Outlining the psychological and communication issues involved in caring for patients with dysphagia after a stroke, and nurses’ role in providing holistic care
Helen Waddington is third-year student nurse, adult branch, University of Nottingham.
Waddington, H. (2009) Psychological and communication issues in feeding post-stroke patients with dysphagia. Nursing Times; 105: 31, early online publication.
This one-part unit on feeding patients with dysphagia after stroke highlights the importance of good communication and considering psychological needs.
Keywords: Stroke, Dysphagia, Communication, Psychological issues
- This article has been double-blind peer-reviewed
- Understand the psychological and emotional issues surrounding dysphagia and feeding.
- Recognise the importance of good communication when helping patients with this impairment during mealtimes.
Each year, more than 110,000 people in England will die or suffer severe disability as a result of stroke (Department of Health, 2009).
NICE (2008) cited the World Health Organization’s definition of stroke as a clinical syndrome consisting of ‘rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin’. However, the NICE guidance points out that there are limitations to this definition.
Within three days of stroke, dysphagia is present in 42–67% of survivors (Trapl et al, 2007). The WHO (2006) described dysphagia as impaired ability to swallow. Richards and Edwards (2004) suggested it can be due to voluntary and involuntary muscle groups not allowing food or liquid to pass from the mouth to the stomach safely.
There are various signs of dysphagia and levels of severity. Signs include: difficulty swallowing one’s own saliva; loss of food or fluid from the mouth; drooling; inability to empty the mouth of food (pouching); and coughing and gurgling after oral intake (Edmans et al, 2005).
As a result of this disability, post-stroke patients may suffer emotional distress, seen in responses such as anger, frustration, anxiety and sadness (National Institute of Neurological Disorders and Stroke, 2009).
Nevertheless, the psychological trauma following stroke can be missed, mistaken or overseen as physical issues take priority (The Stroke Association, 2008). This is because a wide range of physical issues must be considered when helping or feeding post-stroke patients with dysphagia, such as level of impairment, alertness, correct positioning and so on.
For this reason, this article focuses on psychological issues and how communication between patients and nurses at mealtimes can facilitate safe feeding and enable nurses to offer psychological support.
Nurses should adopt a holistic approach when feeding post-stroke patients or adults in acute care presenting with signs of dysphagia.
Terrado et al (2001) argued that complications in post-stroke patients with dysphagia can be reduced and quality of life improved by effective nursing management strategies.
Hinchliff et al (2003) saw nurses’ role as central since they have the most contact with patients. This gives practitioners the opportunity to educate, inform and support patients, relatives and carers about issues surrounding feeding.
While feeding patients, nurses should ensure they deliver patient-centred care, which involves considering individual’s social and emotional needs, to ensure holistic care (Chapelhow et al, 2005), as well as autonomy, dignity and privacy. Mayberry and Mayberry (2003) argued that autonomy allows patients freedom of choice.
It is nurses’ responsibility to ensure patients’ dignity and interests are protected. While it can be difficult to maintain privacy in ward settings (Brooker and Waugh, 2007), careful consideration is needed to provide a suitable environment.
Some trusts have developed training programmes for nurses caring for patients with dysphagia. These address key issues such as providing a safe and reliable first swallowing assessment and communication with patients, relatives and the multidisciplinary team in completing assessment documents.
Physical and cognitive limitations after stroke may compromise patients’ ability to manipulate utensils and eat independently (Perry and Potter, 2002).
Around 50% of patients suffer from significant depression in the year after a stroke, as a result of several factors including loss of independence (The Stroke Association, 2009).
The DH (2003) said patients should receive the care and assistance they need when eating and drinking, while maintaining dignity at all times. Workman and Bennett (2003) agreed, arguing that this support could encourage some patients to regain independence.
The Scottish Intercollegiate Guidelines Network (2004) highlighted the importance of nurses’ awareness of the social aspects of eating when helping patients to eat and drink. To enable patients to understand, cope and manage their disability, they need understandable and relevant information, taking into account age, gender and culture, in accordance with DH (2003) guidelines.
Perry and Potter (2002) emphasised the importance of giving patients as much time, choice and independence as possible when helping with feeding. Thayer (2003) discussed psychosocial well-being, which could be affected as many people see eating as a pleasurable and social activity.
Wilkins et al (2007) highlighted the anxieties of patients with dysphagia. These authors found they presented with high levels of anxiety during mealtimes and avoided eating with others when possible. Nurses should take these feelings into account when feeding patients with the condition.
Jacobsson et al (2000) found patients with dysphagia experienced embarrassment when eating because of the lack of oral control so preferred mealtimes to end as quickly as possible.
Nurses should observe patients, ensuring they give them enough time to chew, swallow food and drink safely, and make them feel comfortable (Baillie, 2001). They should also remove any spillages from the chin, face and neck with a napkin to avoid embarrassment or loss of dignity (Workman and Bennett, 2003).
The Stroke Association (2008) conducted research on stroke survivors’ views, through personal accounts of care in hospital. Some patients said they felt psychological issues were often mistaken or missed because nursing staff were focusing on physical issues.
Terrado et al (2001) argued that nurses must have effective communication skills since they are the first members of the healthcare team to assess patients. This enables them to contact the relevant multidisciplinary team member on a specific aspect of care.
Appropriate communication skills are beneficial during mealtimes with patients with dysphagia. These can be enhanced through using suitable communication models, for example, Heron’s (1990) six-category intervention model.
Rosenvinge and Starke (2005) found that patients are usually unaware of their swallowing problem, so nurses need to take responsibility to ensure safe feeding.
During mealtimes, nurses should sit on a chair next to patients, showing a relaxed and open posture while maintaining sufficient eye contact, in accordance with Egan’s (2002) non-verbal communication model. Baillie (2001) agreed this was good practice as it shows patients that nurses have time to deliver individual care.
However, Giddens et al (2006) found that non-verbal communication could be misleading, so nurses need to be aware of their own personal style and any potential for misinterpretation.
The DH (2003) also included communication in its Essence of Care benchmarks. All patients and carers should experience effective communication, which is sensitive to their individual needs and preferences. The DH (2003) stressed the importance of using straightforward language and avoiding jargon, and the need to adapt approaches to communication to be sensitive to language and cultural differences.
Perry and Potter (2002) said mealtimes should be a pleasant and social event, so talking to patients while helping with feeding increases social interaction for them.
Baillie (2001) found communication could also help nurses to observe any adverse reactions, such as signs of aspiration, during mealtimes. They can listen for a gurgling or ‘wet’ voice; if this occurs, feeding should be stopped immediately and the patient should be ‘nil by mouth’ until reassessed by the speech and language therapist or a nurse specialist.
Ensuring good communication and providing psychological support are vital when caring for patients with dysphagia following stroke. These two issues are often overlooked or neglected in practice as some nursing staff focus on physical issues when feeding patients.
Nurses should develop good communication skills and ensure they take into account patients’ psychological well-being when helping those with dysphagia during mealtimes. This will enable both safe feeding and holistic care.
- Training is needed for all healthcare professionals involved in helping patients with dysphagia to eat and drink, covering psychological and communication issues.
- Time should be allocated for nursing staff to provide information to patients and discuss their concerns with them.
- Appropriate staffing levels are needed to help patients during mealtimes.
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Baillie, L. (2001) Developing Practical Nursing Skills. London: Arnold.
Brooker, C., Waugh, A. (2007) Foundations of Nursing Practice: Fundamentals of Holistic Care. London: Mosby.
Chapelhow, C. et al (2005) Uncovering Skills for Practice. Cheltenham: Nelson Thornes.
Department of Health (2009) Stroke. London: DH.
Department of Health (2003) Essence of Care: Patient-focused Benchmarks for Clinical Governance. London: DH.
Edmans, J. et al (2005) Occupational Therapy and Stroke. London: Whurr Publishers.
Egan, G. (2002) The Skilled Helper: a Problem-Management and Opportunity Approach to Helping. Pacific Grove: Brooks/Cole. Cited in: Chapelhow, C. et al (2005) Uncovering Skills for Practice. Cheltenham: Nelson Thornes.
Giddens, A. (2006) Sociology. Cambridge: Polity Press.
Heron, J. (1990) Helping the Client: A Creative Practical Guide. London: Sage.
Hinchliff, S. et al (2003) Nursing Practice and Healthcare. London: Arnold.
Jacobsson, C. et al (2000) How people with stroke and healthy older people experience the eating process. Journal of Clinical Nursing; 9: 2, 255–264.
Mayberry, M., Mayberry, J. (2003) Consent in Clinical Practice. Oxon: Radcliffe Medical Press.
National Institute of Neurological Disorders and Stroke (2008) Post-Stroke Rehabilitation Fact Sheet.
NICE (2008) Stroke: Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack. London: NICE.
Rosenvinge, S. Starke, I. (2005) Improving care for patients with dysphagia. Age and Ageing; 34: 587-593.
Perry, A., Potter, P. (2002) Clinical Nursing Skills and Techniques. London: Mosby.
Richards, A., Edwards, S. (2004) A Nurse’s Survival Guide to the Ward. London: Churchill Livingstone.
Scottish Intercollegiate Guidelines Network (2004) Management of Patients With Stroke: Identification and Management of Dysphagia. Edinburgh: SIGN.
Terrado, M. et al (2001) Dysphagia: An Overview. BNet Healthcare.
Thayer, K. (2003) Establishing an Effective Dysphagia Program in a Long Term Care Facility. Speech Pathology.com.
The Stroke Association (2009) Psychological Effects of Stroke. London: The Stroke Association.
The Stroke Association (2008) Five Demands for Action: the Stroke Survivor’s View. London: The Stroke Association.
Trapl, M. et al (2007) Dysphagia bedside screening for acute-stroke patients. The Gugging Swallowing Screen. Stroke; 38: 11, 2948–2952.
Wilkins, T. et al (2007) The prevalence of dysphagia in primary care patients: a HamesNet research network study. The Journal of theAmerican Board of Family Medicine; 20: 2, 144–150.
Workman, B., Bennett, C. (2003) Key Nursing Skills. London: Whurr Publishers.
World Health Organization (2006) STEPwise Approach to Stroke Surveillance. Geneva: WHO.