discussion The oral care aides passed a specially designed training period at the dental clinic and after about half a year in their new function they experienced themselves as competent oral care aides (16). The oral care aides and some of their colleagues then seemed to have reached a high level of commitment to oral healthcare. According to Blinkhorn, there are several levels within the knowledge and behaviour change model: unawareness, awareness, self-interest, attitude, belief and commitment (permanent change in behaviour). The levels are not discrete but a continuous whole (20). Principles acquired in formal education are of no avail if practical situations relevant to these principles go unnoticed, or if you do not have the skills to conduct yourself in an ethical manner (21). To bridge the gap between theory and practice, theories must be presented in a more flexible, context-dependent style (22). Putting knowledge into action is difficult. Carers often feel tremendous pressure from the large numbers of elderly in their care in addition to the many problems they pose (23). The present oral care aides learned to act strategically and with courage to meet the daily problems that arise on the ward. They acted in the best interest of the residents in order to fulfil their duties. The aides also had to deal effectively with the relatives of the residents even if many relatives would take all their questions to the nurses. It is necessary to involve family or other concerned third parties in the consent process when a patient s decision-making capacity is in doubt (24, 25). The oral care aides used the opportunity to make a phone call for being able to give sufficient information about the oral healthcare work. Larger nursing homes have tended to show better oral health of their residents, probably because such homes have larger staff and some people that are knowledgeable about dental hygiene (26). The use of a specific aide to coordinate oral care has been rated as useful; however, over half of the aides were not interested in such a position (10). Directors may be concerned that nursing staff members are already heavily burdened and thus may be hesitant to assign additional duties (27). Reviewing one s own practice and that of colleagues is not an easy task. Thus, it is important that the staff members who are involved in the process of change are sure of their role, feel capable of communicating their beliefs and knowledge of the subject and do not feel that the change will be imposed on them (28). In the present case, the oral care aides had to face colleagues that did not have or did not show an interest in oral healthcare. Reasons for inadequacy of oral care have been reported to include lack of time and staff, residents refusing oral care and aides unwillingness to perform oral care (14), similar barriers that this study recognized. The present study showed that the oral care aides felt they could maintain a high level of oral healthcare, even if they did not always receive full support from the other staff members. Professional support has shown to be effective in changing clinical practice in nursing homes (13). The dental clinic was situated away from the close vicinity of both the intervention and control group nursing

6 Oral health education for nursing personnel 255 homes, but nevertheless integration was established and maintained in the intervention units. The oral care aides also felt confirmed in their new position by the nurses in leading positions. They felt they had created a working model with other staff including the nurses who were responsible for the documentation and the quality assurance of the nursing work, and who they kept well informed about the oral healthcare activities. The positive contact with the dental team, especially the dental hygienist, and the confirmation from nurses proved to be important factors which supports the idea that good oral healthcare work depends on effective communication and integration between the nursing and dental professions. The use of specially trained oral care aides seemed to be a powerful approach in creating this integration why the educational model will be further introduced and evaluated in other nursing environments. Acknowledgements This study was supported by Grants from the Health and Disease Department in Västmanland County, Sweden, the Swedish Dental Society and the Foundation of G. Svensson, Göteborg, Sweden. We wish to thank all nursing staff personnel and especially the oral care aides who participated in this study. We are also grateful to the project s dental hygienist, Annette Karlsson Holmén, and to Johanna Hallberg who transcribed the interviews and to Leslie Shaps who revised the English text. Appendix 1. Outline of the oral care aides function Oral care aides should: primarily deal with problems concerning oral healthcare, including questions from the relatives of the residents in consent with the nurse, determine whether an oral healthcare problem should be referred to the dental clinic if necessary, contact the dental clinic inform the other nursing staff members about oral healthcare issues and ensure that exhaustive documentation is performed inform all residents, and especially new ones about the dental insurance system assist whenever follow-up assessments are made of any oral healthcare intervention References 1 Wårdh I, Andersson L, Sörensen S. Staff attitudes to oral health care. A comparative study of registered nurses, nursing assistants and home care aides. Gerodontology 1997; 14: Wårdh I, Hallberg LR-M, Berggren U, Andersson L, Sörensen S. Oral Health Care A Low Priority in Nursing. In-depth interviews with nursing staff. Scand J Caring Sci 2000; 14: Nederfors T. Attitudes to the importance of retaining natural teeth in an adult Swedish population. Gerodontology 1998; 15: Hawkins RJ. Functional status and untreated dental caries among nursing home residents aged 65 and over. Spec Care Dentist 1999; 19: De Baat C, Kalk W, Schuil GRE. The effectiveness of oral hygiene programmes for elderly people a review. Gerodontology 1993; 10: Brown LF. Research in dental health education and health promotion: A review of the literature. Health Educ Q 1994; 21: Paulson G, Fridlund B, Holmén A. Evaluation of an oral health education program for nursing personnel in special housing facilities for the elderly. Spec Care Dentist 1998; 18: Simons D, Baker P, Jones B, Kidd EAM, Beighton D. An evaluation of an oral health training programme for carers of the elderly in residential homes. BDJ2000; 188: Boyle S. Assessing mouth care. Nursing Times 1992; 88: Chalmers JM, Levy SM, Buckwalter KC, Ettinger RL, Kambhu PP. Factors influencing nurses aides provision of oral care for nursing facility residents. Spec Care Dentist 1996; 16: Fitzpatrick J. Oral health care needs of dependent older people: responsibilities of nurses and care staff. J Adv Nurs 2000; 32: O Sullivan C. Certificate in basic oral health promotion. JR Soc Health 1995; 115: Rantz MJ, Popejoy L, Petroski GF, Madsen RW, Mehr DR, Zwygart Stauffacher M et al. Randomized Clinical Trial of a Quality Improvement Intervention in Nursing Homes. The Gerontologist 2001; 41: Pyle MA, Nelson S, Sawyer DR. Nursing assistants opinions of oral health care provision. Spec Care Dentist 1999; 19: Kajser-Jones J, Bird WF, Paul SM, Long L, Schell ES. An instrument to assess the oral health status of nursing home residents. The Gerontologist 1995; 35: Wårdh I, Berggren U, Hallberg LR-M, Andersson L, Sörensen S. Dental auscultation for nursing personnel as a model of oral health care education. Development, baseline and sixmonth follow-up assessments. Acta Odontol Scand 2002; 60: Gift HC. Values of selected qualitative methods for research, education, and Policy. J Dent Educ 1996; 60: Strauss A, Corbin J. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. 1990, Sage, London. 19 Kylhammar M, Nilsson GB. Jantelagen och Grönköpingslagen. The law of Jante and the law of Grönköping. In Det evigt mänskliga: humanismen inför 2000-talet. The eternal human: humanism in the 19th century, (Björnsson A ed.), 1996, Ordfront, Stockholm, Blinkhorn AS. Dental health education. In Dental Public Health, 2nd edn. (Slack GL ed.), 1981, John Wright & sons Ltd, Bristol, Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. 1984, Menlo Park, Addison-Wesley, Calif.

7 256 I. Wårdh et al. 22 Peate I. Nurse-administered oral hygiene in the hospitalized patient. Br J Nurs 1993; 2: Hoad-Reddick G, Heath JR. The carer s perspective: results of a survey of attitudes to dental care in 250 residential homes in Manchester. J Oral Rehab 1993; 20: Shuman SK, Bebeau MJ. Ethical and legal issues in special patient care. Dent Clin N America 1994; 38: Warren JJ, Hand JS, Kambhu PP. Family member and guardian acceptance of dental services for nursing home residents. Spec Care Dentist 1992; 12: Hoad-Reddick G, Heath JR. Identification of elderly in particular need: Results of a survey undertaken in residential homes in the Manchester area. J Dent 1995; 23: Johnson TE, Lange BM. Preferences for and influences on oral health prevention: perceptions of directors of nursing. Spec Care Dentist 1999; 19: Hatton-Smith CK. A last bastion of ritualised practice? A review of nurses knowledge of oral health care. The Prof Nurse 1994; 9:

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