The delivery of oral health care has been identified as an important part of high-quality, holistic patient care (Bestwick et al, 2023; Hewson and Wood, 2023). In previous years, the management of oral health has perhaps been viewed as less important in relation to other health-related interventions and priorities. It has been suggested that hospital staff who are involved in patient care have not prioritised oral health activities. These omissions are detrimental to patients’ wellbeing (Doshi et al, 2021). Many patients may neglect their own oral health, hygiene and self-care when they are hospitalised due to feeling unwell. They may be unaware that this omission is to their detriment because, during illness and lapses in regular oral hygiene, bacteria in the mouth will increase to harmful levels and present health-related risks (Bestwick et al, 2023; Hewson and Wood, 2023). Therefore actions to highlight and address these issues are urgently required.
The Royal Wolverhampton NHS Trust (RWT) nursing quality team endeavoured to change their Trust's culture relating to oral health management for all adult inpatients (Bestwick et al, 2023). To facilitate ongoing action relating to oral hygiene and health education and training, a bespoke digital learning package was designed, developed and delivered for relevant clinical staff at the Trust.
Setting
The RWT is one of the largest NHS trusts in the West Midlands region of the UK and is the largest employer within the local community. It employs more than 10000 multidisciplinary staff, providing primary, acute and community services for the local population (RWT, 2022).
Method
An oral health working group was established within the Trust and consisted of a multidisciplinary team. The group had developed and delivered several objectives relating to improving oral health for all adult inpatients (Bestwick et al, 2023).
The objectives were to:
These tools collectively embedded the concept of good clinical practice and enabled the widespread communication of optimal oral health behaviours. To further ensure organisational embedding, training and education provision was viewed as an obvious goal to pursue for the working group. Health Education England (HEE) commissioned the Mouth Care Matters scheme, which ran a successful oral health campaign between 2015 and 2020. The campaign set out to improve oral health across England. Resources are still available on the website (https://mouthcarematters.hee.nhs.uk). Continuing the excellent work established by Mouth Care Matters, a bespoke, mandated, digital training package was designed for clinical staff delivering personal care within the Trust.
The digital learning team
Responding to the surge of online learning provision post-pandemic, the Trust established a digital learning team to comprehensively manage the development and delivery of its digital curriculum. This dedicated team functions as a consultancy service, guiding each project from conception to publication. Team members are learning specialists, who develop raw educational content into interactive learning experiences. Collaboration is at the heart of the digital learning team's approach. Subject matter experts and stakeholders are actively engaged to ensure content accuracy and appropriate learner engagement. The team comprises two full-time developers, a development assistant and a service lead, each with a critical role in crafting compelling and effective online learning resources.
Oral health training package development
The team was tasked with developing an accessible and customised oral health training package for the Trust that was based on HEE national guidance (HEE, 2022).
Stage 1. Initial conception
The Trust's dental health specialist and subject matter expert (CB) identified the need for accessible and bespoke oral health training and secured permission to use and adapt the HEE Mouth Care Matters content. CB liaised with the digital learning team, to gather content requirements and discussed layout and structure.
Stage 2. Drafting content
CB and the digital learning team collaboratively drafted the training outline, encompassing necessary content and recommendations for organisation and visual design.
The draft was then transferred to the instructional designer (TG), who further refined the layout and discussed any updates or design considerations with CB.
Stage 3. Course development
Development began and, on the advice of the instructional designer (TG), the training centred around four key objectives. These were to:
Stage 4. Further collaboration with the digital learning team and peer review
The digital learning instructional designer (TG) engaged in ongoing discussions with the subject matter expert (CB) relating to content and visual suitability. The focus remained on clarity, accessibility and alignment with training objectives.
During this time CB received a secure link to access various drafts of the training module where she could leave comments and suggest changes. The link was also shared with peers in the oral health multidisciplinary working group, who were encouraged to review and leave their comments and suggestions. These valuable insights were subsequently incorporated into the final version of the training package. The review process provided flexibility for both the instructional designer and the working group members. Communications through emails saved time and enabled peers from the working group to suggest and make changes without having to formally set up meetings.
Stage 5. Final review and testing
When all parties were satisfied with the finished product, a final review of the training was undertaken. The subject matter lead (CB) provided a formal sign-off email to the digital learning team. The completed training package underwent internal testing by the instructional designer (TG) to ensure accessibility, usability and effectiveness.
The final version of the accessible and bespoke oral health training package was launched on the Trust's learning management system in May 2023. The package was added to the current mandatory training portfolio at the Trust. Figure 1 show the Aims of Training slide in the digital package.
Stage 6. Post-launch monitoring
The team continued to monitor and evaluate the training's effectiveness through user feedback and data analysis (for example, how many people accessed the training, the time spent doing the training and so on). Based on these insights, future updates and revisions are planned to maintain relevance, usefulness and to ensure that the most recent evidence is used.
Mandatory training requirement
Oral health involves more than just maintaining teeth (Fiorillo, 2019), and therefore it was agreed that the training should be mandatory to ensure all relevant staff completed it. Up-to-date and evidence-based mandatory training is known to be effective in ensuring that all staff have the knowledge needed for optimal patient care (Dune, 2024).
Gaining approval for mandatory training
Recognising the demands on staff time, the Trust has implemented a robust process for approving new mandatory training courses. This promotes a collaborative and cohesive approach, ensuring that only the most relevant and useful courses are made mandatory. This approach benefits staff by limiting the time that is spent on less safety-critical training.
This process included completing a risk register to highlight the overarching issues and concerns, and why action must be taken to mitigate risk. A case needed to be made to the senior leadership team consisting of the chief medical officer, the chief nursing officer, the chief AHP and the head of corporate education training and development for them all to agree to support the case for the inclusion of the oral health training package in the mandatory training portfolio.
The process was not straightforward and CB was involved in multiple discussions and passionate endorsement for the training's importance and the target audience. The length, content and learning outcomes were debated thoroughly during each meeting.
Targeting the training audience
The senior leadership team ultimately decided to limit the mandatory training, for now, to Nursing and Midwifery Council-registered nurses, HCAs, AHPs, and General Dental Council-registered nurses. This ensures the training reaches those with the most direct patient contact in adult inpatient settings. The working group plans to expand the training to include other specialties such as midwifery and paediatrics in the future.
The training package is hosted on the Trust's learning management system (LMS), which presents some limitations when it comes to course accessibility. The LMS operates on a binary system of mandatory or non-mandatory training packages, with training accessible only by authorised groups. Additionally, the LMS restricts mandatory training assignments to a limited set of staff groups. This works effectively for most training, but the unusual distribution of staff across different departments made targeting the correct audience challenging. This rigidity, unfortunately, resulted in two shortcomings. First, some staff who perhaps would benefit from the training fell outside the designated roles and were unintentionally excluded. Second, individuals whose roles did not require the training were included, potentially wasting their valuable time. Recognising this, the digital learning team is actively exploring solutions to solve this issue. They are working on developing a system that grants optional viewing access to those who find the content valuable but are not mandated to complete it. This would ensure a more targeted and efficient training experience for all staff for existing and future training.
Smile Month launch
The training package was launched during Smile Month in May 2023. Smile Month is an annual, dedicated, month-long, national campaign to promote the benefits of having a healthy smile and good oral health (Oral Health Foundation, 2024).
Results
Collecting feedback
Staff were asked to provide feedback about their training immediately after completing the course. Feedback received from the first cohort of staff to receive it is presented in Box 1 and Box 2. Of the 2870 staff allocated to complete the training, 2696 (93.9%) completed it within the first 3 months of the launch.
Positive feedback on the oral health digital training package
Negative feedback on the oral health digital training package
Positive feedback
The positive comments received about the course praised the training as informative, engaging and well structured. Users appreciated its flexibility (own pace, on-shift completion) and effectiveness as a refresher. Suggestions for further improvements included providing printable resources and developing an infant oral care training package. A selection of this feedback is presented in Box 1.
Negative feedback
Most of the negative comments received remarked on the length and relevance of the course. A selection of this feedback is presented in Box 2.
Conclusion
The mandatory training package was developed to raise the profile of an important area of practice. It was designed to engage, inform, highlight and instigate further debate and discussion about oral health. The oral health working group has achieved what it set out to do.
However, the working group cannot remain complacent and will continue to raise awareness and improve the training provided based on evidence, best practice and feedback from learners. The group will continue to engage with colleagues and develop training with specialist areas to ensure that their training needs are fulfilled. The working group intends to collaborate further with the digital learning team to develop more flexible delivery methods to increase the accessibility of oral health courses for staff who would like the option to complete them for their practice development and personal interest. Furthermore, following the success of the oral health training package launch at RWT, the package has now been integrated at our partner organisation, Walsall Healthcare NHS Trust. The authors look forward to working together in future developments relating to this important aspect of patient care.