Delegation models in dysphagia management: Current policy, clinical perceptions and practice patterns

Delegation of patient related tasks to allied health assistants: a time motion study

Background

Allied health assistants (AHAs) are support staff who complete patient and non-patient related tasks under the delegation of an allied health professional. Delegating patient related tasks to AHAs can benefit patients and allied health professionals. However, it is unclear whether the AHA workforce is utilised optimally in the provision of patient care. The purpose of this study was to determine the proportion of time AHAs spend on patient related tasks during their working day and any differences across level of AHA experience, clinical setting, and profession delegating the task.

Methods

A time motion study was conducted using a self-report, task predominance work sampling method. AHAs were recruited from four publicly-funded health organisations in Victoria, Australia. AHAs worked with dietitians, occupational therapists, physiotherapists, podiatrists, social workers, speech pathologists, psychologists, and exercise physiologists. The primary outcome was quantity of time spent by AHAs on individual task-categories. Tasks were grouped into two main categories: patient or non-patient related activities. Data were collected from July 2020 to May 2021 using an activity capture proforma specifically designed for this study. Logistic mixed-models were used to investigate the extent to which level of experience, setting, and delegating profession were associated with time spent on patient related tasks.

Results

Data from 51 AHAs showed that AHAs spent more time on patient related tasks (293 min/day, 64%) than non-patient related tasks (167 min/day, 36%). Time spent in community settings had lower odds of being delegated to patient related tasks than time in the acute hospital setting (OR 0.44, 95%CI 0.28 to 0.69, P < 0.001). Time delegated by exercise physiologists and dietitians was more likely to involve patient related tasks than time delegated by physiotherapists (exercise physiology: OR 3.77, 95% 1.90 to 7.70, P < 0.001; dietetics: OR 2.60, 95%CI 1.40 to 1.90, P = 0.003). Time delegated by other professions (e.g. podiatry, psychology) had lower odds of involving patient related tasks than physiotherapy (OR 0.37, 95%CI 0.16 to 0.85, P = 0.02).

Conclusion

AHAs may be underutilised in community settings, and by podiatrists and psychologists. These areas may be targeted to understand appropriateness of task delegation to optimise AHAs’ role in providing patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08642-7.

Exploring utilisation of the allied health assistant workforce in the Victorian health, aged care and disability sectors

Background

Allied health assistants (AHAs) support allied health professionals (AHPs) to meet workforce demands in modern healthcare systems. Previous studies have indicated that AHAs may be underutilised in some contexts. This study aims to identify factors contributing to the effective utilisation of AHAs across health, aged care and disability sectors and possible pathway elements that may optimise AHA careers in Victoria.

Methods

Using an interpretive description approach data collection included a workforce survey and semi structured interviews (individual and group). Data analysis included descriptive statistics, independent t-tests and thematic analysis. Participants included allied health assistants, allied health professionals and allied health leaders in the health, aged care or disability sectors; educators, managers or student of allied health assistance training; and consumers of Victorian health, disability or aged care services.

Results

The literature scan identified numerous potential barriers to and enablers of AHA workforce utilisation. A total of 727 participants completed the survey consisting of AHAs (n = 284), AHPs & allied health leaders (n = 443). Thirteen group and 25 individual interviews were conducted with a total of 119 participants. Thematic analysis of the interview data identified four interrelated factors (system, training, individual and workplace) in pre-employment training and workplace environments. These factors were reported to contribute to effective utilisation of the AHA workforce across health, aged care and disability sectors. Study findings were also used to create a conceptual diagram of potential AHA career pathway elements.

Conclusion

This study identified pre-employment and workplace factors which may contribute to the optimal utilisation of the AHA workforce across Victorian health, aged care and disability sectors. Further study is needed to investigate the transferability of these findings to national and global contexts, and testing of the conceptual model.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07171-z.

Four-hour swallow screening target for stroke - from guidelines to practice: A mixed methods knowledge translation study

Purpose: To conduct systematic analysis of compliance with swallow screening against a 4-hour target timeframe and determine barriers and facilitators to compliance.Method: Knowledge translation approach using mixed methods. Quantitative data from a medium sized metropolitan hospital was extracted from 12-months of medical records to review timing of swallow screening from stroke admission using descriptive and inferential statistics. Qualitative data involved 14 semi-structured interviews of speech-language pathologists, registered nurses and medical officers and were analysed using the Theoretical Domains Framework.Result: 74% of eligible patients (271/365) received a swallow screen by trained nursing staff; 189 (52%) were within the 4-hour target. Screening was facilitated by quality training of nurses, strong belief in the benefits for patients and availability of the specialist stroke nurse. Quantitative analysis, confirmed through participant interviews as barriers, revealed that the strongest predictors of not meeting the 4-hour target were overnight admissions and not being admitted to the dedicated stroke unit.Conclusion: 52% of swallow screenings were performed within the 4-hour target timeframe recommended as best practice in the Australian and UK stroke guidelines. Barriers identified may assist other institutions improve compliance with the 4-hour timeframe that will likely be adopted internationally.

Introduction of a speech-language pathology assistant role for swallow screening in a head and neck radiotherapy clinic

PURPOSE

Optimal care suggests that all moderate-high risk head and neck (H&N) cancer patients should receive speech pathology assessment, education and management when commencing radiotherapy. However this is not always feasible due to high patient numbers and limited staffing. The aim of this study was to investigate the implementation of a speech-language pathology assistant (SLP-A) role for swallowing screening and education in a multidisciplinary H&N treatment clinic.

METHOD

A detailed model of care and training module were developed to up-skill the SLP-A in the screening and education to be undertaken. A pre-test post-test design compared outcomes in two separate groups prior to and following SLP-A role implementation. Outcomes included: optimal care compliance, speech-language pathology time spent with complex patients, swallowing-related admissions and patient satisfaction.

RESULT

Twenty-six patients were included pre-implementation and 35 post-implementation, with 16 (46%) patients receiving SLP-A screening/education post-implementation. The proportion of eligible patients seen by speech-language pathology pre-implementation was 62%, compared to 94% seen by speech-language pathology or SLP-A post-implementation (p = 0.002). There was a (non-significant) increase in speech-language pathology time spent with complex patients post-implementation (total minutes per patient: mean 252, SD = 144 vs. 279, SD = 115). There was no increase in swallowing-related admissions, and a (non-significant) increase in patient satisfaction post-implementation, indicating no compromise to patient safety or satisfaction.

CONCLUSION

Implementing a speech-language pathology assistant role for screening patients within the H&N treatment clinic allowed delivery of optimal care and increased time for speech-language pathologists to spend with complex patients, without compromising patient safety or satisfaction.

Physiotherapy service provision in a specialist adult cystic fibrosis service: A pre-post design study with the inclusion of an allied health assistant

What is the impact of including an allied health assistant (AHA) role on physiotherapy service delivery in an acute respiratory service? A pragmatic pre-post design study examined physiotherapy services across two 3-month periods: current service delivery [P1] and current service delivery plus AHA [P2]. Clinical and non-clinical activity quantified as number, type and duration (per day) of all staff activity categorised for skill level (AHA, junior, senior). Physiotherapy service delivery increased in P2 compared to P1 (n = 4730 vs n = 3048). Physiotherapists undertook fewer respiratory (p < 0.001) and exercise treatments (p < 0.001) but increased reviews for inpatients (p < 0.001) and at multidisciplinary clinics in P2 (56% vs 76%, p < 0.01). The AHA accounted for 20% of all service provision. AHA activity comprised mainly non-direct clinical care including oversight of respiratory equipment use (e.g. supply, set-up, cleaning, loan audits) and other patient-related administrative tasks associated with delegation handovers, supervision and clinical documentation (72%), delegated supervision of established respiratory (5%) and exercise treatments (10%) and delegated exercise tests (3%). The AHA completed most of the exercise tests (n = 25). AHA non-direct clinical tasks included departmental management activities (11%). No adverse events were reported. AHA inclusion in an acute respiratory care service changed physiotherapy service provision. The AHA completed delegated routine clinical and non-clinical tasks. Physiotherapists increased clinic activity and annual reviews. Including an AHA role offers sustainable options for enhancing physiotherapy service provision in acute respiratory care.

Dysphagia screening using an allied health assistant delegation model: service considerations for implementation

PURPOSE

Three facilities, involved in introducing a model of Allied Health Assistant (AHA) delegated dysphagia screening, examined barriers and facilitators to service implementation.

MATERIALS AND METHODS

The 3 facilities varied in size, services and location. AHAs (n = 4) and speech-language therapists (SLTs; n = 4) directly involved in implementation at each site completed semi-structured interviews exploring the implementation experience. Analysis was guided by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

There was differential implementation across the sites. Facilitators to implementation fell within the CFIR Innovation Characteristic domain, with the "relative advantage" of the model and "design, quality and packaging" of the training and implementation resources being key facilitators. Barriers related to the Innovation Characteristic domain, regarding the tool's "adaptability" in terms of screening tools selected and the implementation environment. Issues with the Inner Setting domain, specifically the "structural characteristics," the "compatibility" of the model and the "relative priority" of the model's implementation within other organizational priorities were also barriers.

CONCLUSIONS

Although the service model was perceived to have relative advantage, compatibility with local work-flow priorities and service needs must be thoroughly considered if AHA delegated dysphagia screening is to be beneficial as a service model to address increasing dysphagia referral demands.IMPLICATIONS FOR REHABILITATIONDysphagia is a disabling condition which may result in medical, social and operational complications.The demands of screening, assessing, managing and providing rehabilitation for dysphagia are increasing, therefore alternative models of service delivery including delegation are increasingly being considered and implemented.This study provides evidence regarding the context and facilitators of successful AHA dysphagia screening model implementation.This evidence contributes to a growing knowledge base of delegation practices for the management of staffing resources and building of capacity for rehabilitation service delivery.