Raising Awareness of Oral Care Through Co‐Creation: A Qualitative Evaluation Study With Patients and Healthcare Professionals in a Hospital Setting

ABSTRACT

Aim

To explore how oral care is experienced and enacted in clinical practice by patients and staff in hospital wards 6 months after implementing solutions aimed at improving oral care.

Design

A qualitative study exploring the experiences of patients and staff from wards that participated in testing solutions to improve oral care. The solutions were oral care goodie bags for patients and support from dental hygienists.

Methods

Data collection involved participant observation in four hospital wards, 12 individual semi‐structured patient interviews, and four focus groups with 26 staff members. The data analysis was based on Ricoeur's theory of interpretation. Data collection took place from May to June 2024.

Results

Three themes emerged regarding oral care practice: (1) Raising awareness of oral care as a first step towards changes in practice, (2) oral care is deprioritised during hospitalisation, and (3) oral care involves navigating personal and professional boundaries.

Conclusion

The co‐created interventions enhanced awareness of oral care, representing an early stage of cultural change across organisational levels. However, persistent barriers underscore the complexity and gradual nature of cultural change in clinical practice.

Implications for Patient Care

This study proposes an intervention aimed at enhancing sustained oral care practice through the integration of external dental expertise and goodie bags for patients.

Impact

The study demonstrates that strengthening knowledge and support for both patients and staff is crucial to improving oral care practice in hospital settings. Establishing legitimised approaches can help staff overcome personal boundaries, while co‐creation with patients and staff holds promise for sustainable improvements in oral care practice.

Reporting Methods

The study followed COREQ criteria for reporting qualitative research.

Patient Contribution

A patient representative from the department was involved as a contributor in discussions on the study's design, conduct, and results.

1. Introduction

Oral diseases affect an estimated 3.5 billion people worldwide and encompass a range of conditions [1]. Although oral health has long been neglected in global health, many oral diseases are preventable, and oral health is increasingly recognised as essential to overall health. The WHO Global strategy on Oral Health 2023–2030 advocates integrating oral care into universal health coverage and hospital care, emphasising oral care as a vital component of nursing practice [1]. Hospitalised patients are particularly vulnerable, with poor oral hygiene increasing the risk of complications, especially among those with multimorbidity [2, 3]. The oral cavity can naturally host approximately 700 bacterial species, and regular oral care is essential to prevent conditions such as dental caries, periodontitis, and oral infections. These conditions may cause pain, impair nutrition, and increase the risk of systemic complications such as pneumonia and cardiovascular diseases, thus underscoring the importance of oral care for overall health and well‐being [4, 5]. Oral care refers to maintaining the cleanliness and health of the mouth, teeth and gums to prevent infection and promote well‐being [6]. In nursing practice, oral care ranges from providing patients with necessary tools to delivering comprehensive oral care, encompassing various levels of support and intervention [7].

2. Background

Despite growing recognition of its importance, oral care remains underprioritised in hospital nursing practice, often neglected due to time constraints, limited knowledge, and inadequate training, with negative consequences for patients' health and well‐being [7, 8, 9]. Evidence indicates that oral care is frequently omitted and constitutes a recurrent element of missed nursing care [10, 11]. Several studies have sought to explain these omissions, identifying challenges and barriers to delivering oral care in nursing practice. Studies have identified factors such as limited knowledge, insufficient skills, and lack of clinical guidance across diverse settings, including care of older adults, patients who have survived a stroke, and patients in intensive care settings [7, 8, 12, 13, 14]. This points to a need for educational and training initiatives to strengthen staff competences in oral care. Research also highlights organisational barriers, including time constraints, lack of oral care supplies, unclear professional responsibilities, and absence of clinical guidelines. In addition, oral care is often not supported by structured routines or standardised procedures and is not consistently integrated into daily nursing workflows. Limited systems for documentation and assessment of oral health may further contribute to oral care being overlooked in daily practice, as it is not routinely incorporated into care plans or monitored as part of clinical documentation [7, 8, 13, 14, 15]. In addition, staff discomfort with providing oral care has been identified as a further barrier. Nurses often perceive oral care as a potentially transgressive act that may compromise patients' privacy and autonomy, leading them to avoid initiating conversations or assistance with oral care because it is seen as intimate and invasive [7, 13, 14]. However, patients generally perceive oral care assistance as supportive rather than disrespectful and often expect nurses to initiate it [7, 16, 17]. Collectively, these findings highlight how both individual and organisational factors contribute to neglect of oral care in hospital‐based nursing practice.

In response to the challenges in oral care delivery, several interventions have been developed to improve practice in hospitals. Educational programmes for nursing staff have been shown to enhance knowledge, attitudes and skills, leading to improved oral and denture hygiene among patients [12, 18, 19]. However, Schafthuizen et al. found that nurses' attitudes towards oral care did not improve significantly, and adherence to an oral hygiene care protocol decreased among patients dependent on assistance after implementation of the oral care protocol [19]. Interventions with oral care kits or specialised tools have also improved oral care outcomes for example, among patients undergoing treatment for head and neck cancer and in reducing hospital acquired pneumonia in a U.S. hospital [20, 21]. In line with these findings, evidence‐based clinical resources such as the Oral Health in Healthcare Settings to Prevent Pneumonia Toolkit [22] and the AACN Practice Alert [23] provide structured guidance for implementing effective oral care practices and emphasise the role of oral care in preventing respiratory complications in hospitalised patients. However, despite the availability of such guidance, its integration into routine nursing practice remains inconsistent. While different approaches have demonstrated short‐term benefits, these gains have not consistently translated into routine nursing practice [12, 18, 19, 20, 21]. Furthermore, evidence suggests that close interdisciplinary collaboration between nurses and dental professionals can enhance oral care delivery, improve patient oral health and quality of life and strengthen staff competencies; this has been demonstrated in oncology settings and interprofessional student training programmes [24, 25].

The existing literature is highly heterogeneous in design, context and evaluation, which limits comparability across studies and the ability to draw firm conclusions, thereby constraining sustained impact and the integration of interventions into routine nursing practice, as well as limiting sensitivity to contextual factors in implementation. Against this background, the novelty in this paper is the exploration of how oral care can be better approached and integrated into nursing practice to ensure consistent and sufficient delivery of oral care. Including the importance of user involvement and contextual adaptation in creating sustainable change.

3. The Study

3.1. Aim

This study aimed to explore how oral care is experienced and enacted in clinical practice by patients and staff in hospital wards 6 months after the implementation of solutions aimed at improving oral care.

3.2. Solutions to Improve Oral Care

This study is part of a broader research project, the “Oral Care Project”, aimed at improving oral care for hospitalised patients by developing solutions to support change in oral care practice among both patients and staff, based on identified clinical barriers. The project consisted of three sub‐studies: Identification of needs and barriers, design and development of co‐created solutions, and implementation and evaluation in clinical practice.

An initial sub‐study identified four key barriers to oral care: (1) Oral care as a gut feeling, (2) oral care fades into the background, (3) even self‐reliant patients need help with oral care and (4) the mouth reflects the life lived [7]. Overall, these barriers were grounded in a lack of knowledge and limited focus on oral care among both patients and staff. In the second sub‐study, these barriers informed the co‐creation of solutions involving patients, nurses, nurse assistants and clinical specialists in oral care [26]. This paper presents findings from the third sub‐study, which focused on evaluating nursing practice following the implementation of solutions to enhance oral care. Clinical oral care practices, as well as patients' and staff's experiences with oral care, were explored across four hospital wards after a six‐month implementation period.

The oral care solutions were designed to increase knowledge and awareness of oral care. One solution targeted patients in the test wards by providing an oral care “goodie bag” upon admission, containing a toothbrush, toothpaste and a postcard highlighting the heath‐related importance of oral care. This message was reinforced through posters and flyers displayed in the wards.

Another solution targeted staff in the test wards by establishing a network of dedicated key stakeholders from each of the four test wards, in total 7 persons, supported by two dental hygienists. The dental hygienists delivered structured lectures on fundamental oral care knowledge and its health implications, facilitated discussions on topics raised by staff (e.g., specific patient cases and oral care products) and conducted follow‐up visits to the wards every second week. During these visits, they also participated in bedside patient care as role models for oral care practices. In addition, staff could contact the dental hygienists on an ad hoc basis by phone or email for further support. The key stakeholders facilitated local engagement by addressing ward‐specific needs, promoting use of dental hygienists and maintaining focus on oral care.

Overall, the aim was to strengthen knowledge, awareness and engagement in oral care practices within the wards. The oral care solutions were implemented over a six‐month period prior to data collection, after which the present evaluation study was conducted.

The individual patient exposure to specific elements of the intervention was not systematically assessed, as the study aimed to explore experiences of oral care as embedded in routine clinical practice.

4. Methods

4.1. Design

This study employed a qualitative design to explore patients' and staff's experiences with oral care during hospitalisation. The investigation was conducted on four hospital wards following the implementation of solutions aimed at enhancing awareness of and knowledge about oral care. A phenomenological‐hermeneutic approach, inspired by Ricoeur's theory of interpretation, was applied. The approach is grounded in phenomenology through its focus on participants' lived experiences, as expressed by patients and staff, and complemented by observations of clinical practice. Patient and staff perspectives were analysed as complementary expressions of the same clinical phenomenon, enabling an integrated interpretation of oral care as a shared practice within the hospital context. In line with Ricoeur's phenomenological‐hermeneutic philosophy, phenomenological descriptions form the basis for interpretation. Through a dialectical movement from what participants express (what the text says) to an interpretation of underlying meaning (what the text speaks about), this approach enables a deeper understanding through critical interpretation by combining phenomenological insights with a critical hermeneutic philosophy [27]. The study combined semi‐structured individual interviews with patients [28] and focus groups with staff [29]. This approach generated a rich dataset, enabling both experiential descriptions and contextual insights, forming the basis for an in‐depth interpretation of oral care in hospital settings [30].

4.2. Setting

The solutions were implemented in four wards at a large university hospital. These included medical and surgical wards. The wards are presented in Table 1.

TABLE 1.

Characteristics of test wards.

Test ward	Clinical specialty	No. of beds	No. of nursing staff
Ward 1	Surgical, otolaryngology	16	28
Ward 2	Medical, pulmonary medicine	13	35
Ward 3	Medical, infectious diseases	15	35
Ward 4	Surgical, plastic surgery	18	42

4.3. Recruitment

Purposeful sampling was used for recruitment, based on the following inclusion criteria: patients who had been hospitalised for at least 2 days and staff directly involved in personal care. Exclusion criteria comprised patients unable to participate in interviews due to cognitive or language limitations, and staff who were not directly involved in personal care or were employed on a short‐term temporary basis. A total of 12 patients and 26 staff members participated in the study. The patient group included both men and women, aged between 54 and 94 years, with hospital stays lasting between 2 and 35 days (see Table 2). Staff were predominantly female and included both registered nurses and nurse assistants. In this study, “nurses” refers to registered nurses responsible for clinical assessment, care planning, and the delivery of nursing care, whereas “nurse assistants” refers to staff with vocational training who provide basic care and support patients' daily activities under the supervision of registered nurses. Participants ranged in age from 25 to 75 years, with work experience varying from less than 1 year to over 30 years (see Table 3). Overall, the participants were considered representative of staff across the four participating wards.

TABLE 2.

Patient characteristics.

Participant no.	Gender: F = female, M = male	Age: years	Length of hospital stay: days
P1	M	66	9
P2	F	54	7
P3	M	61	2
P4	M	67	11
P5	M	94	5
P6	F	72	3
P7	M	79	35
P8	F	72	10
P9	F	64	7
P10	M	54	3
P11	F	63	21
P12	M	77	14

TABLE 3.

Staff characteristics.

Participant no.	Gender: F = female, M = male	Age: Years	Education: nurse, nurse assistant	Work experience: years
Staff 1	F	47	Nurse	20
Staff 2	F	46	Nurse	> 20
Staff 3	F	37	Nurse	12
Staff 4	F	37	Nurse	3
Staff 5	F	25	Nurse	3
Staff 6	F	30	Nurse	3
Staff 7	F	53	Nurse	> 30
Staff 8	F	55	Nurse assistant	> 20
Staff 9	F	43	Nurse assistant	19
Staff 10	F	54	Nurse	> 30
Staff 11	F	50	Nurse assistant	> 20
Staff 12	F	26	Nurse	0.5
Staff 13	F	26	Nurse	0
Staff 14	F	43	Nurse assistant	> 20
Staff 15	M	37	Nurse assistant	3
Staff 16	F	51	Nurse	> 20
Staff 17	F	37	Nurse	11
Staff 18	F	47	Nurse	> 20
Staff 19	F	36	Nurse	6
Staff 20	F	56	Nurse	> 20
Staff 21	F	63	Nurse assistant	> 20
Staff 22	F	49	Nurse assistant	> 20
Staff 23	F	26	Nurse	> 20
Staff 24	F	46	Nurse assistant	6
Staff 25	F	64	Nurse assistant	> 20
Staff 26	F	75	Nurse	> 30

4.4. Data Collection

Observation and interview guides were collaboratively inductively developed by the research team, guided by the study aim and existing literature on oral care. The questions reflected known barriers but were also designed to open for unknown perspectives [7, 13]. This approach allowed participants to contribute new insights into oral care practices.

Data collection was conducted from May to June 2024 after completion of the six‐month implementation period of the oral care solutions. This timing allowed for exploration of how the solutions were experienced over time and whether increased awareness of oral care was sustained beyond the initial implementation phase. Following this study, the solutions were made available on a more permanent basis across all wards in the hospital due to their perceived usefulness in raising awareness of oral care. Wards now have access to oral care items; however, they are responsible for sourcing materials for “goodie bags” locally. In addition, support from dental hygienists remains available through collaboration with the Department of Oral and Maxillofacial Surgery, where the project originated.

The head nurses and key stakeholders with a particular interest in oral care acted as gatekeepers providing access to the clinical setting and supporting participant recruitment and coordination of the data collection process. Written information about the study was provided in advance, and participants received oral information from the researchers. Oral or written informed consent was obtained for observations prior to each observation; this approach was chosen because the study was low risk, and written consent could be impractical when following staff across wards and shifts. Both oral and written informed consent was secured for interviews and focus groups. This was in accordance with Danish legislation.

The research team consisted of six researchers: five academically trained nurses with clinical and qualitative research experience, and one dental hygienist with a bachelor's degree. The team included both early‐career and senior researchers; the first and last authors are experienced researchers with formal training in qualitative methodologies. Three researchers conducted the data collection. One researcher facilitated focus groups with staff across the four wards, while two other researchers conducted participant observations and patient interviews, each covering two wards. These researchers had clinical backgrounds but had no prior relationship with the staff or patients in the participating wards. However, the staff were familiar with the “Oral Care Project” in general.

All six researchers were involved in the interpretation of the data. The analysis was primarily undertaken by three researchers, including a senior researcher with extensive experience in qualitative analysis, ensuring methodological rigour and consistency. The three researchers' prior involvement in the “Oral Care Project” may have influenced data collection and interpretation; however, this was addressed through reflexive discussions within the research team and the inclusion of researchers without prior involvement, supporting analytical openness.

4.5. Participant Observations

Participant observations consisted of eight sessions conducted over 2 days during both daytime and evening shifts, averaging 6 h per day at each ward. The researcher observed interactions between nurses and patients with a primary focus on oral care, while also observing general daily activities to gain a broader understanding of patients' and staff's experiences and the clinical practice within each ward. The observations were guided by Spradley's nine major dimensions: space, actor, activity, object, act, event, time, goal, and feeling [31] to structure thorough observations and supported the researchers in maintaining an open and explorative approach [31]. The level of researcher involvement was low, and field notes were obtained, expanded, and transcribed immediately after each session. These notes included the researcher's detailed description of the observations and quotations derived from informal conversations. An observational guide, based on Spradley's nine dimensions, was developed to outline the overall observational approach and to define specific areas of focus during data collection.

4.6. Interviews

A total of 12 Individual, semi‐structured interviews with patients were held in a private room on the hospital ward. The aim was to explore their experiences of oral care during hospitalisation. The interviews lasted 10–18 min (average 13 min) and were digitally recorded and transcribed verbatim. A semi‐structured interview guide was used, encouraging the participants to narrate freely about their experiences [28]. Through open‐ended questions, the patients were asked, for example: “How do you experience oral care during hospitalisation?” and “What are your thoughts about oral care?” The interview approach was intended to reveal nuanced experiences, with follow‐up questions used to explore reflections that arose in the interview [28].

4.7. Focus Groups

Nurses and nurse assistants participated together in four focus group sessions, one on each of the test wards. The aim was to explore staff experiences with oral care following the implementation of solutions to improve oral care. Each session lasted 1 h and took place in a conference room on the ward. This setting enabled staff to participate while staying close to their clinical duties. The focus groups were used to build shared understanding and explore their point of view on oral care [29]. The groups were homogeneous, reflecting staff at the wards and consisted of 2–11 participants. The first author moderated the group discussions based on a guide with questions such as “How would you describe oral care for patients in your ward?” and “How do you feel about asking and helping with oral care?” The moderator encouraged interaction to ensure discussions and exchange of experiences and perspectives. The guide contained open‐ended questions to allow new topics and perspectives to emerge [29].

4.8. Data Analysis

The data set consisted of field notes and transcripts from interviews and focus groups. In line with Ricoeur's theory of interpretation, all material was treated as a single, coherent text representing different expressions of the same phenomenon [27]. This approach implies that the analysis does not differentiate findings by data source. Rather, following Ricoeur's concept of the autonomy of the text, meaning is interpreted at the level of the text as a whole, allowing a “surplus of meaning” to emerge across the dataset [27]. Thus, the combination of observations, interviews, and focus groups contributes to a richer and more nuanced interpretation of the phenomenon under study. The material was analysed as one coherent text using the software program NVivo 12. Four researchers from the team worked together on the analysis.

Drawing on Ricoeur's theory of interpretation, the analysis was conducted across three levels: naïve reading, structural analysis, and critical interpretation and discussion [27, 30]. The naïve reading involved forming an initial understanding of the text, gained through reading and re‐reading the text with an open and receptive attitude. The structural analysis led to a deeper interpretation across the text. The structural analysis involved a movement from observations and the participants' quotations (i.e., ‘what the text says’) towards an interpretation of the underlying meaning (i.e., ‘what the text is talking about’). Meaning units were identified, condensed, and interpreted, and subsequently organised into themes representing the text's surplus of meaning (see example in Table 4).

TABLE 4.

Example of the structural analysis.

What the text says ‘units of meaning’	What the text is talking about ‘units of significance’	Theme
Patients ask for toothbrushes, and I think it's because they read the poster on the mirror and think, ‘Oh yes, I don't have my toothbrush.’ There are patients who ask for toothbrushes now (Staff 1) They also look at the brochure and look at the card and are made aware of it (Staff 14) I am now asking the self‐reliant patients, which I didn't do earlier (Staff 17) We've had posters in the patient rooms, bathrooms, and corridors. The doctors have become aware of it because we mentioned it at their morning meeting, so they all know about it now and think it's a good idea (Staff 1) I used them [dental hygienists] for a very complex patient with dry crusts in the mouth. It was beneficial to have them involved. They found many good products, and the patient's teeth and mucous membranes improved. He also received valuable advice on what to do going forward (Staff 12) …	Raising awareness of oral care initiated a gradual yet meaningful shift in clinical practice. Through posters, brochures and staff communication, oral care became more visible in the ward environment, prompting both patients and staff to engage with it in new ways. Patients increasingly requested oral care items, suggesting that the accessible information supported a growing awareness of their own oral health. At the same time, staff began addressing oral care more proactively, even among patients previously considered self‐reliant, reflecting a raising awareness of oral care as part of routine care. This awareness was further strengthened by the involvement of dental hygienists, whose expertise not only improved outcomes in complex cases but also contributed to a broader awareness of oral care. However, this development was not linear or complete. While patients became more attentive to oral care, some still hesitated to ask for help, and staff engagement remained inconsistent. As a result, awareness did not always translate into systematic support for patients' oral care routines. These nuances suggest that raising awareness represents an essential initial step in shifting in practice, but one that remains part of a broader and ongoing process of change	Raising awareness of oral care as a first step towards changes in practice

The analysis followed a dialectical process, moving iteratively between the parts and the whole to validate the developing interpretations against the entire text and the first impressions from the naïve reading. This interpretative process was grounded in the empirical material and remained closely connected to the text through a purely inductive analytic approach. The purpose of the analysis was to gain a deeper understanding and interpretation of the participants' experience, based on the text itself [27]. The final critical interpretation and discussion were developed through engagement with relevant theory and existing research [27]. Theory and existing research were introduced only in the final level of interpretation as an interpretive resource to further unfold the text's meanings and to situate the findings within a broader theoretical and research context.

The themes are presented with illustrative quotations, followed by an interpretation that reflects the shared meaning of the lived experiences across the dataset. The critical interpretation with theory and existing research is presented in the Discussion section.

4.9. Ethical Considerations

The study adhered to ethical guidelines of the Declaration of Helsinki [32]. Head nurses facilitated access to the wards and distributed information about the study in advance. However, participation decisions were made individually, and consent was obtained directly by the researchers to ensure voluntariness and minimise potential undue influence. Participants received both oral and written information about the study, and their right to withdraw at any time without consequences. Written and oral informed consent was obtained prior to participation in interviews and observations. All eligible participants agreed to participate. Confidentiality and participant protection were ensured through anonymisation of all data, with identifying information removed during transcription and analysis. Data were stored securely and accessible only to the research team. The study is registered with the Danish Data Protection Agency, no.: 21/48355, and in accordance with Danish legislation, does not require additional ethical approval.

4.10. Rigour and Reflexivity

The study followed the COREQ checklist (Consolidated Criteria for Reporting Qualitative Research) to ensure transparency and trustworthiness, as the criteria informed both the conduct and reporting of the study [33]. Trustworthiness was addressed through strategies relating to credibility, transferability, dependability, and confirmability. Credibility was supported through engagement in the field across multiple wards, including participant observations across four wards, and through methodological triangulation by combining observations, patient interviews, and focus groups with staff. Researcher triangulation was also applied, as multiple researchers were involved in both data collection and analysis, with ongoing discussions used to explore and validate interpretations. Transferability was enhanced by providing detailed descriptions of the study context, including characteristics of the participating wards and participants, allowing readers to assess the applicability of the findings to other settings. Dependability was ensured through a systematic and transparent analytical process based on Ricoeur's phenomenological–hermeneutic approach. The analysis followed a structured process of naïve reading, structural analysis, and critical interpretation, supported by the use of NVivo software and collaborative analytic discussions within the research team. Confirmability was strengthened through reflexive awareness within the research team. The researchers' backgrounds and roles are described, and their lack of prior relationships with participants supported openness during data collection. Interpretations were grounded in the empirical material and supported by illustrative quotations, ensuring that findings reflect participants' experiences rather than individual researcher bias.

5. Findings

The initial naïve reading offered insights into oral care practices and revealed an increased awareness of oral care among both patients and staff. However, persistent barriers to enhanced oral care remained evident. Through the structural analysis, three themes emerged, presented in Table 5.

TABLE 5.

Themes emerged during the structural analysis.

Themes
Raising awareness of oral care as a first step towards changes in practice
Oral care is deprioritised during hospitalisation
Oral care involves navigating personal and professional boundaries

5.1. Raising Awareness of Oral Care as a First Step Towards Changes in Practice

The focus on oral care led to increased awareness among ward staff, as expressed by one participant:

We've had posters in the patient rooms, bathrooms, and corridors. The doctors have become aware of it because we mentioned it at their morning meeting, so they all know about it now and think it's a good idea. (Staff 1)

Increased awareness of oral care marked a shift in how oral care was perceived in clinical practice. Through various communication strategies, the project encouraged staff's proactive engagement in oral care promotion, fostering dialogue not only in patient care but also among staff. In addition, one staff member expressed how patients had been encouraged to address oral care:

Patients ask for toothbrushes, and I think it's because they read the poster on the mirror and think, ‘Oh yes, I don't have my toothbrush.’ There are patients who ask for toothbrushes now. (Staff 1)

Staff experienced increased patient interest in oral care, likely because the visible and accessible informational material, including posters and goodie bags, were perceived as meaningful and engaging. Participant observations revealed that patients had read and become aware of the implications of poor oral care based on the provided information. However, the observations also highlighted inconsistencies in the visibility and use of these materials. While some wards displayed posters in patient rooms, they were not consistently visible across all wards.

Another important part of the shift in awareness was the involvement of dental hygienists, as one staff member described:

I used them [dental hygienists] for a very complex patient with dry crusts in the mouth. It was beneficial to have them involved. They found many good products, and the patient's teeth and mucous membranes improved. He also received valuable advice on what to do going forward. (Staff 12)

The professional expertise of dental hygienists appeared to play an important role in the collective understanding of oral care. Beyond providing technical guidance on oral care products, they facilitated interdisciplinary collaboration, reinforcing the legitimacy of oral care in clinical practice. As external health professionals, they helped overcome patient resistance, which seemed to support more effective engagement in oral care. Their role was particularly valued in addressing complex oral health needs, positioning them as key partners in patient care.

It was essential that staff took the initiative in addressing patients' oral health needs, as one patient said:

No, I wouldn't ask them for help. Then I would just skip [oral care]. The staff already helps me so much, so there are limits to what I can ask of them, and it would just be weird to ask for help with brushing my teeth. (P 11)

This reflects a reluctance among some patients to ask for help with oral care, highlighting the importance of staff initiating such support.

Staff's involvement in actively guiding patients through oral care routines was inconsistent, so certain barriers remained. While patients received the necessary products, they often lacked effective support in using them. Another challenge arose when patients had personal routines that did not align with the daily routines at the hospital. However, staff experienced that when they took the initiative, patients became more likely to request oral care products and support independently, marking the beginning of a positive behavioural shift. This heightened awareness of oral care could represent the first step towards integrating oral care into nursing practice in a new way.

5.2. Oral Care Is Deprioritised During Hospitalisation

Despite increased awareness of oral care, maintaining it during hospitalisation remained challenging, as one patient said:

Well, I haven't really given it much thought while I've been in hospital. When you're hospitalised in the condition I was in, brushing your teeth isn't the first thing that comes to mind. (P 6)

Patients recognised oral care as important, yet it often became a secondary concern during hospitalisation. The demands of acute illness shifted their focus towards more immediate medical concerns. Factors such as fatigue, reduced mobility, stress, and anxiety contributed to this. Patients described how oral care, previously routine, faded into the background of their awareness as the experience of illness became all‐encompassing.

Staff also found it challenging to maintain awareness of oral care during hospitalisation:

…when they're admitted with a wound on a foot, that's what I focus on. They might have a lot of pain and need to be prepared for surgery. There are other bits of information that are more relevant than oral care, so I think the next person [staff] in line should continue that conversation…. (Staff 16)

Oral care was frequently deprioritised in favour of more immediate healthcare needs, as the focus was on the primary reason for admission. Although staff acknowledge the importance of oral care, it required consistent effort to maintain it as a priority. The tendency to revert to old habits, combined with a lack of continuity in practice and clear guidelines regarding oral care, risked oral care being pushed aside, particularly when daily workloads and established routines took precedence.

This applied even to otherwise self‐reliant patients who were dependent on assistance during hospitalisation, although staff were often unaware of it, as described in this fieldnote:

In our department, patients are predominantly self‐reliant, so we expect them to take care of oral care themselves. (staff, fieldnote)

In addition, a patient said:

Naturally, I would normally do it myself, but my mind is just so overwhelmed… And then stuff like that just slips my mind. (P 7)

Staff played a crucial role in ensuring oral care for hospitalised patients, including those considered self‐reliant. While these patients were expected to manage their own oral care, their ability to do so was often compromised by physical limitations, illness‐related cognitive impairments, or psychological distress, making it difficult for them to initiate or maintain oral care routines without support. A contrast emerged when staff primarily associated the need for support with physical independence, overlooking patients who required support due to cognitive or psychological barriers related to hospitalisation. Additionally, some patients hesitated to seek help, not wanting to impose additional burdens, as oral care was commonly perceived as a basic self‐care task rather than a critical medical intervention. The staff responsibility extended beyond providing oral care products to assessing and responding to needs for guidance and support, recognising that the needs of habitually self‐reliant patients may change during hospitalisation.

5.3. Oral Care Involves Navigating Personal and Professional Boundaries

Staff navigated a tension between their professional responsibilities and personal boundaries in relation to oral care, as the recognised health importance of oral care sometimes conflicted with their personal attitudes.

If I was hospitalised and a nurse asked me if I had brushed my teeth, I'd think, what business is it of yours whether I brush my teeth? (Staff 3).

Staff often acted with restraint when discussing oral care, revealing a tension between professionalism and personal boundaries. Many feared that asking patients about their oral care might be perceived as invasive or as personal criticism. Participant observations also showed that staff perceived oral care as a private matter, with concerns that enquiring about oral care could come across as patronising or condescending. As a result, many felt that oral care fell outside their legitimate scope of enquiry.

However, it could be found less intrusive to ask about specific items:

I don't think it's intrusive to ask if they have a toothbrush with them, but it definitely feels intrusive to ask if they need help brushing their teeth. (Staff 4)

Asking patients about specific items, such as whether they had a toothbrush, was generally considered acceptable. However, the conversation became far more personal when it shifted towards offering help with brushing teeth or inspecting a patient's mouth.

Patients' perceptions differed significantly. There seemed to be a general understanding that other norms applied during hospitalisation. As one patient responded when asked if he found oral care enquiries intrusive:

No not at all… That's how it is when you get sick. You don't worry about that stuff, you worry about your illness. [Asking about oral care] is just natural, I think…. (P 9)

To navigate their discomfort around discussing oral care, some staff used the “Oral Care Project” as a formal context to raise the topic:

It's been good having it as a project. Personally, I find it intrusive to ask a grown man if he remembered his toothbrush or has brushed his teeth. It's so private, and there I am, standing there like a mother…. The project has made it easier to raise the topic, because I can use it as a professional excuse. (Staff 3)

The “Oral Care Project” provided a legitimate framework for addressing the topic, offering a professional basis that made it easier to start conversations about oral care without coming across as intrusive. This helped staff balance their professional responsibilities with respect for patients' personal boundaries, which otherwise could be challenging in daily practice.

6. Discussion

This study shows that the oral care solutions prompted early changes in clinical practice by enhancing awareness among staff and patients through support from dental hygienists and targeted communication efforts. However, the continued deprioritisation of oral care during hospitalisation reflects patterns described in previous research, where oral care is frequently omitted due to competing clinical demands [7, 10]. Even self‐reliant patients encountered difficulties, highlighting the need for consistent professional support. Staff also had to navigate personal boundaries when addressing oral care; however, the project provided a legitimate reason to initiate these conversations, making it easier to address the topic in a respectful and professional manner. Thus, these findings suggest that raising awareness represents an important first step towards integrating oral care as a sustained component of nursing practice, requiring both cultural and structural support.

6.1. Emerging Cultural Change in Oral Care Practice

This discussion integrates caring science and organisational theory to understand oral care practices and emerging cultural change. From a caring science perspective, oral care is a fundamental aspect of nursing, linked to dignity, vulnerability, and attentiveness to patients' bodily needs. However, such care is embedded within organisational contexts that shape what is prioritised and enacted in practice. Schein's theory of organisational culture is applied to understand how oral care is shaped across organisational levels, not only by formal procedures but also by underlying assumptions about bodily intimacy, professional responsibility, and care priorities [34].

The findings suggest that the solutions contributed to early‐stage, rather than fully embedded, cultural change. This is understood through Schein's model of organisational culture, which distinguishes between three interrelated levels: artefacts, values, and basic assumptions [34]. At the level of artefacts [34], visible practices began to shift. The presence of dental hygienists and the use of goodie bags provided awareness of oral care in clinical practice. These changes functioned not only as practical tools but also as cultural signals emphasising the relevance of oral care. At the level of values [34], oral care was increasingly recognised as a professional responsibility. Through targeted communication, education, and engagement, staff expressed greater awareness of its importance for patient health and well‐being. Despite ongoing challenges related to competing clinical priorities, oral care became more clearly positioned as a legitimate component of nursing practice. At the level of basic assumptions [34], the project began to challenge the notion that oral care is a personal matter or a peripheral nursing task. The involvement of dental hygienists and distribution of goodie bags prompted reflection on taken‐for‐granted beliefs regarding personal bodily boundaries, discomfort, and nursing care. Although these assumptions were not fully transformed, the findings suggest that space was created for emerging cultural change. Overall, the findings indicate that change occurred across multiple organisational levels, with shifts in clinical practice and growing awareness gradually influencing professional values and assumptions. However, these changes remain fragile and require ongoing support to be sustained.

This interpretation aligns with previous research. Rasmussen et al. emphasise the need for a cultural shift in nursing, in which oral care is recognised as an essential component of patient care rather than a supplementary task [16]. They argue that oral care should be seen as a fundamental aspect of patient care, essential for preventing complications rather than merely a wellness issue. Furthermore, they highlight the importance of dialogue and education to fully integrate oral care into nursing practice [16]. The oral care solutions applied in the present study have the potential to facilitate both dialogue and education in oral care. Consistent with previous research, the use of oral care kits and selected tools has been shown to positively influence oral care delivery [20, 21]. Similarly, several studies identify education as central to improving oral care in nursing practice [8, 13, 14, 35]. Pai et al. demonstrated that combining oral care kits with training is clinically valuable [20]. However, as noted by Schafthuizen et al., such improvements may diminish over time, highlighting the need for sustained organisational commitment [19]. This highlights how co‐created, small‐scale interventions may initiate cultural change across organisational levels, rather than representing isolated improvements in practice. Integrating caring science and organisational theory thus demonstrates how oral care is shaped by organisational culture, including artefacts, values and underlying assumptions. While caring science clarifies what matters in care, organisational theory explains how such practices are sustained or neglected in everyday clinical settings.

6.2. External Experts as Facilitators of Change

Participants' experiences highlighted how the involvement of dental hygienists shaped everyday oral care practices by providing legitimacy, knowledge, and support in clinical interactions. The dental hygienists functioned as accessible external experts, available for both scheduled and same‐day consultations on weekdays. The findings indicate that their involvement, together with the use of goodie bags, supported reflection and the sharing of professional knowledge among patients and staff. This interpretation aligns with previous research demonstrating that external experts can stimulate reflection, contribute specialised knowledge and support changes in clinical practice [36, 37, 38]. Kousgaard et al. found that external specialists were well‐received in general practice for diabetes care, as they encouraged staff reflection and contributed professional knowledge and guidance [37]. Similarly, Surr et al. identified the involvement of external experts as crucial to the successful implementation of Dementia Care Mapping in home care settings, recommending sustained access to local external experts to support long‐term integration [36]. The use of dental hygienists as external experts also seemed to help normalise interactions around oral care. When oral care was framed as part of preventing complications and as an expected component of hospital care, it became easier for staff to initiate or assist with it, helping to bridge perceived personal and professional boundaries.

From an institutional perspective, these findings can also be understood as reflecting the interaction between different professional logics. Hospital staff and dental hygienists represent distinct but overlapping domains of practice, each guided by specific priorities, knowledge bases and norms. As highlighted by Reay and Hinings [39] organisational actors often need to navigate and balance competing institutional logics, while Levänen et al. [40] emphasise the role of intermediating practices in bridging such differences. In the present study, the dental hygienists' involvement appeared to mediate between dental and general nursing logics, supporting the integration of oral care into everyday clinical nursing practice.

However, both the present findings and existing literature indicate that external expertise alone is insufficient to ensure lasting change. As emphasised by Alagoz et al., single components are inadequate, highlighting the need for a comprehensive, multifaceted strategy to effectively change clinical practice [41]. In this study, a multifaceted approach was employed to enhance oral care by targeting both patients and staff. Dental hygienists acted as external experts, supporting staff through educational sessions, bedside guidance, and instructions on oral care products, while patients were engaged through informational posters, goodie bags, and direct interactions with the dental hygienists. These findings suggest that external experts contribute to change not only by introducing knowledge but also by fostering reflection and engagement in everyday practice. Importantly, they may also support the alignment of different professional logics, thereby facilitating the integration of new practices. This extends existing research by demonstrating how external facilitation, when integrated into co‐created and multifaceted interventions, may support the development of practice change and contribute to emerging cultural shifts, rather than functioning as a standalone implementation strategy.

6.3. Implications for Practice and Future Research

The findings suggest that raising awareness is an important step, but not sufficient on its own, towards sustained change in oral care practice. From a clinical perspective, interventions should be embedded within organisational structures and daily nursing care, including clear guidelines, integration into daily workflows, and ongoing interdisciplinary collaboration with dental hygienists. Leadership support and local key stakeholders may help maintain attention to oral care in the context of competing clinical priorities.

Furthermore, the findings highlight the importance of legitimising oral care as part of professional nursing practice, particularly in relation to navigating personal and professional boundaries. Creating structured opportunities for dialogue and reflection may support staff in addressing these challenges. For future research, longitudinal studies are needed to examine whether early increases in awareness translate into sustained changes in practice and patient outcomes. Further research should also explore how organisational conditions and interactions between different professional groups influence the integration of oral care, particularly in contexts characterised by multiple and potentially competing institutional logics.

6.4. Strengths and Limitations

This study employed methodological triangulation by combining qualitative data from focus groups, individual interviews and participant observation, enabling a comprehensive understanding of clinical practice through multiple perspectives. This approach was particularly important for capturing perspectives related to patients with cognitive impairment, whose experiences could not be explored through interviews and therefore had to be understood through observations [30]. Researcher triangulation further strengthened the study, as both researchers with and without prior involvement in the “Oral Care Project” contributed to data collection and analysis, supporting a balance between contextual insight and analytical openness. The researchers' prior involvement may have influenced data collection and interpretation; however, this was addressed through reflexive discussions within the research team. In addition, the focus on oral care was known to participants, and the focus groups were facilitated by a researcher associated with the project, which may have influenced responses. Conducting the focus groups within the hospital setting may also have limited participants' willingness to speak freely. Nonetheless, the data yielded rich insights into barriers to oral care. A limitation is the relatively limited depth of some patient interviews, which may constrain insight into patients' perspectives on oral care. However, this was mitigated through triangulation with observational data and staff focus groups, strengthening the overall interpretation. In addition, individual patient exposure to intervention components was not systematically assessed, as the study aimed to explore oral care as embedded in routine clinical practice. While this may contribute to variation in experiences, it reflects real‐world conditions, and the findings are supported by patterns identified across data sources, strengthening the overall interpretation. As a qualitative evaluation, this study provides a nuanced understanding of clinical practice. While a quantitative approach could have generated measurable outcomes; however, such outcomes are difficult to isolate due to multiple interacting factors.

7. Conclusion

This study indicates an emerging awareness of oral care, representing an early stage of cultural change following the implementation of co‐created solutions. The findings suggest that a multifaceted approach may support awareness of oral care across different organisational levels by engaging patients and staff in complementary ways. Nevertheless, persistent barriers to oral care remain, illustrating that cultural change in clinical practice is a gradual and complex process that cannot be achieved rapidly or effortlessly. Based on these findings, future efforts may benefit from continued engagement of both patients and staff in the co‐creation of interventions, with strategies tailored to the needs and contexts of different organisational levels. Implications for practice highlight the importance of ongoing education, reinforcement and leadership support to sustain attention to oral care. Addressing organisational and cultural barriers requires long‐term commitment and iterative adaptation of interventions. Implications for future research highlight the need for longitudinal studies to explore how co‐created interventions may contribute to sustained changes in clinical practice and to deepen understanding of how organisational and cultural conditions shape oral care in clinical settings.

Author Contributions

C.N.: conceptualization, methodology, formal analysis, investigation, writing – original draft – review and editing, project administration. N.B.P.: formal analysis, investigation, writing – original draft – review and editing. H.M.D.: formal analysis, writing – review and editing. B.T.: methodology, writing – review and editing.

Funding

This research was supported by grants from the Danish Dental Hygienists’ Association and the Development and Research Fund of Danish Regions. The oral care products used in the study were supplied by Sunstar/GUM and Haelon/Sensodyne, selected based on the research team's professional expertise and judgement.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.