Authors: Mohammadreza Askari, Mohammad Rahimkhani, Masoud Abdollahi, Ali Mohammadabadi, Hamideh Yaghoobi, Mohammad Namazinia
Categories: Research, Oral healthcare, Nurses, Knowledge, Attitudes, Practices, Hospitalized patients, Northeastern Iran
Source: BMC Oral Health
Authors: Mohammadreza Askari, Mohammad Rahimkhani, Masoud Abdollahi, Ali Mohammadabadi, Hamideh Yaghoobi, Mohammad Namazinia
Oral health is a vital component of overall health, particularly for hospitalized patients who are at higher risk of oral complications due to factors such as reduced salivary flow, medication side effects, and limited mobility. Nurses play a critical role in providing oral healthcare, yet studies indicate gaps in their knowledge, attitudes, and practices (KAP) in this area. This study aimed to evaluate the KAP of nurses regarding oral healthcare for hospitalized patients in northeastern Iran, a region with limited healthcare resources.
A cross-sectional study was conducted in 2023 among 112 nurses working in three hospitals in Torbat Heydarieh, northeastern Iran. Data were collected over a two-month period using a convenience sampling method and a validated questionnaire assessing knowledge (11 items), attitudes (16 items), and practices (8 items). The questionnaire underwent face and content validation, and its reliability was confirmed through a pilot study (Cronbach's alpha > 0.8). Data were analyzed using SPSS version 16, with descriptive statistics, chi-square tests, and correlation analysis.
The mean scores for knowledge, attitudes, and practices were 7.01 ± 1.47 (out of 11), 31.58 ± 4.93 (out of 80), and 4.31 ± 1.05 (out of 8), respectively. Significant correlations were found between knowledge and attitudes (r = 0.279, p < 0.01) and attitudes and practices (r = 0.149, p < 0.01). Nurses with higher education levels and more work experience demonstrated better knowledge and attitudes, though these did not always translate into improved practices. Male nurses had significantly higher knowledge scores than female nurses (p = 0.021).
The study highlights moderate knowledge, positive attitudes, and suboptimal practices among nurses regarding oral healthcare. The weak correlation between knowledge, attitudes, and practices suggests that improving oral healthcare requires not only education but also institutional support and resource availability. Given the relatively limited sample size and the use of convenience sampling, caution is advised when generalizing these findings to other populations. Targeted training programs, interdisciplinary collaboration, and systemic changes are recommended to enhance oral healthcare practices in hospitals.
Not applicable.
The online version contains supplementary material available at 10.1186/s12903-025-06363-x.
Oral health is a fundamental component of overall health, playing a critical role in preventing oral infections such as dental caries and gingivitis, while also reducing the risk of systemic complications like aspiration pneumonia, endocarditis, and the exacerbation of chronic illnesses [1, 2]. Hospitalized patients, particularly older adults, immunocompromised individuals, and those in intensive care units (ICUs), are at a heightened risk of oral health deterioration due to factors such as reduced salivary flow, the side effects of certain medications, and limited mobility [3–6]. In this context, nurses, as frontline healthcare providers, bear a direct responsibility to monitor, assess, and implement both preventive and therapeutic interventions to maintain patients' oral hygiene [7].
Despite this critical role, studies have revealed a significant gap between nurses' theoretical knowledge, attitudes, and actual clinical practices in oral healthcare [8–10]. This gap not only adversely affects patients' quality of life but also leads to prolonged hospital stays, increased infection rates, and additional healthcare costs [11–14]. Evidence from various countries points to insufficient training during both academic education and professional practice as a primary cause of this disparity. For instance, a study in Saudi Arabia found that only 34% of nurses were familiar with standard oral care procedures, and fewer than 20% routinely performed preventive interventions [8]. Similarly, a study in Kermanshah, Iran, by Nazarian Pirdosti et al. (2021) reported that nurses' knowledge of toothbrush care and proper cleaning techniques was "moderate," with only 15% using specialized tools like electric toothbrushes [15]. Another study in Yazd province, using the Delphi method, emphasized the urgent need for interdisciplinary training programs involving both dentistry and nursing, both in academic settings and as part of continuing education [16, 17].
However, it is important to note that most of these studies have limitations, including small sample sizes, focus on specific hospital departments (such as ICUs), or restriction to urban and better-resourced regions. Additionally, many studies have primarily evaluated knowledge or attitudes alone, without a comprehensive assessment of actual clinical practices. These limitations restrict the generalizability of their findings and highlight the need for broader, more inclusive research.
Most research in Iran has focused on specific populations or urban areas, leaving a gap in understanding the state of oral healthcare in hospitals in less developed regions, such as Torbat Heydarieh. Contextual challenges, including heavy workloads, staff shortages, and the low prioritization of oral healthcare, further complicate the situation [18]. Research by Mohammed Al-Rababa et al. (2018) highlighted that while nurses may have positive attitudes toward oral care, these attitudes do not always translate into improved practices without institutional support and adequate resources [8].
Given these challenges, a comprehensive evaluation of nurses' knowledge, attitudes, and practices (KAP) is essential to identify gaps and inform the development of targeted educational programs and healthcare policies. The findings of this study could serve as a valuable evidence base for designing region-specific educational interventions, updating clinical protocols, and informing hospital management and health authorities about the importance of integrating structured oral healthcare into routine nursing care. Additionally, it could contribute to shaping health policy by advocating for oral health promotion as a priority within hospital care services in underserved regions. To date, no study has simultaneously examined nurses' KAP regarding oral healthcare in hospitalized patients, particularly in underserved regions like Torbat Heydarieh. This study aims to fill this gap by assessing the level of knowledge, attitudes, and practices among nurses in this region, with the goal of improving oral healthcare delivery, enhancing patient outcomes, and reducing the burden of oral health-related complications.
This cross-sectional descriptive-analytical study was conducted between January and March 2023 to evaluate the knowledge, attitudes, and practices (KAP) of nurses regarding oral healthcare for hospitalized patients in Torbat Heydarieh, northeastern Iran. The study population included all nurses working in three major hospitals in the 9th Dey, Razi, and Imam Hossein (AS) hospitals. These hospitals serve as the primary healthcare centers in the area, providing a representative setting for assessing nurses' KAP. To ensure comprehensive data collection, the census sampling method was employed, including all eligible nurses in the study.
The study population consisted of nurses employed in the three selected hospitals. Inclusion criteria Employment as a nurse in one of the three hospitals.Holding at least a bachelor’s degree in nursing.Willingness to participate and provide informed consent.
Exclusion criteria Refusal to participate or withdrawal from the study at any stage.Incomplete questionnaire responses (missing data exceeding 10% of the total items).
A total of 124 nurses were eligible to participate in the study. Of these, 112 completed and returned the questionnaire, yielding a participation rate of 90.3%. Participation was entirely voluntary, and no coercion was applied during recruitment or questionnaire return.
Data were collected using a structured questionnaire divided into four Demographic Characteristics: This section recorded variables such as age, gender, education level, work experience, and ward.Knowledge Assessment: Ten multiple-choice questions were used to assess knowledge, with each correct answer scored as 1 and incorrect or unanswered questions scored as 0. The total knowledge score ranged from 0 to 11, with higher scores indicating better knowledge.Attitude Assessment: Sixteen items on a 5-point Likert scale were used to evaluate attitudes, with total scores ranging from 16 to 80. Higher scores reflected more positive attitudes.Practice Assessment: Eight self-reported questions, rated on a 5-point scale, assessed practical implementation. Higher scores indicated better practices.
The questionnaire underwent face and content validation by expert faculty members at the Torbat Heydarieh School of Nursing and Midwifery to ensure clarity, relevance, and comprehensiveness. Feedback from experts was incorporated into the final version. Reliability was assessed through a pilot study involving 30 nurses, with Cronbach’s alpha coefficients exceeding 0.8 for all domains, indicating high internal consistency. Test-retest reliability further confirmed the stability of the questionnaire over time.
The English version of the questionnaire is provided as Supplementary File 1, and is cited accordingly in the manuscript.
Data collection was conducted over a three-month period (January to March 2023) using the validated questionnaire. Ethical approval was obtained from the Ethics Committee of Torbat Heydarieh University of Medical Sciences (Approval Code: IR.THUMS.REC.1401.014). An official letter of introduction was issued by the Vice Chancellor for Research. After explaining the study objectives and obtaining written informed consent, questionnaires were distributed in hospital wards. Participants completed the questionnaires at their convenience and returned them confidentially.
Given the use of the census method, all nurses working in the three hospitals during the study period were included, ensuring a comprehensive representation of the target population.
Data were analyzed using SPSS version 16. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize the data. The Kolmogorov-Smirnov test was applied to assess the normality of the data. Chi-square tests were used to examine relationships between categorical variables, and correlation analysis was performed to evaluate associations between knowledge, attitudes, and practices. A p-value of less than 0.05 was considered statistically significant.
A total of 112 nurses participated in this study. The participants had a mean age of 34.52 ± 9.1 years and an average work experience of 8.84 ± 6.64 years. The majority of participants were female (75.0%), while males accounted for 25.0%. In terms of education, 85.7% held a bachelor’s degree, and 14.3% had a master’s degree or higher. Participants were distributed across various hospital wards, with the largest proportion working in the emergency department (17.0%), followed by the intensive care unit (ICU) (10.7%) and the internal medicine department (10.7%). Other wards included the neonatal intensive care unit (NICU) (6.3%), surgery (2.7%), neurology (4.5%), pediatrics (4.5%), coronary care unit (CCU) (7.1%), orthopedics (2.7%), neurosurgery (2.7%), obstetrics and gynecology (2.7%), and infectious diseases (1.8%). Additionally, 26.8% of participants were employed in other hospital departments (Table 1). Table 1Demographic characteristics of the studied patientsVariableN (%)MeanAge (Year)112 (100)34.52±9.1Work history (Year)112 (100)8.84± 6.64Gender Man28 (25.0)- Female84 (75.0)-Education Bachelor96 (85.7)- Master and above16 (14.3)Department Emergency department19 (17.0)- ICU12 (10.7)- NICU7 (6.3)- Surgical3 (2.7)- Neurology5 (4.5)- Pediatric5 (4.5)- CCU8 (7.1)- Medical12 (10.7)- Orthopedic3 (2.7)- Neurosurgery3 (2.7)- Women's3 (2.7)- Infectious2 (1.8)- Other30 (26.8)-
The mean scores for knowledge, attitudes, and practices were 7.01 ± 1.47 (out of 11), 31.58 ± 4.93 (out of 80), and 4.31 ± 1.05 (out of 8), respectively (Table 2). Comparative analysis based on demographic variables revealed that participants aged 40 years and above had significantly higher practice scores compared to those below 39 years (P = 0.021). However, no significant differences were observed in knowledge and attitude scores between the two age groups. Male participants demonstrated significantly higher knowledge scores than female participants (P = 0.021), but no significant differences were found in attitudes and practices between genders. Table 2Mean Scores of Nurses’ Knowledge, Attitudes, and Practices Regarding Oral HealthcareVariableMean ± SDKnowledge7.01 ± 1.47Attitude31.58 ± 4.93Practice4.31 ± 1.05
Regarding education, participants with a master’s degree or higher reported higher mean knowledge and attitude scores compared to those with a bachelor’s degree, although these differences were not statistically significant. Analysis of work experience showed that nurses with less than 5 years of experience had significantly higher knowledge (P < 0.001) and attitude scores (P = 0.019) compared to those with 5 or more years of experience. However, no significant differences were observed in practice scores based on work experience. These findings suggest that gender and professional experience significantly influence knowledge and attitude levels, while other demographic variables have a lesser impact (Table 3). Table 3Comparison of Knowledge, Attitude, and Practice Scores Based on Demographic VariablesVariableKnowledgeAttitudePracticeMean± SDPMean± SDPMean± SDPAge (years) 39>6.88± 1.610.14331.79± 5.170.4924.14± 1.050.021 40≤7.33± 0.9831.09± 4.314.46± 0.98Gender Male7.57± 1.450.02130.32± 4.900.1177.57± 1.450.505 Female6.83± 1.4332.01± 4.896.83± 1.43Education Bachelor6.91± 1.540.07431.38± 4.530.2864.35± 1.100.309 Master and above7.62± 0.7132.81± 6.934.06± 0.68Department General6.95± 1.410.58732.10± 5.610.1854.15± 1.110.053 Special7.10± 1.5530.84± 3.684.54± 0.93Work history (Year) 5>7.29± 1.47P<0.00133.79± 3.880.0194.02± 0.820.108 5≤6.83± 1.4530.16± 5.034.5± 1.15**P*-value <0.05 considered as significant, All analyses were performed using Chi-Square test
Correlation analysis revealed weak but statistically significant positive relationships between the variables. The correlation between knowledge and attitudes was significant (r = 0.279, P < 0.01), as was the correlation between attitudes and practices (r = 0.149, P < 0.01). The relationship between knowledge and practices was also positive but modest (r = 0.106, P < 0.01). These results indicate that while improvements in knowledge and attitudes may contribute to better practices, the association is weak, suggesting that other factors, such as workload or institutional support, may also play a role (Table 4). Table 4Results of Correlation Analysis Between Knowledge, Attitude, and PerformanceVariablesKnowledgeAttitudePerformanceKnowledge1.000.2790.106Attitude0.2791.000.149Performance0.1060.1491.00∙ The correlation coefficient (r) between variables is displayed.∙ Values marked with double asterisks (**) are significant at the 0.01 level (Sig < 0.01)∙ The relationships between variables are positive but weak, indicating a relatively low association among them
This study revealed that nurses in Torbat Heydarieh possessed moderate knowledge regarding oral healthcare for hospitalized patients, with approximately one-third of their responses incorrect. This finding aligns with those of Nazarian Pirdosti et al. (2021), who identified similar knowledge gaps in Kermanshah [15], and a study in Saudi Arabia, where only 34% of nurses were familiar with standard oral care procedures [8]. These consistent findings across diverse contexts suggest that oral health remains an underemphasized component in nursing education and professional development, especially in resource-limited settings.
Importantly, although the participating nurses generally held positive attitudes toward oral healthcare, these attitudes did not consistently translate into effective clinical practices. This pattern is consistent with the results of Al-Rababa et al. (2018), who reported that while positive attitudes are necessary, they are insufficient without institutional support, adequate training, and accessible resources [8]. Similarly, Safaa Rashad (2013) in Egypt identified a weak but significant correlation between knowledge, attitudes, and practices [11], underscoring the role of external factors such as workload, staffing shortages, and competing care priorities in shaping clinical behaviors [19].
Interestingly, some studies from higher-resourced countries, such as Australia, have demonstrated stronger correlations between knowledge, attitudes, and practices [20], highlighting the potential influence of healthcare infrastructure, continuing education opportunities, and institutional policies. This variation underscores the need for context-sensitive interventions.
To address the identified gaps, several practical measures are recommended. First, oral healthcare education should be formally integrated into nursing curricula and continuing professional development programs. Interdisciplinary workshops involving dental professionals could enhance both theoretical knowledge and practical skills. Second, healthcare institutions should develop and enforce clear, evidence-based oral care protocols. These should be supported by adequate resource provision, including access to specialized oral hygiene tools and materials. Third, administrative policies should prioritize oral care by incorporating it into routine nursing care checklists and performance evaluations, thereby increasing its visibility and importance within daily practice.
Future studies should employ longitudinal and interventional designs to assess the effectiveness of educational and policy interventions on nurses' knowledge, attitudes, and practices. Comparative studies across different provinces and healthcare settings could explore the influence of contextual factors such as workload, staffing levels, and organizational culture. Additionally, qualitative research involving nurses, dental professionals, and patients could provide deeper insights into perceived barriers and facilitators to optimal oral healthcare delivery in hospital settings.
This study highlights the need to enhance nurses’ knowledge, attitudes, and practices regarding oral healthcare for hospitalized patients. Integrating targeted oral health education into nursing training and ongoing professional development is essential. Additionally, institutional support and adequate resources are necessary to translate knowledge into practice. Interdisciplinary collaboration between nursing and dental professionals should also be promoted to improve patient outcomes. Future research should address organizational barriers that impact oral care delivery.
Supplementary Material 1.