Academic-practice partnerships to promote evidence-based practice in long-term care: Oral hygiene care practices as an exemplar

Academic-practice partnerships to promote evidence-based practice in long-term care: Oral hygiene care practices as an exemplar Eleanor Schildwachter McConnell, PhD, APRN, BC Deborah Lekan, MSN, RNC, CCCN Catherine Hebert, RN, APRN, BC Lisa Leatherwood, MSN, APRN, BC

Learning in practice disciplines suffers when gaps exist between classroom instruction and students’ observations of routine clinical practices.1 Academic institutions, therefore, have a strong interest in fostering the rapid and effective translation of evidence-based care techniques into routine practice. Long-term care (LTC) practice sites are particularly vulnerable to gaps between classroom teaching and how daily care is implemented, owing to the recent rapid advances in the scientific bases of care for frail older adults, the relative isolation of most LTC sites from academic settings,2 and the relatively small number of registered nurses (RNs) available in LTC settings who can facilitate translation of research-based practices into care.3 The aim of this project was to demonstrate the feasibility and value of an academic practice partnership to implement evidence-based approaches to solving resident care problems in LTC, as many scientifically proven practices hold promise for improving resident outcomes yet adoption is often slow.4 We developed and implemented a clinical practice improvement process, based on diffusion of innovations theory and research,5– 8 to serve as a new model of academic-practice collaboration between a university school of nursing, LTC facility management and direct-care staff, as a means of developing high quality clinical sites for student rotations. The goal was to implement a sustainable evidence-based oral care program as an exemplar of how scientific evidence Eleanor Schildwachter McConnell is an Associate Professor and Gerontological Nursing Specialty Director at Duke University School of Nursing and Clinical Nurse Specialist, Geriatric Research, Education and Clinical Center Department of Veterans Affairs, Durham, NC. Deborah Lekan is a Clinical Associate at Duke University School of Nursing, Durham, NC. Catherine Hebert is a Geriatric Clinical Nurse Specialist at Mission Hospital, Asheville, NC. Lisa Leatherwood is Director of Nursing at Silver Bluff Village, Canton, NC. Reprint requests: Dr. Eleanor Schildwachter McConnell, Duke University School of Nursing, Durham, NC 27710. E-mail: [email protected] Nurs Outlook 2007;55:95-105. 0029-6554/07/$–see front matter Copyright © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2006.12.003

can be translated into LTC practice. This project focused on oral hygiene because the staff was dissatisfied with their existing resident oral care program, and an evidence-base for oral care in LTC existed that had not yet been incorporated into care routines. This article describes a systematic, replicable process for linking advanced practice registered nurse expertise with staff insights about care systems to reduce the gap between teaching and practice in long-term care settings. Our experience demonstrates that translation of research on oral care practices into LTC practice through academic-practice partnerships is feasible, is associated with positive resident outcomes, and illustrates a process that has broader applicability to other common problems in LTC, where incomplete implementation of an extant research base for practice may inhibit student learning.

SCOPE OF PROBLEM & EVIDENCE BASE FOR CARE

S

erious oral health problems exist among adults of all ages. Approximately 1 in 3 US adults has untreated dental decay and is in need of preventive and treatment services9; among frail older adults in long-term care, where access to dental services is even more restricted, the needs are estimated to be greater.10 Many caregivers hold the erroneous belief that it is normal for older adults to lose their teeth and become edentulous; the importance of oral care has, therefore, been dismissed and is a low priority in both health care and nursing practice.11 However, poor oral hygiene has been linked to increased risk for serious medical problems, including pulmonary infection, cardiovascular disease, stroke, brain abscess, and poor control of diabetes mellitus.12,13 Other associated threats to quality of life include chronic oral pain and associated risk of poor nutrition, mouth odor, speech problems, and decreased self-esteem associated with the aesthetics of missing, discolored, or mal-positioned teeth.14,15 Among frail older adults who live in LTC facilities, the problem of achieving adequate oral hygiene stems both from a lack of access to professional dentistry and lack M

A R C H

/ A

P R I L

N

U R S I N G

O

U T L O O K

95

Academic-practice partnerships to promote evidence-based practice in long-term care

of access to nursing staff that are skilled in oral hygiene practices needed to care for older adults with complex cognitive and medical illness.16 –18 Many elders come to long-term care with poor dentition and a history of inadequate oral hygiene owing to limited access to professional dentistry, escalating the severity and magnitude of dental problems confronted by nursing home staff.15 Although visits to a physician increase with age, visits to a dentist do not, owing to economic factors including difficulty affording dental visits on a fixed income, and limited third-party reimbursement for dental services among the elderly. In addition, many long-term care residents are not able to undergo the physical demands associated with an office visit, and mobile dentistry services are not commonly available. Within the long-term care facility, additional barriers exist. First, relative to other activities of daily living, oral care and its effects are less visible and may, therefore, be an aspect of care where direct care staff believe they can “cut corners.”11 Second, staff may lack the education and skills needed to provide oral care to medically complex, cognitively impaired residents, such as those with swallowing disorders, oral pain, feeding tubes, cognitive impairment, or combative behavior.17–20 Third, staff may avoid giving oral care if the teeth are decayed and malodorous or if they fear injuring the resident. Finally, staff may also be fearful of being injured while giving oral care, when residents resist care or become combative. Recent systematic reviews and practice guidelines recommend providing routine oral care for frail elders to improve outcomes.20 Key aspects of recommended care include: (1) routine assessment of the oral cavity by a qualified clinician; (2) assessment of current oral hygiene care; (3) development of an individualized oral hygiene care plan, including daily tooth brushing or removal of dentures and brushing of dentures and oral mucosa; and (4) implementation of oral hygiene practices to prevent oral diseases.21

which an innovation, defined as an idea, new practice or object, is communicated through certain channels over time among members of a social system.5 The DOI framework describes how new practices spread among groups of people over time and achieves a level of acceptance and implementation, or, conversely, why they do not. By identifying and understanding the dynamics associated with adoption or non-adoption, nursing leaders can choose strategic approaches to speed the rate of adoption of new care practices in health care organizations.

METHODS A case study approach was used to demonstrate how a systematic clinical practice improvement process can lead to implementation strategies that increase the likelihood of sustained adoption. Findings are reported using the steps of the Clinical Practice Improvement Process (CPIP) as a means of linking academic and practice settings, and to illustrate how research findings from the DOI framework can inform translation of evidence into practice in LTC.

Step 1: Identify Resident Care Problem Diffusion of innovation (DOI) research highlights the importance of communication processes throughout the adoption process.23 Change is viewed as a social interaction process requiring information exchange. From this perspective, involving key-thought leaders among direct-care staff, along with senior leadership in the LTC facility, during the problem identification phase should enhance the rate of adoption of a new clinical practice. In the case of the oral care program, the LTC facility’s senior leadership and the nursing faculty had already identified the innovation in broad conceptual terms “Oral Hygiene Program for Elders in Long-Term Care,” but had not specified the scope of the problem, nor identified specific new care practices. To narrow the project scope, the clinical faculty member—a geriatric advanced practice nurse (GAPN)—serving in the role of change agent, selected the following key staff, or opinion leaders, to help refine the scope and specific approaches to be used in the practice innovation: (1) certified nursing assistants (CNAs) who had been elected by their peers to the leadership position of “hall mayor,” whose responsibilities include leading direct-care staff meetings focused on finding solutions to difficulties encountered in managing the day-to-day care routines on each hallway or unit; (2) the staff development nurse (SDC), who was well-regarded by staff as knowledgeable and trustworthy when considering new approaches to care; and (3) the resident assessment (Nursing Home Minimum Dataset [MDS]) nurse coordinator, who was most knowledgeable about specialized needs of residents from her role coordinating care plans. In addition to these influential staff, the GAPN also obtained input from potential critics, draw-

DIFFUSION OF INNOVATIONS THEORY: A STRATEGY FOR BRIDGING ACADEMIC-PRACTICE GAPS Duke University School of Nursing has developed a model for clinical site-development in which clinical faculty engage in systematic clinical practice improvements with clinical leaders at sites targeted for future student rotations.22 Based on Diffusion of Innovation theory and research, the process has a dual purpose: (1) to alert nurse leaders in the clinical site preparing to implement new clinical practices to critical elements that influence the likelihood of rapid and sustained adoption, and (2) to guide nursing faculty in key steps needed to facilitate practice change. Key steps in this process compared to Diffusion of Innovations (DOI) research findings are summarized in Table 1. Diffusion of innovation (DOI) is the process by 96

V

O L U M E

5 5

●

N

U M B E R

2

N

U R S I N G

McConnell et al

O

U T L O O K

Academic-practice partnerships to promote evidence-based practice in long-term care

McConnell et al

Table 1. Duke School of Nursing Clinical Practice Improvement Process Step 1. Identify Resident Care Problem

●

●

●

2. Review and Summarize Evidence that Pertains to Resident Care Problem

● ● ●

●

3. Identify Resident Outcomes to be Monitored

Relationship to Diffusion of Innovation Framework

Key Activities

● ●

Include agency opinion leaders in a discussion about clinical topics of interest or importance. Identify opinion leaders, change champions, and those who are connected with diverse groups of staff Consider various sources of information for choosing a CPIP topic such as: State survey results that identify deficiencies in care; corporate or facility priorities; new “hot topics” in geriatric care where there is new literature for evidence-based practice; interest areas among nursing staff, such as “we wish we could do a better job at “. . . . . .”; care issues voiced by residents/families Develop a “short list” of clinical topics that are then taken to the staff for feedback

●

Search for applicable practice guidelines Search for pertinent information from peer reviewed literature Identify clinical experts whose practical information can be combined with best available scientific evidence Summarize findings in easy-to-digest format for clinical staff, identifying target population, benefits to quality of care, & possible components of new practice protocol Identify potential outcomes for the intervention Based on relevance, ability to measure and document, level of importance to facility

●

●

●

●

●

●

●

●

●

4. Design Clinical Intervention

5. Implement staff management strategies

●

●

Discuss intervention options with implementation team focusing on an evaluation of staff perceptions of the innovations attributes of relative advantage, compatibility, complexity, trial-ability, observability, & consider methods to address these factors

●

Assess the communication patterns of the system— how information is transmitted; density of communication, information flow, & local interaction patterns

●

M

A R C H

/ A

●

Taps into the construct or concept of Communication Channels & Social networks in Diffusion of Innovation Identifies supporters of innovation at local and supervisory level who influence others and can be instrumental in persuading others to adopt innovation Helps to gauge tension for change and areas where gaps in practice are perceived to exist Identifies opportunities that are meaningful among local networks and internal and external organization contexts Builds interest and fosters commitment to an innovation from the ground up and top down Fosters internal communication about upcoming practice change; staff frame innovation implementation facilitators and barriers Linkage function to engage internal and external people with knowledge of the innovation in guiding identification, interpretation, & application Builds credibility for innovation to persuade staff of relative advantage of innovation and its compatibility or alignment with beliefs and goals of organization

Fosters monitoring and feedback on innovation implementation; making results visible (observability) strengthens adoption and sustained implementation Forms objective basis for decision about sustainability or discontinuation Fosters decision-making devolved to front-line caregivers to elicit facilitators and barriers to adoption Needed to resolve how to incorporate new role and tasks into current work pattern Identify specific resources needed for successful implementation Fosters compatibility and sustainability of best practices by allowing change agent to build on existing staff management approaches and communication patterns

P R I L

N

U R S I N G

O

U T L O O K

97

Academic-practice partnerships to promote evidence-based practice in long-term care

McConnell et al

Table 1. Continued Step ●

●

6. Implement in selected clinical site

●

●

●

7. Evaluation

●

● ●

8. Sustain, Approach, or Discontinue Program

●

●

98

V

O L U M E

Relationship to Diffusion of Innovation Framework

Key Activities

5 5

●

N

Work with opinion leaders to plan implementation strategy. Consider the social networks used by staff to get work done. Identify how to maximize communication using existing strengths in the local networks. Identify peer mentoring opportunities Develop the components of the staff management and quality monitoring procedures necessary for implementation of the intervention Plan teaching and training component of implementation of the intervention. Consider 2 types of strategies: Mass media strategies: Staff meetings, in-service education sessions, announcements, posters, newsletters or bulletins, Fact Sheets, games, raffles, quizzes Interpersonal strategies: Experiential training, unit-based teaching, peer teaching, bedside clinical teaching, rounds, role play, demonstration/return demonstration, coaching sessions Identify an effective, streamlined strategy for ongoing monitoring and evaluation Conduct evaluation by multiple levels of staff and Communicate results through formal and informal staff channels

CPIP Team meets regularly to review quality monitoring data of resident outcomes and staff continuity of care CPIP Coordinator conducts rounds to assess continuity of care and resident outcomes, identify implementation problems and collaborate with staff to determine solutions

U M B E R

2

N

U R S I N G

O

U T L O O K

●

Develop and use quality monitoring procedures such as audits, run charts, performance evaluation, rounds, and other methods that facility already uses

●

Teaching methods help reframe staff understanding of an innovation to convince users of its merits Mass media builds awareness, interest, knowledge, excitement about the topic Interpersonal approaches are more persuasive in adoption of innovations and are more effective for behavioral change

●

●

High quality data capture and monitoring methods associated with higher rates of adoption of new practices ● Quality improvement methods that are time efficient, easy to use and not burdensome in other ways will be adopted, sustained, and used effectively as a tool more readily ● Build on existing communication channels Promotes staff communication and problem identification that can lead to better resident outcomes and program improvements Keeps the program visible, sustains commitment, and promotes accountability ● Guards against inadvertent discontinuation ● Regular review and feedback keeps innovation and its results visible ● Permits review of innovation and its implementation to determine staff adherence to new practice and if outcomes match expectations. This helps guard against dilution of the innovation effect when the staff modify or leave out key aspects of new procedures or tasks ●

Academic-practice partnerships to promote evidence-based practice in long-term care

ing from the ranks of the charge nurses and CNAs. The administrator, director of nursing, and GAPN wanted to improve the oral condition of residents by increasing staff knowledge about the importance of oral care, increasing staff skill in techniques for oral care and assessment, and incorporating abilities-focused care approaches24 to oral care of residents with cognitive impairment. After consultation with the direct-caregiver opinion leaders, the focus of the oral hygiene program was sharpened to address 3 primary concerns: (1) the general lack of consistent oral care given to residents; (2) the lack of standard procedures for oral care delivery to subgroups of residents including the cognitively impaired, combative resident, the resident with severe periodontal disease, and the resident with dentures; and (3) inconsistent use of oral care products in daily care.

Step 2: Review and Summarize Evidence that Pertains to Resident Care Problem To identify current evidence for oral hygiene programs in LTC, school of nursing faculty conducted a Medline™ literature search designed to answer 3 questions: (1) Among frail older adults in LTC, do new technologies such as special oral rinses, dentifrices, or new equipment designed to facilitate oral care for dependent elders improve plaque control? (2) Is there a clear best practice for assessing and monitoring plaque by a bedside clinician so that oral care outcomes can be measured? and (3) Are there special skills that can be learned by direct-care staff for dental cleaning and gum care that would help maintain oral health among frail elders with limited or no access to professional dentistry? To ensure comprehensiveness, we supplemented the literature search results with articles recommended by 2 geriatric dentistry faculty. Our goals were to identify innovative products and devices that would make oral care easier for staff with limited time who were assigned to physically dependent or cognitively impaired elders; to select bedside assessment strategies that would allow targeting of an oral care program to residents with the greatest potential to benefit; and to determine whether specialized bedside care techniques could be used to reduce resistance to care. Based on this review, we established that, although some new technologies were available—such as electric toothbrushes for residents with limited dexterity, desk-top mirrors positioned to help with self-care, modified manual toothbrushes, and anti-infective oral rinses for periodontal disease—no new breakthrough technology had emerged to manage oral hygiene care in frail elders. In essence, nothing was superior to manual tooth brushing combined with anti-infective oral rinses for cleaning the teeth. The most accurate approaches to assessment for severity of periodontal disease and plaque were not feasible to implement in LTC, as

McConnell et al

published plaque indexes require technical training and special instruments. Rather than using complex tools that would have a low probability of sustained adoption, the GAPN adapted simple observational techniques for the oral assessment form recommended in the clinical practice guideline.21 Special skills, identified to reduce resistance to care, were found in the dementia care literature25–27 and consisted of careful attention to how the resident was positioned for the task, and how environmental and interpersonal cues to behavior were offered to capitalize on preserved physical abilities. To combine the best scientific literature with local expertise and clinical experience,28 the GAPN met with the facility’s senior nursing leadership to review the literature already acquired and to interact with local dental professionals and school of nursing project faculty to discern their opinions about best practices for frail elders in the LTC setting. To reduce the complexity of the information from the literature review, the GAPN summarized key results for staff, so that they could make informed decisions about potential outcomes to monitor, and could customize procedures for their organization. This evidence-based review served as the foundation for development or selection of new assessment instruments and care protocols that were implemented in this project.

Step 3: Identify Resident Outcomes to be Monitored To identify resident outcomes that would be responsive to evidence-based clinical practices for oral hygiene, the GAPN selected a trial unit to (1) assess the oral health status of residents, (2) conduct a pilot test of an oral assessment tool for use by the unit nursing staff, (3) determine the current knowledge and practices of the direct-care nursing staff, and learn what outcomes of oral care they believed to be important, and (4) identify barriers to implementing evidence-based oral hygiene in frail elders. To ensure that the results from the trial unit were not atypical of the facility as a whole, the GAPN conducted facility-wide informational meetings, made rounds with individual direct-care nursing staff, and conducted unit-based inservices and meetings to elicit staff opinions, knowledge, and current practice. During these sessions, staff reported the following concerns regarding oral care: (1) lack of knowledge about oral health issues; (2) insufficient time to give basic oral care; (3) daily staff routines did not include oral care consistently; (4) oral care supplies not consistently available; (5) unlabeled dentures and erroneous beliefs among staff that edentulous residents did not need oral care; (6) staff feeling ill-prepared to provide oral care to resistant or combative residents, fearing personal injury if they attempted to provide care if the resistant or combative behavior escalated, or fearing that they would inadvertently injure a resident who M

A R C H

/ A

P R I L

N

U R S I N G

O

U T L O O K

99

Academic-practice partnerships to promote evidence-based practice in long-term care

became combative during care, which might expose them to accusations of violation of resident’s rights and abuse; and (7) perception that oral care was optional or unnecessary because of a lack of attention to oral health assessment, care planning, and monitoring by licensed nursing staff. After identifying these concerns, the staff and GAPN together identified both resident and staff outcomes to be addressed by the practice innovation. Resident outcomes ultimately selected were: (1) reduced number of residents who had symptoms of poor oral hygiene such as bad breath, “nasty teeth” or discomfort; (2) increased numbers of residents with clean teeth; (3) residents with serious oral health problems referred to dentist; and (4) improved process of care for residents who are resistant to oral care. Staff outcomes focused on providing more consistent care characterized by: (1) oral assessments completed on admission and quarterly, (2) twice-daily oral care given consistently, (3) prompt identification of oral care problems requiring dental consultation and follow-up, (4) ready availability of oral care supplies at the bedside, (5) incorporation of oral care procedures into new employee orientation, and (6) systematic labeling of dentures and denture care.

ity, (4) observability (5) trialability, and (6) potential for reinvention.5,23 With respect to the CNA staff’s perceptions of the relative advantage of the proposed new oral hygiene procedures, all staff agreed that oral care could be improved, particularly among residents who were resistant or combative. The CNAs also saw great advantage to having oral care supplies more readily available. The primary disadvantage to the protocol identified by CNAs was concern about finding the necessary time to do oral care. The oral care program was generally viewed as compatible with the value system and beliefs of the CNAs; however, one instance was identified where the care was discordant: Some CNAs believed that when brushing the teeth resulted in bleeding gums, they were injuring the resident. As a result, CNAs avoided performing oral care for these residents. The oral care procedure itself was not perceived to be complex; however, its implementation in physically dependent and cognitively impaired residents was sometimes difficult. The introduction of abilitiesfocused care techniques24 provided some simple strategies that enhanced resident self-care. For residents who “bit down” on the toothbrush, CNAs were taught to gently brush the gums and outer surfaces of the teeth. For residents who would cooperate, but who had a “bite reflex” which caused them to appear uncooperative, staff were taught how to gently open the mouth to allow for oral assessment and cleaning. The CNAs confirmed that oral care was a less observable task than other components of activities of daily living (ADL) care, where the results of their efforts were visible. Strategies planned to increased visibility of oral care included: (1) conduct regular nursing rounds to assess resident status, engage in collaborative care planning with the CNAs, and monitor improvements in oral hygiene, (2) provide a periodic display of posters that promoted oral care and described common oral care problems in the elderly, (3) increase the availability of oral care supplies for the bedside, and (4) discuss success stories of good resident outcomes on units.

Step 4: Design Clinical Interventions Based on the literature review and outcomes identified by staff, the GAPN wrote a facility policy and procedure guide for oral care that included an assessment and intervention guide, a template for recording individualized goals, and orientation materials. The proposed care protocol had 4 components: (1) Routine oral assessments to be conducted quarterly by a licensed nurse, (2) A bedside oral care plan to be implemented by CNA staff, with resident-specific information communicated via the hall’s “communication book” which all staff were expected to read; (3) New, specific instructions for care of edentulous residents, and (4) A new expectation that CNAs routinely observe for pain behaviors during oral care, and report new findings to the charge nurse. Procedures that were not consistent with the current evidence base for effective oral hygiene—such as use of lemon glycerin swabs or foam toothettes instead of toothbrushes, or substituting mouth fresheners for brushing teeth—were discontinued. Adoption of new care practices often fails because the direct-care staff’s perceptions of the innovation are overlooked. To evaluate the characteristics of the innovation from the perspective of different groups who would be affected by the changes caused by implementing the innovation, the GAPN used a combination of one-to-one communication and interaction with staff in focus groups. The key attributes of the innovation that influence likelihood of adoption are the users’ perceptions of the innovations’: (1) relative advantage, (2) compatibility with current practices, (3) complex100

V

O L U M E

5 5

●

N

U M B E R

2

N

U R S I N G

McConnell et al

Step 5: Implement Staff Management Strategies Schnelle and colleagues have written extensively on the importance of systematic staff management strategies to ensure consistent implementation of new technologies in LTC.29 The staff management practices identified by the school of nursing faculty as critical to implementation of the new protocol included: (1) having a non-threatening means for identifying gaps in staff knowledge; (2) linking clinical experts with directcare staff through routine bedside rounds; (3) targeting residents most likely to benefit from the new care practices; (4) giving staff frequent and timely feedback O

U T L O O K

Academic-practice partnerships to promote evidence-based practice in long-term care

about their care technique; and (5) planning for reinvention of new care practices. Staff inservice education programs were used by the GAPN to assess staff knowledge about the clinical implications of poor oral health and to identify ways in which the new protocol would be incompatible with current practices. Staff had little understanding of the linkage between poor oral health and periodontal disease, heart disease, stroke, and aspiration pneumonia. The GAPN then conducted rounds on the residents on the trial unit in order to ensure that adequate oral care supplies were available at each bedside, and to provide additional expertise to the staff development nurse, MDS nurse coordinator, and the unit CNAs who participated in the bedside oral assessments. After the initial assessment, subgroups of residents were targeted as having the greatest problems and, therefore, the most noticeable benefit. Bedside rounds were then conducted weekly for the duration of the 4-month implementation period, both to ensure that the individualized oral care plan was being carried out as written and to provide a venue for clinical teaching. When a staff member was not implementing the care plan as designed, the GAPN took care to provide direct, specific feedback in a non-punitive manner.30 The bedside care rounds also offered the GAPN the ability to identify instances of “reinvention” of the care practices that she could guide based on her understanding of the evidence base for the practice. Examples of reinvention that occurred are described in the section on sustainability.

Step 6: Implementation in Selected Facility As mentioned previously, a trial unit was identified to allow for targeted assessment of new care practices and resident outcomes. Once designed, the oral care program was then initiated on 1 of 4 clinical units in order to involve frontline caregivers in solving implementation issues, modeling new care approaches in identified residents, and to modify some aspects of the program to facilitate adoption. The GAPN selected the initial unit because it had the greatest number of dependent residents with the most noticeable oral health problems, and because the care team on that unit was cohesive. Successful results from this initial trial created favorable opinions about the feasibility of incorporating these strategies into the daily care of residents on other units. After 1 month of implementation, a second hall was included, and eventually spread to all units within the facility. On each hallway, after assessing all residents, approximately 5 residents were assessed as high risk. Prior to full implementation of the oral care program, several inservice education sessions and information meetings had already been held, and a written implementation protocol had been developed and placed on the unit treatment cart. Thus, at this stage, more emphasis was placed on interpersonal teaching strate-

McConnell et al

gies such as bedside rounds, coaching staff on difficult patients, and bedside demonstrations/return demonstrations. Oral assessments were conducted on admission by the staff development coordinator (SDC) who also reviewed the nurses’ notes on oral care problems and made sure they were addressed in the resident care plan. Weekly oral hygiene rounds were conducted by the SDC, treatment nurse (an RN), and CNAs. Quarterly oral assessments were conducted by the treatment nurse. The clinical intervention guide developed by the GAPN was kept in a book on the treatment cart. Oral concerns identified by the treatment RN were described both in the nurses’ notes and in the unit communications book. When indicated, dental appointments were made by the medical records secretary. Criteria for referral to a dentist included the presence of dental pain, loose or broken teeth, exposed tooth roots, or missing fillings. Access to supplies was addressed by providing each resident with a mesh bag that would hold all the supplies and transfer easily from the bedside table to the bathroom as needed. Each resident was assessed for the proper items for oral care and these were placed in the mesh bag. Staff had a list of the products/ equipment so they could be replaced as needed. The GAPN conducted rounds with the SDC and the CNAs caring for the residents on the high risk list. The GAPN also observed oral care being given by nursing staff and provided positive reinforcement, modeled alternative strategies, and gave corrective feedback. The CNAs identified as opinion leaders, or who were enthusiastic about the program, were coached by the GAPN in oral observations and specialized care techniques and were considered “master technicians” who served as resources to other staff.

Step 7: Evaluation Table 2 contains a display of the oral health problems identified on the pilot unit, strategies used to address the problems, and outcomes of the new care practices. The most common problem identified among the high risk residents were dental caries (29%); less common were dry mouth, bad breath, loose or painful teeth, bleeding gums, and oral candidiasis. Problems with care of the edentulous mouth and dentures were identified in about half of the residents. The process of evaluation is linked closely to sustainability since strategies that are ineffective need to be modified or replaced with alternatives that will yield desired clinical outcomes and are acceptable and feasible for staff. Quality monitoring methods were incorporated into weekly nursing rounds that were initiated by the treatment nurse, MDS nurse, and GAPN. The quality monitoring form developed was based on the University of Iowa protocol, Oral Hygiene Care Outcomes21 to track the resident’s assessments, oral health status, care plan, nursing staff implementation, and identification of resident care problems. This quality monitorM

A R C H

/ A

P R I L

N

U R S I N G

O

U T L O O K

101

Academic-practice partnerships to promote evidence-based practice in long-term care

McConnell et al

Table 2. Oral Care Problems on Trial Unit and Resident Outcomes Following Implementation of Evidence-Based Oral Care Protocol (n ⫽ 31) Problem

N (%)

Dry mouth

3 (10%)

Bad breath

5 (16%)

Loose or painful teeth

4 (13%)

Bleeding gums, gingivitis

10 (32%)

Oral candidiasis

3 (10%)

Dental caries

9 (29%)

Edentulous

16 (52%)

Wears dentures

14 (45%)

Refusing oral care

5 (16%)

Resistant or combative behavior

4 (13%)

Need for dental referral

6 (19%)

102

V

O L U M E

5 5

●

N

Care Plan Intervention

Outcome of Oral Care Program

Encourage adequate fluids; Improved in 2 of 3 residents Artificial saliva Residents did not want artificial saliva Regular oral care Regular use of anti-infective Improved in all 5 residents oral rinse (Listerine™ diluted 50/50) ● Regular tooth brushing including tongue ● Use abilities-focused care approach to promote self-care ● Brush regularly ● Improved due to decreased gingivitis ● Dental referral ● Extractions were necessary for all ● Brush regularly with attention to ● Improvement in 8 of 10 residents ● Improved staff awareness of the gum line ● Professional dental cleaning importance of regular oral care ● Angular chelitis found in ● Improved in all 3 residents residents with no teeth or ill fitting dentures ● Treated with oral antifungal ● Used lip balm at corners of mouth ● Institute oral care hygiene ● Referrals resulted in extractions rather including anti-infective mouth than restorations rinse and fluoride toothpaste ● Monitor for tooth/jaw pain or infection ● Professional dental care referral ● Use anti-infective mouth rinse ● No change in outcome ● Lip balm for angular chelitis ● All residents now receive oral care prevention ● Institute nightly denture ● Improved with regular care; ● 1 resident refused to remove removal & soaking ● Rinse dentures after meals; dentures at night but did agree to label dentures to prevent loss; daily cleaning ● 2 residents needed dental care for assess for adequate fit repair of dentures ● Negotiated with resident on ● Reduced frequency of refusals in all how oral care would be done 5 residents ● 2 residents improved after dental or when oral care would be extractions/treatment; done ● Use same staff if successful ● Enhance self-care abilities ● Offer praise when finished ● Brush gum line only without ● Empowerment of staff to do partial trying to open resident’s jaw care when resistance occurs ● Teach staff techniques to get ● Staff recognized that resistance may some oral care done mean dental pain; ● Use distraction, eg, put ● Decreased resistance to care in most toothbrush or towel in resident’s cases hand ● Manage oral pain ● Refer for dental care ● Infected teeth extracted & infection Referral for severe dental caries treated and loose painful teeth ● ● ● ●

U M B E R

2

N

U R S I N G

O

U T L O O K

Academic-practice partnerships to promote evidence-based practice in long-term care

ing form was incorporated in weekly rounds done by the clinical nurses. Audits of bedside supplies and evidence of their usage provided another aspect of evaluation. Immediate feedback was sought from a resident’s CNAs if products did not appear to be available or used. Based on this success record, oral care became embedded in the direct-care staff’s routines; however, problems in implementation surfaced, requiring collaborative efforts of the GAPN and the facility staff. For example, once care of edentulous residents was made more visible, denture labeling became a concern that was addressed by having the night shift handle this task on the date of admission.

Step 8: Sustain or Discontinue Program Direct involvement of the nursing home’s clinical nursing leadership and the GAPN at the bedside with CNAs was an important and effective strategy promoting sustainability. In particular, participation of clinical nurses and the GAPN conferred high visibility and endorsement of the program. They regularly assisted CNAs with difficult residents and coached CNAs to try various techniques to make oral care successful. The bedside clinical interaction fostered collaborative evaluative feedback about the resident’s oral health status and effects of the interventions delivered by CNAs, and it provided an opportunity for developing alternative solutions to unresolved issues—a key element of sustainability known as “reinvention.” If reinvention is properly managed, users of the innovation can develop more favorable perceptions and attitudes about the innovation and achieve a more rapid rate of adoption. Reinvention of the innovation involves changing or modifying the innovation to promote adoption. Reinvention may occur due to lack of knowledge or understanding of the innovation or to enhance adoption in a unique situation. The academic-practice partnership was key in managing reinvention without changing the interventions to the point that they were no longer evidence-based. One example of how existing practices were reinvented concerned the use of oral rinses for prevention and treatment of periodontal disease. Chlorhexidine has been shown to be effective in reducing plaque and controlling gingivitis but its use requires regular dental supervision, a problem for residents in LTC. Commercially available products (such as Listerine™, Scope™, Cepacol™,) offer limited anti-infective properties and are less costly than chlorhexidine,26 however, when used full strength, alcohol-based products may exacerbate xerostomia and stomatitis due to their drying effect on oral mucosa. To resolve this dilemma, Listerine™ was used at 50% strength to obtain antimicrobial effects while minimizing adverse effects by diluting the alcohol. Because existing care routines allowed the resident to be monitored for adverse side effects, substituting half-strength Listerine for chlorhexidine could be implemented in a safe

McConnell et al

manner. This is a good example of how guideline recommendations may require some modification based on the individual resident situation and clinical judgment. Outcome evaluation of the oral health program from rounds and record-review audits validated the status of the program and provided an alert to possible declines in care delivery. The GAPN noted the following progression of spontaneous staff comments: Originally they would make comments to me such as “I feel like I’m the only one that does oral care,” or, “We don’t have enough time.” But as program implementation progressed, complaints gradually faded away as oral care became an expectation rather than a luxury that residents received only if there was “extra” time. . . CNAs felt that the nurses kept momentum for the program by following up on oral care problems they identified, giving feedback, and by maintaining interest and enthusiasm in their work.” The GAPN and clinical nurses also stimulated the sharing of success stories as resident outcomes improved. In DOI parlance, confirmation occurs when a decision is made to adopt or reject the innovation. If the innovation has not been effectively taken through the clinical practice improvement process, then sustainability of the innovation is threatened, even if direct-care staff and leadership support the idea. The process is iterative and ongoing. In the oral care program, the process allowed for new information to be gathered and incorporated into care systems to meet individualized resident issues and adapt new care innovations as they become known.

DISCUSSION AND CONCLUSIONS A new model of an academic-practice partnership was implemented using a geriatric advanced practice nurse in a liaison role between the LTC practice setting and a research-intensive school of nursing, to facilitate more rapid adoption of evidence-based practices. The new model uses a clinical practice improvement process that is based in research findings from the Diffusion of Innovations literature, as a framework for managing the linkage between evidence base and staff practices in a LTC facility. Long-term care residents suffer unnecessarily when oral care is provided sporadically, inadequately, or not given at all.31 Students’ learning suffers when there is dissonance between classroom teaching and what they observe in practice. The case study of the use of the CPIP to facilitate the implementation of evidence-based oral care among medically complex residents in a LTC facility demonstrates that even the most practical evidence-based guidelines still require interpretation and thoughtful application of staff management practices for successful implementation. AlM

A R C H

/ A

P R I L

N

U R S I N G

O

U T L O O K

103

Academic-practice partnerships to promote evidence-based practice in long-term care

though the protocols are designed to be sufficient to foster translation of the current science into practice, we found the need to augment them with additional review of the literature and expert opinion and consultation with dental professionals. This is consistent with a recent integrative review done by Greenhalgh and colleagues23 on DOI in human services organizations which highlights the importance of system antecedents and readiness for change. These facility attributes may help faculty in selecting prospective clinical sites; the additional detail on the implementation and linkage processes is particularly helpful in explaining new roles of clinical faculty in academic-practice partnerships given this experience in a very high quality LTC facility with stable leadership. In addition, the Greenhalgh model also underscores the importance of effective teaching strategies that take into account the local practice environment in developing sustained improvements. The knowledge base among direct-caregivers is a significant variable contributing to poor oral hygiene practices in LTC.32 The need for new training strategies and ongoing support of direct-care staff that is more practice-oriented, “handson” instruction rather than traditional classroom teaching is well-recognized.33 In this project, information about oral health problems in frail elders and oral care procedures were disseminated using both mass media and interpersonal communication approaches as described in the DOI model to enhance staff knowledge, motivation and skill. Most LTC facilities do not have processes in place to guide nurses through systematic review of evidencebased practice guidelines and protocols and systematic adoption of new care practices. Academic-practice partnerships such as the one described in this case study provide the needed leadership, mentorship and support in collaborative practice to translate and incorporate the best new evidence into practice34 and fosters a high level of professional engagement by nurses. Clinical rotations founded on such partnerships should provide a more effective environment for learning than settings of care where gaps between the evidence-base for practice and its implementation are not addressed systematically.

2. Kovner C, Mezey M, Harrington C. Research priorities for staffing, case mix, and quality of care in US nursing homes. J Nurs Scholarsh 2000;23:77-80. 3. Centers for Disease Control. National Nursing Home Survey. Available at: http://www.cdc.gov/nchs/data/nnhsd/ NNHS99Employees_selectedchar.pdf 2004. Accessed December 1, 2006. 4. Roe B, Watson N, Palmer MH, Mueller C, Viinses AG, Wells M. Translating research on incontinence into practice. Nurs Res 2004;53:S56-S60. 5. Rogers E. Diffusion of Innovations 5th ed. New York, NY: Basic Books; 2003. 6. Titler MG. Methods in translation science. Worldviews Evid Based Nurs 2004;1:38-48. 7. Titler MG, Everitt LQ. Translating research into practice: Considerations for critical care investigators. Crit Care Nurs Clin North Am 2001;13:587-604. 8. Rosswurm MA, Larrabee JH. A model for change to evidence-based practice. Image - the Journal of Nursing Scholarship 1999;31(4):317-22. 9. Vargas CM, Dye BA, Hayes KL. Oral health status of rural adults in the United States. J Am Dent Assoc 2002;133: 1672-81. 10. Coleman PR. Promoting oral health in elder care: Challenges and opportunities. J Gerontol Nurs 2004;30:3. 11. Bowers B, Esmond S, Jacobson N. The relationship between staffing and quality in long-term care facilities: Exploring the views of nurse aides. J Nurs Care Qual 2000;14:55-64. 12. Joshipura K. The relationship between oral conditions and ischemic stroke and peripheral vascular disease. J Am Dent Assoc 2002;133: S23-S30. 13. Shenkin JD, Baum BJ. Oral health and the role of the geriatrician. J Amer Geriatr Soc 2001;49:229-30. 14. Gilbert GH, Shelton BJ, Chavers LS, Bradford EH. The paradox of dental need in a population-based study of dentate adults. Med Care 2003;41:119-34. 15. Chalmers J, Pearson A. Oral hygiene care for residents with dementia: A literature review. J Adv Nurs 2005;52:410-19. 16. Dolan TA, Atchison KA. Implications of access, utilization and need for oral health care by the non-institutionalized and institutionalized elderly on the dental delivery system. J Dent Educ 1993;57:876-87. 17. Preston AJ, Punekar S, Gosney MA. Oral care of elderly patients: Nurses’ knowledge and views. Postgrad Med J 2000;76:89-91. 18. Cohen-Mansfield J, Lipson S. The underdetection of pain of dental etiology in persons with dementia. Am J Alzheimers Dis Other Demen 2002;17:249-53. 19. Adams R. Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. J Adv Nurs 1996;24:552-60. 20. Coleman PR. Improving oral health care for the frail elderly: A review of widespread problems and best practices. Geriatr Nurs 2002;23:189-99. 21. Chalmers J, Johnson V, Tang JH-C, Titler MG. Evidencebased protocol: Oral hygiene care for functionally dependent and cognitively impaired older adults. Journal of Gerontological Nursing 2004;30(11):5-12. 22. McConnell ES, Lekan-Rutledge D, Anderson RA, Nevidjon B. Complexity theory: A long term care specialty practice exemplar for the education of advanced practice nurses. J Nurs Educ 2004;43:84-8.

The authors wish to acknowledge the following people and organizations for their support of this project; Staff at Silver Bluff: Annelle Hines, BSN, RN, BC, Shannon Hayes, BSN, RN, Ted Reid, RN, Sheila Franklin, LPN, Bob Leatherwood, LNHA for implemenation support; Sally Mauriello, RDH, Tom Francis, DMD, and Kathy Odvody, RDH for consultation on dental care; The Helene Fuld Health Trust, HBSC Bank, Trustees for financial support; the Trajectories of Aging and Care (TRAC) Center P20-NR07795 (Elizabeth Clipp, PI) for support in manuscript preparation.

REFERENCES 1. Newhouse RP. Challenges and opportunities for academic and organizational partnership in evidence-based nursing practice. J Nurs Adm 2006;36:441-5.

104

V

O L U M E

5 5

●

N

U M B E R

2

N

U R S I N G

McConnell et al

O

U T L O O K

Academic-practice partnerships to promote evidence-based practice in long-term care 23. Greenhalgh T, Robert G, Macfarlane F, et al. Diffusion of innovations in service organizations: systematic review and recommendations. [see comment]. Milbank Quarterly 2004; 82(4):581-629. 24. Connell BR, McConnell ES, Francis T. Tailoring the environment of oral health care to the needs and abilities of nursing home residents with dementia. Alzheimer’s Care Quarterly 2002;3:19-25. 25. Wells DL, Dawson P, Sidani S, et al. Effects of an abilities-focused program of morning care on residents who have dementia and on caregivers. J Americ Geriatr Society 2000;48:442-9. 26. Beck C, Heacok P, Mercer SO, et al. Improving dressing behavior in cognitively impaired nursing home residents. Nurs Res 1997;46:126-32. 27. Rogers JC, Holm MB, Burgio LD, et al. Improving morning care routines of nursing home residents with dementia. J Americ Geriatr Soc 1999;47:1049-57. 28. Feinstein AR, Horowitz RI. Problems in the ‘evidence’ of evidence-based medicine. Am J Med 1997;103:529-35.

McConnell et al

29. Schnelle J, Ouslander JO, Cruise PA. Policy without technology: A barrier to improving nursing home care. Gerontologist 1997;37:527-32. 30. Stevens A, Burgio LD, Bailey E, Burgio KL, Paul P, Capilouto E, et al. Teaching and maintaining behavior management skills with nursing assistants in a nursing home. Gerontologist 1998;38:79-84. 31. Coleman P, Watson NM. Oral care provided by certified nursing assistants in nursing homes. J Americ Geriatr Soc 2006;54:138-43. 32. Vanobbetgen JN, De Visschere LM. Factors contributing to the variation in oral hygiene practices and facilities in long-term care institutions for the elderly. Community Dental Health; 22(4):260-265. 33. Chalmers JM, Robinson J, Nankivell N. The practical oral care video-evaluation of a dental awareness month campaign. Aust Dent J 2005;50:75-126. 34. Newhouse R, Dearholt S, Poe S, Pugh LC, White KM. Evidence-Based practice: A practical approach to implementation. J Nurs Adm 2005;35:35-40.

M

A R C H

/ A

P R I L

N

U R S I N G

O

U T L O O K

105