Swallowing Problems in the Nursing Home: A Novel Training Response

Dysphagia 13:172 183 (1998) Springer-Verlag New York Inc. 1998 Swallowing Problems in the Nursing Home: A Novel Training Response Grainne O Loughlin, BSc(Hons) 1 and Chris Shanley, MA 2 1 Speech Pathology Department, Balmain Hospital, Balmain, Sydney and 2 Centre for Education and Research on Ageing, Concord Hospital, Concord, Sydney, Australia Abstract. Various studies suggest that between 50% and 75% of nursing home residents have some difficulty in swallowing. Some of these residents are assessed and treated by speech pathologists, but many are managed by nursing staff without specialist input. A training program called Swallowing... on a Plate (SOAP) has been developed by the Centre for Education and Research on Ageing and the Inner West Geriatrics and Rehabilitation Service to help address swallowing-related problems in local nursing homes (Inner West of Sydney, Australia). The training program teaches nursing staff how to identify, assess, and manage swallowing problems, including making appropriate referrals. Several new instruments were developed specifically for this program including two assessment checklists, a set of management guidelines, and a swallowing care plan. Evaluation of the program including 3 months follow-up showed it to be highly successful. A stand-alone training resource has been produced for wide distribution to help staff implement the program as a permanent aspect of their nursing care. This paper describes the development, content, presentation, resource, and evaluation of the above program. Key words: Dysphagia Swallowing problems Nursing home Nurse education Deglutition Deglutition disorders. Incidence and Causes of Dysphagia in Nursing Homes There were very few studies identified in the literature on the incidence of dysphagia in nursing homes. Trupe et al. Correspondence to: Chris Shanley, M.A., Centre for Education and Research on Ageing, Concord Hospital C25, Concord, Sydney, New South Wales 2139, Australia [1] studied 240 residents in a nursing home to estimate the prevalence of dysphagia and found that 74% of residents exhibited one or more types of eating disability, with 59% exhibiting oropharyngeal dysphagia. In a study by O Brien and Barrow [2] it was found that of 83 residents from four nursing home wards, 53% presented with oral, pharyngeal, or laryngeal dysfunction resulting in dysphagia. Groher [3] claims that the incidence of dysphagia is high in the chronic care setting and will continue to be so unless there is a concerted improvement in identification and amelioration of problems associated with dysphagia and poor intake. Many elderly residents in nursing homes have illnesses that may cause dysphagia. These may be systemic or immunological, neurological or neuromuscular, a result of salivary changes, psychological, environmental, or social [4]. Strategies Advocated for the Assessment and Management of Dysphagia Many of the articles reviewed on assessment and management center around the care of patients within the hospital setting where multidisciplinary teams are established and there is relatively easy access to allied health staff such as speech pathologists, occupational therapists, physiotherapists, and dietitians. Dysphagia assessment and management in the hospital setting is usually described as a collaborative approach by these team members. The relevant health professional (often a speech pathologist) makes an assessment and issues management directions set in consultation with team members. Nursing staff within the hospital usually have a major role in implementing these management guidelines when feeding the patients.

G. O Loughlin and C. Shanley: Swallowing Management in the Nursing Home 173 In contrast, in the nursing home setting, access to health professionals such as speech pathologists and dietitians is often limited because of financial constraints. Nursing staff find themselves managing dysphagic residents without specialist input. Moreover, staffing in nursing homes is usually made up of a small number of registered nurses (RNs) and a much larger number of assistants-in-nursing (AINs). These AINs have little or no formal training, yet they are frequently responsible for feeding dysphagic residents. Bedside assessment of dysphagia involves checking a number of parameters including alertness, cranial nerve function (face, lips, jaw, tongue, palate, larynx), protective reflexes (cough, swallow, and gag), vocal quality, and laryngeal movement. It is important for those assessing dysphagia to have an understanding of the anatomy and physiology of the swallowing process, and to be able to interpret their findings accurately so that an effective management plan can be implemented. Some authors [5 8] list tell-tale signs of dysphagia that may help staff identify residents with swallowing difficulties. These signs may include unexplained weight loss, recurrent chest infections, refusal to eat, reporting difficulty swallowing, coughing or choking, drooling, pocketing of food in the cheeks, taking a long time to chew or swallow, a wet or gurgly voice after swallowing, and slurred speech. Other authors [9,10] provide nurses with more detailed descriptions of how to assess patients with swallowing problems. Management of dysphagia and commonly used techniques are also cited in the literature [9,11 18]. For neurogenic dysphagia, basic principles are often employed: sitting the dysphagic person upright with the head in the midline and slightly flexed, modification of food and fluid consistencies, giving verbal and physical prompts, giving the person plenty of time to swallow each mouthful, double swallows, feeding with small amounts only per mouthful, and checking that the mouth is clear between mouthfuls and at the end of meals. In addition, if the person needs to be fed, the feeder should be seated directly in front, placement of food in the mouth should be towards the unaffected side, and the feeder should be readily prepared to deal with episodes of choking. They should also be observing for fatigue, and leave the person sitting upright for at least 30 minutes after meals. In terms of elderly demented residents, Watson [19] cites a number of studies indicating that indirect interventions such as improving the environment, exploiting food preferences, reducing distractions, touch, and caregiver interaction all facilitate increased nutritional intake. Hotaling [20] discusses the important influences that the environment has on preparing residents for eating and describes some of the environmental factors that promote a positive mealtime experience for residents. Kayser-Jones [21] describes a 4-year anthropological study which stressed the importance of individualized attention to mealtime routines for nursing home residents. The use of alternative feeding methods (e.g., percutaneous endoscopic gastrostomy or nasogastric tubes) is also commonly employed as a management strategy for residents with severe oropharyngeal dysphagia, where improvement is slow or minimal. Tube feeding is also used where nutritional intake is poor because of cognitive impairment. The initiation of tube feeding, particularly in the latter group, is often fraught with ethical and moral dilemmas and much debate as to the indications and contraindications of tube feeding in these groups has been addressed in the literature [22 27]. The Nurse s Role in the Assessment and Management of Dysphagia There is no universal agreement about the roles of different health professionals including nurses in the assessment and management of dysphagia. Certainly the backgrounds of the various authors influence what they think the nurses role should be. For instance, speech pathologists in the hospital setting often feel it is their role to carry out initial swallowing assessments and implement management programs in close liaison with the multidisciplinary teams, with the nurses role being that of feeder and implementer of management recommendations [7]. Articles written by nurses [5,6,13,28] suggest that they should have knowledge of the anatomy and physiology of swallowing, know how to assess cranial nerve function, and learn specific nursing techniques to assist with managing dysphagia. Hogstel and Robinson [12] also suggest that RNs should make sure AINs understand the hazards and safety factors involved in feeding the frail elderly. Education Programs on Dysphagia Management in Nursing Homes A review of the literature reveals a small number of education programs about swallowing problems available for nursing home staff. Kolodny and Malek [28] looked at a 450-bed nursing home facility and found that 50% of residents required some assistance for their meals. This led them to devise an education program to assist nursing staff in identifying and managing residents with swallowing difficulties. Their article only describes

174 G. O Loughlin and C. Shanley: Swallowing Management in the Nursing Home the needs analysis but gives no details of the education program they set out to develop. Mullaney [29] developed a Dysphagia Teaching Module aimed at RNs in nursing homes, which consisted of a 1-hour inservice. She wanted them to be able to recognise, refer, prevent and ameliorate swallowing problems. Recommendations from this study included the need to evaluate the impact of teaching materials, a research design to include follow-up assessment of participants after the education program, the need to inform relatives and significant others about dysphagia, and to test the impact the training has had on AINs as well as the RNs who participated in the course. Kohler [30] describes a dysphagia management model for nursing homes and homecare workers in a rural setting. Under this model, staff in these facilities are trained to detect swallowing problems and make referrals to members of a professional resource network, i.e., a group of professionally trained dysphagia therapists. The program does not contain information on assessment and management by nursing staff, and its success is dependent on easy availability of a dysphagia specialist. Lipner et al. [31] report on a program for training and supervising volunteers to assist in feeding residents in a long-term facility. The program involved a 90- minute inservice and supervised hands on practice. By making effective use of volunteers, RNs were able to concentrate on residents with more acute swallowing problems. Lessons from the Literature There is a high incidence of dysphagia among nursing home residents, due mostly to neurogenic conditions or cognitive impairment. Care of residents in nursing homes is mostly administered by untrained assistants-in-nursing. In most cases, there is limited access within nursing homes to specialist input from allied health professionals in the area of dysphagia management. Though there are a number of articles written for nurses about assessment and management of dysphagia, there are no examples of a systematic model of care with an accompanying education program relevant to the nursing home environment. There have been a few inservice programs aimed at nursing staff but these have been of a general nature and have not been evaluated for any medium to long-term impact. The Swallowing... on a Plate (SOAP) Program Background This program developed out of a locally identified problem: many nursing home residents were requiring frequent assessment and management for dysphagia by the community health speech pathologist. With limited time being available from this service, it was seen as essential that nursing home staff gain the knowledge and skills to provide basic assessment and management of swallowing problems within their facilities and have clearer guidelines about referral to a speech pathologist. In developing the SOAP program, the authors attempted to move beyond existing programs that had been reported in the literature. The ways that this program represents a novel approach to the problem are outlined below: It includes new assessment and management forms developed specifically for the nursing home environment. It recognizes the importance of influencing untrained assistants in nursing and is therefore based on a train the trainer model. The program contains a set of inservice lesson plans and handouts for experienced registered nurses to teach the model to other staff. It also promotes role modeling and coaching of untrained staff by senior staff. It provides onsite training of each course participant in his/her own facility. It requires course participants to develop broad strategies for change in care practice within their own nursing homes. These swallowing management plans include staff training; use of assessment proformas; mealtime environment, routines, and staffing; use of adapted equipment for meals; training and equipment available to kitchen staff; emergency procedures; referral procedures. It includes a detailed manual on all aspects of implementing the program within the participants facilities. It involves a comprehensive impact evaluation, including a 3-month follow-up. Needs Analysis The target group for the training program was consulted from the outset. This was by onsite visits and discussions with staff at four local nursing homes, attendance at the local Directors of Nursing meeting, and a mail survey to all nursing homes in the local area. All feedback from these consultations demonstrated to the project coordinators that nursing homes in the local area did perceive the management of dysphagia as an important issue and would support a comprehensive education program targeting nursing home staff. Program Development The aim of the course was to promote optimum care of nursing home residents with swallowing problems. The

G. O Loughlin and C. Shanley: Swallowing Management in the Nursing Home 175 initial reference point for the program was to develop a brief statement of good practice which provided an overall description of appropriate care (Appendix I). The course was to be skills based, with learning occurring in the workplace. For this purpose, several new instruments (described further below) were developed for use in a nursing home setting. Within the context of the overall aim and the above conditions, a number of specific learning outcomes were developed (Appendix 2). These organized into a format of training which involved attendance at three half-day seminars and an onsite visit to each participant from the speech pathologist presenting the course. To increase the likelihood of the information translating into changes in the work practice, participants were expected to provide some form of inservice training to their own staff. They also had to write up a swallowing management plan for their nursing home which took into account staff orientation and training, rostering and supervision at mealtimes, use of adapted equipment and modified diets, emergency procedures and assessment, and referral policies and procedures. The Assessment and Management Instruments The SOAP program is built around the use of four instruments which are illustrated in Figure 1 and further described below. Step One. The first of these is the Prefeeding Assessment Checklist (Appendix 3) which is to be used by RNs when swallowing problems are suspected or as a screening instrument for all new admissions. This assessment is carried out prior to any food trials with the resident. The form allows the RN to assess the following areas: onset of the problem, alertness, tongue movements, cough strength, and voice quality. After completing this checklist the RN is able to make a decision as to whether the resident should be placed on nothing by mouth and the local doctor contacted, or whether it is safe to proceed to the second step of the program assessing the resident during a mealtime. Step Two. If the resident can be tested orally, the RN uses the Swallowing Assessment Checklist (Appendix 4) to fully assess the resident s ability while eating. This checklist looks for the presence or absence of oral phase difficulties (lip seal, tongue movements, pocketing, etc.) and pharyngeal phase difficulties (coughing, choking, changes in voice quality). It also elicits information about posture/positioning difficulties while feeding, level of independence in eating, and any cognitive behaviors that are influencing the feeding or swallowing processes. Fig. 1. Overview of the SOAP Program. Step Three. With the information gained in these two assessments, the RN refers to the Swallowing Management Index, a 10-page document that lists each potential swallowing/feeding disturbance and a corresponding strategy on how to deal with the problem. Suggestions are simple and practical for the caregiver. It also includes a significant section on management of dementia-related problems. Step Four. Armed with the strategies from the Swallowing Management Index, the RN is able to fill out a Swallowing Care Plan (Appendix 5) for any resident with swallowing difficulties. Each swallowing care plan will be unique and tailored to a particular resident; it is a comprehensive guide to care for all staff to use. It includes information on which food and fluid consistency is recommended for that resident; instructions on giving medications; preparation of resident for feeding, positioning, adapted equipment required; and specific assistance needed for each resident (e.g., requires prompting to clear mouth, needs to have cheeks massaged to facilitate chewing). Conducting the Training Program The program was used twice in 1995 within the local health area with 15 senior registered nurses attending each program. This group was targeted because they

176 G. O Loughlin and C. Shanley: Swallowing Management in the Nursing Home were able to make decisions about how care was to be provided, were in a position to educate and supervise untrained staff, and were the most stable part of the workforce. Participants attended three 4-hour workshops. The course coordinators were a speech pathologist with an extensive clinical background in dysphagia assessment and management and an adult educator. Teaching input was also provided by two occupational therapists and a dietitian. Session One. This session dealt with the anatomy and physiology of the normal and abnormal swallow, aspiration, warning signs of dysphagia, the effects of aging on swallowing, the effects of dementia on swallowing, medications and swallowing, introduction of the Prefeeding Assessment Checklist and the Swallowing Assessment Checklist and a video about safe swallowing. Session Two. This session covered management principles and aims of dysphagia management, introduction of the Swallowing Management Index and the Swallowing Care Plan, the role of independence, positioning and adapted equipment for residents with swallowing problems, and ethical concerns regarding the initiation of tube feeding in this client group. Session Three. This session included general nutrition guidelines for the elderly as well as more specific information on how to monitor nutritional status in the nursing home, modifying food and fluid consistencies for residents requiring special diets because of their dysphagia, enteral feeding, and weaning residents off tube feeds. An educator also conducted a session on how to devise, set up, and implement swallowing management plans and inservice programs for staff. Between sessions two and three a period of a month the course coordinator visited each of the participants in his/her own nursing home to supervise the use of the instruments on residents with swallowing problems. To gain a certificate for fully participating in the program, participants are given 2 months to complete some form of inservice training for their staff and to complete a supplied proforma on management of swallowing problems within their own facility. Program Evaluation Written evaluation of the program has occurred on three levels: 1. A process evaluation of each session; 2. An applied knowledge test based on the course content administered before the training, immediately after it, and 3 months later; 3. An impact evaluation done before the training and 3 months later which measures the use of regular procedures and formats, occurrence of inservice education on swallowing management, how clear AINs are about proper management of swallowing problems, the general level of care in swallowing problems, and whether there are documented standards of swallowing care within the nursing home. The process evaluation was a short questionnaire at the end of each session which asked participants to assess the relevance and clarity of the presentation, their general satisfaction, and any suggestions for improvement. This information was used by the course presenters to review their presentations for the following workshops. Participants expressed a high degree of satisfaction with all the workshops, seeing them as highly relevant and clearly presented. The applied knowledge test (Appendix 6) consisted of a 29-item questionnaire with a potential score of 35. All 30 participants answered the questionnaire at the beginning of the workshop (pretest) and at the end of the third seminar (posttest). Twenty-four were contactable 3 months after completing the course (follow-up). Comparisons of pretest and posttest scores is based on the full 30 participants and are presented in Table 1. Comparisons of pretest and 3-month follow-up scores is based on the 24 participants who completed both questionnaires. The 6 who were lost to follow-up were compared with the other 24 participants on a number of variables and there were no significant differences. Comparisons of pretest and follow-up scores are presented in Table 2. The impact evaluation consisted of five questions at the beginning of the course and again 3 months after completion of the course. The following results are based on the 24 participants who completed both questionnaires. Questions 2.1, 2.2, and 2.5 required a dichotomous yes/no answer to the following questions: 2.1 Do you and other RNs in your nursing home use some regular procedures and formats for assessing and managing swallowing problems? 2.2 Has some form of inservice training (including formal sessions or informal one to one sessions) on swallowing for staff been run in your nursing home over the last 3 months? 2.5 Does the nursing home have some form of documented standards of care for managing swallowing problems? As we were interested in the number of subjects who changed their responses from no to yes after attending the program, repeated measures Chi-squared

G. O Loughlin and C. Shanley: Swallowing Management in the Nursing Home 177 Table 1. Comparison of applied knowledge pretest and posttest scores n Mean Standard deviation Significance Pretest 30 24.5333 6.862 <0.0005* Posttest 30 29.6667 5.921 *p value for a 2-tailed t-test. Table 3. Clarity of AINs about swallowing management pretest and 3 months follow-up n Mean SD Significance Pretest 24 2.7917 0.884 0.003* Follow-up 24 3.5000 1.063 *p value for a 2-tailed t-test. Table 2. Comparison of applied knowledge pretest and 3 months follow-up scores n Mean SD Significance Pretest 24 25.000 6.331 <0.0005* Follow-up 24 31.1667 4.824 *p value for a 2-tailed t-test. Table 4. Comparison of overall management pre-test and 3 months follow-up n Mean SD Significance Pretest 24 2.8333 0.917 0.001* Follow-up 24 3.6250 1.013 *p value for a 2-tailed t-test. analysis was used. This technique compared the distribution of subjects at the pretest stage with distribution at the follow-up. For each question, there was a significant shift from no to yes at the 0.05 level of statistical significance. Question 2.3 asked Are AINs in your nursing home clear about the proper management of residents with swallowing problems? Responses were on a 5- point Likert scale, with 1 being not at all clear and 5 being very clear. Response data are presented in Table 3. Question 2.4 asked Overall, how well do you think swallowing problems are assessed and managed by nursing staff in your nursing home? Responses were on a 5-point Likert scale, with 1 being not at all well and 5 being very well. Response data are presented in Table 4. Discussion A model has been developed for the identification, assessment, and management of swallowing problems in nursing home residents. The model has been complemented by a comprehensive education program which helps staff implement the model within their facility. The program has been evaluated for its impact, including a 3-month follow-up. Based on the analysis of this data we are able to say that following participation in the course, there has been: a significant increase in participant s knowledge about swallowing management a significant increase in RN s use of regular procedures and formats for assessing and managing swallowing problems a significant increase in the number of inservice sessions about swallowing occurring a significant increase in the occurrence of documented standards of care for managing swallowing problems an improvement in AIN s clarity about proper management of residents with swallowing problems an improvement in overall assessment and management of swallowing problems. The model and the education program do not try to teach nurses how to perform the role of speech pathologists. Rather, they provide knowledge and skills to assist nurses in an area of their work that is very demanding and for which there is normally little preparation. The authors have developed the material from the course into a comprehensive training package that can be used by an experienced registered nurse to bring about change in work practice within her own facility. As well as containing much practical background information, the kit teaches the reader how to use the SOAP assessment forms. It also provides a systematic approach to implementing the SOAP model, including a set of inservice lesson plans and handouts. The assessment forms that make up the SOAP program were tried in a number of nursing homes but have not had formal tests of reliability and validity. This is an area that requires further research. A more in-depth evaluation of the program will be conducted if resources allow. This will focus on measuring the impact of the training course on patient outcomes, including incidence of aspiration, incidence of choking, admission to hospital, weight gain, dependence on tube feeding, patient satisfaction. This evaluation will be a controlled trial with one group of nursing homes receiving the education program and another group receiving no intervention.

178 G. O Loughlin and C. Shanley: Swallowing Management in the Nursing Home Conclusion Swallowing problems occur in a large proportion of nursing home residents. Nursing staff bear most of the responsibility for assessing and managing these problems because of the low number of speech pathologists employed in nursing homes. Although nurses take on this important responsibility, it is not normally included as part of the nurses formal training or continuing education programs. The literature contains some general articles with guidelines for assessing and feeding residents but does not contain any references to comprehensive, evaluated programs. The authors have developed an education program on assessment and management of swallowing problems specifically for a residential care environment. The program has been run twice and evaluated to have a statistically significant effect on nurses knowledge and on standards of care. The training program has been further developed into a comprehensive stand-alone kit which staff can use to implement change in work practice within their facility. Enquiries and orders for this resource can be directed to the address at the beginning of this article. Acknowledgments. We thank Gay Horsburgh for her determination in setting up the original project, Dr. Matthew Dobson for statistical analysis of the evaluation data, and Judith Smart for literature searches and technical support. References 1. Trupe EH, Siebens H, Siebens AA: Prevalence of feeding and swallowing disorders in a nursing home. Arch Phys Med Rehabil 65:651 652, 1984 2. O Brien P, Barrow D: Prevalence of eating problems of nursing home residents. Aust J Hum Commun Disord 19(1):35 43, 1991 3. Groher ME: Managing dysphagia in a chronic care setting: an introduction. Dysphagia 5:59 60, 1990 4. Sonies B: Oropharyngeal dysphagia in the elderly. Clin Geriatr Med 8(3):569 577, 1992 5. Cole-Arvin C, Notich L, Underhill A: Identifying and managing dysphagia. Nursing 94:48 49, 1994 6. DiIorio C, Price ME: Swallowing: an assessment guide. Am J Nurs 90(7):39 41, 1990 7. Logemann J: Evaluation and Treatment of Swallowing Disorders. San Diego: College Hill Press, 1983 8. Rubin-Terrado M, Linkenheld D: Don t choke on this: a swallowing assessment. Geriatr Nurs (New York) 12:288 291, 1991 9. Baker DM: Assessments and management of impairments in swallowing. Nurs Clin North Am 28(4):793 805, 1993 10. Gauwitz DF: How to protect the dysphagic stroke patient. Am J Nurs 95(8):34 38, 1995 11. Price ME, DiIorio C: Swallowing: a practice guide. Am J Nurs 90(7):42 46, 1990 12. Hogstel MO, Robinson NB: Feeding the frail elderly. J Gerontol Nurs 15(3):16 20, 1989 13. Donahue PA: When its hard to swallow: feeding techniques for dysphagia management. J Gerontol Nurs 16(4):6 9, 1990 14. Matthews LE: Techniques for feeding the person with dysphagia. J Nutr Elder 8(1):59 64, 1988 15. Gresham SL: Clinical assessment and management of swallowing difficulties after stroke. Med J Aust 153:397 399, 1990 16. Burge P: Textured soft diets and feeding techniques among the elderly mentally ill. J Hum Nutr Dietetics 7:191 198, 1994 17. Layne KA: Feeding strategies for the dysphagic patient: a nursing perspective. Dysphagia 5:84 88, 1990 18. Holzapfel SK, Ramirez RF, Layton MS, Smith IW, Sagl-Massey K, DuBose JZ: Feeder position and food and fluid consumed by nursing home residents. J Gerontol Nurs 22(4):6 12, 1996 19. Watson R: Measuring feeding difficulty in patients with dementia: perspectives and problems. J Adv Nurs 18:25 31, 1993 20. Hotaling DL: Adapting the mealtime environment: setting the stage for eating. Dysphagia 5:77 83, 1990 21. Kayser-Jones J: Mealtime in nursing homes: the importance of individualised care. J Gerontol Nurs 22(3):26 31, 1996 22. Raha SK, Woodhouse K: The use of percutaneous endoscopic gastrostomy (PEG) in 161 consecutive elderly patients. Age Ageing 23:162 163, 1994 23. Ciocon JO: Indications for tube feedings in elderly patients. Dysphagia 5:1 15, 1990 24. Ciocon JO, Silverstone FA, Graver M, Foley CJ: Tube feedings in elderly patients: indications, benefits and complications. Arch Intern Med 148:429 433, 1988 25. Campbell-Taylor I, Fisher RH: The clinical case against tube feeding in palliative care of the elderly. J Am Geriatr Soc 35(12):1100 1104, 1987 26. McNabney MK, Beers MH, Siebens H: Surrogate decisionmakers satisfaction with the placement of feeding tubes in elderly patients. J Am Geriatr Soc 42:161 168, 1994 27. Groher ME: Ethical dilemmas in providing nutrition. Dysphagia 5:102 109, 1990 28. Kolodny V, Malek AM: Clinically enhancing nursing practice: improving feeding skills. J Gerontol Nurs 17(6):20 24, 1991 29. Mullaney NS: The Effect of a Dysphagia Teaching Module on Knowledge, Application and Attitudes of Registered Nurses Working in a Nursing Home. Columbia University Teachers College, Dissertation for Degree of Doctor of Education, 1992 30. Kohler ES: A dysphagia management model for rural elderly. Phys Occup Ther Geriatr 10(1):81 95, 1991 31. Lipner NS, Bosler J, Giles G: Volunteer participation in feeding residents: training and supervision in a long-term care facility. Dysphagia 5:89 95, 1990

G. O Loughlin and C. Shanley: Swallowing Management in the Nursing Home 179 Appendix 1: Statement of Good Practice for Management of Swallowing Problems in Nursing Homes Registered nurses who can assess when residents are having swallowing difficulties Registered nurses who can and do document specific swallowing care plans for residents with swallowing problems Registered nurses who can determine when a resident needs a specialist referral for swallowing problems Enrolled nurses and assistants in nursing who can understand and implement a swallowing care plan A nursing home with documented swallowing standards of care Provision for a range of modified diets, including alternative feeding, e.g., nasogastric, gastrostomy feeding Appendix 2: Learning Outcomes for the Three Modules of the SOAP Education Program On completion of Module 1, the learner will be able to: 1.1 Explain the physiology of normal swallowing 1.2 Explain the physiology of impaired swallowing 1.3 Explain the possible impact of dementia on swallowing difficulties 1.4 List indications that residents may be having difficulties with swallowing 1.5 Demonstrate competence in assessing residents with swallowing difficulties using the supplied Prefeeding Assessment Checklist and Swallowing Assessment Checklist 1.6 Assess residents swallowing status on an ongoing basis 1.7 Know when to refer residents with swallowing problems to local medical officer and speech pathologist On completion of Module 2, the learner will be able to: 2.1 Use the results of his/her assessments, together with a Swallowing Management Index to write a Swallowing Care Plan for a particular resident 2.2 List the important features of resident care that will assist swallowing in terms of: texture and type of food preparation of the resident for mealtime positioning of resident use of feeding aides swallowing status swallowing techniques 2.3 Provide appropriate education about swallowing care to enrolled nurses and assistants in nursing caring for residents in the nursing home 2.4 Supervise enrolled nurses and assistants in nursing in feeding residents according to the Swallowing Care Plan 2.5 Recognize the limitations of swallowing care strategies in the care of palliative care residents On completion of Module 3, the learner will be able to: 3.1 Identify aspects of practice within the nursing home that may impact on care of residents with swallowing problems. These would include: use of the protocols taught in this course as regular procedures within the nursing home all staff receiving orientation to and inservice training about Swallowing Care Plans catering issues such as: availability of kitchen equipment for modifying food texture presentation of meals in an appealing way availability of a varied modified texture menu meals that reflect the nutritional requirements of residents flexibility in timing and frequency of means adequate staffing numbers at mealtimes to allow appropriate assistance with feeding guidelines are in place for when to refer residents with swallowing problems to speech pathologist via the local medical officer 3.2 Draw up a document of swallowing care standards that refers to the above aspects of practice and is relevant to their particular nursing home

180 G. O Loughlin and C. Shanley: Swallowing Management in the Nursing Home Appendix 3: Prefeeding Assessment Checklist (Reprinted with permission from the Centre for Education & Research on Ageing and Inner West Geriatrics & Rehabilitation Service.)

G. O Loughlin and C. Shanley: Swallowing Management in the Nursing Home 181 Appendix 4: Swallowing Assessment Checklist (Reprinted with permission from the Centre for Education & Research on Ageing and Inner West Geriatrics & Rehabilitation Service.)

182 G. O Loughlin and C. Shanley: Swallowing Management in the Nursing Home Appendix 5: Swallowing Care Plan (Reprinted with permission from the Centre for Education & Research on Ageing and Inner West Geriatrics & Rehabilitation Service.)

G. O Loughlin and C. Shanley: Swallowing Management in the Nursing Home 183 Appendix 6: Applied Knowledge Test for Use at Pretest, Posttest, and Follow-up of SOAP Program 1.1 How many stages of swallowing are there? One Two Three 1.2 Which structure prevents food or fluid entering the airway? Tongue Soft palate Epiglottis 1.3 In which stage of swallowing does the breathing momentarily stop? Oral phase Pharyngeal phase 1.4 True or False? If a resident has a delayed swallowing reflex they would: (Please circle the correct answer) Be nil by mouth Require a modified diet Be at risk of aspirating/choking Have no adverse effects 1.5 True or False? (Please circle the answer) All residents will cough if they are aspirating 1.6 True or False? A resident is more likely to aspirate when: (Please circle the correct answer) Tired Lying down Sitting upright Has head tilted back 1.7 Name THREE disease processes, other than dementia or C.V.A., which may cause swallowing problems: 1.8 Name THREE aims of dysphagia management: 1.9 Name THREE warning signs of swallowing problems: (other than choking!) 1.10 True or False? (Please circle the correct answer) The normal aging process causes the tongue to enlarge The normal aging process causes taste sensation to change The normal aging process causes an increased appetite The normal aging process reduces saliva production The normal aging process creates less acid in the stomach 1.11 What is a safe feeding position for a resident with swallowing problems? (please circle the correct answer) Sitting upright with head flexed In bed, lying at less than a 60 degree angle In bed, sitting upright with pillows behind the head In a water chair with head extended 1.12. True or False? The following problems would prompt you to use thickened fluids: (please circle the correct answer) A delayed swallow reflex Difficulty feeding self No dentures/teeth Sluggish tongue movements A weak cough reflex