The contributions of continuing education on oropharyngeal dysphagia for pediatric nursing care at a teaching hospital

Abstract:

PURPOSE:

to assess the effectiveness of carrying out educational activities on oropharyngeal dysphagia for pediatric nursing team at a teaching hospital.

METHODS:

it is an evaluation research. The study was carried out in a tertiary hospital from the National Health System. The sample consisted of 62 professionals including nurses, technicians and nursing assistants who deliver care to pediatric patients. A questionnaire was applied to check prior knowledge of dysphagia, and later was held an educational action and its immediate evaluation.

RESULTS:

nursing knowledge on dysphagia was evidenced as positive, especially the question on the concept with 96.77% accuracy, symptoms with 83.87% accuracy, causes with 74.19% accuracy, consequences with 70.97% correctness, identification of the professional qualified for rehabilitation with 85.48% accuracy, and importance of rehabilitation with 87.10% accuracy. Concerning the expected answers for yes, we emphasize the ones not in agreement: the phases of swallowing (50%), specific tests (45.16%) and position for oral nutrition (32.26%). The need for continuing education was justified as 85.48% of the participants reassured training importance.

CONCLUSION:

the study found that nursing knowledge on dysphagia, although fragmented, has had professionals interested and willing to learn if content is available through continuing education. Thus, research participants, after the educational activity, expressed the expansion of knowledge on dysphagia, and recognized its importance, also expressing a desire to receive more information about this and other pathologies.

Keywords:
Continuing Education; Swallowing Disorders; Pediatric Nursing; Speech, Language and Hearing Sciences

Resumo:

OBJETIVO:

avaliar a efetividade da realização de ações educativas em disfagia orofaríngea para a equipe de enfermagem pediátrica em um hospital de ensino.

MÉTODOS:

pesquisa avaliativa. O estudo foi realizado em hospital de referência terciária, vinculado ao Sistema Único de Saúde. A amostra foi constituída por 62 profissionais entre enfermeiros, técnicos e auxiliares de enfermagem que atuam na assistência à pacientes pediátricos. Aplicou-se um questionário para verificação do conhecimento prévio sobre disfagia, posteriormente foi realizada uma ação educativa e sua avaliação imediata.

RESULTADOS:

o conhecimento de enfermagem em disfagia evidenciou-se como positivo, principalmente no quesito do conceito com 96,77% de acertos, sintomas com 83,87% de acertos, causas com 74,19% de acertos, consequências com 70,97% de acertos, identificação do profissional habilitado para reabilitação com 85,48% de acertos e importância da reabilitação com 87,10% de acertos. Concernente ainda às respostas esperadas, ressaltam-se por não estarem de acordo: as fases da deglutição (50%), exames específicos (45,16%) e posição para alimentação via oral (32,26%). Justifica-se a necessidade da educação continuada, pois 85,48% dos participantes assinalaram que é importante a realização de treinamento.

CONCLUSÃO:

o estudo concluiu que o conhecimento fragmentado da enfermagem sobre disfagia, contudo, interessada e disposta para aprender, se for disponibilizado o conteúdo por meio da educação continuada. Haja vista, que os participantes da pesquisa após a ação educativa, expressaram a ampliação dos conhecimentos sobre disfagia, e reconheceram a importância destes, bem como expressaram o desejo de receber mais informações sobre essa e outras patologias.

Descritores:
Educação Continuada; Disfagia; Pediatria; Enfermagem; Fonoaudiologia

Introduction

Eating is an utmost factor to maintain life, a source of pleasure, and important for living beings' development. Any change in this process may lead to serious disorders which consequently affect people's quality of life¹.

Oropharyngeal dysphagia, defined as swallowing disorder, is the difficulty in swallowing, affecting any parts of oral and digestive system, and considered an important symptom for several illnesses. It is manifested by coughing and increase in eating time length during meals, secretion increase, weight loss, malnutrition, dehydration and pneumonia^{2 4} It may occur at all ages, increasing its prevalence at older age, and its occurrence in children may delay their growth and development, compromising their immune, respiratory and nervous systems^{5 6}.

When the cause for oropharyngeal dysphagia is identified, speech therapists are the recommended professionals to select the best treatment and follow up the exams as they are qualified to prescribe food consistency and the practice of specific exercises. Inappropriate intervention may cause complications and extend hospitalization length of stay^{5 7}.

Nursing professionals play an important role to identify swallowing changes⁸, once nurses, nursing technicians and assistants are present at bedside for twenty-four hours, mainly at mealtime. It is recommended that nursing professionals have proper training on oropharyngeal dysphagia by means of continuing education, which would broaden the theoretical background on this condition, improving patients' care delivery⁹. Continuing education is of utmost importance for the professional development of human resources in an institution, taking profit from actual, daily situations as the learning environment¹⁰.

Thus, this study objectified: to assess the effectiveness of educational actions on oropharyngeal dysphasia among the pediatric nursing team at a teaching hospital.

Methods

This research study was held at a teaching hospital, tertiary level, from the Unified Health System (SUS, in Portuguese) with 663 registered beds located in the city of Curitiba, Parana State, Brazil.

Research started after approval by the Research Ethics Board from the Hospital on 08/21/2013 under number 18214813.2.0000.0096, carried out between September and October/2013.

It is an evaluation study. Evaluation research relies on scientific procedures that enable to analyze and understand causal relationships among the different components of the intervention. Intervention model is built to allow relation visualization of the proposed intervention with its expected effects in a way that this flow underpins evaluation research, thus reflecting on the correspondence between the theoretical proposition and intervention functioning¹¹.

Sampling

The sample of 62 subjects took up Nurses, Nursing Technicians and Assistants, a total population of 77 employees from various pediatric sectors, delivering patients' direct care. Inclusion criteria in the study consisted of qualification as nurses, nursing technicians or assistants, working in the nursing area for at least 12 months, 18 years of age or older, and delivering nursing care in pediatric units and outpatient clinics. Among the exclusion criteria, it was adopted the manifestation of discontinuing participation in the study.

Procedures

This research study was developed in three distinctive steps. In the first step, a questionnaire - adapted by the researchers from the questions used in a study held at the same institution - was applied on "Nursing Professionals' knowledge on Care for Dysphasia Patients Admitted to an Intensive Care Unit"⁹. This step consisted of verifying former knowledge and nursing care on oropharyngeal dysphagia held by the pediatric team, as well as determining the intervention model. The instrument used is self-explanatory with two domains: one with three questions for professional and personal identification, and the other comprising questions on specific knowledge: what the disease is about, causes, if guidance on the disease had been received, swallowing phases, diagnosis, oral drug administration, diet for dysphagia patients, disease consequences, treatment and rehabilitation, nursing care, speaking valve and care training for dysphagic patients.

The second step consisted of applying the intervention model, that is, carrying out the educational action, which used strategies such as distribution of an individual, self-explanatory, personalized folder and posters placed on the message board of the Nurse Station, a place of steady flow of nursing teams during their work shifts, easy visualization to fix the theme, with information on oropharyngeal dysphagia, straight correlated to the questionnaire responses: concept, main causes, symptoms and Nursing care.

After two weeks, the third step was held, which consisted of the effective assessment of the strategies used in the educational actions on oropharyngeal dysphagia to the pediatric nursing team at a teaching hospital. Thus, a new instrument - elaborated by the research authors - was used, entailing three questions to assess whether that initiative contributed or not to knowledge refinement of the professionals in this sector. In this assessment, participants were inquired on the importance to get information about dysphagia, if it contributed to refine their knowledge on the investigated theme, and if this knowledge will make a difference in order to deliver care to patients suffering from dysphagia. Fifty-eight (58) people participated in this evaluation, entailing one who did not answer for having retired, and three of them did not participate in this step for unknown reasons.

Statistical Analysis

Data were submitted to statistical analysis and shown in tables for easy t visualization of the results. Quantitative variables were expressed by frequencies in absolute and relative figures. In the variable association, Chi-square test was used, p=0.05. Data were analyzed by statistica 7.0 computer program.

Results

The sample took up 12 Nurses, 23 Nursing Technicians and 27 Nursing Assistants from several pediatric sectors, delivering patients' bedside care. Participants' age was between 30 and 69 years, averaging 50.4 years, standard deviation of 7.16 years. All participants are female and most of them have worked in the researched institution from six to ten years.

In Table 1, frequency distribution of questions 1 and 2 is shown.

Table 1:
Frequency Distribution according to questions 1 and 2 (n=62)

Results showed that 91.94% (n=57) of the participants can define oropharyngeal dysphagia, and 53.23% (n=33) of the participants had never had formal learning in the professional qualification course or in the continuing education at work as Table 1 demonstrates.

Table 2 shows frequency distribution regarding questions 3 to 17.

Table 2:
Frequency distribution according to questions 3 to 17 (n=62)

• Note: * these questions admit different answers.

It can be observed that only 27.42% (n=17) of the participants know the swallowing phases. Asked if they are prepared to render care to patients with oropharyngeal dysphasia, 58.06% (n=36) of the participants feel poorly prepared, and 22.58% (n=14) do not feel prepared for that. Most participants, 85.48% (n=53) pointed that training is important to get frequent information on dysphagia.

Table 3 shows the frequency distribution of the evaluation of the educational action by participants in the study.

Table 3:
Frequency distribution to assess continuing education (n=54)

• Note: four people did not participate in the continuing education evaluation.

Most participants, 91.94% (n=57) agree that the received information by continuing education increased their knowledge on oropharyngeal dysphasia; 56 participants (90.32%) would like to obtain more information about this and other illnesses.

Table 4 shows the association between the variables: professional category and question knowledge.

Table 4:
Association between professional category and question knowledge variables (n=62) Chi-squareTest - significance level p < 0.05

• Note: In order to apply the Chi-square Test, only two professional categories were considered: nurses and technician+assistant.

There wasn't statistically significant association between professional category and question knowledge. A tendency of difference in the questions was verified: swallowing steps (p=0.0885), dysphagia causes (p=0.0932), and dysphagia consequences (p=0.0566).

Association between the following variables: professional time length and question knowledge is shown in Table 5.

Table 5:
Association between professional time length and question knowledge variables (n=62)

• Chi-square Test - Significance level p < 0.05

There was not statistically significant association between professional time length and question knowledge. However, a tendency of difference in the questions was found: dysphagia symptoms (p=0.0569) and best cutlery piece (p=0.0789).

Discussion

The total sample of participants in this study are female, which is understandable because the greatest part of nursing workforce belongs to this sex, and mainly because pediatric services are preferably performed by this age range. In a research study on the relationships of work, health and working conditions in Uberlandia, Minas Gerais State/Brazil, with ten nursing professionals, was pointed out the high number of female staff in hospital work settings, whose analysis on the specificity of nursing actions facilitates the understanding of its conditions¹².

As for the concept of oropharyngeal dysphagia, 96.77% of the participants in this study evidenced the proper knowledge on it; in a study about the nursing team's knowledge on dysphagia, authors claim that nursing professionals delivering care in ICUs should have specialized training, qualifying them for patients demanding more complex care⁹.

National Curriculum Guidelines for the Nursing Graduation Course state that nurses' educations aim to provide these professionals with the required knowledge to render health care. In addition, these professionals should be able to learn steadily, during their qualification as well as along their practice. Thus, health professionals have responsibility and commitment to their education and to service professionals' training¹³.

Regarding dysphagia symptoms, 83.87% of the participants in this study were able to identify them among the ones listed, which is very important because the nursing team remains 24 hours with the patients. Thus, they may identify this disorder eary, taking measures and notifying the multiprofessional team, mainly the speech therapist in order to begin treatment and rehabilitation as soon as possible. Another research study presented different results with 187 participants from the nursing team about nursing knowledge on oropharyngeal dysphasia; subjects had difficulty in its identifying signs and symptoms in a multiple-choice question. Authors concluded that it was due to lack of knowledge about this disorder, suggesting the need of training in continuing education courses⁹.

In this research, 74.19% of the participants identify the main causes of the oropharyngeal dysphasia, which highlights the idea that in some occasions they got in contact with patients presenting this swallowing disorder. In a study entailing 130 participants in the city of Belo Horizonte, Minas Gerais/Brazil to investigate nursing knowledge on swallowing changes, authors observed that 96% of the subjects were able to perceive dysphagia signs and symptoms in admitted patients¹⁴.

This study pointed that there was a division on the specific exams, between endoscopy (45.16%) - the incorrect answer - and videofluoroscopy (38.71%), the correct answer. Although videofluoroscopy is considered the gold-standard exam, it has not been available in many services, therefore it is still unknown to the nursing team, knowledge accessible only to speech therapists. Other authors point out that dysphagia assessment should be carried out with clinical as well as specific exams, videofluoroscopy and videoendoscopy, which verify anatomical structural conditions and swallowing, investigating food consistencies. It must be considered the difficulty in going under these exams due to their restricted access, not always recommended in hospital institutions^{7 15}.

In the question regarding the professional that legislation assigns dysphagia patients' treatment and rehabilitation, most participants (85.48%) agreed on speech therapists, along with dysphagia management already described by other authors, who point out that speech therapists' well-performed assessment warrants work quality, enabling analysis and conduct definition⁷. Other studies found different results, such as ignorance of speech therapists' role for little co-working or absence of such professionals in the institution. Also, the reduced number of care delivery along with the nursing team, making access to such care difficult^{9 14}.

One of this research results unveiled, as participants' answers, poor or no qualification to care for dysphagia patients, rehabilitation as very important and that they would like to get information and training more often on this theme. It must be pointed out the importance of continuing education fostered by the institution or the team head nurse. Accordingly, authors point that participants reported in the research groups that they would like to get more information on swallowing changes, being trainings, team meetings and information provided by the institution the chosen means for such qualification¹⁴.

Due to the scarcity of human resources in the units that participated in this research at the institution, which made them unable to be away from patients' care rendering in order to attend classes, individualized information was preferred by means of folders and posters in the unit as a continuing education strategy. An immediate assessment was applied, which unveiled according to most participants (90.32%), the importance of learning and its use in nursing care, boosting their knowledge on dysphagia as well as the request for more information on this and other pathologies, stressing the importance of continuing education in the institution.

It is worth pointing out the important role and the difficulties in carrying out transforming educational practices, paramount in health education settings, which consider individual and local needs involving the institution¹⁶. Performed educational practices influence the quality of nursing care delivered to patients, once it is grounded on professionals' daily reality, stressing the implementation of nursing care systematization, essential tool for patients' care¹⁷.

In a study with 75 subjects on continuing education assessing nursing team's needs, the authors stressed its importance for qualification and improvement of health workers in the institutional context. They concluded that most professionals ignore the purpose of continuing education in the institution as a result of little discussion on the subject in graduation and high school, and that they could assess the value of their daily job, besides the mentioned qualification¹⁸.

Health professionals' specialization is foreseen by the National Policy of Continuing Education for Social Control in the Unified Health System - SUS, in Portuguese. Such modality takes up educational processes that contribute for the action development of social subjects towards the compliance of the right to health with participating methodologies, through formal and informal processes that value people's experiences (living experiences)¹⁹.

Qualification by means of continuing education needs to be in conformity with work needs regarding the multiprofessional team, as educational themes are related to all health professionals as well as the institution. It is necessary to provide training according to the needs, valuing learning and professional advancement in work settings. To achieve that, managers and care professionals must be involved, reaching the community by a more insightful performance²⁰.

Authors present the need to rely on a multiprofessional team to act upon dysphagia in the conclusion of their study; each professional must know his/her role very well to favor patients' treatment. Therefore, it is imperative further research on this in order to assess knowledge about the theme¹⁴.

Studies stress that the presence of speech therapists and their intervention may mean the reduction of hospitalization time length as well as prevention from re-admittances due to complications²¹. Other authors claim the benefits for patients in their studies regarding the return to oral diet and shorter hospitalization length of stay when rehabilitation by speech therapists occurs facing swallowing disorders²².

Since the 1990s with the search for hospital excellence in order to obtain Hospital Accreditation, patients' safety and damage prevention were aimed by means of Risk Management in order to obtain the quality certification. Standards were described in the accreditation manuals as well as established evaluation rules and criteria. This process, implemented in health institutions, aims to detect situations that may have negative consequences to patients, and measures to minimize them and promote their safety²³. Dysphagia can be included as a risk indicator in speech therapy and hospital settings, connected with speech and eating actions, which needs to be considered, enabling intervention for children's proper developmen^{24 27}.

The venue of this current study has invested in Hospital Accreditation since 2006, with the creation of a quality board, obtaining level one by the National Accreditation Organization (ONA, in Portuguese) in 2012, which shows the interest in the improvement of quality care. Hiring more speech therapists by

the institution will facilitate the management of swallowing disorders as well as the access to treatment and rehabilitation of a higher number of patients and subsequent improvement in the integration with the nursing team.

Conclusions

Initial study assessment identified a picture of nursing team's previous knowledge on oropharyngeal dysphasia evidencing that more than half of the individuals had never received formal guidance on the subject, and demonstrating poor, fragmented knowledge. These data ground the need to continuing education on oropharyngeal dysphagia if the importance of the subject and its implications are considered.

In the results of the investigation, the most relevant data are as follows: correctness in the concept of dysphagia, the causes of oropharyngeal dysphagia, the best cutlery for eating, treatment and rehabilitation by speech therapists and the importance of rehabilitation. In the answers, the ones that call more attention for being incorrect are: swallowing phases, specific exams and position for oral diet, justifying again the need for continuing education and training course.

Proposed educational action applied as continuing education was welcome, showing nursing team's interest and willingness to learn, in spite of the short time due to the scarcity of human resources in the current context presented in the institution. This study provided the researcher with the opportunity of a direct contact with the pediatric nursing team of the institution which takes up Pediatric Emergency, Admittance Unit and Outpatient Clinics, eager and receptive to the knowledge offered by means of continuing education.

Proceeding the post-intervention evaluation, the result was positive as most research participants recognize the importance of obtaining more knowledge on oropharyngeal dysphagia. The study found the deficit of human resources as the main constraint, which hindered the adherence of all population sample, initially proposed to carry out the research.

In the institution, there is a management program on patients' risks and safety; it is suggested that oropharyngeal dysphasia be listed as an aspiration risk by the multidisciplinary team and preventive as well as corrective actions be determined in the occurrence as adverse event.

It is recommended the implementation of training programs on this theme in the institution in order to supply eventual failures in nursing high-school-level and undergraduation of professionals from the institution, as well as research studies on the prevalence of swallowing disorders to assess the actual status of this pathology in the hospital. It is important to point out that further studies on oropharyngeal dysphasia must be developed, covering the whole multiprofessional team, enabling its instrumentalization in order to improve patients' care, facilitating the management of this swallowing disorder.

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Publication Dates

• Publication in this collection
  Oct 2015

History

• Received
  19 Dec 2014
• Accepted
  03 June 2015