Oral Care in Long Term Care Homes - An Institutional Ethnography

Abstract

Purpose: The enigma of poor oral health of residents in long-term care (LTC) homes remains unsolved despite many years of research and intervention. The purpose of this study was to explore why resident oral health in LTC homes remains poor despite many years of research on causes of the problem and interventions to address it. Exploring how institutional processes and social relations influence care providers’ experiences around providing oral care has the potential to inform strategies to address the longstanding issue of poor oral health of residents in LTC. Methods: I investigated how oral care happens and why it happens the way it does, using institutional ethnography from the standpoint of the healthcare aide (HCA). The social organization of oral care in the LTC homes was explored through the observation of the HCAs’ day to day practices and their interaction with institutional texts. Data were collected at two LTC homes through 96 hours of naturalistic observation, 21 in-depth interviews, and document review. As part of the data analysis, and based on what I was observing, hearing in interviews, and reading in texts, I created text-work-text (TWT) mappings to illustrate how oral care was socially organized in LTC homes. In addition, I created an additional TWT map for bowel care, as a comparison to oral care. Findings: Health care aides were primarily responsible for providing oral care to residents in LTC homes, despite having very little textual guidance as to what, when or how care was to be provided. Texts that were available to inform them in providing oral care were underutilized because the HCAs did not consider the texts helpful. The HCAs used their own discretion, primarily relying on their personal experiences, to inform the oral care they provided for their residents. In contrast, bowel care was an effectively textually mediated process and HCAs relied on several texts to provide them with guidance. Implications: Exploring the social organization of work around oral care in LTC homes has illustrated institutional processes that may contribute to poor oral health for residents in LTC homes. Addressing these processes could help existing efforts of those seeking to improve the state of oral health of residents in LTC. Processes may be improved through a multifactorial approach including revision of texts that guide care, better oral health education for care providers, access to dental professionals in LTC settings, and policy changes at national and provincial levels around oral healthcare in LTC.