is particularly pertinent in an interdisciplinary communitysetting.I hope the training enabled staff to be in a better position toengage more fully in rehabilitation programmes instigated bythe team - crucial to this is good communication aided by acommon language. This point was highlighted in question-naire 1, where a fourth category was included because thenurses placed a different emphasis on some words. For exam-ple, most nurses interpreted ‘feeding’ as an activity which they‘did’ to residents (compared with my working definition takenfrom Logeman (1983), which is about the whole process ofplacing 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 nowbeing managed appropriately?•how can we provide robust evaluation to demonstrate thebenefits of training?
Backstrom, A., Norberg, A. & Norberg, B. (1987) Feeding dif-ficulties in long-stay patients at nursing homes. Caregiverturnover and caregivers’ assessments of duration and diffi-culty of assisted feeding and amount of food received by thepatient.
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?
13(2) 69 - 81.Logeman, J. (1983) Evaluation and Treatment of SwallowingDisorders. 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.
(January).Steele, C.M., Greenwood, C., Ens, I., Robertson, C. & Seidman-Carlson, R. (1997) Mealtime difficulties in a home for theaged: Not just Dysphagia.
SPEECH & LANGUAGE THERAPY IN PRACTICE
ur speech and language therapy team runs a two-day introductory course to eating drinking andswallowing problems for people supporting adultswith learning disabilities and dysphagia.Complementing this is the extensive information given on anindividual basis to caregivers and clients for each dysphagiareferral. Training caregivers to manage a client’s dysphagiavaries from client to client and caregiver to caregiver, butthere are commonalities.Dysphagia management involves moving from social sup-port to social and medical support. Historically the social carephilosophy has run the risk of leaving caregivers with nounderstanding of what has caused their client’s learning dis-ability, let alone their dysphagia, yet they are the key peopleadvocating for the client’s health needs. Part of training maywell involve understanding for the first time the kind of neu-rological damage that may have led to a person’s disability.This is important to dispel the myths of a person, ‘coughing forattention’, ‘getting lazy with their eating’ or ‘taking too long’.In my practice dysphagia training always includes providingcaregivers with sufficient anatomical knowledge to under-stand why something has gone wrong. For this, ‘Fred thehead’, an anatomical model of a lateral cross-section of thehead (with moving epiglottis), is invaluable. This helps equipcaregivers with accurate terms and descriptions and estab-lishes a common frame of reference from which to build up apicture of the difficulties the person they support may beexperiencing. It should also help caregivers identify anddescribe clearly symptoms and exacerbating factors of dys-phagia if they see them in other people that they work with.I use management strategies to guide training. Clients whohave had a videofluoroscopy tend to have their tape held aspart of their case notes and these are an invaluable trainingtool. The sight of aspirated tea mixed with a little bariumheading down the wrong tube has been a powerful tool forchange on many occasions. In addition, caregivers can clearlysee why those extra few seconds before the next mouthful areso important when they observe a videofluoroscopy revealingpooling in the valleculae, or food or drink returninginto theoral cavity as a result of poor cricopharyngeal opening.Shared experiences between the speech and language ther-apist, caregivers and clients of managing and living with dys-phagia through the use of safe consistencies, positioning,utensils, support, pacing and prompting, help to not onlyshare good practice, but also to enable a group to challengepractice that may be unsafe and inappropriate. This has beenparticularly apparent when talking about appropriate clothing
Read allabout it!Fred theHead stopsMars Barsin bed
Do you realise howmuch training you doand the many differentways you offer it
oftensimultaneously? RachelSamuels and DarrenChadwick take asystematic look atdysphagia training tobenefit people withlearning disabilities andfind that
the morepeople are involved andunderstand what isrequired
the more theyare likely to do it
protection, meal presentation, and feelings about the use ofspecialised utensils that caregivers may feel are ‘different’.The other outcome is hopefully to ensure caregivers have thesame mental checklist of management as appears in a per-son’s written eating and drinking guidelines.I have found using a risk assessment framework has alsoworked well in equipping caregivers with useable, practicalstrategies. Training will aim to ensure that the risks of aspiration,asphyxiation, dehydration, poor nutritional status, injury, dis-comfort and a loss of personal dignity are highlighted.Formulating common sense risk reduction strategies helps toput the management strategies I may recommend in a mean-ingful form. Research conducted within our service (Chadwicket al., in press) has indicated that the knowledge caregivershave of the risks of non-adherence to dysphagia managementstrategies is a good predictor of actual observed compliance.I wonder if as a profession we are always aware of quitehow much training we do? Most of our training is surely pro-vided through the repeated visits we make to clients andtheir caregivers. Only when my co-author Darren pointed outto me that I didn’t record how I had trained staff, did I beginto think about the different ways in which this is done. Whenwriting up and classifying details of the dysphagia training wehad conducted, using categories outlined by Jahr (1998), Darrennoticed that we used many different types of training simulta-neously. For example, a visit may well involve giving informa-tion, both written and verbal, about the nature of the problem,providing feedback on a caregiver or a client’s technique ofmodifying consistencies or presenting food or drinks, modellingpacing, bolus size, and verbal or physical prompts. I had forgot-ten that I also use role-play to help caregivers understand whyeating and drinking may be so fatiguing for the client. Maybespeech and language therapists would have a clearer idea aboutwhich aspect or combination of aspects of our support and train-ing are most effective if we separated out the different types oftraining we use, or looked at them more systematically. Also itwould be interesting to find out if different types of trainingwere more effective with different caregivers or clients.Just when I think the training is complete I often revisit andfine tune aspects of a client’s guidelines. This can be particularlyuseful in helping caregivers and the client to own the workthat has been done. Consolidation of all of the above trainingstrategies occurs in the formal dysphagia managementguidelines written for each person with dysphagia. Theyinclude the nature of the problem, management strategies,potential risks and also charts for monitoring change (forexample in Body Mass Index).