A Poliuretano antiestático, 57 PIW, 2 capas, bordes

Purpose

Semi-structured interviews were felt to be the most appropriate research tool to obtain information regarding the accuracy of the questions and whether the predicted

responses would be sufficient to inform the development of a swallow screening tool.

Method

The survey tool was subjected to stakeholder review (Fink, 2003) by inviting eight purposefully sampled professionals, four SLTs and four nurses, who had various levels of dysphagia training and experience, to undertake semi-structured interviews (Moser and Kalton, 1971; Neale, 2009).

The interviews ensured that the questions would be reviewed by both experts in the field and potential respondents (Fink, 2003). Interview questions could also be modified in response to interviewees‟ comments and the interviewer would be allowed to clarify or probe further (Aldridge and Levine, 2001). Key themes from the interviews were used to inform a revised survey.

Successive iterative interviews were undertaken until all interviewees responded that the questions were unambiguous, the format comprehensive and no further pertinent information was necessary.

Setting

A local district hospital that provides a dysphagia service across primary and secondary healthcare to stroke patients was identified as able to offer the range of dysphagia trained nursing and SLT staff who work across a variety of locations.

Sampling

The author contacted the Director of Nursing in order to access the register of nurses who had undertaken in-house dysphagia training by the Speech and Language Therapy Department. There were a total of 12 nurses on the register. Similarly a register of eight members of the SLT department who worked across a variety of locations across the acute and community sector and who reported varying levels of dysphagia training was obtained. All candidates were included in the sampling frame (Appendix 16) in order to eliminate any bias but the number of professionals available for sampling was small. This did not allow for simple, systematic or random sampling. Rather the interviewees were purposefully sampled in order to offer a range of opinion resulting from their clinical experience. It was important that the views of the

interviewees reflected that of the population that would receive the survey. In order to achieve this, the interviewees‟ designation, location of work, experience working with the client group and level of dysphagia training was mapped onto a matrix or sampling frame. Four nurses and four SLTs were purposefully identified from the sampling frame. Each professional was identified as providing care for stroke patients either in acute care and/or community care with a collective experience ranging from six months to ten years post-qualification.

All the professionals approached accepted the invitation to be interviewed, with four nurses and four SLTs invited for each stage of the iterative interviews. Different nurses and SLTs were interviewed at each stage of iterative interviews. This small number was chosen so that modifications to the survey could then be re-examined during a second phase of interviewing. Iterative phases of interviews were implemented until the survey was considered comprehensive, able to elicit answers pertaining to the

research questions and in an accessible format to facilitate completion and return.

The individual nurses and SLTs on the register were contacted by telephone. They were given a brief overview of the project, informed of the purpose of the survey and asked if they would be prepared to undertake a 10 minute interview with the researcher and to state convenient times, dates and location to undertake the interview.

Participants were then sent a copy of the survey and were asked to complete it, in order to establish that the instructions for completion were clear, and to comment on each question either in writing or by making mental notes prior to the interview. After two weeks, nurses and SLTs were contacted by telephone and were asked if they had received the questionnaire, whether they had completed the questionnaire and whether they were still prepared to participate in an individual interview. A mutually convenient

An interview protocol was developed to establish a core set of questions aimed at evaluating the validity of each question within the survey, to ensure that each question was specific enough to elicit the desired information and focusing on issues related to layout, format, the sequence of questions, ease of completion, instructions in relation to transition questions, semantic and linguistic syntax of the questions, information

omitted from the survey that would be pertinent to the study and time taken to complete the survey.

The nurse interviews took approximately 11-15 minutes and were audio-taped and transcribed (Appendix 17). The data that identified the interviewees was removed and comments for each section of the survey were collated (Appendix 18). The SLT interviews took between 15-20 minutes and the anonymised comments (Appendix 19) were again collated (Appendix 20).

Survey modification

The section below describes how the survey was modified in accordance with the comments received from the interviews.

Title page

The nurse interviewees reported that the title page reflected the content of the document, however two of the SLTs felt that the title failed to indicate that the document was a survey and one interviewee was only made aware of the content of the document by the information in the footer at the bottom of the page. The word „survey‟ was therefore added to the title page.

Letter of introduction

The nurses reported that the letter of introduction clearly explained the purpose of the survey and that the amount of time completing the questionnaire concurred with the time stated in the introductory letter. Two of the SLTs reported that it took between 10 and 15 minutes to complete the questionnaire; the time stated in the introductory letter was modified accordingly.

One respondent enquired whether the results were going to be made available to those who completed and returned the questionnaire. The feasibility of providing respondents with survey findings were discussed with supervisors. Different methods of delivering

findings were debated: technical difficulties were envisaged in the development of an internet site, there would also be difficulties with updating the site, assigning

responsibility for maintaining the site and financial implications. Asking respondents to provide contact details would be time consuming and sending findings through the post would be a costly option. It was decided that findings would be presented at either a national conference, as part of a regional stroke conference or at a local specialist interest group. A further section was added to the second draft of the survey asking respondents to indicate an interest in attending a forum or a specialist interest group for the dissemination of the findings. The researcher‟s email address was added to the contact details

.

Summary of contents

All interviewees found the summary of contents page useful and felt that the example orientated them to the type of information required and the format of the responses. One interviewee felt that the example was useful but not essential. This page remained unaltered.

Section 1

There was unanimous agreement that the section heading and summary of the section content was both accurate and useful. It was decided to define the word „screen‟ in the second draft and the definition was included in this section heading in order to offer further clarity for the questions in the section.

Question 1: Two of the four nurses were unsure whether the question referred to them personally or to the department. Two out of the four SLTs reiterated this comment. Two nurses and one SLT also commented that there was insufficient space for further comments. The question was modified to read „Do you personally offer a dysphagia service to stroke patients?‟ Further space was allocated to this question.

Question 2: All nurses and SLTs found this question easy to understand and were able to answer the question as it related to their place of work. One of the SLTs felt that more space should be allocated for respondents to elaborate and this was modified in version two.

Question 3: It is at this point that the wording for the two questionnaires changes in order to address the different perspectives of the professional groups involved. Both questionnaires ask if nurses refer patients to SLT for dysphagia assessment. This was

Question 4: Similarly, this question (in both the SLT and the nurse questionnaires) addresses nurse screening but is modified for the two professional groups. This was acceptable to all interviewees and remained unaltered. Two of the nurses who work in the day hospital who do not undertake dysphagia screening ticked „no‟ and were then directed to return the questionnaire. Subsequently, they were not offered the

opportunity to comment further or express opinions regarding their clinical practice. This was corrected in the second version of the questionnaire by removing the signpost asking them to refrain from answering further questions and return the questionnaire if they responded „no‟ to the question. Instead nurses were signposted to move to question 11.

Question 5: This question focussed on ongoing management of dysphagia by nursing staff. All remaining interviewees, two nurses and four SLTs, did not experience any difficulties with comprehending or completing this question and it remained unaltered.

Section 2

The section heading was agreed by all interviewees as acceptable and it remained unaltered.

Question 6: This question asks about the consistencies that SLTs advise nurses to use and asks the nurses directly to identify the textures they use as part of their dysphagia screening. One of the nursing staff felt that she would have preferred the word „texture‟ rather than „consistencies‟ and that examples should not have been given. No other comments were received regarding the acceptability of the word and it remained unaltered in version 2. One SLT commented that not all consistencies were

represented in the examples given which made her question whether her practice was acceptable. The examples were modified in order to include all consistencies; it was hoped this would encourage therapists to give honest answers rather than ones perceived to be acceptable. One therapist questioned whether it was necessary to record actual quantities of food and fluids used in the screening process. As this information was integral to the final development of the swallowing screening tool, it was introduced in the second version of the survey.

Question 7, 8 and 9 for SLT Questionnaire: This set of questions is concerned with nurse compliance with SLT instructions relating to consistencies trialled during the nurse swallow screening. The questions only occur in the SLT questionnaire as the

researcher was unsure how honestly nurses would answer these questions and concerned about possible alienation of the nursing staff who may then fail to complete and return the questionnaire. One generalist SLT stated that she was unable to answer the question as she did not have the training to inform nurses. One specialist therapist commented that she would actively encourage nurses to use different consistencies and to act within the scope of their competence. As the question revealed details of the protocol in different locations within the hospital, and none of the therapists had

difficulty understanding or completing the questions, they remained unaltered.

Section 3

All interviewees agreed that the description of the questions in this section was explanatory and the section heading and description remained unchanged. All respondents agreed with the content, structure and format of the questions in this section (SLT questions 10-14 and Nurse questions 7-11).

All interviewees were able to explain where to return the questionnaires to and had no suggestions for further information required in order to obtain a complete view of nurse swallow screening.

Phase 2: Pre-testing of the survey tool: second cohort of semi-structured