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Similarities and differences Overall, questionnaire results revealed more similarities than differences in reporting between groups. There was strong endorsement of all items overall (see Table 4). An ongoing approach to training for DSWs in dysphagia and mealtime assistance emerged as a priority. There was also agreement across groups that training be mandatory. DSWs identified a multidisciplinary approach, consultation with people with dysphagia, peer support, collaboration and continuity of care as priorities, while family members identified 1:1 meal assistance as particularly important. Both groups highlighted the value of speech pathology services. Significant differences in the reporting of family members, DSWs and AHPs emerged on two questions. For question 15, “making healthy food choices is encouraged and actively promoted”, family members (mean rank = 35.56) endorsed this more frequently than DSWs (29.76) who in turn endorsed it more frequently than AHPs (24.08; chi-square = 6.3, df = 2, p =.04). For the item “greater emphasis on a multidisciplinary team approach to dysphagia management” (Q.20) a significant difference between groups also emerged (chi-square = 11.9, df = 2, p = .003) with DSWs (37.32), then families (30.09), then AHPs (22.38) rating this item of high importance. Significant differences in group reporting were not found for other Responses from DSWs, family members and AHPs indicated overwhelming support for a range of service improvements in dysphagia management. Information and training for DSWs emerged as a priority. Given the current context in Victoria, where a systematic approach to the provision of education in dysphagia and mealtime support is lacking, this finding is not surprising. Further, results from this study indicate that the longitudinal learning needs of DSWs should be addressed. Although this study has provided some insight into the training needs of DSWs, it has not considered how organisations could deliver such training or what would be appropriate indicators of competence. Continuity of care for adults with dysphagia was not included in the questionnaire but emerged as an issue from focus group discussions. DSWs discussed the challenges associated with supervision, the need for adequate handover and transfer protocols and inter-service communication. It is recommended that attention be given to how continuity of care can be optimised in organisational contexts and that it be described in service procedures or standards. The complexity and challenges involved in supporting adults with dysphagia need to be acknowledged, particularly at the level of balancing safety within the context of the person’s preferences and choices. Given the finding of the importance of peer support, teams and organisations may wish to consider how to strengthen opportunities for reflective practice and collaborative problem-solving for DSWs. Teams could also consider how to foster and sustain effective partnerships between all involved in supporting individuals with dysphagia. For speech pathologists, the study draws attention to the importance of responsive and sensitive collaboration with adults with dysphagia, families and service providers for the provision of quality dysphagia support. questionnaire items. Discussion

These findings contribute to our understanding of the perspectives of key stakeholders in the adult dysphagia context – an area that has not been previously reported in the literature. It is important to continue to listen to family members, support staff and individuals with dysphagia about their experiences and preferences. This feedback should inform practice and underpin the continuous improvement of services. This study has provided evidence for needed reforms in dysphagia management and gives direction for achieving service improvements. Limitations There are a number of limitations of this study. The questionnaire was customised and not based on previously published or validated tools. Due to practical difficulties in recruiting sufficient numbers from residential facilities, all DSW participants were day-service employees. The absence of a balanced perspective from residential and day services is a limitation that could be redressed in future research. The response rate from family members was low and is a source of potential bias. A number of factors may have contributed. For example, at the time of the study, very few adult clients in one of the organisations had active family contact. The indirect recruitment method held a risk that service managers might misdirect questionnaires intended for family members of adults with dysphagia. Postal questionnaires also typically result in lower response rates than other methods (Bryman, 2012). Further research into family perspectives is indicated. This study lacked power due to the small sample size. The extent to which findings can be generalised to the broad population of stakeholders or to other contexts may be limited. Conclusion The purpose of this study was to investigate what “good practice” in dysphagia management means to key stake­ holders and to identify the most important service elements to include in organisational standards. Some differences in perspective between groups were found, but also much common ground underpinned by a shared concern to optimise the health and well-being of adults with dysphagia. Findings indicate strong support from stakeholders for a range of service improvements and provide useful evidence with which to advocate for service reform. Acknowledgements The authors gratefully acknowledge the Grosvenor Foundation for funding this project. References Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology , 3 , 77–101. Bryman, A. (2012). Social research methods (4th ed.). New York: Oxford University Press. Chadwick, D. D., & Jolliffe, J. (2009). A descriptive investigation of dysphagia in adults with intellectual disabilities. Journal of Intellectual Disability Research , 53 , 29–43. Hampshire Safeguarding Adults Board. (2012). Reducing the risk of choking for people with a learning disability: A muti-agency review in Hampshire . Hampshire: Hampshire County Council Adult Services Department. Kennedy, M., McCombie, L., Dawes, P., McConnell, K., & Dunnigan, M. (1997). Nutritional support for patients with

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