Identifying Research Components

Project and address each of the following criteria:

· Sample with demographics

· Data collection process

· Variables

· Sampling design

· Instruments, tools, or surveys

· Validity and reliability of the instruments, tools, or surveys.

· Discussed legal/ethical concerns.
NSG3029 W4 Project

Research Template Name

Cite both articles reviewed in APA style:

***In the template, any direct quotes from the articles needs to only include the page number.

Week 4 Template

Quantitative Article

Qualitative Article

Identify and describe the sample including demographics, in the studies chosen in W2 Assignment 2

Discuss the steps of the data collection process used in the studies

Identify the study variables (independent and dependent)

Identify the sampling design

Describe the instrument, tool, or survey used in each article.

Summarize the discussion about the validity and reliability of the instruments, tools, or surveys used in each article

Identify the legal and ethical concerns for each article, including informed consent and IRB approval
January-February 2018 • Vol. 27/No. 138

Hillary Jenson, BSN, RN, PCCN, is Registered Nurse, Providence Portland Medical Center, Portland, OR; and DNP-FNP student, University of Portland, Portland, OR. Sandra Maddux, DNP, APRN, CNS-BC, is Senior Regional Director, Providence Health and Services, Oregon Region, Portland, OR. Mary Waldo, PhD, RN, GCNS-BC, CPHQ, is Regional Director, Providence Health and Services, Oregon Region, Portland, OR.

Improving Oral Care in Hospitalized Non-Ventilated Patients:

Standardizing Products and Protocol

P atients who develop ventila-tor-acquired pneumonia haveestimated attributable mor- tality rates of approximately 10% (Klompas et al., 2014). To reduce these rates, healthcare advocacy groups have endorsed a prevention bundle that includes routine oral care (Centers for Medicare & Medicaid Services, 2017). In a hall- mark study, DeRiso, Ladowski, Dillon, Justice, and Peterson (1996) demonstrated use of the oral anti- septic chlorhexidine reduced rates of hospital-acquired pneumonia in ventilated patients undergoing coronary artery bypass surgery. Although routine oral care histori- cally has been a part of daily patient care, its significance in preventing non-ventilator hospital-acquired pneumonia (NV-HAP) has emerged as an important preventive meas- ure. Maeda and Akagi (2014) linked poor oral health with an increased risk for infection and thus NV-HAP.

Research also has demonstrated that without regular oral hygiene, bacteria remain in the oral cavity and become more pathogenic over time (Ikeda et al., 2014). Despite these risks, research suggests imple- mentation of regular, high-quality oral care by nursing staff often is neglected due to barriers in practice (Letsos, Ryall-Henke, Beal, & Tomaszewski, 2013). These barriers include limited time, resource con- straints, challenging patient behav- iors, and staff knowledge gaps regarding appropriate frequency in oral care.

Although every patient benefits from routine oral care, some groups are at higher risk of developing NV- HAP. These include recently extu- bated persons, postoperative pa – tients, and patients managed on progressive care units (Scheel, Pisegna, McNally, Noordzij, & Langmore, 2016); and patients strictly receiving nothing by mouth or with dysphagia (Maeda & Akagi, 2014). These patients, who are seen commonly in the medical-surgical setting, require heightened aware- ness and sensitivity to their oral care needs.

NV-HAP develops when patients micro-aspirate oropharyngeal path – ogens into the lungs (Di Pasquale, Aliberti, Mantero, Bainchini, & Blasi, 2016). Organ isms responsible for the development of NV-HAP include Staphy lococcus aureus and gram-negative bacteria, which are increasingly antibiotic resistant (Weiner et al., 2016). This knowl- edge of escalating antibiotic resist- ance in conjunction with previous-

ly discussed studies demonstrating the relationship between oral care and reduction of NV-HAP high- lights the urgency for nurses to take action (Kaneoka et al., 2015; Maeda & Akagi, 2014). Medical-surgical nurses are in a position to influence outcomes related to oral care. This fundamental nursing intervention warrants further investigation to ensure these actions become an essential part of daily patient care.

Purpose The purpose of this study was to

determine if staff education, imple- mentation of an oral care protocol, and alterations to bedside oral care tools improved the frequency of oral care in patients who were non- ventilated and did not have a tra- cheostomy. A secondary purpose was to determine if a difference existed in the frequency of oral care provided to high-risk populations, defined as those who had orders to take nothing by mouth, were tube-

Research for PracticeResearch for Practice

Hillary Jenson Sandra Maddux

Mary Waldo

Medical-surgical nurses are in a position to influence outcomes related to oral care. In this study, educating nurses on the impor- tance of routine oral care and moving tools to the bedside improved the frequency of oral care.

January-February 2018 • Vol. 27/No. 1 39

fed or diagnosed with dysphagia, or had been extubated recently.

Review of the Literature A review of the literature from

2013-2017 was conducted in MED- LINE using search terms oral care in acute care and oral care in long-term care.

To determine the effect of oral care on incidence of pneumonia or related mortality in adult patients in hospitals or long-term care facili- ties, Kaneoka and co-authors (2015) conducted a comprehensive litera- ture review and meta-analysis of primary, randomized controlled tri- als. Five studies met defined inclu- sion criteria; one of them had no

reported pneumonia during the data collection period and was not included in the meta-analysis. Authors concluded the pooled effect of oral care with topical chlorhexidine or mechanical oral care contributed to significantly reduced risk for developing pneu- monia compared to control (p=0.02). Additionally, the effect of oral care on reducing fatal pneumo- nia was significant (p=0.02). This meta-analysis dem onstrated routine oral care positively correlates to improved outcomes among non- ventilated patients.

To reduce complications second- ary to pneumonia, Maeda and Akagi (2014) evaluated the effect of regular oral care among 63 immobile older

adult patients (mean age=81.7, + 2.5 years) who received nutrition solely via tube feedings and nothing by mouth. Authors noted lack of oral intake can alter the pathogenicity of the oral cavity and, combined with higher rates of aspiration in elders, lead to increased risk of NV-HAP. A year-long intervention study includ- ed control and oral care interven- tion groups; the intervention group received mechanical oral care using chlorhexidine, a mouth moisturizer with glyceryl gel, and salivary gland massage. The intervention group had significant reduction in the incidence of pneumonia, number of febrile days, number of days with antibiotics, and rate of blood and radiological tests (p<0.05). This study underscores the importance of regular oral care on health to improve outcomes in high-risk per- sons.

Despite evidence of a correlation between oral care and improved outcomes, Pettit, McCann, Schneid – erman, Farren, and Campbell (2012) identified a knowledge gap when surveying a random sample of 98 registered nurses. The mailed 50-question survey assessed oral care knowledge, practices and per- ceptions of importance, and barriers to providing oral care. Results indi- cated 95% of respondents (n=93) believed oral care was important and 79% (n=77) felt responsible for providing oral care; however, 52% (n=51) indicated oral care was addressed minimally in their nurs- ing education. Although the per- ceived lack of education, 67% (n=66) reported being knowledgeable or very knowledgeable about oral care. Participant scores on survey questions related to oral care knowl- edge did not correspond to the per- ceived knowledge reported (mean test score 50.5%, SD=0.132). Per – ceived barriers to performing oral care included low priority, lack of time, lack of resources, and no employer mandate for its provision. These responses reflected a knowl- edge gap regarding oral care and identified potential barriers to rou- tine, nurse-driven oral care. Creat – ing an intervention that educates to deficits in nursing knowledge and


Daily oral care is known to reduce microorganisms in the oral cavity and may reduce the risk of infection caused by aspiration (Kaneoka et al., 2015). This practice may be overlooked among non-ventilated patients.


To determine if staff education, a standardized protocol, and bedside tools improved frequency of oral care.


A pre-post design was used in a study of patients who were non-ventilat- ed and without tracheostomies. Chart reviews determined the frequency of oral care pre-intervention compared to weeks 5, 7, and 9 following intervention. Oral care knowledge and perceived barriers to oral care were assessed and analyzed.


Oral care documentation improved from pre-intervention rates com- pared to weeks 5 and 9 (p<0.01); from weeks 5 to 7 (p=0.00); and main- tained through week 9 (p=0.00). Nurses demonstrated increased aware- ness after intervention for oral care need (p=0.005), high-risk populations (p=0.001), benefits to patient’s self-esteem (p=0.026), and opportunity to assess oral health (p=0.006).

Limitations and Implications

An inability to generalize findings to other populations due to inaccessi- ble demographics on patients was a limitation of the study. Results imply an existing knowledge gap among nurses regarding need for oral care in high-risk patients.


Educating nurses on the importance of routine oral care and moving tools to the bedside improved the frequency of oral care. Longitudinal studies are needed to determine if oral care prevents aspiration…

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