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Oral Care: Exploring Education, Attitudes, and Behaviors Among Nurses Caring for Patients With Breast Cancer

Jennifer A. Suminski
Marita Rohr Inglehart
Stephanie M. Munz
Catherine H. Van Poznak
L. Susan Taichman
CJON 2017, 21(3), 371-378 DOI: 10.1188/17.CJON.371-378

Background: Patients treated for breast cancer often experience severe oral complications, such as mucositis, xerostomia, and infections, which can result in dose reductions and treatment delays, affecting treatment outcomes.

Objectives: The purpose of this article is to explore oncology nurses’ perceptions of their educational experiences, professional attitudes, and behavior related to providing oral healthcare education to patients with breast cancer.

Methods: The Oncology Nursing Society sent an email to 5,000 nursing team members who cared for patients with breast cancer, requesting participation in a web-based survey; 194 responses were received, with 164 meeting study eligibility.

Findings: More oral health–related education was received during clinical experiences than during formal or continuing education. Although patient-driven oral care and diagnostic efforts were frequent, actual behavior was less frequent. No major barriers to providing oral care were indicated. Increased oral health–related education and behavior correlated with the reported importance of increased oral health education for nurses.

Oral health is a critical component of a person’s overall health; in patients undergoing anticancer therapies, oral health is no exception (Clemmens, Rodriguez, & Leef, 2012; Potting, Mank, Blijlevens, Donnelly, & van Achterberg, 2008). About 40% of patients receiving anticancer treatments experience oral side effects (Davison, 2006). Some of the most common and debilitating side effects are mucositis and xerostomia, which affect oral functions such as nutritional intake, speech, and nonverbal expressions of feelings. Anticancer treatments may put patients at greater risk for oral infections and dental caries (Barker, Epstein, Williams, Gorsky, & Raber-Durlacher, 2005; Daniel, Damato, & Johnson, 2004; Eilers & Million, 2011). Oral side effects of anticancer therapies can negatively affect quality of life and may affect the ability to administer the optimal anticancer therapy by causing treatment delays or dose reductions (Armstrong & McCaffrey, 2006; Bruce, 2004; Cawley & Benson, 2005; Harris, Eilers, Harriman, Cashavelly, & Maxwell, 2008). Oncology nursing teams are ideally situated to assess the impact of breast cancer treatments on patients’ oral health, document oral side effects of treatment for multidisciplinary communications, assist in therapeutic interventions, and educate patients about oral health promotion (Wårdh, Paulsson, & Fridlund, 2008; Weber & Eskinazi, 2012).

Although a national call has been made to encourage all healthcare providers to be proactive with oral disease prevention and promotion of good oral health care (Clemmens et al., 2012), oral health–related content has still not been well integrated into general nursing curricula (Parish, Singer, Abel, & Metsch, 2014; Perry, Iida, Patton, & Wilder, 2015). Specialty nursing organizations have comprehensive guidelines for their certifications and include questions related to prevention and management of oral complications within certification examinations (Ohrn, Wahlin, & Sjoden, 2000). In addition, Costello and Coyne (2008) suggested that nurses and nurse practitioners not only learn oral health–related information during their schooling, but also receive oral health–related training on the job. However, they pointed out that on-the-job training may be of short duration and that updates on oral care topics were infrequent (Costello & Coyne, 2008).

Lack of oral health–related on-the-job training and continuing education contributes to nursing team members’ low confidence in their ability to identify and treat their patients’ oral health problems (Southern, 2007). Although 95% of respondents in one study indicated a need for all oncology nurses to have oral health–related continuing education (Ohrn et al., 2000), only 11% of general nurses and about 20% of oncology nurses had attended a continuing education course about oral health–related care within the past year (Clemmens et al., 2012; Potting et al., 2008).

A paucity of oral health education may be one reason why nursing team members consider oral health problems to have a relatively lower priority compared to such treatment side effects as pain, nausea, and dyspnea (Wilberg, Hjermstad, Ottesen, & Herlofson, 2014). These attitudes may be an indication that nursing team members underestimate the impact of negative oral side effects of anticancer treatments, such as mucositis and xerostomia; in turn, this may result in scant proactive oral health–related educational behavior. Oncology nursing team members can reduce symptoms and help their patients cope with oral side effects (Armstrong & McCaffrey, 2006), particularly if they develop and use an oral care protocol that includes patient education (Sieracki, Voelz, Johannik, Kopaczewski, & Hubert, 2009). Oral hygiene care can result in decreased oral discomfort and reduce the frequency of symptoms or infections, and such a regimen is particularly successful if oncology team members regularly assess the health of the oral cavity and keep it moist and free of pathogens (Coke, Otten, Staffileno, Minarich, & Nowiszewski, 2015). In addition, an interdisciplinary team approach to symptom management, particularly with dentists and dental hygienists, may improve patients’ overall quality of life during anticancer treatment (Granda-Cameron et al., 2010).

Given the obvious benefits of nursing team members’ engagement in oral health–related care, it is important to identify whether barriers may prevent these healthcare professionals from providing oral health–related care to patients. The availability of tools necessary to perform oral assessments plays a significant role in providing oral care for patients with breast cancer (Barker et al., 2005; Miller et al., 2007), and the lack of appropriate equipment within the facilities hinders the delivery of adequate oral care for patients with cancer (Barker et al., 2005; Eilers & Million, 2011). For example, many cancer treatment facilities have limited funds that may not allow all patients to be provided with a toothbrush and toothpaste, and nurses instead offer medicated mouthwash to patients (Yin Wee, Ang, & Ng, 2014). In addition, close monitoring, evaluation, and severity grading of various oral lesions, such as mucositis, is important but is not often practiced as sufficiently as it should be (ÇubukÇu & Çinar, 2012). In a study by Araujo et al. (2015), results revealed that nurses only took vital signs and provided the chemotherapy administration, and no interventions concerning prevention or treatment of oral mucositis were recorded.

Considering how oral health–related professional behaviors can be increased is crucial in the care of patients with breast cancer. One step could be to increase oral health–related educational efforts and educate oncology nursing team members about the oral side effects of cancer treatments and about effective oral hygiene methods. These improved educational efforts are expected to motivate oncology team members to engage in increased oral health–related professional behavior.

The current study evaluated the present state of oncology nurses’ educational experiences, professional attitudes, and behaviors related to oral health–related care in patients with breast cancer. Perceived barriers to providing oral care and the relationship between oral health–related education and behavior were explored.

Methods

This research was reviewed and determined to be exempt from institutional review board (IRB) oversight by the Health Sciences and Behavioral Sciences IRB at the University of Michigan in Ann Arbor.

Instrument

The survey was based on a previous study that explored pediatric nurses’ oral health–related educational experiences, attitudes, and professional behavior (Kloostra, 2014). This survey was revised to be applicable to oncology nursing team members. Specifically, changes in wording were made, such as changing “pediatric nurses” to “oncology nurses,” and “children” to “patients with breast cancer.” Any questions specific to oral health–related care for pediatric patients were removed, and questions relevant to breast cancer were added. This revised survey was then piloted with five oncology nurses from the University of Michigan Comprehensive Cancer Center. Their feedback was used to finalize the survey. It was then uploaded to the Qualtrics website (www.qualtrics.com) and made available as an anonymous survey.

The survey asked about the respondents’ demographics, as well as education on oral health topics during their primary, secondary, and continuing education and in clinical settings. The respondents’ attitudes were assessed with 23 Likert-type rating scale questions, and their oral health–related behavior was determined with 17 Likert-type rating scale questions. The final questions inquired how much seven different factors influenced the respondents in engaging in oral health–related behavior.

Respondents

Individuals were eligible to participate in the current study if they were registered oncology nurses or nurse practitioners with a background in treating patients with breast cancer. The participants also had to be practicing (nonretired) and fully licensed at the time of the survey. These inclusion criteria were provided to the Oncology Nursing Society (ONS), which was asked to identify 5,000 of its members who met these criteria and send a recruitment email to these members. The first recruitment email was sent on October 31, 2014, and a second email followed two weeks later. In response, 194 members accessed the anonymous survey through a link provided in the recruitment email. One respondent was not a nursing team member, and 29 respondents did not start the survey. Their data were excluded, and data from 164 ONS members were analyzed (response rate = 3.3%).

Statistical Analysis

The data were downloaded from Qualtrics as an SPSS®, version 22.0, file. Descriptive statistics, such as means, standard deviations, and ranges, were computed to provide an overview of the responses. A factor analysis (extraction method: principal component analysis; rotation method: varimax rotation) with the 22 attitudinal items was conducted for purposes of data reduction to allow for the creation of indices that could be used in the exploration of the relationships between oral health–related attitudes and behavior. This analysis resulted in a three-factor solution:

•  Factor 1: Importance of learning and knowing oral health–related content (Cronbach alpha = 0.939)

•  Factor 2: Importance of oral health–related skills (Cronbach alpha = 0.96)

•  Factor 3: Importance of oral health–related behavior (Cronbach alpha = 0.904)

Therefore, three attitudinal indices were constructed.

A second factor analysis with the 17 behavioral items was done to allow the creation of behavioral indices. This analysis showed that these items loaded on five factors:

•  Factor 1: Oral health–related behavior (Cronbach alpha = 0.671)

•  Factor 2: Patient-driven oral health behavior (Cronbach alpha = 0.797)

•  Factor 3: Assessment of oral health (Cronbach alpha = 0.872)

•  Factor 4: Interprofessional care (Cronbach alpha = 0.739)

•  Factor 5: Oral health–related behavior during the course of the treatment (Cronbach alpha = 0.829)

A final factor analysis with the seven items assessing barriers to care revealed two factors:

•  Factor 1: Nurse-related barriers (Cronbach alpha = 0.874)

•  Factor 2: Uncooperative patient and lack of staff

However, the two items loading on factor 2 did not have sufficient reliability to compute an index. These indices were computed to allow for the exploration of the relationships between oral health–related educational experiences and attitudes and related behavior and perceptions of barriers to care.

Inferential statistics were used to determine whether the Pearson correlation coefficients that were computed to assess the relationships between educational, attitudinal, and behavioral indicators and perceptions of barriers to engage in oral health–related behaviors were significant. A level of p < 0.05 was determined to be significant.

Results

One hundred and sixty-four ONS members participated in the survey. Participants had a mean age of 47.99 years (SD = 11.62, range = 24–77 years). They saw an average of 41 patients per week, of which 35 had cancer; 16 were treated for breast cancer. Table 1 provides demographic characteristics of the participants.

Overall, most oral health topics were reported to have been learned in clinical settings, followed by coverage during second-degree education or certificate training. Table 2 provides an overview of the number of respondents who had been educated about 10 oral health–related issues in four different settings. During their education for their first degree, the majority reportedly had been educated only about basic issues, such as the importance of patients’ oral health and the function of the oral cavity, and only 17 (13%) had been informed about how breast cancer therapies may affect oral health and how to identify oral conditions related to breast cancer therapies. More respondents had been educated about oral health–related care for patients with breast cancer during their second-degree education and in continuing education programs. During their clinical experiences, the majority reported having been educated about all types of oral health–related behaviors.

When asked how well their education had provided them with sufficient knowledge and confidence to perform oral health assessments and with skills to confidently detect or diagnose dry mouth, mucositis, stomatitis, or other oral conditions, the responses were, on average, neutral to slightly positive (see Table 3). Only 51 (31%) indicated that they were well or very well educated to provide oral health instructions, and 58 (35%) felt that they had sufficient knowledge and confidence to perform oral health assessments. However, their reported attitudes concerning the importance that nurses and nurse practitioners learn or know about oral health issues, have oral health–related skills, and engage in oral health–related behavior were, on average, positive. The mean indices for these three constructs ranged from 4.33–4.51 on a five-point Likert-type scale, with 5 indicating the highest level of importance.

The majority of oncology nurses responded that they often or very often assessed patients’ oral health on admission or arrival for an appointment (n = 67, 41%) and prior to initiating a new anticancer therapy (n = 64, 39%). However, only about one-third assessed oral health often or very often prior to invasive procedures (n = 45, 27%) and prior to discharge or at the end of an appointment (n = 38, 23%). When asked how often they assessed specific oral health issues (on a five-point Likert-type scale with 5 indicating very often), on average, the most frequently assessed issue was oral pain level, followed by the presence of mucositis, stomatitis grade, dry mouth, and other intraoral pathologies. However, only 22 (13%) often or very often used an oral assessment guide during patient care. When patients presented with dental symptoms or requested an oral assessment, the absolute majority of nursing team members assessed the patients’ oral health often or very often (n = 113 [69%] and n = 101 [62%], respectively). Table 4 provides an overview of the responses concerning oral health–related behavior for patients with breast cancer.

When asked about oral health–related behavior in general, the majority often or very often educated their patients about oral health (n = 69, 42%). However, only 56 (34%) used a tongue depressor or flashlight for oral assessments, and 28 (17%) performed patient oral hygiene care. The frequency with which the respondents engaged in interprofessional collaboration with a dental specialist was also low. Only 20 (12%) often or very often referred their patients to a dental specialist, and 16 (10%) collaborated with dental specialists during their patients’ treatment.

The survey investigated specific barriers to engaging in oral health–related behavior. Table 5 shows that the majority of oncology nurses did not think that any barriers had kept them much or very much from providing oral health–related care. Only 37 (23%) considered a lack of time as a barrier, and even fewer considered the other factors as important barriers. The more topics the respondents had been introduced to during their education for their first and second degree, during continuing education courses, and during clinical activities, the more they engaged in all types of oral health–related behavior. This demonstrates that oral health–related education is associated with oncology nurses’ behavior.

Discussion

The current results showing that oral health education for nurses is not optimally provided, particularly during the education for a first nursing degree, replicate earlier findings from 2000–2006 (Ohrn et al., 2000; Southern, 2007). In the current study, education for a second degree or certification, as well as continuing education programs, contained more oral health–related content, and on-the-job training in clinical settings was most likely to include education of nursing team members about oral health–related topics. The findings that adherence to oral hygiene care can positively affect patients’ oral health should be a call to action for all oncology nursing team members (Harris et al., 2008; Lalla & Ashbury, 2013).

Several suggestions can be made concerning how to best educate nursing team members about oral health–related care. Given the increasing role of interdisciplinary education and collaborations, developing cross-teaching models in which dental professionals or faculty could participate in teaching nursing students oral care and complications of the oral cavity is crucial (Daniel et al., 2004). Collaborating with dental colleagues equipped to manage oral effects of cancer therapy may contribute to improved care for patients and a better understanding of management strategies for nurse colleagues (Daniel et al., 2004; Southern, 2007). In addition, collaborating through referrals or consultation with oral health professionals is an appropriate way to redirect the responsibility from nurses who may already be overburdened. Ensuring that on-the-job training and updates are offered frequently should also be a priority (Costello & Coyne, 2008).

In the current study, the respondents had positive attitudes concerning receiving oral health–related education and skills training. The reported frequency of assessing oral pain levels, mucositis, stomatitis, and dry mouth was high, showing that the majority of nursing team members are aware of these negative side effects of anticancer treatments. Potential barriers to engaging in oral health–related care were not evaluated as being serious obstacles by the majority of respondents. Overall, these findings show that oral health–related education efforts may be welcomed by the majority of oncology nursing team members.

Limitations

The current study had several limitations. First, the response rate was only 3.3%. Research shows that low response rates to web-based surveys are a common problem (Hardigan, Succar, & Fleisher, 2011; Sheehan, 2001). A mailed survey may have yielded a higher response rate because research shows that response rates to mailed surveys are significantly higher than those to web-based surveys (Hardigan at al., 2011). Considering that the authors received only 164 responses that could be analyzed, the current study should be interpreted as a pilot study. Another limitation is the self-selection of the responders because they may have had more positive attitudes toward oral health–related care because of a greater interest in this topic than those who did not participate in the study. Generalizations cannot be made as to the oral health education, knowledge, attitudes, and behaviors of oncology nurses. Finally, findings based on survey responses may be more positive than findings based on actual clinical observations. Future research should consider conducting an observational study.

Conclusion

Anticancer treatments can cause serious oral side effects (Davison, 2006), which, in turn, can interrupt therapy and reduce patients’ treatment adherence (Barker et al., 2005; Daniel et al., 2004; Eilers & Million, 2011). Therefore, the oncology nursing team needs to be aware of the potential oral health impacts of anticancer treatments for patients with breast cancer. Increasing educational efforts on all levels is crucial given the strong associations between educational experiences and actual behavioral engagement found in the current study. Educating providers comprehensively about prevention, treatment, and the risk factors for developing oral conditions is as important as knowing how to treat the other side effects brought on by anticancer therapies.

Oncology nurses’ attitudes toward learning about oral health–related care, engaging in skills training, providing care, and collaborating with dental providers were positive. However, engagement in actual oral health–related care was reported to be less frequent. The majority of oncology nursing team members did not identify barriers to providing oral health–related care. The more oral health–related education the nursing team members had received, the more likely they were to engage in oral health–related patient care behavior.

About the Author(s)

Jennifer A. Suminski, CPhT, RDH, MS, is an instructor in the Division of Health Sciences at Hagerstown Community College in Maryland; and Marita Rohr Inglehart, Dr.phil.habil., is a professor in the Department of Periodontics and Oral Medicine, Stephanie M. Munz, DDS, is a clinical assistant professor in the Department of Oral and Maxillofacial Surgery, both in the School of Dentistry, Catherine H. Van Poznak, MD, is an associate professor in the School of Medicine, and L. Susan Taichman, RDH, MS, MPH, PhD, is an assistant professor and research scientist in the Department of Periodontics and Oral Medicine of the School of Dentistry, all at the University of Michigan in Ann Arbor. The authors take full responsibility for this content. This study was supported, in part, by a grant from the Rackham Graduate School of the University of Michigan. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Suminski can be reached at jasuminski@hagerstowncc.edu, with copy to CJONEditor@ons.org. (Submitted February 2016. Accepted September 8, 2016.)

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