Socio-demographic characteristics of participants
We interviewed 25 healthcare professionals who are part of the multi-disciplinary team involved in the care of acute stroke patients. Their age ranged between 25 and 60 years, with a mean age of 36.2 ± 4.2 years. The majority of the participants were males; 15 (60.0%) and 10 (40.0%) were females. Also, the majority of the HCPs were registered nurse practitioners, 14 (56.0%), while 7 (28.0%) were medical doctors and 4 (16.0%) were physiotherapists, as shown in Fig. 1 below. Although the mean and median duration of practice of HCPs caring for acute stroke patients was 7.3 ± 2.3 and 4 years, respectively, this ranged from 4 months to 28 years.
Shows the healthcare professionals involved in stroke care who were interviewed.
General knowledge of stoke and oral health in stroke
Healthcare professionals interviewed were experienced in the care of stroke patients and demonstrated adequate knowledge of stroke in general. They willingly described and discussed their expertise in stroke care and the associated or expected complications that stroke patients commonly encounter.
As a clinician, I work in the stroke unit and with the neurology department. Stroke is the most common neurological condition we see, and we have a stroke unit. So when it comes to stroke, you see all kinds of stroke. In the stroke unit, about forty percent of them are haemorrhagic strokes, fifty percent are ischemic strokes, and we have a few subarachnoid haemorrhage, which is again part of the haemorrhagic stroke. (Doctor, D1)
Thematic analysis generated the following main themes
Clinical care is a priority for stroke patients
Healthcare professionals described the various types of stroke cases they attend to and the clinical care rendered to them. In the Korle-Bu Teaching Hospital, some HCPs (doctors, nurses, physiotherapists) attended to stroke patients in the Stroke Unit and some of the medical wards. HCPs (doctors, nurses, physiotherapists) described various aspects of care they considered critical for stroke patients. They also mentioned bed sores and deep vein thrombosis, which stroke patients are usually at risk of. While a few others were also worried about aspiration, stroke patients who are unable to swallow are prone to it.
Most of them cannot swallow, so saliva and food can go the wrong way. (Doctor, D2)
Oral health is essential to prevent health complications
All the HCPs interviewed mentioned oral health’s critical role in the journey of stroke patients toward recovery. They reported that they are concerned when patients have poor oral health, cannot chew, or cannot swallow, which is common in stroke patients.
Some statements by healthcare professionals are captured below to reflect this theme:
Doctors usually check whether a patient can talk, chew & swallow, and if the patient cannot swallow, we fix nasogastric tube for feeding. (Doctor, D3)
Once an unconscious patient starts becoming aware of oral hygiene, we know there is an improvement. (Nurse, N1)
Aspiration is one of the things that we are worried about. So, when a patient comes and the assessment is done, we know that they cannot swallow saliva, so they are pooling. When they pool, it is a medium for bacteria to multiply. We have normal bacteria that live in the mouth, but if this goes down the throat to the lungs, they can have an infection. We check the swallowing, and if they cannot swallow, we check very often, but if they keep drooling, we know that the swallowing is impaired. We tend to position them upright or to their side so that they can drool freely. We also pass a nasogastric tube for feeding because sometimes it is not just the saliva that makes them aspirate. (Doctor D3)
Oral health care is important for good oral health-related quality of life
Healthcare professionals mentioned the importance of oral health care in ensuring and preventing offensive odors among stroke patients. They also explained the importance of cleaning the mouth to prevent infection, dryness, and cracking. Prevention of bad odors or bad breath (halitosis) was emphasized as a motivation for paying attention to oral health.
Generally, oral health has even been associated with depression because of bad breath (halitosis). Unfortunately, most people with halitosis do not even know they have it. Others do not say it to your face, but anytime you talk, they move away, depending on the type of stroke patient. If this is a stroke patient that has good cognition and he can tell that the odor coming out of the mouth is not good but has limb weakness involving his hand, then there is very little he can do to improve it. He has to rely on others to clean his mouth for him, and that can worsen the depression, which is usually high in people with stroke. (Nurse N2)
Some of them might get food pockets in their mouth. Some even come with Candida, especially in people with diabetes, when their oral care is inadequate. I must say it is not part of our core discharge plans, which we should be doing. So, they come back on review, and you realize that the person’s mouth is not being taken care of because,… Imagine brushing someone’s teeth, and you keep wondering how he will spit it out and all that. So those are the challenges we have. (Doctor, D1)
Lack of collaboration and integration of oral health care in stroke care
Doctors and nurses agreed that health workers rarely collaborated to integrate oral health care into the patient’s care plan. In the stroke unit in KBTH, there appears to be some effort to implement a form of collaboration, but in practice, this was rarely achieved.
Aside from the initial assessment, I can check when I ask the person to open the mouth, but the doctors hardly even look into the mouth. It is the nurses who do this when they clean the patient’s mouth. (Doctor, D4)
Although HCPs (Doctors and Nurses) admitted to the importance of oral health in stroke, most of the doctors interviewed mentioned that they do not pay optimal attention to it.
We do not do oral care as Doctors… Ours is to do a clinical evaluation while the nurses do oral and other care. We only guide… and it is not our role. (Doctor, D5)
Although HCPs (Doctors and Nurses) feel inadequately equipped, some try to do their best, as they described.
We are not dental surgeons, but we do our best. What we do as I said, the nurses use mouthwash, gauze, and a spatula and try as much as possible to get the debris and keep the place neat. That is what we do at the stroke unit. (Doctor, D4)
Lack of standardization of tools for the provision of oral health care
The HCPs (Doctors and Nurses) mentioned lacking access to suitable oral healthcare assessment and protocol tools. The lack of this equipment and tools was mentioned as a critical barrier hindering oral health care.
I recommend the use of mouthwash, which the patient has to buy. (Doctor D6)
The HCPs (Doctors and Nurses) interviewed stated that the approaches toward assessing and caring for stroke patients’ oral needs varied between wards.
A doctor described that the initial assessment was sometimes not done well, setting a false preamble for further management.
When it comes to aspiration, sometimes even the health care workers are the worst culprits. What usually happens at the emergency is that a doctor or nurse will give the patient a teaspoon of water (to check if they can swallow); if the patient can swallow, it is assumed that the patient is ok to move on to other food substances”… but swallowing isn’t just a teaspoon of water; so when the patient is given koko (porridge), and their swallowing muscles are fatigued, they can’t swallow. (Doctor, D1)
So you see someone you passed during the swallowing test, and the next moment, you find the patient down and febrile because we did not take the time to check well… that is something we need to be taught…. They have aspiration not because their family caused it but rather because we should have used more than just one and a half tablespoons of water to establish whether the patient is at risk of aspiration. (Doctor, D1)
Furthermore, some HCPs (Doctors and Nurses) use flavored mouthwash for oral care, while others recommend an antibacterial-based mouthwash (such as chlorhexidine).
Try and use chlorhexidine-based mouthwash and try to clean their tongue. (Nurse N3)
Others further argued that the flavored mouthwash is ineffective and that one should use warm saline water, which is also soothing if there are ulcerations in the mouth.
Instead of two times daily, you can do three times daily, and whenever you feed them, try to let them rinse their mouth; if they cannot, use gauze and a spatula so that you do not put your hand in there for them to bite you. (Nurse, N4)
Nurses also mentioned that patients could use the toothbrush if they are able, but in those who are unconscious, we can use gauze, a spatula, and some toothpaste to clean the mouth, the teeth, and the tongue.
Promoting oral health in acute stroke patients
Healthcare professionals emphasized the need for multi-sectoral collaboration to promote oral health care among stroke patients. The importance of good nursing care was reiterated as nurses generally spend more time with the patient.
In KBTH, a doctor said:
Nurses are trained to do this. It is their duty to provide day-to-day care for the patient every day. (Doctor, D7)
A provisional arrangement was described where nurses received skill training and were supervised by doctors. He further explained that:
Usually, when new personnel come in, they go through training on some of the modalities we have in the unit, so there is training on feeding and mood assessment and something like that. Once you have gone through the training, you do not really need supervision, but when we have multi-disciplinary rounds, and somebody is doing it, we are all able to assess, and if they are not doing it right, then we make an input (Doctor, D7)
To strengthen the approach to promoting oral health care among stroke patients, healthcare personnel agreed that the multi-disciplinary approach to care should be institutionalized:
During multi-disciplinary rounds, doctors will carry out their ward rounds, and nurses will give feedback on nursing care and any challenges they may encounter. Physiotherapy will also say if there are any challenges and what needs to be done better… If they haven’t started physiotherapy and why it hasn’t been started. The occupational therapist informs us about their assessment and whether they were able to visit the home. The speech therapist informs us of the patient’s abilities after they have started to evaluate the swallowing and speaking process. So, everyone makes an input, and we all make an input in the discharge planning and what should happen. (Doctor, D2)
In a comprehensive discharge plan, preparation is made for the patient’s discharge and continued management at home. The process involves counseling the patient and preparing them for rehabilitation after the stroke. Helping patients and families to prepare food of the right consistency to prevent aspiration, how to feed and maintain hygiene, physical activities, and performing functions relevant to their functional recovery.