Dysphagia 20:141–148 (2005)

DOI: 10.1007/s00455-005-0007-z

Effectiveness of Computer-Based Dysphagia Training for Direct Patient

Care Staff

Lori Davis, EdD, CCC-SLP,1 and Karen Copeland, MA, CCC-SLP1,2

1
Department of Communication Disorders, University of Tulsa, Tulsa, Oklahoma, and 2St. John Medical Center, Tulsa, Oklahoma

Abstract. Speech–language pathologists (SLPs) in American Speech–Language–Hearing Association

medical settings are responsible for evaluating pa- (ASHA) states that the practice of speech–language
tientsÕ feeding and swallowing. Once an evaluation is pathology includes providing services for individuals
completed, nursing staff typically provides hands-on with swallowing and feeding disorders [1]. ASHA
care and supervision of meals. SLPs seek to improve further emphasizes the role of the SLP in educating
outcomes for individuals with dysphagia by educat- the healthcare team regarding this subject. The SLP
ing direct-care staff. This project sought to determine should be able to identify educational and training
whether a computer-based swallowing safety module needs, develop and provide educational programs,
could produce changes in knowledge levels of nursing and instruct caregivers in the appropriate interven-
staff. This module was designed to replace inservices tion for individuals with swallowing and feeding
conducted by staff SLPs. Nursing staff would be re- disorders [2].
quired to complete the training when hired and as an Competency assessment is being used in many
annual assessment. The training module was designed fields as a measure of basic knowledge and skills nec-
and pilot-tested along with a pre- and posttest to essary for job performance. The process of competency
assess changes in knowledge. Participants in the assessment allows employers to determine the extent to
experimental group took the pretest, completed the which critical information is known and to which key
computer training module, and then took the post- skills can be demonstrated. In response to require-
test. Participants in the control group took the pre- ments of the Joint Commission on Accreditation of
and posttest with no intervening training. Statistically Healthcare Organizations (JCAHO), hospitals now
significant differences were found between the two have extensive programs to address initial and ongoing
groups on posttest scores. Participants in the experi- competence of employees. Other organizations,
mental group demonstrated increased test scores, including ASHA, expect professionals to demonstrate
while the scores of the control group did not change various competencies, usually stated in the form of
significantly. This study indicates that computer- behavioral objectives. The ASHA 2005 certification
based training for nursing staff related to swallowing standards focus upon the competencies that students
safety and dysphagia is effective. must demonstrate throughout and at completion of
their academic careers in order to be certified.
Key words: Computer-based training — Nursing
Competence can be defined in many ways, is
staff — Competency — Dysphagia — Deglutition —
subject to multiple interpretations, and is assessed
Deglutition disorders.
currently with numerous methods and tools. Com-
petency assessment is an ongoing process. Profes-
sionalsÕ skills should be assessed on a continuum,
The role of the speech–language pathologist (SLP) as should be based on job requirements and the
an educator in the medical setting is critical. The changing needs of the organization, and should differ
Correspondence to: Lori Davis, EdD, CCC-SLP, Department of
based upon experience level. A distinction between
Communication Disorders, University of Tulsa, 600 S. College, initial and ongoing competencies must be drawn,
Tulsa, OK, 74104, USA, E-mail: [email protected] with initial competencies being focused on job
142 L. Davis and K. Copeland: Computer-Based Dysphagia Training

knowledge and skills needed in the first six months to viduals completing the training compared with a
one year of employment. Ongoing competencies build control group. Other questions to be answered were
on established knowledge, skills, and abilities and whether computer-based training was effective for
reflect new, high-risk, or problematic aspects of a job. dysphagia education and whether there were differ-
Across disciplines, technical skills, critical thinking, ences in learning based on job classification.
and strong interpersonal skills are requisite job
components. A variety of competency verification
methods are necessary. These include posttests, re- Methods
turn demonstrations of technical skills, peer reviews,
case studies, mock events, self-assessments, and Participants
observations of daily work [3].
Computer-based training is being used more A sample of 123 registered nurses, licensed practical nurses, and
frequently as a component in competency-verification certified nurse assistants from 11 departments who were required to
programs. Web-based and Intranet evaluation models take the computer-based dysphagia competency training were
solicited to participate in the study. Participants were recruited by
of healthcare professionalsÕ performance have been the nurse managers on their respective units. Participation was
found to improve the assessment process by reducing voluntary, and names were not associated with the pre- or posttest.
time and cost and providing a more inclusive and The purpose of the study was described to staff with the support of
efficient evaluation [4–6]. The American Society for nurse management, and volunteers were solicited by the research-
Training and Development cites cost effectiveness, ers. The study had the approval of the Institutional Review Boards
of the hospital and of the university with which the researchers are
timeliness, adaptability, and measurability as major affiliated. Written informed consent was obtained prior to partici-
advantages of computer-based training [5]. Employ- pation in the study.
ees can participate at their own pace and schedule, in a A control group and an experimental group were formed
self-directed fashion. This places responsibility for from the total number of participants. Nursing units as a whole
demonstrating competency on the employee [7]. were assigned to either the experimental or the control group.
Participants within nursing units were not randomized into control
This study explores the effects of computer- and experimental groups to avoid confusion among individuals
based training for caregivers of individuals at risk for about the process. Nursing units were matched as evenly as pos-
swallowing problems in a major medical center. The sible for type of patient care provided so that a unit in the control
medical center currently uses the computer-based group had a corresponding similar unit in the experimental group
training system for lessons such as back safety, in order to develop equivalent samples. The size of the control and
experimental groups was matched as closely as possible. The total
infection control, and customer satisfaction. This number of participants in the control group was 60, and there were
study describes the first effort to address care of 63 in the experimental group. Fig. 1 demonstrates the percent of
individuals with dysphagia using a computer-based nurses versus nursing assistants in each group.
format. All current direct-care staff is required to
complete the training, and all new employees are as-
Pretest and Posttest development
signed the swallowing safety module as an initial and
ongoing competency. The impetus behind the devel- The paper-and-pencil pre- and posttests were parallel-form tests in
opment of the computer module was the belief that a multiple-choice format (see Figs. 2 and 3). Test questions were
staff turnover and productivity expectations limited written by the researchers and were related to the material in the
the effectiveness of traditional inservice training. The computer-training module. The pre- and posttests were equivalent
goal is that increased knowledge will improve patient in content information but were written as two forms of the test to
control learning effects from the first test administration to the
outcomes, enhance the care of individuals with dys- second. The pre- and posttests were reviewed for content and
phagia, and reduce medical complications. construct validity by ten SLPs with extensive dysphagia experience
The purpose of this study was to determine if and training working in medical settings in the city in which the
changes in knowledge levels occurred after complet- study was conducted. Reliability of the pre- and posttests was
ing computer-based dysphagia training. It was not determined by pilot-testing both forms of the test with a group of
SLPs who were skilled and experienced in dysphagia management.
known whether this newly designed computer-based The scores from both tests were statistically analyzed using Cron-
competency module would be effective in increasing bachÕs alpha to assess reliability. The reliability coefficient was 0.78,
knowledge levels of direct-care staff regarding dys- and the tests also had equivalent means of 14.5 which is a further
phagia management. The research hypothesis was indicator of reliability.
that knowledge levels would increase after the com-
puter-based training, and posttest scores would be Computer Training Program
higher than pretest scores for staff completing the
training. It was also hypothesized that changes in The computer-based competency training program used in this
knowledge would be greater for the group of indi- study was developed by an SLP in a 700-bed medical center, with
L. Davis and K. Copeland: Computer-Based Dysphagia Training 143

Fig. 1. Group composition.

content adapted from the wide range of current literature relative tiple-choice pretest, and then completed the computer-based
to swallowing disorders. Content and form of the training module training module. Participants were instructed by their nurse man-
were reviewed for validity by a sample of SLPs working in dys- agers to complete this training ‘‘as soon as possible.’’ Due to the
phagia management. The Swallowing Safety Training module is self-directed nature of the training program, it was impossible to
accessed through the medical centerÕs Intranet system and consists strictly control when employees completed the computer module.
of a 45-slide presentation similar to a PowerPoint presentation (see Within four weeks or less of completion of the computer training,
Figs. 4 and 5). It was developed using the deMedici Training the experimental group took the 15-question multiple-choice
Navigator software previously supported by HealthStream Solu- posttest. Participants in the control group completed the pretest
tions (Nashville, TM). The presentation covers topics related to and then within four weeks completed the posttest without any
dysphagia including normal swallowing anatomy and physiology, intervening training. Participants were not informed of their pretest
risk factors for dysphagia, and guidelines for administering nutri- or posttest scores.
tion, hydration, and medication. The interactive lesson is accessed Pretests were coded to be matched with the participantÕs
at workstations throughout the medical center and can be com- posttest. The coding system was numeric, and the individualÕs name
pleted in approximately 30 minutes. Selected questions are pro- was not associated with test. The pre- and posttests were given
vided by the program and answered throughout the lesson as a during work hours by one of the two principal researchers who are
learning tool. Learners view text combined with animated graphics both ASHA-certified SLPs employed by the hospital. Authoriza-
and use the computer mouse to click on key information for added tion from the nurse manager on each unit was obtained prior to
emphasis. Feedback is provided in the form of audible tones and administering the test.
printed text which appears in response to mouse clicks or mouse-
over. A score of 90% on the moduleÕs posttest must be attained by
Data Analysis
the employee in order to pass the training module.

Pretest and posttest scores were compared to determine if partici-

Procedure pants in the experimental group increased in knowledge levels after
completing the computer training module. Pretest and postest
The first stage of this project was the development and imple- scores of the control group were compared to determine any dif-
mentation of the computer based training module. The second ferences between assessments without intervening training. Parti-
stage was to measure knowledge levels of dysphagia of the direct- cipants were analyzed as a group and also as two subgroups con-
care staff before and after the training. A pretest/posttest design sisting of RNs and LPNs combined, and nursing assistants, to see if
was used to assess the subject-related knowledge of nursing staff results differed based upon education and training level. Analysis
prior to and after completing the computer-based training module. with t-test was used to compare the data with a significance level of
Participants in the experimental group took the 15-question mul- 0.05.
144 L. Davis and K. Copeland: Computer-Based Dysphagia Training

Fig. 4. Swallowing problems.

Results and the experimental group also exhibited a greater

degree of improvement (Table 1). Twenty-seven per-
Significant differences were found on posttest scores cent of individuals in the experimental group scored
between the experimental and control groups 100% on the posttest compared with 0% of individ-
(t = 5.041, df = 42, p = 0.0001), with the experi- uals in the control group. No participant in either
mental group scoring higher. Significant differences group scored 100% on the pretest.
were also found between pretest and posttest scores Nosocomial pneumonia rates for the hospital
among the experimental group participants for the two calendar-year quarters after the computer
(t = )7.518, df = 54, p = 0.0001). Statistically sig- training module became a required competency were
nificant differences were not found among the control compared with rates of infection to the corresponding
group participants on pretest and posttest scores time period prior to introduction of the training
(t = )1.566, df = 42, p = 0.125). Mean scores of module. Rates decreased 59.6% after the computer-
the groups are listed in Table 1 in addition to the based dysphagia training was introduced with no
changes in scores from prettest to posttest. other known changes in hospital policy regarding
Data were also analyzed by job class to management of nosocomial pneumonia. Although
determine whether differences in learning occurred there are many uncontrolled factors that may have
between nurses and nursing assistants. Neither the impacted rates of nosocomial pneumonia, this de-
experimental (t = 0.213, df = 41, p = 0.833) nor crease is an indicator that the computer-based dys-
control group (t = 0.637, df = 53, p = 0.527) phagia training module may improve outcomes
demonstrated significant differences in pretest, post- related to dysphagia.
test score change based upon job classification.
Other comparisons that can be made between
the experimental and control groups are shown in Discussion
Fig. 6. Eighty-two percent of individuals in the
experimental group improved their scores on the Computer-based competency training of direct-care
posttest compared with 49% in the control group, nursing staff for swallowing safety can improve
L. Davis and K. Copeland: Computer-Based Dysphagia Training 145

Fig. 5. Giving medication safely: providing care.

knowledge levels related to dysphagia management. Table 1. Mean scores on pretest and posttest for experimental and
These changes were significantly different for indi- control groups and by job class
viduals who took the training versus a control group.
Pretest mean Posttest mean Change
These data also suggest that changes in knowledge
levels are not affected by the job classification of the Control group 10.62 11.16 0.54
individual among nurses and nursing assistants, Experimental group 11.2 13.23 2.03*
suggesting that this training program is widely Nurses 11.49 13.61 2.12*
Nurse Assistants 9.83 12.14 2.31*
applicable. Of additional importance is the potential
for select outcome measures related to dysphagia, *denotes statistical significance.
such as nosocomial infection rates to be improved.
As with any new process, computer-based
training can pose challenges. Those staff members Annual competency training and assessment
unfamiliar or uncomfortable with computer use may that can be delivered in a flexible format such as a
require additional support. In some settings, the cost computer program and can be initiated by the em-
of computer equipment and information technology ployee is a valuable and cost-saving tool for the em-
support may be a limiting factor. Furthermore, it ployer. The competency training and assessment at
should be emphasized that computer-based training the hospital described in this study are required as
is a component in a comprehensive approach to part of initial orientation and also at yearly intervals.
educating caregivers and cannot entirely replace more Reminders about when employee training is due are
traditional educational efforts. Additional research indicated by an internal scheduling program and
questions to be addressed regarding this or similar provided by the area manager. This system allows
training programs include whether there are changes employees the freedom to participate at their own
in clinical outcomes, such as reduced incidence of pace, on their own schedules, and to be self-directed
dehydration in at-risk populations, or changes in learners. Informal feedback received from caregivers
referral rates to speech–language pathology for dys- following completion of the computer-based module
phagia evaluation and treatment after exposure to the was favorable and included comments such as, ‘‘ItÕs
training module. really good, and taking the lesson annually will
146 L. Davis and K. Copeland: Computer-Based Dysphagia Training

Fig. 6. Score comparisons.

probably be a helpful review.’’ One staff SLP stated, c. pharyngeal stage

‘‘The online lesson saves time and exposes more staff d. esophageal stage
to the information than traditional inservices.’’
The results of this research have practical 3. Which of the following is an indication of a possible swallowing
disorder?
implications for SLPs working in healthcare settings.
With increased workplace focus on productivity and a. excessive thirst
clinical outcomes, computer-based training is a b. weight loss
c. weight gain
powerful tool SLPs can use to meet the demands of
d. abdominal distention
their employers and to fulfill their roles as clinical
educators. After considering the challenges and po-
4. Aspiration is defined as:
tential benefits technology has to offer, SLPs are
encouraged to ride the wave of the future and to a. coughing while eating and drinking
b. a gurgly vocal quality
explore ways they can utilize computers in their
c. food or liquid penetrating below the vocal folds
clinical practices. d. a sensation of food sticking in the throat

5. When patients aspirate:

Acknowledgments. The authors thank Bryan Booth in the Infor-
mation Technology Department at St. John Medical Center, Tulsa, a. They may not show any visible or audible signs
OK, for his help programming the computer-based training mod- b. They will choke and cough
ule. They also express appreciation to the nursing staff at St. John c. They will tell you they are aspirating
Medical Center who participated in this investigation. d. They will stop eating

6. The special test recommended by the speech–language pathol-

ogist to determine an individualÕs swallowing abilities is called:
Swallowing Safety Questions Version 1
a. A modified barium swallow study
1. The oral transit stage of the swallow should take about how b. A bedside swallowing evaluation
long? c. A barium swallow study
d. An upper GI
a. 1 second
b. 5 seconds 7. If a person with a swallowing disorder eats very slowly, the
c. 10 seconds nurse should:
d. 8–20 seconds a. feed the patient with a syringe
2. Which stage of swallowing is not under voluntary control? b. be certain that the patient has a straw so that he/she can
drink faster
a. oral preparatory stage c. assist the person to eat at their own pace
b. oral stage d. use a larger spoon for feeding
L. Davis and K. Copeland: Computer-Based Dysphagia Training 147

8. Thickened liquids should be used:

a. 5 seconds
a. by the majority of individuals with dysphagia to assure their b. 10 seconds
safety
c. 1 second
b. only when the individual coughs on liquids
c. only when recommended by the speech–language pathologist d. 8–20 seconds
d. usually only with water 2. Which stage of swallowing would be most affected in an indi-
vidual who does not have teeth or dentures?
9. Most patients with swallowing disorders do better with medi-
cations given: a. the oral preparatory stage
a. in a handful so that they only have to swallow once b. the oral transit stage
b. one at a time with a swallow in between each pill c. the pharyngeal stage
c. one at a time very quickly d. the esophageal stage
d. on the weak side of the mouth so that they can use their
3. Which of the following would NOT be an indication of a
tongue more
swallowing disorder?
10. Individuals chew food and form it into a cohesive mass during
which swallowing stage? a. pain during swallowing
b. frequent coughing during meals
a. oral preparatory stage
c. ringing in the ears
b. oral transit stage
c. pharyngeal stage d. food remaining in the mouth following a meal
d. esophageal stage 4. Food or liquid entering the airway is known as:
11. Who is most likely to be at risk for a swallowing problem?
a. asphyxiation
a. a 30-year-old woman who has just given birth b. regurgitation
b. a 45-year-old man following removal of his gall bladder c. deglutition
c. an 80 year-old following repair of a hip fracture
d. aspiration
d. an 11 year-old with chronic allergies
5. Food or liquid entering the airway:
12. The use of straws for individuals with swallowing problems:
a. is always forbidden a. will always enter the lungs
b. is helpful so that they do not have to sit upright to drink b. always causes a person to cough
c. should only be allowed if recommended by the speech–lan- c. may go unnoticed
guage pathologist d. is usually fatal
d. is a good practice so that patients do not become dehydrated
6. The person who completes evaluations and provides treatment
13. One way nursing staff can reduce the risk of pneumonia for for people with swallowing problems is a:
individuals with swallowing problems is to:
a. speech–language pathologist
a. complete a calorie count after every meal
b. take a temperature following each meal b. physical therapist
c. count the number of times the individual coughs during the c. charge nurse
meal d. internist
d. provide good oral care for the individual
7. Syringe feeding of a patient who has had a stroke is:
14. Hospitalized, premature infants are at higher risk for swal-
lowing problems because: a. recommended for at least the first two weeks
b. not recommended
a. they do not have a well coordinated suck–swallow reflex
b. they have not been able to bond with their mother c. recommended when a patient cannot hold a spoon or cup
c. their palates are not completely closed d. recommended for patients who eat slowly
d. they weigh less than full-term infants
8. People with swallowing problems:
15. When feeding an individual with a swallowing problem, it is
best to a. should have all liquids thickened
b. should have thickened water with each meal
a. feed them their favorite foods so they eat more
c. should be offered appropriate fluids frequently
b. position them at 90° with the feet supported
c. allow unlimited access to nectar-thick liquids d. should avoid all liquids
d. avoid use of any seasonings 9. Crushing medications and giving them in food such as apple-
Fig. 2. Computer-based dysphagia training pretest. sauce:

a. may be appropriate after checking with the pharmacist

Swallowing Safety Questions Version 2
b. is the safest way for a stroke patient to take medication
1. The pharyngeal stage of the swallow should take about how c. is never a good idea because it tastes terrible
long? d. is the best way to prevent aspiration of medications
148 L. Davis and K. Copeland: Computer-Based Dysphagia Training

10. The larynx raises, the airway closes, and the cricopharyngeus
muscle relaxes during which swallowing stage? a. very elderly people
b. preterm infants
a. oral preparatory stage c. people who are agitated
b. oral transit stage d. people with dementia
c. pharyngeal stage
15. An upright position following meals is often recommended to:
d. esophageal stage

11. Which person would be most likely to have a swallowing a. reduce pocketing of food on the weak side
problem? b. prevent nasal regurgitation
c. reduce the risks of reflux
a. a child with cerebral palsy
d. prevent throat clearing and coughing
b. a 2-year old with an ear infection
c. a 50-year-old man with an abdominal hernia Fig. 3. Computer-based dysphagia training posttest.
d. a 25-year-old woman following outpatient surgery

12. The safest way to provide liquids to individuals with swal- References
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