JCPSLP Vol 20 No 3 November 2018

Table 1. Perceptions of patients regarding standardised mouth care protocol

Question

Very much true

Quite a bit true

Somewhat true

A little true

Not at all true

It is embarrassing for me to be asked about my mouth

0

1

3

1

30

I understand why it is important to keep my mouth and teeth clean

26

5

3

1

0

I found someone assessing my mouth cleanliness uncomfortable, awkward or offensive I found someone asking me if I had cleaned my teeth uncomfortable/ awkward or offensive*

0

3

2

2

28

1

2

1

3

27

I appreciated someone offering to help me clean my mouth*

12

2

3

2

13

Numerical value indicates number of patients who indicated this response (n = 35). * indicates question with missing data

pneumonia, stringent eligibility criteria were required. Patients would only eligible for inclusion if they: 1. tolerated mildly or moderately thick fluids, 2. could be positioned upright for oral intake, 3. could feed independently or with minimal support, 4. demonstrated minimal discomfort when drinking water, 5. had reasonable cognition, 6. had good oral hygiene, 7. were independent with mobility, and 8. had no significant respiratory or severe progressive neurological conditions precluding participation (as confirmed by a consultant medical officer). Stakeholder engagement was led by the SLP and was multidisciplinary, including nursing education, nursing staff in the rehabilitation unit and stroke unit, the hospital legal department and medical specialists. Engagement led to the development of consent forms and work instructions as well as patient and staff education materials. Strategies utilised in response to identified obstacles included the use of training and development opportunities, interactive small group meetings, identification of opinion leaders, auditing and feedback on performance, multi-professional collaboration and the inclusion of patient opinion and engagement (Grol & Grimshaw, 2003). In addition, a

number of resources were developed in order to address key barriers for FWP implementation (Table 2). Evaluating the free water protocol To date, no suitable patients have been identified due to the stringency of the exclusion criteria utilised in order to ensure patient safety. However, all processes are now in place to commence data collection and future discussions may warrant amendments to broaden the inclusion/exclusion criteria to increase the access of FWPs to a greater number of patients in the rehabilitation unit. For eligible patients, the FWP will be implemented alongside the standardised oral care protocol described earlier. As per the protocol, patients will be provided with water only between meals, with medical monitoring of their temperature and chest status 72 hours post commencement of free water. Changes in temperature will be documented by nursing staff as part of routine patient cares, and changes in chest status will be diagnosed by a medical officer either by auscultation or imaging (as clinically indicated). The provision of water is to be ceased immediately if the patient demonstrates deterioration in chest status, oral hygiene scores decline, or if a medical officer deems the patient no longer suitable. Figure 3 outlines the decision-making framework for implementing the free water protocol.

Table 2. Barriers to implementing evidence and activities used to overcome these barriers

Barrier*

Method of addressing barrier

Organisational constraint (such as lack of time)

• Reducing time spent by nursing staff collecting data by introducing patient self reporting methods (particularly for fluid consumption) • Consumer reviewed information forms that clearly outline the risk of developing complications with free water protocol • Informed consent procedure for obtaining consent for commencing free water protocol • Work instruction reviewed by hospital legal department to ensure nil liability • Including mouth care protocol in medication records to prompt protocol use • Creating stickers for patients on free water protocol to highlight documentation requirements in medical chart • Patient identification markers at bedside to highlight participating patients

Perceptions of liability

Standards of practice (such as usual routines)

Clinical uncertainty

• Regular in-servicing to all members of the rehabilitation team • Integrated orientation documents for all members of the multidisciplinary team • Face to face education • Written education • Statement of confidence to participate in the protocol • Auditing and feedback of protocol use and documentation by nursing education

Sense of competency

* Barriers to implementation as described by Grol (2001) and Grol & Grimshaw (2003)

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JCPSLP Volume 20, Number 3 2018

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