JCPSLP Vol 23 Issue 2 2021

Implementation science

Supporting safe drinking in dysphagia Exploring the use, knowledge and skills of United Kingdom speech pathologists with strategies to support safe drinking Angela Crocker, Hannah Crawford, Alessia Nicotera, Carlotta Griseri, and Hazel Roddam

Speech-language pathologists (SLPs) recommend a range of safe drinking

the practitioners’ rationales for their clinical decision- making. The study reported here asked SLPs to rate their knowledge of the EB for a specified area of their practice, as an indicator of one of the cornerstones of EBP. Many clinical populations can have difficulty or discomfort when eating, drinking, and swallowing; this is known as dysphagia (Gillman, Winkler & Taylor, 2017). These populations include people with neurological impairments, neurodegenerative diseases, head or neck cancers, physical difficulties, learning disabilities, mental health problems, and older people (McCurtin & Healy, 2016). For some, dysphagia cannot be cured: it will be lifelong and may worsen as their health condition worsens. For others, it can be transient and may improve as their health condition resolves. The health risks of dysphagia include choking, dehydration, malnutrition, aspiration pneumonia, and not being able to take essential medications (Troche et al., 2014). As well as health risks there can also be often significant emotional and social risks associated with swallowing difficulties (McHorney et al., 2003). Treatment strategies for dysphagia can be broadly divided into strategies that aim to compensate the effects of impaired swallowing by avoiding or reducing them, and rehabilitative interventions that aim to improve the physical swallow (Baijens et al., 2016). Compensatory strategies do not aim to permanently change the swallow. The focus for this study was to look at a range of strategies to compensate and help people adapt and cope with their swallowing difficulties when drinking rather than treatment strategies to rehabilitate the swallow. The strategies included within this study were influenced by Speyer et al.’s (2010) systematic review of dysphagia interventions as well the authors’ clinical experiences. Speyer’s study revealed a variety of compensatory strategies including bolus modifications and management, swallow postures and manoeuvres, facilitation techniques and other interventions. “The diversity in type of therapy is impressive. Some interventions are well known, but certain studies describe rather unconventional therapy concepts” (Speyer et al., 2010, p. 62). For clarity, the seven categories of drinking strategies adopted for this current study are defined succinctly in the “Methods” section below. The evidence base of effectiveness studies is relatively limited across the range of drinking strategies, with some equivocal findings. For example, the use of thickened liquids is a well-established approach with the aim to improve safety by minimising aspiration risk. Many studies have indicated the prevalent use of thickeners

KEYWORDS CLINICAL SKILLS DELIVERY STRATEGIES DRINKING DYSPHAGIA EVIDENCE- BASED PRACTICE (EBP) THIS ARTICLE HAS BEEN PEER- REVIEWED

strategies for people who have difficulties— or suspected difficulties—when drinking. This survey aimed to determine how frequently UK SLPs use and recommend various drinking strategies in clinical practice to support safe drinking with people who have dysphagia. It also explored the relationship between frequency of use of drinking strategies and practitioners’ self-reported confidence in their skills and knowledge of the relevant research evidence base. This sample of 224 SLPs had a range of experience working with different patient populations with dysphagia. The findings help to increase our understanding of variations in current practice, indicating that “alternative delivery” may be a term that clinicians find meaningful to use when categorising strategies, although this requires greater specificity and transparency. Data about the strategies SLPs are recommending—and not recommending—supports more accurate insights into current clinical practice. This study highlights the need for increased access for SLPs to education and training in knowledge of the evidence base, as well as clinical skills. A ll contemporary health care interventions and treatments are expected to be evidence based (EBP), with practitioners being accountable to maintain their awareness of the relevant research evidence base (EB) to underpin their care planning and delivery. “This requires clinicians to make treatment decisions by using and integrating research, practice and patient evidence” (McCurtin & Healy, 2016, p. 69). Evaluating EBP in routine clinical practice poses methodological challenges for all health care disciplines, including speech pathology. Where there is high variability in clinical practice and a relatively limited evidence base of effectiveness, it is particularly important to establish both the range of practice and

Angela Crocker (top), Hannah Crawford (centre) and Alessia Nicotera

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JCPSLP Volume 23, Number 2 2021

Journal of Clinical Practice in Speech-Language Pathology