ii. To examine and explain the possible effects of the ecological validity variables i.e.
patient, clinician, technology and context related factors on the effectiveness of TR in dysphagia assessment.
highlighting the clinical relevance of the findings and its important contribution to the field of TR, specifically for the intervention of dysphagia in resource constrained country.
Figure 1.1: Stages of research for long term implementation of TR for management of dysphagia (adapted from Campbell et. al, 2000 and Craig, et. al, 2008)
The phases in figure 1.1 are adapted from the framework recommended for continuum of clinical evidence by Craig, et.al (2008) and clinical trials for drugs by Campbell, et. al (2000) when new treatment methods needed to be investigated. The first three phases of the continuum have been addressed in the current study, considering that the following phases would be beyond the capacity of this study. There is a need to examine the existing evidence to understand the use of TR for the intervention of dysphagia. This was carried out through a narrative literature review. Phase one helped in developing the conceptual framework for the overall study.
It is clearly recognized that changes are necessary while implementing a new intervention method in a resource constrained country; however, what is not clear is the nature of these changes and the mode of their implementation. A search for an answer to this led to phase two of the study which was developing a theoretical understanding of the different factors that can influence the ecological validity of TR by drawing information from a knowledge of the current status of TR (obtained from phase one) as well as by obtaining new evidence through an understanding of the knowledge, attitude and practice of TR personnel in a resource constrained country. The results from phase one helped in developing the research questions for phase two.
Phase two was conducted through semi structured interviews (Silverman, 2006).
With the core theoretical concepts of ecological validity and effectiveness in place from phases one and two, TR needed to be modelled before a large-scale implementation which would include real patients with neurogenic dysphagia. Technology related, context related, clinician related and some patient related factors that were identified were incorporated in phase three to establish ecological validity of TR. Phase three required the implementation of TR for the assessment and primary management of neurogenic dysphagia on simulated patients (SP) to reduce the risk of any medical harm that could be caused during the study. SPs are used in the initial stage of implementation of TR in a resource constrained country due to the ethical decision of causing no harm to real patients (Charash, et. al, 2011), considering the TR is being used for the first time in such a context. Concept of SP was introduced by Barrows and Abrahamson in 1960s and was used in the field of medical education to give feedback and evaluate student performance (Barrows & Abrahamson, 1964). A well trained SP is considered to be equal to a real life patient, as explained by Beullens, Rethans, Goedhuys and Buntinx
(1997), considering that a real patient maybe unwilling or unable to sustain their participation, as well as there may not be easy access to a wide variety of a medical condition (Watson, Cleland
& Bond, 2009). The use of an SP enhanced the safety of real patients, since the researcher got the exposure to real-life situations without posing any risk to real patients. Skills and procedures can be practised in a real clinical setting and the researcher can become aware of the effect of their actions on patients (Hughes, 2008). Use of SP have gained prevalent use in surgical education owing to its comparative lack of logistics and time restraints imposed by coordinating real patients (Figueroa, et. al, 2016). Use of SP has been found to be beneficial for high risk clinical scenarios where failure on the researcher’s part may lead to grave consequences (Tuttle
& Laakso, 2018; Nicksa, Anderson, Fidler & Stewart, 2015). The researcher acknowledged that the use of real patients in this study could lead to issues such as missing out on aspiration due to poor internet connection or power failure. A real patient may even choke on the food being used leading to grave consequences.
Contribution of SP is expanding into various other fields such as pharmacy, nursing and other health professions since they have the potential to be the highest fidelity simulators (Smithson, Bellingan, Glass & Mills, 2015). Current research supports the use of SPs in clinical skill development and competency assessment of students in the fields of nursing, pharmacy, dentistry, and chiropractic care (Zraick, 2002). Positive outcomes have also been reported about the use of SPs in allied health fields including community health education, dietetics, physical and occupation therapy (Brunner, Probst, Meichtry, Luomajoki & Dankaerts, 2016). Studies have used SP in laboratory settings, and “did not represent real populations who would include
those unable to travel due to chronic disability or aging, or those who lived in rural areas with insufficient access to rehabilitative services’’ (Mani, Sharma, Omar, Paungmali & Joseph, 2017).
Hagge, Noureddine, Brady & Ofstad (2015) used simulated patients to teach speech language pathology graduate students and undergraduate nursing students on inter professional collaboration for dysphagia management. Ward et. al (2015) aimed at studying the benefits of adding human patient simulation as part of university curriculum in paediatric dysphagia. The results demonstrated additive value in knowledge, skills and confidence obtained through this. It was rated as useful when preparing for clinical practice. Hence, it is reasonably assumed, based on the results of the studies that have used SPs (Smithson, Bellingan, Glass & Mills, 2015;
Sharma, Ward, Burns, Theodoros & Russell, 2011) that using SPs will not adversely influence the ecological validity of the strategy being investigated.
Sharma, Ward, Burns, Theodoros and Russell (2011) used simulated patients (SPs) in their pilot study for investigating the feasibility of TR for online dysphagia assessment. The researcher used SPs in phase three which is a pilot phase of TR implementation. Phase three is necessary to progressively refine the design and incorporate the benefits and limitations in further phases four and five. Phase three adopted a mixed methodological design, wherein both quantitative and qualitative methods of analysis were conducted of the data obtained through observation of participants’ responses to the clinical swallow evaluation, with the main idea to understand the effect of the various factors that affect ecological validity on effectiveness of TR.
However, incorporating phase four and five into the current study was beyond its scope.