Evidence based practice

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Colleen J. Klein, PhD, APN, RN, FNP-BC, is Education and Research Scientist, Advanced Practice, OSF HealthCare, Peoria, IL. She was Director of Professional Practice and Research, OSF Saint Anthony Medical Center, Rockford, IL, at the time this study was conducted. Patricia S. Hamilton, BSN, RN, CMSRN, is Registered Nurse, Intensive Care Unit, Mercy Health System, Lake Geneva, WI. She was Nursing Care Manager, Medical Telemetry and Stroke-Designated Unit, OSF Saint Anthony Medical Center, Rockford, IL, at the time this study was conducted. Gayle L. Kruse, RN, ACHPN, GCNS-BC, is Advanced Practice Nursing Instructor, OSF Saint Anthony College of Nursing, Rockford, IL. She was Gerontological Clinical Nurse Specialist, OSF Saint Anthony Medical Center, Rockford, IL, at the time this study was conducted. Christine A. Anderson, APN, RN, ACNS-BC, is Cardiovascular Clinical Nurse Specialist, OSF Saint Anthony Medical Center, Rockford, IL. Andrea S. Doughty, PhD, is Associate Professor, OSF Saint Anthony College of Nursing, Rockford, IL. Acknowledgment: The authors would like to acknowledge Sage Products, Inc. for providing oral care kits at no cost that were used on the treatment unit and representatives for the in-service education.

Delegation, Documentation, and Knowledge of Evidence-Based

Practice for Oral Hygiene

O ral care is a primary compo- nent in the prevention of hospital-acquired infection

(Hanne, Ingelise, Linda, & Ulrich, 2012). Evidence-based protocols have been established for the man- agement of patients in the intensive care unit (ICU) and are deemed effective in reducing the incidence of ventilator-associated pneumonia (Munro, 2014). However, previous research found many nurses fail to integrate current evidence into practice (Chan & Ng, 2012). Research on the topic of oral health has been focused primarily on patients in the ICU, with variations in oral care protocols (Parsons, Lee, Strickert, & Trumpp, 2013). Munro (2014) strongly recommended fur- ther re search outside the ICU to improve quality of care in other set- tings.

Multiple factors may contribute to the delivery or omission of oral care for medical-surgical patients. For example, Chipps and colleagues (2014) suggested oral care may not be considered a high priority. In addition, efforts to provide effi- cient, cost-effective care include use of registered nurses (RNs) and nurs- ing assistants to deliver hospital- based care, resulting in a potential for role blurring and conflict (Kalisch, 2015). Hill, Tuck, Ranner, Davies, and Bolieiro-Amaral (2014) stressed the importance of the RN’s role in completion of oral care assessment and his or her accounta- bility for delegation to the nursing assistant. Because patient care out- comes are influenced by the skill mix of care providers, research

should address not only the hospi- tal unit but also the staff member providing oral care for medical-sur- gical patients (Kalisch, 2015).

Research Questions The following research questions

were used for this study: 1. What is the current level of

knowledge regarding evidence- based oral hygiene among nurs- es and certified nursing assis- tants (CNAs)?

2. Does the completion of an evi- dence-based program improve the frequency of oral assessments, oral hygiene care, and documen- tation by nurses and CNAs?

3. How does delegation of oral hygiene affect the frequency and documentation of patient oral care?

Review of Literature A lack of research exists for adult

medical-surgical patients and oral care. An extensive literature search (2009-2015) was conducted before and after study completion in CINAHL, Ovid MEDLINE, and Evidence-based Medicine, including the Cochrane Library, for English- language literature. The following key words were used: oral hygiene, dental hygiene, dental care, oral care, oral health promotion, and inpatients.

Research for PracticeResearch for Practice

Colleen J. Klein, Patricia S. Hamilton, Gayle L. Kruse, Christine A. Anderson, Andrea S. Doughty

To improve oral hygiene practice for patients on medical-surgical units, authors examined knowledge, practice, documentation, and delegation of oral hygiene among registered nurses and certified nursing assistants.

July-August 2017 • Vol. 26/No. 4 243

Prior research predominantly in - cluded specialized patient groups and nurses (Chan & Ng, 2012; Chipps et al., 2014; Perry, Hiroko, & Patton, 2015). Although the few existing studies are not considered recent publications, their inclusion here is relevant to discussion of oral health in hospitalized patients.

Chan and Ng (2012) used a 31- item questionnaire to assess atti- tudes, knowledge, and oral care practices of nurses caring for criti- cally ill patients. A response rate of 97% (n=244) was reported. Key findings indicated nurses’ oral care knowledge varied with education (p=0.019). The clear majority of nurses (80.2%, n=194) agreed or strongly agreed with the need for more research-proven oral care standards. Researchers noted the limited generalizability of the find- ings beyond the ICU setting.

Pai and Ongole (2015) used a cross-sectional survey design to assess the knowledge of 158 oncol- ogy nurses with at least 1 year of oncology experience working in four hospitals in India. The study was conducted over 4 months. Most nurses (51.3%, n=81) had poor knowledge of oral care in patients with cancer. When questioned, 115 nurses (72.8%) reported lacking basic education for oral care specific to patients with cancer. Authors suggested the need for assessment of existing practices, development of training modules specific to man- agement of patients with cancer, and use of evidence-based protocols for oral care.

Gravlin and Bittner (2010) inves- tigated frequency of and reasons for missed nursing care using a survey and questionnaire in a quantitative, descriptive, exploratory study. Mouth care was one of the most frequently reported missed nursing care items by RNs and nursing assistants, with 84% of RNs (n=241) and 44% of nursing assistants (n=99) reporting this finding. Communi cation, com- petence, and knowledge of the assistant were factors affecting the success of delegation.

Kessler, Heron, Dopson, Magee, and Swain (2010) completed a

three-phase mixed-methods study to investigate the nature and conse- quences of nursing assistants in a hospital setting. Observational data (n=275) indicated nursing assistants spend more time providing direct personal care to patients than nurs- es do. Former patient survey find- ings for overall ratings of oral care (n=1,651) noted a positive and sig- nificant relationship (F=52.20, p=0.000) between patients’ knowl- edge of nursing role differences between RNs and nursing assistants, and quality of care. Recommen - dations included better role prepa- ration for different aspects of the nursing assistant role and greater clarity on delegation of appropriate nursing tasks to nursing assistants.

Gibney, Wright, Sharma, and Naganathan (2015) surveyed 94 RNs and 37 nursing assistants on two aged care wards in different Australian hospitals. Their purpose was to identify current practice and barriers to oral care delivery. Patient care-resistive behaviors were desig- nated by 57.4% of the nurses (n=54) and 41.7% (n=39) indicated no mouth care protocol existed. Rec - ommendations were like those of Pai and Ongole (2015), but with a focus on older adult patients.

Kalisch, McLaughlin, and Dab - ney (2012) captured the patient per- spective using semi-structured, face- to-face interviews. On seven patient care units in an acute care hospital, 38 inpatients described mouth care as one of the fully reportable missed items of nursing care. The nurses’ role involved offering oral care sup- plies upon patient admission to the unit; however, this did not occur for a few patients. Patients in the ICU and rehabilitation unit reported more assistance with mouth care. Limitations of the study were not reported, but results supported the value placed on patients’ perception of quality of care.

Prior investigators identified the need for additional research that considers use of delegation and effective methods for preparing unlicensed staff (Kalisch, 2015; Kessler et al., 2010). Development of optimal oral care interventions is

needed in settings beyond ICU. This study adds new knowledge regard- ing delegation practices, role re - sponsibilities, and appropriate edu- cational methods for nursing assis- tants. Additionally, support for use of an oral care standard for medical- surgical patients is described.

Ethics Approval was obtained from the

Institutional Review Board (IRB) at the study site before research began. The study was introduced in staff meetings with an explanation of voluntary participation. To protect anonymity, researchers provided respondents with a survey invita- tion letter; a separate signed in - formed consent was not required. In consultation with the IRB, a waiver for documentation of con- sent by patients was obtained because the study was guided by the evidence-based protocol and trans- lational research for oral hygiene completed by Johnson and Chalm - ers (2011).

Sample Selection Patients admitted to the medical

telemetry, stroke-designated unit (intervention), and two medical- surgical telemetry units (control) were engaged in the study. Stand - ardized acuity tools and the Braden Scale were used to ensure patients with similar dependency needs were selected for enrollment. Although the proportion of patients who met the criteria for inclusion was different across the three units, enrolled patients were evaluated statistically and confirmed to be comparable by use of chi-square (acuity measures) and analysis of variance (Braden Scale). Nursing staff participants were drawn from approximately 316 nurses and 144 CNAs from all inpatient adult care areas.

Patient enrollment was complet- ed November 8, 2010-March 31, 2011. Patients were selected from Monday-Friday admissions. Approx - imately nine patients were selected each week using census and acuity tools from each unit. Newly admit-

Delegation, Documentation, and Knowledge of Evidence-Based Practice for Oral Hygiene

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ted patients who met the following criteria were considered for inclu- sion in the study: dependent patients requiring assistance with feeding or having swallowing prob- lems, having cognitive or functional impairment, or requiring assistance with oral hygiene or dependent on a caregiver for daily care (Johnson, 2012). The treatment group includ- ed 133 patients; 113 patients met inclusion criteria from the control units. Study inclusion criteria and unit-based acuity tools were used to designate patients from 1 (highest acuity) to 4 (lowest acuity). This stan- dardization allowed researchers to classify patients’ likelihood for need- ing assistance and helped assure complete random selection of pat - ients for inclusion.

Design and Methods This study was conducted at a

250-bed Level 1 trauma center in the midwestern United States. A quasi-experimental, nonrandom- ized prospective design with a non- equivalent comparison group of patients was used. Based on an intent-to-treat analysis, researchers determined all patients would receive oral care as a routine, expected part of nursing care at the study site. A pre-posttest design was used to determine the impact of an educational intervention on nurses and CNAs. The study was complet- ed in four phases: 1. Assessment of knowledge of RNs

and CNAs through use of a pre- test before a formal education session; baseline audit of elec- tronic medical records (EMR) for frequency of oral assessment

2. Education of staff using a newly developed evidence-based oral care protocol (intervention)

3. Assessment of knowledge fol- lowing completion of the educa- tion session (post-test)

4. Implementation of the oral care protocol and alignment of nurs- ing practice across medical-sur- gical units

a. Standardized oral care man- agement, including assess- ment, frequency, indications for product use, delegation,

and documentation require- ments for CNAs and RNs

b. For treatment groups, a pre- packaged oral care kit with six individually wrapped options for oral care before and after meals available to nursing staff in patient rooms; for comparison con- trol group, standard prod- ucts (swabs, toothbrushes, mouth-moisturizer) avail- able on the unit in clean sup- ply areas.

After collection of baseline data, all nurses and CNAs on participat- ing units received mandatory edu- cation in late October before the implementation of the oral care pro tocol. Nurses and CNAs from the internal float pool (supplemen- tal staff) were partnered with treat- ment unit staff because of likely assignment. Separate educational sessions were scripted and delivered by two researchers to ensure all par- ticipants received the same infor- mation. Educational programs en - compassed evidence-based recom- mendations for oral care, delega- tion, and frequency and documen- tation of oral care and product use. Researchers reviewed and approved an additional 10-minute education segment provided to treatment unit staff by a representative from Sage Products, Inc. (Cary, IL). Nurses were instructed to use nursing judg- ment, the evidence-based protocol, and autonomy for selection of products used in the care of pa - tients. A voluntary post-test using the same pre-test questions (re - ordered) was provided to all staff.

Data collection began within 1 week after completion of education on participating units. During the 3-month data collection period, nurses on the treatment unit were given the option of using a pre- packaged oral care kit to deliver oral hygiene. A paper audit tool was used to document staff members’ role for oral care completion and product usage. This tool validated the accuracy of electronic oral care documentation through weekly comparison by the researchers.

Instrument – Questionnaire

Questions regarding evidence- based oral care were developed using previous studies and guide- lines (Johnson & Chalmers, 2011). The pre-survey contained three sec- tions: oral care practices, evidence- based knowledge, and delegation. Separate surveys for RNs and CNAs were used as different questions were needed to assess delegation and documentation from role per- spective. Ten evidence-based know - ledge questions were used in vari- ous formats (e.g., true-false, multi- ple choice, multiple response). Current position, years of nursing experience, highest nursing degree, years of ICU experience, and desig- nated unit also were obtained. The frequency of performing certain ac - tions, including documentation, delegation, and communication, was obtained from RNs and CNAs.

Findings To assure comparability of the

participating units, researchers used one-way analysis of variance (ANOVA) to test for differences before units were combined for analysis. Pre- and post-knowledge tests were analyzed using t-tests for independent samples. Rates were examined using nonparametric sta- tistics. Data were analyzed using IBM Statistical Package for Social Sciences (SPSS) version 19.0 (IBM SPSS Inc.; Armonk, NY).

The pre-survey response rate for nurses was 33.5% (n=106) and 38.9% for CNAs (n=56). In the sec- ond phase of the study, 105 nurses (33.2%) and 68 CNAs (47.2%) from treatment and control units as well as the supplemental staff attended the education program. The post- test was optional following the edu- cation program.

Question One No significant differences were

found across units for nurses or CNAs. However, pre-survey results demonstrated significant difference between the knowledge level of nurses versus CNAs (p<0.01). Nurses

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scored significantly higher, but both groups demonstrated learning needs regarding current evidence for oral care management. At the post-test, a significant difference in knowledge existed between nurses and CNAs, with both groups mak- ing substantial gains in knowledge scores (p<0.01) (see Table 1).

A higher level of evidence-based knowledge was noted among the RNs on question-by-question analy- ses. The contingency coefficient was

significant (p<0.05) for more than half the questions, indicating RNs had a higher percentage of correct answers compared to CNAs. An 80% cut-point was determined as an acceptable passing score for both groups. The topics that failed to reach the target included saliva lev- els and prescribed medications (RNs and CNAs), and age, aspiration, cog - nitive level, denture care, diet, pro- tocol recommendations, and xeros- tomia (CNAs only).

Question Two Randomized chart audits were

completed on inpatient units on five dates. Pre-study chart audits revealed minimal documentation; only 22% of the selected records contained a documented oral assess- ment and 18% included a reference to oral hygiene. After the education session, control and treatment units were reassessed. Information on documentation of oral assessment was collected only if it was noted in

TABLE 1. Participant Survey: Comparison of Percentage Correct Answers, RNs, and CNAs

Question

RN CNA N=106 N=105 N=56 N=68

Pre-Test Post-Test Pre-Test Post-Test 1. Research has shown that foam swabs (toothettes)

are more effective than tooth brushing for plaque removal. (T/F)

80.2 96.2 73.2 92.6

2. If the patient has an oral infection, protocol recommends oral care be completed... (M/C)

70.1 83.8 55.4 72.1

3. Standardized oral care practice increases the risk of aspiration pneumonia to susceptible patients by introducing more microorganisms into the oral cavity. (T/F)

81.3* 82.9** 53.6 60.3

4. Xerostomia is... (M/C) 59.8 92.4** 51.8 69.1 5. Dental plaque is capable of becoming colonized with

MRSA. (T/F) 83.2 96.2** 73.2 85.3

6. Which statement about denture care is false? (M/C) 79.4* 90.5** 57.1 69.1 7. Lemon glycerin swabs are useful in moisturizing the

oral mucosa. (T/F) 22.4 89.5 12.5 85.3

8. Those at increased risk for oral diseases include: (M/C) 97.2* 91.4 82.1 83.8 9. Low levels of saliva influence the development of dental

caries by causing the oral environment to become more alkaline. (T/F)

15.9 67.6** 14.3 38.2

10. Which of the following factors influence the need for an oral assessment to be completed every shift? (M/R) a. Age 87.9 85.7** 80.4 73.5 b. Cognitive level 92.5 91.4** 83.9 79.4 c. Prescribed medications 91.6* 79.0 69.6 67.6 d. Diet modifications 90.7* 86.7** 75.0 67.6

Total Score: # ^ 73.1 ± 16.9*** 87.2 ± 17.3**** 60.2 ± 16.0 72.6 ± 22.2 M/C = multiple choice; M/R = multiple response; T/F = true/false; questions 1, 4, 6-10 referenced by Johnson & Chalmers, 2011 * Contingency coefficient significant (p<0.05) indicating percentage correct different at pre-test on these items. ** Contingency coefficient significant (p<0.05) indicating percentage correct different at post-test on these items. *** RN and CNA total scores significantly different at pre-test (t=4.716, df=160, p<0. 01) **** RN and CNA total scores significantly different at post-test (t=4.585, df=118.321, p<0.01) #RNs’ total score significantly higher at post-test (t= -5.998, df=209, p<0.01) ^ CNAs’ total score significantly higher at post-test (t= -3.626, df=120.06, p<0.01)

Delegation, Documentation, and Knowledge of Evidence-Based Practice for Oral Hygiene

July-August 2017 • Vol. 26/No. 4246

the EMR restricted to RN documen- tation area (CPM Resource Center, 2012). Inter ventions were consid- ered if they were selected from the available choices or specific com- ments were documented about oral care interventions. A two-way con- tingency table analysis revealed sig- nificant differences in the frequency of assessment among the nurses on the treatment unit compared to the control unit (Pearson c2 = 47.28, df=4, p=0.000). Nurses on the treat- ment unit documented an oral assessment at least every 8 hours for 72% of patient days (n=282) com- pared to the control units, where 50.7% of patient days (n=144) had a nurse assessment every 8 hours or more often. No assessment was noted in the EMR for 16.1% of patient days (n=63) on the treat- ment unit compared to 36.6% of patient days (n=104) on the control unit. Documentation for all study units improved from the pre-study audit.

Question Three RNs and CNAs received educa-

tion on delegation responsibilities, with requirement of RN assessment once per shift. For challenging patients, RNs were given the option to provide oral care rather than del- egate the task to CNAs. If problems were noted, RNs were expected to reassess the situation and provide oral care if a higher level of skill/ knowledge was needed.

A significant difference was found between treatment and con- trol units on the amount of care provided by the RNs (Pearson c2 =70.147, df=2, p=0.000). On the treatment units, no oral care was provided by RNs on 68.4% of the patient days (n=270); however, for 12.4% of patient days (n=49), oral care was provided at least once by RNs. Oral care by RNs was provided almost exclusively to patients cate- gorized as the highest acuity. On

the control units, oral care was not documented by RNs on 85.2% of patient days (n=281).

For frequency of oral care provid- ed by CNAs, significant differences were found between treatment and control units (Pearson c2 =174.09, p=0.000). Oral care was performed one to five times on the majority of patient days (67.2%, n=266), with the most frequent report being at least once daily (18.9%, n=75) on the treatment unit. On the control unit, CNAs reported providing oral care one to two times per patient day (49.1%, n=162). Documenta - tion was absent on 12.9% of patient days (n=51) on the treatment unit compared to 34.2% of patient days (n=113) on control units.

Discussion Results of this study supported

other findings of a lack of knowl- edge regarding evidence-based prac- tices for oral care (Chan & Ng, 2012; Pai & Ongole, 2015). Despite desig- nation of oral care as basic care, education specific to each caregiver may result in better knowledge retention (Kessler et al., 2010). The CNA curriculum should emphasize skills, task importance, and symp- tom reporting. CNAs can be instructed to report complaints of dry mouth, visible symptoms such as dry lips, and requests for addi- tional fluids. Approximately 40% of RNs (n=103) reported they frequent- ly perform an oral assessment before oral care is completed by CNAs. Interestingly, only 21.7% of CNAs (n=56) in the pre-survey ques- tionnaire indicated they frequently reported an abnormal finding to an RN. These results confirmed previ- ous findings of communication breakdown with delegation; hud- dles and debriefings may be effec- tive strategies to improve RN/CNA communication and avoid care omissions (Gravlin & Bittner, 2010).

A need exists for a standardized evidence-based protocol. For exam- ple, the frequency of missed oral care by CNAs on the control units was slightly less (34.2%, n=113) than reported by Gravlin and Bittner (2010). In that study, 44% of mouth care (n=99) was reported as missed by nursing assistants. Findings of the current study sup- ported the frequency of documen- tation and provision of oral care by CNAs. More CNAs were likely to document oral care on the treat- ment unit.

Oral assessment and its impor- tance were noted by nurses, but not all nurses indicated they complete an assessment even during patient admission; these findings are signif- icantly different than those report- ed more recently by Gibney and colleagues (2015), who noted nurs- es did not complete an oral assess- ment as it was not required. On the treatment unit, oral assessment was documented more frequently (com- monly every 8 hours). Because patient acuity was higher on the treatment unit, oral assessment may have been viewed by nurses as more important.

Although oral care was primarily a delegated task, RNs on the treat- ment unit performed oral care for patients. Electronic and paper docu- mentation indicated CNAs assume the primary responsibility for docu- mentation and completion of oral care. This study supports the need for increased education for CNAs regarding frequency, process, and associated risks in providing oral hygiene in the hospital setting. Gibney and co-authors (2015) acknowledged the need to expand nurses’ education beyond basic edu- cation, confirming the knowledge deficits reported here.

Limitations Study findings are from one hos-

pital and thus do not reflect nursing management of patients on med- ical-surgical units in other hospi- tals. Survey questions, although drawn from the literature, were not used in prior studies. Educational preparation of RNs and CNAs may

Research for Practice

Patients will benefit in multiple ways from a focus on consistent delivery of oral care

by nursing personnel.

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have impacted the results, as well as differences between treatment and control settings. Potential bias in the results may exist because units to which supplemental staff were assigned could not be controlled by researchers.

Recommendations for Future Research

Further research focused on older adults on medical-surgical units could advance oral care practice rec- ommendations for this complex patient group. Delegation practices that include oral care, more specifi- cally between RNs and nursing assistants during handoffs, should be studied. With the mandate for EMRs in health care, the presence or lack of documentation fields for oral care assessment and manage- ment may impact oral care prac- tices. A retrospective chart review could be performed as a multi-site study. Common data elements for oral care documentation also should be studied. Standardized protocols and educational programs for healthcare workers related to oral care could be compared for simplicity and effectiveness.

Nursing Implications Evidence from this study indicat-

ed a lack of knowledge concerning delegation practices. Role delin- eation and appropriate delegation provide a means for evaluation of accountability within the unit. Prevention of higher mortality rates, increased lengths of stay asso- ciated with complications, better patient satisfaction, and higher costs are important reasons for designing education programs for basic nursing care by CNAs (Fernández & Clavé, 2013; Kessler et al., 2010).

Accountability for the completion of oral care rests with nurses (Kalisch, 2015). Nurses can help cre- ate succinct guidelines that include

expectations for documentation and delegation, and reporting of suspi- cious findings and patient com- plaints. Increased awareness of dele- gation principles may contribute to improved reassessment and evalua- tion of completed tasks. Given typi- cally reported time constraints, an expectation of at least twice-daily oral care may be more achievable for medical-surgical patients. Nurses can determine when the need for more frequent oral care exists. Open com- munication between nursing assis- tants and RNs is vital to providing basic care.

Conclusion Elevating oral care as a priority in

the eyes of nurses and CNAs is essential to the provision of quality care within medical-surgical units (Chipps et al., 2014). Patients will benefit in multiple ways from a focus on consistent delivery of oral care by nursing personnel. This study, which provides a perspective that was missing from the litera- ture, will help to inform the stan- dardization of practice for oral care within the medical-surgical setting.

REFERENCES Chan, E., & Ng, I.H.L. (2012). Oral care prac-

tices among critical care nurses in Singapore: A questionnaire survey. Applied Nursing Research, 25(3), 197- 204.

Chipps, E., Gatens, C., Genter, L., Musto, M., Dubis-Bohn, A., Gilemmo, M., … Landers, T. (2014). Pilot study of an oral care protocol on stroke survivors. Rehabilitation Nursing, 39(2), 94-101.

CPM Resource Center. (2012). Clinical prac- tice guideline: Altered mucous mem- brane. [computer software]. Grand Rapids, MI: Elsevier.

Fernández, O.O., & Clavé, P. (2013). Oral hygiene, aspiration, and aspiration pneu- monia: From pathophysiology to thera- peutic strategies. Current Physical Medicine and Rehabilitation Reports, 1(4), 292-295.

Gibney, J., Wright, C., Sharma, A., & Nagana - than, V. (2015). Nurses’ knowledge, atti- tudes, and current practice of daily oral hygiene care to patients on acute aged

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Gravlin, G., & Bittner, N. (2010). Nurses’ and nursing assistants’ reports of missed care and delegation. Journal of Nursing Administration, 7(8), 329-335.

Hanne, K., Ingelise, T., Linda, C., & Ulrich, P.P. (2012). Oral status and the need for oral health care among patients hospitalised with acute medical conditions. Journal of Clinical Nursing, 21(19, pt20), 2851- 2859.

Hill, K., Tuck, A., Ranner, S., Davies, N., & Boli eiro-Amaral, K. (2014). The use of a nursing and oral nutritional assessment tool to improve patient outcomes – One centre’s experience. Renal Society of Australasia Journal, 10(1), 6-10.

Johnson, V.B. (2012). Oral hygiene care for functionally dependent and cognitively impaired older adults. Journal of Geron - tological Nursing, 38(11), 11-19.

Johnson, V., & Chalmers, J. (2011). Oral hygiene care for functionally dependent and cognitively impaired older adults. Iowa City, IA: University of Iowa College of Nursing,

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Kalisch, B., McLaughlin, M., & Dabney, B. (2012). Patient perceptions of missed nursing care. The Joint Commission Journal on Quality and Patient Safety, 38(4), 161-167.

Kessler, I., Heron, P., Dopson, S., Magee, H., & Swain, D. (2010). The nature and conse- quences of support workers in a hospital setting. Final report. National Insti tute for Health Research Service Deliv ery and Organisation Programme. Retrieved from https://www2.rcn.org.uk/__data/assets/ pdf_file/0009/396981/The_nature_and_ consequences_of_support_workers_in_a _hospital_setting.pdf

Munro, C. (2014). Oral health: Something to smile about. American Journal of Critical Care, 23(4), 282-288.

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Delegation, Documentation, and Knowledge of Evidence-Based Practice for Oral Hygiene

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