The Benefits of the Dysphagia Clinical Nurse Specialist Role

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Dysphagia is a major health problem associated with multiple neurological diseases such as stroke, multiple sclerosis, and Parkinson's disease, among others. Staff nurses lack a consistent approach to managing dysphagia patients. A dysphagia clinical nurse specialist (CNS) may facilitate a consistent approach. As a member of the interdisciplinary team, the dysphagia CNS carries a caseload and serves as a liaison between the interdisciplinary team and the nursing staff to oversee dysphagia nursing care.
Introduction

Dysphagia is a widespread health problem that affects individuals of all ages, ethnic backgrounds, and socioeconomic statuses. Dysphagia management delays may lead to aspiration pneumonia, a life-threatening complication. Nurses have a key role to play in identifying, assessing, managing, and preventing complications related to dysphagia. Because hospitalization stays are shorter, early signs and symptoms of swallowing problems are more likely to go unnoticed by the healthcare team. A dysphagia clinical nurse specialist (CNS) can focus attention on this critical problem.

The role of the nurse in relation to dysphagia has been undefined and undeveloped. A dysphagia CNS role can provide a framework for standardized baseline knowledge in four subroles: expert practitioner, consultant, educator, and researcher. Evidence-based research is necessary to test the efficacy of bedside swallowing assessments and nursing interventions.

The dysphagia CNS collaborates with and participates as a member of the interdisciplinary team. A major outcome of this collaboration can be the development of practice guidelines and protocols that guide staff nurses at the bedside. Introducing the dysphagia CNS role is the first step toward a comprehensive and systematic approach for the nursing care of patients with dysphagia. Although this role has been developed in England, it has not been actualized in the United States. This article identifies the need for the role the dysphagia CNS and explores the potential impact of this role on early detection and the resulting reduction of dysphagia-related complications.


Helen Werner. The Benefits of the Dysphagia Clinical Nurse Specialist Role. J Neurosci Nurs. 2005;37(4):212-215.

Background

Dysphagia, defined as difficulty in swallowing, can vary in severity, with symptoms ranging from mild throat discomfort to an inability to eat (Galvan, 2001). Perry (2001) described findings of dysphagia that included drooling, difficulty chewing, food pocketing, slow swallowing, coughing, choking, wet-sounding voice, food sticking in the throat, weight loss, heartburn, nasal regurgitation, and aspiration pneumonia.

Dysphagia is a condition that is associated with numerous neurological and neuromuscular diseases. Kayser- Jones and Pengilly (1999) identified stroke, Huntington's chorea, medications with anticholinergic effects (e.g., antidepressants and antihistamines), phenothiazines, and poor dentition as being associated with dysphagia. Myasthenia gravis, cerebral palsy, poliomyelitis, toxic or inflammatory encephalopathy, amyotrophic lateral sclerosis, injury from radiation or surgical procedures for head and neck cancer, and cleft palate also have been identified as contributing to dysphagia (Galvan, 2001). Alzheimer's disease, traumatic brain injury, Guillain- Barre syndrome, tonsillitis, dental caries, xerostomia, and chronic gastroesophageal reflux are other conditions that contribute to dysphagia (Perry, 2001).

It is difficult to comprehend the full extent of this major health problem. Doggett et al. (2001) estimated there are 300,000–600,000 new dysphagia cases each year. The reported mortality rates due to aspiration pneumonia are as high as 6% in the first year after a stroke (Teasell, McRae, Marchuk, Hillel, & Finestone, 1996). This is a noteworthy finding, considering that nearly half of all stroke patients experience dysphagia (Smithard et al., 1996). According to Galvan (2001), 30%–60% of persons with stroke history have dysphagia. The incidence of dysphagia in Parkinson's disease may be as high as 50% (Galvan, 2001).

Healthcare providers may appear inattentive to dysphagia among patients with multiple sclerosis (MS). This may be attributable to the relapsing and remitting nature of this disease. Early detection and treatment of dysphagia in MS patients is necessary to prevent complications, such as aspiration pneumonia, malnutrition, and weight loss. De Pauw, Dejaeger, D'hooghe, and Carton (2002) reported permanent dysphagia—swallowing difficulty when a patient is not having an acute relapse—in mildly impaired MS patients according to the Expanded Disability Status Scale. A fluctuating pattern of dysphagia indicates MS dysphagia (Brown, 2000), whereas permanent dysphagia is more constant, occurring frequently in MS patients with moderate-to-severe disability (De Pauw, Dejaeger, D'hooghe, & Carton, 2002). Healthcare professionals must be trained to recognize permanent dysphagia and perform routine swallowing assessments in persons with MS.

Langmore et al. (1998) found that dysphagia alone is insufficient to cause aspiration pneumonia; patients' overall health status must be considered. Risk factors predictive of aspiration pneumonia include poor dental and oral health and functional status, among others. Patients who must be fed by others are especially vulnerable, because feeding dependence is a strong predictor for aspiration of larger quantities of food and/or fluids in dysphagia patients (Langmore). Nurses and nursing assistants who lack sufficient knowledge of dysphagia can inadvertently cause patients to aspirate. Nurses can improve care through training and clinical expertise provided by a dysphagia CNS.

According to Galvan (2001), aspiration in patients who are unable to cough may go undetected until signs of pneumonia occur. Holas, DePippo, and Reding (1994) studied 114 stroke patients using the modified barium swallow examination. A greater pneumonia risk was found in patients who aspirated silently, compared with those who coughed when aspirating (Holas et al., 1994).


Roles of the Dysphagia CNS

Healthcare professionals have been unsuccessful in identifying patients at high risk for aspiration pneumonia. Early screening and intervention is critical. Many available modalities can prevent dysphagia's life-threatening complications. According to Hansell and Heinemann (1996), nursing interventions may prevent dysphagia complications.

A dysphagia CNS can be a role model and resource for nursing practice. Developing the dysphagia CNS role requires careful planning. A clearly delineated job description will prevent an overwhelming workload for the dysphagia CNS; all members of the dysphagia team will benefit from this CNS's unique combination of knowledge, skills, and abilities.

Nurses have an important role in identifying dysphagia patients. According to Travers (1999), nurses are the professionals who most often are present at the bedside, particularly at mealtime, and are the first members of the healthcare team to observe signs and symptoms of dysphagia. By recognizing dysphagia early, nurses can help to prevent complications and decrease the number of deaths associated with dysphagia in those who have had a stroke (Travers, 1999). One of the most important functions of the dysphagia CNS is to train staff nurses to perform bedside swallowing assessments.

Odderson, Keaton, and McKenna (1995) found that nurses can perform bedside swallowing assessments. A swallow screen was performed on stroke patients within 24 hours after admission by a speech language pathologist or a certified nurse. The findings suggested that an initial swallow screen led to a significant reduction in aspiration pneumonia attributable to prompt dysphagia management. A nurse's complete swallowing assessment should include testing of the four phases of swallowing: the oral preparatory phase, the oral phase, the pharyngeal phase, and the esophageal phase (DiIorio & Price, 1990).

The role of the dysphagia CNS includes the subroles of expert practitioner, consultant, educator, and researcher (Hamric, Spross, & Hanson 1996). The ability to diagnose and manage dysphagia requires a consistent and logical interdisciplinary team approach (Travers, 1999). The dysphagia CNS should work with other members of the interdisciplinary team, including physicians, speech language pathologists, dietitians, nursing staff members, radiologists, and occupational therapists. She or he also should work with patients and their families.


Expert Practitioner Role

The dysphagia CNS's caseload should be determined by the severity of dysphagia among the patient population. An interdisciplinary team should meet regularly to determine this caseload. The dysphagia CNS would act as a liaison between the staff nurses and the dysphagia team to follow all identified and potential dysphagia patients. The nursing staff members would consult the CNS for initial identification, bedside swallowing assessment, and complication prevention and management.

Dysphagia management is another facet of the expert practitioner subrole. Many interventions that can be performed by a dysphagia CNS can be taught to nurses at the bedside. Nursing interventions are based on the Results of the bedside swallowing assessment and the modified barium swallow evaluation (MBSE).

Simple nursing interventions taught by the dysphagia CNS may effectively prevent dysphagia's most serious complications. Examples of these interventions include proper positioning, avoiding the use of beverages to wash food down, and avoiding the use of straws. These interventions must be used consistently. Patients with dysphagia must eat their meals in an environment that is free of distractions such as mealtime conversation and television (Galvan, 2001). The dysphagia CNS could coordinate the mealtime environment for dysphagia patients with other disciplines to arrange for uninterrupted blocks of time and train staff members to maintain adequate nutrition and reduce complication risk.


Consultant Role

The dysphagia CNS would be a recognized resource for nurses. Nursing assistants and staff nurses would be more likely to carry out the CNS recommendations with an improved understanding of the topic. Role perception also was identified as a possible factor that influenced noncompliance with recommendations made by speech and language pathologists (Colodny, 2001). Registered nurses (RNs) and certified nursing assistants (CNAs) share the task of feeding patients. Noncompliance among higher-status workers (e.g., RNs) may be the result of their belief that feeding patients is the job of CNAs. This belief may be behind their lack of information about procedures needed for the safe feeding of dysphagia patients.

The roles and the responsibilities of nurses who provide care for dysphagia patients remain unclear. How can RNs supervise CNAs if they lack the knowledge and skills to perform this difficult task? More research regarding nurses' perception of their role has been recommended (Colodny, 2001).

The dysphagia CNS working in a consultant role focuses on managing more severe or complex swallowing cases that have been problematic for staff nurses. The goal is to help staff nurses develop competencies and work independently when confronting similar clinical situations. Staff nurses could request a consultation to perform a bedside swallowing assessment and to develop a plan of care that nurses on all shifts could follow.

Dysphagia practice guidelines and protocols should be evidence-based (Perry & McLaren, 2003). Algorithms also can facilitate early swallowing assessment (Runions, Rodrigue, & White 2004). Dysphagia practice guidelines and protocols that are developed collaboratively by the interdisciplinary team can be clarified and implemented by the dysphagia CNS to provide individualized care. The dysphagia CNS can collaborate with the staff nurse to individualize guidelines, protocols, or algorithms based on the phase or phases of swallowing dysfunction. A template for a nursing plan of care and for documentation can be activated after the initial swallowing assessment has been performed.


Educator Role

A major role for the dysphagia CNS is that of educator. Inservices, dysphagia workshops, and individual instruction all are ways the dysphagia CNS can work with staff nurses. Colodny (2001) found that nurses were compliant with speech and language pathologists' (SLPs) feeding recommendations for dysphagia patients less than 50% of the time. RNs identified a lack of knowledge as the reason for noncompliance, not disagreement with SLP recommendations. By contrast, noncompliance with SLPs' recommendations among CNAs was due to disagreement with their recommendations, not a lack of knowledge. Feeding often becomes one of the first tasks nurses delegate to less-skilled personnel (McHale, Phipps, Horvath, & Schmelz, 1998). CNAs' disagreements may result from their belief that they are the feeding experts. RNs' lack of knowledge regarding feeding techniques for dysphagia patients could support this notion. Bedside swallowing assessments conducted by the dysphagia CNS can inform RNs, LPNs, and CNAs about feeding techniques in a way that creates consensus.

A dysphagia CNS can provide health teaching for dysphagia patients and their families, as well. Lin et al. (2003) conducted a study comparing 40 stroke patients who received swallowing training with a control group of 20 stroke patients who received no swallowing training in terms of direct and indirect therapy. Direct therapy includes positioning, diet textures, and environmental modification. Indirect therapies include thermal stimulation, lip, lingual, and laryngeal exercises. Choking frequency was significantly lower for the experimental group than the control group.

The dysphagia CNS role also would include handson training for nursing personnel at the bedside and didactic sessions in the classroom. Davies (2002) studied the practicality of specially trained nurses who screen patients for the initial signs of dysphagia. This training had three levels: dysphagia nurse 1, dysphagia nurse 2, and the dysphagia clinical specialist. Davies found several differences between the three levels of dysphagia nursing. A dysphagia nurse 1 performed a simple water screen and made referrals to speech and language pathologists for further evaluation. A dysphagia nurse 2 performed a dysphagia assessment using different textures of liquids. Dysphagia nurse specialists evaluated all patients who were found to have dysphagia by a dysphagia nurse 1 or 2. The dysphagia nurse specialist supervised the practice of all the dysphagia nurses and notified speech and language pathologists of any newly identified dysphagia patients and the interventions that currently were in use.


Research Role

The dysphagia CNS also can function as a researcher. Studies evaluating the efficacy of bedside swallowing assessments and management strategies would help bedside nurses recognize effective modalities. Nursing research is needed to explore the relationship between aspiration and pneumonia. Screening tools that have been tested on stroke patients should be modified, if necessary, and validated for patients with MS, Parkinson's disease, Alzheimer's disease, and other neurological conditions for evidence-based practice.

Oral care at mealtime is an area that should be studied. Langmore et al. (1998) identified dependence on others for oral care as a predictor of pneumonia. Wardh, Hallberg, Berggren, and Andersson (2000) found oral health care to be a low priority for nurses working with geriatric patients in nursing homes. A shift in focus among bedside nurses is necessary in light of current research suggesting that good oral health can prevent aspiration pneumonia in the elderly (Marik & Kaplan, 2003). According to Duffy (2002), both nursing-specific outcomes and the contributions that nurses make as members of multidisciplinary teams should be studied. Research should evaluate whether dysphagia is more frequently identified in institutions that employ dysphagia CNSs. The clinical outcome of aspiration pneumonia reduction should be studied in relation to early detection and management by CNSs.


Summary

Nurses currently allow other healthcare disciplines to take the lead in dysphagia assessment and management. As an expert practitioner, consultant, educator, and researcher, the dysphagia CNS can provide a role model for staff nurses at the bedside. Nurses are usually the first members of the healthcare team to observe dysphagia at mealtime. Swallowing assessment and management could reduce the risk of aspiration, pneumonia, and malnutrition. The development of the dysphagia CNS role would facilitiate a greater collaboration with the entire interdisciplinary team, reducing the number of dysphagia patients who go unnoticed in the managed care environment.


References

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Authors and Disclosures

Helen Werner is a nursing supervisor, Veterans Administration Medical Center, Miami, FL, and a doctoral candidate at the School of Nursing, Barry University, Miami Shores, FL.


Reprint Address

Helen Werner, MSN RN, 954/983-6378