Nurses’ perception and attitudes towards oral care practices for mechanically ventilated patients
===================================================================================================

* Mahmoud A. Alja’afreh
* Sultan M. Mosleh
* Sakhaa S. Habashneh

## Abstract

**Objectives:** To explore the perception and attitudes of intensive care unit (ICU) nurses towards oral care practice for mechanically ventilated (MV) patients.

**Method:** A descriptive cross-sectional design was used in this study. A convenience sample of 96 ICU nurses completed a questionnaire on their perception and attitudes towards oral care. The study setting was 3 representative Jordanian hospitals in Al-Karak and the capital, Amman, over a 6-month period between February and September 2016.

**Results:** Ninety-six nurses participated in the study. The response rate was 76.8%. The results revealed that 65% only follow a specific oral care protocol. Nurses did not adhere to minimal standards. Although nurses’ attitude towards oral care was strongly positive, 68% of them perceived it as an unpleasant task and 29% agreed that they had insufficient training; 78% agreed to learn more about the best way to perform oral care. Standard descriptive statistics were calculated for all baseline information (sociodemographic characteristics). Binary variables were expressed as proportions, and normally distributed continuous variables as means and standard deviations.

**Conclusion:** The poor perception and attitudes of ICU nurses regarding oral care for MV patients require the urgent attention of clinical administrators. In-hospital training regarding oral care protocol could improve nurses’ perception and attitudes.

Oral care is an important component of intensive care nursing for mechanically ventilated (MV) patients.1 Oral care aims to maintain their oral condition in a comfortable, clean and moist manner, free of infection.2 Patients in intensive care units (ICUs) may require oral intubation to maintain a clear airway. The endotracheal tube (ETT) can induce potential complications such as ventilator-associated pneumonia (VAP), one of the most common hospital-acquired infections among patients receiving mechanical ventilation in ICUs.3,4 The VAP rate in developing countries ranges from 1.5 to 41.7 per 1000 ventilator-days.5-7 Although the relationship between oral care and VAP prevention is difficult to measure, oral hygiene in combination with a range of other activities such as the VAP bundle care programme is important in decreasing the number of patients with VAP.1,7,8 The effectiveness of oral care has been found to be associated with many factors, such as the unavailability of clear guidelines, the level of knowledge among the healthcare team, and the nurse to patient ratio.9 Some studies have highlighted the importance of nurses’ knowledge and attitudes regarding patients’ oral care.9-12 In a large European survey, 88.1% of ICU nurses reported oral care for their patients as their top priority.13 In another study in Malaysia, 84.7% of ICU nurses reported they needed better methods and updated knowledge for practising oral care.14 Despite nurses ranking oral care as a high priority, many of these studies found that it was perceived as a difficult procedure and an unpleasant task in which they lacked sufficient knowledge.9,11,15-17 Therefore, nurses need to be aware of both the problem and evidence-based preventive strategies, adhering to such practices and integrating them into their nursing care.8,18 Oral care practice varies widely between different healthcare settings.9,19 One of the most effective oral care practices is brushing the patient’s mouth using chlorhexadine plus use of a broad-spectrum antibiotic agent.1,9,20-22 The recommended frequency of performing oral care also varies: every 2 hours, 4 hours, 8 hours or 12 hours.9,13,19,23-25 The literature did not confirm which was better for reducing the risk of VAP. Various surveys of ICUs found in the literature from the USA, Europe and the UK concluded that evidence-based oral care practices could reduce the incidence of VAP in patients.8 In Arab countries, a study by Al-Sayaghi examined nurses’ knowledge in a sample of 37 ICUs in Yemen, and found their knowledge of evidence-based strategies for VAP prevention was low. However, more than 60% of the nurses were most frequently correct regarding regular oral care.26 Oral care is an important nursing care role for MV patients. Nursing studies have identified appropriate tools for providing effective oral hygiene, including, chemical agents, and frequency; however, nursing practice based on clinical evidence and standardized oral care guidelines for VAP prevention are rarely employed.10 Therefore, ICU nurses need a standardized best practice protocol to guide their important work on VAP rates, dissemintated through in-service educational programmes.8,26 Improving their knowledge would give nurses confidence in making the correct decisions, increasing optimal delivery of patient care, and reducing the length of their stay in the hospital.10,27 The risk of VAP increases 1.3 times with each day on MV, and thus adds to treatment costs.6,28 The inadequate provision of oral care may be because nurses view it as contributing less to patients’ health and well-being than other procedures for critically ill patients. Evidence-based recommendations for oral care are not available in Jordan, and training and motivation of all healthcare workers involved in the care of intubated patients is essential. Currently, few studies in Jordanian hospitals have examined this issue. This study aimed to explore the perception and attitudes of ICU nurses towards oral care practice for MV patients to meet this need.

## Methods

Related studies were identified from various scientific sources including Google Scholar, Cochrane Library, PubMed, CINAHL and MEDLINE. The search terms used included oral care, intensive care units, critical care nursing, and mechanically ventilated patients, in different combinations. The publications retrieved were assessed and reviewed.

A descriptive cross-sectional survey design was used in this study, which was conducted in southern Jordan, in the area served by the Al-Karak Government and Prince Ali Hospitals, and the King Hussein Medical Centre in Amman. These hospitals are among the biggest government and military hospitals in Jordan and are teaching hospitals for nursing and medical students for all universities and colleges. They receive all types of patients in critical care units (CCUs) which have beds for coronary care and for general intensive care. These units receive the patients at acute and critical stages of illness.

This study is part of a large project about effective intervention to reduce the risk of VAP. The size of the study sample was based on previous research reported in the literature. The target population was based on the number of ICU nurses (n=125) at the target settings: 25 in the Al-Karak Government Hospital, 22 in the Prince Ali Hospital and 78 in the King Hussein Medical Centre. A poster regarding the study’s aim and the proposal was distributed in all target hospital units. Research assistants then approached the 96 nurses who showed interest in participating in the study.

The inclusion criteria were critical care nurses working in the nominated ICUs of the 3 Jordanian hospitals, with ICU experience of at least 6 months. Participation in the study was completely voluntary. Nurses preferring not to participate in the study and those who did not meet the inclusion criteria were excluded.

Assessment of nurses’ perception and attitude towards oral care in CCUs was obtained through a questionnaire developed specifically for this study. The data were collected through a 3-part questionnaire prepared by the researchers, based on previous studies reported in the literature.9,29 The first section comprised 7 demographic and work-related questions: age, gender, education, experience, nurse-patient ratio, working area, and ICU capacity. The items in sections 2 and 3 were developed based on these studies. The second section had 15 items to assess oral care, ETT suctioning and infection control practices (for details about this section, see **Table 2**, 3 items). The third section comprised 13 statements concerning nurses’ attitudes towards oral care for MV patients, with responses measured on a 5-point Likert scale ranging from strongly agree to strongly disagree.

The content of the questionnaire was reviewed by a research panel (3 academic staff and 2 clinical ICU nurses), who checked the suitability, clarity and understandable wording in the context. To ensure content clarity, cultural sensitivity and internal reliability of the questionnaire, it was tested in a pilot study with 10 ICU nurses; the results were not included in the main study. Feedback and discrepancies in the questions were discussed among the researchers and the required changes made to the final version of the questionnaire. The test-retest reliability of the tool was verified as 0.92. The average scale content validity index for the items ranged from 0.77 to 0.90 with positive internal consistency; Cronbach’s alpha coefficients ranged from 0.74 to 0.83. In relation to section 3, the content validity index for total attitude score was 0.77; internal consistency, measured by Cronbach’s alpha coefficient, was 0.88. All sections of the questionnaire showed good reliability and validity properties. The questionnaire was practical and useful to assess the perception and attitudes of ICU nurses in Jordan.

The study was carried out over a 6-month period between February and September 2016. After ethical approval had been granted by the research ethics committee of the Faculty of Nursing of Mutah University, the Jordanian Royal Medical Service and the Ministry of Health, data were collected to explore nurses’ perception of oral care. The primary researcher met the matron of each participating hospital to explain the purpose of the study, the clinical implications and the data collection process. At these visits, 2 staff nurses were identified to act as research assistants in each hospital. They could not be involved in providing direct care for any of the patients in the study population. To ensure accuracy and consistency between all nominated research assistants across the different settings, a workshop was held to explain the purpose of the research, go through the data collection processes and answer any questions.

The questionnaires were distributed by research assistants to all nurses working in ICUs in the 3 nominated hospitals. Any nurse who was willing to take part was told about the study, and given an information sheet, consent form and a return envelope. Each participant was asked to complete the questionnaire in their break time and to return it to the research assistant or drop it in a designated box in their working area.

### Ethical considerations

The study was approved by the Mutah University Ethics Committee. Researchers ensured application of necessary interventions during data collection from the CCUs of the assigned hospitals. Subjects were assured that their data would be anonymous. All research data were kept in a safe locked place. To ensure safety and confidentiality the computerized data could be accessed by the researchers only through a password.

### Statistical analysis

Standard descriptive statistics were calculated for all baseline information (sociodemographic characteristics). Binary variables were expressed as proportions, and normally distributed continuous variables as means and standard deviations. Study data tests was analyzed using the Statistical Package for the Social Sciences (SPSS) version 21 (IBM Corp., Armonk, NY, USA) and the results reported as mean, frequency and percentage.30

## Results

One hundred and twenty-five nurses were approached, of whom 96 participated in the study, a rate of 76.8%. The average age was 27.97±4.88; 53.1% were women; 78.9% had Bachelor degrees and only 10.4% had less than one year of ICU experience, with 46.9% 1-5 years and 43.8% more than 6 years of ICU experience. More than 50% of nurses were from surgical ICUs. The nurse-patient ratio was 1:2 for most of the participating ICUs (**Table 1**).

View this table:
[Table 1](http://smj.org.sa/content/39/4/379/T1)

Table 1 
Participants by demographic characteristics (n=96).

The results of assessing nurses’ perceptions toward oral care revealed that only 65% follow a specific oral care protocol. Poor practice was indicated by the percentage of participants who completed with correct answers (**Tables 2 & 3**). Forty-six percent of nurses provided the correct answer for frequency of oral care suction, and 63% for the frequency of using a toothbrush.

View this table:
[Table 2](http://smj.org.sa/content/39/4/379/T2)

Table 2 
Nurses’ perceptions of effective oral care.

View this table:
[Table 3](http://smj.org.sa/content/39/4/379/T3)

Table 3 
Nurses’ perceptions of endotracheal tube suctioning.

**Table 4** represents nurses’ attitudes towards oral care and ETT suctioning for MV patients. The attitude scores and their levels were as follows: most of the nurses claimed that oral care has a very high priority (82% strongly agreed and 15% somewhat agreed). The negative attitudes scores were as follows: 68% claimed that cleaning the oral cavity is an unpleasant task and 50% that the oral cavity is difficult to clean. Almost half (47%) stated that the mouth of most ventilated patients became worse whatever they did. Items for training and continuing education scored as follows: although 71% claimed that they had been provided adequate training in providing oral care, 78% would like to learn more about the best methods, as a personal priority, by attending continuing education workshops.

View this table:
[Table 4](http://smj.org.sa/content/39/4/379/T4)

Table 4 
Nurses’ attitudes towards oral care for MV patients.

## Discussion

It is widely understood that critical care nurses play an important role in the prevention of VAP in CCUs. This cross-sectional study assessed the current perceptions and attitudes of these nurses. Our results found them to be poor. Nurses were performing non-evidence-based oral care practices without protocols or guidelines covering the method, cleaning solution, cleaning instruments and the time and frequency. Most participants (94%) claimed that their general perception of oral care for intubated patients is important and a high priority, which is consistent with Alotaibi et al’ study.11 This percentage is higher than that found in other studies,31 who reported that 76.2% of the participants claimed that oral care is important and necessary; 73.5% agreed that VAP can be prevented if oral care is provided and 48.6% did not believe in the effectiveness of oral care.31 Miranda et al32 reported that 83.1% of participants stated oral care is a priority. Our study demonstrates that the methods used by nurses in oral care were not based on standardized protocols or guidelines, such as the 2016 American VAP clinical guidelines.33 Thirty-five percent of nurses claimed that they had no clear protocol for oral care. This is almost half of the result reported by Feider et al9, that 72% claimed that their units had an oral care policy. This could be reflected in our study’s results that showed nurses’ poor practice. For example, “only as needed” was the response provided by 46% of nurses for the frequency of oral suction; 63% for the frequency of toothbrush use; 67% for antiseptic oral rinsing solution using available mouthwash in their critical area; 27% for using chlorhexidine; and 54% for the frequency of lubricating lips. This is similar to the results reported from 4 Turkish hospitals: 99% of nurses working in ICUs reported that they did not use oral assessment guidelines and 53.5% said their healthcare facility did not have a standardized protocol.31 Most nurses in these 4 hospitals used oral care solutions (100%, 92.9%, 44.8% and 86.1%). However, only 27% used chlorhexidine as an oral care solution with tooth brushing in our study, which is low compared to the 38.4% in Turk et al’s34 study and 71.4% in Özveren & Özden’s.31 However, our nurses had good practical knowledge of ETT suction, with 72% washing their hands between patients, and 80% always wearing gloves when performing oral care. This is consistent with Feider et al9 who reported that 73% performed standard precautionary assessment while suctioning the oral cavity, as the risk of contamination is higher than in open aspiration systems.8 Seventy-nine percent of our study’s nurses used closed system suction for ETT suction and half performed hyper-oxygenation for one minute before suctioning. This is consistent with Bagheri-Nesami and Amiri’s35 study, where 80.8% of nurses used a closed respiratory system in prevention of VAP. In terms of our nurses’ attitudes towards oral care practices, the results showed negative attitudes, 68% of our nurses claiming that cleaning the oral cavity is an unpleasant task and almost 50% says that the oral cavity is difficult to clean. Approximately 47% agreed that “the mouth of most ventilated patients gets worse no matter what I do”. Our results are consistent with previous studies.11,22,27,32 For instance, Jahansefat et al36 claimed that the attitude of healthcare workers towards VAP prevention is not very positive, and Özveren and Özden31 that 68.1% of the participants said that cleaning the oral cavity is a difficult and unpleasant task. However, our result is higher than Saddki et al37 which revealed that 40.8% of the participants stated it was difficult and 16.2% unpleasant, using appropriate oral care methods and having positive oral care attitudes.

There is an association between our findings and the conclusions of earlier studies. Nurses’ attitudes are strongly influenced by thinking and reasoning, and by lack of time.31,36 Poor knowledge can also lead to the negative attitudes of healthcare workers towards VAP, and we believe that our scores are for the same reason, that poor perception is illustrated by negative attitudes and non-compliance.38 This could be supported by the training and continuing education item scores. Although 71% of our study nurses claimed that they had been given adequate training in providing oral care, 78% would like to learn more, by attending continuing education workshops; 80% indicated that they needed more information evidence-based standard procedures. One of the powerful variables in prevention measures for MV patients’ health is designing educational programmes for VAP prevention.7,35,36 Education of nurses on oral care can result in effective improvement of their clinical work by translation of evidence-based knowledge into clinical practice, reflected in the clinical outcomes of MV patients.39 This could be effective in our clinical settings if staff adherence is monitored, and an adequate supply of equipment such as toothbrushes and oral cavity care solutions provided.

This study explored ICU nurses’ perceptions and attitudes towards oral care practice for MV patients. Its descriptive design affords limited generalization of the findings; a randomized controlled future study could explore more details about this area. Our study may be further limited by the small sample of nurses, compared to other studies in the same field, although it covers all the healthcare sectors in Jordan: government, military and private.

It is essential to stress that intensive care nurses should have adequate education, accompanied by competent skills in oral care to express a high quality of care given to their ICU patients. Acquiring adequate perceptions and attitudes in oral care for VAP patients in ICUs is not a guarantee of nurses’ compliance and adherence in implementation and application in their daily practice. Therefore, written standards, guidelines or protocol available in nurses’ hands throughout the day in their work area could improve the care of such patients.

In conclusion, the poor perception and attitudes of ICU nurses regarding oral care for MV patients require the urgent attention of clinical administrators. Thus, in-hospital training regarding an oral care protocol for daily use could improve nurses’ perception and attitudes. Further research might assist in explaining any lack of clarity in our results.

## Acknowledgment

*We would like to thank all the intensive care nurses who participated in this study. Also, we are grateful to the Scientific Research Committee of Mutah University, Jordan for funding this study*.

## Footnotes

*   **Disclosure.** Authors have no conflict of interests, and the work was not supported or funded by any drug company. This study was funded by the Scientific Research Committee of Mutah University, Alkarak, Jordan (Grant No. 77/14/120).

*   Received December 4, 2017.
*   Accepted February 28, 2018.


*   Copyright: © Saudi Medical Journal

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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