Högskolan i Skövde

Bakgrund: Det är känt att äldre personer har bättre munhälsa i dag och fler kvarvarande tänder än tidigare generationer. Det är en komplex uppgift att utföra munvård för att förebygga nedsatt munhälsa på någon annan. Nedsatt munhälsa kan påverka allmänhälsan på olika sätt, till exempel genom smärta och nedsatt aptit. Nedsatt munhälsa kan också vara en bidragande orsak till infektioner lokalt i munnen, men även i andra delar av kroppen. Det har dock visat sig att vårdpersonal (sjuksköterskor, undersköterskor och vårdbiträden) inom kommunal äldreomsorg försummar utförandet av munvård hos äldre personer av olika skäl, däribland tidsbrist, okunskap och bristande rutiner. Vårdpersonal värdesätter kunskap om munhälsa och efterfrågar utbildning om munhälsa och munvård. Kompetensutveckling för vårdpersonal tar tid samtidigt som den digitala utvecklingen och tillgången till digitala tjänster ökar. Digital utbildning kan vara en lösning till att sprida kunskap i en hel arbetsgrupp. Studier har visat på stort värde av möjligheten till interaktivitet, repetition och feedback som tydligt förknippas med ett ökat lärande vid användande av digitala utbildningar. Studier visar även att vårdpersonal som kompetensutvecklas genom utbildning om munhälsa tillhandahåller bättre munvård till äldre personer efter utbildning.

Syfte: Det övergripande syftet var att studera äldre personers uppfattning om munhälsa och vårdpersonals attityder till och kunskaper om omvårdnad relaterat till munhälsa. Ytterligare ett syfte var att beskriva vårdpersonals attityder och kunskaper före och efter en digital utbildning i munhälsa och användbarheten av denna.

Metod: Avhandlingen inkluderar fyra delstudier varav två har en kvalitativ design, delstudie I och IV, en med kvantitativ design, delstudie II och en med mixad metod, delstudie III. Delstudie I inkluderar äldre personer och delstudie II-IV inkluderar vårdpersonal. Data har samlats in med hjälp av frågeformulär, individuella intervjuer och fokusgruppsintervjuer. Kvalitativ analys genomfördes med hjälp av kvalitativ innehållsanalys i delstudie I och IV. Kvantitativa analyser genomfördes med Psykometrisk utvärdering med klassisk testteori (CTT) kompletterad med Item Response Theory (IRT) i delstudie II och beskrivande statistik och Wilcoxon signed-rank test i delstudie III.

Resultat: Resultaten visar att det är komplext att utföra munvård på någon annan och kräver att tid ges till att bygga personkännedom mellan vårdpersonalen och den äldre personen som får hjälp med munvård. Personkännedom beskrivs av vårdpersonal främja och ge trygghet i utförandet av munvård. Äldre personer beskriver att de är experter på sina egna upplevelser av munhälsan och att denna kunskap behöver delas med vårdpersonalen. Personkännedom etableras och uppnås genom att vårdpersonalen skapar förtroende, är närvarande, förutser behov, är pålästa och genom att reflektera över vården. Det är ett förtroende att utföra munvård på någon annan, vilket underlättas av personkännedom. Det ger vårdpersonalen information och bättre förutsättningarna att utföra god munvård och att synliggöra hinder som tids-, personal- och kunskapsbrist. Äldre personer värdesätter en god munhälsa och vårdpersonalen värdesätter kunskap relaterad till munhälsa. Ett sätt att sprida kunskap om munhälsa bland vårdpersonalen är genom digitala utbildningsinterventioner. Kombinationen av teoretisk kunskap med hjälp av digital utbildning och praktiska övningar beskrivs av vårdpersonalen som ett sätt att ge både teoretisk och praktisk kunskap. Att arbeta tillsammans över professionsgränser i omvårdnad kring munvården beskrivs ofta brista inom kommunal äldreomsorg. Arbetet tillsammans upplevs dock fungera bra vid palliativ omvårdnad. Äldre personer beskriver en önskan om hjälp med sin munhälsa när behov uppstår.

Slutsatser: Äldre personer värdesätter en god munhälsa och vårdpersonalen värdesätter kunskap relaterad till munhälsa. Munvård är komplex och förutsätter att vårdpersonalen erhåller kunskap, rutiner, tid och samarbetar för att utföra den med god personkännedom om den äldre person. Digital utbildning är ett sätt att öka kunskapen om munhälsa bland vårdpersonalen. En kombination av teori med hjälp av digital utbildning och praktiska övningar bidrar till både teoretisk och praktisk kunskap. Samarbetet kring munvård mellan sjuksköterskor, undersköterskor och vårdbiträden fungerade inte alltid optimalt, däremot fungerade samarbetet bra vid palliativ omvårdnad. Samarbete, tid och kunskap samt reflektion anses vara viktiga faktorer för vårdverksamheter att beakta i framtiden för att god munvård ska kunna utföras inom kommunal äldreomsorg.

The increasing proportion of older adults (persons aged 65 years or older) in society who have their own teeth and advanced dental restorations contributes to new challenges for healthcare professionals in municipality healthcare, such as registered nurses, assistant nurses and care assistants. It has been shown that oral health care is often overlooked when the need for care and nursing increases. Good oral health is a fundamental human right, and poor oral health is not part of normal ageing but is an effect of several factors, such as impaired motor skills, changes in diet, disease, medical treatments, drugs, or reduced saliva secretion. Traditionally, oral health has been defined as the absence of disease and has not taken into consideration a person’s own values, perceptions and disabilities. The World Dental Federation (FDI) has developed a definition of oral health to create a broader understanding of what oral health includes. The FDI definition of oral health includes physical and mental aspects and objective and subjective experiences of oral health. The FDI defines oral health as being: “multi-faceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey emotions through facial expressions with confidence and without pain, discomfort and facial disease”.

The Fundamentals of Care (FoC) framework is defined as care actions performed by healthcare professionals that respect and focus on a person’s basic needs to ensure their physical and psychosocial well-being, regardless of illness, disease or the environment in which the healthcare is provided. These needs, such as oral health care, are met by developing a positive and trusting relationship with the person being cared for and their family/carers. The care relationship is a dynamic process that includes good knowledge of interpersonal communication among health professionals. The care relationship and the holistic approach to healthcare are central to FoC.

The framework includes three dimensions: (1) Relationship, which includes establishing a relationship; (2) Integration of care, where the basic physical, psychosocial, and relational care needs are identified and met and where a continued care relationship is central; and (3) the context of care, which includes the organisation and policies that include laws, regulations, human resources, and cultural and economic conditions to provide person-centred care. Healthcare related to oral health is included under the physical dimension, which encompasses nursing needs, personal hygiene and dressing. Performing FoC related to oral health on someone else is not an easy task, as it can be perceived as a violation of privacy. Studies show that healthcare professionals neglect oral health and oral care in older people for various reasons, such as lack of time, knowledge, procedures and responsibility, as oral care is perceived as unpleasant to perform and shown to be of low priority. However, healthcare professionals are eager to develop this knowledge and training in their practices of oral healthcare. Skills development for healthcare professionals can be challenging to implement, and often only a few are trained in oral health care, and it can be challenging to disseminate such knowledge throughout a workgroup. Rapid technological development in society stimulates an increased implementation of digitalisation and the use of digital forms of education. Digital training can be easily accessible and flexible in terms of time and place. Interactivity, practical exercises, repetition and feedback are associated with increased learning in digital education. Hence, there is a need to study oral health and oral healthcare in Swedish municipality care for older adults based on the experiences of older adults and healthcare professionals.

The overall aim was to study older adults’ perceptions of oral health and healthcare professionals’ attitudes towards and knowledge of FoC related to oral health. Another aim was to describe the attitudes and knowledge of the healthcare professionals’ before and after digital training modules in oral health and the usefulness of this.

The thesis includes four sub-studies, two of which adopted a qualitative design (I and IV), one sub-study adopted a quantitative design (II), and one sub-study used a mixed method design (III). The data were collected using questionnaires as well as individual and focus group interviews. Qualitative analysis was conducted using qualitative content analysis (I, III and IV). Quantitative analyses were performed using psychometric evaluation with classical test theory (CTT) supplemented with item response theory (IRT) (II), descriptive statistics, and Wilcoxon signed-rank test (III).

The findings highlight the importance of nursing care related to oral health, how it promotes general health and how it can lead to more independent living for older adults. The results also highlight the importance of healthcare professionals’ attitudes to and knowledge of oral health and its role in achieving good oral health for older adults. The main results from the studies highlight an often forgotten but essential aspect of municipal health care related to oral health. The results describe oral healthcare and how it must be emphasised, visible, and perceived as complex healthcare.

Healthcare professionals describe obstacles to oral healthcare, such as time and staff shortages and lack of knowledge. Healthcare professionals, however, experienced fewer obstacles to performing oral care after a digital training module in oral health. Older adults also describe the importance of receiving help and support with oral healthcare when the need for help arises. Having personal knowledge of the older adult and establishing a good relationship between healthcare professionals and older adults presents opportunities for providing good oral healthcare. Older adults and healthcare professionals describe that having personal knowledge promotes and gives confidence in the performance of oral health care. Older adults describe that they are experts in their experience and that this knowledge needs to be shared with the healthcare professional. Care relationships are established and achieved by healthcare professionals by creating trust, being present, anticipating needs, being informed and reflecting/evaluating healthcare. Healthcare professionals describe that performing oral healthcare on someone else is a trust facilitated by personal knowledge about the older adult. Getting to know someone can take time, but this creates a sense of security for the older adult and the health care professional. Older adults also describe the importance of healthcare professionals’ knowledge when performing oral healthcare. After a digital training module, the healthcare professionals felt less nervous about performing oral healthcare. Previous research has also described that providing oral health training or education can significantly improve oral health among older adults, including a lack of visible plaque and no detectable denture stomatitis.

Older adults and healthcare professionals describe the importance of receiving/performing oral healthcare to prevent oral health problems. Healthcare professionals highly value knowledge about oral health and see rinsing the mouth as part of performing oral healthcare. Older adults and health professionals describe oral health, general health, and well-being as being connected. By evaluating healthcare professionals’ attitudes to and knowledge of oral health, healthcare’s physical, psychosocial and relational aspects can be integrated. A supportive care context, including organisational culture, resources and evaluation of the care provided, such as nursing care related to oral health, can be facilitated by meeting educational needs, establishing routines, appropriate work scheduling and registered nurse interaction in the team to develop and promote safe healthcare.

Conclusions can be drawn that oral healthcare is complex and requires, knowledge, personal knowledge, and sufficient time to be performed. Older adults value good oral health and oral healthcare. Healthcare professionals value knowledge related to oral health and oral healthcare. One way to increase knowledge about oral health among healthcare professionals is through a digital training module. Combining theory with the help of digital training and practical exercises contributes to theoretical and practical knowledge of oral health care. Good examples of collaboration and organisation around oral health and oral healthcare are seen in palliative care, which should be broadened and applied to other healthcare areas.