ReviewMouth care for orally intubated patients: A critical ethnographic review of the nursing literature
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.
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