Two themes and eight subthemes have emerged from the data (Table 2).
Table 2
Major themes and sub-themes.
Theme | Sub-theme |
Self-perception toward oral care | The target audience, frequency, and importance |
| Role |
| Evaluation |
Barriers and challenges | Patient-related factors |
| Oral care tools |
| Psychology of nursing assistant |
| Lack of education and training |
| Lack of team support |
Self-perception toward oral care
Diverse perspectives on oral care among ICU NAs resulted from differences in education, professional experience, site of employment, and types of illnesses. During our discussion, the following subjects predominated:
The target audience, frequency, and importance
Most NAs thought that patients with coma, inability to eat, high fever, and endotracheal intubation needed oral care; only two caregivers with experience in dental clinics reported that “everyone needs oral care.” [S10] Some NAs described their views on the frequency of oral care in the ICU,
“I think, normally, once each morning, noon, and evening is enough; there is no need to do it twice during the day.” [S2]
Certain coma patients, including those who have suffered traumatic brain injury, must passively tolerate the frequency of brushing. Patients reported that excessive oral nursing frequency impacted their sleep quality. A NA expressed that,
“Normal people do not need [four times a day], but they [unconscious patients] cannot do it. So if they do it a little more often, it would not be a big problem.” [S8]
“Patients who are awake have more questions, like, 'Why am I still doing oral care at this time of night? I am going to sleep.'"[S9]
Lack of standardized training and evidence-based programs in oral care contributes to the variation in the frequency of oral care. Each participant talked about the benefits of oral care, such as keeping the mouth clean, preventing fungal infections, and improving appetite. The benefits of oral care also include preventing rheumatoid arthritis, cerebrovascular diseases, and ventilator-associated pneumonia; however, the relation between oral hygiene and the conditions above has yet to be formally investigated. The participants often expressed like this: “[Hesitating], um... I don't know.’’ [S1]
The workload in the ICU is heavy, and limited time and insufficient human resources make oral care easily neglected, whether by patients, doctors, nurses, or NAs. Some participants stated that oral care was a simple and basic task with almost no difficulty; therefore, few considered it the top priority of their work tasks.
“Basic, special basic, [everyone] can do it, how difficult is it?” [S1]
“In the ICU, [oral care] is essential because the patients cannot take care of themselves, and basic care is essential, outside [the ward], may... If they could care for yourself, there might be no need...” [S8]
Most NAs defined their nursing tasks as temperature measurement, nebulization, oral care, and bathing. Other participants, except the NA mentioned previously, believed oral care for ICU patients was insignificant. This difference was primarily attributable to the frequent emergencies that occurred in the ICU. They cannot proactively provide oral care unrelated to the patient’s life in the ICU.
Role
NAs may come from other institutions without specialized education or corresponding certificates, and there was a clear division of labor between them and professional nursing staff. Almost all participants cannot participate in oral care for tracheal intubation patients as they mainly assisted bed nurses in fixing endotracheal intubation.
“[This]……[patients] who with endotracheal intubation are all done by teachers, and sometimes we will hold this intubation by the side, and we have never done it.” [S3]
Some participants stated that the bed nurse should complete health education on admission and discharge, and the bed doctor should assess patients' oral condition.
“Nurses rarely do it [carry out health education] with their families; bed nurses complete this task, and we rarely talk to them.”[S3]
“Evaluating patients is not what we do.”[S5]
Evaluation
Oral care assessment is crucial before entering the formal process, allowing for a targeted selection of personalized tools and mouthwashes. The most common method for evaluating oral care is to use a tongue depressor and a flashlight for bedside observation. However, there is a lack of evaluation of patients during admission and discharge, and obvious differences exist in evaluation methods and the required tools in the ICU, implying a lack of consensus on oral care assessment.
“If the patient can open their mouth, just look at the tongue coating and brush it. Is not the evaluation just a look?” [S1]
“Is there a denture in the mouth? Is there any damage to the mouth mucosa using a tongue depressor and a flashlight?” [S6]
“We do it [oral care] while evaluating; we all do it in a unified way, and all patients are the same.” [S4]
Observation is the method that is most frequently mentioned. Unexpectedly, neither the evaluation of objective instruments nor the assessment of oral care for special patients (e.g., those with swallowing disorders) were topics of discussion.
Barriers and challenges
The challenges NAs faced in oral care mainly came from four aspects: patient-related factors, oral care tools, psychological factors, and social support.
Patient-related factors
ICU patients were critically ill in a coma, and artificial airways, muscle rigidity, lockjaw, and agitation were the main reasons leading to the difficulty of NAs delivering oral care.
“Some patients are restless and will bite my cotton ball.” [S2]
“When you go to do it for him, he will bite very tightly. This kind of thing requires a tongue depressor, and he also shakes his head, so you can't control him at all... The patient is irritable, he resists you, and you cannot even use a tongue depressor because he keeps moving and cannot put it in his mouth.” [S8]
Conscious patients have a higher level of cooperation than patients with blurred consciousness. They knew more about their oral conditions than NAs and asked to take oral care alone instead of being taken care of.
“Big cotton swabs are quite easy to use... It is very easy to use for awake patients, and it will be cleaner for patients to use them themselves than for us to wipe them by hand.” [S7]
However, some participants said, “He brushes himself just to pound it casually” [S10], and there were also patients companied with anxiety due to illness, which lead to a delay in oral care.
“[The patient] stayed in the ward for a long time and had emotional problems. At that time, [The patient] did not want to do it; we did not give him [oral care] when he is in a better mood in the afternoon, do it for him again.” [S5]
Some patients decline all oral care out of concern that they will lose their dentures, while others abandon treatment voluntarily.
“He does not want to... [They] are afraid that dentures will be lost; it is safest to keep them in his mouth.” [S10]
Oral care tools
The oral care tools include sterilized oral bags, large cotton swabs, and suction tubes. Only two NAs reported using suction tubes, “Suction tubes were used on Monday.” [S7]. “I know we have them in our hospital, but not in our department.” [S1] Conscious patients were more willing to independently use a large cotton swab for oral care. Although the large cotton swab offers convenience in terms of portability, its delicate texture renders it susceptible to breakage and loss in the patient's oral cavity. The oral bag includes curved forceps, straight forceps, tongue depressors, curved discs, and cotton balls. The unpacking and placing of the bag are cumbersome, but the safety index is high.
“It may be that the preparation time is relatively long because when you open the oral bag, you have to take out the bowl, then the pliers and tongue depressor should be distributed one by one, then cotton balls should be added, and the mouthwash should be poured into it. This step is a bit long.” [S7]
“The oral bag distributed uniformly in the hospital... is not very convenient, but it is relatively safe. When I used to work, I used large cotton swabs, which were more convenient, but there were certain safety hazards because they were not sturdy and could break off.” [S4]
Furthermore, mouthwashes containing chlorhexidine and hydrogen peroxide were frequently mentioned. Several NAs reported that patients refused oral care due to the bitter taste of mouthwash.
“They [mouthwash] are very bitter; I have rinsed [chlorhexidine]; many patients don't like this taste.” [S7]
Both mouth packs and large cotton balls have their pros and cons. The foam rod may be immersed in the liquid for a long time, affecting the adhesion strength between the foam and the rod, thus increasing the potential suffocation risk, combining the two for oral care was recommended by nursing assistants. Furthermore, improving the taste of mouthwash is expected to increase patient compliance.
Psychology of nursing assistant
The primary concerns of NAs are the potential degradation of the patient's tracheal intubation and the misplacement of oral tampons. Furthermore, certain NAs have reported that unexpected sputum ejection of patients caused involuntary retraction of their bodies.
“I am afraid that some patients may spit, drool, or have cotton balls lost in their mouths.” [S6]
“[I] fear the tube being pulled out, causing the patient to suffocate.” [S2]
Lack of education and training
Oral care lacks systematic training and professional guidance. Internet, official accounts, books, and bedside education are the most important ways to acquire oral care knowledge.
Most NAs indicated that oral care 'training' had only been conducted at the time of entry; after employment, the 'training' was performed through bedside teaching. Some participants stated that the oral care procedures mentioned in books took a long time and were unsuitable for critically ill patients as only a few people can follow the book for oral care, whereas most will follow their ideas to save time for nursing tasks that they consider important. Furthermore, the ICU has heavy tasks and a lack of human resources, which urges nursing assistants to speed up the operation process of oral care.
“At the time of entry, the team leader organized everyone to participate in the training together for the oral care. In the later stage, the bedside nurse would talk and do while working, which is equivalent to teaching hand in hand.” [S9]
“It is not very standard. I will keep wiping until it is clean according to the patient's needs.” [S7]
“On the night shift, we do oral care for all patients by ourselves. Sometimes, the beds are full. If a person follows the [book] order, we cannot finish it in an hour, and thus, one should speed up the process.” [S8]
Lack of team support
Oral care is primarily the responsibility of NAs and nurses. Surprisingly, few participants mentioned that doctors pay attention to patients' oral care.
“Doctors generally do not pay attention to oral care unless there is some damage, and then they will pay attention to it.” [S11]
“Some nurses might say that a certain patient has a foul mouth and needs to be brushed with hydrogen peroxide, but the doctor... did not hear much about it.” [S8]
ICU patients may face life-threatening situations at any time. Usually, doctors focus on disease treatment, while oral care appears insignificant. Moreover, professional nurses mostly conducted health education for patients upon admission and discharge, with little mention of oral care. Doctors and NAs were not involved in this health education process.