Enhancing Oral Health in Frail Elderly

Introduction:

Oral health is important to overall health and wellbeing. Poor oral hygiene can be harmful and negatively affect the individuals (Public Health England, 2017). Reflecting on the National Health Service (NHS) significantly aim to meet the population health needs, while constantly reviewing the change and improvement. This Literature review will analyse and discuss the features that involve service improvement through change management as per Lewin (1951) to improve oral health among the frail elderly. It will also adhere to the local and national guidelines which further influence nursing care by using evidence-based practice.

According to Samone et al., (2013), oral care is an essential part in nursing care practice and is often missed due to lack of importance. In this piece of work, several oral health primary research papers would be discussed and analysed to enable a successful service improvement plan intending to improve the patients experience by using the health care services. The change management idea will enlighten the challenges and progress of future improvement by highlighting the role of the NHS management and leadership for a delivery of compassionate and high-quality.

Background:

The United Kingdom (UK) has been conducting a national dental survey every ten years since 1968, which enabled them to estimate the adult population dental health and how it has changed over the years (National Health Service Digital, 2011). The UK is an aging population with estimation of 20% of the population. A projection for England population estimates that, share of people aged 65 or above by mid-2028 will increase almost everywhere (Office for national statistics (ONS), 2018). There is a correlation admit aging and tooth loss. A 2009 survey by ADHS said that, more than 5% of adult over the age of 55 experience oral health problems (Adult Dental Health Service (ADHS), 2009). The world is undergoing a fast-aging population and it is forecasted for statistics to grow in the next coming years (Rowland, 2012). Aging is associated with greater risks of physical, cognitive and medical ailments requiring assistance with personal care such as mouth care. Studies show that, there is a direct link between oral health and general health (NHS Great Ormond Street Hospital, 2018). Clegg et al. (2013) stated that, poor oral care may cause complaints and health issues resulting into morbidity and mortality. Clegg et al. (2013) further highlighted the factors, which hinders adequate oral care that are disability, restricted access to oral health care, dependency and frailty as a result of aging. Higgs and Gillard, (2016) added, frailty has remained poorly defined for years. However, Veronese (2020) defined frailty as a physiological deficit, characterised by dependency, cognitive and functional impairment.

As aforementioned, the challenges of ill health and frailty of ageing will result into a pressure on the healthcare services. This is supported by Webb et al., (2013), and the trends show that, senior citizens are more likely to face health challenges, and this will increase the toll on the health services. Those ill health challenges are the onset of ageing related health conditions. Some studies found that, inflammation and onset of aging related diseases. However, the innovation of oral health care development in the last few years have increasingly reduced the number of adults, suffering with tooth related issues (Muller et al., 2017). The statistical rise in elderly people with oral health issues such as (substantial tooth wear, caries, periodontal disease and implants requirement) is obvious. Hence, that classifies them as patients requiring curative and prophylactic health care. Terezakis et al., (2011) added that, hospitalisation greatly contributes on poor oral hygiene. Furthermore, it has also been known that, medical conditions that require oxygen and nil-by-mouth, medications side effects and weight loss contribute to increasing complications susceptibility. Health Education England, (2021) opined that, poor oral care among elderly and frail patients may result into eating and drinking difficulty, which may lead to deficiency in nutritional intake and infections like pneumonia or even death. This was supported by Shwe et al. (2019) study that found potential association poor oral health and malnutrition, resulting into severe health issues and quick deterioration.

Oral hygiene should not be limited to nurses only. While nursing staff is in a perfect place to assist in oral care among the functionally dependant and frail elderly in clinical areas because they spend more time with them than other Multidisciplinary team. It is a responsibility of all healthcare staff to ensure that patients receive adequate oral care (Huber, 2014). However, there are factors hindering due to staff lack of knowledge, inadequate training and patient’s unwillingness. This was supported by the Health Education England (2021) stating that: Deficiency in skills and knowledge of oral health hinders the accomplishment of adequate oral hygiene. Therefore, Health education founded a project called Mouth Care Matters with the aim to improve Oral hygiene of inpatients adults. The initiative will up skill nursing staff and other MDT to support vulnerable adults with oral hygiene, through training. Salamone et al., (2013) support this by arguing that oral care and its importance is one of the basic skills nurses are thought from the start of their training. However, patient’s resistance to oral care may discourage the nursing staff from assisting and prompting oral hygiene (Featherstone et al., 2019)

Thus, there is a divergence among nursing staff’s, aiming to enhance oral care and patient’s compliance to oral hygiene (Featherstone et al., 2019). This makes it indispensable for further training and staff education in optimising oral health. As per Veronese (2020), oral health related problems will continue so significantly arise and negatively impacts on the elderly and frail patient’s health and quality of life. Consequently, authors of nowadays got inspired to explore areas requiring care improvement for the frail and elderly inpatients, which entail a prompt response from the care providers, researchers, local and national policy makers. Therefore, service improvement plans should analyse recent research literature and review evidence-based practice.

Search strategy:

In order to find relevant literature, a search strategy was conducted (Refer to appendix A), by using key words that were entered in different electronic database engines. This was done to maximise the search results and as per Polite and Beck, 2017, different database may produce different results. A collective index to Nursing and Allied Health (CINAHL) and MedLine were utilised to gather academic literature for the chosen topic. Initially the search was Mouth care OR Oral care OR Oral Hygiene OR Oral Health AND Frail Adults OR Elderly Patients AND Hospital OR Acute Setting OR Inpatient in MedLine and this generated 543 results and CIHAHL generated 3,123 this shows that this subject is wide and common. Therefore, an additional criterion was added to avoid prejudice and set boundaries (Aveyard, 2019) for disqualifying irrelevant literature in both databases. The filter involved academic data, published in the UK and Ireland USA, Australia, Europe; English Language; Years 2011-2021 by using the Boolean operators like AND/OR. Search strategy was narrowed and specific (Polit and Beck, 2017).

Critiquing Tool:

To critique and analyse the research critiquing tools were used to appraise the chosen literature (Refer to Appendix B). The critical appraisal skills programme (CASP) (2018) for quantitative and qualitative studies, which enabled an insight into validity, usefulness and reliability of the results. This enables people with less research experience to have an idea of the research question (Aveyard, 2019). This gives an answer to a research question (Hong et al, 2018). It is vital to review and criticise research in to match up with rigour of scientific method validity and value (Aveyard, 2019). A critiquing tool enables the individual to understand if the questions are relevant to the design or not. Therefore, after critiquing, the literatures using CASP some similarities were drawn and these enabled to critically analyse the papers and this proved their validity.

Literature review:

Analysing and appraising the literature draw to a comparison of five research studies (Polit and Beck, 2017) are discussed through a straightforward method as per Aveyard (2019). The main discussion was based on improving oral hygiene among elderly and frail patients. Oral health becomes a wider problem in the UK. Therefore, it is worth looking into research conducted about other countries. This will further enable us to know how some other countries have been able to successfully tackle this issue.

According to Maeda and Mori (2020), oral health is important to maintain overall health. Therefore, assessing oral cavity is vital and aid in early detection of any potential oral problems and this will enable timely management and assess progress (Rohr, 2012). Similarly, evidence has shown that, there is a correlation between poor oral health and mortality in acute hospitals as a result of infection and pneumonia (Maeda and Mori, 2020). This was supported by Bakhtiari et al., (2018) where some studies found that, the patients in acute and rehabilitation care experience poor oral professional. There is an accumulation of dental plaque among elderly patients in hospital (Ewan et al., 2016). This resulted in increased mortality rate. Hence, a cox’s regression analysis for OHAT> 3 mortality demonstrated (Index ratio P = 00.012, odds ratio: 2.514, 95%, confidence of interval 1.220-5.183). Maeda and Mori (2020) study found that, over 80 years, the adults were malnourished as a result of oral problems while in hospital. They use an Oral Health Assessment Tool (OHAT) to investigate oral health in an acute ward, compromised of lips, gums, saliva, tissue, oral cleanness, dentures, natural teeth, dental pain and tongue. Furthermore, the study included nutritional status, -morbidities, cognitive status and activity of daily living. Previous investigations demonstrated 12% of inpatients died within 60 days of hospitalisation, had the poorest oral health (Maeda and Mori, 2020). Therefore, the idea of this study was born with sufficient time and appropriate participants for more reliability of results. After investigating the connection between lack of adequate oral hygiene and mortality, the findings were, 1- Poor oral health could predict mortality of inpatients adults. 2- Individuals with inadequate oral health are more likely to elderly, frail, cognitive, physically dependent, and malnourished (Maeda and Mori, 2020).

Schuler et al., (2021) confirmed that oral hygiene is vital in maintaining patient’s general health. Maeda and Mori, (2020) investigated the correlation between poor oral health and mortality among frail and elderly adults. Ewan et al. (2016) further investigated the prevalence of frailty in community-dwelling elderly populations with dental problems. The study concluded that, there is a relation between frailty in geriatric inpatients and elderly patients tend to have poorer self-reported oral health. Thus, the study created bias response (Polit and Beck, 2017). In Any Case, it could be argued that, the findings of the study cannot be generalised to populations with other factors of aging, sampling method and sample size (Parahoo, 2014).

A qualitative study performed by Chebib et al. (2020) examined the knowledge, perception and perceived barriers of caregivers lack of good oral health and general health. The study demonstrated that inpatients poor oral health is related to reduce ADL, aging and malnutrition. Supported by Niesten et al. (2017), where they identified barriers to oral hygiene as follow, low energy, and lack of support, physical and cognitive impairment. Parahoo (2014) conducted an open-end interview to adopt purposive sampling adaptability as per the subject. This sampling method supports the researchers in choosing the participants with desired quality for the study purpose. A semi-structured questionnaire consisting of 152 caregivers was developed in an elderly ward and further investigated the delivery of dependent and independent patient’s oral care (Chebib, 2020). Unlike Maeda and Mori (2020) study, Chebib (2020) findings did not present deeper insight in different ways through which poor oral health might be fatal to the patients. Supported by Steel (2017), who highlighted factors affecting optimum oral health that are: impaired dexterity and mobility, lethargy, disorientation, chronic pain, poor memory, psychological frailty and lack of support as factors. (Niesten et al., 2017) added that there should be alertness to poor oral health indicators among healthcare staff. Compassion is essential in building relationship and trust between the patients and nurses (Yoon and Steele, 2012). This could increase patient’s adherence and nurse’s willingness to support effective oral care.

A study conducted in an acute geriatric ward found that, oral health could be improved in a 7-day period with one time daily oral care with oral health therapist (Gibney et al., 2019). The study further found 76% of 575 patients on admission had a poor oral health. An Oral Health Assessment Tool was utilised (OHAT) to perform oral health assessment, which found that, the patient’s oral cleanliness was unhealthy ranging with evident plaque, tartar and food particles in different parts of the mouth. On the 7th day 206 were reassessed and 73% (149) of those stayed poor oral health range and the remaining 62% (127) had the same score as on admission. This proves that, inadequate oral health is frequent among the elderly inpatient wards and does not improve in 7 days. Gibney et al. (2019) further claimed that, a bigger proportion of elderly patients during admission are found to have a poor oral health which does not improve within a 7-day period in a ward setting. However, Gibney et al, (2019) confirmed in their discussion that with once-daily oral routine performed by the oral health therapists (OHT) could improve geriatric inpatients within a seven-day period. It could then be concluded that, if the nurses are supported by the (OHT), they could also achieve similar or even better results within the same time frame. Gibney et al, (2019) reiterated that, nurses oral health improvement plan was previously based on minimal oral training consisting in denture cleaning, tooth brushing and care resistance management but not direct support from (OHT) which could make a significant impact in goal achievement.

Schuler et al. (2020) evaluated patients ability to perform their own oral care independently geriatric ward using a simple test timed test for money counting (TTMC) and Shoulder motion by griping the back of the neck (NG) that served as a predictor for patient autonomy to perform effective denture cleaning and tooth brushing. Furthermore, Schuller et al. (2020) considered issues related to fine and gross motor skills along with cognitive and visual impairment and recorded accordingly. The investigation found that, out of 74 patients involved in the study, 66.2% were able to perform oral hygiene independently. There was a weak correlation between the required time to complete the test and plaque reduction on teeth (Schuler et al., 2020). It was shown problems, occurred while performing TTMC was mainly associated with less plaque for the patients with visual and cognitive impairment. Schuler et al. (2020) stated that, less plaque removal were observed with cognitively impaired patients. Schuler et al. (2020) concluded that, TTMC&NG is an effective tool enabling prediction of elderly and dependant patient’s ability to autonomously perform oral care. This would also help geriatric staff to identify the patients who are not able to carry out oral care independently and required assistance that would then be provided. This will enable the staff to effectively manage oral health issues and reduce its impact.

In contrast to the above study, Horne et al, (2014) investigated organisation's experiences and practice oral hygiene 11 stroke units in Greater Manchester area. One quantitative mixed method case study consisting of cross sectional survey to determine oral hygiene provision in stroke units. The second one was a qualitative study that aimed to interview stroke unit staff and stroke survivors to explore experience, perceptions of barriers hindering effective oral care (Horne et al., 2014). It was found that, 72% of the 11 stroke units did not have any oral hygiene protocol. There was a 100% had no training provision for staff among the 11 units. Only two (18.2%) out of the 11 units used an oral assessment tool and only seven (63.6%) had a specific nursing plan for oral hygiene (Horne et al., 2014). This clearly suggests that, dependant adult always face oral health issues due to their physical and psychological impairment (Gibney et al., 2019). Participant reported various issues around oral hygiene in stoke units that are neglect, lack of awareness, lack of information and advice. However, focus groups with healthcare professional argued by stating “Healthcare professional are aware of the impact of poor oral health and are able to demonstrate adequate knowledge of the need of good oral care” (Horne et al., 2014).

Change management :

As discussed in the literature review, it is evident that, there is a need for a service and improvement plan. This makes mandatory to raise responsibility, knowledge and attention towards oral health issue in healthcare staff and empower them to carry this task (Schuler et al., 2021). The focus should be on inpatients elderly and frail adults requiring support in performing ADL (Veronese, 2020). As per the Nursing and Midwifery Council (NMC) 2018, the nurses are required to complete an A-E assessment of patients during admission. Another extensive systematic review demonstrated that hospitalised patients could face serious oral infection leading to aspiration pneumonia or even death if they miss an initial oral assessment during admission Maeda and Mori (2020). Furthermore, an oral plan on admission might result in more favourable oral health outcomes, maintenance and oral disease detection (DH, 2010; Health et al., 2011).

All registered nurses and nursing associates are expected to always maintain evidence-based practice for a safe and effective care delivery (NMC, 2018). This was further argued by Van Bogaert and Clarke (2018) that, emerging evidence is only achieved, if there is a corresponding change in practice guidelines. As such, Steel (2017) added that, there is requirement of philosophy change combined with oral hygiene as a key element in holistic care. Implementing change will enhance the quality of care that patients receive (NHS England, 2016a). This will contribute on tackling oral problems, being faced by the elderly and frail people. As per Lewin (1951), systems are always striving to obtain equilibrium, which is a balance change and restrain. Hubber (2014) opined that, for change to happen a clash between the forces that promotes change and forces inhibiting change and the restraining force should go out of there comfort zone. Hewitt-Taylor (2013) supported this by suggesting that, change takes place when the driving forces are outweighed by the resisting forces Therefore, three stages of change were identified that are unfreezing, changing and maintaining. This has been the foundation of much change theories since the classic models (Cummings, Bridgman and Brown, 2015). Lewin’s theory is an ideal model for quality and service improvement plan to develop a successful organisation (Burnes, 2017). This change theory aims to create a sustainable change within an organisation by modifying its process and culture (Burnes and Cooke, 2012). A successful change is the one that empowers the followers (Northouse, 2019). Accountability, authority, and effective decision making further empower the nurses to change and they are beneficial to lead the changed practice within the healthcare system (Huber, 2014).

As per Lewin (1951) the first step of change is the unfreezing stage. This will enable the participants to measure and know the reliability of the plan and manage as required. The change management theory will allow identification of resistance factors and clearly picture of required outcomes. This shows that, change is acquired through involvement and participation. This would last if the third stage of change has been implemented and successful. This is the refreezing stage with the aim to sustain the change (Lewin, 1951; Burns, 2017). Organisational equilibrium is maintained through implementation of change (Cameron and Green, 2012).

According to the NHS England, (2016a), the change model has been the reflection of quality improvement in the healthcare system for years and could enhance nursing practice and values. Furthermore, Lewin’s (1947, 1951) change model could reflect the nursing ethics and problem solving method. This implies that, change is part of nursing process because the unfreezing stage is considered as the identification of a required service improvement plan. The second stage is the change process, which is the implementation of the identified service or quality improvement. Lastly, the refreezing stage is the process in which the project management will evaluate the outcomes that have been met by auditing and find ways to make them sustainable. Thus, organisations spontaneously strive for equilibrium. This makes the unfreezing stage more frequent as organisations face disequilibrium due changes in the environment such as climate change, aging population and technology disrupting its status quo (Hayes, 2018).

Change influences followers and unsuccessful attempts of change could negatively impact judgement of change. This makes it crucial for change managers to adopt an effective theory for change management (Kotter, 2012). This could be achieved through effective leadership. Doran (1981) supported by Clutterbuck and Spence (2016) outlined a goal setting, which suggests that, targets should be measurable, assignable, realistic, time-related and specific. (Refer to Appendix C). In This context, the unfreezing stage is the process of mentally preparing the followers for change through motivation (Huber, 2018). This closely reflects transformational leadership quality that is intelectual stimulation, where the leader utilises intelligence to strategize by using skills to motivate the followers to share their vision through inspirational motivation (Northouse, 2018). This makes it essential in understanding the benefit and importance of change (Hayes, 2018). Change within the healthcare system aims to increase the likelihood of desired health outcomes which is quality as defined by the US institute of Medicine. In regards to change and quality improvement this literature aims to improve oral health which is crucial in holistic care as per British Dental Association (2020). Other NHS governing bodies also set some guidelines for best practice qualifying oral care as a key component to holistic and general health NMC (2018); Public Health England (2017); Royal College of Nursing (2016).

Thinking of change and improvement can enhance inclusion and acceptance of adequate oral hygiene of impatient care. Inclusion of oral hygiene in curriculum training of healthcare Professionals (doctors, nurses, healthcare assistants and other healthcare allied professional having frequent patients contact). The training should make the use of assessments tools and care plans standardise. In addition, the NHS governing bodies should design recommendations of effective oral care using assessment and management tools. It is also very important for the medical and dental to work hand in hand by being more proactive. However, Chalmers et al., (2009) argued that, despite the publication of various oral health screening tools, none of those was particularly designed for older inpatients and empowering. This is supported by the Department of Health (2014), which suggests that, the patients should be included and empowered regarding their oral image and health during screening.

After focusing on teamwork and relations, the service improvement plan responsibility was shared within the team and everyone was involved in decision-making, which is challenging because of different skills, goals and motivations (Huber, 2018). This would be achieved, if team working skills is taking is rigour, team input would produce a draft on project management to improve the service rather completely switching. Furthermore, Huber (2018) added that, a supportive work environment facilitates nurses’ job satisfaction through positivity and cooperation. This further suggests that, the leaders with vision do not solely rely on charisma but also on their interpersonal skills. It could therefore be concluded that creating change with consideration will make staff and patients adaptation to change less overwhelming (Schultz, 2010). The same method could be applied to this service improvement plan. If the oral care plan is patient centred, this would enable the staff to assist, prompt and empower patients effectively covering (frequency of recommended care, required level of assistance and right hygiene method to be used). Additionally, frequent meeting should be organised to reassess the care plan as our aim is to help patients get better rather than make them dependant. This could be done by considering staff opinion through communication. Team opinion is crucial in nursing (Standing, 2017). NHS England’s core values include communication as the key to successful relationships and effective teamwork. Huber (2018) added that, respect, trust and empathy create and foster effective communication. Meanwhile, ineffective communication may lead to conflict within an organisation (Yoder-Wise, 2003).

The NHS Improvement (2017a) recommended the staff to embrace the advantages of positive aspects that change would bring. The restraining forces would try to influence the advancement by favouring the status quo. However, with an effective teamwork and communication the driving forces would act and promote change (Cummings et al., 2015). Furthermore, supporting team through participation, encouragement and reflection is beneficial. According to Gopee and Galloway (2017), leaders enhance team performance through motivation. Northouse (2014) outlined the importance of by emphasising the democratic approach, enabling both follower and leader to be independent. The democratic leadership style focuses on teamwork and relations. Here, the leader shares responsibility with their followers and involves everyone in decision-making, which is challenging because of different skills, goals and motivations (Huber, 2018). A transformational leader’s qualities are supported by the NMC Code (2018) requirements to prioritise people, practise effectively, preserve safety and promote professionalism and trust. Implementation of change requires more reinforcement and motivation from throughout the project to achieve a desired outcome (Parkin, 2009).

The last stage of change mode is the refreezing step which aims to change staff behaviour regarding the vision of the service improvement plan (Lewin, 1951). According to Bess and Dee (2012), during this stage, the staff will familiarise with the plan that changes their values, attitude and belief in favour of the change. Integration of change is better than incorporation in bringing about change into nurse’s work (Hayes, 2018). A workable plan should be in place to achieve a desired and sustainable change such as appointing champions. These champions will follow up the issues concerning oral care and training for new and upcoming staff (Miegel and Wachtel, 2009; Manchester et al., 2014). A nominated person would take responsibility to follow up effective oral care for patients and documentation. It is also recommended that hospital should appoint oral health manager under the dental hygienists (Theile et al., 2016).

Barriers to change:

In every change process there is restraining forces that would try to resist the change. However, change is known to have driving forces that outweigh restraining forces for change to happen. Resistance happens in many ways and may vary from adaptation, staff and environment (Lumbers, 2018). Burns, (2017) argued that, change could result into failure when resistance surpasses its driving forces. This is supported by Hewitt-Taylor (2013) who stated that, staff conformability with current and regular practice may lead to reduced confidence. The NHS Improvement (2017b) pointed out factors that may hinder change with the healthcare system that are financial and technical factors making it difficult for the NHS Organisation to control change. Change might be left incomplete due to resistance to new document (Hewitt-Taylor, 2013). This is because that the staffs are less motivated to complete new documents as they are more comfortable with the old documentation and they feel more familiar with it. An example of this is Mid Staffordshire’s issues with patient safety due to poor leadership, which was highlighted by the Francis Report (2013). Therefore, the health services required change leaders, project managers and champion's position that would try to positively impact the staff and make change sustainable. According to Lister et al. (2015), clinical decisions must be based on the principles of best practices of nursing values and ethics. She considered the Mental Capacity Act (2005) and assumed that the patient had full capacity. This shows that, she empowered the patient, explained the procedure and gained consent. Ashtons Legal (2019) lists five principles of the Mental Capacity Act 2005:

1. Presumption of capacity

2. Support in decision-making

3. Unwise decisions

4. Best interests

5. Less restrictive option

Recommendations:

In order to maintain adequate oral health further research is required. This will aid in developing the plans and actions that promote and protect elderly oral health (NICE, 2016b). This involves oral health assessment in admission using tools, mouth care plans stating level of required assistance and type of mouth care, daily mouth care type of toothbrush, denture cleaning product and how many times daily, Care staff knowledge and skills by knowing the importance of elderly oral health and its complications. Good oral care could be achieved through effective team working skills. It is essential to value team working and collaboration with the MDT for change to happen. Blane (2017) added that, the leaders should value cultural transformation by being good role models, standing by commitments through consistency, building trust and valuing collaboration for a successful teamwork. It is also recommended by the NMC, (2018) that, the nurses should always maintain an evidence-based practice for a safe and effective care delivery.

It is crucial to develop oral care in elderly care units across the healthcare system. For achieving an effective oral health the NHS should make sure that there are enough resources and adequate staff training and empowerment. According to Lumbers, (2018) Effective leadership will accommodate fast transformation and reduce the risks of restraining forces power. According to Jones and Bennett (2018), Transformational Leadership connects the hearts and minds of a team with the aim of achieving satisfaction through motivation. In TL, the leader acquires power through understanding and trust rather than direct control. This enables change within organisations. Transformational leadership theory was described by Nothouse (2019) as an autocratic leadership style because these leaders led by example for a long lasting change for better patient’s experience. Clinical trials and research around oral care concluded that, service improvement could be strengthened through effective communication (Barr and Dowding, 2019). Effective leadership qualities should closely reflect Jane Cummings’s 6Cs (2012 cited in Ellis, 2018) and NHS England (2012) that are care, compassion, communication, competence, courage and commitment. A transformational leader’s qualities are supported by the NMC Code (2018) requirements to prioritise people, practise effectively, preserve safety and promote professionalism and trust.

Conclusion:

Oral care is an indispensable skill in nursing practice. Nevertheless, it is not considered as such. Some studies confirmed that nurses have a knowledge about the importance of mouth care within elderly and dependant inpatients. However, only their knowledge might not guarantee good oral practice due to conflicting evidence creating a gap in nurses oral care practice in different clinical settings. It could be confirmed that, there is an increasing oral hygiene because of trending aging population. Longevity is welcomed, but it also comes with huge challenges, putting a pressure on the health services. This makes it vital for the health services to have a durable plan that accommodates future needs. Widespread research and literature of elderly and frail inpatients adult's oral care said that extensive evidence is generally poor such as oral health, age, oral hygiene and the maintenance of optimum oral health. This makes the NHS more accountable and responsible for inpatients optimum oral health, although it still does not hold a clear oral care algorithm. At times, change can put pressure on the organisation resulting into united consequences of quality improvement. For example, making sure that, there is enough supply and training that could result into increased financial burden. In such circumstances, project managers should anticipate and monitor such potential consequences. After looking into several research and literatures on oral care, it could be concluded that, Lewin’s (1947) change model fits in more for the NHS to achieve a desired change in oral hygiene within the impatient settings. This change mode has proven to offer realistic information on how the patients and staff behaviours can impact the panned change and ways to handle the change process at every phase of its advancement. This resulted into increased knowledge and skills regarding oral care and its importance in nursing care. It is vital for everyone to embrace the change in their clinical areas and strive for quality improvement. Effective oral health should be taken seriously (ADHS, 2009).

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