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Table of Contents   
ORIGINAL RESEARCH  
Year : 2019  |  Volume : 30  |  Issue : 2  |  Page : 226-230
Oral care in cancer nursing: Practice and barriers


1 Department of Medical Surgical Nursing, Manipal College of Nursing, Mangalore, Karnataka, India
2 Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Mangalore, Karnataka, India
3 Department of Radiation Therapy and Oncology, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India

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Date of Web Publication29-May-2019
 

   Abstract 

Background: Oral health awareness and oral care are crucial aspects of oncology nursing practice. However, very few studies concentrate on the oral care of cancer patients undergoing cancer treatment and nursing practice in the Indian subcontinent scenario/situation. Most of the published studies have been conducted in the Western and European countries. Aims: This study aimed to determine the nurses' practice and barriers regarding oral care in cancer patients undergoing chemotherapy and radiation therapy. Materials and Methods: A cross-sectional descriptive survey was conducted among 158 staff nurses working in oncology-related areas from four different hospitals of Dakshina Kannada district and Udupi district of Karnataka state, India. Statistical Analysis: Descriptive and inferential statistics was used by using SPSS 16 version. Results: More than half of respondents [54 (34.2%)] did not perform oral care as a part of routine duties. Maintenance of various records, lack of manpower, and lack of standard operating procedures were major barriers in providing oral care. Documentation audit revealed that nurses recorded oral care in the chart only when order was present in the care sheet, but oral problem assessment was not recorded at all. In all four hospitals surveyed, there was no protocol specifically designed for oral care of cancer patients. Conclusion: Nurses expressed that oral care in cancer patients was one of the most ignored aspect in oncology nursing. Our result highlights the need to develop evidence-based oral care intervention protocol and motivate staff nurses to attend continuing nursing educations regularly to keep themselves abreast of the latest trends in order to render comprehensive care to the patients.

Keywords: Cancer patients, chemotherapy, oral care, practice and barriers radiation therapy, staff nurses'

How to cite this article:
Pai RR, Ongole R, Banerjee S. Oral care in cancer nursing: Practice and barriers. Indian J Dent Res 2019;30:226-30

How to cite this URL:
Pai RR, Ongole R, Banerjee S. Oral care in cancer nursing: Practice and barriers. Indian J Dent Res [serial online] 2019 [cited 2019 Jun 25];30:226-30. Available from: http://www.ijdr.in/text.asp?2019/30/2/226/259221

   Introduction Top


Chemotherapy and radiotherapy for head and neck cancers and cancers in general are known to cause various deleterious effects on the oral structures such as mucositis, candida infection, xerostomia, loss of taste sensation, radiation caries, and osteochemo/radionecrosis. These oral changes further cause pain and discomfort, difficulty in speaking, and swallowing.[1]

Oral care is essential before and during cancer treatment to prevent oral complications. Nurses have the main responsibility for providing oral care to patients with cancer. However, numerous studies have found that nurses lack the necessary knowledge and skill in oral care of cancer patients and even they lack any specific education in oral care.[2],[3]

The impact that oral dysfunction has on quality of life for patients with cancer eluciated the need for development of clear, research-based oral care protocols and enhanced education for both nursing staff and patients. It clearly is the responsibility of all registered nurses to ensure that the care and treatment they provide is based on sound evidence. However, the confusion and conflict surrounding oral care practices may complicate this. Possible clarifications for this are lack of a knowledge base which leads to a lot of confusions and uncertainties in clinical practice and gaps in specific areas of oral care.[4],[5]

Background

Nurses lack proper assessment and documentation while performing oral care of patients. About 82.4% of nurses found that oral care is not conducted as frequently as it ought to be, 55% of them identified lack of time as a difficulty, and 26.5% recognized that low staff levels hindered oral care.[5] A study conducted among staff nurses revealed that 82.1% recommended daily examination of a patient's oral cavity. However, only 65.1% said that they would examine the patients' oral cavity daily and 16.6% more often than daily.[2]

In the literature, the most commonly suggested intervention for managing oral complications of chemotherapy and radiation therapy is by providing good oral care or by using oral care protocol, assuming that nurses have adequate knowledge and skills to perform oral care correctly.[6],[7]

Providing thorough oral care can avoid life-threatening infections and provide more comfort for patients. Patients undergoing chemotherapy and radiation therapy require nurses with adequate knowledge and education in oral care and oral health assessment specific to cancer patients to care for them.[8] However, practice and barriers in relation to oral care among nurses working in oncology setting have received little research.[9]

As a result, there is a need for studies that analyse nursing practices and barriers of oral care and oral health assessments for patients receiving cancer treatment.


   Materials and Methods Top


The aims of the study were to describe nursing practices and barriers regarding oral care of cancer patients receiving chemotherapy and radiation therapy.

A descriptive cross-sectional survey was conducted between July 2013 and January 2014 among 158 oncology nurses in four preselected hospitals in Udupi and Dakshina Kannada districts, Karnataka. Inclusion criteria were registered staff nurses having at least 1 year of experience caring for cancer patients undergoing cancer treatment and consenting to participate. Nonrandom purposive sampling technique was used for sample selection.

Ethical consideration

The ethical aspects of the research were approved by the institutional review board. Ethical committee approval was obtained from all four hospitals. All nurses signed the written informed consent and were assured of confidentiality of the information collected.

Data collection and analysis

Survey consisted of demographic proforma, practice, and barrier questionnaire. Self administered anonymous questionnaires were used for this study with assurance of anonymity and confidentiality of all responses. The study instrument included demographic proforma and practice questionnaire. Information in demographic proforma was related to staff nurses' age, gender, qualification, special education, experience, and experience in oncology areas. Practice questionnaire including oral examination, oral care routines, documentation, information to patients, resources, and barriers for oral care listed possible hindering factors for oral care.

Data were analyzed using descriptive and inferential statistics (SPSS 16.0 version). Content validity of the questionnaire was established by giving the instrument to five experts from different fields such as nursing, oncology, and oral medicine departments.

In addition, nursing records of 5 patients each from 4 study settings with 20 patients' records were evaluated for the documentation and the content of oral care reports. For this purpose, 2-day nursing documentation audit was done for the five patients' records who had at least 1 day and more long stay and were undergoing cancer treatment.


   Results Top


Of the 200 nurses approached, 158 staff nurses, 8 male and 150 female, participated in this study, producing a return rate of 79%.

Demographic proforma

Most of the staff nurses [86 (54.4%)] were in the age group of 18–25 years. Majority of them [150 (94.9%)] were females. Ninety-four (59.5%) of the staff nurses had a Diploma in Nursing as their qualification, whereas there were only 14 (8.86%) graduate nurses. Amongst them, 119 (75.3%) had 1–5 years of experience and 19 (12%) had 6–10 years of experience of caring cancer patients. There were only 20 (12.7%) staff nurses having experience of more than 10 years in caring for cancer patients [Table 1].
Table 1: Sociodemographic characteristics of the staff nurses (n=158)

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Most [134 (78.5%)] of the participants were staff nurses, whereas 20 (12.7%) were working as ward in-charge [Figure 1].
Figure 1: Distribution of designation of the staff nurses

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Policy/Protocol for oral care of cancer patients

Majority of the staff nurses [109 (69%)] expressed that there is policy or protocol for general oral care in the department, whereas 137 (86.7%) of the respondents expressed that the existing protocol should be modified to be more appropriate to perform good oral care in cancer unit. All the four hospitals did not have an oral care protocol/policy specifically for cancer patients undergoing chemotherapy and radiation therapy.

Oral care practice

Oral care practice questionnaire consisted of following six major areas:

  • Oral examination: Only 33 (20.9%) responded that they performed daily oral examination. Majority [146 (92.4%)] expressed that they have examined the patient occasionally if the patient had any complaints whereas 130 (82.3%) of them reported that they have examined upon physician instructions. Fifty-four (34.2%) of the staff nurses reported that they have not done any oral examination. Majority of the staff nurses [131 (82.9%)] expressed that there have to be more frequent oral examinations in cancer units and only 47 (29%) of them were aware regarding oral assessment tools used to assess the oral cavity.
  • Documentation: Among all respondents, 120 (75.9%) expressed that they have informed physician about oral problems of the patients; among them, only 42 (26.6%) documented findings of oral changes or complications. Most [118 (74.7%)] of the staff nurses expressed that they have recorded oral care in the nursing chart.


Documentation audit report

In addition, nursing records of five patients each from four study settings were evaluated for the documentation and the content of oral care reports. For this purpose, 2-day nursing documentation audit was done for the five patients' records who had at least 1 day and more long stay and were undergoing cancer treatment.

Among the four hospitals surveyed, three hospitals were constituent hospitals under one large university with two general teaching hospitals and one superspeciality hospital. The fourth hospital was a district government hospital with university affiliation through public-private partnership.

The three hospitals under one large university were ISO certified; hence, they had uniform pattern of documentation system in nursing records as per the ISO standards. The government district hospital had a nurses' record that did not have detailed documentation regarding patient problems and other professional communications regarding problems. It did lack a uniform format of documentation for recording various nursing actions. In all hospitals surveyed, records did contain a separate nursing sheet to record the care delivered round the clock, but no record of daily monitoring of the oral cavity was found. Record of implementation of oral care procedures was charted in the nursing records only if the same had been advised in the doctor's chart.

  1. Oral care routines: Routines for oral care were followed by 107 (67.7%) of the nurses, whereas 138 (87.3%) of them expressed that oral hygiene was given as and when required. Most of the staff nurses [131 (82.9%)] informed that they only assisted the patients in performing oral care, whereas only 52 (32.91%) of them educated patients/caregiver on how to perform oral hygiene. Majority of the staff nurses [119 (75.3%)] expressed that they administered oral care only if there were problems reported by the patients; however, 88 (55.7%) of them felt that oral care is the most neglected area in nursing.
  2. Information to patients: Only 54 (34.2%) of the staff nurses educated patients about oral complications during cancer treatment, whereas 117 (74.1%) of them expressed that their knowledge is inadequate to give any information to the patients regarding oral care. A total of 119 (75.3%) of the staff nurses reported that most of the patients were raising questions regarding oral problems, whereas only 67 (42.4%) educated patients regarding preventive practices for good oral health
  3. 3. Resources for oral care: Among all respondents, 110 (68.8%) reported that their hospital provides adequate resources/supplies for the provision of oral care.


Barriers for oral care practice

When nurses were asked about the barriers for oral care; the majority of them reported that lots of writing tasks [126 (79.7%)], low staffing [121 (76.6%)], and different practices [119 (75.3%)] were the major barriers to oral care [Figure 2]. Lack of time [115 (72.8%)] was expressed as a barrier as nurses had many other priority tasks to perform, and documented oral care had least priority. Lack of knowledge [112 (70.9%)] was due to insufficient training as oral care specific to cancer nursing was not included as a component of training in the curriculum.
Figure 2: Bar diagram showing barriers for oral care practice

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   Discussion Top


When discussing regarding barriers for oral care practice, in the present study, majority of the nurses reported that lots of writing tasks [126 (79.7%)], low staffing [121 (76.6%)], and different practices [119 (75.3%)] were the major barriers to oral care. Another similar study noted that reduced staff levels meant that other areas of care had priority over oral care. Lack of time and low staff levels were specifically listed by respondents as being problems in this study.[10] Lack of materials, lack of time, uncooperative patient, and staff shortages were reported as barriers for performing oral care in acute clinical areas.[11]

Only 33 (20.9%) responded that they performed daily oral examination. Majority [146 (92.4%)] expressed that they have examined the patient only upon complaints. Fifty-four (34.2%) of the staff reported that they have never performed an oral examination. A similar study conducted among staff nurses to determine their knowledge and education revealed that most of respondents (82.1%) recommended daily examination of a patient's oral cavity. However, only 65.1% said that they would examine the patients' oral cavity daily and 16.6% more often than daily.[2] Daily examination of the oral cavity was performed by 6% of the staff nurses and 19% never performed oral examination. Eight percent of the staff nurses expressed that they examined patient daily, while 85% examined occasionally.[12]

Majority [120 (75.9%)] of the staff nurses expressed that they have informed physician about oral problems of the patients; among them, only 42 (26.6%) documented findings of oral changes or complications. Most [118 (74.7%)] of the staff nurses expressed that they have recorded oral care in the nursing chart. A parallel study stated that cancer nurses (88.2%) said that they always documented findings when there were complications or changes in the oral cavity.[2] Most of the staff nurses stated that the examinations were done regularly by the physician and that the nurses could sometimes take a brief look at the same time as the physician. About 84% of the nurses stated that they documented findings when there were changes or complications in the oral cavity, and 13% did so irrespective of specific problems.[13]

In the present study, 131 (82.9%) of nurses reported that there have to be frequent oral examinations in cancer units. Similar findings have been reported by other studies too. Nurses recommended more frequent daily examinations than what were carried out.[6] Nearly all nurses believed that oral care is not performed as often as it should be. Respondents recommended more frequent examination than was performed.[13]

Preventive practices for good oral health were informed by most of the staff nurses [67 (42.4%)] to patient/relatives. This mirrors findings from other studies also. Other study states that 46% of nurses recommended thorough oral hygiene as the most common preventive recommendation.[6] Among the nurses, 69% always informed the patient on oral complications, 49% before the start of the treatment, and 20% before each cytotoxic treatment. Preventive recommendations were performed by 63% of the staff nurses.[14]

In the present study, routines for oral care were followed by 107 (67.7%) of the nurses, whereas 138 (87.3%) of them expressed that oral hygiene was given as and when required. Most of the staff nurses [131 (82.9%)] expressed to have assisted the patients in performing oral care while only 52 (32.91%) of them educated patients/caregiver on how to perform oral hygiene. The most common preventive recommendation in oral care given to patients was a general recommendation for thorough oral hygiene (47.2%).[2] Special routines for oral care were reported by 72% of the respondents. Information on oral hygiene was reported to be given to the patients by 36% of the nurses. Most of the staff (97%) assisted patients with their oral care if necessary.[13]

Study limitations

The results of this study cannot be generalized to the broader population because a purposive nonrandom sampling technique was used and data were collected in four hospitals' cancer wards only, and a self-report technique of data collection was used.


   Conclusion Top


In the present study, most of the staff nurses expressed that there have to be more frequent oral examinations in cancer units, and only very few nurses said that they were aware of oral assessment tools used to assess the oral cavity. Many of them even expressed the need to have frequent continuing nursing education specific to cancer patient care, and this could involve input from multidisciplinary team involving dentists, radiation oncologist, and medical oncologist on how to perform oral cavity examination and recognize the signs and symptoms of oral changes. As all the four hospitals surveyed did not have any specific policy/protocol related to oral care of cancer patients, findings of this study emphasizes the need to develop a suitable evidence-based oral care protocol interventions for care of cancer patients receiving cancer treatment.

Acknowledgments

Authors wish to thank the staff nurses who participated in the study for taking their valued time and sharing their knowledge, practice, and educational disputes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Correspondence Address:
Dr. Ravikiran Ongole
Professor and HOD, Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Mangalore - 575 001, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_343_17

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