Review Reports - Assessing the Student Nurses’ Knowledge of Oral Health Care

Round 1

Reviewer 1 Report

Introduction

I saw a few studies that examine your topic, "Student nurses' knowledge of oral health care" You need to include a brief paragraph about these studies.

The knowledge gap still needs to be found; please explain what your study adds to the previous studies.

Methods

The sampling of your study could be higher, with only 72 students; you need to justify why you did not expand your study to other settings so you can expand your sampling.

Regarding the instrument, I think the questionaries are made by the researchers, so I think it is essential that you have more information about the questionaries consisting. Cronbach's alpha for new questionaries is insufficient to ensure the Validity and reliability of the questionaries. Consequently, it is essential to explain more about the Validity and reliability of the questionaries.

Overall comments

Please consider an English language revision of the manuscript

Ethical consideration: Please provide more information about the ethical consideration followed during the study, such as ethical approval no, how to maintain the privacy and confidentiality of the participants, and how to minimize the risk of their participation.

Discussion section: You need to expand the discussion because some results do not discuss, such as the result of oral health.

Please consider an English language revision of the manuscript

Author Response

1-Introduction

1.1-I saw a few studies that examine your topic, "Student nurses' knowledge of oral health care" You need to include a brief paragraph about these studies.

Thank you for this recommendation. We have now added a brief paragraph about the main results of these studies in the introduction section.

“However, some studies have identified inadequate oral care practices in nursing [15,16]. Moreover, other authors have suggested the prevalence of poor knowledge and negative attitude toward oral health among the nursing students [17,18. Therefore, In response to these recommendations nursing programs should equip graduates with core competencies to identify oral disease risks, conduct oral examinations, provide oral health information, connect oral health with diet and lifestyle counseling, and make referrals to dental professionals. An appropriate training and encouragement for promotion of oral health and to provide suitable care for the prevention of dental diseases should be included in the curriculum of nurses training [17] to achieve better results in oral health [17,19].”

1.2-The knowledge gap still needs to be found; please explain what your study adds to the previous studies.

Although in Spain there are many professionals working in oral health, such as dental professionals, dental hygienists, dental technicians, and dental assistants [5, 101], the access to these services is mainly private, which means not everyone has equal opportunities for access [100]. In contrast, the public health system offers a wide range of preventive activities at different levels of care, with many of them being led by nurses. Therefore, it is crucial to have nurses trained in oral health to promote the quality and safety of oral health care for individuals. Unfortunately, in Spain, most nursing degrees only address oral health superficially, without delving into it as they do with other diseases [102-105]. While there are some studies assessing the attitudes and practices of nurses concerning oral health [106-108], to the best of our knowledge, there are no existing studies evaluating the knowledge of nursing students on oral health. As a result, identifying the oral health knowledge of fourth-year nursing students, just before they start practicing as nurses, will be essential in guiding educational strategies both within the nursing degree and in different healthcare institutions.

We have now clarified this point in the introduction section.

“The Spanish healthcare workforce comprises over 316,094 registered nurses [14] that receiving an adequate education and training in oral health would have a potential impact on improving access and quality in this health dimension. However, in Spain, most nursing degrees only superficially address oral health, lacking the in-depth focus given to other diseases [21,24]. For instance, the University of Girona Nursing Faculty includes content on oral health within two subjects: 'Healthy Person Throughout Life' and 'Community Nursing I,' primarily from a preventive health perspective [21]. While some studies have assessed the attitudes and practices of nurses concerning oral health [25,27], to the best of our knowledge, no existing studies have evaluated the knowledge of nursing students on oral health. Hence, the aim of the present study is to analyze the knowledge in oral health of the students of the last grade of nursing degree. Understanding the preparedness of future nurses to provide optimal oral health care in the community is vital for shaping training strategies to acquire necessary nursing competencies during their degree and throughout their careers in various institutions.”

2-Methods

2.1-The sampling of your study could be higher, with only 72 students; you need to justify why you did not expand your study to other settings so you can expand your sampling.

Thank you for this observation.

The study involved a total of 139 participants, comprising all fourth-grade nursing students at the University of Girona Nursing Faculty, representing 100% of the eligible students. However, only 51.8% of these participants responded to the questionnaire. Despite this response rate, the data gathered from the 72 participants who did respond is deemed sufficient to address the objectives of our study.

It's worth noting that the University of Girona Nursing Faculty is the sole nursing faculty in the Girona Health Region, and the majority of nurses working in this region have graduated from this faculty. This unique aspect of our study setting enhances the relevance of our findings for the local healthcare context.

Furthermore, this study represents the first comprehensive assessment of oral health knowledge among nursing students at our faculty. While our sampling was limited to our own institution, we remain open to the possibility of expanding our research to include other nursing faculties across Spain in the future.

2.2-Regarding the instrument, I think the questionnaires are made by the researchers, so I think it is essential that you have more information about the questionnaires. Cronbach's alpha for new questionnaires is insufficient to ensure the Validity and reliability of the questionnaires. Consequently, it is essential to explain more about the Validity and reliability of the questionnaires.

Thank you very much for this observation.

At present, there is no validated instrument available to assess oral health knowledge among nursing students. Consequently, we developed an ad hoc questionnaire in collaboration with experts from both nursing and oral health fields. The development process involved consulting the most recent literature to ensure its accuracy and relevance. Although we had previously mentioned this limitation in the manuscript's limitations section, we have now provided further clarification on this aspect."

“Another limitation is the lack of a validated questionnaire to assess the knowledge of nursing students in oral health. However, we addressed this issue by developing a questionnaire in collaboration with experts in the field and by consulting the most recent literature. The questionnaire demonstrated good internal consistency"

In addition, prior to the study a pilot test was conducted with 10 students in order to evaluate the performance and reliability of the measurement instrument. All participants responded to the different questions of the questionnaire without any problems and no changes were required. Additionally, we assessed the internal consistency reliability of the 12-question test by performing Cronbach's alpha Test, which gave a range between 0.72 and 0.84. Nevertheless, we acknowledge the significance of having a validated questionnaire, which should be pursued as a separate research avenue. The validation of a questionnaire to assess the knowledge of nursing students in oral health could prove invaluable in monitoring the evolution of this knowledge among them. So, we have now added this information in the implication for practices section.

“In this line, we acknowledge the significance of having a validated questionnaire, which should be pursued as a separate research line. The validation of a questionnaire to assess the knowledge of nursing students in oral health could prove invaluable in monitoring the evolution of this knowledge among them. “

2.3-Ethical consideration: Please provide more information about the ethical consideration followed during the study, such as ethical approval no, how to maintain the privacy and confidentiality of the participants, and how to minimize the risk of their participation.

Thank you for your valuable comments and suggestions. For this study, we obtained the approval of the Girona University Committee (code CEBRU0004-23). We can also provide the ethics committee approval document if it is considered necessary.

To ensure participant confidentiality, all questionnaires were distributed using a distribution list, which prevented the disclosure of participants' identities. Additionally, the questionnaires did not include any personal information that could identify the participants.

Regarding potential risks, we want to assure you that participation in this study posed no risks to the participants. We have now incorporated all this relevant information regarding ethical considerations in the "2.6. Ethical Considerations" section of the manuscript."

“This study was approved by the University of Girona Ethics Committee (code CEBRU0004-23). The researchers informed all the participants about the objective of the study. The questionnaires were distributed to the participants through a distribution list and the information collected did not contain any personal data that could identify these participants, so anonymity was always maintained. Moreover, participants were informed that their participation did not have any risk. The completed questionnaires did not contain any personal information that could identify participants. The data were analyzed by a researcher and the principles defined in the Declaration of Helsinki were followed. “

3-Discussion section: You need to expand the discussion because some results do not discuss, such as the result of oral health.

Thank you very much for this recommendation. We have taken it into account and expanded our discussion to include all the results. In addition, we have added eleven new references. (8, 17-19, 21-28, 37-41, 46-48).

4-Overall comments

Please consider an English language revision of the manuscript

Thank you very much for your review and suggestion. A native English speaker has now reviewed the manuscript.

Author Response File: Author Response.pdf

Reviewer 2 Report

Nurses need to have a good understanding of oral health. Although apparently limited to one school of nursing, this study identifies a need to improve the exposure to oral health curriculum by nursing students. The authors are encouraged to repeat this study in additional nursing schools to see if there is a difference in results.

Author Response

Thank you very much for this observation. The curricula of nursing degrees are similar across different Spanish faculties, and oral health is usually approached from a perspective of public health and overall well-being. In the Girona Health Region, where this study was conducted, there is only one Nursing Faculty, and most nurses are trained in this particular institution. Therefore, including all the final year nursing students from this Faculty could provide us with a representative sample from the Girona Health Region. Nevertheless, in the future we can explore other regions as well. Additionally, it's worth noting that the curricula of Nursing Degrees in Spain are generally similar, which gives us an initial idea of the context.

Reviewer 3 Report

To the Authors,

I am content to be a reviewer for the article entitled “Assessing the student nurses’ knowledge on oral health care” submitted to Nursing Reports Journal which aim is to assess the knowledge regarding oral health of nursing student and its relationship with the dental care check-up.

Minor comments

In the introduction the second paragraph address the specific guidelines recommendations for patients with chronic diseases. This aspect is not related with the main outcome of the manuscript which is conducted on a sample of young healthy adults. I suggest to introduce a paragraph regarding oral health recommendation and guidelines for this age group.

Sample – it is a convenience sample. It would be useful to justify the reason why only 4th year students (the last college year) were selected as the study group.

Please specify if oral health was included in the university curriculum in nursing students.

The approval number provided by the ethics committee of the university is not mentioned - it must be included in the corresponding section.

The burden of expenses related to dental care is very important for patients and constitutes a barrier to adequate accessibility. The authors recognize this aspect and discuss it, but do not present results regarding this important aspect that would improve the significance of the research carried out.

Risk factors for dental pathology are not reported in this analysis – smoking, sugar products consumption.

Major comments

The questionnaire covers three important aspects - knowledge, attitudes and practices. However, no results that highlight the association between knowledge and practices (score of the knowledge questionnaire, grade during the year) and practices (number of dental check-ups, oral health status), nor between attitudes and practices are presented. The only correlation analyzed is between knowledge and attitudes (the importance of maintaining oral health). These would be very important results in accordance with the proposed objective of the article and that must be analyzed and presented.

The study covers an aspect with regional importance. Even the relevance for clinical practice was pointed in the discussion section, the aspect of originality and novelty were not addressed in the article.

Sincerely yours,

Author Response

Thank you very much for your comment.

1-Minor comments

1.1-In the introduction the second paragraph address the specific guidelines recommendations for patients with chronic diseases. This aspect is not related with the main outcome of the manuscript which is conducted on a sample of young healthy adults. I suggest to introduce a paragraph regarding oral health recommendation and guidelines for this age group.

Thank you very much for their recommendation. Although the study population are nursing students, often without chronic diseases, we have considered keeping this prior information since these people with chronic diseases are treated by nurses, who may have the opportunity to control and prevent oral health. In addition, we have added a paragraph regarding oral health recommendations and guidelines for young people. We have added a new reference (ref d)

“According to NICE [6], local authorities and partners should incorporate oral health promotion into existing services for all children, young people and adults. Regarding young people, there is a specific recommendation to promote a whole school approach to oral health among high school students. Oral health during childhood and adolescence is crucial for adult life, and in this regard, Spain has developed the Child Dental Health Plan. with the aim to improve oral health, promote healthy eating habits to prevent dental issues, and enhance access to dental health services for children and young people [8]. “

1.2-Sample – it is a convenience sample. It would be useful to justify the reason why only 4th year students (the last college year) were selected as the study group.

The contents in oral health are given in different subjects during the four years of the nursing degree and not only in a specific course, therefore, identifying the knowledge in oral health of the students of the last year of the degree found that it would be the best formula to know the knowledge of the students. In addition, these students are the ones who will soon join as nurses and therefore evaluate what they know about oral health. It is important to know the competencies of nurses in oral health right after finishing a nursing degree.

We have now justified this in the sample section of the article.

“The contents in oral health are given in different subjects during the four years of the nursing degree and not only in a specific course, but this is also the main reason why we included students in the last year, to be able to evaluate knowledge in oral health just before finishing the degree.”

1.3-Please specify if oral health was included in the university curriculum in nursing students.

Thank you very much for this recommendation. We have now added this information in the introduction section.

“However, in Spain, most nursing degrees only superficially address oral health, lacking the in-depth focus given to other diseases [21-24]. For instance, the University of Girona Nursing Faculty includes content on oral health within two subjects: 'Healthy Person Throughout Life' and 'Community Nursing I,' primarily from a preventive health perspective [21].”

1.4-The approval number provided by the ethics committee of the university is not mentioned - it must be included in the corresponding section.

Thank you very much for this observation. We have now added the number provided by the ethics committee of the Girona University in the ethical considerations section. We can also provide the ethics committee approval document if it is considered necessary.

“This study was approved by the University of Girona Ethics Committee (code CEBRU0004-23).

1.5-The burden of expenses related to dental care is very important for patients and constitutes a barrier to adequate accessibility. The authors recognize this aspect and discuss it, but do not present results regarding this important aspect that would improve the significance of the research carried out. Risk factors for dental pathology are not reported in this analysis – smoking, sugar products consumption.

Thank you very much for this suggestion.

Initially, we did not collect variables related to students' lifestyles to assess their potential impact on oral health outcomes and knowledge. However, we recognize the value of these variables in our study. As the first research on oral health knowledge among nursing students, our findings will aid in developing effective strategies to enhance this knowledge. In future studies, we propose to investigate the evolution of oral health knowledge among nursing students while also considering variables related to their health habits, which could provide insights into other potential relationships.

2-Major comments

The study covers an aspect with regional importance. Even though the relevance for clinical practice was pointed in the discussion section, the aspects of originality and novelty were not addressed in the article.

Thank you very much for this recommendation. On one hand, we conducted an analysis that showed no statistically significant association between knowledge of oral health and practices (receiving preventive dental care, experiencing cavities or undergoing orthodontic treatment).

“Students who worked in the healthcare field achieved slightly higher grades on the test compared to those who did not (6.5 vs. 6.2, Range: 0-10), especially those working in nursing homes (7,1 vs. 6,4, Range: 0-10). However, these differences were not found to be statistically significant (p>0.05).

Additionally, no significant differences were observed in test scores based on variables such as having family members working in the healthcare field, receiving preventive dental care, experiencing cavities, or undergoing orthodontic treatment (p<0.05). “

On the other hand, we have now incorporated the results between oral health attitudes and practices in the results section and we have also discussed it in the discussion section.

“Regarding sociodemographic variables, male participants scored higher in the variables "Acquisition of oral health knowledge during the nursing degree" (2.80 (0.45) vs. 1.80 (0.87); p < 0.017) and "Satisfaction with the oral health content received through master classes" (2.00 (0.00) vs. 1.46 (0.012); p = 0.02). Nursing students who had previous experience in the health field expressed a higher need for more oral health content during their nursing degree (1.98 (0.02) vs. 1.86 (0.07); p = 0.04). Participants with family members working in the health field perceived the importance of the nursing role in the prevention and promotion of oral health more positively (4.47 (0.12) vs. 3.94 (0.16); p = 0.01). No significant differences were observed in oral health attitudes based on the rest of the sociodemographic variables.

“Statistically significant differences were not observed in the assessment of different variables related to attitudes based on whether students went to the dentist preventively (p>0.05) or had worn orthodontics (p>0.05). However, students who had not experienced cavities considered the oral health content during their degree to be more sufficient than those who had experienced cavities (2.29 (0.20) vs. 1.75 (0.12); p=0.03). The rest of the variables did not show significant differences.”

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Overall, there is an improvement in the paper, and most comments are addressed. However, some comments still need to be revised

1- The gap of knowledge needs explained to be more to be clearer

2- I think the paper still needs to go for editing

I think the paper still needs to go for editing

Author Response

Overall, there is an improvement in the paper, and most comments are addressed. However, some comments still need to be revised

Dear reviewer, thank you very much for this comment.

1- The gap of knowledge needs explained to be more to be clearer

Thank you very much for this recommendation, we have now further explained the knowledge gap in the introduction section.

“While some studies have assessed the attitudes and practices of nurses concerning oral health [25-27], to the best of our knowledge, no existing studies have evaluated the knowledge of future nurses on oral health.

Being a concerning phenomenon that it can have negative repercussions on the overall healthcare of patients, the existing lack of knowledge about oral health among nurses should be taken into consideration.Although during the nursing degree, competencies, attitudes, and knowledge are assessed on many essential subjects for the profession [25-27], there are no specific outcomes regarding the knowledge of future nurses in oral health. Hence, the aim of the present study is to analyze the knowledge in oral health of the last year students of nursing degree. Identifying the knowledge of future nurses in oral health and determining their readiness to provide optimal oral health care to the community is essential for formulating effective education and awareness strategies within the nursing profession. This may encompass educational programs, workshops, and resources aimed at enhancing the understanding and application of sound oral health practices during their nursing education and in their practical healthcare settings. Ultimately, a more robust integration of oral health into nursing educational programs has the potential to significantly contribute to the overall enhancement of health outcomes for both individuals and communities.”

2- I think the paper still needs to go for editing

Thank you very much for this suggestion. A native English speaker has now reviewed our manuscript.

Reviewer 3 Report

Dear Authors,

The quality of the manuscript has improved after this revision and I appreciate your diligent effort. The importance for clinical practice included in the Discution section provides a better understanding of the purpose of the submitted article.

Sincerely yours,

Author Response

Dear Authors,

Sincerely yours,

Dear reviewer, thank you very much for your comments and also for your previous recommendations and suggestions that helped us to improve the manuscript.