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Can Human Mannequin-based Simulation provide a feasible and clinically acceptable
method for training tracheostomy management skills for speech-language pathologists?
Elizabeth C. Ward1,2
Sonia C. Baker3
Laurelie R. Wall2
Brooke L. J. Duggan4
Kelli L. Hancock4
Lynell V. Bassett3
Trent J. Hyde5
1
Centre for Functioning and Health Research, Queensland Health
The University of Queensland, School of Health and Rehabilitation Sciences
3
Speech Pathology Department, Royal Brisbane and Women’s Hospital, Queensland Health
4
Speech Pathology Department, Princess Alexandra Hospital, Queensland Health
5
Clinical Skills Development Service, Royal Brisbane and Women’s Hospital, Queensland
Health
2
Elizabeth Ward (Contact Author)
Tel: 61-7 34062265
Fax: 61-7 34062267
Email: liz.ward@uq.edu.au
Running head: Using simulation in tracheostomy management
Key words: simulation, tracheostomy training, speech-language pathology
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Abstract
Purpose: Workplace training for tracheostomy management is currently recognized to be
inconsistent and insufficient. A novel approach, employing technology-enhanced simulation,
may provide a solution to training tracheostomy management skills by providing a consistent,
time-efficient and risk-free learning environment. The current research evaluated clinicians’
tracheostomy skills acquisition following training in a simulated learning environment and
explored changes in clinicians’ confidence and perceptions following the experience.
Method: Forty-two clinicians with no or low levels of tracheostomy skill attended one of six,
one-day simulation courses. The training involved both part-task skill learning and immersive
simulated scenarios. To evaluate clinicians’ acquisition of manual skills, performance of core
tasks during the scenarios was assessed by independent observers. Questionnaires were used
to examine perceived outcomes, benefits and perceptions of the learning environment at pre-,
post- and 4 months post-training.
Results: Only one clinician failed to successfully execute all core practical tasks. Clinicians’
confidence significantly (p <0.05) increased pre/post-workshop, and was maintained to 4
months post across most parameters. All clinicians reported positive perceptions regarding
their learning outcomes and learning in a simulated environment.
Conclusion: These findings validate the use of simulation as a clinical training medium and
support its future use in tracheostomy competency-training pathways.
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Introduction
Within the multidisciplinary team managing patients with a tracheostomy, speechlanguage pathologists provide a number of key clinical services; including facilitating
communication, optimizing safe effective swallowing and contributing to the team decision
regarding suitability for decannulation (Speech Pathology Australia, 2005; Ward, Jones,
Solley, & Cornwell, 2007). Due to the inherent complexity of this clinical role, competent
clinical management of tracheostomized patients is not expected of graduating speechlanguage pathologists (American Speech-Language-Hearing Association, 1993; Royal
College of Speech Language Therapists, 2006; Speech Pathology Australia, 2005). Thus, the
advanced training and skill development necessary for proficient management of this
population must be achieved in the workplace. Unfortunately, clinical anecdotes and
published research report that current workplace training opportunities are typically
undertaken on an ad-hoc basis, often inconsistent across settings and perceived as insufficient
(Ward, Agius, Solley, Cornwell, & Jones, 2008; Ward, Morgan, McGowan, Spurgin, &
Solley, 2012). When such training shortfalls are compounded by the often low and infrequent
exposure of clinicians to this population (Ward et al., 2007), there is potential for
compromised patient care (Norwood, Spiers, Bailiss, & Sayers, 2004).
Supplementary training and support is both warranted and desired by speech-language
pathologists managing tracheostomized patients (Manley, Frank, & Melvin, 1999; Ward et
al., 2008) and, to this end, research and professional associations have called for (1) more
systematic training and (2) the development of competency programs for this advanced skill
area (Speech Pathology Australia, 2005; Ward et al., 2008). In a recent study of clinicians in
the United Kingdom, Ward et al. (2012) compared the survey responses of those respondents
who had access to departmental competency-based tracheostomy training (42%) with those
who did not. While limitations to the study methodology connote that the data should only be
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considered preliminary at this stage, there were strong patterns for clinicians with access to
competency training, to be: working more often within an optimal team, undergoing more
formal training, receiving more opportunity for clinical supervised practice, having expert
support available for complex cases, feeling they had better role definition, and being more
confident in the management of tracheostomized patients. Prior research in cognate
professional fields also support the benefits of specific tracheostomy training programs for
advancing knowledge, clinical skills (Day, Wainwright, & Wilson Barnett, 2001) confidence,
practice standards and quality care (Smith-Miller, 2006; Verma, Paterson, & Medves, 2006).
Despite the growing body of literature which demonstrates the benefits of having a
coordinated, structured process of workforce training to develop tracheostomy management
competency, it is acknowledged that the implementation of such training is a complex
endeavour (Parry & Esselman, 2011). A key challenge to implementing training in
tracheostomy management is the inability to provide easy access to a consistent and
repeatable learning environment using available hospital patients. Hence, to overcome this,
there is a need for an alternate clinical learning paradigm through which patient-based
training can be supplemented with clinically valid and repeatable training opportunities for
developing and practicing necessary tracheostomy skills.
A potential solution is the use of new workplace education models, such as technology
enhanced simulation training (including standardized patients, mannequin-based simulators,
virtual reality environments, plastic models, live animals and human cadavers; Cook et al.,
2011). Of these, the mode most suited to training invasive manual skills in complex critical
care environments is the use of human patient simulation (HPS; Ellis & Hughes, 1999). HPS
uses computerized mannequins to mimic real-time physical and physiological patient
responses (Hammond, Bermann, Chen, & Kushins, 2002), allowing clinicians to practice
procedures in a risk-free learning environment (Ellis & Hughes, 1999). In a recent systematic
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review (Cook et al., 2011), technology-enhanced simulation training was associated with
improvements for health care professionals across a range of clinical areas and outcome
measures. The meta-analysis revealed large effect sizes with favourable associations in
knowledge, time and process skills and procedural success after a simulated learning
experience (compared to no intervention). Moderate to large effect sizes were also detected
for positive learner behaviours and improved patient outcomes. Other research has also shown
that students embrace the realism and clinical validity of HPS, considering it an effective
learning tool, and report increases in self-efficacy and confidence after experiencing a
simulated clinical scenario (Euliano, 2000; Sahu & Lata, 2010). HPS also allows health
professionals to experience pre-programmed rare medical phenomena, repeat procedures and
learn by making errors without placing patients at risk (Beyea & Kobokovich, 2004).
Within the field of speech-language pathology, use of HPS in clinical skills training is
only just emerging. Benadom and Potter (2011) were the first to explore the effects of HPS on
the acquisition of transnasal endoscopy skills in speech-language pathology postgraduate
students. The study found that both training environments (HPS and a non-lifelike simulator)
assisted the development of students’ endoscopic skills and enhanced confidence by allowing
repetitive practice without compromising patient safety. Despite some methodological
limitations, this initial research proposes benefits of applying HPS to aspects of speechlanguage pathology training. However, whether or not HPS can be applied with equal success
to provide the necessary realistic and repeatable learning environment for other aspects of
clinical skills learning, such as that required for tracheostomy management, is yet to be
elucidated.
The use of simulation in health service training in general is still in a relatively nascent
stage of development (Cooper & Taqueti, 2004), though in the field of speech-language
pathology it remains largely unexplored. Hence it is important that there is systematic
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evaluation and validation of its use in any new pedagogical application, such as in
tracheostomy management skills training. The aims of the current research were therefore to
(1) determine if clinicians could learn and successfully apply core tracheostomy skills in a
series of immersive HPS scenarios, and (2) explore changes in clinicians’ confidence in
tracheostomy management and perceptions of learning in a simulated environment. The
ultimate clinical objective of the current research is to determine if HPS can be used as a valid
training model that can be incorporated in a tracheostomy management competency pathway
for speech-language pathologists.
Method
Participants
Speech-language pathologists (SLPs) were recruited from public health settings
(Queensland Health) within the state of Queensland, Australia. Potential participants were
identified via a written expression of interest (EOI) process. From the total EOI responses
received (n=64), selection of participants for each workshop was made through consensus
decision by two experienced SLPs. These clinicians employed strategic sampling to ensure
that the participant cohort represented a diverse sample from both metropolitan/nonmetropolitan and small/large hospital settings, and included clinicians with either no prior or
low levels (defined as having involvement in the management of <10 tracheostomy patients in
the past 5 years) of experience in tracheostomy management. Participants were excluded if
they (1) had greater than low levels of prior experience in tracheostomy management, (2) had
no anticipated opportunity to work directly with, or support clinical teams working with
patients with a tracheostomy within their workplace, (3) had limited prior general dysphagia
management experience, or (4) failed to complete the necessary pre-course requirements.
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From the 64 EOIs, 8 SLPs were selected to participate in each of the six workshops (n=48).
The 16 clinicians who were excluded came from clinical teams where multiple clinicians had
applied to attend (e.g., where one service had 6 clinicians apply, the service was contacted
and only 2 were included to spread the opportunity across more services). Of the 48 attendees,
one was unable to attend due to ill-health and data from five participants could not be
included in the analysis as it was later revealed they had greater than low levels of prior
experience in tracheostomy management, leaving a final study cohort of 42 participants.
Table 1 outlines the demographic information of the participants. All were female with an
average of 4.93 years of clinical experience (SD=3.96, range 0.5-15 years). The majority
worked in adult caseloads, predominantly in ward and critical/intensive care settings. Most
had managed no more than five patients with a tracheostomy in the past five years. All
clinicians provided signed consent prior to participation. No participant withdrew from the
study.
[Insert Table 1 near here]
Procedure
Five weeks prior to attending the Tracheostomy and Speech Pathology (TASP) oneday simulated training session, all participants were directed to study the “ClinEdQ Speech
Pathology Management of the Adult Tracheostomized Patient: Clinical Guidelines for
Queensland Health Speech-language pathologists (2010)” document as a compulsory precourse reading package. This was estimated to take about 5 hours to complete. This document
is the sanctioned Clinical Guideline across Queensland Health settings for the management of
patients with a tracheostomy. This precursor task was used to establish clinicians’ baseline
knowledge of the tracheostomy management processes endorsed by Queensland Health prior
to attending the training day. To ensure this pre-reading was completed and all clinicians were
aware of the practices outlined in the guideline, each clinician was subsequently sent a 30
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question multiple-choice online quiz. The multiple-choice questions were developed directly
from the Clinical Guideline and the wording and clarity of each question was cross-checked
by two speech-language pathologists not involved in the project. The quiz was distributed to
participants via a secure online survey website (www.surveymonkey.com) no earlier than
three weeks prior to the workshop to ensure recency of knowledge. Completion of the quiz
with 100% accuracy was mandatory prior to workshop participation. The quiz format was
designed to present each question individually on the screen. Each question had to be
correctly answered before clinicians could progress to the next. If they answered incorrectly,
they were instructed to re-do the question, allowing learning on error if/when this occurred.
Participants, in groups of 8, then attended the 1-day TASP workshop at the Clinical
Skills Development Service (CSDS) at the Royal Brisbane and Women’s Hospital, Brisbane,
Australia. The design and methodology for the workshop was derived from aspects of
published research on simulated learning (Devitt et al., 1998; Howard, Ross, Mitchell, &
Nelson, 2010; Lammers, Byrwa, Fales, & Hale, 2009; McLaughlin, Doezema, & Sklar, 2002;
Tsai, Harasym, Nijssen-Jordan, Fennett, & Powell, 2003) as well as elements from current
existing CSDS training courses. The structure of the workshop involved three key
components: (1) orientation to the simulation environment (2) part-task skill learning and (3)
immersive simulated patient scenarios, as depicted in Figure 1. The same workshop was
delivered each time (6 times) with no content changes. All participants signed a
confidentiality agreement not to discuss the specific scenarios experienced in the workshop to
preserve the integrity of the workshop across time.
[Insert Figure 1 near here]
Orientation to the simulation environment. At the start of the workshop, all 8
participants observed a simulation demonstration session where the session facilitators
orientated participants to the simulated environment and demonstrated how a scenario would
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run, including how to stop and seek assistance or further information. The demonstration
scenario was conducted using a high-fidelity human mannequin (SimMan
http://www.laerdal.com/doc/86/SimMan) with a cuffed tracheostomy tube in situ, positioned
in a simulated standard ward setting with appropriate vital signs monitors on display (Figure
2). Personnel for the scenario included the ‘nurse’, simulation coordinator, session facilitator
and assessing SLP (workshop participant). The ‘nurse’, played by a workshop staff member,
performed simulated oral and tracheal suctioning as requested and provided additional patient
information to the assessing SLP when asked. The simulation coordinator (SimCo) and the
session facilitator (an experienced SLP) were located in an adjoining room. The SimCo was a
member of the CSDS faculty staff and was responsible for changing the mannequin’s
physiological responses (heart and respiratory rate) during the scenario as per the planned
scenario (eg., increasing respiratory rate and lowering oxygen saturation levels to indicate
declining status to trigger the decision to cease assessment). However, if clinicians performed
tasks outside the expected plan for the session (eg., clinician progressed with assessment
when logical decision would have been to cease assessment), the Sim Co could also adjust in
real time the vital signs to respond to the alternate action taken by the clinician. The session
facilitator provided the voice-over for the mannequin and additional clinical data (such as the
results of a swallow trial) during the session.
[Insert Figure 2 near here]
Part-task skill learning. Upon completion of the simulation demonstration,
workshop participants then divided into pairs to complete 60 minutes of repeated practice of
manual skills at part-task stations, under the supervision of workshop staff. This training was
designed to establish a baseline level of participants’ core clinical skills for the 6 specific
tasks which would be required at some time point during the subsequent simulated case
scenarios. Although skills conducting a clinical swallow examination were also required for
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the scenarios, this was not a trained or assessed skill, as participants were only included in the
study if they had prior existing skills in dysphagia management. Stations were equipped with
the Passy Muir® Tracheostomy TOM (http://www.passy-muir.com/products_edu) models
and a range of relevant equipment (Portex® cuffed and Blue Line Ultra® Suctionaid
tracheostomy tubes, manometers, syringes, speaking valves, oxygen adaptors and oxygen
tubing). Skills practiced included: (1) cuff deflation, (2) cuff reinflation, (3) checking cuff
pressure, (4) finger occlusion, (5) using speaking valves (including attaching oxygen
adaptors), and (6) above-cuff suctioning and voicing (using Blue Line Ultra® Suctionaid
tubes). The session also involved discussion of vital signs monitoring of oxygen saturation
and respiratory rate.
Simulated patient interactions. Following the part-task training, the 8 participants
divided into two groups of four. In their groups of 4, they then completed two, 2.5-hr casebased clinical scenarios (Figure 1). The same two simulated scenarios were presented in the
same order across all six workshops. Each patient scenario was developed by two SLPs with
extensive experience in tracheostomy management. The clinical complexity of both cases was
made as comparable as possible. Each 2.5 hour patient scenario consisted of four separate
immersive simulated assessments which could realistically occur at some time-point over the
course of the management of that patient (eg., at 29 days post admission, 36 days post
admission etc - see Appendix A). During each of the four assessments, both communication
and swallowing status were evaluated to some extent, depending on patient presentation. The
assessment sessions each varied in the number of skill tasks each clinician was required to
complete, depending on the clinical presentation of the patient at that time. However in any
assessment session participants were required to complete a minimum of 4 of the skills
practiced in the part task activities. An example of a 2.5 hour case scenario with the 4
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assessment sessions, including the tasks expected to be performed by clinicians in each
scenario has been provided in Appendix A.
Prior to each assessment, the group as a whole discussed the patient’s case history and
possible plans for the assessment session. Then one participant was selected to adopt the role
of the assessing clinician. The assessing clinician was responsible for all clinical tasks and
decision making throughout that assessment session, including instructions to the nurse when
suctioning was required. The other three participants observed the session via video-stream.
Post-simulation, all four participants engaged in a 10-15 minute debriefing session with the
session facilitator. The next participant was then selected and the group commenced the
briefing for the next assessment session. The order in which participants were selected for the
clinician role was random. By the end of the workshop (i.e. after 8 assessments conducted
across two simulated scenarios), participants had interacted with the mannequin in two
assessment sessions and directly observed a further six clinical assessments.
Evaluation measures. Two measures were used to collect outcome data: (1)
observational ratings of key manual skills performed during the simulated case scenarios and
(2) questionnaires conducted immediately prior to, post- and four months post-training.
Observational Ratings. During each assessment session, each participant executed
key manual skills within the assessment of the patient, as required by that specific assessment
scenario (Appendix A). An experienced speech-language pathologist observed each
assessment and graded the clinicians’ performance of each skill task (e.g., cuff deflation) as
either “successful” or “unsuccessful” using set criteria. A rating of unsuccessful was made
when a clinician failed to execute the task as per the steps outlined in the pre-reading and
practiced in the part task training activities. In addition, the examiner rated the participant’s
overall performance during the scenario, taking into account the overall skill, efficiency and
naturalness in which all tasks required in that session were completed using a seven point
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scale (1 = Novice; all tracheostomy management skills require significant improvement, 3 =
Advanced novice; many tracheostomy management skills require moderate improvement, 5 =
Competent; most tracheostomy management skills require minor improvement, and 7 =
Clearly superior; few, if any tracheostomy management skills require only minor
improvement). This scale was an adaptation of the “Overall Performance” indicator of the
Ottawa Crisis Resource Management Global Rating Scale (Ottawa-GRS; Kim, Neilipovitz,
Cardinal, Chiu, & Clinch, 2006). The Ottawa-GRS is a validated tool used for assessing
nursing skills during simulated crisis management scenarios.
Questionnaires. Pre, post and four-month post workshop questionnaires (Appendix
B, C and D respectively) were administered addressing three primary concepts: (1) clinicians’
perceptions of the simulated learning environment, (2) their perceived outcomes and benefits
of the TASP workshop, including their levels of confidence towards aspects of tracheostomy
management, and (3) their opportunities to implement skills learned on return to the
workplace. Elements of these questionnaires were compiled from published research in this
field (Howard et al., 2010; Kim et al., 2006; Lammers et al., 2009) and questions were
presented in a range of formats (multiple choice and yes/no questions; 10 cm visual analogue
scale [VAS] ranging from “no” to “definitely” to explore if clinicians felt HPS was a valuable
medium for learning, and “not confident” to “confident” for confidence ratings; and a series
of agreement statements rated using a 5-point agreement scale: Strongly Disagree, Disagree,
Neutral, Agree, Strongly Agree) (see Appendix B, C, D). A unique identifier was used for
each participant (middle initial, first initial of street name and number of siblings) to allow
matching of responses over time. Each questionnaire took approximately 5-10 minutes to
complete. All clinicians completed the pre- and post- and four month post-workshop
questionnaires.
Data Analysis
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Descriptive statistics were used to determine clinicians’ levels of skill acquisition for
each part-task activity as well as the total number of clinicians reaching sufficient competency
across all skills tested. Questionnaire data obtained from the 5-point agreement scale
questions were collapsed from five levels to three for subsequent analysis: Strongly Agree and
Agree were combined to form an Agree category, Neutral remained a category in itself, and
Disagree and Strongly Disagree were combined into a Disagree category. Responses on the
10 cm VAS lines were converted to millimetres for statistical comparison. Parametric
repeated measures statistics (repeated measures ANOVA) and post hoc paired t-tests were
used to compare changes in participants’ perceived self-confidence over time. The Wilcoxon
signed rank test (non-parametric repeated measures) was used to compare clinicians’
performance of core practical skills across the two simulated patient scenarios. Fisher’s exact
test was used for binary data, to compare changes in the perceived outcomes and benefits of
the TASP workshop. For all comparisons, p<0.05 indicated statistical significance.
Results
Observational Ratings
Forty-one of the forty-two participants (98%) were assessed as performing all tasks in
their clinical scenarios successfully. Regarding overall performance, the average ratings
during the first and second simulated patient scenarios were 5.05 (SD = 1.23), increasing to
5.33 (SD = 1.18) respectively. Although this increase was not statistically significant (z =
1.961, p = 0.057) it was approaching significance (trend). Sub-analysis revealed that 71% (n =
30) of clinicians scored 5 or higher in scenario one which increased to 86% (n = 36) in
scenario two.
Questionnaires
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Perceptions of the simulated learning environment. With respect to clinicians’
perceptions of HPS as a valuable medium for clinical learning (10cm VAS scale with the end
points of 0=no and 10=definitely), there was a significant difference (F = 11.455, p <0.001) in
participants’ ratings across the pre, post and four-month time-points. Whilst pre-workshop
perceptions were generally quite high, post-hoc analysis revealed significant (t = 4.327, p
<0.001) increases in positive perceptions of the HPS environment from pre- (M = 8.57, SD =
1.38) to immediately post-workshop (M = 9.47, SD = 0.79), as well as a significant (t = 4.392,
p <0.001) increase between pre- and the four-month (M = 9.30, SD = 1.10) post-training.
Perceptions of the HPS environment remained positive and did not change significantly
between post to four months post (t = -0.984, p = 0.331).
Specific to the post-workshop questionnaire, analysis of clinicians’ perceptions of
HPS (Table 2) indicated that respondents considered the pre-reading material, simulation
demonstration and part-tasking activities helpful in preparation for the subsequent simulated
case scenarios. Overall, clinicians felt well briefed before and after the case scenarios and
believed there was adequate time to practice clinical decision-making. Most clinicians
considered the simulated patient scenarios relevant to their clinical caseload and the
knowledge gained through the workshop transferable to their clinical settings. Although the
majority of clinicians felt some degree of nervousness during the scenarios, most indicated
that they enjoyed learning in the simulated environment and found the mannequins to be
realistic. All participants agreed that simulation training should be part of clinical preparation
prior to managing tracheostomized patients independently in the workplace.
[Insert Table 2 near here]
Perceived outcomes and benefits of the TASP workshop. Although clinicians
reported low levels of perceived self-confidence pre-workshop (Table 3), results of the
repeated measures ANOVAs across the pre, post and four-month points revealed significant
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
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(p <0.001) improvements in all four confidence ratings over time (Table 3). Post-hoc analysis
(Table 4) confirmed that, for all four parameters, there was a trend of significant (p <0.05)
increases in confidence immediately post-workshop. At four months, three of the four
confidence ratings remained increased from baseline and comparable to the post training
ratings (Table 4). Clinicians’ confidence in their tracheostomy management skills for
conducting a speech and swallow assessment, however, had significantly reduced from the
post assessment, although this remained significantly higher than baseline.
[Insert Tables 3 & 4 near here]
Immediately post-workshop, participants felt that the simulated learning experience
had enhanced their knowledge, clinical skills and critical thinking in tracheostomy
management. At four months post-training, all clinicians continued to believe that the
workshop had enhanced their knowledge and clinical skills. Although fewer felt the workshop
had enhanced their critical thinking by this time-point, this change was not significant (Table
5). Clinicians reported they would attend another TASP workshop and would recommend the
training to other clinicians. They also suggested that the simulated environment could prove
valid as a means for clinical training in other areas of speech-language pathology (e.g.,
laryngectomy voice prosthesis management).
[Insert Table 5 near here]
Opportunities for clinical practice post training. At four months post-workshop,
the majority (79%, n = 33) of the cohort had managed less than four patients with a
tracheostomy, of which 15 of these 33 (36% of total cohort of 42) reported having no clinical
contact with tracheostomized patients at all post training. Hence it was not surprising that
only 69% (n = 29) of clinicians felt that they had transferred their new knowledge to their
clinical work. Sixty percent (n = 25) of clinicians reported they had used materials from the
pre-course reading to assist in their management of tracheostomized patients in the
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workplace. Only half (52%, n = 22) had received further tracheostomy education/training
following the TASP workshop for an average of 8.87 hours (SD = 14.84), through workplace
mentoring, work-shadowing, and workplace tracheostomy competency programs.
As one-third of clinicians had reported no opportunity to consolidate and/or apply the
manual skills and clinical reasoning developed through the simulated training, a sub-analysis
was conducted, comparing the perceived confidence of those clinicians who did and did not
have opportunities to work with patients post TASP workshop on the item “perceived
confidence conducting a speech and swallow assessment”. Data revealed that although the
subgroups did not differ immediately post TASP workshop (z = -0.55, p = 0.581), at four
months the confidence of those who had not had opportunities to consolidate their skills was
significantly (z = -2.72, p = 0.007) lower.
Discussion
This study has demonstrated that simulation can enable the acquisition of core skills
and clinical confidence required for the management of tracheostomized patients. This novel
clinical learning environment was also perceived by clinicians as a realistic and valid medium
for clinical training. Such findings provide initial evidence to support the use of HPS-based
learning as part of a speech-language pathology competency training process for
tracheostomy management.
The results of the current study indicate that all but one clinician successfully
developed the specified tracheostomy manual skills by the conclusion of the simulated patient
scenarios. This positive result was not unexpected as the power of “learning through doing” is
well-established in the literature as an optimal method for skill acquisition (Nel, Pezzolesi, &
Stott, 2012). Evaluation of the clinicians performance in the first scenario revealed good
results, suggesting that the pre-reading, simulation demonstration and opportunities to
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practice in the past task session all helped prepare them for their first assessment session.
There was also a trend for superior performance between the first and second scenario,
suggesting benefits of repeated practice in a simulated environment on skills development.
Benadom and Potter (2011) similarly reported significantly faster pass times and increased
confidence ratings between the first and second passes of the trans-nasal endoscope in their
volunteer trials. These findings stand in accordance with the growing body of evidence that
supports the use of HPS to teach procedural skills (Binstadt et al., 2007; Hravnak, Tuite, &
Baldisseri, 2005; Menon, Kharasch, & Wang, 2011; Wayne et al., 2005). The one individual
who experienced difficulties was able to complete the tasks within the part-task practice
sessions, however made errors when implementing these tasks within a whole scenario. This
highlights the importance of not only providing skills training through repetitive practice
drills, but also the importance of checking these learned skills in realistic clinical scenarios to
ensure skill translation.
Previous research has already established that many speech-language pathologists
have reduced clinical confidence in the management of tracheostomized patients (Ward et al.,
2008; Ward et al., 2012), and that completing competency training programs and having
support in the workplace can help improve clinician confidence (Ward et al., 2012). Results
of the current study indicate that participation in the TASP workshop yielded significant
increases in perceived confidence pertaining to managing patients with a tracheostomy; in
performing tracheostomy management skills required for conducting a speech and swallowing
assessment; and making clinical decisions relating to tracheostomy management. Enhanced
clinician confidence is a common finding following HPS training in other disciplines
(Corbridge et al, 2008; Curtain & Dupuis, 2008; Kaddoura, 2010; Parker & Myrick, 2009). In
a qualitative analysis of graduate nurses’ perceptions of a critical care simulation training
program, Kaddoura (2010) proposed that the provision of a safe and risk-free learning
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
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environment facilitated the development of perceived self-confidence, as participants could
focus on their individual performance without fear of compromising patient safety. Benadom
and Potter (2011) also postulated that increases in confidence were attributable to the ability
for clinicians to repeatedly practice the clinical skills of interest in their study. With its
potential for high frequency practice conducted within an errorless learning environment
(Beyea & Kobovich, 2004), HPS appeared to be innately suitable to training tracheostomy
management skills and fostering clinician confidence.
An enduring theme in the HPS literature is the question of transferability of the skills
and competence acquired in a simulated setting to the actual workplace (Norman, 2012).
Limited research exists regarding the retention of skills developed through simulation
training. Of those studies reporting successful maintenance and transference of knowledge to
the clinical setting (Feingold, Calaluce, & Kallen, 2004; Terman, 2007), the findings are
limited to student models, where learners have opportunities to consolidate skills in
subsequent clinical practice. In the current study, the data collected from the 4 month post
training surveys revealed that as a group, clinicians had maintained their perceived levels of
confidence and skills on return to the workplace. However, closer investigation revealed there
was a subset that had not had the opportunity to apply their new skills clinically, due to an
absence of appropriate patients in the 4 months on their return to work. Hence for this
subgroup of clinicians, there was a lack of opportunity to consolidate their new learning in
clinical practice. Not surprisingly then, this group had significantly lower levels of confidence
at 4 months compared to the others. This finding highlights the importance of ensuring that
post training clinical opportunities are available for clinicians to consolidate their new
learning.
Overall, the results of the current study indicate that clinicians’ perceptions of the
HPS learning environment were overwhelmingly positive, a sentiment which is well
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
19
substantiated by current HPS literature (Partin, Payne, & Slemmons, 2011; Wotton, Davis,
Button & Kelton, 2010). Most participants commended the realism of the simulated patient
scenarios, which is a recognized asset of simulated learning (McLaughlin et al., 2002;
Ogilvie, Cragg, & Foulds, 2011; Tsai et al., 2003). Immediately and four months posttraining, the majority of participants felt that the simulated learning experience had enhanced
their knowledge and clinical skills in tracheostomy management. This stems from the
learner’s ability to actively make connections among and between concepts (Jeffries, 2005;
Kaakinen & Arwood, 2009), bridging the gap between theory and practice (Ogilvie et al.,
2011; Rauen, 2004). HPS provides a risk-free learning environment (McLaughlin et al.,
2002), allowing clinicians to become involved in scenarios as they learn, helping them to
actively acquire requisite skills more efficiently (Gordon, Oriol, & Cooper, 2004).
Although the design of the TASP workshop was chosen to emphasize training of
manual skills in tracheostomy management, consensus among clinicians established that the
simulated scenarios also helped to stimulate critical thinking. Many researchers have
attributed HPS as an effective pedagogic technique for developing critical thinking in
complex patient care situations (Corbridge et al., 2008; Garrett, MacPhee, & Jackson, 2011;
Kardong-Edgren, Starkweather, & Ward, 2008, Menon et al., 2011; Partin et al., 2011).
Kaddoura (2010) suggested that the ability to provide repeatable real-life practical problems,
interactive teaching-learning processes and feedback on performance through HPS demanded
active engagement of learners in critical thinking and built self-confidence in clinical
decision-making. Indeed, all clinicians praised the feedback provided during the debriefing
sessions, particularly for discussing issues around clinical decision-making. Researchers have
acknowledged that the debriefing process is a critical part of the simulation experience
(Fanning & Gaba, 2007; Musselwhite, Kennedy, & Probst, 2010) as it allows learners to
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
20
critically reflect on performance and transform knowledge (Parker & Myrick, 2009) in a
supportive peer environment (Kaddoura, 2010).
Limitations and Future Directions
The current simulation experience described in this research was designed for a
specific purpose, based on the specific training needs of the health service in which it was set
and the known levels of skill of the clinicians participating. Because of this, the exact nature
of the training program described here may not have direct relevance for other services or
meet the desired learning outcomes of other clinical environments or training programs.
Rather, what this study demonstrates is the potential for simulation to be used as a valid and
viable training model. There is great potential for simulation to be used in other ways to
facilitate alternate forms of basic and/or more advanced training opportunities in speech
pathology depending on the training needs. Scenarios can be written for any type of clinical
case (acquired neurological, surgical, degenerative etc) or population group (adult,
paediatric), introduce clinical case complexities which meet the training needs of novice to
advanced clinicians, or be modified to focus more on the development of other component
skills (such as dysphagia management) or on non-technical skills development, such as
communication and interdisciplinary team work.
Equipment type and its level of fidelity/capability can also vary to that presented here,
to allow more or less "reality" in any scenario. The equipment used in our scenarios allowed
for real time adjustment of vital signs, and the chest movements associated with breathing in
an adult patient model. However other low cost options (eg., torso trainers) used with a laptop
to display pre-made videos of vital signs can equally be used to provide less expensive, low
tech options. Other types of equipment can also offer different teaching opportunities eg.,
some models allow suctioning of real "secretions" (placed into the mannequin prior to the
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
21
scenario) and allow more realistic suctioning training. Hence, to is up to the team, the
equipment available and the learning objectives as to what can be achieved. However, it is
important that people who wish to work in simulation, recruit the assistance of experienced
simulation trainers and avail themselves of workshops and training opportunities to ensure
projects are well designed and provide optimal learning opportunities.
While the current study was designed to evaluate the impact of this type of training,
there were limitations and methodological issues which should be addressed in future
research. There was no baseline assessment of clinician skill conducted. This would have
been valuable to more directly explore the levels of skill change post training. There was also
no evaluation of the clinical knowledge and decision making which was learnt through the
pre-reading tasks. Although there was a post reading quiz, the format and questions were
designed to allow multiple attempts until 100% accuracy was achieved, making this quiz a
learning task rather than a discreet assessment of knowledge. How levels of knowledge
actually changed pre and post completion of the readings and then possibly changed again
following the simulation experience, would have been interesting to explore using an
assessment quiz format (i.e., where questions were pass/fail adding to a total knowledge
score). The assessments were also specific only to evaluating technical skills. Future
evaluation of changes in interdisciplinary teamwork and communication skills achieved
through this experience would also be very relevant.
It is acknowledged that clinicians who work in clinical settings where there are
limited numbers of patients with a tracheostomy will continually face issues with maintaining
core skills and confidence. This issue was observed in the current study with a proportion of
clinicians unable to apply their newly learnt skills in the 4 months on return to clinical
practice. A possible solution to this problem could be the use of simulation for ongoing, “justin-time” training. Just-in-time training is a model where clinicians have 24-hour access to a
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
22
HPS mannequin, and can use it for training/revision of clinical skills directly prior to a
potential intervention (Niles et al., 2009). Niles et al. (2009) conducted trials of this novel
approach for the maintenance of CPR skill competence among paediatric ICU staff.
Participants who underwent “refresher” sessions were reported to more habitually display
superior performance during subsequent assessments, with the more frequent use of refreshers
causing significantly shorter times to achieve the required proficiency of CPR skills. Thus,
whilst more research is required, the use of ongoing just-in-time training to supplement and
maintain the new learning achieved through the HPS scenarios may be a useful strategy to
help overcome potential skill decay created by the low incidence of tracheostomy skill
consolidation in the workplace.
Conclusion
The current study demonstrated achievement of core practical skills and a significant
increase in participants’ self-confidence towards the management of tracheostomized patients
following HPS training. Clinician response was also overwhelmingly positive toward HPS
and its value as a medium for clinical learning. These findings support the use of HPS-based
learning within a tracheostomy training pathway for speech-language pathologists, as an
alternate model to help overcome current workplace training shortfalls. Although currently
the use of simulated learning in speech-language pathology training is limited (MacBean,
Theodoros, Davidson, & Hill, 2013), the potential value of simulation is acknowledged and
growth in the use of simulation within training programs in the future is anticipated
(MacBean et al., 2013; Theodoros, Davidson, Hill, & MacBean, 2010). Increasing demands
for quality workplace training across all health disciplines will bring with it greater resources
and training infrastructure, ultimately facilitating more opportunities for practicing speechlanguage pathologists to undertake simulation training. However, determining when and how
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
23
best to further the use HPS to enhance clinical decision-making, teamwork, inter-professional
communication and other core skills necessary for competent tracheostomy management, is
the basis of future research.
Acknowledgements
The authors would like to acknowledge funding received through the Allied Health
Workforce and Training Unit and the Health Practitioner Grant Scheme, Queensland Health.
We also thank the staff at the CSDS service located at the Royal Brisbane and Women’s
Hospital for their training and support, and the research participants for their time.
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
24
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31
Table 1
Participant Demographic Information (N = 42)
Topic
Parameter
n
%
Main clinical population
Children (0-11 years)
1
2
managed
Adolescents (12-17 years)
0
0
Adults (18-65 years)
38
90
Seniors (65+ years)
9
21
Mixed adult/paediatric caseload
1
2
Critical care/intensive care
23
55
Acute care
27
64
Inpatient rehabilitation
4
10
Community Care
6
14
Primary clinical setting
Tracheostomized patients
None
11
26
managed in last 5 years
1-5
24
57
6-10
7
17
Tracheostomized patients
None – senior/administrator role only
2
5
expected to manage per
1-5
20
48
year
6-10
6
14
14
33
Over 10
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
32
Table 2
Post workshop agreement (%agree and %strongly agree data combined) with questions
regarding the Human Patient Simulation (HPS) Learning Environment (N = 42)
Question
% Agreement (n)
Post Workshop
The pre-reading material adequately prepared me for the case scenarios
98 (41)
The simulation demonstration helped me prepare for the case scenarios
100 (42)
I felt well briefed before and after the case scenarios
100 (42)
The part-task stations helped me prepare for the case scenarios
98 (41)
There was adequate time allowed to enable sound decision making
100 (42)
The length of the workshop was appropriate
98 (41)
The clinical scenarios chosen were relevant to my clinical caseload
81 (34)
The knowledge gained through this training is transferable to my
98 (41)
clinical setting
I felt nervous during the scenario
93 (39)
I enjoyed learning in this environment
98 (41)
The mannequins and environment were realistic
98 (41)
Simulation training should be part of clinical preparation and training
98 (41)
prior to managing tracheostomized patients independently
The workshop satisfied my expectations
100 (42)
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
33
Table 3
Results of the Four Confidence Parameters Recorded at Pre-, Post- and Four Months Post
Simulation Training (N = 42) (where 10=high levels of confidence)
Confidence
Pre-workshop
Post-workshop
Parameter
Managing
4 months postworkshop
M
SD
M
SD
M
SD
F
p
2.04
1.93
6.24
1.58
5.93
2.07
158.51
<0.001
2.49
2.25
7.74
1.49
7.11
2.17
141.69
<0.001
2.32
2.10
7.17
1.66
6.34
2.21
145.98
<0.001
2.17
2.03
6.26
2.03
6.14
2.33
109.63
<0.001
tracheostomized
patients
Performing manual
tasks
Conducting
speech/swallowing
assessment
Clinical decision
making
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
34
Table 4
Post-Hoc Analysis of the Confidence Ratings Between Pre-, Post- and Four Months PostWorkshop Evaluations (N = 42)
Pre – Post
Pre – 4 months
Post – 4 months
Post
Post
T
p
t
p
t
p
16.07
<0.0001
13.14
<0.0001
-0.97
0.338
Performing manual tasks
14.91
<0.0001
14.45
<0.0001
-1.84
0.073
Conducting speech/swallowing
15.53
<0.0001
12.84
<0.0001
-2.38
0.022
14.09
<0.0001
11.06
<0.0001
-0.37
0.714
Managing tracheostomized
patients
assessment
Clinical decision making
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
35
Table 5
Clinicians’ Perceptions of the Outcomes and Benefits of the Tracheostomy and Speech
Question
% Agreement (n)
% Neutral (n)
Fisher’s
Exact
Post
4
Post
months
This experience has enhanced my
4
p
months
100 (28) 100 (28)
0 (0)
0 (0)
N/A
96 (27)
96 (27)
4 (1)
4 (1)
1.000
100 (28)
89 (25)
0 (0)
11 (3)
0.116
knowledge of tracheostomy
management
This experience has enhanced my
clinical skills in tracheostomy
management
This experience helped to stimulated my
critical thinking in tracheostomy
management
Pathology (TASP) workshop (N = 42)
Note. N/A = no variance in the data, therefore statistics unable to be calculated
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
36
Demonstration scenario “Bob”–
To orientate participants to the simulated
environment
Part-Task Stations
Cuff deflation, re-inflation, cuff pressure check,
finger occlusion, speaking valve (+02), above cuff
suction/voice, vital signs monitoring
Case-Based Scenario 1 “Max”
Case discussion
4x
Immersive simulated assessment session
(remaining participants observe via video
stream)
Post-session debrief
Case-Based Scenario 2 “Janice”
Case discussion
4x
Immersive simulated assessment session
(remaining participants observe via video
stream)
Post-session debrief
Figure 1. Flow diagram representing learning tasks of the tracheostomy and speech pathology
(TASP) workshop.
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
Figure 2. Image of the immersive simulated assessment environment and mannequin.
37
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
38
Appendix A: An example of four assessment sessions conducted for a single clinical case
(abridged example for journal publication purposes only)
Background history
“Sally”:- Female, 72 years of age. Admitted with 52% burns secondary to house fire.
Burns to scalp, face, upper limbs, right lower limb, and torso. Inhalation injury.
Intubated via ETT for 16 days. Surgical tracheostomy on day 16 (size 8 Portex cuffed
tube). On day 24, tube changed to Portex Suctionaid tube due to copious secretions.
Sally is retired. Family: husband John (married 40years), 3 children, 5 grandchildren.
ASSESSMENT SESSION No 1: 29 Days Post Admission
Information for Clinician No 1
Current
On low flow ward circuit (FiO2 0.5@30l/min) with tracheal suction
status
every 30min - thick yellow sputum. Minimal oral suction. Vital signs =
RR 22, SpO2 98%, HR 90. Chest condition has been variable but
improving. Reasonable cough to tracheostomy hub. Inflated cuff at all
times. Follows basic commands, but confused. Attempts to mouth some
words occasionally. Nil by mouth with nasogastric feeds.
Medical
Cleared by intensivist for cuff deflation, swallow assessment and
plan
speaking valve as per speech pathologist. To transfer to burns unit
tomorrow. Physio review– happy with chest and cough status for trial.
Pre-session Discuss: Why surgical vs. percutaneous tracheostomy?; Impact of
discussion
fatigue/pain/confusion on session?; Impact of burns on positioning?;
Impact of age on swallow?; Why might Sally be dysphagic?; Impact of
intubation (ETT and trache) on voice/swallow?; Inhalation injury,
burns and their impact on voice/swallow?
Speech
Consider cuff deflation?
pathology
Consider voicing (finger occlusion/speaking valve/above cuff voicing)?
plan
Consider swallowing assessment?
Information for Facilitator & Simulation Coordinator
Plan
When clinician removes secretions from above-cuff line with syringe
indicate 3ml secretions pooled above cuff. Allow Sally to manage cuff
deflation initially (stable vital signs) – but then indicate poor tolerance
during finger occlusion with inspiratory and expiratory stridor, wet
coughing and dropping SpO2. Vital signs improve when cuff is
reinflated. Clinician decision should be: not suitable for speaking valve
trial, not suitable for swallow assessment. Encourage trial of above-cuff
voicing. In trial, Sally is to demonstrate soft, weak voice quality and
discomfort with above cuff airflow sensation.
Learning
Clinician will demonstrate ability to: remove secretions from above
outcomes
cuff line with syringe; successfully deflate cuff; perform finger
occlusion voicing trial; determine non-suitability for speaking valve;
identify changes in vital signs and cease trial when indicated; reinflate
cuff accurately; use cuff pressure manometer; trial above-cuff voicing.
Debrief
Encourage self/group reflection and self/group analysis of session.
ASSESSMENT SESSION No 2: 36 Days Post Admission
Information for clinician No2
Current
1 week later. Ward circuit FiO2 0.25 @ 20l/min. Now 2hrly tracheal
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
status
suction of thick yellow secretions. Physio happy with chest status.
Confusion continues, follows basic commands. Continues to mouth
words/short phrases, but reduced intelligibility due to oromotor
burns/contractures. Has not been appropriate for cuff deflations, but has
been receiving ongoing dysphagia rehabilitation.
Continue active rehabilitation.
Medical
plan
Pre-session Is there anything different from last session leading into this session?
discussion
Issue of change in suction frequency?
Speech
Consider cuff deflation?
pathology
Consider voicing (finger occlusion/speaking valve/above-cuff voicing)?
plan
Consider swallowing assessment?
Information for Facilitator & Simulation Coordinator
Plan
Indicate small amount (1ml) of secretions from above-cuff line suction.
Simulate signs supporting successful cuff deflation and finger occlusion
trial. Voice quality with finger occlusion is mildly strained and low
volume. Tolerates speaking valve trial with same voice as with finger
occlusion. Vital signs stable. Clinician should progress to swallow
assessment (prompt if they don’t). Trial extremely or moderately thick
fluids - indicate clinical signs of aspiration + positive tracheal suction.
Once suctioned and settled, patient status should begin to deteriorate
indicating non-tolerance of cuff deflation (increased coughing, stridor
and need for suction). Speaking valve to be removed and cuff
reinflated. Prompt trial of above-cuff voicing – outcome as per prior
assessment, non-functional (poor voice + discomfort).
Learning
Clinician will demonstrate ability to: remove of secretions from aboveoutcomes
cuff line; deflate cuff; perform finger occlusion; place speaking valve;
identify changes in vital signs and proceed/cease trial when indicated;
interpret swallow assessment outcome; reinflate cuff accurately; use of
cuff pressure manometer; voicing with above-cuff suction line.
Debrief
Encourage self/group reflection and self/group analysis of session.
ASSESSMENT SESSION 3: 57 Days Post Admission
Information for clinician No 3
Current
21 days later. Sally has had ongoing swallow assessments over last 3
status
weeks, but continued nil by mouth and nasogastric feeding- aspiration
of all fluids trialled. Ongoing dysphagia rehabilitation. Ongoing
tolerance of only short periods of cuff deflation and speaking valve
trials. Referred to ENT day 39: Mobile vocal cords, but inadequate
airway for speaking valve due to significant oedema at arytenoids.
Review by ENT day 50: oedema settled and now patent airway.
Currently on low flow ward circuit (FiO2 0.25 @ 20l/min) with 2hrly
suction of thick yellow secretions from trache. Less confused.
Mouthing longer utterances, but intelligibility still reduced due to
burns/facial contractures.
Medical
Continue active rehabilitation.
plan
Pre-session Why involve ENT? Impact of oedema on prior speaking valve
discussion
tolerance? How may this have changed?
Speech
Consider cuff deflation?
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USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
pathology
Consider voicing (finger occlusion/speaking valve/above cuff voicing)?
plan
Consider swallowing assessment?
Information for Facilitator & Simulation Coordinator
Plan
Indicate minimal (<1ml) secretions syringed from above-cuff line. Vital
signs stable throughout cuff deflation and finger occlusion. Voice is
improved and easy flowing with reasonable volume. Tolerates speaking
valve trial producing same voice as with finger occlusion. Swallow
assessment: to pass extreme/ moderate thick fluids, but aspirates on
mildly thick fluids/thin. Tolerating cuff deflated and speaking valve
insitu well. Although managing well, nursing staff to request removal
of valve and re-inflation of cuff to allow Sally to go off ward to X-ray.
Learning
Clinician to demonstrate ability to: remove of secretions from aboveoutcomes
cuff line; deflate cuff; perform finger occlusion; place speaking valve;
identify changes in vital signs and proceed/cease trial when indicated;
interpret swallow assessment outcome; reinflate cuff accurately; use of
cuff pressure manaometer.
Debrief
Encourage self/group reflection and self/group analysis of session.
ASSESSMENT SESSION No 4: 68 Days Post Admission
Information for clinician No 4
Current
11 days later. Sally showed period of increased confusion on days 53status
58. Investigation revealed urinary tract infection. Medical team
requested cuff deflation and speaking valve trial to cease and return to
nil by mouth with nasogastric feeds. Infection and confusion settled 6
days ago. Speech pathology trials resumed with daily improvement
seen over past 6 days. Now tolerating 10hrs cuff deflation and speaking
valve when awake. Currently managing mildly thick fluids and a
minced moist diet. On 2l O2. Vital signs: SpO2 98%, RR 21, HR 85.
Needing only 2-3hrly tracheal suction – clear secretions. Confusion
settled. Communication intact with speaking valve.
Medical
Continue active rehabilitation.
plan
Pre-session What would be next step?; Decannulation planning: pathway and
discussion
criteria? Post decannulation management?
Speech
Consider cuff deflation?
pathology
Consider voicing (finger occlusion/speaking valve)?
plan
Consider swallowing assessment?
Information for Facilitator & Simulation Coordinator
Plan
Indicate nil secretions from above-cuff line. Sally to manage cuff
deflation and speaking valve placement with low volume but easy
flowing voice. Swallow assessment: Fails thin fluid trial. Although
managing cuff deflation and speaking valve trial well, nursing staff to
request valve be removed and cuff inflated as Sally is going to
hydrotherapy next and physio preference is for inflated cuff in pool.
Learning
Clinician will demonstrate ability to: remove secretions from aboveoutcomes
cuff line; deflate cuff; perform finger occlusion; place speaking valve;
identify changes in vital signs and proceed/cease trial when indicated;
interpret swallow assessment outcome; reinflate cuff accurately; use of
cuff pressure manaometer.
Debrief
Encourage self/group reflection and self/group analysis of session.
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USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
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USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
42
APPENDIX B: Tracheostomy Pre-Simulation Questionnaire
Unique identifier:
□ Middle initial □1
st
initial of street name
□No. of brothers & sisters
Demographic Information
How many years have you practiced as a Speech-language pathologist? ____ years
What is the main clinical population with a tracheostomy that you currently/will manage?
a. Children (0-11 years), b. Adolescents (12-17 years), c. Adults (18-65 years), d. Seniors
(85+ years), e. I manage a mixed adult/paediatric caseload
What is the primary clinical setting in which you will work with patients with a
tracheostomy? Please indicate all relevant: a. Critical care / intensive care b. Acute Care, c.
Inpatient Rehabilitation, d. Community Care
Please indicate how many patients you have worked with who are tracheostomized over the
last 5 years: a. None, b., 1-5, c. 6-10
Approximately how many patients with a tracheostomy tube do you currently – or will in the
future be expected to - manage per year? a. None (senior/administrator role only), b. 1-5, c. 610, d. Over 10
Prior to today, approximately how many hours of workplace clinical supervision and training
(i.e., training since graduation) have you received in tracheostomy management?
a. None, b. 1-5, c. 6-10, d.11-20, e. More than 20
What has been the nature of the tracheostomy management preparation/training you have
undertaken in the past 3 years (please indicate all completed)? Workshop, Online learning
package, Tracheostomy competency training program, Workplace mentoring,
Workshadowing, Other (detail)
Perceptions of the Simulated Learning Environment
Right now, do you feel case scenarios with human simulation mannequins could be a valuable
medium for clinical learning? Please indicate on the line. (10cm line ranging from “No” to
“Definitely”)
Confidence Ratings (10cm line ranging from “Not confident” to “Very Confident”)
Right now, how confident are you with managing patients with a tracheostomy tube?
Right now, how confident are you performing the manual tasks (cuff inflation, deflation,
checking cuff pressure etc) involved in managing a tracheostomy patient?
Right now, how confident are you in your ability to conduct a speech and swallowing
assessment with a tracheostomy patient?
Right now, how confident are you in your clinical decision making when managing a patient
with a tracheostomy?
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
43
APPENDIX C: Tracheostomy Post-Simulation Questionnaire
Unique identifier:
□ Middle initial □1
st
initial of street name
□No. of brothers & sisters
Perceptions of the Simulated Learning Environment
Right now, do you feel case scenarios with human simulation mannequins could be a valuable
medium for clinical learning? Please indicate on the line. (10cm line ranging from “No” to
“Definitely”)
Rate the following statements (Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)
I felt nervous during the scenarios
I enjoyed learning in this environment
I felt well briefed before and after the case scenarios
The mannequins and environment were realistic
The clinical scenarios chosen were relevant to my clinical caseload
The knowledge gained through this training is transferable to my clinical setting
Simulation training should be a part of clinical preparation and training prior to managing
tracheostomy patient independently
Perceptions of the TASP Workshop
Rate the following statements (Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)
The pre-reading material adequately prepared me for the scenarios
The simulation demonstration I watched in the morning of the workshop helped me prepare
for the type of clinical activities I would do in the workshop
I found completing the part task stations useful as they helped me prepare for case scenarios
with the human simulation mannequins
There was adequate time allowed to enable sound decision making
The length of this workshop was appropriate
This experience has enhanced my knowledge of tracheostomy management
This experience has enhanced my clinical skills in tracheostomy management
The TASP workshop helped to stimulate my critical thinking in tracheostomy management
Did the workshop meet your expectations? a. Yes, b. No
What do you feels were the strengths of the workshop? (Detail)
Would you recommend the TASP workshop to other clinicians? Yes/No
Would you attend another workshop (using different or more complex scenarios)? Yes/No
Confidence Ratings (10cm line ranging from “Not confident” to “Very Confident”)
Right now, how confident are you with managing patients with a tracheostomy tube?
Right now, how confident are you performing the manual tasks (cuff inflation, deflation,
checking cuff pressure etc) involved in managing a tracheostomy patient?
Right now, how confident are you in your ability to conduct a speech and swallowing
assessment with a tracheostomy patient?
Right now, how confident are you in your clinical decision making when managing a patient
with a tracheostomy?
USING SIMULATION IN TRACHEOSTOMY MANAGEMENT
44
APPENDIX D: Four Month Tracheostomy Post-Simulation Questionnaire
Unique identifier:
□ Middle initial □1
st
initial of street name
□No. of brothers & sisters
Opportunities for clinical practice post-training
Approximately how many patients with a tracheostomy have you managed since the
completion of the tracheostomy simulation workshop? a. None, b. 1-3, c. 4-8, d. 9-15, e. 16+
Rate the following statements (Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)
Since the workshop, I have managed similar clinical scenarios in my clinical setting
I have used pre-reading materials to assist in tracheostomy management in my workplace
I have transferred knowledge and skills into my clinical work with tracheostomy patients
Since completing the workshop, have you participated in any further education/training in
tracheostomy management? (Please indicate all completed and estimate number of hours)
a. Workshop on tracheostomy management, b. Online learning package, c. Tracheostomy
competency training program, d. Workplace mentoring, e. Workshadowing, f. Other (detail)
Perceptions of the Simulated Learning Environment
Right now, do you feel case scenarios with human simulation mannequins could be a valuable
medium for clinical learning? Please indicate on the line. (10cm line ranging from “No” to
“Definitely”)
Rate the following statement (Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)
Simulation training should be part of clinical preparation and training prior to managing
tracheostomy patients independently
Perceptions of the TASP Workshop
Rate the following statements (Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree)
Completing the TASP workshop has enhanced my knowledge of tracheostomy management
Completing the TASP workshop has enhanced my clinical skills with this clinical population
The TASP workshop helped to stimulate my critical thinking in tracheostomy management
Would you recommend the TASP workshop to other clinicians? Yes/No
Would you attend another workshop (using different or more complex scenarios)? Yes/No
Do you feel that patient simulation training could be a useful means for developing skills and
building competence in other areas of speech-language pathology? If so, what ____
Confidence Ratings (10cm line ranging from “Not confident” to “Very Confident”)
Right now, how confident are you managing patients with a tracheostomy tube?
Right now, how confident are you performing the manual tasks (cuff inflation, deflation,
checking cuff pressure etc) involved in managing a tracheostomy patient?
Right now, how confident are you in your ability to conduct a speech and swallowing
assessment with a tracheostomy patient?
Right now, how confident are you in your clinical decision making when managing a
tracheostomy patient?