A review of a review

Today was the fourth journal club meeting and, I felt, the most interesting yet. All articles evoked in-depth discussions around both their quailty, and their application to clinical practice: how exciting!

We met at the Jazz Café in Newcastle at 11am-1pm; finally, the perfect venue and the time. From now on we will aim to hold all meetings here (thanks Jazz Café!)

Three articles were discussed, the first of which will be reviewed here today:

Singh, S. & Hamdy, S., (2006). Dysphagia in Stroke Patients. Journal of Postgraduate Medicine, 82, 383-391.

This paper provided a useful overview of dysphagia, assessment, compensatory, and therapeutic, methods. We all felt that it was especially useful for newly qualified SLT graduates as revision.

Although the paper is entitled a ‘review’, there is no clear introduction as to its aims, and the purpose and structure of the paper was muddy at times, though each section was very clearly written and accessible. A significant proportion of the article referenced the author’s own research into the bilateral cortical representation of swallowing and that this neuropathology may be what makes possible the neuroplasticity enabling so many to recover swallow-function after the acute stages of stroke recovery (i.e. swallow function can hop over to the other cortex),

The review highlighted that the goal of assessment in dysphagia was not to determine whether or not someone had dysphagia, but rather to build a profile of that person’s swallowing difficulties (and strengths). It notes that 50% of patients who pass bedside assessment were shown to silently aspirate when assessed using the gold standard of videofluoroscopic assessment. In terms of management, the authors write that the goals of dysphagia therapy are to reduce the morbidity and mortality associated with chest infections, to improve nutritional status and to return patients to a normal diet, with resultant improvement in their quality of life.

It is clear from the paper that there is a lack of good quality evidence for swallowing rehabilitation. The authors suggest this is likely due to the ethical restrictions of randomised control trials in dysphagia studies (using people who aspirate as controls would be unsafe in some instances). The most effective evidence, they note, comes from a study by Shaker et al. (2002), which describes an exercise aimed to strengthen the upper oesophageal sphincter, and thus remove post-swallow pharyngeal residue in patients with chronic dysphagia. This exercise requires the patient to lie in the supine position, raise their head from the bed for a few seconds and then rest their head down again. They are to repeat this 20 times. In addition, pharyngeal electrical stimulation was also found to have a possible therapeutic role (Fraser et al., 2002).

The paper discusses issues around enteral feeding and notes the importance of nutritional considerations when managing dysphagia.

Journal club discussions arising from paper

Interesting that most evidence for dysphagia rehabilitative exercises is anecdotal, or comes from clinical experience (third arm of EBP model).

Paper showed that 50% of patients who passed bedside assessment where shown to be silently aspirating on VFSS. Clinical implication of this and discussion around the fact (not discussed in this paper) that a proportion of the elderly population aspirate without having had a stroke, and some of these are at risk of chest infection and some are not. Without taking pre-stroke baseline, it is impossible to assess effectively. One of the first questions to ask a patient (or care-giver) has to be ‘what was your (their) eating and drinking like before your stroke?’

Some NQPs had seen Shaker’s exercise applied in practice. One felt that most of her (acute) patients would really struggle with this exercise because of mobility impairment/age.

Some people had seen O2 saturation used as a bedside indicator of aspiration within clinical practice.

The paper makes reference to some unpublished data in the authors’ department to support an argument but without giving further details of how to access this data, this was felt to reduce the quality of the review.

There was a quiz at the end of the review to test the reader’s understanding and/or learning. Readers found this very useful: take note potential authors!

References

Fraser, C., Power, M., Hamdy, S., et al. (2002). Driving plasticity in human adult motor cortex is  associated with improved motor function after brain injury. Neuron, 34, 831-840.

Shaker, R., Easterling, C, Kern, M., et al. (2002). Rehabilitation of Swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology, 122, 1314-1321.

Reasonable adjustments in retail: money handling

The other day I was supporting a teenage girl during a shopping trip. On every trip we set goals related to independence. The young woman has cerebral palsy and has little speech that would be understood by unfamiliar listeners. She uses a variety of means to get her message across including gesture and an electronic communication device. Her physical difficulties mean that she is not able to perform fine motor tasks, such as opening a purse.

The teenager, who I will call Jessie, decided she would go into a popular music store by herself, pick out an item, take it to the counter and pay for it. As usual, she was excited to complete this goal. I would wait outside and have nothing to do with the encounter.

When she arrived at the counter, with the chosen CD in her lap, the woman at the counter said she couldn't open Jessie's purse as she was not allowed. Jessie felt frustrated and upset because she was not physically able to open her own purse. A queue began to form. A lovely customer came forward to open Jessie's purse for her, take the money from the purse and give it to the woman working there. It turns out that Jessie was just shy of the amount needed, which added to her embarrassment of being effectively refused service while a queue of people formed behind her. The gentleman insisted on giving her the difference so she could buy the CD. The kind gesture was juxtaposed against the inflexible background of the encounter and she was on her way, grateful, frustrated and dependent.

After Jessie told me what happened we went back in and spoke with the manager to see if we could problem-solve our way to solution which would allow Jessie to feel she could independently come into the shop in the future and buy an item. I acknowledged that we understood staff may not be able to open purses for their own liability, but asked where this left the customer? The manager was understanding and sympathetic; he said that he and the majority of staff there would have, in fact, just opened the purse without making an issue of it. They would have viewed the situation holistically and reasonably - Jessie had just been unfortunate with the member of staff with whom she had had the encounter. I asked him to hold a staff meeting so that all staff would be on the same page regarding this issue, which will affect a lot of customers. He agreed to do this and we left satisfied with the solution.

                                                   

Why am I sharing this?

• Many people with communication difficulties and disabilities will not have the support to bring up this topic themselves and it is something that needs to be discussed.
• It is understandable that staff would want to protect themselves from being a suspect in a possible scenario of money going missing from a vulnerable person's wallet.
• Lots of shops and fast food places do have broad policies regarding not opening a customer's purse to take out money. 
• If the above policy is in place, staff they may understandably feel bound to it and not see room for manoeuvre. They may see it as a safety net for self-protection. If it is there, they are entitled to adhere to it, whether or not this ruins a customer's day. 
• One-size cannot fit all.
• Staff working behind the counter are known and checked by the retailer. Other customers are not. Where is the retailer's concern for the customer with a disability when they force them to choose between relying on an unchecked member of the public to open their purse, or not be served? Is it fair on the other customer, who is in the store as a customer and not as a paid member of staff?

Under the Equality Act (2010), providers must make reasonable adjustments where a practice, policy or procedure makes it impossible or unreasonably difficult for a disabled person to make use of the service. This includes refusing a service which it offers others.

By refusing to open a customer's purse, who is unable to do this for themselves, they are refusing to serve that customer and preventing them making a purchase because of that person's disability.

Suggestions for retailers to ensure reasonable adjustments

A) Staff training around disability and reasonable adjustments.

B) Ensure the shop has adequate security footage so that it records any handling of money behind the counter to protect the employee and the customer.

C) Be explicit about the money you are taking out of the purse so that the exchange is transparent to both the customer and any other customers present "Ok, I'm taking out £10 and your total is £5.50 for items X and Y, so here is your £4.50 change. Shall I put it in your purse with your receipt?"

D) If the above is not possible, consider the following policy: a member of staff can assist a customer in opening their purse and collecting change when observed/signed-off by a second member of staff.

E) View each person as an individual and make adjustments accordingly.

Suggestions for customers with disabilities to ensure reasonable adjustments: know your rights

Programme phrases into your communication aid including "please take my purse and open it as I am unable to do this myself", "can you get another member of staff to watch as you take money from my purse?" "Can I be served by the manager?/I would like to be seen by the manager" and even "I need you to make reasonable adjustments for me".

Remember

Social attitudes make people disabled: with the right support everybody can have the same rights.  Send this post to anybody you know in a customer service position which includes handling money e.g. transport/food/banks/retail. The more people who see this, the greater chance we have of changing things and making the world a more equal place.