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The Massey Bedside swallowing screen.

Abstract: A prospective, one-group, nonexperimental design was used for this study. This design was selected to provide a methodological approach for establishing interrater reliability and content and predictive validity of the swallowing screen. This study was conducted in two phases. In Phase 1 content validity was established by experts in the field of stroke management, and in phase 2 interrater reliability was established. Sensitivity and specificity were determined by monitoring the participants' charts for 5 days to track dysphagia indicators. The experts supported content validity. To test interrater reliability, 2 reviewers evaluated 25 participants within a 2-hour time period. Participants were tested within 48 hours of the stroke. The interrater reliability of the bedside swallowing screen, as calculated in this study, was relatively high. Sensitivity and specificity were calculated as 100%. The chi-square test showed that use of the Massey Bedside Swallowing Screen might provide nurses with a useful tool for assessing swallowing function of patients with a stroke.

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Stroke is one of the most devastating occurrences in the United States. It ranks as the third-leading cause of death, with approximately 160,000 Americans dying per year from stroke (American Heart Association, 2002). Not all strokes, however, are fatal. There are approximately 4.6 million stroke survivors in the United States. Disability related to stroke produces socioeconomic consequences that have an impact not only on the patient and family but also on society. More than $30 billion is spent on stroke patients each year for medical care and lost productivity (Donnarumma et al., 1997).

Stroke survivors may experience residual deficits that range from mild to severe. One of the most frequent deficits that patients encounter after a stroke is dysphagia; nearly one-half of stroke patients may experience some type of dysphagia. Fortunately, most dysphagia resolves in about a week (Smithard et al., 1996). However, if dysphagia is undetected or untreated, it can lead to serious complications, including dehydration, decreased nutritional status, and aspiration pneumonia.

Early detection of swallowing dysfunction can aid in preventing these complications (Ylimaz, Gupta, Mlcoch, & Moritz, 1998). When dysphagia is identified soon after the stroke, treatment can be started, and the risks of aspiration and malnutrition can be diminished (Reynolds et al., 1998).

Nurses play an important patient advocate role caring for a patient with dysphagia. By identifying swallowing difficulties, the nurse can advocate for necessary services. Nurses are important as patient and family educators in the treatment of dysphagia as well.

A review of the literature did not reveal a bedside swallowing screen that would be practical for nurses to use on a daily basis. Therefore, Massey developed a screen that could be used to determine swallowing ability and the need for further evaluation by a speech pathologist (see Fig 1 and 2). The purpose of this study was to establish content and predictive validity and interrater reliability of the Massey Bedside Swallowing Screen used for assessing swallowing function of stroke patients.

[FIGURE 2 OMITTED]

Theoretical Framework

Orem's self-care deficit theory (1995) served as the theoretical framework for this study. Orem's theory supports the goal of nursing, which is to assist the patient in returning to a state in which the ability to manage activities of daily living is maximized. Orem's self-care theory states that when a person is unable to complete activities of daily living, a deficit develops.

A person who has had a stroke may have many self-care deficits (Orem, 1995). One deficit may be impairment in the ability to swallow. It is essential that the patient's swallowing function is assessed by the nurse to determine whether the person has a self-care deficit in this area. After the presence of dysphagia has been established, the nurse can help the person meet therapeutic self-care demands during recovery and rehabilitation.

Literature Review

Of all patients who experience a stroke, 30% will have dysphagia (Homer, Massey, & Brazer, 1990). The presence of dysphagia makes the patient more prone to malnutrition, dehydration, and aspiration pneumonia (Finestine, Greene-Finestine, Wilson, & Teasell, 1996; Homer et al.). Approximately 40%-70% of stroke patients with dysphagia will aspirate (Homer et al.), with aspiration pneumonia occurring in nearly 20% of those patients. The patient can exhibit signs of aspiration pneumonia as soon as 2 hours after aspiration. Although it can be treated with antibiotics, aspiration pneumonia can cause respiratory failure. Aspiration pneumonia is the second-leading cause of death in stroke patients within the first month after the stroke (Odderson, Keaton, & McKenna, 1995).

Aspiration pneumonia also lengthens the patient's stay in the hospital, leading to a higher cost for treatment (Odderson et al., 1995). Therefore, it is important to identify as soon as possible those patients who have dysphagia and are at risk for aspiration (Homer et al., 1990).

Dysphagia can be diagnosed through several types of invasive swallowing studies. Testing should be done on patients who are suspected of having dysphagia. The videofluoroscopy swallowing study, also known as the modified barium swallow (MBS), is the test most often used to diagnose dysphagia. It is considered to be the gold standard for diagnosing dysphagia (Bastian, 1998).

Although the literature supports the use of an MBS as the best indicator of dysphagia (Holas, DePippo, & Reding, 1994), there is the risk that the dysphasic patient also may aspirate the barium during the procedure. An MBS is a valuable diagnostic tool, but should not be performed without considering the aspiration risk for each individual patient.

Besides the risk of aspiration, it is not practical or cost-effective to do an MBS on every stroke patient. A swallowing screen should be performed at the bedside before performing an MBS. A preliminary swallowing screen performed by a nurse can be an effective tool to determine whether there is a need for speech therapy intervention (Odderson et al., 1995).

Method

Design

This study was conducted in a central Ohio acute care hospital. Data were collected over 12 weeks. A prospective, one-group, nonexperimental design was used for this study to provide a methodological approach for establishing reliability and validity of the swallowing screen. The study was conducted in two phases: (1) the establishment of content validity of the tool by experts in the field of stroke management and (2) the establishment of predictive validity and interrater reliability. Sensitivity and specificity were determined by monitoring each patient's chart, via a tracking tool, for up to 5 days for evidence of dysphagia. This included a consult with speech therapy, performance of an MBS, a special diet, or signs of pulmonary infection.

Sample

A convenience sample of adult, acute stroke patients who were admitted to a central Ohio acute care hospital was used for this study. Criteria for study inclusion were (a) patients who were at least 21 years of age with an admitting diagnosis of stroke in an acute care hospital or who experienced a stroke following a procedure during hospitalization; (b) patients who had the ability to follow verbal or visual one-step commands; and (c) patients who were awake and able to respond to verbal or nonverbal cues.

All patients meeting the above criteria were approached for entry into the study. The neurologist made the stroke diagnosis, and informed consent was obtained from all participants. A 95% confidence interval approach was used to estimate a sample size of 36. A pilot study was conducted prior to data collection.

The study consisted of 25 stroke participants. Of this total, 12 of the participants experienced left-brain stroke, 6 had right, and 2 were cerebellar in location; for 5 of the participants stroke locations could not be determined from reading their charts. There were 16 males and 9 females in the study. The length of stay in the hospital ranged from 2 days to 2 weeks (M = 4 days). The participants ranged in age from 39 to 87 years old (M = 75 years).

Development

Several studies concluded that a bedside swallowing evaluation was an effective tool for use with stroke patients. However, the tools for each study differed. Most of the tools did not include an assessment of the function of the muscles involved in swallowing. Few of the studies had established adequate measures of reliability or validity.

A bedside swallowing screen was developed that nurses could use on a daily basis for assessing swallowing function. It was developed from a review of the literature, as well as input from nurses, a speech pathologist, and a neurologist. The screen includes an assessment of motor function of the muscles involved in swallowing and the reflexes involved in swallowing. Procedure

During Phase 1, the bedside swallowing screen was evaluated for content validity by having six experts in stroke and dysphagia review it and complete a questionnaire developed by Massey (Fig 3). All these experts--a neurologist, two speech pathologists, and three nurses--had credentials from national stroke-related organizations. A 10-question, 5-point Likert-type scale was used to query the experts' opinions of the Massey Bedside Swallowing Screen. The respondents were asked to indicate their agreement with several statements about the content and applicability of the screen.

For Phase 2, part 1, the bedside swallowing screens were conducted within 48 hours of the patients' admission to the hospital or within 48 hours of stroke occurrence. To establish interrater reliability, two research assistants independently evaluated the participants' swallowing function using the bedside swallowing screen. Massey initially approached the participants to obtain consent. Then one of the research assistants conducted the bedside swallowing screen. The other research assistant repeated the bedside swallowing screen within 2 hours of the first screening. Neither assistant was aware of the other's results. The order in which the research assistants performed the screen on each participant was chosen randomly.

For Phase 2, part 2, predictive validity was established through determination of sensitivity and specificity. Massey used a tracking tool to track the presence or absence of dysphagia in each participant's medical record. MBS was the gold standard used for comparison in determining the presence of dysphagia. Additional indicators included consult with a speech therapist, a special type of diet (such as thickened liquids or pureed food), and/or clinical symptoms of aspiration pneumonia.

Results

Content Validity

Content validity was established via the 5-point, Likert-type questionnaire. Descriptive statistics were used to analyze results of the questionnaire to assess content validity. The responses ranged from strongly agree to disagree. Most of the responses by the experts were strongly agree. Suggested changes or additions were made to the bedside swallowing screen at the end of Phase 1.

One respondent suggested changing the item "checking of the position of the uvula" to movement of the tongue left and right. The position of the uvula is a good indicator of the patient's ability to swallow. However, movement of the tongue is important in the pre-oral and oral phases of swallowing, Checking movement of the tongue could be an additional part of checking the position of the tongue; therefore, this item was added to that section.

One of the experts suggested changing "checking the swallow reflex" to "checking for a voluntary swallow." The presence of a swallow reflex does not always indicate that the patient can swallow safely (Price & Dilorio, 1990). Checking for the swallow reflex is more effective if it involves having the patient swallow voluntarily. This change, therefore, was incorporated into the bedside swallowing screen.

The results of the Likert-type scale questionnaire are shown in Table 1. The sample size varies for each question because one respondent did not answer all the questions. The majority of respondents strongly agreed or agreed with every statement on the questionnaire. All respondents strongly agreed or agreed that the content was accurate and consistent with current research. All the respondents strongly agreed that the swallowing screen was formatted in an organized manner. All the respondents also strongly agreed or agreed that the information obtained from the swallowing screen would be useful in determining swallowing function.

Interrater Reliability

Interrater reliability was established by having two research assistants independently evaluate each participant within 2 hours. Not all participants could be included in the analysis of every item, because directions on the bedside swallowing screen indicate that the screen should stop if the patient is not alert or is unable to swallow either a teaspoon or a cup of water.

A 95% confidence interval was calculated for the proportion of agreement between the two independent raters, with the level of significance at p < .05. The probability of agreement on the final result of the swallowing screen was calculated as well. In order to determine interrater reliability, an item analysis was performed for each individual item (Table 2). The interrater reliability of the bedside swallowing screen, as calculated in this study, was relatively high. It was established prior to data collection that a proportion of >90, with a confidence interval of .90 to 1.00 would be acceptable. A 95% confidence interval also was calculated to determine predictability from the sample. Alpha was set at .05; the exact p value of each item of the bedside swallowing screen was .000. Therefore, because the exact p value is less than alpha, the interrater reliability for each item of the screen is high (Hopkins, Glass, & Hopkins, 1987). Predictive Validity

According to the assessments made by the research assistants, 40% of the participants had dysphagia and 60% had normal swallowing function. The research assistants concluded that 10 of the 25 participants showed evidence of dysphagia. This was consistent with the chart data. Four had an MBS; four were determined by the physician or speech therapist as not being safe for an MBS; and two participants had their dysphagia resolve within 72 hours and did not require further intervention. Speech therapy was consulted on nine participants. Eight required intervention with a special diet or tube feeding.

Chi-square testing was used to analyze data obtained using the tracking tool. The indicators from the tracking tool provided a statistically significant (p = .00) ability to differentiate between "dysphagia present" and "dysphagia not present." This difference was calculated to determine the association between the bedside swallowing screen results and data from the participants' charts (Table 3).

Discussion

Content validity for the Massey Bedside Swallowing Screen was supported on the basis of results obtained from the questionnaire completed by the stroke management experts. The high interrater reliability may indicate that the research assistants used similar criteria to assess swallowing function of the stroke patients (as reflected in the assessment tool) and that they understood and applied the criteria similarly.

Previous studies on noninvasive swallowing screens reported sensivity and specificity of less than 70%. Logemann, Veis, and Colangelo (1999) attribute this low sensitivity and specificity to the actual design of the swallowing screen. In addition, the U.S. Department of Health and Human Services (1999) indicated that most of the studies conducted on patients with dysphagia had a small sample size. Studies with larger sample sizes are needed to determine which type of diagnostic tool is best for the patient. This study could be replicated using a larger sample size.

Limitations

One limitation of this study was the small sample size, which may limit generalizability of the findings. The study consisted of the assessment of 25 stroke patients who were admitted to one acute medical center. A second limitation is that only one location was utilized for data collection; this also may affect generalizability of the findings. Because a convenience sample was used, it may be more limiting than a random sampling.

History could pose a potential threat to internal validity. Once the subject was screened with the bedside swallowing screen, the second screening by the other researcher took place within 2 hours. During this time, the participant's condition could have changed, which could have altered the results. Data from the participant's chart were monitored to note any change in clinical status.

Only selected measures of validity and reliability were used in this study: content and predictive validity and interrater reliability. Additional studies are needed to determine construct validity and other measures of reliability. Construct validity was not measured in the study because there were no comparable nursing measures available at the time of data collection.

Summary

According to the content experts, the Massey Bedside Swallowing Screen is a valid tool that is accurate and easy to use. Interrater reliability was calculated as having high numbers for this study. Sensitivity and specificity for this study were 100%.

Nurses are the professionals who are present most often at the bedside, particularly at mealtime. Therefore, nurses need to be able to recognize when a patient is having difficulty with swallowing (Travers, 1999). A bedside swallowing screen that is clear, logical, and accurate would help nurses assess swallowing function. According to the experts cited in this study, the Massey Bedside Swallowing Screen is accurate and logical and should be efficient for nurses to use on a daily basis. The Massey Bedside Swallowing Screen could improve the quality of nursing assessments of the stroke patient.

This bedside swallowing screen was developed to identify patients with dysphagia. A bedside swallowing screen performed by nurses could enable the patient to receive appropriate referrals for speech therapy much earlier.

Caring for stroke patients requires interdisciplinary teamwork. Often, !t is the nurse who is able to recognize the need for additional therapies. Assessing the swallowing function of a patient is helpful not only in identifying a self-care deficit, but also in alerting the speech-language pathologist of a patient who is in need of therapy.

Recommendations for Further Study

The Massey Bedside Swallowing Screen was developed for use with stroke patients. However, there are other causes of dysphagia, such as Parkinson's disease, amyotrophic lateral sclerosis, or multiple sclerosis. The Massey Bedside Swallowing Screen also may be beneficial in assessing the swallowing function of children who have neurological deficits. Additional studies should include other populations that could benefit from a nursing assessment of swallowing function.
Fig 1. Massey Bedside Swallowing Screen

Massey Bedside Swallowing Screen

Patient name --
Date of admission --
Date of screen --
Time of screen --

 Yes No Comments
 1. Patient is alert (can follow command) If No Stop
 2. Dysarthia (speech slurred or garbled)
 3. Aphasia (trouble speaking or
 understanding words)
 4. Able to clench teeth
 5. Able to close lips
 6. Face is symmetrical with movement
 7. Tongue is midline
 8. Uvula is midline
 9. Gag reflex is present
10. Has voluntary cough (have patient
 cough 2 times)
11. Able to swallow own secretions (no
 drooling)
12. Swallow reflex is present
13. Give a teaspoon of water
 a. swallows without choking a. a.
 b. voice sounds gurgly b. b.
 c. coughed after water c. c.
 d. water dribbles out of mouth d. d.
14. Give a 60 cc of water (if teaspoon
 was tolerated)
 a. swallows without choking a. a.
 b. voice sounds gurgly b. b.
 c. coughed after water c. c.
 d. water dribbles out of mouth d. d.

Fig. 3. Content validity questionnaire

Please respond to the statements regarding the bedside swallowing
screen. Circle the response that most accurately describes your
agreement with each of the statements below: (1) strongly agree (2)
agree (3) neutral (4) disagree (5) strongly disagree.

 1. Content of the swallowing screen 1 2 3 4 5
 is accurate.
 Comments:

 2. Content of the swallowing screen 1 2 3 4 5
 is consistent with current research
 on dysphagia.
 Comments:

 3. Directions for the swallowing 1 2 3 4 5
 screen are clear.
 Comments:

 4. Terminology used in the swallowing 1 2 3 4 5
 screen is understandable for
 staff nurses.
 Comments:

 5. The swallowing screen could easily 1 2 3 4 5
 be used by staff nurses.
 Comments:

 6. The swallowing screen is formatted 1 2 3 4 5
 in an organized manner.
 Comments:

 7. Information obtained from the 1 2 3 4 5
 swallowing screen is useful in
 determining swallowing function.
 Comments:

 8. The decision tree is easy to 1 2 3 4 5
 follow.
 Comments:

 9. The decision tree is logical. 1 2 3 4 5
 Comments:

10. The length of time to administer the 1 2 3 4 5
 swallowing screen is reasonable.
 Comments:

11. Other comments or suggestions
 related to the swallowing screen.

Table 1. Results of Content Validity Questionnaire

 Strongly
 Agree Agree Neutral Disagree

 1. Content of swallowing 4 2
 screen is accurate
 2. Content is consistent 3 2
 with current research
 3. Directions are clear 4 1 1
 4. Terminology is 4 1 1
 understandable for
 staff nurses
 5. Could easily be used 4 1
 by staff nurses
 6. Screen is formatted in 5
 an organized manner
 7. Information obtained 4 1
 from the screen is
 useful in determining
 swallowing function
 8. Decision tree is easy 5 1
 to follow
 9. Decision tree is logical 5 1
10. Length of time to 3 1 2
 administer screen is
 reasonable

 Strongly N
 Disagree

 1. Content of swallowing 6
 screen is accurate
 2. Content is consistent 5
 with current research
 3. Directions are clear 6
 4. Terminology is 6
 understandable for
 staff nurses
 5. Could easily be used 5
 by staff nurses
 6. Screen is formatted in 5
 an organized manner
 7. Information obtained 5
 from the screen is
 useful in determining
 swallowing function
 8. Decision tree is easy 6
 to follow
 9. Decision tree is logical 6
10. Length of time to 6
 administer screen is
 reasonable

Table 2. Results of Statistical Item Analysis of Reliability Scoring

 Sample
Item N Agree Disagree Proportion

 1. Alert 25 25 0 1.00
 2. Dysarthria 23 22 1 .96
 3. Aphasia 23 23 0 1.00
 4. Clench teeth 23 23 0 1.00
 5. Close lips 23 22 1 .96
 6. Facial symmetry 23 21 2 .91
 7. Tongue midline 23 23 0 1.00
 8. Uvula midline 23 23 0 1.00
 9. Gag reflex present 23 22 1 .96
10. Voluntary cough 23 22 1 .96
11. Swallows secretions 22 21 1 .95
12. Swallow reflex present 22 22 0 1.00
13. Tolerated tsp. water 20 20 0 1.00
14. Tolerated glass water 20 20 0 1.00
15. Same conclusions 25 25 0 1.00

 95% Confidence Exact
Item Interval p value

 1. Alert (.86, 1.00) .000
 2. Dysarthria (.78, 1.00) .000
 3. Aphasia (.85, 1.00) .000
 4. Clench teeth (.85, 1.00) .000
 5. Close lips (.78, 1.00) .000
 6. Facial symmetry (.72, 0.99) .000
 7. Tongue midline (.85, 1.00) .000
 8. Uvula midline (.85, 1.00) .000
 9. Gag reflex present (.78, 1.00) .000
10. Voluntary cough (.78, 1.00) .000
11. Swallows secretions (.77, 1.00) .000
12. Swallow reflex present (.85, 1.00) .000
13. Tolerated tsp. water (.83, 1.00) .000
14. Tolerated glass water (.83, 1.00) .000
15. Same conclusions (.86, 1.00) .000

Table 3. Chi-Square Test Predictive Validity

 C1 C2 Total
1. Dysphagia Present
 observed 10 0 10
 expected 4 6
2. Dysphagia Not Present
 observed 0 15 15
 expected 6 9

Total 10 15 25

Chi-square = 9.00 + 6.00 + 6.00 + 4.00 = 25.00

DF= 1; p = .00; level of significance < .05


References

American Heart Association. (2002). Heart and stroke statistical update. Retrieved July 10, 2002, from http://www.americanheart.org/presenter.jhtml?identifier=3000090

Bastian, R.W. (1998). Contemporary diagnosis of the dysphagic patient. Otolaryngologic Clinics of North America, 31, 489-506.

Donnarumma, R., Kongable, G., Barch, C., Braimah, J., Bratina P., Daley, S., et al. & the NINDS rt-PA Stroke Study Group. (1997). Overview: Hyperacute rt-PA stroke treatment. Journal of Neuroscience Nursing, 29, 351-355.

Finestine, H.M., Greene-Finestine, L.S., Wilson, E.S., & Teasell, R.W. (1996). Prolonged length of stay and reduced functional improvement rate in malnourished stroke rehabilitation patients. Archives of Physical Medicine and Rehabilitation 27, 340-345.

Holas, M.A., DePippo, K.L., & Reding, M.J. (1994). Aspiration and relative risk of medical complications following stroke. Archives of Neurology, 52, 1051-1053.

Hopkins, K.D., Glass, G.V., & Hopkins, B.R. (1987). Basic statistics for the behavioral science (2nd ed.). Boston: Allyn and Bacon.

Horner, J., Massey, E.W., & Brazer, S.R. (1990). Aspiration in bilateral stroke patients. Neurology, 40, 1686-1688.

Logemann, J.A., Veis, S., & Colangelo, L. (1999). A screening procedure for oropharyngeal dysphagia. Dysphagia, 14, 44-51.

Odderson, I.R., Keaton, J.C., & McKenna, B.B. (1995). Swallow management in patients on an acute stroke pathway: Quality is cost effective. Archives of Physical Medicine and Rehabilitation, 76, 1130-1133.

Orem, D.E. (1995). Nursing concepts of practice (5th ed.). St. Louis: Mosby-Year Book Co.

Price, M.E., & Dilorio, C. (1990). Swallowing: An assessment guide. American Journal of Nursing, 7, 42-45.

Reynolds, P.S., Gilbert, L., Good, D.C., Knappaertz, V.A., Crenshaw, C., Wayne, S.L., & Tegler, C.H. (1998). Pneumonia in dysphagic stroke patients: Effect on outcomes and identification of high risk patients. Journal of Neurology Rehabilitation, 12(1), 15-21.

Smithard, D.G., O'Neill, P.A., Park, C., Morris, J., Wyatt, R., England, R., & Martin, D.F. (1996). Complications and outcome after acute stroke: Does dysphagia matter? Stroke, 27, 1200-1204.

Travers, P.L. (1999). Post stroke dysphagia: implications for nurses. Rehabilitation Nursing, 24, 69-73.

U.S. Department of Health and Human Services. (1999). Diagnosis and treatment of swallowing disorders (dysphagia) in acute-care stroke patients (AHCPR Publication No. 99-E023). Rockville, MD: Author.

Ylimaz, E.Y., Gupta, S.T., Mlcoch, A.G., & Moritz, T. (1998). Aspiration following stroke. Journal of Neurology Rehabilitation, 12(2), 61-64.

Questions or comments about this article may be directed to: Regina Massey, MSN RN CNP CNRN, 750 Mount Carmel Mall, Suite 250, Columbus, OH 43222. She is an instructor at Mount Carmel College of Nursing and a nurse practitioner at the Epilepsy Center Mount Carmel West/Neurology Center of Columbus.

Diane Jedlicka, PhD RN CCRN, is a professor of nursing at Otterbein College in Westerville, OH.
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Author:Massey, Regina; Jedlicka, Diane
Publication:Journal of Neuroscience Nursing
Geographic Code:1USA
Date:Oct 1, 2002
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