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Ulla Britt Arvidson-Bufano, DDS, MS, Lawrence W. Blank, DDS, MS, MSOB, Janet A. Yellowitz, DMD, MPH, RDH

Nurses’ oral health assessments of nursing home residents pre- and post-training: A pilot study

The purpose of this study was to determine if instruction in how to perform the MDS (Minimum Data Set) oral health assessment and RAP (Resident Assessment Protocol) Summary required by federal regulations will improve nurses’ accuracy of the assessments. Fifty residents, admitted within 90 days before a training lecture, were assessed by 18 nurses. A 30-minute training session demonstrated how to perform an oral examination, including hands-on practice under a dentist’s supervision. Seven to ten days after the lecture, the nurses re- examined the same residents. These assessments were compared with the admission assessments and a dentist’s findings (reference). The results of this study indicate that a 3Gminute training session made a significant difference in improving nurses’ accuracy in completing the assessments with regard to oral health status and treatment need.

he population of the United States is aging. Since 1900, the percentage of the American

population over 65 years of age tripled (from 4.1% in 1900 to 12.6% in 1990), and the number increased 10- fold (from 3.1 million to 32 million),’ with the most dramatic increase in the 85+-year cohort.2 Longevity is also increasing. With the US population projected to reach 302 million by the year 2040, the 65+ age group will constitute more than 22% of the total popula t i ~ n . ~ These demographic changes will increase the number of individuals with health conditions likely to require management in a long-term care (LTC) fa~ili ty.~ In 1990,1.8 million people lived in long- term care facilities,l and this population is projected to increase one-third by the year 2000 and double by 2020.5

Oral health is critical to an elderly person’s quality of life.6,7 The retained dentition often has complex care needs, presenting difficult oral hygiene challenges for medically compromised elderly.*r9 With an increasing number of retained natur- al teeth and exposed root surfaces, caries is a problem in aging cohorts. Additionally, with increasing age, a smaller percentage of decayed teeth is being treated.4J0 Periodontal disease is present in virtually all elderly populations, and extensive untreated periodontitis is found.”J2 In addi- tion, mucosal disorders are often seen in the very old.13 Despite these oral

problems, as the population grows older, visits to the physician increase, while dental visits decrease.14

State governments assumed responsibility for regulation and quality control of nursing homes in the early 1950’s, and the federal government became involved in the mid- 1960’s. The state governs standards through requirements for licensure, and the federal government requires nursing homes to have a state 1i~ense.l~ Among the most closely regulated of all institutions, nursing homes in the 1970’s were still far from ideal.I6 Studies sponsored by the Federal Health Care Financing Administration (HCFA) and legal action brought by residents of nursing homes during the 1970‘s and 1980’s highlighted the need for change.17

The US Congress called for a study, and the HCFA contracted with the Institute of Medicine of the National Academy of Sciences to evaluate existing regulations and to recommend improvements in nursing home care.I8 Many of these rec- ommendations are included in Congress’ Omnibus Budget and Reconciliation Act (OBRA) of 1987,l7,I9 made effective October, 1990, with final regulationsz0 taking effect on April 1, 1992. Congress required the HCFA to issue regulations and guidelines implementing the new law. The HCFA developed the Resident Assessment Instrument

58 SCD Special Care in Dentistry, Vol16 No 2 1996

Table 1. Oral health conditions recorded by nurses and a dentist (reference).

Oral Health Initial Assessment Condition Assessment (YO) after Lecture (YO) Dentist (“/a) MDS Debris prior to going to bed at night

Has dentures or removable bridges

Teeth lost-does not have or use dentures

Broken, loose, or carious teeth

Inflamed gums; abscesses, ulcers, or rashes

Daily cleaning of teeth/dentures

RAP Summarv Proceed/further dental treatment

0

54

18

2

2

92

6

number of agreements with the dentist.

between the participating residents’ admission assessments and the training lecture given to the nurses by the dentist was 35 days. The lecture pre- sented how to perform an oral assessment and the importance of using the tools demonstrated. Seven to ten days after the lecture, nurses re- examined the same residents. Comparison of these assessments with the admission assessment (before training) and the dentist’s findings constituted the data for statistical analysis.

The mean number of days

Training lecture

The aim of the 30-minute training lecture was to instruct participating nurses on how to perform the oral assessment required in the MDS/RAP assessment, and how to use the information in the RAI Manual. All nurses who participated

44

60

34

30

44

88

56

58

38

38

58

82

46 56

in the study received the same lec- t ~ r e . ~ ~

The lecture consisted of: tool demonstration; infection control discussion; viewing of the videotape, ”Extra Oral and Intra Oral Examination in the Home”?O demon- strating a step-by-step examination routine on a resident; nurses practic- ing a three- to four-minute assessment routine on a resident under the supervision of the dentist; and a slide show of trigger conditions that would result in an indication on the RAP Summary for further evaluation and/or treatment. Topics reviewed included: mouth pain; oral hygiene; debris; broken, loose, or carious teeth; inflamed, swollen, or bleeding gums; abscesses, ulcers, lesions, or rashes, including candidiasis, acute infec- tions, and cancer; and lost or ill-fit- ting dentures. The lecture empha- sized that the purpose of the RAI instrument is not to diagnose specific diseases or conditions, but rather to serve as a screening tool for problem

identification. The lecturer also stressed the importance of referral to a dentist or physician when a trigger is found.17

Statistical tests A matched-pairs t test analyzed the number of agreements on the nurses’ pre- and post-training assessments with the dentist’s findings (N = 18). Chi-square tests compared pre- and post-training assessments on each of the six MDS items and the RAP Summary. Investigators used a 95% confidence level (statistical signifi- cance, p < 0.05).

Results

The residents’ oral health status Participating residents were predom- inantly female (74%), with ages’rang- ing from 65 to 97 years. Table 1 lists the percentage of “yes” responses on each item of residents’ oral health status as recorded on the MDS assessment form by the nurse pre- and post-training, and by the dentist, whose findings served as a reference.

The items with the greatest differences in the nurses’ observations of the residents’ oral health status from before to after the training were: ”Debris prior to going to bed at night” (from 0% to 44%); ”Inflamed gums, abscesses, ulcers, and rashes” (from 2% to 44%); and the ”RAP Summary” (from 6% to 46%). The RAP Summary is positive if any one of the six items is triggered. The item with the smallest difference, “Daily cleaning of teeth and dentures,” decreased from 92% before the training to 88% after (Table 1).

Impact of training on nurses’ performance on the oral health assessment

For the six MDS items and the RAP Summary (combined into one depen- dent variable) studied, investigators recorded the number of agreements with the dentist on the initial and sec- ond assessments for each nurse. According to a matched-pairs t test, there were significantly more agreements with the dentist for assess-


ments completed after (mean = 6.16 k 0.87) than before the lecture (mean = 4.3 1.32) ( t = 3.768, p IO.001).

Investigators also performed a matched-pairs t test on five of the seven items, eliminating ”debris ...” and “daily cleaning...”. This information was considered secondary, i.e., usually collected by the nursing assistants and related to the nurses.25 For the five items, there remained significantly more agreements with the dentist after the nurses’ training lecture (mean = 4.57 f 0.55) than before (mean = 3.08 _+ 1.06) (t = 4.032, p 5 0.001).

The impact of training on assessment of each item A chi-square test evaluated each of the seven items, comparing nurses’ agreements pre- and post-lecture with the dentist (Table 2). Nurses’ agreed with the dentist reference significantly more frequently after than before training on six items (p 50.05). The item ”Daily cleaning of teeth and dentures” was not significant (Table 2).

Direction of disagreement on each item-False-positive or false-negative

Investigators evaluated each item to determine the direction of disagreement with the dentist reference. The nurse marking an item that the dentist did not record constituted a false- positive (over-reporting). A false- negative (under-reporting) occurred when the nurse did not mark a condition or disease that the dentist reported.

At the nurses’ initial assessments, there were 206 agreements, while the number of agreements after the training was 306. The 17 false-positive recordings decreased to 11, and the 127 false-negatives decreased to 33 after the lecture (Table 3). ”Daily cleaning ...” had the greatest number of false-positives both before (9) and after (5) the lecture. ”Broken, loose, or carious ...” and ”Inflamed gums, abscesses ...” had no false-positive disagreements either pre- or post-lecture. The 28 false-negative recordings

Table 2. Nurses’ number and percentage of agreements with the dentist on MDS and

RAP assessments pre- and post-lecture (N 50).

Oral Health Initial Assessment Status Assessment after Lecture X2 Value P MDS Debris prior to going to bed at night

Has dentures or removable bridges

Teeth lost- does not have or use dentures

Broken, loose, carious teeth

Inflamed gums, abscesses, ulcers, or rashes

Daily cleaning of teeth/dentures

RAP Summarv

Proceed/ further dental treatment

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

22 (44%) 28

38 (76%) 12

30 (60%) 20

32 (64%) 18

22 (44%) 28

37 (74%) 13

25 (50%) 25

on ”Debris ...” and “Inflamed gums, abscesses ...” dropped to 8 and 7, respectively, after the lecture.

Discussion The results of this study indicate that a brief educational intervention significantly improved nurses’ accuracy in assessments of six MDS oral health items and the RAP Summary (Proceed / further dental treatment needed). The variability in the nurses’ assessments (shown in the change in standard deviations) also decreased after the lecture. The nurses’ awareness of being part of a study and the dentist’s presence most likely contributed to the results. Significant increases were found on all items except ”Daily cleaning of teeth and

40 (80%) 10

47 (94%) 3

46 (92%) 4

46 (92%) 4

43 (86%) 7

43 (86%) 7

41 (82%) 9

13.752

6.353

14.035

11.422

19.385

2.250

11.408

2 0.0001

2 0.05

5 0.0001

5 0.0001

I0.0001

> 0.05

5 0.001

dentures” (Table 2). Changes in the patient during the time between initial assessment to post-lecture assessment may explain some differences- for example, soft tissue changes. However, conditions frequently noted-such as red, swollen gums and irritations on denture-bearing areas-tend to be long-standing, unless treated. The mean time between nurses’ initial and dentist assessments was shorter (30 days) than between nurses’ initial and post- lecture assessments (45 days). It is unlikely that the peak in incidence of oral conditions should happen to coincide with the time of the dentist’s assessments. This suggests that change in the oral health condition did not account for the differences recorded.

SCD Special Care in Dentlstry, Vol16 No 2 1996 61

Table 3. Nurses’ number and percentage of agreements with the dentist and false-posi-

tive/false-negative disagreements (N = 350, 7 items x 50 assessments).

Disagreements Agreements False- positive

Initial exam 17 (5%)

Exam after lecture 11 (3%)

Analysis of each MDS item and RAP Summary

The nurses’ agreement with control post-training was significantly better on ”Debris in mouth prior to going to bed at night,” while no significant difference existed on ”Daily cleaning of teeth and dentures” before or after the lecture (Table 2). One explanation for this increase could be that the nurses changed their communication with the nursing assistants after the lecture. Since the day shift usually performs the MDS assessments, nei- ther the nurse nor the dentist was able to complete the assessments just ”prior to going to bed at night.” Therefore, the validity of an assessment ”prior to going to bed at night” is questionable. Also, the quality of the cleaning provided is unknown.

Another related issue is the fact that data for the oral hygiene items are collected by secondary sources (nursing assistants) used by nurses and also by the dentist.25 The information was exchanged informally, and structured communication with the nurses was lacking. Therefore, a potential for inaccuracies exists. However, the nurses’ performances on the five-pooled items (excluding the two oral hygiene items) and seven pooled items had similar results: Both significantly improved after the lecture. If nursing assistants continue to collect data for the hygiene items, they need to be trained in how to assess these items as well as on how to carry out oral hygiene on the residents. Also, systems need to be developed to struc- ture the communication between nurses and nursing assistants. Further evaluation is needed to determine the accuracy of secondary

False- negative

127 (36%) 206 (590/,)

33 (9%) 306 (8lY0) ~~

sources. Since the two oral hygiene items basically have the same source of information, and both address oral hygiene problems, the authors sug- gest that they be combined, as one way to improve the MDS instrument.

Nurses agreed with the dentist reference significantly more frequently on “Teeth lost-does not have or use dentures” after than before the lecture (Table 2). A significant improvement also occurred in ”Has dentures or removable bridges,” even though this item had the highest percentage of agreement both before and after the lecture. The disagreement that did exist on this issue reflects the difficulty in locating a denture or determining whether one exists. Facility staff usually complete a form on the day of admission that lists the resident’s prostheses. The lecture, presence of a dentist, and knowing they were part of a study may help to explain the nurses’ evaluating this issue more thoroughly after the training. To determine the reliability of information about dental prostheses on the admission form, further inves- tigations have to be carried out.

late oral soft tissue; consequently, the fewest agreements occurred on “Inflamed gums, abscesses, ulcers, or rashes” before the lecture. However, through step-by-step teaching on how to perform an assessment, pal- pating and ”moving” soft tissue (ie., cheeks, lips, and tongue) to gain visi- bility to all parts of the mouth, the nurses’ ability to detect these conditions improved significantly. This finding indicates the importance of hands-on training. The presence of a dentist most likely contributed to the nurses’ improved performance and

Nurses generally do not manipu-

suggests a need for the presence and involvement of a dentist ( ie . , Advisory Dentist) at the facility.

item had the highest number of under-reportings both before and after the lecture. The RAI Manual presents basic information on differ- ent conditions important for assess- ing oral health.17 The authors recommend that each nurse study and be familiar with the RAI Manual, since it is an important tool for understand- ing the oral health assessment of the MDS. Also, training and hands-on practice under the supervision of a dentist are recommended.

Even though the nurses had a 64% agreement with control on ”Broken, loose, or carious teeth” before the lecture, their accuracy increased significantly (92%) following the lecture (Table 2). Detecting tooth-related conditions seemed easier for the nurses than finding gingival problems or mucosal lesions. They did not have a tendency to make false-positive recordings, and the few false- negatives reported decreased after the lecture. Thus, training increased nurses’ awareness and their accuracy in detecting tooth-related lesions.

The critical RAP Summary (”Proceed/further dental treatment needed”) agreement level with the control significantly increased from 50% before training to 82% after training. However, nurses made fewer referrals than the number of reported triggers, indicating that all oral health problems were not man- aged. The training on how to identify lesions and the importance of refer- ring, plus the presence of the dentist, could have resulted in an over- reporting of ’proceed’ indications (false-positive), but this did not occur. The false-negative recordings also decreased. However, nurses still under-reported on the RAP Summary after the lecture. Even if the nurse perceives a potential problem in treating the resident, a consul- tation with the dentist or physician should always be obtained. This con- cept needs to be stressed in nurses’ training.

Considering the comprehensive

Of all MDS areas, the soft tissue


assessments required for all sections of the MDS, the time spent on the oral component is very limited. This study utilized a three- to four-minute technique for an adequate examination.

service training of LTC facility staff, oral health may not be a specified topic. In Maryland, the Advisory Dentist shall direct the LTC facility in educating the nursing staff about patients’ dentaI problems. Considering the heavy work load and often shortage of staff in LTC facilities, the training has to be kept within a time frame possible for facilities to manage. The participating facilities devoted 30 minutes a year to nurses’ oral health care in-service training. Therefore, a 30-minute lecture on the MDS oral health assessment was considered manageable for the facility. Since the nurses (RN’s and LPNs) complete the MDS assessments, teaching them how to perform oral health assessments is crucial. Hands-on training, with dentist supervision, could be carried out in association with a lecture. Another opportunity for practice could be at the dentist’s oral health examination of newly admitted residents. Each nurse completing oral health assessments could practice under the dentist’s supervision. The nursing assistants, who typically clean the residents’ mouths, should be provided with appropriate training in oral hygiene.

Mere reading about an issue or only awareness of it is insufficient preparation for an individual to practice it. There is no potential for action until one is aware of the issue, has sufficient knowledge about it, and has acquired the necessary skills for implementing it.28 Hands-on practice is therefore a necessary component of training. For successful implementa- tion of this training, nursing home administrators need an increased awareness of the importance of nurses’ training in how to perform MDS oral health assessments. Furthermore, the Advisory Dentist, who is responsible for counseling the nursing home on oral health care in-service train-

Although states may require in-

ing, should make training nurses to perform oral health assessments a priority.

Further studies to evaluate other methods of delivering the material may be necessary. A follow-up study, with a larger sample, is needed to determine the long-term effects of training given in this pilot project. Furthermore, evaluation is needed to determine the validity of the oral health component of the MDS/RAP screening tool.

Conclusions Within the limits of this pilot study, the following conclusions are made:

(1) Training of nurses, including hands-on practice, significantly improved the accuracy of completing the MDS admission assessment and RAP Summary with regard to oral health status and treatment need.

(2) The presence of the dentist most likely contributed to the results. This suggests that the involvement of a dentist, i.e., Advisory Dentist, is important in training and supervis- ing nurses responsible for completing oral health assessments.

(3) Further evaluation is necessary to determine the accuracy of secondary sources. Training should also be offered to them. Systems of structured communication between nursing assistants and nurses need to be developed.

(4) The validity of an assessment ”prior to going to bed at night” is questionable and should be further investigated.

(5) Follow-up study of nurses’ performance on the oral health assessments of the MDS and RAP Summary, using a larger sample, is necessary in determining the long- term effects of training.

Dr. Arvidson-Bufano is Staff Dentist, Advanced Education in General Dentistry,

University of Maryland Dental School, Baltimore, Maryland. Dr. Blank is Associate Professor and Director, Advanced Education in General Dentistry, University of Maryland Dental School, 666 W. Baltimore St., Baltimore, MD 21201. Dr. Yellowitz is Assistant Professor, and Director, Geriatric Dentistry, Oral Health Care Delivery Department, University of Maryland Dental School, Baltimore, Maryland.

This article is part of Dr. Bufano’s Master’s Thesis, completed in partial fulfillment of requirements for a Master of Science Degree at the University of Maryland.

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