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The shocking state of oral health in our nursing homes
The recent report of a nursing home resident found with maggots in her mouth brings home how devastating neglected oral health can be, say Bronwyn Hemsley, University of Newcastle; Andrew Georgiou, Macquarie University; Joanne Steel, and Susan Balandin, Deakin University.
While shocking, this story is far from surprising. Researchers have long highlighted that people living in aged care have substantially poorer oral health and three times the risk of untreated tooth decay than people living in the community.
The aged-care sector should also be well aware of the issue. In 2014, complaints to the government’s aged-care complaints scheme led to an industry-wide alert and training on what to do to improve standards.
What do we mean by oral health and why is it an issue?
Oral health is not just about the health of teeth and gums. It also covers looking after areas including the lips, tongue and inside the cheeks.
Most aged-care residents are aged over 85, frail, have complex health conditions, are on multiple medications, and rely on staff to meet all their care needs. These and other factors, such as lack of access to oral health services, greatly increases their risk of having poor oral health.
Many medications can cause a dry mouth, resulting in painful cracks in the lips or tongue, and an increased risk of infection. A dry mouth can also make chewing and swallowing food more difficult.
Other problems include tooth decay and gum disease, and a significantly increased risk of developing aspiration pneumonia, where inhaled saliva or food moves bacteria into the lungs.
Dentures that no longer fit can not only make eating and speaking more difficult, but can also cause residents to die from choking.
These problems affect people’s health, well-being and quality of life; as well as their dignity and social inclusion, due to an unsightly mouth or bad breath.
What happens in practice?
To learn more about what happens in practice, we asked aged-care nurses and nursing assistants about their experiences of providing oral care.
They agreed with guidance for best practice, for instance brushing people’s teeth twice a day and cleaning their dentures. But they said they could not always perform these tasks. Some blamed lack of time and not enough staff. Others felt staff had enough time but negative attitudes, not seeing oral care as a priority over other daily care tasks.
Staff described not having the appropriate equipment, products, or access to dental-health services like dental hygienists and dentists. They also said family members were sometimes reluctant to pay for things like toothbrushes and toothpaste, or visits to the dentist.
The residents who need the most help with oral care often missed out entirely. Staff avoided tooth brushing if residents had swallowing disorders. They also stopped providing oral care if residents were resistant or aggressive, including people with dementia. Some residents went without oral care “for weeks”.
How to fix the problem
The problem of poor oral health in aged care is not just about some staff being reluctant to provide good routine care. It is not necessarily about a lack of evidence-based standards, care guidelines or education resources.
This complex problem has arisen due to many broader issues in the aged-care system. Some of these are highlighted in a recent report, including insufficient funds and lack of access to dental services.
So we need a collaborative approach to improving oral health in aged care, that involves funders, policymakers, aged-care residents, family members, staff and health professionals working together.
Family members and aged-care staff might feel helpless in the face of such barriers to good oral health. So here are five actions they can take.
1. Advocate for the resident
Aged care residents have the right to the same access to health care as their peers living in the community. This includes having their teeth brushed and dentures cleaned properly, along with regular access to oral health services.
Many people living in aged care cannot communicate their needs and rely on others to speak on their behalf. Raising concerns with the manager or making a complaint can be daunting. So keeping a written record can help family members and staff communicate their concerns clearly when raising complaints with the manager or the Aged Care Complaints Commissioner.
2. Be vigilant at mealtimes
Visiting around mealtimes, or helping the person to eat, can be a chance to pick up problems. Ask the resident permission to look into her mouth to check if she is swallowing or removing leftover food promptly.
Look in particular around the teeth and gums, between the teeth and the cheeks, and on the roof of the mouth. Ask for a referral to a speech pathologist if you think the person has trouble swallowing, as swallowing can get more difficult with age.
Smelly saliva and bad breath are also linked to poor oral health. So, routinely checking if the person has a “clean mouth” could help identify problems. If you see or smell something, say something.
3. Ask for more information
Ask the care staff about your family member’s oral-care routines. How well do these align with the nursing home’s policies and guidance provided to families? Before more problems arise, seek the services of dental health professionals.
4. Discuss costs
Relying on family members being willing or able to fund oral care products leaves residents more vulnerable to poor oral health, particularly if they have no family involvement. Prioritising oral care and discussing any costs involved is important.
5. Help residents participate and take more control
Oral care is considered “personal care”. Knowing how much support to provide during this intimate task can be tricky, particularly if the person doesn’t like others touching their face or brushing their teeth. An occupational therapist can help increase the person’s participation in both mealtime and oral care activities.
Residential care staff may also need information on ways to help residents accept oral care. Consider what a person’s behaviour in response to attempts at oral care, like resisting tooth brushing, might be communicating.
Bronwyn Hemsley, Associate Professor in Speech Pathology, University of Newcastle; Andrew Georgiou, Professor, Centre for Health Systems and Safety Research, Macquarie University; Joanne Steel, Postdoctoral Research Associate, and Susan Balandin, Chair in Disability and Inclusion, Deakin University
This article was originally published on The Conversation. Read the original article.
Progress on safer hospitals
It took a shooting incident to spark action, but serious work to reduce hospital violence is finally underway.
Sixteen months after a dramatic Code Black incident at Nepean Hospital put the issue high on the agenda, the Ministry of Health and health unions have met to review progress on measures to reduce violence at health facilities.
NSWNMA General Secretary Brett Holmes and Assistant General Secretary Judith Kiejda attended the meeting to review progress in implementing a 12-point action plan.
The Ministry and unions adopted the plan in February 2016 following the shooting of a policeman and security guard inside Nepean Hospital’s emergency department a month earlier.
Judith Kiejda told a recent NSWNMA committee of delegates’ meeting that while there was no “quick fix” the union was “confident that the Ministry understands its responsibilities for workplace safety and security” and was committed to making hospitals safer.
ED AUDIT
The 12-point plan included a security audit of 20 hospital emergency departments and self-assessments of all others.
Judith said all 57 audit recommendations are being implemented and some have been completed.
She said the Ministry was “not pleased” with the results of the audit, which showed failure to comply with security requirements across the local health districts.
“The Ministry will play a tighter monitoring role, which will include random spot checks to ensure future compliance,” she added.
Also, future construction and renovation projects will have to be supported by documented safety assessments. This will apply to all departments, not only EDs.
DURESS ALARMS
Judith said the audit showed employees at many facilities did not wear duress alarms, left potentially dangerous implements lying around and failed to lock plaster rooms and other areas containing implements that could be used as weapons.
Workplace visits by the NSWNMA and the Ministry showed “many staff do not take the wearing of duress alarms seriously.”
“Some systems are less than perfect and there are even cases where they do not work, however an employee must use whatever has been supplied.
“If the duress alarm is ineffectual, does not work, or is faulty, the employee has a responsibility to document and report it and the employer has a responsibility to fix it.
“If the unit is faulty but works occasionally, the employee must wear the duress alarm in line with workplace policy.”
Judith said this approach would prevent management from blaming nurses for the outcome of any incident.
“The Ministry now acknowledges that systems must work and these are being upgraded where necessary.”
POLICE HANDOVERS
The Ministry and police are working on a new agreement that goes beyond the current mental health scope and improves handover procedures.
Judith said the new “memorandum of understanding” would require both health services and police to change current practices. Breaches will be dealt with by the local health district chief executive and the police local area commander.
TRAINING
Judith reported that the Ministry is rolling out a comprehensive package to train ED nursing, security and medical staff in the management of disturbed and aggressive behaviour.
She told the delegates that so far, 89 staff had gone through a one-day “train the trainer” course supported by online resources such as videos.
Clinical unit and hospital managers have received training to ensure their workplaces have a zero-tolerance approach to violence.
SECURITY GUARDS
Security staff have been put through a three-day training course designed for health services and 30 additional security staff have been recruited.
The Ministry is reviewing its policy on forcible removal of non-patients from hospitals. The aim is to identify the circumstances in which security staff are able to remove people who are acting aggressively and causing disruption.
The Security Action Plan
In early 2016 health unions and the NSW government agreed to a Security Action Plan that included:
An audit of 20 hospital emergency departments to examine and recommend on a number of issues including compliance with policy and training requirements, adequacy of ED design in managing aggressive patients, adequacy of security staff, and liaison with police including handovers.
The plan also involved an “intensive program of multi-disciplinary training” of ED nursing, security and medical staff.
Clinical unit and hospital managers were to be “trained to understand and give effect to their workplace health and safety obligations and ensure their local workplaces had a zero tolerance to violence”.
Recruitment and training of security officers was to be improved.
A group of expert clinicians was to look at ways of improving the management and treatment of patients presenting to EDs under the influence of psycho stimulants such as ice.
Incident management reporting systems were to be improved.
Global commitment to public health care
International conference agrees on central role of public system and need to invest in health care workforce.
Governments should not offload their responsibility for delivering health care to private operators. And public spending on the health care workforce should be seen as an investment rather than a cost.
These were the key messages endorsed by governments, unions and employers at an international conference on ways to improve employment and working conditions in health services.
Held by the International Labor Organisation in Geneva, Switzerland, it was the first tripartite meeting of its type in almost 20 years.
Assistant General Secretary Judith Kiejda said it was an honour for the NSWNMA to be invited as one of only eight delegates representing unions that cover about 10 million health workers.
Other union representatives came from France, Germany, Korea, South Africa, the USA and Argentina.
They were matched by eight employer delegates – including an Australian – and representatives of 53 governments. The Australian government was invited but did not attend.
Judith said the NSWNMA was invited partly in recognition of its work with the global union federation Public Services International (PSI).
Judith has been the PSI’s Asia Pacific health coordinator since 2010 while NSWNMA staffer Michael Whaites is the PSI’s sub-regional secretary for Oceania.
“The invitation also reflects the fact that Australia is the only regional country to have won mandated ratios or staffing levels in a number of models across various states,” Judith said.
“The language of most government speakers was very helpful and in most discussions were very close to the worker perspectives.
“Importantly, all three parties agreed that mandated staffing is the only way to guarantee decent working conditions in health services.
“As the Brazilian government representative said, delivering safe and quality health care will be difficult without the right numbers of staff with the right skills in the right place at the right time.
“The conference recognised that quality health care is a human right and its decisions can now be used when lobbying governments in Australia on issues of staffing and maintaining quality public health services.
“The conference decisions will be particularly useful in our discussions with future governments which might be more in tune with our thinking on health matters than some current governments.”
Judith said employer representatives spoke in favour of public private partnerships (PPPs) but unions successfully argued against tripartite support for PPPs.
“We all acknowledged there were private systems in every country that complemented the public system but we shouldn’t be handing over public services to private operators.”
PSI General Secretary Rosa Pavanelli told the conference there was “a rich evidence base” for concluding that PPPs simply amount to the subsidising of private interests with public funds.
“While private investments cannot be discountenanced, these have to be adequately regulated and should not be passed off as being in partnership with public health, which is the mainstay of universal access to health care,” she said.
Judith said the NSWNMA would work to organise a similar tripartite meeting on health workforce issues to be attended by Asia-Pacific countries including Australia.
“Through the PSI we are establishing a strong network of Asia-Pacific health unions. We have the same issues everywhere – not enough staff, inappropriate skills, and governments seeking to privatise services.” ■