Expanding speech pathology delegation practices: engaging Allied Health Assistants (AHAs) in dysphagia management in the acute hospital setting

Abstract

Listen

Translate article

Speech Pathologists (SPs) are under increasing workforce pressures as a result of an ageing population and greater prevalence of chronic conditions. Considering this increasing workforce demand, within the context of limited health resources, workforce flexibility such as the consideration of task delegation is increasingly being encouraged within the literature and government policy. Though the use of delegation models within speech pathology has received some attention, particularly in the management of paediatric speech and language disorders, there is a paucity of evidence to support the use of delegation models in dysphagia management. This presents a significant gap, as dysphagia management is an integral part of the SP’s role in the inpatient hospital setting and accounts for a significant proportion of workload demand in that context.Delegation of dysphagia related tasks to a trained Allied Health Assistant (AHA) offers a means to address increased workforce demand, while potentially improving workforce efficiency. Appropriate delegation of ‘low value’ tasks to another professional group may support the SP; to dedicate more time to high risk caseloads; increasing intensity of intervention; and contributing to quality and innovation initiatives. Hence the overall objective of this thesis was to generate new knowledge regarding the design, clinical implementation and evaluation of AHA delegation models in the clinical area of dysphagia management. Two specific aims were identified to achieve this. The first was to design, develop, implement and evaluate AHA delegation models for two key dysphagia related tasks, (mealtime observations and dysphagia screening), to establish accuracy and feasibility of task completion. The second aim was to evaluate stakeholder perceptions regarding implementation of AHA delegation models in the clinical area of dysphagia. Three studies resulting in four manuscripts were conducted to achieve these aims.Study 1 (Chapter 2) involved a mixed method design including a document review of 13 policy documents on AHA delegation and a survey of 44 speech pathology managers regarding current delegation models. Despite policy support for AHA delegation, and 77% of managers reporting that they used delegation models, only 26% of managers reported using delegation fairly often/very often in dysphagia management. To facilitate greater delegation, both document analysis and survey findings supported the importance of AHA training, however, the nature of training remained unclear. Chapter 2 therefore provides context for delegation in the clinical area of dysphagia by demonstrating both policy and stakeholder support.While Chapter 2 demonstrated that emerging support exists for the delegation of dysphagia related tasks to trained AHAs, an evaluation of accuracy and validity of task completion in these models of care has not been undertaken. To address this evidence gap, two separate studies were conducted resulting in Chapters 3, 4 and 5. Chapter 3 involved a mixed method design to explore validity of AHA completed mealtime observations of 50 adult inpatients using a structured observation form. The results of this study identified that exact agreement between AHAs and SPs on the overall pass/fail criteria was high (94%). Where exact agreement was not achieved, the AHA had made a more conservative decision, thus still ensuring patient safety. Qualitative interviews conducted as part of the mealtime observation study (Chapter 3) identified that both SPs and AHAs perceived multiple positive personal and service benefits of delegated mealtime observations. High levels of agreement between the SP and the AHA were also identified in Chapter 4 which utilised a prospective cohort study to examine feasibility and validity of AHA delegation in dysphagia screening. Validity testing in this study confirmed exact agreement between AHAs and SPs on overall pass/fail screening criteria for the first 51 patients to be 100%. Furthermore, the delegation of ‘low risk’ dysphagia screening to a trained AHA was identified to remove approximately 40% of these referrals from the SP’s caseload. Thus, providing evidence to support improved efficiency in workforce management when introducing AHA delegation.In Chapter 5 the perceptions of stakeholders regarding the implementation of delegated dysphagia screening was conducted. The service implementation experience was examined using the Consolidated Framework for Implementation Research (CFIR) analysis framework. Results of this study provided an overview of barriers and facilitators to implementation, which provide vital direction to future services wishing to introduce innovative models, such as AHA delegation in dysphagia management. Chapter 5 also highlighted variation between direct patient delegation and blanket delegation, which was explored in more detail in Chapter 6.The final chapter of this thesis (Chapter 6) provided a summary of the thesis findings, limitations and areas for future research. In conclusion, delegation of dysphagia related tasks to trained AHAs is safe and effective and may provide opportunity for efficiency increases, cost reduction and workforce flexibility in the area of dysphagia management. While training provided for the tasks included in this thesis appeared adequate given the high agreement and accuracy of task completion, variation in context and delegation practices highlight areas of future research.