CLINICAL SCHOLARSHIP

Translation of Oral Care Practice Guidelines Into Clinical Practice

by Intensive Care Unit Nurses
Freda DeKeyser Ganz, RN, PhD1 , Raanan Ofra, RN, MA2 , Rabia Khalaila, RN, PhD3 , Hadassa Levy, RN, MSc4 ,
Dana Arad, RN, MSN5 , Orly Kolpak, RN, MSN6 , Maureen Ben Nun, RN, BSN7 , Yardena Drori, RN, MSN8 ,
& Julie Benbenishty, RN, MSN9
1 Pi, Head, Master’s Program, Hadassah-Hebrew University School of Nursing, Faculty of Medicine, Jerusalem, Israel
2 Lecturer, Sheba School of Nursing, Tel Hashomer, Israel
3 Director, Faculty of Nursing, Zefat Academic College Zefat, Israel
4 Head Nurse, Cardiology, Rambam Health Care Campus, Haifa, Israel
5 Staff Nurse, Ichilov Medical Center, Tel Aviv, Israel
6 ICU Head Nurse, Western Galilee Hospital-Nahariya, Nahariya, Israel
7 Staff Nurse, Kaplan Medical Center, Rehovot, Israel
8 Head Nurse, Cardiac ICU, Haemek Hospital, Afula, Israel
9 Academic Consultant/Trauma Coordinator, Nursing Administration, Hadassah Hebrew University Hospital, Jerusalem, Israel

Key words Abstract

Oral care, intensive care, translation research
Correspondence
Dr. Freda DeKeyser Ganz, Hadassah-Hebrew
University, School of Nursing at the Faculty of
Medicine, Kiryat Hadassah, Box 12000,
Jerusalem, 91120 Israel.
E-mail: Freda@hadassah.org.il
Accepted: April 6, 2013
doi: 10.1111/jnu.12039
[Correction added after online publication
12-July 2013. Author affiliations amended.]
Purpose: The purpose of this study was to determine whether there was a
change in the oral care practices of intensive care unit (ICU) nurses for ven-
tilated patients after a national effort to increase evidence-based oral care
practices.
Design: Descriptive comparison of ICU nurses in 2004–2005 and 2012.
Method: Two convenience national surveys of ICU nurses were collected in
2004–2005 (n = 218) and 2012 (n = 233). After the results of the initial survey
were reported, a national effort to increase awareness of evidence-based oral
care practices was conducted that included in-service presentations; publica-
tion of an evidence-based protocol in a national nursing journal; publication
of the survey findings in an international nursing journal; and reports to the
local press. A repeat survey was conducted 7 to 8 years later. The same survey
instrument was used for both periods of data collection. This questionnaire in-
cluded questions about demographic and personal characteristics and a check-
list of oral care practices. Nurses rated their perceived priority level concern-
ing oral care on a scale from 0 to 100. An evidence-based practice (EBP)[O4]
score was computed representing the sum of 14 items related to equipment,
solutions, assessments, and techniques associated with the evidence. The EBP
score, priority score, and oral care practices were compared between the two
samples. A regression model was built based on those variables that were as-
sociated with the EBP score in 2012.
Findings: There was a statistically significant increase in the use of EBPs as
shown by the EBP score and in the perceived priority level of oral care. In-
creased EBPs were found in the areas of teeth brushing and oral assessment.
Decreases were found in the use of non–evidence-based practices, such as the
use of gauze pads, tongue depressors, lemon water, and sodium bicarbonate.
No differences were found in the use of chlorhexidine, toothpaste, or the nurs-
ing documentation of oral care practices. A multiple regression model was
found to be significant with the time of participation (2004–2005 vs. 2012) and
priority level of oral care significantly contributing to the regression model.

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Translation of ICU Oral Care Guidelines Ganz et al.

Conclusions: The national effort was partially successful in improving

evidence-based oral care practices; however, increased awareness to EBP also
might have come from other sources. Other strategies related to knowledge
translation need to be attempted and researched in this clinical setting such
as the use of opinion leaders, audits and feedback, small group consensus,
provider reminder systems, incentives, clinical information systems, and com-
puter decision support systems.
Clinical Relevance: This national effort to improve EBP did reap some re-
wards; however, other knowledge translation strategies should be used to fur-
ther improve clinical practice.

About 10 years ago, several members of the Israeli Car-
diology and Critical Care Nursing Society formed a group
called the Evidence-Based Nursing Working Group (EBN
group). This group has dedicated itself to promoting nurs-
ing research and evidence-based practice (EBP) in critical
care on a national level. One of the first major projects
of this group was to describe oral care practices of Israeli
ICU nurses for ventilated patients and to compare them
with the current best evidence. One of the results of this
project was a survey, previously published in the Jour-
nal of Nursing Scholarship (Ganz et al., 2009). A major
finding of this study was that a large percentage of nurses
were not practicing according to the best available evi-
dence and there was a lack of consistency between and
among the sampled intensive care units (ICUs). It has also
been shown that oral care has a significant impact on ICU
patient outcomes (Cuccio et al., 2012; Hutchins, Karras,
Erwin, & Sullivan, 2009; Sona et al., 2009). In light of
these results, the EBN group decided to promote the use
of the best evidence related to oral care of the ventilated
patient. This study describes those efforts and compares
these practices on a national level before and after this
project.
Background
In the early 2000s, when the EBN group started its
work, the evidence related to the importance of oral care
and its association to ventilator-associated pneumonia
(VAP) was just beginning to develop. Based on what was
available at that time, the group developed an oral care
protocol for the ventilated patient that was appropriate
for the local climate that included assessment, cleaning of
the mouth, tooth brushing using a soft toothbrush, and
the use of a chlorhexidine rinse (Ganz et al., 2009). It
was recommended that these be completed at least once
per shift.
Studies have been published since that time that have
supported these choices. Several sets of investigators have
recently found that an oral care protocol including tooth
brushing or the use of chlorhexidine decreased VAP in
their units (Adams & Wilson, 2012; Duey et al., 2008;
Fields, 2008; Sona et al., 2009). However, not all inves-
tigators have found such an association. Gu, Gong, Pan,
Ni, and Liu (2012) completed a meta-analysis of random-
ized clinical trials and found that tooth brushing did not
reduce VAP, mortality, ICU length of stay, or ventila-
tor days in ventilated patients in the ICU. It should be
noted that this meta-analysis included only randomized
clinical trials, and several of the studies mentioned above
used other research designs. Johnson, Domb, and John-
son (2012) implemented an oral care protocol similar to
our protocol. They found that this protocol was associ-
ated with a decrease in VAP in a general ICU but did not
apply to trauma patients. The authors of the study, John-
son, Domb, and Johnson, concluded that one protocol is
not right for every ICU patient.
Another goal of the original survey was to determine
the oral care practices of ICU nurses as compared to the
best evidence found in the literature. We found that a
very large percentage of nurses were not practicing ac-
cording to the latest evidence (Ganz et al., 2009). Since
then, several investigators from around the world, using
different survey instruments, have found very similar re-
sults. For example, Lin, Chang, Chang, and Lou (2011)
found that knowledge levels of evidence related to oral
care was low to moderate among Taiwanese nurses. Chan
and Ng (2012) from Singapore described low knowledge
levels and practice that was not evidence based. Turk,
Guler, Eser, and Khorshid (2012) conducted a study very
similar to ours in Turkey and reported similar results.
They found that 60% of the ICU nurses rated oral care
with the highest level of priority, yet 79% used sodium
bicarbonate and 82% used a foam swab. Similar to our
findings, they also found a very wide variety of prac-
tices between units. American nurses also strongly pre-
ferred the foam swab (97%) and often did not perform
oral care according to written policies (Feider, Mitchell, &
Bridges, 2010). Similar results were reported by Soh et al.
(2011) in Malaysia, who found that nurses use cotton and

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Ganz et al.
forceps for oral care but do not use toothbrushes. There-
fore, even though there have been reports in the litera-
ture supporting changing traditional oral care practices,
nurses around the world often are not doing so.
The similarity among these international findings leads
to the conclusion that while publishing the evidence is an
important first step in changing clinical practice, it is not
enough. For example, Titler (2004) commented that pas-
sive dissemination (such as publishing the results) has a
minimal effect on changing clinical practice. Therefore,
it was important for our EBN group to conduct a na-
tional campaign to change oral care practices in Israel.
After completing this campaign, we resurveyed the oral
care practices of the ICU nurses. Thus, the purpose of this
study was to determine whether ICU nurses had changed
their oral care practices when treating the ventilated
patient.
Methods
Sample
The study consisted of two convenience samples, one
collected in 2004–2005 and the second in 2012. Both
samples were collected using the same method. Mem-
bers of the EBN group volunteered to recruit nurses from
their own units, and some members also recruited nurses
from other units in their home institution. Due to the
turnover of members of the EBN group who agreed to
recruit subjects, different units were sampled in the two
time periods. For the most part, different nurses collected
data for the two data collection time periods. Therefore,
different units were studied. In 2004–2005, nurses from
12 units were studied (general or respiratory ICU [n =
5]; cardiovascular-surgical ICU [n = 3]; and neurological
[n = 2] and cardiac care [n = 2]) and in 2012, 12 units
were sampled (cardiac care [n = 6); general or respiratory
ICU [n = 4]; medical ICU [n = 1]; and neurological ICU
[n = 1]), of which three units (two general ICUs and one
cardiac ICU) were sampled at both time periods.
Instrument
The same instrument was used for both data collection
periods. It contained two major sections: a demographic
and professional characteristics section and a checklist
which included a list of oral care practices that included
the type of equipment used, solutions used, technique,
and the type and timing of oral assessment. Of the 27
items on the checklist, 14 were based on evidence from
the literature. An EBP score was therefore determined as
the number of items that were checked off among these
14 items. A higher score shows higher use of EBPs. Nurses
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Translation of ICU Oral Care Guidelines
were also asked regarding their perceived priority level of
oral care on a scale from 1 to 100. This question used a
visual analog format with a range of 0 (lowest priority)
to 100 (highest priority). For further details about the de-
velopment of the instrument, see Ganz et al. (2009).
Intervention
In the time period between the initial (T1: 2004–2005)
and the second data collection (T2: 2012), a national ef-
fort was conducted by the EBN group to increase the
awareness of evidence-based oral care practices among
critical care nurses. An oral care clinical practice guideline
was created based on the group’s review of the literature
(Raanan et al., 2008). This guideline was then sent to ev-
ery adult ICU in the country and to the Nursing Division
of the Ministry of Health. The guideline and the process
by which it was created were published in the journal
of the national nurses’ association (Raanan et al., 2008).
Results of the initial survey and the protocol were also
reported to the local press. In-service presentations of the
importance of EBP using oral care as an example were
also given on the units where the initial survey was con-
ducted. In addition, members of the EBN group acted as
local champions and encouraged the use of EBPs on their
own units. Also during this time period the concept of
EBP became more familiar in the country due to factors
other than the efforts of the EBN group.
Data Collection
Data were collected similarly for both time periods.
Each member of the EBN group obtained both ethical and
institutional approval to collect the data. The study was
explained to nurses during a staff meeting, informed con-
sent was obtained, and questionnaires were distributed,
then enclosed in an envelope that was placed in a conve-
nient location on each unit.
Data Analysis
Descriptive statistics, including measures of central ten-
dency and dispersion, and frequency data were used to
describe the sample as well as responses to the oral care
practices survey. Not all participants completed all of the
items, and these were not included in the missing data
analyses. Differences in responses between data collec-
tion periods were determined using either independent t
tests (for interval level data, the EBP score, and the pri-
ority score) or chi-square analysis (for categorical data for
all of the oral care practices). A multiple regression analy-
sis was conducted to determine what factors were related
to the EBP score. Only those variables that were found to
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Translation of ICU Oral Care Guidelines
Table 1. Sample Professional Characteristics (T1 [2004–2005]: n = 218;
T2 [2012]: n = 233)
T1
Variable n (Valid%)
Level of nursing education∗
LPN 8 (3.8)
RN 78 (36.6)
RN + BA 107 (50.2)
RN + MA/PhD 20 (9.4)
Missing data 5 11
Post-basic critical care certification
Yes 152 (72.4)
No 58 (27.6)
Missing 8 11
Work full or part time
Full time 121 (56.5)
Part time 93 (43.4)
Missing 4 16
Note. LPN = licensed practical nurse; RN = registered nurse; BA = bach-
elor of arts; MA = master of arts. ∗ χ2 (4) = 18.7, p = .001.
be statistically associated with the EBP score on bivariate
analysis were entered into the regression.
Results
A total of 218 nurses participated in the study in 2004–
2005 (T1) and 233 in 2012 (T2). The majority of both
samples were female (2004–2005: n = 172, 82%; 2012:
n = 154, 71%), with an average age of 37.4 + 8.6 years
at T1 and 37.4 + 8.6 years at T2. Nurses were mostly
registered nurses with a baccalaureate degree who had
completed a post–basic certification course (Table 1). The
Israel Ministry of Health requires that staff nurses who
work in an ICU complete an ICU post–basic certification
course. Compliance with this requirement is not always
100% because many units have new nurses who have
not yet completed the course and/or older nurses with
tenure who are unwilling to complete it. This course con-
tains both theoretical and clinical content, is given over
the course of 1 year, and usually consists of two study
days per week.
There was a statistically significant increase in the use
of EBPs as shown by the EBP score (T1: M = 7.6, SD =
2.5; T2: M = 8.3, SD = 2.4; t(436) = 3.05, p = .002)
and in the perceived level of priority of oral care (T1:
M = 67.7, SD = 26.7; T2: M = 73.4, SD = 25.5; t(397) =
2.20, p = .028). Increased EBPs were found in the areas
of teeth brushing and oral assessment. Decreases were
found in the use of non–evidence-based practices such
as the use of gauze pads, tongue depressors, lemon wa-
ter, and sodium bicarbonate. No differences were found
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Ganz et al.
in the use of chlorhexidine, toothpaste, or the nursing
documentation of oral care practices (Table 2).
T2 The EBP score was not related to most of the demo-
n (Valid%) graphic variables (including years of nursing experience,
type of ICU, gender, level of nursing education, and per-
cent employment). However, three variables were found
0
55 (24.8) to be significantly associated with the EBP score: having
139 (66.6) completed a post–basic certification ICU course (a signifi-
28 (12.6) cant difference between those that completed the course
vs. those that did not: t(424) = 2.3, p = .024); age [Pear-
son product moment correlation between age and EBP
175 (78.8)
score: (r(387) = .11, p = .027) and the level of priority
47 (21.2)
given to the ventilated patient’s oral care (Pearson prod-
uct moment correlation between the EBP score and the
139 (64.1) level of priority: r(392) = .15, p = .004).
78 (35.9) These variables were then placed into a multiple re-
gression model along with whether the participant was
sampled at T1, T2, or both times, with the EBP score as
the criterion variable. This model was significant (R = .21,
F(4,349) = 3.98, p = .004) with only the time of partici-
pation (T1 vs. T2, β = .105, p = .048) and level of priority
of oral care (β = .134, p = .014) significantly contributing
to the regression model.
Discussion
The results of this study lend further support to the
challenges associated with the translation of evidence
into clinical practice. Overall, nurses were more aware
of EBPs associated with oral care and increased its level
of priority. Some of the practices that received support in
the literature were implemented more frequently, while
other practices that are not supported were used less of-
ten. However, while a concerted effort was made to alert
critical care nurses to changes in oral care practices, those
nurses who were sampled in 2012 continued to similarly
perform oral care, with some changes in their practice.
Some of the equipment and solutions that have not
been supported in the literature (such as gauze pads,
tongue depressors, sodium bicarbonate, and lemon wa-
ter) decreased in use. On the other hand, there was a
significant increase in teeth brushing, conducting assess-
ments, and using a known tool to conduct this assess-
ment. These practices have also been supported in the
literature (Berry & Davidson, 2006; Berry, Davidson,
Masters, Rolls, & Ollerton, 2011; Berry, Davidson,
Nicholson, Pasqualotto, & Rolls, 2011). However, despite
evidence supporting the practices of cleaning the up-
per and lower mouth as well as the tongue (Berry &
Davidson, 2006; Berry, Davison, Nicholson, et al., 2011;
Berry, Davidson, Masters, et. al., 2011), these practices
were used less frequently. It is unclear why certain spe-
cific evidence-based practices and equipment or solutions
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Ganz et al. Translation of ICU Oral Care Guidelines

Table 2. Frequencies of Equipment and Solutions Used and Assessment Practices Related to Oral Care (T1 [2004–2005]: n = 218; T2 [2012]: n = 233)

T1 T2 Significant difference
Practice n (Valid%) n (Valid%) χ2 (df), p

Equipment
Gauze pad 182 (84) 24 (10) −86.6 (1), < .0001
Tongue depressor 118 (55) 64 (27) −34.8 (1), < .0001
Toothbrush 75 (35) 175 (75) 77.4 (1), <.0001
Gloved finger 46 (21) 38 (16) NS
Solution
Chlorhexidine 161 (75) 176 (76) NS
Sodium bicarbonate 90 (42) 34 (15) −41.1 (1), < .0001
Petroleum jelly 87 (40) 83 (37) NS
Toothpaste 72 (33) 66 (28) NS
Lemon water 55 (26) 24 (10) −18.0 (1), < .0001
Glycerin 40 (19) 37 (16) NS
Saline 30 (14) 43 (19) NS
Sterile water 24 (11) 20 (9) NS
Oral care practice
Clean the tongue 196 (91) 211 (91) NS
Clean the upper mouth 190 (88) 179 (77) −11.2 (1), < .001
Clean the lower mouth 187 (87) 172 (74) −12.2 (1), < .0001
Brush teeth 95 (44) 160 (69) 27.3 (1), < .0001
Assessment
Does oral assessment 205 (95) 175 (75) 34.7 (1), < .0001
Does assessment on admission 53 (25) 82 (35) 6.0 (1), = .014
Does assessment each shift 70 (33) 84 (36) NS
Uses assessment tool 5 (2) 64 (27) 55.5 (1), < .0001
Documents assessment and care 120 (57) 140 (60) NS

were chosen more often as compared with others. One
possible explanation is that practices that required an
active process such as cleaning and documenting were
decreased but passive practices such as not using cer-
tain products like gauze pads or tongue depressors were
increased. Other barriers to performance of the proto-
col might include lack of resources, high cost, and lim-
ited time. One major health fund now stocks a ready-
made kit that includes a disposable toothbrush connected
to suction. This could also explain some of the results.
Chlorhexidine was shown to be commonly used (even in
the first study), so there might not have been room for
improvement, thereby creating a type of ceiling effect.
No difference was found between those units that par-
ticipated in the study one time (either in 2004–2005 or
2012) or both times. It is possible that different nurses
were on staff when the first survey was conducted. This
also suggests that the intervention might not have been as
effective as we would have preferred, given the fact that
those units that participated twice received the entire in-
tervention, including staff presentations and the presence
of local evidence-based champions.
In general, nurses rated oral care as a very high level
of priority. Therefore, they realize the importance of this
practice. But on a practical basis, at least some of the
nurses either are unwilling or are unable to practice what
they believe. A possible reason could be time constraints
associated with performing oral care. However, our re-
sults show that those who view oral care as a priority are
more likely to practice according to the evidence.
In recent years there has been a dramatic increase
in the number of articles in the literature about how
clinicians use evidence and bridge the gap between re-
search and clinical decision making. This type of research
has been given many names, most commonly trans-
lation research or knowledge transfer-translation. Sev-
eral authors (Bhattacharyya, Estey, & Zwarenstein, 2011;
Curran, Grimshaw, Hayden, & Campbell, 2011) have
commented that this area of research is extremely com-
plicated because factors associated with the healthcare
system, the home institution or organization, the local
unit or peer group, and the individual all influence how
research plays a part in clinical decision making.
Some have looked at the barriers in knowledge trans-
fer such as the lack of usable, specific clinical information
reported in systematic reviews or meta-analyses (Tricco,
Tetzlaff, & Moher, 2011). Bosch, Tavender, Bragge,
Gruen, and Green (2012) recommend a stepped process

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to knowledge transfer, where practice recommendations
are developed that are locally applicable and are evidence
based. Gagnon (2011) added that the findings should be
targeted to specific audiences. This process was followed
by our EBN group. Bosch and colleagues (2012) suggest
that the first step is to identify high-quality guidelines,
then to select the strongest recommendations, update the
evidence, create an overview, discuss the evidence and
make an evidence statement, discuss the evidence with
stakeholders, and develop local best practice guidelines.
This could explain our partial success.
Another important resource in the translation process
is the use of clinical leaders or experts to advance the
process. Tuite and George (2010) and Richardson and
Tjoelker (2012) used clinical nurse specialists to facili-
tate clinical change. Others have stressed that it is im-
portant to create a community of practice or a network of
practitioners who can act as knowledge brokers (Gagnon,
2011; Shea, 2011) and who can develop active collab-
orations between researchers and clinicians. Our EBN
group is composed of staff nurses as well as nurse lead-
ers and researchers from many different ICUs through-
out the country. This group has turned into a network of
like-minded nurses who have acted as EBP champions at
their own institutions.
Administration support is another critical element re-
lated to knowledge transfer (Gallagher-Ford, Fineout-
Overholt, Melnyk, & Stillwell, 2011; Gawlinski, 2008).
Aitken et al. (2011) suggested that nursing administra-
tions provide mentors as well as the time and resources,
and create a culture that expects EBP and uses prac-
tical strategies such as working groups, a journal club,
and nursing rounds. They recommend that staff be ed-
ucated by being involved in the process. These actions
help to create internal expertise in knowledge transfer,
the creation of a clinical practice committee, and a nurs-
ing practice research council. Unfortunately, changes in
administrative support were beyond the capabilities of
the EBN group. However, we found a significant dif-
ference between T2 and T1 (including units not tested
at T1), suggesting increased compliance with the com-
ponents of the recommended oral care protocol. These
results show that our efforts and continuing efforts on
the part of some nursing administrations throughout the
country (EBP seminars and conferences at local and na-
tional levels were conducted throughout this time period)
might have influenced clinical practice in this area. The
study therefore might express changes over time on a na-
tional level, not only related to our efforts alone.
Several sources (Agency for Health Quality Research,
2004; Duffy, 2005) have suggested different ways to ef-
fectively transfer evidence to clinical practice. They rec-
ommend a combination of strategies, including opinion
360
Ganz et al.
leaders, continuing education, self-learning, audits and
feedback, small group consensus, provider reminder sys-
tems, incentives, continuous quality improvement initia-
tives, clinical information systems, and computer deci-
sion support systems. While some of these strategies were
used by the EBN group, many were not implemented.
This could be another reason for our partial success.
There were several limitations associated with this
study. This study was a “grass roots” effort by nurses
who were members of an EBN workgroup. They volun-
teered their time and effort to attend meetings and collect
data. There was some turnover among the members of
this group between the two data collection periods, and
most of the units that were surveyed at T1 were not sur-
veyed at T2. Therefore, the study cannot be considered as
a repeated measures study, thereby weakening its design.
There might have been some nurses who completed the
survey at both data collection points. Therefore, the sam-
ple might consist of nurses who were surveyed once or
twice. The goal of the initial study was to describe nurs-
ing practice and so no identifying data were collected that
could be used to determine whether a specific nurse par-
ticipated previously or not. Therefore, there is no way
to test whether nurses who participated once as opposed
to twice differed. However, no difference was found be-
tween those units that collected data once as opposed to
twice. The overall nature of the units could have changed
because at T2 there were more critical care units than at
T1. However, there were no significant differences in EBP
scores based on type of unit. We cannot conclude that
changes in practices were directly due to our efforts be-
cause many other programs were conducted during this
time period throughout the country. However, this inter-
nal validity threat of “history” might not be present be-
cause all of the units might have been exposed equally to
these efforts and there is no way of determining which
units were exposed and the degree of exposure. In addi-
tion, no process measure or measure of uptake was col-
lected. Therefore, there is no quantitative assessment of
how much new information nurses received.
Recommendations
We recommend that further attempts be made to in-
corporate evidence into other aspects of critical care prac-
tice, including the use of other strategies to improve oral
care practices. Such attempts at knowledge translation
should be investigated to determine what strategies work
best. Future studies could include measures of research
uptake as well as investigate which combination of trans-
lation strategies are most appropriate for a specific proto-
col or work environment.
Journal of Nursing Scholarship, 2013; 45:4, 355–362.
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Ganz et al.
Conclusions
Changing practice moves slowly. However, a coordi-
nated national effort can lead to increased EBP and hope-
fully to improved quality of care.
Acknowledgments
We thank the Israeli Cardiology and Intensive Care
Nursing Society and its members for supporting this
study.
Clinical Resources
r National Prevention of ventilator-associated pneu-
monia. Health care protocol. http://guideline.gov/
content.aspx?id=36063&search=oral+care+
intubated
r Oral health: nursing assessment and interventions.
http://guideline.gov/content.aspx?id=15612&
search=oral+care
r Research and Theory for Nursing Practice: An
International Journal http://www.nursing.arizona.
edu/osa/RISE2011/ImportantMaterials-NEW/
PhD%20-%20NEW/NURS%20695a%20RISE%
20materials/Woods and Magyary 2010 Why
Nursings Interdisc collaboration is essential.pdf
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