The Care of Patients Aspects: Tracheostomy

Introduction

The care of patients in hospitals is linked with efficient management strategies. These may often become complicated with the presented case or situation. In order to better cope with the tasks, there is a need for appropriate awareness which could be better accomplished by adopting the methods or models that refine the practicing approaches and even through teaching. The present literature is concerned with highlighting the Traheostmy care’ in a similar context. A tracheostomy is an opening performed through surgery in the neck region that leads to the trachea which is known as the breathing tube. The device used for the opening purpose is a tracheostomy tube (www.medicinenet.com). Tracheostomy comprises assessment; tracheal suctioning; suction pressure; suction catheters; and humidity (www.medicinenet.com). Tracheostomy care was considered a difficult nursing activity with various robust complications (Buglass, 1999). The components of tracheotomy care give an impression to be taken with non-uniformity and vagueness with regard to the outer regions of the ear, nose, and throat and other intensive care areas (Buglass, 1999). There are controversial studies in the literature that enable nurses to come forward with their own guidelines (Buglass, 1999). Generally, nurses are responsible for the care to be extended to the patients and from the evidence accumulated, it is essential for the nurse to sufficiently get educated and become an expert in the practice of tracheostomy care (Buglass, 1999). It was reported that Patients with tracheostomies maybe get admitted to hospitals in different situations (Tanburri, 2000). For instance, they may not be frequently given admission in orthopedic wards (Tanburri, 2000). This could promote difficulties for the nursing care of such patients in those wards as nurses may be unhabituated (Tanburri, 2000).

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This problem could be overcome by thorough knowledge about the indications associated with the tracheostomy tube insertion and following physiologic changes (Tanburri, 2000). In view of these problems, there is a need to thoroughly review and understand the existing literature with regard to the principles of teaching and learning associated with tracheostomy care.

Objective

The main objective of imparting tracheostomy is to teach about the features, guidelines or principles and steps involved in tracheostomy patient care. The objective of the teaching strategy could be to enhance the student’s awareness and build their abilities that contribute to efficiency in the care of patients.

Review of Literature

Tracheostomy care may require the ability to critically thinking. This is because situations demand the nurses to process and make use of a wealth of available information. It may be Data on health care strategies grows rapidly on a daily basis(Bradshaw & Lowenstein,2007). Trends in health care may often make sick patients confined to home that in turn demands complicated health care delivery to home (Bradshaw & Lowenstein, 2007). Similarly, trends in technology influence diagnostic methods and treatment modalities (Bradshaw & Lowenstein, 2007). The nurses must first identify the problem that is worth solving (Bradshaw & Lowenstein, 2007). Hence, the process of tracheostomy care needs to be emphasized on the caregiver and treatment.

The instructor has a great role to play in educating the students on tracheostomy care. As such, there are certain objectives to be met that are to make the students familiar with the techniques employed for performing tracheostomy (Russel, 2005). These include a surgical tracheostomy and a percutaneous dictational tracheostomy (Russel, 2005). Similarly, the influence of tracheostomy on the respiratory system involves complete awareness of respiration, suctioning techniques, humidification methods (Russel, 2005).

Further, tracheostomy also influences swallowing, communication skills and body image (Russel, 2005). Teaching these skills could benefit students and the multidisciplinary team in future care policies (Russel, 2005). It is important for the instructors to teach the students with correct skills, awareness and assistance to face the requirements of tracheostomy patients more safely (Russel, 2005). The students must obtain enough skills with regard to the varieties of tubes employed for performing tracheostomy, the advantages of tracheotomy, and the method of suctioning, inner tube cleaning and the materials necessary for making tube changes and its methodology (Feber, 2006). Next, cognitive and technical skills are important for the students. A study was conducted to evaluate the utility of cognitive task analysis (CTA) to build a paradigm with the intention of teaching the behavioral skills and cognitive strategies of a percutaneous tracheostomy (PT) (Sullivan et al., 2007). The findings revealed the efficacy of the cognitive and technical skills for the successful outcome of PT(Sullivan et al., 2007).

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Therefore, this may indicate that teaching strategies must focus on the above-mentioned skills and ensure that their significance is imparted successfully to students (Sullivan et al., 2007). Teaching programs that evaluate the theoretical aspects of tracheostomy care have good implications. This was revealed when a survey was carried out through a questionnaire session to assess the theoretical awareness of the students who are nursing professionals (Pelaes de Carvalho et al., 2009). Less expenditure and ordinary structure requirements were found to encourage the distribution of such strategies to enhance the reliability of nursing support in the hospital environment (Pelaes de Carvalho et al., 2009). Hence, this model of theoretical educational program could be considered as a good teaching strategy.

The lacunae existing between the practice and education should be recognized by the intervention programs. This model of the competency-based education program is important as it involves an emphasis on outcome, facilitates raising the levels of competency, self-assessment individualized learning experiences, practice-based learning and learner accountability.

Here a method of scaffolded instruction has come up where integration of knowledge and collaboration ensure learning. Collaboration is the responsibility of teachers who model the required clinical abilities and then finally switch the duties of nursing to the student.

Scaffolded instruction was considered as a second-degree bachelor of science in nursing program (Tilley et al., 2007). This may be considered as an intervention as it utilizes creative strategies to education, with a clinical aspect that depends on clinical instructors(Tilley et al., 2007). So, the practice of tracheostomy care should be made accessible to the students of such programs where the approaches to face the relevant challenges could be taught (Tilley et al., 2007). The use of certain teaching strategies that focus on self – administration was proven to yield satisfactory results (Derrickson, Neef & Parrish, 1991). This worked on tracheostomy patients who are children(Derrickson, Neef & Parrish, 1991). Here, the training procedure has recommended the use of dolls in order to facilitate young children to self-administer a suctioning device (Derrickson, Neef & Parrish, 1991). This simulation model was taught to evaluate in vivo skills in tracheostomy patients(Derrickson, Neef & Parrish, 1991). The outcome of this approach was significant as the patients performed well. They reflected the acquirement of skills during the follow-up assessment (Derrickson, Neef & Parrish, 1991). This may indicate that the training procedure was reliable as it has provided the highest levels of satisfaction to the caregivers (Derrickson, Neef & Parrish, 1991).

The application of the self-administration approach among young tracheostomy patients may need to be adopted in the teaching strategies. The field of nursing is concerned with human life and an adverse relationship between these two entities could lead to severe consequences. Tracheostomy care has its uniqueness and it is essential to furnish additional insights on theoretical background with the objective of planning tracheostomy care. Nursing requirements move from cognitivism to constructivism that reflects the focus on the learners (Bosher & Pharris, 2008). In the cognitivism model of learning, the teacher instructs awareness about cultural perspectives to students in a cascade and mechanical fashion (Bosher & Pharris, 2008). This approach is for those students who are younger in their creative thinking and have low contextual experiences (Bosher & Pharris, 2008). Constructivism is learner-focused where the students will be encountered with the questions (Bosher & Pharris, 2008). This makes them to constructivism theory on the basis of training that would facilitate students to use their brains, think seriously, practice reflectively, cooperate with the groups of fellow students and make use of information thoroughly to assist their practical tasks (Young & Paterson, 2007). This will help them to participate in discussions and problem-solving patient situations.

Further, there is a need to build a culturally varied environment for students (Bosher & Pharris, 2008). The timing schedule is essential as the students should not miss out whenever necessary. The availability of students is a significant aspect during teaching sessions (Bosher & Pharris, 2008). Clinically, this would impact the practice in various hospital settings. Tracheostomy care is a complicated task. Its management should not get hindered lack of awareness concerned with rules of respect for persons and nonjudgmental aspects after the clinical conferences and in any discussion sessions (Bosher & Pharris, 2008).

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Next, it is important for educators to become familiar with several pedagogies.

Ian, Aylin and Lyndon (2008) described that a reconceptualization of pedagogy in order to provide a standardized model would facilitate the variation between the accessible networks of practice and understanding to be utilized a positive feature from the learners perspective and their experiences (Ian, Aylin & Lyndon, 2008). Identifying the variations in the student learning modes would further increase the tensions within the system that have not been properly addressed practically for academic staff, instead of solving classroom problems associated with the practice (Ian, Aylin & Lyndon, 2008).

These issues further contribute to the difficulties in the teacher’s routine life and as such, it gives rise to the repetition of non-learning as teachers move back to the well-known communication of content (Ian, Aylin & Lyndon, 2008). Hence, there is a need to restructure the teaching strategy.

Kolb’s model of experiential learning is connected to a constructive theoretical base. As for the instrument used in order to measure the learning styles of nursing students, it will be the Kolb Learning Style Inventory that is reported to be the most commonly used one with nursing students (McGovern Billings & Halstead, 2005).

This model is firm in its applicability and implications. On defining the ratio of learning styles in the group of students, it is necessary to direct the instruction towards prevalent learning styles though those that constitute the minority should not be omitted. Thus, the types of activities during tracheostomy care instruction suitable for accommodators will be group work, discussion, open-ended problems, simulations, etc. (Nilson, 2010). Divergers will benefit from discussion, interactive lectures, simulations, while convergences are successful when demonstrations, case studies, and simulations are used (Nilson, 2010).

Therefore, the use of Kolb’s learning styles is related to the choice of the teaching techniques described below because tracheostomy care instruction should be treated as a multidimensional teaching strategy and this fact accounts for the need for the application of several teaching techniques in complex or in natural succession as established by the instructor.

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Firstly, it is necessary to form a theoretical basis for the students. This can be best accomplished with the help of the application of a traditional teaching method, a lecture. The main peculiarities of the lecture about tracheostomy and tracheostomy care should be a lucid and logical plan, the support of the lecture with schemes and other kinds of visual aids, the best choice will be to provide the students with concise notes pertaining to the flow of the lecture (Carpen, 2005). The flow of the lecture should be logical, with a smooth but clear transition to the succeeding items (Carpen, 2005). The manner of the presentation should be accessible; it is not necessary and even not desirable to overload the lecture with terminology, though the introduction of the necessary terminology is essential(Carpen, 2005). Though the students basically perform a passive role during a lecture, the lecture can be modified so that a student could become an active participant in the instructional process during a lecture (Carpen, 2005). An instructor should encourage students’ feedback, students should ask questions in the course of the lecture (Carpen, 2005).

Besides a lecture, it is advisable to use the teaching strategies that would focus on active learning and critical thinking of the students. It can be the discussion of the material that has been delivered in the lecture. In the case of tracheostomy care, the discussion can be built around the benefits of tracheostomy or patient assessment (Carpen, 2005).

The analysis of a case study can be a perfect strategy to use during the instruction of students on tracheostomy care as it can be “valuable for applying concepts from lecture to clinical practice” (Young & Paterson, 2007). British Journal of Nursing (1999) offers a perfect case study involving a nurse who did not follow init guidelines concerning tracheostomy care. Also, it is possible to build the discussion on the basis of one-minute web-based videos that “reinforce the management of the tracheostomy emergencies” (Tanner, 2006). Moving from the most passive to the active teaching and learning strategies, it is necessary to mention the use of a simulation lab that “provides an opportunity to practice the management of spontaneous decannulation, and to demonstrate skills in recannulation” (Tanner, 2006).

Learning Outcomes

Learning outcomes should demonstrate a sufficient theoretical basis of the students’ knowledge and their acquisition of practical skills necessary for adequate provision of tracheostomy care. They should demonstrate that skills connected with the processes of suctioning, cleaning of the inner tube, and changing of the tube.

Evaluation Strategies

Since the tracheostomy care instruction is directed in two basic ways: theoretical one and practical one, it is necessary to evaluate the student’s knowledge in both spheres. The assessment of theoretical competence can be performed on the basis of oral or written examination according to the choice of the examiner. It is possible to check theoretical knowledge with the help of the analysis of the case studies as it has been done during the process of instruction. However, there is the necessity of the assessment of the development of practical skills of tracheostomy care. Students can be assessed in the simulation lab where they received the instruction and practical training.

Airway assessment and management is one of the important duties of nurses caring for severely unwell adult individuals(St John and Malen, 2004). Most frequent types of artificial airways, like tubes of tracheostomy and endotracheal origin, need clinicians to possess a thorough awareness of clinical usage (St John and Malen, 2004).

Tracheostomy tubes are needed in a small magnitude compared to endotracheal tubes in ICUs. But their usage requires extra awareness and expertise as difficulty and variation in the analysis of the surgical site, and several associated nursing care issues (St John and Malen, 2004). Therefore, current variations in the practice for the care providers is essential to help the adult patient in tracheostomy tube settings (St John and Malen, 2004).

Thus, the use of specifications surgical expertise, and various tubes utilized in the critical care setting has great implications (St John and Malen, 2004). It is essential for the instructors to acquire skills related to these specifications and teach them to the students. There is a need for a narrative approach for the teachers on the grounds of Ethics education(Young and Peterson, 2007).

Narrative and story increase the interest and evaluation of moral problems with regard to the political, cultural, and structural sources and the intricacy of practitioners and patients’ difficulties (Young and Peterson, 2007). Learning ethics might enable to bring the students nearer to the center of the ethical problem to be investigated(Young and Peterson, 2007)

Therefore, the use of narratives in health care ethics will enable to put the learners in several ways of receiving the world, providing more chances for empowerment and depth in ethical evaluation, facilitating public opinions through dialogues on policies and ethical issues(Young and Peterson, 2007)

It is essential for the teaching strategies to get well aware of the ethical concerns that might also likely arise in Tracheostomy care. The teachers should understand the experience of patients faced in daily life, who need changes in tubes used for tracheostomy (Donnelly and Wiechula, 2006). To this end, several descriptions have emphasized on the nursing interventions with regard to their practice associated with the patient’s familiarity in ICUs that require a change in tracheostomy tube(Donnelly and Wiechula, 2006). By using a phenomenological approach, the participants were questioned and their answers were later converted into text (Donnelly and Wiechula, 2006). It was revealed that the changes associated with the tracheostomy tube are complicated when compared to a simple physical sensation (Donnelly and Wiechula, 2006).

Conclusion

In conclusion, special attention of an instructor teaching a tracheostomy care course is caused by significant risk factors associated with caring for a patient that has been given or should be given a tracheostomy (tube obstruction, misplacement), as their possible consequences may result in respiratory and cardiac arrest threatening the patient’s health (Russel, 2005). It is necessary to provide the students with an adequate understanding of the basic principles, characteristics, and stages of care of a patient with tracheostomy. Since a solid theoretical ground is needed for the planning of tracheostomy care instruction, constructivism has been chosen as a suitable educational theory and the choice of the teaching techniques is made on the basis of Kolb’s learning styles. By the end of the tracheostomy care course, students should be able to demonstrate sufficient theoretical knowledge and adequate practical skills of care of a patient with a tracheostomy. An evidence-based approach is strongly recommended l for concrete information to modulate the practice.

References

Tracheostomy. 2010, Web.

Buglass E. (.1999).Tracheostomy care: tracheal suctioning and humidification. Br J Nurs. 8,500-4.

Tanburri, L, M. (2000). Care of the patient with a tracheostomy. Orthop Nurs, 19, 49-58.

Bradshaw, M.J., & Lowenstein A.J. (2007). Innovative Teaching Strategies in Nursing and Related Health Professions. London: Jones & Bartlett Publishers.

Russel, Claudia. (2005). Providing the nurse with a guide to tracheostomy care and management. British Journal of Nursing, 14, 428-433.

Sullivan, M.E., Brown, C.V., Peyre, S.E., Salim, A., Martin, M., Towfigh, S., Grunwald, T. (2007). The use of cognitive task analysis to improve the learning of percutaneous tracheostomy placement. Am J Surg,1, 96-9.

Pelaes de Carvalho, T., Spitaletti Araujo, N,S., Curcio, D., Rebelo Gonçalves, M,I. (2009). Tracheostomized patient’s care efficacy of a brief theoretical education program for nursing personnel. Support Care Cancer, 6,749-51.

Tilley, D.S., Allen, P., Collins, C., Bridges, R.A., Francis, P., Green, A. (2007). Promoting clinical competence: using scaffolded instruction for practice-based learning. J Prof Nurs, 5, 285-9.

Derrickson, J.G., Neef, N.A., Parrish, J.M.(1991). Teaching self-administration of suctioning to children with tracheostomies. J Appl Behav Anal 24, 563-70.

Ian M. Kinchin, Aylin Baysan, Lyndon Bruce Cabot (2008). Towards a pedagogy for clinical education: beyond individual learning differences. Journal of Further and Higher Education, 32, 373 – 387.

McGovern Billings, D., and Halstead J.A. (2005). Teaching in Nursing: A Guide for Faculty. St. Louise, MO: Elsevier Health Sciences. 2nd Edition. The USA.

Nilson, L.B. (2010). Teaching at Its Best: A Research-Based Resource for College Instructors. John Willey and Sons. 3rd Ed. The USA.

Young, L.E., & Peterson, B.L. (2007). Teaching Nursing: Developing a Student-Centered Learning Environment. Ambler, PA: Lippincott Williams & Wilkins.

Tanner, E. (2006). Lions and tigers and tracheostomies, oh my!!! Oncology Nursing Forum, 33, 483.

St John, R,E, & Malen, J,F (2004).Contemporary issues in adult tracheostomy management. Crit Care Nurs Clin North Am, 16, 3413-30.

Donnelly, F & Wiechula, R. (2006). The lived experience of a tracheostomy tube change: a phenomenological study. J Clin Nurs, 15,1115-22.

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