Evidence from local, national and international studies indicate that the strategies for managing dysphagia are challenging for patients, their families and staff (Low et al 2001, Colodny 2001, 2005, Pownall 2009).
A pilot trial, conducted in 2007 in the stroke service at Sheffield Teaching Hospitals highlighted the difficulty of adhering to dysphagia recommendations (Pownall 2009). Sheffield Teaching Hospitals (STH) is the largest NHS Foundation Trust in the England. The Trusts employs more than 13,500 people and in 2008-2009 provided over a million patient episodes of care. Seehttp://www.sth.nhs.uk/ for information about the Trust.
In 2010, the Trust approved a 12 month implementation project to enhance the quality of the management of dysphagia /swallowing difficulties provided by the multi-disciplinary stroke team through improving their knowledge and skills. The project will trial, implement and evaluate workplace-based e-learning programmes as a knowledge translation strategy. If the facilitated e-learning is successful, then the dysphagia programme/s may be rolled out across the hospital and the findings will inform the use of e-learning in general within STH. The learning about dysphagia management and workplace-based e-learning will be disseminated across the CLAHRCs and more widely through publications and presentations.
Dysphagia and stroke
Dysphagia means difficulty swallowing fluids, food or medicines. It is very distressing and can lead to “serious and life-threatening consequences, such as aspiration pneumonia, malnutrition, and immunocompromised health” (Ashford et al 2009 p195). An incidence rate of 37 to 78 per cent has been reported following a stroke (Martino et at 2005). About one half of people with dysphagia either die or recover spontaneously within the first 14 days of stroke onset leaving half with swallowing deficits that can significantly impair function, recovery and quality of life (Bath et al 1999).
The complications of dysphagia are pertinent for local and national quality standards. Chest infections are an indicator in the 2010 Stroke Sentinel Audit. Meeting nutritional needs is one of the outcome standards in the Care Quality Commission guidance for health care providers (2010). Outcome 5C requires providers to identify people with swallowing difficulties and to take appropriate action (CQC 2010).
E-learning and workplace-based e-learning
E-learning or electronic, on-line learning is facilitated and supported through the use of information and communication technology. The term workplace-based e-learning (Carroll et al 2009) better reflects the purpose of this project: which is to evaluate the delivery of on-line learning for members of the health care workforce in an acute Trust.
The value of e-learning is recognised by the Yorkshire and Humber Strategic Health Authority. One of the key objectives in the 2008/09 Annual Report is ‘adopting new technologies in education and knowledge management such as e-learning’ (p25). Sheffield Teaching Hospitals (STH) is a member of the Yorkshire and Humber NHS E-learning Club which aims to improve quality and access to e-learning, as well as influence the national direction for e-learning. STH have invested in e-learning programmes for mandatory and job specific training and also for open learning courses. These e-learning programmes are designed for all staff groups and are intended to be used in the workplace or in the two Open Learning Centres in the Trust.
To enhance the quality of dysphagia management provided by the multi-disciplinary team to patients admitted to the stroke service through improving knowledge and skills.
1. To trial e-learning programmes designed to enhance knowledge about dysphagia in the stroke service, evaluating the barriers and facilitators to job specific, e-learning as a mode of education.
2. To evaluate the application / transfer of learning on adherence and nutritional support provided to patients with dysphagia on the subacute unit of the stroke service.
3. To develop the capacity and capability of the multi-disciplinary team to support patients with dysphagia (and their families) and to reduce the risk of complications from swallowing problems.
4. To conduct an economic analysis of the resource use costs / cost benefit analysis of using e-learning programmes to improve dysphagia management.
5. To disseminate learning across the CLAHRC partnership organisations and beyond, to facilitate its uptake into undergraduate nursing, medical, allied health professional curricula and continuing professional development.
An action research, case study approach is being used to introduce and evaluate the dysphagia e-learning programmes. The knowledge to action cycle (Graham et al 2006) is guiding the case study process. The knowledge translation implementation project has five stages which will be completed over a 12 month period (March 2010-Februay 2011). The five stages are:
1) Preparation when the e-learning programmes will be trialled and the intervention (workplace-based e-learning with skills development/facilitation) will be designed. The three e-learning programmes are STARS 1 and 2 (Stroke Training and Awareness Resources). These are interactive packages for health and social care staff developed in Scotland; see
The third programme is a new e-learning programme produced by the National Patient Safety Agency (NPSA) which will be launched in mid 2010. Facilitation includes putting learning into practice and skills development informed by the National Descriptors for Texture Modification in Adults (BDA/RCSLT 2002).
2) Baseline data collection about staff knowledge, skills and attitudes towards dysphagia management, adherence and e-learning through observation, opportunistic interviews and a brief questionnaire.
3) Implementing the knowledge translation intervention: facilitated e-learning.The intervention is equivalent to job specific training. This means that 80-100% of relevant staff (and students) are expected to participate in the e-learning programme to ensure consistent, quality patient care. Relevant means all staff who are involved with the food, fluid or drug management of patients with swallowing difficulties. Dysphagia is a risk management issue for the stroke service and so priority is given to developing staff knowledge, skills and attitudes towards adherence to the treatment recommendations.
4) Evaluating the outcomes for patients, staff, the team and the organisation by repeating baseline measures. This includes evaluating the implementation of the knowledge translation intervention and economic modelling to estimate the potential cost-effectiveness of e-learning / savings from preventing chest infections and reduced length of stay.
5) Reporting the findings to the stroke service and other dissemination activities. The findings will inform the Trust’s approach to e-learning for mandatory training and the roll-out of the dysphagia programme throughout the hospital to help meet the national quality standards for nutrition (CQC 2010). Wider dissemination activities will include publications and presentations about dysphagia management and workplace-based e-learning.