Co-Author: Nassrine Noureddine RN, MSN, Ed.D
The anatomy and physiology of swallowing is complex; it requires multiple innervations and coordinated functions of approximately fifty pairs of muscles to safely transport a bolus from the lips to the stomach (NIDCD, 2014). Dysphagia occurs when there is an impairment in the movement of the bolus during any stage of the swallowing process (Logemann, 1998). The presence of dysphagia may cause health concerns ranging from nutritional or hydration deficits to aspiration pneumonia (NIDCD, 2014). Swallowing disorders can be caused by multiple etiologies, including neurogenic conditions, medical conditions and other diseases (ASHA, 2001; NIDCD, 2014). The highest incidence of dysphagia is associated with stroke, ranging from 37%-78% (Hinckley, 2014). Individuals with dysphagia may experience a variety of health consequences including malnutrition, weight loss, difficulty with medications, as well as an increased risk for aspiration and aspiration pneumonia (Morley, 2015). Further, dysphagia may create consequences that severely affect a person’s health, emotional and psychosocial well-being, ultimately affecting quality of life (Vesey, 2013).
Role of the SLP
Speech-language pathologists (SLPs) are considered to be experts in diagnosing and managing patients with dysphagia, and “play a primary role in the evaluation and treatment of infants, children, and adults with swallowing and feeding disorders” (ASHA, 2004, p. 1). Medical-based SLPs who work with adult populations report spending 41-58% of their work day delivering services in the area of swallowing (ASHA, 2015; Yvette & Rinki, 2015). These clinicians must integrate a variety of factors when identifying the presence of dysphagia, detecting the risk for aspiration pneumonia, and determining the most appropriate plan of care.
Today’s healthcare environment is dynamic, challenging and fast-paced (Ebright, 2010). Clinicians are frequently taking care of increasingly high acuity patients that are medically-complex and present with multiple comorbidities. In addition to a strong foundation in neurology, today’s medical-based SLPs need to understand and integrate many clinical variables when providing assessment and treatment to patients. Clinicians must also have a working knowledge of medications as well as certain pathologies that interfere or affect a patient’s ability to swallow. For example, clinicians must be aware of the possible medication effects and interactions on mentation and muscle performance.
In addition, SLPs need to be familiar with the different pathologies like alterations in fluids and electrolytes balance as well as infections such as urinary tract infections that often negatively impact a patient’s cognitive functioning. Further, premorbid psychological disorders and psychosocial influences may impact clinical performance during assessment and serve as a barrier to progress with treatment. To assess, continuously monitor and diagnose a patient’s medical status, health care professionals have traditionally used lab values and vital signs as critical clinical data. Although lab values and vital signs are rarely discussed in the speech-language pathology literature (O’Hara & Hagge, 2016), this clinical data can also be used to inform SLPs’ clinical practice including professional diagnosis, prognosis, and plan of care (Wynn, 2014).
Degree of Preparation
SLP graduate students typically complete one course in dysphagia but lack the opportunity to learn and integrate many of the above-reported medical issues, medications or diagnostic data before an internship. A recent e-survey of 719 speech-language pathologists conducted by Yvette and Rinki (2015) revealed that 61% of the participants did not feel adequately prepared to assess and manage persons with dysphagia at the time of graduating from a master’s program. When asked about ways to improve graduate program curriculum in the area of dysphagia, respondents indicated that additional didactic, experiential and clinical experiences related to the assessment, treatment and management of swallowing disorder should be required coursework and/or offered as electives to students.
Historically, the medical-based graduate student internship was expected to provide the experience necessary to facilitate clinical competence in the area of dysphagia (Sheffler, 2015). With healthcare’s ever-increasing productivity demands and time-constraints, however, it is difficult for medical-based SLP supervisors to teach the knowledge and skills now required for success in healthcare. Hence, SLP students may benefit from the opportunity to learn about and practice integrating multiple medical issues and conditions during graduate school. This curricular change may serve to better prepare SLP students for success in medical-based internships, clinical fellowship positions, and beyond.
One university’s solution to the field’s growing recognition of the need to modify the dysphagia curriculum is through interprofessional education (IPE). “IPE occurs when students from two or more professions learn about, from and with each other” (WHO, 2010, 7) with the ultimate goal of creating a collaborate-ready healthcare workforce, improving patient safety, and enhancing patient outcomes (IOM, 2015; WHO, 2010). National and international agencies are recommending the integration of IPE into university curriculum (IOM, 2003, 2013, 2015; IPEC, 2011; WHO, 2010). Multiple health-related disciplines’ accreditation agencies have already mandated IPE including pharmacy (ACPE, 2015), physical therapy (CAPTE, 2016) and speech-language pathology (CAA, 2016), while other disciplines such as nursing strongly encourage the integration of IPE into the curriculum.
A Model of IPE
Faculty from Sac State and other universities, Drs. Noureddine, Hagge, Brady and Ofstad, recognized the need for interprofessional education and established an IPE team called the California-Interprofessional Education Research Academy (CA-IPERA, 2014). The CA-IPERA team purposefully designed IPE events and activities using a variety of teaching pedagogies to support interprofessional student collaboration and learning. Examples of the pedagogies used included didactic instruction, team-, case-, and problem-based learning, simulation, and community-based clinical experiences, and are grounded in the literature (Hagge, Noureddine, Brady, & Ofstad, 2015a) For example, simulation education is reported to enhance the clinical training of nursing and SLP students in the area of dysphagia (Noureddine, Hagge & Brady, 2016). In fact, the American Speech-Language-Hearing Association recently approved the use of time spent in simulation experiences towards meeting the required clinical hours for graduate students (Council for Clinical Certification, 2013).
Interprofessional education is one proposed solution to enhance dysphagia education and prepare students for success in today’s demanding healthcare environment
In terms of community-based interprofessional clinical practice, Drs. Noureddine and Hagge offer undergraduate and graduate students from multiple healthcare disciplines the opportunity to participate in hands-on, experiential learning opportunities. Through the SAHA Health Center for immigrants and refugee and Sac State’s NeuroService Alliance programs for adults with acquired communication disorders, students experience interprofessional training while also serving the needs of the community (Hagge, Gleason, Hauptman, Hamon, & Spangler, 2015; Saha Health Center, 2016). In addition, nursing and pharmacy students had the opportunity to collaborate interprofessionally by hosting community shot clinics and health fairs. Students report that they value the community-based interprofessional programs, and alumni frequently return to continue participating in the programs.
All of the IPE activities described above were designed and implemented by inter-university professors. As a result of these activities and the increasing accreditation requirements for IPE, the need for an IPE Center at Sac State became evident. Consequently, Sac State established the California State University Sacramento College of Health and Human Services Interprofessional Education Center for Innovative Teaching and Learning in May 2016. National IPE Certified faculty will serve to design and assess co-curricular courses, educational activities, and community events.
IPE Activities Involving SLP
Sac State’s Department of Speech Pathology and Audiology has recognized the need for increased dysphagia education, and has already integrated a variety of IPE activities into the graduate program curriculum. To begin, first semester graduate SLP students and first semester undergraduate nursing students receive an introduction to dysphagia, feeding issues, and nursing swallow screen tools. Immediately following the didactic content, the students break into interprofessional teams and practice administering a nurse swallow screen to each other.
Second year graduate students receive didactic instruction from nursing on understanding lab values and vital signs and its’ significance to SLP practitioners. Nursing and SLP students break into teams and solve case-based scenarios that reveal the clinical application of lab values and vital signs. Second year graduate students receive a full course of dysphagia. In addition to rigorous didactic instruction, the professor provides in-class active learning activities including the preparation and administration of PO trials, administration of a bedside swallow evaluation using different case studies and role-play, as well as requiring students to demonstrate clinical understanding of the purpose and differences between a nurse swallow screen and a bedside swallow evaluation.
A reported highlight for SLP graduate students is a two-phase unfolding simulation experience between nursing and SLP students and a new onset middle cerebral artery stroke (Hagge, Noureddine, Brady, & Ofstad, 2015b; Noureddine, Hagge, & Brady, 2014). The fidelity of the simulation is heightened by the use of retired educators as standardized patients, who are actual stroke survivors with aphasia, apraxia of speech and right-sided hemiparesis. In addition, undergraduate SLP student confederates role-play distraught family members during the simulation. Debriefing sessions include all the participants in the scenario which enhances student learning. Undergraduate students highly value the opportunity to volunteer in the simulation because the experience provides relevant clinical insights into the role of the medical-based SLP.
In addition, Drs. Hagge and Kennedy collaborated to integrate social work and SLP students in two IPE activities including a team-building exercise followed by two problem-based team activities. Small groups of SLP and social work students receive two case-based scenarios. One case study involved a medical-based issue and the other included a school-based scenario. Student reflections revealed that the students highly valued the IPE experiences, and indicated a desire for additional IPE events with social work students.
Most recently, Dr. Hagge together with Drs. Noureddine and Brady from Sac State nursing program collaborated with a physician, Dr. Pouria Kashkouli, from the University of California Davis Medical School. The professors created and facilitated an IPE team-based learning case study on palliative care that included approximately 120 nursing and speech-language pathology students. Based on preliminary survey feedback, students valued the learning experience.
To further enhance student learning for medical-based internships and clinical practice, several IPE projects are currently in-progress. Two of these co-curricular IPE experiences include (a) Pharmacy Meets SLP: A Primer of Pharmacology Effects and (b) Nursing, SLP and Social Work: Managing an Acute Neuro Patient with Psychosocial Involvement. In addition, an interprofessional amputee clinic is scheduled for the fall. Clients will receive interprofessional services, including SLP if appropriate. Finally, interprofessional education events, activities, and courses will be offered to healthcare related disciplines at the undergraduate level. This aligns with ASHA’s recommendations for undergraduate programs to embed interprofessional education at the undergraduate level (Crais et al., 2015).
The current healthcare environment is dynamic and challenging with clinicians often providing care to patients who are medically complex. In the past, medical-based SLP clinical supervisors were expected to fulfill graduate student clinicians need for foundational dysphagia knowledge and clinical skills. Today’s increased productivity standards and time constraints, however, often result in reduced opportunities for clinical supervisors to provide graduate student clinicians with time for direction instruction and training. It is not surprising that speech-language pathologists have recently reported that there is a need for increased dysphagia education and training in graduate programs. Interprofessional education is one proposed solution to enhance dysphagia education and prepare students for success in today’s demanding healthcare environment.
Links of Interest
- California-Interprofessional Education Research Academy (CA-IPERA)
- NeuroService Alliance
- Saha Health Center
About the Authors
Darla K. Hagge Ph.D., CCC-SLP: Earned her BA and MS in communication disorders from California State University Fullerton, and her Ph.D. in Education with an emphasis in Disability Studies from Chapman University. She is an assistant professor and graduate coordinator in the Department of Speech-Language Pathology & Audiology at California State University Sacramento, speech-language pathologist at St. Jude Medical Center, and founder/director of NeuroService Alliance, a collection of life-participation approach community-based programs for adults with acquired communication disorders. She is an affiliate of the National Aphasia Association, governance committee member of AphasiaAccess, and consulting editor for Communication Disorders Quarterly. Dr. Hagge is part of the California Interprofessional Education Research Academy (CA-IPERA), co-founded by Drs. Nassrine Noureddine, Darla Hagge, Debra Brady and William Ofstad in 2014. She is the co-primary author for the recently approved California State University Sacramento College of Health and Human Services Interprofessional Education Center for Innovative Teaching and Learning. Dr. Hagge’s area of scholarship focus is in acquired neurogenic communication disorders, interprofessional education, cultural competence, simulation and curriculum development.
Nassrine Mohammad Noureddine Ed.D., MSN, RN: Earned her BSN from the American University of Beirut, Lebanon. She earned her MSN and Ed.D. from CSUS. Has been teaching nursing for close to 22 years in the US and overseas. She has held a full time faculty position at CSUS since 2004. She is the founder and director of SAHA Health Center, a free clinic serving the uninsured and underserved public in Sacramento. She is the recipient of the CSUS Outstanding Community Service award for 2015. Dr. Noureddine is part of the California Interprofessional Education Research Academy (CA-IPERA) Team, and was co-founded by Drs. Nassrine Noureddine, Darla Hagge, Debra Brady and William Ofstad in 2014. Dr. Noureddine is the co-primary author for the recently approved California State University Sacramento College of Health and Human Services Interprofessional Education Center for Innovative Teaching and Learning.
Dr. Noureddine’s area of scholarship focus is in curriculum development, simulation, and interprofessional education, cultural competence, Grit and disadvantaged students’ success in higher education.
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