A Nurse Initiative Oral Hygiene Program for Older Veterans

Older Americans make up a growing percentage of the U.S. population and nearly 40 million are 65 years or older [1]. There is an increased chance of heart disease, stroke, diabetes, and oral cancer for older adults who have poor oral health [2].A regular oral hygiene regimen may be an efficient way to reduce the dental problems associated with aging [3].Achieving optimal oral health outcomes for older adults may be achieved by educating older adults about oral health, understanding patients’ preferences relating to oral hygiene, and encouraging oral health research among clinicians.


Introduction
Older Americans make up a growing percentage of the U.S. population and nearly 40 million are 65 years or older [1]. There is an increased chance of heart disease, stroke, diabetes, and oral cancer for older adults who have poor oral health [2].A regular oral hygiene regimen may be an efficient way to reduce the dental problems associated with aging [3].Achieving optimal oral health outcomes for older adults may be achieved by educating older adults about oral health, understanding patients' preferences relating to oral hygiene, and encouraging oral health research among clinicians.
Poor oral hygiene can be detrimental to the oral health status of older Veterans in long term settings [4]. Nurses as caregivers must recognize the oral health needs of the older Veteran. To address this issue of poor oral hygiene, it is important to assess the current oral hygiene status of older Veterans as little is known about their oral hygiene regimens. A nurse determining and then addressing the individualized dental needs of older Veterans is a crucial component in a plan of care. It is unknown what role nurses play in assisting older Veterans with their oral hygiene. Such information may be critical to the success of initiatives to improve oral hygiene for older Veterans in long term care settings. The purpose of this paper is to describe a nurse initiative oral hygiene program for older Veterans.

Specific Aims for the Nurse Initiative Oral Hygiene Program include the following To assess current oral hygiene regimens of older adults
In order to assess oral hygiene regimens, the Assessment of Current Oral Hygiene Care survey was administered to all patients on four long term care units at one VA medical center. The survey addresses current oral status, self-care ability, brushing aid and frequency, flossing, denture care, and noted difficulties with daily care [5].

To assess knowledge and barriers that nurses have in relation to providing oral care to older veterans
To address this aim, all nurses and nursing assistants from all shifts on all four long term units completed an already established employee course called Healthy Smiles for Veterans for Daily Oral Care. The major objective for this course is to provide education to caregivers on the importance of daily oral care and how it relates to the health and wellness. The content of the course includes the following: oral care basics, performing a mouth check, brushing the teeth of another person, denture care, swabbing the mouth, and managing resistive patients. The nurses and nursing assistants were asked to complete a pretest before the course and a post test after the course.
A survey developed by the author assessed the barriers that nurses and nursing assistants may face when providing oral care to older Veterans. This survey was administered to nurses and nursing assistants on all four long term care units. The survey addressed the perceptions about oral care, the reasons for perceived unpleasantness of oral care tasks, and perceived resistance from residents towards oral care.
A dental hygienist visited each of the four long term units at least one time to identify barriers that were preventing nurses from providing oral care to Veterans. The dental hygienist suggested strategies and techniques to the nurses.

Determine the effectiveness of a nurse initiated oral hygiene education program and oral hygiene care plan
To accomplish this aim, a randomized trial on four long term care units was conducted to compare the effectiveness of a nursing directed educational program and oral hygiene care plan. Four long term care units were randomly assigned to have a nurse initiated oral hygiene education program or an oral hygiene education program in addition to implementation of an oral hygiene care plan. Three nurses from each unit were asked to participate in this component of the study and nine patients from each of the units were asked to participate. Patients who did not have any cognitive impairment were targeted as they were able to give their consent to participate in the study. The three nurses from each of the units conducted an oral hygiene educational program to their selected patients that were enrolled in the study. The oral hygiene educational program consisted of the nurses discussing the following topics with each patient: common oral conditions, effective tooth brushing, mouth rinses, flossing, denture care, dry mouth, and oral swabbing. This educational component took approximately 10 minutes to complete and occurred once a week for two months. A time log and content log were filled out by each nurse to document their educational efforts. Before the education began, each nurse performed an oral assessment on each of their patients by utilizing the Oral Health Assessment Tool (OHAT) for Dental screening as results were used for baseline data. The OHAT for Dental Screening tool has eight categories associated with a score and higher scores indicate more oral health problems [6].After month 1 and month 2, the OHAT for Dental Screening tool along with the "Assessment of Current Oral Hygiene Care" survey were administered to determine if there were any changes in oral hygiene habits/regimens due to the education given by the nurses.
The oral hygiene care plan was implemented in addition to the oral hygiene education program on two of the randomly selected long term care units. The oral hygiene care plan is a tool that can be used to outline what is required to ensure that patients are receiving adequate and appropriate oral care on a daily basis [7]. The nurses were responsible for completing this care plan initially with their assigned patients to determine what oral hygiene care interventions needed to occur. The nurses left a copy of this care plan in the patient's room so that the interventions could be carried out on a daily basis either by the patient, caregiver or nurse/nursing assistant that may be caring for the patient.
The OHAT for Dental Screening tool was implemented prior to oral hygiene care plan and oral hygiene education program and the results were used for baseline data. After month 1 and month 2, the OHAT for Dental Screening tool and the Assessment of Current Oral Hygiene Care survey were administered to the participants on these two units to determine if there were any changes in oral hygiene habits/regimens due to the education program and implementation of the oral hygiene care plan.

Implications
The ultimate goal of this initiative is to promote oral hygiene in order to reduce morbidity or mortality rates associated with poor oral hygiene among older Veterans. Findings from the major components of the initiative provided a snap shot picture of the current oral hygiene practices of Veterans and shed light on the barriers associated with providing oral care for both Veterans and nursing personnel. Dental hygienists served as an important resource for this program as they were able to instruct nurses on how to improve their oral hygiene care with patients. The educational component of the project allowed for both nurses and Veterans to become more confident and knowledgeable about oral care. The aggregate results from this initiative will be presented to nurses, supervisors, and hospital administration. The project has the potential for being replicated at other VA medical centers with various populations across care settings.