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Authors’ responses
206
Clinical Effectiveness in Nursing
Unlike many papers on instrument development, the instrument is presented in full, and as such it is easy to be critical of the descriptors. I was not entirely clear on the distinction between the ‘severity’ of functional impairment and the ‘level’ of functional impairment and some may argue that it may be more politically correct to include residual functional ability rather than emphasizing what the patient is unable to do. However, tying both of these in to the level of dependence, in other words the degree of intervention required by nursing staff, lends weight to the utility of the instrument. It remains to be established whether or not the full descriptors, in terms of severity and level are required; instead, it may be possible, in clinical practice, to concentrate on the level of dependence. Nevertheless, in addition to measuring eating disability, the instrument should also help nurses to decide on an appropriate level of assistance based on impairment. The issues of reliability, validity and influence of independent variable is fully addressed and, in particular, the reliability (inter-rater and test-retest)
and validity, in terms of nutrient intake, are indisputable. The dominant influence of restricted arm movement on protein and calorie intake immediately raises the issue of what nurses were doing while the patients were having difficulty with eating. Surely, if patients are unable to eat due to an inability to move food from plates to their mouths, then nursing assistance with feeding should be the ‘bottom line’ in care? This issue is not really explored in the paper. It may, on the other hand, be the case that despite nursing assistance stroke patients are still receiving inadequate food intake – the prime cause of protein and calorie malnutrition. Some other factors may be working which remain to be investigated. McLaren and Dickerson have left few stones unturned in the development of their instrument. I hope that the future will see further investigation of the phenomena in the regression analysis and the development and specific guidance on ensuring adequate nutritional intake in these patients.
R.Watson
Authors’ responses Both reviewers have made important and constructive comments about the eating disability assessment instrument (EDAS). With regard to clarity of category descriptors, severity of functional impairment and in turn, level of functional impairment the impact on the ability to carry out specific activities related to eating. Further development work may, indeed, make it possible to reduce the descriptors solely to ‘dependence’; this could also facilitate ease in use and the time taken to complete assessments. For purposes of further clarity, within the category of reflex swallowing, definitions of food textures were based on information contained in Martin (1991) and Curran et al. (1991). Informal approaches to assessment possess the advantage of identifying what patients can achieve in a real life situation; offsetting this is their vulnerability to the impact of extraneous variables on performance. Entirely appropriate comment has been made about possible associations between levels of nursing assistance impaired arm movement and nutrient intakes which require further investigation. However, discriminant function analysis identified a combination of impairments including arm movement which discriminated between very low nutrient intakes. It is possible that the complexity and combination of severe functional impairments in eating are extremely difficult for even highly skilled nurses to overcome, and other interventions are necessary. Further work is necessary to establish utility in assisting nurses to identify and feed dependent patients, make effective referrals, improve nutrient intakes and nutritional status in those at risk. Forthcoming publications by McLaren and Perry address some issues raised in the commentary.
REFERENCES Martin AW (1991) Dietary management of swallowing disorders. Dysphagia 6: 129–134. Curran J, Groher ME (1991) Development and dissemination of an aspiration risk reduction diet. Dysphagia 5: 6–12.
S. M. O. McLaren J.W.T. Dickerson
Clinical Effectiveness in Nursing
Unlike many papers on instrument development, the instrument is presented in full, and as such it is easy to be critical of the descriptors. I was not entirely clear on the distinction between the ‘severity’ of functional impairment and the ‘level’ of functional impairment and some may argue that it may be more politically correct to include residual functional ability rather than emphasizing what the patient is unable to do. However, tying both of these in to the level of dependence, in other words the degree of intervention required by nursing staff, lends weight to the utility of the instrument. It remains to be established whether or not the full descriptors, in terms of severity and level are required; instead, it may be possible, in clinical practice, to concentrate on the level of dependence. Nevertheless, in addition to measuring eating disability, the instrument should also help nurses to decide on an appropriate level of assistance based on impairment. The issues of reliability, validity and influence of independent variable is fully addressed and, in particular, the reliability (inter-rater and test-retest)
and validity, in terms of nutrient intake, are indisputable. The dominant influence of restricted arm movement on protein and calorie intake immediately raises the issue of what nurses were doing while the patients were having difficulty with eating. Surely, if patients are unable to eat due to an inability to move food from plates to their mouths, then nursing assistance with feeding should be the ‘bottom line’ in care? This issue is not really explored in the paper. It may, on the other hand, be the case that despite nursing assistance stroke patients are still receiving inadequate food intake – the prime cause of protein and calorie malnutrition. Some other factors may be working which remain to be investigated. McLaren and Dickerson have left few stones unturned in the development of their instrument. I hope that the future will see further investigation of the phenomena in the regression analysis and the development and specific guidance on ensuring adequate nutritional intake in these patients.
R.Watson
Authors’ responses Both reviewers have made important and constructive comments about the eating disability assessment instrument (EDAS). With regard to clarity of category descriptors, severity of functional impairment and in turn, level of functional impairment the impact on the ability to carry out specific activities related to eating. Further development work may, indeed, make it possible to reduce the descriptors solely to ‘dependence’; this could also facilitate ease in use and the time taken to complete assessments. For purposes of further clarity, within the category of reflex swallowing, definitions of food textures were based on information contained in Martin (1991) and Curran et al. (1991). Informal approaches to assessment possess the advantage of identifying what patients can achieve in a real life situation; offsetting this is their vulnerability to the impact of extraneous variables on performance. Entirely appropriate comment has been made about possible associations between levels of nursing assistance impaired arm movement and nutrient intakes which require further investigation. However, discriminant function analysis identified a combination of impairments including arm movement which discriminated between very low nutrient intakes. It is possible that the complexity and combination of severe functional impairments in eating are extremely difficult for even highly skilled nurses to overcome, and other interventions are necessary. Further work is necessary to establish utility in assisting nurses to identify and feed dependent patients, make effective referrals, improve nutrient intakes and nutritional status in those at risk. Forthcoming publications by McLaren and Perry address some issues raised in the commentary.
REFERENCES Martin AW (1991) Dietary management of swallowing disorders. Dysphagia 6: 129–134. Curran J, Groher ME (1991) Development and dissemination of an aspiration risk reduction diet. Dysphagia 5: 6–12.
S. M. O. McLaren J.W.T. Dickerson