A Cross-Sectional Study On Nurses Oral Care Practice For Mechanically Ventilated Patients In Malaysia

CLINICAL ISSUES
A cross-sectional study on nurses’ oral care practice for mechanically
ventilated patients in Malaysia
Kim Lam Soh, Kim Geok Soh, Salimah Japar, Rosna A Raman and Patricia M Davidson
Aims and objectives. This study sought to determine the strategies, methods and frequency of oral care provided for
mechanically ventilated patients in Malaysian intensive care units. The study also described nurses’ attitudes to providing oral
care and their knowledge of the mode of transmission of ventilator-associated pneumonia.
Background. Oral care is an important nursing intervention in the intensive care unit to reduce dental plaque. Dental plaque
provides a repository for respiratory pathogens contributing to ventilator-associated pneumonia in the critically ill.
Design. Cross-sectional study.
Methods. This study used both survey and observational methods. The observational study was conducted by a nurse, trained
in the study protocol. The observation period a selected shift over three weeks in 2007.
Findings. Intensive care unit nurses (n = 284) participated in the survey. Respondents had a positive attitude towards providing
oral care. On a 10-point Likert scale, aspiration of contaminated secretions from the oropharynx was identified by nurses as the
highest risk factor for ventilator-associated pneumonia (mean response 6Æ8, SD 2Æ0). The majority of nurses used cotton and
forceps for oral care. Toothbrushes were not used in any of the study sites.
Conclusions. Although nurses had a positive attitude to oral hygiene, this study found no intensive care units incorporated a
soft toothbrush in oral care protocols which is recommended in best practice guidelines. A review of strategies to implement
evidence-based practice in the intensive care unit is warranted.
Relevance to clinical practice. This study has identified a failure to adhere with evidence-based practice. Implementing and
evaluating protocols for oral hygiene in the intensive care unit has the potential to improve patient outcomes.
Key words: intensive care unit, nurses, nursing, oral care, ventilated patient
Accepted for publication: 19 August 2010
Introduction
Microbial colonisation of the oropharynx and dental plaque
is associated with systemic and respiratory diseases, most
notably ventilator-associated pneumonia (VAP) (Munro
et al. 2004, 2006a,b). VAP affects 8–28% of patients
receiving mechanical ventilation and mortality rates are
reported to be between 13–76% (Fink & Hunt 1999,
Authors: Kim Lam Soh, RN, MHSc, Senior Lecturer, Department of
Medicine, Faculty of Medicine and Health Sciences, University Putra
Malaysia, Serdang, Selangor, Malaysia and PhD Student, Curtin
Health Innovation Research Institute, Curtin University of
Technology, Chippendale, NSW, Australia; Kim Geok Soh, MS,
PhD, Associate Professor, Department of Sport Studies, Faculty of
Education, University Putra Malaysia; Salimah Japar, RN, Bac,
Teaching Assistant, Department of Medicine, Faculty of Medicine
and Health Sciences, University Putra Malaysia; Rosna A Raman,
RN, MHSc, Lecturer, Department of Medicine, Faculty of Medicine
and Health Sciences, University Putra Malaysia, Serdang, Selangor,
Malaysia; Patricia M Davidson, BA, RN, MEd, PhD, Professor of
Cardiovascular and Chronic Care, Centre for Cardiovascular and
Chronic Care, Curtin Health Innovation Research Institute, The
Sydney Campus of Curtin University of Technology, Chippendale,
NSW, Australia
Correspondence: Kim Lam Soh, Senior Lecturer, Department of
Medicine, Faculty of Medicine and Health Sciences, University
Putra Malaysia, 43400, Serdang, Selangor, Malaysia and PhD
Student, Curtin Health Innovation Research Institute, Curtin
University of Technology, Chippendale, NSW, Australia. Telephone:
+603 89472439.
E-mails: kim@medic.upm.edu.my, K.Soh@curtin.edu.au
Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 733–742 733
doi: 10.1111/j.1365-2702.2010.03579.x

Ibrahim et al. 2001, Tierney et al. 2001, O’Neal et al. 2002).
One of the most common causes of VAP in the intensive care
unit (ICU) is aspirated oral secretions with bacterial coloni-
sation, which can result from poor oral care (Munro et al.
2004). Effective oral care can prevent the formation of dental
plaque, often a reservoir for the microbes causing VAP
(Munro et al. 2004, 2006a, Cutler & Davis 2005). The use of
the oral antiseptic chlorhexidine gluconate and subglottic
suctioning has also been shown to be an effective strategy for
preventing VAP (Wip & Napolitano 2009). Several interna-
tional studies and quality improvement initiatives have
involved the implementation of a ventilator bundle which
includes: head-of-bed elevation, daily interruption of sedation
to reduce time on mechanical ventilation, deep vein throm-
bosis prophylaxis and peptic ulcer disease prophylaxis
(Institute for Healthcare Improvement 2004b, Tablan et al.
2004, Clinical Excellence Commission 2006). Institute of
Healthcare Improvement also has suggested to revised oral
care policy to include tooth brushing every 12 hours and
suctioning of oropharyngeal secretions together with venti-
lator bundle to improve VAP prevention (Institute for
Healthcare Improvement 2004a). A study had found that
using of ventilator bundle, oral care policy and subglotic
suctioning significantly reduced rate of VAP after 12 months
implementation (Blamoun et al. 2009).
Oral care is an important nursing activity in the ICU (Berry
& Davidson 2006, Munro et al. 2006b). This activity
traditionally has been focused on patient comfort and hygiene
rather than specifically addressing plaque removal (Kite
1995, Fitch et al. 1999, Bill 2000, Grap et al. 2003, Munro
et al. 2004). Cotton swabs are commonly provided for
cleaning the patient’s teeth, gum and tongue. Although
cotton swabs are effective for stimulating the mucosal tissues,
they are ineffective for removing plaque in between the teeth
(Adam 1996, Barnason et al. 1998, Tunner & Lawler 1999,
Pearson & Hutton 2002). Oral care is frequently designated a
lower priority (Grap et al. 2003) in the highly pressured and
technological critical care setting (Berry et al. 2007). Kite
found that nine of 10 nurses favoured foam sticks to
toothbrushes for cleaning the oral cavity of an intubated
patient. Similarly, Jones et al. (2004) also found foam sticks
to be most popular oral care, being used by 88Æ5% of 103
nurses in the ICU. McNeill (2000) observed that oral care
techniques varied among nurses and considers that the
diversity in oral care methods is due to the vast array of
cleaning tools provided. Nurses may not be aware of the
importance of tooth brushing for critically ill patients, so
choose to use their preferred method even when toothbrushes
are accessible (Kite 1995). Another barrier to oral hygiene is
intubation with oral and nasal tubes hindering tooth brush-
ing, (McNeill 2000, Munro et al. 2004). Fear of dislodging
or displacing the endotracheal tube is a real concern as this
can be life-threatening (Abidia 2007).
When patients are intubated a small head toothbrush is
preferred (Berry & Davidson 2006, Abidia 2007). Browsher
et al. (1999) reported a small headed soft toothbrush to be
the most effective plaque removal tool. Studies also recom-
mend brushing with a child’s toothbrush at least twice a day
for more effective prevention of dental plaque in mechani-
cally ventilated patients (Pearson & Hutton 2002, Schleder
& Pinzon 2004, Cutler & Davis 2005). Even though there are
limited data associating dental plaque removal with reduced
incidence of VAP (Munro et al. 2006a), Fourrier et al. have
found that colonisation of dental plaque with respiratory
pathogens was associated with pneumonia and nosocomial
infections (Fourrier et al. 1998).
Although there are several studies addressing oral hygiene
internationally, there are limited data in the Malaysian
context. Traditionally, in Malaysia, nursing students have
been taught to used swab, gauze and forceps in the oral care
procedure for unconscious and ventilated patients. To date,
the current oral care practice among Malaysia ICU nurses is
unknown. Therefore, this study investigated the type of oral
care provided to ventilated patients in the ICU, nurses’
attitude to providing oral care and their knowledge of risk
factors for VAP.
Methods
A cross-sectional study involving administration of a survey
and an observational study was undertaken. A self-adminis-
tered survey was administered to 284 nurses in ICUs and oral
care practice was observed by a trained nurse using standar-
dised methods.
Sample and setting
Study sites included medical, surgical and cardiology ICUs
from three government hospitals on the East Coast of
Peninsular Malaysia. The number of ICU beds varied, with
a minimum of four to a maximum of 16 open beds and one to
three isolation rooms. The ratio of nurses to patients was
about 1:1 in all the ICUs. All the nurses and nurse managers
in the units were invited to participate in the survey. The total
number of nurses was 314, but 30 were away for reasons
including maternity and study leave. Nurses were informed
verbally about the research by the researcher or ward
managers. They were also given a participant information
sheet together with the survey. They were considered to have
consented if they completed the survey. Observations were
KL Soh et al.
734 Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 733–742

conducted by a nurse, trained in the study protocol; there-
fore, observations are limited to when this particular nurse
was on duty.
Ethical considerations
Ethical approvals were obtained from the Ministry of Health,
Clinical Research Centre from each hospital and University
Putra Malaysia Medical Ethics Committee. This provision for
confidentiality was explained in a participant information
sheet. During the observation periods, none of the nurses
were identified nor any visual recording made in study
documentation. All ward managers in each unit were
involved in the study and identified an assessor for the
observation phase. To avoid the Hawthorne effect, none of
the researchers were present at the units during the observa-
tion period to avoid changing of existing practices during the
assessment and observation phase. (Eckmanns et al. 2006).
The observer was also requested to record the type of oral
care provided and the use of a toothbrush.
Instrument
The survey was adapted, with permission, from that used by
Binkley et al. (2004) in the USA. Modification of the survey
was undertaken to tailor it to the context, language and
practices in Malaysian ICUs. The original survey consists of
27 items. Two items were removed for the study. The
scenario and two items were modified because of the lack of
relevance to the Malaysian ICU setting. Seven new items were
added giving final number of 32 questions in the survey
(Table 1).
Following modification, the survey was first sent to seven
experts for review of face validity – two anesthesiologists, a
surgeon, a nurse manager and three nurses with postbasic
intensive care qualifications. The expert panel agreed on the
survey items and supported the number, format and validity
of the questions posed. Only one question (in the demo-
graphic profile, for the highest qualification attained) needed
to be rephrased for greater clarity based on the expert
feedback. Data items for the survey were arranged in five
domains (Table 2). The respondents’ knowledge on risk
factors of VAP was assessed based on a scenario given with
graded answers on a Likert Scale of 1–10 (1 = least likely;
10 = most likely).
A pilot of the survey was undertaken in a single site with
the survey distributed to 38 nurses. Ten surveys were
returned. Respondents were requested to answer the ques-
tions and also to write directly in the question what, if any,
were not clear to them. No changes were made to the survey
following the pilot as the respondents felt the questions to
be sufficiently clear.
Table 1 Modification of survey items
Removed Modified New
Please read and respond to the following
scenario. An 18-year-old male was involved in
an all terrain vehicle accident five days ago and
was admitted to your intensive care unit (ICU).
He has been mechanically ventilated since
admission and has now developed pneumonia.
On a scale of 1–10, what is the likelihood of
each of the following being the mechanism
of transmission?
A 30-year-old male was involved in motor
vehicle accident four days ago and was
admitted to your ICU. He has been
mechanically ventilated since admission and has
now developed pneumonia. On a scale of 1–10,
what is the likelihood of each of the following
being the mechanism of transmission to acquire
Ventilator-associated Pneumonia?
Whether there is any oral care
protocol in the unit?
What type of hospital are they working? Is there any plan to develop oral
care protocol in the unit?
I prefer that a dental hygienist perform oral care
tasks.
Does hospital provide
toothbrushes for oral care?
I would prefer using an electric toothbrush to
a manual toothbrush for cleaning patients’
teeth.
I would prefer using a common oral toilet
method (gauzes, swabs and forceps/spatulas) to
a toothbrush for cleaning patients’ teeth.
The adult toothbrushes are
provided by the hospital.
Staff would be more likely to brush patients’
teeth with an electric toothbrush than with
a manual toothbrush
Staff would be more likely to use common oral
toilet method (gauzes, swabs and forceps) to
clean patients’ teeth than with a toothbrush
The child toothbrushes are
provided by the hospital.
How many years have you worked
as a nurse?
What best describe your highest
nursing qualification?
Clinical issues Oral care for mechanically ventilated patients in the ICU

Data collection
Survey
Data collection was undertaken over three weeks in 2007.
All nurses were informed verbally and in writing about the
study, and that their participation was voluntary and anon-
ymous. The survey, with a participant information sheet, was
given to the nurse managers to distribute. No reminder or
incentives were provided to nurses to complete the survey.
The nurses were requested to return their surveys, completed
or incomplete, to a box in the nurse manager’s office.
Observation
The second type of data collection was by observation. The
observation of actual oral care provided was made on one
shift a day – either morning, afternoon or night – for five
consecutive days. The observation was conducted on different
days for each of the ICUs studied. After the survey was dis-
tributed, a volunteer nurse from each hospital was asked to
observe the oral care provided in her ICU. Every observer was
briefed using a standardised protocol. A file with a checklist
was given as guidance and a writing pad for documentation.
The checklist was developed based on requirement of what
expected to be observed during the shift. No definition con-
stitute oral care was provided. Data were collected on con-
textual factors in the ICU environment during the observation
period including: activity level; number of intubated patients;
nurse patient ratio and type and frequency of oral care pro-
vided to the patient. Every nurse rostered in the ICUs was
observed only once, without them knowing about the
observation. The observers were requested to be discrete to
minimise changes in behaviours (Eckmanns et al. 2006).
Observation of practice occurred during the seven hours
morning and afternoon shifts and a 10-h night shift.
Data analysis
Data were analysed using the Statistical Package for Social
Sciences (SPSS
SPSS) 13.0.1 Standard Version (SPSS Inc., Chicago,
IL, USA). The response rates and sample characteristics were
analysed using descriptive statistics with the proportions
(percentages) and/or measures of central tendencies. All the
data entered were double-checked for accuracy.
Results
Participant characteristics
There were 344 nurses working in the ten ICUs in the three
hospitals. Fifty did not return the survey, and another 30
were away on approved leave. The remaining 264 (84%) had
a mean age of 34Æ8 (SD 7Æ4) years. Approximately 80% of
them had a diploma in nursing, and 42% had completed a
post-basic critical care nursing course. Approximately 93%
(n = 261) have had four years and more nursing experience
and 70% (n = 261) with three years and more working
experience in the ICU.
Of 264 nurses surveyed 53% indicated they had a
standard oral care protocol of using cotton or gauze and
forceps; tooth brushing was not included in the unit, 13%
were not sure, and 32% indicated that they were unaware of
Table 2 Survey content
Section Content
1 Whether there is any oral care protocol in the intensive care unit (ICU).
2 This section was on knowledge of transmission of ventilator-associated pneumonia (VAP). A scenario was given:
A 30-year-old male involved in motor vehicle accident four days ago and admitted to an ICU. He has been mechanically ventilated
since admission and has now developed pneumonia. On a scale of 1–10, what is the likelihood of the following pathways being
the mechanism of transmission of his VAP? The response was graded on a 10-point Likert Scale. In all, there were five questions
on the mode of transmission of VAP. No question related to the best practice for oral hygiene to minimise VAP.
This section asked the nurses about their oral care practice, their feeling in providing oral care and the type of mouthwash used.
1 What is the frequency of oral care provided?
2 Type of equipment used – cotton/forceps, gauze/forceps, gauze/spatula and toothbrush.
3 Nurses’ feelings on the oral care provided. This was to measure the nurses’ attitudes to providing oral care. Eight questions
were posed for answers on a 5-point Likert scale.
4 Participants were asked to identify their mouthwash used.
4 Nurses were questioned on the support provided by the hospital.
Their responses was graded on a 5-point Likert scale – strongly disagree, somewhat disagree, neither agree nor disagree,
somewhat agree and strongly agree.
5 Demographic profile.
The participants were asked their age, qualifications, ICU work and length of service.
KL Soh et al.

an oral care protocol in their unit. The nurses from ICUs
that did not supply toothbrushes would usually ask the
relatives to provide it if they thought it needed for the
patients. Across all ICU sites in the study, foam sticks and
cotton swabs were provided, and there was no supply of
tooth brushes.
Knowledge on risk factors for VAP in the ICU
There was approximately 91% (n = 240) nurses indicated
that aspiration of contaminated oropharyngeal secretion
(mean response = 6Æ8 SD 2Æ0) as the most likely transmission
of bacteria into the lung of ventilated patients as opposed to
respiratory pathogens from other sources (mean respon-
se = 4Æ4 SD 2Æ3–6Æ2 SD 2Æ1) (Table 3).
Attitude to providing oral care
Nurses’ attitudes were assessed by responses to an eight-item
Likert Scale. More than 89% of the nurses agreed that oral
care is very important for mechanically ventilated patients.
More than 70% have had adequate oral care training and
also adequate time to provide the care at least once a day.
However, more than 40% felt that the oral cavity is difficult
to clean and that it is also an unpleasant task. Overall, the
majority of nurses had a positive attitude towards providing
oral care for ventilated patients (Table 4).
Frequency and mode of oral hygiene
Of 260 nurse respondents, only two indicated that they used
chlorhexidine mouth wash for oral care. The majority of
nurses provided all types of oral care at least once a day –
forceps and gauzes (97%), forceps and cotton (90%), orange
stick (70Æ5%) and spatula and gauze (66Æ8%). Some nurses
even used children’s toothbrushes (17%). Other nurses
indicated that they provide oral care to their patient 2–8
times a day (more than one a day) (Table 5).
Hospital supplies
Many of the participants (62Æ9%) reported that child
toothbrushes were not provided by the hospital, and 49Æ7%
reported that toothbrushes from the hospital were not
suitable for patient use. Most of them (63Æ6%) agreed that
oral care supplies such as forceps, gauze, cotton and orange
sticks were available (Table 6).
Observation
During the five-day observation, most of the ICU nurses used
forceps, gauze, cotton and orange sticks in hospitals one and
Table 3 Nurses’ knowledge on the risk factors of ventilator-associ-
ated pneumonia to ventilated patients
Mechanism Mean response*
From other patients 4Æ4 ± 2Æ3
Aspiration of contaminated secretions from
the oropharynx
6Æ8 ± 2Æ0
From health care workers’ hands 5Æ6 ± 2Æ2
From contaminated respiratory equipment 6Æ2 ± 2Æ1
Preadmission colonisation 5Æ2 ± 2Æ3
*On scale of 1–10; 1, least likely; 10, most likely.
Table 4 Nurses’ attitude to oral care practice in their intensive care units
Question
Strongly
disagree,
n (%)
Somewhat
disagree,
n (%)
Not agree/
disagree,
n (%)
Somewhat
agree,
n (%)
Strongly
agree,
n (%)
Do you have adequate time to provide your patients with
oral care at least once a day? (n = 262)
3 (1Æ1) 4 (1Æ5) 7 (1Æ1) 48 (18Æ2) 200 (75Æ8)
Have you had adequate training to provide your patients
with oral care? (n = 262)
2 (0Æ8) 7 (2Æ7) 10 (3Æ8) 57 (21Æ6) 186 (70Æ5)
Oral care is high priority for mechanically ventilated
patients (n = 264)
2 (0Æ8) 2 (0Æ8) 2 (0Æ8) 22 (8Æ3) 236 (89Æ4)
Cleaning oral cavities is an unpleasant task (n = 258) 38 (14Æ4) 22 (8Æ3) 24 (9Æ1) 68 (25Æ8) 106 (40Æ2)
Oral cavities are difficult to clean (n = 264) 47 (17Æ8) 41 (15Æ5) 15 (5Æ7) 55 (20Æ8) 106 (40Æ2)
The mouths of most ventilated patients get worse no matter
what I do (n = 259)
39 (14Æ8) 31 (11Æ7) 17 (6Æ4) 50 (18Æ9) 122 (46Æ2)
Need better supplies and equipment (n = 263) 7 (2Æ7) Nil 4 (1Æ5) 13 (4Æ9) 239 (90Æ5)
Prefer using a common oral toilet method to a toothbrush
for cleaning patients’ teeth (n = 262)
23 (8Æ7) 24 (9Æ1) 16 (6Æ1) 43 (16Æ3) 156 (59Æ1)

two. However, in hospital three, foam sticks were the most
common. None used a toothbrush (Table 7). The majority of
nurses provided oral care to most of the patients at least once
per shift with foam sticks, gauze or cotton sticks.
Discussion
This study has described the methods and frequency of oral
care provided for mechanically ventilated patients in the ICU
Table 5 Various methods and frequency of
oral care practice
More than
once a day,
n (%)
Once a day,
n (%)
Never*,
n (%)
Not
available ,
n (%)
Forceps and cotton (253) 105 (41Æ5) 123 (48Æ6) 20 (7Æ9) 5 (2Æ0)
Forceps and gauzes (259) 129 (49Æ8) 122 (47Æ1) 6 (2Æ3) 2 (0Æ8)
Spatula and gauzes (253) 78 (30Æ8) 91 (36Æ0) 67 (26Æ5) 17 (6Æ7)
Orange sticks/foam sticks (251) 91 (36Æ2) 86 (34Æ3) 40 (16Æ0) 34 (13Æ5)
Foam sticks (248) 41 (16Æ5) 289 (11Æ3) 70 (28Æ2) 107 (44Æ0)
Manual adult toothbrush (n = 252) 22 (8Æ3) 40 (15Æ2) 61 (23Æ1) 129 (48Æ9)
Manual child toothbrush (n = 251) 19 (7Æ2) 26 (9Æ8) 63 (23Æ9) 143 (54Æ2)
Electric toothbrush (n = 250) 17 (6Æ4) 9 (3Æ4) 65 (24Æ6) 159 (60Æ2)
*Equipment may be available but no use observed.
Equipment not available for use.
Table 6 Hospital supplies for oral care
Statement
Strongly
disagree,
n (%)
Somewhat
disagree,
n (%)
Not agree/
disagree,
n (%)
Somewhat
agree,
n (%)
Strongly
agree,
n (%)
Supplies* for oral care readily available in my unit (n = 262) 51 (19Æ3) 24 (9Æ1%) 19 (7Æ2) 60 (22Æ7) 108 (40Æ9)
Adult toothbrushes provided by the hospital (n = 263) 144 (54Æ5) 52 (19Æ7) 26 (9Æ8) 1 (0Æ4) 40 (15Æ2)
Children’s toothbrushes provided by the hospital (n = 261) 146 (55Æ3) 20 (7Æ6%) 31 (11Æ7) 33 (12Æ5) 31 (11Æ7)
Toothbrushes provided by the hospital are suitable for patient
use (n = 262)
110 (41Æ7) 21 (8Æ0) 57 (21Æ6) 23 (8Æ7) 51 (19Æ3)
*The supplies are mainly forceps, gauze, cotton and orange sticks.
Table 7 Observed oral care practice
Shift Hospital
No.
observation
days, n
No. intubated
patients
observed, n
No. intubated
patients
receiving
oral care, n
Oral care method
Toothbrush, n Foam sticks, n *Other methods, n
Morning One 2 20 2 Not observed Not observed 2
Two 1 3 3 Not observed Not observed 3
Three 3 12 6 Not observed 6 Not observed
Total 6 35 11 Nil 6 5
Afternoon One 1 12 3 Not observed Not observed 3
Total 4 25 15 Nil 4 11
Night One 2 22 22 Not observed Not observed 22
Total 5 38 34 Nil 3 31
*Other methods: forceps, gauze, cotton and orange sticks.
KL Soh et al.

at three government hospitals in Malaysia. The results
indicated that the frequency and method of oral care differed
among nurses. Based on the study findings, it is likely that the
implementation of protocols may help nurses provide evi-
dence-based oral care to patients and reduce their risk of
VAP. Jones et al. (2004) found that there was an increased
uptake in the use of tooth brushes following introduction of
an oral care protocol. Implementing a protocol for tooth
brushing has been shown to improve oral care (Fitch et al.
1999), as well as the attitudes and knowledge of nurses in the
unit (Furr et al. 2004). Furthermore, a standardised, evi-
dence-based oral care protocol has the capacity to improve
the quality of nursing care in the ICU and as a consequence
patient outcomes (Cutler & Davis 2005). Schleder et al.
(2002) found that the use of an evidence-based oral care
protocol for tooth brushing increased the compliance of
nurses in providing oral care in the ICU, as a result reducing
the incidence of VAP.
One of the important causes of VAP is aspiration of oral
colonisation. Oral colonisation is increased in patients with
poor oral care (Ohman et al. 2003, Solh et al. 2004, Jones
& Munro 2008). Only two nurses of 260 indicated that they
are using chlorhexidine for oral care. No data were collected
regarding supply of chlorhexidine. However, the lack of
usage of chlorhexidine may also indicate that nurses may not
aware of current best practice recommendations (Grap 2009,
Wip & Napolitano 2009).
In this study, two hospital ICUs supplied adult tooth
brushes while another did not. Therefore, the nurses did not
use them because a big head toothbrush is not easy to be used
on the intubated patients, preferring instead forceps and
gauze or forceps and cotton – the techniques they were taught
in their nursing schools. Previous studies also found that
many nurses prefer foam sticks to toothbrushes for oral care
(Kite 1995, Grap et al. 2003) which may predispose the
patients to potentially life-threatening nosocomial infections
caused by the ineffectual cleaning (McNeill 2000). Jones
et al. (2004) also found a minority of nurses in their study not
using a toothbrush in their oral care for edentulous patients.
The results of nurses’ oral care practice in this study reflected
that they are not adhering with evidence-based practice
recommendations. During the observation phase of this
study, none of the nurses were observed using toothbrush
for cleaning their patient teeth.
This study only examined the nurses’ knowledge on the
risk factors of VAP, and no question was asked about
the best practice for oral hygiene to minimise VAP. Thus,
the question of whether the nurses knew about tooth
brushing as the recommended oral care to reduce the risk of
VAP is unknown. The nurses indicated that they knew
aspiration of contaminated secretions from the oropharynx
is the main risk factor of VAP with a mean response of 6Æ8
(SD 2Æ0). Binkley et al. (2004) obtained a higher mean
response of 7Æ5 from their survey, indicating that their
nurses were better informed. Intubation and aspiration of
contaminated secretion were recognised as the most likely
mechanisms of bacterial transmission into the lungs, result-
ing in pneumonia in the scenario presented in this survey.
Other factors, such as contamination from the ventilator
equipment, microorganism transmission from the staff
hands, precolonisation and host factors, are also important
risks, but secondary to intubation and aspiration (Visne-
garwala et al. 1998).
The nurses in this study were generally happy to provide
oral care to their patients. However, they were over
optimistic about the quality and standard of care they
provided. Approximately 30–50% (n = 253) (Table 5) of
the nurses indicated that they provide oral care more than
once a day. However, during the observation period, only
hospital two provided oral care to all patients during the
three shift of the day observed. Hospital one provided oral
care to all patients only during the night shift. This can be due
to oral care is required as a routine procedure for these two
hospitals during certain shift. However, at hospital three,
approximately half of the intubated patients did not receive
regular oral care during the observation period. Grap et al.
(2003) found nurses likely to report providing more care than
what they actually did. They discovered that 75% of 77
nurses claimed providing oral care five times per day or more
for the intubated patients. Cutler and Davis (2005) found
that without a protocol for oral hygiene oral care was
performed infrequently. In their study, although the nurses
thought oral care to be very important for mechanically
ventilated patients and had the training and time to provide
it, 40–46% found it an unpleasant and difficult task, and the
mouths of their patients deteriorated if the patient needs
prolonged ventilation although oral care was provided. These
results were similar to those of Binkley et al. (2004). Furr
et al. (2004) stated that having sufficient time to provide oral
care, seeing it as priority and not unpleasant is associated
with providing better oral care for patients. Grap et al.
(2003) in their survey of oral care intervention in ICU also
found oral care to have been accorded low priority as the
greater importance was to stabilise the condition of critically
ill patients.
More than 63% of the responses to the question on
hospital supplies were that they were inadequate, with 62Æ9%
agreed that child toothbrushes were not supplied in their unit.
Hospital factors, such as availability of supplies and equip-
ment, can greatly affect the type and quality of care given by

the nurses (Kite 1995, Moore 1995, Curzio & McCowan
2000, Munro et al. 2004). The lack of appropriate tooth-
brushes hindered nurses in providing oral care (Kite 1995).
It is important to have an oral care protocol in the ICU
with a child toothbrush, so that it becomes part of routine
patient care. Oral care protocols and the ventilator bundle
interventions have been shown to decrease the rate of VAP
(Institute for Healthcare Improvement 2004a). Therefore,
existing oral care protocols should be updated to include
child toothbrush in the procedure.
It is important to address the limitations of this study. This
study was carried out in three government hospitals, and the
findings could not be generalised to all the hospitals in
Malaysia. A further limitation is the potential for the
Hawthorne effect and also inter-reliability assessment be-
tween observers. There is one observer selected for each ICU
observed in the three hospitals. Every observer was briefed
and provided with a checklist to guide the observation
process; however, reliability assessment between observers
was not undertaken. The challenges in structured observation
lies not in the observation itself but rather in the formulation
of a system for accurately categorising, recording and
encoding the observations and sampling the phenomena of
interest (Polit et al. 2001 p. 283). Therefore, in this study,
there is risk of observer error which is the potential weakness
of direct observation. Nevertheless, this study has provided
important insight into nurses’ knowledge on the transmission
of VAP, oral care practice and their attitude to prevention of
VAP in ventilated patients and identified areas for future
improvement.
Conclusion
The majority of respondents knew that aspiration of con-
taminated secretions from the oropharynx is the main cause
of risk factors of VAP and identified the importance of oral
hygiene. Oral care was a routine procedure in the ICU, but
none of them practised tooth brushing as no child tooth-
brushes were supplied. Therefore, there is a need for all ICUs
to update their oral care protocols and stocks to include tooth
brushing and chlorhexidine mouth wash. Evaluation of
implementation of these protocols should be undertaken to
improve patient outcomes.
Relevance to clinical practice
Oral hygiene in the ICU is important not only for facilitating
patient comfort but also for decreasing the risk of nosoco-
mial infections, such as VAP. This study provides insight into
oral care practice in Malaysian ICUs and underscores the
need for protocol development, implementation and evalu-
ation. Updating oral care protocol such as including tooth
brushes and chlorhexidine mouth wash in the protocol may
assist in implementing evidence-based practice.
Acknowledgement
This study was funded by Malaysian Ministry of Higher
Education Fundamental Research Grant. We thank the
hospital directors at Malaysian Ministry of Health hospitals
and the ICU nurses for participating in this study.
Contributions
Study design: KLS, KGS; data collection and analysis: KLS,
KGS, SJ, RAR and manuscript preparation: KLS, PMD, SJ.
Conflict of interest
The authors have no conflict of interest.
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