200 . h ion 5.2

SHARING KNOWLEDGE WITH NURSING HOME STAFF: AN OBJECTIVE INVESTIGATION

Dorothy Shaw and Hannah May

Lanarkshire Primary Care NHS Trust Red Deer Day Hospital

Alberta Avenue East Kilbride

Glasgow G75 8NH

Nursing home staff are at the forefront of coping with swallowing and communication hsorders. Our study, which is ongoing, collates information on the existing knowledge of such staff and demonstrates how their understanding can be increased by speech and language therapists’ input. Twenty nursing homes agreed to participate in training (91% uptake). To date 16 nursing homes ( 113 stam have completed training in swallowing and eight nursing homes (47 staff) in communication problems. Questionnaires were completed before and after training. There was a highly significant improvement after training.

Introduction

A high proportion of elderly people are cared for in nursing homes (Bryan and Maxim 1998) but those most closely involved with the residents’ daily care often have little or no formal training (Dickinson and Brocklehurst 1997). The need for training in recognising and coping with swallowing and communication problems has been identified (Coles et af. 1995, O’Loughlin and Shanley 1998, Shield and Hughes 1998) and a number of training programmes devised (Bryan and Maxim 1996, Ramm 1997).

Coleman and Butler (1 999) laid the foundations for training in South Lanarkshire and our research expands this work. There is a scarcity of objective evaluations of training and so we used identical pre and post training questionnaires to test our hypothesis that knowledge in swallowing and communication can be increased by training.

Method

Questionnaires were designed, one for each session. One or more suggested answers were to be selected fkom a maximum of six choices. A pilot study (excluded from our results) was undertaken in two nursing homes and both questionnaires were slightly modified for use in the main study.

Twenty two nursing homes were invited to participate in a workshop involving two sessions: swallowing and communication. At the start of each session the relevant questionnaire was completed. Theoretical and practical training was then undertaken. Technical terms were explained in lay language wherever possible and the only audio- visual aid used was a pre-prepared flip chart.

The swallowing practical session (with various strategies practised) followed the theory. Theoretical information on communication disorders was interspersed with

Sission 5.2 20 1

practical training using role-play. At the end of each session another copy of the questionnaire was completed.

Table 1. Results for each of the five questions related to swallowing

Question Answer 1. Not Known

Target Misconceptions

2. Not Known Target Misconceptions

Target Misconceptions

Target Misconceptions

5. Not Known Target

3. NotKnown

4. NotKnown

Pre 7

106 8

179 160 63 9

104 20 83

256 16

103 10

Post 1

112 1

38 30 1

19 1

112 2

11 328

2 4

109

Statistical significance (p =) 0.034 0.034 0.020

<0.0005 <0.0005 <0.0005

0.01 1 0.01 1

<0.0005 <0.0005 <0.0005

NS <0.0005 <0.0005

Misconceptions 147 16 <0.0005 NS = not significant p > 0.05

/ 9

8

7

6

e ! 5 s a 4

3

2

1

0 Not Known Target Misconceptions

Figure 1. Median total score before and after swallowing training

The pre- and post-training questionnaires were scored to give information on three parameters, i.e. items the participants did not know (not known), items known to the participants (target), and misconceptions held by the participants (misconceptions). The

202 Session 5.2

effectiveness of the workshop was analysed by comparing responses to the pre and post workshop questionnaires using the Wilcoxon signed ranks test.

Results

Swullowrng To date sixteen nursing homes ( I 13 participants) have received training in

swallowing. The overall results are presented in table 1 and summarised in figure 1. There is a significant reduction in items not known (p < 0.0005) with a significant improvement in achieving the target answers (p < 0.0005). The misconceptions are greatly decreased (p < 0.0005).

Communication To date, eight nursing homes (47 participants) have received training in

communication. The overall results are described in table I and suminarised in figure 2. There is a highly significant reduction in items not known with a significant improvement in achieving target answers. There is an increase in the number of misconceptions, although this is not statistically significant.

Table 2. Results for each of the five questions related to communication

Question Answer 1. Not Known

Target Misconceptions

Target Misconceptions

Target Misconceptions

Target Misconceptions

Target

2. Not Known

3. Not Known

4. Not Known

5 . Not Known

Pre 42

146 32 47 141

9 37

104 14 29 65 7

51 43

Post 7

181 29 29 159

7 16

125 20 26 68 16 20 74

Stptistical Significance 0, =) <0.0005 <0.0005

NS .

0.022 0.022

NS 0.001 0.001

NS NS NS NS

0.0005 0.0005

Mis-mnceptions 10 22 -0.033 NS = not significant p > 0.05

Discussion

There was a very good up-take of training with the majority of participants being care staff, a smaller number of trained nurses and a few kitchen staff. There was an overall improvement &er training in knowledge of both swallowing and communication disorders.

Swallowing Question 1 related to optimum positioning for swallowing. Training increased the

understanding of correct positioning, while in question 3 misconceptions about bolus

Session 5.2 203

consistencies were reduced. Compliance with management recommendations is a known problem (Feinberg et al. 1996). After training, participants were more aware of the reasons for specific recommendations and have greater incentive to follow them. There was also a dramatic improvement after trainiig in question 5 which related to the selection of drinking containers. One study (Shield and Hughes 1998) has raised the question of doctors treating recumng chest infections with antibiotics with little hope of success because aspiration is continuing. Better informed staff should reduce this possibility (Strange 1998)

/ 14

12

10

E * 8 * 6

4

2

0 Not Known Target Misconceptions

i

Figure 2. Median total score before and after communication training

In question 2, knowledge of indicators of aspiration improved and in question 4 the participants became more informed about medical condrtions which can lead to dysphagia One group of researchers (Kayser-Jones et al. 1998) found that of twenty dysphagic residents only four had been identified as requiring referral. Our training has alerted participants to conditions and symptoms which indicate a need for referral.

Communication Responses to question 1 showed an improvement after training in idmtifylng

neurological disorders leading to communication problems while responses to questions 2 and 3 demonstrated an increase in the knowledge of strategies for assisting communication between staff and residents with comprehension or expressive problems. Participants should be more able to communicate with residents leading to a better quality of life for those in their care.

Response to question 4, concerning symptoms of dysarthria, showed little change. This result initially puzzled us so we smtinised our raw data. This question had two target answers, articulation and pronouncing words. Pre-training, almost all the participants (98%) selected pronouncing words, with 40% also selecting the synonym. Post-training, 96% chose pronouncing words with 5 1% also choosing the synonym, while 2% changed the selection from pronouncing words to articulation. Participants were knowledgeable in this area before training with little room for improvement. However, they failed to

understand the meaning of the word, articulation. Ramm (1 997) reports finding that in nursing homes technical language was considered an issue by the staff.

In question 5 , participants had to select from technical words, i.e. dysphasia, dysphagia, dysarthria and dementia. Although there was a significant increase in knowledge, the misconceptions also increased. The latter is again a result of not understanding the terminology.

Conclusion

Training nursing home staff in communication and swallowing disorders is effective. We have shown that nursing home staff can increase their knowledge of communication disorders and will accept new strategies to improve their care of residents. We have also demonstrated that the use of technical terms has to be avoided in training. In the area of dysphagia, training is most beneficial in the areas of indicators of aspiration, use of modified consistencies and particularly selection of drinking containers. There is great potential for a reduction in chest infections and hence admissions to acute hospitals as a result of this training.

Future research

We will re-assess the participants to discover how much knowledge has been retained and whether this training has improved the quality of care. Our data will be re- examined to compare the benefits of training qualified nbses versus care staff.

Our study requires replication by a multi-centred trial with the co-ordinated results made widely available so that training of nursing home staff in communication and swallowing dsorders becomes standard practice.

Acknowledgements

We wish to thank Mr R Hill of Lanarkshire Acute Hospitals NHS Trust for canying out the independent statistical analysis and Mrs N McPhail for secretarial help. We also acknowledge the help and support of our colleagues in Lanarkshire Primary Care NHS Trust, in particular Miss P Ken, Miss K Forbes and Miss G Currie. We are indebted to the staff of the nursing homes who participated in this project.

References

Bryan, K. and Maxim, J., 1996, Just communicate. Bulletin of the Royal College of Speech and Language Therapists, 530, 10- 1 1.

Bryan, K. and Maxim, J., 1998, Enabling care staff to relate to older communication disabled people. International Journal oj Language and Communication Disorders, 33 (supplement), 1 2 1 - 1 5 .

Coleman, A. and Butler, T., 1999 unpublished Feeding and Communication Workshop for Nursing Homes and Long-stay Hospitals

Coles, R., Lester, R., Bryan, K., Maxim, J., Jordan, L., Ken-, J. and Rudd, T., 1995, Coping with communication disability in residential care. In Caring to Communicate (Proceedings of the Golden Jubilee C‘onjerence) (London. Royal College of Speech and Language Therapists).

Session 5.2 205

Dickinson, E. and Brocklehurst, J., 1997, Improving the quality of long term care for older people: lessons from the CARE scheme. Quality in Health Care, 6 , 160- 164.

Feinberg, M., Knebl, J. and Tully, J., 1996, Prandial aspiration and pneumonia in an elderly population followed over 3 Years. Dysphagia 11, 104- 109.

Kayser-Jones, J., Schell, E., Porter, C., Barbaccia, J., Steinbach, C., Bird, W., Redford, M. and Pengilly, K., 1998, A prospective study of the use of liquid oral dietary supplements in nursing homes. Journal o f fhe American Geriatric Society, 46, 1 1,

O'Loughlin, G. and Shanley, C., 1998, Swallowing problems in the nursing home: A

Ramm, B., 1997. How well do we coimnunicate with nursing and residential homes?

Shield, F. and Hughes, S., 1998, Dysphagia in nursing homes. Bulletin of the Royal

Strange. R., 1998, Homing in on quality. Elderly Care, 10, 17-20.

1378-1386.

novel training response. L)yyphagia, 13, 172- 183.

Bulletin of the Royal College of Speech and Language Therapists, 542, 10.

College Of Speech and Language Therapists, 557, 12- 13.