Elizabeth Roberts Lunchtime Seminar 22nd April 2015

BARRIERS AND ENABLERS TO NEW AND DIFFERENT WAYS OF WORKING IN DYSPHAGIA CARE.
CONTEXT

In an effort to curb increasing demands on health care resources, both health policy think tanks (King’s Fund, 2010) and government departments (Department Health 2004, 2008)in the UK have highlighted the importance of various forms of role revision. Despite this, both the benefits, the opportunities and the attitudes of staff towards such developments remain poorly evaluated and researched (Health Foundation, 2010), and uptake remains relatively low across professional groups. This is particularly evident in the area of dysphagia care in stroke, where both dietitians and Speech and Language Therapists (SLTs) roles remain distinct, despite overlapping and closely linked work.

METHODS

The research explored, using grounded theory methods, the barriers and enablers for new and different ways of working in dysphagia care in stroke. Data were collected in two phases usingsemi-structured interviews across two main research settings (an acute and a community care site with limited role expansion in dysphagia, and a combined community and acute Trust with a nationally celebrated programme of role expansion for nurses). Additional data were collected from interviews with profession al body representatives and clinicians expanding the roles of nurses and assistant staff in other dietetic and SLT departments. Interviewees included dietitians (n = 10), SLTs (15 interviews, n = 15), assistant staff (n = 2), nurses and other health care professionals (n = 8) and commissioners (n = 3), as well as service users and their carers (6 interviews, n = 12). Interviews were carried out by the PhD candidate and initially used a topic guide. Developing themes were then explored in more depth in subsequent interviews. Data were analysed using NVivo. A theoretical model was constructed to visualise the barriers to role expansion in the first setting and how this had been enabled in the second setting.

RESULTS

The core phenomenon to emerge that explained the differences was where the line had been drawn along a continuum between explicit and tacit knowledge. Participants in the second setting had shifted their definition of this line and in doing so, were passing on more of the aspects of their roles to other types of workers.

The conditions causing this shift were: 1) A crisis or difficulty in managing the service, such as short staffing coupled with waiting time targets, an inability to fill vacant staff posts, complaints and clinical incidents, 2) An individual with a clear vision for the service (“personalities”), and 3) Having seen it be done somewhere else. Other intervening factors also facilitated this process. These were: 1) Health and professional policy and 2) Having support (both organisational support for the process and Support for those “receiving” skills and knowledge.

The process started small (i.e. dysphagia trained nurses on the stroke ward) and then expanded into other areas, once ignited, in a self-perpetuating cycle, as the benefits of this new way of working were realised by those “giving away” their previously held expert and tacit skills and knowledge. The phenomenon continued to grow into new areas, contracting back from those where the benefits were not realised (dysphagia trained nurses across the whole hospital) while seeking out other areas to grow (dysphagia trained nurses in nursing homes).

The benefits that are realised are: 1) More time to focus one’s own tacit skills and knowledge on the more complex patients, 2) More appropriate referrals, 3) Having a greater professional/ clinical impact, 4) Greater job satisfaction, and 5) Other intrinsic and external rewards, such as awards. The fears that are initially held are other types of workers “overstepping the mark” and “being done out of a job”.

DISCUSSION

Although many aspects of the role of both dietitians and SLTs in the area of dysphagia management could, and have been, codified and taught toother types of workers, this knowledge and these skills are maintained as tacit skill, in order to maintain control over theclinical area. Health policy makers and commissioners may play some role in facilitating this shift, by aligning incentives to encourage this process. The main thrust of the shift in definitions of where the line sits has to come from the professions themselves however, with the support of their professional bodies. Despite initial fears, this shift has brought benefits to the clinicians themselves.

Keywords

diet*, dysphagia, deglutition, health policy, profession*,extended scope practice, Speech and Language Therapist, Speech and Language Pathologist.