JCPSLP Vol 23 Issue 2 2021

drinking strategies were predominantly favoured: alternative delivery, drinking techniques and thickener. Other drinking strategies are used relatively less often, including syringe drinking, postural 45˚recline, free water, and sensory modification. The two most popular strategies—alternative delivery and drinking techniques—are categories that encompass a number of distinctive specific strategies, so this may reflect the high frequency in the survey results. Future studies are needed to explore the frequency of use of the individual strategies within these categories. The findings show that some other strategies are rarely or never used, even where the SLPs report some level of confidence in their clinical skills for these techniques. Some tendency towards polarisation in the responses was noted, as some SLPs reported that they always or never recommend certain strategies. The selection of always may indicate the strategy is considered usual care, with a strong belief that it is always effective. Pacing was an example always was most frequently selected and seems to suggest this strategy is considered usual practice within dysphagia management. For instance, encouraging a slower pace when drinking may be advised as conservative management while patients wait for further assessment. The same could be said for encouraging a small bolus which was the second highest strategy rated as always used. However, some of the other strategies which would not be expected to be considered as usual care were selected by some SLTs as always used, including thickener, sensory modification, postural 45˚ recline, and free water. Syringe drinking was the only strategy that was never selected as used always . Similarly, the selection of never may indicate that SLPs are opposed to the strategy or believe it is not suitable. Over half selected never for syringe drinking. This may be because syringe drinking has been predominantly reported for use with patients who have head and neck cancer but traditionally discouraged with other patients due to increased aspiration risk and bypass the oral phase (Lazarus, 2004). Future studies could specifically explore more deeply the clinical reasoning for why certain strategies are always or never used. This study highlights that a high proportion of SLPs chose the term “alternative delivery” to describe their regular current practice, despite relatively low self-reported knowledge of the evidence base to support the use of this broad range of techniques. In fact, there is little robust research evidence relevant to altering delivery, the impact of various drinking aids or comparing different delivery. The clinical reasons for recommending alternative delivery could vary widely, including: independence, bolus modification, swallow postures, facilitative techniques; and the use of alternative delivery may help a patient compensate for more than one clinical difficulty. Consequently, there is a pressing need for new research of this category of drinking strategies, including the use of various drinking aids (Ney et al., 2009). A small number of studies have investigated SLPs’ clinical reasoning for choice of strategies in dysphagia practice. McCurtin and Healy (2016) explored why clinicians choose the therapies and techniques they do and surmised “two core criteria: they must be suitable for clients and client groups and the therapists must have experience or training in them” (McCurtin & Healy, 2016, p. 69). The findings of this survey may contribute empirical evidence that the most frequently used drinking strategies are those

where the SLPs reported the most confidence in their clinical skills; presumably skills gained through either formal or informal training. The strategies used least were those where the practitioners rated their skills the lowest. Once again, further studies are needed, including more accurate benchmarking of SLPs’ access to dysphagia training, beyond basic or introductory levels. Appropriate research designs are also needed to unpick these assumptions of causal links between training, confidence in clinical skills, and range of drinking strategies implemented, and to access more meaningful insights into the context and influences of real-world clinical decisions. The classification of tools for teaching EBP (Tilson et al., 2011) may be one useful approach. Self-reported knowledge of the evidence base It could be inferred that the tendency towards extreme responses as discussed above, may indicate that the practitioners’ clinical decision-making is influenced by strong beliefs regarding the effectiveness of specific strategies, or by habitual practice routines, rather than explicitly by their awareness and application of research knowledge. The practitioners’ self-reported knowledge of evidence is variable across all drinking strategies, with one-third of SLPs who did not rate their knowledge of the EB as good for any of the strategies. The most frequently recommended strategies appear to be those where the SLPs report greater knowledge of the EB than for the lesser used drinking strategies. This survey did not ask the SLPs to provide any examples to demonstrate their awareness of specific research knowledge, so it is not possible to calibrate the reliability of their self-ratings, the sources of their research information, or their routines for keeping themselves updated. In this survey, the use of thickener is the third most frequently used drinking strategy, with half of SLPs reporting that they frequently recommend this. In addition, most SLPs in this survey sample rated their knowledge of the EB for thickener as high . By implication this would suggest limited knowledge and implementation of the most recently published evidence for the risk of harm and reduced patient experience of quality of life (Groher & Groher, 2012; Lazenby-Paterson, 2020; Lippert et al., 2019; O’Keefe, 2018). Limitations In common with other survey studies, there are potential biases related to the self-selected sample and self-reported practice behaviours. Years of work may only be taken as a proxy indicator of experience, not expertise in dysphagia. Our survey had a high response rate from SLPs working across a range of caseloads and settings, so the experience of clinicians was sufficient for our exploratory benchmarking study. Further understanding of clinician experience would be required with future studies investigating the influence of expertise on use and knowledge with safe swallow strategies. Observational studies would also assist measures of actual practice, and future studies could adopt a range of exploratory designs to better understand situational judgements and clinical decisions. In terms of limitations with our survey, example descriptors were not included for each of the seven

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JCPSLP Volume 23, Number 2 2021

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