Dysphagia Trained Dietitian? with Laura Clark RD

Aaron Boysen: 0:01

Welcome to the dietetics digest podcast with your host and dietitian me Aaron Boysen dietetics digest is a podcast created and produced by dieticians for dietitians, we interview dieticians from around the world to talk about their journey and their groundbreaking work. This podcast will help inspire you and others to become the best dietician possible. Thank you, Laura, for joining us on this episode of The dietetics digest podcast. Great to have you with us today.

Unknown: 0:32

Thank you. Thanks for having me. I'm excited to do

Aaron Boysen: 0:34

it. Thank you for dedicating your morning time ATM to be precise, to record the podcast. So I wanted to start off with a little bit of a questions around yourself but I thought I'd possibly ask you to maybe introduce yourself and a little bit of your sort of background. So I invited Laura on the podcast because she is one of the very few dietitians within the UK that has been dysphasia trained. And I previously had other dietitians on our podcast, which is Sam Francis from Bradford teaching hospital that extended his role in the placement of nasal gastric feeding tubes for patients on a stroke ward. And I think it's very interesting to see how dietitians are extending roles to change patient care or improve patient care. And this is another great example of how it's just to help extend a role and help to provide better patient care. And usually that better patient care quote unquote, becomes a lot faster due to sort of friction and changing and professionals and extra referrals being sent. So Laura, if you just introduce yourself who you are a little bit of your background.

Unknown: 1:39

So my name is Laura Clark. I'm a clinical specialist dietitian and I'm also a dysphasia practitioner. So I currently work in Doncaster so I work for the rather than Doncaster and South number NHS Trust. I've been there for six years. So I've graduated in 2015. And I've worked there ever since I obviously do know what's going off everywhere else, but I'm quite Doncaster lead, and I've been there right from the start. So for Doncaster, born and bred then yes, yes. And it's not I live in bands. So it's obviously a very South Yorkshire based and they're doing a lot of work kind of as a South Yorkshire integrated care system. So it all kind of fits together. It's quite nice.

Aaron Boysen: 2:18

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

Unknown: 2:29

Yeah, so kind of how did it all? Well, I guess, so I obviously wasn't involved right at the very start. So I kind of had to go back to myself as our did, you kind of, I'll do that end up here. So in our dash, our speech therapy team covers a really large geographical area, which is Doncaster. It was spun out quite far, and the input into lots of different teams as well. So like the stroke team, so what they wanted to do is they wanted to look to see who else actually works closely in those teams that they could look at kind of extended roles. So at the minute in our dash, we also have a community matron, who's dysphasia trained, and she works in with progressive neurological conditions. So she now basically manages all of those patients. So that can be things like motor neuron disease, and Huntington's disease. So it's kind of that patient group gets to just see, they get to see the nurse or the nurse a bit, and then we get to see her for the dysphasia part as well. So I think it was some kind of like service manager meeting. Because basically what happens is they have places on the cost the dysphasia costs every year. So the desired amount. Okay, so which new band five speech therapists starting with the trust? Is there any current speech therapists that are band five that have not had the training yet? Is there any nurses who basically go on the course. So my manager, being the manager that she is she's very, she flies a fight for dietetics? She's like, why don't we have a dietician, but you know, this would be a really good idea. And what I found out after is that they actually, I thought that wanted to have a dietitian, as I've just said, well, they said, we actually chose you basically because of my skills at the time what the thought I could I could do so because it's a lot around kind of research question in practice using lots of evidence based formulating hypotheses and then challenging the hypotheses and changing them how swallow because obviously swallow management the impact on so many other things as we know, they thought 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 any opportunity that you get, I thought this is kind of one in a lifetime opportunity. So I'm gonna do it. And yes, that's basically the backstory.

Aaron Boysen: 4:41

And you're a pioneer for training and practice and adjusting slightly and I think helps us all I think obviously, helping other people blend roles and even when we talk about malnutrition management, I think there's definitely a case to make sure it's it's everyone's problem, not just dietitians problem and have Eyes and ears everywhere. sort of basic advice before sort of a dietitian can get there can be provided by lots of other healthcare professionals to support patients early. But I wanted to circle back on one thing you said they chose you. Now, what skills? Did they think? Or do you have that made you suitable for the role? So what sort of skills should a dietitian be? If they're interested in this area? What sort of skills they think would be useful for you?

Unknown: 5:28

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 very confident in asking for help. And asking for advice and knowing when you've gone wrong. So taking constructive criticism, which I know can be quite difficult, because a lot of the times I did get it wrong to start with because it was it, there's a lot of grey areas, when it comes to swallowing in dietetics. Officer, and I'm saying this very broadly, it's quite objective. So you know, if you think anthropometry is numbers, it's way biochemistry, it's numbers. It's, it's all quite factual, it's there. And things like with the clinical stuff, you know, if you've got your skin and your bowels and you die history, and then we're counting calories, that kind of thing. So are very numbers based, whereas dysphasia is not essentially, it's kind of you do a bedside assessment, and you can't, because you haven't got the X ray goggles to sit and see what's going on. You have to basically think it could be that or it could be that it could be that so you've got to be quite flexible. And yeah, and just basically be comfortable with making a clinical decision on what you think is the is the best thing to do. From what you've seen.

Aaron Boysen: 6:34

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

Unknown: 6:41

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 change and we've got to be able to work with them, and use lots of other kinds of information, a bit like we do in dietetics. Still, but yes, it's a completely different skills and approach to what dietetics would be.

Aaron Boysen: 7:02

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

Unknown: 7:10

It was back in 2019. I think COVID has kind of bled all the years together after that, I think when did actually do it. So what 2019 and something I did learn, which is quite interesting is I thought speech therapists would do dysphasia as part of that undergraduate study, but the down is just communication and everything else that they do. So the dysphasia is actually a Master's Course. So it's postgraduate, and even speech therapists once they've done their undergraduate, so they also then have to go on to do the dysphasia Master's Course. So that's basically what I did. So I did it at Sheffield, Hallam University in five days face to face that and I don't know what they'll be doing now. And it's 30 credits masters module. So the title is the assessment and management of adults with dysphasia. So when I did it, there were lots of pre reading, as there always is, and at the time, I was thinking, Oh, my gosh, this is gonna blow my mind this is, you know, it were our exit route very different to what to what I know. So you went on the course, you did the five day course. And then after that, you have to have 80 hours working within dysphasia management. And that would be with a trained speech therapist or with a trained another dysphasia practitioner. And at least 50 of those hours has to do with patients. And obviously, as you go along, your supervisor assesses you. So it's a bit like being a student dietitian, because you there and you know, your supervisors watching you giving you feedback and that kind of thing. And so we did that, and then out to do two case studies. So there was an acute dysphasia case study and a progressive disclosure case study to the acute one would be for example, somebody who might be nil by mouth on a neuro rehab Ward, you're kind of you're trying to improve the swallowing ability and the progressive dysphasia want might be so rare, for example, in a care home, and that's got dementia, so this was not likely to improve so you're up to kind of prove how you can go up and then go down and kind of the textures and the levels and obviously evidence in any exercises and things like that, that the might, you might recommend. So did that and then once you pass those two, I have to do a critical review. So around the ethical dilemmas in decision management so obviously I tried to make it quite relevant to me in my role so I did a lot around risk feeding. And she took a risk feed in it was enteral feeding in dementia thickened fluids and texture modified diets because I thought they're the most kind of relevant to me. So that's kind of just debate the, the literature around what is receding, kind of the evidence based ventral fin and dementia do thickened fluids actually improve what does it improve? Does it improve kind of the reduce the risk of aspiration, but then you've also got quality of life to consider things like that. So essentially, once I've done all that, and it did take me a while because I am a learner who takes longer. I mean it took me 13 months to pass my driving test. So I'm definitely not a quick learner at my time. So I know that I'm really confident With what I'm doing, so I think it took me over a year, I would say to get all of that in because at the same time I'm obviously doing my dietetic job as well trying to balance that. So but luckily, I were able to do quite a lot of it in work time, hour, quite well supported. And I think that's because I'm, I think I would like say, I'm quite good at my time management, so are able to kind of balance everything. So once I've been out, and obviously the supervisor assessments as well. So once all that I've been signed off, so I've got the same competency as a speech language therapist in terms of the dysphasia training. So there is actually a, it's an interprofessional dysphasia framework, and I will reclass probably as a foundation dysphasia practitioner, so there's things like specialists and consultants, and things like that. So So yeah, I was on the cast that I did, I was the only dietitian but there were also some nurses and so physios as well. So when asked to see kind of other HPS, as well, it really got

Aaron Boysen: 10:54

what's been the reception around the idea of other other healthcare professionals, learning how to assess patients following things, what's been their perception and stuff, because I think sometimes it can appear a bit like taking someone's role or taking over someone's job or an area where that particular healthcare professional is an expert in for ages. What's been the perception of that?

Unknown: 11:22

What I received is it's been nothing but great. So the speech therapists, I think, well actually one of them does call me that honorary speech and language therapist. She's, you know, they are really grateful because I can obviously pick up referrals, so it reduces their workload. So the moment in Doncaster, that referrals increased, I think, over the course of three years increased from like, in the hundreds to the 1900s. So massive jump and obviously staffing, it takes a while to get funding and to get the right staffing in place. So a lot of them are heavily dysphasia referral, so I think it helps them it's helped them massively. Also, because I'm quite well known in my dietetic role, and I do a lot of work out and community with other healthcare professionals, they've actually been able to come to me and say, Laura, we've got this question. It's a bit like I'm away into the speech therapy team. So I'll obviously help them if I can, from a dysphasia perspective, but I can also kind of be that point of contact for both teams, if that makes sense. So all the healthcare professionals have been kind of really grateful and said, Laura, please, can you can you just assess this patient for me? So obviously, I'll have to go through the right channels, but I think it's it's basically he's having a voice for the speech therapy team as well. So all the professionals have been, yeah, they just thought it was great. I think it goes I do worry when I go into places and I try and explain what I do, because I don't know about you, and I'm sure everybody else who's listening will think this they confuse the speech therapy team with the dieticians and the kind of micro Mia speech therapists might call them dietician. So when I want to say do both are a bit like Oh, all right. Okay. So that's the only thing I would say is it can be a little bit confusing for staff who are kind of not working with you all the time. For example, I care um, staff something like that.

Aaron Boysen: 13:05

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

Unknown: 13:18

Yeah, definitely, definitely. But hopefully, if there's more of as eventually it will just become a kind of a team effort, really. So yeah.

Aaron Boysen: 13:26

So what's your use of that phrase? What's your current skill level in swallow assessments? Because obviously, I know there's different sorts of levels. And obviously, you've got the bedside assessments that a lot of people do, but also instrumental assessments like video fluoroscopy, or the fibre optic endoscopic evaluation of swallow assessments and things like that. So what's, what's your current skill level? And what what level Do you plan to get to? Is that Is there any progression in the swallow in this role? Or do you feel like it? It fits quite well as it is what how is it working?

Unknown: 13:58

I will say because of so I work predominantly in community so that's patients in their own homes and care homes. And on our side, we I've got some rehabilitation Ward, so we've got acute mental health wards, we've also got some rehabilitation wards. So my skill 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, the video for us based on the acute hospital, so obviously I don't work for them. There is two different trusts in Doncaster. So they do that. So the minute is just bedside assessment. But obviously we would refer on to video first, but if we needed to. So yeah, it's just it's just the bedside assessment. I think because of the type of role that is and because I'm a dietitian, I'm obviously I'm not going to start going out and doing VFX and things like that. I think I will stick to what I know which is which is just out in community. If we did get a piece that will be great. But yeah, I think I'll probably just expand on the conditions that I see. So I started off with care home patients because from a dysphasia point of view, They weren't simple. But the work much easier than kind of a stroke patient, for example, it was common it was nil by mouth. So it was much easier because they're already well established on a diet and fluid, they were just having problems with that day and fluid. So it was kind of easier to manage. So I started doing that, which I found quite helpful. And obviously having 24 hour care, there's always somebody there to watch them. So you've got that extra safety blanket when you are giving you advice. So you can say to them, you know, if you have any problems start revert back to the previous recommendations, give me a ring, so you've got that, when you first started out can be quite daunting, because you know, you are advising what protects you that person can or can't eat safely. Then I've started working on the neurobiol rehabilitation Ward, which is on site, which is really good, because a lot of those I mean, at one point, we had six patients who are feeding tubes in the run various kind of someone nearby mouse, and we're on our trail somewhere on established dyeing fluids, but obviously, maybe I like level four, level five. So we're able to work with the speech surface there and practice my skills doing that. And then now I've just gone on to people in their own homes, but we're feeding tubes, I'm trying to keep it really relevant to role for me as a dietitian, so I can actually give patients, they only have to see one therapist, and they get the kind of both advice at the same time. So I'm kind of graduating, and it's more around my confidence really, the team have kind of said, you know, you can do it, you know, you know when trust route, you know, and trust for support. So just give it a go. And what may be me, I'm quite nervous and want to make sure I'm fully confident before I actually dive into something. So yes, I feel like I'll probably I'll make sure that it works for the patients or whatever is going to benefit the patient most. And the service, that's probably where I'll stay working. So it's not about where I kind of I want to increase my skill level in terms of maybe doing something more complex, like Vf, things like that. It's just more around making it work for the service and patients.

Aaron Boysen: 16:54

So very sort of service focused patient focused and focusing on the area where the the blending of roles is actually advantageous. Yeah, so for example, speech and language can do video fluoroscopy. But what what's a speech language therapists wouldn't be able to do is also assess someone swallow in their home, and then also adjust their feeding regime accordingly. And so doing both of those and actually providing that that mixture of care, but maybe not the more, more instrumental assessments that speech and language therapists would do. And I think that's a that's a brilliant way to ensure that patients get timely service and also reduce the amount of professionals they need to see how many visits they get a day and things like that. And how much extra time do your visits take? Is it like a double book visit? Or is it

Unknown: 17:45

because I'm travelling, so obviously, the care homes, we've got a really robust malnutrition universal screens or pathway for the care homes in Doncaster, they're very managed, not very much managed within the care home itself. So when I was in the care of patients, they wouldn't, I wouldn't necessarily be seen for a dietetic reason. But obviously, that's because I will kind of first started out then when I would see the patients in the neuro rehab setting, I guess it kind of I spend more time doing the dysphasia like kind of hands on type because a lot of the dietetics will be kind of reading through the notes, checking what they've been having check in a tolerance. So I think hands on time, I think actually do less dietetic comes to hands on then I do swallowing I tend to do more of that. So I want to say it takes me too much longer. I think because I'm quite confident in the role of working within dietetics that might only take me like 10 minutes. It's the swallowing that takes me a lot longer because that's kind of what's new to me. So I think because I'm in a position from a dietetic perspective, as well because what we tend to our candidate specialisms as such and Dietetics is an interesting support and his whole mental feeding like the complex gastro and head and neck or centre, the acute or so from a dietetic furtive it is, it's much I'm quite skilled in that area. So it's not it didn't take me as long. So it's just the dysphasia that takes time.

Aaron Boysen: 19:02

When you when you put the swallow assessment, is it like a separate assessment? Or you put a separate note in or let'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 go on to the speech therapy unit, and I type my notes in there. So I've got kind of a bit of a profile that I use a bit like we've got as a two way I've got my own for dysphasia that I've developed, obviously with the speech therapy team, so I have to document everything in there. So then what I would do in the dietetic knows, is that right, please see my speech therapy notes for details, but basically, these are the recommendations. This is what we're doing, because as dietitians well at that time, I just think well, I just need to know what the can and can't have. I don't really want to know the ins and outs of what kind of what happened when the coughed and this kind of thing. So, yeah, it's just a brief kind of note in the dietetic ones,

Aaron Boysen: 19:56

really, um, and I want to bring you back to when you mentioned about The critical evaluation you had to do for your masters and sort of bringing sort of your dietetic knowledge and your dysphasia training together, was there anything that you that sort of as you were writing those evaluations and thinking about those things in regards to patients, you careful with anything that maybe questions your thought process, you thought more about a particular area, or you thought that having that swallow training helps you understand something a lot more when

Unknown: 20:29

I were when I was doing it. So once I wrote it all kind of made sense. I'm not saying it's something I already know already. But you know, when you'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 set that in stone. And it's nice to actually look at the research. And because we knew I knew that as a dietitian, but I'm actually sat and looked at the research. So we're nice to kind of consolidate and solidify that. And then obviously, there was some work around thickened fluids, and texture, modified diet, so the thickened fluids, and again, we know as dietitians, it can reduce people's quality of life, and the compliance of it. And again, this is what the research did show. And the research did also show that thickened fluids don't always reduce the risk of aspiration, because it can cause residue in the pharynx, which if people can't clear it, it sat there, it's right on your airway ready to be kind of aspirated or penetrate. So there were lots of things that I learned thinking, Well, actually, this is quite thought provoking. And you really need to this is why you need this holistic assessment, if you are going to put some traffic and fluids, are you sure it's the right thing to do? Does that make sense? Because obviously, because of the risks of it being kind of a lot thicker, and obviously, with the texture, modified diets, people's quality of life can reduce, and obviously there's weight loss and things like that. And this is where I'm thinking, well, this is where we fit in. Because if we've got somebody on a texture, modified diet, we need to really intervene and kind of help them because I don't know about you, but it's very rare. You find somebody on a level four diet who's kind of in really grey, and there have been lots of you know, the maintaining the weight and things like that, because it does come with its difficulties daunting, so and it might be the safest for that person. And again, is we speeding something we need to consider? Because you know, it really improves somebody else's quality of life when we can't put a measure on that I

Aaron Boysen: 22:19

think and have the speech in obviously you said you're you're the go between between some of the dietitians and the speech language therapists have the speech and language therapists learn anything sort of, obviously, you've learned stuff from their side of the side of the coin, but is it ever gone the other way to where they learn anything from from you or how you maybe view things with a little bit of a years of dietetic experience with 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 taking so long finding MFI, learning their, their profession, after their profession, this is something I want to work on. So I want to work on if the speech Sherpa team feel that they need to refer come to me first, let's talk it through let's you know just again, saving a lot of time kind of documents in around referrals, we are kind of across all professionals wanting to look at increasing how often people would screen using the mouse tool and put in action plans in place. So that's not something I've worked on. As such, I think they've learned a lot from me along the way regarding feeding tubes and weight and kind of decisions around what we do for that person. So for example, we had patients who were on the waiting list already have feeding tubes. So from a speech therapy perspective, they're low priority, because they've got an alternative form of nutrition and hydration. Well, I mean, the waiting lists are quite long, as I said, the referrals have jumped to like 900 from the hundreds. So they will be waiting 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 got a 70 year old chap with a feeding tube, it was in a care home and it's on all trails, I want to get that peg out as soon as possible if I can. Because if somebody is left with a peg in place, and somebody had a stroke, and they're obviously more chance of developing dementia, which then things get really tricky with regards to the feeding tube. So I said, it's really important that when that person comes out of hospital, we get in there and do that rehab with him to see if we can eat to see if we can get them back onto kind of any form of normal diet and fluids to maybe get the feeding tube out because of the complications that can cause eventually so they will also it's actually quite high priority for you into and I said yeah, I know they've got an alternative family nutrition hydration. But actually, that doesn't mean that we can just leave it, we need we still need to do something with it if we can. So I think that that will kind of a learning point for them, which is why they said it will be good if I did take on all those patients with a feeding tube. So they've got that kind of it will quite quick that they've got that intervention.

Aaron Boysen: 24:39

So as low priority patients for them because of the alternative form of nutrition are actually still getting seen by a dietitian with extra dysphasia training and hopefully, who doesn't want to eat quicker. You know, I mean eating is quite an enjoyable part of life just from just from a sort of patient experience perspective and I I always think you meetings are a fundamental part of our life. It's quite social, it's quite, it's just important in life. And as dietitians, we, we obviously talk about the importance, probably a little bit too much. But I think I do think for patients, it means quite a lot. And if we can, if we can progress them slightly faster, it definitely improves that patient experience definitely. Because it's really, it's so nice to hear that the learning is as as sort of gone both ways. And you've learned things from Speech Language therapists, also the course you've been on and having to critically evaluate practices, learning, learning the backstory behind why the nice guidance say that feeding in advanced dementia is not appropriate. And things like that helps to sort of improve your improve yourself as a dietitian, I think understanding a little bit of that backstory. So when we're thinking about your experience in this role, where you've talked a little bit about areas where it's excelled for you, but as you've developed the practice, have you thought about any of the areas of dietetics, maybe you had experience with it on placement, or heard about it from other people where you think that having jewel competencies would be really, really helpful, and how you think it would work and say, obviously, yours is community based, but there might be sort of acute dieticians listening to this or dieticians in different areas, how do you think it would work for them,

Unknown: 26:19

the first thing to do would be to obviously speak with the speech therapy team, when you service leads to figure out if there is a gap, or if there would be a benefit to the service spa patients around obviously being dysphasia trade, obviously the neuro rehab where I work at the moment, again, it fits in really well, their whole mental feed in as well. I think that's definitely got a place for it. But again, with dysphasia, the clinical, it's a bit like when we look at diabetes, for example, we have kind of an idea of a careful interventions that we're going to do. And it's the same with swallowing. So if somebody had a stroke, you will, you might see very similar patterns observations in kind of a patient group who's had a stroke. But for somebody, for example, who have outsider neck cancer, you'd see something completely different. So with enteral feeding, because you might see a variety of conditions, is making sure that you feel competent in all of those areas and all of those conditions. So there is that as an area that will be quite good. I know one of my colleagues who's also dysphasia tray, and she works in learning disabilities. So I think it's more service specific. And is there a need for it there, it could technically work in any condition, I guess. But he's just trying to, to make sure that it benefits patient and any benefits of service as well. But yeah, they're just some of the areas I think, might be quite nice. It might quite work quite well, for

Aaron Boysen: 27:41

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 the future? And or, obviously, you've talked about expanding to different areas. But is there any sort of extra work around sort of dysphasia trained dieticians that you would you'd love to see in the future? It could be something you're working on at the moment or something you see as a possibility?

Unknown: 28:05

Yeah, I think because it's quite a new role. And as I said, I've got a colleague, but she works in learning disability. So again, very different from like a swallowing perspective. And I'm not I'm really not sure what because I feel like we've not really because we've not done it before. We don't know what the future holds. And I am just enjoying seeing patients and enjoying kind of learning and progressing and trying to see what kind of differences we can make. But no, it's really hard to say because I just don't know, it's difficult because you don't know what you don't know, do you really so we'll have to see how it goes. And obviously, in Doncaster, we've done a lot of projects. We've done a lot of innovative work in other areas of dietetics. So I'm open with and kind of continue that in this area as well. So yeah, I'm just hoping to increase my increase my knowledge and my skills in the conditions and more to see where it takes us. But yeah, unfortunately, there's no things like KPIs or anything like that to go off really well kind of adjust a bit. One thing I did want to do is kind of set up maybe like a dieticians do dysphasia whether it's like a Facebook group people are interested or I don't know, obviously, because I feel like I'm the only one if there is any out there please obviously if you're listening to this podcast, please get in touch if I'm not aware of somebody else's, and I know I've got one colleague and we I'd like to you know, it'd be really good if it's something that we can do. And just branch in the two professions together, because we do work very closely together anyway. So it'd be great if we could if we could continue that. Because they said we do we do a bit like OT and physio kind of goes together a little bit. You've got speech therapy and Dietetics. So it'd be nice just to continue that kind of interprofessional working.

Aaron Boysen: 29:42

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

Unknown: 29:53

something I do want to work on. So obviously, what we could be asking them to do is kind of scream from malnutrition, so obviously given our mascar and putting a nutrition action plan in place, and then if that's not working, for example, if they're still losing weight or they're still having difficulties, then obviously they can refer. So we're doing that little bit of first line advice, which our district nurses also do.

Aaron Boysen: 30:14

Anyone on a texture modified diet is at high risk of higher risk of malnutrition. So, why why should we not screen those patients more regularly to catch malnutrition? Say it's more easily resolved quicker, I think that's a really good, useful way for them to do it, and to put in a action plan in place to actually almost Yeah, see if that works and treat that malnutrition. 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, so it's at that level faster, we'd have the diet sheets that will level father speech therapy developed, and I walked him with no offence to my colleagues, there were things on there. And I think one of the exams that stuck out the most to me was meal options, quiche. And I were like, no, that's really not, that's really not a meal option, or like we need to end the suggestions on there is obviously we'll try it with the random miss things, things like avocado or this occasion, I like that we need to make some diet sheets that if somebody is put onto a level five diet, they know how to have a balanced diet, they know how to enrich if they need to enrich it. So what I've done recently is I've worked with the leader and we've developed some leaflets in line with it, too. So we've got one for level four, right up to level seven easy to, and it's really robust around with easy carbohydrates, these a protein, so it is more it's not a healthy eating leaflet, it's more around, you still need to have these food groups, even if you are on a level four date. So don't just live off things like yoghurts and things like that. So I have developed those leaflets, which I think I think will be really helpful. And that might again, that might help with that first line information. So if somebody has changed on to level five diet, they still know what the can eat, because a lot of patients will come to us and say it's dietitians and say, Well, I'm on level four diet, what can I eat. And as we know, while we're on the phone, or while we're talking to him, we can't think of things up top of his head. So it's really good now that we've got these leaflets that we can obviously give out. And he kind of explains everything they need to know about the level whilst also eating everything that they need to eat. So yeah.

Aaron Boysen: 32:23

And it also probably helps the compliance as well. I mean, if the if the diet seems a little bit easier to follow and less less restrictive, and allows them to feel well nourished and feel satisfied, yes, then I know that, for example, I would I wouldn't feel pretty happy with just quiche is my meat option. So I mean, adding that adding that dietetic knowledge along with their extensive experience with dysphasia, managing patients and managing sorts of risks. I think with all of these extended roles, I think one of the things that really stands out is the collaboration. Yeah. So for example, I've interviewed a dietician Sam before who places and G tubes and there's other dietitians working in sort of placing bedside nj tubes in the acute setting. Yeah, obviously, you're working with dysphasia. And it never seems to be a case of Oh, they've come in and they've replaced somebody's role. Yeah, it's always like they, they supplement it. They provide support, they provide extra training they provide, they fill a gap that wasn't already filled, and it almost enhances the collaboration between them. So for example, mg placement and sort of nutrition nurses, through nutrition nurses are still still very busy in that in that setting, but it just helps to provide it helps to be almost like an extra pair of eyes and ears for them as well. Yeah. And I think that really, really works well for I mean, Speech Language therapists, but obviously, as we extend roles, it'd be great to have physiotherapists, occupational therapists, Speech Language therapists, almost screening for most and putting an action plan in place before a dietitian can even get there. I think all of those ahps as well as 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 the pretty in dire straits at that point, because they've been at risk for so long. So like you said, anybody that can get in and do that kind of just that first line advice. It's what we will provide anyway into kind of food fortification, snacks and drinks. So yeah, is the same. And I think from what the speech therapists do also appreciate it. Because I'm a dietician, I come from a different background, I see things in a different way. So when we're talking about patients, it is a different perspective, because unlike most dieticians would get very involved in what we do. And we're very, we're not short sighted, but obviously, we think as dietitians so you know, for me to go in there and say, Well, actually, we thought about this and we thought about that. The speech therapists are like, Oh, yeah, actually, that's a you know, silverpine lets you know, so it's, it's good to have two heads. two heads are always better than one.

Aaron Boysen: 34:52

Definitely. Yeah. two heads about in the morning. Did you have any interesting experience sort of with patients or maybe case study that's that'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 you don't then patients that you always remember certain patients. So I did I kind of almost refer to it before. So we had a fairly new patient who had been admitted for making hospital into a care home, he had a stroke, and he will discharge on eight teaspoons of level three, or level fours. So obviously that could be dying off fluid six times a day. And at the current happening in another, like, he really wants to eat more like he's looking everybody else's food. Like it is really sad. Like, I think he'll be fine. Like, please, can you come and see us? And so I will have right yeah, okay, obviously it will my peg patient as well, because he's got a feeding tube in place. So when we're out to see him on the first assessment are able to help him to kind of no limit of level three and no limit of level four. So obviously, before I run this, the teaspoon so that you're able to manage unlimited amounts. And then from that point, I think he ran a bolus feeding regime from that point, he did not need any enteral feed afterward at all, because of the amount he ate. And he wanted to eat that for us level three, and level four, still quite restrictive, we think and it's still quite modified that I would somebody meet the full nutrition, hydration needs without the use of repair. But this chapter because it was so eager, so it massively improved his quality of life, he was so happy. And then on the second assessment, what I would do normally is and it is partially for my learning and for the patient's benefit is if I make a change, so we have level three fluids where the level four diet, I only changed an assess the diet at that point. So if anything, if he does have any adverse signs, we're quite clear on what caused the problem. If you change fluids and diets together, could it have been the fluid that caused that but you know, if he starts coughing and children and things like that in the counterparts here, as well, because if documentation is not great, and communication sometimes you know, it gets missed on what the problem was. So I went and I assessed diet and he went from level five diet to normal diet. So it was in the second assessment in we're on level three fluids and you're on normal diet. And I left it about two or three weeks to obviously check that in manage that, okay, went back after three weeks, he put on 10 kilos, it'd been having double meals. And then obviously the third time I went with SS fluids and we could only get him up to level two, I'm sorry, we could only you know reduce the spectrum down to level two. But it was still quite happy with that. So you know another another couple of weeks and we'll refer for is really true about so for me is really troughed easy in double meals and double puddings and like you said eating and drinking is so important it is what we think about is what we try and control is is everything in two ways towards other professions. But it's it's definitely really important so for me that really stuck out as being kind of a really successful

Aaron Boysen: 37:53

KPI thing you've definitely experienced that. Yeah, yeah, definitely. Yeah, and also the time of interventions, probably shorter dietetic dietetics, and speech and language therapy as well. So you already know that you're planning to get his feeding tube out you don't need a referral to be sent and then it to be triage and then it to go through all the systems you already know about that. And I know in a lot of community settings obviously, contracts vary and they're all all secretive feed costs more than food I think they usually cost more than food like supplements and all the equipment that's needed all the extra care that's needed. All those things cost extra money and time from nursing staff and by actually reducing the amount of feed that he's on not only does it improve his quality of life, it also reduces costs as well. Yes, definitely a multiple performance indicators there that I would look out for that sort of thing but yeah, that's a that's a I imagine he's really chuffed.

Unknown: 38:51

He is and he's such a lovely chap as well. Yeah, no, it's it's really and I did the same in an impatience as well. So I assessed a truckload at a brain injury It was 12th of August and it was three teaspoons of milk three times a day very rounded but on the milk he wouldn't have anything else and then by the second of September, it were on a run full amount of normal fluid anyone level six soft about size by 18 to September we're on Novaya peg and in revenues peg are a walk on having a referral hopefully to Abby's paper we also run that trial so within six weeks, they've gone from basically being nearby mouth to being able to eat and drink and not have to use a feeding tube. So yeah, like you said, it's quicker for me our interventions and the time is under our case with because we're normally sat waiting for speech therapy to go and do the assessment so we can do our bit whereas now it's it's much quicker like so from both sides. Yeah. And I always think I'm always thinking about the patient. But like I said, it does have that knock on effects was caring for a feeding tube. I said it comes with an ESB. It comes with a lot of costs, you know, even impacts on things like continuing health care and placements that people have if people have a feeding tube, they have to have a certain placement where Back can be cared for. So it does make a massive impact to things like discharge locations, and things like that. So yeah, there's Yeah, it does, it does benefit a lot of a lot of professionals, whether they know it or not.

Aaron Boysen: 40:12

That is a brilliant story. I think it definitely is. Definitely improvements in patient care are the fundamentals, but then the extra is just icing on the cake, but also justify the extra extra cost of the dysphasia trainings. What sort of, if you don't mind me asking what sort of cost? Do they? What's the kind of ballpark that these sort of trainings come out? Maybe not the, you don't need to say that particular one. But what sort of prices are we looking at?

Unknown: 40:37

I think, and I could be completely wrong, but I'm sure it were about 900 pound, I won't, I won't like say for sure. But it's around is around that price. But I don't think price really came into it only because it's such a normal thing that wants to speech therapists have graduated, then they go to the offices that work for a trust, and then the trust will send them on that cost. It's a bit like it's not an easy, obviously it's a 3030 credit masters module is just something that they just do that just kind of because they expect all Speech Language therapists do basically needs to be dysphasia trained, they might not work in that area. And that's obviously different. For example, if the work in a school might just be communication, but as I said, most speech therapists are trained to dysphasia as well. So yeah, I don't think crosswalk, I think it was too important. And like you said, I think we probably just need to sit and work out what this has actually saved. Because we wanted to do that

Aaron Boysen: 41:29

I can imagine it's probably that patient experience would definitely be an area where I think would be the biggest adding that's one of the biggest things, and I think everyone would acknowledge that. And I think it's not a hard thing to grasp that. Obviously, eating is nice and improves people's people's lives. Do you have anything else you want to say in regards to dysphasia? Or this particular from start to finish? What's been the biggest hurdle or barrier that you've encountered to actually implementing this dysphasia training 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 what really was a difficult course because because I didn't have the speech therapy background. And the speech therapists who wanted the class, they have like three to four years of that underpinning knowledge of all the muscle culture for the communication, the swallow, they've got all the aetiology, whereas I didn't have that. So that was a massive, massive learning curve for me. And there's such a variety, radiology and different patients and things like that. It was it was really difficult. I mean, some muscle provides to determine that some speech therapists don't actually pass first time. So the fact that I did pass, I think is quite an achievement in itself. And I think because as I said, it's very subjective. And there's lots of grey areas, and it could be this and it could be that it don't sit well for somebody who likes things in order and a bit OCD and likes to make sure that we know what we're doing. And this is it. And this is this bit like oh, it could be this. It could be that so it's, it's made me be a lot more flexible. It has made me a much better practitioner. But yeah, I would, I would say the actual doing it. I've had amazing support from my team. They're just the fabulous, but from a dietetic perspective, and obviously with speech, though, between actually doing it, and seeing patients getting a competency. Oh, that was it will it will fun, it was really difficult. And then you get to a point it's a bit like I assume, everybody, as we've gone through a study is being a student dietician, you wake up one day, all you see that one patient anything, yeah. Okay, now, I understand what I'm doing. You just have that lightbulb moment, we think it all kind of makes sense. And now I'm kind of getting to that point. And this is kind of two years down the line with the disclosure. So I feel like it just takes a lot longer. And I think it's because I don't I didn't have the background at the speech therapy still, but the actual training and working in this area, there's not really been any barriers. And I said it's because of the amazing support I've had from the managers and from the team. And that's really fundamental, because it is quite a lonely thing to do, especially as you're the only dietitian it was this way to train so you do feel a bit like a bit of an outsider in your own mind even though it weren't like that at all. So yeah, it's important to get this part from everybody but no, it's been a it's been a really good experience. And I definitely think we should have more disposed to join dieticians I think this is this is the future it's the way forward I

Aaron Boysen: 44:18

mean, it's definitely part of common exactly which NHS sort of wider structure document is HPS in action or something. Yeah, using the workforce we already have expanding roles, thinking of ways we can work more collaboratively together. And I do think that's probably one of the fundamentals of teamwork. And if you think about lots of team sports, you'll have people with Assigned Roles such as strikers defenders and stuff underscores a goal no one's gonna go Whoa, what are you doing? You may mean offence May. Yeah, however, but if they, for example, if a defender tries to score a goal, but maybe lacks his fundamental skills of protecting the goal, people might say actually, you know, he shouldn't have been scoring that goal in the first place. So it is I think, what's been gone through it's it's definitely some of these skills are quite advanced skills. And it's important to make sure we've got that underpinning of dietetic knowledge and dietetic experience before we try to, yeah, extend into other roles or do other things.

Unknown: 45:16

Yeah. I think you have to feel confident in your role because it is a huge job. I mean, it's a Master's anyway. So I will never quite interested in doing anything other than undergraduate I will quite happy to learn better from experience than kind of academic work. So the fact that it will, a Masters That in itself, it just kind of shows how hard it is. But you know, how challenging it can be. So yeah, it's really important to to, I think that's really the point that you've made to keep to make sure that you're confident within your own role. If I start branching out and doing other things,

Aaron Boysen: 45:45

definitely, I think there's probably there's probably lots of enthusiastic, say student dieticians out there, or newly qualified dietitians that are looking to just jump straight into this area and thinking I want to do that right now. And that's, that's a wonderful skill to have. Yeah. But also remembering that dietitians are dieticians and we've got to make sure that we're, we we can eventually learn to do other jobs on the pitch. Also, where were our defenders or strikers, or where wherever opposition is, first of all, yeah, and then we extend into other roles and support other professions and things. And I think that that obviously works. Obviously, the more you understand about other people's roles, 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

Aaron Boysen: 46:31

good analogy there. Are there any areas where you think the combination of having both dietetic knowledge and then that dysphasia training would 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 are worked quite well. So obviously, dietetic services in carry on is quite a lot into, we do get quite a lot of referrals, and obviously, the different pathways across country, so that will be really good. I think acute stroke might be quite good as well. And, obviously, because if a lot of patients do become nil by mouth, or if the need and G tubes can be impact made their neuro rehab as well, obviously, I work on your rehab at the moment. And again, patients can come from the acute setting nearby mouth, they might have pictures in place. So again, it's quite relevant there. How much of feeding would be probably a good one, the only thing to consider with that is that there are lots of different conditions, as we know, for people who have enteral, feeding tubes. So obviously, if you're working, for example, on neuro rehab, and his brain injury unit, or if you work on acute certainly stroke, you can focus kind of what observations you might see what kind of swallowing problems you're going to see, the aetiology can be quite similar across those patients. Whereas if you've got somebody who's mentally fed, that, as we know, the condition can really vary. So you've got to feel quite confident in each of those conditions. There's also a learning disability as well. So I've got a colleague who's dysphasia, trained to work through learning disabilities. So again, that could be something there. So I think it's more around, trying to find if there is a gap, and kind of seen, you know, or not even a gap, kind of how can we make things better, this would actually make things better in this service for this team, I think it's gonna be very specific, depending on where you work, and what kind of services are in place. So it's definitely worth going to speak to either your manager or your speech therapy team and just kind of discuss and see if it's anything that like you said, if there's a gap, that would be great. But again, even if you can improve patient care that would, it works both ways. Really.

Aaron Boysen: 48:29

Yeah. So now for some rapid fire questions. So do you have any advice for newly qualified 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 obviously that that can help on placement, you can kind of some people already know from placement experience, and become confident in what in what area you like to work in. And then if this is obviously a dysphasia, something you want to go into, then you can you can tie that in. So once you feel happy and comfortable in your role, it can be something you can think of kind of advanced practice, as well, I'd always say, and it's not quite related to the dysphasia. But if you feel like there's something that's not quite right, and you service on your team, then please speak up. I'm also a freedom to speak up advocate. And there should be one in every in every trust. So I think that's really important to mention, because obviously sometimes we can work in services and because we've always done it that way don't mean it's quite right. Or it's as effective as it could be. So yeah, always be self always speak up and obviously, yeah. Find something that you really like and go with it.

Aaron Boysen: 49:36

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 the lack of that MDT at your fingertips. So it's much more difficult. Obviously we've got GPS, we've got kind of other community staff working in different areas to try to pull people together and don't get me wrong. Being virtual has helped with that quite a lot. Because again, you can just be available on a teams meeting rather than having to go somewhere. But yeah, I would just say it's the lack of robbing people there and kind of knowing who to speak to. Because if you think if somebody is in community, if they're in one care home, they'll have one GP, if it's another county, it's another GP. So you have to kind of spread yourself quite thin, to kind of make all these contacts and kind of network and things like that. Whereas if you're in a hospital, and you work on I don't know, for example, or spiritual Ward, you know, who you're supposed to team is. So it's just that really, I would say, but it's still interesting, because you have to learn a lot of skills around kind of how to speak to the professionals, socially, kind of things to do with funding and carers. And it's like a completely different world. And it's how people live for the rest of their lives. Whereas acute setting could obviously be just a short period of time. So it is a different skill set. But it's good to have both can your under community if you can, if you can get that experience.

Aaron Boysen: 50:54

But thank you so much for your time today. It's been a pleasure talking to you. And I think this area is really of interest to I mean, I've talked about in a few areas, and it always generates discussion. And I think it's definitely an area where a lot of dieticians will be keen to explore and how they can support their patients better. And as you said, it's not it's not just a quick fix. And I think with a lot of these extended roles, it's definitely something that dieticians need to dedicate a lot of time not just to learn the skill and do the proper competencies, but also develop the experience and the knowledge to be able to do it effectively. And well, for sure. So I think all of them, whether it be things like knees, or gastric feed placement, or even, as I've discussed on previous podcast, recommendations around physical activity and things like that, your requires experience implementation, 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 wants to know bit more, I'm more than happy to be emailed or to have a phone call or whatever. Like I said it's just getting out there into

Aaron Boysen: 51:58

and the details for Laura's Twitter handle will be in the show notes. If anyone's interested in getting in contact with it. I think that'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.

Aaron Boysen: 52:10

Thank you very much. Thank you. Thank you for joining us for this episode of The dietetics digest podcast. To share your thoughts in today's episode, please visit our social media. Our main channels are Instagram and Twitter. Also, if you enjoyed the podcast, why not leave us a review on Apple podcasts or a podcast host of your choice or consider telling a friend about the podcast. Finally, make sure that you subscribe and follow the podcast so that you can stay up to date with our latest episodes.