COVER STORY

What Kate Did at Work

I mean to do something grand. I dont know what yet; but when Im grown up I shall find out. (Katy Carr in What Katy Did) Kate Balzer and her team discover that recognising the need for staff training to improve the lives of people living in nursing homes is just the first step on a lengthy and challenging journey.

am one of five whole time equivalent speech and language therapists working with the over 16s in the community for Lambeth Primary Care Trust. My clients have acquired communication and / or swallowing difficulties and about half of them live in nursing homes. Out of 11 nursing homes in the borough of Lambeth, 8 are near my base, the Whittington Centre in Streatham. As Im so involved in nursing homes, I felt that improving the experience of people living in them through effective training of nurses and health care assistants was a major priority for our service. This view is shared locally, nationally and professionally. Locally, in 1997 we had a Challenge Fund Project Specialist On-going Nursing and Therapy Needs in the Private Sector Nursing Homes in Lambeth. This assessed the extent and nature of specialist community nursing, equipment and therapy input required in the private sector nursing homes in Lambeth, in accordance with the NHS Continuing Care Policy. Recommendations were made regarding the level of therapy needed and the potential training required by the nursing home staff. Areas of training need identified included swallowing and communication disorders. The report also made it clear that training has to be ongoing due to the level of staff turnover in homes. The Care Homes Support Team was established across Lambeth, Southwark and Lewisham in 2001 to assess and review the health care needs of residents in care homes and to develop the practice of staff. One way the Care Homes Support Team has progressed this is to collate and offer an annual brochure of training. Local care homes themselves have also identified training needs following piloting of the Essence of Care Food and Nutrition benchmark (DH, 2001). Staff development needs in care homes have also been highlighted at a national level:

Better Care, Higher Standards Charters (DH, 1999) guidance on the development of joint local charters for people who need long term care NSF for Older People (DH, 2001) - eight standards which aim to provide person-centred care, remove age discrimination, promote older peoples health and independence and to fit the services around peoples needs The development of the National Care Standards Commission (2002, arising from the Care Standards Act, 2000), an independent watchdog set up to regulate social care services and private and voluntary health care. Training in nursing homes has long been recognised by speech and language therapists as an area for development (Ramm, 1997) and various means of training have been described (for example Freedman & Booth, 2005). Communicating Quality 3 (RCSLT, 2006) advises that dysphagia referrals no longer require GP consent but rather can come from any member of the multidisciplinary team. It also suggests that professionals involved will usually have had some training in dysphagia identification from the SLTs (p.191). Our nursing homes in Lambeth seemed an ideal setting to trial and explore this model of working.

READ THIS IF YOU WANT TO IMPROVE COMMUNICATION ENVIRONMENTS CATER FOR DIFFERENT LEARNING STYLES MAKE A CASE FOR TEAM AWAY DAYS

Different approaches
Over the years we have tried different approaches to training staff in nursing homes. Firstly, following the Challenge Fund Project (1997), we developed a training package that was implemented in the then seven private sector nursing homes in Lambeth between August 2001 and August 2002. The package was fairly traditional in its classroom style presentation, but we did attempt to involve participants as much as possible. In total 54 staff attended the communication training and 52 attended the swallowing train-

ing. Just under a third of attendees at all sessions were trained Nurses, the others being mainly Health Care Assistants. Evaluation of this training package revealed that staff felt more confident in managing residents with swallow and communication disorders and that their knowledge increased. A difficulty arising from implementing this training package was the lack of input from the homes before and after training (for example failing to complete questionnaires) and low attendance, which in one case meant a session had to be cancelled. Next, we made adaptations to the package and repeated the programme of training between September 2004 September 2005 across all private sector nursing homes (at this point nine) and one NHS home. In total 110 staff attended the communication workshop and 109 attended the swallowing workshop. The different qualifications of staff members were also recorded and the ratio of Registered General Nurses to Health Care Assistants worsened at only one nurse to every assistant. While it is important to train the health care assistants, who will be seeing and feeding residents daily, it is equally important to train the qualified nurses who write care plans and give instructions. New evaluation questionnaires were completed immediately following
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COVER STORY

Figure 1 Evaluation of Communication Workshop 2004 / 5

8 8 8 8.5 8.5 9

on Figure 4 Communication True / False Quiz Tick true or false for each of the following... TRUE FALSE You should pretend to understand if you dont Clients with end stage dementia dont initiate conversation A Speech and Language Therapist only sees clients in therapy centres People only communicate in order to share information You can communicate through posture Dysarthria symptoms always present in the same way A dysphasic client will have difficulty in articulation

Figure 5 Swallowing True / False Quiz Tick true or false for each of the following... TRUE FALSE Dysphagia isnt a disease itself but a symptom Getting enough food and drink is the only reason for safe swallowing Coughing can push food/drink away from the Airway Change in breathing pattern may indicate swallowing problems Soft foods are the first option for managing dysphagia You need thickener to make a thin drink Soft food needs pureeing GPs must sign a referral for a swallow assessment Pocketing of food in the cheeks is dangerous A client with frequent chest infections should be referred to a SLT Figure 7 Evaluation of Swallowing Quiz 2006

confidence - score out of 10 (self-rated) Identifying difficulties Dealing with difficulties Knowing when to refer Knowing where to go Methods and materials Usefulness Overall

Figure 2 Evaluation of Swallowing Workshop 2004 / 5

8.5 8 8 9 9 9.5

confidence - score out of 10 (self-rated) Identifying difficulties Dealing with difficulties Knowing when to refer Knowing where to go Methods and materials Usefulness Overall

When a client gets stuck in communication, you should offer suggestions When a client makes an error you should correct them Low mood can affect communication Figure 6 Evaluation of Communication Quiz 2006

Figure 3 Referrals from nursing home staff 2004 / 5

3.5 3 2.5 2 1.5 1 0.5 0
04 04 04 04 04 04 04 04 04 04 04 04 05 05 05 05 05 05 05 05 05 05 05 05 n b r r y n l g p t v c n b r r y n l g p t v c Ja Fe Ma Ap Ma Ju Ju Au Se Oc No De Ja Fe Ma Ap Ma Ju Ju Au Se Oc No De

9
9

introduction of training
7
question number

7
question number

5 3 1
0 after before 5 10 15 20 number of participants answering correctly 25

5 3 1
0 2 after before 4 6 8 10 12 number of participants answering correctly 14

the training and the results are in figures 1 (communication) and 2 (swallowing). Although the evaluation revealed confidence and satisfaction with the training no before / after comparison was recorded. A measure of knowledge gained had proved too lengthy during the previous training (2001/2) and did not measure carry over to practice so we didnt use it on this occasion. Furthermore, the difficulties of logistics and commitment were repeated - and dont appear to be confined to Lambeth (Freedman & Booth, 2005). The only measure we can draw on to tell if we made a difference is the number of referrals received from nursing home staff before and after training. Figure 3 shows an increase in referrals to one centre (the Whittington Centre) coinciding with the introduction of training sessions to nursing homes in that area in January 2005. This does however only show an increase in awareness rather than any positive changes in practice, and the appropriacy of the referrals isnt recorded. Recognising that we needed a more strategic approach, in August 2005 the speech and language therapy team met to discuss improvements and changes that they would like to see in nursing homes. This included:

staff knowing why were there appropriate and complete referrals an environment that supports communication enough time, support and care at mealtimes. We developed and prioritised possible ways to trigger these changes during further away day sessions. Practical ideas included: 1. recommending the use of pre-thickened drinks rather than simply giving consistency advice 2. introducing Dysphagia Information files to every nurses station 3. developing meal time charts to be put in every dining room explaining and reiterating individual client needs 4. providing staff with a flowchart to ensure that a speech and language therapy referral is the most appropriate course of action 5. setting up an internet page to publicise the speech and language therapy service and referrals procedure 6. using work with individual clients to demonstrate good practice to staff 7. offering classroom training specific to nurses (who might refer) and carers.

New methods
Through discussion we generally agreed that formal classroom based sessions would not suit everyone. Nor would they achieve the aims of training - to develop practice thereby improving the experience of residents in care homes. Kolbs experiential learning theory (1984) and Honey & Mumfords Learning Styles (1982) validate this view, and prompted us to think about new methods. For example a theoretical discussion may benefit some staff while practical experience and / or feedback from colleagues may reinforce knowledge in others. Concurrently, the development of the Care Homes Support Team provided new opportunities to develop training. Speech and language therapy training sessions can be advertised in the Care Homes Support Team training brochure. Attendees register through the Support Team, who then book the venue and arrange audiovisual equipment, handouts, certificates of attendance and analysis of evaluation. The individual Support Team nurses also provide an onsite resource able to follow up and feedback. All costs are met by the Care Homes Support Team. The speech and language therapists

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COVER STORY

Figure 8 Referral considerations Should I refer to Speech & Language Therapy for a swallowing assessment? Before making a referral, consider: Is the person fed through a tube (eg. a PEG)? If yes, consult the Home Enteral Nutrition team* Is the problem due to loose or missing dentures (false teeth)? If yes, refer to the dentist* Is the client eating and/or drinking less? If yes, discuss with the GP and maybe refer to the dietitian * Does the client need equipment to help with eating and drinking? If yes, refer to Occupational Therapy * Does the client need to be better positioned to eat and drink? If yes, refer to Physiotherapy* or discuss with your manual handling advisor Is the only difficulty in swallowing tablets or medication? Discuss with the pharmacist* Has the person been seen by speech and language therapy before? If yes, look to see if there are already recommendations in place and if things have changed Is the client drowsy and unable to stay awake for 15 minutes? If yes refer to GP * if unsure of how to refer to local services. ask GP

Figure 9 September 2006 questionnaire Please complete this form after every visit to a nursing home during the month of September 2006. 1. Was the original referral appropriate? 2. Was the referral complete? 3. Were the staff expecting you when you arrived? 4. Do you feel that the staff knew the SLT role? (i.e. why you were there) 5. Do you feel that the staff knew their role? (eg. referring to dentist first, following care plan) 6. If youve visited before, have the staff acted on your advice? (re: consistencies, AAC charts etc.) 7. Were you able to speak to the relevant staff? 8. Does the environment support communication? (activities, 1:1 time, awareness, choices etc.) 9. Is there enough time, support and care at mealtimes? 10. Does there appear to be good communication between staff? (care planning etc.) 11. Are there any problems obtaining different consistencies for clients? 12. Have you had any communication referrals from this home in the last 3 months?
NB: By staff we include nurses, carers, managers, activity co-ordinators, kitchen staff etc.

YES

NO

N/A

Additional Comments (continue overleaf if necessary).....................................................................

who lead the sessions do so as part of their normal jobs and we hold courses at nursing homes, so our costs are mainly for stationery. In the eight months to date, several of these innovations have been piloted in Lambeth. Classroom sessions - similar to those held in previous years - have been offered centrally through the Care Homes Support Team Training Brochure (rather than in individual nursing homes). The consequent increase in the kudos of the workshops has resulted in a good response (21 and 13 staff have attended single communication and swallowing sessions respectively) and no sessions have had to be cancelled. A before-and-after evaluation in the form of a short quiz (figures 4 & 5) revealed an increase in knowledge in all areas (figures 6 & 7). This classroom training will continue in the forthcoming academic year although the package will be adapted to better suit the needs of Health Care Assistants who form the majority of participants (now three for every one Nurse). This training will focus more on practical problem solving - for example how to feed a client with dementia - rather than theory such as the stages of swallowing. Thanks to the involvement of neighbouring speech and language therapy teams, the training is also to be extended to nursing homes in boroughs of Southwark and Lewisham (also catered for by the Care Homes Support Team). In addition to this the Primary Care Trust employed a locum speech and language therapist to carry out a 6 month level of need project (ending in March 2006) at the largest local nursing home. This gave a unique opportunity to pilot specialised training for trained nurses and the use of a questionnaire to guide referrals (figure 8). The training involved more theory (stages of swallowing; possible reasons for a swallowing problem) and focused on screening before referring to speech and lan-

guage therapy. Pending publication of Communicating Quality 3 (RCSLT, 2006), the GP at this nursing home also allowed a blanket referral system enabling an opportunity to pilot referrals from trained nursing staff. Other non-classroom ideas were also piloted at this nursing home, including the introduction of pre-thickened drinks to improve compliance to dysphagia recommendations and the development of mealtime charts in dining rooms to communicate individual residents needs. Katy was too much in earnest now not to improve. Month by month she learned how to manage a little better, and a little better still. Matters went on more smoothly. (from What Katy Did) The August 2005 wish list of what speech and language therapists in Lambeth wanted to see change in nursing homes will ultimately provide a qualitative measure of our input. During the month of September 2006 therapists were to complete a short questionnaire (figure 9) each time they visited a nursing home. Over the following 6 months all our ideas were being rolled out to all eleven nursing homes in Lambeth. Repeating the questionnaire on all nursing home visits in March 2007, following implementation of all our ideas, should show improvement We will let you know how we get on. Kate Balzer is a Principal Speech and Language Therapist at the Whittington Centre, 11-13 Rutford Road, Streatham, London SW16 2DQ, tel. 020 8243 2500, e-mail kate.balzer@ lambethpct.nhs.uk.

Department of Health (2001) National Service Framework for Older People. Crown Copyright (available online at www.dh.gov.uk). Department of Health, Department of the Environment, Transport and the Regions (1999) Better Care, Higher Standards: A Charter for Long Term Care. Crown Copyright (available online at www.dh.gov.uk). Freedman, N. & Booth, K. (2005) Turn up and tune, Speech & Language Therapy in Practice, Autumn, pp. 20-22. Great Britain. Care Standards Act 2000: Elizabeth II. Chapter 14 (2000) London: The Stationery Office (available online at http://www.opsi.gov.uk/acts/acts2000/20000014.htm). Honey, P. & Mumford, A. (1982) Manual of Learning Styles. Peter Honey Publications. Kolb, D.A. (1984) Experiential Learning. Englewood Cliffs, NJ: Prentice Hall. Ramm, B. (1997) How well do we communicate with nursing and residential homes?, Bulletin of the Royal College of Speech & Language Therapists. June. RCSLT (2006) Communicating Quality 3: RCSLTs Guidance on Best Practice in Service Organisation and Provision. London: SLTP Royal College of Speech & Language Therapists.

References
Coolidge, S. (1872) What Katy Did. London: Puffin Classics. Department of Health (2001; 2003; 2006) Essence of Care: Patient-focused Benchmarks for Clinical Governance. Crown Copyright (available online at www.dh.gov.uk).

REFLECTIONS DO I SPECIFY THE CHANGE I WANT TO SEE AND COME UP WITH PRACTICAL IDEAS TO GET THERE? DO I USE LEGISLATION AND POLICY TO SUPPORT PROJECTS I AM MANAGING? DO I RECOGNISE THAT INCREASED AWARENESS FOLLOWING TRAINING IS NOT THE SAME AS A CHANGE IN PRACTICE?

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