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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 19  |  Issue : 2  |  Page : 51-57

Nurses training, clinical support and confidence in management of tracheostomy patients in Jeddah, Saudi Arabia


1 Department of Otolaryngology, Head Neck Surgery, Faculty of Medicine, King Abdulaziz University, Saudi Arabia
2 Department of Otolaryngology, Head Neck Surgery, Faculty of Medicine, Al Imam Mohammad Ibn Saud, Islamic University, Saudi Arabia

Date of Web Publication7-Jan-2020

Correspondence Address:
Turki Bin Mahfoz
P.O. Box 7544, Riyadh 4233-13317
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.275316

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  Abstract 


Objectives: To identify nurses pre and post graduate clinical support and confidence level for tracheostomy management.
Methods: A cross sectional study was carried out in two tertiary care centers in Jeddah, Saudi Arabia; King Abdulaziz University and King Fahad Military Hospital, during the period from February to October 2014.
Results: Two hundred and six nurses were enrolled in the study. Majority of nurses (69%) had an experience of less than 11 years and they were mostly working for forty hours or more weekly (77.5%). The respondent nurses indicated that they were working in different departments with varied frequencies and they were confronted with different age group of patients. Sixty two point three per cent indicated that they had from 1-10 hours of formal training on managing patients with tracheostomy. It was observed that almost one half of the nurses (53.2%) perceived that they are up to date with the available evidence-based practice regarding tracheostomy management. However, only 11.4% of the nurses perceived that they were very confident in managing patients with tracheostomy and those who require ventilator assistance in addition.
Conclusion: Our study demonstrates the importance of formal training and exposure, which reflect on nurses training, clinical support and confidence in management of tracheostomy patients.

Keywords: Tracheostomy, post tracheostomy management


How to cite this article:
Al-Khatib T, Mahfoz TB, Arif R. Nurses training, clinical support and confidence in management of tracheostomy patients in Jeddah, Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg 2017;19:51-7

How to cite this URL:
Al-Khatib T, Mahfoz TB, Arif R. Nurses training, clinical support and confidence in management of tracheostomy patients in Jeddah, Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2017 [cited 2022 Nov 28];19:51-7. Available from: https://www.sjohns.org/text.asp?2017/19/2/51/275316




  Introduction Top


Tracheotomy is a surgical opening into the trachea, with an indwelling tube that is placed to overcome upper airway obstruction, facilitate mechanical ventilatory support and/or removal of tracheobronchial secretions. Most patients will be decannulated prior to discharge. However, others with permanent tracheostomy will need special care to provide effective tracheostomy care. Overall, the number of tracheotomies being performed internationally was increasing [1]. This increase had led to more patients being discharged to non-specialized areas with the need for tracheostomy care which made more of non-otolaryngology members to be involved in the management. For example, these patients are being nursed in general wards and in the community [2],[3].

Studies highlighted factors associated with inconsistencies in tracheostomy management, such as the lack of knowledge of care givers, including nurses, about the recommended updates in practice, which may result in staff making individual judgments. A number of them even demonstrated potentially unsafe practice [4],[5]. Another factor is the variation in the level of knowledge [6],[7], Moreover; the lack of confidence for non-otolaryngology health professionals involved in airway care may be a factor [8].

In general, researches are very limited in tracheostomy management outside specialized areas, and the focus on the nurses to further explore their experiences and to identify better methods of providing support and tracheostomy education was recommended [2],[3],[9]. Consequently, studies investigating both issues are needed.

The aim of this study was to identify the nurse’s pre and post graduate clinical support and confidence level for tracheostomy management.


  Materials and Methods Top


Ethical approval was obtained from the ethical committee of King Abdulaziz University (KAU) and King Fahad Military Hospital, Jeddah, Saudi Arabia. A pilot study was done to pre-test the questionnaire.

A cross sectional study was carried out in a two tertiary centers; King Abdulaziz University and King Fahad Military Hospital, Jeddah, Saudi Arabia, during the period from February to October 2014 via structured, anonymous self-administered questionnaire consisting of 20 questions. The target population was nurses who dealt with tracheostomy patients as part of their work. A multi-staged stratified random sample method was taken. And for ethical consideration a verbal consent was taken from the participants. All nurses who accepted to participate during the interview were included.

The questionnaire was used previously by Ward et al. (2007, 2008) [9], though only the subset of 21 of these questions that specifically related to the issues of clinician education and training, clinical support and clinician confidence levels were examined as per Ward et al. (2008) and followed either a multi-choice or 1-5 Likert response scale arranged in the following matter:

Section one (5 Questions): Demographic & socioeconomic Data.

Section two (4 Questions): Tracheostomy care exposure.

Section three (11 Questions): undergraduate and postgraduate Tracheostomy Training and confidence level.

The data were coded & entered into statistical computer program SPSS version 18 Descriptive and analytic statistics were conducted. P < 0.05 is considered statistical significance.


  Results Top


The total number of survey respondents was 204 nurses. The majority of the study group had either bachelor (72.4%) or diploma (23.4%) qualifications that were mainly from outside the Kingdom (77.7%). Slightly more than two thirds of the nurse (69%) had an experience of less than 11 years and they were mostly working for forty hours or more weekly (77.5%) [Table 1]. The respondent nurses indicated that they were working in different departments with various frequencies and they were confronted with different age group of patients [Table 2]. Moreover, the overwhelming majority of the nurses stated that they used to deal with tracheostomy patients in the past year. Almost one in every five nurses (18.6%) indicated that they spend 50% of their working hours in caring for tracheostomy patients, as it was noted that one third of the nurses (32%) dealt with more than 50 tracheostomised patients in the previous year [Table 3].
Table 1: Characteristics of the study group (n=204)

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Table 2: Training and sources of information about tracheostomy care

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Table 3: Self reported rating of nurses about their knowledge and confidence in managing tracheostomised patients

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Almost two thirds of the nurses (62.3%) indicated that they had from 1-10 hours of formal training on managing patients with tracheostomy and one half of them (49%) had between 1-10 hours of clinical supervision prior to treating patients independently. In addition to 61.6% of the nurses who reported that they had formal training in their departments, there were 15.3% who expressed that they were currently developing one. Workshops (47.1%) and conferences (25.2%) were the most commonly tracheostomy- related professional development activities undertaken [Table 4].
Table 4: Relationship between confidence of the nurses in management of the majority of tracheostomized patients and different characteristics and training.

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Almost one half of the nurses (53.2%) perceived that they were up to date with the available evidence- based practice with tracheotomy management with a lesser percentage (35.6%) who felt up to date with the advances in tracheostomy care. Although, less than one half of the nurses (42%) pointed that the work setting had an optimal team approach for the managing patients with tracheostomy, a much higher percentage (76.1%) of them indicated that within their teams they had expert clinical support for managing patients with tracheostomy only, and higher percentage (80.8%) had support for patients who had tracheostomy and required ventilator assistance. Lastly, it was observed that only 11.4% of the nurses who perceived that they were very confident in management of patients with tracheostomy and those who required ventilator assistance in addition [Table 5].
Table 5: Self reported rating of the nurses about their knowledge and confidence in managing tracheostomised patient

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Nurses who graduated from universities others than that in Saudi Arabia (65.6%) were significantly more confident in their abilities in management of the majorities of the tracheostomy patients within their team p<0.05. It was noted that the level of confidence of the nurses were consistently escalating with increased number of the years of experience which is up to 15 years, however, it declined after 15 years. The percentage of nurses who were confident in their abilities were significantly higher among those who had previous training (62.8%) when compared to those who hadn’t (39.1%). In the same line, it was found that the percentage of confident nurses was patients (70.4%) when compared to those who addressed that their department was whether currently developing one (41.9%) or there was no training (44.7%) p<0.05 [Table 6].
Table 6: Relationship between the years of working experience in relation to place of graduation. (Chi-Square Tests)

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The percentage of confident nurses was higher among those who spent all or most of their time in intensive care unit (ICU) (67.8%) than those who were sometimes or not at all working in ICU (32.2%), however, this difference was not statistically significant p<0.05 [Table 7], [Table 8]. Saudi nurses had less experience than the non-Saudis, as two thirds (60.9%)of Saudi nurses had experience ranging between 1-5 years, while more than five years (77.5%) in non-Saudi nurses , and this difference was statistically significant p<0.05.{Table 7}{Table 8}


  Discussion Top


Improving tracheostomy care and providing a safe practice is achieved by combining best experiences, skills, knowledge, providing the best teaching methods and latest advances in its management and evaluating the outcome. Applying these recommendations will help nurses to be equipped with the needed skills, knowledge and support to meet the unique needs of each patient in every situation.

Multiple methods to enhance the performance, knowledge and confidence level had been postulated. First, the important rule of education was highlighted [2],[9] whether using theoretical or practical sessions with various results. In a study among new graduate nurses, the comfort level before and after a tracheotomy in-service educational session found no correlation between reported comfort level and knowledge in caring for patients with tracheostomies. The recommendations were toward more of hands on involvement [10]. On the other hand, a standardized theoretical educational module for tracheostomy care teaching among non-otolaryngology health care providers resulted in significant increase in provider knowledge and confidence [11]. Second the standardization of trache- ostomy education, protocols and care is essential in academic hospital medical centers [10]. Other methods including using a self-learning module (SLM) to teach nurses caring with tracheostomies yielded a statistical significant difference toward improvement learning after completion of the SLM. Another suggestion was to implement tracheostomy care in training in basic life support courses (BLS) to protect the abnormal airway [8].

In the current study, most nurses reported fewer than 11 hours of undergraduate and postgraduate formal training prior to treating patient independently (62.2 %), (49 %) respectively. A high statistical significant difference was found between previous training and confidence level, as the percentage of nurses who were confident in their abilities were significantly higher among those who had previous training (62.8%) when compared to those who had not (39.1%). Enhancing undergraduate training before any direct contact with patients as well as postgraduate training is recommended to maintain competency and to improve nurses confidence level. The rule of education was evident, with further exploration to determine the best method to deliver effective education was highlighted in a literature review conducted by Paul [2] when reviewing the adverse events associated with airway management and as we found that the percentage of confident nurses were significantly higher among those who reported that their department in which they were working while providing formal training in managing of patients with tracheostomy (70.4%) if compared to those who addressed that their department was whether currently developing one (41.9%) or there was no training (44.7%) p<0.05. The importance of hands-on experience was also evident by Day et al study and Smith-Miller [4],[10], showing no significant correlation between comfort level and knowledge before and after a tracheostomy in-service theoretical educational session. As a result we recommend to implement a scheduled formal training in each department which focuses on hands-on workshops more than theoretical educational sessions. In a randomized controlled trial on ninety- five qualified healthcare professionals (nurses and physiotherapists) in two acute hospitals were randomly allocated to receive either individualized performance feedback or no additional feedback after a standardized lecture and practical demonstration of tracheal suctioning, Those who received performance feedback had statistically significantly higher knowledge (P = 0004) and practice (P<001) scores. Further research is recommended to identify the amount and the type of the presented material as well as the different techniques of integration between theoretical and practical modalities, which ended by evaluating the feedback in many occasions to assess the sustainability.

On the other hand, the need for standardization of the clinical guidelines and the updates on the recommended practice cannot be underestimated as lack of knowledge of current best practice may result in staff making individual judgments regarding tracheostomy care [5]. In our study sample 46.8% were either not sure or they were not feeling up to date with the available evidence-based practice in tracheostomy management and the percentage increases to 64.4% regarding advances in tracheostomy. The lack of knowledge of the recommended practices noted in our study was also reported by Day T et al [4].

It was noted that the nurses’ level of confidence increased with their years of experience, up to 15 years; however, confidence declined after 15 years of experience (46.9%, 65.4%, 72.7%, and 61.3%, respectively) [8].

We also found that nurses who graduated from universities outside of Saudi Arabia (65.6%) were significantly more confident in their ability to manage most tracheostomised patients within their team p<0.05. This greater confidence may be attributed to different educational systems, different curricula, or variations in the content during different phases of learning such as undergraduate, intern year, or postgraduate education. This difference could also be considered a confounding variable. First, the years of experience of Saudi nurses in our study were less that the other group of nurses studied, and there was a statistically significant difference between experience level and confidence level. Further limiting the findings about Saudi nurses was the small number of such nurses in the study sample (34.4%). We recommend further research to shed light on the details of different approaches used in nursing schools in Saudi Arabia and their effect on nursing performance and knowledge.


  Conclusion Top


The majority of nurses were not very confident in the management of patients with tracheostomies, including patients who require ventilator assistance. Factors including experience level, presence of formal training in the department in which they were working, and the previous training levels were statistically associated with better confidence levels.

Acknowledgments

We thank the Department of Nursing staff, King Abdulaziz University Hospital and King Fahad Military Hospital, for their cooperation. Special thank for Mrs. Sharifah Mohidin who provided insight and expertise that greatly assisted the research, we also thank Dr. Adel Ibrahim for the comments regarding the statistical analysis that greatly improved the manuscript, although any errors are our own and should not tarnish the reputations of these esteemed persons.



 
  References Top

1.
Parker V, Giles M, Shylan G, Austin N, Smith K, Morison J, et al. Tracheostomy management in acute care facilities—a matter of teamwork. J Clin Nursing. 2010; 19: 1275-1283.  Back to cited text no. 1
    
2.
Paul F. Tracheostomy care and management in general wards and community settings: literature review. British Association of Critical Care Nurses. Nursing Critical Care. 2010;15:76-85.  Back to cited text no. 2
    
3.
Garner JM, Shoemaker-Moyle M, Franzese CB. Adult outpatient tracheostomy care: practices and perspectives. Otolaryngol Head Neck Surg. 2007; 136: 301-306.  Back to cited text no. 3
    
4.
Day T, Farnell S, Haynes S, Wainwright S, Wilson-Barnett J. Tracheal suctioning: an exploration of nurses’ knowledge and competence in acute and high dependency ward areas. J Adv Nurs. 2002; 39: 35-45.  Back to cited text no. 4
    
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Veelo DP, Schultz MJ, Phoa KY, Dongelmans DA, Binnekade JM, Spronk PE. Management of tracheostomy: a survey of Dutch intensive care units. Respir Care. 2008; 53: 1709-1715.  Back to cited text no. 6
    
7.
Al Sharhan S, Sohail M, Ahmad K, Siddiqui MI. Self-reported comfort with tracheostomy tube care. Cross- sectional survey of non-ear, nose and throat health care professionals. Saudi Med J. 2014; 35: 63-66.  Back to cited text no. 7
    
8.
Casserly P, Lang E, Fenton JE, Walsh M. Assessment of healthcare professionals’ knowledge of managing emergency complications in patients with a tracheostomy. Br J Anaesth 2007; 99: 380-383.  Back to cited text no. 8
    
9.
Wards EC, Jones C, Solley M, Cornwell P. Clinical consistency in Australian tracheostomy management. J Med Speech-Language Pathol. 2007;15(1): 7-26.  Back to cited text no. 9
    
10.
Yelverton JC, Nguyen JH, Wan W, Kenerson MC, Schuman TA. Effectiveness of a standardized education process for tracheostomy care. Laryngoscope. 2015; 125: 342-347.  Back to cited text no. 10
    
11.
Haines S, Crocker C, Leducq M. Providing continuity of care for patients transferred from ICU. Professional Nurse. 2001; 17: 17-21.  Back to cited text no. 11
    
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Smith-Miller C. Graduate nurses’s comfort and knowledge level regarding tracheostomy care. J Nurse Staff Develop. 2006;22:222-29.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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