how I...

I train others in
Tracy Broadley-Jackson is a speech and language therapist with Stone Rehabilitation Service, Staffs, tel. 01785 271100. She would be interested to hear from others who have experienced changes in practices in nursing homes as a result of training. Rachel Samuels is a speech and language therapist and the dysphagia lead working with the Manchester Learning Disability Partnership. Darren Chadwick is a research fellow in speech and language therapy at the Manchester Metropolitan University working with the speech and language therapists in the Manchester Learning Disability Partnership. Nicole Morrissey is a speech and language therapist working in Medicine for the Elderly in St Jamess Hospital, Dublin.

dysphagia
Still relatively new to the speech and language therapists armoury% skills in dysphagia management are undergoing dramatic development# In particular% there is recognition that dysphagia has to be seen as part of a whole picture and that the client and other team members are crucial to meaningful change# So% how is this affecting the way that speech and language therapists offer dysphagia training to others? The experiences of our three contributors apply not just to training in dysphagia but every other area where we seek to share our expertise and broaden our skills#

Read this
if you want simple ways of training others to problem$solve to involve clients in their own management to be more aware of your skills in training others

1. recognise gaps between what you recommend and what is done 2. target the attitudes and knowledge of key staff 3. build on peoples knowledge of what they already do 4. show the whole picture not parts in isolation 5. draw on a variety of strategies (information, feedback, modelling and role-play) and forums (courses, case-focused) 6. demonstrate using props such as video 7. aim for people to identify and manage problems, or refer on appropriately 8. measure how training has impacted on practice.

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Practical points for training

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mithard (1995) reports that a third of residents in nurscognitive and perceptual considerations and diet, nutritional ing homes have dysphagia. A study carried out by our and ethical issues taught by other members of the rehabilitainter-disciplinary community rehabilitation team tion team. (Shield & Hughes, 1998) corroborated these findings. Three questionnaires were administered before and after This prevalence of dysphagia does not match with the numthe course to the seven nurses attending from four homes. ber of referrals for swallowing assessments. Further, many of Questionnaire 1 asked the participants to explain what they these come from within the team itself when, for example, a understood by the terms dysphagia, swallowing, feeding, client referred having gone off their legs is found to have assessment and screening. The definitions given were coded underlying chest infections resulting from undetected swalas: correct, partly correct, incorrect, and different use of lowing problems. terminology. Overall, the scores were higher after the course Simply teaching nursing staff about eating and swallowing than before and the nurses had a greater depth and breadth difficulties in isolation - giving them one bite rather than the of understanding of terminology. whole apple - seems a limited exercise. In some instances, the Questionnaire 2 asked specific questions about clinical practice eating/swallowing problems are in themselves very minor. and knowledge, such as how many residents in their home had The difficulty lies in the whole picture of feeding, eating and feeding and swallowing difficulties, and would they routinely swallowing difficulties. Very often, correction of posture, proscreen for dysphagia. After the course, four participants stated vision of appropriate cutlery and verbal instruction are the they felt the number of residents in their homes affected was key factors in facilitating safe and efficient eating and swalhigher than they estimated before the course, and the others lowing. Steele et al (1997) and Backstrom et al (1987) showed indicated increased awareness. The nurses felt more confident that problems with posture, cutlery, cognitive status, staff in identifying and helping those residents, and able to pass attitude/knowledge, diet and level of supervision provided their new knowledge on to colleagues. were more prevalent than swalQuestionnaire 3 required lowing problems alone. them to view a video of a roleFigure 1 Alerters checklist Speech and language therapists play, and identify what was have realised the need to relinwrong and what they would ALERTERS TICK IF ACTION TAKEN PRESENT quish their stronghold in dysphado. No one person correctly PREDISPOSING gia. It is important to build on the identified all eight problems Neuromuscular knowledge and experience that either pre or post training. impairment, eg CVA nursing staff possess in feeding Most gave greater detail but, Reduced alertness clients - after all, they do it day-in, as a group, they collectively Reduced awareness day-out. A holistic approach is scored lower after the trainmore consistent with the philosoing. This may reflect some conPoor posture phy of an inter-disciplinary team, fusion and overload of inforDysarthria (weakness of and many problems that arise can mation, or that they were oral and facial musculature) be addressed, at least in the first remembering solutions rather Reduced mobility instance, with routine, practical than really problem-solving. It Increased/high levels of general actions such as ensuring the client might also be that the quesdependency with poor dentition is seated correctly. This is particutionnaire was not sensitive HEALTH larly true of clients in the commuenough to identify subtler Chest infection (recurrent, chronic) nity who often have chronic dyschanges in knowledge; certainDehydration phagia and for whom pneumonia ly some nurses overall scores Weight loss is more associated with the sequeremained the same although lae of long-term disability, such as they put in different informaMEAL TIME reduced mobility (Langmore et al, tion, suggesting they had Eating very slowly 1998). access to a wider range. Eating very quickly Training nursing staff is always In terms of how they would Food left on plate fraught with difficulties such as improve the clients difficulEasily distracted poor attendance and staff ties, all scored better on the turnover. These problems aside, post-course questionnaire. N-G/PEG in situ how do we know that what we These improvements reflected Reluctance to eat have taught them will be rememan increase in knowledge Avoiding foods bered and utilised? A lot of time across all areas of feeding and Food/drink on clothes and energy is put into preparing, swallowing difficulties, includdelivering and receiving any ing diet textures, perceptual SWALLOWING INDICATORS training, so we must feel confidifficulties and positioning. Drooling dent that it meets the clients In the last workshop the nursPooling needs and is cost-effective. es produced a checklist modiDifficulty chewing A two-day course was offered to fied from one of the overheads Coughing/choking before/ local nursing homes to for use in their homes (figure 1). during/after swallow 1) enable staff to identify feeding Twelve months later, staff from Weak cough and swallowing problems. two of the homes reported that 2) enable staff to initiate actions the checklist has influenced Wet or gurgly voice which might wholly or partly their overall screening for new remediate the problems. clients, whilst the other two 3) encourage staff to make timely and appropriate referrals course participants did not recall it. Although the checklist does for further assessment and intervention. not appear to have been incorporated into everyday practice, with As well as teaching about normal and abnormal eating and more support and training it does have considerable potential as a swallowing, the course also covered posture and positioning, screening tool, not only for nurses but other professionals too. This"

One bite or the whole apple?

By addressing the whole picture of dysphagia through training% health$ care professionals gain a wider range of skills to identify and manage the problem# Tracy Broadley$Jackson tested this out with nursing home staff $ and learned that such projects raise as many questions as they find answers#

PIC HAS BEEN REQUESTED BUT AS YET NOT RECEIVED

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is particularly pertinent in an interdisciplinary community setting. I hope the training enabled staff to be in a better position to engage more fully in rehabilitation programmes instigated by the team - crucial to this is good communication aided by a common language. This point was highlighted in questionnaire 1, where a fourth category was included because the nurses placed a different emphasis on some words. For example, most nurses interpreted feeding as an activity which they did to residents (compared with my working definition taken from Logeman (1983), which is about the whole process of placing food/drink in the mouth, regardless of who does it). The study has raised a number of other questions: to what extent has the training impacted upon the nurses practice in the short and long term? are residents feeding and swallowing difficulties now being managed appropriately? how can we provide robust evaluation to demonstrate the benefits of training?

References
Backstrom, A., Norberg, A. & Norberg, B. (1987) Feeding difficulties in long-stay patients at nursing homes. Caregiver turnover and caregivers assessments of duration and difficulty of assisted feeding and amount of food received by the patient. Int. J. Nurs. Stud 24 (1) 69-76. Langmore, S.E., Terpenning, M.S., Schork, A., Chen, Y., Murray, J.T. & Loesche, W.J. (1998) Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia 13(2) 69 - 81. Logeman, J. (1983) Evaluation and Treatment of Swallowing Disorders. Texas: Pro-ed. Shield, S. & Hughes, S. (1998) Dyphagia in Nursing Homes. Royal College of Speech & Language Therapists Bulletin (September). Smithard, D.G. (1995) Dysphagia should be investigated. Geriatric Medicine (January). Steele, C.M., Greenwood, C., Ens, I., Robertson, C. & SeidmanCarlson, R. (1997) Mealtime difficulties in a home for the aged: Not just Dysphagia. Dysphagia 12:43-50.

Read all about it! Fred the Head stops Mars Bars in bed
Do you realise how much training you do and the many different ways you offer it% often simultaneously? Rachel Samuels and Darren Chadwick take a systematic look at dysphagia training to benefit people with learning disabilities and find that% the more people are involved and understand what is required% the more they are likely to do it#

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ur speech and language therapy team runs a twoday introductory course to eating drinking and swallowing problems for people supporting adults with learning disabilities and dysphagia. Complementing this is the extensive information given on an individual basis to caregivers and clients for each dysphagia referral. Training caregivers to manage a clients dysphagia varies from client to client and caregiver to caregiver, but there are commonalities. Dysphagia management involves moving from social support to social and medical support. Historically the social care philosophy has run the risk of leaving caregivers with no understanding of what has caused their clients learning disability, let alone their dysphagia, yet they are the key people advocating for the clients health needs. Part of training may well involve understanding for the first time the kind of neurological damage that may have led to a persons disability. This is important to dispel the myths of a person, coughing for attention, getting lazy with their eating or taking too long. In my practice dysphagia training always includes providing caregivers with sufficient anatomical knowledge to understand why something has gone wrong. For this, Fred the head, an anatomical model of a lateral cross-section of the head (with moving epiglottis), is invaluable. This helps equip caregivers with accurate terms and descriptions and establishes a common frame of reference from which to build up a picture of the difficulties the person they support may be experiencing. It should also help caregivers identify and describe clearly symptoms and exacerbating factors of dysphagia if they see them in other people that they work with. I use management strategies to guide training. Clients who have had a videofluoroscopy tend to have their tape held as part of their case notes and these are an invaluable training tool. The sight of aspirated tea mixed with a little barium heading down the wrong tube has been a powerful tool for change on many occasions. In addition, caregivers can clearly see why those extra few seconds before the next mouthful are so important when they observe a videofluoroscopy revealing pooling in the valleculae, or food or drink returning into the oral cavity as a result of poor cricopharyngeal opening. Shared experiences between the speech and language therapist, caregivers and clients of managing and living with dysphagia through the use of safe consistencies, positioning, utensils, support, pacing and prompting, help to not only share good practice, but also to enable a group to challenge practice that may be unsafe and inappropriate. This has been particularly apparent when talking about appropriate clothing

protection, meal presentation, and feelings about the use of specialised utensils that caregivers may feel are different. The other outcome is hopefully to ensure caregivers have the same mental checklist of management as appears in a persons written eating and drinking guidelines. I have found using a risk assessment framework has also worked well in equipping caregivers with useable, practical strategies. Training will aim to ensure that the risks of aspiration, asphyxiation, dehydration, poor nutritional status, injury, discomfort and a loss of personal dignity are highlighted. Formulating common sense risk reduction strategies helps to put the management strategies I may recommend in a meaningful form. Research conducted within our service (Chadwick et al., in press) has indicated that the knowledge caregivers have of the risks of non-adherence to dysphagia management strategies is a good predictor of actual observed compliance. I wonder if as a profession we are always aware of quite how much training we do? Most of our training is surely provided through the repeated visits we make to clients and their caregivers. Only when my co-author Darren pointed out to me that I didnt record how I had trained staff, did I begin to think about the different ways in which this is done. When writing up and classifying details of the dysphagia training we had conducted, using categories outlined by Jahr (1998), Darren noticed that we used many different types of training simultaneously. For example, a visit may well involve giving information, both written and verbal, about the nature of the problem, providing feedback on a caregiver or a clients technique of modifying consistencies or presenting food or drinks, modelling pacing, bolus size, and verbal or physical prompts. I had forgotten that I also use role-play to help caregivers understand why eating and drinking may be so fatiguing for the client. Maybe speech and language therapists would have a clearer idea about which aspect or combination of aspects of our support and training are most effective if we separated out the different types of training we use, or looked at them more systematically. Also it would be interesting to find out if different types of training were more effective with different caregivers or clients. Just when I think the training is complete I often revisit and fine tune aspects of a clients guidelines. This can be particularly useful in helping caregivers and the client to own the work that has been done. Consolidation of all of the above training strategies occurs in the formal dysphagia management guidelines written for each person with dysphagia. They include the nature of the problem, management strategies, potential risks and also charts for monitoring change (for example in Body Mass Index).

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Difficulties, despite the most thorough training, have been known. Training caregivers who are promptly moved two months later is common in all services. Challenging peoples firmly held beliefs and myths regarding food and drinks needs to be carried out with sensitivity, but does need to be achieved if the beliefs and myths are detrimental to a clients health. Julie, who is in her 70s, had refused a range of food options. When she was offered tripe almost as a joke, her reaction obviously indicated that she would like this. However, staff didnt feel this was a healthy or nice option. Hence, training was required to challenge staff preconceptions about food. This is a vivid example of a situation I often face, the need to work with staff and clients to establish the details of preferences and consistencies. Paid caregivers may well be trained and have a good understanding of safe practice. Families can be particularly resistant to speech and language therapy input around dysphagia management. In my experience this has ranged from not believing dysphagia exists to not believing that slowing the pace of the meal may reduce the risks of aspiration and asphyxiation. One method my team have used with some success in such cases is to ask paid caregivers to act as a model for the parent or family member.

The aspect that brings perhaps the greatest sense of satisfaction is the training I provide for the person with dysphagia. When we understand we are more likely to do. David only agreed to stop eating Mars bars in bed lying down when Fred The Head had demonstrated the risks. Once David understood why I was asking him to modify aspects of his eating and drinking he not only complied, but co-wrote his guidelines and prompted me to add please chop my meat up and add more gravy to his Delta Talker!

References
Chadwick, D.D., Jolliffe, J. & Goldbart, J. (2002) Carer Knowledge of Dysphagia Guidelines. International Journal of Language and Communication Disorders (In press). Jahr, E. (1998) Current issues in staff training. Research in Developmental Disabilities 19 (1) 75-87.

Resources
Fred The Head, an anatomical head with moving epiglottis and removable larynx is available from Adam Rouilly ltd, Castle Road, Eurolink Business Park, Sittingbourne, Kent ME10 3JG. Delta Talker is supplied in the UK by Prentke Romich International ltd, see www.prentromint.com.

n the course of dysphagia management, thickening fluids is a frequent recommendation made by the speech and language therapist. There is a wide base of evidence to suggest that changes in viscosity of fluid alter the biomechanics of the swallow (Smith et al, 1997). Reviews of the literature highlight changes with increased viscosity of a fluid: increased oropharyngeal transit times, intrabolus pressure, duration of pharyngeal peristalsis, duration of tongue base contact to the posterior pharyngeal wall and duration and excursion of hyoid movement. Upper esophageal sphincter parameters are also modified due to increased viscosity, and increased duration of relaxation (Smith et al, 1997) and opening (Kuhlemeier et al, 2001) have been reported. Therefore the patient who may be at risk of aspiration with free fluids may be able to tolerate fluids of a thicker consistency. However a significant difficulty with this line of management is patient compliance. Anecdotal evidence suggests that the majority of patients do not like drinks being thickened and there is a lack of standardisation across consistencies being prepared. To address such issues I carried out a study to: 1. evaluate inter-rater reliability of various consistencies among speech and language therapists, nursing staff, ward attendants 2. compare and contrast general consensus within each group tested
Figure 1 Questionnaire to aid judgement Figure 2 Correct judgement

3. highlight the need for further training for specific groups 4. improve quality of thickened fluids being made by staff 5. improve patient compliance with thickener in fluids secondary to increased staff knowledge regarding thickened fluids. Five glasses of water (125mls each) were measured out. Each was thickened to a different consistency using a commercial thickening agent, Nutilis. Three of the consistencies were those as recommend by speech and language therapists: syrup consistency (two scoops), semi-solid consistency (two and a half scoops), set consistency (three scoops). Two distractors were used, a consistency too thin for a patient (one and a half scoops) and a consistency too thick for a patient (four scoops). Each consistency was made up by the same speech and language therapist, and each group of five left standing for approximately 10 minutes. Before being asked to identify the consistencies each participant Frustrated by the lack of was told that three of the consistencies were those recommended by speech and language therapists. They were also given written literature on the use of criteria for each (syrup, semi-solid, set). Each participant was also thickener in dysphagia% told that two of the consistencies were acting as distractors and Nicole Morrissey carried were to be described as generally too thin or too thick to be given to a patient. Each participant had then to fill in a short out a small study across questionnaire (figure 1) for each of the five consistencies and, based on the answers, decide on the category (figures 2, 3 and 4). " the Medicine for the

Consistent with consistencies

Occupation _________________

Occupation

Rating Scale
Please tick the appropriate box for each consistency Consistency A : Description Is fluid smooth ? Does fluid flow easily ? Can a figure of 8 be easily traced ? Will a plastic spoon stand up in consistency? Does fluid fall off slowly ? This is _____consistency Yes No
nurse ward attendant
Figure 3 Incorrect judgement

No. of participants

This consistency was correctly identified this percentage of the time: Syrup S/solid Set Too thin Too Thick 100% 80% 67% 100% 80% 67% 100% 100% 80% 50% 100% 100% 100% 80% 100%

speech and language therapist 5 5 6

Figure 4 Error analysis

Elderly Directorate# Her findings have led to a training programme for ward attendants to help them understand why their consistency with consistencies is so important#

This description of consistency syrup semi-solid set too thin too thick

...was wrongly applied this percentage of the time: 31.25% 25% 31.25% 0% 12.5%

This consistency ...was most frequently described as : syrup semi-solid set too thin too thick too thin syrup semi-solid or too thick n/a (no errors) set

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Of the three groups, the speech and language therapists were the most consistent in accurately identifying each consistency. This would be expected given that the department had drawn up the criteria defining each consistency. The group of ward attendants were the least accurate which is significant given that, at ward level, the majority of fluids are thickened by this group. This study highlights that discrepancies exist between what the speech and language therapist recommends and what the patient is getting. Inter-rater reliability is inadequate to ensure a patient is consistently receiving one of the three consistencies recommended on a daily basis by speech and language therapists. This in turn illustrates the need for inservice and further training that includes not only clear definitions of consistency but also rationales for the various consistencies used (Colodny, 2001) to reduce the risk of patients not receiving consistent treatment across the continuum from assessment to daily intake (Glassburn & Deem, 1998). Appearance of a food item is considered a major factor contributing to its acceptance (Ballou Stahlman et al, 2001) therefore if patients are receiving fluids that are over thickened, poor compliance should be expected. From the findings of this study a speech and language therapist is to offer a trial education period of all ward attendants starting in Med-El. After six months staff will be randomly assessed again. It is hoped that identification of consistencies as recommended by speech and language therapists will be improved. There are many limitations with this study. Small numbers of participants make it impossible to draw general conclusions. Some had more experience and education regarding use of thickener than others. One of the aims of this study was to increase patient compliance secondary to greater staff education. However as this was not objectively measured prior to assessment it cannot be measured objectively post-trial training period of

staff. It is also quite difficult to measure patient compliance with speech and language therapy recommendations. It can be subject to limitations such as recall bias and is dependent on the persons initial understanding of instructions (Low et al, 2001). This study highlights the point that recommendations need to be clearly explained to all other relevant members of staff involved with the patient. It cannot be taken for granted by speech and language therapists that what is being recommended is automatically what the patient is receiving.

References
Ballou Stahlman, L., Mertz Garcia, J., Chambers, E., Bosma Smit, A., Hoag, L. & Chambers, D.H. (2001) Perceptual Ratings for Pured and Molded Peaches for Individuals With and Without Impaired Swallow. Dysphagia 16: 254- 262. Colodny, N. (2001) Construction and Validation of the Mealtime and Dysphagia Questionnaire. An Instrument designed to Assess Nursing Staff Reasons for Non-Compliance with Speech and Language Pathologists Dysphagia and Feeding Recommendations. Dysphagia 16: 263-271. Glassburn, D.L. & Deem, J.F. (1998) Thickener Viscosity in Dysphagia Management: Variability among Speech and Language Pathologists. Dysphagia 13: 218- 222. Kuhlemeier, K.V., Palmer, J.B. & Rosenberg, D. (2001) Effects of Liquid Bolus Consistency and Delivery Method on Aspiration and Pharyngeal Retention in Dysphagia Patients Dysphagia 16: 119-122. Low, J., Wyles, C., Wilkinson, T. & Sainsbury, R. (2001) The Effect of Compliance on Clinical Outcomes for Patients with Dysphagia on Videofluoroscopy. Dysphagia 16: 123-137. Smith, C.H., Logemann, J.A., Burghardt, W.R., Carrell, T.D. & Zecker, S.G. (1997) Oral Sensory Discrimination of Fluid Viscosity. Dysphagia 12: 68-73.

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Swallowing Disorders in Dementia

Are you looking for a text which combines research based information on feeding and swallowing in dementia with practical management strategies? Author Jacqueline Kindell - speech and language therapist and therapy services manager in Old Age Psychiatry - encourages a focus on the individual and a step-by-step approach of observation, documentation and management. Feeding and Swallowing Disorders in Dementia normally retails at 34.95 but Speechmark Publishing Ltd (formerly Winslow Publishing) is making FIVE copies available FREE to lucky readers of Speech & Language Therapy in Practice. To enter, simply send your name and address marked Speech & Language Therapy in Practice - FSDD offer to Su Underhill, Speechmark, Telford Road, Bicester, OX26 4LQ. The closing date for receipt of entries is 25th October and the winners will be notified by 31st October. Feeding and Swallowing Disorders in Dementia is available, along with a free catalogue, from Speechmark, tel. 01869 244644.

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002