Harris et al. contends the development of an oral care protocol represents a foundation of mucosal health, integrity, and function. This is consistent with reports by Rubenstein et al. (2004) and McGuire et al. (2006) which similarly maintain adherence to oral care protocols helps minimise the duration and severity of OM in patients receiving treatment for cancer. Moreover, guidelines for oral mucositis from the Multinational Association for Supportive Care in Cancer (MASCC, 2005) and the International Society of Oral Oncology (ISOO) (Rubenstein, 2004) both suggest that there is limited evidence of benefit from pharmacological interventions, oral care protocols along with staff and patient education being the primary key recommendations for mucositis prevention and management. Harris et al. (2008) maintain the need to focus on feasibility, adherence, and patient education when designing oral care protocols, and highlight the need for a collaborative multidisciplinary team approach, including participation of a dentist.
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Despite these recommendations there is disparity in the literature regarding the precise design of oral care protocols. The value of intensive dental care interventions, such as visiting a dentist for the removal of plaque/calculus prior to chemotherapy is especially contentious. In a small study in leukaemia patients, Djuric et al (2006) failed to show any statistical difference between those receiving an intensive protocol and those receiving limited/normal care. Whilst Borowski et al (1994) described this approach as “not clinically impressive” based on their rather larger trial in bone marrow transplantation patients. Likewise, Dodd et al (1999) agreed, maintaining that risk factors for OM are not as simple and direct as many medical personnel would suggest. Perhaps an intensive oral care protocol would be more appropriate for high-risk patients, such as those with head and neck cancers. This is in keeping with the recent review by Rodriguez et al (2012), and the report by Scully et al (2007) which contend such patients should have a thorough oral and dental examination before starting treatment. Within my practice setting, currently there is little attention paid to patients’ oral care. Moreover, since many patients are neutropenic from cytotoxic treatment they are especially poorly and any intensive dental protocol would be inappropriate. Nevertheless, a simple and flexible oral care protocol to improve patient outcomes could be feasible and applicable, but would require commitment from all relevant parties. Unfortunately McGuire et al (2004) cites lack of interdisciplinary collaboration and diverse oral care regimens and practices as potential barriers to implementing oral care protocols. Moreover, Southern (2007) discovered that oncology nurses feel they lack knowledge and training about providing oral care. Addressing such issues is vital if an oral care protocol is to be proposed and successfully implemented in my practice. These issues will be discussed in depth in Chapter 5.
Transferability of other oral care protocols to my practice setting should be critically evaluated. There was clear room for improvement in the oral care diary assessed by Miller et al. (2007) his Scottish cohort, since over half of the participants did not find their oral care diaries easy to complete. This is similar to patient’s perception during the early development of the PRO-SELF program aimed at helping them manage their symptoms of cancer and its treatment via information giving and provision of nursing support (Dodd and Miaskowski, 2003). This valuable initiative was developed, simplified and consolidated into individual programs for each morbidity; thus for the mouth awareness mucositis program, patients were taught, supervised and evaluated on how and when to care for their mouths (Larson et al. 1998). Interestingly the equipment was kept to a minimum: simply a toothbrush, floss, watch and torch. Any oral care protocol adopted within my setting would need to be sympathetic to the fact that many patients are extremely ill, indeed Miller et al.’s (2007) study showed patients’ enthusiasm for completing their diaries was negatively affected by both design flaws and patients’ treatment related fatigue. The PRO-SELF program has been tested on patients who were very ill (Dodd and Miaskowski, 2003) and could conceivably be adjusted for my setting, possibly with greater emphasis on aspects of educating and supporting nursing staff.
A further aspect of the Miller et al. (2007) study were issues surrounding patients perception of OM, with many feeling unprepared for their mouth problems; whilst another finding was the usefulness of the educational nature of the diary. This recognition of the need for improved consistency of information provision to patients is a view held by several researchers in the field (Larson et al. 1998, Daniel et al., 2004, Quinn et al., 2008 and McGuire et al. 2006) who all emphasis that patients/caregivers must be educated regarding why effective oral hygiene is vital throughout treatment. Patient participation could empower patients to take more control over their lives, an approach which has been demonstrated to improve health outcomes and increase patient satisfaction (DoH, 2005). Another useful outcome from Miller et al. (2007) was evidence that, in general, patients can easily perform an oral self-assessment. However, in my clinical setting, nursing staff will largely be responsible for assessment and, in accordance with the sentiments of Harris et al. (2008), will represent key players in championing an effective oral-care program. Interestingly, Borbasi et al. (2002) confirmed that patients value the role nurses play in providing encouragement, reminding them to care for their mouths, making useful suggestions when things are not going well, or just listen to their wishes and making them feel they are in control.
Harris et al. (2008) highlight that
“Studies to date have not consistently used valid and reliable instruments to document changes in the oral cavity”
Harris et al. (2008, p146)
The authors emphasise this lack of consistency is partly due to the high number of different tools available for assessment, measurement and grading of OM. A commonly used guide is the Oral Assessment Guide (OAG) (Eilers, Berger, & Petersen, 1988), whilst the WHO grading system (1979) shown in Table 4 is a simple and easy to use scale (Lalla et al., 2008). It combines both subjective and objective measures of oral mucositis and would be suitable for daily use in my clinical setting. The National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) which is rather more involved was developed for patients receiving radiation therapy and includes separate subjective (functional/symptomatic) and objective (clinical examination) scales for mucositis. Harris et al. (2008) recommend the use of reports by Eilers and Epstein (2004) plus Sonis et al. (2004) to guide the selection of a suitable tool. The approach specifically considers the information needed, and how and by whom that information will be collected. Thus the Miller et al. (2007) study involved ambulatory patients and utilised the OAG. To optimise assessment for the inpatients in my clinical setting, a collaborative approach to decision making would be taken regarding the chosen tool. It must be appreciated that many patients would require nurses’ to perform their oral assessment and would also often need assistance for their general oral hygiene. Whichever tool is adopted, consistency of practice through staff and patient education would be necessary to ensure correct identification of detrimental changes across the mucositis trajectory.
Table 4 World Health Organization (WHO) scale for oral mucositis
Grade 0 = No oral mucositis
Grade 1 = Erythema and Soreness
Grade 2 = Ulcers, able to eat solids
Grade 3 = Ulcers, requires liquid diet (due to mucositis)
Grade 4 = Ulcers, alimentation not possible (due to mucositis)
Dougherty and Lister (2011) suggest a combination of methods may be necessary for a thorough assessment. One example of an alternative and useful adjunctive assessment is the Oral Mucositis Daily Questionnaire (OMDQ) (Stiff et al., 2006), comprised of 6 question, aimed at evaluating patients’ mouth and throat soreness and its impact on daily activities (Tonks et al., 2011). This validated instrument correlates with oral mucositis severity based on the WHO score and since symptoms have been found to precede objective findings by 1-3 days (Treister et al., 2012) its use could trigger the need for early action prior to clinical manifestations. The OMDQ could prove of considerable value in my clinical setting, however, nurse assistance would probably be needed in completing the OMDQ.
The onus is on medical staff to effectively identify patients who are developing mouth problems. Notably, a recent study by Maree et al. (2012) in people who had completed their chemotherapy treatment reported that nearly a quarter of individuals who had suffered from mucositis told no one. The authors fail to suggest reasons for this, but perhaps patients felt they were burdening their caregivers or maybe they thought it was a normal part of their treatment which they simply had to endure. Maree et al. (2012) maintain this finding reiterates the importance of assessment. A further enlightening fact is that, a large proportion of respondents (nearly a third) who did report problems found the prescribed oral and throat preparations unhelpful and chose self-care measures instead, mostly recommended by a family member/friend, pharmacist or nurse (Maree et al., 2012). The authors highlight that some of the products used, such as commercial mouthwashes and glycerine may be harmful, thus nurses should be vigilant and disuade patients from such practices. Currently, the standard treatment a nurse would recommend, alongside basic oral care, consists of a rinse of water, salt and/or baking soda (Dougherty and Lister, 2011). However, this is only to maintain oral hygiene and does not have any impact on the severity or duration of the mucositis itself. In this context, the study with topical oral honey performed by Rashad et al. (2008) is highly pertinent. Despite study design issues, the ability of honey to markedly reduce the incidence/severity of mucositis and protect against candida colonisation and bacterial infection appears convincing. This natural product, with its rich nutritional qualities, could prove a pleasant, simple, and economic modality for the management of mucositis. Indeed, Philippa Hawley of the British Columbia Cancer Agency has recently completed a larger placebo-controlled study involving regular topical oral application of manuka honey to assess its ability to reduce the severity and duration of oral mucositis in radio-chemotherapy patients (Hawley, 2011). The results of this study have not yet been fully published and therefore the investigator was contacted to enquire about the data. Results were not as positive as other studies and nausea was a major factor of poor tolerability (personal communication, 2012). However, the patient population for the study only included patients with head and neck cancer which represents a high risk population tending to require a strict antiemetic regime and often requiring parental feeding to maintain nutritional support. Hawley directed me to other studies with more positive outcomes.
Therefore, other than the Rashad et al. (2008) study, there are a number of other similar studies (Biswal et al., 2003; Motallebnejad et al., 2008; Khanal et al., 2010) all showing positive outcomes. Notably the populations here are not limited to head and neck cancer patients. Recommending topical application of honey to patients in an attempt to decrease the severity of radio-chemotherapy induced oral mucositis may warrant consideration in our clinical setting.
In conclusion, the evidence-based knowledge I have gained has allowed me to answer my research question by identifying relevant, new, more effective nursing interventions for the prevention of mucositis. Their applicability to and feasibility in my clinical setting has been briefly considered here. Although from the evidence it appears clear that there is certainly a need for nursing staff to provide greater focus to oral care involving standardised methodology, development of an optimised formal oral care protocol will require further evidence. “In house testing” of proposals will be required in order to ensure universally feasibility and acceptability, and to ensure any changes made improve both patient morbidity and quality of life. These issues will be focused on further in Chapter 5.
Chapter 5
The definitive aim of evidence based practice (EBP) is to support practitioners in their decision making in order to promote best practice and to eliminate the use of ineffective and inappropriate practice (Hamer and Collinson 2005). The evidence reviewed here has demonstrated the need to develop and implement an EBP oral care protocol in my clinical area. Here I will explore this further by discussing the plan for implementation and consider influencing factors such as leadership, individual roles in facilitation of change, implementation strategies and evaluation. Finally, I shall reflect on how the process of writing this dissertation has influenced my practice.
Translating research findings into practice procedures, facilitating acceptance of a change process and implementing these measures to initiate new patterns of care for patients requires a rational, systematic and collaborative approach involving all key stakeholders (Keele, 2010). A number of evidence-based practice (EBP) models exist which essentially comprise of:
Information gathering to identify the clinical problem (Chapter 2)
Synethsising the gathered evidence (Chapters 3 & 4)
Translating evidence into recommendations for practice change (Chapters 4 & 5)
Implementation and evaluation of the practice change (Chapter 5)
Reavy and Tavernier’s (2008) “EBP model for staff nurses” is pertinent to my practice as it recognises the importance of utilising staff nurse expertise to ensure process success, also where appropriate getting buy-in from the patients themselves by pilot testing the protocol. The composition of the stakeholders team is flexible; the Iowa model (Titler et al 2001) suggests the team comprise of clinicians, staff nurses and other champions of EBP. Likewise Stout et al. (2009) suggest an appropriate multidisciplinary working group be set-up. My setting would require a small team of key stakeholders including representatives from certain other clinical areas to ensure transferability. The development team could comprise of:
Senior sister for the clinical area responsible for treating neutropenic patients (my role)
Lead nurse for in-patient care
Practice development nurse (PDN) for in-patient care
PDN for the Intensive Treatment Unit
Oncology nurse involved in ambulatory care
Charge nurse for stroke unit
The first step in translating the reviewed evidence into a practice process is developing a proposal for practice change (Keele 2010). Carey et al (2008) maintain that any clinical guidelines must be “actionable”, involving a description of levels of adoption and prioritisation of the most relevant recommendations. Moreover, the proposal must be realistic regarding the scale of change that can be achieved (NICE, 2007). This is demonstrated by the oral-care protocols adopted by other hospitals/institutions which vary considerably in the level of complexity of the clinical interventions recommended, for example Plymouth NHS trust (2010), Greater Manchester and Cheshire Cancer network (2012), and Imperial College Healthcare NHS trust (2012).
NICE guidelines describing implementing EBP state “even small changes can have a positive impact, especially if the change involves an action that is repeated often”
NICE (2007, p4). This is relevant to my clinical setting which, due to the infrastructure and the patient populations, would benefit from a simple and flexible proposal for improving oral care health.
The highest priority nursing interventions identified in Chapter 4 which are relevant for my practice involve those which keep the oral mucosa and lips clean, soft, moist and intact, which keep natural teeth plaque and debris free and which maintain denture hygiene. To achieve these objectives the basic key elements should include:
Instigation of systematic oral assessments by a nurse: on admission and regularly thereafter
Provision of written instruction and education for nursing staff in assessment methods and in procedures for mouth care (Dougherty and Lister, 2011, p491-500)
Regular tooth brushing using a soft tooth-brush and fluoride toothpaste
Regular flossing (unless contraindicated e.g. clotting abnormality/thrombocytopenia)
Rinsing using bland oral rinses (saline and/or sodium bicarbonate)
Moisturising lips
Ingesting bland, soft food, taking frequent sips of water and using pure honey to sooth sore mouths
Note that it is anticipated that the degree of nursing assistance required will be negotiated with the patient and the procedures tailored accordingly.
Other considerations are:
Using mouth care assessment tools to establish an individualised plan of care
Providing information regarding oral care plus written instruction and/or a tailored care plan to patients/carers
Using Oral Mucositis Daily Questionnaire (OMDQ) (Stiff et al. 2006)
Further details can be found in the example of a Mouth-care Policy and Standard Mouth Care Protocol taken from NHS Plymouth (Appendix 1), elements of which may be transferable to my clinical setting. Adopting a simple and flexible protocol would enhance its transferability to other clinical areas. Notably ventilated patients would benefit since appropriate oral care has been shown to reduce ventilator-associated pneumonia (Schleder and Pinzon, 2004). Similarly enhanced oral health care has been shown to be of value in post-stroke survivors by reducing the incidence of pneumonia (Brady et al. 2009). A definitive proposal for change can initially be presented at clinical sister’s meetings and/or management days. Further considerations needing discussion would include budgetary constraints, the project schedule (see Table 5) and resource needs (Keele, 2010).
The next stage would involve implementation through practice change. According to the National Institute for Health and Clinical Excellence (NICE, 2007, p7)
“To develop a successful strategy for change, you need to understand the types of barriers
faced in healthcare”
Interestingly, Grol and Wensing (2005) maintains habits are hard to break even when clear evidence for potential improvement is provided. The field of change management is committed to the identification of mechanisms that confine or facilitate practice change in response to research (Travaglia et al 2011). Decades ago Hunt (1981) recognised a common failure of nurses to use EBP. This theory-practice gap apparently still persists in clinical practice with literature evidence emerging from key studies on the subject highlighting nurses’ lack of awareness/understanding of research and EBP (Clifford and Murray 2001, Newhouse et al 2005 and Pravikcoff et al 2005). Effectively disseminating research findings via ongoing education of nurses is therefore important if this gap is to be bridged. Resistance to changing practice is a further barrier (Grol and Grimshaw 2003). Moreover, Rogers’ (2003) change theory framework identifies three aspects which are central to the adoption of change: user’s perception of benefit to the practice, compatibility with practice setting and population and its complexity. These would largely be addressed in my practice by adopting a simplistic and flexible approach to the protocol, along with collaborative methods for implementing a practice change. Also, since nurses prefer interpersonal contact as a source of practice knowledge (Titler, 2008), I would focus on communicating effectively with my peers to provide all necessary information to help educate them, hence clearly demonstrate the advantages of the new process to patient care and quality of life. A major purpose of the oral care protocol would be to:
Raise staff awareness of the importance of oral health
Provide guidance to staff on the oral assessment of in-patients and how to identify individual care needs
Provide nursing staff with clear guidance on the provision of basic oral care to in-patients
The PDN for in-patient care is a key driver in the multidisciplinary team, championed with developing an infrastructure geared towards improving patient care through EBP. The PDN would ensure applicability for the new mouth-care protocol and focus on developing skills/training programs to support the new policies, through classroom teaching, clinical workshops and mentorship/clinical supervision schemes for both qualified nurses and health care assistants. This approach should empower staff to delivery higher quality oral care and allow longevity of the practice change by ensuring it becomes ingrained in the organisation’s culture. Although the PDN would essentially be leading the way in EBP, all members of the team would need to embrace leadership qualities.
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The subject of leadership in the process of implementing EBP in nursing has been widely researched, and organisational structure and culture is believed to greatly influence leadership roles (Sandström et al., 2011; Huber, 2006; Mortlock, 2011; Cummings et al, 2005 and Akerjordet and Severinsson, 2010). Fortunately, my practice culture is one which encourages ward managers to develop and nurture leadership skills. According to Huber (2006) good leaders should maintain consistency of purpose, establish clear goals and expectations, and foster a respectful positive culture. They should also build knowledge and review and reflect on actions (Huber, 2006). These are all attributes which team members would need to embrace. The type of leadership style adopted could range from autocratic, where the leader makes the decisions and directs the behaviour of the followers, to diplomatic, where although the leaders ultimately makes decisions, suggestions and ideas are sought from all involved parties. In my clinical setting, it would be appropriate to adopt an autocratic leadership approach during initial stages of design and implementation, but take a more diplomatic approach as the team gains experience. One aspect to leadership, which might facilitate implementation, is to adopt a change champion mentality. A change champion is passionate about the innovation and committed to using it to improve quality of care. I would represent the change champion for the new oral care protocol and drive the initiative forward. Titler (2008) highlights the importance of more than one change champion for each patient-care unit; consequently, a lead nurse in the oncology unit could also fulfil this role. Together we would spearhead the steering group whilst maintaining a positive, supportive working relationship with all other health care professionals throughout.
Of considerable significance it that the whole process of practice change must conform to Clinical Governance (NHS Executive, 1999), hence maintain standards set for Health Care Organisations, whether NHS or private. The Royal College of Nursing (RCN) describes Clinical Governance as a term that covers activities that help sustain and improve high standards of patient care (Currie et al, 2003, p7). Within my clinical setting, guidance and clarity for oral care protocol implementation will be required from the Care Quality Group; this group assumes corporate responsibility for the quality and safety of patients’ care locally. Formal risk analysis regarding the strategic plan for the protocol will need to be provided to this group via SWOT (Strengths, Opportunities, Weaknesses and Threats) analysis. According to Barker (2010) SWOT analysis represents a straightforward means of assessing potential issues surrounding a change. SWOT analysis for this proposal can be found in Appendix 2. One significant barrier/threat may be budgetary and/or resource competition due to the recent introduction of other practice initiatives/policy changes, such as the care bundles for clostridium difficile, the Liverpool care pathway and essence of care benchmarking. Conversely, these may also bode positive, as they are also EBP-based initiatives and therefore demonstrate the organisation’s commitment to quality improvement and innovation in practice.
A proposed timetable for implementation can be found in the Gantt Chart (Table 5). It is anticipated that the draft guidelines will be completed in three months. Senior management review and ratification will take a month, followed by roll-out of the training and education. A practice trial of one month and a pilot trial of three months will allow staff to familiarise themselves with the guidelines and ensure consistency in practice. In order to determine the effect of the protocol on minimising the risk of OM, ongoing evaluation along with a formal six months audit will monitor adherence and outcomes.
Table 4: Gantt Chart/timeline for design and implementation of an oral care protocol
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Presentation to Management
start of month
Formal Protocol Submitted
mid month
Literature Distribution
In-house Education
Unit Practice Trial
Pilot Unit Implementation
START
END
Facility Implementation
Evaluation
Ongoing from 7/2013
Audit
The audit will comprise of formal measures to determine the impact of the protocol on patient outcomes. This could include:
Patient oral status – degree of mucositis (based on an appropriate OM assessment) plus oral comfort (based the OMDQ)
Compliance audit – the frequency of oral care by nursing staff pre-implementation and post-implementation
Nursing staff questionnaires and/or interviews to determine satisfaction with and perceived effectiveness of the new oral care regimen
The measures would comprise mostly of quantitative measures, augmented with some qualitative information. Baseline evidence would be needed to allow a formal post-implementation comparison. A positive outcome will justify the practice initiative and demonstrate that applying evidence to practice can have positive outcomes for patients and staff.
Having undertaken this dissertation I now have the ability to adopt a systematic approach to a literature search, hence select research based evidence relevant to a specific practice-related question. By adopting suitable critiquing methods I can now appreciate strengths, limitations and transferability of published research. I have also developed an ability to analyse and interpret research results and to understand specific underpinning research paradigms and methodologies such as quantitative, qualitative and mixed method approaches. Additionally, I now recognize how best to facilitate translation of evidence based research findings into practice processes hence enhance patient care, whilst appreciating the plethora of difficulties that arise when implementing such change practice.
I have also gained considerable appreciation of the negative impact of OM on patients. Not only does it affect their sense of well-being and quality of life but can significantly increase the risk of infection and sepsis. Previous to undertaking this study, my main emphasis in caring for this patient group focused on their treatment plan. I now realise that by ensuring basic oral care, through a quick and simple initial oral assessment followed by implementation of the necessary oral care interventions, nurses can significantly influence outcome; specifically prevent the detrimental effects associated with poor oral health. I therefore now also focus on oral care as an important part of the overall care plan, a practice process which would also be of benefit to a number of other clinical units. This dissertation will give me the opportunity to champion this initiative through the design and implementation of a standardised oral care protocol, and raise the profile of OM by educating patients and nurses regarding the importance of oral healthcare. Ultimately, the objective is to produce a suitable, applicable and sustainable oral care protocol for my practice setting to improve patient care and quality of life.
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