“A nursing student’s · “A nursing student’s ... • Curtis et al (2007) –prioritisation of advanced practice leaves little room for mouth care, the most basic of nursing

“A nursing student’s experience of a quality improvement project on mouth care in an acute setting”

Caitlin Griffiths

Why mouth care? - Scenario

• Inpatient receiving chemotherapy

• Last days of life

• Came to unit with a dry mouth and

bleeding lip

• Shocked and disappointed in the quality

of his care

• Mouth swabs left for him to use

• No tooth brushing since admission

Why is mouth care an issue? -

Research

• Daniel et al (2004) – educational needs in relation to oral

care, training for HCPs, patients, families and carers is

needed to increase knowledge and therefore standards

• Coleman (2005) – Need for attention to oral hygiene,

increased awareness = increased standard for oral care in

the elderly

• Forsell et al (2011) – statistical correlations between poor

oral hygiene an incidences of systemic diseases eg

pneumonia

• Curtis et al (2007) – prioritisation of advanced practice

leaves little room for mouth care, the most basic of

nursing activities. Mouth swabs are ineffective.

Rationale continued - Headlines

I, for one have seen too

much of this...

So what can we do about it?

What changes can be made to

improve mouth care? – My ideas

• Provide inpatients with a toothbrush and toothpaste

• Assess whether patient needs assistance with oral

hygiene and assist with oral hygiene if necessary

• Strictly adhere to oral regime for patients on chemo

• Educate patient, family, carers, and staff on mouth

care and its importance

• Establish collaborative working between nursing and

dental staff

• Implement oral care record chart including daily

assessment

My QI Project

• One week of observation on the ward – very

little mouth care seen

Plan

DoStudy

Act

My PlanPlan

Objective: To test a change idea

Where: On a medical ward where I am on

placement

Who: All nursing/HCA staff on shift, no

training, just introduction of change

Data collection and interpretation: I decided

to follow up all results – small scale project

Prediction: To have valuable data feedback

from staff following change

My PlanPlan

•Implementation of the “Inpatient Mouth Care Chart”Date

and

Time

Indication for

mouth care

1 = 12 hourly brush

2 = 2 hourly

moistening

3 = other indication

(please state)

Condition pre-mouth

care

1 = Dry/cracked

2 = Healthy/moist

3 = other (please

state)

Action taken

1 = Teeth/denture brush

2 = mouth care using

sponges

3= other (please state)

Evaluation post-mouth

care

1 = Moist/healthy

2 = To repeat mouth

care after (?) hours

3=other (please state)

Initials

• Implemented the chart over a period of 4 days

• Support from ward Sister – “Safety Briefings”

• Identified whether patients had a “need” for mouth

care chart based on if they had a problem identified

in their nursing admission or if they were for “all care”

• Put chart on bed clip board alongside intentional

roundings and fluid balance etc – easily visible to

staff

Do Do

Positive• I found that compliance of filling in of the

charts was very good on day one

• On day two, some charts were filled out

for some patients

• Some nursing staff/HCAs were very

receptive of the chart and filled it in well

• When used well, it prompted staff to

return to patients after two hours and

moisten the mouth

• Patients appreciated time being taken to

bushing their dentures/teeth

• Mouths did appear in healthier condition

(those patients who the chart was used

properly)

Study Study

Negative• By day three and four, the charts were

no longer being completed

• Some staff seemed disinterested by the

subject

• Some saw it as another piece of

paperwork

• Filling in an extra form was seen as time

consuming

• Comparison to the intentional rounding

chart which mentions mouth care too

• Next stage – improve and change idea

• Positive that some improvements to patient mouth care occurred

as a result of using the mouth care chart – build on this

• No cooperation = no change = no improvement

• So...

• Reduce paperwork

• Alter Intentional Rounding instead by expanding on what is

already on it

ActAct

• In order to implement a (hopefully) more effective

change, altering the Intentional Rounding is my

next stage

• Will now read:

My Plan

Mouth Care Needs:

Is mouth dry? Y/N

Is mouth sore? Y/N

12 hourly brush done today? Y/N

Mouth care given? Y/N

Treatment given? Y/N (eg, Nystatin)

Mouth moist following mouth care? Y/N

Benefits of this:

•Includes pre and post mouth care

assessment

•Tracks whether mouth care and 12

hourly brush is being done as well as

treatment

•Has to be done as part of IR – cannot

be avoided

•Not an extra paper exercise

What we have learned - Key

messages• You must be committed to making a change and must use your

time wisely

• Get support from a mentor, ward sister, academic in your

university

• At first, trying to change a small part of practice felt a bit daunting

and we thought it would be a major task

• Since working through IHI we have realised that implementing a

small change is not such a big task, but it can have excellent

benefits.

• Our aim is to show other students that it is possible to make big

improvements in health care by initiating small changes.

• These skills will enable us to become better practitioners, team

members, leaders and a greater workforce that our patients can

trust in.

REMEMBER - We are the future of

healthcare and must continually

seek to improve it.