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TRAINING

A practical focus
Trish Morrison and Eugenie Smuts want to ensure pupils with eating, drinking and swallowing difficulties receive the safest and most appropriate help at school lunchtimes. Here they consider what lessons they can learn from a project to develop and evaluate a multidisciplinary refresher course for special needs assistants.

READ THIS IF YOU WANT TO PROVIDE TRAINING THAT IS MULTIDISCIPLINARY TIME EFFICIENT MOTIVATING FOR PARTICIPANTS

e are involved in assessment and management of individuals with eating, drinking and swallowing difficulties at a centre which provides services to people with physical disabilities from birth throughout life. As we spend considerable time in our schools eating, drinking and swallowing service on training, we were interested in developing and evaluating a refresher package for special needs assistants. In highlighting the pitfalls and what we found worked best, we hope this article gives you food for thought when developing your own staff training. Given the number of communication training packages around (see for example Manolson, 1992), we were struck by the paucity of training packages for people supporting children with eating, drinking and swallowing difficulties. In an attempt to locate what might already be available we googled, as per the first port of call in the 21st century! This identified some online dysphagia training (at www.nursingtimes.net) and articles (such as Miller & Krawczyk, 2001) which focus on training for nurses working with adults with acquired dysphagia. Bailey et al. (2008) address dysphagia services in a school setting and examine speech-language pathologists perspectives. Among the concerns highlighted is the need for the therapist to be appropriately trained and supported by a team. Our training has the advantage of being delivered by members of the core multidisciplinary team involved in dysphagia management. Miller & Krawczyk (2001, p.38) cite Pediani & Walsh (2000) as providing useful guidelines for effective training, including: Keeping new ideas simple, understandable and communicating effectively. Ensuring that new ideas are obviously and immediately useful. Supporting the teaching with clear practical demonstration. Miller & Krawczyk also recommend engaging the learners from the outset by agreeing objectives and learning expectations. In terms of core content, an informal discussion with colleagues indicated the importance of including: a. The normal swallow b. The effects of physical disability on eating, drinking and swallowing

Trish

Eugenie

The need to be aware of eating, drinking and swallowing issues d. Aspiration e. Positioning f. Utensils g. How to make feeding safe h. Information on food consistencies i. Oesophageal reflux j. Effect of hyper- and hypo- sensitivity on eating, drinking and swallowing. From our reading and clinical experience, we believed that: i. carer knowledge would improve following refresher training ii. carers would prefer training that includes a one-to-one practical component iii. feeder compliance with management recommendations and strategies would increase following training.

c.

Our course

The course we developed and coordinated is run by a multidisciplinary team comprising an occupational therapist, physiotherapist, dietitian and speech and language therapist. It takes approximately 3.5 to 4 hours and can be comfortably fitted into a morning or afternoon. Topics covered are supported by practical activities, video clips and handouts. The session begins with a 7 point questionnaire we developed to assess participants knowledge prior to training. Questions are practical, and probe the participants awareness of signs of aspiration and ability to identify and describe why and how utensils might be used. Finally it asks them how to prepare food and drink of a specified consistency. The course includes a review of the normal swallow and revision of aspiration and reflux led by the speech and language therapist. The

physiotherapist and occupational therapist then jointly present positioning to maximise safe swallowing. This includes information on cerebral palsy, tone and patterns of flexion and extension. They particularly emphasise repositioning a child before feeding them to achieve a correct seating position. The presentation then moves on to look at the impact of the feeders position. At a later stage the speech and language therapist relates patterns of extension and flexion to what is observed in the childs oral motor structures and the implications for management. Sensory aspects of eating, drinking and swallowing are covered jointly by the speech and language therapist and occupational therapist. The occupational therapist then reviews use of utensils to enhance oral motor skills and independence. In an effort to make the training practical and relevant, yet feasible within our centre, we look at the influence of environmental factors and both the childs and the feeders communication. We practise strategies such as providing jaw support, and review when and why they might be useful. The morning concludes with a presentation from our dietitian, who looks at the importance of good nutrition and reviews the guidelines for nutritional intake in children and how these change with age. She covers the effects of poor weight gain, spillage, nutritional deficiencies, and the use of supplements. The participants are then shown how to use thickeners and have the chance to practise producing drinks of a specified consistency. The theory part of the course ends with readministration of the questionnaire.

Evaluation

This course was part of a week-long training package in July 2009 for Special Needs Assistants working in the Central Remedial Clinic School. It was offered to 27 people, of whom 26 attended on the day (1 was absent due to illness). We evaluated the impact in three ways. Firstly, we asked those attending to complete a general feedback form. Secondly, we looked at the pre- and post- training questionnaire responses. Finally, we allocated each assistant a number between 1 and 9,

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2011

TRAINING
and used a random sampling table from the internet to select 10 people who would be offered additional one-to-one training. a) Written feedback We received written feedback on the training from 13 of the assistants, and in general it was positive. They liked the opportunity to have a refresher, particularly as it was presented by members of the multidisciplinary team. Three of the respondents rightly did not appreciate questions that went off topic, which was a lesson to us as presenters that we need to be more proactive in crowd control! Other comments reflected a broad range of themes and were mainly practical questions relating to clients the respondents were feeding. b) Questionnaire responses A number of people arrived late on the day so didnt complete the first questionnaire. Others left early before completing the second, so just 14 of the 26 completed and submitted both the pre- and post-training questionnaires. We had to exclude one of these where the person had answered same as before on a number of occasions, as it was unclear whether this referred to the previous question or to their previous questionnaire. Of the 13 remaining, we scored correct answers as 1, partially correct as and wrong as 0. All post-questionnaires showed improved total scores, but some were minimal; for example, 3 of the 13 only improved by to 1 point. Interpretation of the results is tricky, particularly as it could be argued the percentage of errors in most areas was already relatively low on the pre-questionnaire. Our conclusion was that our coverage of aspiration had an impact, and that there may have been small positive changes in terms of utensils. However, the assistants knowledge of food consistencies and how to prepare them did not change, and we have therefore decided we need to review and alter this aspect of the course. c) One-to-one The one-to-one sessions took place during lunchtime while the assistants were feeding their client. As 2 of the 10 selected were repeatedly absent for the scheduled observations, 8 people were included in this phase of the project. Special Needs Assistants usually feed the same client for a period of 6-12 months, and allocation of feeders to clients falls under management of the nursing department. The first one-to-one training session took place during October-November 2009 and the second in January-February 2010, approximately 8 weeks later. During each of these sessions the speech and language therapist completed a feeding observation checklist which we had devised for this project, and provided advice and on the spot training as needed. Every client attending the school eating, drinking and swallowing clinic receives a laminated placemat. This lists recommended food and liquid consistencies and supplements for the individual, along with guidelines on pacing, spoon placement and communication as well as seating and positioning. The placemats are updated as required. Copies are kept in the nursing department, and responsibility for distribution and collection falls under the remit of the nursing department. During the one-to-one sessions the speech and language therapist monitored compliance to the placemat guidelines, putting yes if recommendations were followed and no if they were not. The checklist included an area to note down any additional comments, and the speech and language therapist followed up any concerns or queries reported by the assistants with relevant professionals. Overall, the checklist used in the first oneto-one observation session showed there was already generally good compliance for use of recommended utensils, for solid and liquid consistencies and supplements, and for following feeder guidelines. Only 2 of the 8 assistants needed a practical demonstration or additional guidelines, and at the second session they maintained the strategies recommended. We were somewhat concerned that 3 of the 8 placemats were missing on the first occasion, and 2 on the second. Reasons ranged from accidental misplacing on another table to a client not having a placemat as they had been discharged from the eating, drinking and swallowing service and were awaiting review. Of the 8 assistants, 3 reported not receiving sufficient and appropriate guidelines from staff prior to feeding a client for the first time, and 7 said they had concerns about the high number of pupils they are supervising whilst feeding a client. They find this distracts their attention and eats into the time needed to feed their client. via an online module, which we would update regularly to keep pace with development of knowledge. We would then focus our time on supporting assistants on a practical level. We would welcome comments or contact from other services offering paediatric SLTP feeding training packages. Trish Morrison (email tmorrison@crc.ie) and Eugenie Smuts (email esmuts@crc.ie) are speech and language therapists at the Central Remedial Clinic in Dublin.
References Bailey, R.L., Staner, J.B., Angell, M.E. & Fetzner, A. (2008) School-based Speech Language Pathologist Perspectives on Dysphagia Management in the Schools, Language Speech and Hearing Services in Schools 39(4), pp.441-450. Manolson, A. (1992) It Takes Two To Talk: A Parents Guide to Helping Children Communicate. Toronto: The Hanen Centre. Miller, R. & Krawczyk, K. (2001) Dysphagia Training Programmes: Fixes That Fail or Effective InterDisciplinary Working, International Journal of Communication Disorders 20(S1), pp.374-384. Bibliography American Speech-Language-Hearing Association (2007) Guidelines for speech-language pathologists providing swallowing and feeding services in schools. Available at: http://www.asha.org/docs/html/ GL2007-00276.html (Accessed 26 September 2011.) Colodny, N. (2001) 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, Dysphagia 16(4), pp.263-271. Crawford, H., Leslie, P. & Drinnan, M.J. (2007) Compliance with Dysphagia Recommendations by Carers of Adults with Intellectual Impairment, Dysphagia 22(4), pp.326-334. Homer, E.M. (2008) Establishing a Public School Dysphagia Program: a Model for administration and Service Provision, Language Speech and Hearing Services in Schools 39(2), pp.177-191. Huffman, N.P. & Owre, D.W. (2008) Ethical Issues in Providing Services in Schools to Children with Swallowing and Feeding Disorders, Language Speech and Hearing Services in Schools, 39(2), pp.167-176.

The implications

Overall our three beliefs about training at the start of this project were reinforced, but the process raised a number of issues we need to reflect on. Even when a course is mandatory, and is run by core members of the on-site multidisciplinary team, levels of engagement by participants differ. Some are already knowledgeable and comply with recommendations, but we do not know about those who didnt complete both questionnaires, or who were unavailable for the observations. Furthermore, while the majority of those giving feedback on the 13 point questionnaire wanted both theoretical and practical components, 2 wanted only practical training. Throughout the process it was the practical aspects, including the activities and videos used during the initial days training, and the person-specific elements that appeared to motivate the assistants and make a direct difference to clients. Given this, and the current financial pressures on the health service, we are considering providing the theoretical training

REFLECTIONS DO I ACCEPT THAT PEOPLE NEED DIFFERENT BALANCES OF THEORETICAL AND PRACTICAL TRAINING? DO I CAPITALISE ON AN INDIVIDUALS INTEREST IN THEIR OWN CLIENT AND SITUATION? DO I ADDRESS ANY WIDER SYSTEM PROBLEMS REVEALED THROUGH TRAINING AND ITS EVALUATION?
What feedback can you offer? Let us know via Speech & Language Therapy in Practices Critical Friends, www. speechmag.com/About/Friends.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2011