The role of the nurse in oral health: there are few registered nurses working in district health board oral health services around the country. But one who has remained describes her role and work.

Improving the oral health of all New Zealanders is one of the 13 priority areas for population health identified by the New Zealand Health Strategy. (1) The Primary Health Care Strategy also urges district health boards (DHBs) to focus on oral health. (2) The National Health Committee has recognised that oral health is often considered in isolation from other health issues and tends to be poorly integrated into health services. Its aim is to increase awareness of the inter-relationships between the wider determinants of health. (3)

Historically, registered nurses (RNs) have played a role in acute dental care in various DHBs. However, over the past decade many of these RN positions have been disestablished. The Oral Health Service at Capital and Coast DHB (CCDHB) is one of the few oral health services that employs an RN exclusively in oral health. The role embraces a wide variety of clinical responsibilities. The service has outpatient and inpatient services and is delivered from both Wellington and Kenepuru Hospitals. Referrals come from the greater Wellington region and the Wairarapa. Patients range in age from 18 months to 99 years and the service is provided to people from many diverse cultural, social and ethnic backgrounds. As a team, we provide dental treatment, oral surgery and oral medicine services. Our team consists of several first-year dentists as house surgeons, senior dentists and dental specialists, clinical technicians and a dental hygienist. They are supported by dental chair-side assistants, dental technicians, one RN, a receptionist and administration staff. Our team of approximately 30 has staff from Vanuatu, Egypt, South Africa, Iraq, Argentina, China, Samoa, Korea, Malaysia and the Phillipines. Each team member brings their own individual and cultural identities to care delivery.

A key component of my role is facilitation and staff teaching to ensure the safe administration of medications, the correct procedures for managing workplace injuries and to support the patient in an emergency. I assist the dentists to navigate complex hospital systems and help patients, primarily haematology and cardiology patients, negotiate service requirements before they are able to receive their dental treatment. We also visit inpatients who have been referred to the service.

I liaise with our primary referral agencies--Hutt Valley DHB, the Community Dental Service, school dental therapists, public health nurses, doctors and private dentists. Interpreters and cultural support groups may also contact me seeking information on behalf of a family or person they are working with.

Community outreach

We conduct a community outreach programme targeting children and young adults. The outreach team is a senior dentist, a school dental therapist, her chair-side assistant and myself. We endeavour to visit an inner city school for severely disabled children once every six to nine months, to assess and treat the children. This has been a very successful initiative with positive outcomes for the children and their families. As a result, our service is now including another special needs school. Managing this programme requires gaining permission from the school and parents' consent before our arrival. Gathering all the relevant hospital and community dental files, finding the day when most children will be there, and organising the various team members with the mobile equipment, involves significant co-ordination. I love participating in these clinics, working with the staff at the schools and providing a practical service. This diminishes the need for these children to attend departmental appointments. Like all the clinicians in the service, I move between the departments. However, I am primarily based at Wellington Hospital's dental department where I provide nursing support. This includes canulation and administration of intravenous antibiotics, as prophylactic treatment to those with cardiac conditions. I also provide general nursing assistance, eg with immobile patients. This can include assisting a mother with her cerebral patsy child, toilet assistance for wheelchair, frail or disabled patients, or support for ward and emergency department patients. I also monitor medical changes, such as a diabetic patient who has missed a meal due to waiting too long for their appointment and feels hypoglycaemic. I also deal with medical emergencies such as anaphylaxis. The role is unique because I am also the pre-assessment and theatre nurse for our oral health patients. A key aspect of my role is to identify what makes it difficult for patients to access the oral health service. I am passionate about patient advocacy and the importance of multidisciplinary collaboration to improve patients' experiences of the service. I need to be available to patients and families who are on a Long waiting List to receive dental care under general anaesthetic. Those on the waiting list include new migrants, refugees, and those who are medically complicated and who cannot undergo dental treatment in outpatients. Adults from all walks of life and of all ages have oral surgery for an array of conditions, including extractions of paediatric supernumerary teeth, removal of impacted wisdom teeth and biopsies of oral cavity cysyts.

I organise the Wellington operating theatre list for both dental treatment and oral surgery, as the service has very limited theatre time. I endeavour to maximise theatre time by taking into account the patient's needs, the dentist's expertise and how much anaesthetist's time is required, particularly for some of our medically complex patients. This requires an understanding of how each team member Likes to work. I have an excellent working relationship with many anaesthetists and have direct access to them when preparing to book a patient for surgery. Each patient is assessed individually, taking into account their age, medical history and past anaesthetics. Where possible, I direct patients to Kenepuru Day Surgery Unit, using Wellington Hospital theatre for those who do not meet the anaesthetic criteria for Kenepuru. I then match the dentist and anaesthetist to the patient, thus providing optimal care for that patient. Working directly with the theatre team enables all professions involved to be aware of the patient's needs before surgery.

My initial contact with patients can be at their outpatient appointment when the decision is made to complete treatment under general anaesthetic. The health questionnaire is completed and I assess this and place it into the appropriate treatment category--dental surgery, oral surgery or combined surgery. I document where surgery will occur, either at Wellington or Kenepuru Hospital, and which pre-assessment services they will require, eg attending a clinic or receiving a phone call before surgery.

I accompany our patients to theatre. I find this valuable for establishing a relationship with both clients and family. I believe patients are Less anxious on the day of surgery because we have established our nurse-patient partnership and they know a pivotal person will accompany them through their hospital experience.

Due to Limited pre-anaesthesia clinic availability, I endeavour to minimise hospital appointments for our patients by assessing whether a telephone pre-assessment can be provided by the anaesthetic department nurses, rather than the patients having to attend clinic. I also liaise with other specialties to ensure a patient with other surgical needs can have just one operation, especially when special needs children or intellectually impaired adults are involved. This decreases the need for repeated general anaesthetics and there is the added bonus of minimising DHB expenditure.

Many of our oral health clients are often socially isolated and have minimal support networks. They may have mental health problems; they may be former intravenous drug addicts wanting to improve their oral health and appearance; they may have on going addiction issues; they may be refugees. Preparation for their pre-surgery and post-surgery care may involve other services such as mental health community support, drug and alcohol treatment services, or community support groups, eg the City Mission.

Finally, I am also the anaesthetic-circulatory nurse for all the dental and oral surgery sessions in Wellington Hospital theatre. If our team is invited into another specialty theatre (or I am alerted to one of our patients undergoing another surgical procedure) I arrange for a dentist and their assistant to cancel their outpatient clinic so we can attend.

I provide a seamless continuum of care from the decision to book a patient for surgery, through assessment and admission, the surgical procedure, post-operative care and follow-up.

The role is challenging and fascinating. As the case studies (see right and on p22) demonstrate, each patient and their family require individual assessment and planning to provide seamless care. (* Names and some details have been changed to protect patient confidentiality.) I want to provide a service where the client is heard and valued and we achieve positive outcomes for all.

A sense of achievement

My position has three main strands; the department, the pre-assessment clinic and theatre. They are interwoven and of equal importance, and each requires a blend of nursing skills and expertise. When the discharge form is filed for one of our patients I feel a real sense of achievement. Often a great deal of effort has been required by the patient and me to reach this point, but it is worth every ounce of persistence. Finally, I am never completely free of the rote. During a recent holiday weekend, my family and I were basking in the Wairarapa sun, when a van of special needs children stopped for lunch beside us. Their caregiver said "Look here's Pip, the dental nurse", and the children scrambled to show me their teeth, tell me their dental stories and join us for lunch. The experience confirmed for me that I play a valuable role in the oral health of an important group of patients.

ARRANGING A DUAL PROCEDURE

* Mark, an intellectually impaired 18-year-old, had toothache and varucus. My challenge was to find an orthopaedic surgeon operating in an adjacent theatre to where dental surgery was taking place, and to ask him if he would be prepared to start his surgery list Late so he could operate on Mark, who was not his patient. I liaised between the medical practitioner, parents, anaesthetic team, and the senior dentist, who all know Mark well.

Funding and resource allocation issues were raised by the orthopaedic service and there were concerns about post-operative management. His parents were aware of the resource debate, as Mark had had two previous anaesthetics and the varucas had not been removed during either of them. Mark's parents were agitated, as they were concerned another opportunity for a dual procedure would slip away. It took me three months to co-ordinate, but eventually the orthopaedics service arranged for a private podiatrist to attend theatre. The anaesthetist who orchestrated the theatre team planned the pre-operative management to the last detail as Mark's challenging behaviour and physical strength affected care provision. Due to excellent teamwork all went to plan and Mark's family were happy with the outcome.

* I wish to thank Karen McBride-Henry, RN, Research Fellow, Clinical Effectiveness Unit, Capital and Coast District Health Board and Victoria University, Wellington, for her assistance with this reflection on my role.

References

1) The Ministry of Health (2000) The New Zealand Health Strategy Discussion Document. Wellington: The Author.

2) The Ministry of Health (2003) The New Zealand Primary Health Care Strategy. Wellington: The Author.

3) The Ministry of Health (2003) Improving child oral health and reducing child health inequalities, www.nhc.govt.nzpublications/PDFS/ChldOralHth. Retrieved 09/05/06.

A VISION FOR ORAL HEALTH CARE IN NEW ZEALAND

The oral health of New Zealand children is declining, with the latest statistics showing only 52 percent of five-year-olds have no caries, a lower percentage than the average for the 1990s. Statistics recently released by the Minister of Health Pete Hodgson show a continuing decline in children's oral health, with Maori and Pacific children and children in rural areas having significantly worse oral health than the national average.

In this year's budget, the Government announced it would invest $40 million in oral health services over the next four years, on top of $100 million in capital spending. It has also launched an action plan for re-investment in oral health, Good Oral Health for All, for Life. One of the major initiatives is the re-orientation of services from the existing school dental service to community oral health services. "Community-based clinics will provide treatment but will also be an outreach base for all oral health activities," the Minister said when launching the plan in August. District health boards are now working on business cases to implement the government's plan and the Ministry of Health wilt consider the first round of funding applications in November.

Oral health services are a mix of publicly and privately funded care, depending on age group and socio-economic status. Publicly funded oral care amounts to $100 million a year.

Good Oral Health for All, for Life focuses on four key groups: children and adolescents; older adults; MAori, Pacific and low-income populations; and people of all ages with physical, intellectual, behavioural or cognitive disabilties or who are medically compromised. As well as re-orientating child and adolesecent services, the other key action areas in the plan are: reducing inequalities in oral health access and outcomes; promoting oral health; building links with primary care; building the oral health workforce; developing oral health policy; and research, monitoring and evaluation.

A major survey of the state of the nation's teeth is underway. The survey will include 7000 participants from around the country and from all ethnic groups, take 12 months to complete and cost $1.5 million. Launching the survey, Hodgson said there was little national oral health data..

Reference

1) Ministry of Health (2006) Good Oral Health for All, for Life: The Strategic Vision for Oral Health in New Zealand. Wellington: Ministry of Health.

MANAGING COMPLEX MEDICAL NEEDS

* Jill is a 50-year-old woman with a blood clotting disorder who required full dental treatment, including x-rays, restorations and extractions. Her daughter, who has similar health needs, had previously required urgent dental care. Jill had accompanied her daughter to the appointment and that was when I first became aware of Jill's oral heath needs. I listened to her story, encouraged her to make an appointment and offered to support her, if she sought treatment. Jill required assistance from other services to provide the treatment she needed. She had previously had cardiac surgery and, to comply with National Heart Foundation guidelines on preventing endocarditis, required intravenous antibiotics 30 minutes before treatment, and which had to be completed within an hour. To counteract post-treatment bleeding, she required special medication administered by haematology staff. This required liaison with Cancer Centre staff to arrange a suitable time for them to assess and administer the medication before her oral health outpatient appointment. She was to undergo her first dental treatment in two stages, each involving the oral surgeon and senior dentist. Appointment times had to be synchronised to ensure both were available. Jill also had anxiety about cannulation, due to terrible veins and many unpleasant experiences. I arranged for an expert cannulator to Lessen the probability of multiple attempts to find a vein. As time was important, I offered to accompany her from one department to the next in our department wheelchair. This was a successful experience for Jill and all involved with providing care for her.

Since then, Jill has been back several times to complete her treatment. Unfortunately she also had a dental emergency and all our staff had to juggle their clinics to provide care for Jill. The expert cannulator was on night shift but he offered to wait for Jill before heading home to bed. This typifies the team's commitment to providing excellent clinical care that meets patients' individual needs.

ALLEVIATING A DEAF CLIENT'S ANXIETY

* Arthur is a Deaf (formerly referred to as deaf mute) person who has schizophrenia and who had had severe dental pain. He had failed to attend several appointments at both our departments but he had attended the pre-anaesthetic clinic. The information given at that appointment increased his anxiety and he did not show for his surgery. He has minimal lip reading or reading skills and has no amplified telephone. To ensure Arthur received the oral health care he needed, just one appointment had to occur.

One appointment attended by many

I arranged a consultation with the oral surgeon, a mental health worker who "signs", plus another "sign" interpreter for Arthur, and a friend, who agreed to support Arthur through his hospital experience. To gather everyone together in one place took some time to organise.

I requested that we complete all Arthur's dental treatment and oral surgery in one operating session. We visited the perioperative areas and met the staff who would be caring for him the next day. This alleviated his anxieties about how he would communicate with staff in the post-anaesthetic care unit and how the staff would understand him. The operation was successful, as was Arthur's experience of being in hospital. Because of these successes, Arthur has attended further oral health outpatient appointments unaccompanied.

Phillipa Brown, RN, BN, is the registered nurse at the Oral Health Service, Capital and Coast District Health Board. She has been in the role for three years.