Knowledge, Attitudes, and Practices of Oral Care in Mechanical Ventilated Patients

Overview

Aim: To identify the intensive care unit nurses' (ICU) knowledge, attitudes, and practices of oral care in orally intubated patients.

Method: A descriptive, cross-sectional, correlational design was used to describe the current knowledge, attitudes, and practice of oral care among ICU nurses' in two university-affiliated teaching hospitals, using a self-administered questionnaire that was developed by Lin et al., (2011) and Soh et al., (2011).

Results: A total of 135 questionnaires were analyzed and showed that the mean percentages of critical care unit nurses' knowledge, attitudes, and practices of oral care were 53.6%, 67.5%, and 43.25% respectively. The main source of learning regarding oral care for intubated patients was the senior nurses in their units followed by nursing school, also, nurses who had more than one source for learning about oral care had greater knowledge regarding oral care, and performed oral care practices more frequently. The results also indicated that the nurses did not have adequate knowledge and clear perception about the characteristics of various oral cleaning solutions and the effective equipment that is used to remove dental plaque.

Conclusion: The study results provide insight into oral care in ICU nurses' and the need for protocol development, implementation, and evaluation; moreover, enhancing nurses to get knowledge about oral care from different educational sources to improve their practices.

Keywords:

Knowledge – attitudes – nursing practice – oral care – Jordan

Introduction

Mechanical ventilation is an essential, life-saving therapy for patients with critical illness and respiratory failure which aims to maintain adequate gas exchange (Stayt et al., 2015). Despite its importance as a lifesaving therapy, mechanical ventilators had many common complications and systematic diseases affect patients, including ventilator-associated pneumonia (VAP) (Morris et al., 2011; Sedwick, et al., 2012).

Oral care is considered as an important nursing activity in the ICU (Barr et al. 2013). Traditionally this activity has been focused on patient comfort and hygiene rather than specifically addressing plaque removal (Barnes, 2014; Soh, et al., 2011). Oral care is a nursing intervention that decreases the incidence of VAP (Bouadma et al., 2012). Oral care policies and practices vary from country to country, hospital to hospital, and even within the same intensive care units (Ganz et al., 2013). Also, protocols guiding oral care may be inconsistent, impractical, difficult to follow, or lacking altogether (Majumdar, et al., 2012.).

In a study conducted by Batiha et al., (2013) in ten major hospitals in Jordan using a non-participant structured observation to explore the competency of the Jordanian intensive care nurses towards ETT and oral care practices for a mechanical ventilated patient; None of the participants were observed to use the toothbrush at all, on the other hands 40% of the participants were observed to do an oral swap with hydrogen peroxide solution (H₂O₂) or 2% Chlorhexidine solution to clean the mouth every 2-4 hours for their patients.

The literature shows that the majority of nurses had positive attitudes toward providing oral care, and considered as a very important for mechanically ventilated patients (Ullman et al., 2014; Kiyoshi-Teo, et al., 2014; Batiha, et al., 2015; Batiha et al., 2016), on the other hands it was not provided in a standardized methods (Soh et al., 2011), and therefore the importance of oral care is often underestimated (Feider et al., 2010).

Aim

To identify the intensive care unit nurses’ (ICU) knowledge, attitudes, and practices of oral care in orally intubated patients.

Method

Design and sample

A descriptive, cross-sectional, was conducted on 135 ICU nurses in selected two affiliated teaching university hospitals of Jordan. Inclusion criteria included any registered nurse (BSN or master degree) who were currently working at ICU’s, and having at least 1-year experience in providing oral care for intubated patients and consent to participate.

Instrument

The instrument that was used in the current study was a combination of two questionnaires used by Lin et al., (2011), and Soh et al., (2011). Both authors designed their questionnaire based on the literature and their clinical experiences. The last two questions (6, 7) in the practice part were developed by the researcher.

The reliability of the knowledge part in the questionnaire of Lin et al., (2011) using test-retest reliability was 0.9 (p = 0.003). In this study, the internal consistency of the knowledge scale was tested using Cronbach’s Alpha. The Cronbach’s Alpha coefficient of internal consistency reliability of the knowledge part was 0.52.

The questionnaire was sent to three expert’s panel for content validity. The expert panel agreed on the survey items. Only one question in the demographic profile was added (total years of nursing experience) for greater clarity based on the expert’s feedback.

Data Analysis

The data obtained from study participants were analyzed using SPSS version 19.0 (SPSS, Inc., Chicafo, IL, USA). The level of significance was set at 0.05. Data were cleaned and screened for missing data, outliers, and wide codes by inspecting frequency distributions for all study variables.

Descriptive statistics were used to draw summaries including the computation of means, standard deviations, and frequencies of the studied variables and describing the socio-demographic characteristics of the participants.

Results

Demographic data for nurses

Two hundred and ten nurses met the inclusion criteria. Of these, 194 agreed to participate and 135 questionnaires were returned with a response rate of (74.2%). The mean age of the nurses was 27.07 years, the mean total nursing work experience and the total ICU work experience were approximately the same, and almost half of the sample was females. Most participants had a bachelor‘s degree and worked in GICU (Tab. 1).

The main source of the nurses‘ knowledge regarding oral care for intubated patients was the instructions from senior ICU nurses in their units followed by information from nursing school. The mean number of sources of learning regarding oral care for intubated patients was 2.47 (SD 1.18, range 1-7).

Knowledge, attitudes, and practices of oral care for intubated patients

The mean knowledge score was 18.23(SD= 3.49), where was the potential range from (0-34); the actual range scores in the current study were from 9-27 points. The mean score was converted to a percentage to ease comparison by dividing the mean score by total score and then multiplied it by 100 % (18.23/34X100%= 53.6%).

Tab. 2 shows the percentage of responses to each question. In terms of the attitude towards oral care of intubated patients, the mean attitude score was 13.5 (SD= 4), where the range was 4-20 points.

The average percentage of nurses‘ attitude scores was 67.5 %. (13.5/20X100%) (Tab. 3).

 The ICU nurses ranked oral care forth in the order of priority of physical care activities and eighth in order of priority of nursing treatment activities (Tab. 4).

Nurses‘ attitudes also assessed using 6 yes/no questions. More than 80 % of nurses thought that oral care was very important and had a high priority for intubated patients as they had the adequate time to provide oral care, however approximately half of nurses had adequate oral care training. Also more than half of nurses agreed that oral care was an unpleasant task and felt that the oral cavity was difficult to clean. Overall, the nurses had a positive attitude toward providing oral care for orally intubated patients based on total scores of yes/no questions (out of 6) (M = 3.63, SD = 1.40). The mean ideal practice score was 1.73 (SD=1.07), where the range was 0-4 points The percentage of mean practice scores was 43.25% (1.73/4X100%) (Tab. 5).

In terms of the current supplies that were readily available in their hospitals, the majority of nurses indicated that they used gauze or cotton in performing oral care. In terms of the current solutions that were readily available in their units, most of the participants indicated that they used chlorhexidine solution while performing oral care for intubated patients and less than 40% of them used normal saline.

An open-ended question, „Do you want to add anything related to this topic about oral care study such as barriers, facilitators…etc.?”

Ten of the participants respond to this open-ended question. Two of them indicated that the unavailability of the equipment in their hospital may be a barrier to apply oral care, on the other hand, two participants mentioned that the availability of equipment especially toothbrush can help in providing oral care more frequently and efficiently. Three of them reported that the shortage of nursing staff and thus increased number of the patient: staff ratio play an important role in ignoring oral care performance. Furthermore, 4 participants indicated that the lack of time and work overload also play a role in ignoring oral care practice. Two participants indicated that the oral mouth is difficult to clean, and the bad odor remains whatever they do, so they did not feel the benefit of performing such procedure. Finally, one nurse indicated that the nurses are not oriented about the relationship between VAP and oral care.

Discussion

The mean age of participants was 27 years which is consistent with the average age of the nursing taskforce in Jordan (Al‐Nawafleh et al., 2013). The level of education for most of the study participants was a baccalaureate degree (85.2%). This is consistent with the national data, in which most of the registered nurses held a baccalaureate degree, and few of them had a graduate degree (Al-Ma’aitah & Shokeh, 2009). The average years of experience in nursing for the study participants were around five years, and the average years of their experience in critical care units were four years. This might refer to that, registered nurses had a young age and preferred to stay working at the same unit that they were familiar with, and considered themselves possessing enough experience to provide efficient and safe nursing care.

The main source of learning regarding oral care for intubated patient was the senior nurses in their units (71.1%) followed by a nursing school (58.8%) and the study participants had around 2 to 3 sources for learning about oral care, these are consistent with the studies by Lin et al (2011) and Sole et al (2003). Few nursing schools ensured the importance of oral care for mechanically ventilated patients despite it considered as a part of the fundamental nursing curriculum (Lin et al., 2011), so instructions from senior nurses will be the main source of knowledge regarding oral care for mechanically ventilated patients.

The main results of this study were that the mean percentage of critical care unit nurses‘ knowledge, attitudes, and practices of oral care were 53.6%, 67.5%, and 43.2% respectively.

Knowledge of Oral Care for Intubated Patients

The mean scores for critical care unit nurses’ knowledge of oral care for intubated patients were 18.23 (out of a total of 34 points) meaning that nurses answered 53.6% of the questions correctly. This is consistent with the results of Lin et al., (2011) in which the mean percentage score was 58.8% and Labeau et al., (2008) who found that the nurses had low knowledge regarding the risk factors of developing VAP with an average score of 4.06 (45.1%). The lack of knowledge was indicated as a barrier for adhering to evidence-based practice (Labeau et al., 2008), this may refer to many reasons like lack of continuing education in the participants’ hospitals concerning oral care as an important preventable measure for developing VAP, absent of standardized oral care protocol and the poor or lack of following the updated evidence regarding oral care in the participants‘ units.

Concerning the characteristics of various cleaning solution, 89.6% of nurses selected „anti-bacterial or inhibits bacteria“ as the main characteristic for ideal cleaning solution indicating that nurses think that cleaning solutions should have an antibacterial or bacterial inhibiting effect and this is consistent to what was found by Lin et al., (2011). The three wrong options that most often selected were (1), “eliminate debris attached to oral mucous” as a characteristic of sodium chloride, (2)“gauze pad” as a characteristic of effective equipment for removing dental plaque, (3) “maintain oral moistness” as a characteristic of sodium chloride. These results indicate that the nurses didn‘t have adequate knowledge and clear perception about the characteristics of sodium chloride as oral cleaning solution and the effective equipment that is used to remove dental plaque.

On the other hand, the five options that were correct and least often selected in this study: (1) “cause oral pain” as a characteristic of chlorhexidine, (2) ”tends to encourage bacterial growth” as a characteristic of sodium bicarbonate, (3) “appropriate concentration is 0.1-0.12 %” as a characteristic of chlorhexidine, (4) “tend to cause mouth dryness” as a characteristic of sodium chloride and (5) “promote wound healing” as a characteristic of sodium chloride. These results indicate that the nurses did not have adequate knowledge and a clear perception of the characteristics of various cleaning solutions. 1, 2, 4, and 5 options were consistent with Lin et al., (2011).

Despite the availability of chlorhexidine as oral cleaning solution in the hospitals of participants (88.1%), few of them know the appropriate concentration for chlorhexidine and if it causes oral pain or not. Also nearly half of them did not know that chlorhexidine treats the oral infection. This indicates that the nurses did not clearly understand the properties of chlorhexidine as oral cleaning solution. Although the literature emphasized that toothbrush was the tool of choice in removing dental plaque (Garcia et al., 2009, Garcia, 2005), half of the nurses selected it as an effective tool in removing dental plaque and above 80 % of them selected cotton swab and foam swab. This indicates that nurses did not have a clear idea about the effective cleaning tools for removing dental plaque. Although toothbrushing is effective in minimizing the microorganisms of the oral cavity and thus removing dental plaque, it is an independent nursing action that is not routinely performed in critically ill patients (Grap et al.,  2003).

The researcher recommends that chlorhexidine, sodium chloride, and sodium bicarbonate should be used as oral cleaning solutions and pediatric toothbrushes an effective tool for removing dental plaque in the hospitals, through the in-service education and infection control unit and should be provided with evidence from previous literature on its importance and effectiveness in removing dental plaque and thus reducing the incidence of VAP. On the other hand, the adult toothbrush was not suitable for performing oral care to orally intubated patients due to its big head (Soh et al., 2011 & Binkley et al., 2004)

The nurses indicated that the most common risk factors of VAP were aspiration from contaminated secretions from the oropharynx (72.6%) which is the main risk factor, followed by contaminated from respiratory equipment (51.1%). This is similar to Soh et al., (2011) and Binkley et al., (2004) results. This indicates that nurses have a good idea about the main risk factors for developing VAP.  

The mean scores for critical care unit nurses‘ attitudes of oral care for mechanically ventilated patients were 13.5 (out of 20) (67.5 %). This is consistent with the attitude score of Ganz et al., (2009) and higher than the results of Grap et al., (2003) and Feider et al., (2010), which illustrates that the nurses had a positive attitude toward the importance of providing oral care.

The nurses ranked oral care forth in the order of priority of physical activities next to physical assessment, chest physiotherapy, and changing position, however, they ranked oral care eighth in order of priority of nursing treatment activities which is consistent with Lin et al., (2011). The nurses believe that oral care is moderately important as physical care activities, but when oral care competing with other nursing treatment activities that have greater survival effects on the patient like O2 therapy, observing patient status and suctioning sputum, nurses considered oral care the least important. This may be explained that oral care has been occupied low priority when the greater importance activities to stabilize the condition of critically ill patients. This is consistent with what was found by (Grap et al., 2003 & Yeung and Chui, 2010).

Although more than 80% of participants had adequate time for oral care and considered it as a high priority, and 57.8% had adequate training to provide oral care, more than half of them expressed that oral care was an unpleasant task and oral cavity of their patients was difficult to clean. These results were similar to what was found by Soh et al., (2011), Cutler and Davis (2005), and Binkley et al., (2004). The essential goal of oral care is minimizing the accumulation of bacteria and thus the formation of dental plaque which in turn causing VAP, however nurses in CCUs neglect performing oral care because they consider it a patient comfort action rather than VAP prevention action. Allen Furr, et al., (2004) found that having sufficient time to provide oral care, considering oral care as a high priority and the not unpleasant task was associated with providing better oral care for patients.

The mean scores for critical care unit nurses of ideal oral care practice for mechanically ventilated patients were 1.73 (out of 4) (43.2 %). The percentage of nurses who removed patients’ oral secretion every 2-4 hours or more often as an ideal practice in this study was 85.5% which is similar to Lin et al (2011). This is due to the policy in the nurses’ hospital that forces them to do suctioning every two hours and remove secretions from the oral cavity. Less than 50% of nurses in this study performed ideal oral care with cotton or foam swab every 6-8 hours or more often and with a toothbrush every 8-12 hours or more often, which are significantly less frequent than the results of Grap et al., (2003), Sole et al., (2003), Ganz et al., (2009) and Jones et al., (2004). This may be referred to that cleaning the oral cavity is an unpleasant task and difficult to clean. Also, the lack of standardized oral care policy and effective equipment’s in the selected hospitals may contribute to the less frequent and accurate performance of ideal oral care.

More than 90 % of nurses selected cotton or gauze as available supplies in their units because their hospital did not provide them with a toothbrush to demonstrate oral care and didn‘t adhere to the evidence-based practice recommendation.

Study limitations

Although the study‘s strength is to identify the Jordanian critical nurses‘ knowledge, attitudes, and practices of oral care in orally intubated patients, there were few limitations to be addressed. The main limitation of the study was the use of the convenience sampling method rather than the randomized sampling method, which increased the probability of systemic sampling error and reduced the power of the study by limiting its generalizability. The use of long self-report questionnaire as a data collection method could have influenced the process of sample recruitment, and thus decreased the response rate among staff nurses; furthermore, this type of studies can‘t determine the actual oral care practices and procedure used in different CCUs by nurses.  Also, the lengthy questionnaires could have caused nurses‘ answers to vary due to time constraints, or unwillingness of nurses to read each question before they responded. There is no consensus on the definitions of the knowledge, attitudes, and practices and there is controversy about how the concepts should be measured. Therefore, deciding with this type of research was difficult.

Findings were limited to the extent of the research design and methods of data analysis. The study was limited to respondents who agreed to participate voluntarily. Also, the study was limited to the number of respondents surveyed and the amount of time available to conduct the study. Despite the limitations, this study addressed important issues concerning the nurses‘ knowledge, attitudes, and practices regarding oral care for mechanically ventilated patients. The findings of this study have important implications for clinical practice, research, education, and policy.

Conclusion and implication for nursing and health policies

This study has contributed to the research regarding the identification of the Jordanian critical care unit (CCU) nurses‘ knowledge, attitudes, and practices of oral care in orally intubated patients, to identify the relationship between the nurses‘ knowledge, attitudes and practices of oral care in orally intubated patients and their demographical data and to identify the predictors of nurses‘ practices.

The results indicated that the main source of learning regarding oral care for intubated patients was the senior nurses in their units followed by nursing school and the study participants had around 2 to 3 sources for learning about oral care. The knowledge of the CCU nurse regarding oral care was low (53.6%). The results also indicated that the nurses didn’t have adequate knowledge and clear perception about the characteristics of various oral cleaning solutions and the effective equipment that is used to remove dental plaque. In terms of attitudes regarding oral care, nurses have moderate positive attitudes, but when oral care is compared with nursing treatment activities with greater survival impact to stabilize the condition of critically ill patients, oral care was ordered the least priority. Also, the results indicated that less than half of the participants performed the ideal practice, which is referred to as the lack of standardized oral care policy in the selected hospitals that contribute to the less frequent performance of ideal oral care.

The findings supported positive significant relationships between attitudes and practice, Furthermore, this study provided evidence that the senior nurses tend to perform oral care more frequently for intubated patients. Also, Participants who took instructions from senior CCUs‘ nurses and infection control unit, participated in in-service courses outside the hospital and read related studies and material of their own accord, have greater knowledge about oral care for mechanically ventilated patients. Also, nurses who had more than one source for learning about oral care for mechanically ventilated patients had greater knowledge regarding oral care and performed oral care practices more frequently. Master degree nurses tend to have greater knowledge regarding oral care for orally intubated patients than those with a bachelor‘s degree but perform oral care less frequently. The model of regression explained 16% of the variance in the total practice scores in which nurses’ attitudes, GICU, bachelor‘s degrees had a unique contribution to nurses‘ practice.

Ethical Aspects and Conflict of Interest

Ethical approval of this study was obtained from Jordan University Science and Technology Research and Ethics Committee, as well as the Institutional Review Board of the participating hospitals’ Data collection, which began in June to August 2013. Following the approval of the current study, the researchers met with the hospitals’ nursing administrators and unit head nurses in each hospital to explain the study. Then the researchers explained the study to nurses in a staff meeting. All nurses who agreed to participate signed the written informed consent and were assured of confidentiality.

Assoc. Prof. Fadwa N Alhalaiqa, Ph.D., RN

Faculty of Nursing, Philadelphia University

fhalaiqa@philadelphia.edu.jo

Mohammad Bani Younis, MSN, RN

Faculty of Nursing, Al-Hussein Bin Talal University

mbaniyounis@yahoo.com

Asma Ahmad Al-Talla, MSN, RN

Ministry of Health, Jordan

Prof. Abdul-Monim Batiha, Ph.D., RN

Faculty of Nursing, Philadelphia University

abatiha@philadelphia.edu.jo

Assoc. Prof. Ibtisam Al-Zaru, Ph.D., RN

Faculty of Nursing, Jordan University of Science and Technology

ibtisam@just.edu.jo