Survey of oral hygiene knowledge and practice among Mississippi nursing home staff.
In America today, people are living longer and retaining their teeth longer, resulting in greater dental and overall health issues for the general population, but specifically the nursing home resident (1). It is estimated that one in five individuals in the United States (U.S.) will be sixty-five years and older by 2050 (2, 3). The same demographic studies also suggest that those over the age of 85 will account for 4.5% of the population in the next half century (4). In 2005, 12% of the Mississippi population was sixty-five years old (5). Of the residents in Mississippi nursing homes in 2005 17.2% were sixty-five years to seventy-four years, 35.2% were seventy-five years to eighty-four years, and 35.7% were older than eighty-five years old (5). Furthermore, it has been estimated that 73% of nursing home residents currently retain at least some of their natural teeth, and that the number of edentulous (without teeth) residents living in nursing homes has decreased by 80% since 1980 (6).
Progress of dental care in the general population has led to unprecedented "good" dental health in the aging population; however if the oral healthcare needs of the nursing home residents are not met by the nursing staffs, multiple health issues could develop (1). The "Baby Boomer" generation (1946-1964) is the first generation of children who benefited from fluoridated water and toothpaste, an awareness of the importance of annual dental checkups, and dental hygiene education in the classroom and through the media. Consequently this generation is more likely to retain its natural dentition than previous generations (7, 8, 9). As a result of improved oral practices and the greater likelihood of residents retaining their natural dentition, nursing home staffs will face growing challenges for the nursing home populations' oral care (10).
Current research shows that those living in nursing homes often lack appropriate dental hygiene care (11). Nursing homes and assisted living facilities often lack sufficient personnel with appropriate knowledge and practice skills, physical facilities, and financial support to meet this growing demand for appropriate dental hygiene (12). Consequently, residents in nursing homes could possibly have inadequate oral care, which will only increase as the number of residents doubles by 2020 (13).
RESEARCH METHODS AND STUDY DESIGN
The research design for this study involved describing and analyzing the population of the nursing staff in rural- and urban-based nursing home facilities in Mississippi. This is the first comprehensive research study in Mississippi to examine oral care in this confined elderly population. The survey included both a 10-question demographic component to identify variables in the survey population and a formal survey specifically related to oral care. The latter, a 53-question survey instrument, tested the attitudes, knowledge, and practice of oral care in nursing homes. The nondemographic portion of the survey included validated questions from four different sources (14, 15, 16, 17, 18) that were modified for this project. The oral health practice, attitude, and knowledge of nursing staff were assessed using self administered questionnaires. Some practice questions were recoded into correct/incorrect responses based on ADA recommended standards. Others were on a 4 point Likert scale of "never", "seldom", "frequently", and "always" with "never" scored as -1, "seldom/frequently" as 0, and "always" as +1. Responses on a 5-point Likert scale to 9 statements on oral health care (including nursing staff's own oral health) tested attitudes. Positively worded statements scored from +2 for "strongly agree" through zero for "no opinion" to -2 for "strongly disagree". Negatively worded statements were reverse-coded. The main outcomes were composite knowledge and attitudes scores. Knowledge was tested by true/false responses to 33 statements, each correct answer scoring one.
The investigator ensured the content validity of the survey instrument by following Carmines and Zeller's (19) guidelines. These authors describe three types of validity: criterion, content, and construct. Criteria refers to a statement of need, rules, standards, or tests that must be used in evaluating research, in this project the American Dental Association (ADA) Standards. Specifically, these include twice daily tooth brushing and once a day flossing for patients retaining their dentition. The ADA does not have a specific protocol for edentulous patients. Content validity is the degree to which elements of an assessment instrument are relevant to and representative of the targeted construct for a particular assessment purpose. The term construct refers to the concept, attribute, or variable that is the target of measurement. Prior to deploying the instrument, a review panel of physicians, dentists, nurses, dental hygienists, and laypeople were asked to complete the survey to ensure face validity (20). Additionally, this prescreening indicated the estimated time of completion for the instrument.
Fifty-three questions on the nursing home survey targeted the practices, attitudes, and knowledge of the staff. The participants recorded their responses on a scan sheet with a number 2 pencil, and they were collated electronically in an Excel spreadsheet. The survey instrument was divided into sections: The first 10 questions concerned the nursing staffs' oral care practices; questions 11 through 19 determined their attitudes toward oral care, both their clients' and their own; and questions 20 through 53 queried their oral care knowledge. Some of the questions related primarily to practice to determine the level of oral care that the nursing staff provided, and the responses to these yes/no questions were reported as percentages. The responses to the questions on attitude were not necessarily deemed as correct responses, but rather as a spectrum of choices with regard to outlook. Other questions, especially those on knowledge, contained both correct responses and distracters to ascertain the knowledge of standard of care.
The researcher selected the survey population from the Mississippi Nursing Home Certification Register of 2007, which was available from the Mississippi Nursing Home Registry through the Mississippi Board of Nursing Home Administrators (21. However, the information is no longer available at this site and can now be found at MembeoftheFamily.net. The investigator administered the 63-question survey (which included both demographic and content questions) to the nursing staffs in 30 randomly selected nursing homes.
The U.S. Census Bureau (22) classifies as "urban all territory, population, and housing units located within an urbanized area or urban cluster" (para. 4). These are core groups or blocks that have a population density of approximately 1,000 people per square mile. A rural area consists of all territory, population, and housing units located outside of urban areas and urban centers. Of the 30 Mississippi nursing homes that were selected for survey, by definition, 15 were rural and 15 were urban.
RESULTS AND DISCUSSION
Demographic Characteristics of Mississippi. The demographics of Mississippi influence nursing home care and the composition of staff, making these statistics relevant to the current study. Mississippi is the fourth most rural state in the United States, and by most measures, the poorest and unhealthiest state in America. Mississippi ranks 50th in per capita income and 50th in overall health (23, 24). Furthermore, Mississippi health care problems are compounded by the lack of educated and trained healthcare providers.
It is pertinent at this point to provide a brief snapshot of Mississippi in terms of race and ethnicity, education and training, poverty levels, and dental health. The population is slightly greater than 2.9 million with 60.9% Caucasian, 37.2% African American, 2.2% Hispanic, and less than 1% Asian (23, 24). The United States Census reports that high school graduates under the age of 25 years comprise 71.4% of Mississippi graduates, compared to the national average of 84% graduates (23, 24). In Mississippi, 16.9% of college students complete a bachelor degree, which is 8% lower than the national average (23, 24). The median income for a Mississippi family is $15,853/year compared to $21,587/year nationally. Overall, 23% of the population in Mississippi lives below the poverty level. A total of sixty of eighty-two counties in Mississippi have poverty levels below the national average (Figure 1).
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Especially relevant to this study are the statistics concerning oral health in Mississippi (24). Only 59.4% of adults in Mississippi visited a dentist or dental clinic in 2008 compared to 71.3% nationally. Routine prophylaxis by dental health professions was obtained by only 56.5% of adult Mississippians compared to 68.4% adults nationally. Of the population over 65 years of age, 27.3% in Mississippi are edentulous compared to 18.5% nationally.
Staff Demographics of Mississippi Nursing Homes. A total of 945 nursing staff responded in this study. There were 483 (51%) rural and 462 (49%) urban nursing staff responses. Initial analysis of survey data showed no statistical differences between rural and urban respondents. Therefore, all results presented represent the combined data sets. As with most surveys, response rates to individual questions was not 100%.
The survey divided responders into three age groups: 18-25 year olds (11.5%), 26-55 year olds (80%), and over 55 years old (8.5%). The majority of nursing staff were female (93.5%) (Figure 2). It should be noted that the survey instrument provided options for reporting ethnicity as Caucasian, African American, Hispanic, Native American, and Asian. However, due to the demographic makeup of Mississippi, the number of individuals responding as Asian, Hispanic or Native American was very small and these groups were added to the totals for Caucasians. A total of 25% of nursing staff identified themselves in this group. African Americans constituted the majority of staff, 74.9%. (Figure 2).
The largest group of employees in nursing homes has an entry education level equivalent to a high school degree and some additional training at the certificate level. The education levels were divided into 4 categories: high school/high school graduate (20.3%), certified nursing assistant (CNA; 47%), licensed practical nurse (LPN; 23.3%), or registered nurse with a Bachelor's degree/Registry Exam (RN; 9.5%) (Figure 2). Job titles were based on educational levels: high school/high school graduate education, nursing specific training (including CNA, LPN or RN education), and administrators. The majority of nursing home staff holds a job title requiring CNAs, LPNs and RNs training (85%). The nursing aids category constituted 14.2% of staff (Figure 2). Lecture time dedicated to oral care in a formal training setting was reported by 85.8% of nursing staff with CNA, LPN and RN credentials (Figure 2).
The nursing home staff was surveyed on how much in service training they received in the nursing home where they worked. Most staff (70.6%) reported in service training 1 to 2 times a year. The remaining (29.4%) had received no in-service training at all or training at intervals of longer than 2 years (Figure 2). The question of "hands on experience" concerning the oral care during formal education was also addressed. Most staff reported some hands on experience during training 81.3% (Figure 2).
The survey also asked nursing staff about their own personal dental visits (Figure 2). The responses were divided into three categories: never any dental visits (2.1%), only if in some to severe pain (48.5%), and regular check-ups once a year or more (49.4%).
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Oral Care Practice in Nursing Homes. A series of questions included in the survey instrument were employed to determine the amount and type of oral care provided to the residents in nursing homes by the staff (Figure 3). Staff reported that 40% of residents required help from the nursing staff to brush their teeth (Panel A, Figure 3). The second component of routine oral care is flossing of the teeth. There was a sharp decrease in the number of patients receiving assistance with this task: nursing staff assisted only 13% of residents with flossing (Panel A, Figure 3), about one-third of those who reported assisting with brushing. An additional question concerning flossing specifically addressed daily flossing, for which the staff reported that 19% of the residents received daily flossing assistance. Interestingly, 64 % of nursing staff reported sufficient time available to provide both these procedures, in sharp contrast to other studies which cited time as a factor in failure to provide these services (12). In our study, the available personnel was not a limiting factor. Sixty-nine% of nursing staff reported that there was adequate personnel to provide oral care in contrast to the Wardh study (12).
Several adjunct or alternatives to brushing and flossing include the use of rinses, swabs, or denture care. A daily fluoride mouth rinse is recommended to protect roots exposed at the gingival interface and many mouth rinses contain an antimicrobial activity to control infection. Forty nine percent of nursing home staff reported daily fluoride rinse use. The percentage of this group using a combination of fluoride/antimicrobial rinse was not determined. The use of any mouth rinse was reported for residents 63.5% of the time by nursing staff. The use of oral swabs is the most appropriate alternative for brushing, flossing or rinses. The nursing staff reported providing oral swabbing for 4% of the residents (Panel A, Figure 3). Daily denture care was reported by 85% of nursing staff, by far the most common form of oral care assistance provided.
Attitudes of Nursing Staff toward Oral Care. The attitudes of nursing staff toward their role in oral care depend in large part on their personal oral care and the perception of its importance to their patients. Generally, staff reported that 60.8 % of residents requiring assistance were receptive to oral care. A second factor in the attitude of staff regarding oral care is the level of confidence a staff member feels in providing such service. Nursing staff self reported (51%) feeling competent when providing oral care (Panel B, Figure 3). Thus, 49.5% of staff never felt able or were unsure of their ability to assist patients with routine daily oral hygiene practices. Furthermore, 35% of caregivers felt that special oral skills and training were needed to improve their confidence in providing oral care. Indeed, the majority of staff (80%) reported that oral hygiene is equally as important as other duties.
Knowledge of Oral Care. As a baseline assessment, the survey asked the respondents about their perceived level of knowledge about oral care. The majority of staff (84%) self reported good to excellent knowledge of oral care (Panel C, Figure 3). However, following a series of questions concerning standards of care and dental health, a much different picture emerges. Specifically, questions about standards of practice, dental plaque, dentures, oral cancer, periodontal disease, medications, and systemic health as related to dentition were included in the survey. Overall, nursing staff correctly answered only 63% of these objective questions, which is much lower than their self reported excellent knowledge (Panel C, Figure 3).
The correct daily hygiene regimen suggested by ADA was identified by only 68% of nursing staff respondents. The characterization of dental plaque as a biofilm which may contribute to decay and systemic disease was reported by 85% of staff. Overall, 77% of staff had appropriate knowledge of denture care. Few nursing staff (31%) recognized the association of signs and symptoms of oral cancer such as bleeding of the gums or white patches in the mouth or risk factors such as smoking, dentures, and age. The category of periodontal disease was reported correctly by 58% of nursing staff, recognized by bleeding of the gums, loose teeth, and diabetes as common phenomenon of this disease. The extensive use of medications by residents in nursing homes may also play a role in conditions of the mouth, including dry mouth, increased dental caries, ability to eat/drink/swallow, and speak. The majority of nursing staff (62%) perceived medications as potential mediators of these symptoms. Further, the correlation of poor dental hygiene and systemic diseases or diabetes was recognized by 68% of the respondents.
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Clearly, Mississippi has unique problems associated with poverty, lack of education, and the overall health of its population. Although some areas of the state met the definition of urban, we found no differences between nursing staff of urban and rural facilities. In this study, we found the vast majority of nursing staffs were African American. The number of African Americans in this population was almost twice what would have been expected based on the general population of the state (74.9% vs 37.2%). Indeed, Hispanic and Asian populations are underrepresented in both Mississippi's general population compared to national trends and even more so in staffs of our nursing homes, where their numbers were in single digits.
In terms of educational level, the population surveyed had a higher level of education than the general population of the state due to the requirements for employment in this field. These employees generally receive compensation at levels above minimum wage, commensurate with their education above a high school degree. Thus, employment in nursing facilities may represent some of the more desirable positions for individuals who have received specialized training such as that required for CNAs, LPNs, and RNs. Nationally, only 6% of nursing home staffs (25) were RNs; in Mississippi, RNs account for 9.5%.
The issue of dental care in nursing homes is often neglected. Typically, no dental professional is retained by any nursing home in a full time capacity (26, 27, 28, 29, 30, 31, 32). Personal attitudes and beliefs concerning the importance of oral care have been shown to be predictive of not only self-care but use of dental services in general (33, 34,35). Individuals who report negative attitudes toward dental health professionals and dental care were more likely to have tooth loss than individuals with a positive attitude (32). In our study, only 49.4% of nursing staff sought routine annual dental care compared to 59.4% of Mississippians state wide and 71.3% nationally. Other studies have also shown that race and poverty contribute to negative attitudes toward dental care and dental health as well as lack of knowledge of dental services (36).
Regardless of personal attitudes about oral care, the majority of nursing staff reported feeling competent to provide dental care services for patients. Indeed, 86% of staff felt that they had good to excellent knowledge of oral care. Only 37% of nursing staff felt it necessary to have special training to acquire skills pertinent to oral care. Over 80% of nursing staff reported that oral care services were as important as any other duty. Further, they reported adequate time for such duties and the support of the administrative staff.
By law, nursing homes in the United States are mandated to meet the routine and emergency dental needs of nursing home residents (6). This includes oral exams, cancer screening, tooth brushing three times a day, partial and denture cleaning and daily tooth flossing. Nursing staff reported providing less than 50% of patients with brushing and less than 15% with flossing. It is important to note that none of the nursing facilities included in this study had an on-call/on-staff dental hygienist or dental health care professional. Therefore, any screening or routine care would have to be provided by nursing staff, principally nurses' aides.
These staff members would need to have a high level of knowledge of dental health. Cognitively, nursing staff self reported adequate (52%) practice of standards of oral care (brushing, flossing, and fluoride rinses). Indeed, of these, the staff responded correctly to queries concerning this basic level of knowledge (63%). Denture care was specifically addressed by 4 of the 14 standards questions. Nursing staff had much higher levels of knowledge and appreciation for denture care (approximately 78%) than for dental hygiene of dentate patients. Less than 65% of nursing staff respondents correctly noted the importance of daily brushing in dentate patients with even fewer (less than 31%) noting flossing as a daily requirement.
While it is not possible to determine the amount of emphasis in an in-service training session, it is clear that staff have incorporated more information concerning denture care than care for dentate patient oral hygiene. Further, manuals provided to nurses' aides clearly placed priority on denture care. Therefore, an important question to be addressed in any future study would concern emphasis on education about dentate patients and their long term needs. Certainly, a lack of appropriate care in these nursing home patients will result in an increasing number of edentulous patients.
Mississippi is largely rural and is one of the poorest, least educated, and least healthy states. Although some areas of the state technically qualify as urban, there were no significant differences between urban and rural respondents in the survey, indicative of a homogenous population. Even though the nursing staff population had higher levels of education than the state's general population, the majority still had only high school degrees and/or some specialty training. In the context of the state demographics, they represent a more educated workforce than the general population. Even though the staff reported adequate time, personnel, and administrative support, the level of knowledge and degree to which the staff translated that knowledge into practice of oral hygiene was self reported as inadequate. Specifically, the amount of time spent by nursing staff in Mississippi has been reported at 2.86 hours per resident day (HPRD), well above the national median of 2.32 HPRD but below the recommended 3.0 HPRD by the Centers for Medicare and Medicaid Services (25). Further, nursing staffs are ill prepared in both didactic and practical dental application for the care of nursing residents. Given the potential boom in the nursing home population, the majority of whom will retain some or all of their natural dentition, there is a pressing need to establish national training and educational standards for dental care for the nursing home staff.
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Robin M. Howard and Donna C. Sullivan
School of Health Related Profession and School of Medicine, University of Mississippi Medical Center, Jackson, MS 39216.
Corresponding Author: Corresponding author. E-mail: firstname.lastname@example.org