Dysphagia Education in SNFs: Effective Partnering With Non-SLP Staff

Editor's note: This text-based course is a transcript of the webinar, Dysphagia Education in SNFs: Effective Partnering With Non-SLP Staff, presented by Gopika Shah, M.A., CCC-SLP.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

• After this course, participants will be able to identify three common challenges unique to SNFs that SLPs face due to a lack of dysphagia awareness among non-SLP staff.
• After this course, participants will be able to identify complications related to identify and describe the roles of different long-term care staff members(e.g., nurses, dietary staff, CNAs) in dysphagia management.
• After this course, participants will be able to list five key topics that non-SLP staff need to be educated on to improve dysphagia care in SNFs.
• After this course, participants will be able to apply effective strategies and interactive training methods to educate non-SLP staff on dysphagia awareness and promote behaviors that enhance the management of swallowing difficulties.

Through This Course, I Hope To:

Through this course, I hope to provide insight into the lives of speech-language pathologists working in skilled nursing facilities and to shed light on some of the common challenges we face, particularly the disconnect between us and the rest of the staff in the building.

This disconnect not only leads to frustration for us as SLPs but also affects other staff members and, most importantly, has a significant impact on our patients in various ways. My goal is to share knowledge, along with practical tips and strategies, that can support the development of healthy working relationships between SLPs and other team members within the facility. Ideally, some of the topics we explore will resonate with you and offer immediate, actionable steps that you can begin applying in your workplace. These small, consistent efforts can gradually help close the gap between what we, as SLPs, understand and what we wish others on the team understood about our work.

This course is not intended to be a directive on how to do your job. I fully recognize and respect that each professional brings valuable knowledge and experience. The purpose here is to complement that existing expertise—not to override or replace anyone's professional judgment or perspective.

Introduction-Food for Thought

Let's get started. Before I begin, I want to share something interesting I came across that really got me thinking. Staff working in skilled nursing facilities encounter an incredibly wide variety of cases during their time in these settings. Think about the patients you know and care for—we work with individuals in post-acute nursing units, restorative care, rehabilitative care, and palliative care.

Many of these patients have chronic and progressive conditions like dementia, Parkinson’s disease, and ALS, along with more commonly recognized issues such as strokes, fractures, and head and neck cancers. The staff in these facilities often spend a significant amount of time with patients because of the long-term nature of these illnesses. If I were a nursing student and had a clinical rotation in this setting, I imagine the depth and breadth of experience would be incredible. The understanding I could gain of the entire continuum of care would be so valuable.

However, research indicates that nurses with undergraduate, associate, and bachelor degrees rarely have clinical experiences in nursing homes. Faculty often go so far as to discourage these placements, suggesting they do not offer viable career paths. Given that context and the reputation that SNFs carry among healthcare professionals, how motivated do you think the staff really feels about pursuing continuing education? And how much incentive and support do you think they receive from leadership to stay current and grow professionally?

If the staff does not feel they are working in a place that is viewed as important, that can affect their motivation to strive for excellence. That lack of external recognition can lead to feelings of being less significant or impactful, which, in turn, may prevent them from seeking the high-quality education and continuing professional development they truly need to provide the best care possible to these complex patients.

Challenges: The Why

Let's focus on the challenges that speech-language pathologists face in addressing dysphagia within skilled nursing facilities. In other words, this is the “why” behind the need for interdisciplinary collaboration.

As I mentioned earlier, the staff in these facilities manage a wide variety of issues every day. Among these, the incidence of dysphagia is incredibly high—and it rarely exists in isolation. Dysphagia is frequently compounded by overlapping medical conditions such as GERD, hypertension, CVAs, and dementia. This places residents at increased risk for relapses, malnutrition, dehydration, hospital readmissions, weight loss, and ultimately, a reduced quality of life. These outcomes contribute to a vicious cycle: patients return to the therapist's caseload, caregiving responsibilities increase, and staff across disciplines—SLPs and non-SLPs alike—experience heightened burnout and frustration.

Another major challenge we encounter is the poor transition of care from the hospital to the skilled nursing facility. For example, when a patient is discharged from the hospital, we may receive information that the patient is on a specific diet consistency. But what about the level of supervision required? What about the type and frequency of oral care? Are there any compensatory strategies the patient is using? These small but essential details often get lost in the transition. A similar issue arises even within the facility itself when an SLP discharges a patient. The discharge plan may include recommendations, but are these recommendations actually being implemented? Beyond just diet, how are strategies being maintained? Who is responsible for training the staff? And what about float staff—who ensures they are trained as well?

This breakdown in communication is critical and needs to be addressed. Another persistent issue is the general lack of awareness and education about dysphagia—and more importantly, how dysphagia treatment has evolved over time. I have been guilty of assuming that others automatically understand what I am doing and why I am doing it. It may seem like common sense to me, but it is not fair to expect that level of knowledge from non-SLP staff. They are not in our field, and they do not have the same access to current research and continuing education that we do.

Take, for example, patients on modified diets. We now understand that for some patients, particularly those on thickened liquids, the modified diet may not always be in their best interest. In fact, it might do more harm than good. Whereas 10 or 20 years ago, that is what many staff members observed SLPs recommending. If they have not received any updates since then, it is understandable that they would be operating under outdated assumptions. When a newer SLP comes in and performs an instrumental on a patient who is coughing on thin liquids but still recommends continuing those thin liquids without explanation, the staff may become confused or even skeptical. The SLP might feel pressure to justify their clinical decision-making, and if communication does not happen, this misunderstanding can lead to a divide. The staff may feel the SLP is not doing their job, while the SLP may feel disrespected and misunderstood. This miscommunication only reinforces existing gaps between disciplines.

Sometimes, even medical directors and administrators push back against instrumentals, particularly for patients with progressive illnesses, dementia, or those who are at the end of life. They may believe these procedures won’t significantly change the course of treatment. But we know that, in some cases, they absolutely can. In those cases, advocating for an instrumental is worth it.

Lastly, a fundamental barrier continues to be the lack of understanding about the role of the speech-language pathologist. What do we actually do? These studies are especially compelling because they illustrate how little is often known about our role among the broader staff, and they underscore why bridging this knowledge gap is so important.

Frontline Staff Perspectives on Nutrition Care and Training

A survey conducted by Mertz Garciato revealed that 44% of staff believed the responsibility for upgrading and downgrading diet consistencies fell to nursing personnel, and 16% believed it was the responsibility of CNAs—not speech-language pathologists. Another study found that when nursing staff and CNAs were asked about their continuing education, they reported that it was often limited to their initial orientation or to the training they received during their CNA certification coursework. Additionally, another study showed that many staff members did not believe that texture modification or dietary changes had any real impact on the nutritional content of the food. We now understand that this is not the case. Texture modifications can significantly affect nutritional intake, and it is crucial that all team members are aware of these implications.

There also tends to be limited awareness among non-SLP staff when it comes to dysphagia treatment, particularly in relation to patients with cognitive impairments. Some staff may have unrealistic expectations, assuming that if a patient is in therapy, they will eventually be able to swallow and eat normally. Others may swing to the opposite extreme, adopting a defeatist attitude—believing that there’s nothing that can be done. But the truth often lies somewhere in the middle. For instance, if a patient with dementia is holding food in their mouth, an SLP can assess the situation and try strategies to help the patient initiate a swallow. We can then train the caregiving staff on how to use those strategies effectively. I will go into this in more detail later in the presentation.

There are also a few terms and concepts that are commonly misunderstood or confused by staff, such as the differences between coughing, choking, aspirating, and aspiration pneumonia. This misunderstanding can have a real impact. It can lead to fear among staff about feeding a patient who is coughing or even about completing oral care, particularly if the patient is on a less restrictive diet than they expect. When we choose not to thicken liquids, despite a cough, staff may become concerned or upset, feeling that we are not doing our jobs properly. These misunderstandings can erode trust. That is why it is so important to address these concerns openly. We will be discussing these concepts more thoroughly later on as well.

Lack of Knowledge Regarding Need, Impacts Of, and Proper Protocols for Oral Hygiene

Last but certainly not least, one of the most important topics to address is oral care—how it is done, why it is necessary, and what happens when it is not prioritized. Many staff members may not be fully aware of the significant impact that poor oral hygiene can have on increasing the risk of aspiration pneumonia. In some cases, staff may not even have the proper resources or training to understand how oral care should be completed effectively.

Several studies highlight just how widespread this issue is. In one study involving approximately 120 nursing homes, oral hygiene strategies were found to be lacking in 80% of the facilities. Many of them had no structured oral care protocols in place, and around 50% of these nursing homes did not have access to external experts, including speech-language pathologists. Another study surveyed 160 nursing homes and found that nursing staff tended to have more negative than positive attitudes toward oral care. These negative attitudes were strongly associated with high work pressure, insufficient staff training, and a lack of incentives.

All of this underscores the importance of oral care, not just as a routine task, but as a critical component of patient health and safety. This brings us to the conclusion of the challenges section—the “why” behind the need for interdisciplinary collaboration, and the wide-reaching impacts when that “why” is not adequately addressed.

The "Who"

Now we are going to move on to the “who”—who we are actually training and who makes up the team that SLPs can collaborate with in skilled nursing facilities.

First, we have our CNAs—also known as my besties. Honestly, they are the closest to the patients. They work incredibly hard, often around the clock, providing hands-on care during ADLs, feeding, positioning, oral care, and so much more. They are absolutely essential to day-to-day patient support and are often the first to notice subtle changes in a resident's condition.

Nursing staff are responsible for managing medications, relaying information to the medical team, carrying out orders, and communicating with upper management. They are an extremely important communication link when you need something done for your patients. Whether it is updating a care plan, monitoring symptoms, or adjusting interventions, their role is crucial.

Doctors and nurse practitioners are responsible for examining patients, assessing medical conditions, and prescribing appropriate treatments. Let’s be honest—you can’t really move forward with many of your recommendations unless the doctor signs off on them. Whether it is initiating a diet modification, ordering an instrumental study, or requesting changes to medication timing, these decisions usually require the provider’s approval.

The dietary department also plays a vital role in implementing therapeutic diets based on patients’ medical needs. They monitor weights and caloric intake and serve as a key link between the SLP and the kitchen staff for any required diet modifications.

The kitchen staff, in turn, prepares food according to these guidelines, ensuring that patients receive their meals on time and with the correct consistencies and nutritional content. Their ability to follow through on what’s been prescribed is critical to patient outcomes.

The recreational staff helps keep residents and patients engaged in activities that support their mental, physical, and social well-being. They can also have a positive impact on PO intake by offering fun, engaging snacks throughout the day, often encouraging patients to eat and drink more through casual, enjoyable interactions.

Lastly, the administrative staff—your CEOs, ACOs, Directors of Nursing, business office personnel, medical directors, care coordinators, and social workers—play a huge role in patient care support. They manage staffing efficiency, oversee building operations, and ensure the overall quality of care. Their buy-in is often necessary for making lasting systemic changes.

Depending on your audience, it may be helpful to choose an appropriate setup for your meetings. One-on-one meetings tend to be more effective with physicians, nurse practitioners, and administrative leaders, especially since these discussions usually focus on specific patients or targeted operational needs rather than broad educational topics.

Small group meetings work well for training sessions involving dietary staff, kitchen department heads, administrative team members, or recreational staff. These are great opportunities to rotate topics since what you discuss with these groups is likely to vary and evolve—you won’t be covering the same material in every session.

Given their size, nursing staff typically receive large group training and in-services. These sessions usually focus on more general topics and might occur once or twice a year. Of course, this is in addition to more individualized in-services or patient-specific training that may occur within patient rooms or on an as-needed basis.

The "What"

I have covered the why and the who. Now, the meat and gravy of the presentation: What should we discuss with these individuals to create a collaborative team to improve patient care?

MDs and Nurse Practitioners

Starting with MDs and nurse practitioners, these conversations are typically centered around individual patients and residents. It might be about why you need an instrumental for a patient or discussing the results of that instrumental with the doctor.

Sometimes, you might notice something anatomical—for instance, during your FEES evaluation, you see a strange bump at the back of the pharyngeal wall—and you might say, “Hey, can you take a look at this?” or suggest getting an ENT consult. These are just some examples of ideas you can bounce off the physician that could be beneficial for the patient. Depending on the clinical presentation, you might also consider referring to RTs, ENTs, or neurologists.

Another common point of discussion involves potential changes in medication timing, particularly in conditions like Parkinson’s disease. Adjusting medication schedules can have a direct impact on swallow function.

This next one can be a bit tricky. Sometimes doctors may not be up to date on the latest literature in our field and may still be influenced by older practices. I had an experience where a doctor came to me saying a patient had to sign out AMA because they disagreed with the diet recommendation provided. That really caught me off guard. I took some time to develop a solid, evidence-based plan and presented it to the doctor. We were able to give the patients what they wanted in a relatively safer manner while explaining the associated risks to both the patient and their families. that is a concept a doctor may or may not be comfortable with right away, but if you present the data and make a strong, well-supported case, it is a conversation worth having—for the sake of your patient.

It can also be a good practice to have certain protocols, such as EMST or electrical stimulation, run by your physicians before initiating them, just to ensure alignment and transparency in your care plan.

Administration

Moving on to admin and what we can discuss with them, this is honestly a great opportunity for speech-language pathologists to initiate meaningful changes within the facility that could serve as solutions to existing problems. For example, if your facility does not currently have standardized dysphagia diet levels in place or hasn’t adopted IDDSI, you could consider bringing up the idea of training staff and implementing the IDDSI framework.

If you have noticed that patients are not getting enough water throughout the day, hydration stations could be proposed for placement in hallways or common areas. If you feel there’s a need for specific instrumentation or equipment to support your evaluations and treatments, that is a conversation worth having as well. You could consider pitching the idea of bringing in mobile FEES or MBS services if these are not already available.

These conversations can be supported with strong evidence—not just regarding patient outcomes but also how such measures can benefit the facility financially. Plenty of literature is available to help make a compelling case.

You can also suggest in-service or staff training to increase awareness about dysphagia and the importance of oral care. If a free water protocol could be appropriate for certain patients in your building, that is another valuable topic to raise. These discussions with the administration can be a catalyst for improved patient care and better interdisciplinary collaboration across the board.

Recreational Staff

Moving on to the recreational staff, they honestly play a huge role because they help keep our patients well-nourished between meals. They encourage participation in activities and are often the ones handing out snacks throughout the day.

First, it is important for them to be familiar with the different levels of modified diets. Once they understand those levels, the next step is figuring out how they are keeping track of which patients are on which diet. Are they using bracelets? Are they using a roster that is regularly updated? And how often is that roster being reviewed and maintained?

One activity we have implemented in our facility that is really helpful is having everyone brainstorm snack options that can be placed on a daily snack cart or stored in the fridge. We keep a running Google Sheet where anyone can add snack ideas. If someone comes across a fun food option—like cottage cheese with pureed fruit—they can add it under the minced and moist category. This gives patients more variety and choice, rather than being limited to just applesauce, chocolate pudding, or chocolate chip cookies.

The beauty of the Google Sheet is that it is ongoing. There is no need to sit down all at once to plan it out. Whenever someone thinks of an idea, they just add it in and ask if it is appropriate, and then we can verify and approve it.

Along the same lines, recreational staff often organize events like Waffle Wednesdays or Milkshake Mondays. It is a great idea to remind them to include different modified diet options for residents with special dietary needs, and these activities can be inclusive. Since these events revolve around food, they should be enjoyable for everyone.

One of my favorite recent collaborations with recreation staff and the dietary team was working on a modified menu based on a restaurant that our residents frequently visit. For example, this menu was adapted from Hungry Hobo, a local restaurant that the residents enjoy going to during outings. Now, if someone is on a modified diet, they still have options to choose from when they go out.

The menu even includes notes about the level of supervision required, especially if CNAs or other staff are accompanying the residents. It specifies what adjustments need to be made to match the diet level—like cutting food into smaller bites or adding gravy to make it more moist.

The residents have really loved this. It has opened up more opportunities for them to participate in outings they’ve been looking forward to for a long time, and it helps make those experiences safer and more enjoyable.

Kitchen Staff and Dietitians

All right, so when we are discussing things with kitchen staff and dietary staff, the first thing I felt I needed to get in place was clarity around how meal tickets are being updated and what steps I need to take when a diet consistency needs to be changed. Every building seems to have its own system. For example, at my VA building, I have to write a note or an order, which then gets signed by the doctor. After that, I hand it over to nursing, who informs dietary, and dietary inputs it into the computer and notifies the kitchen. It is a well-organized system that works for us.

In contrast, at my per diem job, the process is different. The SLP is responsible for informing the dietary staff directly—not nursing—and also for entering the change into the computer and providing a written form to the kitchen. It just goes to show that systems vary, but establishing a more straightforward, smoother process that keeps everyone aligned might be worth exploring early on.

Another system I am grateful to have in place is the one for preparing trays used during feeding trials and evaluations. If I need multiple consistencies on a tray—whether for a FEES exam or to trial a patient—I just go to the kitchen and hand them a sticky note with the patient’s name, what I need, and a note that says "trials" or "evaluation tray." The kitchen staff then prepares and sends the tray at lunch or at the designated time, and the CNAs know not to touch it because the sticky note clearly indicates that it is for SLP use only. It is a simple process, but it saves time and keeps everything running smoothly.

I also like to request to be included in the weekly menu email thread between the kitchen and dietary teams. I find it really helpful, not just as a tool for language and communication activities with residents, but also as a way to boost PO intake, especially for residents who are picky eaters. And if I happen to notice something on the menu that might not be suitable for patients on a soft and bite-sized diet, I will gently bring it to the kitchen staff’s attention. For example, I might say, “Hey, I noticed this item on the menu—do you think we could switch it up a bit? It might be hard for some residents to manage.” In my experience, when these kinds of suggestions are made gradually and one at a time, they are received much more openly than if I came in saying, “Everything here is wrong.” It keeps the communication collaborative and not overwhelming.

If you are planning to implement IDDSI in your building, it might be helpful to keep a few strategies in mind. IDDSI itself is a comprehensive topic and is usually covered over a two-hour presentation. There are some fantastic resources on the IDDSI website that are worth reviewing. That said, here are a few things that have worked well in my experience: provide educational material ahead of time, use practical and hands-on methods like the fork drip test or spoon tilt test, and have staff taste the liquids themselves. You can also brainstorm fun ways to make thickened liquids using natural ingredients if that is an option. These approaches tend to make the learning process more engaging and memorable for everyone involved.

Dietitians

Along with food-related discussions, I like to work closely with dietitians to address specific patient considerations. For instance, if a patient is on a continuous tube feed, I will ask whether it might be appropriate to transition that patient to a bolus feed to better mimic real mealtime patterns. This can help support the return to oral intake. I explore whether tube feedings can be reduced as the SLP works on increasing PO trials and adding oral meals back into the patient's diet.

For patients who are at risk for weight loss, it is important to discuss whether they might benefit from additional supplements like Boost or ice cream or whether they should be placed on a calorie-tracking program—especially in cases where there is a suspected or observed decline in PO intake or body weight.

Registered dietitians are also fantastic sounding boards for patient-related concerns and a wealth of knowledge. I have learned so much just from asking them questions, especially about interpreting lab values related to dehydration, kidney function, and liver function. They are often happy to share their expertise, especially when they feel their opinion is valued and respected. Yes, I ask them many questions, and those conversations have been incredibly helpful in shaping the overall care plan.

Nurses and CNAs

All right, the last and largest chunk of the presentation was nurses and CNAs.

I usually conduct an in-service in the training room once or twice a year. This can be done with all the nurses and CNAs together or separately, depending on your timing and what works best with their schedules. The session typically lasts about 20 to 25 minutes and is presented in PowerPoint. Ideally, the timing should be arranged so that both shifts can attend. For example, if the first in-service is from 2:30 to 3:00, the second can run from 3:00 to 3:30—covering the end of one shift and the beginning of the next.

Whenever I present to them, I start with a big slide that simply says, "Thank you, thank you, thank you, thank you." I truly want to show them how important they are and how much of a difference they make—not only in the lives of our residents but also in making our jobs as therapists smoother. While I am guilty of complaining about them sometimes, I honestly believe nursing and CNAs are the backbone of the building.

I make a point to encourage them to speak up and share their opinions. Many CNAs have valuable insights about patients, but often feel unheard by upper management. Knowing someone is there to listen and take their concerns seriously means a lot. I tend to leave the session's beginning or end open for them to voice any issues or feedback. I write everything down and follow up with them afterward. I will try what they suggest if it relates to a specific patient. If it works, great. If it does not, I will return to them and say, “Hey, I tried it. It didn’t work well, but let’s devise another plan.” And if I am delayed and can’t get to it for a month or two, I will still make a point to mention it when I pass them in the hallway—just so they know I have not forgotten.

I try to avoid using too much jargon and instead give real-life examples they can relate to because it is directly tied to their daily experience with patients. I also encourage participation by asking questions throughout the presentation. Every slide—or at least every other slide—includes a question. I have even thrown candy at staff for giving great answers or asking thoughtful questions. That idea was shamelessly borrowed from Miranda Bailey on Grey’s Anatomy.

The presentation usually begins with the question: “What do you look for when identifying a swallowing problem?” While we know the common signs—coughing, changes in voice quality, altered breathing, watery eyes—I walk through each one with them. Then we ask, “What do you do when you notice a swallowing difficulty?” If their answer is, “We inform nursing,” that is great. It is even better if nursing informs the SLP, and the patient is referred. However, if the patient is downgraded to a different diet without an SLP consult, we must discuss that. And if the answer is “nothing,” that is the worst possible scenario—and exactly why we are having this conversation.

CNAs know their patients so well that it is critical for them to report any changes they see. Returning to downgrading diets, even if nurses see that a patient has lost their dentures and is struggling with regular textures, they switch to a softer diet temporarily. That is understandable, especially if the SLP is not available in the building. Similarly, if a patient suddenly becomes altered in their level of consciousness and can’t tolerate food, and the SLP is not accessible right away, adjusting the diet may be necessary.

However, that conversation must happen if a patient coughs once while drinking a soda and is immediately placed on pureed foods and thickened liquids without consultation. We must ensure that our responses are appropriate and collaborative and that staff feel confident in knowing when and how to reach out to the SLP.

What is the Safest Diet?

That leads to my next favorite question: What is the safest diet?

Not surprisingly, the most common answers I get—and I have a slide in my presentation dedicated to this—are "puree and nectar thick" or "puree and honey thick." Those responses come up all the time. But then a few nurses gave my absolute favorite answer: “There’s no safest diet for everyone. It depends on the patient.” 

Anything that shows patient-centered thinking, anything with the response, “We need to see what the test shows,” or “Let’s wait for the SLP’s assessment,” are great answers. But then, of course, someone usually chimes in with, “But my patient stops coughing when I give them thickened liquids.” That opens the door for a really important conversation.

Role of an SLP

That leads us to a shift in the conversation, where we explain the importance of swallow studies—specifically instrumental swallow studies—and our role as SLPs.

This slide is self-explanatory for us, but the nursing and CNA staff benefit from seeing it. The two main points I emphasize during this part of the presentation are:

Number one: SLPs need instrumentals to determine whether a patient is aspirating, not aspirating, or has pharyngeal dysphagia. Just because a patient is referred to speech therapy does not mean we can automatically diagnose what’s wrong and determine the correct diet. We rely on these studies to make accurate and safe recommendations.

Number two: I explain the two most common types of instrumental studies we use. The first is FEES, where we insert a small camera through the nose to view the swallowing mechanism from the top and assess if food and liquids are going down the correct way. The second is MBS, a video X-ray that gives us a dynamic image of the swallowing process in real time. I keep the jargon to a minimum and focus on how both tools help us determine whether the foods and liquids the patient consumes are safe and appropriate.

One of my favorite things to do here is show pictures from FEES studies—typically of patients from the building that the staff are familiar with. I show one patient who coughs on thin liquids but does not aspirate, and another patient who does not cough but silently aspirates on thin or thickened liquids. This is always eye-opening for the staff. They often react with surprise—“How is that even possible?”—and it helps them understand that coughing can be a protective reflex and is not necessarily something to fear.

Another impactful piece of information I share is the study by Bice et al., which found that 60% of patients on modified diets in skilled nursing facilities didn’t actually have dysphagia and that 61% of patients with feeding tubes also didn’t have dysphagia. These statistics are shocking, and they tend to stick with the audience. They are powerful reminders of why individualized, evidence-based assessment is important and instrumental studies are critical to our work.

Positioning

Moving on to the next question. What is the best way to position the resident? Figure 1 shows an example.

Figure 1. Proper bed positioning.

Everyone knows the basics—yes, the patient needs to be upright and sit up straight, and most people can even name the exact angle. Then I show a picture of a patient lying in bed, like the one on the left side of the slide, and ask, “How would you position this patient upright?”

Someone usually says, “Well, raise the head of the bed.” If you raise the head of the bed in that position, the patient ends up crouched over with their neck bent and likely in pain. A CNA may say, “You have to pull the resident up in bed first while they are lying flat and then raise the head of the bed.” That is exactly it. To prevent the patient from sliding back down, the knees of the bed can be raised, too.

The same goes for the chair. If the patient is slouched, you must pull them up before adjusting the backrest to an upright position. There is a practical challenge here—pulling up a patient in bed is usually a two-person job. That is why I always remind CNAs that if any trained staff is passing by in the hallway, ask them for help. It only takes two seconds.

I tell my therapy team and my DOR to always be willing to assist. I encourage CNAs to do the same with their teams—ask. It is quick and simple, and it makes a big difference. I have often been pulled in to help reposition a patient after one of these trainings, and it has worked. It is just a matter of reinforcing that idea, and once the light bulb goes off, they start doing it consistently.

Dysphagia, Dementia, and Dignity

Since the prevalence of dementia in nursing homes is so high, in addition to positioning, there are many safe swallow strategies that we need to go over with the nursing staff to promote safety. Many of the training and goals for patients with dementia will often focus on staff education, and the patient’s safety will largely depend on how well the staff is trained. These are some of the strategies we use frequently—like alternating solids and liquids, allowing time between bites, and other similar techniques—that can be helpful to share with nursing staff.

In addition to these general safe swallow strategies, it is also important to make staff aware that goals for patients with dementia differ significantly from those for individuals with non-progressive conditions. Dementia is a progressive disease, and it is not going away. Our goals might focus more on improving the quality of life or training staff to help patients get what they need and want, rather than strictly aiming for maximal safety. Sometimes, this can be as simple as identifying a few favorite foods and developing strategies to help the patient enjoy them while minimizing risk. It is a delicate balance between safety and quality of life, and it is important to keep that balance in mind when developing goals.

I often say that if I were 80 years old and had dementia—or even if I did not—I would probably only want to eat chocolate chip ice cream. We encourage staff to remember the patients' preferences and honor their wishes. We should also advocate for our patients and encourage the staff to do the same.

There are many residents who’ve lived in skilled nursing facilities for 10, 12, or even 15 years. Over time, the CNAs and nurses become like family to them. They know the patients inside and out and can provide invaluable information to the SLP and other staff. They can help shape goals, note behavioral changes, track preferences, and advocate for what’s best for the patient as the disease progresses. For example, if a patient with dementia suddenly stops communicating and I am new to the case, the CNA who’s been working with that patient for years might know that he’s always disliked loud environments or never tolerated spicy foods. That is not something I would know unless I reached out to the family or relied on staff input.

It is also important to remind everyone that dementia and dysphagia often bring a range of additional challenges. These may be sensory or behavioral. Because of that, we need to use more specific, patient-tailored strategies. These might include reducing lighting, placing food into the mouth from a certain angle due to visual field deficits, and many others. The list is long; honestly, it could be a separate course. However, even a basic awareness of these strategies can be helpful, so I have included a few examples for reference.

Coughing=Choking=Aspiration= Aspiration Pneumonia?? 

A few other concepts that need to be brought to the attention of the nursing staff are the differences between aspiration, aspiration pneumonia, choking, and coughing. I can't tell you how often I have been walking down the hallway and heard, “Can you see my patient? He’s choking on water,” or “He aspirated during lunch.” It is important to explain that these terms are not interchangeable, and one does not automatically lead to the other.

For instance, choking occurs when the airway is partially or completely blocked. Signs of choking typically include difficulty breathing, inability to speak, color changes, or the patient suddenly stopping breathing. Coughing, on the other hand, can occur during eating or drinking, but it does not necessarily mean the patient is aspirating.

Aspiration is when material enters—or tries to enter—the airway. I usually skip the explanation about passing the true vocal cords to avoid too much jargon. What is important for staff to know is that imaging can only confirm aspiration. So, just because a patient coughs does not mean they are aspirating. Conversely, aspiration can be clinically silent without outward signs like coughing.

Aspiration can happen with food and liquids, but it can also happen with saliva, bacteria, secretions, and even gastric contents. Just because a patient aspirates does not mean they’ll develop aspiration pneumonia—that is another key point. Patients on tube feeding can also be at risk for aspiration pneumonia. So, the idea that a patient is safe from aspiration just because they are not eating or drinking is not accurate.

It is essential to communicate these differences clearly to help reduce the staff's anxiety while feeding their patients. They may think, “If my patient is coughing, he’s going to end up in the hospital with pneumonia.” While it is good to be cautious, understanding the whole picture helps them provide care with more confidence and less fear.

Reducing the Risk of Aspiration PNA

Also, what can nursing staff do to help reduce the risk of aspiration pneumonia?

One of the most important things they can do is follow the specific and general guidelines provided by the SLP. If a patient has been identified as at risk for aspiration, encouraging that patient to get out of bed, change positions, move around if they can, and maintain as much independence as possible, particularly with feeding and oral care, can be extremely beneficial.

There was a study by Langmore involving stroke patients that showed an increased risk of aspiration pneumonia when patients were dependent on others for feeding or oral care and when they were bedridden. This highlights how impactful mobility and independence can be for the patient’s overall well-being and for reducing medical complications like aspiration pneumonia.

Another helpful strategy involves monitoring medication timing and dosage. If there’s a suspicion that a certain medication may be impairing swallowing function, the doctor should be informed. Nurses can be instrumental in initiating those conversations.

For individuals on feeding tubes, it is important to ensure the head of the bed is elevated, that the tube placement is being monitored for any signs of dislodgement, and that staff are alert for any signs of GI intolerance.

All of these topics could be standalone discussions on their own, but even a brief overview like this can help increase awareness and empower staff to take proactive steps in supporting their patients’ health and safety.

Oral Care

Last but not least, oral care is probably the most important aspect of our nursing homes. These studies highlight how critical oral care is in preventing systemic conditions like aspiration pneumonia. Unfortunately, it is often one of the most neglected areas in nursing facilities, largely due to a lack of resources and the challenges of implementing structured oral care programs.

Studies also show that patients with dementia tend to have more dental issues. This is often due to a decline in salivary gland function and the buildup of plaque and tartar. These issues place them at an even higher risk for aspiration pneumonia, so the need for consistent, high-quality oral care becomes even more important in this population.

The slide highlights some of the general guidelines for oral care. While these provide a good foundation, it is essential to remember that every patient has unique needs. Their physical and cognitive abilities will dictate the most appropriate oral care type.

Generally, it is best to use a soft toothbrush with toothpaste to remove bacteria thoroughly. Gently brushing the gums is still necessary for edentulous patients. If a patient cannot spit, consider using suction or a suction toothbrush. For patients who are unconscious or severely cognitively impaired, you’ll likely need an entirely different oral care regimen tailored to their condition.

The key takeaway is that oral care is not just about hygiene—it’s critical to keeping our patients safe, healthy, and out of the hospital.

Building Relationships: An Ongoing Process

I know that was a lot of information packed into a short amount of time. It can feel like there’s so much we have to do to get things moving in the right direction. It is important to remember that change does not happen overnight. This is a long-term process that needs to be nurtured and reinforced daily for it to take root and become part of the culture. I know many of you are probably thinking the same thing right now:

What about productivity?

I completely understand that productivity is a concern. However, many things we have discussed today will help streamline your workflow and make your treatments more efficient in the long run. Yes, there is some initial work involved—especially with larger in-services that take 20 to 25 minutes—and yes, you might take a temporary productivity hit. But that is something you can discuss with your DOR ahead of time. It becomes much easier to justify if you frame it as something that only happens once or twice a year and will ultimately support patient care and team cohesion.

The rest of it is about relationship-building—something that happens steadily over the year and does not require formal scheduling. I used to take these simple things for granted, but once I saw how effective they were, it really changed my perspective.

Greeting staff in the hallway, using their names as much as possible, and remembering little personal details can go a long way. For instance, once I talked about oral care, a CNA mentioned that her son does not brush his teeth. We ended up brainstorming some strategies together, and now we chat about how her son is doing every time we pass each other. That kind of rapport makes a difference.

Paying compliments, acknowledging their hard work, and letting them know that we see how well they know their patients builds mutual respect. When we approach them with an understanding of shared responsibility, rather than saying, “This is your job,” we create a sense of collaboration. Offering help when they need it—not just expecting them to do it all—motivates them to stay engaged.

I will admit, I complain, too. I get frustrated when things do not get done as I expect or when communication breaks down. At the end of the day, I remind myself that they are doing the best they can, just like we are. Their schedules are just as intense, and they face many of the same stressors.

I want to share a quick example that stuck with me. In one of the units in my building, there was a sudden increase in feeder patients—21 of them in one unit. The CNAs were completely overwhelmed, and understandably so. How were they supposed to feed five patients in just 20 or 40 minutes, especially when those patients were so deconditioned that each one took 30 to 40 minutes to feed?

Along with some nursing staff, I brought this up with the admin. Of course, hiring more people was not an option at the time. I did not have any authority to make staffing changes. However, the solution we came up with was simple: we changed the meal delivery schedule so that the busiest unit received its meals first. That alone gave them an extra hour to feed their patients.

Within two days, the change was in place. The CNAs were still busy but were not as rushed, and the patients had a safer, less stressful mealtime. That is just one example of how working together and finding practical solutions can really make a difference, not only for staff but also for the residents.

In Conclusion

That brings us to the end of this presentation. I want to say that staff education and collaboration are key to caring for patients with dysphagia. They are not just for improving patient outcomes; they truly help with your frustration and the staff's frustration and burnout as well. There is always scope to learn more and room for improvement because medicine is constantly changing. Do not stop learning, and do not stop training. Thank you.

Questions and Answers

How do kitchen personnel respond when included in dysphagia diet planning, such as with initiatives like Milkshake Mondays?

Kitchen staff tend to be much more receptive when they understand the why behind recommendations. Including them in the conversation and offering to help when needed fosters continuity and collaboration. It shows that clinicians care about their roles and value the kitchen team's contributions. When kitchen staff are engaged in decision-making—such as being asked for suggestions instead of being told what to do—they often provide insights that match clinical recommendations, highlighting their strong relationships with the patients and valuable knowledge of their needs.

What strategies can SLPs use when their care recommendations are ignored or negated by nursing staff, CNAs, or administration despite repeated education?

This is a common and complex issue. Persistence is key—SLPs must continue reiterating their recommendations using evidence-based practices. Sharing research, clinical reports, and patient data helps support their points. it is often effective to share recommendations with multiple team members, as at least some may understand and support the plan, which can influence others. Additionally, utilizing allies such as the Director of Rehab (DOR), often supportive, can be instrumental. Administrators are more likely to listen and cooperate when SLPs show they are informed, backed by research, and aligned with the patient and family’s interests.

How do you navigate family buy-in for diet texture modifications, especially when they wish to provide culturally familiar foods?

Acknowledging cultural values and working collaboratively improves family buy-in. One effective approach is to create culturally relevant versions of modified diets—for example, adapting Indian foods into an IDDSI-appropriate form. Families can be invited to bring traditional foods, and clinicians can help determine how to modify them safely. It is crucial to reassure families that clinicians are advocating with them, not against them. Emphasizing the patient’s safety, comfort, and cultural preferences are priorities to help build trust and compliance.

References

See the additional handout.