1

Integrative Review of the Literature

Kate Hardrick

NUR 4322

Bon Secours Memorial College of Nursing

Arlene Holowaychuk, EdD, RN, CNE

November 10, 2020

Honor Code: “I pledge”

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Abstract

Purpose: The purpose of this integrated review of the literature is to determine if increased oral care in

the acute care setting decreases the occurrence of hospital-acquired pneumonia (HAP) in patients.

Background: Poor oral care can lead to tooth decay, plaque buildup, and cracks in the oral mucosa. All

of these factors create an opening in the mouth for bacteria to enter and cause further damage. The

PICO question, “For patients in the acute care setting does increased oral care reduce the occurrence of

HAP when compared to normal oral care?” represents the basis of this integrative review. Design and

Method: Ovid MEDLINE was the computer database search engine utilized to find the discussed articles.

Five articles were selected that related to the researcher’s PICO question and fulfilled the inclusion

criteria. All of the articles are peer-reviewed, written in English, and published between 2010-2020.

Results and Findings: The results of this review concluded that increased oral care in patients admitted

to the hospital does decrease the occurrence of HAP. A standardized oral care protocol is an important

factor in maintaining positive oral health for patients. Limitations: The researcher has no experience

writing an integrative review. Implications for practice: Nursing staff need to make time to implement

oral hygiene in their daily patient care. This will reduce the patient’s risk of complications as well as the

length and cost of stay. Recommendations for future research: Future research should be focused on

creating a standardized oral care protocol that can be implemented in every healthcare facility.
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Integrative Review of the Literature

The purpose of this integrated review is to determine if increased oral care in the hospital

setting reduces the rate of hospital-acquired pneumonia (HAP) in patients. HAP represents a major drain

of facility and patient resources as well as a significant contributor to increased morbidity/mortality and

admission length (Schutte & Warren, 2020). Oral care has been shown to disrupt the bacteria that live in

dental plaque and prevent periodontitis which increases the buildup of plaque (Warren et al., 2019).

Research has shown that proper oral care can be impeded through many factors including: patient

resistance to participation, a lack of evidence-based research on appropriate protocols, a need for

adequate supplies, and a lack of time on the part of the nursing staff (Coker et al., 2016). Nursing staff

are the healthcare providers who provide the care and education to their patients while in the hospital;

it is important that they themselves understand how to perform proper oral care and why it is needed

(Schutte & Warren, 2020).

Increased oral care can be seen in practice as utilizing evidence-based oral care supplies; any

practice that encourages improved oral health falls under this definition. Intensive care units provide

increased oral care in the form of standardized protocols, staff education, appropriate documentation,

and adequate supplies because research has shown that it can prevent ventilator-associated pneumonia

(VAP). This practice has not been expanded to include the acute care population at large. This review

aims to analyze the current evidence that addresses the researcher’s PICO question: “For patients in the

acute care setting does increased oral care reduce the occurrence of HAP when compared to normal

oral care?”

Design and Methods

The design of this research is an integrated review of the literature. The research articles utilized

in this review were found on Ovid MEDLINE, which is a computer database search engine. The search

terms of ‘oral’ and ‘care’ returned 926 results. A filter was applied to the search in order to obtain only
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full text articles. Articles were only evaluated if they met the criteria of being peer-reviewed qualitative

or quantitative studies, published within the years of 2010-2020, written in English, and met the

researcher’s PICO question, “For patients in the acute care setting does increased oral care reduce the

occurrence of HAP when compared to normal oral care?”. Finally, the selected articles had to meet the

following inclusion criteria: acute care setting, adult population, and an evaluation of oral care practices

by nursing staff. Articles were excluded if they didn’t meet the inclusion criteria or relate to the

researcher’s PICO question. A total of five research articles were selected, which included four

quantitative studies and one qualitative study.

Findings and Results

The findings and results of the five reviewed articles demonstrate that increased oral care

practices through standardized protocols improve oral health in patients (Castillo et al., 2019; Coker et

al., 2016; McNally et al., 2018; Schutte & Warren, 2020; Warren et al., 2019). A summary of the five

articles is presented in Appendix 1. The researcher identified the following themes from the articles:

standardized oral care protocols and decreased rate of infections.

Standardized Oral Care Protocols

All five studies identified discussed the importance of creating a standardized oral care protocol

in order to increase the effectiveness of oral care provided (Castillo et al., 2019; Coker et al., 2016;

McNally et al., 2018; Schutte & Warren, 2020; Warren et al., 2019). Oral care protocols define the

appropriate frequency of oral care, the type of supplies utilized, and documentation methods. These

protocols have the ability to increase nursing staff’s knowledge and perceived importance of oral care

which represent major barriers to consistent intervention (Schutte & Warren, 2020).

The purpose of the study by Castillo et al. (2019) was used to determine how implementing a

nursing documentation initiative regarding oral care affected documentation compliance and patient

oral health outcomes. The single-group pretest-posttest study observed the admission and discharge
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oral health documentation of 1,303 patients admitted to the hospital within a three month period. The

electronic health record (EHR) was used to gather data in order to determine if the patient’s oral health

was maintained, improved, or worsened by the inpatient stay. Patient demographics, length of

admission, and health conditions were recorded. The SAGE Oral Cavity Assessment Tool was utilized to

determine an oral health score that ranged from a normal score of five to a score of 20 which indicated

severe dysfunction. These results were then analyzed using paired-sample t tests to determine the

average oral health score received. A statistically significant improvement in oral health was observed in

patients who were admitted with moderate to severe dysfunction (Castillo et al., 2019). This indicates

that increased oral care documentation can lead to improved patient outcomes.

The article by Coker et al. (2016) studied the oral care practices of nurses, the barriers to care,

and what supplies are used to provide this care. The researcher’s designed an exploratory multiple-case

study of 25 nurses in the hospital setting. Nurses were chosen from different units in order to represent

a wide variety of patients. The nurses were shadowed in order to observe their normal routine;

conversations were recorded and notes were taken for later evaluation. Nursing staff were shadowed

for approximately 70 hours to obtain an appropriate amount of data. The researcher’s were primarily

interested in how oral care was performed, what knowledge the nurses had regarding oral care, and

what supplies were used to provide the care. Within-case and cross-case analysis was used to generate

patterns observed across the data. Common themes identified were inconsistent oral care and care

being seen as optional and not a priority. This study shows how a lack of an oral care protocol can lead

to missed care and an increased rate of infections.

The study by McNally et al. (2018) determined the effect of an increased toothbrushing

frequency on the rate of HAP over a three-and-a-half month period. The nonrandomized controlled

clinical trial was composed of 2,891 non-critical care patients who were broken into a control group and

an experimental group. Patients were required to have been in the hospital for more than two days and
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not be diagnosed with community-acquired pneumonia (CAP), healthcare-associated pneumonia

(HCAP), or VAP. The control group received normal oral care and the experimental group was to have

their teeth brushed three times a day. Data was gathered based on the documentation of oral care by

nurses; the average number of times toothbrushing occurred in a day was recorded. Data was analyzed

using unadjusted and adjusted multivariate logistic regression, an odds ratio, the Wald chi-square test,

and Type 3 Analysis of Effects. During the primary analysis no statistically significant difference in

pneumonia rates was detected between the control and experimental group. The researcher’s realized

that the experimental group only received an average of 1.6 toothbrushing interventions a day instead

of the goal of three. A secondary analysis demonstrated a statistically significant odds ratio between an

increased number of toothbrushing occurrences in a day and a decreased chance of acquiring

pneumonia. This study demonstrates that a consistent oral care protocol can decrease the rate of HAP.

The purpose of the study by Schutte & Warren (2020) is to determine nurse’s understanding of

and feelings towards oral care as well as what characteristics influence the care being given while in the

hospital. The researcher’s assessed these same factors after an oral care protocol was put in place to

measure the change in response. Data was collected via surveys distributed to employee mailboxes and

during unit huddles. 199 nursing staff responded, including 125 before the protocol was implemented

and 74 after implementation. This longitudinal, descriptive correlation study utilized the Likert scale to

measure survey responses ranging from strongly disagree to strongly agree. The Oral Care Questionnaire

contained 33 questions that determined nurse’s current interventions, understanding, supplies, and

barriers of oral care (Schutte & Warren, 2020). Descriptive and inferential statistics were used to analyze

the pre- and post-implementation surveys; this included frequency distribution, mean, and standard

deviation. Chi-square, independent t tests, and ANOVA analytical tools were also utilized. The

implementation of an oral care protocol discovered statistically significant findings in many aspects of

the nurse’s care, including: an increase in planning oral care, favorable feelings towards oral care
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supplies provided, and being able to easily document the care. This study demonstrated that an oral

care protocol not only increases the ease in which oral care is provided but also increases the chance

that nurses will provide oral care in the first place.

The purpose of the study by Warren et al. (2019) was to determine how a new oral care

protocol influences the incidence of HAP. This quasi-experimental pretest-posttest study included 417

patients with a pneumonia that wasn’t present on admission. 202 patients were in the control group

and didn’t receive the new oral care protocol while the 215 patients in the experimental group did. The

protocol standardized the frequency and length of toothbrushing; it also provided new oral care supplies

such as an ergonomically appropriate toothbrush, toothpaste with baking soda, and alcohol-free

antiseptic mouthwash. The experimental group was educated on proper oral health and received

consistent oral health assessments from the nurses. Documentation in the EHR by the nursing staff and

the incidence of pneumonia was used to determine outcomes. Data analysis was done using SPSS

Version 24, summary statistics, and the chi-square test. Several statistically significant differences were

shown between the two groups, including: a lower number of nonventilator hospital-acquired

pneumonia (NV-HAP) cases and deaths in the experimental group. This shows that a standardized oral

care protocol can directly influence the number of patients who get pneumonia.

Decreased Rate of Infections

Three of the five articles offered definitive evidence that increased oral care in hospitalized

patients can decrease the rate of infections (McNally et al., 2018; Schutte & Warren, 2020; Warren et al.,

2019). Healthcare is expensive and it’s made even more costly by the presence of HAP which is a

pneumonia that occurs directly related to healthcare intervention. According to Warren et al. (2019),

HAP is the second most frequent infection that patients can get while in the hospital and it can add

more than a week to an admission. These three articles conclude that standardized oral care by nursing
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staff leads to statistically significant lower infection rates (McNally et al., 2018; Schutte & Warren, 2020;

Warren et al., 2019).

Discussion and Implications

The five articles facilitated a deeper understanding regarding the importance of oral care as it

relates to the researcher’s PICO question: “For patients in the acute care setting does increased oral care

reduce the occurrence of HAP when compared to normal oral care?”. The articles displayed the

importance of the nurse’s role in providing and educating on oral care to patients in the hospital setting

(Castillo et al., 2019; Coker et al., 2016; McNally et al., 2018; Schutte & Warren, 2020; Warren et al.,

2019). An admission to the hospital messes up patient’s normal rhythms and can even physically prevent

them from performing oral care in the way that they’re used to. Since infections are a lot easier to get

while in the hospital it’s important for oral care to be provided more often than patients are used to;

McNally et al. (2018) demonstrated that an increase in oral care creates an increased benefit in infection

prevention. The implications of these studies are decreased patient morbidity and mortality, shorter

admission length, and a decreased cost of stay (Castillo et al., 2019; Coker et al., 2016; McNally et al.,

2018; Schutte & Warren, 2020; Warren et al., 2019). A hospital admission should not put further strain

on a patient’s health and resources and improved oral care is a way to decrease these negative

outcomes. Further research should be into creating a standardized oral care protocol that can be used in

every part of the world. Three of the five articles reviewed outlined a specific oral care protocol and

none of them were the same, in fact they didn’t even use the same supplies to deliver the care (Castillo

et al., 2019; McNally et al., 2018; Warren et al., 2019). An oral care protocol that is used everywhere

would minimize confusion and create a more cohesive system of delivery.

Limitations

The researcher experienced several limitations while writing this integrative review of the

literature. First, the researcher has never written an integrative review and is therefore new and
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inexperienced with the process. The review is being written for a class assignment which limits the

amount of time available to work on it. The articles in the review were limited to a 10 year timeframe

which greatly reduces the number of articles accessible. Finally, the review was restricted to five articles

and is therefore not necessarily indicative of the complete body of research that is currently available.

A limitation found that is common to all five articles is the lack of randomized sampling which

increases the risk of bias (Castillo et al., 2019; Coker et al., 2016; McNally et al., 2018; Schutte & Warren,

2020; Warren et al., 2019). The samples are either the product of seeking out patients with a specific

type of disease or they represent a sample of convenience. The sample size in the study by McNally et

al. (2018) didn’t meet the requirements set by the power analysis which could have influenced their

outcomes. Furthermore, the experimental group in this study didn’t reach their stated goal of

toothbrushing three times a day which skewed the data and forced the researchers to make

assumptions in the conclusions (McNally et al., 2018). Reliability and validity in three of the articles was

not discussed which could indicate an improper use of measurement tools (Castillo et al., 2019; McNally

et al., 2018; Warren et al., 2019).

Conclusion

This integrative review analyzes the delivery of oral care and its relation to the occurrence of

HAP. The evidence in this review indicates that increased frequency, quality, documentation, and

knowledge of oral care results in lower rates of HAP and infections in general (Castillo et al., 2019; Coker

et al., 2016; McNally et al., 2018; Schutte & Warren, 2020; Warren et al., 2019). Nursing staff have an

important role in providing the assessment, intervention, and education surrounding oral care that is

essential in preventing HAP. The data in this review concludes that increasing oral care has the ability to

reduce the rate of HAP in the hospital setting which answers the researcher’s PICO question of, “For

patients in the acute care setting does increased oral care reduce the occurrence of HAP when

compared to normal oral care?”.

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References

Castillo, D. H., Smith, D. J., & Rosenfeld, P. (2019). Implementing and evaluating the impact of a nurse-

led oral care initiative. Journal of Nursing Care Quality, 35, 123-129.

doi:10.1097/NCQ.0000000000000426

Coker, E., Ploeg, J., Kaasalainen, S., & Carter, N. (2016). Nurses’ oral hygiene care practices with

hospitalized older adults in postacute settings. International Journal of Older People Nursing,

12(1). https://onlinelibrary.wiley.com/doi/abs/10.1111/opn.12124

McNally, E., Krisciunas, G. P., Langmore, S. E., Crimlisk, J. T., Pisegna, J. M., & Massaro, J. (2018). Oral

care clinical trial to reduce non–intensive care unit, hospital-acquired pneumonia: Lessons for

future research. Journal for Healthcare Quality, 41, 1-9. doi:10.1097/JHQ.0000000000000131

Schutte, D., & Warren, C. (2020). Staff knowledge and attitudes toward oral care in an acute care

hospital pre- and post-implementation of an evidence-based practice change. Retrieved from

https://ovidsp.dc2.ovid.com/ovid-a/ovidweb.cgi?

&S=IDDAFPMCCIEBLFJFJPAKIGBHGDODAA00&Link+Set=S.sh.51%7c1%7csl_10&Counter5=SS_vie

w_found_article%7c00008484-202005000-00008%7cyrovft%7covftdb

%7cyrovftv&Counter5Data=00008484-202005000-00008%7cyrovft%7covftdb%7cyrovftv

Warren, C., Medei, M., Wood, B., & Schutte, D. (2019). A nurse-driven oral care protocol to reduce

hospital-acquired pneumonia. American Journal of Nursing, 119, 44-51.

doi:10.1097/01.NAJ.0000553204.21342.01
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Appendix 1: Summary of the Literature Table

APA Citation Author APA Citation: Castillo, D. H., Smith, D. J., & Rosenfeld, P. (2019). Implementing and evaluating the impact
Qualifications of a nurse-led oral care initiative. Journal of Nursing Care Quality, 35, 123-129.
doi:10.1097/NCQ.0000000000000426
 Castillo (2019) – MA, RN, CCRN, Department of Nursing, NYU Langone Health, NY
 Smith (2019) – MA, Department of Nursing, NYU Langone Health, NY
 Rosenfeld (2019) – PhD, Department of Nursing, NYU Langone Health, NY
Background/Problem Statement  This study discusses applying an oral care protocol in the hospital, documentation practice by
nursing staff, and the consequent effects on patient’s oral health.
 Poor oral health can lead to higher rates of infection.
Conceptual/theoretical  There is no conceptual/ theoretical framework provided.
Framework
Design/  Quantitative study – Single-group pretest-posttest design.
Method/Philosophical  A literature review was performed on studies discussing the benefit of appropriate oral care.
Underpinnings
Sample/ Setting/Ethical  The sample was 13,303 patients admitted to the hospital during a 3-month period.
Considerations  66 patients were excluded due to a lack of oral health documentation on admission and
discharge.
 The researchers did not utilize an institutional review board because it was quality improvement
study.
 Written consent wasn’t obtained because the data was accessed retrospectively.
 There is no discussion of patient confidentiality and protection.
Major Variables Studied (and  Primary outcome: how the oral care protocol effected patient outcomes and if an oral health
their definition), if appropriate assessment was completed on admission and discharge.
 Researchers determined if patient oral health was maintained, improved, or worsened by a
hospital admission.
Measurement Tool/Data  Data was measured as the change in oral health from admission to discharge.
Collection Method  A score of 5 indicated normal oral health, 6-10 represented moderate dysfunction, 11-20
represented severe dysfunction.
 Data was collected through the electronic health record. Oral health assessments, demographics,
length of admission, and health conditions were noted.
 There is no discussion of validity and reliability.
Data Analysis  Percentages were used to analyze the oral health outcomes of patients during an admission
 12

period.
 Paired-sample t tests were used to analyze the mean effect of the protocol based on scores from
the SAGE Oral Cavity Assessment Tool.
 Statistical significance was P < 0.001 with a confidence interval of 95%.
Findings/Discussion  The importance of continuing education, a standardized protocol, documentation, and proper
assessment were discussed.
 These practices have been shown to improve oral health outcomes in patients with moderate to
severe oral dysfunction.
 It was concluded that a consistent oral assessment tool and oral care protocol can improve a
patient’s general oral health during a hospital admission.
Appraisal/Worth to practice  This review focused on all patients in the hospital setting.
 A standardized oral care protocol can improve oral health outcomes.
 Proper documentation is key to ensuring consistent oral care.
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APA Citation Author APA Citation: Coker, E., Ploeg, J., Kaasalainen, S., & Carter, N. (2016). Nurses’ oral hygiene care practices
Qualifications with hospitalized older adults in postacute settings. International Journal of Older People
Nursing, 12(1). https://onlinelibrary.wiley.com/doi/abs/10.1111/opn.12124
 Coker (2016) – Clinical Nurse Specialist, Hamilton Health Sciences, Hamilton, ON, Canada
 Ploeg (2016) – Professor, School of Nursing, McMaster University, Hamilton, ON, Canada
 Kaasalainen (2016) – Associate Professor, School of Nursing, McMaster University, Hamilton, ON,
Canada
 Carter (2016) – Associate Professor, School of Nursing, McMaster University, Hamilton, ON,
Canada
Background/Problem Statement  The goal of the study is to determine the practices of nurses related to oral care, what can
prevent oral care from being given, and what tools are utilized to provide that oral care.
 A lack of oral care or a lack of appropriate oral care results in an increased rate of infections.
 Nurses represent the primary healthcare providers who can intervene in this setting.
Conceptual/theoretical  The conceptual framework used was within-case and cross-case analysis. This type of framework
Framework identifies common themes which allow large amounts of data to be condensed.
Design/  Qualitative study – exploratory multiple-case study
Method/Philosophical  Literature review was not mentioned directly but many studies were referenced; the studies
Underpinnings found significant oral care deficits.
Sample/ Setting/Ethical  The sample included 25 nurses from 5 different units in the hospital setting.
Considerations  The study was approved by the Hamilton Integrated Research Ethics Board.
 Participants provided written consent.
 Confidentiality was ensured through the use of aliases.
Major Variables Studied (and  Participants oral care practices were observed.
their definition), if appropriate  Participant’s knowledge of how to provide oral care was assessed.
 Factors that influence oral care delivery relating to the participant, patient, and hospital unit were
assessed.
Measurement Tool/Data  Data was collected by shadowing the participants and having conversations during the
Collection Method experience.
 Notes were taken during the experience shadowing experience.
 Construct validity and reliability of the data were discussed.
Data Analysis  A general analytic strategy was used which involved utilizing within-case and cross-case analysis
to generate patterns seen across the data.
Findings/Discussion  Findings show that oral care is frequently described as optional by nursing staff, patients are
 14

usually required to perform oral care themselves, oral care isn’t consistent or based on research,
and oral care isn’t a consistent bedtime activity.
 It was concluded that oral care is frequently missed or improperly administered care by nursing
staff that can lead to poor oral health.
Appraisal/Worth to practice  This review focused on nurse-driven oral care practices.
 Supports frequent and adequate oral care to improve patient’s oral health.
 Recommends incorporating an oral care routine into the nurse’s daily list of tasks and using
evidence-based research to guide the care given.
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APA Citation Author APA Citation: McNally, E., Krisciunas, G. P., Langmore, S. E., Crimlisk, J. T., Pisegna, J. M., & Massaro, J.
Qualifications (2018). Oral care clinical trial to reduce non–intensive care unit, hospital-acquired pneumonia: Lessons for
future research. Journal for Healthcare Quality, 41, 1-9. doi:10.1097/JHQ.0000000000000131
 McNally (2018) – Senior Inpatient Speech Language Pathologist, Boston University Medical
Center, Boston, MA
 Krisciunas (2018) – Research Assistant Professor, Department of Otolaryngology, Boston
University Medical Center, Boston, MA
 Langmore (2018) – Speech Language Pathologist, Boston University Medical Center, Boston, MA;
professor at Sargent College, Boston University
 Crimlisk (2018) – Clinical Nurse Educator and Clinical Nurse Specialist, Boston Medical Center,
Boston, MA
 Pisegna (2018) – Director of Speech Language Pathology, Boston University Medical Center,
Boston, MA
 Massaro (2018) – Professor of Biostatistics at Boston University School of Public Health, Boston,
MA; Senior Biostatistical Consultant, Harvard Clinical Research Institute
Background/Problem Statement  The purpose of this study was to determine if increased toothbrushing leads to decreased rates of
hospital-acquired pneumonia (HAP).
 Studies have identified the importance of standardized oral care in intensive care units but there
is a lack of evidence in non-intensive care units.
Conceptual/theoretical  No conceptual/ theoretical framework was identified.
Framework
Design/  Quantitative study – nonrandomized controlled clinical trial.
Method/Philosophical  No literature review was stated but cited sources show reduced rate of pneumonia in patients
Underpinnings who are provided oral care.
Sample/ Setting/Ethical  Sample size was 5,306 patients before exclusion criteria were applied. 2,891 patients were
Considerations included in the final sample.
 1,487 patients were in the control group and 1,403 patients were in the experimental group.
 The hospital’s Institutional Review Board (IRB) approved the study.
 The IRB waived the right to informed consent for the study.
 No discussion of patient confidentiality or protection was provided.
Major Variables Studied (and  The control group received standard oral care.
their definition), if appropriate  The experimental group was supposed to receive a toothbrushing 3 times a day using a SAGE
 16

Toothette Suction Toothbrush Kit.

 The rate of pneumonia was used to determine outcomes.
Measurement Tool/Data  Average number of times toothbrushing occurred in a day as reported by nursing documentation
Collection Method was used as the measurement tool.
 Reliability and validity were not discussed.
Data Analysis  Unadjusted and adjusted multivariate logistic regression was used for analysis. Odds ratio (OR)
was determined in the unadjusted data.
 The Wald Chi-square test and Type 3 Analysis of Effects were used for analysis.
 A 95% confidence interval was established.
 Statistical significance of P < 0.05.
Findings/Discussion  The experimental group experienced similar levels of pneumonia to the control group.
 It was concluded that even though the experimental group did receive more toothbrushing, it
wasn’t close to the specified 3 times a day.
 A secondary analysis showed pneumonia rates decrease by a certain percentage with increased
toothbrushing.
Appraisal/Worth to practice  This study focused on patients admitted to a non-intensive care unit.
 Increased toothbrushing frequency can decrease the rate of pneumonia but, a minimum number
of toothbrushing episodes must occur to provide significant results.
 17

APA Citation APA Citation: Schutte, D., & Warren, C. (2020). Staff knowledge and attitudes toward oral care in an acute care hospital
Author pre- and post-implementation of an evidence-based practice change. Retrieved from
Qualifications https://ovidsp.dc2.ovid.com/ovid-a/ovidweb.cgi?
&S=IDDAFPMCCIEBLFJFJPAKIGBHGDODAA00&Link+Set=S.sh.51%7c1%7csl_10&Counter5=SS_view_found_article
%7c00008484-202005000-00008%7cyrovft%7covftdb%7cyrovftv&Counter5Data=00008484-202005000-
00008%7cyrovft%7covftdb%7cyrovftv
 Schutte (2020) – Associate Professor, Wayne State University College of Nursing in Detroit; Nurse Research
Consultant, Sparrow Health System, Lansing, MI
 Warren (2020) – Clinical Nurse Specialist, Sparrow Health System, Lansing, MI; Assistant Professor, Michigan
State University College of Nursing
Background/Proble  The purpose of the study is to determine what nursing staff knows about oral care, how they feel about
m Statement providing it, what characteristics might influence this care, and how these factors are changed after an oral care
protocol is introduced.
 Oral care can decrease the rate of hospital-acquired pneumonia (HAP) but it isn’t routinely provided.
Conceptual/theore  No conceptual/ theoretical framework was discussed.
tical Framework
Design/  Quantitative study – longitudinal, descriptive correlation design
Method/Philosoph  An extensive literature review was discussed related to the understanding of how oral care should be provided
ical and the beliefs about its importance.
Underpinnings
Sample/  The sample included 199 nursing staff working in the hospital setting.
Setting/Ethical  125 nurses were in the pre-protocol group and 74 nurses were in the post-protocol group.
Considerations  Consent was implied because participation required filling out and returning a survey.
 Protection was assured by placing the surveys in a locked filing cabinet in a locked office.
 Approval was granted by the Nursing Research Council and the Institutional Review Board of the hospital.
Major Variables  Oral care routines, knowledge, supplies, barriers, and beliefs were assessed using a survey before and after an
Studied (and their oral care protocol was put in place. Demographics of the staff were also determined.
definition), if  The goal was to see a positive change in these categories after implementation of a protocol.
appropriate
Measurement  The 5-point Likert scale was used to measure survey responses (1 – strongly disagree, 5 – strongly agree).
Tool/Data  Internal consistency and face validity of survey questions was indicated.
Collection Method  Surveys were distributed during unit huddles or through staff mailboxes. Responses were placed in a sealed box
 18

located on the unit.

Data Analysis  Descriptive and inferential statistics were utilized for analysis (frequency distributions, mean, standard
deviation)
 Chi-square, independent t tests, and ANOVA analytics were used.
 Statistical significance of P < 0.05.
Findings/Discussio  Oral care frequency increased after a standardized oral care protocol was established.
n  Nursing staff reported increased understanding and importance of oral care.
 It was concluded that an oral care protocol can increase nursing staff’s compliance and knowledge regarding
oral health.
Appraisal/Worth  This review focused on nursing staff in the hospital setting.
to practice  Improved oral care reduces the risk of HAP, shortens hospital admissions, and lowers associated costs.
 Researchers recommend further research into effective ways to implement evidence-based protocols and ways
to encourage patients to perform oral care.
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APA Citation Author APA Citation: Warren, C., Medei, M., Wood, B., & Schutte, D. (2019). A nurse-driven oral care protocol to
Qualifications reduce hospital-acquired pneumonia. American Journal of Nursing, 119, 44-51.
Doi:10.1097/01.NAJ.0000553204.21342.01
 Warren (2019) – Clinical Nurse Specialist, Sparrow Health System, Lansing, MI; Assistant
Professor, Michigan State University College of Nursing
 Medei (2019) – RN, Sparrow Health System, Lansing, MI
 Wood (2019) – RN, Sparrow Health System, Lansing, MI
 Schutte (2019) – Associate Professor, Wayne State University College of Nursing in Detroit; Nurse
Research Consultant, Sparrow Health System, Lansing, MI
Background/Problem Statement  The study is used to evaluate a new oral care protocol on the incidence of hospital-acquired
pneumonia (HAP).
 Previously, patients didn’t like the oral care products provided and oral care wasn’t delivered
regularly by nursing staff.
Conceptual/theoretical  No conceptual/ theoretical framework was identified.
Framework
Design/  Quantitative study – Quasi-Experimental pretest-posttest design.
Method/Philosophical  A literature review was performed which showed that oral care does reduce the risk of adverse
Underpinnings pulmonary outcomes and there is no standardized high-quality oral care protocol.
Sample/ Setting/Ethical  The sample size was 417 patients who were identified as having pneumonia that wasn’t
Considerations diagnosed on admission.
 202 patients were in the control (baseline) group and 215 patients were in the experimental
(intervention) group.
 It is not clear if every patient concluded the study; 24 patients died related to nonventilator
hospital-acquired pneumonia (NV-HAP).
 The study was approved by the hospital’s institutional review board.
 The study was performed retrospectively so no consent was obtained, it is indicated that no
patient-specific data was used.
Major Variables Studied (and  The new oral care protocol was not utilized on the baseline group.
their definition), if appropriate  The intervention group received an ergonomically appropriate or a suction toothbrush, baking
soda toothpaste, and alcohol-free antiseptic mouthwash. Brushing would last 120 seconds every
4-6 hours. Oral assessments were performed and oral health education was provided to patients.
 Primary process indicator: how well the nursing staff utilized the protocol.
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 Primary outcome: incidence of NV-HAP pneumonia and ventilator-acquired pneumonia (VAP).

Measurement Tool/Data  The number of NV-HAP and VAP cases was measured as indicators of oral care protocol success.
Collection Method NV-HAP rate per 1,000 discharges, NV-HAP death rate, and VAP rate per 1,000 ventilated days
was also measured.
 Reliability and validity were not discussed.
 The researchers utilized the electronic health record to collect data.
Data Analysis  Data analysis was done using SPSS Version 24, summary statistics, and Chi-square test.
 Statistical significance was P < 0.05.
Findings/Discussion  The intervention group reported lower rates of NV-HAP, lower rate of infection per 1,000
discharges, and a lower death rate. Lower rates of VAP and ventilator-associated events (VAE), as
well as lower rates of infection per 1,000 ventilated days were reported.
 Nursing staff utilized the protocol between 36%-100% per month, with an average of 76%.
 It was concluded that the oral care protocol reduced the risk of pneumonia in admitted patients.
Appraisal/Worth to practice  This review focused on patients diagnosed with pneumonia after admission to the hospital.
 Oral care protocols lower the risk of pneumonia which lowers hospital costs, length of stay, and
patient morality.