Community service speech language therapists practising in adult dysphagia: Is the healthcare system failing them?

Abstract

Performing community service is a necessity prior to practising speech language therapy in South Africa. This system allows for improved access to these specialised services in the more rural areas. The current challenges of practising in complex settings with little access to mentorship can result in these community service therapists feeling underprepared to assess and manage patients presenting with adult dysphagia (swallowing disorders). This paper explores this topic through the theoretical lens of decision-making, from both clinical and academic perspectives. It aims to pose potential solutions on how to better transform the current practices to be contextually responsive to these challenges.

A retrospective review of speech-language therapy services provided to adult inpatients at a central-level hospital in Gauteng, South Africa

“…It is thus concerning that for patients with dysphagia, therapeutic interventions were relatively infrequently recommended, and that dysphagia-specific interventions were not recommended at all for at least 9.29% of patients with dysphagia. Studies have found that newly graduated SLTs in South Africa lack confidence and feel unprepared with regard to dysphagia management (Singh et al, 2015 ; Yiannopoulos, 2016, as cited in Coutts, 2019 ), which may underlie a more conservative approach to dysphagia management in recommending enteral nutrition over other interventions. This likely impacts on outcomes and quality of life of patients presenting with dysphagia and suggests a need for further undergraduate training on the management thereof, as well as access to clinical supervision and evaluation in this area of practice.…”

“…In this study, the relationship between the number of days from admission to referral and the number of SLT sessions was not significant. However, it is well known that public-sector hospitals in South Africa are challenged by limited physical and human resources (Andrews & Pillay, 2017;Coutts, 2019), and hospital capacity and pressure for beds have both been documented as reasons for premature hospital discharge locally and internationally (Dreyer & Viljoen, 2019;Glette, Kringeland, Røise, & Wiig, 2019). For this reason, the possibility of earlier hospital discharge based on medical stability, regardless of the need for continued inpatient rehabilitation, should not be excluded.…”

Decision making and the bedside assessment: The Speech Language Therapists’ thinking when making a diagnosis at the bed

“…This raised an interesting point as the relationship between colleagues may then have a role to play in this learning and/or mentoring process. This highlights the importance of placing junior SLTs in facilities where they can be mentored by more experienced SLTs in dysphagia, as this is a valuable learning opportunity (Coutts, 2019).…”

“…One of the participants summed it up well and supports the use of the term 'clinical instincts' when she said, 'It made me realise how much of my decision-making is unspoken and based on very subtle things … it was difficult to explain those subtleties…'. This is important when considering undergraduate teaching, as well as mentorship for junior SLTs as they proceed into their community service year (Coutts, 2019). As shown in the table, clinical instincts are a predominant feature of critical thinking, and needs to be nurtured and developed from junior years.…”

“…recently wrote an opinion paper on dysphagia during the coronavirus disease 2019 (COVID-19) era, in which she brought up the topic about the significance around the bedside assessment and the decision-making processes around assessment at the bedside (Coutts, 2019). This research article is a follow-up from the opinion paper and her PhD study.…”