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. 2022 Jul 20;10(1):202–207. doi: 10.1002/nop2.1295

Self‐efficacy and attitudes of nurses providing oral care in geriatric care facilities: A cross‐sectional study in Shanghai

Liyan Gu 1, Lan Chen 2,3, Xianchen Li 4, Wenyao Chen 3, Lingjuan Zhang 3,5,✉
PMCID: PMC9748059  PMID: 35856707

Abstract

Aims

To investigate nurses' self‐efficacy and attitudes of providing oral care in geriatric care facilities (GCFs) and compare differences between individuals, facilities and countries.

Design

A cross‐sectional and multicentre study.

Methods

Data were collected from 852 nurses in 42 GCFs using two scales, “Self‐Efficacy for Providing Mouth Care” (SE‐PMC) and “Attitudes for Providing Mouth Care” (A‐PMC), and analysed using t‐test and ANOVA.

Results

Totally 852 nurses (844 females, 99%) participated in this study with an effective response rate of 85.2%. Scores of SE‐PMC and A‐PMC of nurses varied significantly among GCFs with different sizes, types and years of establishment and differentiated among staff about the length of employment (p < .05). Nurses (N = 434) in North Carolina scored higher than nurses in Shanghai both in SE‐PMC and A‐PMC (p < .05). Establishment and implementation of Oral health promotion programmes were desired based on characteristics of different institutions and nurses' clinical ladder.

Keywords: a cross‐sectional study, attitude, geriatric care facilities, oral health, self‐efficacy

1. INTRODUCTION

Oral health is a primary global public health concern, with 46% of the world's population suffering from varying degrees of oral disease (Bernabe et al., 2020). The trend of declining oral function in older people should be especially noted in an ageing society (Lauritano et al., 2019). According to the fourth oral health epidemiological survey report in China in 2017, the number of surviving teeth was 22.5, and the proportion of total edentulousness was 4.5%, periodontal health and oral hygiene were poor among the older persons aged 65–74 years (Yu et al., 2021).

Good oral health is a critical factor in healthy ageing, associated with general health, morbidity and mortality in older people (Lauritano et al., 2019). Many studies have reported that oral disease is a risk factor for cardiovascular disease, cancer, chronic respiratory disease and cognitive impairment, affecting overall health (Kang et al., 2020; Kumar et al., 2021; Zhang et al., 2021).

Caregivers in geriatric care facilities (GCFs) often meet with unique oral care challenges for residents (Goestemeyer et al., 2019). After admission, residents' oral health declined, combined with an increased risk of malnutrition (Schmalz et al., 2021). Researchers also further determined that oral frailty was associated with nutritional status among community‐dwelling older people (Iwasaki et al., 2020). At the same time, many vulnerable residents who suffer from stroke or cognitive impairment have reduced swallowing ability, which further increases the risk of oral diseases (Chen et al., 2021). Therefore, adequate dental care for frail older persons, especially those with remaining teeth, is essential (Hoeksema et al., 2017).

Nevertheless, Hoben's study reports that 24% (7%–47%) of care providers in nursing homes lack knowledge, education or training in providing oral care, suggesting effective strategies desired to overcome barriers and increase facilitators in oral care (Hoben et al., 2017). Since dental care provided in GCFs in China was rarely reported, the healthcare staff's self‐efficacy and attitude towards dental care also remained unknown. However, this knowledge gap needs to be filled out because proper measurement of self‐efficacy and attitude could be presented as objective data that helps nursing administrators grasp the current situation and give evidence for care promotion programmes.

Oral health issues of Chinese older people are attracting growing attention recently (Liu et al., 2018). However, rare studies have focused on nurses' self‐efficacy and attitude towards oral care in GCFs. In preliminary studies, our research team developed and psychometrically tested the Chinese Version of “Self‐Efficacy for Providing Mouth Care” (SE‐PMC) and “Attitudes for Providing Mouth Care” (A‐PMC) created by Wretman et al. (2020), which can give an instrument for nurses' self‐efficacy and attitude towards providing oral care in GCFs. Therefore, this study aimed to assess the baseline status of Chinese nurses' oral care self‐efficacy and attitudes in GCFs and compare differences between individuals, facilities and countries.

2. MATERIALS AND METHODS

2.1. Study design and participants

This cross‐sectional study was conducted using cluster sampling from February to March 2021. We calculated a sample size of 1,000 to allow for stratification by GCFs depending on an α of 0.05, a relative error of sampling of 3%, and a non‐response rate of 10%. A proportional sampling method (10%) with a stratification factor of GCF was used to obtain a representative sample of nurses in all 42 GCFs in shanghai. The inclusion criteria for participants were: (a) officially Registered Nurses in GCFs; (b) nursing experience in GCFs over 1 year; (c) informed consent and voluntary participation in this study. However, nurses who did not work in GCFs during the survey period were excluded (off‐site training or sick leave). A total of 1,000 nurses were obtained by using computer‐generated random numbers.

2.2. Questionnaire design

The Institutional Review Board of Shanghai General Hospital, affiliated with Shanghai Jiao Tong University, approved this study, and participants signed informed consent online. Data were collected using a set of questionnaires to evaluate Chinese nurses' oral care self‐efficacy and attitudes in GCFs. The questionnaires covered two domains, including background information (age, gender, length of employment, etc.) and the Chinese Version of the SE‐PMC and A‐PMC scale. The Chinese Version of the SE‐PMC and A‐PMC scale was translated, culturally adapted and psychometrically tested in our previous study, originating from Wretman et al.'s research (2020), including 22 items, with adequate construct validity and reliability using exploratory and confirmatory factor analysis. The total Cronbach's coefficient of the Chinese Version of SE‐PMC was 0.831, and the Cronbach's coefficients of the sub‐dimensions of Promoting Oral Hygiene (POH), Providing Mouth Care (PMC) and Obtaining Cooperation (OC) were 0.906, 0.793 and 0.811 respectively. The total Cronbach's coefficient for the Chinese Version of A‐PMC was 0.768, and the Cronbach's coefficients for the sub‐dimensions of Care of Residents' Teeth (CPT) and Care of Own Teeth (COT) were 0.824 and 0.814 respectively.

2.3. Data collection

From February to March 2021, 900 of the 1,000 Registered Nurses from 42 GCFs in Shanghai were recruited with a response rate of 90%. GCFs involved in this study mainly provided long‐term medical care, rehabilitation promotion and hospice care to older persons unable to take care of themselves. Informed consent was obtained before the investigation. We issued an online survey to collect data via Wen Juanxing (www.wjx.cn). A total of 900 questionnaires were recovered in the study anonymously. Due to the considerate settings of the online survey system, there were no missing items from the submitted 900 questionnaires, but 48 of them were invalid (option selection all “1” or all “4”). Therefore, 852 questionnaires were valid, and the effective response rate was 85.2%.

2.4. Statistical analysis

The statistical software SAS 9.4 (SAS, Cary, NC) was used to analyse the collected data. Continuous variables were displayed as mean with standard deviation or median with 25 percentile and 75 percentile. Age and length of employment of nurses were stratified by reference to the quartiles of the sample. Group differences were compared according to the self‐rated scale status using t‐test or ANOVA for continuous variables. A statistically significant difference was accepted at a p‐value <.05.

3. RESULTS

3.1. Characteristics of the sample

Table 1 shows the characteristics of the study sample. The average age of the 852 nurses who participated in the study was 30.27 ± 7.245, with 99.1% female and only 0.9% male. The proportion of nurses working in institutions of a different type was similar, with 50.7% of nurses working in public GCFs and 49.3% in private GCFs. The average length of employment of participants in GCFs was 5.91 years.

TABLE 1.

Characteristics of staff and settings (n = 852)

Variables Total sample (mean ± SD/n, %)
Age 30.27 ± 7.245
Gender
Male 8 (0.9)
Female 844 (99.1)
Type of institution
Public 432 (50.7)
Private 420 (49.3)
Experience of work 5.91 ± 5.927
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3.2. Differences of SE‐PMC and A‐PMC of nurses in GCFs about characteristics of institutions

Table 2 shows that scores of SE‐PMC and A‐PMC of nurses in public GCFs were higher than those of nurses in private GCFs and sub‐dimensions of PMC, OC and CRT. Scores of SE‐PMC and A‐PMC of nurses in GCFs with less than 100 beds were higher than those of nurses in GCFs with more than 100 beds and sub‐dimensions of PMC, OC and CRT. Furthermore, data reflect SE‐PMC of nurses in GCFs established in 10 years higher than those in GCFs established over 10 years and in sub‐dimensions of PMC and CRT. The differences were statistically significant (p < .05).

TABLE 2.

Differences of self‐efficacy of providing mouth care (SE‐PMC) and attitude of providing mouth care (A‐PMC) of nurses in GCFs based on characteristics of institutions

Factors Type of institutions Size of institutions Year of establishment of institutions
Public (n = 432) Private (n = 420) Bed number <100 (n = 249) Bed number >100 (n = 603) <10 years ≥10 years
SE‐PMC (11 items) 2.93 ± 0.373* 2.92 ± 0.375* 2.94 ± 0.362* 2.87 ± 0.389* 2.93 ± 0.366* 2.87 ± 0.392*
Promoting oral hygiene 3.19 ± 0.449 3.19 ± 0.471 3.19 ± 0.405 3.21 ± 0.490 3.18 ± 0.445 3.23 ± 0.480
Providing mouth care 2.79 ± 0.559* 2.76 ± 0.566* 2.79 ± 0.539* 2.65 ± 0.619* 2.79 ± 0.563* 2.62 ± 0.615*
Obtaining cooperation 2.82 ± 0.505* 2.80 ± 0.511* 2.82 ± 0.493* 2.74 ± 0.559* 2.80 ± 0.506 2.74 ± 0.564
A‐PMC (11 items) 3.00 ± 0.346* 3.00 ± 0.352* 3.02 ± 0.337* 2.96 ± 0.349* 3.00 ± 0.338 2.96 ± 0.352
Care of residents' teeth 2.83 ± 0.463* 2.83 ± 0.465* 2.85 ± 0.427* 2.73 ± 0.527* 2.83 ± 0.466* 2.72 ± 0.521*
Care of own teeth 3.18 ± 0.420 3.18 ± 0.443 3.20 ± 0.407 3.19 ± 0.449 3.17 ± 0.412 3.20 ± 0.454
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Note: Variables with * means significant differences between groups (t‐test at p < .05).

3.3. Differences of SE‐PMC and A‐PMC of nurses in GCFs about characteristics of individuals

Table 3 shows that no differences between SE‐PMC and A‐PMC were found about the age of nurses. However, nurses with different lengths of employment differ in SE‐PMC. Nurses with 1–2 years and 3–4 years of work experience had higher SE‐PMC scores than those with 5–8 years and ≥9 years of work experience, and the differences were statistically significant (p < .05).

TABLE 3.

Differences of SE‐PMC and A‐PMC of nurses in GCFs based on characteristics of nurses

Factors Age of nurses Length of employment Multiple comparison
18–25 (n = 216) 26–29 (n = 271) 30–33 (n = 172) 34–64 (n = 193) 1–2 (n = 280) 3–4 (n = 176) 5–8 (n = 181) ≧9 (n = 200)
SE‐PMC (11 items) 3.24 ± 0.459 3.18 ± 0.425 3.19 ± 0.502 3.23 ± 0.499 3.25 ± 0.470* 3.22 ± 0.433* 3.14 ± 0.455* 3.21 ± 0.496* a, b>c, d
Promoting oral hygiene 2.76 ± 0.633 2.71 ± 0.562 2.60 ± 0.602 2.68 ± 0.606 2.80 ± 0.600 2.73 ± 0.598 2.66 ± 0.576 2.53 ± 0.598
Providing mouth care 2.81 ± 0.534 2.77 ± 0.508 2.74 ± 0.582 2.74 ± 0.558 2.85 ± 0.548* 2.78 ± 0.523* 2.68 ± 0.486* 2.72 ± 0.579* a>c, d; a, b, c>d
Obtaining cooperation 2.94 ± 0.390 2.89 ± 0.372 2.84 ± 0.369 2.88 ± 0.396 2.97 ± 0.383* 2.91 ± 0.388* 2.83 ± 0.357* 2.82 ± 0.378* a>c, d
A‐PMC (11 items) 2.75 ± 0.493 2.78 ± 0.467 2.72 ± 0.527 2.80 ± 0.538 2.82 ± 0.510 2.77 ± 0.489 2.76 ± 0.488 2.69 ± 0.513
Care of residents' teeth 3.21 ± 0.440 3.17 ± 0.416 3.17 ± 0.487 3.21 ± 0.417 3.21 ± 0.451 3.17 ± 0.413 3.16 ± 0.454 3.20 ± 0.421
Care of own teeth 2.98 ± 0.346 2.98 ± 0.341 2.95 ± 0.352 3.00 ± 0.348 3.02 ± 0.346 2.97 ± 0.345 2.96 ± 0.357 2.95 ± 0.332
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Note: Variables with * means significant differences between groups (ANOVA at p < .05). About multiple comparisons in length of employment, a means 1–2; b means 3–4; c means 5–8; d means ≥9.

3.4. Comparison of SE‐PMC and A‐PMC of nurses in GCFs between Chinese and USA

Table 4 compares nurses' scores of SE‐PMC and A‐PMC between the USA and China. Overall, nurses (n = 434) in North Carolina nursing homes (Wretman et al., 2020) had higher scores than nurses (n = 852) in Shanghai, except in the sub‐dimension OC.

TABLE 4.

Comparison of scores of SE‐PMC and A‐PMC of nurses between Chinese and American GCFs

Factors Chinese nurses (n = 852) American nurses (n = 434) t p‐value
SE‐PMC (11 items) 2.89 ± 0.38 3.03 ± 0.38 −6.247 <.001*
Promoting oral hygiene 3.21 ± 0.47 3.32 ± 0.46 −4.025 <.001*
Providing oral hygiene 2.69 ± 0.60 2.87 ± 0.64 −4.870 <.001*
Obtaining cooperation 2.77 ± 0.54 2.71 ± 0.56 1.839 .066
A‐PMC (11 items) 2.98 ± 0.35 3.19 ± 0.38 −9.620 <.001*
Care of residents' teeth 2.77 ± 0.50 3.10 ± 0.48 −11.494 <.001*
Care of own teeth 3.19 ± 0.44 3.29 ± 0.47 −3.686 <.001*
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Note: Variables with * means significant differences between groups (t‐test at p < .05).

4. DISCUSSION

In recent years, oral care has been highlighted in GCFs. Well‐provided oral care should include care from the acute phase of hospitalization to the rehabilitation phase. Self‐efficacy refers to an individual's expectation and perception of achieving a specified capability. Self‐efficacy influences behaviour, cognition and emotional processes and is related to one's ability to cope with a particular task and confidence in accomplishing that task (Sheeran et al., 2016). Therefore, exploring caregivers' attention to oral care needs is particularly important. In this study, we found that scores of SE‐PMC and A‐PMC of nurses varied significantly between GCFs with different sizes, types and years of establishment and differentiated among staff about the length of employment. Moreover, Chinese nurses in GCFs experienced a slightly lower self‐efficacy and attitude towards oral care than data reported in a previous study (Wretman et al., 2020).

Literature has shown that multiple factors (institutional factors, nurse characteristics, etc.) could affect self‐efficacy and attitudes. In Weening‐Verbree's study, the most frequent barriers to providing oral care were lack of support from dental staff, residents with cognitive impairment and lack of education (Weening‐Verbree et al., 2021), consistent with results in Göstemeyer's systematic review (Göstemeyer et al., 2019). In this study, nurses' self‐efficacy was higher in GCFs established for a shorter time. The possible reason is that the newly established GCFs may have an advantage over facilities that have been established for more than 10 years in terms of infrastructure, staffing and standardized routines. We also noted that the self‐efficacy and attitude of nurses in providing oral care in institutions with <100 beds were better than those in larger institutions, possibly because the smaller size of the institution might encourage closer cooperation and more substantial support among staff. As the literature mentioned, nurses could have better self‐efficacy and a positive attitude in a congenial and harmonious working environment (Iwanow et al., 2021; Yang et al., 2021).

Interestingly, nurses of different ages did not show statistical significance in self‐efficacy and attitude. However, nurses aged 18 to 25 years had higher self‐efficacy scores than other age groups. Nurses in the age group of 34–64 years had higher attitude scores than the other age groups, implicating senior nurses appear to have more stable and responsive attitudes towards oral care. Notably, the overall SE‐PMC varied with the length of employment. Nurses with lower levels of seniority showed better self‐efficacy, especially in the “Providing Mouth Care” and “Obtaining Cooperation” dimensions. This may be explained by their optimistic approach to effectively regulating and facilitating professional practice behaviours in clinical settings. Nurses' attitudes towards providing oral care did not show statistical differences concerning the length of employment.

An innovative attempt was additionally achieved in this study to compare the SE‐PMC and A‐PMC of Chinese and American nurses. The US data were taken from a study of 434 nurses in 14 GCFs in North Carolina by Dr Wretman et al. (2020). Interesting results showed differences between Chinese and American geriatric facilities, with American nurses showing better self‐efficacy and attitudes. Similar to Wretman's findings, we likewise found consistently higher scores reported in non‐profit GCFs (public facilities) and nursing providers with lower seniority. The possible explanation may be that nurses in non‐profit institutions have better access to continuing nursing education opportunities and are equipped with more specialized knowledge and technical skills. In another study in Canadian long‐term care facilities, 80% of caregivers felt knowledgeable and confident in providing oral care, although they still desired to improve their skills to overcome barriers and needed appropriate oral care materials (Keboa et al., 2019).

Understanding the knowledge and beliefs about oral health and debility of nursing staff in hospitals, communities and long‐term care facilities helps improve administrators' awareness. Training courses tailored to nursing staff's existing weaknesses and needs with different seniority are needed. Notably, it is reported that dental specialty teams can improve caregivers' knowledge and attitudes towards oral health (Janssens et al., 2018). Dental providers should be integrated into GCFs (Hugo et al., 2021), which would be valuable in addressing barriers to providing daily oral hygiene and supporting the continuous integration of oral health care into general care. About how to improve oral care skills, it is also a topic for nurses to communicate and learn from dentists who practise dental specialty care regularly.

4.1. Limitations of the study

We made a great effort in data recruitment. However, data collected were self‐reported, possibly leading to measurement subjectivity because of recall bias. Moreover, the current research did not include the relationship between the scores of SE‐PMC and A‐PMC of nurses and residents' oral health outcomes. Thus, our next step is to measure oral care directly by looking at a randomized number of patients' mouths to investigate the completion of oral care and complication rates of lack of oral care.

5. CONCLUSIONS

This study takes the initiative to investigate nurses' oral care self‐efficacy and attitudes in GCFs in China and to compare differences between individuals, facilities and countries. In future studies, we will devote ourselves to enhancing nurses' clinical oral care practice in GCFs. The characteristics of self‐efficacy and attitudes of GCF nurses towards oral care in Shanghai can give a rich reference value for constructing and implementing oral health promotion programmes.

6. RELEVANCE TO CLINICAL PRACTICE

Administrators need to pay attention to the relatively low status of self‐efficacy and attitude of nurses in oral care provision in GCFs compared to US institutions. A reasonable curriculum should be developed according to the characteristics of the dimensions related to our study. Furthermore, cultivating a learning atmosphere and mechanism is preferred to assist career planning. In this way, nursing staff might enhance professional interest and stimulate enthusiasm towards elder care.

AUTHOR CONTRIBUTIONS

Zhang Lingjuan designed the study. Chen Lan and Chen Wenyao collated the data, designed and developed the database. Li Xianchen carried out data analyses and Gu Liyan produced the initial draft of the manuscript. Zhang Lingjuan contributed to drafting the manuscript. All authors have read and approved the final submitted manuscript.

CONFLICT OF INTEREST

All authors declare there are no conflicts of interest.

ACKNOWLEDGEMENTS

The authors appreciate all the staff who participated in the research funded by a grant from the Standardization Pilot Program of Shanghai Quality and Technical Supervision Bureau (S18‐04‐017) and the Science and Technology Research Project of Health and Health Committee of Songjiang District (Oral health promotion strategies for the elderly population in long‐term care institutions in Songjiang District‐316).

Gu, L. , Chen, L. , Li, X. , Chen, W. , & Zhang, L. (2023). Self‐efficacy and attitudes of nurses providing oral care in geriatric care facilities: A cross‐sectional study in Shanghai. Nursing Open, 10, 202–207. 10.1002/nop2.1295

Liyan Gu and Lan Chen contributed equally to this work.

DATA AVAILABILITY STATEMENT

The data presented in this study are available on request from the corresponding author.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

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