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بسم هللا الرحمن الرحيم
An-Najah National University
Faculty of Nursing
Knowledge of the critical care nurses about the evidence based practice of mouth care
Prepared by:
Lama Sayeh
Mays Al- Hussain
Dalia Rajab
(Bachelor degree)
Supervisor:
Miss Mahdia Al- kony, (MA)
2010
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Essay title: Knowledge of the critical care nurses about the evidence based practice of mouth care
Authors: Lama Sayeh, Mays Al – Hussain, Dalia Rajab
Level and credits: BSc, 2Cr.
Course: Nursing Graduation Project.
Supervisor: Miss. Mahdia Al-kony (M.A)
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Table of content
Subject Pages
Acknowledgement 4
Abstract 4 - 5
Chapter 1 :
1.1 Definition of key words
1.2 introduction
1.3 Significant of the study
1.4 Aim of the study
1.5 Research question
5 - 7
Chapter 2 :
Literature Review
8 - 9
Chapter 3 :
3.1 Methodology
3.2 Data analysis & results
10 – 48
Chapter 4 :
4.1 Discussion
4.2 limitations
4.3 Conclusion
4.4 Recommendation
4.5 References
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Acknowledgement
To our fathers and mothers who were the kind embrace
for their sons, who supported their sons financially and
emotionally to the last day of their study. To the
University to which we belong “Al-Najah National
University” represented by Dr.Rami Hammdallah who
always support us and our faculty. To the dean of our
faculty which we appreciate her support Dr. Aida
Al_kaisi the person who was the kindhearted mother for
all of his students, the person who taught us the
principles of research, the person who taught us this
material from her experience we were benefited .TO
miss Mahdeia Al-kony who supervised our work
supervisor and support us by her experience to finish
this work perfectly. To the ministry of health which
accepted us in its hospitals as guests.
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Abstract
Background: Oral care for patients in the hospital’s Intensive Care Unit (ICU) is important, and this is usually the responsibility of nurses to have sufficient knowledge in oral care and comprehensive protocols to follow. The problems performing oral assessment, guidelines for oral hygiene care, frequency of oral care needed, and suggested mouth care protocol followed by recommendations are presented and discussed in this study.
Aim and Objective:
The aim of the study is to investigate the critical care nurses knowledge of the latest
evidence regarding oral care in the critical care units in the governmental hospitals.
Methods:
Descriptive quantitative design was used for its suitability for the study purposes. A
convenient heterogeneous sample of (38) participating ICU nurse’s governmental
hospital at north of Palestine in 2010. Questionnaire for collecting information has
been developed after surveying some previous studies dealing with the same subject.
Results: Study shows that nurses who are working in the critical care units in the governmental hospitals are lack of knowledge about latest evidence of oral care and adequate training program in providing oral care is needed. Conclusion:
Attempts to encourage all critical care nurses to be updated with last evidence regarding nursing skills is advised, and an internal policies and protocols regarding oral care is of great importance in the governmental hospitals at the north of Palestine. Key words:MouthCare,IntensiveCareUnit,knowledge,GovernmentalHospitals.
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Chapter 1
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Chapter 1 1.1 Definitions of the key words:
Mouth care: is defined as the scientific care of the teeth, the achievement and
maintenance of clean, moist and infection-free oral tissue, which are set in the context
of each person’s care needs.
Intensive care unit (ICU): A hospital unit in which is concentrated special equipment
and specially trained personnel for the care of seriously ill patients requiring
immediate and continuous attention.
Critical care nursing: Is the field of nursing with a focus on the care critically ill or
unstable patients.
Governmental hospital: Is a hospital which is owned by a government and receives
government funding. This type of hospital provides medical care free of charge, the
cost of which is covered by the funding the hospital receives.
1.2 Introduction
Mouth care is a short and easy procedure, it doesn’t take much time to do (the duration that need to do mouth care, according to our believes it doesn’t exceed 5 minuets). The equipment which requires to providing mouth care is simple and available in all nursing department. Mouth care has a great importance of increasing satisfaction, comfort, safety for patient and reduces the duration of stay in hospital by prevention of infection and
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reduction of possible complication.( Barnett ,1991).
Mouth care is an essential aspect of nursing care and important component of
intensive care nursing, but it is observed that often given low priority when compared
with other critical practices(Jones et al,2004). Good mouth care practice is important
for the patient’s comfort, well being, the maintenance of the health of the oral cavity,
and the prevention of infection (Homes et al, 1993, Xavier, 2000). Poor mouth
care can lead to several complications that may affect communication, nutritional
intake, sense of taste and can cause pain, infection, unnecessarily extend a patients
hospital stay, and may predispose ICU patients to nosocomial infections. ( Evans,
2001).
The nurse is central to the provision of high quality mouth care, which includes good
assessment, planning, evaluation and documentation (Wilkin, 2002).
Providing adequate oral care for patients in intensive care units (ICUs) is particularly
challenging, because the Problems of caring for critical patients in ICU which is a
busy stressful environment that may result in having oral care as a lower priority for
nurses rather than other aspects of care (McNeill,2000).
In the high technological ICU environment, it is important that the nurse anticipates not only the patients mechanistic but also their holistic needs. This nursing knowledge, epistemology, gives insight and understanding for appropriate and relevant knowledge development for practice (McKenna,1997).
According to Wilkin (2002) knowledge is a product of knowing and encompasses
experience, understanding and facts. This knowledge has been described by
( McKenna, 1997 ) as ‘know how’ skills-based and ‘know that’ empirical knowledge.
This knowing becomes knowledge when it is communicated in the practice of mouth
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care. To ensure appropriate and effective clinical practice, it is essential that existing
knowledge be disseminated. Nurses need to have an understanding of the knowledge
they possess and more importantly what they do not know or understand
(Wilkin,2002).
Nursing needs an identifiable knowledge base to develop and to support its existence and practice. This encompasses an awareness of mouth care problems and their effective management, which can increase significantly patient comfort, self-esteem and body image (Price,1990). Good knowledge and sufficient assessment of mouth care has a great role in
improving oral health and reduction of possible complication. On the other hand lack
of education and oral care knowledge in caregivers raises the risk of poor oral care.
1.3 Significant of the study:
According to Joan (1997) Selection of oral care agents must be based on knowledge
of product characteristic, oral physiology, and an assessment of oral cavity.
Staff may have a lack of knowledge about what good oral care. The performed oral
care may not be based on standardized methods of providing oral care.
Although oral care is an essential aspect of care for every patient admitted to
hospital (Jenkins 1989, Watson1989), it would appear that oral care procedures are
not based on research evidence but on tradition that may be because the culture of
nursing research is not well developed.
1.4 Aim of the study: The aim of the study is to investigate the critical care nurses knowledge of the latest
evidence regarding oral care in the critical care units in the governmental hospitals.
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1.5 Research question Does the critical care nurse have adequate knowledge about the current best evidence of providing mouth care?
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Chapter 2
Literature review
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Chapter 2
2.1 Literature review
A study conducted by DeKeyser (2008) shown that while nurses ranked
oral care a high priority, many did not implement the latest evidence into their current
practice. Therefore Attempts should be made to encourage all ICU nurses to introduce
and use Evidence- based, oral-care.
Wilkin(2002) conducted a study about critical analysis of the philosophy, knowledge and theory underpinning mouth care practice for the intensive care unit patient The results were as follows :Philosophy, knowledge and theory contribute to mouth care practice for the ICU patient. Despite the high technological environment of the ICU, mouth care is still a fundamental practice undertaken by the nurse in her/his professional work. Peate(1993) suggests there is a theory-practice gap in relation to nurse administered oral hygiene, while Adams (1996) found a lack of general knowledge about oral health in asample of 34 qualified nurses. The most commonly used equipment was gauze pads followed by tongue depressors and toothbrushes (DeKeyser et al,2008) . Chlorhexidine as the most common solution used , Less than half reported brushing their patients’ teeth. The majority performed an oral assessment before beginning oral care (DeKeyser et al,2008).
Furr (2004) suggested that the primary methods of oral care involved the use of
foam swabs, moisturizers, and mouthwash. Toothbrushes and toothpaste were used
infrequently by almost 80% of respondents. The majority of nurses indicated a need
for research-proven oral care standards and desired to learn more.
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Some investigators have shown that nurses based their oral-care practices on
tradition, used many different techniques and products for oral care, and had no
uniform method of oral assessment (Binkley et al, 2004; Bowsher et al1999; Evans,
2001; Furr et al, 2004; Grap et al, 2003; Jones et al, 2004; McNeill, 2000;
Munro et al, 2004; Stiefel et al, 2000; White, 2000).
Berry (2006) reached that, to date, there is no definitive evidence to determine
the most appropriate Method of oral hygiene including the use of beneficial mouth
rinses.
Research conducted by Miller (1987) and Adams (1996) indicated that
nurses, pre- and post-registration, lack the necessary knowledge to assess a
patient’s oral status. Poor assessment strategies can lead to inappropriate selection
of equipment and agents that can be detrimental to patient mouth care (Bowsher et
al,1999).
. Binkley (2004) shows that oral care methods were not consistent with current
research and oral care protocols.
A survey of the oral care practices of intensive care nurses found that an average of oral care was given a similar priority to other aspects of personal care. 13.5% nurses rated oral care as a low priority. Whilst 98% nurses routinely performed an oral needs assessment, only 26% used a written assessment tool. Toothbrushes were used at least once a day by 85.5% nurses and Chlorhexidine products were routinely used by 50.5% nurses. Most oral care methods were appropriate, based on the available evidence ( Jones et al,2004). Fitch (1999) recommended implementation of a well developed oral care protocol by
bedside nurses to improve oral health of patients in the ICU. McNeill (2000)
suggested that generally, nurses have not been formally trained in assessing the oral
status of patients in ICUs, and oral care protocols for these patients are not usually
available.
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Chapter 3
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Chapter 3
3.1 Methods
Design:
Descriptive quantitative design was used for its suitability for the study purposes. Study Sample: A convenient heterogeneous sample was selected of ICU nurses who are working in the critical care units.The study sample consists of 38 individuals (22 male and 16 female) of nurses who work in critical care units.
Inclusion criteria:
Nurses who are working in the critical care units more than one year experience,
nurses were chosen from all levels of education, diploma, bachelor's and Master's
degree, gender difference male &female are selected for the purpose of heterogeneity
of the sample.
Setting:
The study community consists of all critical care nurses in governmental hospitals in
north of Palestine which includes:
Nablus :( Rafedia ( 20 nurses) & AL -Watani hospital(12 nurses))
Tulkarm: (Thabet Thabet hospital( 9 nurses))
Jenin ( jenin governmental hospital( 10 nurses)).
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Instrument:
Questionnaire for collecting information has been developed after surveying some
previous studies dealing with the same subject.
The questionnaire include a listing of the current oral-care practices including type
equipment used, solutions used, technique, frequency and the type and timing of oral
assessment.
Some of the items on the questionnaire were based on current best evidence, for
example the use of chlorhexidine or toothpaste; however, other items listed were not
recommended, such as bicarbonate or lemon water.
The questionnaire consisting of three parts as the following:
Part One:
Includes the introduction, several elements which emphasize the target of the study,
kindly request to nurses by using a paragraph aims to encourage the targeted
individuals to respond frankly on the study questions after satisfying the tested
people that the information will be secret and will not be used except for the
scientific research only.
Part Tow:
Includes general information dealing with the independent variables of the study like
gender, age, type of ICU, years of employment, academic qualification, post basic
critical care unit and total number of nurses in ICU.
Part Three:
Includes 22 paragraphs dealing with the questions that the nurses will response to it.
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Reliability :
The study tool was subjected for the test by experts who recommended for its validity
for the achieving of the study purposes
Pilot testing :
Was tested by using Khronapach Alpha test which was (0.72), splitting art. And this
result is acceptable for the study purposes.
Procedure
The topic was proposed by the dean of nursing faculty, the reading and thinking about
this topic was developed by searching in the following database (ScienceDirect,
HINARI, and Oxford). During searching specifically on ScienceDirect we found
article titled “ICU Nurses’ Oral-Care Practices and the Current Best Evidence “by
Freda DeKeyser Ganz,which give us insight to promote our graduation project.
Permission request to use the questionnaire that she used in her article was sent to
author as an email (Appendix 2), permission was received (Appendix 3) after three
weeks. But questionnaire we received was in Hebrew, because of the region on which
the study conducted.
Then we translating it to english language, the results are not accurate and there were
some questions was not understandable and clear For this reason, questionnaire has
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been developed and modified based on the aim of study (appendix 1).
Research has been done by using more articles related to subject and aim of the study.
Start the study during the period of waiting for a reply from the author.
The questionnaire were prepared,ethical and institutional approval was obtained to
collect the data, then questionnaire were tested by a pilot study in 10 intensive care
nurses, use splitting art test was (0.72). . Reliability was examined with a test, and
then the group members explained the study to nurses in intensive care unit during
meeting, and obtain informed consent from participants and distributed the
questionnaires on an individual basis.
Nurses were asked to return the questionnaires to an envelope placed in a suitable
location in ICU. The group member made regular visits to the ICUs during the period
of the study to distribute and collect the completed questionnaires. The nurses will
assure that their answers would be confidential and to ensure anonymity.After that,
the collected data was analyzed by using the statistical package for social science
(SPSS).
Table of articles:
Data base Key words # of articles
(abstract)
#of reading
articles
# of
choosing
articles
Science
direct
Oral care 252,758 14 5
HINARI Oral care 5034 24 6
19
Oxford Mouth care 280639 20 8
Science
direct
Mouth care 87,417 11 7
Total 26
Ethical consideration
Take a permission to conduct the study from university administer, consent form for
the top manager in ICU to distribute the questionnaires to the participants,
also obtained informed consent from participants and distributed the questionnaires on
an individual basis, we was take into consideration the relevant principles, these
include (principle of beneficence, respect for dignity, justice, ensure anonymity,
confidentiality and informed consent).these principles will discus with participants
before the study conducted, and every participant in the study will receive an
explanation about the purpose of the study.
Nurses asked to return the questionnaires to an envelope placed in a suitable
location in ICUs, after the data had been collected and analysis it would be kept in
private place.
3.2 Analysis & results
The study includes the following variables:
- Independent variables:
1- Gender: which has two levels (male and female)
2- Age: which has three levels (20-30, 31-40, 41-50, and 51-60)
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3- Type of ICU: which has for levels (general, neurosurgery, cardiac surgery and
children in general)
4- Years of Employment: which has four levels (2-10, 11-19, 20-28 and 29-37)
5- Academic qualification: which has four levels (Diploma, B.A, M.A and PhD)
6- Post basic critical care certification: which has two levels (ICU and other)
7- Total number of nurses in ICU.
- Dependent variables:
The knowledge of critical care nurses about the evidence based practice of mouth
care.
Results :
Part one: demographics (main variable)
Table (1): The distribution of the study sample according to the variable of Gender
Percentage No. Gender
57.9 22 Male
42.1 16 Female
100% 38 Total
Table (2): The distribution of the study sample according to the variable of Age
Percentage No. Age
52.6 20 From 20-30 years old
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31.6 12 From 31-40 years old
13.2 5 From 41-5 years old
2.6 1 From 51-60 years old
100% 38 Total
It has been shown from the previous table that 52.6% are aged between 20-30 years
old, 31.6% between 31-40 years old, 13.2% between 41-50 years old, and 2.6%
between 51-60 years old.
Table (3): The distribution of the study sample according to the variable of type of
ICU:
Percentage No. Type of ICU
100% 38 General
___ ___ Neurosurgery
___ ___ Cardiac Surgery
___ ___ Children in general
100% 38 Total
It has been shown from the previous table that all intensive care units in the north of
Palestine are general units.
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Table (4): The distribution of the study sample according to the variable of Number of
years of employment:
Percentage No. Number of years of employment
73.7 28 From 2-10
18.4 7 From 11-19
5.3 2 From 20-28
2.6 1 From 29-37
100% 38 Total
It has been shown from the previous table that 73.7% of the nurses have 2-10 years
working experience, 18.4% of the nurses have 11-19 years working experience, 5.3
have 20- 28 years working experience, and 2.6 of nurses have 29-37 years of
employment.
Table (5): The distribution of the study sample according to the variable of Number of
Academic qualification:
Percentage No. Academic qualification
36.8 14 Diploma
47.4 18 B.A
15.8 6 M.A
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It has been shown from the previous table that 36.8% of the nurses have Diploma,
47.4% have B.A degree, 15.8 of nurses have master degree, and no one has PHD
qualification.
Table (6): The distribution of the study sample according to the variable of Number of
Post basic critical care unit:
Percentage No. Academic qualification
86.8 33 Intensive care
13.2 5 Other
100% 38 Total
86.8
13.20
50
100
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Post Basic Critical Care Certification
Figure (6): Shows the distribution of the study sample according to the variable of
Post basic critical care unit.
It has been shown from the previous table that 86.8% of nurses have intensive care
___ ___ Ph.D.
100% 38 Total
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qualification and 13.2% have other academic qualification.
Table (7): The distribution of the study sample according to the variable of Number of
Total number of nurses in ICU:
Statistical processing:
After gathering the responds, they have been codified, entered the computer and
statically processed by using the statistical package for social science (SPSS)
The statistical procedures used in the study are:
- Frequencies and percentages.
No. Total number of nurses in ICU
10 Serial number 1:
9 Serial number 2:
20 Serial number 3:
12 Serial number 4:
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Part two :
Table (8): Guideline of the Mouth Care
(No) Number& Percentage
(Yes) Number& Percentage The question
14 (36.8%) 24 (63.2% ) 1. Is there protocol for mouth care in ICU?
18 (47.4%) 20 (52.6%) 2. Does the protocol include guidelines for implementing
mouth care?
18 (47.4%) 20 (52.6%) 3. Guidelines include evaluating mouth?
18 (47.4%) 20 (52.6%)
4. Guidelines include the
frequent implementation of
mouth care?
19 (50.0 % ) 19 (50.0 % ) 5. Guidelines include solution to be used ?
19 (50.0 % ) 19 (50.0 % ) 6. Guidelines include equipment to be used ?
24 (63.2%) 14 (36.8%) 7. Guidelines include method to be used?
18 (47.4%) 20 (52.6%)
8. Guidelines include documentation?
it has been concluded from the previous questions that the responds on the
questions dealing with the knowledge of the nurses about the guidelines were
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somehow balanced between (yes) and (no).
But it is noted that a one of the four hospitals which included in the study had a
formal protocol to follow. But the highest percentage of participants in the study as a
whole responded to presence of protocol to follow. This is due to that, only one
hospital follows formal protocol has the largest number of nursing in the intensive
care unit. In the remaining hospitals, which do not follow a formal protocol, some
nurses follow a particular protocol, but not formally, and this response was to prove
the existence of a protocol for mouth care in ICU.
Part three:
Table (9): Building a protocol for mouth care of patients in ICU
(No)
Number&
Percentage
(Yes) Number&
Percentage
The question
3 (7.9%) 35 (92.1%) 9. Do you think that nurses should be
responsible for cleaning the oral cavity
of critical care patient?
23 (60.5%) 15 (39.5%) 10. Have you been given adequate
training program in providing oral care?
20 (52.6%) 18 (47.4%) 11. Are there any gap between the lack
of basic education and the skills that
needed in the ICU for providing oral
care?
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Question (12): At what shift you make mouth care to the ICU patients?
Table (10): The distribution of the study sample on the question number 12
It has been shown from the table (10) that 65.9% of nurses make mouth care to
the ICU patients at morning shift, 2.6% at evening,2.6% at night, and 28.9 make
mouth care at all shift
Question (13): Do you consider mouth care for you?
Table (11): The distribution of the study sample on the question number 13
Percentage No. At what shift you make mouth care
to the ICU patients
65.9 25 Morning
2.6 1 Evening
2.6 1 Night
28.9 11 All shifts
100% 38 Total
Percentage No. Do you consider mouth care for
you?
57.9 22 Pleasant
42.1 16 Unpleasant
100% 38 Total
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it has been shown from the table (11) that 57.9% of all nurses consider mouth
care is pleasant to do, while 42.1% consider mouth care is unpleasant to do it.
Question (14): Would you like to receive more training in oral care?
Table (12): The distribution of the study sample on the question number 14
It has been shown from the table (12) that 23.7% of nurses responded (strongly
agree), 60.5% responded (Somewhat agree), 15.8% responded (Neither agree
somewhat disagree), and no one responded (Strongly disagree) about the like to
receive more training in oral care.
It has been shown from the results of part two that nurses should be responsible
to mouth care, adequate training program in providing oral care is needed,
mouth care is preferable to the nurses for its importance, gap between the lack
of basic education and the skills that needed in the ICU for providing oral care is
Percentage No. Would you like to receive more
training in oral care
23.7 9 Strongly agree
60.5 23 Somewhat agree
15.8 6 Neither agree somewhat disagree
_____ ____ Strongly disagree
100% 38 Total
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not founded and receiving more training in oral care is needed.
Part four: used equipments, solutions, method of doing mouth care and
assessment for the mouth.
Question (15): The equipment that you are using for mouth care
Table (13): The distribution of the study sample on the question number
19.2
11.6
3
12.1215.65
11.67.83
0
5
10
15
20
1234567
Questin 15 ( Equipments)
No. The equipment that you
are using for mouth
care
8 1. Gauz
23 2.Toothbrush
6 3.Pumping System
24 4.Suction catheter
31 5.Syringe
23 6.Your finger
15 7.Other
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Question (16): The solutions that you are using for mouth care
Table (14): The distribution of the study sample on the question number16
0.8
15.65.7
28.721.4
9951.63.2051015202530
12345678910
Question 16 (Solutions )
.
No. The solutions that you are using
for mouth care
1 1.Lemon Juice
19 2.Glycerin
7 3.Chlorhexidine
35 4.Saline
26 5.Tap Water
11 6.Toothpaste
11 7.Sterile water
6 8.Vaseline (peritoneum gel)
2 9.Sodium bicarbonate
4 10.Other
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Question (17): The methods that you are using for mouth care
Table (23): The distribution of the study sample on the question number
0
10
20
30
1234567
Question 17 ( Method)
Question (18): Did you made an assessment of the mouth?
Table (15): The distribution of the study sample on the question number 18
Percentage No. : Did you made an assessment of
the mouth?
94.7 36 Yes
No. The methods that you are
using for mouth care
34 1.Upper Jaw: cleaning
gums, teeth cleaning
32 2.Lower jaw: cleaning
gums, teeth cleaning
26 3.Tongue cleaning
16 4.Brushing teeth
21 5.Washing
7 6.Pumping
___ 7.other
32
5.3 2 No
100% 38 Total
It has been shown from the table (15) that 94.7% of nurses responded (yes)
about made an assessment of the mouth, while 5.3% responded (no).
Question (19): If so, when?
Table (16): The distribution of the study sample on the question number 19
Percentage No. According to question 18. If so,
when?
5.3 2 No
68.4 26 Before and after any mouth care
18.4 7 Before
7.9 3 After
___ ___ One shift
___ ___ Other
100% 38 Total
It has been shown from the table (16) that 68.4% of nurses who make an
assessment of the mouth responded they do assessment before and after any
mouth care, 18.4% responded before, 7.9% responded after, and no one
responded other or one shift.
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Question (20): Dose your assessment based on assessment tool?
Table (17): The distribution of the study sample on the question number 20
Percentage No. Dose your assessment based on
assessment tool?
44.7 17 Yes
55.3 21 No
100% 38 Total
it has been shown from the table (26) that 44.7% of nurses responded (yes), and
55.3% responded (no).
Question (21): Are you documenting your assessment?
Table (18):The distribution of the study sample on the question number21
Percentage No. Are you documenting your
assessment?
68.4 26 No
31.6 12 Yes
100% 38 Total
It has been shown from the table (18) that 68.4% of nurses not documented
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their assessment while 31.6% responded documented.
Question (22): Oral care is a very high priority?
Table (19): The distribution of the study sample on the question number 22
Percentage No. Oral care is a very high priority?
55.3 21 Strongly agree
21.1 8 Somewhat agree
21.1 8 Neither agree somewhat disagree
2.6 1 Strongly disagree
100% 38 Total
It has been shown from the table (19) that 55.3% of all nurses responded
(Strongly agree), 21.1% responded (Somewhat agree), 21.2% responded
(Neither agree somewhat disagree), and 2.6% responded (Strongly disagree)
about the priority of oral care.
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Chapter 4
.
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4.1 Discussion
4.1.1 Methodology discussion
According to the study design, which is using of descriptive quantitative design has
some advantages which are relatively inexpensive, many outcomes and variables can
be assessed, good way of finalizing results and answer the research question, ease of
reaching a comprehensive , and the results legitimately discussed and published. Also
this type has disadvantages which include: takes much time to conduct, require
extensive statistical analysis, requirements for the successful statistical
confirmations of results are very stringent.
Questionnaire instrument was the most suitable tool to use it, according to our data
which was collected, the study's research question, aims of the study and relevant
questions. The type of the questions were closed ended questions which include
multiple choice with an option for "other" to be filled in, also include two kinds of
questions: (1) using a simple "yes" or "no" questions, and (2) likert scale.
The advantages of closed questions type are: easier and quicker to record responses,
Respondents can only answer in a predefined way, quick and easy for respondents to
tick boxes that might be more likely to answer all the questions. Also there are some
disadvantages: loss of spontaneity and expressiveness and the answers of the question
don’t always reflect the actual behavior of the participant.
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4.1.2 Results discussion
Part one: demographics (main variable)
The distribution of the study sample according to the variable of Gender shows that
the intensive care nurses male more than female.
Most of the nurses have high qualifications 47.4% BA, and 15.8 MA, the majority of
intensive care nurses age was from 20-30 years old, 73.7% of intensive care nurses
are from 2_10 years of employment this will be contribute to the accuracy of the
data, because age has a strong relationship with many years of employment, so they
will have lack of knowledge despite the high qualifications of nurses.
Part Two: Questions
In our study one of the all units has protocol to follow and there is a lack of well
defined and updated protocol regarding mouth care. In previous study (Fitch 1999)
recommended implementation of a well developed oral care protocol by bedside
nurses to improve oral health of patients in the ICU.
Ninety-tow percent of participants reported that nurses should be responsible for
cleaning the oral cavity of critical care patients, but no adequate training program
present 60.5% reported that no adequate training program given to providing oral
care, the result of this study is consistent with studies by McNeill who suggested that
Generally, nurses have not been formally trained in assessing the oral status of
patients in ICUs, and oral care protocols for these patients are not usually available.
(McNeill 2000).
38
Gap between the lack of basic education and the skills that needed in the ICU for
providing oral care is founded the result of this study is consistent with study by
(Peate, 1993) who suggests there is a theory-practice gap in relation to nurse
administered oral hygiene.
The most nurses (71.1%) make mouth care to the ICU patients once daily, and 28.9
make mouth care at all shift. According to American Association of Critical Care
Nurses [AACN], 2007) describing recommended oral care in the critically ill that
included developing oral care hygiene program which includes brushing patients’
teeth, gums, and tongue at least twice a day.
All nurses reported use of gauz in procedure while about half of them reported use of
toothbrush .high percentage of nurses used normal saline for mouth. On the other
hand previous study shows that the most commonly used equipment was gauze pads
followed by tongue depressors and toothbrushes (DeKeyser et al,2008) . According
to American Association of Critical Care Nurses [AACN], 2007) describing
recommended oral care in the critically ill that included developing oral care hygiene
program which include using a soft pediatric or adult toothbrush.
High percentage of nurses used normal saline, tap water for mouth. However, almost
all of the respondents claim to clean their patients’ tongue and upper and lower
mouth. In previous study (DeKeyser et al 2008) shows that Chlorhexidine is the most
common solution used, less than half reported brushing heir patients’ teeth, and the
majority performed an oral assessment before beginning oral care.
39
94.7 of nurses reported that they made an assessment of the mouth but most of their
assessment not based on assessment tool (55.3%), and not documented (68.4%). This
result is confirmed by other studies ( Jones et al,2004) shown that whilst 98% nurses
routinely performed an oral needs assessment, only 26% used a written assessment
tool , also the study confirmed by (Miller 1987) and (Adams 1996) which indicated
that nurses, pre and post-registration, lack the necessary knowledge to assess a
patient’s oral status.
Fifty- fife percent of nurses respond strongly agree for the priority of oral care, ( Jones
et al,2004) in previous research found that an average of oral care was given a similar
priority to other aspects of personal care. 13.5% nurses rated oral care as a low
priority.
4.2 Limitations of the study:
Little information is available in the literature regarding oral care evidence based Knowledge including (type equipment used, solutions used, technique, frequency and the type and timing of oral assessment).There is no enough time to wait some nurses who were taken holidays to distribute questionnaire for them. Also the numbers of nurses whose involve in the study were few related to lack
number of intensive care units in the north governmental hospital.
Failed to respond from number of nurses resulting their feeling that they had no interest or time to fill the questionnaires because the busy ICU stressful environment
40
CONCLUSION: While oral care is an essential aspect of nursing care and given high priority of
intensive care nursing. , levels of evidence based knowledge were found to be
relatively low.
There is a clear need to promote the development of a research-based
nursing approach in relation to mouth care. Theory and practice need to be
closely integrated to discourage traditional practice.
The results of this research shown that there is a lack of well defined and
updated protocol regarding mouth care in governmental hospitals at north of
Palestine. And despite the high qualifications of nurses who are working in
critical care units (47.4% BA, and 15.8 MA), they lack knowledge of the latest
evidence regarding mouth care.
So nurses should be involved in educational programs related to oral care
and evidence-based knowledge and should be encouraged to introduce and
utilize written protocols for mouth care in ICUs based on the latest evidence
that attempt to decrease several complications that may progress to ICUs
patients.
Recommendation; The following are recommended for the oral care of ICU patients: There is a clear need to provide adequate training for nurses in evidence based oral health care, both in their initial and post basic education. Nurses require mechanisms for assessing patient’s oral care needs on an individual basis and be provided with adequate tools to enable them in this task. Encourage nurse to document their assessment for mouth. Further research is needed to determine the most effective way to perform oral
41
hygiene care in critically ill patients as well as deciding on the most appropriate frequency of oral care.
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Time table
Date
Title
AUGUST
September
October
November
December
Introduction
Background
Aim of the study
Research question & hypotheses
Literature review
Methods
44
Ethical consideration
Statistical analysis
limitations
Discussion
Conclusion
References
