Mouth care training and practice: a survey of nursing staff working in National Health Service hospitals in England (2024)

Abstract

Introduction

Over 12 months, between 2018 and 2019, there were 20.8 million recorded admissions to National Health Service (NHS) hospitals in England. Of these admissions 42% of patients were aged over 65 years and 64% required an overnight stay (NHS Digital, 2019). A growing body of evidence has shown that following hospital admission oral health deteriorates, with an increase in dental plaque, gingival inflammation and subsequent deterioration in oral mucosal health (Needleman etal., 2012; Sachdev etal., 2013; Terezakis etal., 2011; Van Noort etal., 2020).

Deterioration in an individual’s oral health is important due to its impact on general health and wellbeing and quality of life (Spanemburg etal., 2019). Poor oral health can affect nutritional uptake and patient recovery (Petersen, 2003). Oral health-related problems can impact negatively on an individual if they struggle to eat, are not comfortable or their appearance is affected (Beacher and Sweeney, 2015). There is increasing evidence linking oral health to general health, with links to systemic diseases including cardiovascular disease (Dietrich etal., 2017), diabetes (D’Aiuto etal., 2017) and respiratory infections (Manger etal., 2017). Of particular relevance, in the hospital setting, is evidence that poor oral health is implicated as a factor in the development of hospital acquired infections such as hospital and ventilator acquired pneumonia (El-Rabbany etal., 2015; Hua etal., 2016; Scannapieco, 2006).

Effective regular mouth care in hospital is essential to prevent deterioration in oral health and maintain a healthy, comfortable and functional mouth (Public Health England, 2014). Due to cognitive, physical or medical conditions, when in hospital, many patients will require support with their personal care and this may include oral hygiene. Prior to admission, patients may have previously been able to carry out their mouth care independently. However, when in hospital, they may become dependent on hospital staff or family to maintain good standards of oral care (Sachdev etal., 2013).

The Department of Health and Social Care (2010) document ‘Essence of care: benchmarks for personal hygiene’ states that oral hygiene is a key aspect of nursing, especially when patients are unable to manage themselves. The National Institute for Health and Care Excellence (NICE) has published guidance regarding oral health standards in residential care homes through increasing training and awareness for nurses and carers. Unfortunately, to date there is no comparable guidance for nurses working with patients in secondary care (NICE, 2016).

There is a wealth of studies on nurses’ knowledge, attitudes to, and practice of oral care. Studies have found that nurses often recognise the importance of oral care but lack adequate knowledge about oral health and the practice of oral care (Adams, 1996; Daniel etal., 2004, Van Noort etal., 2020). Oral care is often considered as a low priority compared to other aspects of care and it has been found that there is a need for more training in the area (Bonetti etal., 2015; Costello and Coyne, 2008; Davis, 2019; Odgaard and Kothari, 2019; Southern, 2007).

Hands-on training in mouth care has been shown to improve oral hygiene provision, and consequently clinical outcomes for hospitalised patients (Ross and Crumpler, 2007). Training in oral health varies during nurse training, and no updates or refresher training may be received after initial qualification. In a survey of 71 stroke wards in Scotland, only a third of nurses had received oral care training in the preceding year and it had been mostly ward based (Talbot etal., 2005). Healthcare assistants, who often provide the majority of the mouth care to hospital inpatients in England, frequently receive no training in oral care (Binks etal., 2017; Care Quality Commission, 2019). The curriculum for the care certificate released in 2014 for healthcare assistants and carers in hospital and social care, which sets standards for healthcare assistants did not include mouth care, which may contribute to it not being considered as an essential part of patient care (Care Quality Commission, 2019).

An absence of oral health protocols and policies included within hospital governance indicates that oral health is given a low priority in nursing compared to other aspects of care (Salamone etal., 2013). A study carried out in Ireland showed that only 31% of nurses assessed patients’ mouths on admission and only 4% had used an oral assessment tool. In addition, there was no guidance on the delivery of oral care, resulting in inconsistencies in how mouth care was delivered, and lack of equipment, such as toothbrushes, meant that nurses were improvising with forceps and gauze (Stout etal., 2009). Lack of suitable equipment is a frequent barrier to providing mouth care. Binks etal. (2017) found that many hospitals stocked and used foam swabs to brush teeth rather than toothbrushes, or the toothbrushes were of poor quality, with large heads and hard bristles and not practical to use for people with limited mouth opening and sore mouths.

Other commonly reported barriers to the provision of mouth care included lack of time and increased workload due to increasing patient complexities and staffing shortages (Davis, 2019). These additional constraints and pressures may lead to nurses struggling to have the capacity to support patients with all aspects of care including mouth care (Pearson and Chalmers, 2004).

This paper reports a survey of nurses, conducted as part of the Health Education England (2017) oral health in hospital quality improvement programme Mouth Care Matters, which was developed to improve the standards of oral health of inpatients in English hospitals. Mouth Care Matters training raises the awareness of oral health conditions among healthcare professionals and aims to improve oral hygiene standards for hospital inpatients. Mouth Care Matters leads, with a nursing, dental nursing or speech and language therapy background, were appointed in hospitals to implement the programme, collect baseline data, implement changes and evaluate changes in practice. The baseline data collection included a survey of nursing staff’s oral hygiene knowledge and ability to assess patients' mouths. Training was provided for the leads by a small central team.

The initiative was initially implemented in 2017 across all 13 NHS Trusts (hospital groups) in Kent, Surrey and Sussex (phase 1) and then in a further 33 Trusts (phase 2) in other parts of the country, as part of the national roll-out of Mouth Care Matters, which took place in 2018.

This paper presents and discusses the results of a survey of nursing staff that was carried out in hospital Trusts in phase 2 that engaged with the programme. The survey assessed current and previous mouth care training, practice and confidence.

It was part of a baseline exercise to measure current mouth care practice in hospitals. The aim was to use the findings to: (a) help design the ‘intervention’ to improve mouth care as part of Mouth Care Matters; (b) to demonstrate to the hospital Trusts the need to improve mouth care and for it to form part of their individual quality improvement programme.

Methods

The questionnaire for the survey (Figure 1) was developed and piloted at East Surrey Hospital using themes from existing literature and focus groups with nurses. It was designed to gather information about previous training, views on the importance of oral hygiene and the current mouth care products being used to provide oral care to inpatients. The sample population were all members of the nursing team, including nurses and nursing assistants who provided hands-on clinical care.

At the pilot site the survey questionnaire had been sent to participants by email. However, the response rate was very poor as it was found that many staff did not access their work emails regularly. It was then decided that paper copies of the survey and information sheet would be distributed on medical and surgical wards and collected at the end of each day to improve the response rate.

For the national roll-out the survey questionnaire was modified, following the guidance of the Mouth Care Matters project team. The final version (Figure 1) was distributed by the Mouth Care Matters lead at each of the 33 NHS hospital Trusts which had adopted Mouth Care Matters in phase 2 and had agreed to take part in the survey. Data from the 13 Trusts in Kent, Surrey and Sussex were omitted as the questionnaire was slightly different to the one used in phase 2.

NHS ethics approval was not required as this survey of NHS staff was conducted as part of a service evaluation and not for research purposes. The anonymity of all respondents was assured.

The designated mouth care lead at each of the 33 hospital Trusts was responsible for registering the survey with the governance department at their hospital trust. An Excel data collection tool was designed by Kent Surrey Sussex Academic Health Science Network (KSS AHSN) to collate the data from the completed questionnaires. Mouth care leads sent the aggregated data to KSS AHSN for analysis and in return gained access to the Mouth Care Matters national dashboard, a quality improvement interactive tool at the disposal of the Trusts to track their progress in the Mouth Care Matters programme, developed and administered by KSS AHSN.

The estimated total number of nursing staff at the 33 hospital Trusts was 66,000. A power calculation indicated that for a 95% confidence level and a 0.05 confidence interval, 382 completed questionnaires, completed by a random sample, would be required.

Frequency and percentages were calculated. Linear regression analysis was conducted to help understand the influence of training and training type on level of confidence in undertaking mouth care tasks and recognising signs of mouth care needs.

Results

A total of 1576 completed questionnaires were collected from 33 Trusts. Of the total number of participants surveyed, 1249 (79%) were nurses, 208 (13%) were nursing assistants, 29 (2%) were specialist nurses, and 90 (6%) were classified as other. The results presented in this paper are those at baseline. A further survey took place after Mouth Care Matters training, the results of which will be reported in a subsequent paper.

Discussion

The majority of respondents to the questionnaire were supportive of the need, with 86% wanting further oral health training for nursing staff. Supporting patients with mouth care is an essential element of nursing care, contributing to maintaining good standards of oral health during a hospital admission (Salamone etal., 2013). Good oral health can contribute to reducing the length of a hospital stay as it is linked to nutritional status, comfort, quality of life and the incidence of bacterial hospital acquired pneumonia (Terezakis etal., 2011). The role of nurses in carrying out mouth care assessments and supporting patients with mouth care cannot be undervalued. The results from this multicentre survey indicate that there are mouth care training needs for nursing teams that would help to improve the oral health of patients during their admission.

In this study less than half (42%) of those surveyed answered they had not received any previous training in oral health. For those who had had oral health training, half received it during their pre-qualification training, suggesting that there may be inconsistencies in the undergraduate nursing training curriculum. The results indicate only a third of hospitals included mouth care training in their induction programmes. Not including oral health training as part of overall nursing training and induction programmes can lead to the subject being undervalued and not considered an important element of care. Mouth care should be mandatory training for all nursing staff as it is for infection control, patient falls and tissues viability. This can be delivered as part of the induction and then followed up by refresher training and can be classroom or ward based. Mouth care training should be added to the care certificate for nursing assistants; the authors are aware this has been done locally in several Trusts in England. Although focussing on care homes in England, a Care Quality Commission report ‘Smiling matters’ released in 2019 advised that the omission of oral health within the care certificate was also a major factor in the low prioritisation of oral health training (Care Quality Commission, 2019). There is also a range of oral health training resources and e-learning modules that nursing staff can be directed to via the link https://mouthcarematters.hee.nhs.uk/links-resources/mouth-care-matters-resources-2/ (Mouth Care Matters Resources, 2017). Many of the comments made by nurses in this survey focussed on the lack of training, which then results in oral health care not being provided.

Over half (56%) of the respondents reported that they felt there were barriers which prevent them carrying out mouth care. A lack of patient cooperation (70%) followed by time constraints (45%) were the two most commonly reported barriers. These two issues have been repeatedly identified as barriers in other studies (Coker etal., 2017; Davis, 2019). Nursing shortages are frequently reported in the UK, and together with the increasing care needs and the complexity of inpatients result in mouth care being an aspect of care that can be overlooked (Moore, 2017). Due to work pressures on nursing staff, mouth care has been identified as an area that is not prioritised compared to other elements of care (Salamone etal., 2013). Care-resistant behaviour, in which the person opposes the action of a care giver, is common in patients in hospital in all areas of care. It is more common in patients with learning disabilities, mental health issues and older patients with cognitive conditions such as dementia or those experiencing delirium (Brennan and Strauss, 2014). Unfamiliar settings and staff may mean they do not understand when carers are trying to support them with mouth care and may become agitated in either or both a verbal or physical manner (Jablonski etal., 2011). A gentle approach using mouth care products that a patient is familiar with and a kind manner are some methods that have been shown to be useful (Jablonski etal., 2011). Gentle clinical holding is sometimes required to carry out care for patients in their best interests; however, without training this is sometimes a grey area in care. Training focusing on the importance of mouth care including advice for staff in managing care-resistant behaviour is needed. A similar smaller survey carried out across six wards at a hospital in Ireland found that nurses had problems delivering oral care due to time constraints, lack of availability of toothbrushes and toothpaste, poor training and patients being uncooperative or confused (Costello and Coyne, 2008). A study of factors affecting the delivery of and attitudes to oral care by nurses found that oral care training, providing sufficient time to practice and desensitising nurses towards the perceived unpleasantness of cleaning the mouth (Binkley etal., 2004) improved the quality of mouth care. Hands-on practical training with patients or simulation is important just as it is for other nursing skills such as phlebotomy or taking clinical observations (Jansson etal., 2017).

Over half of those surveyed responded that they use foam swabs to carry out mouth care. In 2012, the Medicines and Healthcare products Regulatory Agency (MHRA) issued an alert about pink foam swabs being a danger to patients, due to a risk of foam detachment from the stick when being used (MHRA, 2012). This was prompted by the death of an elderly patient in a care home in Wales, through detachment of the foam, which could not be retrieved during oral care. The pink foam swabs have also not been found to be effective for removing plaque from teeth compared to toothbrushes (Marino etal., 2016). As in Wales, foam-ended mouth care products are increasingly being banned in hospitals across England where similar safety issues have been reported (Binks etal., 2017). There are alternative products available to use to moisten the mouth, soft small-headed toothbrushes are a good option for inpatients (Otukoya and Doshi, 2018).

Around two-thirds of respondents in the current survey brushed teeth and cleaned dentures, fewer brushed the tongue and only one-third used dry mouth gels. Mouth care should be carried out for 100% of patients including patients with and without teeth. Again, this can be improved by training to emphasise the importance of mouth care in relation to overall health and dignity. Nurses reported using dry mouth care products and lip lubrication for around a third of patients. Dry mouth is common is hospitalised patients due to age, oxygen therapy and polypharmacy and can impact on comfort, speaking, eating and quality of life. Supporting patients with dry mouth care that may involve lubricating the lips and using dry mouth products is an important part of mouth care (Gibson etal., 2019; Huang etal., 2014).

Forty-seven per cent of respondents in this survey said that they never or only occasionally recorded mouth care. Recording mouth care provision, as well as instances when it is refused, helps ensure that all necessary care is provided and prevents the duplication of care. There is currently no standardised mouth care tool consistently used in hospitals in England. As part of the Mouth Care Matters rollout in Kent, Surrey and Sussex only five Trusts out of 12 had somewhere to record mouth care, albeit in different documents or sections of patients’ notes (Binks etal., 2017). None of the documents indicated whether or not patients had been asked if they were experiencing current oral problems, nor whether they had access to products such as a toothbrush, toothpaste or denture pot. None of the Trusts recorded whether patients had refused mouth care or it had not been carried out for any other reason. All hospitals should have a designated mouth care assessment form and recording form as part of their nursing records. This will positively contribute to standardisation of care for patients (Royal College of Surgeons, 2017).

In general, respondents felt confident in providing mouth care and recognising common oral conditions with the exception of oral cancer (14%). Oral cancer is the sixth most common cancer, with high morbidity and mortality, and can present in a similar manner to fungal infections or other benign pathologies (Warnakulasuriya, 2009). It is important that nursing staff are aware of common signs and symptoms of oral cancer.

Regarding the low correlation between perceived confidence and training, there are numerous limitations to the data collection process which may help explain this. Although this outcome should not be seen as a comprehensive answer, it suggests an area for further investigation. The majority of nursing staff who participated in this study were keen to have training in mouth care, indicating that there is a perceived need to improve knowledge and practical skills. Training needs to focus on how to assess the mouth, mouth care recording and include appropriate mouth care tools and how to overcome care-resistant behaviour. Reoccurring themes from the additional comments were a lack of appropriate mouth care products on the wards, the need for oral health training and a change in culture towards mouth care.

Conclusions

Improving the standards of supportive mouth care can be achieved by increasing access to training for nurses. This survey of nursing staff identified that there is a felt need for training targeting on patient compliance and oral assessments. There is also a need for wards to stock appropriate mouth care products. The information in this study was used to plan part in the intervention for Mouth Care Matters training including focusing on compliance and appropriate products.

Key points for policy, practice and/or research

• The paper indicates that 42% of nursing staff have not had training in oral health.

• The most common reported barriers to providing mouth care were lack of patient cooperation (70%) and time pressures (45%).

• Although nurses in general feel confident in carrying out more mouth care, they feel less confident in assessing the mouth.

Biographies

Footnotes

Contributor Information

Mili Doshi, Consultant in Special Care Dentistry, Surrey and Sussex Healthcare Trust, UK.

Jessica Mann, Specialty Registrar in Special Care Dentistry, Bristol Dental Hospital, UK.

Léa Quentin, Kent Surrey Sussex Academic Health Science Network Hospital, UK.

Luke Morton-Holtham, Senior Analyst, Kent Surrey Sussex Academic Health Science Network Hospital, UK.

Kenneth A Eaton, Visiting Professor, University College London, UK; Honorary Professor, University of Kent, UK.

References