effect of an oral health assessment education program on nurses’ knowledge and patient care...

O R A L H E A L T H A S S E S S M E N T E D U C A T I O N F O R N U R S E S I N S N F

A R T I C L E

Spec Care Dent is t 29(4 ) 2009 179©2009 Special Care Dentistry Association and Wiley Periodicals, Inc.doi: 10.1111/j.1754-4505.2009.00084.x

A B S T R A C TThis pilot intervention study measured

the impact of an oral health education

intervention on nurses’ knowledge and

patient care practices in regard to oral

assessments of institutionalized elders.

Two 1-hour education sessions were

completed over a 3-week period; a

pretest and a posttest were adminis-

tered immediately preceding the first

session and immediately following the

second session. Medical records were

reviewed prior to and after the interven-

tion to assess practices including

completeness of oral health assessment

and congruency with the Minimum

Data Set 2.0 (MDS).

Nine nurses attended the education

intervention. Retrospectively, 176

records were reviewed preintervention

and 80 postintervention. There was no

significant change in knowledge from

the pre- to posttest (p � .262).

Completeness of all oral health assess-

ment variables increased significantly

(p � .001) as did the congruency of data

between the nursing assessment (NA)

and MDS assessments (p � .002).

Providing nurses with education on

oral health assessments in skilled nurs-

ing facilities has a positive impact on

completeness of data and congruency

between the NA and the MDS.

Effect of an oral health assessment education program on nurses’ knowledgeand patient care practices in skillednursing facilities

Nancy Munoz, DCN, RD;1* Riva Touger-Decker, PhD, RD, FADA;2

Laura Byham-Gray, PhD, RD;2 Julie O’Sullivan Maillet, PhD, RD, FADA2

1Clinical Nutrition Specialist, Genesis HealthCare Corporation, New Jersey; 2University of Medicine

and Dentistry of New Jersey, School of Health Related Profession, New Jersey.

*Corresponding author e-mail: [email protected]

Spec Care Dentist 29(4): 179-185, 2009

Federal regulations mandate thatnurses have the required knowledge andcompetencies to complete an accurateand comprehensive oral health assess-ment on all patients admitted to this caresetting.8,10 The Minimum Data Set 2.0(MDS) assessment includes an oralhealth component that must be com-pleted within 14 days of admission to anSNF by a dentist, physician, or nursewith demonstrated competence.10-12

Nurses are often the first health careprovider to interact with the newlyadmitted patient, so the responsibility ofidentifying non-normal oral conditions islargely a nursing role.

In-service education aimed atimproving the competencies needed toperform adequate oral health assessmentscan impact the nurses’ performance incompleting this assessment.13,14

Knowledge can also be improved within-service education targeted at the spe-cific practice needs of nurses.13

The primary purpose of this pilotstudy was to measure the impact of anoral health education intervention onnurses’ knowledge and patient care prac-tices in regard to oral assessment ofinstitutionalized elders. Patient care prac-tices were defined as completeness of theNA and congruency between the NA and

I n t r oduc t i onOral health may be affected by a variety factors in the elderly.1 Chronic diseases,1,2 insti-tutionalization, and being homebound can negatively impact the integrity of the oralcavity.2-4 Approximately 25% of elders over the age of 65 are edentulous.3 Edentulism,dentures, and poor oral health can contribute to decreased intake of calories, macro-and micronutrients, and lead to involuntary weight loss and malnutrition.5-7

Nurses in skilled nursing facilities (SNFs) play a critical role in assessing the oralstatus of the institutionalized elderly.6 When patients are admitted to an SNF, nursesare required to conduct an admission nursing assessment (NA), which includes an oralhealth component. They evaluate oral hygiene and report all nonnormal oral healthconditions to the primary care provider.8 Accuracy and completeness of the oral healthassessment and its documentation in the medical record is essential for the delivery ofappropriate care and the timely referral of patients for dental treatment.9

KEY WORDS: oral health assess-

ment; nursing practice in skilled nursing

facilities; knowledge and practices

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180 Spec Care Dent is t 29(4 ) 2009 Ora l hea l th assessment educat ion for nurses in SNF


the documented MDS. This pilot researchstudy was designed to explore twohypotheses. First, providing nurses withan education intervention on how toconduct oral assessments would result inchange in knowledge on how to do oralhealth assessments for patients in an SNFas measured by a significant change inthe scores between the pre- and theposttest. Second, providing nurses withan education intervention on how toconduct oral health assessments wouldimprove patient care practices as itrelated to completeness of the NA andcongruency of the NA and MDS assess-ments conducted upon residents’admission to the SNF.

MethodThe University of Medicine and Dentistryof New Jersey’s Institutional ReviewBoard and the SNF’s CorporationResearch Committee approved the study.A convenience sample of nursing staff (n � 9) employed at a suburban south-ern New Jersey SNF comprised thenursing population. Inclusion criteriawere limited to licensed nurses responsi-ble for completing the NA and the MDSassessments in the participating SNF

The pilot intervention study wascomposed of two 1-hour education pro-grams. These sessions focused on how todo oral assessments of institutionalizedelders and were given to the nurses inthe SNF over a 3-week period. Educationsessions were provided to the profes-sional licensed nurses responsible forcompleting the NA and the MDS assess-ments for the patients admitted to theSNF participating in the study. Patientcare practices regarding oral healthassessment were assessed in the sameSNF via a retrospective chart review. Thechart reviews were conducted over a 2-month period immediately precedingthe intervention and for 2 months imme-diately following the intervention as wellas 1 year prior to the postinterventionperiod as a way of accounting for sea-sonal differences. The sample of chartswas a convenience sample of all medicalrecords of elders admitted to the facilitywho met the inclusion criteria. Inclusion

criteria were limited to medical recordsof patients older than 65 years, whichhad both a nursing and an MDS assess-ment in the chart. Charts were reviewedsequentially for admission data goingback until a sufficient number of chartswere reviewed. The Arvidson-Bufanoet al.’s study was used as a model.14 Inthat study, 18 nurses from three facilitiesassessed 50 patients. Based on thenumber of admissions in the facilitywhere our study was conducted, it wasdetermined that the data collectionperiod would have to be at least 2 months in order to have at least 50 charts for each data collection period.Due to the short period (2 months foreach period), all admissions werereviewed for inclusion in the study. Theinformation collected as part of thisstudy was preliminary data. No poweranalysis was done.

To examine patient care practices, themedical records were reviewed for com-pleteness of the NA, congruency of theNA and MDS assessment, the ResidentAssessment Protocol (RAP) summary,and completion of all variables related tothe completion of the NA and the MDSassessments. For all patients admitted toSNFs that receive Medicare benefits, theCenter for Medicare and MedicaidServices requires the completion of acomprehensive assessment. The MDS isthe assessment tool used to gather infor-mation on a patient’s functionalcapabilities and to help identify healthproblems. The NA used in this study isthe assessment form designed by the SNFCorporation and used in all the SNFsowned by this company. Congruency wasdefined as 100% agreement between theconditions selected on the NA, MDS, andRAP summary.

The education intervention wasdesigned by the principal investigator(PI) in conjunction with an expertreview panel of two dental school facultymembers trained in nutrition and oralassessment. The intervention addressedthe nursing processes and documenta-tion of the oral health assessmentexamination (Table 1). The sessions werediscussion-based seminars that incorpo-rated a lecture, viewing of a CD-ROM on

oral health assessment of adults, andhands-on practice sessions. Policies andregulations associated with the conductof the examination, reasons for theexamination, and the components of thenursing and MDS assessments along withthe care plan were reviewed. The educa-tion intervention was delivered by twodental school faculties who are registereddietitians trained in oral health assess-ment. These individuals were selected asthey are trained in and teach oral healthassessment to nondental professionals.To assess change in knowledge, a 15-itempretest was given immediately prior tosession one and a 15-item posttest weregiven at the end of session two by the PI.The pre- and posttest questions weredeveloped to address the conditions out-lined in the NA and MDS assessments.They were subject to content validity byexperts in oral heath assessment for non-dental professionals. The pre- andposttest contained the same questionsbut in different order.

To analyze the change in practice,pre- and postintervention practices datawere collected for all residents admittedfor the 2 months preceding and 2 monthsfollowing the education program.Documentation of the dental section ofthe admission NA, section L of the MDS,the RAP summary, and “proceed careplan” were collected (Figure 1).

Ana lyse sMeasurable outcomes for this pilot studyincluded change in knowledge as meas-ured by change from pre- to posttestscore, as well as completeness of the NAassessment, congruency between the NAand the MDS, completion of RAP sum-mary, and completion of all variablesrelated to nursing practice for complet-ing the NA and MDS assessments. Theparameters evaluated from the NA andMDS assessments are described in Table 2.Completeness of the NA was measuredas either 100% complete (yes) or notcomplete (no). A complete NA includedevaluation of dentures in mouth (partialupper and/or lower dentures, full upperand/or lower dentures), condition ofteeth, and color of gingiva. The condition

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of the teeth and gingiva were based on the factors in the MDS and NA(healthy, decayed, broken, or missingteeth, gingiva pink or red). The NA was considered congruent with the MDS if all areas checked on the NA were congruent with a correspondentcondition in the MDS. If there was not100% congruency, it was marked asbeing incongruent.

The RAP summary and the care plancomponent of the assessment were evalu-ated for the presence of a check mark inthe RAP problem area of its summaryand a statement of justification for pro-ceeding or not proceeding to develop acare plan. If the RAP summary waschecked as a “proceed to care plan,” careplan records were reviewed to see if theplan was actually written. The number of

residents with an oral care plan was com-pared to the total number that shouldhave had a care plan.

Medical records were evaluated forcompletion of all variables. This includedcompleteness of the NA, congruencybetween the NA and the MDS, comple-tion of the RAP summary including“proceed to care plan,” and compliancewith oral health care plan development.A “yes” indicated that the NA was com-pleted, there was congruency betweenthe NA and the MDS, the RAP summarywas completed, and that the section on“proceed to care plan” was addressed. Ifany of the components were not addressed,the medical record was coded as “no.”

The Statistical Package for SocialSciences (SPSS) version 13.00 softwarewas used for data entry and analysis.15

Alpha was set at p � .05. Pre- andposttest scores were used to assessknowledge. Data were described usingfrequency distributions, numbers (n) andpercents (%). Paired t-tests were used toanalyze the change in nurses’ knowledgebased on difference between the mean.Completeness of the NA, congruencybetween the NA and the MDS, complete-ness of the RAP summary, and care planswere analyzed using frequency distribu-tions. Change in completeness of allvariables related to completion of the NAand the MDS and changes in nursingpractice regarding completion of the NAand MDS assessments were analyzedusing chi-square analysis.

Resu l t sNine nurses attended both educationprograms and completed the pre- and theposttest. The mean pretest score was11.33 (out of 15.0) (SD � 1.5; range �9–14) and the posttest mean score 11.78(SD 1.02; range � 10–14) out of 15.0.Although there was an increase in scores,there was no significant change in score(p � .262) from pre- to posttest.

To evaluate nurses’ practices for com-pleting the nursing oral health and MDSassessment, a retrospective chart reviewwas conducted. Four hundred and nine-teen (n � 419) patients were admittedand readmitted during the study period.

Munoz et a l . Spec Care Dent is t 29(4 ) 2009 181


Table 1. Education intervention content.Introduction

Review importance of oral health in the elderly individuals

• Maintaining oral health in elderly individuals is essential to ensure comfort, health, and

well-being

• Poor oral health in geriatric populations can lead to life-threatening conditions, including

malnutrition and dehydration

Specific conditions resulting from poor oral hygiene

• Tooth loss, dental caries, periodontal disease, denture stomatitis, xerostomia

Regulations

Center for Medicare and Medicaid Services Regulation

• Dental condition: Per regulation, dental evaluations must be performed on all patients

Literature review

Literature review—oral care in SNF

• Research shows that the oral health status of the institutionalized elderly is poor. Studies

in the United States and other countries have demonstrated high prevalence rates of

caries, poor oral hygiene and denture care, gingival inflammation, dry mouth, bleeding

gums, and periodontal disease among nursing home elders

Oral component of the nursing (NA) and nutrition assessment

Extraoral examination

• Inspect the face and neck; look for symmetry

• Lips: Smooth, pink, moist versus dry, chapped, or red at corners

• Oral hygiene-following protocol

• Intraoral examination

• Lips: Inspect labial mucosa for consistent pink, smooth surface that is wet with saliva;

feel tissue

• Buccal mucosa: Tissue should be pink and moist with saliva. Feel for nonnormal nodules.

White homogenous line horizontally along the buccal mucosa, linea alba, is normal. White

or red patches, bleeding, hardness, ulcers are nonnormal

• Gums: Pink versus red inflamed gums

• Floor of the mouth: Bimanual palpation of the floor of the mouth may reveal nonnormal

nodules. Look for consistent color and salivary wetness from the submandibular salivary

ducts (Wharton’s ducts)

• Dentition: Observe and count number of decayed or broken teeth. How many teeth are

missing? Look at condition of artificial teeth. Do they have full or partial dentures? Are

the partial dentures and bridges removable? Do they fit properly?

• Tongue: Look for normal roughness, pink, and moist, no normal coated, smooth, patchy,

some redness

• Oral cleanliness: Look for debris, no food particles

• Oral pain

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Ninety records were excluded from theretrospective chart review: 43 recordswere excluded from the study due tomultiple admissions and readmissions tothe long-term care setting during the

study period, and an additional 47 recordswere not available for data abstraction.When a name appeared more than onceduring the same chart review period, onlythe admission record for the first admis-

sion or readmission was examined. Threehundred and twenty-nine records werereviewed during the study period, 256were included in the statistical analysis.Seventy-three records were excluded as

Figure 1. Data collected from nursing documentation.

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they did not have both an NA and anMDS as part of the record.

As shown in Table 3, a higher per-centage of NAs were completed afterproviding the education program(97.5%) compared to prior to interven-tion (92.6%). Congruency between theNA and the MDS (p � .002) improvedsignificantly following the educationintervention. Completion of all variables

also improved significantly postinterven-tion (p � .001). There was no significantdifference from pre- to posttest in thecompletion of the RAP (Table 3).

Di scus s i onThe hypothesis that an education inter-vention would improve nursing practiceswas supported by the results of this

study. Completeness of documentation ofall variables and congruency between theNA and MDS improved significantly.These data suggest that prior to the edu-cation intervention the oral healthconditions selected on the oral healthassessment were not consistently docu-mented on the MDS. As seen in Figure 1,the conditions listed on the NA are notentire compatible with the conditionslisted on the MDS, which can be a factorin the lack of congruency between thetwo assessments.

The hypothesis that providing nurseswith an education program on how toconduct oral assessments would promotechange in performing oral assessmentsfor patients in an SNF was not sup-ported. Although knowledge increasedfrom pre- to postintervention, the differ-ence was not large enough to detect asignificant statistical change. Theincrease in total mean scores suggeststhat an oral health assessment educationintervention has the potential to increaseknowledge among the nurses. A powercalculation was not conducted prior tothe study, as it was not possible to alterthe sample. This was a conveniencesample. With nine nurses, this study wasunderpowered thus reducing the chancesof showing significant changes in knowl-edge from pre- to postintervention.

Our results are similar to a study con-ducted by Arvidson-Bufano et al.14 whoexplored the impact of a 30-minute edu-cation session for nurses in SNFs on thecompletion of the oral health assessmentsection of the MDS. The purpose of theirstudy was to determine if training nurseson how to perform the oral component ofthe MDS for patients admitted to SNFimproved nurses’ accuracy for definingnonnormal oral conditions and determin-ing treatment needs for elderly patients incomparison to dental professionals.Postintervention, the congruency betweenthe nurses and the dentist accuracyincreased significantly. Similar to theArvidson-Bufano et al.’s study,14 this pilotstudy found that providing nurses with aneducation intervention could affect nurses’practices by increasing the completenessof the NA and the congruency betweenthe nursing and MDS assessments.



Table 2. Oral health conditions evaluated through the nursingassessment and the Minimum Data Set assessment.Nursing oral health assessment (12) MDS triggers (10)

Debris present: yes/no, minimum/excessiveA. Debris present in the mouth prior to going

to bed at night

Dentures in mouth: partial U/L, full U/L B. Has full or partial dentures

Condition of teeth: healthy, decayed, broken,

1–3 missing, more than 3 missing

C. Some/all natural teeth lost—does not use

partial dentures/plates

D. Broken tooth or carious teeth

Color of gums: pink, redE. Inflamed, swollen, or bleeding gums, oral

abscess or rash

F. Daily cleaning of teeth, dentures, or daily

mouth care by resident or staff

G. All of the above

Mouth: symmetrical, asymmetrical, sores

in mouth, irregular tongue/palate/floor/

throat/nose

Not addressed

Mucous membrane: pink, red, pale Not addressed

U/L � upper/lower.

Table 3. Completeness and congruency of the NA and MDS persection pre-intervention and posteducation.

Variable Preintervention (n � 176) Posteducation (n � 80)

n % n % p-Value**

Completeness of the NA 163 92.6 78 97.5 .145

Congruency between NA

and MDS 40 22.7 33 41.3 .002*

Completion of the RAP

summary 98 55.7 43 53.8 .439

Proceed to care plan 124 70.5 63 78.8 .107

Completion of all

variables (yes/no) 19 10.8 23 28.8 <.001*

NA � nursing assessment; MDS � Minimum Data Set 2.0; RAP � resident assessment

protocol summary.

All variables include completeness of the NA, congruency between the NA and the MDS,

completion of the RAP summary, and proceed to care plan.

*Statistically significant at p � .05.

**Analyses were completed using chi-square.

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Oral assessments, maintenance oforal hygiene, and provision of mouthcare are considered basic nursing inter-ventions in SNFs, where institutionalizedelderly patients have higher levels of oraldisease than the elderly people that liveindependently.16 Improvement in oralassessment of institutionalized elders canlead to early identification of oral prob-lems and earlier referral for interventionby dental professionals. Such interven-tions may prevent the impact of oralproblems on nutritional status anddietary habits. Prior research has demon-strated that older adults with oralproblems are at increased risk for weightloss, infection, and systemic diseases.17

Impaired chewing function and oral con-ditions, such as painful mucosaldisorders, xerostomia,18,19 and the painand discomfort associated with periodon-tal disease, can lead to poor foodselection, an unbalanced diet, and poormeal consumption.18,19 Prior research hasshown a positive impact on the nurses’ability to conduct and document oralassessments after an education interven-tion,14,20 thus improving the oral careprovided to institutionalized elders.

The Surgeon General’s Report onOral Health in America states that non-dental health care providers cancontribute to improving oral healthstatus by identifying oral health needsand initiating referrals to dental profes-sionals.21,22 The provision of aneducation intervention can improvepatient care practices of nondentalproviders such as nurses in the SNF set-ting and enhance their skills inperforming oral health assessments.6

S tudy l im i t a t i on s and ba r r i e r sThis study was a pilot study, whichdemonstrated positive outcomes.However, there were limitations and bar-riers worthy of recognition andconsideration in the design of futureresearch. Nursing time to attend two 1-hour education programs was a barrierto participation in this study. Differentnurses may have completed the NA and

the MDS assessment on the same patient,which may have affected the congruency.Neither the intervention nor the pre-/posttests were previously validated. Thesample size of nurses and use of only oneSNF was also a limitation that preventsgeneralization of the study findings.

Conc lu s i onsNurses have an important role in provid-ing oral care for residents in an SNF. Theprimary outcome of this study supportsthe hypothesis that providing nurses witheducation on how to perform oral healthassessments can improve nursing prac-tices for performing and documenting oralhealth assessments of elderly residents.

Imp l i ca t i on s f o r p rac t i c e and re sea rchNursing practices regarding oral assess-ment of institutionalized elders canimprove with targeted education inter-ventions delivered in the practice setting.The importance of oral assessments inidentifying oral conditions early and doc-umenting findings has been reported inprevious studies,23,24 which have demon-strated the impact of poor oral health onsystemic and nutritional well-being ofresidents in nursing homes. The resultsof our study suggest the need for qualityassurance monitoring and chart audits tocontinually evaluate completeness andcongruency of assessment practices.

Future research is needed in a largercohort of nurses and SNFs to explore thehypotheses tested in this study. A largerstudy, with 34 nurses testing at an alphaof 0.05 and 80% power in four SNFs, isplanned as a follow-up to this study. Aprospective study exploring accuracy ofthe NA of oral health is needed to deter-mine the skill level of nurses conductingthe assessments and the impact of educa-tional interventions on skills in additionto knowledge.

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