published_or_final_version / Dentistry / Doctoral / Doctor of Philosophy

Intubated and mechanically ventilated patients are vulnerable to respiratory tract infections. In response, the Ontario government has recently mandated surveillance and reporting of ventilator-associated pneumonia (VAP). Serious respiratory infections, and the related costs of additional care can be reduced in part, through oral hygiene. However, the literature asserts that oral care is neglected in busy, high-tech settings. Despite these concerns, little research has examined how mouth care happens in the critical care unit. The purpose of this institutional ethnography (IE) was to explore the social organization of mouth care in one critical care unit in Ontario, Canada. As a reflexive and critical method of inquiry, IE focuses on features of everyday life that often go unnoticed. In paying special attention to texts, the ethnographer traces how institutional forces that arrive from outside the practice setting coordinate experiences and activities. Inquiry began in the field with day/night participant observation to better understand the particularities of nursing care for orally intubated patients. Other data sources included reflexive fieldnotes, stakeholder interviews, and transcripts as well as work documents and artifacts. Over time, the analysis shifted from the critical care unit to the larger social context of Ontario’s Critical Care Transformation Strategy. Analysis traced the discursive and translocal social relations that permeate nursing work. Findings revealed a disjuncture between the ideals of VAP prevention and the actualities of mouth care. Tensions and contradictions emerged as nurses described their location within an expansive accountability network: nursing duties now extend beyond oral care to a controversial project of epidemiological surveillance. Patient comfort and safety now rest upon a hidden nursing agenda to overcome limited time, training and tools in oral care. Nurses worried that the effectiveness of preventative oral care was inhibited by technical problems of application that remain uninvestigated and unresolved. As a counterpoint to assertions that oral care is neglected, this study demonstrates how nursing knowledge and agency is obscured. Because international infection-prevention guidelines increasingly endorse oral care, novel research investigating the practice problems nurses encounter is warranted.

Intubated and mechanically ventilated patients are vulnerable to respiratory tract infections. In response, the Ontario government has recently mandated surveillance and reporting of ventilator-associated pneumonia (VAP). Serious respiratory infections, and the related costs of additional care can be reduced in part, through oral hygiene. However, the literature asserts that oral care is neglected in busy, high-tech settings. Despite these concerns, little research has examined how mouth care happens in the critical care unit. The purpose of this institutional ethnography (IE) was to explore the social organization of mouth care in one critical care unit in Ontario, Canada. As a reflexive and critical method of inquiry, IE focuses on features of everyday life that often go unnoticed. In paying special attention to texts, the ethnographer traces how institutional forces that arrive from outside the practice setting coordinate experiences and activities. Inquiry began in the field with day/night participant observation to better understand the particularities of nursing care for orally intubated patients. Other data sources included reflexive fieldnotes, stakeholder interviews, and transcripts as well as work documents and artifacts. Over time, the analysis shifted from the critical care unit to the larger social context of Ontario’s Critical Care Transformation Strategy. Analysis traced the discursive and translocal social relations that permeate nursing work. Findings revealed a disjuncture between the ideals of VAP prevention and the actualities of mouth care. Tensions and contradictions emerged as nurses described their location within an expansive accountability network: nursing duties now extend beyond oral care to a controversial project of epidemiological surveillance. Patient comfort and safety now rest upon a hidden nursing agenda to overcome limited time, training and tools in oral care. Nurses worried that the effectiveness of preventative oral care was inhibited by technical problems of application that remain uninvestigated and unresolved. As a counterpoint to assertions that oral care is neglected, this study demonstrates how nursing knowledge and agency is obscured. Because international infection-prevention guidelines increasingly endorse oral care, novel research investigating the practice problems nurses encounter is warranted.

published_or_final_version / Dentistry / Master / Master of Philosophy

Ching Ho-hong Boby. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2005. / Includes bibliographical references (leaves 63-78). / Abstracts in English and Chinese. / List of Tables --- p.vii / Chapter Chapter 1: --- Introduction --- p.1 / General Oral Health Status in Hong Kong --- p.2 / """How"" is the Message Constructed： Gain versus Loss Frames" --- p.3 / """Who"" are the Recipients： Individual Differences in Self-Construal" --- p.4 / What Accounts for the Message-Self Compatibility Effects： The Mediating Factors --- p.6 / Stage One： Cognitive Integration of the Message Contents --- p.6 / Stage Two: Acceptance of the Messages --- p.8 / Stage Three： Perceptions of Health Behavior --- p.9 / An Addition to the Three-Stage Model: The Role of Anticipated Feelings --- p.11 / Overview of the Present Study --- p.12 / Chapter Chapter 2: --- Method --- p.15 / Participants --- p.15 / Oral Health Message --- p.15 / Independent Measures --- p.16 / Self-Construal --- p.16 / Principle Dependent Measures --- p.17 / Recognition Memory --- p.17 / Subjective Evaluations of the Messages --- p.17 / Self-Efficacy to Perform Oral Health Behavior --- p.18 / Outcome Expectancy of Performing Oral Health Behavior --- p.19 / Anticipated Feelings to Perform Oral Health Behavior --- p.20 / Intentions to Perform Oral Health Behavior --- p.21 / Behavioral Measures --- p.22 / Potential Covariates Measures --- p.22 / Personality --- p.22 / Need for Cognition --- p.23 / Dispositional Optimism --- p.24 / Oral Health Locus of Control --- p.25 / Dental History --- p.26 / Cognitive Ability --- p.26 / Mood --- p.26 / Perceived Threat of Developing Oral Diseases --- p.27 / Perceived Normative Pressure of Performing Oral Health Behavior --- p.28 / Fear and Worry Toward Developing Oral Diseases --- p.28 / Other Potential Covari ates --- p.29 / Procedure --- p.29 / Chapter Chapter 3: --- Results --- p.31 / Manipulation Checks --- p.31 / Different Operationalizations of Gain- and Loss-Framed Messages --- p.31 / Principle Analyses： General --- p.33 / Moderation of the Framing Effects by Self-Construal on Behavioral Intentions --- p.34 / Moderation of the Framing Effects by Self-Construal on Subjective Evaluations --- p.37 / The Mediating Effect of Personal Outcome Expectancy on Behavioral Intentions --- p.39 / The Mediating Effect of Social Outcome Expectancy on Behavioral Intentions --- p.42 / The Mediating Effect of Anticipated Feelings on Behavioral Intentions --- p.44 / Chapter Chapter 4: --- General Discussion --- p.46 / How to Frame the Message: Tailoring Messages to Match Self-construal --- p.47 / Identifying the Mediating Factors of Compatibility Effects Between Message and Self-Construal --- p.49 / The Importance of Anticipated Feelings --- p.55 / The Intention - Behavior Relationships --- p.56 / Improvements and Further Studies --- p.59 / Concluding Remarks --- p.61 / References --- p.63 / Appendix A --- p.79

Background: Comprehensive oral care is an evidence-based, cost effective, essential routine nursing intervention that nurses ought to provide with good knowledge/understanding as it prevents and controls nosocomial infections especially Ventilator Associated Pneumonia (VAP) that is associated with increased morbidity and mortality in critically ill patients in Intensive Care Units (ICU). Aim of study: To determine ICU nurses’ knowledge, describe their practices and identify their perceptions regarding comprehensive oral health care to critically ill patients in order to refine or develop evidence based oral care protocol. Methods: A quantitative approach with a descriptive, exploratory survey was used for this study. A non probability convenience sample of thirty-four (34) ICU nurses from two public referral hospitals participated in this study. A questionnaire with a combination of open and closed ended questions was used to collect data on comprehensive oral care to critically ill patients. Results Thirty-four nurses responded to the questionnaire (response rate 89%). Only 18% (n=6) were knowledgeable about important aspects of oral care, while the majority, 82% (n=28) lacked knowledge on important aspects of oral care. Fifty-nine percent (59%) n=20 had received training on comprehensive oral care at basic nursing training and 44% (n=15) had orientation at unit level. Ninety-seven percent (97%) n=33 of the participants requested further updates on comprehensive oral care. No significant relationships were found between nurses’ demographic characteristics and knowledge of comprehensive oral care. All (100%) n=34 of nurses gave oral care a high priority and 91% ranked it very important for critically ill patients. Toothbrushes and toothpaste were used by 85% (n=29) of nurses and only 50% (n=17) used mouthwashes. The reason for non- use of mouthwashes was lack of supplies and not having been foreseen in unit protocol although neither of the units had an oral care protocol in place. / Thesis (M.N.)-University of KwaZulu-Natal, Durban, 2011.

<p>The aim of this study was to compare the oral health status between well and malnourished children under five years old attending Mother and Child Health clinic in Queen Elizabeth II Hospital in Maseru, Lesotho.</p>

This study reviews the three-year Bachelor of Dental Therapy curriculum, which was introduced at the University of KwaZulu-Natal in 1980. The dental therapist was introduced to the health care system during the apartheid era, to improve access to basic dental services to disadvantaged sectors of the population. However thirty years later, this situation has not improved. Therefore the purpose of this study is to evaluate the dental therapy curriculum offered at this university, to determine whether it is able to produce graduates who are adequately prepared to practice competently, according to the scope of practice prescribed by the regulatory body, and to meet the oral health needs of the population. To conduct a comprehensive evaluation, it was necessary to evaluate the multiple influences on this curriculum. As a result, the Hicks model called Typical Influences on Curriculum was selected to serve as the theoretical framework. This resulted in the use of the mixed methods research approach. Pragmatism was consequently selected to form the philosophical foundation of this study due to the fact that it allowed for the combination of methodological tools to answer the research questions. The first question defined the role of the dental therapist in the health care system. Qualitative interviews with all stakeholders who are associated with this profession, in the context of the needs of the country, provided the answer to this question. The second question, on how the curriculum prepared its graduates to perform this role, was conducted by a combination of methods. The evaluation of the form and content of the curriculum, and the training facilities, were combined with the interviews conducted with students, graduates and academics, on their perceptions of the educational process and the competence of graduates. The third question about the perceptions of stakeholders on the appropriateness of training and clinical competence was established by qualitative interviews. This led to the development of the inferences and recommendations for this study. The overall inference was that the dental therapy curriculum did not produce appropriately-trained graduates to meet the needs and challenges of South Africa. This resulted in the development of a new curriculum evaluation model for health science education, which was considered to be an extension of the Hicks model. Recommendations were also made on how this model could be implemented with respect to the dental therapy curriculum. / Thesis (Ph.D.)-University of KwaZulu-Natal, Edgewood, 2011.

<p>The aim of this study was to compare the oral health status between well and malnourished children under five years old attending Mother and Child Health clinic in Queen Elizabeth II Hospital in Maseru, Lesotho.</p>

[Truncated abstract] Periodontal disease is a common and underdiagnosed disease in humans that may have adverse effects on pregnancy outcomes. The aim of this thesis was to investigate the effects of periodontal disease in pregnancy by means of two observational human studies and the development of animal models of fetal and uterine exposure to periodontopathic bacteria and lipopolysaccharide. I performed a prospective study examining the rates of preterm birth, small for gestational age neonates and neonatal inflammation in 277 women who had undergone a detailed antenatal periodontal examination and oral health questionnaire. Periodontal disease was associated with small for gestational age neonates, and increased CRP levels in umbilical cord blood, but no effect was seen on the rate of preterm birth. Maternal oral health symptoms predicted both periodontal disease and newborn biometry. In a retrospective case control study, I examined the role of periodontal disease in perinatal mortality. Participants included 53 women who had experienced a perinatal loss for which no cause could be found after thorough investigation, and 111 control women. Women who had experienced a perinatal loss were more than twice as likely as controls to have periodontal disease. The incidence of periodontal disease was even higher in women in whom the perinatal loss was due to extreme prematurity. In contrast to my prospective study, risks to the pregnancy could not be predicted by maternal oral health behaviours or oral health symptoms. In order to better understand the mechanisms regulating the associations described in the human studies, two animal models were developed; one to investigate acute exposure and the second to investigate long-term exposure to periodontal pathogens. The first study examined the effects of administration of a bolus of periodontopathic bacteria and lipopolysaccharide to the pregnant sheep. Injection of bacteria and lipopolysaccharide in the amniotic fluid of the pregnant preterm sheep caused a high rate of fetal lethality, disturbance of fetal acid base status and inflammation of the fetus and membranes. Given the circumstances of exposure to periodontopathic pathogens in human periodontal disease, a model investigating long-term exposure to periodontopathic lipopolysaccharide on pregnancy outcomes was developed. ... Overall, I have demonstrated that maternal periodontal disease is associated with adverse pregnancy outcomes including fetal growth restriction and possibly perinatal loss. Mechanisms regulating these effects are likely to be mediated by fetal adaptations to intrauterine inflammation resulting in altered fetal development, growth or survival. Randomised controlled trials that are currently in progress will provide further information on the effects of periodontal disease in human pregnancy, and the efficacy of treatment to reduce these adverse outcomes.