INT J LANG COMMUN DISORD, JANUARY/FEBRUARY 2020,

VOL. 55, NO. 1, 70–84

Research Report
Evaluation of a tracheostomy education programme for speech–language
therapists
Anna Miles† , Lucy Greig‡, Bianca Jackson† and Melissa Keesing§
†Speech Science, The University of Auckland, Auckland, New Zealand
‡The University of Canterbury Rose Centre for Stroke Recovery and Research, Christchurch, New Zealand
§Starship Children’s Hospital, Auckland District Health Board, Auckland, New Zealand
(Received April 2019; accepted September 2019)

Abstract
Background: Tracheostomy management is considered an area of advanced practice for speech–language therapists
(SLTs) internationally. Infrequent exposure and limited access to specialist SLTs are barriers to competency
development.
Aims: To evaluate the benefits of postgraduate tracheostomy education programme for SLTs working with children
and adults.
Methods & Procedures: A total of 35 SLTs participated in the programme, which included a 1-day tracheostomy
simulation-based workshop. Before the workshop, SLTs took an online knowledge quiz and then completed a
theory package. The workshop consisted of part-task skill learning and simulated scenarios. Scenarios were video
recorded for delayed independent appraisal of participant performance. Manual skills were judged as (1) completed
successfully, (2) completed inadequately/needed assistance or (3) lost opportunity. Core non-medical skills required
when managing a crisis situation and overall performance were scored using an adapted Ottawa Global Rating
Scale (GRS). Feedback from participants was collected and self-perceived confidence rated prior, immediately post
and 4 months post-workshop.
Outcomes & Results: SLTs successfully performed 94% of manual tasks. Most SLTs (29 of 35) scored > 5 of 7 on
all elements of the adapted Ottawa GRS. Workshop feedback was positive with significant increases in confidence
ratings post-workshop and maintained at 4 months.
Conclusions & Implications: Postgraduate tracheostomy education, using a flipped-classroom approach and low-
and high-fidelity simulation, is an effective way to increase knowledge, confidence and manual skill performance
in SLTs across patient populations. Simulation is a well-received method of learning.

Keywords: tracheostomy, speech–language therapy, simulation, education.

What this paper adds

What is already known on the subject
Tracheostomy management is considered an area of advanced practice for SLTs internationally, but competency
development is difficult for many owing to low patient numbers and poor access to specialist supervision. Simulation
has shown benefits in low-frequency, high-risk patient populations.

What this paper adds to existing knowledge

SLTs are positive about simulation and gained confidence, knowledge and tracheostomy-specific skills with an online
theoretical package and a 1-day simulation workshop.

Address correspondence to: Anna Miles, Speech Science, School of Psychology, The University of Auckland, Private Bag 92019, Auckland,
New Zealand; e-mail: a.miles@auckland.ac.nz
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online  C 2019 Royal College of Speech and Language Therapists

DOI: 10.1111/1460-6984.12504
Tracheostomy simulation for SLTs 71

What are the potential or actual clinical implications of this work?

SLTs often have limited on-the-job opportunities to develop competency in tracheostomy management. Simulation
is a well-received mode of learning and the present study suggests participants build adequate skills to feel confident
to practice and engage with their multidisciplinary team.

Introduction tion and teamwork (MacBean et al. 2013, Shorland et al.

2018, Ward et al. 2014).
Tracheostomy management is considered an area of ad-
Despite its longevity in medical education, the use
vanced practice for speech–language therapists (SLTs)
of simulation in SLP education, at both undergraduate
internationally (New Zealand Speech–Language Thera-
and postgraduate levels, has seen rapid growth only in
pists’ Association 2015, Royal College of Speech and
the last 5 years (Dudding and Nottingham 2018). In an
Language Therapists 2014, Speech Pathology Aus-
Australian review paper, low-fidelity simulation modes
tralia 2013). Caring for a child or adult with a tra-
(e.g., written case studies and peer learning) were the
cheostomy requires a highly skilled and knowledge-
most frequently used simulation techniques with high-
able multidisciplinary team including SLTs (Bedwell
fidelity simulated learning environments (e.g., use of
et al. 2019, Mah et al. 2017, Watters 2017). In addi-
computerized interactive manikins) much less common
tion to competent tracheostomy-specific manual skills
(MacBean et al. 2013). Internationally, simulated learn-
(such as placing a speaking valve), SLTs need advanced
ing is becoming more widely accepted within the profes-
leadership, communication and reasoning skills in line
sion, especially within graduate SLP training (Dudding
with the medical complexity of patients who require
and Nottingham 2018, MacBean et al. 2013). This is
tracheostomies.
in part due to a small but growing body of evidence
More than 7000 patients receive a tracheostomy
(Butina et al. 2013, Hill et al. 2013, Miles et al. 2015,
each year in Australia and New Zealand (Garrubba et al.
2016, Rose et al. 2017, Shorland et al. 2018, Wagner
2009). This equates to only 4–10% of adults admitted to
2016, Ward et al. 2014, 2015) as well as an increase
Australian tertiary hospital intensive care units (ICUs)
in access to specialist simulation centres (Dudding and
with even fewer patients reaching provincial hospitals
Nottingham 2018). Miles et al. (2016) demonstrated en-
(Choate et al. 2009, Freeman-Sanderson et al. 2011).
hanced clinical reasoning and self-reported confidence
Fewer children receive a tracheostomy with the proce-
and knowledge in SLP and dietetic students following
dure being performed in < 3% of patients (Watters
two half-day simulation workshops in adult and paedi-
2017). Opportunities for practitioners to gain specialist
atric inpatient dysphagia assessment. Ward et al. (2015)
skills within a clinical setting can be limited, and achiev-
compared students’ perceptions of anxiety, confidence,
ing competency can take time. This is particularly ev-
clinical skills and clinical readiness relating to paediatric
ident in low-density populations such as many regions
dysphagia management after completing a traditional
of New Zealand (Burgess et al. 2016). Infrequent expo-
academic curriculum compared with completing addi-
sure to patients with tracheostomies and limited access
tional human patient simulation sessions. They found
to specialist SLTs for work-shadowing, supervision and
that although lectures were perceived to be effective in
mentoring are barriers (Rose et al. 2017). One teaching
increasing knowledge, skills and confidence, the use of
and learning method that offers an alternative to on-
simulation scenarios resulted in further significant per-
the-job training is simulation-based learning (MacBean
ceived gains in all three areas.
et al. 2013).

Simulation in speech–language pathology Simulation in advanced practitioner skill training

Simulation has been used for over 100 years in nurs-
ing and medical education. It has been described as
a learner-centric educational technique that integrates
cognitive, psychomotor and affective domains, training
both manual and procedural skills in a highly realis-
tic but non-threatening and safe environment (Rodgers
2007). A substantial body of evidence demonstrates
positive learner outcomes including: successful trans-
fer of skills into clinical practice, long-term retention
of knowledge, reduced anxiety in managing complex
patients, and improved clinical reasoning, communica-
At a postgraduate level, use of simulation is well-
established in specialized medical settings such as criti-
cal care incident team training. However, simulation in
SLP postgraduate education is still emerging. Ward et al.
(2014) evaluated the acquisition of tracheostomy com-
petency in 42 SLTs attending a well-established com-
prehensive 1-day simulation course. SLTs demonstrated
competent performance in manual skills as well as clini-
cal reasoning by the end of the course. Courses were well
received, and participants reported increased confidence
up to 4 months post-training.
72
Simulation (particularly high-fidelity simulation) is
labour intensive and can be costly (Dudding and Not-
tingham 2018, Ward et al. 2014). In order to jus-
tify the development of such training opportunities,
more research is needed. The University of Auck-
land Tracheostomy Workshop (endorsed by the New
Zealand Speech–Language Therapists’ Association) has
been running annually since 2010 and incorporated
simulation in 2012. This workshop, while originally
designed based on the successful course held in Queens-
land (Ward et al. 2014), uses original materials (includ-
ing simulated scenarios) and uniquely covers both pae-
diatric and adult tracheostomy management.
This study evaluated 3 years of the New Zealand Tra-
cheostomy Education Programme. Research questions
included: (1) Are SLTs satisfied with the Tracheostomy
Education Programme?, (2) Do SLTs gain manual tra-
cheostomy skills, as well as tracheostomy-specific knowl-
edge, advanced leadership, communication and reason-
ing skills from the Education Programme?; (3) Is there
a change in SLTs self-perceived confidence and com-
petence following the Tracheostomy Education Pro-
gramme?; and if so (4) Is this change in self-perceived
confidence and competence maintained 4 months after
the Tracheostomy Education Programme? In addition,
we collated data on the frequency of tracheostomy man-
agement in SLTs in New Zealand and perceived barriers
to tracheostomy competency development.
Methods
This study was approved by an appropriate ethics com-
mittee (UAHPEC/013051) and all participants pro-
vided written informed consent.
Participants
A total of 35 SLTs participated in the Tracheostomy
Education Programme, which included attending one
of three 1-day tracheostomy simulation workshops in
Auckland offered in 2015, 2016 and 2017. All con-
sented to participating in the study (n = 35). Pro-
gramme participation was limited to a maximum of
12 participants per year. The programme was advertised
via the New Zealand Speech–Language Therapists’ As-
sociation and participants were accepted on a first-come,
first-serve basis. No previous tracheostomy management
experience was required.
Educational package
The education programme aimed to prepare SLTs for
confident, competent tracheostomy management either
with paediatrics, adults or across the lifespan depending
on the participant’s personal choice on registration. It
Anna Miles et al.
was created by the researchers, all experienced SLTs and
experienced educators, and was designed with a ‘flipped
classroom’ teaching model (McLaughlin et al. 2014).
It comprised of an online module, a 1-day simulation-
based workshop and ongoing online support.
Online module
Six weeks before the workshop, participants gained ac-
cess to the programme website to complete the theo-
retical online module. First, the participants were re-
quired to complete a 20-question general knowledge
quiz on tracheostomy management. This enabled facil-
itators to gauge participants’ prior knowledge. Partici-
pants were then provided with their online theoretical
training module created in CourseBuilder (Apache 2.0,
The University of Auckland). This comprised of a com-
pulsory reading list (10 texts including policy papers,
original research articles, opinion papers and webinars)
with a primary focus on paediatrics or adults at the
participant’s discretion. Participants had access to ad-
ditional recommended readings, relevant websites and
webinars, as well as programme resources. Participants
were requested to retake the 20-question tracheostomy
general knowledge quiz (receiving automated feedback
this time) until they achieved 100%. The online mod-
ule was peer reviewed by four experienced SLTs in the
field and modified based on feedback. The module is
reviewed by the educators annually to ensure it remains
up to date.
Workshop contents
The 1-day workshop took place at the specialized
university-based Simulation Centre for Patient Safety
and comprised of three components: part-task skill
learning, orientation to the ward environments and
high-fidelity simulated scenarios. Five experienced SLTs
and four experienced simulation centre technicians fa-
cilitated the workshop. All five SLTs were experienced in
simulation training. Three simulation technicians were
experienced nurses now specializing in simulation train-
ing. The fourth staff member, the director of simulation-
based training centre, was an experienced anaesthetist
who oversees the centre.
Part-task skill training
Participants worked through eight part-task manual skill
stations with an emphasis on repeating each task as many
times as possible within a 15-min time frame (table 1).
These skills represented key manual skills required by
SLTs working in tracheostomy management and all sit
within SLP scope of practice in New Zealand. Partici-
pants completed all skill stations. While some skills were
Tracheostomy simulation for SLTs
Table 1. Part-task manual skill stations
1 Cuff inflation and deflation
2 Blue dye test
3 Speaking valve placement—paediatric
4 Speaking valve placement—adult
5 Suction aid tracheostomy—suctioning above the cuff and
speaking through a suction aid
6 Identifying tracheostomy tube types
7 Oral suctioning
8 Inner cannula changes and digital/finger occlusion of stoma
generic, others were specifically paediatric or adult-based
skills. Facilitators interacted with participants at each
station (figure 1).
Orientation to the ward environment
Participants were orientated to the simulated environ-
ments (a paediatric ward, a child’s home and an adult
high-dependency unit) as per standard simulation pro-
tocol (Rodgers 2007). Participants completed a ‘trea-
sure hunt’ in order to locate equipment that is typi-
cally used in tracheostomy management, for example,
Figure 1. Examples of skill stations. [Colour figure can be viewed at wileyonlinelibrary.com]
73
tracheostomy tube and inner cannula, suction catheters,
syringes. Following this, participants observed a 20-
min exemplar scenario acted out by the facilitators
demonstrating process and scope of interaction with
the manikins and confederates (actors).
High-fidelity-simulated scenarios
Participants took part in 4 h of small group high-fidelity-
simulated learning either in paediatric or in adult sce-
narios (table 2). Participants requesting both paediatric
and adult scenarios switched at a natural midway point
(i.e., when the simulated patient was being seen in a new
health setting, for example, acute ward to rehabilitation
ward). Through careful scenario planning, facilitators
attempted to maximize participants’ opportunities to
practise manual skills as well as challenging clinical rea-
soning, leadership and communication. The number of
opportunities individual participants had to complete
manual skills across the 3 years are displayed in figure 2.
Although scenarios were not fixed and reacted to the par-
ticipants’ lead, several critical incidents/stress tests were
inserted where appropriate (table 2).
74 Anna Miles et al.
Table 2. Simulated scenarios

Scenario features
‘Victoria/Victor’a adult scenario ‘Bob’ infant scenario ‘Ava’ paediatric scenario

Case details
31-year-old man, post-excision of a brainstem 4-month-old infant with complex cardiac 4-year-old girl with complex medical history.
tumour condition and congenital subglottic Tracheostomy placed as a neonate.
stenosis Gastrostomy secondary to aspiration both
antegrade and retrograde
Patient
R  R
Manikin (Laerdal SimMan 3G) (Phases 1–5) Manikin Laerdal SimBaby (Phases 1–2) Manikin (Laerdal SimJunior) (Phases 1–4)
 R
Standardized patient (Phases 6–10) with Manikin Laerdal SimJunior (Phases
tracheostomy inserted into fake skin (figure 3) 3–6)
Staff
Administrative roles: Administrative roles: Administrative roles:
Facilitator: in observation room with Facilitator: in observation room with Facilitator: in observation room with
participants participants participants
Clinical expert: instructing technician and Technician: providing infant’s voice in Technician: providing child’s voice in
providing patient voice over (figure 3) line with patient, confederate and line with patient, confederate and
participant actions participant actions
Technician: changing vital signs in line with Confederates: Confederates:
patient, confederate and participant Mother Mother
actions PICU nurse
Confederates: Community nurse
Nurse
Neurosurgeon: via telephone
ORL surgeon: via telephone
Phases
Acute: Acute and community: Community:
Phase 1: Day 4 post-surgery (first day after Phase 1: post-surgery in PICU (blue Phase 1: Recently home (blue dye test as part
transfer from ICU to HDU) dye test as part of swallowing of swallowing assessment)
Phase 2: Day 6 post-surgery assessment) Phase 2: 1 week later (digital occlusion)
Phase 3: Day 13 post-surgery (transferred to Phase 2: Recently home (blue dye test Phase 3: 1 week later (speaking valve
general neurosurgical ward) as part of swallowing assessment) assessment and trial)
Phase 4: Day 15 post-surgery Phase 3: 2 months later Phase 4: two months later (speaking valve
Phase 5: Day 16 post-surgery (communication assessment, no air assessment post-surgery)
Rehabilitation: leak)
Phase 6: 1 month post-surgery (speaking Phase 4: 1 month later
valve trial) (communication assessment, air
Phase 7: 1 day later (speaking valve review) leak and trial of digital occlusion)
Phase 8: 1 week later (swallowing assessment) Phase 5: 2 months later (speaking
Phase 9: 1 day later (swallowing review) valve assessment)
Phase 10: 3 months later (rehabilitation Phase 6: 2 months later (not tolerating
ward—meal observation) speaking valve)
Expected procedural skills
Behavioural objective:
Practice within own (SLT) scope of practice and understands the scope of other team member’s practice when managing patients with
tracheostomies
Technical objectives:
Apply a systematic approach to
(1) assessment of secretion management/readiness for cuff deflation;
(2) assessment of swallow function; and
(3) tracheostomy removal (as appropriate)
Plus:
Optimize communication through use of verbal means (including systematic assessment of readiness and tolerance of speaking valve)
Perform practical tracheostomy tasks that are within the scope of practice for an SLT (e.g., cuff deflation, placing a humidifier, placing a
speaking valve)
Respond appropriately and safely to an emergency situation

Continued
Tracheostomy simulation for SLTs 75
Table 2. Continued

Scenario features
‘Victoria/Victor’a adult scenario ‘Bob’ infant scenario ‘Ava’ paediatric scenario

Stress tests/critical incidents

Cuff leak Anxious mum with challenging questions Relaxed but busy mum with other children
Anxiety-related stridor and O2 sats desaturation that are in and out of scope, e.g., Cessation of breathing on trial of speaking valve
Coughing on fluids criteria for decannulation, PEG feed Not tolerating speaking valve when unwell after
Nurse ‘pushing’ for SLT to act out of volumes, gastro-oesophageal reflux previously tolerating it
scope/within team liaison medications No nursing staff available at the home at the
time of appointments
Note: a Gender changes year to year depending on the simulation fellow in position at the time of the workshop.

Figure 2. Average number of opportunities to perform part-task manual skills within the simulated scenario across the three workshops.

Scenarios were split into phases allowing the case
to ‘fast-forward’ in time (table 2). Participants entered
the scenario in pairs, allowing one to take the lead
and the other to give support. This approach was cho-
sen as it provides a more supportive learning environ-
ment and also reflects normal practice where a junior
SLT would perhaps have the support of another team
member for complex areas of practice. The remain-
ing participants observed the phase from the observa-
tion room with a facilitator. This facilitator led brief-
ing and debriefing conversations using an established
pause and reflect simulation-based learning model (Von
Heukelom et al. 2010). Pause and reflect is common
practice in the simulation centre allowing for reflection
and consolidation of clinical reasoning. The scenario was
‘paused’ by the facilitator at the end of each phase. This
also enabled rotation of the participants between the
simulation room and observation room, and allowed
time for task-orientated reflective discussions. Each par-
ticipant had at least four opportunities to be in the
simulation room during the scenarios. Participants were
able to pause phases at any point if they felt unable
to stay in a role or needed support from the group in
decision-making.
Ongoing online support
For the final component of the education programme,
participants were encouraged to continue to use the web-
site. ‘Just-in-time’ demonstration videos of real patients
and short clips of previous workshop scenarios were
made available (Killi and Morrison 2015, McQuillin
et al. 2019). Participants were able to enter the website
chatroom where they could read previous chat room
conversations or ask clinical questions.
76 Anna Miles et al.

Figure 3. Illustrations of immersive simulations: (1) technician room view, (2) example of tracheostomy in a standardized patient and (3)
recorded view with multiple angles. [Colour figure can be viewed at wileyonlinelibrary.com]

Outcome measures completed based on the clinical situation, but the partic-
ipant paused the scenario or asked their peer or the nurse
All simulated scenarios were recorded using the simula-
to complete it for them. Manual tracheostomy skills in-
tion centre recording equipment which allows multiple
cluded: oral suctioning, digital occlusion—checking air-
view recording with the ability to zoom in for enhanced
flow, digital occlusion—checking voice, speaking valve
visuals (figure 3).
placement and removal, placement and removal of hu-
midification filter (Swedish nose), cuff deflation, cuff in-
Assessment of manual tracheostomy skills flation with pressure test, inner cannula removal, inner
cannula replacement, above-cuff suctioning, above-cuff
All manual tasks were judged as: (1) completed suc-
voicing, and blue dye test. There was 100% agreement
cessfully, (2) completed inadequately/needed assistance,
between judges. Manual skill judgement was previously
or (3) lost opportunity by two authors independently
used by Ward et al. (2014) with similar strong agreement
1 month after the workshop. A lost opportunity
between assessors.
was defined as a manual task that should have been
Tracheostomy simulation for SLTs 77
Table 3. Participant demographics (n = 35)

Demographic Data

Gender Female: n = 30, 86%

Male: n = 5, 14%
Country of practice New Zealand, n = 33, Brunei, n = 2
Years of SLT practice Mean = 6.6 years, range = 1–17 years, SD = 4.66 years
Population of clinical caseload Paediatrics (0–11) n = 12, 34%
Adolescents (12–17) n = 0, 0%
Adults (18+) n = 20, 57%
Mixed (paediatrics and adults) n = 3, 9%
Primary clinical setting (multiple Inpatient ward based n = 21, 34%
responses allowed) Critical care n = 20, 32%
Community n = 13, 21%
Slow-stream rehabilitation n = 8, 13%
Number of tracheostomy patients in the None n = 0, 0%
past 5 years that the SLT has been 1–5 n = 23, 66%
involved in the management of 6–10 n = 6, 17%
11–20 n = 2, 6%
> 20 n = 4 11%
Hours of professional development in 0 n = 8 2%
tracheostomy management before 1–5 n = 16, 46%
workshop enrolment 6–10 n = 4, 10%
11–20 n = 4, 11%
> 20 n = 3, 9%
Types of professional development in Formal education (workshop, online n=8
tracheostomy management reported learning, webinars, course)
(multiple responses allowed) Work-based learning (in-house n = 35
competency package, mentoring,
shadowing, in-service)
Self-directed reading n=4
Preliminary knowledge quiz scores Pre-access to website and workshop Mean = 12, range = 10–16, SD = 3
(maximum 20) Post-access to website and before the Mean = 20, range = 20, SD = 0
workshop

Adapted Ottawa Global Rating Scale (GRS) (Kim
et al. 2006, Ward et al. 2014)
The seven-point Ottawa GRS is a validated nursing edu-
cation tool for assessing performance in simulated crisis
management (Kim et al. 2006). The Ottawa GRS was
adapted and used by Ward et al. (2014) for the pur-
pose of assessing SLP skill development. Similarly in
the current study, this rating scale was also adapted to
rate leadership skills, problem-solving skills, situational
awareness skills, resource utilization skills, communica-
tion skills and an overall rating of performance in tra-
cheostomy management during the simulated scenarios.
For each category, a participant could score from 1 =
novice, all skills require significant improvement, to 7 =
superior, few if any skills require minor improvement.
Using the recorded scenarios, all participants were dou-
ble judged independently by two of the authors 1 month
after the workshop. Consensus was reached through dis-
cussion where scores differed. A total of 10% of videos
were rated a third time by an experienced SLP indepen-
dent of the workshop staff with 100% agreement (±1
point) with the decisions of the workshop facilitators.
Again, similarly to Ward et al. (2014), there was strong
agreement between assessors.
Questionnaires pre-, post- and 4-month
post-workshop
Participants were invited to complete questionnaires
pre-workshop, immediate post-workshop and 4 months
post-workshop via e-mail. Questionnaires were devel-
oped by the educators using Qualtrics and participants
completed them in their own time on personal com-
puters. Questionnaires were designed, with permission,
based on the work of Ward et al. (2014), in order
to allow comparisons. The pre-workshop questionnaire
asked for demographic information including clinical
experience. It asked participants to estimate the number
of patients seen with a tracheostomy as well as details
of professional development related to the tracheostomy
management they had received. Participants were asked
to describe any barriers to tracheostomy competency.
The post-workshop questionnaire allowed participants
to provide feedback on the workshop. All questionnaires
asked participants about their confidence on a scale of
1–10 (1 = not confident, 10 = very confident) across
several parameters including performing specific tra-
cheostomy manual tasks and clinical reasoning in tra-
cheostomy management. Participants were also asked
to rate on a scale of 1–10: ‘Right now, do you feel
78 Anna Miles et al.
Table 4. Pre-workshop themes of barriers to confidence and workshop. Participants’ reports of barriers to confident
competency in tracheostomy management and competent tracheostomy management were themed
Theme Illustrative quotes from questionnaires into topics with illustrative quotes. Participant perfor-
mance in both manual skills and on the adapted Ottawa
Number of patient ‘limited no. of patients’ GRS was graphically presented. Parametric repeated-
referrals ‘smaller hospitals with fewer trachy patient
makes it difficult to obtain skills and
measures analysis of variance (ANOVA) with post-hoc
confidence’ paired t-tests were used to explore confidence over time.
‘may have months between patients so can’t P < 0.05 was considered as statistically significant.
use skills straight away’ Quotations were used to illustrate participants’ percep-
‘great lengths of time with no suitable tion of maintenance of confidence 4 months after the
patients = reduced confidence’
workshop.
Training ‘no one to mentor me’
opportunities ‘lack of clinical supervision’
‘limited training opportunities’
Results
Team relationships ‘differences in opinion with ICU staff. Participants demographics are displayed in table 3. Par-
Patients not referred’
‘poor relationship with ICU’ ticipants reported several barriers to confident and com-
petent tracheostomy management before the workshop
(table 4).
case scenarios with human simulation manikins could
be a valuable medium for clinical learning?’ (1 = no,
10 = definitely). Participant performance
A total of 94% of all part-skill manual task opportunities
Data analysis
were successfully performed with only five completed in-
Descriptive statistics were used to describe partici- adequately and seven lost opportunities across the three
pants, their clinical experiences and satisfaction with the workshops (figure 4). The majority of participants (29

Figure 4. Proportion of successfully completed, not successfully completed and lost opportunities for part-skill manual tasks during scenarios.
Tracheostomy simulation for SLTs
Figure 5. Adapted Ottawa GRS scores for participants.
of 35) scored > 5 of 7 on all elements of the adapted
Ottawa GRS (figure 5).
Workshop satisfaction
In the post-workshop questionnaires, participants re-
ported that the pre-readings and quiz prepared them
for the workshop scenarios. They also reported that the
demonstration of a simulation scenario and the comple-
tion of part-task manual drills were valuable in preparing
them for the scenarios they participated in themselves.
All participants completed the pre-workshop question-
naire, 94% (n = 33) completed the post-workshop ques-
tionnaire and 66% (n = 23) completed the 4-month
post-workshop questionnaire. Table 5 displays partic-
ipant satisfaction pre- and post-workshop. Only one
participant reported not enjoying the simulated learn-
ing environment; all participants agreed that the pro-
gramme had enhanced knowledge, clinical skills and
critical thinking. At 4-month follow-up, 13 of 23 par-
ticipants reported they had used the just-in-time videos
after the workshop and that they had been beneficial.
Confidence
All confidence parameters, including managing a tra-
cheostomy patient (F(22.92), p < .001), performing
manual tasks (F(14.10), p < .001), conducting commu-
nication and swallowing assessments (F(9.71), p < .001)
and clinical decision-making (F(15.45), p < .001) were
79
significantly greater post- compared with pre-workshop
(figure 6). All confidence parameters remained signif-
icantly greater at 4 months post- compared with pre-
workshop (managing a tracheostomy patient (F(15.65),
p < .05), performing manual tasks (F(10.32), p <
.01), conducting communication and swallowing assess-
ments (F(8.99), p < .01) and clinical decision-making
(F(11.21), p < .01)).
Four months after the workshop, participants were
asked to consider the statement: ‘Completion of the
Workshop has changed my clinical management of tra-
cheostomy patients.’ Responses covered topics of: (1)
autonomous confident practice ‘I can step up/step down
now based on skills . . . I hadn’t learnt that before the
workshop’; ‘I am more confident’; ‘I’m no longer reliant
on my tertiary centre [for help with this population]’; (2)
increased knowledge to allow critical thinking and deci-
sion making ‘I still reflect on the workshop when I work
with patients’; ‘I feel I have a solid theoretical back-
ground now’; and (3) greater ability to manage com-
plex/stressful situations ‘[the Workshop has] increased
my ability to critically think under pressure’; ‘I’m able to
have a reasonable discussion with other professionals’.
Discussion
This paper provides further evidence of the use of
simulation training in SLP postgraduate education
as well as novel insights into tracheostomy exposure
and competency development in both paediatric and
80 Anna Miles et al.
Table 5. Participant satisfaction and attitudes to simulation pre- and post-workshop

Illustrative comments from participants: ‘What

Questions Responses do you feel were the strengths of the workshop?’

This experience has enhanced my knowledge of Strongly agree n = 30; 86%
tracheostomy management Agree n = 5;14%
This experience has enhanced my clinical skills Strongly agree n = 26; 74%
in tracheostomy management Agree n = 9; 26%
This experience has helped to stimulate my Strongly agree n = 26; 74%
critical thinking in tracheostomy Agree n = 9; 26%
management
I felt nervous during the scenarios Strongly agree n = 5; 15%
Agree n = 18; 51%
Neutral n = 8; 22%
Disagree n = 3; 9%
Strongly disagree n = 1; 3%
I enjoyed learning in this environment Strongly agree n = 19; 54%
Agree n = 15; 43%
Disagree n = 1; 3%
The manikins and environment was realistic Strongly agree n = 19; 54%
Agree n = 13; 37%
Neutral n = 3; 9%
Because of completing this workshop, I will feel Strongly agree n = 14; 41%
less nervous when providing care to Agree n = 21; 59%
tracheostomized patients
Right now, do you feel case scenarios with Pre = 8.24, 1.99
human simulation manikins could be a Post = 9.65, 0.84
valuable medium for clinical learning? 4 months post = 0.58, 1.02
(1 = no, 10 = definitely), mean, SD
Note: Scale = strongly disagree, disagree, neutral, agree, strongly agree.
‘loved the online resource—very informative
and useful’
‘knowledgeable and approachable instructors’
‘skill stations for repetitive learning’
‘watching how others explained things was
helpful’
‘getting hands on and being able to try practical
skills’
‘hands on’
‘making us justify our clinical rationales’
‘discussions were exceptionally good’
‘chance for discussions’
‘I was nervous, but a good nervous’
‘you feel safe to ask lots of questions and give
things a go’
‘watching others was good—I learnt a lot’
‘safe environment’
‘very practical and realistic’
‘the environment and actors made it real and
believable’
‘I can’t believe how realistic the scenarios were!’
‘gaining confidence through action’
‘practical’

adult tracheostomy management. The postgraduate Tra-
cheostomy Education Programme was completed by 33
New Zealand-based SLTs and two SLTs from the Mid-
dle East. Participants came from a range of healthcare
settings, with more participants reporting an inpatient
adult caseload. This is reflective of general tracheostomy
demographics worldwide with more adults (> 16 years
of age) than children receiving tracheostomies and the
majority of tracheostomies decannulated before hospital
discharge (Choate et al. 2009, Freeman-Sanderson et al.
2011). Participants had minimal prior education and lit-
tle experience in tracheostomy management. This may
reflect participants’ general level of clinical experience,
with some being relatively newly qualified.
Low-frequency, high-risk populations
SLTs perceived low patient numbers as a barrier to
gaining competence in tracheostomy management. Yet,
work-based training was the only professional devel-
opment mode accessed by two of three participants.
This is concerning given low patient numbers would
suggest limited opportunities for experiential learning.
A survey of SLTs in Australia found a similar range
of self-directed tracheostomy-specific professional de-
velopment activities available for SLTs and the majority
of their respondents felt more training opportunities
were needed (Ward et al. 2008). Training health pro-
fessionals in low-volume, high-risk practices has always
been a challenge in rural and lesser populated coun-
tries. In the United States, online theoretical self-study
followed by the practise of focused skills have proven
successful in rural nurse training (Banks et al. 2010).
Simulation focused on low-frequency, high-risk events
has also shown enhanced critical thinking in US nursing
residency programmes (Beyea et al. 2007). Where there
are reduced real-life opportunities, reliance on in-house
shadowing and experiential learning may be unpre-
dictable and clinically unsafe. Additional teaching and
learning methods, such as simulation, are perhaps the
only option for health professionals in areas of advanced
practice.
Tracheostomy simulation for SLTs
Figure 6. Participant confidence pre-, post- and 4 months post-workshop (1 = no confidence, 10 = very confident).
Team relationships
Interestingly, SLTs perceived challenging ICU team re-
lationships as a barrier to tracheostomy competency de-
velopment. On a positive note, participants described
feeling more confident talking to multidisciplinary col-
leagues after the workshop. Similar concerns regarding
team working have been voiced in international sur-
veys, with only 16% of Australian SLTs (Ward et al.
2008) and 35% of UK SLTs (Ward et al. 2012) report-
ing ideal team environments. Strong multidisciplinary
ICU teams are essential for positive patient experiences
and outcomes. For the sole practitioner or infrequently
visiting SLP, the support of team members in ICU is
critical for safe practice and learning opportunities. SLTs
must prioritize building positive work relationships in
their ICUs. Research is needed that identifies the causes
of relationship breakdown and explores ways to opti-
mize teamwork in clinical settings where the SLP does
not work regularly. The positive role interprofessional
simulation-based learning may play in the workplace
cannot be ignored (Abu-Rish et al. 2012, Potter and
Allen 2013).
Participant satisfaction
Participants’ had positive attitudes towards simulation
before the workshop and this opinion was maintained
4 months later when there had been an opportunity
for reflection on return to their workplaces. Similarly
to Ward et al. (2014), all participants agreed that the
simulation experience enhanced their knowledge, clini-
cal skills and critical thinking in tracheostomy manage-
ment. High-fidelity simulation is demanding on a per-
81
son’s cognitive capacities and generates stress and anxiety
(Bauer et al. 2016). Two-thirds of participants admitted
feeling nervous during the simulations, which is similar
to findings in previous studies (Clarke et al. 2014, Miles
et al. 2015, 2016, Nielsen and Harder 2013). While we
often consider anxiety a negative state, psychologists de-
scribe more positive effects of heightened arousal, with
enhanced attention and performance including addi-
tional effort and increased use of prior knowledge and
resources (Eysenck 1985). Participants felt the workshop
provided a safe learning environment. They described
a willing acceptance of nerves: ‘I was nervous, but a
good nervous’; and all but one participant reported they
enjoyed the learning experience. Four months after the
workshop, survey results reported a sustained reduction
in anxiety in working with patients with tracheostomies,
a finding in line with other studies (Megel et al. 2012,
Szpak and Kameg 2013).
All parts of the education programme were valued,
and it is difficult from the data to attribute particular
gains in confidence or competence to specific activities
within the programme as a whole. Participants were pos-
itive about all aspects of the programme. They felt the
pre-readings, quiz, part-task manual drills and demon-
stration all prepared them for the simulated scenarios. A
total of 68% of participants (23 of 34) specifically iden-
tified the high-fidelity simulation as being a strength of
the programme. Feedback reflects this positive response
to the ‘real-life’ ‘hands on’ learning environment. Each
component of the programme was designed to provide
learning activities that met the needs of a diverse group
of learners consistent with the principles of adult learn-
ing, for example, self-directed, multi-modal, timely and
flexible (Banks et al. 2010).
82
Confidence and performance
Objective ratings of performance align with participants’
self-perceived increases in knowledge, clinical skills and
critical thinking, which is comparable with other re-
ported benefits of simulation (Ward et al. 2014). Par-
ticipants were sufficiently comfortable in the simulated
environment to take multiple opportunities to practise
newly learnt skills, suggesting that this learning plat-
form is an effective tool for teaching and gaining com-
petence in manual tracheostomy skills. High scores on
the adapted Ottawa GRS perhaps demonstrate strong
pre-existing clinical competency in the cohort; however,
they also positively demonstrate the opportunities for
SLTs to incorporate new tracheostomy knowledge into
clinical reasoning.
Like previous work, confidence and perceived com-
petence were maintained at 4 months despite low patient
opportunities to practise skills (Ward et al. 2014). At 4
months participants felt more knowledgeable and more
confident to have conversations with others about tra-
cheostomy care. This ability to share knowledge and also
expose vulnerability in what they do not know is a hall-
mark of professional confidence (Hsu et al. 2007, Jack-
son et al. 2017, Treem and Leonardi 2015). This suggests
that the education programme offered an opportunity
for professional development and learning that extended
beyond the course content itself, which is positive for
advanced patient care.
Limitations and future directions
Participants’ confidence and competency was self-
declared and there was no formal assessment of perfor-
mance in the workplace. Future studies should explore
further the longer term retention of skills and knowl-
edge, particularly when frequency of clinical exposure
is low. Outcomes measures were individualized to the
programme and therefore not validated; however, they
were aligned with Ward et al. (2014) for comparisons,
and agreement between raters was strong.
Time and group size prevented all participants com-
pleting all phases of the scenarios. However, while health
professionals have expressed a preference for hands-on
learning, the value of observation is well recognized
(Reime et al. 2017). Participants observed all phases and
actively participated in observation room discussions.
They performed their active phase of a scenario in pairs.
This peer-support can significantly enhance confidence
and feelings of safety in an active phase, allowing some
participants to perform at a more advanced level than
they may have if alone (Gazula et al. 2017, Maas et al.
2014). Supportive peer working is a positive model for
clinical practice and allows participants to enjoy the sim-
ulated experience. It maximizes opportunities for critical
Anna Miles et al.
thinking, albeit at the possible cost of reducing oppor-
tunities for practising manual skills.
The number of hours spent on the online education
module and interactive quiz was not recorded. It would
be useful in future to monitor the hours of theoretical
learning in participants and its impact on performance
at the workshop. Use of the ongoing online support
(post-workshop) was also not recorded and it would be
an interesting follow-up enquiry for the educators.
Future studies should explore the barriers and fa-
cilitators to creating effective ICU tracheostomy teams
where resources are limited and staff itinerant. High-
fidelity simulation centres are costly and require a heavy
facilitator-to-participant ratio. The future of simulation
through use of virtual reality may bring down simulation
costs and potentially increase the accessibility and fre-
quency of exposure. Further investigation of the benefit
of telehealth-based mentorship and use of just-in-time
videos is warranted.
Conclusions
SLTs often have limited on-the-job opportunities to de-
velop competency in tracheostomy management. Low
patient numbers and limited access to specialist supervi-
sion are challenges to upskilling in this advanced field of
practice. Simulation is a well-received mode of learn-
ing and the present study suggests participants gain
confidence, knowledge and skills. With increased con-
fidence, SLTs felt sufficiently able to seek other learning
opportunities beyond the bounds of the workshop, in-
cluding greater engagement in multidisciplinary team
case discussions. Just-in-time video resources, virtual
patients, online professional chatrooms and telehealth-
based mentor partnerships may have merit and deserve
further investigation.
Acknowledgements
The authors thank Dr Jane Torrie and The University of Auckland
Simulation Centre for Patient Safety for their expertise and support.
Thanks also to Professor Elizabeth Ward for her generous time in the
development of the Tracheostomy Education Programme and giv-
ing permission to replicate her assessment methods. Declaration of
interest: The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the paper. No
funding source was involved in this research. This study was approved
by an appropriate national ethics committee (UAHPEC/018753)
and all respondents provided written informed consent. All proce-
dures were in accordance with the ethical standards of the institu-
tional ethics committee and with the 1964 Helsinki Declaration.
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