Barriers and facilitators in providing oral care to nursing home residents, from the perspective of care aides: A systematic review and meta-analysis

doi:10.1016/j.ijnurstu.2017.05.003

International Journal of Nursing Studies

Volume 73, August 2017, Pages 34-51

https://doi.org/10.1016/j.ijnurstu.2017.05.003 Get rights and content

Abstract

Background

Oral health of nursing home residents is generally poor, with severe consequences for residents’ general health and quality of life and for the health care system. Care aides in nursing homes provide up to 80% of direct care (including oral care) to residents, but providing oral care is often challenging. Interventions to improve oral care must tailor to identified barriers and facilitators to be effective. This review identifies and synthesizes the evidence on barriers and facilitators care aides perceive in providing oral care to nursing home residents.

Methods

We systematically searched the databases MEDLINE, Embase, Evidence Based Reviews—Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. We also searched by hand the contents of key journals, publications of key authors, and reference lists of all studies included. We included qualitative and quantitative research studies that assess barriers and facilitators, as perceived by care aides, to providing oral care to nursing home residents. We conducted a thematic analysis of barriers and facilitators, extracted prevalence of care aides reporting certain barriers and facilitators from studies reporting quantitative data, and conducted random-effects meta-analyses of prevalence.

Results

We included 45 references that represent 41 unique studies: 15 cross-sectional studies, 13 qualitative studies, 7 mixed methods studies, 3 one-group pre-post studies, and 3 randomized controlled trials. Methodological quality was generally weak. We identified barriers and facilitators related to residents, their family members, care providers, organization of care services, and social interactions. Pooled estimates (95% confidence intervals) of barriers were: residents resisting care = 45% (15%–77%); care providers’ lack of knowledge, education or training in providing oral care = 24% (7%–47%); general difficulties in providing oral care = 26% (19%–33%); lack of time = 31% (17%–47%); general dislike of oral care = 19% (8%–33%); and lack of staff = 22% (13%–31%).

Conclusions

We found a lack of robust evidence on barriers and facilitators that care aides perceive in providing oral care to nursing home residents, suggesting a need for robust research studies in this area. Effective strategies to overcome barriers and to increase facilitators in providing oral care are one of the most critical research gaps in the area of improving oral care for nursing home residents. Strategies to prevent or manage residents’ responsive behaviors and to improve care aides’ oral care knowledge are especially needed.

Section snippets

What is already known about the topic?

•
Oral health is generally poor in nursing homes, and care aides − a largely untrained and unregulated workforce that provides up to 80% of the direct care (including oral care) to nursing home residents − encounter multiple barriers in providing oral care to nursing home residents.
•
Interventions to improve oral care must tailor to barriers and facilitators as perceived by care aides in order to be effective.

What this paper adds

•
The multiple barriers and facilitators in providing oral care to nursing home residents, as perceived by care aides, are related to 1 residents, 2 residents members, 3 care providers, 4 organization of care services, and 5 social interactions.
•
Residents resisting oral care is the barrier most frequently reported, followed by care aides lack of time, and care aides lack of oral care knowledge, education or training.
•
Effective strategies to help care aides prevent or manage residents responsive

Background

Oral care in nursing homes needs urgent improvement. Internationally, studies have reported persistently high rates of preventable or treatable oral/dental problems for decades:

a)
Caries in residents with natural teeth: 41%–79% (Arpin et al., 2008, Chalmers et al., 2002, Matthews et al., 2012, Maupome et al., 2002, Patrick et al., 2010, Porter et al., 2015, Shimazaki et al., 2004, Wyatt, 2002)
b)
Gingivitis: 66%–74% of all residents (Matthews et al., 2012, Patrick et al., 2010)
c)
Need of periodontal

Methods

We registered this review with PROSPERO (CRD42015032454) and published a systematic review protocol (Hoben et al., 2016a, Hoben et al., 2016b, Hoben et al., 2016c).

Study selection

Fig. 1 summarizes the steps of our search and the number of records included and excluded at each step. We did not identify any additional records in the key author and key journal searches, but we included six additional records from screening reference lists of records included from the database search. In total, we included 45 records that represent 41 unique studies. Four technical reports (Fallon, 2009, Fricker and Lewis, 2009, Jones and Sleeman, 2009, Tan et al., 2009) describe the

Barriers and facilitators identified

In this systematic review and meta-analysis, we identified barriers and facilitators that care aides perceived in providing oral care to nursing home residents. These barriers and facilitators relate to broad categories of: 1) residents, 2) residents’ family members, 3) care providers, 4) organization of care services, and 5) social interactions. This aligns with categories of barriers and facilitators for knowledge translation processes (Chaudoir et al., 2013, Damschroder et al., 2009).

Conclusion

This systematic review clearly highlights the need for more rigorous research on barriers and facilitators, as perceived by care aides, in providing oral care to nursing home residents. Dominant barriers and facilitators are relatively well understood: a) residents resisting oral care; b) care providers’ lack of knowledge, education or training in providing oral care; c) care providers’ attitudes toward oral care; d) staffing and time issues; and e) quality of communication/collaboration among

Conflict of interest

The authors declare that they have no conflicts of interest.

Funding

MH conducted this research as part of his post-doctoral work, funded by an Alberta Innovates—Health Solutions Post-Doctoral Fellowship (201300543). This research has been supported by intramural funds from the School of Dentistry, University of Alberta, and the Faculty of Nursing, University of Alberta. Furthermore, HH, RACP, TX, KY, and HX each conducted this research as part of a summer studentship, funded by the University of Alberta Research Experience (UARE) program and Dr. Carole

Author contributions

MH and MNY conceptualized the protocol of this review and meta-analysis, supervised and participated in the screening of abstracts and full texts, data extraction, thematic analysis of barriers and facilitators, and supervised the reconciliation of discrepancies at any stage of the review. MH carried out the search and meta-analyses, and drafted the manuscript, including tables, figures and Supplementary files. AC, KTH, NK, AK, HH, RACP, TX, KY, and HX carried out the screening of abstracts and

Acknowledgments

We would like to thank Dr. Carole Estabrooks for her mentorship and support of this study. We would also like Thane Chambers for her valuable assistance with developing the search strategy for this review and meta-analysis. Furthermore, we would like to thank Cathy McPhalen for editing this manuscript.

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View full text

Barriers and facilitators in providing oral care to nursing home residents, from the perspective of care aides: A systematic review and meta-analysis

Abstract

Background

Methods

Results

Conclusions

Section snippets

What is already known about the topic?

What this paper adds

Background

Methods

Study selection

Barriers and facilitators identified

Conclusion

Conflict of interest

Funding

Author contributions

Acknowledgments

J. Am. Med. Dir. Assoc.

J. Am. Med. Dir. Assoc.

Int. J. Nurs. Stud.

J. Am. Med. Dir. Assoc.

Physiotherapy

J. Am. Med. Dir. Assoc.

Geriatr. Nurs.

J. Am. Med. Dir. Assoc.

Appl. Nurs. Res.

Geriatr. Nurs. (Lond.)

Geriatr. Nurs.

The effect of dental insurance on the ranking of dental treatment needs in older residents of Durham Region's homes for the aged

J. Can. Dent. Assoc.

Oral health educational interventions for nursing home staff and residents

Cochrane Database Syst. Rev.

World Alzheimer Report 2015: The Global Impact of Dementia – An Analysis of Prevalence, Incidence, Cost and Trends

Dental caries, problems perceived and use of services among institutionalized elderly in 3 regions of Quebec, Canada

J. Can. Dent. Assoc.

Canadian Educational Standards for Personal Care Providers: Environmental Scan

Oral health and mortality risk from pneumonia in the elderly

J. Dent. Res.

Separating fact from fiction: use of high-level evidence from research syntheses to identify diseases and disorders associated with periodontal disease

J. Can. Dent. Assoc.

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

Cochrane Database Syst. Rev.

Tailored interventions to address determinants of practice

Cochrane Database Syst. Rev.

Prevalence and correlates of potentially undetected dementia among residents of institutional care facilities in Ontario, Canada, 2009–2011

Int. J. Geriatr. Psychiatry

Planning Health Promotion Programs: An Intervention Mapping Approach

Labor mobility of the direct care workforce: implications for the provision of long-term care

Health Econ.

The evolving role of health care aides in the long-term care and home and community care sectors in Canada

Hum. Resour. Health

An intervention to improve the oral health of residents in an aged care facility led by nurses

Health Educ. J.

A comparison of statistical methods for meta-analysis

Stat. Med.

CASP International Network: Appraisal Tools

Improving Access to Oral Health Care for Vulnerable People Living in Canada

New Directions for Facility-based Long Term Care

Influence of individual and contextual characteristics on the provision of individualized care in long-term care facilities

Gerontologist

Oral hygiene care for residents with dementia: a literature review

J. Adv. Nurs.

Attitudes of nurses aides concerning oral health

J. Dent. Res.

Factors influencing nurses' aides' provision of oral care for nursing facility residents

Spec. Care Dentist.

Caries experience in existing and new nursing home residents in Adelaide, Australia

Gerodontology

Individual and organizational predictors of health care aide job satisfaction in long term care

BMC Health Serv. Res.

Measuring factors affecting implementation of health innovations: a systematic review of structural, organizational, provider, patient, and innovation level measures

Implement. Sci.

Dental care to elderly in institution: an interview of care givers

J. Dent. Res.

Dental care of elderly in nursing homes: perceptions of managers, nurses, and physicians

Spec. Care Dentist.

The effect of programs to improve oral hygiene outcomes for older residents in long-term care: a systematic review

Res. Gerontol. Nurs.

Oral care provided by certified nursing assistants in nursing homes