In this changing era specialist nurses are expected to triage, diagnose and treat minor injuries. Recently prescribing, ordering investigations, meeting targets and providing out-of ours care are some aspects of the changing role of nursing staff. Nursing staff have the opportunity to be fundamental in changing the outcome of patients with undiagnosed oral cancer by recognising the early signs of the disease. The significance of their role in oral cancer detection has been previously outlined [9
]. Interaction with nurses may allow high risk patients to increase their level of awareness and confidence to seek help when required.
The respondents to this questionnaire were nurses from a varied specialty background with the specialties grouped into surgical, medical, critical care, accident and emergency and bank nurses. The accident and emergency and bank nurse groups were small with only five and seven nurses in each group respectively. Results from these groups must be generalised with caution. Unfortunately demographic data regarding age and gender were not recorded as part of this pilot study. The time from graduation was recorded for those nurses attending nursing school which may provide a rough guide to the nursing experience as well as the age of the nurses questioned. Auxiliary nurses were also included in the study; although these nurses did not attend nursing school they did perform a significant proportion (up to 48 percent) of the oral health care of patients. Smoking and alcohol habits of the respondents were also not recorded, these could have affected responses; especially risk factors for oral cancer.
Over 80 percent of nurses agreed that it is important to examine a patient's mouth on admission; however, only 49 percent reported performing this task regularly. Performing an oral health check may depend on the nature and the projected length of admission. Sixty nine percent of nurses reported that their ward had a mouth care protocol. Oral examination has traditionally been the remit of doctors, dentists, and dental auxiliaries; however nurses who perform oral health care tasks should have the knowledge of basic surface anatomy of the oral cavity and be able to identify common pathological changes (red patches, white patches and ulcers) thus making examination of the mouth and opportunistic screening for oral cancer a realistic possibility.
This study did not investigate the anatomical knowledge of the nursing staff but did enquire as to which tissues were examined during an oral health check. The most common sites for oral cancer are the floor of mouth and ventral/lateral tongue. Seventy four percent of nurses reported examining the tongue; however only seven percent reported examining the floor of mouth despite the preponderance of oral cancers and pre-malignant changes in this area.
Signs of oral cancer were generally identified poorly. Ulceration is the most common presenting sign of oral cancer and less than 25 percent identified this. Up to 50 percent of red patches (erythroplakia) may have already progressed to invasive carcinoma yet a 'red patch' was identified as a sign of oral cancer by less than five percent of respondents. Interestingly, whether or not a nurse attended regular dental care did not seem to have an impact on clinical sign identification.
Over 60 percent of nursing staff questioned identified smoking as a risk factor for oral cancer with just less than 30 percent identifying alcohol. Other risk factors were identified less well. This data parallels work undertaken by one of the authors on medical and dental students' awareness of oral cavity carcinoma [16
]. The surgical and intensive care nursing staff scored significantly higher than their colleagues; these groups included staff from wards where Maxillofacial and Otorhinolaryngology patients' are cared for. Nursing staff within one to three years of qualification identified a significantly greater mean number of risk factors than their more senior counterparts. This highlights a need for continuing medical education, supported by Wardh et al
., who used a questionnaire to test nursing and auxiliary nursing staff on oral healthcare. The two groups underwent a four hour teaching programme and repeated the questionnaire two years later [18
]. It was apparent from these results that specific knowledge was not retained thus demonstrating the key to continuous use of the new skill and this aspect should be covered in undergraduate and postgraduate teaching for reinforcement.
Interestingly only five nurses reported advising patients regularly about risk factors for oral cancer. Delivering advice on oral cancer may directly depend on the nature of the hospital admission. Also hospital nurses may not feel that it is their role to deliver advice regarding cancer risk without further training. Nurse practitioners, i.e. nurses educated at graduate level, have the skill-set to conduct physical examinations, assess risk factors and screen patients for disease. Unfortunately this study did not identify which nurses were educated to this level but should be investigated in future studies. Lack of awareness of oral cancer risk and clinical signs may also prohibit nurses from delivering preventive advice. Our results demonstrated only 61 percent of nursing staff in this study received oral healthcare training at nursing school with 34 percent receiving postgraduate education. It was not assessed whether this was related purely to oral hygiene maintenance or encompassed oral diseases. Seventy-four percent of staff requested further training to improve patient care.
The results of this study indicate that whilst there is desire to increase patient total care, teaching is required to enhance awareness of oral cancer risk factors and signs. Adams (1996) through a questionnaire targeted nurses on acute elderly care and general medical wards on their knowledge of oral healthcare [19
]. The study was not focused at cancer detection but to oral hygiene issues. The study highlighted, in keeping with our work, that nurses thought oral care was an important part of hospital care. The paper went onto surmise that although nurses do receive oral healthcare training as part of their curriculum, this is most often not taught by a specialist in that area. It is therefore appropriate that medical or dental staff that have specialist interests in this area; oral medicine specialists, oral and maxillofacial surgeons, otorhinolaryngologists, plastic surgeons, specialist nurses in these areas, specialist oncology nurses, dentists, dental hygienists, dental therapists or oral health educators could in future train nursing staff on oral healthcare including oral cancer awareness. It is essential to include adequate training in the nursing curriculum as clinical observation and oral examination by nurses may prove effective in improving survival rates for oral cancer [20
]. Oral health checks were performed by nursing staff on patients with haematological malignancies by Andersson and colleagues [21
]. The nurses' evaluation of the oral cavity was comparable to a dental hygienist. The nurses had been trained for two hours prior to implementation of this and on average the examination took five minutes and was undertaken every day. Although this study was not investigating oral cancer detection, but oral and oral related issues in general, it can be inferred that teaching with regular use of the new skills could allow for a 'screening' process which is effective without adding too much extra burden to already hard working nursing staff.
Our data is consistent with research published elsewhere in that targeted education is needed to prepare oral health providers to undertake oral cancer prevention activities [22
]. This study highlighted weakness in the training of nurses similar to those reported previously involving the training of medical and dental students [16
]. In addition the results in this study reflect those obtained in a previous study involving general practitioners that identified the need for improved education [17
]. All of these studies highlighted a need to emphasize the role of alcohol as well as tobacco as a risk factor; and to emphasize the importance of early oral mucosal changes in particular ulcerative lesions and red and white patches. The government has already stated that a key area is earlier detection of cancer which affords quicker treatment that can save lives. The department of health, cancer reform strategy (2007); states that non-medical screening for oral disease may be the focus of the future as individuals at risk from oral cancer are unlikely to have a general dental practitioner [23
]. The possibility of community nurse clinics or pharmacy advice on oral ulceration would allow increased awareness in the community. There will always be patients who avoid such initiatives and therefore, a hospital oral health check would hopefully pick-up those individuals who had been admitted to hospital. Whilst this is not a formal screening programme the ability to 'screen' individuals especially those at risk who are admitted to hospital would allow detection of tumours at an earlier stage.