TRACHEOSTOMY HYBRID SIMULATION EDUCATION2AbstractThis study aimed to evaluate the effects of a didactic plus hybrid simulation educationintervention on medical-surgical nurses’ knowledge and confidence levels when providingtracheostomy care. Current literature reports a general lack of confidence and knowledge ofevidence-based tracheostomy care practices amongst healthcare providers. A pretest-posttestdesign was used to study the effects of a brief didactic session combined with hybrid simulationon medical-surgical nurses’ knowledge and confidence test scores. Nineteen medical-surgicalnurses, 14 intensive care nurses, and three respiratory therapists at a small, rural hospital insouthwest Virginia participated in the study. Mean scores of confidence and knowledge beforeand after the education intervention were analyzed using paired t-tests. There was a statisticallysignificant difference in the pretest scores for knowledge and confidence compared to posttestscores for all nurses in the study. Years of experience and confidence pretest scores were foundto be positively correlated to current knowledge and confidence scores, r(34) .30, p .042. Nostatistically significant correlations were found among the other variables. Limitations to thisstudy included the small sample size and limitation to one hospital. Tracheostomy care is animportant technical skill that must be performed safely and appropriately to prevent patientcomplications. The study results contribute to the development of best practices when teachingthe important skill of tracheostomy care to increase healthcare providers’ knowledge andconfidence levels and improve patient outcomes.Keywords: nursing care, tracheostomy, simulation, confidence, knowledge

TRACHEOSTOMY HYBRID SIMULATION EDUCATION3Table of ContentsAbstract . 2CHAPTER ONE. INTRODUCTION . 4CHAPTER TWO. LITERATURE REVIEW . 11CHAPTER THREE. METHODOLOGY . 21CHAPTER FOUR. RESULTS . 29CHAPTER 5. DISCUSSION . 35References . 49Appendix A- Permission letter from LewisGale Hospital Alleghany . 54Appendix B- Theoretical Framework Diagrams . 55Appendix C- PRISMA Flow Diagram . 56Appendix D- Literature Review Tables . 57Appendix E- Tracheostomy Pretest Study Instrument . 75Appendix F- Tracheostomy Neck Piece Simulated Task Trainer . 87Appendix G- NLN Simulation Design Template. 88Appendix H- Research Compliance Office, Not Human Subjects Determination . 98List of TablesTable 1- Paired samples t-test results for All Study Participants . 30Table 2- Paired samples t-test results for Medical Surgical Nurses . 30Table 3- Paired samples t-test results for Intensive Care Nurses . 31Table 4- Paired samples t-test results for Respiratory Therapists 31Table 5- Pearson Correlations Among Knowledge and Confidence Scores .32Table 6- Descriptive data comparing pretest posttest scores .33

TRACHEOSTOMY HYBRID SIMULATION EDUCATION4The Impact of Hybrid Simulation Education on Medical-Surgical Nurses’Knowledge and Confidence in Tracheostomy CareCHAPTER ONE. INTRODUCTIONPatients are vulnerable to potentially serious complications when undergoing high riskhealthcare procedures such as tracheostomy care and suctioning. Approximately 1,000 serioustracheostomy related adverse events occur in the United States every year, with 500 of thoseincidents resulting in death (Klemm & Nowak, 2017). Tracheostomy care and suctioning arehigh-risk nursing skills often learned during students’ undergraduate education. Decreasedknowledge and skill in tracheal suctioning is evident in practicing nurses, not just undergraduatestudents (Day et al., 2009). These deficits in knowledge and skill competency in trachealsuctioning are significant in healthcare because they lead to patient harm, such as hypoxia,tracheal irritation, bleeding, cardiac dysrhythmias, infection, and even cardiac death(Mwakanyanga et al., 2018).Educational interventions involving simulation have positive effects on knowledge andconfidence of healthcare providers (Harjot et al., 2016). Many of these studies reportedly utilizedexpensive mannequin simulators requiring operator training and storage space when not used inan on-site simulation laboratory. A unique aspect of this study is the use of hybrid simulation,which combines more than one simulation modality during one educational session. This projectcombined a low-fidelity task trainer (Appendix F) with a standardized patient resulting in a highfidelity simulation experience. The mobile task-trainer is low-cost and eliminates the need for anexpensive simulator and the cost of operator training. Using the concepts from simulation theoryand the International Nursing and Clinical Simulation and Learning (INACSL) best practice

TRACHEOSTOMY HYBRID SIMULATION EDUCATIONstandards, high quality simulation is possible with hybrid simulation methodology that is morecost-effective and feasible for hospitals.Background and SignificanceTracheostomy care and patient safety became a worldwide focus in 2012 with theformation of the National Tracheostomy Safety Project (NTSP) in the United Kingdom. TheNTSP began when a small group of physicians wanted to improve the care of tracheostomypatients who suffered complications, many times due to lack of knowledge of providers (NTSP,n.d.). The NTSP took a multidisciplinary approach to tracheostomy care by focusing on the keysteps to prevent tracheostomy related emergencies, including training frontline staff, ensuringbasic care was done well with adequate equipment, considering where these patients aremanaged within the healthcare system, and involving patients and families in their care (NTSP,n.d.). The Global Tracheostomy Collaborative (GTC) was also initiated in 2012 to addresstracheostomy patient safety around the world through individual and institutional networking toshare resources and information (GTC, 2020). The GTC reported that multidisciplinary teamtraining/education and collaboration while collecting and evaluating data about patient care arenecessary to improve patient safety.Cheung and Napolitano (2014) reported that the number of tracheostomies in the UnitedStates increased from approximately 64,000 to over 100,000 from 1996 to 2014. Furthermore,the current COVID-19 pandemic is an evolving healthcare emergency. The number of patientsrequiring prolonged mechanical ventilation and tracheostomies due to this virus is currentlyunknown. If the current pandemic is protracted, issues of tracheostomy care integrity couldbecome even more salient. The timing of this project is paramount to improve patient outcomes5

TRACHEOSTOMY HYBRID SIMULATION EDUCATION6by educating nurses on the best care practices for tracheostomy patients suffering fromrespiratory related complications.Regardless of the extent of the current crisis, tracheostomy care will continue to be anissue to address, as it has been in recent years. Tracheostomy care education, particularly in nonotolaryngology healthcare providers, has been studied over the past two decades. Studiesconducted over the past two decades report the further need for tracheostomy care education.Historically nurses have reportedly learned tracheostomy care skills “on-the-job” from practicingnurses. Dorton et al. (2014) reported that calling the otolaryngologist in addition to the code teamwhen a patient emergency occurs involving a tracheostomy is appropriate, but most airwayemergency treatment and troubleshooting should be initiated by the bedside nurse as firstresponder. Therefore, it is imperative that medical-surgical nurses be competent in tracheostomycare and how to handle tracheostomy related emergencies.Problem StatementIn southwest Virginia, a small hospital has employed an otolaryngologist who will beperforming tracheostomies, a new procedure for the medical-surgical healthcare team. There wasa current need for continued tracheostomy education for all of the medical-surgical nurses in thishospital. Nurses working in non-critical care areas report a lack of knowledge and confidencewhen caring for patients with tracheostomies (Day et al., 2009). Tracheostomy care is considereda high-risk, low-volume procedure (Harjot et al., 2016). Studies by Clec’h et al. (2007) andMartinez et al. (2009) reported that mortality rates of tracheostomy patients increased whendischarged from intensive care units to medical-surgical floors. Deficient knowledge ofevidence-based tracheostomy care is shown as a major contributing factor (Dorton et al., 2014).

TRACHEOSTOMY HYBRID SIMULATION EDUCATION7Current literature suggests there is a lack of evidence-based clinical practice when nursescare for patients with tracheostomies (Harjot et al., 2016). Deficient tracheal suctioning skillperformance amongst nurses is a patient safety concern (Harjot et al., 2016). Identifying methodsto teach those best practices is necessary to improve skill performance. Studies suggest thatperformance feedback and simulation improve knowledge and skill retention over time (Harjot etal., 2016). Simulation is an evidence-based teaching methodology used to improve assessment,critical thinking, and technical skills (Davis, 2019). This study combined didactic teaching withhybrid simulation to address the need to improve nurses’ knowledge and confidence levels withevidence-based tracheostomy care.Purpose Statement, Research QuestionThe purpose of this study was to evaluate the effectiveness of didactic plus hybridsimulation education on medical-surgical nurses’ knowledge and confidence when caring fora patient with a tracheostomy. Research is lacking in studying the effects of hybrid simulationcombining the use of low-cost task trainers with standardized patients for hospital continuingeducation. The study answered the following PICO question: For medical-surgical nurses(Population), how does a tracheostomy education session with simulation (Intervention) affectpost-intervention knowledge and confidence scores (Outcomes) compared to pre-interventionscores (Comparison)? The independent variable was a simulation education intervention.Dependent variables were knowledge and confidence scores of medical-surgical nurses. Thenull hypothesis was there was no significant relationship between tracheostomy educationwith hybrid simulation and knowledge and confidence scores before and after the educationsession.

TRACHEOSTOMY HYBRID SIMULATION EDUCATION8Theoretical FrameworkBandura’s self-efficacy theory provides the primary theoretical framework for this study.Self-efficacy is the belief in one’s ability to take action to overcome challenges and completetasks appropriately. The formal definition of the theory states self-efficacy leads to behavioralchanges, completion of performance tasks, and overall personal well-being (Bandura, 1997). Apictorial diagram of Bandura’s self-efficacy theory is included in Appendix B. Applied tohealthcare, Bandura’s self-efficacy theory postulates that believing in one’s ability leads totaking appropriate actions to achieve positive patient outcomes. Confidence is one of sixconstructs in this theory that was operationalized using a self-efficacy questionnaire in this study.Confidence along with knowledge were two dependent variables measured in this pilot study thattheorized that increased confidence and knowledge will lead to appropriate care of tracheostomypatients using evidence-based guidelines for tracheostomy care.Knowledge, another study variable, is the acquisition of information through education orexperience. A brief didactic presentation plus simulation provided the opportunity for learners toacquire the knowledge needed to care for tracheostomy patients safely. Simulation enhancesknowledge and confidence through experiential learning in a realistic practice setting withoutdanger of harm to real patients. The National League for Nursing (NLN) Jeffries simulationtheory proposes that an evidence-based simulation experience that provides opportunity for skillpractice and knowledge acquisition results in improved learning outcomes. This simulationtheory was used to design the simulation component of the education intervention. The appliedassumption of using this theory to guide the development of the simulation intervention is that awell-designed simulation session will help learners acquire the knowledge and confidenceneeded to care for patients with tracheostomies. Coupled with Bandura’s theory, the researcher

TRACHEOSTOMY HYBRID SIMULATION EDUCATION9anticipated knowledge acquired through simulation learning will result in increased confidenceto improve tracheostomy care resulting in positive patient outcomes.The NLN Jeffries simulation theory is a new theory in nursing education. The Jeffriessimulation framework demonstrated relationships between identified concepts in simulation andbecame a middle range theory in 2015. The concepts in this theory are context, background,design, the simulation experience, facilitator and educational strategies, participants, andoutcomes (Jeffries, 2016, p. 40). Each concept consists of several factors (Appendix B, Figure 2).The context, background, and design influence the effectiveness of the simulation experience.With more appropriate planning in the design phase, the more pertinent and worthwhile thesimulation experience is for the learner. Within the simulation experience, the interaction of thefacilitator and participant is dynamic and learning must occur in order to result in a positiveoutcome.In order to achieve this positive outcome, each concept of the Jeffries theory wasincluded in the design of the hybrid simulation education in this study in a structured, intentionalmanner. Incorporating every concept ensures the simulation experience is experiential,collaborative, and learner centered. The concept of context encompasses the entire simulationexperience. The context (setting) for the study was a rural hospital setting. The concept ofbackground consists of learning objectives, time, and equipment. The learning objective was toincrease the knowledge and confidence levels of medical-surgical nurses in performingtracheostomy care according to evidence-based guidelines. The time for the study was estimatedto occur over four or five educational sessions. Equipment needs were minimal. Hybridsimulation equipment was already available along with the innovative task trainer. Space wasreserved for the educational session through coordination with the hospital’s clinical educator.

TRACHEOSTOMY HYBRID SIMULATION EDUCATION10The simulation design was high fidelity with realistic moulage. The study incorporated all theattributes of the simulation experience concept by being experiential, collaborative, and learnercentered. The concept of facilitator and educational strategies was met by involving dynamicinteraction between a certified healthcare simulation educator (the researcher) and nurse learners.The independent variable, an educational intervention, in the research question aligned with thisconcept. The concept of participants involves attributes such as level of anxiety and selfconfidence and role assignments. Participants are all medical-surgical nurses. Anxiety and selfconfidence were relieved by facilitator experience in promoting an environment conducive tolearning. The concept of outcome may be at the participant, patient, or system level. This studyfell under the participant level on the outcomes pyramid. Ideally, future research will beconducted to evaluate the effect of competent tracheostomy care on individual patient outcomesand hospital-wide outcomes. In this study, the desired participant level outcomes were increasedknowledge and confidence.A recent study utilizing the Jeffries simulation theory discussed the effects of simulationon the competency of medication administration in nursing students. The authors discussed howthe context, design, and facilitator strategies resulted in demonstrated competence of medicationadministration by the nursing students in the study (Jarvill et al., 2018). The principles ofthoughtful planning of simulation activities along with the INACSL standards for best practiceyield the best results when applied to the simulation experience concept of the Jeffries simulationtheory. This study utilized this theory in designing the simulation education intervention with theaim of improving knowledge and confidence.

TRACHEOSTOMY HYBRID SIMULATION EDUCATION11CHAPTER TWO. LITERATURE REVIEWA review of the literature revealed a variety of education intervention strategies utilizedto study the effects on knowledge and confidence of tracheostomy management. The literaturereview aided in establishing the design and appropriateness of the didactic plus simulationintervention and measurement of knowledge and confidence as dependent variables. This sectiondiscusses the factors that were considered when developing the education intervention anddesign of the study. Refer to the integrated/synthesized tables of evidence in Appendix D fordetailed information of the review of studies discussed in this section.Search Strategies and Search OutcomesAn integrative review of the literature was first conducted using the super search optionthrough Radford University’s McConnell Library. The super search option includes relevantfields of study pertinent to this project including the healthcare, psychological, behavioral, andsocial sciences. Keywords in the search included tracheostomy, nurse, simulation, andknowledge using the scholarly, peer-reviewed filter in the 2015-2020 date range. The Cochrane,OVID Medline, PubMed, and CINAHL databases were searched with confidence” and“simulation” included as additional keywords. Finally, a hand search through relevant articlereferences, specialty journals, and Google Scholar with the same keywords and filters wasconducted. After duplicates were removed and irrelevant articles were excluded, 14 articles wereincluded in this literature synthesis. Inclusion criteria were articles discussing tracheostomymanagement, and pre and post licensure nurses, physicians, healthcare students, respiratorytherapists, speech therapists, physical, and occupational therapists. Though reviewing articleswith a simulation education intervention versus general education for practicing nurses was thefocus, the inclusion criteria were broad as there was not a large number of articles pertaining to

TRACHEOSTOMY HYBRID SIMULATION EDUCATION12such a specific focus, indicating a need for further research in the area of simulation education inacute care. The PRISMA diagram and search summary table are located in Appendices C and D.An identified lack of randomized controlled studies on the best way to educate healthcareprofessionals on tracheostomy care also exists. The majority of the reviewed studies were LevelIV evidence studies. Two studies were ranked as level III, one study ranked as level II, and onesystematic review was included in this review. Levels of evidence in the summary table inAppendix D are based on the Melnyk and Fineout-Overholt (2015) rating system.Effective Education Interventions for Tracheostomy CareEducation Modality and Its EffectsDifferent educational modalities have been used to improve the learners’ knowledge andconfidence with tracheostomy care, including didactic lectures, simulation, and didactic plussimulation sessions.Didactic. Several studies used didactic lecture-type education as the education modalityand most studies reported increased knowledge and confidence right after the education.Colandrea and Echkardt (2016) reported statistically significant differences in the group meansof pretest and posttest scores of comfort and competency following a lecture with p 0.001.Thirty-six nurses participated in the study to look for the effect of lecture on comfort andcompetence (Colandrea & Echkardt, 2016). Similarly, Harjot et al. (2016) also reported thatposttest knowledge and skill scores increased after use of didactic education.Didactic and Simulation. Dorton et al. (2014) reported increases from pre to postknowledge and comfort scores with p 0.0001 for both variables following the use of a didacticand simulation educational intervention. Similarly, Mehta et al. (2019) reported statisticallysignificant increases in knowledge and comfort scores following a didactic teaching session with

TRACHEOSTOMY HYBRID SIMULATION EDUCATION13simulation, but the knowledge scores were not statistically significant at 6 months postintervention, indicating the need for re-training every 6 months. Furthermore, Davis et al. (2019)measured skill performance in addition to knowledge and confidence following a didactic plussimulation education session. The authors reported a statistically significant increase from pretestto posttest scores when assessing physicians’ knowledge, skill, and comfort with tracheostomycare (p 0.009 comfort, p 0.001 knowledge, p 0.001 skill) (Davis et al., 2019).The McDonough et al. (2016) study, which reported increased knowledge andconfidence of nurses, included the largest sample size of 1,450 hospital nurses that completedhands-on training about tracheostomy care followed by online tutorials. After the intervention,the knowledge and confidence increased. An inference from these findings is that the combineddidactic plus low-fidelity hands-on simulation session was effective in improving knowledge andconfidence in a short timeframe versus hours or days of training.Sandler et al. (2020) reported increased confidence scores post intervention with didacticplus hybrid simulation when using a low-cost tracheostomy task-trainer in settings with limitedresources. This finding implies that high-cost mannequin simulators and equipment may not benecessary for improving knowledge and confidence of providers and that high-fidelity educationwith a task-trainer can still improve knowledge and confidence of tracheostomy care.Simulation: low fidelity versus high fidelity. Two studies reported using simulationonly in the education intervention. Bayram and Caliskan (2019) reported using a virtual realityapplication to teach tracheostomy care to nursing students, and the knowledge scores were notstatistically significant. When using high-fidelity scenarios with virtual simulation, statisticallysignificant increases in knowledge and confidence were reported (Goldsworthy et al., 2019).These findings indicate that meaningful learning occurred when incorporating high fidelity

TRACHEOSTOMY HYBRID SIMULATION EDUCATION14scenarios requiring clinical reasoning. Low-fidelity task trainers are effective for psychomotorskill acquisition. Al-Qadhi et al. (2014) concluded that an innovative chest-tube insertion tasktrainer was superior to large and expensive mannequin simulators when teaching the skill topediatric physicians. An inference from the study is that lower cost task trainers may be just as ormore effective than traditional expensive mannequin simulators for psychomotor skill training.Low-fidelity task trainers combined with other simulation modalities in a hybrid manner can beused to provide a more realistic, or higher fidelity, simulation experience versus a lower fidelitysimple skill check-off.Duration and Frequency of Education SessionsA relationship may exist between the length and frequency of the education interventionand its effects on knowledge and confidence. The literature review revealed that the duration andfrequency of the education interventions ranged from 30 minutes to 4 months. Yelvert et al.,(2015) and Colandrea and Eckardt (2016) used a didactic-only approach through 45 minutes to 1hour of lecture, and knowledge and confidence increased in both of these studies. When nursesin Japan completed a 4-month-long educational program to achieve tracheostomy carecertification, statistically significant improvements in patient complications, ICU readmissions,decannulations, and lengths of hospital stay occurred (Sodhi et al., 2014). However, mosthospitals that do not regularly treat patients with tracheostomies very often do not have theresources and time to certify all nurses. Perhaps hospitals could consider training tracheostomynursing care specialists to serve on a multidisciplinary care team and provide in-services andongoing staff education for other nurse and providers. Many hospitals are considering this teambased approach but are located in urban areas with larger hospitals (Davis, 2019).

TRACHEOSTOMY HYBRID SIMULATION EDUCATION15Timing of Variable MeasurementIn most studies, measurements of the study outcomes occurred at the time of theeducation intervention up to 6 months post-intervention. When outcome variable (knowledge,confidence, and/or skills) measurement occurred immediately following the interventioncompared to 6 months post-intervention, knowledge levels increased significantly no matter thetimeframe in all studies except one. The effect of education has shown to persist over 6 months.Mehta (2019) studied the effects of a didactic and simulation education intervention on medicalresidents’ post-session levels of knowledge and confidence with tracheostomy management.Post-session knowledge scores at 6 months remained increased although it was not statisticallysignificant (Mehta, 2019). The reason for the lack of a statistically significant change inknowledge is not discussed, though several reasons exist such as exposure and experience withtracheostomy patients during the 6-month timeframe. One conclusion is that confidence levelsare not always indicative of knowledge attainment and retention. This study analyzed bothknowledge and confidence scores.Study VariablesKnowledgeThe predominant dependent variables in the reviewed studies are knowledge andconfidence of tracheostomy care. A few studies included skill performance as an outcome. Skillwas not measured in this study due to time and feasibility. Skill measurement in small groups ofnurses may result in distorted metrics as psychomotor skills are individually assessed on mostchecklists. The exclusion of skill measurement did not appear to affect the significance ofknowledge and confidence level scores in several studies (Colandrea & Echardt, 2019; Gaur &

TRACHEOSTOMY HYBRID SIMULATION EDUCATION16Mudgal, 2018; Goldsworthy et al., 2019; McDonough et al., 2016; Mehta, 2019; Sandler et al.,2020; Smith-Miller, 2006; Sodhi et al., 2014; Yelver et al., 2015).The effect of the education intervention on knowledge was measured in this study. Inthis literature review, statistically significant increases in knowledge levels post-interventionwere reported in all studies that measured this dependent variable except one study utilizingvirtual reality (Bayram & Caliska, 2019). Knowledge retention was also a factor reported inseveral studies. Knowledge was reportedly retained in studies that measured posttest scores againat 6 months. However, the literature does not mention collecting information on whether thesestudy participants who retained knowledge also gained experience and exposure to tracheostomypatients during the posttest and 6-month repeat posttest time periods. The effect of experienceand exposure was collected in most studies as a demographic variable, but the literature islacking in how influential this experience is on the retention of knowledge as opposed to theeducation interventions alone. Skills must be practiced to be maintained, so the question fornurse leaders is how often continuing education should be conducted to maintain staff nursecompetency. Most hospitals implement annual competencies. Future research to determine theadequacy of annual training is necessary. In Yelverton et al.’s (2014) study, nurses andphysicians retained tracheostomy care knowledge; however, these study participants reportedlyhad frequent exposure to tracheostomy patients. This finding leads to the question of whichvariable is more effective over time. Whether the educational intervention or frequent exposureand experience is more effective needs to be studied. A comparison study of the degree ofdifference in k

Radford University DNP Final Scholarly Project . TRACHEOSTOMY HYBRID SIMULATION EDUCATION 2 Abstract . and the International Nursing and Clinical Simulation and Learning (INACSL) best practice . TRACHEOSTOMY HYBRID SIMULATION EDUCATION 5 standards, high quality simulation is possible with hybrid simulation methodology that is more .