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Nurse understanding of oral health in RACFs will remain poor unless advanced oral health education and the teaching of appropriate care interventions in RACF

becomes part of the nursing undergraduate education curriculum.

Through the researchers’ earlier experiences, not related to this study, attempting to introduce nurse assisted brushing and oral health programs within the Montefiore Nursing Home have met with various levels of success. There is a wide range of competencies in the nurses’ ability to understand oral health education and their ability to carry out assisted brushing programs and use preventive products appropriately.

Prior to commencement of this study, a specific request was made to Montefiore managers to select four nurses who were competent team leaders and be able to be responsible for and manage untrained nurses to follow care plan protocols. Of the 4 nursing staff selected only 2 were registered nurses. The nurses participating in the study were very well chosen by Montefiore managers for their leadership skills and seemed to be able to absorb and understand the educational material and training.

The time/cost involved in training nurses and nurse assessment/saliva testing was an unexpected major barrier. Temporary agency staff had to be employed to cover for the 12 hours that 4 nurses would be involved in the study and not be able to perform their normal floor duties. Montefiore employs temporary agency nurses according to nurses’ award (AN120387 – Nursing Homes, &C., Nurses' (State) Award). The Award requires a minimum 4 hour working shift. As a result, RACF nurse training and testing sessions had to be in 4 hour blocks. Furthermore, agency staff costs vary depending on nurse experience and whether nurses work morning, afternoon or evening shifts with morning shifts being the least expensive. A budget and a nurse roster schedule had to be developed in order to employ nursing agency staff which needed to be booked one month ahead.

Three 4-hour training/testing blocks were scheduled in the mornings as testing protocols required morning saliva testing. One 4-hour block was allocated for

education and training and two 4 hour blocks for volunteer and resident assessments and saliva testing. Nurses in this pilot study received over 12 hours of education and practical hands on training in saliva testing and OHAT assessments before creating NSCOCPs.

Most other studies in this field usually have one 60-90 minute education session often without further follow up training. A review article investigating nurse training strategies showed training / education sessions varied between one 45 minutes to 4 hours with the majority between 1 and 3 hours. (38, 44, 87)

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Literature reviews of oral health initiatives attempt to implement oral health programs by providing special training of some nurses to become ‘Dental Champions’ or ‘Oral health promotor’ within the RACF. Most oral health program content implementation strategies focus on theoretic lectures and demonstrations of the importance of oral health through PowerPoint presentations and other visual aids, various plaque control methods including assisted brushing, and in some studies the use of high fluoride toothpaste and chlorhexidine rinses or toothpaste.(38, 48)

A literature review of studies investigating interventions to improve oral hygiene delivered by nurses or nursing assistants yielded eight moderate to strongly rated studies reporting in-service educational sessions, either alone or augmented in some way (i.e., single in-service education sessions, single in-service education sessions supplemented by a “train-the-trainer” [or pyramid] approach and educational

sessions supplemented with ongoing active involvement of a dental hygienist).(48)

In this study, nurses effectively received 12 hours of education and training on saliva testing and OHAT assessments before creating NCOCPs. This level of training is probably far greater than most other oral health studies involving nurses in oral care programs in RACFs.(47)

The training of nurses, in this study was much more advanced in both content and in the time spent in training as compared to other studies found in the literature. The 12 hours of training including both theoretical and practical components allowing nurses to have a more thorough understanding of assessments to detect oral disease, the use of a much wider range of preventive interventions needed to maintain oral health and how to implement these interventions through care plans in a RACF. The author suggests that this study shows this level of training is possible and is an effective method to deliver an oral health programs in RACFs.

Trained nurses may require special recognition within the Aged Care Industry and among dental professionals as a subspecialty in nursing due to their advanced training to formulate and implement NSCOCPs.

Additional funding to be found for agency staff to replace 2 nurses at the AIN pay rate and 2 nurses at RN rates for 3 sessions of 4 hours each totalling 48 hours. (4x4x3 = 48 hours -24 hours @ RN rate and 24 hours @ AIN rate). Furthermore, pay rates vary with additional loadings for afternoon shifts and a further loading for an evening shift.

The most senior of the four RNs, completed her training and formulated her allotted care plans but left her employment at Montefiore within 2 weeks of the start of the study. This RN did not participate in overseeing her care plans over the 10 week period of the study, nor did she complete nurse questionnaires. The three remaining

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nurses were all able to easily complete their responsibilities and those of the nurse that had left Montefiore.

Three out of four nurses completed the questionnaires. The first part of the

questionnaire sought to find out whether nurses felt they had adequate training to understand how to create care plans and whether they had enough support by the researchers and trainers to do so.

The second part of the questionnaire focused on the use of the preventive

interventions while the final part of the questionnaire enquired about assisted and unassisted brushing.

All three nurses gave positive responses (100%) to all 21 questions, except question 9 concerning hydration. Nurses during their training were advised that this study would not monitor hydration as the participants were too independent to monitor their fluid intake. Although nurses needed to be aware of the importance of hydration in general, hydration may be more suited to monitor in high care nursing where residents are less physically independent.

This pilot study examined a wider range of nurse related research questions than was examined in the Chalmers 2009 study. Although OHAT assessments were common, this study used a more complex approach to create nurse care plans by the inclusion of complex saliva testing procedures and the interpretation of

participant answers to OHIP14 and SXD-I questionnaires. The nurse assessments and testing were then verified by repeating the same tests and assessments by OHT’s.

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