Factors affecting quality of oral care in intensive care units

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Factors affecting quality of oral care in intensive care units

  1. 1. ISSUES AND INNOVATIONS IN NURSING PRACTICE Factors affecting quality of oral care in intensive care units L. Allen Furr PhD Associate Professor, Department of Sociology; and Department of Epidemiology and Information Sciences, University of Louisville, Louisville, Kentucky, USA Catherine J. Binkley DDS MSPH Associate Professor, School of Dentistry, University of Louisville, Louisville, Kentucky, USA Cynthia McCurren PhD RN Associate Professor and Associate Dean, School of Nursing, University of Louisville, Louisville, Kentucky, USA Ruth Carrico PhD RN Director of Infection Control, School of Nursing, University of Louisville Health Care, Louisville, Kentucky, USA Submitted for publication 15 September 2003 Accepted for publication 28 April 2004 Correspondence: Allen Furr, Department of Sociology, 118 Lutz Hall, University of Louisville Health Care, Louisville, KY 40292, USA. E-mail: allenfurr@louisville.edu ALLEN FURR L., BINKLEY C.J., MALLEN FURR L., BINKLEY C.J., McCURREN C. & CARRICO R. (2004)CURREN C. & CARRICO R. (2004) Journal of Advanced Nursing 48(5), 454–462 Factors affecting quality of oral care in intensive care units Aims. This paper presents a study to assess to nurses’ attitudes and practices con- cerning oral care and to determine predictors of the quality of oral care in intensive care units. Background. The oropharynx of critically ill patients becomes colonized with potential respiratory pathogens; oral care has been shown to reduce oropharyngeal bacteria and ventilator-associated pneumonia. Methods. In April 2002, a random and national sample of 420 intensive care unit directors was asked to participate in the survey. Of invited directors, 126 (30%) agreed to participate and were sent questionnaires to be completed anonymously by their staff, and 102 institutions returned 556 surveys. This gave a response rate of 83% of those who consented to participate. Results. The path model shows that nurses’ oral care education, having sufficient time to provide care, prioritizing oral care, and not viewing oral care as unpleasant had direct effects on the quality of provided care. Intensive care unit experience, oral care education, and having sufficient time had indirect effects. Conclusion. Improving the quality of oral care in intensive care units is a multi- layered task. Reinforcing proper oral care in education programmes, de-sensitizing nurses to the often-perceived unpleasantness of cleaning oral cavities, and working withhospitalmanagerstoallowsufficienttimeto attendto oralcarearerecommended. Keywords: oral care, intensive care, nursing, nurse attitudes, nurse education, management support Background Oral care is an important component of intensive care nursing but is often given low priority when compared with other critical practices. Recent evidence indicates that colon- ization of the mouth with respiratory pathogens may contribute to ventilator-associated pneumonia (VAP). Oral care may be an important preventive measure against VAP 454 Ó 2004 Blackwell Publishing Ltd
  2. 2. and not merely a comfort measure. The purpose of this study was to describe factors associated with providing oral care in intensive care units (ICUs). Literature review Nosocomial infections Pneumonia is the most common nosocomial infection in ICUs and significantly contributes to morbidity patterns and mortality (Torres et al. 1990, Trouillet et al. 1998) among these patient populations. The risk of nosocomial pneumonia among mechanically ventilated patients is as much as 21 times greater than among non-ventilated patients, and the mortality rate in these patients may exceed 50% (Torres et al. 1990, Garrouste-Orgeas et al. 1997, Trouillet et al. 1998). It is generally accepted that micro-aspiration of respiratory path- ogens that colonize in the mouths of both older and critically ill patients can be a contributor to the development of nosocomial infections, particularly pneumonia (Scannapieco et al. 1992, 2001, Fourrier et al. 1998, Mehta & Niederman 2002, Mojon 2002). In addition to the human cost, nosocomial pneumonia has a considerable economic impact. Wilbin (1997) estimated that 250,000 annual cases of nosocomial pneumonia in the United States of America (USA) account for 1Æ75 million excess hospital days and $1Æ5 billion in extra health care costs. Bacteria responsible for nosocomial pneumonia colonize the oral habitat of ICU patients (Scannapieco et al. 1992, Garrouste-Orgeas et al. 1997, Ewig et al. 1999). Scannapieco et al. (1992) found that 65% of the plaque and/or oral mucosa in 34 medical ICU patients was colonized by respiratory pathogens, compared with only 16% in 25 preventive dentistry clinic patients (P £ 0Æ05). Similarly Treloar and Stechmiller (1995) showed that cultures grown from oropharyngeal and sputum specimens of 37Æ5% of orally intubated critical care patients grew either nosocomial bacterial or fungal pathogens. Dental plaque bacteria are likely aspirated along with respiratory pathogens, and may affect the adhesion of respiratory pathogens to the respiratory epithelium and inflammation of respiratory epithelium (Scannapieco et al. 2001). Oral care practices Several oral care protocols have proved effective in reducing oropharyngeal colonization and nosocomial pneumonia risks. Chlorhexidine rinses and gels, administered either two or three times daily, have resulted in significant reduc- tions in pneumonia in ICU patients (DeRiso et al. 1996, Fourrier et al. 2000, Genuit et al. 2001). Toothbrushing after each meal, combined with oral care given once a week by dental professionals, significantly decreases pneumonia in dependent nursing home patients (Okuda et al. 1998, Yoneyama 2001, Yoshida et al. 2001, Adachi et al. 2002, Yoneyama et al. 2002). Toothbrushing with a child-size brush is superior to foam swabs in removing dental plaque and bacteria in nurse- administered oral care (Pearson & Hutton 2002). Twenty years ago, Gibbons (1983) recommended an oral care protocol that included a child-size toothbrush, petroleum jelly, and whole mouth brushing with either fluoride tooth- paste or chlorhexidine gel. More recently, evidence-based oral care protocols for ICU patients have been published; all include an oral assessment, toothbrushing with a child-size brush, oral rinses and moisturizers at a frequency of every 2–6 hours (Fitch et al. 1999, Stiefel et al. 2000, Schleder & Lloyd 2002). Despite evidence that toothbrushing is superior to foam swabbing, studies indicate that swabbing is still the preferred method of oral care in ICUs (Sole et al. 2002). Barriers/facilitators of oral care in ICUs The literature reports that, although sound oral care is efficacious in reducing infection, oral care may be under-used in ICUs. Nurse education in oral care practice has remained relatively unchanged over the past 120 years (Turner & Lawler 1999). An analysis of 68 nursing textbooks published between 1870 and 1997 revealed that descriptions of actual nursing oral care practices have not significantly changed, although variation in the types of equipment and materials recommended was noted. Turner and Lawler concluded that oral care practices do not reflect the influence of more recent conceptual or rhetorical standpoints on oral care in nursing. Researchers have found indicators of this dissonance. Observing a sample of English nurses, Adams (1996) concluded that nurses, including those fully qualified, lacked adequate knowledge about oral health. The hospital environment has been demonstrated both to promote (by the provision of support for health promotion) and hinder (via time limitations and lack of continuity of care) nursing care (e.g. Berland et al. 1995). Similarly, hospital factors such as availability of supplies and equipment and allocation of time affect the type and quality of oral care given by nurses (Kite 1995, Moore 1995, Curzio & McCowan 2000). The availability of appropriate tooth- brushes influences their use in ICUs (Kite 1995); however, many units stock mouthwash and foam swabs rather than toothbrushes, or the toothbrushes provided are of poor quality, large, and not readily accessible (Moore 1995). Issues and innovations in nursing practice Quality of oral care in intensive care units Ó 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 454–462 455
  3. 3. Having sufficient time to provide oral care is also an important factor. The current shortage of nurses in the USA, which began in ICUs and operating rooms, may be responsible for many nurses reporting that they feel overworked – a critical barrier in providing quality patient care (Buerhaus et al. 2000, Aiken et al. 2002, Steinbrook 2002). When nurses are overworked and their time is rationed, oral care is often the first practice to be deferred (Wardh et al. 1997, 2000). Archibald et al. (1997) investigated the relationship between nurse staffing, over- crowding, and nosocomial infection rates and found that factors affecting nurse staffing had detrimental effects on patient outcomes. Finally, nurses’ attitudes towards particular health and treatment issues have been shown to affect nursing care (Dalton et al. 1998, Roman et al. 2001). Nurses’ attitudes to oral hygiene have been associated with oral care practice as well. Wallace et al. (1997) studied the effect of nurses’ attitudes and subjective norms on the intention to give oral care and found that they were important predictors of actual provision of care. Many nurses believe that oral health care carries low nursing priority (Wardh et al. 2000), and others recognize the importance of oral care yet believe that they lack adequate preparation and feel inadequate in their abilities (Moore 1995, Paulsson et al. 1999, 2002). Proposed model Our proposed model suggests that the provision of oral care in ICUs is more than a function of education and experience of individual nurses, and includes both the organizational effects of the hospital environment and subjective attitudes that nurses may hold about oral care. Figure 1 shows a conceptual presentation of the proposed inter-relatedness of these variables. It was expected that nurses’ backgrounds would affect the quality of oral care provided, but that these qualities would be mediated by potential barriers posed by hospital practices. Despite the best intentions of nurses, lack of hospital support for oral care was expected to affect care delivery negatively. Furthermore nurses’ subjective attributes, including the priority they give to oral care and the perception that oral care is unpleasant, would have a moderating influence on the delivery of care and would serve as intervening factors. A hospital may provide adequate support for oral care, for example, but the perception that this is a less critical task compared with other ICU responsibilities may reduce the care provided. The study Aim The aim of the study was to investigate how hospital factors and nurses’ background, education, and attitudes influence the quality of oral care in ICUs. Design A two-step analytical process was undertaken. First, several hypotheses were tested to determine the relationship between nurses’ background, attitudes, and perception of hospital factors and the quality of oral care in ICUs: Hypothesis group A: background characteristics HA1: The more education in oral care, the better the oral care practice will be. HA2: The more experience in ICUs, the better the oral care practice will be. Hypothesis group B: hospital factors HB1: If nurses believe they have sufficient time to provide oral care, the better the oral care practice. HB2: Nurses who believe they have sufficiently available supplies for oral care will provide better care. Facilitating factors – Oral care education – Years of ICU experience Moderating factors – Value/importance of oral care (priority) – Perceived unpleasantness of providing oral care Barriers – Time available – Supplies provided by hospital – Equipment available Outcomes – Higher quality of oral care – Brushing vs. swabbing – Increased frequency Figure 1 Proposed model of ICU oral care provision. L.A. Furr et al. 456 Ó 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 454–462
  4. 4. HB3: Nurses who think that their hospital needs better equipment to perform oral care will provide less quality care. Hypothesis group C: nurses’ attitudes HC1: The more priority given to oral care, the better the oral care practice. HC2: The more unpleasant oral care is to provide, the lower the level of oral care practice. The second step of the analysis involved constructing a series of hierarchical multivariate regression equations to test the model proposed in Figure 1. Source of data and sample Data for the study were taken from the 2002 National Survey of Oral Care Practices in Intensive Care Units, a project funded by the University of Louisville School of Dentistry. This used a relatively short 27-item questionnaire developed by the investigators to gather literature-based information related to current oral care practices, education, and attitudes among nurses in ICUs across the USA. Demographic infor- mation and nurses’ education experiences were also included. Dentists, an infectious disease specialist, an ICU director, nurses, and a sociologist with expertise in survey research methods reviewed the instrument, which was pre-tested in the ICUs of the University of Louisville Hospital. A two-stage cluster sampling technique was used to draw a national sample of nurses working in ICUs. In the first stage, 421 ICUs were randomly selected from a sampling frame provided by the American Hospital Association of the names and addresses of all USA ICUs and their directors. Units were selected using a systematic interval technique. ICUs in military installations and USA territories were excluded; the District of Columbia was included. Second, directors of each selected unit were contacted by mail to request participation. In addition to asking for participation, the contact letter described the study and asked for basic classifying information about the unit itself, e.g. number of shifts worked in the unit and how many nurses staff each shift. Among the 126 agreeing to respond, targeted shifts were rotated so that nurses who worked days or nights had equal chances of being included in the sample. A packet of questionnaires was sent to those directors who agreed to distribute them to the nurses in their unit working the shift identified by the researchers. Directors retrieved the forms from the participating nurses and mailed them to the primary investigator. Nurses’ participation in the study was volun- tary, as stated on the informed consent document. Responding units were eliminated from the sample upon receipt of the contact letter if hospitals had closed their ICUs or the ICU was no longer a separate unit. Directors from 102 institutions participated (80% response). An average of 5Æ5 questionnaires per institution was completed, giving a total sample of 556 of the 680 mailed (82%). Characteristics of the responding nurses indicate consider- able heterogeneity within the sample. In the study group, 56Æ3% worked in private non-profit hospitals, 19Æ4% were from university hospitals, 15Æ9% from private for-profit hospitals, and the remaining 8% were from ‘other’ facilities. Respondents’ mean age was 39 years (SDSD 10Æ1) and, on average, had gained 10Æ7 years ICU experience (median ¼ 9 years). Over 97% of the sample was Registered Nurses. Approximately 29% of the respondents’ original nursing education was a 2-year associated or diploma programme, 30% had taken a 3-year programme, while 39% held bachelor’s degrees, and about 2% held master’s degrees. Variables Dependent variable The dependent variable for this study was an indexed item representing the quality of the provision of oral care by nurses to patients in ICUs. A quality of care score was derived by a two-step procedure in which an ordinal ranking of the type of oral care provided was multiplied by an ordinal score indicating how often the technique was used. Using current literature-based standards, a hospital-trained dentist ranked the quality of the oral care techniques based on each tech- nique’s relative ability to maintain a hygienic oral cavity and lower the risk of infection (Day 1993, Kite & Pearson 1995, Pearson 1996, Day et al. 1998, Fitch et al. 1999, Stiefel et al. 2000, Evans 2001, Pearson & Hutton 2002, Schleder & Lloyd 2002). The techniques were ranked as follows (higher scores reflect superior hygienic quality): using an electric toothbrush, 5; manual toothbrushes, 4; mouthwashes, 3; foam toothettes, 2; and moisture agents, 1. The second step of the operationalization of quality of oral care multiplied the ranking score by frequency of use: 6, ‘every 1–3 hours’; 5, ‘every 4 hours’; 4, ‘every 8 hours’; 3, ‘every 12 hours’; 2, ‘once a day or less’; and 1, ‘never.’ A high score reflects higher level of the oral care rendered in each nurse’s ICU practice. Independent variables The seven independent variables were clustered into three conceptual groups: experience and education, nurses’ perception of their hospital’s facilities and support for pro- viding oral care, and nurses’ attitudes toward oral care practices. Nurses’ professional backgrounds were represented by two variables: years of ICU experience and oral care education. Education was a measure of nurses’ sources of Issues and innovations in nursing practice Quality of oral care in intensive care units Ó 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 454–462 457
  5. 5. learning about oral care for intubated patients. Responses were ranked so that formal sources received higher scores (nursing school, 4 points; continuing education, 3 points; in-service, 2 points; and self-taught, 1 point) and each nurse could check all that applied. Nurses’ perceptions of hospital support for oral care were measured by responses to three 5-point Likert-scaled state- ments. A high score on the first two measures – ‘There are supplies readily available to provide oral care in our unit’ and ‘I have adequate time to provide oral care at least once a day’ – represents greater facility support for oral care. A high score on the third, ‘I need better supplies and equipment to perform oral care in ICU,’ represents lower institutional support. Two Likert-scaled items indicated attitudes specific to the provision of oral care: ‘I find cleaning the oral cavity to be an unpleasant task’ and ‘Oral care is a very high priority for mechanically ventilated patients’. A high score on the former indicates a higher degree of unpleasantness while a high score on the latter represents a higher priority to the management of oral care. Ethical considerations The Human Studies Committee of the University of Louisville approved the protocol for this survey project. Anonymity, confidentiality, and privacy were strictly maintained. Results Table 1 shows the correlation coefficients for variables used in the analysis. Four of the seven variables had the predicted relationship with quality of care: education, adequate time, assigning high priority to oral care, and perceiving oral care to be unpleasant. Quality of care, as measured here, was not associated with experience in ICUs and the two hospital environment variables concerning supplies and equipment, although the available supplies approached significance in the predicted direction. Therefore, hypotheses A1, B1, C1, and C2 were supported. The findings of the regression analyses used in developing the path relationships among the variables are reported in Table 2. As can be seen in Figure 2, education in oral health and experience had very dissimilar influences on the other terms. Education had direct effects on the two attitude variables, which in turn had direct effects on quality of care, and a direct and positive effect on quality of care. Higher scores on the education variable predicted high priority and lower unpleasantness scores. Education was not associated with perceptions of the hospital environment. Experience, on the other hand, was related to neither the attitude variables nor quality of care directly, but predicted scores on each of the hospital support variables. Of the hospital factors, only adequate time had a direct effect on quality of care. Because of its negative effect on perceived unpleasantness, that is, the more time allotted to oral care the less unpleasant nurses found it to be, adequate time for oral care also had an indirect impact. The supplies and equipment variables had no effect on either attitudes or the quality of delivered care reported by this sample. Comparable with the bi-variate analysis, the regression equations showed that prioritizing oral health and finding oral care less unpleasant were among the strongest predictors of quality of care. When quality of care was regressed on all variables simultaneously (Table 3), these factors, along with adequate time, produced the highest Betas. All seven varia- bles entered together explained about 12% of the variance in quality of oral care in ICUs. Discussion This study reports on data gathered by the 2002 National Survey of Oral Care Practices in Intensive Care Units. The Table 1 Bivariate correlations (Spearman’s rho) Quality of care Experience Education Time Supplies Needs equipment Priority Unpleasant Quality of care – Experience 0Æ062 – Education 0Æ170** 0Æ038 – Adequate time 0Æ199** 0Æ089 0Æ014 – Available supplies 0Æ101 À0Æ104* 0Æ056 0Æ235** – Needs equipment À0Æ098 0Æ178** À0Æ070 À0Æ094 À0Æ289** – Priority 0Æ198** 0Æ051 0Æ082 0Æ202** 0Æ069 À0Æ074 – Unpleasant À0Æ175** À0Æ072 À0Æ123* À0Æ146** À0Æ071 0Æ068 À0Æ119* – *P < 0Æ05; **P < 0Æ01. L.A. Furr et al. 458 Ó 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 454–462
  6. 6. investigation’s aim was to identify factors associated with differential levels of the quality of oral care provided in ICUs. Results of bivariate analyses indicated that education, having sufficient time, seeing oral care as a priority, and not viewing oral care as unpleasant were associated with higher quality care. Experience in ICUs and the hospital factors concerning supplies and equipment were not related to care, contrary to expectations. As shown in Table 1, education, but not ICU experience, correlated with reporting oral care to be less unpleasant. Neither education nor experience was associated with prior- ity, however. The two attitude variables correlated with each other, although not to the degree one might expect. Having time to provide oral care correlated with both attitude variables: having more time was associated with higher priority and a lower ‘unpleasant’ score. These findings suggest that oral care among intubated patients in ICUs is a multi-tiered dynamic. Experience, although perhaps necessary, is not sufficient to improve quality of oral care in ICUs. The intersection between nurses’ experience and attitudes and institutional support in terms of providing adequate time is clear from these data and further Time 0.174** 0.106* Experience –0.122** –0.100* Priority 0.195** Quality of careAvailable supplies0.174** 0.125** –0.168*** Unpleasant –0.125**Oral care education index 0.165** Needs equipment Figure 2 Path model showing regression coefficients. *P < 0Æ05; **P < 0Æ01; ***P < 0Æ001 Table 2 Regression coefficients used to determine path model Independent variables Dependent variables, b (SE) Beta Adequate time Supplies available Needs equipment Priority Unpleasant Quality of care Nurses’ background Education 0Æ002 (0Æ010) 0Æ008 0Æ006 (0Æ010) 0Æ033 À0Æ027 (0Æ027) À0Æ062 0Æ038 (0Æ015) 0Æ125* À0Æ055 (0Æ023) À0Æ125* 0Æ519 (0Æ168) 0Æ165** Experience 0Æ007 (0Æ003) 0Æ106* À0Æ007 (0Æ003) À0Æ140* 0Æ026 (0Æ008) 0Æ174** À0Æ001 (0Æ005) À0Æ006 À0Æ009 (0Æ008) À0Æ058 0Æ075 (0Æ058) 0Æ069 Hospital factors Adequate time 0Æ144 (0Æ084) 0Æ090 À0Æ294 (0Æ126) À0Æ122* 20Æ911 (0Æ902) 0Æ174** Supplies available 0Æ073 (0Æ074) 0Æ048 À0Æ031 (0Æ126) À0Æ014 0Æ592 (0Æ885) 0Æ037 Needs equipment À0Æ063 (0Æ037) À0Æ091 0Æ048 (0Æ055) 0Æ046 À0Æ535 (0Æ406) À0Æ072 Attitudes Priority 20Æ029 (0Æ539) 0Æ195** Unpleasant À10Æ200 (0Æ368) À0Æ168** *P < 0Æ05; **P < 0Æ001. Table 3 Quality of care regressed on all independent variables simultaneously b SESE Beta Education 0Æ379 0Æ164 0Æ120* Experience 0Æ062 0Æ058 0Æ056 Adequate time 20Æ517 0Æ907 0Æ149** Supplies available 0Æ257 0Æ911 0Æ016 Needs equipment À0Æ399 0Æ407 À0Æ054 Priority 10Æ713 0Æ541 0Æ166** Unpleasant À0Æ866 0Æ374 À0Æ121* R2 ¼ 0Æ10. *P < 0Æ05; **P < 0Æ01; ***P < 0Æ001. Issues and innovations in nursing practice Quality of oral care in intensive care units Ó 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 454–462 459
  7. 7. suggests that attempts to change oral care nursing practices will require interventions that involve hospital managers and peer leaders. In attempts to improve oral hygiene in ICUs, these data support two avenues for intervention. First institutional factors must be addressed. Nurses in this sample reported that having the necessary time was key to providing quality care. Hospitals should attend to these needs in the planning of care and the scheduling of nurses. Second, personal responses to providing care should also be considered. Nursing education was shown to increase prioritizing oral care and reduce the perception that oral care is unpleasant. Thus, continuing education should reinforce the importance of oral hygiene in reducing nosocomial infections among ICU patients and teach strategies for delivering the best care. Limitations Several aspects of this research limit the robustness of its findings. First, the number of ICU directors agreeing to participate was 30%. Nevertheless, the random sample resulted in a good geographical and institutional distribu- tion within the USA, and the 83% response rate from consenting directors yielded a normally distributed sample of 556 participants, which was adequate for our analysis. A much larger sample might have given somewhat different results. Second, we failed to assess whether the institution had an oral care protocol or standard of care; this indicator of institutional support may have affected the variable relationships found. Third, respondents were working in ICUs in the USA and the results of the study cannot be generalized to other health care workers in other countries or health care facilities. Fourth, the R2 for the regression equation containing all independent variables was rather small at 0.12. However, the goal of the regression analysis was to organize the variables in terms of a select set of direct and indirect effects rather than to construct a fully comprehensive model that might more fully explain quality of care. Fifth, as in any study of this type, selection bias among participants may pose problems when drawing conclusions from the data. In this case, it is possible that only unit directors and nurses who were proficient in or knowledgeable about oral health volunteered to participate. The wide range of scores on the researched variables, diverse geographical profile of the sample, and representa- tion of several hospital types, however, indicate that selection bias was minimal. Conclusions Our results suggest that oral care provision for mechanically ventilated patients can be improved by providing oral care education, providing nursing staff with adequate time, redu- cing the perception that oral care is unpleasant, and making oral care a priority in nursing care in ICUs. Multifaceted interventions to improve oral care nursing practices are required to reduce the incidence of pneumonia in mechanic- ally ventilated patients, thereby improving patient safety. Acknowledgements We thank the Journal’s anonymous reviewers for their expert advice in revising this paper. Funding support: This research was supported by an intramural research incentive grant from the University of Louisville School of Dentistry. References Adachi M., Ishihara K., Abe S., Okuda K. & Ishikawa T. (2002) Effect of professional oral health care on the elderly living in nursing homes. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 94(2), 191–195. Adams R. (1996) Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. Journal of Advanced Nursing 24(3), 552–560. What is already known about this topic • Pneumonia is the most common nosocomial infection in intensive care units. • Bacteria responsible for nosocomial pneumonia colon- ize the mouths of intensive care unit patients. • Oral care practices are effective in reducing pneumonia risks, yet research indicates that oral care carries a low priority among intensive care unit nurses. What this paper adds • Facilitators and barriers to oral care in intensive care unit are multi-faceted. • Oral care education, having sufficient time to provide oral care, seeing oral care as a priority, and not viewing oral care as unpleasant are associated with providing better oral care. • Multifaceted interventions to improve oral care nursing practices are required to reduce the incidence of pneu- monia in mechanically ventilated patients, thereby improving patient safety. L.A. Furr et al. 460 Ó 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(5), 454–462
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