Exploring nursing and allied health perspectives of quality oral care after stroke: A qualitative study (2024)

Introduction

Globally, stroke is a major health concern, being the second leading cause of death and accounting for approximately 5% of years lost due to disability.^1,–3 An Australian economic report estimated that the cost of loss of healthy life and disease burden due to stroke was AUD$49.3bn.⁴ The disabilities experienced by stroke survivors increase their risk of poor oral health, with stroke survivors experiencing the highest prevalence of missing teeth and the lowest frequency of dental visitation among all Australians with a chronic condition.⁵ This is concerning, as poor oral health can negatively impact general health and wellbeing and contribute to poor quality of life.⁶ For example, stroke survivors in Australia who experience poor oral health have the highest frequency of food avoidance among those with a chronic condition.⁵ Furthermore, poor oral care practices among stroke survivors may contribute to overall worse health outcomes through the development of healthcare acquired complications such as aspiration pneumonia.⁷

Pneumonia is a common complication seen in Australian hospitals, with 17,854 patients diagnosed with hospital acquired pneumonia in public hospitals during 2015–2016.⁸ There is increasing evidence of the association between improved inpatient oral healthcare practices and a reduction in rates of hospital acquired pneumonia.^9,10 Beyond pneumonia, poor oral health after stroke can also contribute to poor nutritional intake and increased duration of hospital stay, and negatively impact quality of life and overall wellbeing.⁷ As a result, there has been an emphasis on addressing the changed oral healthcare needs of stroke survivors immediately post stroke in the acute setting, in the later stages of recovery in the rehabilitation setting and beyond.^7,11,12 Oral disease is a major public health concern that is estimated to affect over 3.5 billion people, globally. Yet, dentistry has been unable to address this issue in isolation. A paradigm shift in the current models of care is urgently required.¹³

Nurses and allied healthcare professionals are best placed to undertake oral care in the hospital setting,^7,14,15 particularly with oral care being a core component of fundamental nursing care.¹⁶ Some studies have found that the oral health of patients improved when these staff undertook oral health training.^9,17 In addition, partnering with patients and their informal caregivers in the oral healthcare practices may contribute to better outcomes post-discharge.¹⁸ There is need to improve how oral care is delivered in the acute stroke setting to improve patients’ overall satisfaction and potentially reduce the incidence of hospital acquired pneumonia, and reduce length of hospitalisation, morbidity and mortality.¹⁹ In order to achieve this, it is imperative to gain an understanding of the perceptions of stroke nurses and allied healthcare professionals regarding current knowledge, practices, challenges and needs for oral health care in the stroke setting. However, to date, no such research has been conducted among Australian stroke nurses and allied healthcare professionals.

Aims

The aim of this study was to explore the perspectives of nursing and allied health stroke clinicians regarding quality oral care for stroke patients across both acute care and stroke rehabilitation settings. Specifically, this study sought to: i) investigate the current oral health knowledge and practices of stroke clinicians; ii) explore the challenges stroke clinicians experience in providing oral care to stroke patients; and iii) gain insight into the perceptions and needs of stroke clinicians regarding an integrated dental care after stroke (IDeAS) programme or model of care.

Design

This exploratory qualitative study followed a constructivist approach,^20,21 to obtain an in-depth understanding of current oral health care processes in place for stroke clinicians, and the requirements to improve these processes.

Setting, sample and participants

Participants were recruited from two metropolitan public hospitals in Sydney, Australia. One hospital (Site 1) is a large tertiary hospital, where acute care is provided to stroke patients, and the other (Site 2) is a community-based facility, where multidisciplinary teams provide rehabilitation to stroke patients following their treatment in acute care. A purposive sampling technique was used to target the staff who provide day-to-day care to stroke patients, which were nursing staff at Site 1, and the multidisciplinary team at Site 2. Since a pragmatic approach was adopted during recruitment, only the staff that were available participated in the focus groups. This would provide a proportionate representation of staff working in the stroke units. Study recruitment flyers informing clinicians of the study were distributed across both sites by the nursing unit managers, and interested staff were invited to participate in a one-off focus group scheduled at their respective site. A total of 15 nurses participated in the focus group at Site 1, which was an estimated 50% of staff present that day. At Site 2, six staff from the multidisciplinary team participated in the focus group, with only one team member not participating due to being on leave from work.

Data collection

An overview of the study aims, participant requirements and information about the study investigators was provided to interested participants through an information sheet before each focus group. All participants were provided with the opportunity to ask any questions about the study before written consent was obtained. Both focus groups were facilitated by one of the study investigators (SA) in a private room at each hospital and lasted approximately 60 min. SA had a professional interest in this study due to previous experience in interdisciplinary oral health research. No previous relationship was established between the facilitator and any of the participants, and aside from the facilitator and participants, no other individual was present during both focus groups. The facilitator guided conversation according to a schedule of focus areas (Supplementary Material online). Strategies such as prompting, repeating questions, clarifying responses, monitoring the group and ensuring all participants had voiced their opinions were employed to foster interaction within the focus groups and to further identify the meaning constructed by participants. The focus groups were audio-taped to facilitate analysis.

Ethical considerations

The investigation conforms with the principles outlined in the Declaration of Helsinki.²² Ethical approval for this study was obtained from the Sydney Local Health District Ethics Committee (X16-0067). All participants were aware of the voluntary nature of consent, and written informed consent was obtained prior to study commencement. The funding organisations were not involved in the collection, analysis or interpretation of the data, and were not involved in deciding whether to approve of the publication of the finished manuscript.

Data analysis

Audio files from the focus groups were transcribed verbatim for analysis. Prior to analysis, transcripts were de-identified and pseudonyms were assigned to each participant. Transcripts were combined for the purposes of analysis since the same focus group guide was used to explore the perspectives of participants, and not to compare the differences between groups. NVivo software was used facilitate the analysis of transcribed text, whereby thematic analysis was conducted using an inductive approach. From a constructivist standpoint, an inductive approach would enable the participants’ perspective to emerge from data instead of limiting their realities to generalised categories.²⁰ Through this process and the use of triangulation, open codes from each focus group were progressively related to form one list of minor and major themes that depicted the perspectives of the participants regarding the provision of oral care to stroke patients. Although a single investigator conducted the initial coding (ARV), a peer-checking approach was implemented, where two additional investigators (CF and SA) examined the codes and the final thematic structure was developed through consensus, to ensure coherence of ideas and credibility of results.

Rigour

Multiple strategies were adopted in this study to ensure rigour and trustworthiness. Specifically, these strategies addressed issues of credibility, confirmability, dependability and transferability.²³ Credibility of findings was ensured through the use of a peer-checking process, as well as through the use of triangulation in analysis. This triangulation process, which involved relating and contrasting the perspectives expressed in each focus group, also ensured that findings were confirmable. The audio recording of focus groups also increased the confirmability of results, as well as ensuring their dependability. Finally, transferability of findings was increased through the recruitment of staff from multiple disciplines and settings.

Results

Demographics

All but one participant provided demographic data to the researchers. Of those, the mean age of the participants was 32 years (range 20–56 years) and 80% were female. Although the average length of experience in the stroke setting was three years, it ranged from zero to 15 years with a median of one year of experience. Four participants were student nurses. Almost three-quarters (74%) of participants had attained a Bachelor’s degree or higher. Aside from the 15 nurses in the focus group at Site 1, three nurses participated in the focus group at Site 2, along with two physiotherapists and one speech pathologist.

Thematic analysis

Thematic analysis yielded four key themes which elucidated the perspectives of nursing and allied health stroke clinicians regarding oral care for stroke patients. These included: i) oral health knowledge and practices; ii) the challenges; iii) education and training needs; and; iv) IDeAS as a model of care (Table 1).

Oral health knowledge and practices

Oral health knowledge

Overall oral health knowledge could be improved. Some participants had some misconceptions regarding oral care. Most stroke clinicians were aware of the importance of oral health for stroke patients, highlighting that stroke patients are at higher risk of poor oral health because ‘. . .they’re unable to do that independently’ (F2_S2). They further explained that ‘stroke victims will often have a problem with swallowing’ (F1_S2) and therefore poor oral hygiene could increase risk of aspiration pneumonia as ‘. . .they might aspirate [pooling saliva]. . .that will cause pneumonia.’ (M1_S1). Despite this knowledge, nurses and allied health stroke clinicians also had some misconceptions about oral health, including thoughts that dentures made oral care easier, that patients who choose to smoke do not care for their oral health and that lifelong oral care habits are impossible to change. ‘[Having dentures] makes it easier to do their dental hygiene’ (F1_S2); ‘And some patients smoke. So I think brushing their teeth is the last thing that they [care about]’ (F5_S2); ‘We’re not going to change lifelong habits’ (F4_S2).

Oral care practices

Clinicians reflected on their role and contributions to oral health maintenance. All nursing and allied health stroke clinicians agreed that they all had a role in maintaining good oral health among their patients. An allied health clinician reflected, ‘I think if we brush our teeth every day I think the patients should too’ (F5_S2). They agreed that nursing staff were responsible for oral hygiene assistance, and that this fits well with their existing practices. One nurse reflected, ‘. . .you’re taking their blood pressure every four hours, so you just stick a swab in their mouth at the same time, like it fits in as a routine’ (F7_S1). There was further discussion that speech pathologists were also engaged in oral care in the rehabilitation setting, particularly from the standpoint of swallowing risk assessment and management, ‘So we [speech pathology] would lead from the swallowing risk side of things and nursing would lead from the nursing care’ (F4_S2).

Nurses reported providing oral care to patients, particularly to those who were nil by mouth. These patients would receive oral care every 2 to 4 h, where ‘we use the swabs that are provided and make sure we. . .use the aqua spray as well. . .’ (F7_S1). In addition, nurses reported providing oral hygiene assistance to other patients, particularly if ‘. . .they’ve had a serious stroke and they’ve [reduced] function in their limbs. . .’ (M1_S1). Oral care provided to these patients varied, with some nurses reporting, ‘. . . the routine oral care is often individualised for patients with higher risk [of] swallowing difficulties’ (F4_S2). Oral health promotion and education was also given by nursing staff to patients’ family members. ‘. . .the nurses do speak to the family about that; they’ll talk about why are they doing mouth care. . .’ (F10_S1).

In addition, some nurses reported referring patients for further specialised dental care, indicating that this was often completed ‘if there’s a major problem’ (F1_S2). Others stated dental referrals were made ‘if we think that’s the source of stroke. . .’ (F8_S1). However, the most common referral pathway used was ‘telling them to go to their own dentist. . .’ (F1_S2).

Speech pathologists reported performing ‘an intra-oral examination on every new patient on the ward. . .[including] an assessment of their oral hygiene. . .’ (F4_S2) and this ‘. . .would be documented in the body of the medical records’ (F4_S2). Other clinicians concurred that speech pathologists sometimes assisted with oral care, commenting ‘Speech pathologists have been known to clean a mouth’ (F8_S1). Speech pathologists also provided oral health promotion to patients ‘about oral care as one of the risks for chest infections. . .’ (F4_S2). However, it was reported, ‘not all stroke patients. . .need speech pathology. So we wouldn’t be a blanket source of that information. . .’ (F4_S2).

Gaps in care

Many gaps in care were evident. There were many barriers to providing quality oral care. Nursing and allied health stroke clinicians reported poor oral hygiene among their patients, with one explaining, ‘They all have bad breath’ (F5_S2). It was stated that ‘Most of the ward patients have dentures’ (F6_S2), and that ‘. . .sometimes dentures are pretty dirty’ (F10_S1). When asked, one stroke clinician recounted ‘I’m thinking of the eight [patients] I had today, at least two of them have got some issues in the mouth’ (F10_S1). Further discussion highlighted that oral care was sometimes not sufficiently implemented into routine practice, with stroke clinicians commenting that there was no formal process for them to follow in the provision of oral care. One clinician reflected, ‘. . .it doesn’t get done as it should’ (F1_S2), with another stating, ‘there are no formal [oral] assessments that we’re doing’ (F8_S1). Further, it was highlighted that oral health was not addressed in outpatient programmes for discharged stroke patients, with one clinician reporting, ‘. . .they really wouldn’t do much about oral health’ (F1_S2).

The challenges

Barriers to clinicians providing care

Participants reported experiencing several challenges when providing oral care to stroke patients. Some discussed that clinicians had limited time and resources for the oral care of patients, commenting, ‘I think we do the best that we can given the resources we have’ (F4_S2) and ‘time is definitely a barrier’ (F7_S1). Further, some participants cited a lack of prioritisation of oral care, particularly in the acute setting, as, ‘potentially at that point in time it’s not necessarily always an urgent priority’ (F5_S2). Even if care was prioritised by clinicians, it was reported that patients did not always cooperate with recommended oral care for many reasons, including cognitive status, desire to care for themselves and disliking oral care techniques or products. ‘I think with some of the stroke patients that are quite confused, when you have a swab. . .they’re wanting to suck on it. . .’ (M2_S1); ‘Some patients, they become really upset if they are unable to do it by themselves. . .’ (M3_S1); ‘They don’t like the swabs, they don’t like the taste of them. . .’ (F10_S1).

Finally, nurses highlighted their lack of knowledge and formal training regarding oral health, particularly surrounding referral options. This was emphasised by two clinicians, stating, ‘. . .we don’t have a particular, you know, training in [oral health]. . .’ (F7_S1) and ‘We don’t know what services are available. . .’ (F5_S2).

Barriers to patients performing self-care

Nursing and allied health stroke clinicians also reflected on challenges stroke patients may experience in performing their own oral care. These included the physical changes patients may experience post stroke, potentially affecting their ability to care for their oral health, with one clinician explaining, ‘. . .the difficulty is within the limitations of their physical impairments post-stroke. . .’ (F4_S2). Further, clinicians described the competing priorities for stroke patients, including their new health care needs following stroke, and other life demands, particularly for patients with low socioeconomic status. ‘. . .when they’re in hospital. . .they’re overwhelmed a little bit by information. . .’ (F5_S2); ‘We have a lot of people too from very poor socio-economic backgrounds,. . .and that’s not something they put high on their agendas, unfortunately’ (F1_S2).

In addition, it was reported that people from culturally and linguistically diverse backgrounds may have difficulties due to ‘. . .language barrier or communication. . .’ (F12_S1).

Education and training needs

Education needed for patients

Nursing and allied health stroke clinicians discussed in detail the need for oral health education to be provided for patients in the hospital setting, particularly by ‘incorporating it into their therapeutic goals’ (F4_S2). Acute care nurses highlighted that ‘. . .you could start talking to them about [oral health] here and. . .at rehab. . .it’s reinforced and then practised. . .’ (F10_S1). Although clinicians emphasised the need for face-to-face education and to ‘. . .teach them while the patient’s practising. . .’ (F10_S1), it was still considered important to provide written resources for patients post-discharge. One clinician even suggested a ‘. . .website where they can go to like, when they go home they can find out more information. . .’ (F5_S2). It was concluded that a mixture of both modes would be beneficial for educating patients, with one participant summarising, ‘People like getting written information as well as verbal. . .they may benefit from both’ (F10_S1). Although there was a consensus that patient education should be ‘starting on admission’ (F1_S2), clinicians emphasised the need to educate patients towards the end of their stay to ensure ‘. . .they can have a bit of a practice before they go home’ (F10_S1).

Training needs of staff

There was demand for an increase in training and education on oral health. All participants agreed that they would ‘. . .benefit from more information. . .’ (F10_S1). Clinicians recommended the use of both general oral care education for all staff, and specialised education for different professions. ‘So you could have a general information session with the basics and then more targeted smaller groups for the specific professionals. . .’ (F4_S2).

Specifically, they requested information regarding ‘identification of oral health issues’ (F4_S2), ‘different methods of oral hygiene’ (F1_S2), how to proceed ‘if they’re cognitively impaired’ (F5_S2), ‘follow-up services’ (F1_S2) for dental care, and how to care for patients ‘depending on their situation’ (F12_S1). Some participants proposed the need for face-to-face practical skills training including, ‘practical examples, like practising on each other how to do oral care. . .’ (F4_S2). Other clinicians explained the merit of other education resources as education sessions would need to be conducted ‘a few times because of shifts. . .’ (F1_S2) and ‘. . .people also like to be able to take things away or do it in their own time. . .’ (F10_S1). Some clinicians suggested the use of ‘written information’ (F1_S2), ‘a picture or a PowerPoint so we know what to refer to’ (F5_S2) or ‘a short like four or five-minute video. . .to show nurses how to deliver oral care’ (F11_S1).

Who else should be educated

In addition to patients and stroke clinicians, participants also discussed the need to educate other individuals such as assistants in nursing (AINs) employed from agencies that may not be educated as part of in-service sessions. They explained, ‘. . .I think it would be quite important for. . .some of the agency AINs to be educated’ (F1_S2) as ‘They don’t usually go to these education sessions. . .’ (F5_S1). In addition, nurses discussed the need to educate those who may be caring for more dependent stroke patients post-discharge, including residential care staff. ‘. . .if their mouth care isn’t too hot, [we should provide] written information for the nursing home. . .’ (F11_S1).

IDeAS as a model of care

Who could play a role

Participants discussed the need for a multidisciplinary oral health model of care that fostered collaboration between stroke clinicians. One clinician emphasised, ‘. . .we talk as a team, we set the goals as a team. So if their goal is around oral care then it’s usually a team goal’ (F4_S2). They commented that although nurses and speech pathologists could promote oral health among patients, it was essential for this to be reinforced by doctors on the wards and in the community, as ‘If they hear it from the doctor that kind of supports everyone else saying it. . .’ (F5_S2). In addition, they highlighted the potential for occupational therapists to play a larger role in oral care for stroke patients, ‘. . .because they do a lot of activities of daily living, so they would be actually working with the patient. . .when they. . .performed oral hygiene’ (F10_S1). Nursing and allied health stroke clinicians also suggested involving family members of stroke patients to ‘do the oral care as well. . .especially post-discharge’ (F9_S1). There was some concern regarding who would have primary responsibility in this model of care, with one commenting, ‘I think the only problem I foresee is how we work in who leads it because. . .we’ve got different specialist skills. . .’ (F4_S2). However, it was discussed that involving ‘a case manager’ (F1_S2) would help with this.

The need for patient-centred care

All stroke clinicians agreed that this model of care needed to incorporate principles of patient-centred care to account for patient needs and preferences, as oral care provided ‘depends on their deficits and how unwell they are when they first get here’ (F10_S1). It was also discussed that this would help increase cooperation with care, as oral care is ‘a matter of determining what they prefer. . .’ (F10_S1), and if they ‘find out why the patient was refusing it. . .it could be something very simple and you can fix the issue. . .’ (F12_S1). In addition, the importance of encouraging patients as they regain their ability to self-care was emphasised, with one clinician stating: ‘. . .especially if they’re doing rehab,. . .[we should be] reassuring them that. . .they will get better,. . .that way you will change their perspective and maybe [they will]. . .want to change or try in some way’ (F12_S1).

Discussion

The aim of this study was to explore the perceptions of stroke nurses and allied healthcare professionals regarding quality oral health care post stroke. Overall, this study demonstrated inadequate clinician knowledge and practices related to oral healthcare for stroke patients in the acute and rehabilitation settings. Although most staff were aware of the importance of oral health care post stroke, staff had some misconceptions regarding oral care and felt that they lacked knowledge and formal training in oral health care. Findings were similar from both study sites, providing a broad view of health professionals’ knowledge and practices. Our findings are consistent with a similar study conducted in the United Kingdom, which also highlighted the need for further education and training for staff despite a general awareness of the importance of oral health care for stroke patients.²⁴

Clinicians perceived oral care as important; however. they expressed the challenges of implementing oral care, identifying that this was often a low priority in a time pressured, busy clinical environment with a lack of resources. Conversely, an earlier study conducted in the United States at a hospital providing both acute and non-acute care found that around two-thirds of clinicians felt they had adequate time to provide oral care for stroke patients, and the majority believed they had appropriate supplies available to them.²⁵ Further, stroke nurses and allied healthcare professionals in this study discussed a lack of formal oral health assessment tools and protocols available, which presented issues in ensuring adequate care was provided to patients. The study by Horne et al.²⁴ and a study conducted in Malaysia have both highlighted similar concerns, discussing a lack of oral health care guidelines and assessment tools available to stroke clinicians.^24,26 Generally, clinicians understood oral care to be primarily a nursing responsibility. However, there was discussion on task and role shifting, in contrast to a shared ‘oral care is everyone’s business’ approach.

This study has highlighted an urgent need for high quality training and education for all stroke clinicians in relation to oral health. There is a clear gap in stroke nursing and allied health educational curricula in adequately addressing the oral healthcare needs of stroke patients. There is scope to address this within formal undergraduate and postgraduate nursing and allied health training and continuing professional development activities. Further, educational opportunities for patients and informal caregiver training were scant or non-existent. Quality of patient resources is poor, often not very easy to understand and not readily available at point of care. This is a concern in the era of patient-centred care. Patients and their caregivers must be activated and engaged as partners in oral healthcare in acute and stroke rehabilitation settings.

Last, there is scope for the development and evaluation of a new integrated and patient-centred model of oral healthcare in stroke. Central to this new model would be partnership with patients and their informal caregivers and their family members. Nurses and allied health clinicians need to be adept and skilled in behaviour change modification to improve oral health in this vulnerable population. Nurses in particular need to have a suite of skills in their oral health toolbox that includes adapting oral care techniques for stroke survivors with functional impairments alongside the promotion of self and supported oral healthcare practices. Having support from oral health professionals to assist in education and training as well as providing referral pathways for patients who need dental treatment will assist in integrating and sustaining oral health care for stroke patients in both acute and rehabilitation settings.

Strengths and limitations

This study has several strengths. We were able to elicit rich and in-depth insight into the knowledge and practices of nurses and allied health clinicians in relation to their oral care. Our sampling and robust design contributed to the generation of high quality themes. However, this study is not without its limitations. Firstly, Site 2, where both allied health professionals and nursing staff were recruited, had a smaller number of participants than Site 1, where only nursing staff were recruited. Many of the participants had only a few years of experience in the stroke setting, which could have impacted on the richness of the data. Furthermore, the use of clinicians’ perceptions is not always a useful or accurate indicator of actual practices. We plan to explore the perceptions of stroke survivors and their carers in a future study. Last, the transferability of our study findings is limited. Although a range of clinicians and settings were explored, this was only in one area of Sydney, Australia. There is opportunity to explore this through future studies.

Conclusion

This study provided rich insight into nurses’ and allied health stroke clinicians’ current knowledge and practices of oral care in the setting of acute stroke and rehabilitation. It revealed many gaps in current care and highlighted areas for improvement. The next phase following this study will include improving stroke nurses’ and allied healthcare oral health knowledge and practice gaps through education and training, evaluating the feasibility of implementing this training, developing quality point of care resources and partnering with patients and informal caregivers through training. There is scope for the development and evaluation of a new IDeAS model of health care in future research.

Supplemental Material

Supplemental_Material – Supplemental material for Exploring nursing and allied health perspectives of quality oral care after stroke: A qualitative study

Supplemental material, Supplemental_Material for Exploring nursing and allied health perspectives of quality oral care after stroke: A qualitative study by Caleb Ferguson, Ajesh George, Amy R Villarosa, Ariana C Kong, Sameer Bhole and Shilpi Ajwani in European Journal of Cardiovascular Nursing

The authors would like to acknowledge the partnership grant received from Western Sydney University and Sydney Local Health District, which enabled the conduct of this study.

Implications for practice

Most nurses did not feel prepared to provide oral care.

Participants felt the need for improved education and point of care resources.

Formalised education programmes that address oral health after stroke are needed.

Integrated models of dental care after stroke offer promise.

Declaration of conflicting interests

The authors declare that there is no conflict of interest.

Funding

This work was supported by Western Sydney University and Sydney Local Health District. Dr Caleb Ferguson is supported by a 2018 Postdoctoral Research Fellowship (Ref: 102168) from the National Heart Foundation of Australia.

References

© The European Society of Cardiology 2020