What is known about the topic?
- Oral mucositis may further complicate cancer treatment by contributing to oral discomfort and pain, poor nutrition, delays in drug administration, increased hospital stays, and costs.
- Patients should complete education regarding oral hygiene care before receiving chemotherapy, including the use of soft-bristled brushes, the timing of brushing, proper brushing techniques, and how to assess oral health.
- Assessing the oral cavity and oral pain is essential to oral health; however, it is not commonly implemented due to various barriers.
What does this article add?
- Standardized, evidence-based oral hygiene care protocols for patients with cancer receiving chemotherapy or radiotherapy should be implemented.
- Based on Lewin's Change Theory, integration of blended learning strategies and communication skills contributed to the success of this implementation project.
- The current evidence-based practice project demonstrates how new oral hygiene care standards can be developed in concert with key stakeholders to implement best practice standards for care of cancer patients in the treatment and prevention of oral mucositis.
The term ‘mucositis’ emerged in 1980 to describe ulcerative lesions of the oral mucosa in patients undergoing radiotherapy or chemotherapy.1 Oral mucositis refers to mucosal damage and occurs in the oral, pharyngeal, and laryngeal cavities. The signs and symptoms of oral mucositis include erythema, edema, and a burning sensation.2 The erythematous areas usually occur 3–4 days after the chemotherapy infusion.3 The incidence of mucositis, as well as its severity, varies from patient to patient. When oral mucositis occurs, the painful condition can cause difficulties in eating, drinking, and swallowing and may compromise the patient's nutritional status as well as the patient's quality of life.4
According to clinical guidelines, in hematology–oncology patients, oral mucositis occurs in approximately 20–40% of patients receiving conventional chemotherapy,5,6 90% of acute leukemia patients receiving induction chemotherapy, and up to 100% of patients undergoing high-dose chemotherapy for hematopoietic stem cell transplantation.7,8
Different interventions have been investigated that prevent oral mucositis in cancer patients receiving treatment.9 A systematic review indicated that there were interventions that resulted in significant benefits in more than one trial, including amifostine cryotherapy (ice chips), granulocyte-colony stimulating factor, intravenous glutamine, honey, and keratinocyte growth factors.10 They also found that cryotherapy (ice chips) is the most effective intervention to prevent mucositis.10 Based on systematic review findings, standard oral care should include the incorporation of the use of a soft-bristle toothbrush that is replaced regularly, flossing, bland rinses, and moisturisers.11
Observing and recording the signs and symptoms of oral mucositis are an important part of oral care and essential to the prevention and treatment of mucositis. Structured symptom assessment has been shown to result in health professionals having a greater awareness of their patients’ experience of cancer-related symptoms.12 Initial and ongoing assessment of the oral cavity is required and should include professional examination and patient self-reports.13 The National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) system14 (Table 1) is a longstanding empirically developed lexicon and has been widely used as a standard tool for documenting toxic effects caused by cancer treatments in clinical trials. In clinical practice, the use of a suitable assessment tool and regular oral assessment during therapy are critical components of a program to assure maximum oral health.3
TABLE 1 -
Audit criteria, sample, and method for measuring nurses’ and patients’ compliance with best practice
||Methods used to measure % compliance with best practice
|1. Staff education regarding oral mucositis and oral care protocols was conducted
||Nursing staff marked a: ‘Yes’ if he/she received the education or passed and examination (≥90 score)‘No’ if he/she did not receive the education or failed the examination (<90 score)
||Conducting staff surveys and referring to the education record and exam scoresGoal: 100% compliance
|2. Patient education regarding oral mucositis and oral care protocols was conducted
||Patients marked a: ‘Yes’ if he/she received the education‘No’ if he/she did not receive the education‘N/A’ if he/she was not sure that they had received the education
||By checking patients’ medical records or asking the patientsGoal: 100% compliance
|3. Standard oral hygiene care protocols including brushing of teeth were in place for patients
||The auditor checked if all prescribed standard oral hygiene care was given including brushing of teeth
||Auditing and asking the patientsGoal: 100% compliance
|4. Initial assessment of the oral cavity was conducted using a validated tool
||The auditor checked to determine if patients who were admitted or transferred into the hematology–oncology unit received an initial assessment. It was marked as a: ‘Yes’ if the patient received the initial assessment‘No’ if the patient did not receive the initial assessment‘N/A’ if it could not be determined if the patient received the initial assessment
||Checking the patients’ medical records for an initial oral mucositis assessmentGoal: 100% compliance
|5. Ongoing assessment of the oral cavity was conducted using a validated tool
||Based on hospital policy, if patients have no mucositis, the ongoing assessment is conducted before discharge. However, patients with oral mucositis must be evaluated weekly. If there was a weekly assessment it was marked as:‘Yes’ if the patient received the ongoing assessment‘No’ if patient did not receive the ongoing assessment
||Checking the patients’ medical records for ongoing oral mucositis assessment‘N/A’ if it could not be determined if the patient had received ongoing assessmentGoal: 100% compliance
|6. Oral pain was assessed using a validated tool including self-report
||It was marked as a: ‘Yes’ if the patient was assessed for oral pain using a validated tool including self-report‘No’ if the patient was not assessed for oral pain using a validated tool including self-report‘N/A’ if it could not be determined if the patient was assessed for oral pain using a validated tool including self-report
||Checking the patients’ medical record for pain scoresGoal: 100% compliance
|7. For patients with mucositis, therapeutic oral care regimens were in place
||If patients had oral mucositis it was marked as a: ‘Yes’ if he/she received a therapeutic oral care regimen‘No’ if he/she did not receive a therapeutic oral care regimen‘N/A’ if it could not be determined if he/she received a therapeutic oral care regimen
||Checking the patients’ medical recordsGoal: 100% compliance
As oral mucositis is an extremely serious and challenging complication of chemotherapy or radiotherapy in cancer patients, both patients and staff should be educated about it and oral care intervention protocols should be used.11 Patients should be educated on the value of good oral health relative to cancer therapy. Oral hygiene protocols should be provided, which includes brushing and flossing of teeth and rinsing with bland (sodium chloride 0.9% or sodium bicarbonate) solutions.6,7 A clinical practice guideline for the management of cancer-related mucositis indicated that the use of oral care protocols for its prevention had a beneficial effect.6
The evidence-based project was to promote best practices related to oral mucositis prevention and treatment for cancer patients. We implemented an audit and feedback strategy to promote healthcare change and utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI PACES) audit and feedback tool. The project was implemented on four hematology–oncology wards of Taipei Veterans General Hospital which is a large medical center and located in Taipei city of Taiwan. The four wards have 109 beds, mainly for patients receiving chemotherapy or admitted for either autologous or allogeneic stem cell transplantation. In 2017, the average occupancy rate of four wards was 97%, the turnover rate was 3.72, and the average number of chemotherapy infusions was 947 per month. There were 68 nurses on the four wards. To provide a snapshot of the type of patients on the wards, the author performed a medical record review on 4 December 2017. There were 22 patients suffering from oral mucositis by using the CTCAE scale and this showed varying scores. Five patients (23%) had asymptomatic or mild symptoms (grade 1), 12 patients (55%) complained of moderate pain that did not interfere with oral intake (grade 2), and five patients (23%) experienced severe pain that interfered with oral intake (grade 3). To improve quality of life for patients with cancer undergoing chemotherapy, the team expected that the project could prevent oral mucositis in these cancer patients after implementing best practice strategies.
The team implemented the JBI recommended practice for prevention of oral mucositis, which has nine criteria.15 These nine criteria received either JBI recommendation of A or B in which A indicates a ‘strong’ recommendation for a certain healthcare management strategy and B indicates a ‘weak’ recommendation.16 The JBI recommendations include the following:
- (1) Staff education regarding oral mucositis and oral care protocols has been conducted. (Grade B)
- (2) Patient education regarding oral mucositis and oral care protocols has been conducted. (Grade B)
- (3) Standard oral hygiene care protocols including teeth brushing are in place for patients. (Grade B)
- (4) Prior to receiving cancer treatment, dental examinations are carried out. (Grade B)
- (5) Initial assessment of the oral cavity is conducted using a validated tool. (Grade B)
- (6) Ongoing assessment of the oral cavity is conducted using a validated tool. (Grade B)
- (7) For patients receiving cancer treatment, preventive oral care regimens are in place. (Grade B)
- (8) Oral pain is assessed using a validated tool including self-reporting. (Grade B)
- (9) For patients with mucositis, therapeutic oral care regimens are in place. (Grade B)
Since Criterion 4 Prior to receiving cancer treatment, dental examinations are carried out and Criterion 7 For patients receiving cancer treatment, preventive oral care regimens are in place were the responsibility of physicians in our hospital, we deleted those two criteria. Thus, seven criteria were chosen to be used for monitoring the project.
Nursing metrics and clinical observations have consistently identified poor documentation of structured oral assessment of identification of signs and symptoms in the Taipei Veterans General Hospital, thus compromising patient quality of care. The aforementioned JBI recommendations should enable early prevention and treatment of oral mucositis in patients receiving chemotherapy for cancer.
Aim and objectives
The aim of this project was to evaluate current practice and implementation of best practice related to oral mucositis prevention and treatment in cancer patients in the hematology–oncology setting.
The specific aims were:
- (1) To identify and engage a quality improvement project team to promote evidence-based practice for the prevention and treatment of oral mucositis among cancer patients undergoing chemotherapy in hematology–oncology settings.
- (2) To conduct a baseline audit determining current compliance, identifying barriers and facilitators to achieve compliance, and developing strategies to address areas of noncompliance with best practice in the prevention and treatment of oral mucositis among cancer patients undergoing chemotherapy.
- (3) To undertake a follow-up audit to assess the extent of compliance with evidence-based practice on prevention and treatment of oral mucositis in cancer patients undergoing chemotherapy.
The project used the JBI PACES software. The JBI Getting Research into Practice (GRiP) audit/feedback tool was utilized to identify gaps and barriers as well as to design the final implementation plan. The team used the pre and postimplementation audit strategy for data collection. Furthermore, by using Lewin's Change Theory, the leaders implemented downward communication skills to develop GRiP and implementation strategies to improve the quality of care in the prevention and management of oral mucositis. The team also used upward communication skills to invite all nurses to participate in identifying the problems, barriers, and resources related to care of patients to prevent or manage oral mucositis. The current project was conducted in three phases within a period of 4 months, from 1 January to 30 April of 2018. A Gantt chart was used to plan the project activities and timelines.
The current project was considered as a quality improvement project within the Taipei Veterans General Hospital in Taiwan and therefore did not require ethical approval.
Phase 1: Stakeholder engagement, team establishment, and baseline audit
Phase 1 involved establishing a quality improvement project team consisting of various stakeholders in the prevention of oral mucositis in cancer patients undergoing chemotherapy. The team members were engaged early in the process to identify the setting and sample size and to conduct the baseline audit.
Establish the project team
The project team included two supervisor nurses, two head nurses, and two assistant head nurses. The members of the team were invited to participate in the project on the basis of their clinical expertise, quality improvement experience, positive attitude of evidence implementation, and the ability to engage others with change on their wards. Two supervisor nurses acted as coleaders of the team. They were responsible for project coordination, process control and promotion, strategy development, data analysis, protocol, and report writing. The other members of the team were two head nurses and two assistant head nurses who were responsible for preparing educational materials such as videos, handbooks, and presentations. They were also in charge of data collection and education implementation.
Identifying sample size and audit criteria
The current project conducted a preimplementation audit of 30 nurses and 30 cancer patients who were receiving chemotherapy. The audit criteria shown in Table 2 were the foundation for our audit tool (Appendix 1).
TABLE 2 -
Getting Research into Practice matrix
|1. Only 40% of nurses had received education about SOP to prevent oral mucositis or the use of oral care protocols
||Provide training sessions about SOPConducting educational programs on prevention of oral mucositisDeveloping a video on implementing oral hygiene
||Prevention of mucositis guidelineLocal SOPSelf-learning videos about oral hygieneAccess to computer
||Number of staff receiving education about SOPMeasured by attendance rates of nurses in education session training sessions
|2. Only 23% of the patients were familiar with prevention of oral mucositis or oral care
||Delivering education within 24 h after admissionRevising handouts related to oral care
||Printing of handoutsEducational packagesAccess to a computer
||Patients receiving education about oral careMeasured by the percentage of patients receiving oral care education
|3. There were no specific and standardized oral hygiene audits
||Develop an oral hygiene audit formConduct an oral hygiene audit
||Staff timeDesigning of a audit formPrinting of audit forms
||Staff receiving the course of introduction of the oral hygiene auditsMeasured by the nurses attending the course of introduction of the oral hygiene audits
SOP, standard operating procedures.
Conducting the baseline audit
All of the team members, except two supervisors, participated in the data collection process that included direct observation, asking the patients, and reviewing nursing documents along with checking the medical records. The supervisor nurses were responsible for data analysis and process control. Our team conducted the preimplementation audits for 2 weeks from 1 January to 14 January 2018 during which 30 nurses were assessed on their knowledge of the prevention of mucositis, and 30 patients were audited on whether or not they had received the standard oral hygiene care protocol (Table 1). The leader entered the data into the online JBI PACES program and generated the results.
Phase 2: Design and implementation of strategies to improve practice (Getting Research into Practice)
Our team adopted the Lewin's Change Theory17,18 which is a bottom-up approach to implementation planning by presenting the preimplementation audit results to the ward staff. Phase 2 was conducted over 10 weeks, from 15 January to 31 March 2018. The project team analyzed the data for criteria that did not achieve 100% compliance. Lewin's Change Theory17,18 indicated that before the change, we needed to assess the driving and restraining forces. Lewin's Change Theory includes three steps: The first stage is to ‘unfreeze’. The goal of this stage is to have all of the nurses come to understand the importance of prevention and management of oral mucositis in cancer patients undergoing chemotherapy. Group meetings were held to discover the nature of the problems and to brainstorm for ideas to increase compliance with oral care. Barriers to change, possible resources to overcome them and strategies to improve compliance with best practice were identified by discussing the audit results with project team members. Furthermore, team members pointed out the evidence of assessment and management of oral care to the four wards to inspire staff awareness of importance and urgency of making a change in routine oral care. Lewin's second stage is ‘change’, which refers to transitioning into a new reality. Team members developed the change action plan, and then senior nurses from four wards were invited to participate in the discussion and final decision making of the GRiP strategies. The third stage is to ‘become refrozen’, which refers to implementing the GRiP strategies into daily routine care.
Phase 3: Follow-up audit post implementation of change strategy
Following implementation of the evidence practice project for prevention and treatment of oral mucositis, a follow-up audit was conducted 4 months later. Fifty nurses on the four hematology–oncology wards and 50 patients admitted to hospital to those units during the follow-up period were involved. The follow-up audit was conducted using the same evidence-based audit criteria as those used in the baseline audit. The postimplementation audits were performed from 1 April to 14 April 2018.
Phase 1: Baseline audit
The results of the baseline audit (Fig. 1) demonstrated that there were four criteria which had good compliance (over 80%). There was 96% compliance rate with Initial assessment of the oral cavity is conducted using a validated tool (Criterion 4). A compliance rate of 97% was found for Ongoing assessment of the oral cavity was conducted using a validated tool (Criterion 5). A total of 97% of patients were assessed using a validated pain scale. For patients with mucositis, therapeutic oral care regimens are in place (Criterion 7) had an 88% compliance rate. Poor compliance was found for three criteria. There was only 40% compliance with Staff education regarding oral mucositis and oral care protocols has been conducted (Criterion 1). Compliance with Patient education regarding oral mucositis and oral care protocols has been conducted was only 23% (Criterion 2). Compliance with Standard oral hygiene care protocols including brushing of teeth are in place for patients was 27% (Criterion 3).
Phase 2: Strategies for Getting Research into Practice
The main barriers, strategies, resources, and outcomes that were identified are presented in Table 2. Strategies to overcome barrier 1, Only 40% of the nurses had received education about standard operating procedures (SOP) to prevent oral mucositis or the use of oral care protocols, included providing an educational program for all nurses on the four wards. The educational program developed by two head nurses and two assistant head nurses included education materials on prevention of oral mucositis and a video on how to provide oral hygiene. Throughout, the blended learning method19 included face-to-face teaching, self-directed learning using a DVD about oral health, and using tooth models to demonstrate how to brush teeth.
Furthermore, training sessions were provided about SOP for oral care. The resources required were the local SOP, self-learning videos, and access to a computer. The outcomes were that all staff received education about SOP and that they completed the self-learning videos related to oral hygiene care.
To address barrier 2, Only 23% of the patients were familiar with prevention of oral mucositis or oral care, education was provided for patients within 24 h of their admission using a revised handout about oral hygiene care. The resources required included the printing of handouts, an educational package, and access to a computer for patient education about prevention of oral mucositis and oral hygiene care. The outcomes were that all patients received education about oral care.
To overcome barrier 3, there were no specific oral hygiene audits. The strategy was to develop an SOP of oral hygiene care and an oral hygiene care audit checklist to be used by all patients hospitalized for chemotherapy treatment. The necessary resources were staff time to implement the clinical audit, designing the checklist, and the printing of the checklist. The outcomes were improved compliance with data collection.
Phase 3: Follow-up audit
The post implementation audit on 50 nurses in the hematological-oncology wards showed good compliance. The results of the postimplementation audit are compared with the preimplementation (baseline) audit in Fig. 2. One hundred percent of the nurses had received education regarding oral mucositis and oral care protocols, which was a significant improvement over the 40% compliance rate at baseline. Using Criterion 2, Patient education regarding oral mucositis and oral care protocols was conducted, the audit showed a 98% compliance rate, which is a huge improvement over the 23% compliance rate at baseline. The audit of Criterion 3, Standard oral hygiene care protocols including brushing of teeth were in place for patients, showed a 96% compliance rate, which is a large improvement over the 27% compared with the baseline. Criteria 4, 5, 6, and 7 concerning initial and ongoing assessment of the oral cavity, oral pain assessment, and oral care regimes achieved compliance rates of 96, 100, 98, and 100%, respectively, which demonstrates continuing good compliance.
The findings of this project showed improvement in several criteria: nurses who received education about oral care protocols increased from 40 to 100%, patients who received education about oral care protocols increased from 23 to 98%, and patients who followed oral hygiene care protocols, including brushing of teeth, increased from 27 to 96%.
Based on Lewin's Change Theory, blended learning strategies and communication skills were integrated, which contributed to the success of this implementation project. This project provided education for nursing staff and patients regarding oral hygiene care through using a blended education strategy and also provided a standard audit tool for ongoing monitoring of care. We successfully used evidence-based knowledge to prevent and treat oral mucositis in patients receiving chemotherapy. Clinical guidelines indicate that the use of oral care protocols should include patient education in an attempt to reduce the severity of mucositis from chemotherapy or radiotherapy.8 As nurses are the health professionals who provide oral care for patients to prevent and treat oral mucositis, the project team determined nurses would be trained before teaching the patient regarding oral hygiene care. The project team conducted a patient education program which included using soft-bristled brushes, the timing of brushing, proper brushing techniques, and an oral mucosa assessment. The team members, using an audit checklist, confirmed that the patients could perform oral care independently.
The first improvement of this project was related to Criterion 1 which showed a 60% increase over baseline in compliance with the education of staff. As this information became available, a training program regarding oral hygiene was implemented for all nursing staff and a pamphlet was created for them to use as a reference when providing education for patients. We required the training program about oral hygiene care in the form of a self-directed learning packet to be completed by all nurses who were new to the hematology–oncology unit.
The most improvement was found with Criterion 2 which concerns patient education regarding oral mucositis and oral care protocols. At baseline only 23% of the patients were educated about oral mucositis and oral care protocols, while post intervention 98% had been educated about them, demonstrating a significant improvement of 75%. As this information became available, a standard operating procedure was created and all of the nursing staff now provide education on mucositis prevention for patients undergoing chemotherapy.
The third improvement is related to Criterion 3 which is about brushing of teeth, which showed an improvement of 69% above baseline. Although in the past the staff educated patients who were receiving chemotherapy on the importance of preventing oral mucositis, the patients were not actually taught how to do it for themselves. So now, the staff provide oral hygiene guidance for patients so that they can carry out this procedure on their own.
Three factors contributed to the success of this project, which included leadership, communication, and education. Related to the first success factor, the leaders of the project included two nursing supervisors, two head nurses, and two assistant head nurses. Based on Lewin's Change Theory17,18 the leaders developed GRiP and implementation strategies to improve the quality of care in preventing and managing oral mucositis. Furthermore, in this project all nurses could participate in the decision making related to development of GRiP strategies. To that end, the team invited all nurses to participate in the project and to provide input from their own knowledge about how to decrease mucositis in cancer patients undergoing chemotherapy. All of the nurses participated in identifying the problem, barriers, and resources, as well as making the action plan and monitoring the compliance of each evidence criterion. Bottom-up strategies seem to have inspired nurses to participate in the project.
The second factor was good communication about the project. In this study, four types of communication were provided.20 By using the downward communication skill, the team leaders introduced the project to the members, highlighting the importance of the recommended practice, which contributed to excellent teamwork in the oncological area. All of the nurses openly expressed concerns about implementing the project in terms of barriers or difficulty (upward communication). The quality improvement committee from the hospital provided consultations to overcome the barriers and provided resources for the project (lateral communication). Furthermore, open discussion among team members and with all nurses regarding the evaluation of preaudit, setting up the goals of the projects, and supporting each other were performed (diagonal communication).
The third success factor was using blended leaning strategies in education. Enhancing knowledge that staff members had about prevention of mucositis in patients receiving chemotherapy increased their confidence and clinical autonomy. The blended learning method which includes face-to-face teaching, self-directed learning about oral health, and using tooth models for demonstrating teaching and learning methods enhanced the learning experience.
There were some challenges encountered with this project. The first one was that not all nurses of the four hematology–oncology wards could participate in the classroom education, because some nursing staff worked on the night shifts. To overcome this barrier we developed a self-directed learning packet. The second challenge was that it was the project team member's responsibility to check whether the patient could perform oral care by themselves correctly, but team members also had their own daily workload or they might not have been on duty. Therefore, to overcome this barrier we trained two audit members on each hematology–oncology ward to ensure that audits could be completed. Through the implementation of these two strategies, the project was effectively implemented among those cancer patients receiving chemotherapy or radiation to prevent and treat oral mucositis. The small sample size of the project was a limitation. In the future, this best practice implementation project should be more widely used for all patients to prevent and treat oral mucositis when they are undergoing chemotherapy, and keep an ongoing clinical audit.
The evidence-implementation project successfully used a clinical audit and feedback process integrating change theory, leadership communication skills, and blended learning methods to improve nursing practices related to the prevention of oral mucositis in cancer patients. The project demonstrated that using a variety of strategies, such as an effective training program, utilization of multiple education materials for nurse self-directed learning, and development of an evidence-based checklist for ongoing regular audits about oral care for the patient could facilitate implementation of best evidence into clinical practice to prevent and treat oral mucositis for patients undergoing chemotherapy or radiation.
The authors express sincere appreciation to the Oncology Centre staff members, Taipei Veteran General Hospital, for the Strategies into Practice.
Conflict of interest
The authors report no conflict of interest.
Appendix I: Audit tools
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after cancer treatment. Int J Cancer Manag
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in cancer patients and clinical practice guidelines. Support Care Cancer
2019; 27:3949–3967. doi:10.1007/s00520-019-04848-4.
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in patients receiving chemotherapy. J Clin Exp Dent
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18. Shirey MR. Lewin's theory of planned change as a strategic resource. J Nurs Adm
19. Boelens R, De Wever B, Voet M. Four key challenges to the design of blended learning: a systematic literature review. Educ Res Rev
20. Sullivan EJ. Effective leadership and management in nursing. 8th ed.Boston:Pearson; 2012.