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The team tackling dysphagia

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As part of a trust initiative in Sheffield, nurses are training alongside speech and language therapists to assess and manage dysphagia.

As part of a trust initiative in Sheffield, nurses are training alongside speech and language therapists to assess and manage dysphagia.

HOW MANY times have you known patients who have suffered because they had difficulty swallowing but no one to properly assess their problem? Most nurses are trained in basic screening for dysphagia, but even if they spot the problem it can be hours, perhaps days, before a speech and language therapist performs a thorough assessment.

Now nurses in Sheffield are tackling this problem through a novel expansion of their role. An intensive dysphagia training course for speech and language therapists (SALTs), followed by a six-month period of supervision, is equipping nurses to make dysphagia assessments autonomously.

Fiona Claydon (pictured right), stroke nurse coordinator at Sheffield Teaching Hospitals NHS Foundation Trust, was one of the first nurses in the trust to learn the new skill. 'Back in 2000 I did some fact finding and found that patients were waiting for swallowing screening and assessment. There just weren't enough staff for the numbers of patients, and also the speech and language therapists work 9am-5pm, five days a week,' Ms Claydon recalls.

So she was very pleased to be invited to join the SALTs dysphagia course. At first it was just herself and one other nurse. 'It was another world, very scary, but also exciting,' she says. 'It was something we wanted to learn about and we knew we could make instant changes.'

Ms Claydon was carrying out basic screening at the time to see if patients could eat and drink but this did not go far enough. 'I felt that if I had more training I could do a more in-depth assessment or try them with a modified diet, and the patient wouldn't have to wait to see a speech and language therapist,' she explains.

To prepare her for the course Ms Claydon was given a reading list on anatomy and physiology. Dysphagia affects many fields of nursing including learning disability, elderly mental health, neurology, cancer, multiple sclerosis and stroke care. So the SALTS training Ms Claydon received was very generic. Then for six months she spent two days a week assigned to a qualified SALT, initially observing, then carrying out the assessments herself.

Now all four stroke coordinators on the trust's stroke unit have done the course and the results have been dramatic. 'It's one of the most satisfying expansions of roles - you see instant results,' says Ms Claydon. 'Patients are now seen within 24 hours, it's a very different service. You see the pleasure of patients and relatives when they find out they can have something to eat. We work bank holidays too - why should things stop just because it's a bank holiday?'

The nurses and therapists have a close working relationship. If a therapist is doing a complicated assessment, she or he will invite Ms Claydon or a nurse colleague to observe. 'I've been qualified to do the dysphagia assessment for over four years, but occasionally I'll ask a therapist to come and watch me,' Ms Claydon explains. 'But sometimes they ask for my advice - I find that very satisfying. I'm realising that I'm quite an expert in the field, it's very rewarding.'

The initiative has enjoyed support from consultants, matrons and the director of nursing. 'You feel that your work is very recognised,' Ms Claydon points out. And the fact that the course is accredited at Sheffield Hallam University means she can earn 30 points towards a master's degree.

Sue Pownall (left) is the speech and language therapist who led the initiative to provide dysphagia training for nurses. Increasing referrals had meant there were not enough therapists to see patients in a timely fashion. The NHS Plan had already fostered a general modernising drive to share skills and then in 2000 the Royal College of Physicians issued stroke guidelines that patients should be seen for dysphagia within 48 hours.

'We had to look at dysphagia services in a different way, with interdisciplinary working and training nurses to the same level as ourselves,' Ms Pownall recalls. 'Also we wanted to look at who was best placed to provide the service to patients.'

But blurring professional boundaries is not always easy. For example, the issue of one professional group supervising another is difficult, so the SALT supervisors developed a system of long-term support to allow nursing colleagues to share their experiences.

'We have to recognise that changes in working practices take a long time, and the biggest issue is to ensure competencies are maintained,' Ms Pownall says. 'Often projects like these work for the period people are paying attention to them, but they are unable to embed themselves.' Ms Pownall and her colleagues have introduced update days and much of the support is aimed at integrating the new skills into everyday practice. The course has now gone into the post basic education opportunities. 'It's become part of the furniture,' Ms Pownall adds.

The SALTs and nurses work so closely they are even able to cover for each other over annual leave. Sometimes the nurses will take over the duty of care for a patient during her or his dysphagia experience, sometimes the therapists will do so.

Apart from helping ease the demand on their services, the therapists benefit from this partnership by seeing dysphagia from a different angle and acquiring a broader understanding of chest care, blood gases and more holistic patient care.

A full quantitative and qualitative evaluation of the nurses' expanded role will take place soon, but anecdotal evidence shows that patients are being seen more quickly and that SALTs are able to target referrals better. Also there has been a positive change among nurses on the wards as their awareness has risen through working alongside their dysphagia-trained colleagues.

Ms Claydon also presented a poster at a stroke nurses' conference, which generated lots of interest. 'We have many visitors, and people are continually phoning us up to ask about it,' she explains.

The stroke nurses are also cascading their screening skills, taking on the training of other nurses instead of the SALTs doing it.

'I don't know what the magic ingredient is but it has fallen into place really well,' Ms Claydon says. 'Some therapists around the country still want to hold onto their "domain", but with my hand on my heart I can say that here in Sheffield they've been very pleased and grateful for the support nurses can now give them.'

Benefits of the SALTs project

 Nurses now conduct in-depth dysphagia assessments instead of speech and language therapists

 Staff shortages no longer mean patients have to wait to be assessed for dysphagia

 Nurses take a five-day dysphagia course run by speech and language therapists

 They then work alongside the therapists two days a week for six months

 The training is generic and is not focused on stroke alone

 The course is university accredited and contributes towards a master's degree

 Long-term support ensures new skills are embedded into everyday nursing practice

 Stroke patients are now seen for dysphagia within 24 hours

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