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www.nature.com/bdjopen ARTICLE OPEN A survey of pediatric oncology nurses’ oral health knowledge, attitudes, practices, and perceived barriers in a Singapore Tertiary Children’s Hospital 1✉ 1 1 2 3,4 2 Ruixiang Yee , Pui Ling Chay , Melissa Mei-Yi Khor , Yvonne Siew Ling Lim , Nicole Kim Luan Lee , Wee Fang Kam , 5 2 Seyad Ehsan Saffari and Mei Yoke Chan © The Author(s) 2023 AIM: To explore oral health-related knowledge, abilities, attitudes, practices, and barriers of pediatric oncology nurses at an Asian children’s hospital. METHODS: A cross-sectional study was conducted via a self-administered anonymized questionnaire. Data was analyzed to summarize knowledge, conﬁdence, and practice behaviors. RESULTS: All sixty-three pediatric oncology nurses responded. Fifteen participants had >80% of the knowledge questions correct. Majority (97.3%) agreed on their roles in helping patients maintain their oral health. However, 75.8% of participants felt need for training in giving oral health advice. Notably, 74.6% checked patients’ mouths at least once daily but only 57.1% felt adequately trained. Though a high proportion (>90%) of nurses felt conﬁdent to assist with oral care, only 65% would assist patients to do so; “Uncooperative patient” was the major barrier reported. DISCUSSION: Nurses have high general awareness of importance of oral health, but had incomplete knowledge. Compared to previous studies, most (90.5%) did not ﬁnd performing oral care unpleasant but other barriers might have hindered actual oral care practice. CONCLUSION: Nurses were motivated to assist in oral care of children with cancer but sometimes felt ill-equipped. Updated national and institution guidelines, didactic and hands-on training, and implementation of practical support could be considered. BDJ Open (2023) 9:3 ; https://doi.org/10.1038/s41405-023-00130-2 INTRODUCTION However, studies in Ireland, Sweden, and USA showed that both Oral complications (e.g., oral ulcerations, mucositis, xerostomia and adult and pediatric oncology nurses have insufﬁcient knowledge secondary infections) may happen in 90% of children with cancer as and education in oral care, and felt uncomfortable performing oral a result of their disease or treatment, impacting their quality of life care for patients [6–8]. and survival [1, 2]. To minimize this, it is important to optimize oral Approximately 70% of Singapore’s pediatric oncology patients health before, during, and following cancer treatment , by are diagnosed and managed at KK Women’s and Children’s Hospital referring newly diagnosed patients to dentists who will identify and (KKH). There is currently no published data on the oral health- manage any oral diseases, and advise on preventive care to practice related knowledge, attitudes, practices, and barriers of pediatric during the course of oncology treatment . oncology nurses in Singapore. This study aimed to examine the However, once the oncology treatment commences, dentists knowledge, perceived abilities, attitudes, practices and barriers of often have limited or no interactions with the oncology patient KKH pediatric oncology nurses in meeting the oral healthcare needs and are not rightly sited to reinforce preventive oral care. The of children with cancer, so to identify gaps to be addressed. pediatric oncology patient would spend a substantial amount of time as a hospital inpatient during treatment, where oncology METHODS nurses involved in the care of the child can play a crucial role in This is a cross-sectional study conducted via a self-administered oral assessment, oral care, and education. Furthermore, all anonymized questionnaire, from 13th–27th Aug 2018. Ethical approval pediatric patients are dependent on adult caregivers to some was obtained from the SingHealth Centralized Institutional Review Board degree and it is noteworthy that about half of Singapore’s (Reference number: 2018/2591). childhood cancers occurs in children below 5 years old . Hence, Currently, there is no validated comprehensive questionnaire available nurses also have to step in to reinforce and guide oral care in the in the literature for this purpose. Hence, the questionnaire (Details: wards, if parents require assistance in caring for the sick child. Supplemental File S1) was designed by the multidisciplinary study team 1 2 Dental Service, KK Women’s and Children’s Hospital, Singapore, Singapore. Hematology/Oncology Service & Pediatric Palliative Service, KK Women’s and Children’s Hospital, 3 4 Singapore, Singapore. Division of Surgery, KK Women’s and Children’s Hospital, Singapore, Singapore. Surgery ACP, SingHealth Duke-NUS Medical School, Singapore, Singapore. Health Services & Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore. email: firstname.lastname@example.org Received: 17 November 2022 Revised: 13 January 2023 Accepted: 17 January 2023 1234567890();,: R. Yee et al. Table 1. Key aspects explored by survey questions. Section A: Demographics and Training History a. Demographics–gender, job position, nursing experience b. Qualiﬁcations–basic and advanced nursing training c. Oral health training history Section B: Oral Health Knowledge a. Oral health and oncology b. Oral habits–ﬂuoride and toothbrushing c. Diet habits Section C: Attitudes and Beliefs a. Self-perceived importance in identifying and referring oral conditions b. Perceived importance of oral health in oncology patients c. Perceived need for further training in oral care for patients Section D: Perceived Practices and Abilities a. Referring and oral assessment practices b. Self-conﬁdence to advise and assist with oral healthcare with their patients c. Self conﬁdence in diagnosis of existing oral problems Section E: Barriers a. Perceived barriers to referring patients for dental treatment b. Perceived barriers to providing oral care for patients based on a literature search of studies involving nurses and oral healthcare Senior Staff Nurse or Assistant Nurse Clinician (58.7%, n = 37). [8–10], and oral healthcare guidelines for children with cancer [11, 12]. It Over three-quarters had Bachelor of Nursing degrees (76.2%, was pre-tested on two oncology nurses from the study team and ﬁve non- n = 48) from countries such as Singapore, Philippines and India. oncology ward nurses, and revised so that the questions were ﬁt for Many did not have oral health-related training (58.7%, n = 37), purpose and easily understood. clinical competency during nursing training (76.7%, n = 46), or Five key areas covered were: (1) demographics and training history, (2) oral Continuing Professional Education (CPE) related to oral health in health knowledge, (3) attitudes and beliefs, (4) perceived practices and past 5 years (68.3%, n = 41) (Details: Supplemental Table S1). abilities, and (5) barriers related to oral care in pediatric oncology nursing (Table 1). Knowledge questions were in the format of true/false or multiple- Knowledge choice questions. For other areas, questions were in yes/no format, or Likert scales (e.g. strongly agree, agree, neutral, disagree, strongly disagree). No participant answered all knowledge questions correctly. Four All 63 nurses involved in clinical care in pediatric oncology wards were (6.3%) had over 90% of questions correct (13 questions); 11 invited to participate. Invitations and participant information sheets were (17.4%) had more than 80% of questions correct (≥12 questions). distributed during a team meeting. The survey was voluntary and The majority (92.1%, n = 58) did not know of any local or anonymized. No respondents’ identiﬁers were recorded. The completion/ international guidelines on oral healthcare in pediatric oncology return of the questionnaire implied consent to participate. Completed patients. questionnaires were collected via a drop-box in the wards. The nurses were All participants knew that children undergoing cancer therapy given reminders during subsequent team meetings to maximize participa- can potentially develop oral complications, and that good oral tion. Questionnaires with at least 90% answers were considered acceptable hygiene is important to reduce the severity of oral mucositis. All to be included in the analysis. Continuous variables were described as mean and standard deviation, and Student’s t-test was used to compare means of but one (98.5%) responded correctly that caregivers should assess independent samples; categorical variables reported as frequency and patients’ mouth every day during active cancer therapy. Three- percentage. Data was analyzed using SPSS Statistics software for Windows, quarters (75.8%, n = 47) knew that oral cavity is the most common Version 21.0 (IBM Corp, Armonk, US). A p-value of <0.05 was considered source of sepsis in immunocompromised patients with cancer. statistically signiﬁcant. All data was stored on secure systems and there was The majority knew the best timing to refer patients is before no dispersal of anonymized or averaged data beyond the study team. Data cancer treatment (81.0%, n = 51). will be retained for a minimum of 7 years after the date of publication to The majority knew that patients should brush at least twice facilitate inspection by authorized authorities. daily with a soft toothbrush (98.4%, n = 62), regardless of their red blood cell (87.1%, n = 54), or white blood cell levels (83.9%, n = 52). However, half (52.4% n = 33) were mistaken that tooth- RESULTS brushing should not continue if platelet counts are low. Moreover, All 63 surveys were completed and returned. All had over 90% not all (72.6%, n = 45) knew that a ﬂuoride toothpaste should be answers completed and were deemed satisfactory to include for used. Approximately half (55.6%, n = 35) knew that oral swabs analysis. Most questions had 100% responders, several had 1-3 should not be used for oral hygiene as a long-term substitute for missing data; only the question “How conﬁdent are you in your toothbrushing. ability to examine if patient experiences dysphagia?” had 19 nil Knowledge regarding dietary practices were poor. Only 37.1% responses. (n = 23) knew that frequency of sugary intake is a greater risk factor for dental caries than total amount of sugary intake. Demographics Although upward trends in the overall knowledge scores were All participants were female. Most were experienced with clinical observed in nurses regardless of their specialty, after attending up experience ≥6years (69.8%, n = 44). Over half had ≥6years of to 3 hours of Continuing Professional Education (CPE) related to speciﬁc experience in pediatric oncology (54.0%, n = 34). The oral care (Table 2), this did not reach statistical signiﬁcance. majority were Staff Nurse grade and above; over half were either BDJ Open (2023) 9:3 R. Yee et al. Table 2. Comparison of years of nursing experience and Continuing Professional Education (CPE) hours with overall knowledge score. Knowledge scores (mean ± SD) Working as a nurse p-value Working in a pediatric ward p-value ≤5 years � 0 CPE hours 10.2 ± 1.48 0.686 9.9 ± 1.60 0.984 � ≤ 3 CPE hours 9.8 ± 2.63 9.9 ± 1.95 6-10 years � 0 CPE hours 9.7 ± 1.49 0.199 9.9 ± 1.55 0.155 � ≤ 3 CPE hours 10.7 ± 1.38 10.7 ± 1.38 ≥11 years � 0 CPE hours 10.3 ± 1.74 0.443 10.2 ± 1.92 NA � ≤ 3 CPE hours 11.0 ± 0.82 11.0 (n = 1) SD = standard deviation. Student’s t-test was performed to compare the means of two independent groups. No nurses declared to have CPE > 3 hours. Attitudes and Beliefs All participants believed that oral hygiene is important. The majority felt they play an important role in maintaining patients’ oral health (93.7%, n = 59) and ensuring patients brush teeth at least twice daily (95.1%, n = 58). In fact, 92% (n= 57) felt it was “very or somewhat important” to help brush the child’s teeth, if the parents/ patients do not do so. However, three-quarters (75.8%, n = 47) felt they needed further training in oral hygiene education. Perceived Practices The nurses reﬂected that it was mostly doctors (85.7%, n = 54) who referred patients to dentists. Moreover, only 61.9% (n = 39) were aware of an existing in-hospital dental referral form. The majority would check patients’ mouths at least once daily (74.6%, n = 47) (Fig. 1). Oral conditions evaluated most commonly were: oral mucositis (98.4%, n = 62), oral ulcerations (87.3%, n = 55), oral bleeding (85.7%, n = 54), swollen gums (79.4%, n = 50), and oral pain (79.4%, n = 50). Dental caries, inﬂamed soft tissues, dysphagia, fungal infection, clinical abscess, dental plaque, bad breath, and oral pathology were less frequently evaluated (Details: Supplemental Table S2). Concerning toothbrushing, 85.7% (n = 54) advised patients to do so “often”/“always”; the rest “seldom”/“never did so”. Only 65% (n = 41) assisted patients to brush their teeth “often”/“always”; the rest “seldom did so”. About three-quarters would recommend ﬂuoride toothpaste (74.2%, n = 46), 9.7% (n = 6) advised non- ﬂuoridated toothpastes, and the rest were “not sure”/”did not” give advice (16.1% n = 10). Common oral health aids advised were Fig. 1 Frequency of oral examination by nurses. foam brush, soft-bristled toothbrush, mouthwash, and lip balm (Details: Supplemental Fig. S1). About half (51.7%, n = 32) advised Barriers patients to reduce sugary intake “often”/“always”; the rest The most common barriers to dental referral reported were beliefs “seldom” or “never did so”. that it is not their responsibility or authority, followed by inadequate knowledge of dental conditions to refer for (Fig. 3). In terms of barriers to performing oral care, the most common Perceived abilities theme was patient-related e.g. poor patient cooperation, patient The majority felt comfortable (92.1% n = 58), and adequately being unwell or having sore mouth. This was followed by staff and trained (90.5%, n = 57) performing oral care, including assisting operational factors e.g. inadequate time, staff knowledge, skills, with toothbrushing, mouthwash use, and application of oral and oral care resources in ward. Most did not ﬁnd oral care an topical medications. unpleasant task (90.5%, n = 57) but 42.9% (n = 27) felt it was Over 80-90% were conﬁdent to examine for the health of teeth/ parents’ responsibility (Table 3). gums, presence of oral pathology and oral pain, and discuss importance of regular professional dental care. Over 70-80% were conﬁdent to examine for presence of tooth decay, oral appliances DISCUSSION or dry mouth, and providing parents with oral hygiene home care and dietary advice to prevent decay. However, only 57.1% (n = 36) Limited studies on oral health-related practices and knowledge of were conﬁdent in advising ﬂuoride toothpaste use. Likewise, just pediatric oncology nurses exist. Surveys conducted in a conference over 60% were conﬁdent in identifying speciﬁc problems like at Pennsylvania, USA , and the Children’s Medical Centre in trismus and dysphagia (Fig. 2). Texas, USA , had 235 respondents (78% response rate) and 33 Only 65.1% (n = 41) felt adequately trained to give oral care respondents (83% response rate) respectively. In comparison, this instructions. Just over half (57.1%, n = 36) felt adequately trained study had a smaller targeted sample, but 100% participation. There to perform oral examinations. were limited unanswered questions by individuals, with the BDJ Open (2023) 9:3 R. Yee et al. Fig. 2 Perceived abilities of nurses in parental education and oral examination. a Conﬁdence in examination of oral conditions. b Conﬁdence in advising parents on oral care of child. oncology nurses , critical care nurses [9, 13], and adult general and oncology nurses . For instance, the Pennsylvania study had about 75% of respondents with 3 hours of oral health-related education; about 60% did not have competency regarding assessment of teeth and gums in nursing schools . The upward trends in overall knowledge scores after attending ≤3 hours of CPE was not statistically signiﬁcant. CPE could be useful for increasing knowledge scores, but we need a bigger sample size to prove this, and ascertain if number of hours matters. None in this group had >3 hours of CPE. The lack of training could have contributed to the knowledge gap, as no one answered all knowledge questions correctly. Currently, the only national nursing guidelines on nursing management of oral hygiene readily available may be outdated Fig. 3 Responses to “Concerns preventing you from referring your and is not speciﬁc to children or oncology care . Hence, a patients to see a dentist”. pediatric oncology evidence-based oral nursing guideline is needed. The majority did not know of any international guidelines exception of a question on conﬁdence in examining for dysphagia; on oral care for pediatric oncology patients, despite the possible reasons could be that nurses did not examine this information being readily available online. Past research has condition or were unsure what it meant. Moreover, both previous found that only a minority of critical care nurses would refer to surveys did not ask pediatric oncology nurses speciﬁcally about hospital policies/guidelines . Instead, most relied on previous perceived barriers; our study is likely the ﬁrst to do so. experience or basic nursing training as a primary source of Most participants were experienced and many worked in information on oral healthcare [9, 15]. However, in our study, pediatric oncology over 6 years. However, the majority had no experience (years as pediatric oncology nurse) did not improve speciﬁc training or CPE in oral healthcare. Such inadequacy in oral oral health knowledge scores. This underlines the importance of health-related training has also been observed in other pediatric BDJ Open (2023) 9:3 R. Yee et al. Table 3. Responses to “Barriers that hinder me from performing oral care for the patients”, compared to a similar previous study . Barriers Singapore Pediatric Oncology Nurses Singapore Critical Care Nurses (Our study) (%) (Chan & Ng 2012)  (%) Staff factors Lack of time 31.7 – Inadequate stafﬁng 25.4 11.3 Lack of oral toilet requisites 19 8.4 Lack of knowledge 17.5 3.8 Not sure what to look out for 17.5 – I have other more important tasks 11.1 – Doctors are the ones responsible 9.5 – It is an unpleasant task 9.5 0.4 Patient factors Uncooperative patient 90.5 88.7 Unwell patient 41.3 28.0 Patient has a sore mouth 38.1 – Intubated patients 11.1 11.3 Others – 8.8 Parents are the ones responsible 42.9 – Multiple responses possible. including formalized oral health training as part of nursing training patient cooperation, the main barrier highlighted by 90.5% of programs. The importance of CPE beyond nursing school and in nurses. This was also the main barrier corroborated in another inter-disciplinary cooperation with dental professionals have also local study on critical care nurses (Table 3). This highlights been highlighted by past surveys [6–8]. that apart from structured training and oral care protocols to Based on the knowledge answers, participants had high standardize and increase the frequency of evidence-based oral general awareness of the importance of oral health. However, care, local nursing training also needs to address strategies to therewereknowledge gaps in themorespeciﬁcoralhygiene manage the uncooperative patient, to target improvement of and dietary habits conducive for oral health. Less than three- the practical delivery itself. Effort should be invested in tools or quarters knew that ﬂuoridetoothpasteshouldbeused, and less means to improve competence in oral care provision e.g. than half knew that toothbrushing should continue regardless of behavioral strategies for uncooperative patients and effective platelet counts . In addition, most were unaware that the brushing techniques. These would further empower nurses who frequencyofsugaryintakeismorecrucial than theamountof are willing to take on the responsibility but struggle in delivering sugar intake in causing decay. These knowledge results oral care. corroborated with the practice frequencies for recommenda- Oral care examinations performed were inconsistent and tions of ﬂuoride toothpaste use (74.2%) and advice to reduce incomplete. While most were conﬁdent in examining the mouth sugar intake (51.7%). Foam brush, toothbrush and lip balm were for simple or common conditions e.g. oral pain, mucositis, ulcers, the most common oral aids our participants would recommend, and cold sores, they were less conﬁdent in examining more severe similar to the Texas study . However, there was no consensus complications e.g. trismus and dysphagia. Such phenomenon is regarding the use of other oral healthcare aids. A local oral care similar in past studies [8, 10], highlighting the need to train nurses to protocol may help bridge knowledge gaps and ensure correct identify common oral diseases and complications in children with oral hygiene and dietary recommendations are made to cancer. This is further reinforced by past research that demonstrated patients/parents. the correspondence between the level of conﬁdence in oral health It is heartening that a high proportion (>90%) of nurses felt knowledge and frequency of oral examination . conﬁdent to assist with oral care including toothbrushing, and did It is likely that the environment and equipment in hospital not ﬁnd it an unpleasant task, unlike ﬁndings in other countries’ wards are not the most conducive for comprehensive oral studies [6–8]. This difference may be attributed to our study examinations, with the Texas study reporting about half of examining paediatric oncology nurses, whereas Ohrn  and pediatric oncology nurses using just room light for oral examina- Southern  surveyed general oncology nurses. In addition, tion . Hence, in addition to improving nurses’ knowledge of oral Tewogbade  and Southern  did not survey nurses on their conditions, encouraging referral for dentists’ diagnosis and direct provision of oral care, and this may be due to oral care management should be done in tandem. falling outside their scope of responsibility, given that care Most knew the right timing to refer but few had initiated assistants in the US typically adopt the responsibility of such tasks. referrals, with more than half citing that they have no authority or Conversely, nurses in Singapore may feel that oral care is part of responsibility to do so. This might be related to local policies and their job scope and thus not ﬁnd it an unpleasant task. This theory practices where doctors are deemed responsible for referrals. was also evident in a previous survey of Singapore critical care Nonetheless, as team members who have an active role in oral nurses , with only 0.4% citing oral care provision to be examination and care for patients in the wards, nurses can remind an “unpleasant task” (Table 3). doctors. This is in line with Perry et al.’s conclusions that a form of However, in practice, fewer nurses in the present study (85%) ‘inter-professional collaboration’ is important between nurses and would advise patients to brush and only 65% would assist doctors to improve patients’ oral health . Another major patients to do so. This discrepancy is likely attributed to poor barrier to referral was parents’ notions of high cost and long BDJ Open (2023) 9:3 R. Yee et al. waiting time for dental treatment. Most nurses were unaware of 3. 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Practical training should focus on empowering nurses to identify common oral diseases and ACKNOWLEDGEMENTS complications, with complementary guidelines on oral exam- We wish to thank the assistance of Yap Shu Ting, Chui Ru Wei, Christina Ong Mei ination and referral criteria. A clearer referral workﬂow and Zhen, and Merrilynn Thng in entering the relevant patient data, and Dr. Danny Wong for vetting the manuscript. We would also like to thank all the nursing staff who responsibility outline may also improve referral practice, where participated in the study. beliefsthatitisthe doctors’ responsibility to refer, perceived parental reluctance, and poor awareness of existing resources are key challenges. Existing resources e.g. hospital dental service and referral templates should be made known. Finally, AUTHOR CONTRIBUTIONS practical support is recommended (e.g. provision of oral aids in RY and PC conceived the idea; NL, YL, WK, SS contributed and assisted with study design and wards and speciﬁc allocation of time for oral nursing) to address statistical analysis; MC and YL led data collection and entry; RY, PLC, YL led the writing; RY, PC, barriers in assisting toothbrushing, that is largely attributed to YL, WK, NL, MK and MC revised the manuscript for important intellectual content. the lack of time or physical aids and patient cooperation. COMPETING INTERESTS DATA AVAILABILITY The authors declare no conﬂict of interest. All authors have made a substantive Data is available on request from the authors. contribution to this study and/or manuscript, and all have reviewed the ﬁnal paper prior to its submission. REFERENCES 1. Fayle SA, Curzon ME. Oral complications in pediatric oncology patients. Pediatr Dent. 1991;13:289–95. ETHICS APPROVAL 2. American Academy of Pediatric Dentistry. Guideline on dental management of This study obtained ethical approval from the SingHealth Centralized Institutional pediatric patients receiving chemotherapy, hematopoietic cell transplantation, Review Board (Reference number: 2018/2591). Completion/return of the question- and/or radiation. Pediatr Dent 2013;35:E185–93. naire implied consent to participate. BDJ Open (2023) 9:3 R. Yee et al. ADDITIONAL INFORMATION Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, Supplementary information The online version contains supplementary material adaptation, distribution and reproduction in any medium or format, as long as you give available at https://doi.org/10.1038/s41405-023-00130-2. appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party Correspondence and requests for materials should be addressed to Ruixiang Yee. material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the Reprints and permission information is available at http://www.nature.com/ article’s Creative Commons license and your intended use is not permitted by statutory reprints regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http:// Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims creativecommons.org/licenses/by/4.0/. in published maps and institutional afﬁliations. © The Author(s) 2023 BDJ Open (2023) 9:3
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