Implications for Future Research

4.2.1 The Need to Improve Undergraduate Training for Speech-Language Therapists and Nurses in the Area of Dysphagia and Tracheostomy

Lubinski and Frattali (1994) maintain that it is critical for universities to continually update and modify existing curricula according to the changing needs of the profession. It is hoped that the information obtained from current practicing speech-language therapists and nurses in the present study will assist in providing universities and nursing colleges with feedback on possible gaps in existing curricula. It is therefore suggested that a key step towards improving undergraduate training in dysphagia and tracheostomy would be to make the relevant universities and nursing colleges aware of this need for improvement. From the results of the present study, specific recommendations could be made about the importance of including theory on aspects of the role of multidisciplinary team members in tracheostomy and dysphagia management, and the development of protocols and guidelines on blue dye testing, suctioning and cuff inflation/deflation protocols. The need to allocate more time for clinical practical training in undergraduate dysphagia in tracheostomy patients could also be highlighted.

4.2.2 The Need to Alert Professional Health Regulatory Bodies Regarding Further Specialised Licencing/ Training in the Area of Dysphagia and Tracheostomy

A foreseeable problem that may be encountered by South African universities in increasing the theoretical and practical content of the dysphagia and tracheostomy curricula would be the lack of time allocated to teaching in the area of dysphagia, especially since dysphagia in tracheostomy patients is considered a specialised skill, often requiring further licensing. However, the researcher feels strongly that these recommended improvements in theoretical and practical curricula should not be compromised, since dysphagia intervention is the only area of work of a speech-language therapist where lack of intervention holds potentially life-threatening risks for patients (Tippett, 2000). Moreover, with the current compulsory community service to hospitals post graduation, newly graduated therapists

University of Witwatersrand (community service therapists) are often immediately faced with patients with dysphagia whom they are required to assess and manage. This brings to the forefront an ethical dilemma which many new graduates face, namely, do they provide a service being the only therapist (but lacking experience), or do they refuse to see the patient due to their inexperience? Despite the above challenges it is imperative that health professional regulatory bodies be alerted regarding these challenges and that systems be put into place to initiate additional training/licencing in the area of Dysphagia and tracheostomy.

4.2.3 The Need to Improve the Situation of Clinicians Practising in Dysphagia and Tracheostomy Management

While it is important that practicing clinicians identify the strengths and limitations of their knowledge and skills in tracheostomy and dysphagia practice, a general lack of guidelines, protocols and a core set of standards for these clinicians to follow in the assessment and management of dysphagia in tracheostomy patients was revealed. Therefore, once again, an important role of academic institutions and professional regulatory bodies is to provide clinicians with the support to improve their knowledge and skills by ensuring accessibility to protocols and guidelines which can be followed.

Tracheostomy and dysphagia guidelines/protocols

The development of a tracheostomy and dysphagia guideline is expected to have many benefits. This guideline should be drawn up by a multidisciplinary team using evidence where it exists and best practice standards. The development of such a guideline should be intended for use by all South African health care professionals involved in the care of adults with a tracheostomy presenting with dysphagia. Care should be taken that a guideline of this nature should not be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve.

Tracheostomy position paper

The aims of the development of a tracheostomy and dysphagia position paper are as follows:

 To reflect current best practice in tracheostomy management and, where possible, to identify evidence based practice

University of Witwatersrand  To address the major issues in current tracheostomy management

 Involvement in the evaluation and management of patients with tracheostomy tubes is within the scope of practice of nursing and speech-language therapy. However, practising within this area is seen as a specialist skill and management of patients with tracheostomy should not be undertaken by those without additional and specialist training.

 The involvement of the speech-language therapist in tracheostomy management must be determined by the policies and procedures of their employing organisation.

 The involvement of a multidisciplinary team approach should be advocated.  Management of a patient with a tracheostomy is not a competency expected of a

new graduate, nor is it appropriate for a new graduate to practice in this area. It is the responsibility of the speech-language therapist and the nurse to obtain basic tracheostomy management competency. Competency should be obtained through reading, workshops, directly supervised clinical experience and discussions with specialist clinicians. Nurses and speech-language therapists working in the area of tracheostomy management must maintain and update their knowledge and skills on a regular basis.

 Adherence to the safety guidelines of health care facilities as well as awareness regarding risks and management of risks involved in tracheostomy care should be addressed.

 Consistent, accurate recording and documentation of all areas of patient management should occur.

 Projects on tracheostomy management should be incorporated into general departmental quality assurance and quality improvement programmes.

(SPA Tracheostomy Position Paper, 2005; RCSLT Tracheostomy Position Paper, 2006)

4.2.4 The Need to Identify the Barriers to Implementing Evidence based Practice Regarding Dysphagia and Tracheostomy in Critical Care in Government Hospitals

While many participants in the current study reported many challenges within the government health sector that was preventing successful positive attitudes towards evidence based practice, it was not within the scope of this research study to probe for further detail

University of Witwatersrand regarding evince-based practice barriers. Therefore, a possible future research implication could entail obtaining information about the greatest barriers faced by speech-language therapists and nurses in SA government hospitals, whether there is an association between rank or salary grade and/or years of experience and perceived barriers and whether there is an association between specific perceived barriers and workplace settings. It would also be interesting to ascertain what access nurses and speech-language therapists have to professional academic journals to further their knowledge and to improve clinical skill.

4.2.5 Establishing the Need for a Dysphagia Training Programme for Speech- Language therapists in Dysphagia and Tracheostomy

While the main aim of the present study was to establish the need for a dysphagia training programme for nurses in critical care of tracheostomised patients, it was evident from the results obtained from interviews with speech-language therapists that a training programme of this nature is deemed as valuable by them. As a result the current studies title was modified to include the need for a training programme for speech-language therapists as well. Future research can focus on areas of training in assessment and management pertaining to speech-language therapists specifically.

4.2.6 Conducting a Training Programme for Nurses in Critical Care of Dysphagia and Tracheostomy, and thereby Monitoring the Efficacy of the Programme.

The results of this study have highlighted a need for a dysphagia training programme for nurses working with patients with tracheostomies. The results from this study highlighted only a few speech-language therapists are confident and skilled in conducting a training programme of this nature. Therefore, the finding of the current study have implications for future research whereby speech-language therapists who have the necessary knowledge and skills in the area of dysphagia and tracheostomy may conduct and monitor training programmes with nurses in their institutions, following the guidelines on proposed content that was provided in chapter four.

4.2.7 Measuring/monitoring the Outcomes of Multidisciplinary Team Work in the Assessment and Management of Dysphagia and Tracheostomy in Critical Care

The benefits of multidisciplinary tracheostomy team approaches have been clearly demonstrated and are consistent with those reported in the literature (Norwood et al., 2004; Tobin & Santamaria, 2008). Improved staff knowledge and also confidence and awareness

University of Witwatersrand have been reported, together with patient-centred improvements such as shorter review time and shorter hospital stay. Complications resulting from early cuff deflation have also been minimised with a shift to team based, case-specific decisions rather than the application of blanket protocols that required cuff deflation prior to discharge from critical care. Findings from previous studies internationally indicate improved monitoring and surveillance results in streamlined cross-professional decisions around dysphagia assessment, management, weaning and decannulation which reduces delays associated with the need to reconcile multiple separate opinions (Tobin & Santamaria, 2008). Organisational benefits arising from the team approach include rationalisation of resources and reduction in duplication of services. Greater numbers of patients are being discharged from critical care units internationally to general care wards with a tracheostomy in situ and this has freed up scarce resources and improved bed access. The current study was unable to explore the benefits of multidisciplinary team work at such an intricate level. Therefore, it is advised that further research be conducted in the South African context in an attempt to highlight the critical importance of multidisciplinary team working towards achieving effective outcomes for patients and health facilities.