ORIGINAL ARTICLES

Trained nurses’ knowledge and practice of oral care on three wards in acute care hospital in Abu Dhabi, UAE

Belal Hijji¹

¹University of Ulster

ABSTRACT
Background. Mouth care is an essential nursing procedure that nurses are expected to have good knowledge of. Poor knowledge may compromise the quality of patient care and result in unsafe practice. Documentation of nurses’ current knowledge and practice is crucial if improvement efforts are to proceed. 
Aims. To investigate nurses’ reported knowledge and practice of oral care, to identify the relationship between nurses’ knowledge and practice and their demographics, and to identify nurses' perceived barriers to good practice. 
Methods. Cross-sectional descriptive survey. 58 nurses on three wards represented the target population. The questionnaire generated information about personal data, education and level of knowledge and practice of mouth care. 
Results. 46 nurses (79%) completed the questionnaire. Questionnaire analysis revealed knowledge deficits about several important aspects of oral care and inadequate practice.However, no statistically significant differences were detected among groups. Lack of materials, lack of time, and uncooperative patients were perceived barriers to good practice. 
Conclusion. It is now time for action. Paste and brush should be regularly provided. Hydrogen Peroxide 3% to be withdrawn. Nurses’s knowledge to be improved. Individual results to be disseminated to each ward.   
Descriptors: Oral care; Knowledge; Practice. 

INTRODUCTION

Mouth care, an essential nursing procedure (Evans 2001)⁽¹⁾ helps to maintain comfortable, clean, moist and infection- free mouth (Watson 1989)⁽²⁾ and thereby improve the patient’s quality of life (Holmes & Mountain 1993)⁽³⁾. Poor knowledge has the potential to compromise the quality of patient care and result in unsafe practice (Bayraktar & Erdil 2000)⁽⁴⁾. Therefore, it is crucial for nurses to have up-to-date knowledge and skills of oral care.

The literature review indicates that nurses' knowledge and practice of oral hygiene is a very important issue and, thus, had been investigated from mid seventies onwards. These studies used different sampling frames and methods of data collection, making it difficult to draw reasonable comparisons among them. However, lack of knowledge in relation to the important aspects of oral care resulting in inadequate practice had been a common feature  (Howarth (1977)⁽⁵⁾, Morton 1980 ⁽⁶⁾, Miller & Rubinstein 1987 ⁽⁷⁾, Boyle (1992)⁽⁸⁾, Adams (1996) ⁽⁹⁾, Milligan et al (2001) ⁽¹⁰⁾, Honnor & Law (2002) ⁽¹¹⁾).

In the UAE, the Ministry of Health (2001)⁽¹²⁾ requires nurses to base their care on the best available evidence and research. However, there is no published work on trained nurses' knowledge and practice of mouth care of the hospitalised patients. The results of other studies undertaken elsewhere, though useful and valuable, may not be generalisable to the UAE's unique context in which multicultural staff forms most of the nursing workforce. Therefore, this study will collect baseline data on which to build in terms of improving clinical practice.

AIMS

The principal aims of the study were to:1) Investigate nurses’ reported knowledge and practice of the important aspects of oral care; 2) Establish association, if any, between nurses’ reported knowledge and practice of mouth care and their demographics; and 3) Identify perceived barriers to good oral practice.

RESEARCH METHODS
This was a descriptive, exploratory, one-event study following a survey approach.

Population, sample and setting.  

The target population was all 58 trained nurses working on three wards in a general hospital in Abu Dhabi, UAE (19 on a male medical ward, 19 on neuro-renal-surgical ward and 20 on the female medical ward). These are the wards where patients with chronic conditions are admitted in, a matter that necessitates ongoing oral care. A convenience sample representative of the target population participated in the study.

Ethical approval
The Hospital Research Ethics Committee approved the study. Each nurse signed a consent and ;was identified by a code to ensure anonymity. All data obtained during the course of the study were kept confidential.

Instrument
Data were collected from nurses by means of a modified version of a questionnaire  developed by Adams (1996) ⁽⁹⁾.

A 24-item structured and pre-tested questionnaire was used to obtain information about personal data; nurses' training and their knowledge and practice of oral care. Participants' qualifications, age and length of experience were identified from the human resources database in the hospital. The questionnaire, containing both open and closed questions was modified following a pretest in 10 nurses who were unrelated to the study. Face validity and content validity of the questionnaire were assessed by the investigator, an epidemiologist and senior nurses.

Data collection
The main study took place in November 2002. Names of all trained nurses were listed from the duty rosters and were used to identify which nurses returned the questionnaires, as three members of staff collected data from participants. Two days were planned for data collection. However, due to heavy workload, the procedure was completed in three days. It was felt that with a longer period of time, participants might access literature or converse with colleagues with potential invalidation of the results. On the actual days of data collection, every qualified nurse on each ward was approached face-to-face with an information sheet about the study. Upon agreement to participate, he/she consented before completing the questionnaire. Two nurses, who assisted in data collection, received training on the administration of the questionnaires and guidelines sheet. Participants were fully supervised when completing the questionnaire.

Coding
Data were coded and entered onto a computer programme running SPSS (version 11) for windows.

Data analysis
Descriptive statistics were used to analyse data obtained from the questionnaire using percentages, frequencies and cross-tabulation between different variables to establish associations.

Sample characteristics:

 Forty-six participants (79%) took part in the study, while the other 12 could not be approached because one nurse refused while the other 11 were on holiday. However, the basic demographic characteristics of respondents and non-respondents are similar enough to assume the absence of sampling bias. Sample characteristics are displayed in Table ⁽¹⁾. Participants received nursing education in the United Arab Emirates, the Philippines, India, Tunisia and Pakistan. 2 were Assistant Nurses A; 38 were Qualified Nurses and 6 Charge Nurses.

Nurses' knowledge of oral care
Oral assessment
The majority of participants indicated that all patients admitted to wards should have assessment of the mouth. However, 18 participants believed that mouth assessment is not necessary and that some admitted patients should have an oral assessment.

Indicators of healthy mouth

Thirteen indicators of a healthy mouth were listed and participants were asked to tick as many indicators as applicable. The results are presented in Table 2. The second column shows the total number of participants who identified each individual indicator. The third column shows the sum of indicators and the number of participants identifying them.

Frequency of mouth care

Participants were asked to indicate how often mouth care should be performed on certain categories of patients such as those who are dehydrated, oxygenated, unconscious, those having oral infections or as a preventive measure. The results in Table 3 describe the proposed frequencies of oral care for each category and the number of participants suggesting each frequency.

Knowledge of adverse drugs effects

Of the 46 participants, 26 (56.5%) reported awareness of adverse drug effects. Sixteen participants (34.8%) were unaware, while four answers (8.7%) were missing.

Results in relation to drug effects are presented in Table 4. As indicated, the list of drugs is very limited in terms of the number of drugs identified by each participant and in the total number of participants who identified each individual drug. Only three nurses identified three drugs; nine identified two, and fourteen identified only one correct drug. However, some participants named drugs with no adverse effects such as Vitamin C, Mycostatin, Anti-TB drugs and Rifampicin.

Materials ideal for oral hygiene

Results concerning participants' knowledge of materials ideal for oral care are presented in Table 5. Many participants preferred oral care sets (swab, tongue depressor and gauze) provided by the hospital, toothbrush and toothpaste. Others preferred hydrogen peroxide 3% and normal saline. However, some participants gave both oral care sets and toothbrushes equal weight by including them in their answers.  The majority of participants (67%) who preferred brush and paste were on ward N.

Practice of mouth care                                            
Oral assessment
Of the 46 participants, 26 (56.5%) reported that patients with certain conditions had oral assessment on admission. However, many participants (n = 19) said that no patients are assessed. One nurse did not answer the question.  

Types of patients assessed

Participants identified 16 categories of patients reported to have oral assessment on admission. The main categories identified appear on Table 6. The other categories not shown on the table had two or less responses. The question, however, was not directed at individual level, but aimed at understanding what generally occurred in practice. In terms of who carries out mouth care, all participants reported that trained nurses in fact do. However, it should be noted that the wards studied are mainly staffed by trained nurses.

Materials used for mouth care
In relation to materials reported to be used, forty five participants reported using oral care materials, while one new nurse reported using nothing. Seventeen nurses reported using toothbrush and toothpaste, of whom 12 worked on ward N. Other equipment included spatulas, swab sticks, and artery clamps. 62 % of participants reported using Hydrogen peroxide 3%. Other solutions included Mycostatin, Orofar, Glycerin, and Potassium Permanganate.

Oral assessment tools
Participants were asked to indicate whether they use any oral assessment guide and to name it if applicable. 39 participant (85%) replied "no", while 7 (15%) replied "yes", despite the fact that the hospital does not use any guide. Whether the participants used their own guides was not asked about. However, most participants (n = 45) indicated their agreement on the importance of using such a guide.

The influence of demographics on nurses’ knowledge and practice
At 95% CI, no statistically significant differences were detected among groups to indicate that certain demographic characteristics (age, sex, experience and education) were associated with better performance than the other on the knowledge and practice sections of the questionnaire.  This conclusion may be attributed to the fact that the numbers of participants having certain demographics were very small to detect significant differences. 

Barriers prohibiting nurses from delivering high quality mouth care
Participants were asked to identify if barriers existed to prohibit good mouth care. Thirty-six nurses (78.3%) replied "yes", while ten (21.7%) replied "no". Those who replied "yes" identified several barriers, such as lack of materials (n=19), lack of time (n=17), uncooperative patient (n=16), staff shortages (n=15) and no assignments (n=4). 17 nurses identified one barrier, while the other 19 nurses identified more than one barrier. The list of barriers is not exhaustive and although the hospital was having a bad staffing crisis that culminated in the recruitment of new locum nurses, only fifteen participants indicated that understaffing is a problem. The reason for this perception could be that some participants indicated that oral care is a simple and non-time consuming procedure that nurses found no difficulty to perform. However, an individualised patient care system does not exist on any of the wards studied and nurses are task oriented and thus may lose focus of individual patient's needs.

Suggestions put forth by participants     
Further research into ICU nurses' knowledge and practice of mouth care. It appears from comments put forth by some participants that patients who are transferred from the intensive care areas suffer poor oral care that culminates in some oral health problems.

More information about the use of oral care solutions
Providing oral care guide
Supplying supportive equipment ( suction machines)
Recruitment of dental hygienist
Offering in-service education on oral hygiene in order to update nurses and combat knowledge deficits
Offering family education pertinent to oral care of their patients.

DISCUSSION

The study sought to explore trained nurses’ reported knowledge and practice of oral hygiene and to identify whether nurses' basic training and demographics influenced their knowledge and practice. In addition, the study aimed to identify perceived barriers to good practice.

Nurses' knowledge of important aspects of oral care
The results suggest that nurses' overall knowledge of oral hygiene was poor or at baseline level, although most participants (80.4%) reported to have mouth care instruction during training. 37% of participants reported having post-training instruction; 26% could not remember, while 37% said that they received no mouth care instruction since qualifying. However, participants were not asked to comment on the quality and quantity of instruction they received during or after training. Although the majority (61%) of participants believed that oral assessment is required for all patients, 39% of them felt that oral assessment is not necessary for all admitted patients as opposed to earlier recommendations (Fitzpatrick 2000)⁽¹³⁾. Indeed, every patient admitted should have a thorough oral assessment, because the percentage of the population undergoing regular dental checkup in the UAE is not known and many of them could potentially have some oral disorders. In Adams’ (1996)⁽⁹⁾ study, the majority of participants felt that oral assessment of all patients was not needed and only 38.2% felt that all patients should be assessed.  One or more aspect of knowledge deficits identified in this study concurs with findings from previous studies. Knowledge gaps concerning healthy mouth indicators, frequency of oral hygiene and drug effects were reported (Adams 1996)⁽⁹⁾.

Lack of knowledge in relation to healthy mouth indicators has implications for participants' ability to carry out proper assessment. Adams (1996)⁽⁹⁾, however, found that none of the respondents stated oral care frequency of less than 6 hours, whereas, in this study, many nurses stated a frequency of less than 4 hours. Gooch (1985)⁽¹⁴⁾ and Krishnasamy (1995)⁽¹⁵⁾ recommended hourly mouth care of dehydrated and unconscious, oxygenated patients with oral infections respectively; Honnor & Law (2002)⁽¹¹⁾ recommended mouth care every 6 hours for all patients. In addition, Krishnasamy (1995)⁽¹⁵⁾ recommended 4 to 6 hours as a preventive measure against potential infection. Howarth (1977)⁽⁵⁾ concluded that mouth care every 4 hours was inadequate. However, there is no consensus on the optimal frequency of mouth care (Bowsher et al 1999)⁽¹⁶⁾. Taking this into consideration, and given the fact that the nursing department is understaffed, it would seem practical to suggest mouth care every 6 hours.  

In addition, poor knowledge of drug effects mirrored in other studies (Rak & Warren (1990)⁽¹⁷⁾, Honnor & Law (2002)⁽¹¹⁾). Addressing the issue of materials among nurses, more nurses were aware of brush and paste as materials ideal for mouth care (39%) than in previous studies (Trentor-Ruth & Creason (1986)⁽¹⁸⁾), Rak & Warren (1990)⁽¹⁷⁾, Kite (1995)⁽¹⁹⁾, Adams (1996) ⁽⁹⁾, Miller & Kearney (2001) ⁽²⁰⁾).

Nurses' reported practice of oral care
As a result of knowledge deficits and, possibly, other barriers, nurses' reported practice was inadequate. Such a conclusion can be deduced from the fact that only some participants reported oral assessment of very limited categories of patients and that the reported assessment remained an individual preference not following a systematic approach.The number of nurses who reported oral assessment of the bedridden, unconscious, stroke patients and patients with oral problems were 11, 9, 9, and 3 respectively.

Poor assessment was reported by Adams (1996)⁽⁹⁾ and Honnor & Law (2002)⁽¹¹⁾). If nurses were to give individualised patient care as recommended (McCord & Stalker 1988)⁽²¹⁾, then patients should have a proper oral assessment in order to identify individual needs. Poor assessment could be attributed to knowledge deficits concerning healthy mouth indicators and lack of oral assessment guide. Using an assessment guide is of vital importance (Holmes & Mountain (1993)⁽³⁾, Hatton-Smith (1994)⁽²²⁾). This hospital treats cancer patients and, therefore, it is very important for nurses to be competent in performing appropriate oral assessment.  Another finding was that participants on the medical wards rarely reported using toothbrushes and toothpaste, supporting findings reported by Adams (1996)⁽⁹⁾. In contrast, many nurses on ward N reported using toothbrushes and toothpaste as recommended  (Hallet (1984)⁽²³⁾, Levine (1993)⁽²⁴⁾, Bowsher et al (1999)⁽¹⁶⁾).

Ward N nurses were said that they adopt a questioning approach towards their practice and that many of them surf the internet. Water which is the safest and most moisturising agent (Gooch (1985)⁽¹⁴⁾, Clarke (1993)⁽²⁵⁾) was mentioned only by few nurses supporting early findings (Adams 1996)⁽⁹⁾.  Nurses espoused using oral care sets, tongue depressors and gauze and, other equipment, that are of unproven value and not recommended by research, supporting early findings (Rak & Warren (1990)⁽¹⁷⁾, Adams (1996)⁽⁹⁾, Fitzpatrick (2000)⁽¹³⁾). Furthermore, Hydrogen peroxide should not be used (DeWalt & Haines (1968)⁽²⁶⁾, Hatton-Smith (1994)⁽²²⁾) because of its detrimental effects on oral mucosa, its unpleasant taste and as Segelman and Doku (1977) ⁽²⁷⁾ point out it forms an excellent medium for candidiasis.

The influence of nurses' basic training on their reported knowledge and practice
Participants' poor knowledge of oral care reported may suggest inadequate educational input and lack of regular updating, although most of them indicated that they needed such updates on annual basis. Good preparation and updating are required for nurses working in hospitals (Fitzpatrick(2000)⁽¹³⁾). However, variations in participants' knowledge may indicate variations in educational provision across different countries. However, others (Miller & Rubinstein (1987)⁽⁷⁾, Wallace & Freeman (1987)⁽²⁹⁾, Barnett (1991)⁽²⁸⁾) are critical of the issue that mouth care instruction during training is rarely carried out by experts in the field. In an evaluative study, Longhurst (1998)⁽³⁰⁾ found out that many nursing training establishments' (NTEs) oral care coverage was deficient.

The influence of demographics on nurses’ knowledge and practice
The small numbers of nurses having certain dempgraphics did not enable meaningful comparisons among groups. In order to identify statistically significant differences to be detected, larger samples are required. However, this aim did not feature in previous studies targetting multinational staff.

Barriers prohibiting nurses from delivering high quality oral care
Lack of time and nursing shortages, as reported barriers, are congruent with early findings (Rak & Warren (1990)⁽¹⁷⁾, Adams (1996) ⁽⁹⁾, Pyle (1999)⁽³¹⁾). In addition, lack of knowledge reported above mirrored other studies (Rak& Warren (1990)⁽¹⁷⁾, Adams (1996) ⁽⁹⁾). Lack of supplies was reported by Fiske & Lloyd (1992)⁽³²⁾. Lack of cooperation on the part of dependent patient and lack of assignments system reported here did not feature in previous studies.

Study Limitations:

Language difficulty
The questionnaire was designed in English which is not the native language of any of the study participants, despite the fact that it is the language of instruction for all study participants and a medium of communication in the hospital. It could be that some participants misunderstood some questions. Where participants were judged to have misunderstood the question, the answers they gave were coded as "missing variables" and were excluded from analysis.

Limitations of reported practice
Caution needs to be exercised when interpreting participants' reported practice, as nurses may report a knowledge that is not reflected in practice and a practice that may not actually be performed. The other problem for this study relates to the superficiality of information obtained through fixed-choice questionnaires (Polit & Hungler 1999) ⁽³⁴⁾, although there is a set of open-ended questions capable of producing more in-depth understanding of participants’ views.

Limitations of generalisability of the results
Participants were trained under five different educational systems. Small numbers of participants represented each country and therefore, it may not be possible to generalise the study findings to all nurses from any of these countries who work in other hospitals. However, the findings could be confidently generalised to other nurses on the same wards, as they are not significantly different.

CONCLUSIONS AND RECOMMENDATION

Despite its limitations, this study accomplished the first important step in providing useful information on trained nurses' knowledge and practice of mouth care, which were reported to be deficient with an obvious need for improvement.

It might be a sound idea to appoint a dental hygienist, who would take the issue of mouth care forward as Howarth (1977) ⁽⁵⁾ and Lewis (1984)⁽³³⁾ argue. In the UK, some hospitals used to recruit dental hygienists (Rak & Warren 1990)⁽¹⁷⁾ who provided oral care for inpatients and offered advice to nurses. In addition, policy and procedure guidelines on mouth care might improve the quality of oral care delivery.

As the percentage of nurses who receive their education in this country is ever increasing, reexamination of the extent of oral care coverage in nursing curricula in this and other countries who supply nurses may be warranted. In-service education and ward based learning may play a positive role in the process of preparing and updating of nurses on this important aspect of nursing care.

Nurses in this hospital, like many others around the world, need a library with access to nursing journals or electronic databases that publish research literature.

As the results suggest, nursing shortages have a negative impact on the quality of mouth care provided to patients. Therefore, it is the responsibility of policy makers to ensure that the hospital has adequate staffing. Lack of materials such toothbrushes and toothpaste influence nurses either to use other methods of oral cleansing that are of less quality or to totally ignore mouth care. There is an urgent need to withdraw Hydrogen Peroxide 3%. Based on the results of this study, the hospital administration, for the first time, provided a regular supply of paste and brushes to different hospital departments. Work is underway to disseminate the results of the study to individual wards and prepare an oral care protocol to guide practice in the studied wards.

The available evidence from literature is conclusive and bly indicates poor oral care for patients across different cultures and boundaries. Instead of re-inventing the wheel by recommending further research, action needs to be taken to correct the existing situation that may, hopefully, improve patient care. 

ACKNOWLEDGEMENTS
I would like to thank the following people for their support:

Our Director of Nursing, Linda Jackson, for the valuable support she offered throughout the study.
All nurses who participated in the study.
Professor Mohammad Musaddaque Hussein, the UAE University, who supervised the study and offered a statistical advice.
City pharmacy, Abu Dhabi, for funding the study by providing 1500 UAE Dirhams.
Salma Al Hanaie and Ikram Abdul Zahra for the time and effort the spent on data collection.
Dr. Claes Henning, Head of Pathology and Laboratory department, Mafraq Hospital for his advice on the methodology.
Professor Andrea Baumann, for her comments on the protocol and her encouragement.

REFERENCES

1. Evans G. A rationale for oral care [ Art&Science: Literature Review ]. Nursing Standard 2001: 15(43): 33-36.

2. Watson R. Care of the mouth. Nursing 1989: 3(44): 20-24.

3. Holmes S, Mountain E. Assessment of oral status: evaluation of three oral assessment guides. Journal of Clinical Nursing 1993: 2(1): 35-40.

4. Bayraktar N, Erdil F. Blood Transfusion Knowledge and Practice Among Nurses in Turkey. Journal of Intravenous Nursing 2000: 23(5): 310-317

5. Howarth H. Mouth procedures for the very ill. Nursing Times 1977: 73(10): 354-355

6. Morton J. Identification of the level of knowledge of the SRN on the causes and prevention of dental disease. Diploma in Dental Health Education project 1980.

7. Miller R, Rubinstein L. Oral health care for hospitalised patients: the nurse's role. Journal of Nursing Education 1987: 26(9): 362-366.

8. Boyle S.  Assessing mouth care. Nursing Times 1992: 88(15): 44-46.

9. Adams R. Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. JAN 1996: 24(3): 552-560.

10. Milligan S, McGill M, Sweeney M, Malarkey C. Oral care for people with advanced cancer: an evidence- based protocol. International Journal of Palliative Nursing 2001: 7(9): 418-426.

11. Honnor A, Law A. Mouth care in cancer nursing: using an audit to change practice. British Journal of Nursing 2002: 11(16): 1087-1096.

12. Ministry of Health. Professional Code of Conduct 2001: Abu Dhabi: Ministry of Health.

13. Fitzpatrick J. Oral health needs of dependent older people: responsibilities of nurses and care staff [ Integrative literature reviews and meta-analyses ]. Journal of Advanced Nursing 2000: 32(6): 1325-1332.

14. Gooch J. Mouth care. Professional Nurse 1985: 77-78.

15. Krishnasamy M. Oral problems in advanced cancer. European Journal of  Cancer Care 1995: 4; 173–177

16. Bowsher J, Boyle S. and  Griffiths J. Oral care: a clinical effectiveness-based systematic review of oral care.  Nursing Standard 1999: 13(37): 31

17. Rak O, Warren K. An assessment of the level of dental and mouth care knowledge amongst nurses working with elderly people. Community Dental Health 1990: 7; 295-301.

18. Trentor-Roth P, Creason N. Nurse administered oral hygiene: is there a scientific basis? Journal of Advanced Nursing 1986: 11; 323-331.

19. Kite K. Changing mouth care practice in intensive care: implications of the clinical setting context. Intensive and Critical care Nursing 1995: 11; 203-209.

20. Miller M, Kearney N. Oral Care for Patients With Cancer: A Review of the Literature. Cancer Nursing 2001: 24(4): 241-254

21. McCord F, Stalker A. Brushing up on oral care. Nursing Times 1988: 84(13): 40-41

22. Hatton-Smith C. A last bastion of a ritualised practice? A review of nurses' knowledge of oral health care. Professional Nurse 1994: 9(5): 305-308.

23. Hallet N. Mouth care. Nursing Mirror 1984: 159(21): 31-33.

24. Levine R. The Scientific Basis of Dental Health Education. A Policy Document. 3rd ed. London, Health Education Authority; 1993

25. Clarke G. Mouth care and the hospitalised patient. British Journal of Nursing 1993: 2(4): 225-227.

26. DeWalt E, Haines A. The effects of specific stressors in healthy oral mucosa. Nursing Research 1969:  18; 124–130.

27. Segelman A, Doku H. Treatment of the oral complications of leukemia. Journal of Oral Surgery 1977: 35(6): 469-77.

28. Barnett J. A reassessment of oral health care. Prof Nur 1991: 703-708.

29. Wallace J, Freeman P. Mouth care in  patients with blood dyscrasias. Nursing Times 1978: 74 (22): 921-922

30. Longhurst R. A cross-sectional study of the oral health care instruction given to nurses during their basic training. British Dental Journal 1998: 184(9): 453-457.

31. Pyle M, Nelson S, Sawyer D. Nursing assistants' opinions of oral health care provision. Special Care in Dentistry 1999: 19; 112-117.

32. Fiske J, Lloyd H. Dental needs of residents and carers in elderly people's homes and carers' attitudes to oral health. European Journal of Prosthodontic Restorative Dentistry 1992: 1; 91-95.

33. Lewis I. Developing a research based curriculum: an exercise in relation to oral care. Nursing Education Today 1984: 3(6): 143-144.

34. Polit D, Hungler B. Nursing Research: principles and methods. 6th edition. London: Lippincott; 1999.

Received: 10/25/2003 
Revised: 11/21/2003  
Aprovado: 12/04/2003