competencies

When is good
When does a speech and language therapist have sufficient competency to manage a client whose difficulties fall outside the remit of standard training? Lorna Gamberini explores this in relation to people with dysphagia associated with head and neck cancer and finds that, as a profession, we have much to ponder.

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reflecting most caseloads, but to what extent does this prepare them to treat dysphagia in head and neck cancer patients? In 1999 the RCSLT Education Committee Dysphagia Working Group published recommendations as to the necessary knowledge base and skills level for pre-registration, post-registration and advanced level dysphagia education. Figure 1 shows my interpretation of how this applies to patients with head and neck cancer.
Figure 1 Expected competence

No. of speech and language therapists All

Level of training

Expected competence (dysphagia associated with head and neck cancer)

PreGood knowledge of normal registration anatomy and physiology of the head and neck, and of the normal swallow. PostKnowledge of the needs of registration clients with complex conditions. Advanced Ability to manage clients postwith complex conditions. registration

All of those working with adults with dysphagia Relatively few of those working with adults with dysphagia

ollowing the Calman-Hine Reports standards for patient-centred delivery of cancer services (1994), we have seen a shift in organisation and delivery, including centralisation to cancer centres or units. This allows patients to have access to multidisciplinary teams with knowledge, expertise and experience in specific cancers. The downside is that patients may have to travel considerable distances, especially where there is a need for ongoing rehabilitation. Head and neck cancer patients often need to attend speech and language therapy for communication and swallowing difficulties resulting from their treatments. Because of the distances involved, responsibility is often devolved to the local community therapist. All speech and language therapists working with adults with dysphagia are required to have post-graduate training. For the majority this is at a post-registration level, as relatively few go on to the Advanced level (RCSLT, 1999). It is likely that their training is largely neurologically based,

While there is a wealth of literature on the effects of surgery and radiotherapy on the swallowing process, there is relatively little about speech and language therapy intervention and even less on the level of expertise or experience on which that intervention should be based. The BAO-HNS Consensus Document (2000), for example, in its chapter on speech and swallowing rehabilitation talks of team members having sufficient post-qualification experience (as well as a major clinical component in this field). The case example in figure 2 (p.5) shows why it is important that the therapist dealing with people with head and neck cancer has knowledge of:

1) Staging of tumours
The first time I encountered the staging classification of tumours (BAO-HNS, 2000) in medical notes, it was a complete mystery. Although the speech and language therapist is not involved in the staging progress it is important to have a clear understanding of the implications in terms of the likely surgery and prognosis, and of the nature of cancer generally.

Post-registration training should give a therapist the tools, but they may need to be applied a little differently to this group than to neurological patients.

2) Pre-operative counselling

The head and neck client group is unique in that the patient is seen firstly with a normal / functional (albeit diseased) swallowing process, before the sudden onset of dysphagia brought about by surgery and / or radiotherapy and / or chemotherapy. Doyle (1999) states that pre-operative counselling provides the single most important dimension in patient care, therefore therapists working with this client group need to ensure they have the necessary skills. Doyle (1999) talks about using the process of

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003

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Figure 2 Case example

pre-operative counselling for the therapist and patient to set common goals for rehabilitation. Logemann (1983) discusses the difficulty of initiating therapy post-operatively with a patient who has been unprepared for the problems of swallowing. Although consent for surgery or radiotherapy is obtained primarily by medical and surgical members of the team, the speech and language therapist has an important role in ensuring that the patient is fully aware of the consequences for speech and swallowing.

Pre-operatively Mary (64), retired, married A social drinker and ex-smoker. Year-long history sore throats (initial tonsil biopsy no significant abnormality) New investigations found - poorly differentiated squamous cell carcinoma - a lesion within the left tonsillar fossa, extending anteriorly to the anterior pillar and floor of mouth, and posteriorly to the posterior tonsillar pillar - Classification: T2 N1 M0 Combined clinic (ENT surgeon, maxillo-facial surgeon, oncologist, speech and language therapist, head and neck nurse) Consented to extensive surgery with adjuvant radiotherapy Pre-operative counselling with speech and language therapist and head and neck nurse. Surgery left selective neck dissection: level I-III resection of tonsillar tumour, involving posterior pharyngeal wall and soft palate mandibulectomy radical forearm free flap skin graft tracheostomy. Post-operatively (acute) transferred to Intensive Treatment Unit with naso-gastric tube in situ, and cuffed no8 Shiley tracheostomy tube. 24 hours: ENT ward on intravenous fluids, cuff deflated on tracheostomy tube (speech and language therapist contact for support; communicating effectively by writing and mouthing) 2 days: naso-gastric feeds 4 days: tracheostomy tube removed by surgeon speech and language therapy assessment: left sided tongue weakness and loss of sensation to the left side of tongue, lip and jaw. Trial swallows with fluids triggered effectively; no obvious pharyngeal stage problems but some pooling of fluid on the left. Recommended trial of free fluids, with postural modification to aid transit of bolus. 5 days: managing fluids well. Assessed on smooth, semi-solid consistency, some pocketing in the left sulcus, remedied by postural modification. Oral transit slow, but no pharyngeal stage problems. Naso-gastric tube removed; started on liquidised diet. 6 days: managing fluids well and tolerating liquidised diet 8 days: discharged home into care of local therapist. Post-operatively (community) Week 2: Coping with free fluids (including fortified drinks) and smooth semi-solids. Complying well with postural modifications. After clearance from the surgeon, range of motion exercises introduced. Reiterated advice re- range of motion exercises, particularly in lessening build up of fibrotic tissue and discussed possible deterioration in swallow during radiotherapy. Week 3: Radiotherapy started, continuing with range of motion exercises, oral intake increased substantially. Week 4: Tolerating radiotherapy. Some discomfort, but not interfering with oral intake. Continuing exercises - managing without postural modification. Week 5: Struggling with range of motion exercises - very painful. Fluids easiest (relying heavily on dietary supplements). After discussion with head and neck nurse and oncologist, prescribed Oromorph to help with pain and advised on strategies for coping with dry mouth (xerostemia). Weeks 6/7: Mary rather disheartened. Very particular about appearance and, although oedema and suture lines as a result of the surgery tolerated, added disfigurement from radiotherapy skin changes is proving difficult. Some difficulty triggering swallow, fibrotic tissue in tongue base. Losing weight as oral intake decreases. Candida and taste changes affecting appetite. Very tired from radiotherapy. Reassured should see improvement in 2-3 weeks. Dietitian to contact again to advise about food choices. Week 8: Pain and oedema reduced. Candida cleared. Oral intake easier. Coping with xerostemia well. Feels able to start range of motion exercises again - encouraged. Week 10: Less pain. Appetite returning, despite continuing taste changes. Swallow triggering faster. Does not need postural modification. Mary trialling new textures herself and feeling much more optimistic about returning to pre-operative diet. Four months post-operatively: Good progress. Range of motion exercises regularly, rapidly putting weight back on. Able to eat most foods, even if modified form. Xerostemia and taste changes persist.
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3) Tracheostomy tubes and their effect on swallowing

Knowledge of the needs of clients with tracheostomy is included in the Dysphagia Working Groups recommendations for inclusion in postregistration courses. Any patient who presents with a compromised airway because of a head and neck tumour may require a tracheostomy (Ridley, 1999) Additionally, a tracheostomy may be performed as a temporary measure until soft tissue swelling has resolved post-operatively.

4) Swallowing assessment
Skill in selection and interpretation of swallowing assessment procedures such as videofluoroscopy and FEES (Fiberoptic Endoscopic Evaluation of Swallowing) covers all client groups (RCSLT, 1999b). Here, however, to interpret the results of any assessment accurately, the therapist must have a very good understanding of the nature of cancer, of the structural changes that have taken place after surgery and of the effects of any concomitant treatment (Ridley, 1999).

5) Management of swallowing problems

Ability to use appropriate compensatory techniques, exercises, positioning and change in consistencies is a desired outcome of post-registration training. Sullivan (1999) states that, for people with head and neck cancer, therapy goals typically focus on compensation rather than long-term improvement of swallowing function. Post-registration training should give a therapist the tools, but they may need to be applied a little differently to this group than to neurological patients.

6) Multidisciplinary team working

Post-registration courses aim to give speech and language therapists knowledge of multidisciplinary team working. The therapist is very much a core member of the team providing an integrated service to people with head and neck cancer, and has an important role in raising awareness of swallowing problems with the other team members.

7) Radiotherapy and its effects

Any therapist working with this client group needs to be aware of potential treatment induced swallowing problems, and prevention and therapy strategies. The speech and language therapist has the best knowledge of a patients swallowing status postoperatively. She can therefore advise the team

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before the onset of radiotherapy or chemotherapy as to any need for non-oral nutrition once the treatment effects are added to the effects of surgery. It is unlikely that this specialised and highly important knowledge would be included in general training.

8) Body image

Both head and neck cancer and the treatments for it can affect an individuals appearance. Burgess (1994) includes not only physical change but also change in bodily function or control of the bodys activities, and the speech and language therapist needs to have an awareness of the possible psychological implications.

Issues of competence and asking for support do not take account of factors such as Trust boundaries, geography and politics

Writing about the background to the RCSLT Competencies Project, Williamson (2000) states that: Although some skills and knowledge are core to speech and language therapy professionalism, their profile and depth will vary according to particular clients demands, contexts and therapists responsibilities. On its own, attendance at a dysphagia course does not make a therapist competent. A therapist who has attended a postregistration course, and has much clinical experience, can easily be as competent to treat dysphagia in a head and neck patient as someone like me who attended an Advanced course, but had relatively little clinical experience. Experience may come about by direct patient contact, or simply from working with the multidisciplinary team. In attending the Combined Clinic each week, I learned a significant amount about the whole spectrum of head and neck care - prevention, recurrence, palliative care, carotid blow out for example - all of which informed my practice. Communicating Quality 2 (RCSLT, 1996) states that therapists working with this client group tend to learn by experience. In outlining the content of dysphagia courses, the Dysphagia Working Group makes it clear that, while a therapist completing the course would be expected to be able to work without supervision, the ability to know when to ask for support would mean the therapist is working competently. What may be problematic is ensuring that that support is available. The literature suggests that speech and language therapy intervention for this client group is optimally delivered by therapists with specific responsibilities for head and neck cancer (RCSLT, 1996; Ridley, 1999; BAO-HNS, 2000), who will be part of multidisciplinary teams working in cancer centres. If the therapist linked to a particular centre has the ability to be peripatetic, this may not be a problem. However, if geographical or time constraints prevent this, there is a dilemma as to whether the patient will travel for rehabilitation, or be seen by the local speech and language therapist. Would a local therapist, without specialist training or specific clinical experience be appropriately qualified, and would they be able to deliver high

quality, safe and effective treatment (Calman & Hine, 1994)? I believe the answer is possibly. I cannot be more positive due to uncertainty over the amount of support the therapist would receive. Issues of competence and asking for support do not take account of factors such as Trust boundaries, geography and politics, which can hamper communication between therapists and the contact that is needed to provide appropriate support. Harris (2001) describes a clinical liaison group set up to improve communication between professionals, vital when patients are travelling across Trusts. At the acute stage, there should be support from the other members of the multidisciplinary team, whereas a community therapist may be working in isolation, and dealing with the head and neck cancer patient at what is often the most traumatic time. Discharge home can bring about a stark realisation of problems they have to overcome. The swallowing problem may take on more significance when the choice is no longer from a hospital menu and the social aspect of eating comes to the fore, and all this at a time when further treatment may start and worsen the dysphagia. General dysphagia training gives therapists a good basic grounding in managing dysphagia in head and neck cancer patients. If there are very good support systems in place, it is possible that a generally trained therapist could successfully manage the dysphagia. However, there are still aspects of care, such as pre-operative counselling, that are so important to the outcome of the rehabilitation that they should remain within the remit of a therapist with specific responsibilities to this client group. Robinson (1999) reports on the drawing up of the Head and Neck Oncology Consensus document, and the fact that some of the objectives were unachievable in certain areas because of issues such as geography. Despite this, they were included because, ultimately, they were good practice, and could be used to help highlight deficiencies in local service provision. This process needs to continue to ensure parity of service for head and neck cancer patients, no matter where they live. I am not sure if it is possible to quantify the level of expertise and training required to work with this client group, but it is an area that the profession needs to explore. For the sake of career progression, continuing professional development and ultimately patient care, it would be helpful to have some way of gauging when ones experience is sufficient. Lorna Gamberini is a speech and language therapist who works with ENT clients for Morecambe Bay Primary Care Trust. This article is based on the essay component of the Advanced Dysphagia Course (Head & Neck Module) which was written while Lorna worked for West Cumbria Primary Care Trust.

Acknowledgement
With thanks to Linda Slack, Macmillan speech and language therapist for North Cumbria who looked after Mary at the acute stage.

References
British Association of Otolaryngologists - Head and Neck Surgeons (2000) Effective Head and Neck Management - Second Consensus Document. Burgess, L. (1994) Facing the reality of head and neck cancer. Nursing Standard 8 (23): 30-34. Calman, K. & Hine, D. (1995) A Policy Framework for Commissioning Cancer Services. London: Department of Health. Doyle, P. (1999) Postlaryngectomy speech rehabilitation: contemporary considerations in clinical care. Journal of Speech-Language Pathology and Audiology 23 (3): 109-115. Harris, C. (2001) Ahead and neck of the field. Speech & Language Therapy in Practice. Autumn: 12-13. Logemann, J. (1983) Evaluation and Treatment of Swallowing Disorders. Pro-ed, Austin, Texas. Ridley, M. (1999) Effects of surgery for head and neck cancer. In Sullivan, P. & Guildford, A. (Eds) Swallowing Intervention in Oncology. Singular Publishing Group: San Diego/London. Robinson, H.F. (1999) How I manage head and neck cancer: Setting the standard. Speech & Language Therapy in Practice. Autumn: 23-24. Royal College of Speech & Language Therapists (1996) Communicating Quality 2. RCSLT: London. Royal College of Speech & Language Therapists (1999a) Dysphagia Working Group: Recommendations for Pre and Post-registration Education and Training. RCSLT: London. Royal College of Speech & Language Therapists (1999b) Invasive Procedures Guidelines. RCSLT: London. Sullivan, P. (1999) Clinical Dysphagia Intervention. In Sullivan, P. & Guildford, A. (Eds) Swallowing Intervention in Oncology. Singular Publishing Group: San Diego/London. Williamson, K. (2000) The best things for the best reasons. Bulletin of the Royal College of Speech & Language Therapists. October.

Reflections
Do I recognise when to ask for support and do I know where to get it? Do I see myself as an individual or part of a network of service provision? Do I expand my knowledge through involvement in multidisciplinary ventures?

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003