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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 8


Basic strategies
Swallowing......on a plate (OLoughlin & Shanley, 1996)
is an Australian dysphagiamanagement (training) pro-
gramme designed for use in nursing homes so that,
following training, nursing home staff would be able
to provide basic assessment and management strate-
gies for their patients. It provides information about
swallowing problems and their management in
user-friendly handouts and information sheets. It
introduces specific forms and protocols that provide
a model to help implementation of the package
within the home. Five modules cover the following
topics: understanding the swallowing process; the
assessment and management of swallowing prob-
lems; implementation of the SOAP programme in
the nursing home; supplementary information and
resources. The modules are designed to be taught
to other staff by an experienced registered nurse.
SOAP includes four instruments:
1. a prefeeding checklist (swallowing screening tool);
2. swallowing assessment checklist (observation at
mealtime, noting consistency of food and drink,
position of client, level of dependence and
obviously presence of swallowing problems);
3. swallowing management index (details of possible
problems and related strategies such as feeding
techniques to aid lip closure) and
4. swallowing care plan. Importantly the care plan
provides details of supervision required, special
procedures necessary, positioning - location and
posture, equipment required and client-specific
advice gained from the swallowing management
index (see figure 1, p.9).
A pilot SOAP project within a Renfrewshire NHS
continuing care hospital is reported fully else-
where (Bain, 2003) so we will summarise it here
before we compare it to one
undertaken in Tayside.
Renfrewshire is a mixed urban and
rural community situated southwest
of Glasgow with approximately
30,000 people over the age of 65
years. A very limited specialist com-
munity / domiciliary speech and
language therapy service of assess-
ment and advice (with no review)
for clients over 65 years with swal-
lowing problems is available. It is
therefore necessary to consider
any model of care that will max-
imise the effectiveness of this limited service.
The essential features of the Renfrewshire project
were the introduction of a new model of care which
ensured that, following the training and implemen-
tation period, regular speech and language therapy
review of clients could be achieved. Rather than
relying on self-directed study, all nursing staff
(including auxiliaries / nursing assistants) in a long
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Read ths
his article is not about infection con-
trol, but a training package called
Swallowing......on a plate (SOAP for
short). Our two Scottish speech and
language therapy services coinciden-
tally and simultaneously piloted this
package in markedly different ways and we thought
it would be useful to compare them. Importantly, we
found that, even though it is slow and difficult to
achieve successful new multidisciplinary working,
this model of care can be used and adapted to dif-
ferent environments.
So, why is such a package needed? Dysphagia is
recognised in the literature and in clinical experi-
ence as a widespread problem in the long-term
care settings of residential and (especially) nursing
homes as well as in continuing care wards for
older people (Smithard, 1996; Steele et al, 1997;
Kayser-Jones & Pengilly, 1999). Management of
swallowing difficulties may however not be part of
the training or knowledge-base of staff
in these institutions and so residents
and clients with dysphagia may be
experiencing unnecessary malnutrition,
dehydration, chest infections and
problems taking medication among
other side-effects of inadequately
managed dysphagia, including acute
hospital admissions.
Specialist speech and language
therapy and dietetic services to these
locations are often restricted by
resource limitations. One solution to
this problem has been to provide
training to staff in swallowing and dysphagia
management. Speech and language therapy
training programmes however have been devel-
oped locally and mainly for hospital settings
(acute wards and stroke units), without validity
and reliability being established (Gravill, 1999;
Magnus, 2001). Long-term effectiveness is rarely
reported.
T
We included a
control home so
that measures
devised for the
project could be
assessed for
test-retest
reliability.
The need
When Linda Armstrong and
Alison Bain found out they were
piloting the same off-the-shelf
package, they were naturally
interested to compare methods
and results. Swallowing......on a
plate (SOAP) may benefit people
with dysphagia, but the principles
are relevant to any client group
where the aim is to train other
professionals in basic assessment
and management.
Linda Armstrong
stay hospital received training (either one or two
sessions) over eight consecutive days. Link nurses
were identified to screen clients for swallowing
problems and develop care plans for managing their
dysphagia. The speech and language therapist
assessed the appropriateness of each care plan and
monitored each identified client fortnightly over the
six month pilot period. Assessment of the effective-
ness of the training was measured in terms of
increased staff knowledge and more appropriate
feeding behaviour (as deemed by observation of
mealtimes by the speech and language therapist).
Effects of training
The aim of the project undertaken in rural Tayside
was to evaluate the short- and longer-term effects
of in-service training on acquired dysphagia with
residential and nursing home staff using a published
training package. The project objectives were:
to evaluate SOAP as a training package for local use
to evaluate the effectiveness of SOAP in increasing
knowledge and changing working practices
and so to improve the quality of care for people
with acquired neurological swallowing problems.
The project focused on the two residential and two
nursing homes in the catchment area for GPs based
in one of the five geographical localities of Perth
and Kinross Local Health and Social Care Co-opera-
tive (LHSCC). The local community hospital was also
initially included, as there was an identified training
need which had not been met as part of the rolling
community hospital training programme (because
of staff shortage in the hospital). Its client popula-
tion is more transient than that of the homes and it
has a different balance of trained and untrained
staff. However, the SOAP training package and its
protocols appeared possibly to be applicable also in
the hospital setting. In addition we reckoned that, if
both the community hospital and the homes in the
locality were using the same method of identifying
and managing swallowing problems, transfer of
information about individual people in either direc-
tion would be expedited. We also included a control
home in another locality, so that measures devised
for the project could be assessed for test-retest reli-
ability. For this home, the initial day-long training
was offered following two baseline assessments.
We used a number of outcome measures pre- and
post-training to examine the short- and long-term
effectiveness of the programme. These were: com-
parison of referral / re-referral rate and quality of
referral (speech and language therapy and dietetics);
resident profiles and swallowing environment obser-
vations (nutrition checklist, swallowing environment
checklist); a food / fluid customer satisfaction ques-
tionnaire; SOAP knowledge quiz and training day
evaluation sheets. At the end of the project, we sent
a short questionnaire to home managers / matrons.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 ,
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for SOAP
Figure 1 Sample Care Plan
Background:
Step 1: Prefeeding Assessment Checklist
May lead to either Nil-by-mouth / onward referral or Step 2: Swallowing Assessment Checklist
Refer to solutions in Swallowing Management Index and develop Step 4: Swallowing Care Plan
Case history:
This case history is taken from the SOAP Manual (p48)
Mrs White had a right CVA three years ago. She has a left facial droop, slurred speech and has no dentures. She sometimes
coughs with thin fluids, takes a long time to eat her meals, is losing weight and has difficulty swallowing her medication.
She often slips down in her chair, and pockets food in her mouth.
SOAP step 4:
Swallowing Care Plan (See SOAP Manual, p51)
Devised by Grainne OLoughlin & Chris Shanley 1996
USE: To be filled out by a registered nurse and reviewed as necessary. To be used by all persons feeding or super-
vising a resident at mealtimes, as a guideline for safe swallowing.
Residents Name: Mrs White
(Please tick any boxes that apply)
DIET
Diet consistency:
Normal
Soft
Minced & Mashed
Puree
Diabetic Diet: Yes No Other Special Diet:
PREFEEDING
Supervision:
Needs to be fed
Needs to be supervised
Doesnt need supervision
Comments:
POSITIONING
Location for mealtime:
Upright in bed
Upright in chair
At dining table
Comments:
EQUIPMENT
Adapted cutlery Plate guard Cut-out cup
Straw for drinks Spouted cup Clothing protection
Other equipment
Comments:
SPECIFIC ASSISTANCE FOR RESIDENT
Please insert specific instructions needed to assist this resident.
(Use the information from the Swallowing Management Index)
* Massage Mrs Whites left cheek to prevent pocketing
* Prompt Mrs White to clear residue from her cheek using her tongue
* Reposition Mrs White if she slips down the chair
* Prevent drooling by getting Mrs White to hold her lips closed on the left side
* Note change in diet to Puree and Thick Fluids
* Note change to crushed medications
STOP FEEDING if resident is drowsy, coughing, choking or aspirating.
Staff to be aware of procedure in event of choking.
Signed
M. Assessor
Date
26/3/96
1996 Centre for Education & Research on Ageing and Inner West Geriatrics & Rehabilitation Service. Reproduced with permission.
Fluid Consistency:
Thin
Thick
Very thick
Administration of Medications:
Give as normal
Liquid form only
Crush and mix with puree
Special Instructions
Additional requirements:
Dentures
Glasses
Hearing Aid
Special procedures:
Suction on standby
To be fed by specified staff only
Posture for feeding:
Keep head in midline
Cushion/pillow for support:
- behind head
- behind back
- under arm L / R

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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 +o
Do l seek out exstng o-the-
she packages beore spendng
tme deveopng my own'
Do l network wth other speech
and anguage therapsts to
compare methods and resuts'
Do l pan how l w assess
reabty, vadty and ong-term
eectveness o a project'
Reectons
Response to the project varied among the care
homes and the hospital (see table 1). Two baseline
measures were taken at the control home but two
planned training days were cancelled by this home
because of staffing problems; staff shortage was
given as the reason at the community hospital too.
The referral rate to speech and language thera-
py and dietetics did not increase post-training.
Resident profiles (describing swallowing prob-
lems and their management) pre- and post-train-
ing depended on the member of staff reporting -
there was little reliability. Swallowing environ-
ments in the residential homes were very positive.
In the nursing homes, post-training improvement
was seen in one (NH1) but not the other (NH2,
whose commitment to the project appeared to
peter out). In the control home, no change was
noted from the first baseline measure to the sec-
ond. Satisfaction among a sample of residents
varied among the homes. Participants at the
training day showed a significant improvement in
knowledge immediately post-training. This
improvement was sustained over six months by
the staff who attended the follow-up half-day
(several of the participants had left by then).
There are several implications for the use of
SOAP in care homes:
This package can promote increased knowledge
about dysphagia and change in working practice
and should be rolled out on an ongoing basis to
other homes in the Local Health and Social Care
Co-operative.
Small changes are needed to reflect UK
circumstances (for example, food items and
vocabulary).
Responses among the homes varied. Perhaps in
future homes that are willing to commit to change
(if necessary) and able to give staff protected
time should be targeted.
Another way forward would be the development
of a dedicated team of allied health professionals
for residential and nursing homes. The remit of
this team would include both ongoing training
and assessment / management of residents
chronic problems. A model for this exists in
Glasgow (Scott, 1999).
Used quite differently
SOAP was used quite differently in the two pro-
jects (see summary in table 2). The composition of
project staff in the two areas shows that either
one person or a team can run a training project.
There was also variation in planning time, with
protracted discussions required in Renfrewshire
and a much shorter lead-in time in Tayside. In
both projects we trained staff looking after older
people in institutions where turnover of clients /
residents is likely to be slow, but where the same
cannot necessarily be said for staff turnover. The
number of staff trained was very different. The
model used in Renfrewshire is our preferred one,
in which all staff received training. In Tayside the
range of staff grades and experience was prob-
lematic in terms of generalisation of the training
to the homes. Training time was longer in Tayside
than in Renfrewshire but the model of care in
Renfrewshire was introduced in the continuing
care hospital rather than in any care homes.
The Tayside project included a wider range of
outcome measures, most of which were developed
specifically, for example customer satisfaction ratings
and quality and rate of referrals. Three of the
homes changed working practice after their train-
ing as measured by observation of swallowing
environment and feeding practices at mealtimes;
however the changes were much less widespread
than those achieved by the blanket training in the
continuing care hospital. There it was noted that
length and quality of mealtimes had improved,
and that appropriateness of feeding strategies had
improved significantly. Importantly, the speech and
language therapist was able to monitor clients reg-
ularly and thus, we feel, provided a more effective
speech and language therapy service as a result of
implementing the SOAP model.
So, would we use the SOAP training package
again? YES.
And do we recommend it for use either in care
homes or long stay hospitals? YES.
Linda Armstrong is a speech and language therapist
working for Perth & Kinross LHSCC, NHS Tayside,
e-mail linda.armstrong.slt@tpct.scot.nhs.uk and Alison
Bain a speech and language therapist with NHS Argyll
and Clyde at New Sneddon Street, Paisley (contact via
e-mail Wendy.Toner@renver-pct.scot.nhs.uk).
References
Bain, A. (2003) Swallowing on a plate. Bulletin of
the Royal College of Speech and Language
Therapists. May.

Table 2 Comparing our use of SOAP


Renfrewshire Tayside
Project team 1 speech and language therapist 3 speech and language therapists and 1 dietitian
Project length 6 months 1 year
Time in planning 18 months 3 months
Locations involved 1 continuing care hospital 5 care homes and a community hospital
Staff trained 82 trained nursing staff and auxiliaries18 care home staff
Length of training One day (repeated x8) One and a half days
Outcome measures Knowledge and feeding environment Knowledge, referral rate, swallowing
environment, resident profiles, customer
satisfaction, manager questionnaire
SOAP model of care introduced yes no
Difficulties Huge speech and language Control home training
therapy commitment Community hospital could not send staff
Limited funding Range of levels of staff trained
Changes as an outcome of Speech and language therapy Individual to homes
the project service offered in different way
SOAP documentation in place
Table 1 Response to the Tayside project
RH1 RH2 NH1 NH2 Hospital
Interested in participating Yes Yes Yes Yes Yes
Able to send staff Yes Yes Yes Yes No
to training
Pre-training measures Yes Yes Yes Yes N/A
Post-training measures Yes Yes Yes Yes N/A
Changes in working Yes Yes Yes No N/A
practice observed
Staff sent to 6-month Yes Yes Yes No N/A
follow-up
Manager questionnaire Yes Yes Yes No N/A
returned
RH= residential home, NH = nursing home
Gravill, P. (1999) SIGNs of progress in dysphagia.
Speech & Language Therapy in Practice Spring: 12-15.
Kayser-Jones, J. & Pengilly, K. (1999) Dysphagia among
nursing home residents. Geriatric Nursing 20: 77-82.
Magnus, V. (2001) Dysphagia training for nurses in
an acute hospital - a pragmatic approach.
International Journal of Language &
Communication Disorders 36 (supplement): 375-378.
OLoughlin, G. & Shanley, C. (1996)
Swallowing......on a Plate: A Training Package for
Nursing Home Staff Caring for Residents with
Swallowing Problems. The Centre for Education
and Research on Ageing: Concord, Australia.
Scott, D. (1999) Communication and swallowing
training for care home staff. Nursing &
Residential Care 1: 318-321.
Smithard, D.G. (1996) Feeding and swallowing
problems in the institutionalized elderly. Clinical
Rehabilitation 10: 153-54.
Steele, C.M., Greenwood, C., Ens, I., Robertson, C.
& Seidman-Carlson, R. (1997) Mealtime difficulties
in a home for the aged: not just dysphagia.
Dysphagia 12: 43-50.
Resources
Further information about SOAP and other training
resources is at www.cera.usyd.edu.au.
Acknowledgements
Alison Pendlowski and Alison Cuthbertson were the
speech and language therapists also involved in the
Tayside SOAP project and Alison Gibb the dietitian.
Funding for the Renfrewshire project was received
from the Directorate of Continuing Care and Old
Age Psychiatry and in Tayside from the Initiatives
Fund of Tayside Primary Care NHS Trust.