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A nurse champion of oral care in community services

A palliative care nurse’s successful oral care initiative has been adapted by other teams

A palliative care nurses successful oral care initiative has been adapted by other teams

  • Palliative care nurse Marie Roberts is the winner of the 2020 RCNi Nurse Awards General Practice and Community Nursing award
  • She had concerns about oral care standards and organised care and training while still doing her full-time job
  • Her project was set up for care homes but has spread to care services throughout the community

A project empowering care home staff to provided excellent oral care has been such a success that it has been adapted by

A palliative care nurse’s successful oral care initiative has been adapted by other teams

  • Palliative care nurse Marie Roberts is the winner of the 2020 RCNi Nurse Awards’ General Practice and Community Nursing award
  • She had concerns about oral care standards and organised care and training while still doing her full-time job
  • Her project was set up for care homes but has spread to care services throughout the community
Palliative care nurse Marie Roberts
Marie Roberts, winner of the General Practice and Community Nursing awards, sponsored by NHS England, in the RCNi Nurse Awards 2020. Picture: Neil O'Connor

A project empowering care home staff to provided excellent oral care has been such a success that it has been adapted by acute and community teams throughout Salford and is now being taken up all over Greater Manchester.

Salford Royal NHS Foundation Trust palliative care nurse Marie Roberts started the CHORUS programme – CHampioning ORal care in CommUnity Services – in response to concerns about mouth care at end of life, and her passion and commitment has seen it grow until it is improving oral health for all.

RCNi Nurse Awards logoAnd now Ms Roberts has been chosen as winner of the 2020 RCNi Nurse Awards’ General Practice and Community Nursing award, sponsored by NHS England.

Treatment for thrush prolonged man’s life for another year

In 2016, Ms Roberts was called to a care home because staff thought a resident was approaching the end of life. He was not eating or drinking and had generally declined over the previous few days.

‘One of my first assessments was to look in his mouth to see if there was a reason why,’ Ms Roberts recalls. ‘It was evident that he had a terrible problem with thrush.

‘With treatment, the man started to get much better and started to eat and drink again. He lived for another 12 months.’

Mouth ulcers, unlike leg ulcers, are not documented

Ms Roberts saw other issues. ‘Some patients who were approaching the end of life had a dry, odorous mouth,’ she says. ‘It was worrying that those were the lasting memories of people – that they weren't able to kiss their loved one goodbye because their mouth was so dry and cracked.

Marie Roberts
Marie Roberts Picture: Neil O'Connor

‘A mouth ulcer is not documented but if you've got an ulcer on your leg it's documented and reviewed on a regular basis. Other people know about it. It's about making sure people understand that the mouth is at the gateway to everything. We eat, we drink, we speak, we kiss our loved ones, and it's important that we identify those problems.

‘It's an airway, but none of us had had any specific training on how to provide oral healthcare. We needed to make a change urgently.’

CHORUS was set up to develop and deliver training for more than 35 care homes in Salford.

The multidisciplinary working group – including Salford Safeguarding Provider Forum, the community dental team and company RIS Healthcare – met monthly.

Comprehensive oral hygiene resources and training for care homes

‘It was important that we included the care homes to understand their challenges and thoughts,’ says Ms Roberts. ‘We had a member of the learning difficulties and complex needs team who helped us to understand how we can support people who have problems with communication or difficulties understanding how to manage their own health needs.’

The result was a comprehensive oral hygiene resource file and training for care homes delivered in-house by RIS Healthcare.

Key questions in oral care audit

  • Is the patient receiving oral care?
  • Do they have a dentist?
  • How often is it documented if they receive oral care?
  • Is oral care part of a care plan?
  • How often are their orals reviewed?

A pilot in three care homes first gathered data through an anonymous oral hygiene documentation review – most people didn't have daily documented oral hygiene or a documented dental review – and audit of GP prescribing.

The training covered types of oral conditions, their management and how to perform oral care. There was a practical and interactive session and case studies to highlight different issues.

‘For example, there are case studies around people undergoing chemotherapy and radiotherapy and how they might have dry mouths,’ says Ms Roberts.

Fun training, with a bit of humour

‘Or how we can support someone missing a tongue to maintain good oral hygiene.

‘Making the training fun was important, with a bit of humour. It wasn't just a boring PowerPoint presentation but interactive, punchy and quick, and at the point of need as well, with coaching alongside and role modelling.’

A second audit four months after the training and resource file were implemented showed a significant increase in the number of prescriptions, mainly made up of treatment for thrush and also for dry mouth.

‘Those who are approaching end of life now will be prescribed something so they can have a comfortable mouth without any dryness,’ says Ms Roberts.

Dental hygiene kit
Picture: Neil O'Connor

Feedback from participants about the training was also very positive.

One of the care homes that took part in the pilot was the Broughtons Care Home, whose manager Amanda Collins describes the training as a ‘joy’.

Oral care needed improving throughout all care services

‘The confidence it gave to the staff is unbelievable,’ she says. ‘Every member enjoyed it and enthusiastically took it forward. Now residents have a happy, healthy mouth. When the Care Quality Commission recently came for an unannounced inspection the inspectors were really impressed with the oral care training and the knowledge staff had.’

Ms Roberts says it became clear that oral care needed improving throughout all care services.

‘Once we started to focus on oral health we could see a much bigger need not only for the homes, but for nurses in the acute sector, GPs and the community nurses. The more we raised the issues the more people got involved and could see its need in their area,’ she says.

12 signs of dental issues in people with communication problems

  1. Agitation
  2. Refusal to eat and drink
  3. Pulling at ears and face
  4. Banging head
  5. Drooling
  6. Grinding
  7. Temperature
  8. Swollen and bleeding gums
  9. Odour coming from mouth
  10. Oozing pimple/yellow spot at side of tooth
  11. Swelling of the face or neck
  12. Loose or mobile teeth

(Source: CHORUS resource)

Ms Roberts contacted the learning and development team for her trust. ‘It was evident that there was no oral health policy or training.’

Success of oral care project meant it got funding for a dental nurse

She was part of a ‘task and finish’ group, and with some money from Mouth Care Matters – a Health Education England programme that raises awareness of the importance of good mouth care – they adapted the resource file and assessments for the electronic patient record system, completed a baseline audit and started teaching one on one with ward staff.

‘We joined forces for the classroom teaching, and the acute team eventually took this over.’

The project’s impact has been such that a pitch for funding for a dental nurse to continue the project full-time was successful.

A typical oral health equipment tray
A typical oral health equipment tray

‘They continue what I started with more in-depth dental knowledge and the ability to focus solely on oral health,’ says Ms Roberts. ‘We initially applied for a three-day post but the commissioners were overwhelmed by the need for this service and they gave us the money for a full-time role.’

‘Marie was proactive in making a difference to the community she serves and is a strong champion for the staff of care homes’

Ruth Oshikanlu, one of the 2020 RCNi Nurse Awards judges

Commenting on her success in the RCNi Nurse Awards 2020, judge Karen Storey, primary care nursing lead at award sponsor NHS England and NHS Improvement, says: ‘Oral care is such an important issue and is often neglected or overlooked. Marie is a passionate champion of improving that care.’

Fellow judge Ruth Oshikanlu, chief executive of Goal Mind, a Queen’s Nurse and a fellow of the Institute of Health Visiting and of the RCN, agrees: ‘A simple and sustainable project with great impact. Marie was proactive in making a difference to the community she serves and is a strong champion for the staff of care homes.

10 tips for providing oral care to care-resistant patients

Non-foaming toothpaste
Non-foaming toothpaste Picture: iStock
  1. Create a calming environment – for example, turn off any television
  2. Be approachable – smile and have a friendly manner
  3. Distraction – give the patient something to hold, for example another toothbrush, or some people may like some music in the background
  4. Give reassurance
  5. Show pictures and/or mimic actions you want them to do, such as spitting
  6. Use aids, such as a mouth rest for people who bite down
  7. Persevere – try with different members of staff, or different times of the day
  8. Never use force
  9. Involve friends and family members
  10. Document all attempts in care notes, including all successful attempts and refusals of oral care. If refusal continues you should escalate and document it

(Source: CHORUS resource)

‘Now each care home and district nursing team in Greater Manchester has received training and has been provided with a handheld resource. Marie epitomises great leadership in her commitment, relentless drive and personal sacrifice, while placing residents’ and patients’ safety and quality care first.’

Determination and commitment essential in pushing for better oral care

Palliative and end of life care practice development lead Victoria Mcloughlin nominated Ms Roberts for the award. She says: ‘This working group would not have evolved without the determination and commitment of Marie. She recognised a deficit and actioned an organisational group, training and evaluation as well as continuing with her full-time palliative care role.

‘It will shine a light on good oral care and hopefully will spark an interest in other nurses’

Marie Roberts, General Practice and Community Nursing award winner, RCNi Nurse Awards 2020

‘Interestingly, the hospital has now appointed a full-time person to solely implement this into the hospital whereas Marie implemented this into all community settings while continuing her other role, illustrating her determination and commitment.’

Ms Roberts says she is ‘overjoyed’ to win. ‘It is recognition of the hard work the team and I have completed and the support we received from the trust,’ she says. ‘It is not only for everyone who has contributed to the project and is improving oral care in Salford, but also for everyone who receives good oral care in the future.

‘It will shine a light on good oral care and hopefully will spark an interest in other nurses. Together we can continue to make changes and improve our patient care.’

A summary of what is in the CHORUS programme guide

A woman with cheilitis Picture: iStock
A woman with cheilitis Picture: iStock
  • Oral assessment flow chart, admissions assessment and care plan templates.
  • Visual overview on what a healthy mouth looks like, and common oral conditions: ‘We'd often see people with cracked corners of the mouth, which is angular cheilitis and easy to treat,’ explains Ms Roberts. ‘Staff didn’t know what it was and put Vaseline on it rather than treating the problem’
  • A guide to delivering oral care to complement the training: ‘One thing that I learnt is that you should never brush someone's teeth facing forward,’ says Ms Roberts. ‘You should brush teeth from the side. This has proven to be a useful tip and feedback shows carers found it helpful to understand how to deliver that care’
  • Advice on equipment, issues around obtaining consent and an example of a mouth care regimen at the end of life
  • Products to help with oral symptom control – Ms Roberts gives the example of non-foaming toothpaste: ‘Staff were not cleaning the mouth of people who were PEG fed or nil by mouth patients, as they were concerned what might happen if they swallowed toothpaste. People with autism also like it because it doesn’t create a funny sensation in their mouth’
  • Referral forms for special dentistry, speech and language therapy, and claim forms for dental care
  • National guidance on oral health for adults in care homes from the National Institute for Health and Care Excellence, and local policy and documents

The 2020 RCNi Nurse AwardsGeneral Practice and Community Nursing award is sponsored by NHS England

NHS England logo


Find out more

National Institute for Health and Care Excellence – Oral Health for Adults in Care Homes

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