Review
Mouth care for orally intubated patients: A critical ethnographic review of the nursing literature

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Summary

Objectives

The aim of this critical ethnographic literature review was to explore the evolution of nursing discourse in oral hygiene for intubated and mechanically ventilated patients.

Methods

The online databases CINAHL and MEDLINE were searched for nurse-authored English language articles published between 1960 and 2011 in peer-reviewed journals. Articles that did not discuss oral problems or related care for intubated adult patients were excluded. Articles that met the inclusion criteria were chronologically reviewed to trace changes in language and focus over time.

Results

A total of 469 articles were identified, and 84 papers met all of the inclusion criteria. These articles presented an increasingly scientific and evaluative nursing discourse. Oral care originally focused on patient comfort within the literature; now it is emphasized as an infection control practice for the prevention of ventilator-associated pneumonia (VAP). Despite concern for its neglected application, the literature does not sufficiently address mouth care's practical accomplishment.

Conclusions

Mouth care for orally intubated patients is both a science and practice. However, the nursing literature now emphasises a scientific discourse of infection prevention. Inattention to the social and technical complexities of practice may inhibit how nurses learn, discuss and effectively perform this critical aspect of patient care.

Introduction

Maintaining oral health in the critically ill patient is an essential nursing activity (Berry and Davidson, 2006). In the intensive care unit, the mouth often facilitates entry for life-sustaining interventions, such as endotracheal intubation for ventilation and orogastric tubes for enteral nutrition. Unfortunately, these interventions require the patient to maintain an open mouth (Kite, 1995) and impair the natural airway defenses (O’Keefe-McCarthy, 2006). This vulnerable position, in combination with other treatments, can contribute to a rapidly deteriorating oral state and a dependence on nursing (Stonecypher, 2010) to alleviate tube-related discomfort (Samuelson, 2011), thirst (Landström et al., 2009), oral lesions (Treloar and Stechmiller, 1995) and the accumulation of saliva, sputum and oral bacteria (Blot et al., 2008). Therefore, the state of a patient's mouth can be an index of nursing care received (Crosby, 1989).

Of the many oral problems that can arise during critical illness, ventilator-associated pneumonia (VAP) is now the major justification for frequent oral hygiene. Since the early 1970s, increasing concerns about the morbidity and mortality associated with nosocomial pneumonia prompted research to try to identify precursors to this often-lethal infection (Stevens et al., 1974, van Uffelen et al., 1984). Cumulative evidence suggested that inadequate mouth care for intubated patients may contribute to the aspiration of bacteria in oropharyngeal secretions, which can cause VAP (Kunis and Puntillo, 2003). Therefore, the current practice of nursing-led oral care is based upon this understanding that mouth care, together with other preventive measures, may reduce serious respiratory infection. Although the most effective regimen is yet to be determined in orally intubated patients (Berry et al., 2007), mouth care is known to reduce the risk of VAP (Chan et al., 2007).

Unfortunately, oral care is not always a priority in a busy critical care setting (Munro and Grap, 2004). Barriers to effective hygiene practices are contextual factors (e.g., time limitations) and nursing characteristics (e.g., lower education levels) (Furr et al., 2004). However, discussion of hygienic problems within the literature is often fraught with conceptual and pragmatic tension (Kitson, 2010). For example, oral hygiene is often described as “basic” care although critical care nurses define it as “difficult” (Binkley et al., 2004). Given the importance of oral care as nursing work, one would expect to find in the current literature clear explanations about patient oral hygiene and detailed solutions to the known bedside challenges. Instead, the available literature frequently focuses on its neglected features.

In considering the tensions posed by language, Smith's (1987) attention to discourse and “work” offers some assistance. Smith states that formal professional and expert accounts of work, such as those found it the established literature, offer a partial version of actual events and practices. This is because words can shift attention from the actualities of everyday practice to clean, logical concepts, thereby removing the conditions and means for practical activity. In turn, the literature may elide the fact that knowledge is inseparable from the body; expert practice requires a tacit sense of how and when to proceed.

Smith (1987) suggests that our “discourse” (a particular way of talking, writing and reading) about oral care may be the problem. McCoy (2006) points to the scientific and health professions as examples and notes how they create distinct ways of speaking about particular health problems. For example, the nursing literature has recently represented VAP as a problem to be addressed through oral hygiene. In turn, it became important for nurses to enhance this practice. However, prominent ways of discussing VAP may be inadequate to describe the material practice of mouth care.

This paper is an institutional ethnographic review of the nursing literature on oral hygiene. Whereas previous systematic reviews (Berry et al., 2007) summarised a hierarchy of evidence, this paper traces how discussion of oral hygiene has evolved and considers how nursing activities are made visible or obscured within the literature (Rankin and Campbell, 2006). The first objective of this paper is to explore the evolution of nursing discourse in oral hygiene for intubated and mechanically ventilated patients. The second objective is to open a space for dialogue within the nursing community about the complexities of the work involved in mouth care.

Section snippets

Methods

A search of the literature was performed using the online databases MEDLINE and CINAHL. The following medical subject headings (MeSH) and keywords were used: oral hygiene OR mouth care AND critical care OR intensive care. Inclusion criteria were: (1) written in English, (2) published in a peer-reviewed journal, (3) published between 1960 and 2011 to include the inception of critical care as a specialty, (4) article described oral problems or related care for adult intubated patients and (5)

Results

Of the 469 articles initially identified, 84 met all of the inclusion criteria (Fig. 1). The majority were descriptive evaluation studies (44%), followed by narrative reviews (21%), nursing surveys (18%), randomised controlled trials (7%), literature reviews (5%), systematic reviews (2%) and qualitative investigations (2%). No ethnographic reports were retrieved. For organisational purposes, the literature was divided into two 25-year time periods; early (1960–1985) (Table 1) and late

Discussion

As an essential activity, oral hygiene is now defined as both a “science and practice” of health maintenance (Vollman, 2009). Scientific views to patient outcomes have recently highlighted the critical nature of this work. However, there is still an opportunity to balance these large-scale views with insights drawn from proximal accounts of practice. Within a context of health resource conservation and prioritisation of patient safety, inquiry into the situated undertaking of oral hygiene lags

Conclusion and implications

The provision of mouth care for orally intubated patients is a complex, multifaceted practice. Changes in nursing discourse over time have produced a gap between the scientific and practical issues of mouth care. Nurses, educators and administrators may benefit from a critical discussion of the work being encouraged and the limitations of the literature in offering solutions to identified problems. Reuniting the practice of mouth care with a body of scientific literature may be further

Conflict of interest statement

The authors have no conflict of interest to report.

Financial support

A Frederick Banting and Charles Best Canada Graduate Scholarship (GCS) Doctoral Award through the Canadian Institutes of Health Research (CIHR) supported this review.

Acknowledgment

The authors wish to thank Kristine Thornley for her editorial assistance.

References (93)

  • D.J. Jones et al.

    Oral care and bacteremia risk in mechanically ventilated adults

    Heart Lung

    (2010)
  • H. Jones et al.

    A survey of the oral care practices of intensive care nurses

    Intensive Crit Care Nurs

    (2004)
  • K. Kite

    Changing mouth care practice in intensive care: implications of the clinical setting context

    Intensive Crit Care Nurs

    (1995)
  • K. Kite et al.

    A rationale for mouth care: the integration of theory with practice

    Intensive Crit Care Nurs

    (1995)
  • A. Kitson

    Reclaiming nursing care

    Collegian

    (2010)
  • S. Labeau et al.

    Evidence-based guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test among European intensive care nurses

    J Hosp Infect

    (2008)
  • M. Landström et al.

    Perceptions of registered and enrolled nurses on thirst in mechanically ventilated adult patients in intensive care units—a phenomenographic study

    Intensive Crit Care Nurs

    (2009)
  • D.T. Li et al.

    A pilot study on coexisting symptoms in intensive care patients

    Appl Nurs Res

    (2006)
  • H.E. McNeill

    Biting back at poor oral hygiene

    Intensive Crit Care Nurs

    (2000)
  • L. Nelsey

    Mouthcare and the intubated patient—the aim of preventing infection

    Intensive Care Nurs

    (1986)
  • M. O’Reilly

    Oral care of the critically ill: a review of the literature and guidelines for practice

    Aust Crit Care

    (2003)
  • A. Ross et al.

    The impact of an evidence-based practice education program on the role of oral care in the prevention of ventilator-associated pneumonia

    Intensive Crit Care Nurs

    (2007)
  • K.A.M. Samuelson

    Adult intensive care patients’ perception of endotracheal tube-related discomforts: a prospective evaluation

    Heart Lung

    (2011)
  • R.W. Schlosser et al.

    Asking well-built questions for evidence-based practice in augmentative and alternative communication

    J Commun Disord

    (2007)
  • T. Sinuff et al.

    How qualitative research can contribute to research in the intensive care unit

    J Crit Care

    (2007)
  • K. Vollman

    Back to the fundamentals of care: why now, why us!

    Aust Crit Care

    (2009)
  • K.M. Vollman

    Ventilator-associated pneumonia and pressure ulcer prevention as targets for quality improvement in the ICU

    Crit Care Nurs Clin North Am

    (2006)
  • A.M. Berry et al.

    Systematic literature review of oral hygiene practices for intensive care patients receiving mechanical ventilation

    Am J Crit Care

    (2007)
  • M. Bingham et al.

    Implementing a unit-level intervention to reduce the probability of ventilator-associated pneumonia

    Nurs Res

    (2010)
  • S. Blot et al.

    Oral care of intubated patients

    Clin Pulm Med

    (2008)
  • M. Bopp et al.

    Effects of daily oral care with 0.12% chlorhexidine gluconate and a standard oral care protocol on the development of nosocomial pneumonia in intubated patients: a pilot study

    J Dent Hyg

    (2006)
  • C.L. Cason et al.

    Nurses’ implementation of guidelines for ventilator-associated pneumonia from the centers for disease control and prevention

    Am J Crit Care

    (2007)
  • E.Y. Chan et al.

    Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis

    BMJ

    (2007)
  • Y.C. Chao et al.

    Removal of oral secretion prior to position change can reduce the incidence of ventilator-associated pneumonia for adult ICU patients: a clinical controlled trial study

    J Clin Nurs

    (2009)
  • C. Crosby

    Method in mouth care

    Nurs Times

    (1989)
  • C.J. Cutler et al.

    Improving oral care in patients receiving mechanical ventilation

    Am J Crit Care

    (2005)
  • E.M. DeWalt et al.

    The effects of specified stressors on health oral mucosa

    Nurs Res

    (1969)
  • L.L. Feider et al.

    Oral care practices for orally intubated critically ill adults

    Am J Crit Care

    (2010)
  • L.L. Feider et al.

    Oral care practice survey for the orally intubated adult critically ill patient

    Commun Nurs Res

    (2007)
  • J.A. Fitch et al.

    Oral care in the adult intensive care unit

    Am J Crit Care

    (1999)
  • L.R. Fromme et al.

    High frequency jet ventilation

    Am J Nurs

    (1984)
  • A.L. Furr et al.

    Factors affecting quality of oral care in intensive care units

    J Adv Nurs

    (2004)
  • F.K. Ganz et al.

    ICU nurses’ oral-care practices and the current best evidence

    J Nurs Scholarsh

    (2009)
  • R. Garcia et al.

    Reducing ventilator-associated pneumonia through advanced oral–dental care: a 48-month study

    Am J Crit Care

    (2009)
  • M.K. Ginsberg

    A study of oral hygiene nursing care

    Am J Nurs

    (1961)
  • L.K. Goss et al.

    A review of documented oral care practices in an intensive care unit

    Clin Nurs Res

    (2011)
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