There has been little research on the provision for patients with dysphagia in nursing homes.

http://ajslp.pubs.asha.org/article.aspx?articleid=1774778

Thank you very much.

I have found only one similar research done in Brazil. KNOWLEDGE OF NURSING PROFESSIONALS ABOUT THE CARE TO DYSPHAGIC PATIENTS IN INTENSIVE CARE UNITS, authors, Rejane Maestri Nobre Albini, Vânia Muniz Néquer Soares, Aline Epiphanio Wolf, Claudia Giglio de Oliveira Gonçalves.

This one you sanded me, has very important findings about the lack of knowledge among nurses, which confirms my own observations.

At a recent conference on palliative care, two speakers provided some superb insight to caring for patients with dysphagia.   While the speakers were not nurses, the essence of palliative care philosophy is collaboration of an interdisciplinary team.  The speakers were Amanda Warren, MS, CCC-SLP, Speech-Language Pathologist

Mary K. Buss, MD, MPH, Director, Ambulatory Palliative Care, Medical Oncologist, both at Beth Israel Deaconess Medical Center.  You might try to contact them to see how they evaluate nursing care for these patients.  

Buss, M; Warren, A. (2014). The meeting abstract was published:  Death by Chocolate: How to Palliate to Dysphagia, JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, 02/2014, Volume 47, Issue 2.  

Using the basic search engine at my university's library, on "evaluation of nursing caring for patients with dysphagia," I got 158 results dating from 2012.  I've attached part of that list - quite a bit of lit globally.      Also, an interesting view from a patient's perspective or that of their families: Tanner, Dennis C. (2010). Lessons from nursing home dysphagia malpractice litigation. Journal of Gerontological Nursing, 36(3)

Charlotte, thank you for tremendous help. I have already found some literature, the rest will follow. I find the paper Death by Chocolate very interesting.

Thank you again.

Good morning.  I did a quick check on EBSCO, and your idea is correct.  These are a few items I found that identified a need for additional nurse education in dysphagia.

Ilott, Irene Bennett, Bev; Gerrish, Kate; Pownall, Sue; Jones, Amanda; Garth, Andrew

Journal of Clinical Nursing (J CLIN NURS), 2014 May; 23 (9/10): 1354-64. (32 ref)

Evaluating a novel approach to enhancing dysphagia management: workplace-based, blended e-learning.

In many countries, nurses play a crucial role in supporting the management of patients with swallowing problems, yet the literature reports a need for training. Dysphagia should be viewed as a patient safety issue because of the risks of malnutrition, dehydration and aspiration pneumonia. As such, it is pertinent to many members of the interdisciplinary team. Consideration should be given to including dysphagia management in initial education and continuing professional development programmes.

Hsin-Ling Chung; Ia-Ling Chen; Hui-Lin Lee

Tzu Chi Nursing Journal (TZU CHI NURS J), 2013 Jun; 12 (3): 89-101. (6 ref

A Program to Improve Accuracy Rate of Dysphagia Screening for Patients with Stroke [Chinese].

Stroke patients often suffer from aspiration pneumonia due to dysphagia, thus performing swallowing screening test accurately is important. The current situation analysis found that the nurses of stroke patients conducting the swallowing screening test inconsistently and without a standard procedure, caused primarily by the lack of knowledge and skills on swallowing screening, and the absence of training programs, record forms, standard operating procedures and an audit system.

Durgude, Yuwrajh; Cocks, Naomi

Nurses' knowledge of the provision of oral care for patients with dysphagia.

British Journal of Community Nursing (BR J COMMUNITY NURS), 2011 Dec; 16 (12): 604-10. (28 ref)

There has been little research on the provision and adaptation of oral care for patients with dysphagia in nursing homes. This study collected data via a questionnaire specifically on the knowledge of oral hygiene and the current oral care practices for patients with dysphagia. Fifty-three registered nurses (RNs) completed the questionnaires. The results of the questionnaire indicated that although RNs gave more oral care daily to their patients with dysphagia than to their patients without dysphagia, they had limited knowledge of drugs that affect oral care and of medical conditions associated with poor oral hygiene. Of particular concern was the limited knowledge of the link between dysphagia, oral hygiene and pneumonia and that some of the current oral care practices may be putting patients who have dysphagia at increased risk of developing pneumonia. These results are discussed in light of previous research on the topic and recommendations are made with regards to oral care training.

Thank you Carol,

yes, I also agree that dysphagia should be viewed as a patient safety issue and nurses are the ones that should recognise the signs first. Population is getting older and dysphagia will be even a bigger problem. 

Evaluating a novel approach to enhancing dysphagia management sounds very interesting I am looking forward to reading it.

Your topic is very interesting and timel. I feel it is also applicable to knowlege of recognizing dysphagia in children of all ages.

Yes, Goldie I agree with you. I found some articles that demonstrate the absence of knowledge in detecting dysphagia among children. I have only my own finances and I have to limit my research to adults.

Although in my hospital we also have a childrens department. Our doctor Katja Groleger Sršen and others published the article: INTER-RATER RELIABILITY OF THE SLOVENIAN TRANSLATION OF THE DYSPHAGIA DISORDER SURVEY. You can find it in RG.

O, and 

Conference Paper

Inter-rater reliability of Slovene translation of Dysphagia Disorder Survey: preliminary results Authors: Barbara Korošec, Valerija Marot, Gaj Vidmar, Katja Groleger Sršen

In proceeding of: 25th Annual Meeting of European Academy of Childhood Disability, At Newcastle, Volume: DMCN 2013, October, Supplement

ABSTRACT Introduction: Dysphagia affects one or more phases of swallowing and behaviours in connection to feeding. Clinical signs may be obvious or "silent". The first step in managing dysphagia is to identify those children with the disorder. Dysphagia Disorder Survey was developed to differentiate those people who have dysphagia and unsafe eating behaviours from those who do not (Sheppard, 2002; DDS).

Aim: To evaluate inter-rater reliability of Slovene translation of DDS.

Methods: Two speech therapists, who were additionally educated for evaluation with DDS, evaluated convenient sample of children that were referred to them in the last year and were reported by parents to have feeding problems. Evaluation was done independently. Statistical analysis was done for the second part of DDS, which is dedicated to evaluation of eating liquid, chewable and not chewable food.

Results: We evaluated 24 children, with the mean age of 6.1 years (SD 3.9). 16 were children with cerebral palsy (1 classified in GMFCS level II, 7 in level IV and 9 in level V). 4 children were referred due to significant developmental delay, 2 after traumatic brain injury, one after congenital brain tumour and one with squeals after tick-borne encephalitis. The two-way random ICC model for single measurement (ICC (2, 1)) for absolute agreement was used. All the ICC's were statistically significantly different from zero (p

At our hospital, we began to use a new nursing dysphagia screen.  To do this, we first investigated several screening tools in current use.  The literature with the screening tools might be of interest to you in your paper (because they might mention some background information on how the tools were developed, how they educated the nurses in the tool's use, and interrater reliability, which is influenced by the knowledge that the nurse brings to using the tool). 

Tools we investigated were the Massachusetts General Swallowing Screen, the Gugging Dysphagia Screen (GUSS), Toronto Swallowing Evaluation Tool (TOR-BSST), and Palms of Pasadena Swallow Tool. 

Carol, which tool do you use now?

I also found this article, but only the abstract is in english.

ASSESSMENT OF SWALLOWING IN CHILDREN Katja Groleger Sršen, Barbara KorošecRehabilitacija 03/2013; XII(Suppl1):63-73.

ABSTRACT We summarise the early development of sucking and swallowing in the foetus, the neonate and the infant, and the later development of eating and swallowing in children. The development of sucking, feeding and swallowing is entangled and depends on a number of systems. Brain development and functioning plays a key role in the development of sucking and swallowing. It is also important to understand and follow the critical periods for learning.Assessment of sucking, feeding and swallowing is essential for further therapeutic treatment. Some tests and scales for assessment of sucking, feeding and swallowing are presented, and some imaging methods also used in the assessment are described.

Hello,

yes we have looked at this. Our preliminary version of a nursing dysphagia tool was published in a Japanese journal Nursing and Health Sciences, in 2011 (IF).

http://www.ncbi.nlm.nih.gov/pubmed/21883767

Since then, I final version was developed, nurses were trained (in a nursing-led training session using a video). A preliminary article looking at this was published, in English, at:

http://www.osetrovatelstvo.eu/archiv/2014-rocnik-4/cislo-1/a-vision-for-dysphagia-screening-by-nurses

more details will be sent for a publication in a journal with an IF again. The teaching aspects and what it does to inter-rater reliability, for example, are something that we are looking at...if interested to know more, please let me know. you may also view my profile and some other related publications on LinkedIn. good luck.

Petra Mandysova

http://www.osetrovatelstvo.eu/archiv/2014-rocnik-4/cislo-1/a-vision-for-dysphagia-screening-by-nurses

http://www.ncbi.nlm.nih.gov/pubmed/21883767

Carol,

GUSS - valuable I think, but perhaps too complicated for nurses, and maybe the decision-making that goes with it (instrumentál testing, diet) is not in the scope of nursing practice in some countries. I believe it is ideal for speech therapsists / physicians. Also, based on a rather small sample. TOR-BSST - copyrighted, so the hopsital has to pay a fee, training via a speech therapist, not sure about the price. Also based on a sample of about 60 patients or so, if I recall (those who underwent gold standard testing). I do not know the Palms Pasadena swallow tool. In my reply to Bojana, I provided a link to a brief description of results of my dissertation thesis - a nursing tool, gold standard = FEES, sample = 106 neurological patients, sensitivity and negative predictive value comparable to TOR-BSST. Not just for stroke patients, but also for other neuro diagnoses. Part 2 of the thesis focused on studying the effectiveness of a nurse education program. Part 3 - time required to do the screening and inter-rater reliability. I am keen to discuss our experience, internationally and I value nursing input (since I am a nurse) while I recognize the importance of multidisciplinary collaboration.

I would love to hear more.

Petra Mandysova

Petra, I read you publications and you truly are an expert, thank you.

In our hospitals SLTs are included after nurses evaluation. Nurses have problems because we don’t have evaluating standards or protocols. We do the swallowing test; patient must sit upright at least 15 min, teeth must be cleaned. Then they are given a spoon of water and observed for any choking, coughing, inability to keep the water in the mouth, or any other concerns, three times. If they pass, they are given a glass of water 30-60 ml. If it is ok they are carefully feed. If not, we contact our doctor and SLT.

The SLT performs Mann Assessment of Swallowing Ability screening test.

But there are not a lot of nurses trained in the procedure and I would like to discover where the main problems are and develop a standard to help them (us).

Not an easy one to answer. In our department which deals with severly brain injuries (acquired/traumatic) the SALT makes a formal assessment. Nurses experienced in this are are generally consistant with the assessment made by the SALT when onserving for signs of cough, requiring oral clearence of secretions, in babies its pretty much easier when observing if they can suck a dummy or not?

This article was recently published and may be helpful for you.

OJIN: The Online Journal of Issues in Nursing

Avoiding Negative Dysphagia Outcomes

Dennis C. Tanner, PhD, William R. Culbertson, PhD

DisclosuresOnline J Issues Nurs. 2014;19(2)

I noticed that you are Slovenian;  we had the opportunity of visiting Slovenia last year.  What a lovely country!  We visited the Julian Alps, the national park, hiked through a ravine, and enjoyed the friendly people and good food.  We have very nice memories of Slovenia.

Just something to consider... Nurses should only do a dysphagia screening.  Is it safe to take any oral medication...but the Swallow evaluation is only done by a Speech Pathologists, and should be kept NPO until such time as the eval is done.  Aspiration especially for stroke/neuro symptoms is a real threat and can lead to many more complications beside the original diagnosis.  As nurses we should be advocating for SLP's to do an evaluation asap.  Thanks. Walt

Nurses at Morristown Medical Center in NJ have just completed a study on nurse education and assessment of patients with dysphagia. This is an interesting and important topic. The findings will be released at a national conference soon. DeFillipis and Leaton are two of the lead researchers. 

Best regards, Mildred Ortu Kowalski, PhD, R

Thank you Carol, the article was helpful. I am so happy you visited Slovenia. It was a big surprise to hear that you know my country and I am glad you liked it. I hope you will visit us again.

Walter I totally agree with you, but unfortunately SLPs have too much work (and we don’t have enough of them) and we nurses are the ones feeding the patient in hospitals or nursing homes. If we don’t see the signs, do the screening, test and then talk to the doctor and SLP, the patients would be hungry. In my hospital the nurses do the swallowing test as I described earlier.

Mildred thank you for the info. How can I contact DeFilips and Leaton and find out witch questioner did they use to evaluate nurses knowledge. Maybe they would be interested in making international comparison. I came up with my own questioner and I am in the process of making a pilot survey now.

Yes, Bojana, unforutnately, the SLPs cannot see all patients or they see them after a few days and what do you do in the meantime? You need to look at the diagnostic parameters - if a nursing screening instrument (which ideály should be an easily administered method, without the necessity to engage in complicated training) has good negative predictive value, then those patients who are negative on the screening do not have to be seen by an SLP. If they are positive - well, they may be falsely positive, as we prefer to err on the side of caution (since missed dysphagia can have potentially serious consequences) -then yes, the SLP should be able to identify that and come up with a recommendation, either what kind of measures to implement or perhaps sometimes more detailed testing is necessary...the literature get confusing as some people are not clear about the goal of screening and who does it and what constitutes a good screenign instrument - and what is the difference between screening and a full clinical exam. Screening should be quick, it can také a few minutes, can be done by nurses whereas full clinical exam by SLP, I have seen SLPs spend perhaps up to 45 minutes or more with the patient. Obviously, they cannot examine everyone. So, before choosing the right method, ask yourself: has the research been of good quality? Is the screeninf tool easy and quick? What are its diagnostic parameters? Literature reviews are good for this. In neurological patients, one review was done by Kertscher et al (2014), journal Dypshagia. Our tool that I mentioned was included and they pointed out two weaknesses, however, of the four tools they recommend, only one was developer while using a nurse screener....we have since then developer a revised version and will be submitting it to a journal with an IF soon (and abstract will be presented at a nursing management konference in Bodrum, Turkey, in October 2014). I would love to engage in more conversation on the issue and I do thank everyone for their ideas and provided references,

Petra Mandysova

Bojana, 

This article may be useful http://onlinelibrary.wiley.com/doi/10.1111/j.1745-4603.2011.00319.x/abstract

It does not consider a questionnaire of nursing knowledge but, looks at the variability of  thicken fluids prepared in practice. 

Thank you Victoria, I will definitely read it.

Petra, I totally agree with you. If we nurses do a good screening and then include SLTs, MDs, respiratory therapist, nutritionists, physio and occupational therapists, social worker and family members the outcome can be very good. But mostly it is not so and the consequences are bad. I think if I start by evaluating nurses knowledge and then try to make the nursing care better and safer by enhancing knowledge, is the right way to start. But I must say it is difficult to admit when your weaknesses are. That is why I struggled with the questioner for so long.

So true, yes I also saw many cases of undetected dysphagia. Patients were fed inappropriately, then they developed aspiration pneumonia, they were dehydrated, undernourished and had a very low quality of life. Now, I hope to discover where is the main lack of knowledge and then try to establish some guidelines for the nurses and hopefully get that in the curriculum.

It is a difficult and complex issue and most healthcare professionals don't like to talk about it. I understand it is hard to admit you are not good at something, but if we don't do that, we can never be better.

Thank you all for your contributions, for raising awareness of these important issue.

I think the days are gone when nurses of my generation were all things to all people.  We did our owb Respiratory Therapy treatments, drew our own labs, performed our own EKG's, etc.  Healthcare has evolved so much that all of the disciplines that participate in patient care today bring special skills and knowledge to the patient.  Its fine to admit that we do not have to be expert and knowledgeable about everything.  SLP are experts in the area of dysphagia and our patients deserve that expertise.  If nurses can screen patients carefully and deal with solely evaluating swallowing ability for safe P.O. medication administration during the early admission period, SLP's should be able to step in within a short period of time and evaluate swallowing to allow for proper nutritional needs to be met.  Neuro symptom patients do not need the threat of aspiration, pneumonia, and fear of chokinng, they need an expert evaluation and I say let the SLP do that.

Yes, but if we don't see the signs, don't involve MDs and SLPs, dot' communicate about it, than there will be now progress. Nurses screening must be easy and reliable. SLPs evaluation is difficult and time demanding and we cant expect that they examen every patient. And dysphagia can affect everyone, in hospitals, nursing homes, elderly living at home,... So no matter what kind of a nurse you are, when you see the signs of dysphagia, call the MD, SLP,.. But you must see them.

I think the best practice is having a multidisciplinary dysphagia tim and preventative education.

Bojana, I agree with you totally regarding screening and recognizing signs of dysphagia.

SLP's have been kept in the background for years., and have a lot of expertise to contribute here.

For a start, I would take "common knowledge" e.g., as found at http://en.wikipedia.org/wiki/Dysphagia and turn it into a series of questions for an exam to test each nurse. Your percentage mark for each nurse is the quantity you are looking for. Your exam can become the benchmark test.

For you interest Bojana I am attaching a screen shot of the dyspagia resources we offer to Residential Care sites in the Interior Health Authority in BC Canada. I can discuss the screening tool and education tools with you if it appeals to you. I am following this discussion with interest

Just my 2c:

There is quite some literature regarding this topic! On a more general note: Int J Lang Commun Disord. 2002 Jul-Sep;37(3):345-57. Carer knowledge of dysphagia management strategies. Chadwick DD1, Jolliffe J, Goldbart J. 

On a practical note: the reasons for non-compliance were most excellently studied by Colodny, I cannot advice these articles strongly enough! 1) Dysphagia. 2008 Mar;23(1):47-58. Epub 2007 Nov 14. Validation of the Caregiver Mealtime and Dysphagia Questionnaire (CMDQ). 2) Dysphagia. 2001 Fall;16(4):263-71.

Construction and validation of the mealtime and dysphagia questionnaire: an instrument designed to assess nursing staff reasons for noncompliance with SLP dysphagia and feeding recommendations. Colodny N.

Hope it is useful to your researchproject!

Thank you all so much. You all are a great help to me. I am now finishing my research and thanks to that, we are now forming a special dysphagia team. I am sooooo happy. I hope we develop a good protocol and educate our nurses how to detect patient and that they are than referred to our special team. I strongly believe if we use good screening and detect the problem we can, with the help of a good team improve the quality of patients lives.   

Bojana - Please post your article when you have completed writing it up.  I lok forward to seeing your results.

Bojana, I was wondering if you finished your master, Im interested in assessing nurses knowledge in our hospital and would love to see your research

Hi Bojana

I found the recent publication of your survey very interesting. I have just finished a similar survey asking multi-disciplinary staff (doctors, nurses, physiotherapists, speech therapists and dietitians) about their understanding, assessment and management of dysphagia (amongst other things) for those patients after a cervical spinal cord injury. This is important as many of these are the gatekeepers of referral to SLT.  I also found poor understanding and a tendency to wait until the patient already has a chest infection and is eating before considering there is a problem.

I'm hoping to submit a paper for ESSD conference - will you be going?

Hi Jackie,

Can’t wait to read your survey. Thanks for the info. I also found that 73,6 % of patients with potential to suffer from dysphagia are not or rarely seen by SLT within 24h of admittance to the hospital. And that 22,7 % of patient are always and often feed without a prior examination.

Now my main focus must be finishing my masters. I had so many smaller workshops and was organizing educational programs, lecturing and doing my regular job. I am doing all this in my free time and try to put more awareness to this problem in Slovenia. Now I must focus on this.

Hi Bojana

Well done on your hard work. I understand the challenge of trying to do it all - I did the same for my Masters, fortunately I finished that and am now studying full-time for my doctoral research.

It is a problem about what to do if patients do not seem to have a swallowing problem. It would be crazy to say that SLT have to see them all, but I think there are clues and these should be used to make the right decision.

If my abstract is accepted, I shall post my talk/poster on here afterwards.

Hi,

Yes I totally agree. But nurses must have the skills and knowledge to detect patients with swallowing problems, talk to the doctors and refer them to the SLT.

Good luck with your doctoral research.