Dysphagia Competency Model North West The Big Picture · Manchester Metropolitan University 2 designed to scope current practice within the North West. This was circulated to practising

Dysphagia Competency Model North West

The Big Picture

Final Project Report

Jois Stansfield

John Lancaster

Susan Guthrie

July 2015

Manchester Metropolitan University

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CONTENTS

Contents ......................................................................................................... i

Executive Summary ....................................................................................... 1

North West model for implementing dysphagia competency in newly qualified Speech and Language Therapists (NQP). Recommendations from project funded by Health Education North West 2015 .................................................................................................. 4

Summary of Recommendations ............................................................................................ 5

Acknowledgements ....................................................................................... 8

Acronyms ....................................................................................................... 9

1.0 Introduction: Background to the Project ................................................ 10

1.1 Phase 1 ..................................................................................................................... 10

1.2 Phase 2 ..................................................................................................................... 11

1.3 Phase 3 ..................................................................................................................... 12

1.4 Phase 4 ..................................................................................................................... 12

1.5 Dissemination .......................................................................................................... 12

2.0 Project Outcomes .................................................................................. 14

2.1 Postgraduate formal training needs Further information: NQ SLT theoretical knowledge development and non-contact learning opportunities. ................................... 14

2.1.1 Self-directed learning ........................................................................................... 14

2.1.2 Formal course attendance ................................................................................... 15

2.1.3 Study days ............................................................................................................ 16

2.1.4 In house knowledge / theory training ................................................................. 18

2.1.5 Distance learning ................................................................................................. 19

2.1.6 E-Learning ............................................................................................................ 19

2.1.7 Simulation ............................................................................................................ 19

2.1.8 Videos ................................................................................................................... 20

2.1.9 Skype .................................................................................................................... 20

2.2 Further CPD opportunities: CEN meetings, study days and dysphagia support groups (see guidance notes section 4) ................................................................................ 21

2.2.1 Sharing of resources ............................................................................................ 21

2.2.2 Summary .............................................................................................................. 21

2.3 Development of Practical Skills Further information on gaining practical skills, hands on development ........................................................................................................ 22


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2.3.1 Structured development of practice ................................................................... 23

2.3.2 Progression of skills .............................................................................................. 23

2.3.3 Measurement of skills .......................................................................................... 24

2.3.4 Summary .............................................................................................................. 25

2.4 Supervision: Further information: supervision for competency development ....... 26

2.4.1 Definitions ............................................................................................................ 26

2.4.2 RCSLT guidance .................................................................................................... 26

2.4.3 Current situation for dysphagia supervision in NW ............................................. 26

2.4.4 Informal / peer support (includes peer supervision, buddy systems) ................. 28

2.4.5 Sharing supervision between organisations / individuals ................................... 30

2.4.6 Supervision training ............................................................................................. 31

2.4.7 Monitoring performance, signing off competencies ........................................... 31

2.4.8 Governance .......................................................................................................... 32

2.4.9 Summary .............................................................................................................. 34

2.5 Role of Clinical Excellence Networks ....................................................................... 35

2.5.1 Current CEN groups in the North West ............................................................... 36

2.5.2 Summary .............................................................................................................. 37

2.6 Workforce planning Further information on workforce planning: attitudes, risks and solutions ........................................................................................................................ 38

2.6.1 Attitudes............................................................................................................... 38

2.6.2 Perceived risks around potential for harm, potential life threatening aspects of dysphagia ......................................................................................................................... 39

2.6.3 Attitudes around signing off competency. .......................................................... 40

2.6.4 Risks around supervision ..................................................................................... 40

2.6.5 Perceived risks around staff retention ................................................................ 41

2.6.6 Risks around working across organisational boundaries .................................... 42

2.6.7 Solutions............................................................................................................... 43

3.0 Business case planning for setting up a dysphagia supervision structure: Business case template ................................................................................ 45

A. Project title, background, strategic context and need .................................................... 46

B. Summary of financial implications (please see section 7 cost consequence analysis) ... 46

C. Timescales ........................................................................................................................ 47

D. Staffing considerations .................................................................................................... 47

E. Risks and uncertainties .................................................................................................... 48


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F. Summary of benefits/ value added .................................................................................. 49

3.1 Cost consequence analysis ...................................................................................... 50

3.2 Wider client/patient costs for reduced dysphagia cover during NQ SLT competency development ........................................................................................................................ 51

3.3 Summary .................................................................................................................. 51

4.0 Case studies: examples of successful dysphagia competency development programmes ................................................................................................ 52

4.1 Example 1. Paediatric caseload across rural and urban settings (hospitals, schools and community). Wide geographical area linking SLTs from several neighbouring trusts. 52

4.2 Example 2. Adult acquired caseload covering acute hospital and community settings. ................................................................................................................................ 53

4.3 Example 3 Adults with learning disability, wide geographical area covering residential, secure and community settings. ....................................................................... 53

5.0 Summary and conclusions ...................................................................... 55

6.0 References ............................................................................................. 56

Appendix 1: Glossary of Terms ..................................................................... 58

Appendix 2: Suggested Tasks for CEN Meetings (may be used as a rolling agenda) ........................................................................................................ 61

Appendix 3: Template for Business Case Planning ........................................ 62


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EXECUTIVE SUMMARY

The assessment and management of eating,

drinking and swallowing (EDS) difficulties,

known as dysphagia, is covered within the

theoretical component of the UK Speech

and Language Therapy (SLT) pre-registration

curriculum. Some students also gain

practical experience in the management of

these difficulties through their clinical placements. However to date there is a variation

in the level of competency of SLT graduates.

The current project was proposed through Profnet, the North West speech and language

therapy clinical leads’ network. Health Education North West commissioned the project

in order to meet the needs of the speech and language therapy services to develop

dysphagia competence in newly qualified speech and language therapy graduates.

The specific aims of the project were to:

Scope current practice of developing competencies and supervisory frameworks

for the management of eating, drinking and swallowing (EDS) difficulties for

newly qualified speech and language therapists (NQ SLTS);

Identify the characteristics of current successful models of supervision;

Develop a new consensus model for developing competencies for the

management of EDS difficulties for all levels of SLT practitioners;

Recommend systems for NQ SLTs to access the appropriate level of supervision

to enable timely achievement of, and a consistent approach to, post-qualification

EDS competencies in the North West.

The project was designed to be inclusive and consensus based. A steering group

comprised of stakeholders including a service user representative, SLT practitioners,

representatives from the University of Manchester and MMU and the commissioner.

Interviews, questionnaires and a Delphi process involved SLTs from across the North

West.

The work scheme comprised of 4 phases:

Phase 1. Literature was reviewed and expert practitioners were interviewed to

elicit their views on dysphagia competency development. Data were synthesised.

Based on the findings from the literature and interviews, a questionnaire was


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designed to scope current practice within the North West. This was circulated to

practising speech and language therapists and students. Questionnaire responses

covered the entire North West region, with representation from paediatric, adult

acquired, adult learning disability and mental health services;

Phase 2. Drawing on questionnaire responses, a two-round Delphi study took

place, to elicit informed decisions on dysphagia skills development and lead to a

consensus model of dysphagia competency. The results from this indicated

changes in respondents’ views on the practicalities in developing dysphagia

competency over the two rounds of the survey.

Phase 3. Results from the Delphi rounds were analysed and all areas which

achieved a 75% consensus were incorporated into a draft model. Final

clarification of opinions and concerns was conducted at the RCSLT NW Hub

meeting in April 2015, where the new Royal College of Speech and Language

Therapists Dysphagia Framework was launched; and at the meeting of Profnet in

June. Feedback from SLTs in these feedback sessions indicated general

agreement that the model was robust. A cost consequence analysis indicated

costs associated with differing approaches to competency development and the

costs if this development was not pursued.

Phase 4. The model was launched in June 2015. Recommendations for

competency development are organised into five areas these being

recommendations on:

Postgraduate formal training needs

Development of practical skills

Supervision

The role of Clinical Excellence Networks

Workforce development

The following resources have resulted from this project:

A project web site with regular updates over the period of the project

http://rihsc.mmu.ac.uk/projects/profile.php?projectid=6;

A new consensus model for developing competencies for the management of

EDS difficulties for all levels of SLT practitioners;

Recommendations on systems for NQ SLTs to access the appropriate level of

supervision to enable timely achievement of, and a consistent approach to,

post-qualification EDS competencies in the North West;

A report detailing the process of developing the model and

recommendations;

A cost consequence analysis for the recommended systems to support

managers in workforce planning.

http://rihsc.mmu.ac.uk/projects/profile.php?projectid=6


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The project has been disseminated locally, nationally and internationally.

It is anticipated that this model and recommendations, grounded in consensus from

across the SLTs in the North West, will support and enable dysphagia competence to be

attained in an efficient and effective manner for new graduates in the region.


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North West model for implementing dysphagia competency in newly qualified

Speech and Language Therapists (NQP). Recommendations from project funded

by Health Education North West 2015

UndergraduateUndergraduate

•Curriculum has included dysphagia knowledge to core 'specialist level' level C (Boaden et al 2006, RCSLT 2014)

•Personal experience/competencies listed in Dysphagia framework (RCSLT 2014)

•Practical skills - Placement experience variation (NW consensus 2015)

•May have volunteering/other work experience (NW consensus 2015)

First year of dysphagia work

First year of dysphagia work

•Year 1 entry Threshold status HCPC (2013)

•NQP competency framework RCSLT (2007)

•Dysphagia competency framework in place (RCSLT 2014) working through levels

•Supervision weekly (RCSLT 2003) - includes direct observation

•Informal support from specialist and/or peer SLT (RCSLT 2012)

•Protected CPD/competency development time: recommended equivalent to 1 session/week pro rata (NW consensus 2015)

•May attend formal training at 6-12 months (NW consensus 2015)

•Will usually include MDT experience

Second year of dysphagia workSecond year of dysphagia work

•Year 2

•Standards of proficiency HCPC (2013)

•NQP framework RCSLT (2007) usually signed off 12-24 months - transfer to full RCSLT membership

•Dysphagia competency framework RCSLT (2014) in place, working through levels

•Supervison every 2-4 weeks RCSLT (2012) - direct and distant contact

•CPD time - minimum 30 hours per year pro rata (RCSLT, 2006)


Continuing SLT dysphagia practice

Continuing SLT dysphagia practice

•Year 3 +

•Standards of proficiency HCPC (2013)

•RCSLT (2007) NQP framework - may need further consolidation

•RCSLT (2014) Dysphagia competency framework in place, working through levels

•Supervision ongoing (min 12 weeks) + appraisal process (RCSLT 2012)

•CPD ongoing minimum 30 hours per year pro rata (RCSLT, 2006)


•Will attend CEN sessions relevant to clinical setting (NW consensus 2015)


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Summary of Recommendations

Section 1 Postgraduate formal training

needs

1.1 Recommendation: protected CPD time

of 3.5 hours per week (pro rata for part

time dysphagia caseloads) for period of

6 months to develop competency skills

in dysphagia.

1.2 Recommendation: Theoretical knowledge training (to refresh and extend knowledge

covered at undergraduate level) to start after 6 months experience, this may be in

house or external teaching sessions.

1.3 Recommendation: study days and CPD events should have clearly outlined agenda,

learning objectives and application process with details advertised giving enough

time for participants to complete funding application process (typically at least 3

months advance notice).

1.4 Recommendation: Clinical Excellence Networks (CENs) to explore funding

opportunities available such as RCSLT minor grants, MPET funding, HENW and

regional initiatives relevant to their members.

1.5 Recommendation: CEN meetings should include regular agenda item re

offers/opportunities to discuss and promote in house training events relevant to the

clinical specialism. Sharing of plans for training courses between organisations in the

NW would be cost effective and allow recruitment of larger numbers for a course to

mutual benefit.

1.6 Recommendation: to set up a working group coordinated by the RCSLT NW hub to

create a directory of current e-learning resources available (covering both NHS and

non NHS); to evaluate and determine need for further resources; to commission

development of virtual training; to explore other resources for distance learning.

Section 2 Development of practical skills

2.1 Recommendation: individualised approaches used across the region should include

adequate supervision and use of clear structure such as that offered by the new

RCSLT Framework.


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Section 3 Supervision

3.1 Recommendation: each dysphagia CEN for the NW region to develop a matching up

service; advising and supporting sharing of training and matching supervisor with

supervisee.

3.2 Recommendation: each dysphagia CEN to offer opportunities (eg breakout sessions

attached to main meeting) for supervisors to discuss competency issues and receive

peer supervision for their role in dysphagia training and competency development

3.3 Recommendation: supervision training to be offered at NW venues. This may lead to

further events such as refresher training and support sessions for experienced

supervisors. An easily accessible HEI venue offering twilight sessions may facilitate

attendance.

3.4 Recommendation: external supervision is formally supported by a contract including

procedures for governance, confidentiality, safeguarding and complaints. The

structure should clarify accountability and management responsibility.

Section 4 Clinical Excellence Networks

4.1 Recommendation: paediatric dysphagia group to be coordinated at regional level

running as CEN to coordinate meetings and electronic network through the RCSLT

NW Hub (NB North West ALD dysphagia group is already successful).

4.2 Recommendation: new dysphagia group (adult acquired) to be set up at regional

level running as CEN to coordinate meetings and electronic network through the

RCSLT NW Hub (NB North West ALD dysphagia group is already successful).

4.3 Further recommendations for CENs;

4.3.1 CEN sessions should have a formal agenda and clear structure as this

improves support from managers for attendance. Planning ahead is recommended

with an outline for a full year’s meetings and topics publicised to help SLTs planning

attendance.

4.3.2 Venues to be easily accessible across the NW region. Venues could rotate

across HEIs in Preston, Lancaster, Manchester to facilitate regional access.

4.3.3 Use of HEI as venue: these are generally easily accessible, offering links with

academic hosts and adding prestige/status further supporting application to

managers.


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4.3.4 Use of Eventbrite www.eventbrite.co.uk or similar for application process

4.3.5 CEN meetings/networks to cover sharing of supervision opportunities

matching supervisors and supervisees.

4.3.6 CEN meetings/networks to publicise or share in-house training opportunities

across organisations. This will help with recruiting for training (increasing number of

potential participants) and offering potential for income generation as larger number

of participants will help support/fund access to external speakers.

4.3.7 CEN meetings/networks to cover sharing of research updates and

opportunities for critical appraisal of articles.

4.3.8 Experienced dysphagia SLTs to form additional groups or break out from CEN

general meeting to discuss issues around supervision and support (see 3.2).

Section 5 Workforce Planning

5.1 Recommendation: job descriptions and budgets to be coordinated so that new

recruits have protected time and funding for dysphagia competency development

Note: detailed information is provided in chapter 2 of the document. In addition, chapter 4

presents case studies and appendices give added support.


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ACKNOWLEDGEMENTS

Thanks to:

• HENW for funding this project

• Expert SLTs who gave up their time to be interviewed

• All North West SLTs and students who responded to the questionnaire and

surveys

• The steering group members for their wisdom, advice and support

MMU Project Team

This project was led by Prof Jois Stansfield, with Dr John Lancaster as chief investigator

and Susan Guthrie as research associate. Additional support during the period of the

project came from Dr Sue Caton (literature review), Janet Edwards, Dr Francis Fatoye

(economic analysis) Professor Carol Haigh (Qualtrics), Dr Julie Lachkovic and Dr Janice

Murray.

Steering Group

Sian Davies (University of Manchester)

Kay Faulkner (Manchester Metropolitan University)

Rebecca Haworth (Speech and language therapy manager, paediatric service: Central

Manchester Hospitals NHS Foundations Trust)

Susan Jones (Head of Clinical Professions: Pennine Acute NHS Trust)

Sue Louth (North West Allied Health Professionals Workforce Lead: HENW)

Anne Lucas (Trafford Carers’ Centre)

Sue McCormick (Speech and language therapy manager, adult acquired disorders:

Pennine Acute NHS Trust)

Lorna Pink (Speech and language therapy manager, adult learning disability: 5

Boroughs NHS Trust)


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ACRONYMS

ALD Adults with learning disabilities

ASLTIP Association of Speech and Language Therapists in Independent Practice

CA Cervical auscultation (the use of a stethoscope in clinical practice, to assess swallow sounds)

CEN Clinical Excellence Network

CPD Continuing professional development

FEES Fibreoptic endoscopic evaluation of swallowing

HCPC Health and Care Professions Council

HENW Health Education North West

MMU Manchester Metropolitan University

MPET Multi-Professional Education and Training

NQ SLT/ NQP

Newly qualified speech and language therapist

NW North West

ProfNET Professional network of speech and language therapy professional leads in the North West

RCSLT Royal College of Speech and Language Therapists

SLT Speech and language therapy/ therapists

TUPE Transfer of Undertakings (Protection of Employment)

UCLan University of Central Lancashire, Preston

VF Videofluoroscopy

WTE Whole time equivalent


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1.0 INTRODUCTION: BACKGROUND TO THE PROJECT

Speech and Language Therapists (SLTs) work with clients/patients with dysphagia. Newly

qualified (NQ) SLTs usually need to develop practical competencies after graduation, which

requires clinical supervision by experienced SLTs. The project was instigated following

debate in the profession regarding how best to support NQ SLTs in developing dysphagia

competency given the context of limited time and resources for supervision. It was funded

by HENW.

Project aims:

• Scope current practice of developing competencies and supervisory frameworks

for the management of eating, drinking and swallowing (EDS) difficulties for

newly qualified speech and language therapists (NQ SLTS);

• Identify the characteristics of current successful models of supervision;

• Develop a new consensus model for developing competencies for the

management of EDS difficulties for all levels of SLT practitioners;

• Recommend systems for NQ SLTs to access the appropriate level of supervision

to enable timely achievement of, and a consistent approach to, post-qualification

EDS competencies in the North West.

1.1 Phase 1

The team reviewed relevant literature in the field of competency development. From the

review, themes regarding best practice for developing competency and in particular

developing competency in the field of dysphagia were highlighted.

Interviews with experts in the field of dysphagia from across the UK were carried out to

investigate expert opinion regarding best practice for developing competency in managing

dysphagia. Experts interviewed were from a range of backgrounds including adult learning

difficulties, paediatric, adult acute, mental health. The themes that emerged from the

interviews were combined with the themes from the literature review to produce a set of

themes related to best practice in developing competency in newly qualified SLTs working in

the field of dysphagia.

The themes from the interviews and literature review were used to construct a

questionnaire to investigate current practice for developing competencies in newly qualified

SLTs working with individuals with dysphagia. This questionnaire was sent out using email

lists from Profnet and university student placement contacts, to all NHS speech and

language therapy (SLT) departments in the north-west of England and cascaded by these


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recipients to SLTs in their departments. It was also sent to the independent SLT

practitioners’ organisation (ASLTIP).

An amended questionnaire was sent out to final year SLT undergraduate students at the

Manchester Metropolitan University (MMU) and the University of Manchester. A total of 70

responses were received from SLTs and 30 from students. Respondents represented

multiple work settings and multiple clinical specialisms. Respondents worked with paediatric

and adult caseloads, in rural and urban settings and covered hospital, school, community

and domiciliary settings. The survey questionnaire was anonymous so it was not possible to

track all to indicate county or Trust however the SLT responses showed a spread across NW.

The majority of respondents were NHS based, with 2 responses from NGO/charities.

Questions focussing on caseload size and type gave a snapshot of current SLT working

situations and practice. One third of SLTs replying to the survey had been working with

dysphagia for less than 2 years, the rest had experience over 2-36 years. Ideas for

supervision and competency development showed some consensus but concerns around

supervision were evident.

There was clear support for formal teaching courses. Perceived barriers included availability

and funding. Time for competency development was the other main concern particularly in

smaller departments. There was some interest in sharing across trusts.

1.2 Phase 2

Delphi Study. A Delphi approach was adopted involving a series of surveys sent to SLTs and

other professionals across different levels of experience, settings and clinical specialisms

across the NW region to establish opinions on items for inclusion in the final dysphagia

competency model.

Delphi voting on implementing dysphagia competency was a repeated process during

January to April 2015 to establish consensus on a final model for the NW. Participants were

asked to vote on a series of statements drawn from the findings of our interviews and the

preliminary survey. For each item we asked for opinion and also rationale. This allowed us

to redesign the survey and repeat the process to measure consensus across different

settings and caseloads.

The returns showed consensus for many aspects of implementation of dysphagia

competency. The attitudes and opinions sections gave insight into how SLTs view the

process of training up new graduates but there were some aspects which remained

contentious. The results informed this project’s recommendations for a model of good


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practice. Variation in settings and flexibility are acknowledged in the accompanying

guidance notes.

Ideas and opinions were also canvassed at meetings including Profnet, the ALD dysphagia

CEN and the CEN for clinical education (Leeds). These discussions fed back into the Delphi

survey (round 2) to resolve remaining aspects with SLTs encouraged to vote on the options

appropriate to their individual situations.

1.3 Phase 3

Results from the Delphi rounds were analysed and all areas which achieved a 75%

consensus were incorporated into a draft model.

Final clarification of opinions and concerns was conducted at the RCSLT NW Hub meeting in

April 2015, where the new Royal College of Speech and Language Therapists’ Dysphagia

Framework was launched; and at the meeting of Profnet in June 2015. Feedback from SLTs

in these feedback sessions indicated general agreement that the model was robust.

A cost consequence analysis (chapter 3) indicated costs associated with differing approaches

to competency development and the costs if this development was not pursued.

1.4 Phase 4

The model was launched in June 2015.The new RCSLT Framework is a welcome resource for

the profession. Our project incorporates the recommendations of the RCSLT Framework and

informs implementation for SLTs working in the North West. Participation has included SLTs

across the region representing a wide range of clinical and geographical settings from both

independent and NHS organisations. The recommendations for a final model entirely reflect

the ideas and solutions of SLTs working in the North West.

Case studies indicating differing successful approaches to developing competence appear as

chapter 4. This project has been funded to consider newly qualified SLTs but the findings

indicated a need for longer term considerations of competence development and this is

mirrored in the model which appears at the start of this document. As a result, the project

outcomes may inform SLTs with more experience who wish to move into dysphagia

practice.

1.5 Dissemination

To date the project has been disseminated locally, nationally and internationally as follows:

• Regular updates on the project web site


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• Quarterly reports to the steering group

• Updates to each Profnet meeting

• Informal discussions at the RCSLT national conference, September 2014

In April 2015, MMU presented our current findings at the RCSLT launch of the new

Dysphagia Framework in Manchester and learned more about the different barriers and

solutions for SLTs in the North West implementing competency development.

In May 2015, we presented the project at the European SLT conference (CPLOL) in Florence,

Italy. This was well received and brought the work to the attention of a wider audience. We

gained insight into the ways SLTs work with dysphagia and education across Europe.

The model and recommendations were launched at an event in MMU in June 2015 and was

presented at the Research Institute of Health and Social Change conference in July 2015.

This document is the full resource, and is available on line from August 2015 at the MMU

Research Institute for Health and Social Change (RIHSC) website.

A summary of the project will be submitted for publication.


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2.0 PROJECT OUTCOMES

2.1 Postgraduate formal training needs

Further information: NQ SLT theoretical knowledge development and

non-contact learning opportunities.

Knowledge and skills development were key concerns in the driving of this project.

Limitations in time and capacity of SLT clinicians for supervision and knowledge

development were central to the difficulties reported. The surveys show a consensus in SLTs

considering how further knowledge can be developed in NQ SLTs using resources available.

Recommendations were offered by SLTs reflecting the different situations across the region

and for varied clinical settings.

Survey results: The surveys reflected the changing situation in HEI syllabus for dysphagia

knowledge teaching. There was 100% agreement that formal teaching should refresh and

update NQ SLTs building on knowledge covered as an undergraduate.

Interest in indirect options for learning intensified as the surveys progressed. There is a

potential to develop e-learning for post qualification SLTs. Further options for distance

learning are through resources such as simulation, video, skype and other media. Other

countries’ use of distance learning offers useful information.

2.1.1 Self-directed learning

Surveys showed that there was consensus regarding the need for protected time for NQ

SLTs competency development to work through the competency framework (RCSLT 2014).

Survey results: 90% agree/strongly agree that NQ SLT should have 3.5 hours per week (part

time pro rata) for first 6 months protected competency development time.

Recommendation 1.1: protected CPD time of 3.5 hours per week (pro rata for

part time dysphagia caseloads) for period of 6 months to develop competency

skills in dysphagia.

The new RCSLT framework will inform both the content and the evidence needed to

structure this learning and is expected to be carried out with the support of the supervisor.

Comment: “I encourage staff to do this self-directed study in work time as part of their

dysphagia training time” survey 1 Q10


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Comment “I think dysphagia competency is already working well in my team, and that using

an existing framework like we do to support staff through dysphagia competencies would be

manageable for the majority of adult dysphagia services. However I can imagine that some

strategies, especially to increase time for appropriate support/supervision and standardised

systems to measure competence (to increase supervising SLT confidence in the process), would

enable certain services to move towards a similar model like we use”. Survey 1 Q20

2.1.2 Formal course attendance

Currently, taught dysphagia courses for graduate SLTs are available across the UK. Aimed at

post qualification SLTs and related disciplines, typically these are based on formal classroom

teaching of knowledge usually with some input from different professions. Some courses

cover several clinical specialisms, some are specific to paediatric or adult topics. Generally

teaching is through lectures but courses may also have arrangements for assessed case

studies, written theory examinations, and may require specific supervision procedures.

Survey comments showed strong support for the formal training accessed.

Comment: “For several years we have used the North West Work-Based Dysphagia

Competency Course with all our Band 5 staff completing competencies. This has always proved

a useful format with taught elements in University (I think 3 separate study days) exploring

different theoretical aspects of dysphagia. Combined with in-house structured practical

experience and reflective sessions with a named mentor within the team. There needs to be

an integrated approach to provide good quality learning and skill development, and also to

promote equity of learning across different settings” Survey 3 Q7

Comment: “Attend Post Basic course. Have access to regular supervision from direct

supervisor. Have access to expert opinion when needed. Have access to further learning

opportunities when needed or as they arise. Use a log. This all happens in my department”

Survey 1 Q22

RCSLT website1 offers a list of available courses in dysphagia, although this is only updated

as members inform the organisation of new opportunities on offer.

Survey results: Consensus from NW SLTs was that for NQ SLTs, attending a formal training

course is an effective one-stop solution to acquiring and signing off dysphagia competency

(83% agreed/strongly agreed, none disagreed).

1 http://www.rcslt.org/members/docs/post_reg_training_sept_2012

http://www.rcslt.org/members/docs/post_reg_training_sept_2012


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Timing of this training was considered in the surveys leading to a consensus of 80%

agree/strongly agree that NQ SLTs should attend after 6 months of experience in post (15%

disagreed). Some respondents indicated timing was most appropriate between 3 months

and 12 months post qualification and generally comments reflected a perception that NQ

SLTs should have some general SLT experience in post before attending this type of training.

Recommendation 1.2: Theoretical knowledge training (to refresh and extend

knowledge covered at undergraduate level) to start after 6 months experience,

this may be in house or external teaching sessions.

Comment: “They are only deemed competent once they have completed an accredited

qualification” Survey 1 Q9

Comment: “Basic dysphagia awareness in house training but they would not be expected to

assess unless they had done the post basic dysphagia course” Survey 1 Q12

Concerns about post-graduate courses were described by some respondents, these included

delays in NQ SLT acquiring sufficient knowledge base due to difficulties in accessing funding,

waiting lists for places and finding a supervisor. Comments showed a strong interest in

meeting NQ SLTs’ needs by running ‘in house’ training and offering shorter duration of

training.

Comment: “Currently it feels like a lot of postgrad dysphagia courses are very expensive and

require a big commitment in terms of time and supervision. Trusts can't afford this and unless

we can obtain funding to secure that SLT a band 6 post, it is common that the training and

investment in the therapist is quickly lost as they move into new posts once their dysphagia

competencies are complete. A series of shorter, cheaper one day courses may make it more

achievable for the NQP to gain knowledge and training which can then be supported with

practical experience in work.” Survey 3 Q7

Postgraduate masters level courses are also currently available at different HEIs across the

UK and separate modules are available to SLTs.

2.1.3 Study days

Solutions were also given showing strong interest in accessing study days and CEN training

(see section 4). Respondents in both surveys and interviews suggested that events

presented as structured and formally organised were recognised favourably by managers

and funding streams. In contrast, meetings advertised as informal support groups were less

likely to be supported in terms of funding, travel and paid time.


17

Survey results: There was strong interest in attending one day events run by HEIs on

dysphagia topics (100% agree/strongly agree). A popular example was given as Advancing

Dysphagia Practice study days (UCLan) for SLT and non SLT dysphagia practitioners.

Study days offer lectures and workshops on varied topics and are open to any level of

experience for SLTs and related disciplines. Advancing dysphagia practice study days

(Uclan2), have a national focus for SLT and non SLT dysphagia practitioners. Typically the

offer is 2 study days per year. Recent topics have covered ethics, outcomes, and updates on

current research. These study days are frequently oversubscribed and funding is required.

The coordinators of this group also offer to come and deliver on-site training for a minimum

number of participants.

Comment: “We actively encourage attendance at CEN's relevant meetings. Despite the

pressure of the job, we have no pressure from commissioners or senior managers not to attend

and this really helps. As a department we have always tried to give a small amount of

protected CPD time each month. A previous band 5 set up an early evening journal club for

other NQPs and this was well attended and appreciated. I think similar groups for NQPs

working in dysphagia could be encouraged.” Survey 3 Q12

Comment: “To date we have provided the trainee dysphagia practitioners with protected

learning time of 3.5 hours per week during the 6 months of Manchester training- this time

included: Diary reflective time, reading and research, the case study, attendance at other

workshops that are relevant eg MH medication and side effects; as well as revision for the

exams.” Survey 3 Q12

Specific clinical training for techniques such as FEES, VF, CA are advertised nationally. These

tend to be hands on workshops with both practical and theoretical training elements. There

were frequent comments that for courses which are perceived as more formally organised

then it was easier to agree funding and paid time to attend.

Recommendation 1.3: study days and CPD events should have clearly outlined

agenda, learning objectives and application process with details advertised

giving enough time for participants to complete funding application process

(typically at least 3 months’ notice).

Recommendation 1.4: CENs to explore funding opportunities available such as

RCSLT minor grants, MPET funding, HENW and regional initiatives.

2 http://www.uclan.ac.uk/conference_events/advancing_dysphagia_practice_conference.php

http://www.uclan.ac.uk/conference_events/advancing_dysphagia_practice_conference.php


18

2.1.4 In house knowledge / theory training

Some departments have been able to offer in house training. Successful examples were

described involving 2-3 days classroom teaching relevant to the clinical setting and led by

local SLTs drawing on MDT and SLT experts.

Survey results: Consensus of 70% agree/strongly agree were in favour of in house training

(20% disagree/not relevant).

Typically this is more feasible where a group of SLTs with similar training needs can be

collected as a cohort. Costs for local participants and speakers are reduced to a minimum

and offering paid places to neighbouring SLTs can help to defray costs further (see cost

consequence analysis section 7). Surveys showed varying commitment to this approach.

Comment: “As a large department we are able to offer formal/theoretical training from our

dysphagia lead, followed by mentoring, supervised practice and sign off. The theoretical

aspect is an area which could be traded to support smaller Trusts in helping staff achieve

competency” Survey 3 Q7

Comment: “I felt we could have worked around challenges however most of the time, and had

the scope to train staff in dysphagia "in-house" if the wider team had been on board with

prioritising this and having more of a long term view on developing the skills of NQ staff”

survey 1 Q19

Movement of NQ SLTs may be expected across the region and shared training may

compensate and accommodate for this. The new RCSLT competency framework will inform

and protect continuity in competency development.

Recommendation 1.5: CEN meetings should include regular agenda item to

discuss and promote offers or opportunities for in-house training events

relevant to the clinical specialism. Sharing of plans for training courses

between organisations in the NW would be cost effective and allow

recruitment of larger numbers for a course to mutual benefit.

This may also encourage sharing of costs for speakers and for specific training initiatives

such as FEES, VF, and CA techniques and other more specialist technique training.


19

2.1.5 Distance learning

This may take different forms and the surveys suggested that SLTs may lack experience and

understanding of the wide potential of options available to support learning. Interest moved

from 8% to 95% as the surveys progressed.

Some options are discussed below with recommendations for relevance to implementing

dysphagia competency.

2.1.6 E-Learning

Interest in e-learning intensified as the surveys progressed. Initially unsure, SLTs showed

increasing interest in finding out more. Survey 1 showed 1% interest moving to final survey

showing 95%. The potential for e-learning for post qualification SLTs needs further

consideration.

Comment: “E -learning would help with answering questions, clarifying doubts, signposting to

relevant research etc., and learning about other services.” (Survey 2)

The packages which currently exist are not widely shared or understood and there is a need

for wider recognition by SLTs at all levels. There may be opportunity to explore further

options for distance learning through resources such as simulation, video, skype and other

media. Information from other AHP/medical/nursing professions in the UK and from SLTs in

other countries such as USA and Australia could offer solutions for resources and techniques

for competency development. In the future a wider range of e-learning resources may be

available.

Recommendation 1.6: to set up a working group coordinated by RCSLT hub to

create a directory of current e-learning resources available (covering both NHS

and non NHS); to evaluate and determine need for further resources; to

commission development of virtual training; to explore other resources for

distance learning.

2.1.7 Simulation

Low and high fidelity simulation suites are an increasingly common feature of

undergraduate education for AHPs, nursing and medical professions. There is a wide

spectrum of learning opportunities from learning basic practical skills to sophisticated mixed

techniques using manikin and real people jointly to simulate a range of scenarios. Role play

is an integral part of this approach. There is evidence showing concerns and anxieties in


20

students towards simulation and role play as well as the benefits to confidence and

professional learning.

Currently HEIs are developing the use of manikins with AHP students but the current

technology does not yet include palpable swallowing and there is a very limited range of

sounds available. It may be useful to explore learning of specific techniques or skills such as

suction and pulse oximetry using more basic models as happens for first aid training.

For the future combining standardised patients (ie real humans acting as a patient) with

detailed dysphagia scenarios is an area for further exploration in clinical education.

Comment: “Simulation learning could also be brought in at an earlier stage to develop

confidence and the soft skills eg at the observation and observed stages.” Survey 2 Q5

2.1.8 Videos

Surveys showed strong interest in this media as a means of widening experience supported

by discussion with peers and supervisor. Comments included need for careful consideration

of confidentiality and adequate consent procedures.

Survey results: 90% agree/strongly agree that video should be used more widely in

developing competency, none disagreed (survey 2 ques 4).

Comments showed that for video and for other indirect learning techniques the NQ SLT needs

to support this with adequate supervision and reflection

Comment: “I feel the use of e-learning should only be in addition to face to face learning. The

use of videos, role plays and discussion will support learning about real life examples and

support skills in direct management of cases.” Survey 2 Q5

2.1.9 Skype

Recent research (Boaden et al, 2014) has indicated a role for Skype as a cost and time

effective solution to overcome geographical barriers. Surveys suggested only 2% of

respondents had some experience of Skype and that this was used for supervision rather

than knowledge development (compared to 41% use of phone supervision) but comments

suggested there was some interest in what this could offer for distance learning.

Comment: “I feel the geography and time constraints can make it difficult for observation by

a specialist therapist, however, videoing and discussion should be encouraged to reflect and

check progress with EDS skills.”


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2.2 Further CPD opportunities: CEN meetings, study days and dysphagia

support groups (see guidance notes section 4)

The function and availability of regional dysphagia groups and ongoing CPD sessions were a

key finding offering a solution for most SLTs surveyed. There was strong consensus showing

value and interest in attending CENs and study days. Affiliated CENs are now coordinated

through the regional RCSLT hub structure.

Consensus showed that these groups are valued, accessible and offer primarily an

opportunity for knowledge exchange/update and also support, peer supervision, and

networking.

2.2.1 Sharing of resources

Large departments with large dysphagia caseloads tend to have a larger pool of experts to

draw on. Surveys showed they can spread the supervision workload sharing between staff,

combine resources (eg formal teaching in-house) and fast track NQ SLTs’ experience and

learning. Comments indicated willingness to offer places on in-house training sessions which

may be income generating for the host department.

Smaller departments with fewer dysphagia cases will take longer to offer an adequate

number and breadth of dysphagia experiences. Supervision can be difficult to source when a

smaller number of wte SLTs are available.

2.2.2 Summary

Single SLTs: NQ SLT at band 5 may occasionally be employed to work in more isolated

settings with supervision having to be sourced from another organisation or by a private

arrangement. This requires careful consideration and robust implementation of governance,

supervision and safeguarding structures to ensure adherence to RCSLT guidelines and HCPC

standards. (see section 3 supervision)

Generic posts combining multiple clinical specialisms across children and adults are

becoming increasingly rare. Surveys showed that NQ SLTs typically now work with a smaller

range of ages and populations than historically. This has led to smaller staff teams with a

smaller pool of expertise. In some places professional SLT links are maintained across clinical

specialisms and/or organisations but for some this is challenged by structures, business

models and perceived competition.

The recommendations in this section offer a range of formal post graduate training

approaches to take account of the varying working environments.


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2.3 Development of Practical Skills

Further information on gaining practical skills, hands on development

Throughout the survey process there was consensus on the need for direct supervised work

experience to develop competency. Many commented on the generic professional craft

skills which transfer across all areas of SLT clinical work and which are consolidated over the

first year of work.

Survey results: currently 94% of SLTs offer joint visits for observation initially leading onto

87% offering subsequent supervised practice. Students were keen (97% respondents) to

have supervised practice from the outset.

Timing of the move to competency development in dysphagia work was clearly felt to be

better when the NQ SLT has had some experience in post. Theoretical knowledge training

was recommended by respondents to start after 6 months experience (see further

information section 1)

Comments:

“For our NQPs we recognise that they require time to develop competency within the area of

dysphagia and as such they would not have dysphagia caseload initially but would be

encouraged to do joint visiting with the specialist staff to enable competencies to develop.”

Survey 3 Q16.1

“We would normally not offer any postgraduate training until the therapist had been working

for 6-12 months and had got to grips with basic caseload handling and clinical decision

making. Depending on the posts and on the therapist’s level of confidence/placement

experience, there would be opportunities for observation and co-working around dysphagia

during that time.” Survey 3 Q 16.2

“3 day training (in house) then a progression through the above, shadowing, supervised visits,

unaccompanied visit with a de-brief as competency develops.” Survey 1 Q9

There was consensus that hands on work is most important in competency development,

that knowledge from undergraduate level offers a foundation level of skills but that wider

practical experience ‘on the job’ is fundamentally important:

Comment: “don't feel learning more at university would help - as it is when you start work that

you really begin learning what is necessary and needed to do the job.” Survey 1 Q19.1

Comment: “I feel that on-site training is the most vital for NQPs in the early stages of

dysphagia practice” Survey 2 Q3


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2.3.1 Structured development of practice

The survey comments show a consensus that NQ SLT competency develops by moving from

observation to joint work to more distant supervised practice.

Comment: “Caseloads- access to regular dysphagia clients varies dependent on individual

caseload- can be difficult to gain enough experience or keep skills up to date.” Survey 1 Q19.2

Comment: “As used currently, attend post-basic course, then observe a competency EDS

trained SLT, discuss cases in assessment and management outcomes, be supervised carrying

out assessments, carry out unsupervised assessments then feedback. Then progress to

working independently feeding back and discussing cases as needed.” Survey 1 Q22

Comment: “I feel that given the nature of dysphagia, general experience should be gained

before commencing on further study. Although e-learning is a powerful tool, nothing can

replace hands on learning and experiences.” Survey 2 Q3

2.3.2 Progression of skills

There were no recommendations from the surveys on specific timescales, instead interviews

and surveys advocated individualised programmes of supervision and knowledge training.

The consensus showed that SLTs surveyed respond to individual need in competency

development and reject the idea of prescriptive approaches:

Comment: “different people learn at different speeds so hours not necessarily the best

measure” (interview 11.14)

Comment: “I think it is essential to avoid prescriptive approaches. There is no 'one size fits all'

- in learning or in provision of support/supervision. I think different approaches may be

required for each context. My own experience is that I learnt enough to function on a ward

(where the MDT is generally more accessible) ..... And it took me longer to acquire the skills to

work more independently in the community. I think supervision is essential - but the time/type

of support must fit each individual and each context.” Survey 2 Q11

Comment: “We use a stepped model to assess competencies: check the person has observed,

shown knowledge about; demonstrated the skill under observation twice; then applied alone

and discussed in supervision. If having difficulty would arrange more shadowing and joint case

management opportunities.” Survey 3 Q13

Comment: “I would expect regular case discussion and feedback from experienced SLTs to

continue, especially for more complex cases. Some SLTs may require more than this, being

determined by ongoing assessment of dysphagia skills development. I think specifying an


24

exact number of hours can be misleading, and level of SLT competence is a different thing.”

Survey 1 Q17

Comment: “We have a specified number of shadowing visits, supervised visits, unsupervised

visits with debrief (3 each) and a case study. We aim for 6 months for basic competence but

this can be extended if it is felt that the staff does not have the basic level of competence.

Once basic training is complete they join our internal clinical excellence network/clinical

supervision group which runs every 3 months. Therapists also have immediate access to a

therapist with experience if they need adhoc supervision around an individual client outside of

formal supervision timetable.” Survey 1 Q13

2.3.3 Measurement of skills

There was consensus that the new RCSLT framework was key to structuring competency

development and would be used to support discussions around goals and evidence by NQ

SLT and supervisor.

Survey results: 100% agree/strongly agree that framework/log approach should be used to

structure and monitor progress but this is more robust when combined with discussion with

supervisor

The most appropriate measurement of skills was agreed to be direct observation by

competent SLT or supervisor.

Survey results: 95% agree/strongly agree that assessment requires direct observation of

practice (5% neither agree nor disagree)

Comments:

“as with students it always feels tricky to decide competency levels, descriptions of

competency standards are good and provide structure, I would need to seek outside my dept

help supporting for NQP's who were struggling. Already have a robust system of direct

observation/case note audits/discussion to identify stages of competency - competency is

ongoing and as such we only sign off competency to fulfil the job role they are currently in.”

Survey 2 Q13.1

“We use a stepped model to assess competencies: check the person has observed, shown

knowledge about; demonstrated the skill under observation twice; then applied alone and

discussed in supervision. If having difficulty would arrange more shadowing and joint case

management opportunities.” Survey 2 Q13.2


25

“I think the current dysphagia competency framework works well. If there was a particular

area of difficulty I would suggest more opportunities to observe and practise with supervision.

This would need to be agreed on an individual level and would be difficult to formalise.” Survey

2 Q13.3

Recommendation 2.1: individualised approaches should be used across the

region and should be supported by adequate supervision and use of clear

structure such as that offered by the new RCSLT framework.

2.3.4 Summary

Varied approaches were considered and adopted across the region in addition to

observation of practice. Additional assessment strategies included use of case studies,

written assessments/exams, audit of case notes, self-monitoring and reflection. Case studies

varied from formalised arrangements with marked written assessment to less formal peer

group discussions and verbal reflection around a case presentation. Appraisal of articles and

exploring the evidence base around a topic were also seen as helpful in developing

competency and allowing measurement of progress. Some respondents were keen to

involve other members of the multidisciplinary team to assess the NQ SLT skills but others

felt this was not valid.


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2.4 Supervision: Further information: supervision for competency

development

2.4.1 Definitions

Clinical supervision creates a learning environment that promotes critical reflective practice

helping practitioners to overcome the demands created by the nature of the work,

promotes health, well-being and confidence across the area of clinical practice. It should be

at least weekly during the first 3 months and monthly thereafter (RCSLT 2012).

Supervision will include setting objectives jointly, collaborative problem solving and review

of competency development where relevant (RCSLT 2012).

Discussions and interviews suggest that the term ‘mentor’ is not popular with SLTs and the

consensus is to use the term ‘supervision’ following RCSLT practice (RCSLT 2012).

2.4.2 RCSLT guidance

The RCSLT website states that: ‘’Supervision is the formal arrangement that enables an SLT

or assistant practitioner to discuss their work regularly with someone who is experienced

and qualified. It’s an essential component of a good quality speech and language therapy

service that is able to respond to service users and identify and manage risks. It’s also critical

to the development and growth of a practitioner’s professional life.”

Clinical supervision is designed to provide SLTs with advice and guidance outside the line

management structure. It aims to create a non-judgemental, confidential environment

where cases can be discussed and critical reflective practice is promoted. Supervisors should

be able to provide feedback and guidance on specific cases whilst also supporting clinical

reasoning around treatment programs etc. (RCSLT 2012)

2.4.3 Current situation for dysphagia supervision in NW

Surveys and interviews explored the different options currently used by SLTs across the

region.

Survey results: when asked about current type of supervision offered, 90% respondents

selected option ‘One to one face to face discussion with EDS competent SLT (ie supervisor

competent to specialist level or above)’. Other choices included joint visits (83%), peer

group sessions (49%) and expert led groups (43%).


27

Information from NW surveys and interviews showed widespread concerns regarding time

and capacity for supporting NQ SLT dysphagia competency development. However

respondents had many solutions and were motivated to share practice and resources where

feasible.

Large and small departments have different needs and opportunities for NQ SLT

competency development. Consensus across the surveys was clear that clinical practice

supported by supervised direct observation is a key component of learning and assessment

for dysphagia competency. Sharing of resources and supervision across organisations was

agreed to benefit the profession.

Large departments and those with large dysphagia caseloads tend to have a larger pool of

experts to draw on. Surveys showed they can spread the supervision workload sharing

between staff, combine resources (eg formal teaching in house) and fast track NQ SLTs’

experience and learning.

Smaller departments with fewer dysphagia cases will take longer to offer an adequate

number and breadth of dysphagia experiences. Supervision can be difficult to source when a

smaller number of WTE SLTs is available.

Single SLTs: A NQ SLT at band 5 may occasionally be employed to work in more isolated

settings with supervision having to be sourced from another organisation or by a private

arrangement. This requires careful consideration and robust implementation of governance,

supervision and safeguarding structures to ensure adherence to RCSLT guidelines and HCPC

standards.

As noted in section 2, generic posts combining multiple clinical specialisms are becoming

increasingly rare. Surveys showed that NQ SLTs typically now work with a smaller range of

ages/populations than historically. This has led to smaller staff teams with a smaller pool of

expertise. The surveys showed that for some SLT teams dysphagia caseloads were restricted

to a few specialists with no commitment to developing NQ SLT working with dysphagia.

Rationale for this included concerns expressed around NQ SLT potential to move away at a

loss to the department.

Survey results: 47% respondents agreed/strongly agreed with the statement ‘In our setting

dysphagia caseload is covered by experienced SLTs not NQ SLTs’. 26% disagreed/strongly

disagreed.

However generally comments showed commitment to developing NQ SLT dysphagia

competency and comments that this would benefit the profession and service users across

the North West. Some organisations were actively working to extend dysphagia competency


28

within teams to ensure continuity of cover and improve sustainability of dysphagia

expertise.

Comment: “Competency training is seen as a high priority, barriers are usually minimised.”

Survey 1 Q19

Comment: “There are no NQPs in our service and there is unlikely to be. Our issues stem from

non slt/dysphagia trained managers understanding the needs dysphagia trained professionals

and the range of routes to developing and maintaining competence. Our service would

struggle to support a non-dysphagia trained professional to access the number of cases

needed to develop confident and competent practice. I personally had a mix of acute and

community experience when I did my dysphagia training and I feel that NQPs in our service (if

they ever exist) would benefit from this mix. This would require good local links across trusts.

In order to support dysphagia competency development a supervisor would need to have this

as an identified part of their job role and their caseload adjusted accordingly.” Survey 3 Q13

Comment: “I am not against NQPs working in dysphagia and believe it works very well in some

settings.”

Comment: “I would like to aim for NQ SLTs beginning dysphagia competencies in future in my

current setting but there are some other service development steps needed first (e.g. writing

dysphagia policy). We do not find that NQPs move on quickly as we offer them other CPD

opportunities and try to create progression where possible in other areas. The reasons we do

not invest in dysphagia development are because, as mentioned above, we are not able to

support NQPs in their dysphagia practise and it is not priority for our whole service needs at

this time.” Survey 3 Q16

2.4.4 Informal / peer support (includes peer supervision, buddy systems)

SLTs also benefit from access to less formal support networks within and outside the

profession. RCSLT recognises this as additional to the formal arrangements for supervision

(RCSLT 2012). Informal support networks can either be peer support sessions, where

therapists discuss issues about their own experiences, or one to one with colleagues or co-

workers. This informal support can be especially important for newly qualified practitioners

or those finding themselves working in relative isolation.

Support networks also incorporate:

• RCSLT Hubs at a regional level

• RCSLT Clinical Excellence Networks (CENs)

• Virtual networks such as RCSLT Basecamp or other social media.


29

Surveys showed that the majority of departments include informal contact.

Survey results: 68% offer daily contact for NQ SLT to support dysphagia practice (includes

informal or formal supervision). 10% strongly disagree/disagree.

However some NQ SLTs working with dysphagia responded that no supervision or informal

contact was available.

Survey results: 4% never have formal or informal opportunities for discussion with specialist

level SLT. 8% have contact once per month or less often.

Comments highlighted the level of concern regarding this:

Comment: “On-going - there is a hierarchy of experience and we all provide on-going support

to each other when needed. Typically the newer and less experienced staff will require more

supervision and the more experienced staff less - though we all have access to the expert once

a month for second opinions, to show videos, discuss cases, plan intervention, receive training

and advice etc.” Survey 1 Q13

Comment: “Sharing of ideas/concerns/experiences helps to build a well-rounded clinician and

therefore contact with both experienced and newly qualified therapists should be encouraged

at every opportunity. This can be done via peer support groups set up on an in house or a wider

network, for example North-West.” Survey 2 Q5

Comment: “Always a risk making people responsible for their own competency.” Survey 2 Q7

Responses showed variation in how much NQ SLTs may be expected to self-monitor.

Generally comments suggested that supervisors should monitor NQ SLT skills in identifying

and then accessing support as part of the competency development process.

Comment: “NQ SLT's may need direction when determining their competencies - it is

unrealistic to say they bear responsibility solely for their competency.” Survey 2 Q7

Comment: “in order to develop competently there has to be some expectation on the therapist

to seek out support/learning as and when needed. As previously mentioned, the supervision

process need to be weaned in accordance with the clinicians skill set.” Survey 2 Q7

Phone supervision, skype and email were also identified as feasible strategies for

supervision but these were less popular. Respondents acknowledged that phone, video and

email were used to save time and travel, skype was rarely used.


30



check progress with EDS skills.” Survey 2 Q9

Comment: “As services are limited at the moment, telephone and email clinical supervision is

sometimes the only option. I find this works well in our service, although if possible I would

always prefer face to face supervision.” Survey 3 Q11

2.4.5 Sharing supervision between organisations / individuals

Interviews and surveys in 2014-2015 raised concerns regarding supervision when attempted

across organisational boundaries eg between SLTs in different NHS Trusts, between NHS and

non NHS organisations, or between NHS and individual private SLTs. Some arrangements

were described as being paid and some as unpaid (described as a ‘good will’ basis).

Comment: “we should be working together more across the profession. In community it is

harder to get the volume you can achieve in the acute setting, the issue re community acute

are also very different. However if the department is too small to give regular contact to SLT's

then that is a sig risk.” Survey 2 Q13

Comment: “I think sharing resources and expertise of staff and training sessions would be

extremely beneficial coming from a small rural team perspective.” Survey 2 Q13

Areas of concern included:

• Clinical governance arrangements

• Understanding of SLT role and responsibilities across professional/organisational

boundaries.

• Appropriate and effective support from line management

• Appropriate support and competency level of clinical supervisor

• Confidentiality and consent procedures for case discussions

• Confidentiality for discussions between supervisor/supervisee

• Complaints procedures in place

• Safeguarding, the risks to the service user that may be identified and procedures

to address any concerns.

Recommendation 3.1: Each dysphagia CEN for the NW region could offer

opportunities to develop a matching up service; advising and supporting sharing of

training, and matching supervisor with supervisee.


31

Recommendation. 3.2: Each CEN to offer opportunities (eg break-out sessions

attached to main meeting) for supervisors to discuss competency issues and receive

peer supervision for their role in dysphagia training and competency development.

2.4.6 Supervision training

The pressures experienced by supervisors were discussed by some respondents. Interviews

gave examples of good practice in other regions where supervisors meet regularly as a

group for consultant level peer supervision and support.

The surveys showed strong interest from all levels of SLTs in receiving training in

supervision.

Survey results: 89% agreed/strongly agreed that supervisors should have training in this

role; none disagreed.

Training can improve confidence and enhance the quality of supervision and is currently

available nationally.

Learning objectives may include:

• Definitions of clinical supervision and clarification of the role of a supervisor

• Consideration of professional standards in supervision, the benefits and

expectations for all. Opportunities and challenges.

• Exploration of structures, processes and boundaries to guide supervision

contracts and management.

RCSLT website lists current courses available:

http://www.rcslt.org/members/docs/post_reg_training_sept_2012. Other training is

available through NHS and other national organisations.

Recommendation 3.3: Supervision training to be offered at a NW venue. This

may lead to further events such as refresher training and support sessions for

experienced supervisors. An easily accessible HEI venue offering twilight

sessions may facilitate attendance.

2.4.7 Monitoring performance, signing off competencies

The surveys showed that supervising SLTs are using direct observation as the preferred

method of assessment but that there is some reliance on the assessments offered by formal

courses. The RCSLT Dysphagia training and competency framework (2014) and the

Interdisciplinary Dysphagia Framework (2006) were acknowledged as helpful in structuring

http://www.rcslt.org/members/docs/post_reg_training_sept_2012


32

progress and measurement of skills. Comments showed that the new RCSLT Dysphagia

Framework (2014) was welcomed and that SLTs would move to using this in the future.

Survey results: 95% use direct observation to assess competency

Comment: “The fully integrated use of direct supervision, case discussion /reflection,

monitored decision making and report writing... all vital in signing off competency There will

always be cases which challenge decision making and risk management, careful exploration

of the issues are very important learning opportunities at every level. If particular

issues/difficulties are identified then individual learning objectives need to be set and a

pathway agreed to achieve them. Important not to get tempted to sign off on anything unless

you can stand behind the decision as the supervisor.” Survey 3 Q13

2.4.8 Governance

Interviews with SLTs in the region raised concerns regarding the management arrangements

for supervision across organisational boundaries. Examples were described of SLTs working

without adequate supervision at different levels of competency (including SLTs at NQ SLT

level).

Survey results: 86% agreed with recommended RCSLT (2012) guidelines that NQ SLTs should

have supervision at least weekly in the first 3 months; 14% disagree/strongly disagree.

Comments show that time constraints are a constant challenge:

“Regular supervision, especially in the early stages is vital to discuss concerns and ensure

continued development.” Survey 2 Q11.1

“I think that it is hard to set an arbitrary time frame for how often supervision should take

place, some people need weekly for less or more time - it is for the supervisor to agree with

the therapist - both must be happy with decision. No one should be practicing without some

sort of supervision.” Survey 2 Q11.2

“I think most effective supervision is face to face. I have disagreed with weekly supervision as

a formal session but in my dept there is constant informal supervision and discussion of cases

with NQ. A specific weekly formal session would not always be possible.” Survey 2 Q11.3

RCSLT (2012) guidelines recommend:

‘’A supervision contract should be agreed between all parties (for example the line manager,

supervisor and supervisee). The contract should include details of the frequency and length of

meetings and should have a confidentiality statement and a process for taking difficulties that


33

cannot be resolved to an appropriate third party. It is good practice to discuss this in the first

supervision session.

The supervisor’s role and responsibilities to the supervisee will be clearly negotiated. When

planning a supervision structure it may be useful for the supervisor to think about: (i) what

evidence they will need to be confident that the supervisee is competent to the level required

for their post; and (ii) where and how to access advice from specialists (e.g. RCSLT Advisers

and others) when encountering particularly challenging cases and difficult situations.

All clinicians, particularly NQ SLTs, should be encouraged to seek alternative clinical

supervision or support if their current supervision relationship is not working out or has broken

down.’’(RCSLT, 2012p5)

A further useful source of information is the document General Principles for Speech and

Language Therapy Managers undergoing structural changes within organisations (RCSLT,

2004) which gives further clarification and detail regarding negotiating and supporting

structured supervision arrangements.

Interview responses for this project showed that structures for external supervision are very

varied and may be informal or run on a ‘good will’ basis. There was acknowledgement of the

potential for difficulty in informal arrangements and respondents discussed need for clear

safeguards to be in place including procedures for complaints.

Comment: “There would have to be formal agreement to rationalise inter Trust agreements

of this sort, as mentoring and supervision does need time. It would be great if this could be

formalised, so that this type of issue stops causing problems.” Survey 2 Q13.2

Comment: “Sharing and negotiating between trusts is way forward for smaller depts. We have

SLA with neighbouring trust having TUPE'd across for professional support and competency

development. We also use CEN, ALD leads, NW ALD dysphagia support group. I also offer

supervision on private basis with contracts…. sending invoice for time.”Survey 2 Q13.3

Comment: “Although sharing expertise is in theory a good idea it seems that the same

departments may more frequently be asked for extra support.” Survey 2 Q13.1

Recommendation 3.4: external supervision is formally supported by a contract

including procedures for governance, confidentiality, safeguarding and

complaints. The structure should clarify accountability and management

responsibility.


34

2.4.9 Summary

Supervision is a key to developing from threshold to proficient practice. It is something that

every new graduate should expect as part of their employment. Supervision in dysphagia

also carries with it the need to assess and confirm attainment of skills. The

recommendations give a range of differing approaches to supervision which can be adopted

in the way which best fits the working environment concerned.


35

2.5 Role of Clinical Excellence Networks

Further information: Continuing Professional Development (CPD) opportunities, Clinical

Excellence Network (CEN) meetings, study days and dysphagia support groups.

The value, function and availability of regional dysphagia groups, CENs and CPD was a key

theme from our surveys. Interest centred on the role of CEN (previously known as Special or

Specific Interest Groups) meetings, which offer a solution for most SLTs surveyed: consensus

showed keen interest in attending.

Survey results: 95% would welcome support group or CEN in specialist area. Additionally

55% would welcome a separate expert peer supervision group (recurring 3-6 monthly) to

support SLTs at specialist & consultant level.

RCSLT guidelines state that for CENs, meetings or study days will be held at least twice per

year and students should be offered a concessionary rate or free attendance (RCSLT 2014).

RCSLT affiliated CENs are now coordinated through the regional RCSLT hub structure.

Currently there is some confusion, inconsistency and apprehension among SLTs regarding

use and access to the electronic hub process but developing familiarity with RCSLT hub and

CEN system is anticipated over the next year.

Consensus showed that in principle CEN/SIG groups are valued, accessible and offer

primarily an opportunity for knowledge exchange and updating, with a strong role in

support, peer supervision, and networking. Some larger organisations can offer local

meetings in house to support SLTs working with dysphagia but these appear to be limited to

adult acquired and paediatric focus.

Comment: “I find utilising support from outside own dept can be very beneficial, especially for

smaller teams and for most of our CPD we have to travel across the region and nationally and

find the networking opportunities invaluable.” survey 3 Q15.1

Comment: “An expert group would be useful or perhaps a clinical /case study discussion group

and a separate dysphagia service development group. Although it is good to keep a broad

skills mix during peer support, it would be challenging for me to find time to attend another

additional group. Perhaps in the existing peer support group we could have some discussion

as a whole group and then split off into two smaller groups (which would not have to be the

same each meeting - they could perhaps be topic based).” survey 3 Q 15.2

The RCSLT CEN structure offers more than regular meetings. The use of email and the

network generally promotes sharing of advice and support as demonstrated by the

successful ALD regional (and national) dysphagia networks. The CEN structure could be


36

extended through the RCSLT hub to offer similar networks for SLTs working with adult

acquired and paediatric dysphagia.

2.5.1 Current CEN groups in the North West

ALD dysphagia NW group: this is well attended by SLTs, and includes other related

disciplines such as dietitians, nursing, and specialist dysphagia practitioners. SLTs’ clinical

interests include a majority working with ALD, but also may include topics around MH and

adult acquired aspects of dysphagia. 3 meetings are offered per year, these are currently

held in Sale at NHS/Social services premises.

Paediatric dysphagia: respondents described attending local groups available in Manchester,

Lancashire and Merseyside. During the project, no information was returned on the current

regional group, however further investigation found that it is reported to be in the process

of becoming a CEN attached to RCSLT NW hub.

Adult acquired dysphagia: no active regional dysphagia groups currently run for this clinical

specialism. Some Trusts run regular ‘in house’ peer group meetings with dysphagia focus.

Recommendation 4.1: paediatric dysphagia group to be coordinated at

regional level running as CEN to coordinate meetings and electronic network

through hub.

Recommendation 4.2: new dysphagia group (adult acquired) to be set up at

regional level running as CEN to coordinate meetings and electronic network

through hub.

Wider relevant national groups/networks were also described by respondents in interviews

and surveys including ALD dysphagia research network; AHP network; and UK Swallowing

Research Group.

Recommendation 4.3: further recommendations for CENs;

4.3.1 CEN sessions should have a formal agenda and clear structure as this

improves support from managers for attendance. Planning ahead is

recommended with an outline for a full year’s meetings and topics publicised

to help SLTs planning attendance.

4.3.2 Venues to be easily accessible across the NW region. Venues could rotate

across HEIs in Preston, Lancaster, Manchester to facilitate regional access.


37

4.3.3 Use of HEI as venue: these are generally easily accessible, offering links

with academic hosts and adding prestige/status further supporting application

to managers.

4.3.4 Use of Eventbrite www.eventbrite.co.uk or similar for application process

4.3.5 CEN meetings/networks to cover sharing of supervision opportunities

matching supervisors and supervisees.

4.3.6 CEN meetings/networks to publicise or share in-house training

opportunities across organisations. This will help with recruiting for training

(increasing number of potential participants) and offering potential for income

generation as larger number of participants will help support/fund access to

external speakers.

4.3.7 CEN meetings/networks to cover sharing of research updates and

opportunities for critical appraisal of articles.

4.3.8 Experienced dysphagia SLTs to form additional groups or break out from

CEN general meeting to discuss issues around supervision and support (see also

3.2).

2.5.2 Summary

CEN meetings and related networks offer an effective means of sharing professional

strengths and needs across the region overcoming organisational boundaries. Despite

strong interest it appears that, for some specialisms, CENs are not currently active. The

profession can develop these through the RCSLT NW Hub, which serves as a focus for

innovation and collaboration


38

2.6 Workforce planning

Further information on workforce planning: attitudes, risks and solutions

The project was initiated following widespread concern regarding implementation of

competency development in dysphagia. Concerns centred on lack of time and capacity to

support new graduates but there was interest in finding effective solutions.

Survey results: Question - Would you say NQ SLT dysphagia competency development is

working well in your dept?

65% agree/strongly agree; 11% disagree/strongly disagree; 14% neither agree/disagree.

The interviews and surveys illustrated the different aspects of dysphagia competency

development which are most frequently causing concern amongst Speech and Language

Therapists. Themes around risks and attitudes are described below selected from the

comments describing barriers and those identifying solutions.

2.6.1 Attitudes

Responses to the surveys showed wide variation in SLT opinions. Discussing NQ SLT

confidence levels the comments showed contrasting attitudes:

Survey results: 82% indicated that NQ SLTs lack confidence in themselves however 19%

indicated that NQ SLTs can be overconfident.

Opinion also varied on supervisors’ confidence in new graduates:

Survey results: 28% thought that supervisors can lack confidence in NQ SLTs and be over

cautious/risk averse (38% disagreed).

Comment: ‘’supervision is a must have for grounding and maintaining competency, this allows

lone working and decision making (NQPs vulnerable without). Without this skills and

competency diminish. Thinking out loud helps breadth includes peer contact, expert

supervision, listening from supervisor as sounding board, for NQP a higher degree of

intervention is needed from supervisor but should still encourage them, not spoon feeding,

offering dynamic conversation at varying levels with shaping as some need more guiding to

come up with answer. Not directive but supportive and encouraging.’’ Survey 2 Q11.


39

2.6.2 Perceived risks around potential for harm, potential life threatening

aspects of dysphagia

Survey results: 59% agreed/strongly agreed that ‘’ Many SLT professional skills are

transferable across clinical settings. Dysphagia should not be seen as different from other

specialisms which also require further development post registration.’’ 14% disagreed.

Comments included varying opinions:

“I feel that dysphagia is slightly different as the risk of death (or at least death more quickly)

is higher, though lots of skills are transferable - I 'm not yet convinced that NQ SLT's leave Uni

with enough experience/knowledge to practice dysphagia effectively without further training

and supervision.” Survey 2 Q7.1

“The risks associated with dysphagia are high and therefore I feel it should be viewed as

different from other clinical specialisms” Survey 2 Q7.2

In contrast, some comments evidenced opposing views on risk

“Feel very strongly that dysphagia be regarded just like any other clinical area in this regard.”

Survey 2 Q7.1

“Observing and emulating good practice is a good way to learn new skills and provides

assurance of a reduction of risk as well as competency. I do think however that an overcautious

approach can have a negative effect on the individual’s confidence in this area.” Survey 2 Q9

Solutions were offered and an emphasis on supervision was clear

“NQ SLTs do bear responsibility for their own professional competency but this should not be

relied on too much as some individuals may not have good self-awareness. Poor dysphagia

practice may do immediate irretrievable harm to an individual which separates it from other

SLT specialities.” Survey 2 Q7.2

“Given that we work in such a diverse and potentially life altering area, assessment of the

therapist must be thorough to ensure a sound theoretical and practical knowledge base has

been acquired.” Survey 2 Q3

Comments reiterated that support from colleagues, at all levels of skill, was essential.

Survey results showed the wide-ranging situation across region for SLTs: 4% have no

supervision, 7% have less than 1/month but 51% have daily formal or informal contact with

colleague SLTs


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2.6.3 Attitudes around signing off competency.

Some respondents showed reliance on the formal postgraduate training process to define

competency levels

Comment: “They are only deemed competent once they have completed an accredited

qualification.” Survey 1 Q9

Comment: “We give basic dysphagia awareness in house training but they would not be

expected to assess unless they had done the post basic dysphagia course.” Survey 1 Q12

Some responses identified risk associated with unsupervised assessments

Comment: “I think the written exam and case studies are ineffective at measuring knowledge

and definitely does not tap competencies. The supervising clinician can easily spot poor

knowledge and understanding which can be missed by a written piece of work.” Survey 2 Q3.1

Comment: “The formal courses are brilliant but don't hone your observation skills - you can

hide in the crowd if you are not seeing what others are seeing. Writing one case study proves

nothing other than you have managed one person and understand their needs. Two case

studies would require a broader knowledge.” Survey 2 Q3.3

For questions about timescales for achieving competency, attitudes varied considerably. The

majority of comments emphasised the need for flexibility but some respondents felt it was

helpful to offer suggested timescale. Some examples of diverse opinions include:

Comment: “Hours are only a guide, we vary this according to a clinician’s growing

competency. We will increase the number of supervised visits if we feel a therapist needs it or

offer additional debriefs after an independent visit etc.” Survey 1 Q17.1

Comment: “6-8 weeks progression towards independent practice.” Survey 1 Q17.2”

Comment: “I think honing in these skills could take a whole career to perfect.” Survey 1 Q17.4

Additional comments acknowledged the difference between routine and complex

dysphagia, with more complex cases requiring greater support for NQ SLTs.

2.6.4 Risks around supervision

Please see further information section 2.4 for discussion of supervision options used

currently in the North West. The attitudes and risks associated with supervision of NQ SLTs

were exemplified by varied comments:


41

Comment: “NQT's in the two NHS departments I have worked in so far do not currently have

a clinical role in dysphagia other than observations. Lack of supervising therapists appears to

be the main difficulty.” Survey 1 Q9

Comment: “In our setting: a typical goal of first 3 months of working in the team, for focused

dysphagia training and supervision with meetings every 3 weeks (approx) in this time-

informal support and training embedded in daily working while this is happening. However

this is flexible depending on the needs of the NQ SLT.” Survey 1 Q 16.1

Many comments showed consensus for graduated ‘weaning’ process in supervision to

ensure competency is monitored, for example:

Comment: “We have a specified number of shadowing visits, supervised visits, unsupervised

visits with debrief (3 each) and a case study. We aim for 6 months for basic competence but

this can be extended if it is felt that the staff does not have the basic level of competence.”

Survey 1 Q13

Some comments raised the issue of supervision for SLTs working in an isolated post or

outside the NHS

Comment: “If SLT so isolated that completing competencies is a real challenge and accessing

support very difficult then I would have real concerns on how they would manage day to day

clinical risks. Would need pretty robust systems in place to ensure adequate clinical

governance. These things are not impossible but need committed managers to facilitate it and

keep it working.” Survey 3 Q5.2

RCSLT (2012) guidelines clearly state the recommendations for supervision at different

stages of experience.

2.6.5 Perceived risks around staff retention

Comments acknowledged the impact of lack of funding and staff capacity to invest in NQ

SLTs. Some responses linked this to difficulties in retaining staff:

Comment: “When you have a smaller department you are not inclined to train newly qualified

SLTs as they move on so quickly. Our trust only allows us to employ mainly band 5 SLTs at

present so it is a huge investment of time and money, which we tend to avoid. It is a shame.’’

Survey 2 Q8.2

Comment: ‘’Trusts can't afford this (training) and unless we can obtain funding to secure that

SLT a band 6 post it is common that the training and investment in the therapist is quickly lost

as they move into new posts once their dysphagia competencies are complete.” Survey 3 Q7.1


42

However, the surveys in the final Delphi phase suggest this is only relevant to a few areas:

Survey results: 10% SLT depts. do not invest in NQ SLTs due to concerns about retention.

58% did not agree with this statement.

Generally comments showed commitment to working across the SLT profession with

support for new graduates accessed across different organisations (16% indicated they

could not access this supervision in house).

Comment: “We need to act as one profession on this and work together. Part of the problem

is this 'cost' of dysphagia training and the then perceived loss of skills when that therapist

moves on. We all need to share the costs and then there is no loss!!!!.” Survey 2 Q8.1

Comment: “We do aim to have band 5 posts that develop into band 6 posts where budget

allows so that if the NQT develops dysphagia competency they don’t leave for a band 6 post

however if we didn’t have the money to preceptorship to a band 6 it wouldn’t stop us investing

in their training as it helps us and the profession generally.” Survey 3 Q16

And sustainability of dysphagia provision was also discussed in comments illustrating the

concerns of some departments where only a few Specialist SLTs are identified to work with

dysphagia.

Comment: “I believe all SLTs should have a baseline knowledge and transferable skills and

whilst specialist knowledge is important there should never be one dysphagia trained SLT for

a team (which has been common practice in the past in some areas for paediatrics).” Survey

2 Q8.4

2.6.6 Risks around working across organisational boundaries

Interviews and surveys flagged up risks around cross-organisational supervision

arrangements including issues such as lack of support, governance, formal contracts,

accountability, complaints, confidentiality. Please see further information section 3.

Comments indicated that some SLTs were concerned about how this could be sustained:

“Although sharing expertise is in theory a good idea it seems that the same departments may

more frequently be asked for extra support.” Survey 2 Q 13.1

“supervision arrangements outside of the therapist’s employment have significant governance

and financial implications which would need to be addressed. There would need to be clear

lines of accountability and a structure to facilitate liaison between the supervising therapist


43

and the supervisee's managers, with clear expectations as to the quantity and quality of

practice and of supervision.” Survey 3 Q5.3

Comments suggested that a majority of these arrangements were informal but there were

repeated comments supporting the development of more formalised options.

2.6.7 Solutions

The new RCSLT Dysphagia Framework (2014) was welcomed as a means of formalising and

unifying the competency development of new graduates across the region. The responses

showed that SLTs were, in some cases, able to prioritise competency development.

Comment: “Competency training is seen as a high priority, barriers are usually minimised.”

Survey 1 Q19.1

Comment: “in my current job these barriers don't exist, but in previous jobs many of the above

have been identified by my colleagues and managers as reasons why dysphagia training new

staff is difficult, or can't be done. I felt we could have worked around these challenges however

most of the time, and had the scope to train staff in dysphagia "in-house" if the wider team

had been on board with prioritising this and having more of a long term view on developing

the skills of NQ staff.” Survey 1 Q19.2

Respondents showed a commitment to finding ways to support and develop NQ SLTs

describing a variety of methods to provide supervision. Throughout there was consensus

that this must be individually focussed and that time scales and supervision need to be

flexible responding to need.

Comment: “Consultant Dysphagia SLT is currently contracted to come in once a month to

support learning and development of all the dysphagia trained therapists in our team.” Survey

1 Q10

Comment: “We provide dysphagia supervision in group and 1:1 with a mentor until

competencies signed off.” Survey 1 Q12



check progress with EDS skills.” Survey 2 Q9.2

Respondents were in favour of structures protecting CPD and supervision but practical

constraints (including time, funding and lack of management support) gave many cause for

concern.


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Comment: “Think it is important for all staff to be able to identify their training needs, priorities

and gaps in knowledge. It is important that time to attend courses, events etc are protected

and supported by management”. Survey 2 Q19

Survey 2 results: Consensus of 91% agreed/strongly agreed that ‘’Workforce planning: Job

descriptions and budgets should be coordinated so that new recruits have protected time

and funding for dysphagia competency development’’ (9% neither agree/disagree)

Recommendation 5.1: job descriptions and budgets to be coordinated so that

new recruits have protected time and funding for dysphagia competency

development.


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3.0 BUSINESS CASE PLANNING FOR SETTING UP A DYSPHAGIA

SUPERVISION STRUCTURE: BUSINESS CASE TEMPLATE

IssueIssue

• NQP requires supervision to develop independent dysphagia practitioner skills

SolutionSolution

• Supervised support over 6 month period

ApproachApproach

• 1 hour weekly for sign-off supervision

• independent learning

• peer supervision

Risk assessment

Risk assessment

• Without supervison: lack of sufficient dysphagia trained clinicians; reduction in scope of service to [ ] patients; cost to service in longer term impairments etc etc

• With supervision: temporary reduction in clinical contacts

Value addedValue added

• Higher patient throughput long term

• Reduced cost long terms (discharge) as more SLTs able to work with dysphagia patients

• Increased patient satisfaction


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‘’Members of the speech and language therapy workforce have a duty to understand the level

at which they are working in dysphagia and to seek out appropriate supervision to support

their ongoing reflection and development, for the safety of the patient/client and themselves.’’

(RCSLT 2014 p11).

The RCSLT Dysphagia Training and Competency Framework should be used ‘’to direct support,

supervision and training until the NQ SLT reaches a level where they can operate safely and

autonomously with clients with dysphagia. Competency, acquisition and maintenance can

then be based on review of the competency framework alongside the needs and requirements

of the SLT’s department or team.’’ (RCSLT 2014 p13)

It is important to negotiate for adequate supervision to support NQ SLTs to become

proficient in dysphagia practice. In order to do this, business planning can be used to

negotiate for dedicated supervisory time. NQ SLTs who are supported with in house

supervision have great commitment to their employing service and higher morale.

When writing a business case to set up a robust supervisory structure it will be important to

consider all aspects that are listed below. This list is non-exhaustive.

A. Project title, background, strategic context and need

• Establish needs and demands that are to be addressed and any deficiencies in

existing provision

• If possible, quantify needs, demands and deficiencies

• Evidence base for supervision, also for dysphagia assessment and intervention:

RCSLT (2012) guidelines clarify supervision and highlight the role in promoting

safety of the service user experience and addressing any areas of concern. The

RCSLT dysphagia training and competency development framework reiterates

this (RCSLT 2014).

• It will be necessary to ensure approval has been obtained from the relevant

managers/organisation to commence the process of setting up supervision. This

should be documented within the business case.

B. Summary of financial implications (please see section 7 cost consequence

analysis)

• Include staffing costs associated with:

o Time and travel for supervisor to meet and supervise NQ SLT

o Time away from caseload for both supervisor and supervisee (include any

backfill costs)

o Any accommodation, IT and other resource costs for supervision.


47

• Costs associated with patients on waiting lists which may include:

Deterioration of patients with dysphagia, increased hospital admissions

(considering morbidity and mortality), deterioration in quality of life and impact

on caregivers.

• Training the SLT supervisor: the cost of training staff in supervising through

attending HEI, RCSLT or other organisations to include course fees and time.

Some training may be online but travel costs should be calculated for external

courses.

• Training NQ SLT in additional postgraduate level knowledge of dysphagia theory

and also in practical skills; this may require attendance at external courses,

particularly for specialist knowledge and techniques.

• Ongoing supervision that will continue past the period of NQ SLT competency

development as recommended for all SLTs (RCSLT 2012).

• SLT staffing and administrative support etc.

C. Timescales

It is agreed that new graduates will benefit from 6 to 12 months in post to consolidate their

entry level professional skills and knowledge, consensus indicates that the process of

dysphagia competency development should follow after this initial phase of work based

learning (NW survey 2015).

Achievement of Dysphagia competency to specialist Level C is dependent upon various

factors (RCSLT 2014) including:

• Amount of previous individual practical experience

• Individual skills and learning ability

• Availability, number and variety of patients with dysphagia

• Availability and expertise of SLT supervisor

• Opportunities for formal training

• Opportunities for CPD and support networks

Where adequate dysphagia caseload numbers and SLT supervision is available NQ SLTs may

reach specialist Level C in dysphagia competency after 6 months, occasional examples of

faster progression may be due to intensive and accelerated supervised experience in

working with dysphagia. This needs to be quantified in business case planning.

D. Staffing considerations

• Ensure Specialist (Level C) SLT dysphagia practitioner(s) have been identified who

are available and willing to carry out the supervision.


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• Where supervisor is provided by another organisation then ensure structures are

in place to support both parties in the case of competency not being signed off

within the expected timescale.

• Ensure governance and complaints procedures are in place to cover both

supervisor and supervisee.

• Ensure confidentiality and consent procedures are addressed for both supervisor

and supervisee.

• Ensure there are adequate information governance procedures in place for

caseload discussions, particularly if crossing organisational boundaries.

• Frequency of supervision is clarified in the RCSLT supervision guidelines (RCSLT

2012).

• Manage failing supervisees so that they may enhance their performance and

capabilities for safe and effective practice or be able to understand their failure

and the implications of this for their future.

E. Risks and uncertainties

Supervision:

• Managers who are from a non SLT background need information on expectations

for good practice in dysphagia competency development and on appropriate

models of supervision for NQ SLTs.

• Where competency has not been established there will be implications for safe

practice in the NQ SLT continuing to work with people who have dysphagia.

• Management of failure: support for the supervisor and supervisee is essential so

that they may enhance their performance and capabilities for safe and effective

practice or be able to understand their failure and the implications of this for

their future. Clear structures for accountability should be in place from the

outset.

Qualified staff availability: Where a dysphagia service is restricted to just 1 or 2 highly

experienced individuals (specialist dysphagia or consultant SLTs) to cover a wide dysphagia

caseload then sustainability of the service is vulnerable.

Staff retention: Concerns regarding retention of newly qualified staff have been raised

during our surveys but the consensus suggests widespread support for investing in NQ SLT

training to the benefit of the profession locally and also across the region (NW survey 2015).


49

F. Summary of benefits/ value added

Improved SLT staffing levels and expertise following competency development (usually

expect NQ SLT to achieve specialist dysphagia level (RCSLT 2014) after 3-6 months with

sufficient caseload experience) would be expected to lead to:

• Improved productivity, absence rate, skill development, benefits to staff morale

and retention with support and motivation from supervision.

• Related benefits to patients with dysphagia such as reduced waiting times,

reduced morbidity and mortality, improved quality of life for patient and society.


50

3.1 Cost consequence analysis

Table 3.1 - Training / knowledge acquisition: costs for SLT service for NQ SLT attending training

Option 1 3 day local training for min

5 staff

Option 2 Online training

Option 3 Formal course including

supervision period

NQ SLT time - band 5 backfill

£247x5 = £1237 £55 5 hours band 5

Lack of availability

5 days £412 (Waiting

list)

Teaching staff time (SLTs band 7 ) 2 tutors per course / backfill

£818 0 Requires additional

supervision to support learning and further

training

Weekly supervision in house band 7 over 6

month: £454

Exam invigilator band 3 for 3 hours:

£27

Preparation time for tutors (10 days) Includes assessment & marking

£2726 Reduces for subsequent

courses

0 Supervisor report – 3 hours band 7:

£55

Resources for training course

Handouts, DVDs & text books /

journals

£250 0 Access to computer

0 Included in fee

Room hire £150 0 0

Cost of training course - fee

0 None for local

0 None usually

£776

Travel (within region) 0 0 £50

Accommodation 0 0 £400

Software/IT resources 0 Hours vary Online exam

Assessment process: costs of time/backfill

£110x5 = £550 £33+£55 = £88 £143 + £73 =

£216

2 case studies (10 hours band 5)

Multiple choice, discussion with supervisor

(3 hours band 5 +7)

3 hour exam, 2 case studies, supervisor report

(Band 5 +7)

Total financial cost for basic training

for 5 SLTs = £5731 £143 For 1 SLT £2390

(for 1 SLT = £1146)

Potential income generation

Yes Could offer to 5+ external

SLTs @ £200 each with resulting cost for each

internal: £946

No No

Competency level? Requires further supervision to reach

Specialist Level C

Requires further supervision and training to

reach Specialist Level C

Supervision and training included, usually achieves

Specialist Level C.


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Supervision costs 4 hours/month

Employ external supervisor Use in house supervisor (band 7)

Supervision fee £300 0

Backfill hours 0 £73

Travel £200 0

Total £500 £73

3.2 Wider client/patient costs for reduced dysphagia cover during NQ SLT

competency development

These potentially include increased number and length of hospital admissions, increased GP

contact and use of antibiotics for increased likelihood of chest infections and ill health;

increased nursing care; carer loss of work days; impact on quality of life for client/patient

and family, increased likelihood of choking.

After 3 - 6 months of training and supervision a NQ SLT would normally be expected to have

gained sufficient competency to begin to address waiting lists and training needs in non-

complex settings. Supervision would continue as per RCSLT recommended practice.

Note: band 5 costs calculated at spine point 16 (entry level), currently £21,692; band 7

calculated at mid-spine point 30, currently £35,891.

3.3 Summary

Work force development is important for all areas of professional practice. This section

indicates approaches, which as described in other sections, demonstrate an overwhelming

consensus for improvements to the CEN structures both electronically and at venues across

the North West. This was seen as instrumental in addressing concerns regarding risks,

supervision opportunities, sharing of resources and helping to improve consistency in

developing and supporting the profession. Business case planning and cost consequence

analyses enable managers to make a convincing case for specific areas of work force

development, including dysphagia competency development, to be addressed.


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4.0 CASE STUDIES: EXAMPLES OF SUCCESSFUL DYSPHAGIA

COMPETENCY DEVELOPMENT PROGRAMMES

4.1 Example 1. Paediatric caseload across rural and urban settings (hospitals,

schools and community). Wide geographical area linking SLTs from

several neighbouring trusts.

NQ SLTs start working with just communication and develop professional skills over first 6

months consolidating skills and knowledge in post.

Supervision shared across region’s specialist and consultant SLTs so spreads the load for

specialists. Good contact and ongoing communication between neighbouring trusts.

Reciprocal sharing for supervision arrangements and clear governance structures in place.

Supervisors offer joint visits from outset with long car journeys giving time for discussion

and guided reflection.

Formal knowledge training of group of NQ SLTs (1 week of lectures and practical sessions in

house) with extra places bought by external NQ SLTs. However individual NQ SLTs do access

external post basic if not sufficient number of NQ SLTs (after 6 months practice). Use of

electronic learning, role play, video and client/patient contributions also in place to support

competency development.

Complex cases are seen by specialists, working with clear understanding of level of skill of

band 5. Front sheet of notes shows risk level/complexity of each patient. NQ SLTs have small

non-complex caseload at first.

Assessment of competency and signing off is by combined options including direct

observation, case presentation to group, and MDT and peer SLT feedback is also considered.

Ongoing monitoring by specialists but key aspect is looking for NQ SLT to show self-

monitoring and will ask for support when needed.

Peer groups meet 1/term (about 3 times a year) to discuss issues, caseloads, dysphagia

topics, share resources and offer mutual support. Confidence building occurs throughout

this process.

2 times/year regional CEN study days are held. This includes all dysphagia SLTs and helps to

coordinate supervision, EBP and journal articles, with a range of topics and speakers

offered.


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Regional expert (consultant) dysphagia SLTs meet to discuss supervision issues and support

at a separate session every 6 months.

Participation is widely encouraged in local HEI projects/research to widen experience and

learning at all levels of experience.

4.2 Example 2. Adult acquired caseload covering acute hospital and

community settings.

Supervisors offer joint visits at the beginning of dysphagia competency process moving into

independent visits with discussion afterwards when NQ SLT shows development of

knowledge, skill and self-awareness (ie readiness to ask for advice).

Small office base allows end of day contact both formal and informal as relevant.

Supervision is part of normal practice following RCSLT standards and is ongoing at all levels.

SLTs are encouraged to feel comfortable asking for help and discussing patients. Competent

SLTs have good self-awareness of needs and self-monitor skills and competency (supported

by supervisors and peers).

Large fast paced caseload allows accelerated learning and wide experience.

Monitoring of competency continues through shared practice ie shared caseload and shared

office space.

Formal training (3 days teaching building on undergraduate knowledge and skills) is offered

for a cohort of NQ SLTs.

A detailed business case was developed to extend service whole time equivalent staffing

levels allowing for ‘lead in time’ of 6 months. This allowed protected time for NQ SLTs to

develop skills and a group of NQ SLTs were supported to develop simultaneously as a

cohort. The negotiations made the case for some reduction in productivity for an initial 6

months whilst competency levels were developed but described the longer term benefits of

increased staffing and competency addressing waiting times and outcomes for patients.

4.3 Example 3 Adults with learning disability, wide geographical area covering

residential, secure and community settings.

New graduates meet with experienced SLTs to discuss competency framework and to set

objectives for developing skills and knowledge. Weekly SLT meetings offer informal support


54

and peer supervision, some joint visits offered moving from observation to hands on to

distant supervision. Formal supervision for NQ SLTs following RCSLT guidelines.

Monthly wider team meetings to discuss topics, case studies and recent articles. This also

includes formal training sessions by specialist colleagues.

3 monthly CEN attendance by 1 or 2 SLTs who then feedback to larger team. Attendance is

shared out so that all have opportunities to attend over the year.

Use of phone and video recordings of service users allows distant support and supervision.

Confidential storage and appropriate consent procedures in place to ensure adequate

governance for using videos.


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5.0 SUMMARY AND CONCLUSIONS

The following resources have resulted from this project:

A project web site with regular updates over the period of the project

http://rihsc.mmu.ac.uk/projects/profile.php?projectid=6;

A new consensus model for developing competencies for the management of

EDS difficulties for all levels of SLT practitioners;

Recommendations on systems for NQ SLTs to access the appropriate level of

supervision to enable timely achievement of, and a consistent approach to,

post-qualification EDS competencies in the North West;

A report detailing the process of developing the model and

recommendations;

A cost consequence analysis for the recommended systems to support

managers in workforce planning.

Case studies demonstrating differing ways to achieve dysphagia competency

The project has been disseminated locally, nationally and internationally.

It is anticipated that this model and recommendations, grounded in consensus from

across the SLTs in the North West, will support and enable dysphagia competence to be

attained in an efficient and effective manner for new graduates in the region.


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6.0 REFERENCES

ASHA (2002) Survey Report on Telepractice Use Among Audiologists and Speech-Language

Pathologists [online] [accessed 19.1.15]

www.asha.org/uploadedFiles/.../telepractice/SurveyofTelepractice.pdf

ASHA (2007) What should I know about telehealth and telepractice? How does telepractice

apply to audiology and speech-language pathology? [online] [accessed 19.1.15]

http://www.asha.org/academic/questions/Telehealth-and-Telepractices/

ASHA (no date) ASHA Mentoring manual [online] [accessed 24.7.15]

http://www.asha.org/uploadedFiles/ASHAsMentoringManual.pdf

Barrows, H. S. (1971) Simulated patients (programmed patients): The development and use

of a new technique in medical education. Springfield, IL: Charles C. Thomas.

Boaden, E., Davies S., Storey, L. and Watkins, C. (2006) Inter-professional dysphagia

framework. London: RCSLT

http://www.rcslt.org/members/publications/publications2/Framework_pdf

Boaden, E., Southern, V., House, L. and Nickson, S. (2014) Distance is no longer an object.

RCSLT Bulletin August

Bradley, P. (2006). The history of simulation in medical education and possible future

directions. Medical education, 40(3), 254-262.

HCPC (2014) Standards of Proficiency – Speech and language Therapists [online] [accessed

19.1.15]

http://www.hpc-uk.org/publications/standards/index.asp?id=52

NHS employers (2006) National Profiles for Speech and language Therapists [online]

[accessed on 8.6.15]

http://www.nhsemployers.org/~/media/Employers/Documents/Pay%20and%20reward/Spe

ech_and_Language_Therapists.pdf

NHS National Innovation Centre (2012) Template for Business Case. [online] [accessed on

8.6.15]

http://knowledge.nic.nhs.uk/documentDetails.aspx?docId=40&breadcrumb=taskDetails&ta

skId=29

http://www.asha.org/uploadedFiles/.../telepractice/SurveyofTelepractice.pdf

http://www.asha.org/academic/questions/Telehealth-and-Telepractices/

http://www.asha.org/uploadedFiles/ASHAsMentoringManual.pdf

http://www.rcslt.org/members/publications/publications2/Framework_pdf

http://www.hpc-uk.org/publications/standards/index.asp?id=52

http://www.nhsemployers.org/~/media/Employers/Documents/Pay%20and%20reward/Speech_and_Language_Therapists.pdf

http://www.nhsemployers.org/~/media/Employers/Documents/Pay%20and%20reward/Speech_and_Language_Therapists.pdf

http://knowledge.nic.nhs.uk/documentDetails.aspx?docId=40&breadcrumb=taskDetails&taskId=29



57

RCSLT (2004) General Principles for Speech and Language Therapy Managers undergoing

structural changes within organisations. London: RCSLT [online] [accessed on 8.6.15]

http://www.rcslt.org/docs/free-pub/general_principles.pdf

RCSLT (2006) Communicating Quality 3. London: RCSLT (currently under review)

RCSLT (2007) Speech and Language Therapy Competency Framework to Guide Transition to

Certified RCSLT Membership. Newly Qualified Practitioners. [online] [accessed on 8.6.15]

http://www.rcslt.org/members/professional_roles/competency_framework

RCSLT (2009) Resource Manual for Commissioning and Planning Services for Speech

Language and Communication Needs (SLCN) – Dysphagia (updated 2014) London: RCSLT

[online] [accessed on 8.6.15]

www.rcslt.org/speech_and_language.../dysphagia_manual_072014

RCSLT (2010) Guidelines for preregistration speech and language therapy courses in the UK

(curriculum guidelines) [online] [accessed 9.1.15]

http://www.rcslt.org/about/Courses_and_training/curriculum_guidelines_2011

RCSLT (2012) Supervision guidelines for Speech and Language Therapists [online] [accessed

19.1.15]

http://www.rcslt.org/members/supervision/supervision_guidelines_for_speech_and_langu

age_therapists

RCSLT (2014) Dysphagia training and competency framework. Recommendations for

knowledge, skills and competency development across the speech and language therapy

profession [online] [accessed on 24.7.15]

http://www.rcslt.org/members/clinical_areas/dysphagia/dysphagia_training_competency_f

ramework

http://www.rcslt.org/docs/free-pub/general_principles.pdf

http://www.rcslt.org/members/professional_roles/competency_framework

http://www.rcslt.org/speech_and_language.../dysphagia_manual_072014

http://www.rcslt.org/about/Courses_and_training/curriculum_guidelines_2011

http://www.rcslt.org/members/supervision/supervision_guidelines_for_speech_and_language_therapists

http://www.rcslt.org/members/supervision/supervision_guidelines_for_speech_and_language_therapists

http://www.rcslt.org/members/clinical_areas/dysphagia/dysphagia_training_competency_framework

http://www.rcslt.org/members/clinical_areas/dysphagia/dysphagia_training_competency_framework


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APPENDIX 1: GLOSSARY OF TERMS

Client/patient

These terms are both used to refer to the person with dysphagia. Client tends to be used

when referring to a child or an adult with learning disabilities, while patient is used by many

SLTs working with adults in acute care and with other adults who have acquired dysphagia.

The terms are both used in this document, to reflect the relevant service user group

concerned.

Competency development

“In broad terms, a transitional supervised period of working helps the practitioner to:

develop a detailed knowledge of a particular working context and its impact on practice;

build up a bank of supervised cases in relevant areas of casework to support future fully

independent clinical judgements and decisions; reinforce certain key aspects of fully

independent professional practice’’ (RCSLT 2007, p4).

Complex patient

RCSLT documents clarify this term: ‘’It can be helpful to consider complexity from several

perspectives:

• the client;

• the client communication environment;

• state of professional knowledge;

• local context;

• the therapist’s level of expertise” (RCSLT 2007, p21).

“A less complex case might therefore be characterised by a client who is presenting at a low

level of clinical risk and who is part of a larger client group with a strong practice evidence-

base, where the therapist will be engaged in a single working-context which allows for

relatively straightforward judgement and decision-making supported by a strong team-

ethos and more procedural ways of working’’ (RCSLT 2007, p22).

Dysphagia

We have used the term “dysphagia” in line with RCSLT documents which currently use this

term in place of EDS (eating, drinking swallowing). RCSLT define dysphagia as “eating and

drinking disorders which may occur in the oral, pharyngeal and oesophageal stages of

deglutition. Subsumed in this definition are problems positioning food in the mouth and in

oral movements, including sucking, mastication and the process of swallowing.”

(Communicating Quality 3, 2006, p320).


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Framework

“… a useful tool to structure support and discussion, and to jointly identify development

needs” (RCSLT 2007, p6).

“… used for goal setting and appraisal, and as a self-assessment tool for the NQP with

support from their supervising therapist. 1:1 sessions were reported to be the most

effective way to review progress and to agree whether or not the competencies in the

framework were being achieved” (RCSLT 2007, p6).

Mentor

This term is not recommended by this project. A mentor ‘’assists each NQP in learning about

everyday workplace practice and procedures’’ (RCSLT 2007, p4). Mentoring is a

‘’developmental partnership through which one person shares knowledge, skills,

information, and perspective to foster the personal and professional growth of someone

else’’ (ASHA 2015, p3). This term was not favoured by local focus groups and we have used

the term ‘supervisor’, which appears in most other RCSLT documentation, throughout.

RCSLT basecamp

Basecamp is an online space designed to connect people in different organisations/roles. It

is valuable for networking, and can act as a repository, holding discussion boards, sharing

documents, and a calendar of events, for example. RCSLT has adopted Basecamp to support

and share the work of the Hubs at local and national level.

Specialist

Please see Level C of the RCSLT Training and Competency Development Framework (RCSLT

2014) and the Interdisciplinary Dysphagia Framework (Boaden et al, 2006). The

Specialist/Level C dysphagia practitioner can demonstrate competent performance in the

assessment and management of dysphagia, working autonomously with routine and non-

complex cases.

Simulation

Re-creation of a clinical environment to assist in learning and teaching (Bradley, 2006).

Standardized patients (SPs)

Actors or real patients who are carefully trained to accurately portray a patient or an aspect

of a patient’s illness according to educational need (Barrows, 1971).

Supervisor

‘’Regular line-management supervisory meetings (weekly during the first three months and

monthly thereafter) to assess progress and to identify further development needs. The

manager will also be expected to support the NQP in finding appropriate ways of meeting


60

those development needs” (RCSLT, 2007, p4). A clinical supervisor [is assigned] to support

the development of critical reflective practice (RCSLT, 2007). “It is the responsibility of the

NQP and employer to ensure the direct line manager/supervisor is both a registered

member of HPC and RCSLT’’ (RCSLT, 2007).

Telehealth/Telepractice

Telemedicine (telepractice) is defined as the provision of health services over a

telecommunications network. In practice, telemedicine uses high-speed interactive video

and remote computing applications to provide speech-language and hearing services to

consumers living in underserved areas (ASHA, 2007).

Telepractice is the application of technology to deliver audiology and speech-language

pathology services at a distance. Telepractice was defined for the survey to include any or all

of the following services: treatment; screening and assessment; follow-up; counselling;

professional consultation; equipment check; prevention activities; or bilingual/multicultural

and other services (ASHA, 2002).

Please also see key RCSLT documents in the reference list


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APPENDIX 2: SUGGESTED TASKS FOR CEN MEETINGS (MAY BE USED

AS A ROLLING AGENDA)

1. Check email addresses and discuss use of network for sharing advice and

opportunities

2. Discuss any current CPD training offered by each participant, opportunities for

sharing events

3. Discuss any requests for NQ SLT and CPD training; discussion of sharing

resources/sessions

4. Supervision needs and availability; matching NQ SLTs with specialist Level C

dysphagia SLTs

5. Supervision support for Specialist Level C SLTs (may run as break out or separate

session)

6. Setting calendar for 12 months with topics following members interests/RCSLT

initiatives

7. Identify speakers for future meetings

8. Agreeing committee members which may include Chair, Secretary, Treasurer,

training coordinator, supervision coordinator

9. Delegating topics to members to lead discussions around evidence base, critical

appraisal of articles, present research topics etc.

10. Explore further links with HEIs (eg for venue, speakers, joint events etc)

11. Discuss options for moving venues to enhance accessibility across region

12. Identify options for livestreaming or similar to include wider membership across

region.

13. Set up Eventbrite or similar to formalise application process for meetings and

events


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APPENDIX 3: TEMPLATE FOR BUSINESS CASE PLANNING

NHS National Innovation Centre (2012) Template for Business Case. [online] [accessed on

8th June 2015]

http://knowledge.nic.nhs.uk/documentDetails.aspx?docId=40&breadcrumb=taskDetails&ta

skId=29

Project Name:

Author: [Name]

Version [n.n]

dd Month yyyy

Distribution List

Name Department / Organisation




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Contents

Page 1 Executive Summary X 2 Introduction and Overview X 3 Market Analysis X 4 Cost / Benefits Analysis X 5 Options Appraisal X 6 Resource Requirements and Cost X 7 Timescales X 8 Assessment of Benefits X 9 Staffing Considerations X 10 Risk Analysis X 11 Conclusions / Recommendations X 12 Appendices X


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SECTION A: Project Title, Background, Strategic Context and Needs

1: Executive Summary

2: Introduction and Overview

3: Market Analysis

SECTION B: Summary of Financial Implications

4: Cost / Benefits Analysis


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5: Options Appraisal

6: Resource Requirements and Cost

SECTION C: Timescales

7: Timescales

SECTION D: Summary of Benefits

8: Assessment of Benefits


66

SECTION E: Staffing Considerations

9: Staffing Considerations

SECTION F: Risks and Uncertainties

10: Risk Analysis

11: Conclusions and Recommendations

12: Appendices


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