Experiences of dysphagia trained nurses in the screening and early management of swallowing in acute stroke: A qualitative study

1Introduction

Post stroke dysphagia is common (Cohen et al., 2016; Martino et al., 2005) and early screening and assessment are important to reduce pneumonia (Bray et al., 2016; Yeh et al., 2011). The Royal College of Physicians (RCP) and National Institute for Clinical Excellence (NICE) guidelines recommend that all patients who present with a stroke are nil by mouth (NBM) until they have their swallowing screened by a trained professional (NICE, 2019; Royal College of Physicians Intercollegiate Stroke Working Party, 2016). The aim of swallow screening is to identify those with dysphagia so they can be directed to Speech and Language Therapists (SLT) to assess swallowing to determine the nature and severity of the impairment and provide ongoing management. In the UK, SLTs do not cover stroke units 24 hours a day and often are only commissioned to provide a 5 day service. Therefore, nurses and other professionals are often trained to screen swallowing in stroke prior to SLT assessment (Eltringham et al., 2022). These may be simple water swallow tests (WST) or more comprehensive screening tests (CST) allowing for recommendations of modified oral intake (Benfield et al., 2020). Research has shown that nurse administered swallow screening tools have good sensitivity to identify dysphagia (Benfield et al., 2020; Schepp et al., 2011). WSTs require little training to administer and patients can either pass, and so commence normal oral intake, or fail and remain NBM. CSTs usually require more training and test the safety and efficiency of different diet and fluid consistencies, making recommendations for these as indicated. One such CST is the Dysphagia Trained Nurse assessment (DTNAx) which can be used by nurses who have undergone theory and practical training and had their competency signed off by an SLT. This tool has been shown to be highly accurate in identifying dysphagia when compared to SLT assessment (Benfield et al., 2021).

Nurses have been involved in the development of these tools and pathways (Davies et al., 2001; Heritage, 2001) and a survey conducted with 60 nurses and 45 SLTs working in the north-west of the UK found that screening for dysphagia was accepted as part of the nursing role (Boaden, 2011). In a recent interview study, nurses report swallow screening and assessment pathways vary across stroke units in the UK (Eltringham et al., 2019). Nurses identified several barriers to timely swallow screening in stroke units in the UK and Australia such as multiple simultaneous admissions or not being admitted to stroke units within 4 hours (Eltringham et al., 2022; Murray et al., 2021). However, little is known about the experiences of the nurses who carry out these swallowing screening tests.

2The study

3Results

Nine nurses were consented and recruited for a single interview; one declined to participate due to not wanting to be audio-recorded. Table 1 gives demographic information of the included nurses. Most nurses were female, UK trained, Band 5 or 6 and worked full time day, night or mixed shifts. There was representation from two nurses who trained abroad, one male nurse and one part time nurse. Experience as a nurse ranged from two years to 30 years and experience as a DTN ranged from one to 15 years. This sample was not proportionate to the actual population of DTNs working on the ASU but represented the diversity of the population.

Interviews lasted between 10 and 22 minutes. The thematic framework with its themes and sub-themes is shown in Table 3. Four main themes were identified. No new themes or sub-themes were coded or identified after the sixth participant.

4Discussion

DTNs screen acute stroke patients for dysphagia and make recommendations for commencing oral intake if deemed safe on the DTNAx. Given there has been no research to date regarding the opinions of nurses in such a role, we interviewed nurses clinically active in acute stroke care and asked them to share their experiences.

The interviews highlighted that nurses positively valued being a DTN. The DTN role can be seen as an extended nursing role and previous studies have found that nurses value additional responsibility, as has been found with prescribing (Lennon & Fallon, 2018), thrombolysis (Catangui & Roberts, 2014) or developing another speciality in their field of practice (Fry et al., 2012).

The fear some of the DTNs experienced when starting out was not specific to dysphagia, but to taking on new skills. This was also found with nurses who take on thrombolysis responsibilities in acute stroke (Catangui & Roberts, 2014). We found that workload and time pressures often impaired the ability to fulfil the role, also seen in previous studies assessing the responsibilities of nursing on the HASU (Catangui & Roberts, 2014). Multiple admissions to the HASU and competing priorities have also been reported as challenges which delay swallow screening in acute stroke (Eltringham et al., 2019; Murray et al., 2021).

Improving patient care was seen as an important benefit of the DTN role. Quantitative studies have shown that early swallow screening reduces pneumonia in acute stroke (Bray et al., 2016); however, the nurses interviewed identified other benefits such as patient comfort and early medication administration. Extended or specialist roles mean that nurses can offer continuity of care to their patients, which is perceived as beneficial to the patient’s quality of life (Catangui & Roberts, 2014; Fry et al., 2012; Lennon & Fallon, 2018).

There is limited documentation in the literature of the role and responsibilities of a DTN or in fact how CSTs such as the DTNAx are used in practice. This study shows that DTNs may also have a role in monitoring and reviewing swallowing after patients leave the hyperacute unit due to patient variability and the complexity of swallow recovery. Another CST, the Volume Viscosity Swallowing test (V-VST) has also been used to review swallowing by nurses (Guillen-Sola et al., 2013). Further research is indicated to understand the role of dysphagia trained nurses and how they would best work alongside SLTs in screening and assessment of swallowing in acute stroke. Exploration of how these pathways are perceived by other members of the MDT, such as medical teams, when they have to manage competing priorities is also needed.

Assessing patients with no, mild or unrelated symptoms using the DTNAx was viewed by the nurses as unnecessary and in some cases adherence to the test proforma was reduced. This finding brings into question whether a CST such as the DTNAx is necessary with all stroke admissions. WSTs are also commonly used as quick screening tools in the stroke pathway. These tools have good sensitivity in identifying dysphagia for this group of patients (Schepp et al., 2011). Many of these tools ‘fail’ patients with oromotor dysfunction or speech difficulties, assessing only those with no, mild or unrelated symptoms so they tend to have lower specificity (Schepp et al., 2011). The DTNAx has been shown to have good sensitivity and specificity to identifying dysphagia but takes longer to carry out (Benfield et al., 2021). Therefore, a 2-stage test, whereby only those failing a WST are assessed with a CST, or a combination of the two may be more practical, acceptable and time efficient to carry out.

The DTNs are trained up to a level of competency in the Interprofessional Dysphagia Framework whereby they can complete a protocol guided assessment (Boaden & Davies, 2008). The nurses reported that it wasn’t always possible to follow the protocol, and they had to adapt it to certain patients such as those that cannot follow instructions, have allergies or organisational reasons such as limited range of foodstuffs on offer. The level of competency they achieve includes learning key knowledge about swallowing and dysphagia. The nurses that were interviewed stated that training was essential for the role. Given the findings of this research, this training is essential as it is likely they have to use expert clinical reasoning skills to pragmatically deal with situations that might occur in practice therefore adapting and deviating from the strict proforma. The training they receive is carried out in the workplace and offers practice using the DTNAx with patients on the ASU. Workplace training has been indicated as a factor that improves the transfer of knowledge into practice (Manley et al., 2018). Competency based education is essential in developing healthcare staff to work successfully in a modern healthcare setting (Frenk et al., 2010) and also increases satisfaction with training and transfer of skills (Meyer et al., 2007). A culture where there is support from peers as well as assessors or clinical educators as described by the nurses also contributes to successful learning and transfer of skill (Meyer et al., 2007). Maintaining skill, knowledge and competence is the backbone of all registered healthcare professionals, built in to registration with the Health and Care Professions Council and with professional bodies. Little is known about whether DTNs maintain their knowledge and skills over time nor how many they need to perform per year to maintain competence. However, considering this was valued by the nurses, regular updates or refresher courses may be beneficial for reassurance (Harrison & Hogg, 2003), improving confidence, self-efficacy and perceived competence (Shahsavari et al., 2017). Consideration about how refreshers are delivered is important as nurses find it difficult to prioritize CPD during their clinical shifts due to workload pressures (Rees et al., 2021). Further studies could explore the efficacy of such updates to inform their mode of delivery, content and frequency.

The nurses perceived the role as complementary rather than as a replacement to the SLT role which is important given that DTNs are only trained to use diet and fluid modification to compensate for dysphagia where this demonstrates reduced risks of aspiration and choking (Bolivar-Prados et al., 2019; Cichero, 2015). The nurses are not trained in other adaptations (for example, swallowing strategies, carbonation, use of cups, transition foods) or for use of instrumental assessment, longer term management or planning dysphagia interventions. Importantly, all of these patients go on to be managed by the SLT for assessment and review of the current management with the aim to achieve normal diet/fluids where possible.

5Conclusion

DTNs in an acute stroke setting value their role and the training they receive to screen patients’ swallowing and recommend oral intake. They found the test easy to use and perceived it’s use in the stroke unit was beneficial for patient’s health and wellbeing. Sometimes the role was challenging but nurses developed skills and knowledge to overcome these barriers through accessing support from more experienced staff. Further research is needed to understand the impact DTNs can have on the outcomes of stroke patients and explore which swallow screening and assessment pathways are the most clinically and cost effective.