Dysphagia is a common health risk for the elderly. Due to physical and / or cognitive disabilities, many long-term care service users are dependent on  their caregivers’ skills and knowledge in many aspects of their lives. This study investigated the effects of an 1-day dysphagia training delivered to long-term  care workers, and eighty workers took part in the study. Two questionnaires were completed by each participant: one immediately before and one after  training delivery. The questionnaires measured the knowledge, attitude, and skills of long-term care workers for dysphagia. The findings indicated a significant  increase in knowledge and skill scores. The study found that dysphagia training was effective at increasing staff’s knowledge and skills regarding dysphagia  detection and management. It is recommended that this study should be replicated with a control group, and improved feasibility could be achieved through  long-time follow up.

• Dysphagia

• Knowledge

• Skill

• Training

• Long term care

Hsiang CC, Chang CM, Chen CH, Hwu YJ (2018) Effects of Training on the Knowledge and Skills of Long Term Care Workers in Managing Clients with Dysphagia. Ann Otolaryngol Rhinol 5(2): 1210.

With the rapid advancements of medical and health care, the life spans of people around the world have been prolonged. The sequelae derived from aging and disease, although not acute, may affect people’s quality of life. Oropharyngeal dysphagia is one of these topics. Dysphagia can be defined as a difficulty in oral preparation for swallow or in moving a bolus from the mouth to the stomach [1]. The prevalence of impaired swallowing capacity among elderly people over 65 years of age is 11-80% [2]. For residential long-term care facilities, the prevalence of dysphagia among the elderly is as high as 68%, which is significantly higher than that of community senior residents [3].

With regard to eating and drinking difficulties, a person may require verbal or tactile reminders to maximize swallowing safety. In addition, modified diet or fluids may be needed; otherwise, dysphagia can lead to malnutrition [4] , dehydration [5], and aspiration pneumonia [6], which makes people unable to enjoy eating, and reduces their interpersonal interactions during eating, thus, affecting quality of life [7]. Dysphagia causes aspiration pneumonia, which is an important risk factor for repeated hospital admissions [8]. The associated risk of requiring hospital admission also places a demand on health and social care resources. To reduce hospital treatments and avoid serious consequences, dysphagia must be addressed and well managed by long-term care services; therefore, staffs must appropriately identify and manage dysphagia.

Training may be offered to staffs who work in the long-term care field to ensure they have the necessary knowledge and skills to optimize swallowing safety. For any person engaged in health care work, having sufficient training and knowledge is essential for them to assume their clinical duties, and provide quality care services. To maintain professional development, health care professionals can read literature and participate in workshops, group discussions, seminars, and practical workshops, in order to learn new knowledge and skills or continuously improve their professional capabilities [9].

When long-term care workers equip themselves with related knowledge and / or skills, people with dysphagia may avoid adverse events, such as choking or aspiration. Chiang and Hwu [10] explored the feeding experiences of nursing aides for residents with dysphagia, and found that staff required more training to ensure that adults with dysphagia were managed with optimum safety. Training is therefore an emergent issue for longterm care workers.

There is a small body of research regarding the effectiveness of training delivered to staff working with people with intellectual disabilities [11], and the trainees expressed that their most favorite components of training were group activities, discussions, and practice.

It is clear that training is important for the care of people with dysphagia. However, few researches have explored the effectiveness of training delivered to those who care for adults with dysphagia. The aim of this study was to establish whether or not an 1-day dysphagia course delivered to staff who cared for adults with dysphagia was effective in increasing staff knowledge, attitude, and skills after the course was attended.

Design, participants and setting

A quasi-experimental, pretest-posttest method was used to investigate the impact of training on dysphagia capacity for longterm care workers. In Taiwan, all staff in the facility will help with feeding the residents during each meal, including the head nurse, registered nurse, administrative staff, etc., so as to guarantee one-to-one feeding-especially for those patients with dysphagia. Therefore, employees working in long-term care institutions in Taichung District were taken as the study population, and the convenience sampling method was adopted to ask professionals (such as nurses, social workers, etc.), nursing aides, and others (e. g. administrators) to participate in the 1 – day dysphagia training course. Regarding the specificity of intervention, the principle of random sampling was not adopted, and no control group was arranged.

Measures

According to the researchers’ qualitative interviews with the staffs of the long-stay type of long-term care facilities, the staff said that what is needed most is to identify the symptoms and care strategies for dysphagia [11]. There are five evidencebased guidelines for the management of dysphagia, which refer to the clinical guidelines developed by the Joanna Briggs Institute (JBI). Therefore, the researchers comprehensively followed the guidelines for the evidence-based care of dysphagia [12-16], and developed a total of 50 items as the guidelines for the care of dysphagia, including comprehensive review (5 items), screening assessment for dysphagia (8 items), safe eating for people with dysphagia (10 items), position of people with dysphagia (8 items), diet for people with dysphagia (3 items), oral motor exercises for people with dysphagia (9 items), swallowing manipulation techniques for people with dysphagia (5 items), and staff training (2 items). In addition, 13 experts were invited (3 nursing scholars, 6 nursing staff, 3 speech and language therapists, and 1 nutritionist) to attend the focus group. After the meeting, which considered safety issues, we removed the items that must be performed by speech and language therapists, including one item of screening assessment for dysphagia, 8 items of position of people with dysphagia, and 5 items of swallowing manipulation techniques for people with dysphagia. The consent levels among the other items and were all over 70%, thus, they were retained, and the total number of items was revised to 36.

The expert meeting was followed by the assessment of the dysphagia screening tools, and the four scales consent levels were: Gugging Swallowing Screen (GUSS) 90%, standardized swallowing assessment 50%, conscious dysphagia scale 44%, and risk assessment of dysphagia 44%. Therefore, three assessment scales, other than the GUSS scale, were deleted. Only GUSS Part 1 could be used after the discussion of the GUSS assessment form.

According to the guidelines for dysphagia care, a questionnaire measuring the knowledge, attitudes, and skills of long-term care workers of dysphagia was developed, and divided into four parts (Table1).

Table 1: The contents of dysphagia questionnaire.

1. Demographic data: such as job title, gender, education level, marital status, whether or not receiving care training for dysphagia, age, years of service, and years of experience in long term care.

2. Knowledge: the knowledge of guidelines for dysphagia care included 7 questions for identifying the symptoms of dysphagia, such as food stagnation on the buccal side and coughing after eating; and 8 questions of dysphagia care, such as feeding for dysphagia, administration, etc.; where 1 point is given for each correct answer and 0 points for each wrong answer. The score range was 0 to 15 points.

3. Attitude: There were 6 questions in the guidelines for dysphagia care, including that the guidelines for dysphagia care could improve the quality of care, receiving dysphagia education and training could improve elders’ ability to eat, etc. Where 1 to 5 points were given depending on the consent level, with scores ranging from 6 to 30 points.

4. Care skills: The care skills of dysphagia included 9 items of general measures, 5 items of swallowing assessment methods, and 7 items of oral motor exercises. Where 1 point was given for each correct answer and 0 point for each wrong answer.

The participants were also saked to send the pictures regarding their application of training program in the facility through e–mail after three months (Table 1).

The training program

After the teaching plan was developed according to the 36 items of the guidelines for dysphagia care, as revised by the meeting of the expert group, an 8-hour 1-day education and training course was developed, including screening assessment for dysphagia, safe eating for dysphagia, and oral motor exercises for dysphagia (singing), as well as dietary practices for people with dysphagia. According to the theme, speech and language therapist, nurses, activity leader, and nutritionist were invited to give lectures, and all handouts were bound and distributed to each study participant. Training focused on the anatomy and pathophysiology of swallowing, as well as the signs of dysphagia, in order to equip participants with the knowledge and skills to detect and manage dysphagia. Furthermore, there were workshop activities to introduce different food textures and modified fluid consistencies. This opportunity to practice the assessment of swallowing and oral motor exercises could equip participants with the required skills, as well as form positive attitudes towards dysphagia.

Data collection procedure

After approval to carry out this study was obtained, the researcher held an1-day dysphagia seminar on 25 November 2017, and a free online registration system was provided to the attendants. The total number of attendants was 84, and the principal investigator explained the detailed information about the study before training. Those who chose to participate completed their first questionnaire at the start of the training day.

Then, after the attendants received the 1-day training program, which included PowerPoint presentations, discussions, and workshop activities, post-testing was conducted. Four attendants left the class early for personal factors; therefore, the data of eighty pairs were processed.

Ethical considerations

This study was reviewed and approved by the research ethics committee (approval number HP170036), and the attendants who agreed to participate signed informed consent. The participants could withdraw from participation at any time without influencing their rights to attend the training. The researcher collected the required data twice: at the baseline (pretest) and after the training program (posttest). Collected questionnaires were kept in a private cabinet to keep the participants’ information private and confidential.

Data analysis

SPSS version 23.0 was applied to examine the data (SPSS, Inc., Chicago, IL, USA). Descriptive statistics were used to describe the characteristics of the sample, and paired-t test was utilized to examine if there were any statistically significant differences between the mean pretest and posttest scores of knowledge, attitude, and skills for dysphagia.

Demographics of participants

Eighty participants took part in this study. All of the participants were professionals (e.g. registered nurse, social workers), nursing aides, or others (e.g. administrators), who worked with adults with physical and / or cognitive disability in home services, day care centers, community care stations, or nursing homes. The participants attended an 1-day dysphagia training course.

Sixty-six (82.5%) of the 80 participants were female, the education levels of 67.6% of participants were above university, over one half of the participants are married, and most of the participants (82.5%) have never received dysphagia training. The mean and standard deviations of age, years in service, and years of experience in long-term care were 42.2±13.0, 5.1±9.3, and 2.6±5.5 years, respectively (Table 2).

Table 2: Demographics of participants. (N = 80)

Effects of dysphagia training program

Paired-t test was applied to examine the changes in knowledge, attitude, and skills towards dysphagia care (Table 3).

Table 3: Changes in knowledge, attitude, and skills of dysphagia care.

Two thirds of children with vocal nodules and functional dysphonia were boys.

1. Knowledge towards dysphagia care

Results showed that participants had changes in their overall knowledge and strategies of dysphagia care scores, and these changes were statistically significant. While the participants experienced slight improvement in identifying the signs of dysphagia scores, these changes were not statistically significant.

2. Attitude of dysphagia care

Regardless of the pretest or posttest, the attitude scores of the samples regarding the 6 items of the guidelines were between agreement and strong agreement. The aggregate average of the 6 items was 27.16 points (±5.63), and the posttest was 28.43± (±4.19). The paired t value was 1.67, with a p value of .099, which is not statistically significant (Table 3).

3. Slills of dysphagia care

Table 3 showed the changes in the skills of dysphagia care, which were statistically significant for generalized intervention (p= .000), assessment of dysphagia (p =.000), and oral motor exercise (p =.000).

The hierarchy needs of Abraham Harold Maslow are originated from motivation theory. When people’s basic physiological needs for eating are not satisfied, it will affect the quality of their lives, as the needs of other classes cannot be satisfied at all [17]. In order to overcome the increased number of elderly people suffering from dysphagia, long-term care workers with adequate knowledge will help the early detection to reduce the harm of dysphagia to the elderly.

The aim of this study was to establish whether or not an one-day dysphagia training program was effective in increasing participants’ knowledge, attitude, and skills to care for adults with swallowing difficulty. Results confirmed that participants gained knowledge and skills for dysphagia care.

Although the results of this study showed slight changes in the scores of identifying the signs of dysphagia among the 80 participants, these changes were not statistically significant. According to the previous studies [10], both nurses and nursing aides were anxious to know how to identify the signs of dysphagia. The ability to differentiate the signs of dysphagia in various stages is a high challenge for long-term care workers through an1-day training program. Simulation is an effective teaching strategy that can help students develop cognitive and practical skills [18]. Prospect research should be conducted to test the effects of simulation on the identifying signs of dysphagia for long-term care workers. The results showed that the pretest of attitude toward using the dysphagia care guideline falled between agreement and strong agreement, thus, the level of improvement for attitude scores was limited.

Endoscopy and modified barium swallow (MBS) are usually used for the assessment of dysphagia, where the latter is the most commonly used method at present, and is respected as the gold standard for the determination of dysphagia due to its efficacy to distinguish between oral and pharyngeal anatomy and physiology abnormalities. The findings of modified barium swallow can be used as a basis for selecting swallowing training programs and tracking efficacy [19]. There are many difficulties in frequently performing modified barium swallow, as it must be performed by the Department of Diagnostic Radiology, and there is the problem of exposure to radiation. Therefore, simple and easy-to-follow evaluation methods, such as swallowing tests and throat vocal swallowing screening, can be easily performed by care workers. Assessment focuses on the identification of dysphagia, and determines if a person’s swallowing is safe. If health care workers can know how to operate these simple assessment methods, it will help the early detection of dysphagia cases, and serve as a basis for tracking the development of the disease. The long-term care workers who participated in this educational training generally agreed that it was easy to perform the preliminary assessment of Gugging Swallowing Screening (GUSS) for dysphagia [20] (Table 4),

Table 4: Gugging Swallowing Screen: Preliminary Assessment.

Note: continuous observation or assessment is required for 1-4 points; refer to further treatment is required for 5 points.

and it was helpful to initially identify if there is dysphagia.

Long-term care workers must face feeding problems day-byday; however, their practices may be unsafe due to unaware of the eating, drinking, and swallowing problems, or lack the skills to detect problems in a timely manner. To examine the retention of effect, the practices of the staffsare video recorded when supporting a client with a meal before and after training. This kind of research will show evidence for improvement.

Modifying the consistency of food and drink is a strategy commonly used in the management of dysphagia. Although products with different consistencies of foods and drinks were provided and demonstrated in this training program, the participants deemed them as difficult to follow, and high-lighted the need for longer training in the area of food modification.

Tongue muscle strength, mobility, and endurance will change with aging, thus, affecting people’s ability to speak and swallow. The swallowing part may impact the oral phase, and result in difficulty in chewing, clearing of bolus, and aspiration during swallowing [21]. Therefore, the educational training of dysphagia focuses on the enhancement of tongue muscle strength during oral motor exercises, particularly the training of the tongue muscle resistance. In addition, music was integrated to the oral motor exercises, and participants could feel the movement of tongue, palate, and pharynx when they sang songs.

When the participants sang the songs, the musical components could facilitate oral, tongue, vocal, and respiratory functions, which restore the swallowing function [22]. Our exercise programs focused on improving the range of motion among the jaw, lips, tongue, and larynx during swallowing. Singing and vocalization interventions can incorporate these movements, and may produce significant results for clients with swallowing difficulties.

This study was limited to the long-term workers of the Taichung area. Due to the specific nature of curriculum development, random sampling was not adopted; instead, the principle of convenience sampling was used, and there was no control group. Therefore, the sample could not represent all longterm-care workers. The results of this study showed that, after the education and training of the guidelines for dysphagia care, the capacity of the long-term care workers had improved the accuracy of their knowledge of dysphagia, and they showed remarkable results in the skills of dysphagia care. The results of this study can be applied to the in-service education and training programs for long-term care workers, and it is also recommended that the guidelines for dysphagia care might be included in the training program of novice, in order to enhance their care quality for cases with dysphagia.

While the findings of this study are important and valid, this study did have a small sample size, thus, future research should include a larger sample size. The training effects should be followed up to know whether the retention of the good practice or not. A 3-month or 6-month follow-up questionnaire could be useful to determine whether knowledge and skills gains are maintained. Furthermore, we propose that future educational efforts need to be focused on actual benefits to residents, for example how many episodes of aspiration come down.

The authors thank the attendants of the training program from long-term care facilities in Central Taiwan for their enthusiasm, and acknowledge the participants who provided invaluable data for this study. This study is supported by grants from the Ministry of Science and Technology (No. Most 05-2632-H-166-001) and Changhua Christian Hospital (CTU106- CH - 005).

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