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Turkish Nurses’ Attitudes and Practices
Regarding Oral Care
Hüsna Özveren, PhD, MSc, and Dilek Özden, PhD, MSc
Hüsna Özveren, PhD, MSc, is an Assistant Professor at the Nursing Department, Faculty of Health Sciences, Kirikkale
University, Kirikkale, Turkey, and Dilek Özden, PhD, MSc, is an Assistant Professor at the Nursing Department, Faculty of
Health Sciences, Dokuz Eylül University, Izmir, Turkey.
Search terms:
Nurse, oral care, professional
practice
Author contact:
ozverenhusna@gmail.com, with a
copy to the Editor:
journal@nanda.org
PURPOSE: This study was conducted to determine the attitudes and practices of
nurses working in intensive care units of four different hospitals regarding oral
care.
METHODS: One hundred eighty-five nurses who worked in adult intensive care
units comprised the sample of this cross-sectional descriptive study.
CONCLUSION: It can be said that intensive care nurses perform oral care without
an oral care protocol and assessment guideline, and that the methods and fre-
quency of oral care and solutions and tools used for oral care differ from one
institution to another.
IMPLICATIONS FOR NURSING PRACTICE: The results emphasized the need
for continuing training in this area.
AMAÇ: Bu aras¸tırma, dört farklı hastanede yog˘un bakım ünitelerinde çalıs¸an
hems¸irelerin ag˘ız bakımına ilis¸kin tutum ve uygulamalarını saptamak amacıyla
yapılmıs¸tır.
YÖNTEM: Kesitsel tanımlayıcı tipteki bu çalıs¸manın örneklemini yetis¸kin
yog˘un bakım ünitelerinde çalıs¸an 185 hems¸ire olus¸turmus¸tur. Verilerin
deg˘erlendirilmesinde yüzdelik dag˘ılım ve ki-kare testi kullanılmıs¸tır.
SONUÇ: Yog˘un bakım hems¸irelerinin deg˘erlendirme rehberi ve protokolü
olmadan ag˘ız bakımı yaptıg˘ı, ag˘ız bakım yöntem, sıklık, solüsyon ve araçlarının
kurumlara göre farklılık gösterdig˘i söylenebilir.
HEMS¸I
˙RELI
˙K UYGULAMALARI I
˙ÇI
˙N ÖNERI
˙LER: Sonuçlar bu alanda sürekli
eg˘itime ihtiyaç oldug˘unu vurgulamaktadır.
Oral care is an essential and integral part of the nursing
care provided to ensure cleanliness and moisture of the oral
mucosa (Abidia, 2007; Chan & Ng, 2012; Costello & Coyne,
2008; Cutler & Davis, 2005; Yeung & Chui, 2010). Patients
staying in intensive care units (ICUs) are exposed to oral
health problems more than patients staying in other clinics
due to reasons such as immune suppression, intubation,
high-dose drug and oxygen therapy, not being able to take
liquid or food orally, reduction in saliva secretion, and not
being able to perform oral care themselves (Chan & Ng,
2012; Cutler & Davis, 2005; Kozier, Berman, Snyder, & Erb,
2008; McNeill, 2000; Türk, Güler, Eser, & Khorshid, 2012). In
addition, due to the presence of the endotracheal tube,
patients’ mouths remain open permanently; thus, bacteria
can easily enter the airways, and the impaired cough reflex
and mucociliary activity may lead to an increase in secre-
tion. In this case, Gram-positive bacteria forming the normal
flora of the oral mucosa are replaced by Gram-negative
bacteria, which leads to plaque formation on the tooth
surface and changes in the oral flora (Augustyn, 2007;
Berry, Davidson, Rolls, & Masters, 2007; Harris & Miller,
2000; Munro & Grap, 2004).
Changes in the oral flora increase the risk of developing
ventilator-associated pneumonia (VAP) in patients staying
in ICUs (Chan & Ng, 2012; Yeung & Chui, 2010). In the litera-
ture, it has been reported that 22.8% of patients receiving
mechanical ventilation developed VAP and that the mortal-
ity rate was between 24.0% and 50.0%. The development
of VAP increases the duration of mechanical ventilation 10
more days and the length of stay in the ICU 6.5 more days
(Augustyn, 2007; Munro & Grap, 2004; Safdar, Dezfulian,
Collard, & Saint, 2005). Therefore, it is extremely important
for nurses to provide and maintain oral care for patients
staying in ICUs in order to prevent oral health problems
and VAP (Lin, Chang, Chang, & Lou, 2011; Soh, Soh, Japar,
Raman, & Davidson, 2012). Poor oral care can deteriorate
the integrity of oral tissue and lead to halitosis, dryness of
the mouth, an increased risk of bacteremia, and respiratory
tract infections, all of which ultimately cause pain and dis-
comfort to the person (Chan & Ng, 2012; McNeill, 2000;
bs_bs_banner
163© 2014 NANDA International, Inc.
International Journal of Nursing Knowledge Volume 26, No. 4, October 2015
O’Reilly, 2003; Türk et al., 2012). The development of these
problems extends the length of stay in ICUs, and thus may
lead to increased cost and mortality rate (Cutler & Davis,
2005). Hence, nurses working in ICUs can reduce the risk of
complications and the development of VAP by conducting
regular oral assessment and implementing evidence-based
oral care (Abidia, 2007; Cutler & Davis, 2005; Feider,
Mitchell, & Bridges, 2010; Ganz et al., 2009; Katherason
et al., 2009; Rello et al., 2007).
Literature Review
Several studies reported that materials and solutions
used in oral care differ from one clinic to another (Binkley,
Furr, Carrico, & McCurren, 2004; Rello et al., 2007; Türk
et al., 2012), that nurses do not implement oral care in
accordance with recommendations based on the results
of the latest research (Ganz et al., 2009; Grap, Munro,
Ashtiani, & Bryant, 2003; Johnstone, Spence, & McClain,
2010; Stout, Goulding, & Powell, 2009), and that they lack
knowledge to assess oral care (Johnstone et al., 2010; Stout
et al., 2009; Thurgood, 1994; White, 2000). In the interna-
tional literature, there are a lot of studies conducted to
determine intensive care nurses’ knowledge, attitude, and
practices regarding oral care (Chan & Ng, 2012; Costello
& Coyne, 2008; Ganz et al., 2009; Grap et al., 2003;
Johnstone et al., 2010; Stout et al., 2009; Yeung & Chui,
2010). On the other hand, in our country, there has been
only one study conducted to determine intensive care
nurses’ practices regarding oral care (Türk et al., 2012). In
Türk et al.’s study (2012), the methods and frequency of oral
care implemented by intensive care nurses differed from
one nurse to another, and that oral care was not performed
in accordance with recommendations based on the results
of the latest research. However, they did not give any infor-
mation about nurses’ attitudes toward oral care. Thus, in
our country, there is a need for studies investigating oral
care practices and attitudes of nurses working in ICUs in
different hospitals. This study was conducted to determine
the attitudes and practices of nurses working in ICUs of four
different hospitals regarding oral care.
Method
Setting and Sample
The study was carried out in the adult ICUs of four train-
ing and university hospitals located in four provinces of
Turkey. The population of this study consisted of 230
nurses working in the adult ICUs of four training and uni-
versity hospitals that are located in four provinces in the
Central Anatolia region of Turkey between April 20, 2012
and June 20, 2012. Of these 230 nurses, 185 who agreed to
participate in the study comprised the study sample. The
participation rate was 80.43%.
Instrument
The study is a cross-sectional descriptive study. The
data were collected through a questionnaire prepared by
the researchers based on the literature (Binkley et al.,
2004; Grap et al., 2003; McNeill, 2000; Munro & Grap,
2004; O’Reilly, 2003; Rello et al., 2007; Soh et al., 2012).
The questionnaire consists of three sections: The first
section includes 11 questions to determine nurses’ age,
gender, marital status, educational level, total length of
service, the clinic they are working in, the number of
patients nurses provide care for, and the method that
nurses use at work. The second section comprises 12 ques-
tions that determine the most frequent nursing care prac-
tices performed in ICUs, daily evaluation of oral care,
performing oral care regularly, implementing oral assess-
ment guidelines and standards, methods, frequency, tools,
and solutions regarding oral care. The third section com-
prises 10 questions to determine the attitudes of nurses,
with the following possible responses: I agree, I disagree,
or I am undecided.
Data Collection
After the questionnaire was prepared, it was given to 10
nurses who were not included in the study between Decem-
ber 15, 2012 and December 21, 2012. Questions considered
incomprehensible, unclear, or badly prepared were revised,
and then the study was conducted.
Each nurse was instructed how to respond to the ques-
tions in the questionnaire and then asked to fill in the ques-
tionnaire in their clinical environment. It took approximately
20 min to fill in the questionnaire. The participating nurses
completed the questionnaire between April 20, 2012 and
June 20, 2012.
Ethical Considerations
Before the study was carried out, the written permis-
sions of the hospitals where the study was to be conducted
and the approval of the ethics committee (Decision No:
2012-01/13) were obtained.
The nurses were first told that it was entirely their own
decision whether to participate in the study, that they
should not write their names on the questionnaire, that the
data gathered in this study would only be used within the
scope of the study, and that confidentiality was definitely
ensured, and then their verbal informed consents were
obtained.
Data Analysis
The data were evaluated with the SPSS 18.00 computer
program (SPSS Inc., Chicago, IL, USA), the percentage dis-
tribution, and the chi-square test.
Turkish Nurses’ Attitudes and Practices Regarding Oral Care H. Özveren and D. Özden
164
Results
The nurses’ mean age was X = 29.42 ±6.06 years. Of the
nurses, 83.2% were female, 65.4% had undergraduate edu-
cation, 74.0% had a length of service ranging between 1 and
10 years, 33.7% worked in the ICU of an internal diseases
department, 18.4% worked in the ICU of a general surgery
department, and 78.9% had training on oral hygiene.
Nurses stated that they carried out mostly oral care
(30.8%) after intravenous catheter care (33.0%) in the ICU.
Nurses’ Knowledge and Attitudes Toward Oral Care
All of the nurses working in the ICUs of hospital B (Erciyes
University Hospital) and hospital C (Gaziosmanpas¸a Univer-
sity Hospital), 57.1% of the nurses working in hospital A
(Cumhuriyet University Hospital), and 69.4% of the nurses
working in hospital D (Ankara Dıs¸kapı Teaching Hospital)
said that they performed oral assessment. Almost all of the
nurses (98.9%) working in the intensive care clinics in all of
the four hospitals reported that they did not use oral assess-
ment guidelines (Table 1).
Of the nurses, 53.5% said that their clinics did not have
a standard oral care protocol, 41.6% said that their clinics
had an oral care protocol and they implemented it, and
4.9% reported that although there was an oral care proto-
col in their clinics they did not implement it. The statistical
evaluation revealed a statistically significant difference
between the hospitals in terms of performing oral care, oral
assessment regularly, and the implementation of oral care
protocol (p= .001) (Table 1).
Oral-Care Related Practices by Nurses
All the nurses in hospital C (100.0%), 92.9% of the
nurses in hospital A, 44.8% of the nurses in hospital B, and
86.1% of the nurses in hospital D said that they used solu-
tion for oral care, and more than half of the nurses (55.2%)
in hospital B reported that they used the toothbrushing
method. When the frequency of oral care provided by hos-
pitals was evaluated, it was found that 71.4% of the nurses
in hospital A performed oral care when necessary, 76.2% of
the nurses in hospital C three times a day, half of the nurses
(50.0%) in hospital B every 6 hr, and 38.9% of the nurses in
hospital D twice a day. The statistical evaluation revealed a
statistically significant difference between the hospitals in
terms of the methods used for oral care and of the fre-
quency of providing oral care (p= .001) (Table 2).
More than half of the nurses in all of the four hospitals
used a depressor wrapped in gauze for oral care, whereas
69.0% of the nurses in hospital B and 85.7% of the nurses
in hospital C used a sponge stick. Very few nurses said that
they used suction foam swabs for oral care (11.9%). There
was a statistically significant difference between the hospi-
tals in terms of using foam swabs, suction toothbrushes,
mouthwash, toothpaste and brushes, and suction foam
swabs for oral care (p= .001); however, the difference was
not statistically significant in terms of using a depressor
wrapped in gauze (p= .192).
Most of the nurses in all of the four hospitals used
sodium bicarbonate solution for oral care, whereas 72.4%
of the nurses in hospital B and 71.4% of the nurses in
hospital C used chlorhexidine solution. The statistical evalu-
ation revealed that there was a significant difference
between the hospitals in terms of the types of solutions
(sodium bicarbonate, chlorhexidine, distilled water, lip mois-
turizer) used for oral care (p<.05) (Table 2).
Nurses’ Perception of Oral Care
When the nurses’ responses regarding oral care given in
Table 3 were evaluated, it was determined that 76.2% of
Table 1. Distribution of How Intensive Care Nurses Perform Oral Care and How They Implement Oral Assessment
Guidelines and Protocol (n= 185)
Hospital A
(n= 70)
Hospital B
(n= 58)
Hospital C
(n= 21)
Hospital D
(n= 36) Total (n= 185) Statistical evaluationa
n%n%n%n%n%χ2;p
Oral assessment
Was done 40 57.1 58 100 21 100 25 69.4 144 77.8 χ2= 41.342; p= .001
Was not done 30 42.9 0 .0 0 .0 11 30.6 41 22.2
Oral assessment guidelines
Used 0 .0 1 1.7 0 .0 1 2.8 2 1.1 χ2= 2.188; p= .534
Not used 70 100 57 98.3 21 100 35 97.2 183 98.9
Oral care protocol
Not present 52 74.3 19 32.8 3 14.3 25 69.4 99 53.5 χ2= 66.775; p= .001
Present and used 9 12.9 39 67.7 18 85.7 11 30.6 77 41.6
Present but not used 9 12.9 0 .0 0 .0 0 .0 9 4.9
Regularly oral care
Was performed 36 51.4 58 100.0 20 95.2 25 69.4 139 75.1 χ2= 45.418; p= .001
Was not performed 34 48.6 0 .0 1 4.8 11 30.6 46 24.9
aThe chi-square test was performed.
H. Özveren and D. Özden Turkish Nurses’ Attitudes and Practices Regarding Oral Care
165
the nurses agreed with the statement “Oral care should
certainly be performed in intensive care units strictly.” Of
the nurses, 93.0% agreed with the statement “Oral care
should take precedence for patients in intensive care units”;
88.6% agreed with the statement “Standard oral care pro-
tocols should be implemented to patients staying in inten-
sive care units”; 73.5% agreed with the statement “Oral
problems and mechanical ventilator-associated pneumonia
(VAP) can be prevented when patients in intensive care
units are given oral care”; and 68.1% agreed with the state-
ment “Cleaning oral cavities is an unpleasant task”
(Table 3).
Discussion
Oral assessment is the most important step in planning
effective oral care. Good oral care starts with an appropri-
ate assessment (Binkley et al., 2004; White, 2000). In this
study, it was found that the majority of nurses (77.8%)
evaluated patients’ mouths in their clinics daily, but that
approximately half of the nurses working in ICUs of two
hospitals (A and D) did not perform oral assessment and
that the difference between the hospitals was statistically
significant (Table 1). This finding is important since it indi-
cates that there is a significant difference between the
hospitals in performing oral assessment. It is striking that
while some of the nurses stated that they evaluated
patients’ mouths in their clinics daily, almost all of them
(98.9%) said that they did not use oral assessment guide-
lines (Table 1). Several studies in the literature also report
that nurses do not use oral assessment guidelines for oral
assessment (Berry et al., 2007; Jones, Newton, & Bower,
2004; Yeung & Chui, 2010). This was due to the fact that
nurses lacked knowledge and time regarding oral assess-
ment tools, and that it was not easy to use these oral
assessment tools (Adams, 1996; Furr, Binkley, McCurren, &
Carrico, 2004).
It is important to use a standard oral care protocol
in ICUs developed by institutions themselves. When these
protocols are implemented, not only are patients given
regular and proper oral care, but also the incidence of
oral problems and VAP is minimized, differences between
nurses regarding oral care practice are eliminated, and the
quality of nursing care is improved because implementation
of the protocols prevents nurses from spending unneces-
sary time and energy (Özveren, 2010; Soh et al., 2012).
Schleder, Stott, and Lloyd (2002) stated that the use of
protocol, including toothbrushing, increased nurses’ com-
pliance with oral care, and thus reduced the incidence of
VAP.
A large number of the nurses (88.6%) who participated in
our study noted that intensive care clinics should have an
oral care protocol (Table 3). A great number of nurses
working in ICUs of hospitals B and C stated that there was an
Table 2. Practices Regarding Nurses’ Oral Care
Oral care
Hospital A
(n= 70)
Hospital B
(n= 58)
Hospital C
(n= 21)
Hospital D
(n= 36) Total (n= 185) Statistical evaluationb
n%n%n%n%n%χ2;p
Methodsa
Wiping with solution 65 92.9 26 44.8 21 100.0 31 86.1 171 92.4 χ2= 73.131; p= .001
Brushing teeth 2 2.9 32 55.2 0 .0 2 5.6 40 21.6
Just rinsing 3 4.3 0 .0 0 .0 3 8.3 15 8.1
Frequency
When necessary 50 71.4 8 13.8 4 19.0 8 22.2 70 37.8 χ2= 159.840; p= .001
Three times a day 2 2.9 7 12.1 16 76.2 9 25.0 34 18.4
Two times a day 6 8.6 11 19.0 1 4.8 14 38.9 32 17.3
Once a day 12 17.1 3 5.2 0 .0 2 5.6 17 9.2
Every 6 hr 0 .0 29 50.0 0 .0 3 8.3 32 17.3
Toolsa
A depressor wrapped in
gauze
42 60.0 35 60.3 8 38.1 24 66.7 109 58.9 χ2= 4.737; p= .192
Foam swab 14 20.0 40 69.0 18 85.7 22 61.1 94 50.8 χ2= 46.000; p= .001
Suction toothbrush 6 8.6 30 51.7 0 .0 0 .0 36 19.5 χ2= 57.591; p= .001
Mouthwash 4 5.7 19 32.8 5 23.8 3 8.3 31 16.8 χ2= 19.346; p= .001
Toothpaste and brush 8 11.4 14 24.1 1 4.8 3 11.4 26 14.1 χ2= 7.759; p= .001
Suction foam swab 9 12.9 21 36.2 3 14.3 6 16.7 39 21.0 χ2= 11.826; p= .008
Solutionsa
Sodium bicarbonate 52 74.3 31 53.4 13 61.9 32 88.9 128 69.2 χ2= 14.671; p= .002
Chlorhexidine 3 4.3 42 72.4 15 71.4 11 30.6 71 38.4 χ2= 73.44; p= .001
Moisturizing agents 4 5.7 32 55.2 10 47.6 15 41.7 61 33 χ2= 39.737; p= .001
Saline 5 7.1 4 6.9 2 9.5 9 25.0 20 10.8 χ2= 9.451; p= .024
Hydrogen peroxide 2 2.9 4 6.9 0 .0 5 13.9 11 5.9 χ2= 6.67; p= .083
aMore than one answer was marked.
bThe chi-square test was performed.
Turkish Nurses’ Attitudes and Practices Regarding Oral Care H. Özveren and D. Özden
166
oral care protocol in their hospitals and they implemented it,
whereas the nurses working in ICUs of hospitals A and D
stated that their hospitals lacked an oral care protocol. The
difference between the hospitals was found to be significant
(Table 1). In line with these findings, it can be said that while
some of the hospitals have oral care protocols, others do not
have one and that these protocols are not implemented in
ICUs by nurses. However, studies indicate that solutions,
tools, and methods used for oral care by nurses differ from
one nurse to another due to lack of evidence-based oral care
protocols in hospitals (Fitch, Munro, Glass, & Pellegrini, 1999;
Grap et al., 2003; Soh et al., 2012).
Our study demonstrated that the methods used by
nurses in oral care were not based on the latest research
evidence, that a great number of nurses (92.4%) performed
oral care by cleansing the mouth with solution, and half of
the nurses (58.9%) achieved this cleansing with a depres-
sor wrapped in gauze and the other half (50.8%) with a
foam swab, and that there was not a significant difference
between hospitals (Table 2). Although there is evidence in
the literature that toothbrushing is the best method to
remove dental plaque in ICU patients (Abidia, 2007; Berry
et al., 2007; Chan & Ng, 2012; McNeill, 2000; Pearson &
Hutton, 2002), in our study it was observed that this
method was not used much (21.6%).
Performing oral care with a depressor wrapped in gauze
is a traditional method used in clinics. In their study, Türk
et al. (2012) reported that, of the intensive care nurses,
49.5% performed oral care with a depressor wrapped in
gauze and 82.2% with foam swabs, which is in line with our
findings. In their studies, Grap et al. (2003), Binkley et al.
(2004), and Chan and Ng (2012) reported that foam swabs
were widely used for oral care in ICUs. The reason why
nurses prefer foam swabs for oral care in ICUs might be due
to the fact that foam swabs are easy to use and cheap.
However, several studies report that although foam swabs
are effective for the stimulation of mucosal tissue in the
mouth, they are ineffective in removing dental plaque
(Abidia, 2007; Pearson & Hutton, 2002; Soh et al., 2012).
Although there are several recommendations related
to the use of oral care tools and solutions in the literature,
in the hospitals and ICUs where we conducted our study,
traditional methods were still in use and there were differ-
ences between these hospitals regarding oral care prac-
tices. In this study, nurses mostly used sodium bicarbonate
solution (69.2%) for oral care, followed by chlorhexidine
solution (38.4%) (Table 2). Several other studies report
that sodium bicarbonate is an oral rinse product frequently
used in clinics (Binkley et al., 2004; Chan & Ng, 2012; Miller
& Kearney, 2001; Türk et al., 2012). These results support
the results of our study. In a study by Türk et al. (2012),
using sodium bicarbonate solution was the most common
way to provide oral care (79.2%), followed by chlorhexidine
gel use (9.9%). On the other hand, in Ganz et al.’s
study (2009), it was reported that 75.0% nurses used
chlorhexidine for oral care. In their study, Rello et al. (2007)
found that 61.0% of the healthcare workers performed oral
care with chlorhexidine solution.
It can be said that factors such as lack of material, the
availability of solutions, the hospital’s policy, and nurses’
knowledge and preferences play a role when a nurse
decides what kind of solution should be used for oral care.
How often oral care should be performed in patients in
ICUs is controversial (Abidia, 2007; Çelik, 2006; Cutler &
Davis, 2005; Jones et al., 2004; Türk et al., 2012). In some
studies (Cutler & Davis, 2005; McNeill, 2000), it is stated
that oral care should be performed in patients connected to
a mechanical ventilator every 2–4 hr or when necessary.
However, according to some other studies (Çelik, 2006;
Cutler & Davis, 2005), oral care should be performed every
4–8 hr or 12 hr. In our study too, in line with the literature,
nurses’ responses on how often oral care should be per-
formed varied from one nurse to another. While a vast
majority of nurses in hospital A said that they performed
oral care when necessary, the nurses in hospital C said that
they performed it three times a day, and there were differ-
ences between the hospitals in terms of the frequency of
performing oral care (Table 2). This might be due to the fact
Table 3. Nurses’ Statements on the Implementation of Oral Care (n= 185)
I agree I disagree I am undecided
n%n%n%
Oral care should certainly be performed in intensive care units. 141 76.2 5 2.7 39 21.1
Oral care should take high priority for patients in intensive care units. 172 93.0 2 1.1 11 5.9
Standard oral care protocols should be implemented to patients staying in
intensive care units.
164 88.6 12 6.5 9 4.9
Oral cavities are difficult to clean. 132 71.4 39 21.1 14 7.6
Cleaning oral cavities is an unpleasant task. 126 68.1 41 22.2 18 9.7
Oral care is not my job to do. 53 28.6 117 63.2 15 8.1
I did not do enough training to make oral care. 76 41.1 97 52.4 12 6.5
The mouths of most mechanical ventilated patients get worse no matter
what I do.
90 48.6 68 36.8 27 14.6
A dentist can perform oral care instead of me. 61 33.0 99 53.5 25 13.5
Oral problems and mechanical ventilator-associated pneumonia (VAP) can
be prevented when patients in intensive care units are given oral care.
136 73.5 18 9.7 31 16.8
H. Özveren and D. Özden Turkish Nurses’ Attitudes and Practices Regarding Oral Care
167
that the hospitals where the study was conducted did not
implement oral care assessment guidelines or oral care
protocols and that information on the frequency of oral
care in the literature is not clear enough or is not based on
the results of randomized trials.
Costello and Coyne (2008) reported that of the nurses,
21.0% provided oral care every 4 hr, 24.0% twice a day, and
24.0% when necessary. This finding is similar to ours. Türk
et al. (2012) reported that 44.5% of the nurses in ICUs
provided oral care fewer than four times a day.
Nurses’ attitudes toward oral care affect oral care
(Yeung & Chui, 2010). In this study, the fact that the major-
ity of nurses (76.2%) stated that oral care should definitely
be provided in the clinics (Table 3) is of importance because
it indicates that nurses believed in the necessity of oral care
and thus performed it. The vast majority of the nurses in
our study (75.1%) stated that they provided oral care regu-
larly (Table 1), which supports this finding of ours. This is
striking because it indicates that nurses’ positive attitudes
toward oral care affect their oral care practices positively.
In addition, the fact that the vast majority of the nurses
(73.5%) stated that regular oral care can prevent oral prob-
lems and VAP is something desired. In their study, Yeung
and Chui (2010) found that one of the purposes of the
nurses in providing oral care was to prevent VAP.
Almost all of the nurses in this study pointed out that
oral care should be provided for patients in ICUs in the
first place (Table 3), but it was found that it took the
second place in conducting nursing care practices. A study
performed in Hong Kong and Singapore on nurses’ oral
care practices reported that the nurses provided oral care
after fulfilling other tasks (Chan & Ng, 2012; Yeung & Chui,
2010). While several studies in the literature (Binkley et al.,
2004; Chan & Ng, 2012; Fitch et al., 1999; Grap et al., 2003;
Kite & Pearson, 1995; Rello et al., 2007) state that oral
care is often neglected, some other studies (Ganz et al.,
2009; Grap et al., 2003; Jones et al., 2004) report that
providing oral care has a priority. In a study conducted in
Turkey, it was stated that 61.3% of ICU nurses performed
oral care in the first place (Türk et al., 2012). However,
the nurses in our study did not put oral care in the first
place, which might be due to the fact that they considered
cleaning the inside of the mouth to be a difficult and
unpleasant task. Soh et al. (2012) reported that 40.2% of
the nurses considered cleaning the oral cavity to be a
difficult task.
When compared with our results, it is quite noteworthy
that the majority of nurses in our study (68.1%) considered
oral care to be an unpleasant task and that 71.4% of them
thought it was difficult to clean the inside of the mouth.
Moreover, almost a similar proportion of nurses both in
Soh et al.’s (2012) study and in our study (46.2% and
48.6%, respectively) reported that the mouth worsened in
patients connected to the mechanical ventilator no matter
what they did for oral care (Table 3). This finding is very
important since it indicates that almost half of the nurses
(48.6%) did not believe in the effectiveness of oral care.
Conclusion
This study demonstrated that ICU nurses performed oral
care without oral care assessment guidelines or an oral care
protocol, that the frequency of oral care, methods, and
solutions used for oral care varied from one hospital
to another, and that they did not use evidence-based
guidelines.
“Patients in intensive care units have the priority to
receive oral care,” “standard oral care protocols should be
implemented to patients staying in intensive care units,”
and “if patients in intensive care units receive oral care, oral
problems and mechanical ventilator associated pneumonia
decrease.” It is determined that nurses agreed with these
statements in a high rate.
In line with our study findings, it can be proposed that in
our country, education programs should be provided for
nurses to improve their knowledge, attitudes, and practices
regarding oral care, that oral care guidelines should be
prepared, used, and periodically evaluated, and that obser-
vation studies should be performed in different populations.
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