Survey of Australian paediatric critical care nurses' attitudes, practice, knowledge and education surrounding oral care

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1 Survey of Australian paediatric critical care nurses' attitudes, practice, knowledge and education surrounding oral care Amanda J Ullman* Master of Applied Science (Research), Graduate Certificate PICU Nursing, Bachelor of Nursing Senior Research Assistant: NH&MRC Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Griffith Health Institute, Griffith University, Nathan, QLD, Australia Clinical Nurse Researcher: Paediatric Intensive Care Unit, Royal Children s Hospital, Brisbane, QLD, Australia a.ullman@griffith.edu.au Georgia Letton Bachelor of Nursing, Clinical Practice Coordinator Clinical Research: Paediatric Intensive Care Unit, Women s and Children s Hospital, Adelaide, SA, Australia * Corresponding author Abstract Aims To determine the attitudes, current practice, knowledge and education of paediatric critical care nurses regarding oral care. Background Treatment modalities used to support children experiencing critical illness and the progression of critical illness may result in dysfunction in the oral cavity. Poor oral health is linked to health care-associated infections, particularly ventilator-associated pneumonia. Critically ill children are dependent on health care workers to provide all aspects of their oral care. Design and methods A cross-sectional study was undertaken at two Australian children s hospitals. A -item questionnaire was developed and distributed to registered nurses working within the paediatric intensive care and high dependency units. Results Of the participants, the majority perceived oral care as being a high priority. There was substantial variation within the choice of oral care solution, device and frequency. The majority of nurses surveyed made the decision of treatment based on information learned from nursing colleagues or previous employment, felt unhappy with current practice and desired to learn more. Practice implications Paediatric critical care oral hygiene nursing practice needs to be better supported by implementation strategies including adequate resources, education and evidence. Keywords: Paediatric, nursing, oral health, intensive care, attitudes, clinical practice. What is known about this topic Critically ill children frequently develop poor oral health. Poor oral health and associated systemic infections, such as ventilator-associated pneumonia (VAP), are associated with significant economic costs and mortality and morbidity outcomes for critically ill children. Previous research in adult critical care has found that oral care practices are not evidence-based; instead they are often based on individual preferences and tradition. What this paper adds Current paediatric critical care oral care practice is frequently informed by non evidence based resources and involves variation between clinicians. Paediatric critical care nurses are keen to improve their knowledge in this area. The successful implementation of paediatric critical care oral care practices require the provision of adequate educational resources, availability of suitable oral care products and oral care protocols that recognise the diversity of the paediatric critical care population. Volume Number March 0

2 Declarations Competing interests: The authors report no actual or potential conflicts of interests. Funding: No external or intramural funding was received. Ethical approval: Ethical approval was gained through the Royal Children s Hospital, Brisbane; Human Research Ethics Committee (HREC//QRCH/) prior to study commencement. The Women s and Children s Hospital Adelaide HREC was notified of the study; however, we did not require HREC approval as it met the criteria of a quality activity. Guarantor: AJU. Contributorship: AJU conceptualised the study, data collection, data analyses, main composition of the manuscript. GL conceptualised the study, data collection, revision of the manuscript. Acknowledgements: We would like to thank all the nurses who took the time to complete the survey. Introduction The provision of oral hygiene to maintain oral health is an important health issue throughout all stages of a child s development. When confronted by critical illness and its necessary treatment, a child s oral cavity is challenged by a disruption to normal protective mechanisms and frequently becomes dysfunctional,. Critically ill children are a heterogeneous population of patients. Ranging in age from newborn baby to adolescent, many children are pre-morbidly healthy, while others have an acute episode related to a pre-existing condition. Critically ill children sometimes require rescue-therapy in the form of complicated and invasive respiratory, cardiovascular and renal support, while some simply require postoperative monitoring. An unconscious or intubated child is unable to speak, eat or drink, which limits the production and movement of saliva around the mouth. The endotracheal tube presents a source of pressure for the oral cavity, especially in non-dentate patients where the tube rests on the gingivae rather than on the teeth. Additionally, the orally intubated patient is forced to keep his or her mouth open for extended periods. Even when not intubated, children are often exposed to high-flow facial oxygen and oral suctioning, causing drying of the mucosa. This makes the delivery of quality oral care to maintain a clean, moist environment vitally important, but difficult. Not only is oral health impacted by critical illness and the necessary consequential therapies, but it has the potential to influence systemic health. In the paediatric critical care environment, respiratory and bloodstream infections caused by fungal and bacterial pathogens are associated with substantial financial, morbidity and mortality costs -. The relationship between poor oral health, in the form of pathogenic oropharyngeal colonisation, and hospitalacquired pneumonia, especially ventilator-associated pneumonia (VAP), has been well documented in robust adult critical care clinical research -9. These sometimes preventable infections place a significant burden on health care and are associated with increased morbidity, longer hospital stay, increased health care costs and higher mortality rates 0,. The provision of oral hygiene in critical care has been increasingly recognised as a priority by international health care bodies, including the Centers for Disease Control and Prevention (CDC) and the Institute of Health Improvement (IHI). Currently there is a paucity of literature surrounding the effectiveness and appropriateness of oral hygiene practices in paediatric critical care. Literature provides little information on the current attitudes, practice, knowledge and education of paediatric critical care nurses regarding oral care in paediatric critical care patients and this may impact on the successful implementation of evidence-based oral hygiene practices. The aim of this study was to determine the attitudes, practice, knowledge and education of paediatric critical care nurses regarding oral care. This would provide information for clinicians to support them in developing and successfully integrating evidence-based oral care within paediatric critical care. Additionally, recruitment outcomes were collected to evaluate the feasibility of a national study. Background Critically ill children are dependent on health care workers to provide all aspects of their oral care. However, a number of authors suggest that oral care regimens are often based on tradition, individual preferences, availability of products, anecdotal and subjective evaluation rather than evidencebased protocols -. Oral health is supported by mechanical and chemical cleansing and moisturising. The use of a toothbrush to clean the teeth and gums has been widely accepted as a simple and efficient method of mechanically removing plaque and debris. Despite these recommendations, many dentate patients in critical care have their oral care carried out with the use of foam or cotton swabs alone, rather than with toothbrushes 8-0. Chemical cleansing is generally assisted by fluoride-containing toothpastes, chlorhexidine gluconate mouthwashes and sodium bicarbonate. The majority of research advocates the use of a combination of toothpastes and chlorhexidine gluconate mouthwashes, for children greater than six years of age, with time between to reduce interaction between the two products. The application of oral health research requires the cooperation and adoption by clinical staff. Multiple descriptive studies have been conducted surveying adult intensive care nurses throughout North America 8,-, Asia 8, the United Kingdom 9 Volume Number March 0

3 and Europe 0,0 regarding their attitudes, education, current practice and the availability of resources surrounding oral hygiene provision. Within these adult studies, they identified that while nurses recognise the importance of oral hygiene practices, they may be hesitant to provide oral care to patients who are intubated for fear of causing accidental extubation. Practices varied with regard to the frequency, requisites and methods used for oral care and the majority of the adult intensive care nurses surveyed did not follow an evidence-based pathway for oral care. There was variability in the nurses description of oral hygiene as a high priority or essential when taking care of critically ill adult patients. The inability to access adequate resources had a direct impact on the quality of provided care and the majority of the adult intensive care nurses expressed a need for further education and training. Similar results have been seen in adult oncology, adult medical 9 and neonatal intensive care research; however, none have surveyed paediatric critical care nurses, so it is not necessarily reflective of current paediatric critical care practice or nursing attitudes. Additionally, no questionnaire has addressed questions which are specific to the paediatric critical care community, particularly regarding variation in practice in recognition of the critically ill child s developmental stage and clinical condition. Methods Design, setting and sample A prospective, cross-sectional study was undertaken at the a hospital (ah), A and the b hospital (bh), B. Questionnaires were distributed to all nurses within the paediatric intensive care unit (PICU) and high dependency unit (HDU) at the two sites (n=). Participation was voluntary and responses were collected anonymously. An information sheet was provided and by completing the questionnaire, the participants implied informed consent. Ethical approval was gained through the ah Human Research Ethics Committee (HREC//QRCH/) and notification was made to the bh HREC, prior to study commencement. Questionnaire A -item questionnaire was developed using elements of a questionnaire previously utilised by research teams in the United States 8 and Europe 0. Their questionnaire was designed based upon similar research questions and had established face and content validity 8,0,. After an extensive literature review, fictional scenarios were developed to demonstrate the typical diversity and complexity present in the paediatric critical care population. These were used to examine the decision-making processes behind the nurses practice with regard to differing clinical conditions and age groups specific to this population. The questionnaire was divided into sections including demographics, attitudes, practice, knowledge, education and resources. A combined approach was utilised to gain feedback, comprising of a five-point Likert scale, multiplechoice, and open-ended rationales. The five-point Likert scale ranged from strongly agree (=), somewhat agree, neither agree nor disagree, somewhat disagree, or strongly disagree (=). Multiple-choice questions involved multiple-response alternatives or options. For scenario-based questions, respondents were able to choose more than one answer in order to fully describe their practice. Open-ended questions were utilised to examine the respondents decision-making processes and to provide greater opportunity for feedback. The questionnaire was piloted for face and content validity via a panel of five experts. The experts were senior members of the PICU nursing team at the ah, including the nurse manager, nurse educator and nurse researchers. All experts had at least 0 years' paediatric, paediatric intensive care or intensive care nursing experience. Each panel member was asked if any questions were unclear or confusing, not applicable to their clinical practice or if any areas were not adequately covered in the questionnaire. The remarks of the panel were collected, discussed and used to revise the questionnaire. The experts examined the revised questionnaire and unanimously declared agreement with its content and clarity. In preparation for a potential national survey, feasibility was assessed via collecting information on recruitment rates at the two study sites,. Data analysis Data were processed statistically using SPSS 0 (IBM SPSS Statistics 0). Normality in distribution of the data was assessed and descriptive statistics used. Continuous variables were described as mean and range values. Categorical data were described using frequencies and percentages. Missing data are described in the results table. Content analysis was used to identify themes in the open-ended questions,. RESULTS Recruitment and sample characteristics A total of nurses participated from the two study sites, with an overall response rate of 8%. Table demonstrates the recruitment and demographic characteristics of respondents. The majority of respondents were active clinicians (9%; n=), working as registered or clinical nurses within paediatric critical care (9%; n=) with an average of.8 years (range 0. to years) of paediatric critical care nursing experience. Attitudes Nurses were asked to respond to multiple statements, using a Likert scale, to assess their attitudes and beliefs towards oral care (Table ). Almost half of respondents (8%; n=) felt that oral care is currently not provided to patients with enough frequency and quality to ensure a healthy mouth. Oral care was perceived as a high priority for critically ill children by 9% (n=) of nurses. Although % (n=9) of nurses found cleaning the oral cavity to be difficult, only % (n=) found it to be unpleasant. Volume Number March 0

4 Table : Recruitment and demographic characteristics of sample Characteristic n % Hospital ah bh Gender Female Male Main work activity Clinical (Education, Research) Highest educational attainment Diploma Bachelor Postgraduate certificate or diploma Masters or PhD Title of position Registered nurse (RN) Clinical nurse (CN) Clinical nurse consultant, nurse manager or nurse educator Mean Range Years of paediatric critical care nursing.8 0. Total years of nursing Current practice There was a wide variety of practice described by the nurses in response to scenarios describing an orally intubated premature neonate, an orally intubated adolescent recovering from traumatic brain injury and a nasally intubated four-yearold child recovering from liver transplant (Table ). For the neonatal scenario, the majority of respondents reported performing oral care every four hours (8%; n=), with sterile water (%; n=) using either a cotton (%; n=) or foam (%; n=) swab. The diversity of rationale for the chosen oral care was primarily around the safety when choosing the device and solution. This included comments such as foam is better than cotton swabs as some residual cotton can be left in mouth. Saline has mild healing properties and if the foam swab was too big then I would wet a small cotton swab and clean just inside the baby s mouth. ETT (endotracheal tube) positioning is very important so would not want to force a pink swab in the baby s mouth". For the adolescent scenario, the majority of respondents reported performing oral care every four hours (%; n=), using either a foam swab (%; n=) or paediatric toothbrush (8%; n=) and chlorhexidine mouthwash (%; n=0), sterile water (9%; n=) or toothpaste (9%; n=). The rationale for choosing the solution varied considerably, including: Chlorhexidine for cleaning as reduces oral bacteria that might build up around teeth, Chlorhexidine gets rid of the smell and cleans the mouth and usually their mouths are smelly, sometimes need bicarb (sodium bicarbonate). For the child s scenario, the majority of respondents reported performing oral care every four hours (%; n=), using either a foam swab (%; n=) or paediatric toothbrush (%; n=) and chlorhexidine mouthwash (%; n=9), sterile water (%; n=9) or toothpaste (%; n=). The rationale for the choice of device varied between concern for the child s coagulation and immune status (for example, foam swab is gentle for a child who may be prone to oral bleeding and immunosuppressed patient so I would use foam pink sponge as not to damage mucus membranes ) to general ease of use for the practitioner (for example, easier to use foam swab instead of toothbrush for a small child ). The variety in current practice was further demonstrated when the nurses were asked to list four signs and symptoms they would use to assess the health of an oral cavity (Table ). While six respondents did not answer all four options (total missing = 9), the remaining respondents varied their responses between the moisture of mucosal membranes, colour, odour, ulcer presence, and teeth, tongue, lip or gum appearance. Table : Attitudes and beliefs regarding oral care Oral care is currently provided to patients Oral care is a high priority in caring for a Cleaning the oral cavity is an unpleasant The oral cavity is difficult to clean The risk of accidental extubation is higher with enough frequency critically ill child task than the benefits and quality to ensure a of mouth care for healthy mouth an orally intubated patient Strongly agree () (0) (). () () Somewhat agree () () (9). () () Neither agree nor disagree (9) () (). (9) (9) Somewhat disagree () 0 (8) 0. () () Strongly disagree () 0 0 () 9. () () Missing () Volume Number March 0

5 Table : Current practice reported via scenario Orally intubated neonate How often would you perform his oral care? (circle hourly hourly 8 hourly Twice a day What device would you use for his oral care? (circle Cotton swab Foam swab Cleansing wipe Paediatric toothbrush What solution would you use for his oral care? (circle Normal saline Tap water Sterile water Chlorhexidine mouthwash Toothpaste Sodium bicarbonate Orally intubated adolescent recovering from traumatic brain injury How often would you perform his oral care? (circle hourly hourly 8 hourly Twice a day Once a day or less What device would you use for his oral care? (circle Cotton swab Foam swab Paediatric toothbrush What solution would you use for his oral care? (circle Normal saline Tap water Sterile water Chlorhexidine mouthwash Toothpaste Sodium bicarbonate Nasally intubated child recovering from liver transplant How often would you perform her oral care? (circle hourly hourly 8 hourly Twice a day What device would you use for her oral care? (circle Cotton swab Foam swab Paediatric toothbrush What solution would you use for her oral care? (circle Normal saline Tap water Sterile water Chlorhexidine mouthwash Toothpaste Sodium bicarbonate n % Table : Signs and symptoms to assess the health of an oral cavity Characteristic n % Moist mucosal membranes 9 Pink Absence of breath odour 9 Clean teeth, without dental decay and/or 9 cavities No erosions or ulcers 9 Moist and/or uncoated tongue 9 Moist, pink and/or uncracked lips 0 Pink, intact gums 9 8 Adequate saliva volume and appearance Knowledge To determine whether current evidence has been disseminated to practising nurses, we asked the question How often should you apply chlorhexidine without causing adverse effects? with multiple response options. The majority of the respondents answered incorrectly, with only % (n=) correctly answering twice a day,. Additionally, nurses were asked to respond to the statement Oral hygiene helps reduce the risk of healthcare-associated infections for my patient using a Likert scale. The mean response was., with the majority of nurses (9%; n=9) correctly agreeing,,8. Education The large majority of nurses surveyed (9%; n=8) indicated they would like to learn more about the best way to provide oral care. Nurses were asked what resource they utilised to inform their current oral care practice, with multiple responses possible. Nursing colleagues was the primary source of education for % (n=9); while previous nursing experience was the source for % (n=) of respondents. Only a small percentage of nurses reported their resource for informing oral care practice came from hospital policy (%; n=), textbook or journal article (%; n=) or university training (%; n=). Resources To assess the effect of resource availability on the provision of oral care, nurses were asked to respond to the statement I have adequate time to provide comprehensive oral care using a Likert scale. The mean response was.0, with 8% (n=) of respondents agreeing that they had adequate time for oral care. General oral care supplies provided by the hospital were perceived as being available to 80% (n=) of respondents who gave a mean response of. on a Likert scale, to the statement There are enough supplies readily available to provide oral care including toothbrushes, toothpaste and mouthwash. Volume Number March 0

6 Discussion These results demonstrate that paediatric critical care nurses perceive that oral care is an important element in the care of their patients. However, only a minority of respondents reported using evidence-based guidelines or formal training to inform their oral care practice. There was obvious variation in practice between clinicians when providing oral care to critically ill children. It has not been established whether the lack of evidence-based guideline usage, formal training or variety in practice has an adverse impact on the health of the children under their care. However, current literature suggests that the use of evidence-based strategies to promote oral health results in a significant improvement in the local and systemic health of the adult critical care population. This includes a reduction of VAP, with an associated reduction in length of ICU and hospital stays,,,8. The clinical information presented in the scenarios provided an opportunity for nurses to demonstrate tailoring the practice used when confronted by different situations, which is reflective of real-life, diverse, clinical practice. The orally intubated neonate provided challenges in relation to access to the oral cavity and risk for colonisation and infection. The majority of respondents reported using either a cotton or foam swab to clean and moisten the mouth. This decision displays the compromise that paediatric critical care nurses are faced with when choosing an implement for this patient group. The physical design of the cotton swabs suggests that they may break down while in the mouth, leaving cotton filaments, which may then be micro-aspirated; however, the majority of foam swabs available are large and difficult to safely manoeuvre in a small mouth. Appropriate oral care commercial products for neonates in critical care may be lacking. The scenario outlining the oral care for the orally intubated adolescent recovering from traumatic brain injury was complex when considering the difficulty accessing the oral cavity, intracranial pressure stability 9, and the risk of colonisation of dental plaque by opportunistic pathogens. The most effective device for the removal of dental plaque is a toothbrush ; however, like in previous adult critical care studies 8-0, the majority of respondents chose to use a foam swab for the provision of oral care (.%; n=). The choice of device and solution was challenging when responding to the scenario describing the oral care of a nasally intubated four-year-old child recovering from liver transplant. Concerns regarding the child s immune and coagulation status resulted in the majority of respondents using a foam swab (.%; n=) and either sterile water (.9%; n=9) or chlorhexidine mouthwash (.9%; n=9) for the provision of oral care. However, research does not recommend the use of chlorhexidine gluconate mouthwashes for children under six year of age. Throughout the scenarios, the majority of respondents reported performing oral care every four hours. Available guidelines for oral care for intubated patients recommend the second-hourly moistening of the oral mucosa in order to prevent dryness and combat decreased saliva production,. A potential patient safety issue was identified within the survey surrounding the use of sodium bicarbonate mouthwashes. Research recommends against its use as, when incorrectly diluted, it can cause superficial burns,. However, several of the respondents reported using it within their practice. The majority of respondents would like to receive more education and training in the provision of oral care. There is a growing recognition that oral hygiene provision and the link between oral and systemic health needs to be better integrated into the undergraduate curricula of nursing programs 0. In addition to undergraduate education, implementation of evidence-based oral care practices into the clinical setting requires the use of planned implementation strategies such as educational programs and evidence-based guidelines. Limitations Limitations of this study include its observational design and low sample size (n=) which means it lacks the ability to generate powered correlations and is limited in its generalisability. This study only included nurses from two Australian paediatric hospitals, and may not reflect the knowledge, attitudes and practices of other regions. However, the overall response rate at the two sites was.8%, which is acceptable although not high and is encouraging when considering a national study. Although the survey was anonymous, it is to be expected that participants who consider oral care to be of high importance were more likely to participate, a problem of self-selection bias inherent in questionnaire research 0. The potential for response bias exists in the self-report questionnaire, with respondents providing what they perceive to be the preferred answer and practice may be overestimated. However, efforts were made to minimise this type of response by ensuring the anonymity of the respondent. Conclusion While limitations are present in the study, to our knowledge, this is the first survey on oral care practices in paediatric critical care. Current practice is frequently informed by non evidence based resources, involves variation between clinicians and nurses are keen to improve their knowledge in this area. Considerable evidence exists to support a relationship between poor oral health, the oral microflora and bacterial pneumonia, especially VAP,,8,0. Yet clinical practice and nursing attitudes surrounding oral care provision frequently vary and are contrary to evidence-based practice. Research and other evidence regarding oral care in critically ill children are published, but full integration of evidence-based practices often depends on planned implementation by the health care team. Volume Number March 0

7 Implications for clinical practice The attitudes, practice, knowledge and education of the surveyed paediatric critical care nurses demonstrate the poor oral care that critically ill children receive. The current inadequate implementation of evidence-based oral care practices and prevalence of poor oral health during childhood critical illness supports the development of evidence-based paediatric oral hygiene resources. When developing resources to support oral care practices in this setting, consideration needs to be taken to incorporate the diversity of patients, devices and solutions. In order to successfully implement evidence-based oral care interventions, nursing leaders need to focus on the provision of adequate educational materials, the availability of appropriate supplies (for example, paediatric toothbrushes and neonatal-sized foam swabs) and the development of decision-making protocols which encompass the diversity of the patient group. References. 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