Oropharyngeal dysphagia (OPD) is a common complication after stroke, with a highly variable frequency of occurrence (Daniels, Huckabee & Gozdzikowska 2019; El-Koussy et al. 2016). Post-stroke, OPD has been associated with increased mortality and morbidity because of malnutrition, dehydration and aspiration pneumonia (Suntrup-Krueger et al. 2017). Appropriate and timeous management of stroke-related OPD across health care professions may reduce the occurrence of aspiration pneumonia (Bray et al. 2016). Nurses are often the first health care professionals who have contact with patients admitted with a stroke (Khoja 2018). This positions nurses to identify signs of OPD and initiate referral to the appropriate professionals, including speech-language therapists (SLTs), before further complications arise (Liu et al. 2016). The occurrence of stroke and associated comorbidities continue to be highly prevalent in low- and middle-income countries (LMICs), such as South Africa (Andrews & Pillay 2017). In LMICs, there is a shortage of skilled allied health care professionals such as SLTs, who can perform timely, comprehensive bedside swallowing examinations (Pierpoint & Pillay 2020). The Health Professions Council of South Africa (HPCSA) has only 2643 SLTs registered (Pillay et al. 2020). A limited workforce may negatively affect patient management and can result in general health complications (Robbertse & De Beer 2020).

Previous studies reported limited knowledge of nurses in identifying symptoms of post-stroke OPD, because of a lack of information presented in tertiary education settings (Khoja 2018; Seedat & Strime 2021). Because of insufficient undergraduate and in-service training, nurses have better knowledge of the symptoms rather than the complications and management of OPD, negatively affecting overall practices (Knight et al. 2020). A swallow disorder may result in food or liquid entering the lungs and causing pneumonia. Most stroke-related pneumonia is because of OPD and subsequent aspiration of ingested food or liquid (Feng et al. 2019). Screening and training programmes to prepare nurses working in an acute stroke setting are frequently described in high-income countries (Pierpoint & Pillay 2020); however, the same cannot be said of LMICs (Robbertse & de Beer 2020) warranting further research. This is particularly crucial given that nurses often bear the responsibility of providing post-stroke care, owing to shortages of SLTs.

Role sharing between nurses and other allied health professionals such as SLTs, is recommended to address the shortage of SLTs and the need for timeous OPD identification to ensure patient-centred care in acute settings (Pierpoint & Pillay 2020; Seedat & Strime 2021). Role sharing between nurses and SLTs refers to the comprehension, appreciation and sharing of one another’s scope of practice and professional responsibilities (Pierpoint & Pillay 2020). There is guidance in high-income countries, such as the United Kingdom, regarding structured information sharing relating to the management of patients post-stroke (Barnard et al. 2021); however, dysphagia guidelines and services need to be better streamlined in LMICs. There is a need to explore the knowledge and practices of nurses in stroke-related OPD management within LMICs. The aim of this study was thus to integrate available research and identify caveats in the current literature on nursing knowledge and practices in stroke-related OPD in LMICs.

This scoping review identifies several nursing practices related to stroke-related OPD. This includes screening for OPD upon admission, evaluating swallowing ability, modifying diets, teaching compensatory strategies or swallowing manoeuvres, monitoring safety of oral intake and referring to relevant members of the multidisciplinary team. However, the effectiveness of these practices may depend on nurses’ knowledge and undergraduate training regarding OPD, as well as their experiences in managing stroke-related OPD. In particular, nurses in LMICs may face additional challenges because of limited resources and few training opportunities.

It is crucial that nurses are knowledgeable and skilled in screening for OPD, to ensure safety, as they are often the primary care providers for stroke patients (Gurevich, Osmelak & Osentoskia 2021). Studies suggest that nurses recognise gaps in their own knowledge and see further training as the best way to increase competence and confidence in managing OPD (Seedat & Strime 2021). An important clinical implication of the study is to use well-designed training programmes, courses and continuous professional development events that are developed and tailored to improve specific dysphagia knowledge and skills in LMICs. In-service training should be dynamic and inclusive of daily patient care to facilitate functional learning and scheduled to avoid adding to workload stress (Robbertse & de Beer 2020; Seedat & Strime 2021).

Although nurses may not always receive training on dysphagia management during undergraduate training, transfer of skills and knowledge from other members of the health care team, particularly SLTs, is essential (Gilbert, Yan & Hoffman 2010). Limited knowledge about OPD and its complications, such as aspiration pneumonia, has been identified among nurses in LMICs and high-income countries alike (Diendéré et al. 2016). Silent aspiration is a particularly concerning complication, as it may go unnoticed by nurses during informal swallowing screenings (Dondorf, Fabus & Ghassemi 2015; Liu et al. 2016). Therefore, integrating a screening sheet into daily nursing progress reports may ensure that all acute stroke patients are formally screened for OPD, which may identify signs of possible aspiration, leading to improved patient outcomes (Liu et al. 2016).

Nurses experienced in OPD management are able to identify life-threatening symptoms and take heed to provide high-quality care to patients following stroke (Abu-Snieneh & Saleh 2018). The use of screening tools allows nurses to confidently identify factors (i.e., a poor oral phase, signs of aspiration and a weak cough) and characteristics such as neurological impairment, mechanical obstruction and limited awareness, which are reliable and valid in diagnosing OPD (Jeng et al. 2001).

Screening tools, such as the South African Dysphagia Screening Tool (SADS), may be useful in identifying patients at risk of OPD following stroke. However, research is required on the feasibility of available tools in LMICs (Ostrofsky & Seedat 2016). Future education for nurses should include formal screening tools and guidelines or protocols for managing stroke-related OPD, as well as education on other aspects of stroke care, such as acute treatment and prevention of complications (Abu-Snieneh & Saleh 2018). Empowering nurses in accurate identification and effective management of stroke-related OPD will not only ensure evidence-based practice in patient-centred care but also support hospital-based SLTs in LMICs who have large caseloads. The implementation of validated dysphagia screening programmes has been identified as a need, specifically in LMICs (Pierpoint & Pillay 2020).

In reality, many hospitals in LMICs have overworked nurses, with a limited number of specialty nurses, attending to large patient loads in settings with limited material resources (Robbertse & De Beer 2020), and thus strict adherence to management protocols may not always be possible. Regular in-service training and support of nurses by other MDT members and hospital management may ensure adherence to the South African Stroke Society (SASS) (Bryer et al. 2010) guidelines in LMICs. Stroke guidelines for optimal patient care in both high-income (Hebert et al. 2016) and LMICs convey similar information, but contextual constraints place additional pressure on nurses and hinder compliance with SLT recommendations. As further identified in the study, SLTs and nurses are called to action to work collaboratively with confidence in each other’s skills to effectively manage patients with stroke-related OPD (Dondorf et al. 2015). Training of interprofessional collaborative practice on an undergraduate level for health care professions is therefore essential to optimise referral systems, reduce time constraints and ensure best practice (Dondorf et al. 2015; Gurevich et al. 2021). Speech-language therapists rely on nursing staff to screen patients presenting with OPD symptoms before referral for a comprehensive swallowing assessment is made (Seedat & Strime 2021). Clarification of professional roles and clear communication channels between nurses and SLTs may assist in achieving agreement about the care of patients with stroke-related OPD (Dondorf et al. 2015). Interprofessional collaboration is an asset in patient-centred care, and it is the responsibility of all members of the MDT to pursue (Hickey & Livesay 2015). Upskilling nurses with continuous education opportunities will not only likely result in improved knowledge and confidence but may also reduce SLTs’ workload and improve patient outcomes (ASHA 2021; Sandhaus et al. 2009). Nurses with training in dysphagia care are more likely to make appropriate referrals to SLTs, reducing the chances of associated complications (Gilbert et al. 2010).

This scoping review has several limitations that should be acknowledged. Firstly, the sample size was small and the number of sites within each study for data collection were relatively few, which limits the generalisability of the findings. Secondly, many studies used a non-randomised/non-probability sampling method, which limits external validity and generalisability. Thirdly, five of the studies used a survey design, which is subject to bias because of self-reported data and may not always provide an accurate depiction of nurses’ knowledge and performance. Additionally, 1 of the 59 studies were excluded because of being in a language other than English, which may have introduced a language bias.

Various needs have been identified in the care of patients with stroke-related OPD, and further research is required to address these needs. One area that requires attention is the need for education and continued professional development, as well as collaboration among health care professionals working with stroke-related OPD. This is a common need identified in both low- and high-income countries requiring ongoing research effort (Cameron, Gignac & Ahmad 2014).

Another area that requires investigation is the implementation of in-service education and support regarding interprofessional collaboration between nurses and SLTs in LMICs. This is particularly important given the scarcity of resources and time constraints in these countries. Large-scale, well-designed studies should be conducted to explore the development and implementation of contextually relevant validated screening tools such as the SADS.

To ensure that the identified barriers in resource-constrained countries are accounted for, it is essential to conduct context-specific research. Moreover, studies exploring the implementation of supportive strategies and education to improve nurses’ skills in dysphagia care should be conducted. Such studies should focus on improving nurses’ skills and not exploring just their perceptions or experiences of working in a team. Overall, these areas require further investigation to improve the quality of care for patients with stroke-related OPD.

The scoping review has identified a clear need for further training for nursing practitioners to improve knowledge and skill acquisition in the management of stroke-related OPD, as well as the benefits of collaboration between nurses and SLTs in LMICs. To address these needs, future research endeavours should focus on offering creative solutions to improve education and collaboration in dysphagia care in resource-constrained settings. Rather than solely evaluating nursing practices and perceptions, future research should target the identified needs of nurses to improve dysphagia care in LMICs.