Supervising Nurse Administrators Knowledge, Attitudes, and Practices related to Oral Care

Provided in Long-Term Care Facilities

Janelle Y. Urata, BA, MS Candidate, RDH, Department of Preventive Restorative Dental

Sciences, University of California San Francisco.
8030 La Mesa Blvd. #126 La Mesa, California 91942
janelleurata@gmail.com (619) 244-1561

Elizabeth T. Couch, MS, Assistant Professor, RDH, Oral Epidemiology and Dental Public
Health Preventive Restorative Dental Sciences, University of California, San Francisco.

Margaret M. Walsh, MA, MS, EdD, Professor Emerita, RDH, Oral Epidemiology and Dental
Public Health Preventive and Restorative Dental Sciences, University of California, San
Francisco.
3333 California Street, Suite 495 San Francisco, CA 94143
Margaret.walsh@ucsf.edu (415) 476-9883

No disclaimers/disclosures
Funding provided by M.S. Candidate in student research, Janelle Y. Urata.
IRB Approval Number: 14-15185
Acknowledgements: wed like to thank NADONA organization for distributing survey among
their members.

Supervising Nurse Administrators Knowledge, Attitudes, and Practices related to Oral Care
Provided in Long-Term Care Facilities

Purpose: To investigate Supervising Nurse Administrators (SNA) knowledge, attitudes, and

practices related to the role of dental professionals, and oral care provided to Long Term
Care (LTC) Facility residents using an electronic survey.

Methods: This cross-sectional study partnered with the National Association of Nursing
Administrators who forwarded the survey to all of their SNA members. The 35-item survey
assessed SNAs awareness and support of dental professionals providing care in LTC
facilities, knowledge of oral care, attitudes about the importance of oral care, oral care
practices, and guidelines used to assess oral care. The survey consisted of multiple choice,
close-ended, and Likert-type scale items.
Results: Of the 2,359 emails sent, 171 members completed the survey, for a 7% response
rate. 25% of SNAs were aware of the practice of dental hygienists in LTC facilities. The
majority of SNAs were interested in dental hygienists presenting staff oral health training,
performing oral screenings, making dental referrals, and instituting fluoride varnish
programs. Almost all SNAs correctly answered the oral health-related knowledge items,
believed oral care is an important part of general health, and regarded their LTC residents
oral health was good or fair. However, most SNAs were not very satisfied with the
quality or the way the oral care needs of their residents were met. Over half of the SNAs
reported nurses provide oral care training for staff, but only a third reported training how to
identify dental caries. More than half of SNAs reported no dentist on staff, or having on-site
dental equipment. Of those without on-site dental equipment, 77% reported they would
consider on-site oral care services.

Conclusion: This study provides insight into the practices of oral care, SNAs levels of
awareness and support for dental professionals providing services in LTC. To improve SNAs
attitudes regarding quality of residents oral health, inter-professional collaboration is
needed.

Keywords: Keywords: Directors of Nursing, Oral health, Elderly, Nursing homes, Dental
hygienist, Oral Care Practices

NDHRA priority areas:

A-2

Identify, describe and explain mechanism that promote access to oral health care.

B-2

Investigate how alternative models of dental hygiene care delivery can reduce health

care inequities.
B-5

Evaluate strategies that position and gain recognition of dental hygienists as a primary

care providers in the health care delivery system.

INTRODUCTION
Geriatric adults living in long-term care (LTC) facilities often depend on others to assist
them in daily activities and personal care needs, including oral care. 1-3 For the purpose of
this paper, oral care is defined as daily oral hygiene, denture care, periodic oral assessments
for symptoms of oral pain, signs of dry mouth and oral disease, and referral to a dental
professional for periodic mouth examination.

Oral care among residents living in LTC is essential not only to reduce the risk of oral
diseases, but also to reduce the potential for other systemic health problems and to
promote quality of life. 1, 4, 5 Studies report, however, that only 16% of those living in LTC
receive any oral care, with an average tooth brushing time of 16 seconds.3, 4 Certified
nurses assistants (CNA) have been reported to be responsible for assisting LTC residents
with activities of daily living, including bathing/oral care, dressing and feeding, while
Supervising Nursing Administrators (SNA), consisting of Directors of Nursing, Assistant
Directors of Nursing and Registered Nurses, are responsible for overseeing the CNAs. 6, 7
CNAs acknowledge the importance of oral hygiene care for patients, yet some reports
indicate that minimal oral care, if any, is being done in practice.2, 8 One study suggests that
SNAs are in a key position to supervise and support CNAs who provide oral care by
providing necessary equipment, offering training, advice, and evaluating the quality of care
being provided. 7

To help address overall care of residents, federally funded LTC requires resident evaluation
within 14 days of admission, annually and with any major changes in status, following
guidelines including the Minimum Data Set.9, 10 The MDS is a standardized, primary
screening and assessment tool of health status that forms the foundation of the
comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-

term care facility. The MDS contains items that measure physical, psychological and
psychosocial functioning 10 in various areas, including oral/dental status. Yet according to
the Agency for Healthcare Research and Quality, sections of the MDS pertaining to
oral/dental status are minimal and may tend to overlook the health of oral tissues and the
presence of xerostomia. Although this tool is used nationwide, the law and regulations do
not provide consistent directions or training in how to conduct oral assessments using the
MDS. 11 Other types of dental professionals are also licensed to provide oral care services to
residents in LTC, such as the Registered Dental Hygienist in Alternative Practice (RDHAP) in
California. Such services include dental screenings, dental cleanings, and oral health
education.

Although other dental professionals such as dental hygienists and RDHAPs are able to
provide oral care to LTC residents, little is known about their presence in LTC facilities.
Moreover, little is known about SNAs awareness and support of dental professionals in LTC,
their involvement in the oral care of LTC residents, and to what extent their responsibilities
include training, supervising, and evaluating CNAs in oral care activities. To address these
gaps, the purpose of this study was to determine among SNAs in LTC, their knowledge,
attitudes, and practices related to oral care provided to their LTC residents and the role of
dental professionals in their LTC facilities, using an electronic survey. The study research
questions were:
1. What is the level of awareness and support for dental professionals providing
services in LTC facilities?
2. What is the knowledge and attitudes of LTC SNAs related to oral care provided
to their LTC residents?
3. Who is responsible for conducting oral assessments, providing oral care
training, and providing dental care for LTC residents?

METHODS AND MATERIALS

Study Design

This descriptive, cross-sectional study used an anonymous electronic

survey to assess LTC SNAs knowledge, attitudes, and practices related to oral care provided
to their LTC residents and the role of dental professionals in their LTC facilities. The
Institutional Review Board at the University of California, San Francisco accepted this study
on January 14, 2015.

The survey was pilot tested for feasibility, acceptability and reliability with a convenience
sample of 8 SNAs, and 6 RDHAPs and was refined after feedback. Participants were
recruited for the survey through the National Association Directors of Nursing Administration
(NADONA). The Director of NADONA was contacted to explain the study and ask for help
with recruiting their members for the study. The NADONA Director agreed to forward a link
to the survey along with a study informed consent-cover letter to their members for whom
they had email addresses. The cover letter included the study purpose, risks and benefits,
and the telephone numbers and email addresses of the researchers for potential participants
to contact with any questions. Potential participants were informed they could opt out of the
survey at anytime. Informed consent was indicated when participants clicked the next
button to begin the survey. All participants who completed the survey and submitted their
email address were eligible for a drawing to receive one of four $50 Amazon gift cards
selected at random as a thank you for participating in the study. One month after sending
the original survey, all NADONA members were emailed a survey reminder in attempt to
capture non-respondents. Surveys were sent out in March and April 2015. A disclaimer on
the reminder email stated that if they had already completed the survey, to disregard the
email.

Measurements

The 35-item survey consisted of close-ended questions comprising four

different sections. The first section contained 12 questions on general demographics of SNAs

(practice setting, educational background, years worked as SNA and oral care they receive).
The second section contained 3 knowledge items related to geriatric oral care: 1 true/false
response options and 2 yes/no response options. The third section of the survey consisted
of 6 attitude items related to oral care of their residents: Four of these items were
measured on a 5-point Likert-scale ranging either from very/extremely important to not
at all important, or from excellent to poor with an additional response option of
unsure, or from strongly agree to strongly disagree. The 2 remaining attitude questions
were a multiple-choice item and a yes/no item regarding SNAs perceived importance of oral
health. The fourth section consisted of 14 practice items assessing oral health care practices
in LTC and how oral care was guided among staff (7 multiple choice items with an option to
fill in other health professionals not listed; 6 yes/no items and 1 item to denote the
estimated percentage of the LTC population who required assistance with oral care). Eight of
the survey items on knowledge, attitudes and practices related to dental professionals.
Some of these items were taken from 4 previous studies and modified to accommodate this
area of focus. 12-15

Analysis of Data

This study used Qualtrics to analyze survey responses. Results were

assessed using non-parametric measures formatted into frequency distributions to analyze

the research questions. All survey responses were analyzed using frequency distributions for
categorical variables. In analyzing 5-point Likert scale items ranging from Strongly Agree
to Strongly Disagree the bottom 2 categories and the top two categories were combined
respectively to form two new categories of Strongly Agree/Agree and Disagree/Strongly
Disagree. The same collapsing of categories was performed in analyzing 5-point Likert
scales ranging from Extremely Interested to Not Interested at all and another item
ranging from Very Important to Very Unimportant. One survey item included 6-point
Likert scale ranging from Good to Poor and Unknown.

RESULTS
A total of 171 responses were received for an overall response rate of 7% (excluding emails
that were invalid and bounced back). Most of the respondents were female, Caucasian,
between the ages of 50-59, from the southern region of the U.S, held the title of Director of
Nursing, had an educational background in registered nursing, and reported a Bachelors
Degree as their highest level of education (Table I).

Almost all respondents worked in a facility that had both private and federal funding and
focused on skilled nursing. Over half of the respondents worked in facilities where the
primary population consisted of geriatric residents 60 years and older (Table II).

Well over half of the respondents reported that their residents required supervision or
assistance with daily oral hygiene care (data not shown).

Perceptions related to dental professionals

About a quarter of SNAs reported being

aware of the preventive oral care services registered dental hygienists in alternative practice
(RDHAPs) or dental hygienists can provide in LTC facilities (Table III).

A majority of SNAs in our study who were unfamiliar with the services dental hygienists can
provide in LTC facilities were extremely interested to somewhat interested in dental
hygienists presenting oral health training for staff, performing oral health screenings and
making referrals to dentists at their facility. They also said they were interested in dental
hygienists instituting a fluoride varnish program at their LTC facility (Table III).

Knowledge Almost all SNAs knew that tooth brushing is a very important activity to be
completed on a daily basis, and that residents with dentures need an annual dental
examination. All respondents knew that residents can lose teeth, experience decay, or

become physically ill from dental disease (Table IV).

In addition, most also agreed that hair

brushing and getting dressed were very important daily activities to be completed as well
(data not shown).

Attitudes

The majority of respondents agreed that oral health is an important part of

general health and that dental care is extremely important for residents at their facility. Only
about a quarter felt that although dental care is important, it would fall below the priority of
general medical care. Slightly less than half of respondents classified the oral health of their
residents was good, while a little over a third classified it as fair. Almost half (48%)
strongly agreed/agreed that they were very satisfied with the quality of oral treatment
provided to their residents and that they were very satisfied (45%) with the way oral care
needs of residents were met at their facility (Table V).

Practices

SNAs in our study reported that the oral/nutritional status and oral dental

status sections within the Minimum Data Set were performed most often by other staff
consisting of CNAs or MDS nurse/coordinators. Slightly over half of the respondents
reported that they have a written dental plan of care for their residents dental needs beyond
daily tooth brushing, and that LTC nurses provide oral care training for their staff (Table VI).
The majority of respondents reported that this training covered the importance of oral care
90%), tooth brushing (85%), referral to a dentist (73%), identification of sores or infections
in the mouth (72%) and techniques to address barriers to oral care (69%). Yet only 32% of
respondents reported receiving training on how to identify dental cavities (data not shown).
The majority of SNAs reported no dentist on staff nor having any on-site dental equipment.
Of those who reported not having on-site dental equipment, over three quarters (77%) said
they would consider on-site mobile oral care services where a dental professional would
bring in equipment.

With regard to basic categories of activities of daily living (ADLs), over half of SNAs reported
that mouth care is combined with other ADLs and marked as completed together. Slightly
more than a third reported that mouth care is separately listed and checked off when
completed and a few reported that mouth care is not accounted for at all. Although almost
all SNAs reported that their facility conducted periodic performance evaluations for those
providing assistance with ADLs, only about half of these respondents reported that the
quality of oral care is taken into consideration as part of the performance evaluation (Table
VI).

Almost all SNAs reported that residents receive daily oral care. A little over a third reported
that residents received oral health assessments or exams twice a year; only a quarter
reported that residents received oral health assessments or exams bi-monthly. Almost a
third of SNAs reported that residents at their facility received referrals for dental evaluation
twice a year while almost half reported that residents received referrals only when there is a
dental emergency (data not shown).

DISCUSSION
In this study, we found that SNAs were largely unaware that dental hygienists could offer
oral disease prevention services in LTC facilities. However, after reading a explanation of
services dental hygienists could provide in LTC facilities, over half of respondents were
interested in dental hygienists providing staff oral health training, oral screenings, dental
referrals, dental cleanings and fluoride varnish applications for their LTC residents. These
findings are similar to those of Wintch et al. who reported that Executive Directors of LTC
facilities supported the inclusion of registered dental hygienists in their facilities. 15

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With regard to oral health-related knowledge, we found that SNAs were knowledgeable
about the relationship of oral health to general health, the need for daily tooth brushing and
annual dental exams for all residents and those with dentures.

In our study we also found that SNA respondents had positive attitudes toward the
importance of oral health for residents in LTC facilities, but nevertheless rated their
residents oral health as good or fair. These findings are consistent with those of Pyle et
al. who reported that the majority of Executive Directors had high oral health knowledge but
rated their residents oral health as either good or fair.

12

Less than half of respondents in our study agreed that they were very satisfied with the
quality of dental treatment and the way oral care needs were met in their LTC facility. These
findings are inconsistent with those of Smith et al. who reported that the majority of SNAs
in their study were satisfied with the quality of dental treatment and the way oral care
needs were met for their LTC residents. An explanation for this discrepancy could be that
their respondents reported higher on-site dental treatments provided at their facilities than
our SNA respondents.14

In terms of identifying who was responsible for conducting oral assessments, providing oral
care training, and providing dental care for LTC residents, like Smith et al., we also found
that oral/nutritional and dental status assessments were completed by the other nurses
(i.e., certified nurse assistants and MDS nurse/coordinator). We also found that only half of
the LTC facilities had a dental care plan beyond daily tooth brushing for their residents,
similar to that reported by Smith and colleagues.

Our study findings differed from Pyle et al.s findings that a majority of the Executive
Directors surveyed reported having a dentist on staff whereas less than half of the SNAs

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reported having a dentist on staff and that a majority of residents go out of facility for
dental care. This discrepancy may be explained because they surveyed Executive Directors
whereas we surveyed SNAs. Executive Directors may have an administrative focus and not
be as close to the nursing aspects of LTC facilities as SNAs who maybe be more are involved
in direct patient care. Yet, our study findings were similar to Pyle et al.s findings that most
of the Executive Directors reported that their residents went out of their facility for dental
care. 12We also found that three quarters of respondents would consider mobile oral care
services, unlike Johnson et al.s findings, more than half of their respondents reported
having no on-site dental services available yet were unsure when asked if they would
consider on-site mobile oral care services. Johnson and colleagues were unsure as to why
SNAs would oppose having on-site services as SNAs reported sufficient space available; yet
hesitate to implement such services. 13 This discrepancy could be explained by the fact that
change is difficult to adopt, despite available space. Their respondents might have been
uncomfortable with adding a new professional into the environment.

Most SNAs reported offering staff oral care training by a nurse at their facility, but only a
third reported training on how to identify dental caries. Because less than half of SNAs
reported they were satisfied with residents health and quality of care suggests a stronger
dental presence might be needed to improve the oral care of LTC residents. While the
majority of SNAs reported oral assessments were performed monthly or twice a year by
nurses, they may be overlooking dental caries due to lack of training on how to identify
dental caries.

There are several limitations to this study. First, our low response rate increases the
potential for response bias in that those who participated in the study may have been more
interested in oral health than those who did no participate. Second, our low response rate
prevents generalizing our findings to the population of SNAs who are members of NADONA.

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CONCLUSION
This study helps to provide preliminary insight into SNAs levels knowledge, attitudes and
practices of oral care in LTC facilities. Most importantly our study investigated SNAs
awareness and support for dental professionals providing services for residents in LTC. Our
findings suggest SNAs are open to innovative changes to improve residents oral health.
Participants in this study exhibited high knowledge and positive attitudes towards oral
health yet room remains to improve SNAs attitude towards satisfaction of oral care and the
way oral care needs are met. To improve the oral status of residents in LTC, interprofessional collaboration is needed.

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