Improving oral care for stroke survivors

Each year 100,000 people in the UK experience a stroke. Dental disease is common among stroke survivors and is a contributory factor in secondary strokes. We worked with staff, patients, and carers at Salford Royal Hospital to design new ways to help stroke survivors manage their oral health.

Detail of a service map we created with health and social care professionals

Project overview

I assisted Matthew Lievesley to design and facilitate 4 co-design workshops at Salford Royal Hospital
We worked with stroke survivors from diverse backgrounds, family carers, and health and social care professionals
Created service maps, identified multiple opportunities in the existing service provision, and prototyped new ways to address oral health during and after hospital admission
Identified 13 potential ways to improve the patient journey
Rapid development, testing, and refinement of prototypes
Recorded and transcribed notes, sketches, and reflection logs

Designing the workshops

We had multiple questions we needed to address in a short space of time:

What is oral care currently like for stroke survivors and their families?
How have their routines changed? Are there situational, permanent, or comorbidity challenges we need to address? What value do they assign to oral health?
What does the service currently look like?
What opportunities can we help people to identify? How does community-based support change over time? Are there existing products or services that might help us to meet user needs? What are the constraints? Who will take ownership of any changes to the service?

We adopted an experience-based co-design (EBCD) approach recognising the expert, lived knowledge of service stakeholders. We situated ourselves as facilitators helping the participants to come up with ideas they felt would be impactful and feasible across in-patient and community settings.

Workshop 1 - stroke survivors and informal carers

We guided the participants through exploratory exercises to better understand how their oral health routines had changed and the specific challenges they faced, including fatigue, forgetfulness, and dexterity issues.
We helped each stroke survivor to map out their personal support network and discussed how this evolved as family dynamics and professional support changed over time. We noted that:

The stroke survivors felt that while they received good quality care overall, they were usually “given the wrong things at the wrong time” when it came to oral health
Family carers often used smartphones to search for medical information and practical advice in hospital and at home. They watched videos to see how to deal with specific challenges as they arose - explaining that it was usually more helpful to see a practical example than simply be told what to do

This helped us to understand their relationships with stroke support professionals, identify valuable informal support networks, and begin to prototype new interventions to assist them with the challenges they highlighted.

Workshop 2 - health and social care professionals

We created a map of the existing in-patient and community-based service journeys. This helped everyone to understand the wider context and framed discussions about gaps in the existing service. This helped us gather insights about the service and compare them to patient experiences.

Oral care support was available in hospital but it didn’t always get the attention it needed because of more urgent co-morbidities
Oral care was not a consistent part of their electronic patient records or care needs assessments, so it could be overlooked by professional caregivers in the community
They advised patients to visit their community dentist as soon as possible after leaving hospital. This did not always happen because of mobility issues and a lack of accessible dental practices. When appointments did take place, they often didn’t have enough time to properly address new needs

By the end of the workshop we‘d identified 13 possible ways to improve the existing service journey.

Details of a handmade future service map developed with health and social care professionals

At each stage we framed the journey around specific user needs and challenges

This approach helped us to identify where the current journey could be amended and where new interventions were needed

Workshop 3 - bringing everyone together

Ahead of this session we designed several prototypes aimed at promoting behaviour change, sustaining new habits, and training new techniques. The prototypes included:

Informal teaching sessions for carers and patients. Led by a dental nurse, these were weekly informal sessions to raise concerns, share ideas, and try new brushing tools and techniques with expert supervision
A patient and carers factsheet to reinforce messaging around the value of oral care, techniques and tools, and QR codes linking to video demonstrations. The factsheet also offered guidance on finding an accessible community dentist and other options such as home visits
Vouchers for double-length dental appointments, to give people more time to discuss the impact of their stroke and receive tailored advice
Reminder stickers to use at home, gently reinforcing advice on brushing techniques and frequency.
Take-home-and-test packs of oral care equipment such as brushes and handle attachments, mouthwashes, and dental flossers.

Participants gave us lots of feedback about the usefulness, content, visual clarity, and timing of each idea. We used this feedback to refine the prototypes ahead of the final workshop.

Prototype ward posters and take-home postcards

A voucher for a double-length dentist appointment

Workshop 4 - starting to implement these ideas

All the participants returned for a final workshop to further critique the refined prototypes and identify where they could be added to the existing service journey. The “show, don’t tell” approach towards training new brushing techniques was particularly well-received and implemented immediately.

Some of our other proposals could not be implemented straight away. For example, we couldn’t add oral care to the electronic patient records because changes had to sync with 2-year software update cycles. Similarly, the double-length dental appointment vouchers need more research into their effectiveness, ownership, and future funding.

Limitations

As external designers, our involvement with staff and patients at Salford Royal Hospital was relatively short-term. Although we helped to deliver some valuable changes to the service, I’m confident that a longer-term collaboration would unearth even more improvements and help us to fully assess the impact of all these changes to the experience of stroke survivors.