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A Stepwise, Mixed-Method Study Approach to Identify the Barriers to Dysphagia Care in Hospice Care Nurses

Tan, Laurence, M.Med (Family Medicine), MBBS; Gan, Grace, M.Ph; Hum, Allyn, MBBCh (BaO); Lee, Angel, MBBS

Journal of Hospice & Palliative Nursing: February 2018 - Volume 20 - Issue 1 - p 88–94
doi: 10.1097/NJH.0000000000000404
Feature Articles

Dysphagia is common in palliative patients and worsens quality of life. Nurses are the main provider of dysphagia care. An audit showed poor compliance with dysphagia measures among nurses, but little is known about what the barriers are. We sought to evaluate barriers to dysphagia care among hospice nurses. This was a stepwise, mixed-method study. Baseline knowledge and attitudes were assessed, and a lecture was crafted based on the assessment. The knowledge and attitudes were then reassessed to investigate for any change. A focus group and an open-ended questionnaire were then used to assess for other barriers and for the effectiveness of training. Knowledge scores were low at baseline, and training improved the scores. Nurses cited the lack of time and lack of families’ involvement as barriers to dysphagia care. While nurses believed that preventing aspiration is important, they also felt that most patients would refuse a modified diet and that respecting their wishes is important. Most nurses felt that the training increased their ability to care for patients with dysphagia. Our study demonstrated that knowledge deficit was an important barrier in dysphagia care for nurses, and this can be improved with a short training. Even though nurses rightly believed that patients’ preferences are important, they struggled with trying to balance these preferences with preventing aspiration. Supporting them in making these decisions, having more time for feeding patients, and involving family members may be important to reduce barriers to care for patients with dysphagia.

Laurence Tan, M.Med (Family Medicine), MBBS, is consultant, Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore.

Grace Gan, M.Ph, is independent speech therapist, Singapore.

Allyn Hum, MBBCh (BaO), is member of the Royal College of Physician and senior consultant, Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore.

Angel Lee, MBBS, is fellow of the Royal College of Physician and senior consultant, Changi General Hospital, Singapore.

Address correspondence to Laurence Tan, M.Med (Family Medicine), MBBS, Department of Geriatric Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828 (

The authors have no conflicts of interest to disclose.

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© 2018 by The Hospice and Palliative Nurses Association.