With their wide breadth of expertise and the ability to leverage the therapeutic relationship, community nurses are ideally placed to manage the complications and challenges associated with a diverse range of conditions and to provide treatment and support to an extensive variety of patients, from newborns to multimorbid or older demographics. Their close contact with this wide range of patients means that community nursing teams are also in a good position to promote and reinforce positive health messages, particularly to vulnerable groups. This is in alignment with the principles of the approach outlined in the consensus statement ‘Making Every Contact Count’, a strategy to initiate behavioural change promoted by Public Health England, NHS England and Health Education England, which uses the multiple daily interactions that organisations and teams have with patient groups to support them in making positive changes to their physical and mental health, and wellbeing (NHS England, 2016; Sibanda et al, 2023). This includes the efforts of community nurses to promote good oral health and address the conditions that affect oral health status.
Despite global efforts to promote oral health, this aspect of healthcare remains a major challenge among disadvantaged and marginalised populations, such as older people, and is often neglected by both patients and community healthcare professionals in favour of more immediately pressing health concerns. If untreated, oral conditions can impact quality of life and lead to pain, infection and difficulty eating, with an increase in tooth loss, dental decay, gum disease and denture-related problems, all of which can negatively affect nutrition (Daly and Smith, 2015; Sibanda et al, 2023). There are indications that oral health has improved dramatically in England and Wales, with people retaining their natural teeth well into older age, but a 2011 survey of adults' dental health found that, compared with younger cohorts, older people tended to have fewer healthy natural teeth and more dental decay and gum disease (Daly and Smith, 2015). To maintain this upward trend in good oral health in the community, nurses must be aware of the common barriers related to oral health care and promotion, in order to overcome these and remain attentive to the oral health needs of their patients.
Barriers to oral healthcare promotion and provision in the community
To date, few studies have explored community nursing experiences in the delivery and support of oral healthcare for older people living at home, and, until recently, the barriers to the provision of this type of support remained relatively unclear. However, insights from other nursing areas, such as long-term care, reveal that oral care is often deprioritised due to time constraints, inadequate staffing and poor knowledge (Mitchell et al, 2023). To verify whether this also applies to community nursing, the interviews of 15 practising community nurses were analysed through constant comparative analysis, to identify common experiential patterns and the relationships between these identified thematic categories (Mitchell et al, 2023). A total of four categories were identified from the data: education; practice; confidence; and motivation. An overarching core category, which was apparent across all other categories, was also identified, defined as ‘uncertainty’. Participants expressed uncertainty in relation to their education about oral healthcare; in their practice through delivery of good oral health assessment and care; about their confidence in supporting patients with a variety of oral healthcare needs; and about their motivation to optimise their oral healthcare delivery in the future (Mitchell et al, 2023).
While participants expressed satisfaction at their formal education in relation to oral health, continuing professional development in the form of postgraduate university modules or programmes, or in-house training led by the NHS, did not appear to provide many opportunities for nurses to revisit the skills that were initially developed in their pre-registration training (Mitchell et al, 2023).
All community nurses interviewed stated that oral healthcare assessment was not routinely completed as part of their practice, mainly due to the fact that no standardised assessment document seemed to be available to complete as part of their visit (Mitchell et al, 2023). The nature of community nursing practice—namely, that community nurses may only see patients for a very short period of time and provide very specific care that may not necessitate an oral health assessment, such as administration of insulin or wound care—also acts as a barrier to providing oral healthcare (Mitchell et al, 2023). Overall, participants agreed that oral health assessment was not standardised or routine; that oral health assessment was often prompted by patients who had mouth pain; and that implementing good oral health practice was often the role of domiciliary or home care workers who assisted patients with their personal care (Mitchell et al, 2023).
In the data analysis, it was noted that low levels of education often led to decreased confidence and inconsistent oral healthcare practice in terms of patient care, referrals and multidisciplinary collaboration. Of the 15 participants interviewed, only five had experience of liaising with community dentists; while there was some evidence of collaborative working, most community nurses were uncertain of how to contact an oral health professional if the need arose (Mitchell et al, 2023). Participants demonstrated high confidence in providing oral healthcare that focused on patients' oral mucosa, but this was not maintained when it came to caring for patients' teeth. In relation to providing health promotion advice about oral health care, few community nurses discussed modifiable lifestyle factors with their patients, with some participant interviews indicating that this may be related to lack of confidence in this area (Mitchell et al, 2023).
The category that presented the greatest variance in responses among participants was related to motivation, with some community nurses stating they were keen to develop the skills associated with oral healthcare delivery and support, while others expressed that the community nursing workload was already high and that dental and oral care was not within the scope of community nursing practice (Mitchell et al, 2023). Many community nurses interviewed were uncertain about their ability and desire to be part of future change in oral healthcare service provision and the extent to which oral health was part of their role (Mitchell et al, 2023).
Conclusions
The aforementioned study discussed has shed a clear and necessary light on the uncertainty experienced by community nurses in providing oral healthcare to older people and other patient demographics in the community.
The lack of continuing professional development activities explicitly linked to oral health may have deprioritised this area of care for community nurses. There is an uncertainty about how best practice should look, likely owing to suboptimal education pre- and post-registration, as evidenced by Mitchell et al (2023). Mitchell et al's (2023) findings underscore the need for comprehensive and ongoing education in oral health for community nurses, to enhance their confidence and efficacy in supporting patients. Interprofessional collaboration and clearer delineation of roles with oral health professionals could also help to address uncertainty and improve oral health outcomes for vulnerable populations (Mitchell et al, 2023). Ultimately, understanding and resolving the uncertainty in this domain expressed by community nurses will be essential in developing effective strategies to improve oral healthcare in community settings.