Dysphagia Trained Dietitian? with Laura Clark RD

Episode Transcript
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Aaron Boysen (00:01):
Welcome to the dietetics digest podcast with
your host and dietitian me AaronBoysen dietetics digest is a
podcast created and produced bydieticians for dietitians, we
interview dieticians from aroundthe world to talk about their
journey and their groundbreakingwork. This podcast will help
inspire you and others to becomethe best dietician possible.

(00:26):
Thank you, Laura, for joining uson this episode of The dietetics
digest podcast. Great to haveyou with us today.

Unknown (00:32):
Thank you. Thanks for having me. I'm excited to do

it. Thank you for dedicating your morning time ATM
to be precise, to record thepodcast. So I wanted to start
off with a little bit of aquestions around yourself but I
thought I'd possibly ask you tomaybe introduce yourself and a
little bit of your sort ofbackground. So I invited Laura
on the podcast because she isone of the very few dietitians

(00:56):
within the UK that has beendysphasia trained. And I
previously had other dietitianson our podcast, which is Sam
Francis from Bradford teachinghospital that extended his role
in the placement of nasalgastric feeding tubes for
patients on a stroke ward. And Ithink it's very interesting to
see how dietitians are extendingroles to change patient care or

(01:18):
improve patient care. And thisis another great example of how
it's just to help extend a roleand help to provide better
patient care. And usually thatbetter patient care quote
unquote, becomes a lot fasterdue to sort of friction and
changing and professionals andextra referrals being sent. So
Laura, if you just introduceyourself who you are a little

(01:38):
bit of your background.

Unknown (01:39):
So my name is Laura Clark. I'm a clinical specialist
dietitian and I'm also adysphasia practitioner. So I
currently work in Doncaster so Iwork for the rather than
Doncaster and South number NHSTrust. I've been there for six
years. So I've graduated in2015. And I've worked there ever
since I obviously do know what'sgoing off everywhere else, but
I'm quite Doncaster lead, andI've been there right from the

(02:02):
start. So for Doncaster, bornand bred then yes, yes. And it's
not I live in bands. So it'sobviously a very South Yorkshire
based and they're doing a lot ofwork kind of as a South
Yorkshire integrated caresystem. So it all kind of fits
together. It's quite nice.

If I asked you what, like, what triggered the
motivation to become sort ofdecides you're trained, and be
able to ride these assessmentsto patients? What, what
triggered this within thesetting that you work in?

Unknown (02:29):
Yeah, so kind of how did it all? Well, I guess, so I
obviously wasn't involved rightat the very start. So I kind of
had to go back to myself as ourdid, you kind of, I'll do that
end up here. So in our dash, ourspeech therapy team covers a
really large geographical area,which is Doncaster. It was spun
out quite far, and the inputinto lots of different teams as

(02:51):
well. So like the stroke team,so what they wanted to do is
they wanted to look to see whoelse actually works closely in
those teams that they could lookat kind of extended roles. So at
the minute in our dash, we alsohave a community matron, who's
dysphasia trained, and she worksin with progressive neurological
conditions. So she now basicallymanages all of those patients.

(03:11):
So that can be things like motorneuron disease, and Huntington's
disease. So it's kind of thatpatient group gets to just see,
they get to see the nurse or thenurse a bit, and then we get to
see her for the dysphasia partas well. So I think it was some
kind of like service managermeeting. Because basically what
happens is they have places onthe cost the dysphasia costs
every year. So the desiredamount. Okay, so which new band

(03:34):
five speech therapists startingwith the trust? Is there any
current speech therapists thatare band five that have not had
the training yet? Is there anynurses who basically go on the
course. So my manager, being themanager that she is she's very,
she flies a fight for dietetics?
She's like, why don't we have adietician, but you know, this
would be a really good idea. Andwhat I found out after is that
they actually, I thought thatwanted to have a dietitian, as

(03:56):
I've just said, well, they said,we actually chose you basically
because of my skills at the timewhat the thought I could I could
do so because it's a lot aroundkind of research question in
practice using lots of evidencebased formulating hypotheses and
then challenging the hypothesesand changing them how swallow
because obviously swallowmanagement the impact on so many

(04:17):
other things as we know, theythought this is rightful are
basically so they were like,Laura, would you like to do it?
And I want maybe me, I said, Oh,yeah, that's fine. I'll do that.
I've no idea what it entailed.
But yeah, I always think anyopportunity that you get, I
thought this is kind of one in alifetime opportunity. So I'm

(04:38):
gonna do it. And yes, that'sbasically the backstory.

And you're a pioneer for training and
practice and adjusting slightlyand I think helps us all I think
obviously, helping other peopleblend roles and even when we
talk about malnutritionmanagement, I think there's
definitely a case to make sureit's it's everyone's problem,
not just dietitians problem andhave Eyes and ears everywhere.

(05:03):
sort of basic advice before sortof a dietitian can get there can
be provided by lots of otherhealthcare professionals to
support patients early. But Iwanted to circle back on one
thing you said they chose you.
Now, what skills? Did theythink? Or do you have that made
you suitable for the role? Sowhat sort of skills should a
dietitian be? If they'reinterested in this area? What

(05:24):
sort of skills they think wouldbe useful for you?

Unknown (05:28):
I think you have to question you have to question a
lot of things and say, well,could it be that awkward like
this, you have to be veryconfident in asking for help.
And asking for advice andknowing when you've gone wrong.
So taking constructivecriticism, which I know can be
quite difficult, because a lotof the times I did get it wrong
to start with because it was it,there's a lot of grey areas,

(05:48):
when it comes to swallowing indietetics. Officer, and I'm
saying this very broadly, it'squite objective. So you know, if
you think anthropometry isnumbers, it's way biochemistry,
it's numbers. It's, it's allquite factual, it's there. And
things like with the clinicalstuff, you know, if you've got
your skin and your bowels andyou die history, and then we're
counting calories, that kind ofthing. So are very numbers
based, whereas dysphasia is notessentially, it's kind of you do

(06:13):
a bedside assessment, and youcan't, because you haven't got
the X ray goggles to sit and seewhat's going on. You have to
basically think it could be thator it could be that it could be
that so you've got to be quiteflexible. And yeah, and just
basically be comfortable withmaking a clinical decision on
what you think is the is thebest thing to do. From what

(06:33):
you've seen.

You just talking about the differences between
say, sort of dietetic practiceand swallow assessments.

Unknown (06:41):
So yeah, so as I said, the the dietetics can be quite
objective, quite numbers based,but the swallowing is very
subjective. And like said,You've got different hypotheses,
you've got to be able to changeand we've got to be able to work
with them, and use lots of otherkinds of information, a bit like
we do in dietetics. Still, butyes, it's a completely different
skills and approach to whatdietetics would be.

So when we think about this training, how did it
become How did it start? Whattraining Did you need to get and
what are you trained to be ableto do?

Unknown (07:10):
It was back in 2019. I think COVID has kind of bled all
the years together after that, Ithink when did actually do it.
So what 2019 and something I didlearn, which is quite
interesting is I thought speechtherapists would do dysphasia as
part of that undergraduatestudy, but the down is just
communication and everythingelse that they do. So the
dysphasia is actually a Master'sCourse. So it's postgraduate,

(07:33):
and even speech therapists oncethey've done their
undergraduate, so they also thenhave to go on to do the
dysphasia Master's Course. Sothat's basically what I did. So
I did it at Sheffield, HallamUniversity in five days face to
face that and I don't know whatthey'll be doing now. And it's
30 credits masters module. Sothe title is the assessment and
management of adults withdysphasia. So when I did it,

(07:54):
there were lots of pre reading,as there always is, and at the
time, I was thinking, Oh, mygosh, this is gonna blow my mind
this is, you know, it were ourexit route very different to
what to what I know. So you wenton the course, you did the five
day course. And then after that,you have to have 80 hours
working within dysphasiamanagement. And that would be
with a trained speech therapistor with a trained another

(08:16):
dysphasia practitioner. And atleast 50 of those hours has to
do with patients. And obviously,as you go along, your supervisor
assesses you. So it's a bit likebeing a student dietitian,
because you there and you know,your supervisors watching you
giving you feedback and thatkind of thing. And so we did
that, and then out to do twocase studies. So there was an
acute dysphasia case study and aprogressive disclosure case

(08:37):
study to the acute one would befor example, somebody who might
be nil by mouth on a neuro rehabWard, you're kind of you're
trying to improve the swallowingability and the progressive
dysphasia want might be so rare,for example, in a care home, and
that's got dementia, so this wasnot likely to improve so you're
up to kind of prove how you cango up and then go down and kind

(08:58):
of the textures and the levelsand obviously evidence in any
exercises and things like that,that the might, you might
recommend. So did that and thenonce you pass those two, I have
to do a critical review. Soaround the ethical dilemmas in
decision management so obviouslyI tried to make it quite
relevant to me in my role so Idid a lot around risk feeding.

(09:20):
And she took a risk feed in itwas enteral feeding in dementia
thickened fluids and texturemodified diets because I thought
they're the most kind ofrelevant to me. So that's kind
of just debate the, theliterature around what is
receding, kind of the evidencebased ventral fin and dementia
do thickened fluids actuallyimprove what does it improve?

(09:40):
Does it improve kind of thereduce the risk of aspiration,
but then you've also got qualityof life to consider things like
that. So essentially, once I'vedone all that, and it did take
me a while because I am alearner who takes longer. I mean
it took me 13 months to pass mydriving test. So I'm definitely
not a quick learner at my time.
So I know that I'm reallyconfident With what I'm doing,
so I think it took me over ayear, I would say to get all of

(10:03):
that in because at the same timeI'm obviously doing my dietetic
job as well trying to balancethat. So but luckily, I were
able to do quite a lot of it inwork time, hour, quite well
supported. And I think that'sbecause I'm, I think I would
like say, I'm quite good at mytime management, so are able to
kind of balance everything. Soonce I've been out, and
obviously the supervisorassessments as well. So once all

(10:24):
that I've been signed off, soI've got the same competency as
a speech language therapist interms of the dysphasia training.
So there is actually a, it's aninterprofessional dysphasia
framework, and I will reclassprobably as a foundation
dysphasia practitioner, sothere's things like specialists
and consultants, and things likethat. So So yeah, I was on the
cast that I did, I was the onlydietitian but there were also

(10:46):
some nurses and so physios aswell. So when asked to see kind
of other HPS, as well, it reallygot

what's been the reception around the idea of
other other healthcareprofessionals, learning how to
assess patients followingthings, what's been their
perception and stuff, because Ithink sometimes it can appear a
bit like taking someone's roleor taking over someone's job or
an area where that particularhealthcare professional is an

(11:16):
expert in for ages. What's beenthe perception of that?

Unknown (11:22):
What I received is it's been nothing but great. So the
speech therapists, I think, wellactually one of them does call
me that honorary speech andlanguage therapist. She's, you
know, they are really gratefulbecause I can obviously pick up
referrals, so it reduces theirworkload. So the moment in
Doncaster, that referralsincreased, I think, over the

(11:43):
course of three years increasedfrom like, in the hundreds to
the 1900s. So massive jump andobviously staffing, it takes a
while to get funding and to getthe right staffing in place. So
a lot of them are heavilydysphasia referral, so I think
it helps them it's helped themmassively. Also, because I'm
quite well known in my dieteticrole, and I do a lot of work out

(12:04):
and community with otherhealthcare professionals,
they've actually been able tocome to me and say, Laura, we've
got this question. It's a bitlike I'm away into the speech
therapy team. So I'll obviouslyhelp them if I can, from a
dysphasia perspective, but I canalso kind of be that point of
contact for both teams, if thatmakes sense. So all the
healthcare professionals havebeen kind of really grateful and
said, Laura, please, can you canyou just assess this patient for

(12:25):
me? So obviously, I'll have togo through the right channels,
but I think it's it's basicallyhe's having a voice for the
speech therapy team as well. Soall the professionals have been,
yeah, they just thought it wasgreat. I think it goes I do
worry when I go into places andI try and explain what I do,
because I don't know about you,and I'm sure everybody else
who's listening will think thisthey confuse the speech therapy

(12:48):
team with the dieticians and thekind of micro Mia speech
therapists might call themdietician. So when I want to say
do both are a bit like Oh, allright. Okay. So that's the only
thing I would say is it can be alittle bit confusing for staff
who are kind of not working withyou all the time. For example, I
care um, staff something likethat.

Yeah, I can imagine it is confusing cuz they
already get us confused.
Regardless, let alone if one ofthe one on one dieticians roam
around and swallow assessmentsand stuff that's that's extra
confusing to people.

Unknown (13:18):
Yeah, definitely, definitely. But hopefully, if
there's more of as eventually itwill just become a kind of a
team effort, really. So yeah.

So what's your use of that phrase? What's your
current skill level in swallowassessments? Because obviously,
I know there's different sortsof levels. And obviously, you've
got the bedside assessments thata lot of people do, but also
instrumental assessments likevideo fluoroscopy, or the fibre
optic endoscopic evaluation ofswallow assessments and things
like that. So what's, what'syour current skill level? And

(13:48):
what what level Do you plan toget to? Is that Is there any
progression in the swallow inthis role? Or do you feel like
it? It fits quite well as it iswhat how is it working?

Unknown (13:58):
I will say because of so I work predominantly in
community so that's patients intheir own homes and care homes.
And on our side, we I've gotsome rehabilitation Ward, so
we've got acute mental healthwards, we've also got some
rehabilitation wards. So myskill level is obviously at the
moment, we don't have fees,sadly, or really nice to have
these kind of stats, obviously,mobile, you can take that route,

(14:21):
the video for us based on theacute hospital, so obviously I
don't work for them. There istwo different trusts in
Doncaster. So they do that. Sothe minute is just bedside
assessment. But obviously wewould refer on to video first,
but if we needed to. So yeah,it's just it's just the bedside
assessment. I think because ofthe type of role that is and
because I'm a dietitian, I'mobviously I'm not going to start

(14:42):
going out and doing VFX andthings like that. I think I will
stick to what I know which iswhich is just out in community.
If we did get a piece that willbe great. But yeah, I think I'll
probably just expand on theconditions that I see. So I
started off with care homepatients because from a
dysphasia point of view, Theyweren't simple. But the work

(15:02):
much easier than kind of astroke patient, for example, it
was common it was nil by mouth.
So it was much easier becausethey're already well established
on a diet and fluid, they werejust having problems with that
day and fluid. So it was kind ofeasier to manage. So I started
doing that, which I found quitehelpful. And obviously having 24
hour care, there's alwayssomebody there to watch them. So
you've got that extra safetyblanket when you are giving you

(15:23):
advice. So you can say to them,you know, if you have any
problems start revert back tothe previous recommendations,
give me a ring, so you've gotthat, when you first started out
can be quite daunting, becauseyou know, you are advising what
protects you that person can orcan't eat safely. Then I've
started working on the neurobiolrehabilitation Ward, which is on
site, which is really good,because a lot of those I mean,

(15:44):
at one point, we had sixpatients who are feeding tubes
in the run various kind ofsomeone nearby mouse, and we're
on our trail somewhere onestablished dyeing fluids, but
obviously, maybe I like levelfour, level five. So we're able
to work with the speech surfacethere and practice my skills
doing that. And then now I'vejust gone on to people in their
own homes, but we're feedingtubes, I'm trying to keep it

(16:06):
really relevant to role for meas a dietitian, so I can
actually give patients, theyonly have to see one therapist,
and they get the kind of bothadvice at the same time. So I'm
kind of graduating, and it'smore around my confidence
really, the team have kind ofsaid, you know, you can do it,
you know, you know when trustroute, you know, and trust for
support. So just give it a go.
And what may be me, I'm quitenervous and want to make sure

(16:29):
I'm fully confident before Iactually dive into something. So
yes, I feel like I'll probablyI'll make sure that it works for
the patients or whatever isgoing to benefit the patient
most. And the service, that'sprobably where I'll stay
working. So it's not about whereI kind of I want to increase my
skill level in terms of maybedoing something more complex,

(16:49):
like Vf, things like that. It'sjust more around making it work
for the service and patients.

So very sort of service focused patient focused
and focusing on the area wherethe the blending of roles is
actually advantageous. Yeah, sofor example, speech and language
can do video fluoroscopy. Butwhat what's a speech language
therapists wouldn't be able todo is also assess someone
swallow in their home, and thenalso adjust their feeding regime

(17:16):
accordingly. And so doing bothof those and actually providing
that that mixture of care, butmaybe not the more, more
instrumental assessments thatspeech and language therapists
would do. And I think that's athat's a brilliant way to ensure
that patients get timely serviceand also reduce the amount of
professionals they need to seehow many visits they get a day
and things like that. And howmuch extra time do your visits

(17:40):
take? Is it like a double bookvisit? Or is it

Unknown (17:45):
because I'm travelling, so obviously, the care homes,
we've got a really robustmalnutrition universal screens
or pathway for the care homes inDoncaster, they're very managed,
not very much managed within thecare home itself. So when I was
in the care of patients, theywouldn't, I wouldn't necessarily
be seen for a dietetic reason.
But obviously, that's because Iwill kind of first started out
then when I would see thepatients in the neuro rehab

(18:07):
setting, I guess it kind of Ispend more time doing the
dysphasia like kind of hands ontype because a lot of the
dietetics will be kind ofreading through the notes,
checking what they've beenhaving check in a tolerance. So
I think hands on time, I thinkactually do less dietetic comes
to hands on then I do swallowingI tend to do more of that. So I
want to say it takes me too muchlonger. I think because I'm

(18:29):
quite confident in the role ofworking within dietetics that
might only take me like 10minutes. It's the swallowing
that takes me a lot longerbecause that's kind of what's
new to me. So I think becauseI'm in a position from a
dietetic perspective, as wellbecause what we tend to our
candidate specialisms as suchand Dietetics is an interesting
support and his whole mentalfeeding like the complex gastro
and head and neck or centre, theacute or so from a dietetic

(18:51):
furtive it is, it's much I'mquite skilled in that area. So
it's not it didn't take me aslong. So it's just the dysphasia
that takes time.

When you when you put the swallow assessment, is
it like a separate assessment?
Or you put a separate note in orlet's I'm just thinking like,
logistically, do you put it in?
Which section do you put it in?

Unknown (19:15):
Yes, so there's, we use Electronic Arts. So we've got
system one for dietetics. I goon to the speech therapy unit,
and I type my notes in there. SoI've got kind of a bit of a
profile that I use a bit likewe've got as a two way I've got
my own for dysphasia that I'vedeveloped, obviously with the
speech therapy team, so I haveto document everything in there.
So then what I would do in thedietetic knows, is that right,

(19:37):
please see my speech therapynotes for details, but
basically, these are therecommendations. This is what
we're doing, because asdietitians well at that time, I
just think well, I just need toknow what the can and can't
have. I don't really want toknow the ins and outs of what
kind of what happened when thecoughed and this kind of thing.
So, yeah, it's just a brief kindof note in the dietetic ones,

really, um, and I want to bring you back to when
you mentioned about The criticalevaluation you had to do for
your masters and sort ofbringing sort of your dietetic
knowledge and your dysphasiatraining together, was there
anything that you that sort ofas you were writing those
evaluations and thinking aboutthose things in regards to
patients, you careful withanything that maybe questions

(20:19):
your thought process, youthought more about a particular
area, or you thought that havingthat swallow training helps you
understand something a lot morewhen

Unknown (20:29):
I were when I was doing it. So once I wrote it all kind
of made sense. I'm not sayingit's something I already know
already. But you know, whenyou've kind of got a feeling so
when I wrote about the enteral,feeding and dementia, we know
what that is quite well known,we don't do people with advanced
dementia. So that kind of it setthat in stone. And it's nice to
actually look at the research.
And because we knew I knew thatas a dietitian, but I'm actually

(20:50):
sat and looked at the research.
So we're nice to kind ofconsolidate and solidify that.
And then obviously, there wassome work around thickened
fluids, and texture, modifieddiet, so the thickened fluids,
and again, we know asdietitians, it can reduce
people's quality of life, andthe compliance of it. And again,
this is what the research didshow. And the research did also

(21:13):
show that thickened fluids don'talways reduce the risk of
aspiration, because it can causeresidue in the pharynx, which if
people can't clear it, it satthere, it's right on your airway
ready to be kind of aspirated orpenetrate. So there were lots of
things that I learned thinking,Well, actually, this is quite
thought provoking. And youreally need to this is why you
need this holistic assessment,if you are going to put some

(21:34):
traffic and fluids, are you sureit's the right thing to do? Does
that make sense? Becauseobviously, because of the risks
of it being kind of a lotthicker, and obviously, with the
texture, modified diets,people's quality of life can
reduce, and obviously there'sweight loss and things like
that. And this is where I'mthinking, well, this is where we
fit in. Because if we've gotsomebody on a texture, modified
diet, we need to reallyintervene and kind of help them

(21:56):
because I don't know about you,but it's very rare. You find
somebody on a level four dietwho's kind of in really grey,
and there have been lots of youknow, the maintaining the weight
and things like that, because itdoes come with its difficulties
daunting, so and it might be thesafest for that person. And
again, is we speeding somethingwe need to consider? Because you
know, it really improvessomebody else's quality of life

(22:18):
when we can't put a measure onthat I

think and have the speech in obviously you said
you're you're the go betweenbetween some of the dietitians
and the speech languagetherapists have the speech and
language therapists learnanything sort of, obviously,
you've learned stuff from theirside of the side of the coin,
but is it ever gone the otherway to where they learn anything
from from you or how you maybeview things with a little bit of

(22:39):
a years of dietetic experiencewith a bit of a dietetic hat on
Yeah, so

Unknown (22:43):
this is something I definitely want to work on. I
think because I've been takingso long finding MFI, learning
their, their profession, aftertheir profession, this is
something I want to work on. SoI want to work on if the speech
Sherpa team feel that they needto refer come to me first, let's
talk it through let's you knowjust again, saving a lot of time
kind of documents in aroundreferrals, we are kind of across

(23:05):
all professionals wanting tolook at increasing how often
people would screen using themouse tool and put in action
plans in place. So that's notsomething I've worked on. As
such, I think they've learned alot from me along the way
regarding feeding tubes andweight and kind of decisions
around what we do for thatperson. So for example, we had
patients who were on the waitinglist already have feeding tubes.

(23:26):
So from a speech therapyperspective, they're low
priority, because they've got analternative form of nutrition
and hydration. Well, I mean, thewaiting lists are quite long, as
I said, the referrals havejumped to like 900 from the
hundreds. So they will bewaiting quite a long time on the
waiting list. And as I said,they're a low priority. But I
said, but actually, if I've gota 70 year old chap with a
feeding tube, it was in a carehome and it's on all trails, I

(23:49):
want to get that peg out as soonas possible if I can. Because if
somebody is left with a peg inplace, and somebody had a
stroke, and they're obviouslymore chance of developing
dementia, which then things getreally tricky with regards to
the feeding tube. So I said,it's really important that when
that person comes out ofhospital, we get in there and do
that rehab with him to see if wecan eat to see if we can get
them back onto kind of any formof normal diet and fluids to

(24:12):
maybe get the feeding tube outbecause of the complications
that can cause eventually sothey will also it's actually
quite high priority for you intoand I said yeah, I know they've
got an alternative familynutrition hydration. But
actually, that doesn't mean thatwe can just leave it, we need we
still need to do something withit if we can. So I think that
that will kind of a learningpoint for them, which is why
they said it will be good if Idid take on all those patients

(24:35):
with a feeding tube. So they'vegot that kind of it will quite
quick that they've got thatintervention.

So as low priority patients for them because of the
alternative form of nutritionare actually still getting seen
by a dietitian with extradysphasia training and
hopefully, who doesn't want toeat quicker. You know, I mean
eating is quite an enjoyablepart of life just from just from
a sort of patient experienceperspective and I I always think

(24:59):
you meetings are a fundamentalpart of our life. It's quite
social, it's quite, it's justimportant in life. And as
dietitians, we, we obviouslytalk about the importance,
probably a little bit too much.
But I think I do think forpatients, it means quite a lot.
And if we can, if we canprogress them slightly faster,
it definitely improves thatpatient experience definitely.
Because it's really, it's sonice to hear that the learning

(25:21):
is as as sort of gone both ways.
And you've learned things fromSpeech Language therapists, also
the course you've been on andhaving to critically evaluate
practices, learning, learningthe backstory behind why the
nice guidance say that feedingin advanced dementia is not
appropriate. And things likethat helps to sort of improve

(25:41):
your improve yourself as adietitian, I think understanding
a little bit of that backstory.
So when we're thinking aboutyour experience in this role,
where you've talked a little bitabout areas where it's excelled
for you, but as you've developedthe practice, have you thought
about any of the areas ofdietetics, maybe you had
experience with it on placement,or heard about it from other

(26:01):
people where you think thathaving jewel competencies would
be really, really helpful, andhow you think it would work and
say, obviously, yours iscommunity based, but there might
be sort of acute dieticianslistening to this or dieticians
in different areas, how do youthink it would work for them,

Unknown (26:19):
the first thing to do would be to obviously speak with
the speech therapy team, whenyou service leads to figure out
if there is a gap, or if therewould be a benefit to the
service spa patients aroundobviously being dysphasia trade,
obviously the neuro rehab whereI work at the moment, again, it
fits in really well, their wholemental feed in as well. I think

(26:39):
that's definitely got a placefor it. But again, with
dysphasia, the clinical, it's abit like when we look at
diabetes, for example, we havekind of an idea of a careful
interventions that we're goingto do. And it's the same with
swallowing. So if somebody had astroke, you will, you might see
very similar patternsobservations in kind of a

(27:01):
patient group who's had astroke. But for somebody, for
example, who have outsider neckcancer, you'd see something
completely different. So withenteral feeding, because you
might see a variety ofconditions, is making sure that
you feel competent in all ofthose areas and all of those
conditions. So there is that asan area that will be quite good.
I know one of my colleagueswho's also dysphasia tray, and

(27:22):
she works in learningdisabilities. So I think it's
more service specific. And isthere a need for it there, it
could technically work in anycondition, I guess. But he's
just trying to, to make surethat it benefits patient and any
benefits of service as well. Butyeah, they're just some of the
areas I think, might be quitenice. It might quite work quite
well, for

me. And in particular with yourself. what's
the what's the future of your,your role? How do you how do you
see it advancing into thefuture? And or, obviously,
you've talked about expanding todifferent areas. But is there
any sort of extra work aroundsort of dysphasia trained
dieticians that you would you'dlove to see in the future? It
could be something you'reworking on at the moment or

(28:02):
something you see as apossibility?

Unknown (28:05):
Yeah, I think because it's quite a new role. And as I
said, I've got a colleague, butshe works in learning
disability. So again, verydifferent from like a swallowing
perspective. And I'm not I'mreally not sure what because I
feel like we've not reallybecause we've not done it
before. We don't know what thefuture holds. And I am just
enjoying seeing patients andenjoying kind of learning and

(28:26):
progressing and trying to seewhat kind of differences we can
make. But no, it's really hardto say because I just don't
know, it's difficult because youdon't know what you don't know,
do you really so we'll have tosee how it goes. And obviously,
in Doncaster, we've done a lotof projects. We've done a lot of
innovative work in other areasof dietetics. So I'm open with
and kind of continue that inthis area as well. So yeah, I'm

(28:48):
just hoping to increase myincrease my knowledge and my
skills in the conditions andmore to see where it takes us.
But yeah, unfortunately, there'sno things like KPIs or anything
like that to go off really wellkind of adjust a bit. One thing
I did want to do is kind of setup maybe like a dieticians do
dysphasia whether it's like aFacebook group people are
interested or I don't know,obviously, because I feel like

(29:11):
I'm the only one if there is anyout there please obviously if
you're listening to thispodcast, please get in touch if
I'm not aware of somebodyelse's, and I know I've got one
colleague and we I'd like to youknow, it'd be really good if
it's something that we can do.
And just branch in the twoprofessions together, because we
do work very closely togetheranyway. So it'd be great if we
could if we could continue that.

(29:33):
Because they said we do we do abit like OT and physio kind of
goes together a little bit.
You've got speech therapy andDietetics. So it'd be nice just
to continue that kind ofinterprofessional working.

Yeah. What about the speech language, maybe
taking over some of the sort ofcare for sort of nutrition
support and speeding have thatcharacter any talk about that
within your, within your team orwithin your service. This is

Unknown (29:53):
something I do want to work on. So obviously, what we
could be asking them to do iskind of scream from
malnutrition, so obviously givenour mascar and putting a
nutrition action plan in place,and then if that's not working,
for example, if they're stilllosing weight or they're still
having difficulties, thenobviously they can refer. So
we're doing that little bit offirst line advice, which our
district nurses also do.

Anyone on a texture modified diet is at high
risk of higher risk ofmalnutrition. So, why why should
we not screen those patientsmore regularly to catch
malnutrition? Say it's moreeasily resolved quicker, I think
that's a really good, useful wayfor them to do it, and to put in
a action plan in place toactually almost Yeah, see if

(30:35):
that works and treat thatmalnutrition. And think that
would be really helpful. Yeah,

Unknown (30:40):
we've also I came across, when we're doing
assessments there would be, soit's at that level faster, we'd
have the diet sheets that willlevel father speech therapy
developed, and I walked him withno offence to my colleagues,
there were things on there. AndI think one of the exams that
stuck out the most to me wasmeal options, quiche. And I were

(31:03):
like, no, that's really not,that's really not a meal option,
or like we need to end thesuggestions on there is
obviously we'll try it with therandom miss things, things like
avocado or this occasion, I likethat we need to make some diet
sheets that if somebody is putonto a level five diet, they
know how to have a balanceddiet, they know how to enrich if
they need to enrich it. So whatI've done recently is I've

(31:25):
worked with the leader and we'vedeveloped some leaflets in line
with it, too. So we've got onefor level four, right up to
level seven easy to, and it'sreally robust around with easy
carbohydrates, these a protein,so it is more it's not a healthy
eating leaflet, it's morearound, you still need to have
these food groups, even if youare on a level four date. So

(31:46):
don't just live off things likeyoghurts and things like that.
So I have developed thoseleaflets, which I think I think
will be really helpful. And thatmight again, that might help
with that first lineinformation. So if somebody has
changed on to level five diet,they still know what the can
eat, because a lot of patientswill come to us and say it's
dietitians and say, Well, I'm onlevel four diet, what can I eat.

(32:06):
And as we know, while we're onthe phone, or while we're
talking to him, we can't thinkof things up top of his head. So
it's really good now that we'vegot these leaflets that we can
obviously give out. And he kindof explains everything they need
to know about the level whilstalso eating everything that they
need to eat. So yeah.

And it also probably helps the compliance as
well. I mean, if the if the dietseems a little bit easier to
follow and less lessrestrictive, and allows them to
feel well nourished and feelsatisfied, yes, then I know
that, for example, I would Iwouldn't feel pretty happy with
just quiche is my meat option.
So I mean, adding that addingthat dietetic knowledge along
with their extensive experiencewith dysphasia, managing

(32:45):
patients and managing sorts ofrisks. I think with all of these
extended roles, I think one ofthe things that really stands
out is the collaboration. Yeah.
So for example, I've intervieweda dietician Sam before who
places and G tubes and there'sother dietitians working in sort
of placing bedside nj tubes inthe acute setting. Yeah,

(33:06):
obviously, you're working withdysphasia. And it never seems to
be a case of Oh, they've come inand they've replaced somebody's
role. Yeah, it's always likethey, they supplement it. They
provide support, they provideextra training they provide,
they fill a gap that wasn'talready filled, and it almost
enhances the collaborationbetween them. So for example, mg

(33:26):
placement and sort of nutritionnurses, through nutrition nurses
are still still very busy inthat in that setting, but it
just helps to provide it helpsto be almost like an extra pair
of eyes and ears for them aswell. Yeah. And I think that
really, really works well for Imean, Speech Language
therapists, but obviously, as weextend roles, it'd be great to

(33:47):
have physiotherapists,occupational therapists, Speech
Language therapists, almostscreening for most and putting
an action plan in place before adietitian can even get there. I
think all of those ahps as wellas nurses would be perfect place
to do that.

Unknown (34:03):
We can't see everybody can we like you said it's, it's
an easy to do get towards thepretty in dire straits at that
point, because they've been atrisk for so long. So like you
said, anybody that can get inand do that kind of just that
first line advice. It's what wewill provide anyway into kind of
food fortification, snacks anddrinks. So yeah, is the same.
And I think from what the speechtherapists do also appreciate

(34:27):
it. Because I'm a dietician, Icome from a different
background, I see things in adifferent way. So when we're
talking about patients, it is adifferent perspective, because
unlike most dieticians would getvery involved in what we do. And
we're very, we're not shortsighted, but obviously, we think
as dietitians so you know, forme to go in there and say, Well,
actually, we thought about thisand we thought about that. The
speech therapists are like, Oh,yeah, actually, that's a you

(34:47):
know, silverpine lets you know,so it's, it's good to have two
heads. two heads are alwaysbetter than one.

Definitely. Yeah.
two heads about in the morning.
Did you have any interestingexperience sort of with patients
or maybe case study that'sthat's really exemplified how
how this works well together.

Unknown (35:06):
And so I think my favourite one, because obviously
they always stick out if youdon't then patients that you
always remember certainpatients. So I did I kind of
almost refer to it before. So wehad a fairly new patient who had
been admitted for makinghospital into a care home, he
had a stroke, and he willdischarge on eight teaspoons of

(35:27):
level three, or level fours. Soobviously that could be dying
off fluid six times a day. Andat the current happening in
another, like, he really wantsto eat more like he's looking
everybody else's food. Like itis really sad. Like, I think
he'll be fine. Like, please, canyou come and see us? And so I
will have right yeah, okay,obviously it will my peg patient

(35:47):
as well, because he's got afeeding tube in place. So when
we're out to see him on thefirst assessment are able to
help him to kind of no limit oflevel three and no limit of
level four. So obviously, beforeI run this, the teaspoon so that
you're able to manage unlimitedamounts. And then from that
point, I think he ran a bolusfeeding regime from that point,
he did not need any enteral feedafterward at all, because of the

(36:09):
amount he ate. And he wanted toeat that for us level three, and
level four, still quiterestrictive, we think and it's
still quite modified that Iwould somebody meet the full
nutrition, hydration needswithout the use of repair. But
this chapter because it was soeager, so it massively improved
his quality of life, he was sohappy. And then on the second
assessment, what I would donormally is and it is partially

(36:29):
for my learning and for thepatient's benefit is if I make a
change, so we have level threefluids where the level four
diet, I only changed an assessthe diet at that point. So if
anything, if he does have anyadverse signs, we're quite clear
on what caused the problem. Ifyou change fluids and diets
together, could it have been thefluid that caused that but you
know, if he starts coughing andchildren and things like that in

(36:49):
the counterparts here, as well,because if documentation is not
great, and communicationsometimes you know, it gets
missed on what the problem was.
So I went and I assessed dietand he went from level five diet
to normal diet. So it was in thesecond assessment in we're on
level three fluids and you're onnormal diet. And I left it about
two or three weeks to obviouslycheck that in manage that, okay,

(37:09):
went back after three weeks, heput on 10 kilos, it'd been
having double meals. And thenobviously the third time I went
with SS fluids and we could onlyget him up to level two, I'm
sorry, we could only you knowreduce the spectrum down to
level two. But it was stillquite happy with that. So you
know another another couple ofweeks and we'll refer for is

(37:30):
really true about so for me isreally troughed easy in double
meals and double puddings andlike you said eating and
drinking is so important it iswhat we think about is what we
try and control is is everythingin two ways towards other
professions. But it's it'sdefinitely really important so
for me that really stuck out asbeing kind of a really

(37:50):
successful

KPI thing you've definitely experienced that.
Yeah, yeah, definitely. Yeah,and also the time of
interventions, probably shorterdietetic dietetics, and speech
and language therapy as well. Soyou already know that you're
planning to get his feeding tubeout you don't need a referral to
be sent and then it to be triageand then it to go through all
the systems you already knowabout that. And I know in a lot

(38:14):
of community settings obviously,contracts vary and they're all
all secretive feed costs morethan food I think they usually
cost more than food likesupplements and all the
equipment that's needed all theextra care that's needed. All
those things cost extra moneyand time from nursing staff and
by actually reducing the amountof feed that he's on not only

(38:37):
does it improve his quality oflife, it also reduces costs as
well. Yes, definitely a multipleperformance indicators there
that I would look out for thatsort of thing but yeah, that's a
that's a I imagine he's reallychuffed.

Unknown (38:51):
He is and he's such a lovely chap as well. Yeah, no,
it's it's really and I did thesame in an impatience as well.
So I assessed a truckload at abrain injury It was 12th of
August and it was threeteaspoons of milk three times a
day very rounded but on the milkhe wouldn't have anything else
and then by the second ofSeptember, it were on a run full

(39:13):
amount of normal fluid anyonelevel six soft about size by 18
to September we're on Novaya pegand in revenues peg are a walk
on having a referral hopefullyto Abby's paper we also run that
trial so within six weeks,they've gone from basically
being nearby mouth to being ableto eat and drink and not have to
use a feeding tube. So yeah,like you said, it's quicker for

(39:33):
me our interventions and thetime is under our case with
because we're normally satwaiting for speech therapy to go
and do the assessment so we cando our bit whereas now it's it's
much quicker like so from bothsides. Yeah. And I always think
I'm always thinking about thepatient. But like I said, it
does have that knock on effectswas caring for a feeding tube. I
said it comes with an ESB. Itcomes with a lot of costs, you
know, even impacts on thingslike continuing health care and

(39:55):
placements that people have ifpeople have a feeding tube, they
have to have a certain placementwhere Back can be cared for. So
it does make a massive impact tothings like discharge locations,
and things like that. So yeah,there's Yeah, it does, it does
benefit a lot of a lot ofprofessionals, whether they know
it or not.

That is a brilliant story. I think it
definitely is. Definitelyimprovements in patient care are
the fundamentals, but then theextra is just icing on the cake,
but also justify the extra extracost of the dysphasia trainings.
What sort of, if you don't mindme asking what sort of cost? Do
they? What's the kind ofballpark that these sort of
trainings come out? Maybe notthe, you don't need to say that

(40:34):
particular one. But what sort ofprices are we looking at?

Unknown (40:37):
I think, and I could be completely wrong, but I'm sure
it were about 900 pound, Iwon't, I won't like say for
sure. But it's around is aroundthat price. But I don't think
price really came into it onlybecause it's such a normal thing
that wants to speech therapistshave graduated, then they go to
the offices that work for atrust, and then the trust will
send them on that cost. It's abit like it's not an easy,

(40:59):
obviously it's a 3030 creditmasters module is just something
that they just do that just kindof because they expect all
Speech Language therapists dobasically needs to be dysphasia
trained, they might not work inthat area. And that's obviously
different. For example, if thework in a school might just be
communication, but as I said,most speech therapists are
trained to dysphasia as well. Soyeah, I don't think crosswalk, I

(41:20):
think it was too important. Andlike you said, I think we
probably just need to sit andwork out what this has actually
saved. Because we wanted to dothat

I can imagine it's probably that patient experience
would definitely be an areawhere I think would be the
biggest adding that's one of thebiggest things, and I think
everyone would acknowledge that.
And I think it's not a hardthing to grasp that. Obviously,
eating is nice and improvespeople's people's lives. Do you
have anything else you want tosay in regards to dysphasia? Or

(41:50):
this particular from start tofinish? What's been the biggest
hurdle or barrier that you'veencountered to actually
implementing this dysphasiatraining into practice? Or even
the training itself?

Unknown (42:04):
I would say the biggest hurdle was was the training
itself, I think, is it whatreally was a difficult course
because because I didn't havethe speech therapy background.
And the speech therapists whowanted the class, they have like
three to four years of thatunderpinning knowledge of all
the muscle culture for thecommunication, the swallow,
they've got all the aetiology,whereas I didn't have that. So

(42:25):
that was a massive, massivelearning curve for me. And
there's such a variety,radiology and different patients
and things like that. It was itwas really difficult. I mean,
some muscle provides todetermine that some speech
therapists don't actually passfirst time. So the fact that I
did pass, I think is quite anachievement in itself. And I
think because as I said, it'svery subjective. And there's
lots of grey areas, and it couldbe this and it could be that it

(42:47):
don't sit well for somebody wholikes things in order and a bit
OCD and likes to make sure thatwe know what we're doing. And
this is it. And this is this bitlike oh, it could be this. It
could be that so it's, it's mademe be a lot more flexible. It
has made me a much betterpractitioner. But yeah, I would,
I would say the actual doing it.
I've had amazing support from myteam. They're just the fabulous,
but from a dietetic perspective,and obviously with speech,

(43:08):
though, between actually doingit, and seeing patients getting
a competency. Oh, that was itwill it will fun, it was really
difficult. And then you get to apoint it's a bit like I assume,
everybody, as we've gone througha study is being a student
dietician, you wake up one day,all you see that one patient
anything, yeah. Okay, now, Iunderstand what I'm doing. You

(43:31):
just have that lightbulb moment,we think it all kind of makes
sense. And now I'm kind ofgetting to that point. And this
is kind of two years down theline with the disclosure. So I
feel like it just takes a lotlonger. And I think it's because
I don't I didn't have thebackground at the speech therapy
still, but the actual trainingand working in this area,
there's not really been anybarriers. And I said it's
because of the amazing supportI've had from the managers and

(43:52):
from the team. And that's reallyfundamental, because it is quite
a lonely thing to do, especiallyas you're the only dietitian it
was this way to train so you dofeel a bit like a bit of an
outsider in your own mind eventhough it weren't like that at
all. So yeah, it's important toget this part from everybody but
no, it's been a it's been areally good experience. And I
definitely think we should havemore disposed to join dieticians

(44:14):
I think this is this is thefuture it's the way forward I

mean, it's definitely part of common
exactly which NHS sort of widerstructure document is HPS in
action or something. Yeah, usingthe workforce we already have
expanding roles, thinking ofways we can work more
collaboratively together. And Ido think that's probably one of
the fundamentals of teamwork.
And if you think about lots ofteam sports, you'll have people
with Assigned Roles such asstrikers defenders and stuff

(44:39):
underscores a goal no one'sgonna go Whoa, what are you
doing? You may mean offence May.
Yeah, however, but if they, forexample, if a defender tries to
score a goal, but maybe lackshis fundamental skills of
protecting the goal, peoplemight say actually, you know, he
shouldn't have been scoring thatgoal in the first place. So it

(45:00):
is I think, what's been gonethrough it's it's definitely
some of these skills are quiteadvanced skills. And it's
important to make sure we've gotthat underpinning of dietetic
knowledge and dieteticexperience before we try to,
yeah, extend into other roles ordo other things.

Unknown (45:16):
Yeah. I think you have to feel confident in your role
because it is a huge job. Imean, it's a Master's anyway. So
I will never quite interested indoing anything other than
undergraduate I will quite happyto learn better from experience
than kind of academic work. Sothe fact that it will, a Masters
That in itself, it just kind ofshows how hard it is. But you
know, how challenging it can be.
So yeah, it's really importantto to, I think that's really the

(45:39):
point that you've made to keepto make sure that you're
confident within your own role.
If I start branching out anddoing other things,

definitely, I think there's probably there's
probably lots of enthusiastic,say student dieticians out
there, or newly qualifieddietitians that are looking to
just jump straight into thisarea and thinking I want to do
that right now. And that's,that's a wonderful skill to
have. Yeah. But also rememberingthat dietitians are dieticians
and we've got to make sure thatwe're, we we can eventually

(46:06):
learn to do other jobs on thepitch. Also, where were our
defenders or strikers, or wherewherever opposition is, first of
all, yeah, and then we extendinto other roles and support
other professions and things.
And I think that that obviouslyworks. Obviously, the more you
understand about other people'sroles, you can actually work
better as a team as well,

Unknown (46:25):
I think as well. But in terms of like your 2020, as
well, definitely. So

good analogy there. Are there any areas where
you think the combination ofhaving both dietetic knowledge
and then that dysphasia trainingwould be helpful in combination?
Yeah.

Unknown (46:41):
So I think obviously, the role that I'm in now, so in
community in care rooms areworked quite well. So obviously,
dietetic services in carry on isquite a lot into, we do get
quite a lot of referrals, andobviously, the different
pathways across country, so thatwill be really good. I think
acute stroke might be quite goodas well. And, obviously, because
if a lot of patients do becomenil by mouth, or if the need and

(47:05):
G tubes can be impact made theirneuro rehab as well, obviously,
I work on your rehab at themoment. And again, patients can
come from the acute settingnearby mouth, they might have
pictures in place. So again,it's quite relevant there. How
much of feeding would beprobably a good one, the only
thing to consider with that isthat there are lots of different

(47:25):
conditions, as we know, forpeople who have enteral, feeding
tubes. So obviously, if you'reworking, for example, on neuro
rehab, and his brain injuryunit, or if you work on acute
certainly stroke, you can focuskind of what observations you
might see what kind ofswallowing problems you're going
to see, the aetiology can bequite similar across those
patients. Whereas if you've gotsomebody who's mentally fed,
that, as we know, the conditioncan really vary. So you've got

(47:47):
to feel quite confident in eachof those conditions. There's
also a learning disability aswell. So I've got a colleague
who's dysphasia, trained to workthrough learning disabilities.
So again, that could besomething there. So I think it's
more around, trying to find ifthere is a gap, and kind of
seen, you know, or not even agap, kind of how can we make
things better, this wouldactually make things better in

(48:09):
this service for this team, Ithink it's gonna be very
specific, depending on where youwork, and what kind of services
are in place. So it's definitelyworth going to speak to either
your manager or your speechtherapy team and just kind of
discuss and see if it's anythingthat like you said, if there's a
gap, that would be great. Butagain, even if you can improve
patient care that would, itworks both ways. Really.

Yeah. So now for some rapid fire questions. So do
you have any advice for newlyqualified dieticians starting
off just fresh in a career?

Unknown (48:38):
Well, I would, I would say, always be self, find out
what you like. And obviouslythat that can help on placement,
you can kind of some peoplealready know from placement
experience, and become confidentin what in what area you like to
work in. And then if this isobviously a dysphasia, something
you want to go into, then youcan you can tie that in. So once
you feel happy and comfortablein your role, it can be

(48:59):
something you can think of kindof advanced practice, as well,
I'd always say, and it's notquite related to the dysphasia.
But if you feel like there'ssomething that's not quite
right, and you service on yourteam, then please speak up. I'm
also a freedom to speak upadvocate. And there should be
one in every in every trust. SoI think that's really important
to mention, because obviouslysometimes we can work in

(49:22):
services and because we'vealways done it that way don't
mean it's quite right. Or it'sas effective as it could be. So
yeah, always be self alwaysspeak up and obviously, yeah.
Find something that you reallylike and go with it.

And what is the most challenging thing about
being a community dietitian,

Unknown (49:42):
I would say it's, and I'm only comparing it to the
acute setting. I think it's thelack of that MDT at your
fingertips. So it's much moredifficult. Obviously we've got
GPS, we've got kind of othercommunity staff working in
different areas to try to pullpeople together and don't get me
wrong. Being virtual has helpedwith that quite a lot. Because
again, you can just be availableon a teams meeting rather than

(50:02):
having to go somewhere. Butyeah, I would just say it's the
lack of robbing people there andkind of knowing who to speak to.
Because if you think if somebodyis in community, if they're in
one care home, they'll have oneGP, if it's another county, it's
another GP. So you have to kindof spread yourself quite thin,
to kind of make all thesecontacts and kind of network and
things like that. Whereas ifyou're in a hospital, and you
work on I don't know, forexample, or spiritual Ward, you

(50:24):
know, who you're supposed toteam is. So it's just that
really, I would say, but it'sstill interesting, because you
have to learn a lot of skillsaround kind of how to speak to
the professionals, socially,kind of things to do with
funding and carers. And it'slike a completely different
world. And it's how people livefor the rest of their lives.
Whereas acute setting couldobviously be just a short period

(50:45):
of time. So it is a differentskill set. But it's good to have
both can your under community ifyou can, if you can get that
experience.

But thank you so much for your time today. It's
been a pleasure talking to you.
And I think this area is reallyof interest to I mean, I've
talked about in a few areas, andit always generates discussion.
And I think it's definitely anarea where a lot of dieticians
will be keen to explore and howthey can support their patients
better. And as you said, it'snot it's not just a quick fix.
And I think with a lot of theseextended roles, it's definitely

(51:16):
something that dieticians needto dedicate a lot of time not
just to learn the skill and dothe proper competencies, but
also develop the experience andthe knowledge to be able to do
it effectively. And well, forsure. So I think all of them,
whether it be things like knees,or gastric feed placement, or
even, as I've discussed onprevious podcast,

(51:38):
recommendations around physicalactivity and things like that,
your requires experienceimplementation, and practice to
be able to become better at it,

Unknown (51:47):
of course, and if anybody who is listening, just
want to get in touch and wantsto know bit more, I'm more than
happy to be emailed or to have aphone call or whatever. Like I
said it's just getting out thereinto

and the details for Laura's Twitter handle will
be in the show notes. Ifanyone's interested in getting
in contact with it. I thinkthat's probably the best way to
get in contact with you or

Unknown (52:08):
Yeah, Yeah, that'll be fun. Yeah, that'd be great.

Thank you very much. Thank you. Thank you for
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(52:31):
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