Supporting safe swallowing of care home residents with dysphagia: How does the care delivered compare with guidance from speech and language therapists?

INTRODUCTION: Dysphagia affects up to 70% of care home residents, increasing morbidity and hospital admissions. Speech and language therapists make recommendations to support safe nutrition but have limited capacity to offer ongoing guidance. This study aimed to understand if recommendations made to support safe and effective care are implemented and how these relate to the actual care delivered. METHODS: Eleven mealtimes with residents with dysphagia were observed during 2020 using a tool capturing 12 elements of expected practice. Staff actions during mealtimes were compared with adherence to residents' care plans and speech and language therapist recommendations. RESULTS: Written recommendations predominantly focused on food and fluid modification. Observations (n = 66) revealed food texture, posture, and alertness were adhered to on 90% of occasions, but alternating food and drink, prompting and ensuring swallow completed adherence was less than 60%. Thickened fluids frequently did not align with required International Dysphagia Diet Standardisation Initiative levels. Nutrition care provided in the dining room was less safe due to a lack of designated supervision. CONCLUSION: Care homes need to be supported to establish a safe swallowing culture to improve residents' safety and care experience. WHAT THIS PAPER ADDS: What is already known on this subject? Dysphagia is associated with considerable morbidity and mortality and has been identified as an independent risk factor for mortality in nursing home residents. There is evidence that compensatory swallowing strategies, safe feeding advice and dietary modifications can reduce the risk of aspiration pneumonia. Care for nursing home residents at mealtimes is often task-centred and delegated to those with limited training and who lack knowledge of useful strategies to support the nutrition and hydration needs of residents with dysphagia. What this study adds? Written advice from speech and language therapists on safe nutrition and hydration for residents with dysphagia is focused mainly on food and fluid modification. Nurses and healthcare assistants have limited understanding of International Dysphagia Diet Standardisation Initiative levels or safe swallowing strategies and recommended practices to support safe nutrition care for residents with dysphagia are inconsistently applied especially when residents are eating in dining areas. Care homes are not aware of Royal College of Speech and Language Therapists guidance on how safe nutrition care of residents with dysphagia should be supported. What are the clinical implications of this work? Care homes need to prioritise a safe swallowing culture that ensures that residents with swallowing difficulties are assisted to eat and drink in a way that enhances their mealtime experience and minimises adverse events that may result in hospital admission. Speech and language therapists could play an important role in training and supporting care home staff to understand and use safe swallowing strategies with residents with dysphagia. The Royal College of Speech and Language Therapists could provide more assistance to care homes to support and guide them in how to implement safe feeding routines. Care home staff have limited knowledge about how to implement safe feeding routines and need more guidance from speech and language specialists on how they can support residents with dysphagia to eat safely. Creating a safe swallowing culture within care homes could help to improve nutrition care and enhance patient safety.

The Non-speech Oral Movement Assessment Children (NOMAC).

INTRODUCTION: Examination of oral movements is often part of an assessment undertaken by a speech and language therapist (SLT). Until now there have been no specific instruments or tests with reference values for typically developing children in Dutch that exclusively evaluate non-speech oral movements in young children. Therefore, a non-speech oral-motor observation list was designed to attempt to bridge this gap: The Non-speech Oral Movement Assessment Children (NOMAC). The aim of this study was to evaluate the psychometric properties of the NOMAC in terms of inter-rater reliability and its' construct validity. In addition, we aimed to collect reference values for the non-speech oral movements in children. METHODS: Data from typically developing Dutch children aged 2 to 8 years were collected. Inter-rater reliability was studied by estimating the intra-class correlation coefficient (ICC). Construct validity was investigated by assessing the effect of age group and gender on the mean execution score per item (general linear model). To present normative data the percentage of the children performing a normal oral - motor execution was calculated. RESULTS: The study includes a total of 318 children, divided into 9 age groups. The inter-rater reliability shows a [sufficient] to [good] ICC for most items. A significant effect of the factor age group for almost all items was seen, confirming a robust construct validity. Normative data are presented with the percentage of the children performing a normal oral movement execution. CONCLUSION: Non-speech oral movements can be assessed with the NOMAC in children between 2 to 8 years old and can be compared with values obtained from a normative group. It should be used as part of a clinical feeding and speech assessment. Despite the fact that current insights indicate that oral- motor training has no value for improving mastication, swallowing and speech, it is important to know the status of non-speech oral motor capabilities. With this assessment a complete profile of the child's oral-motor abilities can be achieved, supportive for clinical decision making in SLT.

Nurses' strategies to provide emotional and practical support to the mothers of preterm infants in the neonatal intensive care unit: A systematic review and meta-analysis.

AIM: To synthesize and integrate current international knowledge regarding nursing strategies for the provision of emotional and practical support to the mothers of preterm infants in the neonatal intensive care unit. METHODS: A systematic review and meta-analysis was undertaken. Four English-language databases including EMBASE, PubMed (including MEDLINE), Scopus, and Web of Science were searched from January 2010 to October 2021. Original quantitative studies that were written in English and focused on nursing strategies for the provision of emotional and practical support to the mothers of preterm infants in the neonatal intensive care unit were included. Eligibility assessment, data extraction, and methodological quality appraisal were conducted independently by the review authors. A narrative synthesis of the review results and a meta-analysis were performed. RESULTS: Twenty studies that were published from 2010 to 2021 were included in the review. Three categories concerning the review aims were identified: 'nursing strategies related to mothers' emotions and infant-mother attachment', 'nursing strategies related to mothers' empowerment', and 'nursing strategies related to mothers' participation in care process and support'. Eight interventional studies that reported mothers' stress as the study outcome were entered into the meta-analysis. Interventions consisted of the educational programme, spiritual care, telenursing, parent support programme, skin-to-skin care, and guided family centred care. Significantly lower maternal stress was found in the intervention group compared with that of the control group (g: -1.06; 95% confidence interval: -1.64, -0.49; Z = 3.62, p < 0.001). CONCLUSION: This review identified and highlighted key nursing strategies used to provide emotional and practical support to the mothers of preterm infants in the neonatal intensive care unit. They included family centred care, skin-to-skin care, parent support and education programmes, interpersonal psychotherapy, spiritual care, newborn individualized developmental care and assessment programme, and telenursing.

Nursing physical workload and mental workload in intensive care units: Are they related?

AIM: In order to ensure patient safety and quality of care, it is important to consider factors which may impact on nursing workloads. This study aimed to investigate the simultaneous physical and mental workload and any relationships between these concepts on nurses working in intensive care units. DESIGN: A cross-sectional design was undertaken. METHOD: Participants were nurses (N = 105) recruited from six adult intensive care units which met the inclusion criteria. Nursing Activities Score (NAS) to measure physical workload and NASA Task Load Index (NASA-TLX) to measure mental workload were used. Data were collected for each participating nurse in three shifts (morning, evening and night). Data were analysed using bivariate correlation and multivariable linear regression analysis. RESULTS: The mean (SD) of nurses' physical and mental workload was 72.84% (22.07%) and 70.21 (12.36), respectively. A significant relationship between physical and mental workload (p <.001) was identified.

Identification of the Range of Nursing Skills Used to Provide Social Support for Mothers of Preterm Infants in Neonatal Intensive Care.

BACKGROUND: Hospitalization of preterm infants in neonatal intensive care units (NICUs) is a stressful experience for parents. Iranian NICUs do not have specified levels of care, nor do they integrate supportive methods of parent support such as family-centered care approaches. This study investigated the range and types of neonatal nursing support, as perceived by mothers of preterm infants, and its association with mothers' satisfaction with infant care in the NICU. METHODS: This is a descriptive, correlational study of mothers of preterm infants who were hospitalized in three different NICUs in Iran. A convenience sampling method was used. Data were collected using three questionnaires that identified (i) demographic information; (ii) social support available; and (iii) parent satisfaction with infant care. RESULTS: Mothers (N = 110) generally rated the support from nurses as being moderate. Correlation analysis identified a moderate association of neonatal nurse social support domains for affirmational (r = 0.44) and concrete aid (r = 0.41), a moderately strong association for affectional support (r = 0.64), and total social support (r = 0.60) with mothers' satisfaction. CONCLUSION: There were positive associations between social support from nurses and mothers' satisfaction with the care of their infants. Therefore, planning to promote and create opportunities for neonatal nurses to support mothers in NICU is important to promote increased maternal satisfaction in infant care.

Nursing workload in intensive care units and the influence of patient and nurse characteristics.

BACKGROUND: Understanding factors that can potentially influence patient care and nursing workload in intensive care units is important. Previous studies have shown contradictory outcomes about the relationships between nursing workload and patient and nurse characteristics. AIMS AND OBJECTIVES: This study aimed to investigate nursing workload in intensive care units and examine the association between this in relation to patient and nurse characteristics. DESIGN: A cross-sectional design was conducted. METHODS: All nurses who were working in the intensive care units of five hospitals and met the study criteria were enrolled in the study. Two demographic questionnaires collected nurse and patient demographic information. The Nursing Activities Score was applied to determine nursing workload in three shifts (morning, evening, night) for each nurse. Data were analysed using the independent sample t-test, one-way analysis of variance, and multivariable linear regression analysis. RESULTS: The Nursing Activities Score was calculated for 509 patients who were under the care of 105 intensive care unit nurses. The mean (SD) Nursing Activities Score was 72.84% (22.07%). Morning shifts, male patients, medical treatments, and referred patients from the emergency ward and other intensive care units imposed a higher workload for nurses. Specifically, female nurses, increased number of patients receiving care, and increased patient length of intensive care unit stay were directly associated with increased Nursing Activities Scores. Work in surgical and burn intensive care units were inversely associated with the Nursing Activities Score. CONCLUSION: This study suggests that the workload of nurses in intensive care units can be affected by both nurse and patient characteristics. RELEVANCE TO CLINICAL PRACTICE: The findings can be used to ensure appropriate staffing of intensive care units by nurses. However, nurse and patient characteristics should not be considered the only factors that influence nursing workload in intensive care units.

A service evaluation of parent adherence with dysphagia management therapy guidelines: reports from family carers supporting children with complex needs in Greece.

Purpose: Many children with complex needs exhibit eating, drinking, and/or swallowing disorders (dysphagia). These children often have associated learning needs, and require assistance from carers for daily tasks such as eating and drinking. The aim of this study was to identify which strategies to manage dysphagia were challenging for family carers, and reasons for any non-adherence.Method: In this service evaluation researchers observed carers during mealtimes, and investigated carer opinions of strategies used to minimise the risks of dysphagia. Eight children with complex needs aged 3.4-7.5 years and their primary family caregiver participated.Results: Adherence with speech and language pathologists' dysphagia recommendations overall was over 50% in all but one case. For specific strategies, the highest adherence was observed for diet modifications of foods (89%), communication during the mealtime (83%), amount of food to present (81%), and the pacing of fluids and foods (81%). Lower levels of adherence were identified in relation to postural management (58%), environmental changes (58%), utensils (56%), and preparatory strategies (49%).Conclusions: Adherence with use of strategies to support mealtimes was over 50% in all but one case. Findings suggest that support is essential to promote safe mealtimes, reduce family carers' stress and increase knowledge, confidence, and adherence in implementing dysphagia guidelines in the family home. Implications for rehabilitationDifficulties with eating, drinking and swallowing (dysphagia) can impact on the parent-child mealtime experience.Mealtime strategies as recommended by a speech-language pathologist can support children who have difficulties eating, drinking, and swallowing.Some strategies to support eating, drinking, and swallowing are easier for carers to adhere to than others.

Pediatric feeding and swallowing rehabilitation: An overview.

Children with neurological disabilities frequently have problems with feeding and swallowing. Such problems have a significant impact on the health and well-being of these children and their families. The primary aims in the rehabilitation of pediatric feeding and swallowing disorders are focused on supporting growth, nutrition and hydration, the development of feeding activities, and ensuring safe swallowing with the aim of preventing choking and aspiration pneumonia. Pediatric feeding and swallowing disorders can be divided into four groups: transient, developmental, chronic or progressive.This article provides an overview of the available literature about the rehabilitation of feeding and swallowing disorders in infants and children. Principles of motor control, motor learning and neuroplasticity are discussed for the four groups of children with feeding and swallowing disorders.

Managing eating and drinking difficulties (dysphagia) with children who have learning disabilities: What is effective?

People who work with children who have neurological and learning disabilities frequently need to manage the health and emotional risks associated with eating, drinking and swallowing (dysphagia). Some approaches can support children to develop oral feeding competence or to maximise their ability to maintain some oral intake supplemented with tube feeding. However, some clinicians feel that oral-motor exercises can support eating and drinking skills as well as speech and language development, whereas there is little evidence to support this.The implied "beneficial" association between oral-motor exercises, speech and swallowing skills gives a false impression in terms of future outcomes for parents and carers of children with learning disabilities. This paper considers oral-motor approaches in the remediation of dysphagia and the need for a cultural shift away from this view. Realistic and useful outcomes for people with learning disabilities need to be an essential part of therapeutic intervention.

Drinking speed using a Pat Saunders valved straw, wide-bore straw and a narrow-bore straw in a normal adult population.

BACKGROUND: Straw drinking is often recommended as a strategy for managing swallowing difficulties in adult clinical populations. This study presents a range of normal adult straw drinking speeds and discusses clinical applications. METHOD: Straw drinking speed in a normal healthy population of 70 adults from 18 to 95 years of age was measured. Three types of straws were used: a Pat Saunders valved straw (PSVS), a wide-bore straw and a narrow-bore straw (NBS). Participants drank 40  ml of water for each straw tested. All participants were asked to comment on the straws used. A mixed-method design was used wherein both quantitative and simple structured qualitative data were collected. RESULTS: Drinking speed was quickest for the wide-bore straw, followed by the NBS and slowest for the PSVS. This was supported by qualitative comments from the adults who reported that the PSVS was the most difficult straw to use. There were no significant differences between straw flow or straw type and sex of the participants. There were significant changes with aging and a decrease in flow speed with the NBS. Weight and height had some effect on straw drinking speeds. There was a slight correlation between age and sex and age and height, but not between age and weight. CONCLUSION: This article presents data for a normal range of straw drinking speeds in a healthy adult population. It can be used in the assessment and monitoring of straw drinking in acquired disorders of swallowing.

The benefits of a 5-day dysphagia intensive placement.

Finding practical dysphagia opportunities for students pre-qualification is challenging. Discussions with clinicians led to the development of a new placement model. The placement was just five days and had an accompanying workbook. The current study aimed to evaluate the benefits of the placement. Data were analysed from 40 students who attended an adult dysphagia placement and 13 who attended a paediatric dysphagia placement. Measures included a pre and post self-rating questionnaire, qualitative feedback from clinical educators and students and a pre and post measure of knowledge using concept maps. Student self-rating data indicated gains in experience, awareness, knowledge, clinical skills, competence, confidence and interest in dysphagia. Clinical educators and students also reported a range of benefits from this placement. Students who undertook a placement that focused on adult dysphagia significantly increased their knowledge of adult dysphagia, but this did not generalize to paediatric dysphagia. Despite reporting that they felt they had gained in knowledge of dysphagia, the students who did a paediatric dysphagia placement did not significantly increase their knowledge of dysphagia. The study raises a number of important considerations when designing placements including length, timing, intensity, how best to encourage generalization of knowledge, and how best to measure learning.

The use of nonnutritive sucking to facilitate oral feeding in a term infant: a single case study.

This individual case study presents an evaluation of and reflection on the use of nonnutritive sucking as a technique to facilitate nutritive sucking with an infant with feeding difficulties. Nonnutritive sucking is used in a variable way with mainly premature or sick infants. However, the rationale underpinning use of such an approach is not clear. The infant participant in this study, Baby H, was born at 37 weeks. This case illustrates the use of nonnutritive sucking as an approach with supported rationales for promoting transition toward oral feeding with infants who have complex needs and who are term infants. The literature focuses on using nonnutritive sucking with premature infants who have no additional difficulties such as hypoxic neonatal encephalopathy, meconium aspiration, sepsis, or severe perinatal asphyxia. The intervention carried out with Baby H demonstrates that nonnutritive sucking can contribute toward the management of an infant's feeding development. Baby H took 23 days to develop a sequential nonnutritive sucking pattern, but her ability to transfer this to nutritive sucking and safe feeding took the first 17 months of this infant's life. This study is unique in that it explored the issues involved with a term infant who had complex needs that impacted on feeding development. It is important because many practitioners use nonnutritive sucking with infants who have complex needs.

Drinking speed using a valved Pat Saunders straw, wide bore straw and a narrow bore straw in school-age children.

BACKGROUND: To understand the nature of straw drinking in relation to a group of children with specific eating and drinking difficulties, it is first necessary to ascertain the range of normal function. Straw drinking is often recommended as a method that can support children with eating and drinking difficulties. METHOD: This study looked at straw drinking performance in a normal population of 125 children aged between 6 and 11 years of age. Three types of straws were used: a valved Pat Saunders straw, a wide bore straw and a narrow bore straw. Children drank 40 mL of water for each straw tested. RESULTS: Children increased their speed of intake significantly for all straw types as they matured. Drinking speed was quickest for the wide bore straw followed by the narrow bore and slowest for the valved Pat Saunders straw. This was supported by qualitative feedback from the children with most finding the wide bore straw the easiest one to use and the valved Pat Saunders straw the hardest. There were significant differences in speed of flow between the valved Pat Saunders straw and wide bore straw, between the valved Pat Saunders straw and the narrow bore straw and between the wide bore straw and the narrow bore straw. There were no significant differences between straw flow or straw type and gender. CONCLUSIONS: This normative data for straw drinking in a paediatric population can be used to develop baseline measures for clinical assessment.

Evaluation of an intensive desensitisation, oral tolerance therapy and hunger provocation program for children who have had prolonged periods of tube feeds.

BACKGROUND: Some children with feeding difficulties may require nasogastric tube feeding or insertion of a percutaneous endoscopic gastrostomy (PEG) from a young age. A small cohort of these children can develop severe oral aversions that can delay the re-introduction of oral feeding. Multidisciplinary approaches that provide an intensive approach are deemed the most effective method of intervention to reduce nasogastric and PEG dependency. METHODS: Two children and their parents received an intensive approach to reduce PEG feeds (Child A and Child B), while one child and her parents elected to receive a traditional feeding clinic approach (Child C). The mean age of the participants was 4 years 4 months. RESULTS: Child A initially took 2090 kJ (44% daily nutritional requirement) via her PEG before the intensive program, and Child B took 100% daily nutritional requirement via his PEG. Three months post the intervention, Child A took 100% of her nutritional requirements orally and Child B had reduced PEG requirement significantly to 38% of daily nutritional requirement. Child C showed no changes in PEG versus oral intake. Children who received the intervention were able to remain focused on mealtimes for longer, with fewer instances of leaving the table. Parents altered their language styles post coaching on the intensive intervention using fewer reprimands. No changes with these behaviours were noted with Child C. CONCLUSIONS: Although this was a small pilot study, there are some strategies used within an intensive multidisciplinary context that can enable children to reduce their reliance on PEG feeds significantly.

New developments in the management of speech and language disorders.

Speech and language disorders, which include swallowing difficulties, are usually managed by speech and language therapists. Such a diverse, complex and challenging clinical group of symptoms requires practitioners with detailed knowledge and understanding of research within those areas, as well as the ability to implement appropriate therapy strategies within many environments. These environments range from neonatal units, acute paediatric wards and health centres through to nurseries, schools and children's homes. This paper summarises the key issues that are fundamental to our understanding of this client group.