Rev. Enferm. UFSM - REUFSM
Santa Maria, RS, v. 11, e18, p. 1-17, 2021
DOI: 10.5902/2179769247245
ISSN 2179-7692
Submission: 06/18/20020 Acceptance: 09/29/2020 Publication: 02/23/2021
Original Article
Knowledge and attitudes of nursing professionals regarding oral hygiene in critically ill patients
Conhecimento e atitudes de profissionais de enfermagem sobre higiene bucal em pacientes críticos
Conocimientos y actitudes de los profesionales de enfermería sobre la higiene bucal en pacientes críticos
Adriana Maria da Silva FelixI
Isabela Di Tilia Alves do AmaralII
Rosemeire Ângela de Queiroz SoaresIII
Regina Claudia da Silva SouzaIV
I Nurse. PhD in Sciences. Professor of the Nursing course at the Faculty of Medical Sciences of Santa Casa de Sao Paulo, São Paulo, SP, Brazil. E-mail: adriana.felix@fcmsantacasasp.edu.br Orcid: http://orcid.org/0000-0002-3559-3729
II Nurse. Bachelor’s in nursing. Faculty of Medical Sciences of Santa Casa de São Paulo, SP, Brazil. E-mail: isabela.tilia@hotmail.com Orcid: http://orcid.org//0000-0002-2498-4521
III Nurse. PhD in Health Sciences. Professor of the Nursing course at the Faculty of Medical Sciences of Santa Casa de São Paulo, Sao Paulo, SP, Brazil. E-mail: roseenfh@gmail.com Orcid: http://orcid.org/0000-0002-3752-6634
IV Nurse. Master’s in nursing. School of Nursing, University of Sao Paulo, São Paulo-São Paulo, Brazil. E-mail: rclaudiasouza@uol.com.br Orcid: http://orcid.org//0000-001-6433-7700
Abstract. Objective: to compare the knowledge and attitudes of nursing professionals working in public and private hospitals on oral hygiene in critically ill patients. Method: a cross-sectional study carried out in two adult Intensive Care Units, one public and the other one private, between the period of December 2018 and January 2019, using a structured and self-administered questionnaire. Results: the knowledge rate of professionals in the public hospital was 76.6% and the attitude was 62.7%, while in the private hospital, these rates were 81.8% and 67.1%, respectively. There were significant differences regarding the existence of a protocol (p <0.006), participation in training (p <0.004), and the use of a toothbrush with soft bristles and suction (p <0.001) in the private hospital. Conclusion: the knowledge level was higher, and the attitudes toward oral hygiene were more positive among nursing professionals at the private hospital compared to the professionals at the public hospital.
Descriptors: Nursing; Health knowledge, Attitudes and practices; Oral Hygiene; Intensive Care Units; Cross-Sectional Studies
Resumo: Objetivo: comparar conhecimentos e atitudes dos profissionais de enfermagem atuantes em hospital público e privado sobre higiene bucal em pacientes críticos. Método: estudo transversal, realizado em duas Unidades de Terapia Intensiva Adulto, uma pública e outra privada no período entre dezembro de 2018 e janeiro de 2019 por meio de um questionário estruturado e autoaplicável. Resultados: a taxa de conhecimento dos profissionais do hospital público foi de 76,6% e a atitude foi de 62,7%, enquanto no hospital privado essas taxas foram de 81,8% e 67,1%, respectivamente. Houve diferença significativa quanto à existência de protocolo (p< 0,006), participação em treinamento (p< 0,004), uso de escova de dentes com cerdas macias e sucção (p< 0,001) no hospital privado. Conclusão: o nível de conhecimento foi mais elevado e as atitudes sobre higiene bucal foram mais positivas entre os profissionais de enfermagem do hospital privado em comparação com os profissionais do hospital público.
Descritores: Enfermagem; Conhecimentos, Atitudes e práticas em saúde; Higiene Bucal; Unidades de Terapia Intensiva; Estudos Transversais
Resumen: Objetivo: comparar los conocimientos y actitudes de los profesionales de enfermería que laboran en un hospital público y privado sobre higiene bucal en pacientes críticos. Método: estudio transversal, realizado en dos Unidades de Cuidados Intensivos de Adultos, una pública y otra privada, entre diciembre de 2018 y enero de 2019, mediante un cuestionario estructurado y autoadministrado. Resultados: la tasa de conocimiento de los profesionales del hospital público fue del 76,6% y la actitud del 62,7%, mientras que en el hospital privado estas tasas fueron del 81,8% y 67,1%, respectivamente. Hubo diferencia significativa con respecto a la existencia de protocolo (p <0,006), participación en entrenamiento (p <0,004), uso de cepillo de dientes con cerdas blandas y succión (p <0,001) en el hospital privado. Conclusión: el nivel de conocimiento fue mayor y las actitudes sobre higiene bucal más positivas entre los profesionales de enfermería del hospital privado en comparación con los profesionales del hospital público.
Descriptores: Enfermería; Conocimientos, Actitudes y prácticas de salud; Higiene Bucal; Unidades de Cuidados Intensivos; Estudios Transversales
Introduction
Oral hygiene (OH) is daily nursing care provided to critically ill patients which improves comfort, reduces colonization of the oropharynx by microorganisms and contributes to reducing the incidence of infection, for example, ventilator-associated pneumonia (VAP).1 National and international guides emphasized that the OH program is one of the strategies used for the prevention of VAP.1-2 The gold standard of intervention in the oral care of intubated patients includes the observation with assessment tools for oral health, the use of 0.12% chlorhexidine gluconate, and tooth brushing techniques.1
Critically ill patients depend entirely on the care provided by health professionals, and the knowledge and attitudes of these professionals directly affect the patients' recovery.3 Descriptive studies conducted in public and private hospitals, which implemented self-administered questionnaires for data collection, describe that nursing professionals present a lack of knowledge, attitudes and practices regarding OH, and that factors such as insufficient knowledge, little professional experience, training gaps, discomfort, fear of causing adverse events, the type of Intensive Care Unit (ICU) and uncooperative patients contribute to this reality.3-10
The first step in changing the attitude of nursing professionals regarding OH is to make them aware that it is not just a measure of comfort, but a strategy that also qualifies as nursing care, reduces the risk of infection and improves patient results; and that this can be achieved through evidence-based protocols, periodic training and an appropriate care structure.11 Positive attitudes were strong influencing factors in adhering to infection prevention protocols in hospitals in South Korea, followed by administrative support, types of hospitals and the security measures.12
Care quality must be prioritized by health institutions and their professionals. Regardless of whether it is public or private, the health service is expected to provide safe patient care. In this segment, nursing presents a crucial role, since it represents the largest workforce, providing individualized and full-time assistance to the patient, with the goal of administering a rapid recovery.
Researching the knowledge and attitudes regarding OH of nursing professionals who work in ICUs at public and private institutions is essential, as it allows for the identification of opportunities for improvement, developing strategies aimed at qualifying care and also fostering a culture of evidence-based practices. Thus, studies that allow shedding light on the reality of the knowledge and attitudes of professionals in health organizations regarding the practices under question, contribute to a better understanding of the impact that organizational and individual aspects have on the quality of care. Thus, the aim of this study is to compare the knowledge and attitudes of nursing professionals working in public and private hospitals on OH in critically ill patients.
Methods
The cross-sectional study was carried out in two adult ICUs from two health institutions located in the city of Sao Paulo. The ICU of the public hospital (Hospital A) had 42 beds, while the ICU of the private hospital (Hospital B) had 20 beds, with patients of clinical and surgical specialities care profiles. Data collection took place from December 2018 to January 2019. To meet the objective of the present study, a structured and self-administered questionnaire was developed based on national1 and international2 guidelines for preventing pneumonia associated with health care and scientific publications on OH.3-16 This instrument included 37 items and was organized into two parts. The first consisted of 10 items referring to sociodemographic and professional characteristics, and the second part consisted of 13 items related to knowledge and 13 items related to attitudes regarding OH, which were presented on a 4-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = agree; 4 = strongly agree).
Before application, the instrument was subjected to content validation by eight nurses specialized in Infection Prevention and Control and four nurses specialized in Intensive Care using two rounds of the Delphi technique. The content validity index (CVI) of the instrument was 0.92 and Cronbach's alpha reliability coefficient was 0.88, highlighting the validity and reliability of the instrument.17
For operational purposes, the definitions of knowledge and attitude proposed by the literature were used,14 where knowledge is the awareness of nursing professionals on OH, and attitude is the way nursing professionals think and behave in relation to OH in critically ill patients. “Good knowledge” and “good attitude” was considered to be positive responses when the rate was greater than or equal to 70% (knowledge rate = number of responses “3 = agree” and “4 = totally agree” / total responses of the knowledge questionnaire X 100; attitude rate = number of responses “3 = agree” and “4 = strongly agree” / total responses of the attitude questionnaire X 100).8
The list of potentially eligible ICU nursing professionals with their respective work shifts and functions was obtained from the units' nursing coordinator. During the study period, 146 nursing professionals worked in the ICUs. The inclusion criteria were nurses and nursing technicians who had been admitted to work at the institutions for 3 months or more, and who provided direct assistance to the patients. Professionals who had a double bond (Hospital A and B) in the same hospital complex, as well as those who were on sick leave, vacation or any leave from their work activities, were excluded.
The eligible professionals for the study were approached by one of the researchers during their shifts and in their workplaces. Upon accepting to participate in the study, the professional received the self-administered questionnaire, after which they were instructed to answer it and hand it over to the researcher. The average time to complete the questionnaire was approximately 15 minutes.
The questionnaire variables were coded and catalogued in a codebook. A database was prepared in an Excel spreadsheet (Microsoft Office 2008 for Mac), with double entry and data validation in order to identify possible typing errors. Qualitative variables were described by absolute frequencies and percentages, while quantitative variables were described by means and standard deviations, or medians and quartiles. For the comparison between the proportions of agreement and disagreement in the two types of institutions, as well as for the other qualitative variables, chi-square tests or Fisher's exact tests were used. Age was compared in groups by the Student's t-test for homogeneous variances; the other quantitative variables were compared using the non-parametric Mann-Whitney test. The analyses were performed with the aid of the SPSS program, considering a significance level of 5%.
The research was approved by the Ethics Committee of the institution of study on November 22, 2018, under the protocol No. 3033243. All the precepts of Resolution No. 466/2012 of the National Health Council on research involving human beings were observed.18 The Term of Informed consent was applied by the researcher before the professional filled out the questionnaire.
Results
Of the 146 ICU nursing professionals, 65 (44.5%) did not participate in the study for the following reasons: 18.4% refused (n = 12), 15.4% were on vacation (n = 10), 15, 4% were on leave (n = 10) and 50.8% were working at Hospitals A and B (n = 33). Of the 81 professionals (55.5%) who agreed to participate in the study, 63 were female (77.8%). The most common level of education was technical education which represented 59.2% of participants (n = 48); and regarding function, 59 participants were nursing technicians (72.8%). The work shifts were distributed homogeneously and, of the total participants, 17 (21%) cited employment in another institution (Table 1).
The existence of a protocol on OH in the sector was stated by 54.3% (n = 44) of the professionals. However, differences were observed between institutions, with a higher rate at Hospital B (p <0.006). This was also observed regarding participation in training on OH: 46.9% (n = 38) answered in the affirmative, but at Hospital B the rate was higher (p <0.004) (Table 1).
Table 1 – Distribution of sociodemographic and professional data of the study participants. São Paulo-SP, 2019. (n=81)
|
Variables |
Type of institution |
|
|
||||
|
Hospital A (n= 59) |
Hospital B (n= 22) |
Total (n= 81) |
p-value |
||||
|
n |
% |
n |
% |
n |
% |
|
|
|
Sex |
|
|
|
|
|
|
0,769* |
|
Female |
45 |
76,3 |
18 |
81,8 |
63 |
77,8 |
|
|
Male |
14 |
23,7 |
4 |
18,2 |
18 |
22,2 |
|
|
Education |
|
|
|
|
|
|
>0,99* |
|
Technical education |
34 |
57,6 |
14 |
63,6 |
48 |
59,2 |
|
|
University graduate |
13 |
22 |
4 |
18,2 |
17 |
21 |
|
|
Postgraduate |
12 |
20,4 |
4 |
18,2 |
16 |
19,7 |
|
|
Function |
|
|
|
|
|
|
0,298* |
|
Nursing assistant |
7 |
11,9 |
0 |
0 |
7 |
8,7 |
|
|
Nursing technician |
42 |
71,1 |
17 |
77,3 |
59 |
72,8 |
|
|
Nurse |
10 |
17 |
5 |
22,7 |
15 |
18,5 |
|
|
Shift work |
|
|
|
|
|
|
0,891 |
|
Morning |
21 |
35,6 |
7 |
31,8 |
28 |
34,6 |
|
|
Afternoon |
19 |
32,2 |
8 |
36,4 |
27 |
33,3 |
|
|
Night |
19 |
32,2 |
7 |
31,8 |
26 |
32,1 |
|
|
Employment in another institution? |
|
|
|
|
|
|
>0,99* |
|
Yes |
12 |
20,3 |
5 |
22,7 |
17 |
21 |
|
|
No |
47 |
79,7 |
17 |
77,3 |
64 |
79 |
|
|
OH protocol / routine†? |
|
|
|
|
|
|
<0,006* |
|
Yes |
28 |
47,4 |
16 |
72,7 |
44 |
54,3 |
|
|
No |
27 |
45,8 |
3 |
14,0 |
30 |
37 |
|
|
Uncertain |
4 |
6,8 |
3 |
14,0 |
7 |
8,7 |
|
|
OH training† |
|
|
|
|
|
|
<0,004 |
|
Yes |
22 |
37,3 |
16 |
72,7 |
38 |
46,9 |
|
|
No |
37 |
62,7 |
6 |
27,3 |
43 |
53,1 |
|
Notes: * Fisher's exact test. In the other cases, a chi-square test was used. † OH= Oral Hygiene.
The average age of the participants was 36.6 years (between 20 and 58 years), the average professional experience was 7 years (0.3 - 30) and the average time in the ICU was 6 years (0 , 3 - 25). Regarding the weekly workload, the average was 37.4 hours (30 - 48) (Table 2).
Table 2 – Mean value, standard deviation, minimum and maximum values, and the p-value of the variables age, years of experience, years of experience in ICU and weekly workload of the study participants. São Paulo-SP, 2019. (n=81)
|
Variable |
|
|
Type of institution |
|
|
|
|||||
|
Public (n= 59) |
Private (n= 22) |
Total (n= 81) |
p-value |
||||||||
|
Mean |
SD |
min-max |
Mean |
SD |
min-max |
Mean |
SD |
min-max |
|
||
|
Age (years) |
37,1 |
8,5 |
20 – 58 |
35,5 |
9,3 |
21 – 53 |
35,5 |
9,3 |
20 – 58 |
0,470* |
|
|
Years of experience |
7 |
6 |
0,3 – 30 |
7 |
7 |
0,3 – 30 |
7 |
7 |
0,3 – 30 |
0,646† |
|
|
Years of experience in ICU |
6 |
7 |
0,3 – 25 |
5 |
5 |
0,3 –18 |
5 |
5 |
0,3 – 25 |
0,392† |
|
|
Weekly workload (hours) |
37 |
3,8 |
30 – 48 |
37,6 |
4,4 |
33 – 48 |
37,6 |
4,4 |
30 – 48 |
0,880† |
|
Notes: SD: Standard Deviation; min: minimum; max: maximum; ICU= Intensive Care Unit. *Student’s t-test; †Mann-Whitney test.
Regarding the knowledge and attitudes about OH of critically ill patients, the categories "agree" and "totally agree", and "disagree" and "strongly disagree", were grouped to allow the comparison between the different institutions (Tables 3 and 4).
When analyzing the rate of positive responses regarding knowledge and attitudes about OH, it was found that the knowledge rate of professionals at Hospital A was 76.6% (588 responses “agree” and “totally agree” / 767 responses), while those at Hospital B were 81.8% (234 responses “agree” and “totally agree” / 286 responses). No statistically significant differences were identified between professionals from Hospital A and B regarding knowledge about OH (Table 3).
Regarding attitudes, at Hospital A the rate of positive responses was 62.7% (481 responses “agree” and “totally agree” / 767 responses) and at Hospital B it was 67.1% (192 responses “agree” and “Totally agree” / 286 responses). There was a statistically significant difference regarding the use of a toothbrush with soft bristles and suction, in which 15.3% (n = 9) of the participants in Hospital A and 54.5% (n = 12) of the participants in Hospital B agreed with this statement (p <0.001) (Table 4).
Table 3 – Distribution of the study participants' responses according to knowledge about OH in critically ill patients. São Paulo-SP, 2019. (n=81)
|
Affirmative |
Type of institution |
p-value |
|||||||
|
Hospital A (n= 59) |
Hospital B (n= 22) |
||||||||
|
Agree and strongly agree |
Strongly disagree and disagree |
Agree and strongly agree |
Strongly disagree and disagree |
||||||
|
n |
% |
n |
% |
n |
% |
n |
% |
||
|
1. VAP† can be prevented with strategies that include OH. |
57 |
96,6 |
2 |
3,4 |
21 |
95,5 |
1 |
4,5 |
>0,99* |
|
2. OH‡ must be performed at least once every shift. |
56 |
94,9 |
3 |
5,1 |
19 |
86,4 |
3 |
13,6 |
0,337* |
|
3. OH‡ includes brushing teeth / dentures. |
57 |
96,6 |
2 |
3,4 |
22 |
100 |
0 |
0,0 |
>0,99* |
|
4. OH‡ includes gums. |
58 |
98,3 |
1 |
1,7 |
22 |
100 |
0 |
0,0 |
>0,99* |
|
5. OH ‡ includes the tongue. |
58 |
98,3 |
1 |
1,7 |
22 |
100 |
0 |
0,0 |
>0,99* |
|
6. OH‡ includes hydration of the peribucal and buccal mucosa. |
57 |
96,6 |
2 |
3,4 |
22 |
100 |
0 |
0,0 |
>0,99* |
|
7. OH‡ includes measuring cuff pressure before the procedure. |
42 |
72,2 |
19 |
32,2 |
18 |
81,8 |
4 |
18,2 |
0,222 |
|
8. OH‡ includes measuring cuff pressure after the procedure. |
50 |
84,7 |
9 |
15,3 |
19 |
86,4 |
3 |
13,6 |
>0,99* |
|
9. OH‡ includes checking the position of the tube before the procedure. |
45 |
76,3 |
14 |
23,7 |
19 |
86,4 |
3 |
13,6 |
0,214* |
|
10. OH‡ includes measuring the position of the tube after the procedure. |
40 |
67,8 |
19 |
32,2 |
19 |
86,4 |
3 |
13,6 |
0,114 |
|
11. OH‡ includes subglottic aspiration. |
46 |
78,0 |
13 |
22 |
19 |
86,4 |
3 |
13,6 |
0,331* |
|
12. In my unit, the evaluation of the oral cavity is done up to 72 hours after admission to the ICU§. |
19 |
32,2 |
40 |
67,8 |
12 |
54,5 |
10 |
45,5 |
0,092 |
|
13. In my unit, the oral cavity is evaluated by a dental surgeon. |
3 |
5,1 |
56 |
94,9 |
0 |
0 |
22 |
100,0 |
0,565* |
Notes: * comparison with Fisher's exact test. Other comparisons were done with the chi-square test. †VAP= Ventilator-Associated Pneumonia; ‡OH= Oral Hygiene; §ICU= Intensive Care Unit
Table 4 – Distribution of the responses of the study participants (n = 81) according to attitudes about OH in critically ill patients. São Paulo-SP, 2019
|
Affirmative |
Type of institution |
|
p-value |
|||||||||||||||
|
Hospital A (n= 59) |
Hospital B (n= 22) |
|||||||||||||||||
|
Agree and strongly agree |
Strongly disagree and disagree |
Agree and strongly agree |
Strongly disagree and disagree |
|||||||||||||||
|
n |
% |
n |
% |
n |
% |
n |
% |
|||||||||||
|
1. Sometimes I don't have time to perform OH†. |
25 |
43,4 |
34 |
56,6 |
10 |
45,5 |
12 |
54,5 |
0,850 |
|||||||||
|
2. The lack of material prevents me from performing OH†. |
40 |
67,8 |
19 |
32,2 |
11 |
50 |
11 |
50 |
0,140 |
|||||||||
|
3. I feel safe to perform HB on a patient on MV‡. |
56 |
94,9 |
3 |
5,1 |
21 |
95,5 |
1 |
4,5 |
>0,99* |
|||||||||
|
4. I record the performance of OH† in the medical records. |
50 |
84,7 |
9 |
15,3 |
19 |
86,4 |
3 |
13,6 |
>0,99* |
|||||||||
|
5. I use a toothbrush with soft bristles and suction during OH†. |
9 |
15,3 |
50 |
84,7 |
12 |
54,5 |
10 |
45,5 |
<0,001 |
|||||||||
|
6. I use gauze wrapped in a spatula during OH†. |
48 |
81,4 |
11 |
18,6 |
15 |
68,2 |
7 |
31,8 |
0,236* |
|||||||||
|
7. I use 0.12% chlorhexidine gluconate during OH†. |
43 |
72,9 |
16 |
27,1 |
17 |
77,3 |
5 |
22,7 |
0,688 |
|||||||||
|
8. I hydrate the peribucal and oral mucosa after OH†. |
56 |
94,9 |
3 |
5,1 |
22 |
100 |
0 |
0,0% |
0,563* |
|||||||||
|
9. I measure the cuff pressure before OH†. |
21 |
35,6 |
38 |
64,4 |
7 |
31,8 |
15 |
68,2 |
0,822 |
|||||||||
|
10. I measure the cuff pressure after OH†. |
23 |
39 |
36 |
61 |
6 |
27,3 |
16 |
72,7 |
0,394 |
|||||||||
|
11. I check the position of the tube before OH†. |
38 |
64,4 |
21 |
35,6 |
19 |
86,4 |
3 |
13,6 |
0,054 |
|||||||||
|
12. I check the position of the tube after OH†. |
40 |
67,8 |
19 |
32,2 |
19 |
86,4 |
3 |
13,6 |
0,114 |
|||||||||
|
13. I do subglottic aspiration during OH†. |
32 |
54,2 |
27 |
45,8 |
14 |
63,6 |
8 |
36,4 |
0,217 |
|||||||||
Notes: * comparison with Fisher's exact test. Other comparisons were done with the chi-square test; †OH= OH= Oral Hygiene; ‡MV= mechanical ventilation
Discussion
There is a divergence in the literature on significant associations between demographics, professional characteristics and attitudes towards OH in critically ill patients. A previous study did not confirm this association5 and another study that described that the level of education, professional experience and training in OH are relevant factors in the nurses' attitudes.14
In this study, participants presented similar sociodemographic and professional profiles as reported in previous studies where the majority were female3,5-8,10,13-14, approximately 37 years of age5, high school education6, less than 6 years of professional experience10,14 and 4 years’ experience in the ICU9. They also recognize the importance of OH when stating that VAP can be prevented with strategies that include OH. These results are consistent with the literature on the subject.6-8,10,13-14
The execution of OH suffers the interference of individual factors, for example, the level of knowledge and time of professional experience, and organizational factors, such as the offer of training, a sufficient number of professionals and adequate inputs19. Therefore, knowing these factors help identify barriers and outline corrective strategies that can improve the knowledge, attitudes, and practice of OH in critically ill patients.
Regarding the presence of protocols on OH, there was a significant difference between the institutions, and this aspect was more affirmed by professionals from Hospital B. Research carried out in hospitals in India9 and Saudi Arabia10 pointed out that the adherence to the OH protocol was 65% on average.
Care protocols are useful in the field of nursing. It is a tool based on scientific evidence that helps to reduce variations in the care provided to the patient, providing greater satisfaction for the nursing staff, greater safety for the patient, in addition to having an educational purpose.20
With regard to participation in training on OH, there is a significant difference between institutions, with Hospital B presenting better performance than Hospital A. This finding deserves attention, as it suggests that knowledge about OH is obtained empirically, which can result in variations in care and unsafe practices.
Permanent education is a determining factor to increase the theoretical framework of professionals and adherence to good practices16. In addition, it is provided in the Resolution of the Collegiate Board (RDC) no. 36 as a strategy to reinforce patient safety practices21. Therefore, health services need to provide training that is linked to the work process, in sufficient quantity and at regular intervals to develop and maintain the competence of its employees. It is essential that healthcare professionals are aware and up to date on best practices, demonstrating to the service users that they are continuously working to ensure that high standards of care are provided.
The prevention of VAP is a common objective of professionals working in the ICU, regardless of whether the service is public or private. Therefore, they need to understand the pathophysiology of VAP and the role of preventive measures - for example, OH - in preventing the transmission of pathogenic microorganisms. Training on the prevention of this type of pneumonia can be given in partnership between professionals from the Infection Control Service, Permanent Education, ICU, and the content must be focused on the needs of the professionals. As teaching-learning strategies for this content, we suggest those that enable meaningful learning, such as problem-based learning (PBL) and realistic simulation.22
The international literature points out that the knowledge rates on OH vary from 31.8% to 97.4% 3-4,7-10,14,16, while attitudes and practices vary from 57% to 91% 4-5,8,10,14,16. In the present study, both hospitals presented adequate levels of knowledge and fragile attitudes towards OH. When compared, the rate of knowledge and self-reported attitudes by professionals at Hospital B were higher than those professionals at Hospital A.
It is noteworthy to point out the fact that even with adequate knowledge, professionals from both hospitals showed fragile attitudes, which may suggest weaknesses in the culture of patient safety in the institutions studied here. The culture of patient safety is the set of values, skills and behavioural patterns that determine the commitment of the service to the management of the health and safety of its patients through the implementation of safe practices and the reduction of incidents.21 In this context, health service managers are in a better position to induce changes in the attitudes and practices of professionals, which may contribute to the establishment of a culture of patient safety as a prerequisite for assistance.23
In this study, approximately half of the professionals at Hospital B know and perform the assessment of the oral cavity within the first 72 hours of the patient's admission to the ICU, while less than half of the participants at Hospital A know and apply this recommendation. Proper assessment of oral health and early intervention usually prevent serious complications before they can compromise therapeutic results.1 Through the nursing process, professionals are able to recognize and intervene early on changes in patients' basic human needs.
According to the recommendation guide of the National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária - ANVISA), colonization of the oral cavity of patients using mechanical ventilation by Gram-negative microorganisms tends to occur between 48 to 72 hours after intubation and, often, periodontal complications, as well as periapical and mucositis occur.1 Thus, the evaluation of the oral cavity is relevant for the care of these patients.
The presence of a dental surgeon was not considered important by the participants from either hospital, contrasting studies carried out in Ethiopia and Brazil, for which the presence of this type of professional was considered relevant by the nursing teams due to the help in the diagnosis, treatment of complications and guidance on the proper technique of OH.13-14 However, regardless of the interdisciplinary collaborative practice, one of the pillars of person-centered care, namely nurses, can and are able to take the lead in this process.24
Studies describe several barriers to the performance of OH, the most relevant being the lack of time, lack of materials,3-5,7,9,25 inadequate proportion between nurses and patients,6,8,12 lack of patient cooperation,4 training gaps,3,10 perception of the procedure as unpleasant,10,25 and fear of dislocating the endotracheal tube.9 In the present study, the lack of time and materials were the most significant in both hospitals.
As for the materials used OH, there was a significant difference between institutions regarding the use of a soft-bristled toothbrush and suction for OH. Similar to previous studies, 6,10,13 the use of this material is not yet fully implemented in services, showing that nursing professionals perform oral care that is not based on evidence.1
Regarding the registration of the procedure in the patient's medical record, the present research points out that the nursing professionals from both hospitals adopt this practice - a contrasting result as reported in the literature, in which the registration rate varied between 46% to 73.8%.6,8,26 It is noteworthy that this aspect is among the best care practices and its adoption reflects the quality of care.
In agreement with a previous study, 8 it is noted that most nursing professionals from Hospitals A and B do not implement the recommendation to evaluate the cuff before and after conducting OH, nor do they perform subglottic aspiration according to a practice strongly recommended by a national guide, 1 reinforcing the need for an evidence-based protocol and strengthening the safety culture in the studied hospitals.
This study presented limitations such as the use of a self-administered questionnaire, which, despite being considered valid and reliable by specialists, does not reflect the real circumstances in which it was answered, as the professional practice has not been evaluated. Other limitations include the comparison between institutions with different realities and also to the study design, which compromises the external validity, allowing the identification of knowledge and attitudes only in a certain time frame.
Conclusion
The nursing professionals of the studied ICUs have adequate knowledge and fragile attitudes about OH in critically ill patients. Hospital B professionals had a better rate of knowledge and attitudes when compared to Hospital A professionals.
Participation in training, the presence of an OH protocol and the use of a toothbrush with soft bristles and suction presented statistical significances between institutions, with the nursing professionals at Hospital B presenting more affirmative responses to these aspects.
It is recommended that ICUs reinforce the culture of patient safety through the implementation of guidelines based on scientific evidence regarding OH, periodic provision of permanent education programs, and provision of appropriate inputs so professionals can perform OH effectively.
References
1. Agência Nacional de Vigilância Sanitária (BR). Medidas de prevenção de infecção relacionada à assistência à saúde [Internet]. Brasília (DF): Anvisa; 2017 [acesso em 2020 abr 08]. Disponível em: https://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/item/caderno-5
2. Torres A, Niederman MS, Chastre J, Ewig S, Fernandez-Vandellos P, Handerger H, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia. Eur Respir J. 2017 Sept;50(3):1700582. doi: https://dx.doi.org/10.1183/13993003.00582-2017
3. Nagarakanti S, Avuluri J, Chava VK. Evaluation of nurse’s attitude toward the provision of oral hygiene care to hospitalized patients at two private hospitals in South India. Iran J Nurs Midwifery Res. 2019;24(6):472-74. doi: https://dx.doi.org/10.4103/ijnmr.IJNMR_39_19
4. Lin YS, Chang JC, Chang TH, Lou MF. Critical care nurses’ knowledge, attitudes and practices of oral care for patients with oral endotracheal intubation: a questionnaire survey. J Clin Nurs. 2011 Nov;20(21-22):3204-14. doi: https://doi.org/10.1111/j.1365-2702.2011.03819.x
5. Saddki N, Sani FEM, Tin-Oo MM. Oral care for intubated patients: a survey of intensive care unit nurses. Nurs Crit Care. 2017;22(2):89-98. doi: https://doi.org/10.1111/nicc.12119
6. Rodrigues SS, Caminha MFC, Ferraz MGG, Arruda MA, Kozmhinshy VMR, Guerra CARM, et al. Knowledge, attitude and practice of the nursing team regarding oral health care in intensive care units in a reference hospital of Recife, Brazil. Pesqui Bras Odontopediatria Clín Integr. 2016;16(1):129-39. doi: https://doi.org/10.4034/PBOCI.2016.161.14
7. Aboalizm SE, Kasemy ZAA. Nurse’s knowledge, attitude and practice toward mouth hygiene among critical ill patients. Int J Novel Res Healthc Nurs [Internet]. 2016 [cited 2020 Apr 10];3(3):1-15. Available from: https://www.noveltyjournals.com/issue/IJNRHN/Issue-3-September-2016-December-2016
8. Asia M, Muhammad NA, Hajra S, Wagas A, Sarwar H, et al. Knowledge, attitude and practices of nurses to oral care to hospitalized patients in services hospital Labore. Saudi J Med Pharm Sci. 2017;3(5):399-407. doi: https://doi.org/10.21276/sjmps
9. Sreenivasan VPD, Ganganna A, Rajashekaraiah PB. Awareness among intensive care nurses regarding oral care in critically ill patients. J Indian Soc Periodontol. 2018 Nov-Dec;22(6):541-45. doi: https://doi.org/10.4103/jisp.jisp_30_18
10. Alja'afreh MA, Mosleh SM, Habashneh SS. Nurses' perception and attitudes towards oral care practices for mechanically ventilated patients. Saudi Med J. 2018;39(4):379-85. doi: https://doi.org/10.15537/smj.2018.4.21749
11. Dagnew ZA, Abraham IA, Beraki GG, Tesfamariam EH, Mittler S, Tesfamichael YZ. Nurses’ attitude towards oral care and their practicing level for hospitalized patients in Orotta National Referral Hospital, Asmara-Eritrea: a cross-sectional study. BMC Nurs. 2020;19(63). doi: https://doi.org/10.1186/s12912-020-00457-3
12. Oh E, Choi JS. Factors influencing the adherence of nurses to standard precautions in South Korea hospital settings. Am J Infect Control. 2019;47(11):1346-51. doi: https://doi.org/10.1016/j.ajic.2019.05.015
13. Silva DP, Silva MS, Silva DP, Ferraz MAAL, Falcão CAM, Moura CDVS. Práticas de higiene bucal aplicadas em pacientes internados em Unidades de Terapia Intensiva. Rev Ciênc Saberes [Internet]. 2018 [acesso em 2020 maio 10];4(1):815-19. Disponível em: http://www.facema.edu.br/ojs/index.php/ReOnFacema/article/view/368/185
14. Andargie ST, Kassahun CW. Knowledge and attitude of nurses’ towards patient’s oral care at University of Gondar comprehensive specialized hospital, Northwest Ethiopia. Int J Afr Nurs Sci. 2019;11:100165. doi: https://doi.org/10.1016/j.ijans.2019.100165
15. Tanguay A, Reeves I, Lemay S, Khadra C, Gosselin E, St-Cyr-Tribble D. Survey of oral care practices in Quebec for intensive care patients receiving mechanical ventilation. Can J Crit Care Nurs [Internet]. 2018 [cited 2020 Jun 19];29(3):39-44. Available from: https://www.caccn.ca/files/CJCCN/29-3-2018%20CJCCN.pdf#page=39
16. Tembo E. Intensive care nurses’ knowledge, attitudes and practices of oral care for patients with oral endotracheal intubation [Internet]. Johannesburg: University of the Witwatersrand, Faculty of Health Sciences; 2016 [cited 2020 May 04]. Available from: https://pdfs.semanticscholar.org/f96f/3624167d593302393ce7b9da2403e0c19b82.pdf?_ga=2.101741057.1695240205.1587994223-292557316.1557689665
17. Souza AC, Alexandre NMC, Guirardello EB. Propriedades psicométricas na avaliação de instrumentos: avaliação da confiabilidade e da validade. Epidemiol Serv Saúde. 2017;26(3):649-59. doi: https://doi.org/10.5123/s1679-49742017000300022
18. CONSELHO NACIONAL DE SAÚDE. Resolução nº 466, de 12 de dezembro de 2012. Diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Brasília, DF, 2013. Disponível em: http://conselho.saude.gov.br/resolucoes/2012/Reso466.pdf. Acesso em: 30 maio 2020.
19. Ciampoli N, Bouchoucha S, Currey J, Hutchinson A. Evaluation of prevention of ventilator-associated infections in four Australian intensive care units. J Infect Prev. 2020 May;21(4):147-54. doi: 10.1177/1757177420908006
20. Sales CB, Bernardes A, Gabriel CS, Brito MFP, Moura AA, Zanetti ACB. Protocolos Operacionais Padrão na prática profissional da enfermagem: utilização, fragilidades e potencialidades. Rev Bras Enferm. 2018 Feb;71(1):126-34. doi: https://doi.org/10.1590/0034-7167-2016-0621
21. BRASIL. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada (RDC) nº 36, de 25 de julho de 2013. Institui ações para a segurança do paciente em serviços de saúde e dá outras providências. Brasília, DF: Ministério da Saúde, 2013. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2013/rdc0036_25_07_2013.html. Acesso em: 23 jul. 2020.
22. Felix AMS, Soares RAQ. Metodologias ativas no ensino de enfermagem em doenças transmissíveis. Rev Enferm UFPE On Line. 2019;13:e241816 doi: https://doi.org/10.5205/1981-8963.2019.241816
23. Andrade LEL, Lopes JM, Souza Filho MCM, Vieira Júnior RF, Farias LPC, Santos CCM, et al. Cultura de segurança do paciente em três hospitais brasileiros com diferentes tipos de gestão. Ciênc Saúde Colet. 2018 jan;23(1):161-72. doi: https://doi.org/10.1590/1413-81232018231.24392015
24. Harnagea H, Couturier Y, Shrivastava R, Girad F, Lamothe L, Bedos CP, et al. Barriers and facilitators in the integration of oral health into primary care: a scoping review. BMJ Open. 2017;7(9):e016078. doi: https://doi.org/10.1136/bmjopen-2017-016078
25. Tanguay A, LeMay S, Reeves I, Gosselin E, St-Cyr-Tribble D. Factors influencing oral care in intubated intensive care patients. Nurs Crit Care. 2019 Jul;25(1):53-60. doi: https://doi.org/10.1111/nicc.12456
26. Ashour AA. Knowledge, attitudes and practices regarding oral health and oral care among nursing staff at a mental health hospital in Taif, Saudi Arabia: a questionnaire-based study. J Adv Oral Res. 2020 May;11(1):34-44. doi: https://doi.org/10.1177/2320206820910300
Scientific Editor: Tania Solange Bosi de Souza Magnago
Associate Editor: Rhanna Emanuela Fontenele Lima de Carvalho
Corresponding author.
Adriana Maria da Silva Felix
E-mail: adriana.felix@fcmsantacasasp.edu.br
Adress: Rua Doutor Cesário Motta Júnior, 61.
CEP: 01221-020
Authorship contributions
1 – Adriana Maria da Silva Felix
Conception or design of the study / research, analysis and / or interpretation of data, final review with critical and intellectual participation in the manuscript
2 – Isabela Di Tilia Alves do Amara
Conception or design of the study / research, analysis and / or interpretation of data, final review with critical and intellectual participation in the manuscript
3 – Rosemeire Ângela de Queiroz Soares
Analysis and / or interpretation of data, final review with critical and intellectual participation in the manuscript
4 –Regina Claudia de Souza
Analysis and / or interpretation of data, final review with critical and intellectual participation in the manuscript
How to cite this article
Felix AMS, Amara IDTA, Soares RAQ, Souza RC. Knowledge and attitudes of nursing professionals regarding oral hygiene in critically ill patients. Rev. Enferm. UFSM. 2021 [Acess: year month day]; vol.11 e18: 1-17. DOI:https://doi.org/10.5902/2179769247245