Intensive and Critical Care Nursing (2010) 26, 33—43
avai lab le at www.sc iencedi rec t .com
journa l homepage: www.e lsev ier .com/ iccn
ORIGINAL ARTICLE
More than nothing: The lived experience oftracheostomy while acutely ill
Andrew Foster ∗
Critical Care Outreach Team, 4th Floor, Princess Alexandra Hospital, Essex CM20 1QX, United Kingdom
Accepted 23 September 2009
KEYWORDSTracheostomy;Lived experience;Acute illness;Critical care
Summary While the physical sensations surrounding tracheostomy tube insertion have beenreported within nursing and allied healthcare literature, the lived experience of these sensa-tions is poorly described. This appears relevant given the imminent results of the Tracman study(2008).
A purposive sample of three participants who had tracheostomy tubes previously within a crit-ical care area or still in situ were recruited. They described their experiences in a face-to-facesemi-structured interview that were audio taped. The interviews were transcribed verbatimand analysed using Giorgi’s 5 concrete steps of the human scientific phenomenological method(1997).
Findings revealed themes that drew attention to the fundamental aspects of the experience.These were:
1. Necessity of communication2. Retaining normality3. Psychosocial discomfort4. Painful procedures5. Fear of the unknown6. Relationships with staff
Practical recommendations draw attention to the organisational support required for staffexpected to care for these patients in the ward environment. This involves the introductionof evidence based guidelines and competency based care to promote the acquisition of skills
echanical ventilation within the intensive care unit (ICU).here is unconvincing evidence (Griffiths et al., 2005) thatarly tracheostomy tube placement may markedly reduceuration of ventilation and shorter stays in critical care andhe advent of the Tracman trial (2008) explores this fur-her. This completed multicentre, unblended, randomisedontrolled trial investigated early versus late tracheostomyube placement in the critically ill and is to be publishedmminently.
While it can be argued that reduction in ICU length of stayas clear advantages for the cost of and quality of care, its uncertain what impact this intervention has on the wholeatient, their experience of being critically ill and any issuesuring recovery. This illustrates an imperative to investi-ate peoples’ experience of these tubes so that they maye represented in parallel with the findings of the abovetudies to gain a human understanding of what has becomeidespread use of these artificial airways. Nursing staff on
he ward and critical care areas are exposed to these tubesurrently yet there is little information available regardinghe lived experience of tracheostomy.
This information is critical for nursing knowledge givenhe understanding that the heart of nursing people with anyllness is consideration of their needs based on the effecthat the illness has on them (Cronin and Rawlings-Anderson,004). Therefore investigating a nursing concern, what peo-le have to say about their tracheostomy, permits us toetter understand these patients needs and provides a cor-erstone for their holistic care along with the practical skillsequired to care for these people to a high standard.
iterature review
n integrated search for literature was undertaken to deter-ine what is already known about tracheostomy and, inarticular the patient experience of these artificial air-ays. An electronic search was performed of the followingatabases:
CINAHL—–Cumulative Index to Nursing and Allied HealthLiteratureMedlineBNI—–British Nursing IndexEMBASE Psychiatry
Secondary references were investigated as well as net-orking with colleagues within the multi disciplinary teamnd a nationally acclaimed expert in the area of tra-heostomy tubes.
Much of the popular nursing literature focuses on main-aining a safe environment with the discussion of suctionechnique, infection control, humidification of inspired oxy-en and cleaning the inner cannula and tracheal stomaGriggs, 1998; Burglass, 1999; Woodrow, 2002; Dochertynd Bench, 2002; Moore, 2003). While others discuss thesessues, they also include the relevance of psychosocial issues
uch as anxiety, communication and expression of sexualityHooper, 1996; Day et al., 2002; Bond et al., 2003; Higgins,005). These are excellent ‘‘how to’’ guides of the complexare of a person with tracheostomy however they do not givedirect patient account of the experience of these tubes.
ttcdr
A. Foster
There is some evidence that pointed to the lived experi-nce of tracheostomy within critical care however it tendedo be unspecific to the tube itself, rather the experiencef being critically ill in general. This evidence may be sum-arised into four broad categories:
Mechanical ventilation (Bergbom-Engberg and Haljamae,1989; Jablonski, 1994; Hafsteinsdottir, 1996; Wunderlichet al., 1999; Arslanian-Engoren and Scott, 2003; Johnson,2004).Memory and recall (Green, 1996; Russell, 1999; Stein-Parbury and McKinley, 2000; Adamson et al., 2004;Magarey and McCutcheon, 2005; Lof et al., 2006).Transfer out of critical care (Odell, 2000; McKinney andDeeny, 2002; Strahan and Brown, 2005).Psychological disturbance (Granberg et al., 1998, 1999;Maddox et al., 2001; Roberts and Chaboyer, 2004).
While there is mention of tracheostomy within sampleharacteristics, there is little direct description from thearticipants therefore a discussion of this work is warrantedo support the need for this study.
The theme of communication repeats itself throughouthe previously mentioned work though this is appears toe limited in relation to tracheostomy. Johnson (2004),n a report of one theme from a phenomenological studyccounts that her participants’ inability to communicateuring long term mechanical ventilation was anxiety pro-oking. While she does not specify whether her participantsad a tracheostomy tube in situ, it is likely that some did asll had been ventilated for more than seven days. Magnusnd Turkington’s study (2006) to investigate patient andtaff communication in the ICU revealed a disparity betweenhese groups perception of communication. Although theyo not state how many of their participants had a tra-heostomy tube (n = 8), they go on to highlight that 6/8 didot realise that this tube was temporary suggesting that ateast six participants did. At least two participants reporthe tracheostomy tube as being a barrier to communica-ion. They conclude that failure in communication due tohe inability to verbally communicate results in feelings ofrustration and powerlessness and it is noteworthy that staffkills were reported to be a key factor for success in com-unication.This would appear to confirm previous findings (Jablonski,
994; Hafsteinsdottir, 1996). Jablonski (1994) also reportshat those with tracheostomy suffered intermittent dis-omfort, dysphagia and burning which supports a previoustudy by Bergbom-Engberg and Haljamae (1989), where peo-le reported agony, anxiety, fear and panic as significantlyelated to an inability to talk. They also found that trachealoilet and suctioning became a more annoying problem asentilator treatment wore on and that tracheal suctioningas recalled as discomforting for 30% of their respondents.hese findings were not specific to tracheostomy tube,ather those who were mechanically ventilated in general.he reviewed literature does not clarify any differences in
he experience of endotracheal tube (ETT) or tracheostomyube although Johnson et al. (2006) mention that the ETTaused gagging and choking and that suction caused greatiscomfort for one participant. Uncertainty, anxiety and fearelated to ineffective communication caused by the ETT are
hile
datWtoeate
(ak1gopttTp(
qseioeaisfuge
P
Tm
More than nothing: The lived experience of tracheostomy w
also discussed in this study which is a further report fromthe same study by Johnson (2004).
Donnelly and Wiechula (2006) investigated the livedexperience of a tracheostomy tube change, a procedurenot uncommon within critical care areas. They depict theirinformants’ descriptions of this procedure and establishedthat the need to maintain communication and the ability tospeak was significant for their participants. Loss of voice forone of their participants was more of an issue than physicaldiscomfort and they go on to discuss the challenge to theperson’s self-concept when the ability to represent oneselfis lost in this way.
By inductive reasoning, we can assume that those withtracheostomy do indeed have problems with communicationand discomfort during procedures such as tracheal suction.However it is unclear whether these are their only concernsand whether this extends to the ward environment giventhe assumption that they will be interacting more with theircaregivers. Aside from Donnelly and Wiechula (2006) noneof the above studies describes directly the experience oftracheostomy tube as lived by our patients. It is thereforeargued that the experience of this artificial airway in thecontext of an acute illness be explored further to enable ourunderstanding of what it is like to live and breathe throughthis tube.
Purpose of the study
The purpose of this study was to overcome this gap in the lit-erature by describing the experience of tracheostomy tubeas lived by a group of people who had this tube inserted asa part of their critical illness or as a procedure related to anacute event.
Methodology
This study concerns itself with gaining descriptions from theexperience of the tracheostomy tube rather than quantify-ing the experience through measurement or searching forexplanations. I share van Manen’s understanding (1990) thatfrom a human scientific perspective, methodology refers to aphilosophical framework and the fundamental assumptions
and principles of a particular perspective. The philosophyof phenomenology offers such a framework. Phenomenol-ogy tries to give a direct description of our experience asit is without taking into account any casual explanations(Merleau-Ponty, 1962).
icPhe
Table 1 Participant characteristics.
Namea Gender Ethnicity Reason fo
Angela Female White British Facilitateventilatio
Barry Male White British Facilitatetype II re
Colin Male White British Symptomcompress
a Names coded to maintain confidentiality.
acutely ill 35
The phenomenological attitude has evolved to severalifferent methodological approaches within nursing inquirynd would appear to answer many of our nursing questionshat cannot be made clear by other means (Madjar andalton, 1999). The aim of phenomenological investigation is
o expand our understanding through first hand descriptionf the way things present themselves to us in and throughxperience (Sokolowski, 2000). This approach can thereforellow the dynamic, holistic and individual aspects of theracheostomy tube to be explored and to help capture thexperience in its entirety.
The specific approach used here is found in what Giorgi2000) titles ‘‘scientific phenomenology’’, wholly appropri-te here given the purpose of science is to produce a body ofnowledge in an organised way (Parahoo, 1997; van Manen,990). This study is scientific in the sense that it seeks toain knowledge for nursing as a human science using anrganised approach based on the fundamental principles ofhenomenology. Merleau-Ponty’s work and thinking was usedhroughout this study. His phenomenological approach seeshe body as the self and that consciousness is embodied.his embodied consciousness as the self is the subject oferception in that we perceive our world through our bodyMerleau-Ponty, 1962).
Perception allows us to experience our world. Theualities that we glean from seeing, touching or hearingomething gives us our sensation of it and underpins ourxperience of it. Experience is not only sensing an object,t is the quality perceived from the associated sensationsf it. Perception of the same object can give rise to differ-nt experiences depending on how and when it is perceivednd from what standpoint. Thus we come to an understand-ng of his way of looking at things as a foundation for thistudy. There are unquestionably several views from the dif-erent perspectives of the phenomenon of being acutelynwell with tracheostomy tube. These several views mayive rise to similar experiences; therefore a commonality ofxperience may enable our understanding.
articipants
hree adults participated in this study of which two wereale. All had been hospitalised within an acute NHS Trust
n the United Kingdom. Table 1 summarises participantharacteristics and provides some context to the findings.otential participants were initially identified as those whoad a tracheostomy tube inserted within the ICU. How-ver the complexity of surviving a critical illness involving
r tracheostomy Length of time withtracheostomy
weaning from mechanicaln following severe sepsis
36 days
mechanical ventilation forspiratory failure
14 days
atic relief of trachealion from thyroid tumour
Permanent
3
l(22amtTwtswal2
E
TtwoaNcigprda
wobhsmoaaaa
D
DuPtsecfpvTeoac
tctpi
D
Ccm
iifaWrv2spub
atavodsontTptitto
6
ack of recall, distressing memories is well documentedGreen, 1996; Hupcey, 1999; Stein-Parbury and McKinley,000; Papathanassoglou and Patiraki, 2003; Adamson et al.,004). This limited recruitment to those able to articulatend reflect on their experience therefore a decision wasade to broaden inclusion to those who had a tracheostomy
ube inserted as an unplanned or semi-planned procedure.his is in keeping with the purposive sampling method usedhere the sample may be selected according to the poten-
ial participant’s knowledge on the research topic as thetudy progresses (Morse, 1991; Coyne, 1997). The sampleas small, though consistent with the phenomenologicalpproach where the sample tends to be small due to thearge amount of verbal data that is analysed (Polit et al.,001).
thical issues
his study operated with the principle of doing no harmo others, a concern highlighted by Jones and Lyons (2003)ho discuss the difficulties of researching the experiencef being critically ill. Professional standards of the Nursingnd Midwifery Council NMC (2004) and the Royal College ofursing RCN (2004) also guided this study. Approval to pro-eed was granted by the Local Research Ethics Committeen parallel to organisational approval in terms of researchovernance required by the Trust were the research tooklace. Post-interview counselling was offered as a means ofeducing the harm caused by the revisiting of potentiallyistressing memories or the unpleasantness of rememberingt all.
Information about the study was given verbally with andithout significant others’ present. Written information wasffered in simple everyday language, in large font with dou-le spacing given the concerns that Jones and Lyons (2003)ave regarding the poor concentration and focus of someurvivors of a critical illness. Consent was both written for-ally and given verbally which was recorded at beginning
f interview. Interviews were conducted in private eithert the participant’s home or in a well ventilated room withclosed door on a ward. Audio tapes were coded immedi-
tely following interview, were kept in a locked cupboardnd heard only by the researcher.
ata collection
ata was collected between July 2007 and November 2007sing semi-structured, audio taped, face-to-face interviews.reviously reported sensations related to tracheostomyubes cited in the literature provided the framework to givepecific descriptions of these. For example, while Oermannt al. (1983) describe physical sensations following tra-heostomy as reported by their sample of 34 patients auller description of these are not detailed. These sensationsrovided a basis in which to build a semi-structured inter-iew schedule so that fuller descriptions could be elicited.
o capture the experience in its entirety, general, opennded questions were included to allow discussion outsidef theses boundaries. The purpose of this semi-structuredpproach suits Merleau-Ponty’s thinking. There is no tra-heostomy tube in isolation but it is there in relation to
edvfo
A. Foster
he many aspects of being acutely ill. Thus the situatedontext of the experience was considered while harvestinghoughts, memories and feelings from that period of theseeoples’ lives. Participants were interviewed once each andnterviews ranged from 48 to 63 min.
ata analysis
ollection of verbal data is the first step in Giorgi’s 5oncrete steps of the human scientific phenomenologicalethod (Giorgi, 1997) (Box 1). He believes that certain mod-
Box 1 Giorgi’s 5 concrete steps of the human scientificphenomenological method (Giorgi, 1997).
1. Collection of verbal data2. Reading of the data3. Breaking the data into some kind of parts4. Organisation and expression of the data from a dis-
ciplinary perspective5. Synthesis or summary of the data for purposes of
communication to the scholarly community
fications from the philosophy of phenomenology have to bentroduced for scientific analysis. This thinking has broughtorth his method to provide structure and allow a systematicnd rigorous approach in terms of phenomenological inquiry.hile the steps are linear in progression there was the same
evisiting of things in a cyclical fashion that is championed byan Manen (1990), Munhall (2001) and Giorgi himself (1997,000, 2005). It is this way of delving in and out of eachtep and back again that is consistent with the principles ofhenomenological methodology in that this approach, whilesing pre determined steps, has not been totally governedy the way that they have been sequenced.
The audio taped interviews were transcribed verbatims soon as was possible following the interview itself. Theranscripts were read at first in isolation of the audio tapend then read while listening to the audio taped inter-iew. While Giorgi (1997) does not specify how many timesne must re-read the transcripts ‘‘many times’’, this wasone until a sense of the descriptions was understood. Alower re-reading of the transcripts enabled a breaking upf the data into parts; ‘‘meaning units’’ were discrimi-ated from the descriptions using the open attitude gainedhrough the phenomenological reduction described below.hese meaning units are in the everyday language of thearticipants and are derived from their descriptions relatingo the sensations of their tracheostomy tube. These mean-ng units (summarised in Table 2) were further transformedo describe them as broad themes from a nursing perspec-ive (step 4). From a phenomenological view, the experiencef their tracheostomy is entwined within the whole experi-
nce of being acutely ill, therefore to remain true to theirescriptions, meaning units were derived from other rele-ant data. These are summarised in Table 3, are separatedor convenience and mentioned here because they are partf the whole experience.
More than nothing: The lived experience of tracheostomy while acutely ill 37
Table 2 Meaning units of tracheostomy tube.
A rigorous phenomenological approach
The trustworthiness of this study may in part be determinedthrough the use of criteria for qualitative data (Lincoln andGuba, 1985):
• Credibility. Participants with specific experience oftracheostomy tube were chosen and a rigorous phe-nomenological approach used to gain descriptions of theirexperience. The term rigor is understood here to per-tain to a robust and systematic approach used within theepistemological and theoretical principles of phenomeno-logical inquiry, a convincing argument put forward byRolfe (2006) and a belief pre dated by van Manen (1990).Three phenomenological principles were used so as not
to sever the spirit of this study from its philosophicalfoundation. These were:
Description. Descriptions in this study are obtainedfrom the participants from the perspective of theirworld or their experience.
Assuming the phenomenological reduction. The atti-tude of the phenomenological reduction allowed meas a researcher in this study to place myself outsideof my ‘‘natural attitude’’. Placing myself outside ofmy own natural attitude after 12 years of critical carenursing was not beyond possibility with the help oftwo phenomenological principles, the use of which wasessential given that the method used for data analysisdoes not require the use of peer or member checking.
The first was to ‘‘bracket’’ my own past knowl-edge and experience of tracheostomy to examine myown prejudices during data analysis. This takes theparticipants’ memory as what happened precisely asdescribed (Dowling, 2007) and allowed me to be truth-ful to what they said without my own presuppositionsinfluencing how I analysed what they had to say. A‘‘reflective diary’’ suggested by Wall et al. (2004) was
helpful during data analysis to remind myself to beever present to the descriptions. The second princi-ple was to withhold any existential claim which meansto consider the description as precisely the concreteexperience presenting itself. That is, when interview-
38 A. Foster
Table 3 Meaning units of other relevant experiences.
•
•
p
astdttaS
F
Stb
N
Tracasuntwo
ing, reading transcripts and listening to the interviews Iwas present to how the participants’ construe their sit-uation as their reality rather than any other perspectiveof events, including my own.A search for scientific essences. While the philo-sophical method of phenomenology seeks universalphilosophical essences, Giorgi (1997) emphasises thathis human scientific method cannot be universal aswhat is unique is not a universal truth as such butdepends on a particular disciplinary perspective. Thesearch for ‘‘scientific’’ essences in this study relate toa nursing perspective where what is of scientific inter-est is peoples’ experience of tracheostomy tube andhow this impacts on their life.
Dependability and confirmability. This study was an aca-demic endeavour; the transcripts and reflective diarywere under scrutiny of my research supervisor. An audittrail of sorts was evident throughout this study as theverbatim transcripts and reflective diary were submit-ted with the final dissertation which was checked bya second marker. The addition of tables to illustrateparticipant characteristics and how meaning units werederived demonstrates transparency within my approachand therefore an auditable trial of decisions madethroughout data analysis.Transferability. I have submitted sufficiently rich descrip-tions in order to have resonance with those caring forpeople with tracheostomy tubes in acute settings and per-haps those working in long term residential type care also.Only they can decide whether my findings are applicable
to those areas.
There is however some tension with the exclusive usere-set criteria in this way. My use of one of many a
pproaches and a belief that reality is constructed througheveral viewpoints determines that the trustworthiness ofhis study may go beyond the above criteria. While I canemonstrate trustworthiness in this way, I would like to thinkhat it is also revealed within the writing of the text wherehe quality of this study is also subject to your keen insightsnd judgement as a reader (Emden and Sandelowski, 1999;andelowski and Barosso, 2002; Rolfe, 2006).
indings and discussion
ix broad themes were derived from the data analysis andhese convey an understanding of what it is like to live andreathe with a tracheostomy tube.
ecessity of communication
his theme was central to all of the participants’ expe-iences. The meaning of verbal communication as being
fundamental aspect of social interaction appears to belear. This resonates clearly with the findings of Donnellynd Wiechula (2006) when they describe that the ability topeak is a fundamental need for most of us. Speaking allowss to be explicit, be understood and allows others to recog-ise us as the people that we are. To have this taken awayakes away a part of our identity, a part of who we are. Colinas surprised but pleased to be able to speak particularlynce he was able to use a speaking/phonation valve.
Colin, ‘‘I was very, very pleased! . . .when you gave methis (speaking valve), one hell of a difference!’’
In contrast to this, Barry and Angela relate very differentccounts. Both were offered a common, alternative form of
hile
cfa
hta
tircobcipt
dac(p
P
Tpo
dEahgp
More than nothing: The lived experience of tracheostomy w
communication; writing. Ironically this led to enormous frus-tration for them both as they were unable to write properlydue to unco-ordination or physical weakness.
Barry, ‘‘. . .the first thing that I do remember about thetracheostomy was towards the end. . . a great frustrationabout being unable to talk.’’
‘‘. . .I couldn’t control my writing which increased myfrustration and I can remember throwing it away, acrossthe ward I think. . .’’
Angela, ‘‘. . .my writing was all over the place. . .I think Iwas destructive. . .no one listened; I wanted to lash outand break things. It was horrible!’’
Much in the same way described by Johnson et al. (2006)weakness and fatigue impaired their non-verbal communica-tion. A possible residual effect of sedative drugs and/or thestate of the illness may also have interfered with the abilityto communicate in writing (Jablonski, 1994). A lack of voiceeither verbal or non-verbal was frustrating for them andthis manifest as anger which has been previously reportedin those who have been mechanically ventilated (Jablonski,1994; Hafsteinsdottir, 1996; Magnus and Turkington, 2006).
Barry describes finding it easier to use a picture/alphabetboard to communicate,
‘‘. . .and presented with this and I think that worked alittle better.’’
This has been recommended as an ‘‘assistor to successfulcommunication’’ (Magnus & Turkington, 2006, p. 175).
Angela also describes the apathy reported byHafsteinsdottir (1996) when her participants gave uptrying to communicate because alternative forms hadfailed, ‘‘. . .because I couldn’t communicate, sometimes Ididn’t bother. I just felt that well, ‘I’ll just lay here, I can’treally be bothered’. . .and that’s what I done, just switchyourself off with things’’.
Retaining normality
This theme is situated within the participants’ responsesrelating to deviations of normal communication, coughing,swallowing and diet. This is a similar notion to Johnson et al.(2006) who describe a theme for their participants as livingin an unfamiliar body where they told of living in a body thatdid not respond in its usual or normal way. Barry describedan experience related to tracheostomy that he recounted asa part of a collection of vivid, unreal experiences.
‘‘. . .I mean in this situation, one has some very weird-I wouldn’t call them dreams necessarily, it’s almostreality. . .a recurring theme is that there is another doc-tor whom I imagined my wife was going off with whichis very unfair! That doctor had a tracheostomy! He had ahole in his throat. . .quite ridiculous!’’
He also described an alteration in his coughing and swal-
lowing that is so subtle that he is unclear whether thetracheostomy tube caused this or whether it already existed.
‘‘. . .very, very occasionally I think things are more proneto go down the wrong way than er maybe they should or
ipae
acutely ill 39
they did. . .you tend to say oh, tracheostomy. . .(Coughsand then laughs) there you are!’’
Colin found it annoying and irritating to be persistentlyoughing because of the need to change the inner cannularequently. This left him tired, particularly during the days he had been awake with this coughing in the night.
‘‘The inconvenience of tube out, washing it, brushing itall out, putting it back in and it starts me off coughingagain! Sometimes. . .and sometimes I use the nebuliserand it loosens it all up and I start coughing all over again!’’
Due to a constant sore throat and mouth ulcers, Angelaad enormous problems eating and drinking and although atime of interview this had resolved, she remained fearful ofrecurrence that would disrupt her return to a normal diet.
‘‘I can’t bear the thought of having a sore mouth again. . .Iget frightened that it will because that’s the worstthing, not being able to breathe and not being able toswallow. . .’’
It would appear that loss of normal body functions albeitemporary has an ongoing impact longer than when the phys-cal discomfort has ended. Johnson (2004) reported thateclaiming the everyday world for critically ill, mechani-ally ventilated people involves gaining a sense of controlr power over the environment to regain life as it wasefore they became unwell. Perhaps these people with tra-heostomy tube have a need to have some form of normalityn their life and while this may not be a return to their life asreviously lived, control over the things that are importanto them may enable this.
There is implicit understanding from the participants’escriptions that patients experience procedures, eventsnd alterations in body image rather differently than health-are professionals do. This supports Donnelly and Wiechula2006) and their contention that it is unlikely that ouratients consider anything as just another task.
sychosocial discomfort
his theme derives from how one participant viewed therocedure of suctioning but also relates to how other effectsf the tracheostomy tube impact on our patients’ daily lives.
While she did not associate suctioning with the physicaliscomfort or choking described by others (Bergbom-ngberg and Haljamae, 1989; Jablonski, 1994; Johnson etl., 2006), Angela felt relieved that it was coming out ofer chest. She describes her relief as having something dis-usting being taken away rather than the relief at clearinghlegm from her chest to make it easier to breathe.
‘‘It well it’s a horrible feeling . . . knowing all this muck isbeing taken from your throat, knowing that it’s in there. . .
I was grateful that the more they could take it away, thebetter I would be.’’
Colin described his persistent coughing at night as leav-ng him tired and this affected his life during the day. Thisrevented him from engaging with people as he once dids he had little energy leaving him to withdraw from socialncounters that he once would have welcomed.
4
wh
icfctatd
P
At
dp
ptsTspipovspfp
F
Whtb
hh
mdc
ad1aoMusnfwllp
R
Awr
rcc
0
‘‘Last night was nearly an hour and I was sore and aching!. . .it wears off but then I’m [very tired]’’
Barry’s tracheostomy stoma took several weeks to healhich worried him and also made him a focus of attention inis community which he began to feel uncomfortable with.
‘‘. . . you walk around with this plaster on your throatand you perhaps you would rather people didn’t ask youquestions about it’’
These issues are not highlighted in previous studies whichs unsurprising given that their focus was on mechani-al ventilation rather than life after critical care. Asiderom the recognised physical sensations associated with tra-heostomy tubes, there remains the potential experiencehat our patients are aware of and suffer disgust, revulsionnd loathing of their own pathophysiological processes evenhough those of us caring for them regard these as ‘‘normal’’uring our working day.
ainful procedures
side from her mouth ulcers, Angela described dressing ofhe tracheostomy stoma as painful.
‘‘Oh that was spiteful yeah! That was very sore thatwas!’’
Colin had similar experiences but also developed retchinguring persisting coughing episodes which made his stomaainful.
‘‘Ahhh! That’s when you get a bit of pain, becausearound this bit (indicates the tracheostomy stoma). . .isvery tender. . .You can feel it all the way around becausewhen you cough, you’re retching at the same time. . .andthen it is painful’’
Apart from Arroyo-Novoa et al. (2008) who investigateain related to tracheal suctioning, there is little descrip-ion of pain related to procedures though these commentsupport the sensations reported by Oermann et al. (1983).here is a sense that pain appeared to be accepted as a con-equence of the illness for the participants in this study, aart of the ‘‘tracheostomy package’’. The nasogastric tubensertion procedure or stoma pain related to the dressingrocedure as examples were endured miseries in the worldf recovery where nutrition, infection surveillance and pre-ention were essential to survive. Responses within thistudy suggest that tracheostomy dressings are potentiallyainful, coughing for people with these tubes causes discom-ort and that we should communicate this to our patients inreparing them for procedures.
ear of the unknown
hile Barry had little recollection of the acute onset ofis illness and no memory regarding the reason for the
racheostomy tube, Angela could remember being short ofreath as a frightening experience.
‘‘. . .I was very, very bad at breathing. . .I know that was mylast resort. . .It was scary but I was very weak anyway.’’
wtWwi
A. Foster
Colin became concerned that his cough is so strong thate could dislodge the tube, a frightening occurrence whichad almost happened previously.
‘‘All I’m worried about is coughing this thing out, (indi-cates the tracheostomy tube) which I nearly did!!. . .’’
Barry faced uncertainty while his stoma took around sixonths to heal. His concern over this is evidenced by hisescription of seeking help from his district nurse, pharma-ist and GP.
‘‘. . .it wasn’t really a problem at that time but I think I’ma bit of concern about how long this was going to go onfor. And I probably did go back to the local surgery onceor twice to get their opinion but it did clear up. . .’’
Fear and anxiety because one is unable to breathe wouldppear an obvious assumption. While uncertainty has beenescribed in those mechanically ventilated (Hafsteinsdottir,996) this was related to the realisation of being intubatednd being unable to communicate rather than uncertaintyver what we may consider as minor inconveniences. 6/8 ofagnus and Turkington’s (2006) participants reported beingncertain whether their tube was temporary indicating aimilar fear of the unknown. The tracheostomy tube was aew experience for these people and as such symbolised aear of the unknown caused by uncertainty and worry. Thisas characterised not only by the battle for breath but the
ong term anxiety over the frequency of the tube changes,ength of wound healing and the dread of being without arecious airway that sustains life.
elationships with staff
ll participants described positive and negative experiencesith staff though these were often related to care that they
eceived rather than the tracheostomy tube specifically.
Colin—–‘‘. . .she was good!. . .suctions, just looking afterme in general, she was good. A lot of them are inthere. . .’’
‘‘Sometimes they come straight in but other times, ‘I’llbe back in a minute’. . .Yeah, one hour! They got so muchto do, they can’t cope with everybody.’’
Angela—–‘‘She used to come in, to your room and if youwas reading she would pull the thing off you, if it wastelly, she would push the telly out of the way. . .take thething out of your hand and I thought, ‘bloody cheek!’’’
Barry—–‘‘. . .one of the most useful people that I met wasan auxiliary. . .I just thought she was very helpful, sheseemed to know all the wrinkles.’’
Patient relationships with staff can be complex andeliant on a number of factors, not least open communi-ation. Good relationships with staff were characterised byonfidence and trust. This confidence extended to those who
ere seen as competent and skilled with procedures but also
he manner and sensitivity in which they performed them.hile Magnus and Turkington (2006) discuss this impactithin the ICU, this understanding also extends beyond crit-
cal areas where staff are expected to provide a quality of
hile acutely ill 41
Box 3 Recommendations for practice: organisationalsupport of staff caring for people with tracheostomytube.
• Develop care of tracheostomy competencies• Provide allocated time for the education of the-
ory and skills for ward staff caring for people withtracheostomy tube to support competency develop-ment
• Ensure tracheostomy guidelines are in place• Allow clinical support and mentorship for compe-
tency development• Introduce patient acuity scoring system Trust wide to
ensure safe ward care of people with tracheostomy
dscoo
More than nothing: The lived experience of tracheostomy w
care for these people that is at least comparable to specialistareas.
Implications for future research and care
The findings regarding communication, normality and rela-tionships with staff have similarities with those who havedescribed the experience of mechanical ventilation althoughthese studies are inconsistent or not explicit when men-tioning tracheostomy within their sample characteristics.Future research could use similar methods to explore theexperience of communication in people with tracheostomyon the ward environment further and this may shed lighton this particular theme to add to others findings (Donnellyand Wiechula, 2006). The same could be done for any ofthe other themes and this would add further to our under-standing of the experience of the tracheostomy tube. Futureresearch could also expand on Magnus and Turkington’s work(2006) where patients with tracheostomy and staff per-ceptions of communication are explored further. This mayyield more information regarding what they suggest are stafftraining needs in communication.
The information contained within this study has beenused to enhance the current care of people with tra-
cheostomy tubes on the ward environment whether they be‘‘stepped down’’ from critical care or be admitted throughthe emergency department with an existing tube. This workprovided the motivation to produce an evidence based policy
Box 2 Recommendations for practice: nurses caring forpatients with tracheostomy tube.
• Acknowledge the lack of voice to the patient• Engage the patient with alternative methods of com-
munication• Be mindful that writing is an impaired skill with some
survivors of a critical illness• Be consistent with using the same alternative
method of communication• Anger and frustration may be a sign that communi-
cation is not effective• Learn how to suction and dress the stoma site effec-
tively• Be aware that the tracheostomy tube presents the
person with a new and uncertain experience—–thepatient does not view suction and stoma dressing as‘‘just another task’’
• Prepare patients with information about proceduressuch as suction, stoma dressings and nasogastric tubeinsertion as being potentially painful and psychoso-cially uncomfortable.
• Allow for privacy when suctioning• Leave the call bell within reach and answer with
minimal delay• Regularly assess need for regular analgesia when tra-
cheostomy tube in situ.• Offer the option of own clothes/bed garments
swafi
nstB
C
Nicmptccoectfw
wrplmatTt
tube and revise staffing ratios accordingly
ocument to guide the care of this group of people and hasignificantly added to the evidence regarding psychosocialare within the policy. Staff competencies regarding caref the person with tracheostomy are currently being devel-ped in parallel to this to ensure that specific skills of wardtaff are of a minimum standard. Nursing staff from specificards where people with tracheostomy tube are admittedre now provided with mandatory teaching to give them theoundation of theoretical knowledge to support this and thenformation taken from this study is included on this day.
Recommendations generated from this study for futureursing practice are summarised in Box 2. Organisationalupport to ensure not only that risk is managed but to sus-ain a high quality of care for these people is presented inox 3.
onclusion
urses in both critical care and ward environments can benfluential in determining how people with these tubes areared for effectively in the holistic sense. Adequate com-unication as a minimum can involve a creative, consistent,atient centred approach that involves the patient choosinghe best approach for them. Demonstrating proficiency withommon skills such as suction and stoma care can engenderonfidence from the patient and this is seen as crucial whenne considers that the tracheostomy tube is a new experi-nce for patients. While Diagram 1 may misrepresent theomplexities of the interrelatedness of the experience ofracheostomy, it does enable some understanding of how dif-erent aspects of this experience interlink and have meaningith each other.
The essence of the lived experience of tracheostomyithin this study therefore is not a single thing or entity
ather the interrelatedness of each theme and how this com-rises the totality of the experience. The lived experience ofiving and breathing through the tracheostomy tube is not so
uch the sum of its parts but a complex blend of these parts
nd these parts evolve from each person’s perception of theube against the background of their illness and recovery.his represents a new experience for these people whetherhey are faced with the unknown, attempt to find new ways
42
Dc
tw
L
T(at
R
A
A
A
B
B
B
C
C
D
D
D
D
E
G
G
G
G
G
G
G
G
H
H
H
H
J
J
J
J
L
L
M
iagram 1 Interrelatedness of themes of living with tra-heostomy while acutely ill and during recovery.
o communicate, have to put up with the pain associatedith it and/or come to terms with a new self-image.
imitations
his study formed the dissertation module of a recent M.Sc.Nursing). Recruitment was limited to time constraints,vailability of potential participants willing to take part andherefore the number was small.
eferences
damson H, Mungo M, Boyle M, Kerr S, Crawford M, Elliot D. Mem-ories of intensive care and experiences of survivors of a criticalillness: an interview study. Intensive & Critical Care Nursing2004;20:257—63.
rroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA, Stanik-Hutt J,Thompson CL, White C, et al. Pain related to tracheal suctioningin awake acutely and critically ill adults: a descriptive study.Intensive & Critical Care Nursing 2008;24:20—7.
rslanian-Engoren C, Scott LD. The lived experience of survivorsof prolonged mechanical ventilation: a phenomenological study.Heart & Lung 2003;32(5):328—34.
ergbom-Engberg I, Haljamae H. Assessment of patients’ expe-rience of discomforts during respirator therapy. Critical CareMedicine 1989;17(10):1068—72.
ond P, Grant F, Coltart L, Elder F. Best Practice in the care ofpatients with a tracheostomy. Nursing Times 2003;99(30):24—5.
urglass E. Tracheostomy care: tracheal suctioning and humidifica-tion. British Journal of Nursing 1999;8(8):500—4.
oyne IT. Sampling in qualitative research. Purposeful and theoret-ical sampling; merging or clear boundaries? Journal of AdvancedNursing 1997;26:623—30.
ronin P, Rawlings-Anderson K. Knowledge for contemporary nursingpractice. Edinburgh: Mosby; 2004.
ay T, Farnell S, Wilson-Barnett J. Suctioning: a review of currentresearch recommendations. Intensive & Critical Care Nursing2002;18:79—89.
ocherty B, Bench S. Tracheostomy management for patients ingeneral ward settings. Professional Nurse 2002;18(2):100—4.
onnelly F, Wiechula R. The lived experience of a tracheostomy tubechange: a phenomenological study. Journal of Clinical Nursing2006;15:1115—22.
M
M
A. Foster
owling M. From Husserl to van Manen. A review of differentphenomenological approaches. International Journal of NursingStudies 2007;44:131—42.
mden C, Sandelowski M. The good, the bad and the relative, PartTwo: Goodness and the criterion problem in qualitative research.International Journal of Nursing Practice 1999;5:2—7.
iorgi A. The theory, practice, and evaluation of the phenomeno-logical method as a qualitative research procedure. Journal ofPhenomenological Psychology 1997;28(2):235—60.
iorgi A. Concerning the application of phenomenology to car-ing research. The Scandinavian Journal of Caring Sciences2000;14:11—5.
iorgi A. The phenomenological movement and research inthe human sciences. Nursing Science Quarterly 2005;18(1):75—82.
ranberg A, Engberg IB, Lundberg D. Patients’ experience of beingcritically ill or severely injured and cared for in an intensive careunit in relation to the ICU syndrome, Part I. Intensive & CriticalCare Nursing 1998;14:294—307.
ranberg A, Engberg IB, Lundberg D. Acute confusion and unrealexperiences in intensive care patients in relation to the ICUsyndrome, Part II. Intensive & Critical Care Nursing 1999;15:19—33.
reen A. An exploratory study of patients’ memory recall of theirstay in an adult intensive therapy unit. Intensive & Critical CareNursing 1996;12:131—7.
riffiths J, Barber V, Morgan L, Young JD. Systematic review andmeta-analysis of studies of the timing of tracheostomy in adultpatients undergoing artificial ventilation. British Medical Journal2005;330(May (7502)):1243.
riggs A. Tracheostomy: suctioning and humidification. NursingStandard 1998;13(2):49—53, 55—56.
afsteinsdottir TB. Patient’s experiences of communication dur-ing the respirator treatment period. Intensive & Critical CareNursing 1996;12(5):261—71.
iggins D. NT practical procedures: tracheal suction. Nursing Times2005;101(8):36—7.
ooper M. Nursing care of the patient with a tracheostomy. NursingStandard 1996;10(34):40—3.
upcey J. Looking out for the patient and ourselves—–the processof family integration into the ICU. Journal of Clinical Nursing1999;8(3):253—62.
ablonski RS. The experience of being mechanically ventilated.Qualitative Health Research 1994;4(2):186—207.
ohnson P. Reclaiming the everyday world: how long-term venti-lated patients in critical care seek to gain aspects of power andcontrol over their environment. Intensive & Critical Care Nursing2004;20(4):190—9.
ohnson P, St. John W, Moyle W. Long-term mechanical ventilationin a critical care unit: existing in an uneveryday world. Journalof Advanced Nursing 2006;53(5):551—8.
ones C, Lyons C. Researching the experience of being criticallyill: some methodological difficulties. Intensive & Critical CareNursing 2003;19:365—9.
of L, Berggren L, Ahlstrom G. Severely ill ICU patients recall offactual events and unreal experiences of hospital admission andICU stay-3 and 12 months after discharge. Intensive & CriticalCare Nursing 2006;22:154—66.
addox M, Dunn SV, Pretty LE. Psychosocial recovery following ICU:experiences and influences upon discharge to the community.Intensive & Critical Care Nursing 2001;17:6—15.
adjar I, Walton JA. Nursing and the experience of illness. Phe-nomenology in practice. London: Routledge; 1999.
agarey JM, McCutcheon HH. ‘Fishing with the dead’—–recall ofmemories from the ICU. Intensive & Critical Care Nursing2005;21:344—54.
hile
R
R
R
S
S
S
S
T
v
W
WNursing Standard 2002;16(44):39—48.
More than nothing: The lived experience of tracheostomy w
Magnus VS, Turkington L. Communication interaction in ICU—–patient and staff experiences and perceptions. Intensive &Critical Care Nursing 2006;22:167—80.
McKinney AA, Deeny P. Leaving the intensive care unit: a phe-nomenological study of the patients’ experience. Intensive &Critical Care Nursing 2002;18:320—31.
Merleau-Ponty M. Phenomenology of perception (translated bySmith, C.). London: Routledge & Kegan Paul; 1945/1962.
Moore T. Continuing professional development. Suctioning tech-niques for the removal of respiratory secretions. NursingStandard 2003;18(9):47—55.
Munhall PL. Nursing research. A qualitative perspective. 3rd ed.Boston: Jones and Bartlett Publishers; 2001.
Nursing Midwifery Council. The NMC code of professional conduct:standards for conduct, performance and ethics. London: Nursingand Midwifery Council; 2004.
Odell M. The patient’s thoughts and feelings about their transferfrom intensive care to the general ward. Journal of AdvancedNursing 2000;31(2):322—9.
Oermann MH, Boyll RM, McHugh NG, Deitrich J. Patient sensationsfollowing a tracheostomy: a discussion. Critical Care Quarterly1983(September):53—8.
Papathanassoglou EDE, Patiraki EI. Transformations of self: aphenomenological investigation into the lived experienceof survivors of critical illness. Nursing in Critical Care2003;8(1):13—21.
Parahoo K. Nursing research. Principles, process and issues. Bas-ingstoke: Palgrave; 1997.
ods, appraisals, and utilization. 5th ed. Philadelphia: Lippincott;2001.
RCN Research Society. The Royal College of Nursing ResearchSociety: nurses and research ethics. Nurse Researcher2004;11(1):7—21.
W
acutely ill 43
oberts B, Chaboyer W. Patients’ dreams and unreal experiencesfollowing intensive care unit admission. Nursing in Critical Care2004;9(4):173—80.
olfe G. Validity, trustworthiness and rigour: quality and theidea of qualitative research. Journal of Advanced Nursing2006;53(3):304—10.
ussell S. An exploratory study of patients’ perceptions, memoriesand experiences of an intensive care unit. Journal of AdvancedNursing 1999;29(4):783—91.
andelowski M, Barosso J. Reading qualitative studies. InternationalJournal of Qualitative Methods 2002;1(1):1—47.
okolowski R. Introduction to phenomenology. Cambridge: Cam-bridge University Press; 2000.
tein-Parbury J, McKinley S. Patients’ experiences of being in anintensive care unit: a select literature review. American Journalof Critical Care 2000;9:20—7.
trahan EHE, Brown RJ. A qualitative study of the experiences ofpatients following transfer from intensive care. Intensive & Crit-ical Care Nursing 2005;21:160—71.
racheostomy Management in Critical Care (TracMan trial)(ISRCTN28588190). Accessed April 23, 2008, at http://www.controlled-trials.com/isrctn/search.html?srch=tracman&sort=3&dir=desc&max=10.
an Manen M. Researching the lived experience: human science foran action sensitive pedagogy. 2nd ed. New York: SUNY Press;1990.
all C, Glenn S, Mitchinson S, Poole H. Using a reflective diary todevelop bracketing skills during a phenomenological investiga-tion. Nurse Researcher 2004;11(4):20—9.
oodrow P. Managing patients with a tracheostomy in acute care.
underlich RJ, Perry A, Lavin MA, Katz B. Patients’ perceptionsof uncertainty and stress during weaning from mechanicalventilation. Dimensions of Critical Care Nursing 1999;18(1):2—10.
