Eating, drinking and swallowing difficulties (EDS) practice placement case studies

North East London NHS Foundation Trust

Following the first COVID-19 lockdown, the North East London NHS Foundation Trust (NELFT) speech and language therapy team, like so many across the country, spent time considering how we could tackle the challenges of closed caseloads, increased referrals and staffing challenges.

The team had had success in working with the University of Essex practice placement team to develop a learner-supported Intensive Comprehensive Aphasia Programme (ICAP) for people with aphasia and were inspired to think of other ways in which the learner workforce could be supported to not only complete their practice placements, but positively contribute to improvements in services at the same time.

The challenge

Before COVID-19, the team had started to roll out a new swallowing awareness training package to local nursing homes, but faced the challenge of how to ensure adequate and ongoing training opportunities.

Opportunity to address the challenge

With the RCSLT developing pre-registration EDS competencies for learner SLTs, the option of expanding the nursing home programme while supporting learners to complete the new EDS competencies seemed like a perfect match.

Practice placement structure

The team aimed to develop a practice placement which would meet the following aims:

1. Offer swallowing awareness training to one, two, or three nursing homes (depending on practice placement length) with training sessions delivered on multiple days and at different times to meet staffing needs in the homes
2. Support two learners on a paired practice placement to work through practical EDS competencies, getting as close as possible to full competency
3. Ensure that the practice placement did not place undue pressure on supervising SLTs

A timetable (PDF) was drawn up to meet these aims, and the team took two learners on practice placement.

Nursing home training

During the pandemic, the team had developed an online version of the nursing home training programme. This was used to support the learners (paired) to engage in self-directed learning to familiarise themselves with the content of the programme.

In the first week of the practice placement, the learners undertook 3 training sessions with one nursing home:

1. The first session was led by one of the NELFT SLTs and observed by the learners
2. The second was led by the learners under direct supervision by one of the NELFT SLTs
3. The third was led independently by the learners, with the supervising SLT available but not directly present. The learners were advised to answer any queries which were within their current knowledge, and to make a note of any other queries and to feed back to the nursing home, following discussion with the supervising SLT.

The learners carried out weekly telephone calls to the nursing home during the practice placement to troubleshoot any issues with the new programme and to discuss any individual cases.

Completing EDS competencies

The NELFT team had developed an intensive EDS training programme for Band 5 SLTs and planned to use this with the learner SLTs. The programme is based on the King’s Dysphagia Schedule and takes the trainee through the various aspects of swallowing assessment, management and therapy, with graduated levels of supervision. To complete the full programme requires 60 hours of face-to-face practice. At the end of the programme, learners reviewed their progress against the pre-registration EDS competencies.

The programme allows trainees to work with a different supervising SLT each day with every patient contact and which aspects of the framework the contact met is recorded briefly and signed off.  There is a section for reflection at the end of the day, where the trainee records three strengths and one area to work on for the next day.  This document is then passed to the supervisor for the following day, to ensure that trainees are supported at the correct level for their experience.

The team allocated time for the learner SLTs to attend videofluoroscopy and FEES clinics and offered a training session with our clinical lead regarding the benefits/disbenefits of both techniques and referral criteria.

Sharing the load

The team planned to share the work involved in the practice placement across the team, so that responsibility did not fall too heavily on any particular staff member.

As much as possible of practice placement learning was undertaken through self-directed learning.  The team developed resources to support the learners to undertake self-directed sessions on:

• Nursing home training programme
• IDDSI diet and fluid levels
• Swallow therapy techniques and manoeuvres
• Oromotor/cranial nerve assessments
• Case study

The learners were required to select a service user during their first practice placement week and to prepare this as a case study considering how the assessment and management of the patient was informed by the evidence base.  This case study was presented to the speech and language therapy team during a meeting in the final week of the practice placement.

Face-to-face practice placement days working on practical EDS competencies were shared among appropriately experienced team members, with each team member taking the learners for no more than one day each week.

Assessment

At the end of the practice placement, the learners reviewed their progress against the pre-registration EDS competencies (PDF), the standard RCSLT dysphagia training and competency framework (PDF) and their university practice placement paperwork.

This process was led by the clinical lead SLT. To determine which competencies should be signed off, they:

• gathered informal feedback from staff members
• used the evidence from the learners’ case studies
• used feedback from the nursing home
• reviewed the King’s Dysphagia Schedule
• had reflective discussion with the learners

Evaluation

What the learners thought

The learners reported that the practice placement had been well structured and supported.  They liked the pre-planned timetable of learning and felt that they had been able to work through their EDS competencies at an appropriate rate.

In a three-week block practice placement, the learners were able to achieve the following:

• Delivery of swallowing awareness training to one nursing home
• Sign off of most level A and B competencies from the RCSLT dysphagia training and competency framework
• Sign off of 14/20 pre-registration EDS competencies
• Successful completion of university practice placement paperwork
• The practice placement provided 19 hours of face-to-face and 36 hours of non-face-to-face learning

When reflecting back, one learner said, “What surprised me was that I really enjoyed community working – you get to see patients more long term and really follow through with them on goals and plans. This is something you don’t get so much in the fast-paced acute working environment.” They appreciated being able to lead on the training, explaining that it was “invaluable experience for a student, as training others is usually on the person specification for a band 5 post.”

Another said that attending the practice placement made them more likely to consider applying for an NQP role within the service, noting that it was “a really great supportive team who are focused on helping students/NQPs work through their competencies” and that they were “really made to feel part of the team.”

What the staff thought

Staff in the team felt that the workload associated with the practice placement was manageable. The team were really pleased that we had been able to offer such a high quality and successful practice placement with minimal pressure on any specific individuals.

One staff member commented that “having a placement dedicated to dysphagia meant that we could think about all the aspects of managing swallowing difficulties in the community setting; so not just assessment but also training and upskilling those who care for people with eating and drinking difficulties on a daily basis. Getting the students involved in delivering ‘Swallowing Matters’ training to nursing homes gave them a chance to integrate theory into giving practical advice to nurses, HCAs and kitchen staff in care homes, but it also helped our service to expand our training offer to local organisations. A win-win.”

Another staff member appreciated the structured timetable, and confirmed that they “would definitely be happy to support with future dysphagia placements.”

What the nursing home thought

The staff trained at the nursing home were asked to provide feedback on the training provided. Feedback on the quality of training was good, although many staff would have preferred face-to-face training. They noted improvements in care as a result of the training; one staff member mentioned that, “One of the main benefits of the training is that communication between kitchen staff and care staff around the importance of diet modifications has significantly improved, e.g. kitchen staff now really appreciate why a resident’s food has to be prepared in a certain way and do not mind care staff approaching them explaining that a resident’s meal is not appropriate for them.”

What we would do differently next time

Going forward, it was suggested that the practice placement should be offered for a longer period of time – five or seven week block, to allow the learners more time to progress through their practical competencies and to allow training to be offered to more nursing homes.

Additionally, both learners and staff agreed that having back-to-back days together rather than one day per week would be beneficial; learners noted that it “may improve faster development of competencies,” and staff confirmed that this would also be easier for them.

Due to the ongoing pandemic at the time of the practice placement, face-to-face training for the nursing home was not an option, but could certainly be offered as part of the package in future practice placements.

Many thanks to Elaine Holden and her team in adult services at NHS Lanarkshire (@adultSLTLan on Twitter) for sharing the swallowing matters training package and allowing its adaptation and local use. For queries or further detail, please contact the NELFT team via Twitter at @NELFTAdultSLT.