Difficulty swallowing (dysphagia) is a hidden, very distressing, relatively common and potentially life-threatening problem. It includes difficulty swallowing saliva, food, drinks and medicines. Swallowing problems can be caused by stroke, Multiple Sclerosis, Parkinson's Disease, head and neck tumours and dementia. Once dysphagia has been diagnosed, strategies are introduced to make the person's swallowing abilities safer. This is vital because dysphagia can lead to serious problems, such as people not eating and drinking enough, choking episodes or chest infections.
In 2010-2011, we evaluated a training package about swallowing problems with the ultimate aim of enhancing patient care on a stroke rehabilitation ward in a large NHS Trust. This small scale study involved blended e-learning, which means we combined practical training with on-line/e-learning programmes about swallowing problems. Important findings that have influenced the next stage are that most stroke nurses learned about dysphagia 'on the job;' all 32 ward staff achieved a nationally recognised level of competence (Boaden et al 2006); and changes in clinical practice were sustained six months after the training. See the executive summary here for more information.
This research will build on the success of the blended e-learning project by extending the learning so that more patients will benefit from being treated by staff with a basic understanding of swallowing problems. The aim is to follow-up the recommendations targeted at the Trust and the Stroke Service, especially those about training the healthcare workforce and considering swallowing problems as a patient safety issue. We will do this by tracking if, and how, the recommendations are accepted, modified or rejected by the Trust; and whether they spread from the stroke rehabilitation ward to other parts of the Stroke Service and throughout the Trust. Three approaches to looking at change will be considered. These are:
- 'Making it happen' or hierarchical control. This involves formalising the dysphagia recommendations in Trust-wide policies and procedures, for example including dysphagia awareness in local induction programmes.
- 'Helping it happen' or participatory adaptation. We are training a cadre of local trainers working in the research sites to share their new knowledge about how to help patients to eat and drink safely. This approach emphasizes collaborative support for the uptake and local adaptation of the recommendations.
- 'Letting it happen' or facilitated evolution. A dysphagia toolkit - a set of resources to support the essentials of dysphagia management - will be put on the Trust intranet and promoted using the mantra 'patient safety: dysphagia matters.' This reflects the facilitated evolution approach whereby resources are made available so they can be found, adapted and tailored to a local problem.
These three approaches come from the international healthcare literature (Ovretveit 2011). By doing this research, we hope to better understand how innovations in healthcare can be implemented more effectively.
- To examine the processes and outcomes associated with the diffusion of a locally developed innovation about dysphagia. The characteristics of the innovation are explicit in the dysphagia e-learning recommendations (Ilott et al 2011), see the executive summary, here
- To identify the factors that influence the adoption, adaptation, scale-up, spread and sustainability of the dysphagia innovation.
- To develop guidance to support wider, longer-term change in a healthcare organisation.
The recommendations from the dysphagia project are being used as a tracer innovation to understand the substance and process of change in context, specifically along two care pathway in a large, integrated healthcare organisation. The care pathways are those for patients with stroke and fractured neck of femur and extend from acute services to rehabilitation in community facilities. These care pathways are complementary on a number of dimensions. For example, dysphagia is a common problem following a stroke, whereas frail, older people who have fallen and fractured their femur may have age-related dysphagia or dysphagia due to dementia or another pre-existing condition. Dysphagia may be a secondary, but important problem due to the risks of malnutrition and dehydration due to swallowing problems.
The research will comprise prospective tracking of the dysphagia recommendations along the two care pathways, over nine months (October 2012-June 2013) and at two levels, namely:
- Organisational: across the Trust through the formalisation of the recommendations in Trust-wide policies and procedures; and accessing the dysphagia toolkit. This reflects the 'make it happen' and 'let it happen' approaches. These will be explored through documentary analysis, interviews with senior managers, as key decision makers, and by monitoring downloads from the intranet.
- Clinical: a training the trainer intervention, with support for cascade training, will be evaluated along the two care pathways, using a pre-post design with interviews, questionnaires and mealtime observations, to examine the 'help it happen' approach.
The processes and outcomes associated with adopting and adapting the dysphagia recommendations will be explored to identify success factors that may be generalisable to other healthcare innovations and settings. Finally, the lessons learned will be summarised in a briefing paper for the CLAHRC-SY website, see here