Gap Analysis:
Oral Health: Nursing Assessment and Intervention, 2008
Work Sheet
This guideline can be downloaded for free at:
http://rnao.ca/bpg/guidelines/oral-health-nursing-assessment-and-intervention
The RNAO Toolkit: Implementation of Best Practice Guidelines, Second Edition is also available at:
http://rnao.ca/bpg/resources/toolkit-implementation-best-practice-guidelines-second-edition
What is a Gap Analysis?
Uses of a Gap Analysis
A process comparing your organization’s current
practice with evidence-based best practice
recommendations to determine:
 Existing practices and processes that are currently
implemented and supported by best practices. This
information is useful to reinforce practice strengths.
 Recommendations that are currently partially
implemented in practice. These would be good first
targets for change efforts.
 Recommendations that are not currently being met.
 Recommendations that are not applicable to your
practice setting.
 Contributes to annual evaluation by allowing you to
compare practice from year to year and choose
which areas to focus on changing within the year.
 Focuses on needed practice change which prevents
a total overhaul of practice and builds on
established practices and processes.
 Informs next steps such as development of
infrastructure to support implementation,
stakeholder engagement, identification of barriers
and facilitators, resource requirements, selection of
implementation strategies and evaluation
approaches.
 Leads to sustained practice change by informing
plans related to process, staff and organization and
reinforces current evidence based practices.
Conducting a Gap Analysis
Engage the team, and internal and external stakeholders as needed in gathering information for the gap analysis.
Collect information on:
 Current practice – is it known and is it consistent?
 Are there any barriers to implementation? These
(met, unmet, partially met)
may include staffing, skill mix, budget, workload
issues, etc.
 Partially met recommendations may only be
implemented in some parts of the home, or you
 What are the time frames in relation to specific
may feel it is only half done.
actions and people or departments who can
support the change effort?
 Are there some recommendations that must be
implemented before others?
 Are there links with other practices and programs in
the LTC home?
 Can any recommendations be implemented
quickly? These are easy wins and build confidence
 Are there existing resources and education that
in the change.
your LTC home can access?
 Are there recommendations based on higher levels
 Are there any must-do recommendations that are
of evidence than others?
crucial to resident and staff safety?
Next Steps
What do Levels of Evidence mean?
1. Celebrate the recommendations you are
meeting.
2. Prioritize the areas you want to work on. Start
with practice changes that can be made easily
or are crucial to resident and staff safety. Start
by reinforcing success and focusing on quick
wins.
3. These priority areas become the foundation for
planning your program or implementing
practice change.
4. For more information on taking your gap
analysis to the next level see the RNAO Toolkit:
Implementation of Best Practice Guidelines
(Second edition).
After each guideline recommendation you will notice a
level of evidence. Levels of evidence is a ranking
system used to describe the strength of results
measured in clinical trials and other types of research
studies.
Ia: Evidence obtained from meta-analysis of
randomized controlled trials.
Ib: Evidence obtained from at least one randomized
controlled trial.
IIa: Evidence obtained from at least one welldesigned controlled study without randomization
IIb: Evidence obtained from at least one other type of
well-designed quasi-experimental study, without
randomization
III: Evidence obtained from well-designed nonexperimental descriptive studies, such as
comparative studies, correlation studies and case
studies.
IV: Evidence obtained from expert committee reports
or opinions and/or clinical experiences of
respected authorities
Long-Term Care Homes:
Contact your Long-Term Care Best Practice
Co-ordinator to assist you in completing a gap
analysis. Visit RNAO.ca/ltc.
Gap Analysis – Updated September 2013
Page 2 of 6
Gap Analysis Work Sheet - Oral Health: Nursing Assessment and Intervention, 2008
Date Completed:
Team Members participating in the Gap Analysis:
Unmet
Partially
Met
RNAO Best Practice Guideline
Recommendations



Met



Notes
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
other programs or partners)
Practice Recommendations
1.0 Nurses should be aware of their personal oral
hygiene beliefs and practices, as these may
influence the care they provide to their clients.
(Level of Evidence = III)
2.0 As part of their client admission assessment,
nurses obtain an oral health history that
includes oral hygiene beliefs, practices and
current state of oral health.
(Level of Evidence = IV)
3.0 Nurses use a standardized valid and reliable oral
assessment tool to perform their initial and
ongoing oral assessment.
(Level of Evidence = III)
4.0 Oral health status information is regularly
reviewed with all members of the health care
team to monitor client progress and facilitate
the development of an individualized plan of
care. (Level of Evidence = IV)
5.0 Nurses provide supervised and remind or cue
oral care for clients at least twice daily on a
routine basis. This includes clients who:
 have diminished health status
 have decreased level of consciousness
 and who have teeth (dentate) or do not have
teeth (edentate)
(Level of Evidence = IV)
6.0 Nurses provide or supervise the provision of oral
care for clients at risk for aspiration.
(Level of Evidence = III)
7.0 Nurses provide ongoing education to the client
and/or family members regarding oral care.
(Level of Evidence = III)
8.0 Nurses are knowledgeable of oral hygiene
products and their applications as they pertain
to their specific client populations.
(Level of Evidence = IV)
9.0 Nurses are aware of treatments and medications
that impact on the oral health of clients.
(Level of Evidence = IV)
Gap Analysis – Updated September 2013
Page 3 of 6
Unmet
Partially
Met
RNAO Best Practice Guideline
Recommendations
Met
Gap Analysis Work Sheet - Oral Health: Nursing Assessment and Intervention, 2008
Notes
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
other programs or partners)
10.0 Nurses use appropriate techniques when
providing oral care to clients.
(Level of Evidence = IV)
11.0 Nurses advocate for referral for those clients
who require consultation with an oral health
professional (e.g. dental hygienist, denturist,
dentist)
(Level of Evidence = IV)
12.0 Nurses ensure that all oral health-related
history assessment and care be documented.
(Level of Evidence = IV)
Educational Recommendations
13.0 Nurses require appropriate oral health
knowledge and skills acquired through entry
level nursing education programs and ongoing
professional development opportunities.
(Level of Evidence = IV)
14.0 Nurses who provide oral hygiene care to their
clients, either directly or indirectly, must
participate in, and complete, appropriate oral
hygiene education and training.
(Level of Evidence = IV)
Organization and Policy Recommendations
15.0 Health care organizations develop oral health
care policies and programs that recognize the
components of oral health assessment oral
hygiene care and treatment are integral to
quality client care.
(Level of Evidence = IV)
16.0 Health care organizations develop partnerships
and increase capacity among providers to
deliver collaborative practice models that
improve the oral health care they provide to
their clients.
(Level of Evidence = IV)
17.0 Health care organizations implement
continuing education opportunities for nurses
and support them to complete oral hygiene
education and training that is applicable to their
health care setting.
(Level of Evidence = IV)
18.0 Health care organizations develop oral hygiene
care standards that are based on the best
available evidence and ensure they are
implemented and monitored as part of the
organizations commitment to providing quality
oral health care and services.
(Level of Evidence = III)
Gap Analysis – Updated September 2013
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Unmet
Partially
Met
RNAO Best Practice Guideline
Recommendations
Met
Gap Analysis Work Sheet - Oral Health: Nursing Assessment and Intervention, 2008
Notes
(Examples of what to include: is this a priority to our home,
information on current practice, possible overlap with
other programs or partners)
19.0 Organizations should encourage and offer
support including time and resources for nurses
top participate in oral hygiene research to assist
in better understanding the issues related to
oral hygiene care provisions in various health
care settings.
(Level of Evidence = IV)
20.0 Oral hygiene care is monitored and evaluated
as part of the organizations’ quality
management program utilizing a variety of
quantitative and qualitative approaches.
(Level of Evidence = IV)
21. Organizations develop a plan for
implementation of best practice guideline
recommendations that include:
 An assessment of organizational readiness and
barriers/facilitators
 Involvement of all members (whether in a
direct or indirect supportive function) who will
contribute to the implementation process
 Ongoing opportunities for discussion and
education to reinforce the importance of best
practices
 Dedication of a qualified individual to provide
the support needed for the education and
implementation process
 Ongoing opportunities for discussion and
education to reinforce the importance of best
practices
 Opportunities for reflection on personal and
organizational experience in implementing
guidelines
 Strategies for sustainability
(Level of Evidence = IV)
Gap Analysis – Updated September 2013
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Gap Analysis Work Sheet - Oral Health: Nursing Assessment and Intervention, 2008
Appendix A
Applicable Ministry of Health and Long Term Care Regulations for Oral Health
General Requirements for Programs
General requirements
30. (1) Every licensee of a long-term care home shall ensure that the following is complied with in respect
of each of the organized programs required under sections 8 to 16 of the Act and each of the interdisciplinary
programs required under section 48 of this Regulation:
1. There must be a written description of the program that includes its goals and objectives and relevant
policies, procedures and protocols and provides for methods to reduce risk and monitor outcomes,
including protocols for the referral of residents to specialized resources where required.
2. Where, under the program, staff use any equipment, supplies, devices, assistive aids or positioning aids
with respect to a resident, the equipment, supplies, devices or aids are appropriate for the resident
based on the resident's condition.
3. The program must be evaluated and updated at least annually in accordance with evidence-based
practices and, if there are none, in accordance with prevailing practices.
4. The licensee shall keep a written record relating to each evaluation under paragraph 3 that includes the
date of the evaluation, the names of the persons who participated in the evaluation, a summary of the
changes made and the date that those changes were implemented. O. Reg. 79/10, s. 30 (1).
(2) The licensee shall ensure that any actions taken with respect to a resident under a program, including
assessments, reassessments, interventions and the resident's responses to interventions are documented. O. Reg.
79/10, s. 30 (2).
Nursing and Personal Support Services
Oral care
34. (1) Every licensee of a long-term care home shall ensure that each resident of the home receives oral
care to maintain the integrity of the oral tissue that includes,
(a) mouth care in the morning and evening, including the cleaning of dentures;
(b) physical assistance or cuing to help a resident who cannot, for any reason, brush his or her own teeth;
and
(c) an offer of an annual dental assessment and other preventive dental services, subject to payment being
authorized by the resident or the resident's substitute decision-maker, if payment is required. O. Reg.
79/10, s. 34 (1).
(2) The licensee shall ensure that each resident receives assistance, if required, to insert dentures prior to
meals and at any other time as requested by the resident or required by the resident's plan of care. O. Reg. 79/10,
s. 34 (2).
Personal items and personal aids
37. (1) Every licensee of a long-term care home shall ensure that each resident of the home has his or her
personal items, including personal aids such as dentures, glasses and hearing aids,
(a) labelled within 48 hours of admission and of acquiring, in the case of new items; and
(b) cleaned as required. O. Reg. 79/10, s. 37 (1).
(2) The licensee shall ensure that each resident receives assistance, if required, to use personal aids. O. Reg.
79/10, s. 37 (2).
Gap Analysis – Updated September 2013
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