The use of a train-the-trainer model to educate non-dental healthcare professionals for oral care

Abstract

Background: Associations between oral health and systemic conditions have been well established in recent literature. Improvements in oral hygiene have consistently shown to significantly reduce the incidence of respiratory infections, which has high morbidity and mortality rates in the frail elderly. However, the simple low-cost intervention of good oral care remains overlooked in healthcare institutions and nursing homes, due to limited awareness and knowledge. Previous efforts for oral care training of non-dental healthcare professionals have been largely sporadic, with little impact and reach to the medical fraternity.

Purpose: To overcome these challenges, we utilized a train-the-trainer model, where seven senior nurses from the long-term stay wards of a public community hospital were educated on the importance of good oral health and trained to administer a comprehensive oral care protocol in patients requiring assistance. The Oral Health Education Programme (OHEP) consisted of a full-day workshop on Common Dental Conditions, Oral Health Assessment Technique (OHAT), and oral hygiene instruction for normal and assisted tooth brushing in independent and mechanically ventilated patients respectively.

Results: Majority of the nurses felt that the training was effective and applicable to their work. The number of patients with chronic respiratory infections in the wards were reduced after commencement of OHEP.

Conclusion: This interprofessional education collaboration using the train-the-trainer model provides a standardized curriculum, while allowing autonomy for the trainers to customize modules relevant to their respective institutions. This partnership model between medical nurses and oral health professionals allows for better sustainability of the programme.

Introduction

Improvements in oral hygiene have consistently been shown to significantly reduce the incidence of aspiration pneumonia,^1,2 which has high morbidity and mortality in the frail elderly population. Good oral care is a simple, low-cost intervention often overlooked in healthcare institutions and nursing homes due to insufficient awareness of its impact on general health and inadequate knowledge of patients and their caregivers in carrying out proper oral hygiene measures.^3,4 Nursing assistants, who provide oral care in long-term care facilities, lack standardized training and face high turnover. Insufficient time, coupled with cognitive and behavioral impairments among residents, results in inconsistent and lower-priority oral care practices. ⁴

Dental professionals from the National Dental Centre Singapore designed a 1-day Oral Health Education Programme (OHEP) intending to train medical nurses about common dental conditions, recognizing oral conditions using the Oral Health Assessment Tool (OHAT), ⁵ and oral hygiene instruction (OHI) for normal and assisted tooth brushing in independent and mechanically ventilated patients respectively. This pilot project aimed to empower nurses with oral health knowledge, enabling them to implement a comprehensive oral care regimen for patients at Bright Vision Hospital (BVH), subsequently lowering the incidence of respiratory-related infection. To overcome mindset barriers and manpower challenges, we utilized a train-the-trainer model, where senior nurses in the respective institutions were educated on the importance of good oral health for maintaining general health, recognition of oral pathologies, assessment of the need for a dental referral, and familiarisation with procedures in assisted oral care. These trainers would then impart the knowledge and skills to junior staff.

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Seven nurses from four chronic sick wards in Bright Vision Hospital participated in the programme after our initial engagement with the nursing team in May 2018. Bright Vision Hospital is a step-down care community hospital with approximately 235 nurses taking care of a total of 317 patients, serving 1500 new patients per year. Pre-workshop questionnaires {adapted from Wardh ⁶ }to test participants’ oral health knowledge, their daily oral health care habits as well as their attitudes about performing oral health care in the ward were sent to the participants 2 months before the workshop in September 2018 (Figure 1).

Figure 1.

Timeline of the study.

The OHEP consisted of a full-day workshop with a total of four components namely lectures, videos, hands-on demonstrations, and clinical case discussion. Three lectures cover common dental conditions, OHAT and OHI for independent patients and patients with special medical conditions such as stroke or tracheostomy. Two videos were used to reinforce OHAT, and OHI concepts, followed by a live demonstration by the trainers, after which the nurses paired up to practise OHAT and OHI. Three simulated clinical cases related to scenarios in the ward and dental conditions were discussed. At the end of the OHEP, the nurses participated in an online survey to answer 12 statements on a 5-point Likert scale (5 = strongly agree and 1 = strongly disagree) related to their level of satisfaction with the learning programme, individual learning, and overall assessment of the programme.

Three months after the programme in December 2018, the nurses were assessed by performing OHI in the wards, and guidance was provided in overcoming certain logistical and behavioural challenges faced in the wards. All seven nurses who had attended OHEP were assigned as Oral Health Champions to coach a total of 30 nurses in four chronic sick wards over 3 months. We provided the same OHEP training materials and video to the seven oral health champions. Six months after the programme, the seven OHEP-trained nurses were assessed for their application of OHAT and OHI with a patient in the ward. The number of patients with respiratory infections in the respective wards was measured before and after the commencement of OHEP, spanning from July 2017 to September 2019 as part of the hospital audit. These infections included aspiration pneumonia, upper respiratory tract infection, and chest infection.

Results

A total of seven female nurses working in the chronic sick wards from Bright Vision Hospital (mean age 37.1 ± 5.1, range: 30-50 years) participated in OHEP. Five out of seven nurses had more than 5 years of working experience in the hospital. Based on the pre-workshop questionnaire, the nurses strongly agreed that good oral health is important for general health (Table 1). However, only one nurse answered oral health knowledge questions relating to caries and gum disease correctly. Two out of the seven nurses had received previous training about providing oral care to their patients in the ward, however, they found that the training was inadequate. Three nurses used sodium bicarbonate swab sticks to perform oral hygiene care for their patients while the other four included tooth brushing and mouth rinsing with chlorhexidine as part of their regime. All nurses disagreed that oral care was a repulsive nursing activity. The top three barriers to performing oral hygiene care in the ward were inadequate time (4/7, 57.1%), uncooperative patients (4/7, 57.1%), and lack of knowledge (2/7, 28.6%). The analysis of pre-and post-OHEP results revealed a significant improvement in participants' oral health knowledge. Knowledge on causes of dental caries was demonstrated by only two participants before the course (28.6%) but increased to five participants (71.4%) post-programme. Similarly, understanding of the causes of periodontitis improved from 0% to 42.8%. Knowledge about the cause of bleeding gums increased from 14.3% to 57.1%. Additionally, knowledge about the factors determining tooth cleanliness after brushing rose from 14.3% to 85.7%.

Table 1.

Nurses’ beliefs and attitudes about oral health.

Statement (N = 7)	Strongly agree	Agree	Disagree	Strongly disagree
I only visit the dentist when I have pain	1 (14.3%)	3 (42.8%)	2 (28.6%)	1 (14.3%)
Good oral health is important to general health	7 (100%)	0	0	0
Visiting the dentist is important even for person without teeth and/or dentures	0	6 (85.7%)	1(14.3%)	0
Tooth loss is a normal part of aging	0	3 (42.8%)	4 (57.1%)	0
Regular visits to the dentist help to prevent problems to the teeth and/or dentures	5 (71.4%)	2 (28.6%)	0	0

The participants provided feedback on the OHEP as indicated in Figure 2. The average scores of the programme learning, individual learning questions, and overall assessment were 4.6, 4.7, and 4.8 (out of 5) respectively. These score suggest the positive impact of the OHEP on their knowledge about oral health and indicate that the acquired knowledge gained can be applied to their work. Most participants found the hands-on practice and clinical case discussions useful in their nursing practice. Based on the audit in the ward, there was a reduction in the number of patients reported with respiratory infections (from a baseline median of 7.5 to 3.5 after commencement of OHEP) (Figure 3). The median over 6 time points is a better measure to show a decreasing trend over 6 months because it is more robust to outliers and extreme values than the mean. This is particularly crucial in the analysis of time series data, where rare events or anomalies may occur.

Figure 2.

Learners’ feedback on Oral Health Education Program. None of the participants rated Neutral, Disagree, Strongly Disagree to any of the statements.

Figure 3.

Number of patients reported with respiratory infections in the ward (before and after the OHEP workshop).

Dentists and oral health therapists play a crucial role in interprofessional education for frail patients in long-term care, contributing expertise to develop comprehensive care strategies that emphasize education and empowerment for the healthcare team. Frail individuals are susceptible to oral infections ⁷ which leads to systemic infections like aspiration pneumonia, impacting overall well-being and potentially increasing healthcare costs. Despite this, oral health is often overlooked in practice. ⁸ Recognizing the significance of non-dental professionals, the Institute of Medicine underscores the role of nurses in oral health knowledge dissemination. ⁹ Furthermore, nursing staff can promote effective oral care for ward patients, ensuring they receive sufficient nutrition for recovery. ¹⁰ Initiating interprofessional oral health education involves engaging hospital management, evaluating policies, and conducting a needs analysis for nursing staff. Securing management support for protected training time and replacing sodium bicarbonate swab sticks with recommended toothbrushes and end-tufted brushes are key factors contributing to the project's success. The OHEP empowers nurses, enhancing oral care and reinforcing practices during the three and 6-month site visits, when they demonstrated improved oral care practice. Junior nurses had the chance to observe and emulate Oral Health Champions during their dedicated education session, potentially fostering behavioral changes and enhancing oral care skills in the ward, in line with the social cognitive theory. ¹¹ The train-the-trainer model allowed OHEP-trained nurses to act as champions, training 30 nurses, with potential scalability to all nurses. This project aligns with the Interprofessional Education for Collaborative Patient-Centered Practice model ¹² where there is an education system (OHEP) improving knowledge, skills, and practice of learners (nurses), and a professional system (nursing team) providing oral care in the ward leading to good patient outcome (improvement in oral hygiene). The reduction in respiratory infections post-OHEP reflects the indirect benefit of enhanced oral hygiene, aligning with reports of reduced aspiration pneumonia in the frail elderly with good oral hygiene.^1,2 However, our dataset did not account for factors like aging, immunocompromised status, and smoking that influence respiratory infections. Future recommendations include conducting a randomized clinical trial to establish causality, assessment of patients' dental conditions before and after OHEP, and gathering trainers’ and learners’ insight through focus group interviews. Policymakers should consider standardizing oral health modules in nursing schools and collaborating with dental schools for interprofessional learning to enhance nurses' oral health knowledge.

Conclusion

Recognition of oral health’s importance in frail elderly patients, particularly in the medical field, is crucial. This pilot study shows that fostering interprofessional collaboration through OHEP positively impacts ward patients' oral health. Oral health champions, trained with the train-the-trainer model, ensure a standardized curriculum with customization flexibility. Providing post-OHEP guidance and support to OHEP-trained nurses for up to 6 months is vital to sustain the positive impact of OHEP in community hospital.