International Journal of Speech-Language Pathology
ISSN: 1754-9507 (Print) 1754-9515 (Online) Journal homepage: http://www.tandfonline.com/loi/iasl20
The bedside assessment practices of speechlanguage pathologists in adult dysphagia Brittany Vogels, Jade Cartwright & Naomi Cocks To cite this article: Brittany Vogels, Jade Cartwright & Naomi Cocks (2015) The bedside assessment practices of speech-language pathologists in adult dysphagia, International Journal of Speech-Language Pathology, 17:4, 390-400, DOI: 10.3109/17549507.2014.979877 To link to this article: http://dx.doi.org/10.3109/17549507.2014.979877
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Date: 06 November 2015, At: 02:39
International Journal of Speech-Language Pathology, 2015; 17(4): 390–400
The bedside assessment practices of speech-language pathologists in adult dysphagia
BRITTANY VOGELS, JADE CARTWRIGHT & NAOMI COCKS
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School of Psychology and Speech Pathology, Curtin University, Perth, Australia
Abstract Purpose: The current study aimed to investigate what Australian speech-language pathologists frequently include in their bedside assessments in adult dysphagia, what factors influence these bedside assessments and whether they are consistent with the current evidence base. Method: These aims were achieved via an online questionnaire and a series of semi-structured interviews. In the questionnaire, respondents were asked to rate how frequently they utilized bedside assessment components on a scale of five ranging from never to always. Result: One hundred and forty practicing speech-language pathologists completed the online questionnaire in full. Eight interviews were then conducted. Respondents reported utilizing predominantly motor elements of their oro-motor examination with very few sensory elements being frequently utilized. Five main themes arose from the interviews including the influence of the individual patient and participant, the current evidence base, the participants’ clinical practice and the participants’ workplace. Conclusion: The findings from this research have implications for current clinical and education practices, in particular the impact of education and training and caseload demands on current practice.
Keywords: Dysphagia, assessment, swallowing
Introduction
Bedside assessment practices
Due to the risk of choking and aspiration, dysphagia is one of the few areas of speech-language pathology practice in which patient mortality is a concern (Cichero, 2006). In order to ensure patient safety the speech-language pathologist (SLP) must make decisions regarding oral vs non-oral feeding, diet and fluid modifications and treatment options. These decisions are made on the basis of the SLPs assessment, the first step of which is the bedside assessment (Cichero, 2006). This involves collecting a case history, making patient observations, cranial nerve examination and, when appropriate, food and fluid trials (Speech Pathology Australia, SPA, 2012). The decisions that are made from this assessment can have a significant impact upon the health, safety and quality-of-life of the patient (Threats, 2007). Despite the importance of this assessment, there are no strict protocols guiding what specific components SLPs should and should not include in their bedside assessment. Therefore, it is difficult to determine what SLPs actually do during their bedside assessments.
Studies in the US and UK that have investigated what SLPs frequently include in their bedside assessments via surveys have found that only some components are used frequently. For example, a study in the US found that just over half of the assessment components listed were utilized with a high frequency (Mathers-Schmidt & Kurlinski, 2003). A similar study in the UK found less than 35% of components were utilized with a high frequency (Bateman, Leslie, & Drinnan, 2007). Furthermore, these studies found consistency of practice among clinicians (i.e. respondents’ agreement as to how frequently components were used) to be low. For example, in the US, Mathers-Schmidt and Kurlinski (2003) found that only 57% of the assessment components listed were being utilized consistently (defined as 75% or more of respondents reporting the same frequency of use). In their UK study, Bateman et al. (2007) found that only 32% of bedside assessment components were being used consistently. This suggests that, across different samples, times and locations, consistency of practice in
Correspondence: Jade Cartwright, Bachelor of Science (Speech Pathology) Hons, Curtin University, School of Psychology and Speech Pathology, GPO Box U1987, Perth, 6000 Australia. Email: [email protected] ISSN 1754-9507 print/ISSN 1754-9515 online © 2014 The Speech Pathology Association of Australia Limited Published by Informa UK, Ltd. DOI: 10.3109/17549507.2014.979877
Bedside assessment practices in adult dysphagia
bedside assessments across SLPs is low. The results of these studies are limited to SLPs within the US and UK and may not represent the practices within Australia. Furthermore, within these studies there was no exploration into why these patterns in practice exist and what SLPs were considering when they were indicating their frequency of use.
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Factors influencing the bedside assessment There are few studies investigating what factors influence SLPs’ bedside assessment practices. Martino, Pron, and Diamant (2004) and McCullough, Wertz, Rosenbek, and Dinneen (1999) found that there was a pattern for highly utilized assessment components to also be rated as ‘highly important’ by respondents. However, there was considerable variability in these ratings of importance, with some respondents rating a component as ‘highly important’ and others rating the same component as ‘definitely not important’. In light of this variability, investigating what factors clinicians were taking into consideration when judging importance would have provided insight into what influences their bedside assessments. McCullough et al. (1999) also compared questionnaire responses to the available evidence and found that the highly utilized assessment components did not necessarily have research to support their use. However, this study took place 14 years ago and the research to support the use of assessment items has since changed. For example, McCullough et al. (1999) found that the assessment of jaw strength, which had high frequency of use, had no research to support its use in dysphagia assessment. However, jaw strength has since been found to be one of the most useful oral motor signs for detecting aspiration at bedside (McCullough, Rosenbek, Wertz, McCoy, Mann, & McCullough, 2005). In addition, McCullough et al. (1999) had a low response rate (20%) and used a questionnaire that had not been pilot-tested. Therefore, reliability was not established. This brings the validity of the survey into question and, thus, the results. Further research is required in order to establish whether the available evidence influences SLPs’ use of bedside assessment components. More recently, Smith-Tamaray (2010) conducted a study involving semi-structured interviews with eight SLPs working with stroke patients in rural and remote Victoria and New South Wales. These interviews revealed that the participants’ university education, first clinical placements and first jobs influenced their bedside assessment more than the current literature. This highlights the importance of under-graduate training in current practice. However, these results were regarding general practices in dysphagia assessment rather than the use of specific components. Furthermore, Smith-Tamaray’s
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(2010) sample was restricted to rural parts of Australia, suggesting that the results may not be generalized to SLPs across all of Australia. In summary, there is limited evidence in the literature regarding the bedside assessment practices of Australian SLPs. Considering the differences between countries in healthcare practices and university education (Newman & Long, 2012), the existing literature investigating what clinicians include in their bedside assessment cannot be reliably generalized to Australian practice. In addition, there are gaps and methodological limitations identified in the literature, thus suggesting further research is necessary to establish what is included in, and the factors that influence, a SLPs’ bedside assessment. Aims of the present study Based on the gaps identified in the literature and the importance of the bedside assessment in Australian dysphagia practice, the aim of the current study was to investigate the bedside assessment practices of Australian SLPs, including what bedside assessments frequently consist of and what influences them. To achieve these aims an online questionnaire and follow-up interviews were conducted. Guiding this research were the following research questions: (1) What components of the bedside assessment are utilized with the most and least frequency? (2) How consistently are bedside assessment components utilized? (3) What factors influence what SLPs include in their bedside assessments?
Method Participants Participants for both the questionnaire and the interview were recruited from the Dysphagia Interest Groups from Western Australia (WA), New South Wales (NSW), Victoria, Queensland (QLD) and South Australia (SA). To be included in the study participants had to be currently working as a SLP with adult dysphagia in Australia and must have completed the questionnaire in full. There were no incentives offered to participants. Questionnaire Materials. The online questionnaire was created using Qualtrics (2013). The questionnaire was designed based on those used in previous research (Bateman et al., 2007; Mathers-Schmidt & Kurlinski, 2003) and with reference to the dysphagia assessment outline provided in SPA’s Clinical Guidelines in Dysphagia (SPA, 2012). The questionnaire was
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anonymous and consisted predominantly of multichoice questions. However, open-ended questions were included to allow respondents to elaborate on their responses. In order to determine what components of a bedside assessment are used most and least frequently respondents were required to indicate their frequency of use on a 5-point Likert scale consisting of never, rarely, sometimes, usually and always. The first page of the questionnaire was the participant information sheet outlining purpose, procedures, risk and benefit, confidentiality, participant rights, ethics information and the researcher’s contact details. Following completion of the questionnaire participants were thanked for their participation and the first researcher’s email address was provided for those participants who wished to receive a summary of the results. In total the questionnaire was pilottested three times. The first pilot test was conducted with two SLPs who provided feedback on the content, layout and question structure. Based on this feedback changes were made to two questions. Question 9 was changed from ‘Full-time equivalent clinical load’ to ‘Full time equivalent workload’ and Question 14 was changed from ‘Components of the bedside assessment’ to ‘Components of the INITIAL bedside assessment’, with examples provided for ‘tubes in situ’, ‘nutritional status’ and ‘hydration status’. The second pilot test was conducted in order to establish test–re-test reliability of the questionnaire. This was done with an additional two SLPs who completed the questionnaire twice with a 7-day gap in between. Re-test reliability was measured using percentage agreement between all questions. In previous research the Likert scale has been condensed to three points when analysing and reporting questionnaire results (i.e. usually combined with always and never combined with rarely) (Bateman et al., 2007; Mathers-Schmidt & Kurlinski, 2003). As a result, a difference of one point on the Likert scale was allowed during the analysis of re-test reliability (for example, if the two responses were usually and always they were not considered to be different). The re-test agreement was 90%, with questions 14 and 15 answered inconsistently. In response to this, more examples were provided for ‘hydration status’ for question 14 and more examples were provided for ‘touch sensation’, ‘temperature sensation’ and ‘movement of the base of tongue’ for question 15. Due to these changes, a third pilot test was conducted with two different SLPs to establish re-test reliability of the adapted questionnaire. This resulted in improved re-test reliability, with 95% agreement between responses. The SLPs that had completed the pilot test were asked not to complete the final questionnaire when released so as to ensure that involvement in the pilot would not influence their responses. In order to ensure the maximum number of participants were
available to complete the final questionnaire, only two speech pathologists were asked to trial the questionnaire for each pilot. The final questionnaire consisted of 17 questions regarding participant demographics and bedside assessment practices. Additional components that would not typically be included in a dysphagia bedside assessment were included as distracters to detect and deter self-report bias, for example corneal reflex and palpation of sternocleidomastoid. It was a possibility that participants would view the list of assessment components as ‘gold standard’ and, therefore, indicate that they ‘always’ assessed each component. As a result, items that would not typically be included in a dysphagia assessment were included to detect if participants were indicating ‘always’ for each component and deter participants from doing so. The questionnaire is available in the Supplementary Appendix to be found online at http://informahealthcare.com/doi/abs/10.3109/ 17549507.2014.979877. Procedure. The questionnaire was distributed via an email to the co-ordinators of the five Dysphagia Interest Groups, who then forwarded this email to their members. Approximately 580 emails were sent. The email consisted of a brief summary of the research project and the electronic link to the questionnaire, which was available online for 6 weeks in July and August of 2013. A second reminder email was distributed via the same method 4 weeks later to encourage further responses. No financial incentives were offered for participation; however, participants were offered a summary of the research results following its completion. In order to receive this summary participants were required to email the first author expressing their interest. The average time taken to complete the questionnaire was 16.8 minutes. A total of 177 SLPs across Australia responded to the questionnaire, providing an approximate response rate of 30%. However, respondents who had not completed the entire questionnaire were excluded, providing a final sample size of 140. It is unclear why some participants did not complete the questionnaire. Some questions could have been missed by accident or it could have been due to competing work demands. Forced choice questionnaire responses were analysed and summarized via frequency distribution using percentages and the open-ended questions were analysed using content analysis. Interview Materials. The interview schedule was designed based on previous research (Smith-Tamaray, 2010) and the current study’s research questions. The interviews were semi-structured with questions pertaining to the participants’ professional history,
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experiences and their practices related to certain bedside assessment components.
Results
Procedure. Emails were distributed via the Dysphagia Interest Groups regarding the interview phase of the study; SLPs were invited to participate by expressing interest via email. In order to comply with ethics committee recommendations and to ensure the anonymity of the questionnaire participants, it was not possible to determine whether the interview participants had completed the questionnaire. However, the recruitment process was the same, so it is likely that the interview participants had completed the questionnaire as well. The aim of the interview was to explore the reasons why participants used particular bedside assessment components with a particular frequency. Prior to the interview commencing, participants were asked to complete questions 12, 13 and 14 from the questionnaire. This allowed comparison of interview participants’ responses to those received from the online questionnaire and enabled the interview questions to be specific to the individual participant and their bedside assessment. Following questions regarding demographic details, participants were asked to explain their responses to these questions. For example, if one interview participant indicated they never utilized an assessment component that had a high frequency of use in the online questionnaire, they were asked to elaborate on their response. This allowed insight into the factors that influence the use of specific assessment components. All questions followed a similar structure and format. For example, when asking about hydration status the following question was always used: ‘You’ve said you never/rarely/sometimes/usually/ always look at hydration status. Can you tell me why this is?’ Minor adjustments to question wording were made as required. For example, when exploring the reasons why a participant ‘sometimes’ assessed sense of smell, the following wording was used ‘For sense of smell you put sometimes, can you tell me why this is something you ‘sometimes’ include?’ Following the specific bedside assessment questions, each participant was asked the following: Has your bedside assessment changed over time? (For example, from when you first graduated until now? What stimulated the change? How did it change?); Is there anything you’d like to add or talk about? The interviews were conducted by the first researcher and were either face-to-face or via telephone and were audio-recorded. The first author then transcribed these audio-recordings verbatim immediately following the interview. Thematic analysis was undertaken on the interview transcripts using the steps outlined in Braun and Clarke (2006) as a guide. NVivo 10 (2012) was used to supplement the coding process.
Demographic information. Respondents were from a variety of backgrounds, settings and workplaces. Respondents’ location of training was spread across Australia, with 27% (37/140) being educated in NSW, 21% (29/140) in SA, 18% (25/140) in WA, 13% (20/140) in Victoria and 12% (17/140) in QLD. Nine per cent (12/140) of respondents reported that they had not received their SLP training in Australia; open-ended questions revealed these respondents were trained in the UK and Ireland (n ⫽ 7), New Zealand (n ⫽ 2), the US (n ⫽ 1), India (n ⫽ 1) and South Africa (n ⫽ 1). Further demographic information is provided in Table I. A third of all respondents (33%) had completed post-graduate training in dysphagia; including modified barium swallow competencies (24%), further tertiary education (20%), various continuing profession development events (19%), cervical auscultation training (10%) and fibre-optic endoscopic evaluation of swallowing competencies (8%). On average, respondents’ caseloads consisted of stroke (30% of caseload), dementia (20%), degenerative diseases (14%), other (14%), head and neck cancer (11%), traumatic brain injury (7%) and motor neurone disease (4%). Other populations indicated by participants included chronic obstructive pulmonary disease, spinal cord injury, general ageing, general surgery, burns, tracheostomy, acute neurological conditions, palliative care and gastroenterology. Only 7% of respondents utilized a published bedside assessment protocol, with most (10/12) indicating use of the Mann Assessment of Swallowing Ability (Mann, 2002). Sixty-three per cent of respondents also reported their department utilized its own bedside assessment protocol. Demographic data were also collected from the interview participants. Six participants were from WA, one from SA and one from Victoria. Five of the eight participants worked in an acute hospital, the other three were based in rehabilitation or sub-acute hospital settings. Participants’ years of speech-language pathology experience ranged from 3–23 years, with six out of the eight participants having over 5 years of experience.
Questionnaire
Frequency and consistency of component use. The questionnaire divided the bedside assessment into three separate sections, the initial assessment, the oro-motor examination (OME) and oral trials. Following the procedure of Bateman et al. (2007), frequency of component use was determined by calculating the proportion of respondents that reported usually or always utilizing a certain component. Consistency of practice was measured in the same method as in Mathers-Schmidt and Kurlinski (2003) and Bateman et al. (2007). That is, components were considered to have highly consistent use when over 75% of
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B.Vogels et al. Table I. Demographic information of questionnaire respondents.
Demographic question
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Experience as a SLP ⬍ 1 year 1–5 years 5–10 years 10–15 years ⬎ 15 years
Percentage of respondents (%) 9* 32 27 12 19
Rural vs metropolitan setting Rural Metropolitan Experience in adult dysphagia ⬍ 1 year 1–5 years 5–10 years 10–15 years ⬎ 15 years
10 34 27 12 17
Place of current employment WA VIC NSW QLD SA
25* 17 22 11 24
Demographic question
Percentage of respondents (%)
Current workplace setting Acute hospital Rehabilitation hospital Aged care facility Community centre Outpatient services Home services Disability services
68 35 20 19 37 28 4
22 78 Full-time equivalent workload 0.2 0.4 0.6 0.8 1.0 Other Percentage of caseload dysphagia 0–20% 20–40% 40–60% 60–80% 80–100%
2 4 8 13 68 5 9* 16 19 27 30
*Numbers have been rounded and do not add up to 100.
respondents indicated the same frequency of use (i.e. usually, always, sometimes, rarely or never). Moderately consistent use was defined as 50–75% and inconsistent use was defined as less than 50% of respondents indicating the same frequency of use. Across all three sections consistency of practice was low, with 32.69% of components being utilized highly consistently. Initial bedside assessment. The proportions of respondents indicating they usually or always utilize each component of the initial bedside assessment are displayed in Figure 1. The following five components had the highest levels of use, with over 95% of respondents reporting they usually or always included them in their bedside assessment: medical history (100%), oral trials (99%), the patient’s ability to participate in the assessment (97%), the patient’s posture and positioning (99%) and their dental status (96%). These same components, as well as OME and presence of tube in situ were highly consistently always used (over 75% of respondents indicated that they always assessed that component). Three components (hydration status, presence of tubes in situ and patient, family or carer interview) had at least one respondent indicating they never utilized the component. Another five components were used inconsistently with less than 50% of respondents agreeing on frequency of use, including nutritional status, hydration status, patient/family/carer interview, assessment of speech function and assessment of language abilities. Oro-motor examination. Of the 26 components of the OME listed in the questionnaire, four had the
highest levels of use with more than 95% of respondents usually or always including them in their OME, including adequacy of lip seal (97%), dentition (97%), volitional cough (95%) and range of tongue movement (96%). These components were also highly consistently always used. All sensory components except touch sensation to the face were utilized the least frequently, with over 50% of respondents reporting they never or rarely include them in their OME. Ten out of the 26 components were utilized inconsistently, this included all sensory components, gag reflex, lateral jaw movement and base of tongue movement. The full list of OME components and the proportion of respondents indicating they usually or always utilized each component are displayed in Figure 2. Oral trials. Half of the oral trials components had a very high frequency of use with over 95% of respondents usually or always utilizing them. This included using a variety of texture modified food and fluids (96%), efficiency of oral movements (98%), promptness of swallow reflex (99%), strength and range of laryngeal excursion (99%) and oral residue (99%). Five components were highly consistently always used, including efficiency of oral movements, promptness of swallow reflex, laryngeal excursion, alterations to client state and oral residue. Another four components were utilized inconsistently, including cervical auscultation, pulse oximetry, estimate of swallow duration and trialling compensatory techniques. Pulse oximetry and cervical auscultation had the lowest levels of use with 43% of respondents
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Figure 1. Consistency and Percentage (%) of respondents usually or always utilizing components of the initial bedside assessment (n ⫽ 140). HC, Highly consistent use; MC, Moderately consistent use; IC, Inconsistent use.
never or rarely using them in oral trials. The frequency of respondents indicating usually or always and consistency of use for oral trials components are displayed in Figure 3. Interview Thematic analysis of the interview transcripts took a phenomenological approach, as the transcripts were subjective reports of experience and behaviour in dysphagia assessment rather than objective descriptions (Brocki & Wearden, 2006). Five main themes arose from the analysis as factors that influence the bedside assessment. Themes included the influence of the current evidence base, the influence of the individual participant, the individual patient, the participant’s clinical practice and the participants’ workplace. The current evidence base. All eight participants mentioned the current evidence base in response to questions regarding what influences their use of certain assessment components. Participants reported inconclusive or a lack of evidence was part of their rationale for infrequently including the gag reflex, trials of compensatory techniques, pulse oximetry and cervical auscultation in their assessment. For example, participant three stated, ‘it’s [gag reflex] not something I do because I don’t think there’s a
lot of evidence for it’. Participant one also reinforced this theme, ‘So it’s [trialling compensatory techniques] just not something I tend to do, there’s not a lot of evidence for it’. Three participants discussed being aware of the inconclusive evidence base for assessing strength and range of laryngeal excursion and one of these participants then reported they frequently utilize this in their bedside assessment, … there’s very little evidence in terms of that you can feel the strength … I do think it’s important to feel the swallow, palpate the larynx, I think it can give you a great deal of information … (participant three)
Four participants reported that reading up to date literature is one of the greatest factors that influences them to change their practice, ‘the evidence now suggests that dysarthria is the biggest characteristic that is going to represent dysphagia so that’s what I look for …’ (participant eight). The influence of participants’ clinical practice. Seven of the eight participants reported they would exclude assessment components if they believed it would not add information to their clinical picture of the patient and their dysphagia. For example, participant five stated, ‘… I tried it [cervical auscultation] and I didn’t find that it particularly added a lot of informa-
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Figure 2. Consistency and Percentage (%) of respondents usually or always utilizing OME components (n ⫽ 140). HC, Highly consistent use; MC, Moderately consistent use; IC, Inconsistent use.
tion that was helping me make my decisions’. Participants did not appear to agree on whether certain bedside assessment components did or did not add useful information to their clinical picture. For example, when discussing use of pulse oximetry, participant one reported, ‘… if I was doing a standard clinical assessment on a ward patient I wouldn’t go to the trouble of going and getting a portable pulse oximeter because I don’t think it would add that much information’. Whereas participant three reported the opposite, ‘I want to have another objective piece of information that’s going to help me build this picture of what my recommendation is …’. Four participants reported that an influencing factor to their use of oral sensation, gag reflex, base of tongue movement and hydration status was whether or not these components would change their management of a patient. For example, participant one reported, ‘It [oral sensation] wouldn’t change my assessment for a patient or my recommendations …’. Four participants reported that their clinical practice consisted of informal and indirect assessment
where possible. In particular, oral sensation was included in the assessment indirectly by inferring information from the oral trials rather than directly assessing sensation during the OME, hence their indication of never or rarely assessing this during the OME. ‘I don’t assess it directly as part of my OME, for sensation in the mouth I usually see it as part of oral trials …’ (participant four). The influence of participants’ workplace. This theme refers to the influence of colleagues, team members and workplace resources. One participant discussed the influence of her colleagues on the use of cervical auscultation, ‘I used to use it because other people in my workplace were using it regularly’ (participant four). Six participants frequently reported that time and resource constraints impact their bedside assessment and the inclusion of certain components. In particular, the need to simplify the bedside assessment due to time constraints was reported, ‘… I sort of hit myself a little bit over that [infrequently assessing
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Figure 3. Consistency and Percentage (%) of respondents usually or always utilizing oral trials components (n ⫽ 140). HC, Highly consistent use; MC, Moderately consistent use; IC, Inconsistent use.
oral sensation]. But I guess it’s probably more to do with resources and time’ (participant six). Not only was it their own time that was restricted, but their patient’s time as well, ‘… it’s not just our time, I don’t mean that but I mean that the patient’s window of opportunity …’ (participant three). Four participants reported they would infrequently utilize pulse oximetry and assessment of oral sensation in their bedside assessment due to restricted access to the necessary equipment, … it’s [assessment of oral sensation] not something that I think that we shouldn’t do, probably something that we should do, but I just, I don’t know, just don’t do it, probably because I don’t have the tools available in—at a bedside to be able to assess those things quickly and readily. (participant eight)
of pulse oximetry and hydration status in the bedside assessment. For example, participant one reported ‘I would always use it with my ICU patients because it’s always there and they’re critically unwell so more inclined to have the desaturation because of what I’m doing’. Six participants reported they utilized certain assessment components because for their particular caseload of patients it was more appropriate. This came down to the aetiology of the patient’s dysphagia, such as head and neck cancer, stroke, geriatric medicine or tracheostomy. For example, participant four reported, ‘… with stroke I do a much more thorough OME than I would have working a geri’s [geriatric] caseload … just because of the nature of the patients’.
The influence of the individual patient. Participants frequently discussed the individual characteristics of their patients and the way in which that guides and influences their assessment. Five participants referred to patient cognition as one of the greatest barriers to their use of certain assessment components, in particular trialling compensatory techniques and assessing sensation, ‘I don’t always do it [trialling compensatory techniques] because cognitively patients aren’t always in a position to be able to implement them consistently’ (participant four). Two participants also reported the patient’s severity and level of acuity would influence their inclusion
The influence of the individual participant. All eight participants reported that their own experience and feelings influenced their bedside assessment. For example, the exclusion of cervical auscultation from the bedside assessment was attributed to a lack of confidence and skill in the area for five of the eight participants, ‘… probably more because of confidence so … I’ve done one very quick training session on it. Um, and I don’t feel that I walked away from that having enough knowledge of what I was hearing’ (participant six). Two participants reported that one of their reasons for frequently assessing base of tongue movement and strength and range of laryngeal excursion was that it is ‘something that I’ve always done from
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habit’ (participant six), suggesting an automaticity to conducting bedside assessments in dysphagia. Furthermore, it appeared this habitual inclusion of certain assessment components was not dependent upon whether the component was evidence-based, as stated by participant seven, ‘something that you’ve always done but I don’t know whether there’s actually any evidence—or firm evidence behind why we’re palpating [laryngeal excursion]’. Participants reported that their education, both under-graduate and post-graduate, influenced their bedside assessment. Post-graduate education appeared to have greater influence on dysphagia practice than under-graduate, with six participants reporting the influence of post-graduate education. However, only one participant reported their undergraduate training influenced their assessment of laryngeal excursion. Post-graduate education mainly consisted of continuing professional development (CPD) events and it appeared that attending these events was a major influence on clinicians’ bedside assessments as a whole, ‘I went to see Maggie Lee Huckabee in 2007… she said you should be a … dysphagia diagnostician not a technician … so really that shifted my thinking …’ (participant four). Personal opinion of an assessment component also influenced the use of that component. For example, in response to discussion around the assessment of the gag reflex participant two responded, ‘I find it overly invasive …’. This was reinforced by responses from four other participants.
Discussion This is the first study to investigate what Australian SLPs frequently include in their bedside assessment and what factors influence the use of individual bedside assessment components and the assessment as a whole. In particular it identified the content of bedside assessments and that the decisions made regarding this content are complex, with a number of factors influencing the use of a single component. Overall, consistency of practice across respondents to the questionnaire was low, with only 32% of components being utilized highly consistently, suggesting different respondents conduct different bedside assessments. This result was similar to the UK study by Bateman et al. (2007), who also found that 32% of components were utilized highly consistently but was lower than the US study by Mathers-Schmidt and Kurlinski (2003), who found 57% of components were highly consistently utilized. While overall consistency was low, there was a trend for questionnaire respondents’ OME’s to consist predominantly of motor components, with only 16% of respondents usually or always assessing a sensory component. Previous research found a higher frequency of assessment of sensation. Fifty-six per cent of participants in Bateman et al. (2007) and
74% of participants in Mathers-Schmidt and Kurlinski (2003) usually or always assessed sensation. This suggests genuine differences in practice between the UK, the US and Australia that should be investigated further in future research. It is possible that this is due to different clinical demands in Australia or across countries, as five of the eight interview participants in this study reported that they knew the benefits of assessing sensation but did not do so due to external or clinical factors. This included factors such as time, resource availability, resource access and patient cognition. It is important to highlight that four interview participants reported that their assessment of sensation was included during oral trials via questioning and inferring information from factors such as oral residue rather than assessed directly during an OME. Considering 99.28% of questionnaire respondents indicated they usually or always include evidence of oral residue in their oral trials, perhaps the frequency of assessing sensation would have been higher had the sensory components been listed under oral trials rather than OME. The low frequency of sensation testing has clinical implications, given the important role that sensory input plays in the planning, modulation and execution of swallowing (Cichero, 2006). Impaired sensation can impact the swallow and patient safety, while taste, smell and touch can modulate both the disordered and normal swallow (Wahab, Jones, & Huckabee, 2010; Steele & Miller, 2010). For example, Wahab et al. (2010) found that taste and olfaction stimuli resulted in greater efficiency of the volitional swallow in unimpaired individuals. The authors highlighted the possibility of utilizing taste and smell in dysphagia rehabilitation. Therefore, assessing sensation during dysphagia assessments may provide further insight into the patient’s dysphagia and swallowing safety, as well as providing information important for possible therapy approaches (Wahab et al., 2010). In light of this evidence, it is of concern that so few respondents reported they would include sensation testing in their bedside assessment. Seventy-four per cent of respondents indicated they usually or always assessed speech function. Bateman et al. (2007) and Mathers-Schmidt and Kurlinski (2003) found similar frequency of use in their studies. However, considering dysarthria and intelligibility has been found to be a key clinical indicator of both oral and pharyngeal dysphagia (Daniels, Brailey, Priestly, Herrington, Weisberg, & Foundas, 1998), it is therefore concerning that 26% of respondents did not frequently assess this component. It is possible that those respondents who did not frequently include assessment of speech function were not aware of this evidence. Alternatively, since no example was provided in the questionnaire it could be speculated that respondents were considering different methods of assessing speech function. For example, considering standardized speech assessment vs informal observa-
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Bedside assessment practices in adult dysphagia
tions of intelligibility may have influenced the respondents’ indications of frequency. Cervical auscultation was utilized both inconsistently and infrequently, with only 26.43% of respondents usually or always utilizing it. This result is not surprising given the inconclusive evidence base surrounding cervical auscultation and what clinical information the tool can provide (Cichero, 2006). While Mathers-Schmidt and Kurlinski (2003) found lower levels of frequency (14% of respondents reported usually or always utilizing it), Bateman et al. (2007) found cervical auscultation had higher levels of frequency, with 36% of respondents usually or always including it. Only one interview participant reported regularly using cervical auscultation. Three participants reported they did not frequently use cervical auscultation due to the inconclusive evidence base. Five participants reported it was due to a lack of confidence and skill in the area as a consequence of no training. Considering only four participants in the questionnaire indicated they had completed postgraduate cervical auscultation training, this lack of training and the consequent lack of confidence and skill may, therefore, be a contributing factor to the low frequency of use of cervical auscultation. The participants’ knowledge of its inconclusive evidence base appears to be another contributing factor. Similarly, pulse oximetry had both inconsistent and infrequent use, with only 12.86% of questionnaire respondents indicating they usually or always include the component. Bateman et al. (2007) found very similar levels of frequency with their UK respondents, with 9% usually or always including the component. During the interviews participants did report their knowledge of the evidence base as an influencing factor. However, they also reported that time and resource availability affected their use, as they did not always have quick and easy access to pulse oximeters. The influence of education and training on bedside assessment practices emerged as another finding of interest. While only one third of questionnaire respondents indicated they had received post-graduate training in the area of dysphagia, for the interview participants’ post-graduate training was a considerable influence over their bedside assessments. Furthermore, the interviews suggested that there was a greater perceived influence of post-graduate training over under-graduate training for these participants, perhaps reflecting the advanced nature of this training and the opportunity to further develop or hone existing skills. This finding should be considered in future research to determine whether further opportunities for post-graduate training and continuing professional development may help to improve the consistency of bedside assessment practices in Australia.
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influences this practice in Australia, there were some limitations. The self-report nature of the questionnaire and interviews meant that it captured only what the SLPs reported they do with regards to dysphagia assessment practices rather than what they actually do. While it is difficult to design a study which captures actual practice, it is important to consider that there may be differences between reported practice and actual practice. The study’s sample was limited to SLPs who were members of an Australian Dysphagia Interest Group. This, therefore, may not represent the practices of all SLPs within Australia who work with adults who have dysphagia. The main focus of this research was to capture current practice. This information was obtained from the questionnaire. The addition of the interview component was designed to explore the possible reasons why components are included and or excluded. While some important findings and themes emerged from the interview, it is important to note that the interview sample consisted of just eight participants. All eight of the participants were based in an acute or rehabilitation hospital and some had research experience. Therefore, these findings and the views represented by this sample may not reflect that of all SLPs in Australia. As such, further research is needed with a larger sample size and with participants recruited from a variety of sources and workplace settings in order to further explore these preliminary findings. Similarly, while the interview questions used a standard structure for each of the participants, some of the questions asked were based on their responses to questions 12, 13 and 14 of the questionnaire. As a result, there was some variation in the interview content across the eight participants. This could have influenced the results of the study and should be addressed in future research. As the Australian speech pathology community is small and the number of SLPs who work in the adult field even smaller, it was not possible to recruit all interview participants that were not known to the interviewer. The interviewer knew three of the participants in a professional capacity. While this may have resulted in the potential for interviewer bias, all questions were asked in the same manner, with the same structure. Finally, as respondents only completed the questionnaire once, the results reflect the practice of a group of SLPs at a single point in time. Future studies may consider repeating the questionnaire to examine whether or not practice patterns change over time. Conclusion
Limitations of the study While the current study captured important information about dysphagia practice patterns and what
The current study highlights the variability in bedside assessment practices of Australian SLPs. The interviews revealed considerable complexity in the
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decisions made by SLPs regarding their bedside assessments. This study provides important insight into the dysphagia assessment practices of a sample of SLPs across Australia and identifies factors, such as post-graduate training, which can be used to influence or maintain dysphagia practice in Australia.
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Acknowledgements Many individuals supported and participated in this research. Thank you to the Dysphagia Interest Group co-ordinators across Australia for their support in participant recruitment and the six SLPs who took the time to complete the pilot tests and provide feedback. Finally, thank you to the SLPs who took the time to complete the questionnaire and participate in the interviews. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Bateman, C., Leslie, P., & Drinnan, M. J. (2007). Adult dysphagia assessment in UK and Ireland: Are SLT’s assessing the same factors? Dysphagia, 22, 174–186. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. Brocki, J. M., & Wearden, A. J. (2006). A critical evaluation of the use of interpretative phenomenological analysis (IPA) in health psychology. Psychology and Health, 21, 87–108. Cichero, J. (2006). Clinical assessment, cervical auscultation and pulse oximetry. In J. A. Y. Cichero, & B. E. Bruce (Eds.), Dysphagia: Foundation, theory and practice (pp. 149–190). West Sussex, UK: John Wiley and Sons.
Supplementary material available online Supplementary Appendix available online at http:// informahealthcare.com/doi/abs/10.3109/17549507. 2014.979877.
Daniels, S. K., Brailey, K., Priestly, D. H., Herrington, L. R., Weisberg, L. A., & Foundas, A. L. (1998). Aspiration in patients with acute stroke. Archives of Physical Medicine and Rehabilitation, 79, 14–19. Mann, G. (2002). MASA: The Mann assessment of swallowing ability. Clifton Park, NY: Singular Thomson Learning. Martino, R., Pron, G., & Diamant, N. E. (2004). Oropharyngeal dysphagia: Surveying practice patterns of the SLP. Dysphagia, 19, 165–176. Mathers-Schmidt, B. A., & Kurlinski, M. (2003). Dysphagia evaluation practice: Inconsistencies in clinical assessment and instrumental decision-making. Dysphagia, 18, 114–125. McCullough, G. H., Rosenbek, J. C., Wertz, R. T., McCoy, S., Mann, G., & McCullough, K. (2005). Utility of clinical swallowing examination measures for detecting aspiration poststroke. Journal of Speech, Language and Hearing Research, 48, 1280–1293. McCullough, G. H., Wertz, R. T., Rosenbek, J. C., & Dinneen, C. (1999). Clinicians’ preferences and practice conducting clinical/bedside and videofluoroscopic swallowing examinations in an adult, neurogenic population. American Journal of Speech Language Pathology, 8, 149–163. Newman, R. D., & Long, T. (2012). A transatlantic comparative study of acute dysphagia services. American Journal of Medicine and Medical Sciences, 2, 96–102. NVivo10 [computer software] (2012). Victoria, Australia: QSR International Pty Ltd. Qualtrics. (Version 49164) (2013). [Online computer software]. Utah, USA: Qualtrics. Smith-Tamaray, M. (2010). The provision of dysphagia assessment following acute stroke in non-metropolitan New South Wales and Victoria. (Doctoral thesis). Charles Sturt University, Wagga Wagga, New South Wales. Speech Pathology Australia. (2012). Dysphagia clinical guideline. Melbourne, Australia: The Speech Pathology Association of Australia Ltd. Steele, C. M., & Miller, A. J. (2010). Sensory input pathways and mechanisms in swallowing: A review. Dysphagia, 25, 323–333. Threats, T. T. (2007). Use of the ICF in dysphagia management. Seminars in Speech and Language, 28, 323–333. Wahab, N. A., Jones, R. D., & Huckabee, M.-L. (2010). Effects of olfactory and gustatory stimuli on neural excitability for swallowing. Physiology and Behavior, 101, 568–575.
ISSN: 1754-9507 (Print) 1754-9515 (Online) Journal homepage: http://www.tandfonline.com/loi/iasl20
The bedside assessment practices of speechlanguage pathologists in adult dysphagia Brittany Vogels, Jade Cartwright & Naomi Cocks To cite this article: Brittany Vogels, Jade Cartwright & Naomi Cocks (2015) The bedside assessment practices of speech-language pathologists in adult dysphagia, International Journal of Speech-Language Pathology, 17:4, 390-400, DOI: 10.3109/17549507.2014.979877 To link to this article: http://dx.doi.org/10.3109/17549507.2014.979877
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Date: 06 November 2015, At: 02:39
International Journal of Speech-Language Pathology, 2015; 17(4): 390–400
The bedside assessment practices of speech-language pathologists in adult dysphagia
BRITTANY VOGELS, JADE CARTWRIGHT & NAOMI COCKS
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School of Psychology and Speech Pathology, Curtin University, Perth, Australia
Abstract Purpose: The current study aimed to investigate what Australian speech-language pathologists frequently include in their bedside assessments in adult dysphagia, what factors influence these bedside assessments and whether they are consistent with the current evidence base. Method: These aims were achieved via an online questionnaire and a series of semi-structured interviews. In the questionnaire, respondents were asked to rate how frequently they utilized bedside assessment components on a scale of five ranging from never to always. Result: One hundred and forty practicing speech-language pathologists completed the online questionnaire in full. Eight interviews were then conducted. Respondents reported utilizing predominantly motor elements of their oro-motor examination with very few sensory elements being frequently utilized. Five main themes arose from the interviews including the influence of the individual patient and participant, the current evidence base, the participants’ clinical practice and the participants’ workplace. Conclusion: The findings from this research have implications for current clinical and education practices, in particular the impact of education and training and caseload demands on current practice.
Keywords: Dysphagia, assessment, swallowing
Introduction
Bedside assessment practices
Due to the risk of choking and aspiration, dysphagia is one of the few areas of speech-language pathology practice in which patient mortality is a concern (Cichero, 2006). In order to ensure patient safety the speech-language pathologist (SLP) must make decisions regarding oral vs non-oral feeding, diet and fluid modifications and treatment options. These decisions are made on the basis of the SLPs assessment, the first step of which is the bedside assessment (Cichero, 2006). This involves collecting a case history, making patient observations, cranial nerve examination and, when appropriate, food and fluid trials (Speech Pathology Australia, SPA, 2012). The decisions that are made from this assessment can have a significant impact upon the health, safety and quality-of-life of the patient (Threats, 2007). Despite the importance of this assessment, there are no strict protocols guiding what specific components SLPs should and should not include in their bedside assessment. Therefore, it is difficult to determine what SLPs actually do during their bedside assessments.
Studies in the US and UK that have investigated what SLPs frequently include in their bedside assessments via surveys have found that only some components are used frequently. For example, a study in the US found that just over half of the assessment components listed were utilized with a high frequency (Mathers-Schmidt & Kurlinski, 2003). A similar study in the UK found less than 35% of components were utilized with a high frequency (Bateman, Leslie, & Drinnan, 2007). Furthermore, these studies found consistency of practice among clinicians (i.e. respondents’ agreement as to how frequently components were used) to be low. For example, in the US, Mathers-Schmidt and Kurlinski (2003) found that only 57% of the assessment components listed were being utilized consistently (defined as 75% or more of respondents reporting the same frequency of use). In their UK study, Bateman et al. (2007) found that only 32% of bedside assessment components were being used consistently. This suggests that, across different samples, times and locations, consistency of practice in
Correspondence: Jade Cartwright, Bachelor of Science (Speech Pathology) Hons, Curtin University, School of Psychology and Speech Pathology, GPO Box U1987, Perth, 6000 Australia. Email: [email protected] ISSN 1754-9507 print/ISSN 1754-9515 online © 2014 The Speech Pathology Association of Australia Limited Published by Informa UK, Ltd. DOI: 10.3109/17549507.2014.979877
Bedside assessment practices in adult dysphagia
bedside assessments across SLPs is low. The results of these studies are limited to SLPs within the US and UK and may not represent the practices within Australia. Furthermore, within these studies there was no exploration into why these patterns in practice exist and what SLPs were considering when they were indicating their frequency of use.
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Factors influencing the bedside assessment There are few studies investigating what factors influence SLPs’ bedside assessment practices. Martino, Pron, and Diamant (2004) and McCullough, Wertz, Rosenbek, and Dinneen (1999) found that there was a pattern for highly utilized assessment components to also be rated as ‘highly important’ by respondents. However, there was considerable variability in these ratings of importance, with some respondents rating a component as ‘highly important’ and others rating the same component as ‘definitely not important’. In light of this variability, investigating what factors clinicians were taking into consideration when judging importance would have provided insight into what influences their bedside assessments. McCullough et al. (1999) also compared questionnaire responses to the available evidence and found that the highly utilized assessment components did not necessarily have research to support their use. However, this study took place 14 years ago and the research to support the use of assessment items has since changed. For example, McCullough et al. (1999) found that the assessment of jaw strength, which had high frequency of use, had no research to support its use in dysphagia assessment. However, jaw strength has since been found to be one of the most useful oral motor signs for detecting aspiration at bedside (McCullough, Rosenbek, Wertz, McCoy, Mann, & McCullough, 2005). In addition, McCullough et al. (1999) had a low response rate (20%) and used a questionnaire that had not been pilot-tested. Therefore, reliability was not established. This brings the validity of the survey into question and, thus, the results. Further research is required in order to establish whether the available evidence influences SLPs’ use of bedside assessment components. More recently, Smith-Tamaray (2010) conducted a study involving semi-structured interviews with eight SLPs working with stroke patients in rural and remote Victoria and New South Wales. These interviews revealed that the participants’ university education, first clinical placements and first jobs influenced their bedside assessment more than the current literature. This highlights the importance of under-graduate training in current practice. However, these results were regarding general practices in dysphagia assessment rather than the use of specific components. Furthermore, Smith-Tamaray’s
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(2010) sample was restricted to rural parts of Australia, suggesting that the results may not be generalized to SLPs across all of Australia. In summary, there is limited evidence in the literature regarding the bedside assessment practices of Australian SLPs. Considering the differences between countries in healthcare practices and university education (Newman & Long, 2012), the existing literature investigating what clinicians include in their bedside assessment cannot be reliably generalized to Australian practice. In addition, there are gaps and methodological limitations identified in the literature, thus suggesting further research is necessary to establish what is included in, and the factors that influence, a SLPs’ bedside assessment. Aims of the present study Based on the gaps identified in the literature and the importance of the bedside assessment in Australian dysphagia practice, the aim of the current study was to investigate the bedside assessment practices of Australian SLPs, including what bedside assessments frequently consist of and what influences them. To achieve these aims an online questionnaire and follow-up interviews were conducted. Guiding this research were the following research questions: (1) What components of the bedside assessment are utilized with the most and least frequency? (2) How consistently are bedside assessment components utilized? (3) What factors influence what SLPs include in their bedside assessments?
Method Participants Participants for both the questionnaire and the interview were recruited from the Dysphagia Interest Groups from Western Australia (WA), New South Wales (NSW), Victoria, Queensland (QLD) and South Australia (SA). To be included in the study participants had to be currently working as a SLP with adult dysphagia in Australia and must have completed the questionnaire in full. There were no incentives offered to participants. Questionnaire Materials. The online questionnaire was created using Qualtrics (2013). The questionnaire was designed based on those used in previous research (Bateman et al., 2007; Mathers-Schmidt & Kurlinski, 2003) and with reference to the dysphagia assessment outline provided in SPA’s Clinical Guidelines in Dysphagia (SPA, 2012). The questionnaire was
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anonymous and consisted predominantly of multichoice questions. However, open-ended questions were included to allow respondents to elaborate on their responses. In order to determine what components of a bedside assessment are used most and least frequently respondents were required to indicate their frequency of use on a 5-point Likert scale consisting of never, rarely, sometimes, usually and always. The first page of the questionnaire was the participant information sheet outlining purpose, procedures, risk and benefit, confidentiality, participant rights, ethics information and the researcher’s contact details. Following completion of the questionnaire participants were thanked for their participation and the first researcher’s email address was provided for those participants who wished to receive a summary of the results. In total the questionnaire was pilottested three times. The first pilot test was conducted with two SLPs who provided feedback on the content, layout and question structure. Based on this feedback changes were made to two questions. Question 9 was changed from ‘Full-time equivalent clinical load’ to ‘Full time equivalent workload’ and Question 14 was changed from ‘Components of the bedside assessment’ to ‘Components of the INITIAL bedside assessment’, with examples provided for ‘tubes in situ’, ‘nutritional status’ and ‘hydration status’. The second pilot test was conducted in order to establish test–re-test reliability of the questionnaire. This was done with an additional two SLPs who completed the questionnaire twice with a 7-day gap in between. Re-test reliability was measured using percentage agreement between all questions. In previous research the Likert scale has been condensed to three points when analysing and reporting questionnaire results (i.e. usually combined with always and never combined with rarely) (Bateman et al., 2007; Mathers-Schmidt & Kurlinski, 2003). As a result, a difference of one point on the Likert scale was allowed during the analysis of re-test reliability (for example, if the two responses were usually and always they were not considered to be different). The re-test agreement was 90%, with questions 14 and 15 answered inconsistently. In response to this, more examples were provided for ‘hydration status’ for question 14 and more examples were provided for ‘touch sensation’, ‘temperature sensation’ and ‘movement of the base of tongue’ for question 15. Due to these changes, a third pilot test was conducted with two different SLPs to establish re-test reliability of the adapted questionnaire. This resulted in improved re-test reliability, with 95% agreement between responses. The SLPs that had completed the pilot test were asked not to complete the final questionnaire when released so as to ensure that involvement in the pilot would not influence their responses. In order to ensure the maximum number of participants were
available to complete the final questionnaire, only two speech pathologists were asked to trial the questionnaire for each pilot. The final questionnaire consisted of 17 questions regarding participant demographics and bedside assessment practices. Additional components that would not typically be included in a dysphagia bedside assessment were included as distracters to detect and deter self-report bias, for example corneal reflex and palpation of sternocleidomastoid. It was a possibility that participants would view the list of assessment components as ‘gold standard’ and, therefore, indicate that they ‘always’ assessed each component. As a result, items that would not typically be included in a dysphagia assessment were included to detect if participants were indicating ‘always’ for each component and deter participants from doing so. The questionnaire is available in the Supplementary Appendix to be found online at http://informahealthcare.com/doi/abs/10.3109/ 17549507.2014.979877. Procedure. The questionnaire was distributed via an email to the co-ordinators of the five Dysphagia Interest Groups, who then forwarded this email to their members. Approximately 580 emails were sent. The email consisted of a brief summary of the research project and the electronic link to the questionnaire, which was available online for 6 weeks in July and August of 2013. A second reminder email was distributed via the same method 4 weeks later to encourage further responses. No financial incentives were offered for participation; however, participants were offered a summary of the research results following its completion. In order to receive this summary participants were required to email the first author expressing their interest. The average time taken to complete the questionnaire was 16.8 minutes. A total of 177 SLPs across Australia responded to the questionnaire, providing an approximate response rate of 30%. However, respondents who had not completed the entire questionnaire were excluded, providing a final sample size of 140. It is unclear why some participants did not complete the questionnaire. Some questions could have been missed by accident or it could have been due to competing work demands. Forced choice questionnaire responses were analysed and summarized via frequency distribution using percentages and the open-ended questions were analysed using content analysis. Interview Materials. The interview schedule was designed based on previous research (Smith-Tamaray, 2010) and the current study’s research questions. The interviews were semi-structured with questions pertaining to the participants’ professional history,
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experiences and their practices related to certain bedside assessment components.
Results
Procedure. Emails were distributed via the Dysphagia Interest Groups regarding the interview phase of the study; SLPs were invited to participate by expressing interest via email. In order to comply with ethics committee recommendations and to ensure the anonymity of the questionnaire participants, it was not possible to determine whether the interview participants had completed the questionnaire. However, the recruitment process was the same, so it is likely that the interview participants had completed the questionnaire as well. The aim of the interview was to explore the reasons why participants used particular bedside assessment components with a particular frequency. Prior to the interview commencing, participants were asked to complete questions 12, 13 and 14 from the questionnaire. This allowed comparison of interview participants’ responses to those received from the online questionnaire and enabled the interview questions to be specific to the individual participant and their bedside assessment. Following questions regarding demographic details, participants were asked to explain their responses to these questions. For example, if one interview participant indicated they never utilized an assessment component that had a high frequency of use in the online questionnaire, they were asked to elaborate on their response. This allowed insight into the factors that influence the use of specific assessment components. All questions followed a similar structure and format. For example, when asking about hydration status the following question was always used: ‘You’ve said you never/rarely/sometimes/usually/ always look at hydration status. Can you tell me why this is?’ Minor adjustments to question wording were made as required. For example, when exploring the reasons why a participant ‘sometimes’ assessed sense of smell, the following wording was used ‘For sense of smell you put sometimes, can you tell me why this is something you ‘sometimes’ include?’ Following the specific bedside assessment questions, each participant was asked the following: Has your bedside assessment changed over time? (For example, from when you first graduated until now? What stimulated the change? How did it change?); Is there anything you’d like to add or talk about? The interviews were conducted by the first researcher and were either face-to-face or via telephone and were audio-recorded. The first author then transcribed these audio-recordings verbatim immediately following the interview. Thematic analysis was undertaken on the interview transcripts using the steps outlined in Braun and Clarke (2006) as a guide. NVivo 10 (2012) was used to supplement the coding process.
Demographic information. Respondents were from a variety of backgrounds, settings and workplaces. Respondents’ location of training was spread across Australia, with 27% (37/140) being educated in NSW, 21% (29/140) in SA, 18% (25/140) in WA, 13% (20/140) in Victoria and 12% (17/140) in QLD. Nine per cent (12/140) of respondents reported that they had not received their SLP training in Australia; open-ended questions revealed these respondents were trained in the UK and Ireland (n ⫽ 7), New Zealand (n ⫽ 2), the US (n ⫽ 1), India (n ⫽ 1) and South Africa (n ⫽ 1). Further demographic information is provided in Table I. A third of all respondents (33%) had completed post-graduate training in dysphagia; including modified barium swallow competencies (24%), further tertiary education (20%), various continuing profession development events (19%), cervical auscultation training (10%) and fibre-optic endoscopic evaluation of swallowing competencies (8%). On average, respondents’ caseloads consisted of stroke (30% of caseload), dementia (20%), degenerative diseases (14%), other (14%), head and neck cancer (11%), traumatic brain injury (7%) and motor neurone disease (4%). Other populations indicated by participants included chronic obstructive pulmonary disease, spinal cord injury, general ageing, general surgery, burns, tracheostomy, acute neurological conditions, palliative care and gastroenterology. Only 7% of respondents utilized a published bedside assessment protocol, with most (10/12) indicating use of the Mann Assessment of Swallowing Ability (Mann, 2002). Sixty-three per cent of respondents also reported their department utilized its own bedside assessment protocol. Demographic data were also collected from the interview participants. Six participants were from WA, one from SA and one from Victoria. Five of the eight participants worked in an acute hospital, the other three were based in rehabilitation or sub-acute hospital settings. Participants’ years of speech-language pathology experience ranged from 3–23 years, with six out of the eight participants having over 5 years of experience.
Questionnaire
Frequency and consistency of component use. The questionnaire divided the bedside assessment into three separate sections, the initial assessment, the oro-motor examination (OME) and oral trials. Following the procedure of Bateman et al. (2007), frequency of component use was determined by calculating the proportion of respondents that reported usually or always utilizing a certain component. Consistency of practice was measured in the same method as in Mathers-Schmidt and Kurlinski (2003) and Bateman et al. (2007). That is, components were considered to have highly consistent use when over 75% of
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B.Vogels et al. Table I. Demographic information of questionnaire respondents.
Demographic question
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Experience as a SLP ⬍ 1 year 1–5 years 5–10 years 10–15 years ⬎ 15 years
Percentage of respondents (%) 9* 32 27 12 19
Rural vs metropolitan setting Rural Metropolitan Experience in adult dysphagia ⬍ 1 year 1–5 years 5–10 years 10–15 years ⬎ 15 years
10 34 27 12 17
Place of current employment WA VIC NSW QLD SA
25* 17 22 11 24
Demographic question
Percentage of respondents (%)
Current workplace setting Acute hospital Rehabilitation hospital Aged care facility Community centre Outpatient services Home services Disability services
68 35 20 19 37 28 4
22 78 Full-time equivalent workload 0.2 0.4 0.6 0.8 1.0 Other Percentage of caseload dysphagia 0–20% 20–40% 40–60% 60–80% 80–100%
2 4 8 13 68 5 9* 16 19 27 30
*Numbers have been rounded and do not add up to 100.
respondents indicated the same frequency of use (i.e. usually, always, sometimes, rarely or never). Moderately consistent use was defined as 50–75% and inconsistent use was defined as less than 50% of respondents indicating the same frequency of use. Across all three sections consistency of practice was low, with 32.69% of components being utilized highly consistently. Initial bedside assessment. The proportions of respondents indicating they usually or always utilize each component of the initial bedside assessment are displayed in Figure 1. The following five components had the highest levels of use, with over 95% of respondents reporting they usually or always included them in their bedside assessment: medical history (100%), oral trials (99%), the patient’s ability to participate in the assessment (97%), the patient’s posture and positioning (99%) and their dental status (96%). These same components, as well as OME and presence of tube in situ were highly consistently always used (over 75% of respondents indicated that they always assessed that component). Three components (hydration status, presence of tubes in situ and patient, family or carer interview) had at least one respondent indicating they never utilized the component. Another five components were used inconsistently with less than 50% of respondents agreeing on frequency of use, including nutritional status, hydration status, patient/family/carer interview, assessment of speech function and assessment of language abilities. Oro-motor examination. Of the 26 components of the OME listed in the questionnaire, four had the
highest levels of use with more than 95% of respondents usually or always including them in their OME, including adequacy of lip seal (97%), dentition (97%), volitional cough (95%) and range of tongue movement (96%). These components were also highly consistently always used. All sensory components except touch sensation to the face were utilized the least frequently, with over 50% of respondents reporting they never or rarely include them in their OME. Ten out of the 26 components were utilized inconsistently, this included all sensory components, gag reflex, lateral jaw movement and base of tongue movement. The full list of OME components and the proportion of respondents indicating they usually or always utilized each component are displayed in Figure 2. Oral trials. Half of the oral trials components had a very high frequency of use with over 95% of respondents usually or always utilizing them. This included using a variety of texture modified food and fluids (96%), efficiency of oral movements (98%), promptness of swallow reflex (99%), strength and range of laryngeal excursion (99%) and oral residue (99%). Five components were highly consistently always used, including efficiency of oral movements, promptness of swallow reflex, laryngeal excursion, alterations to client state and oral residue. Another four components were utilized inconsistently, including cervical auscultation, pulse oximetry, estimate of swallow duration and trialling compensatory techniques. Pulse oximetry and cervical auscultation had the lowest levels of use with 43% of respondents
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Figure 1. Consistency and Percentage (%) of respondents usually or always utilizing components of the initial bedside assessment (n ⫽ 140). HC, Highly consistent use; MC, Moderately consistent use; IC, Inconsistent use.
never or rarely using them in oral trials. The frequency of respondents indicating usually or always and consistency of use for oral trials components are displayed in Figure 3. Interview Thematic analysis of the interview transcripts took a phenomenological approach, as the transcripts were subjective reports of experience and behaviour in dysphagia assessment rather than objective descriptions (Brocki & Wearden, 2006). Five main themes arose from the analysis as factors that influence the bedside assessment. Themes included the influence of the current evidence base, the influence of the individual participant, the individual patient, the participant’s clinical practice and the participants’ workplace. The current evidence base. All eight participants mentioned the current evidence base in response to questions regarding what influences their use of certain assessment components. Participants reported inconclusive or a lack of evidence was part of their rationale for infrequently including the gag reflex, trials of compensatory techniques, pulse oximetry and cervical auscultation in their assessment. For example, participant three stated, ‘it’s [gag reflex] not something I do because I don’t think there’s a
lot of evidence for it’. Participant one also reinforced this theme, ‘So it’s [trialling compensatory techniques] just not something I tend to do, there’s not a lot of evidence for it’. Three participants discussed being aware of the inconclusive evidence base for assessing strength and range of laryngeal excursion and one of these participants then reported they frequently utilize this in their bedside assessment, … there’s very little evidence in terms of that you can feel the strength … I do think it’s important to feel the swallow, palpate the larynx, I think it can give you a great deal of information … (participant three)
Four participants reported that reading up to date literature is one of the greatest factors that influences them to change their practice, ‘the evidence now suggests that dysarthria is the biggest characteristic that is going to represent dysphagia so that’s what I look for …’ (participant eight). The influence of participants’ clinical practice. Seven of the eight participants reported they would exclude assessment components if they believed it would not add information to their clinical picture of the patient and their dysphagia. For example, participant five stated, ‘… I tried it [cervical auscultation] and I didn’t find that it particularly added a lot of informa-
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Figure 2. Consistency and Percentage (%) of respondents usually or always utilizing OME components (n ⫽ 140). HC, Highly consistent use; MC, Moderately consistent use; IC, Inconsistent use.
tion that was helping me make my decisions’. Participants did not appear to agree on whether certain bedside assessment components did or did not add useful information to their clinical picture. For example, when discussing use of pulse oximetry, participant one reported, ‘… if I was doing a standard clinical assessment on a ward patient I wouldn’t go to the trouble of going and getting a portable pulse oximeter because I don’t think it would add that much information’. Whereas participant three reported the opposite, ‘I want to have another objective piece of information that’s going to help me build this picture of what my recommendation is …’. Four participants reported that an influencing factor to their use of oral sensation, gag reflex, base of tongue movement and hydration status was whether or not these components would change their management of a patient. For example, participant one reported, ‘It [oral sensation] wouldn’t change my assessment for a patient or my recommendations …’. Four participants reported that their clinical practice consisted of informal and indirect assessment
where possible. In particular, oral sensation was included in the assessment indirectly by inferring information from the oral trials rather than directly assessing sensation during the OME, hence their indication of never or rarely assessing this during the OME. ‘I don’t assess it directly as part of my OME, for sensation in the mouth I usually see it as part of oral trials …’ (participant four). The influence of participants’ workplace. This theme refers to the influence of colleagues, team members and workplace resources. One participant discussed the influence of her colleagues on the use of cervical auscultation, ‘I used to use it because other people in my workplace were using it regularly’ (participant four). Six participants frequently reported that time and resource constraints impact their bedside assessment and the inclusion of certain components. In particular, the need to simplify the bedside assessment due to time constraints was reported, ‘… I sort of hit myself a little bit over that [infrequently assessing
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Figure 3. Consistency and Percentage (%) of respondents usually or always utilizing oral trials components (n ⫽ 140). HC, Highly consistent use; MC, Moderately consistent use; IC, Inconsistent use.
oral sensation]. But I guess it’s probably more to do with resources and time’ (participant six). Not only was it their own time that was restricted, but their patient’s time as well, ‘… it’s not just our time, I don’t mean that but I mean that the patient’s window of opportunity …’ (participant three). Four participants reported they would infrequently utilize pulse oximetry and assessment of oral sensation in their bedside assessment due to restricted access to the necessary equipment, … it’s [assessment of oral sensation] not something that I think that we shouldn’t do, probably something that we should do, but I just, I don’t know, just don’t do it, probably because I don’t have the tools available in—at a bedside to be able to assess those things quickly and readily. (participant eight)
of pulse oximetry and hydration status in the bedside assessment. For example, participant one reported ‘I would always use it with my ICU patients because it’s always there and they’re critically unwell so more inclined to have the desaturation because of what I’m doing’. Six participants reported they utilized certain assessment components because for their particular caseload of patients it was more appropriate. This came down to the aetiology of the patient’s dysphagia, such as head and neck cancer, stroke, geriatric medicine or tracheostomy. For example, participant four reported, ‘… with stroke I do a much more thorough OME than I would have working a geri’s [geriatric] caseload … just because of the nature of the patients’.
The influence of the individual patient. Participants frequently discussed the individual characteristics of their patients and the way in which that guides and influences their assessment. Five participants referred to patient cognition as one of the greatest barriers to their use of certain assessment components, in particular trialling compensatory techniques and assessing sensation, ‘I don’t always do it [trialling compensatory techniques] because cognitively patients aren’t always in a position to be able to implement them consistently’ (participant four). Two participants also reported the patient’s severity and level of acuity would influence their inclusion
The influence of the individual participant. All eight participants reported that their own experience and feelings influenced their bedside assessment. For example, the exclusion of cervical auscultation from the bedside assessment was attributed to a lack of confidence and skill in the area for five of the eight participants, ‘… probably more because of confidence so … I’ve done one very quick training session on it. Um, and I don’t feel that I walked away from that having enough knowledge of what I was hearing’ (participant six). Two participants reported that one of their reasons for frequently assessing base of tongue movement and strength and range of laryngeal excursion was that it is ‘something that I’ve always done from
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habit’ (participant six), suggesting an automaticity to conducting bedside assessments in dysphagia. Furthermore, it appeared this habitual inclusion of certain assessment components was not dependent upon whether the component was evidence-based, as stated by participant seven, ‘something that you’ve always done but I don’t know whether there’s actually any evidence—or firm evidence behind why we’re palpating [laryngeal excursion]’. Participants reported that their education, both under-graduate and post-graduate, influenced their bedside assessment. Post-graduate education appeared to have greater influence on dysphagia practice than under-graduate, with six participants reporting the influence of post-graduate education. However, only one participant reported their undergraduate training influenced their assessment of laryngeal excursion. Post-graduate education mainly consisted of continuing professional development (CPD) events and it appeared that attending these events was a major influence on clinicians’ bedside assessments as a whole, ‘I went to see Maggie Lee Huckabee in 2007… she said you should be a … dysphagia diagnostician not a technician … so really that shifted my thinking …’ (participant four). Personal opinion of an assessment component also influenced the use of that component. For example, in response to discussion around the assessment of the gag reflex participant two responded, ‘I find it overly invasive …’. This was reinforced by responses from four other participants.
Discussion This is the first study to investigate what Australian SLPs frequently include in their bedside assessment and what factors influence the use of individual bedside assessment components and the assessment as a whole. In particular it identified the content of bedside assessments and that the decisions made regarding this content are complex, with a number of factors influencing the use of a single component. Overall, consistency of practice across respondents to the questionnaire was low, with only 32% of components being utilized highly consistently, suggesting different respondents conduct different bedside assessments. This result was similar to the UK study by Bateman et al. (2007), who also found that 32% of components were utilized highly consistently but was lower than the US study by Mathers-Schmidt and Kurlinski (2003), who found 57% of components were highly consistently utilized. While overall consistency was low, there was a trend for questionnaire respondents’ OME’s to consist predominantly of motor components, with only 16% of respondents usually or always assessing a sensory component. Previous research found a higher frequency of assessment of sensation. Fifty-six per cent of participants in Bateman et al. (2007) and
74% of participants in Mathers-Schmidt and Kurlinski (2003) usually or always assessed sensation. This suggests genuine differences in practice between the UK, the US and Australia that should be investigated further in future research. It is possible that this is due to different clinical demands in Australia or across countries, as five of the eight interview participants in this study reported that they knew the benefits of assessing sensation but did not do so due to external or clinical factors. This included factors such as time, resource availability, resource access and patient cognition. It is important to highlight that four interview participants reported that their assessment of sensation was included during oral trials via questioning and inferring information from factors such as oral residue rather than assessed directly during an OME. Considering 99.28% of questionnaire respondents indicated they usually or always include evidence of oral residue in their oral trials, perhaps the frequency of assessing sensation would have been higher had the sensory components been listed under oral trials rather than OME. The low frequency of sensation testing has clinical implications, given the important role that sensory input plays in the planning, modulation and execution of swallowing (Cichero, 2006). Impaired sensation can impact the swallow and patient safety, while taste, smell and touch can modulate both the disordered and normal swallow (Wahab, Jones, & Huckabee, 2010; Steele & Miller, 2010). For example, Wahab et al. (2010) found that taste and olfaction stimuli resulted in greater efficiency of the volitional swallow in unimpaired individuals. The authors highlighted the possibility of utilizing taste and smell in dysphagia rehabilitation. Therefore, assessing sensation during dysphagia assessments may provide further insight into the patient’s dysphagia and swallowing safety, as well as providing information important for possible therapy approaches (Wahab et al., 2010). In light of this evidence, it is of concern that so few respondents reported they would include sensation testing in their bedside assessment. Seventy-four per cent of respondents indicated they usually or always assessed speech function. Bateman et al. (2007) and Mathers-Schmidt and Kurlinski (2003) found similar frequency of use in their studies. However, considering dysarthria and intelligibility has been found to be a key clinical indicator of both oral and pharyngeal dysphagia (Daniels, Brailey, Priestly, Herrington, Weisberg, & Foundas, 1998), it is therefore concerning that 26% of respondents did not frequently assess this component. It is possible that those respondents who did not frequently include assessment of speech function were not aware of this evidence. Alternatively, since no example was provided in the questionnaire it could be speculated that respondents were considering different methods of assessing speech function. For example, considering standardized speech assessment vs informal observa-
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tions of intelligibility may have influenced the respondents’ indications of frequency. Cervical auscultation was utilized both inconsistently and infrequently, with only 26.43% of respondents usually or always utilizing it. This result is not surprising given the inconclusive evidence base surrounding cervical auscultation and what clinical information the tool can provide (Cichero, 2006). While Mathers-Schmidt and Kurlinski (2003) found lower levels of frequency (14% of respondents reported usually or always utilizing it), Bateman et al. (2007) found cervical auscultation had higher levels of frequency, with 36% of respondents usually or always including it. Only one interview participant reported regularly using cervical auscultation. Three participants reported they did not frequently use cervical auscultation due to the inconclusive evidence base. Five participants reported it was due to a lack of confidence and skill in the area as a consequence of no training. Considering only four participants in the questionnaire indicated they had completed postgraduate cervical auscultation training, this lack of training and the consequent lack of confidence and skill may, therefore, be a contributing factor to the low frequency of use of cervical auscultation. The participants’ knowledge of its inconclusive evidence base appears to be another contributing factor. Similarly, pulse oximetry had both inconsistent and infrequent use, with only 12.86% of questionnaire respondents indicating they usually or always include the component. Bateman et al. (2007) found very similar levels of frequency with their UK respondents, with 9% usually or always including the component. During the interviews participants did report their knowledge of the evidence base as an influencing factor. However, they also reported that time and resource availability affected their use, as they did not always have quick and easy access to pulse oximeters. The influence of education and training on bedside assessment practices emerged as another finding of interest. While only one third of questionnaire respondents indicated they had received post-graduate training in the area of dysphagia, for the interview participants’ post-graduate training was a considerable influence over their bedside assessments. Furthermore, the interviews suggested that there was a greater perceived influence of post-graduate training over under-graduate training for these participants, perhaps reflecting the advanced nature of this training and the opportunity to further develop or hone existing skills. This finding should be considered in future research to determine whether further opportunities for post-graduate training and continuing professional development may help to improve the consistency of bedside assessment practices in Australia.
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influences this practice in Australia, there were some limitations. The self-report nature of the questionnaire and interviews meant that it captured only what the SLPs reported they do with regards to dysphagia assessment practices rather than what they actually do. While it is difficult to design a study which captures actual practice, it is important to consider that there may be differences between reported practice and actual practice. The study’s sample was limited to SLPs who were members of an Australian Dysphagia Interest Group. This, therefore, may not represent the practices of all SLPs within Australia who work with adults who have dysphagia. The main focus of this research was to capture current practice. This information was obtained from the questionnaire. The addition of the interview component was designed to explore the possible reasons why components are included and or excluded. While some important findings and themes emerged from the interview, it is important to note that the interview sample consisted of just eight participants. All eight of the participants were based in an acute or rehabilitation hospital and some had research experience. Therefore, these findings and the views represented by this sample may not reflect that of all SLPs in Australia. As such, further research is needed with a larger sample size and with participants recruited from a variety of sources and workplace settings in order to further explore these preliminary findings. Similarly, while the interview questions used a standard structure for each of the participants, some of the questions asked were based on their responses to questions 12, 13 and 14 of the questionnaire. As a result, there was some variation in the interview content across the eight participants. This could have influenced the results of the study and should be addressed in future research. As the Australian speech pathology community is small and the number of SLPs who work in the adult field even smaller, it was not possible to recruit all interview participants that were not known to the interviewer. The interviewer knew three of the participants in a professional capacity. While this may have resulted in the potential for interviewer bias, all questions were asked in the same manner, with the same structure. Finally, as respondents only completed the questionnaire once, the results reflect the practice of a group of SLPs at a single point in time. Future studies may consider repeating the questionnaire to examine whether or not practice patterns change over time. Conclusion
Limitations of the study While the current study captured important information about dysphagia practice patterns and what
The current study highlights the variability in bedside assessment practices of Australian SLPs. The interviews revealed considerable complexity in the
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decisions made by SLPs regarding their bedside assessments. This study provides important insight into the dysphagia assessment practices of a sample of SLPs across Australia and identifies factors, such as post-graduate training, which can be used to influence or maintain dysphagia practice in Australia.
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Acknowledgements Many individuals supported and participated in this research. Thank you to the Dysphagia Interest Group co-ordinators across Australia for their support in participant recruitment and the six SLPs who took the time to complete the pilot tests and provide feedback. Finally, thank you to the SLPs who took the time to complete the questionnaire and participate in the interviews. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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