Children with tracheostomies are complex and require extensive resources to manage both in the hospital and in the home setting.1 Indications for pediatric tracheostomy include the need to maintain airway patency, help manage secretions, and provide long-term mechanical ventilation due to a chronic medical condition.2,3 Literature about management of pediatric tracheostomy is limited, and expert consensus statements reveal gaps that need to be addressed through prospective research and standardization of care.4-6 Few studies have focused on training of the caregiver.7-16
Well-trained caregivers are essential to ensure the best outcomes for children with tracheostomies and their safe transition from the hospital to home. Inadequate training may result in increased morbidity, readmission, and even mortality.17 Training these caregivers presents interesting challenges: we are attempting to teach people with varying backgrounds and abilities an understanding of anatomy and physiology while providing a toolkit of skills in a time frame of weeks. Different teaching strategies with proven efficacy are used to train clinicians to master and maintain competency within their respective roles: instructional materials, hands-on training, and use of task trainers and high-fidelity simulation, followed by competency assessment.18 Many of these same strategies are used to train caregivers of medically complex children, but the efficacy for these learners is not as well described. We must identify additional approaches that bolster not only the competence but also the confidence of caregivers. The goal of a training program should be to make caregivers as familiar and comfortable with their child’s care as possible, with the hope they will have the skill set needed to help them troubleshoot and address new problems as they arise.19 The study by Wise et al20 in this issue of Respiratory Care aims to ascertain whether the introduction of a training doll into a caregiver's educational regimen will improve his or her confidence and lead to other measurable benefits, such as a reduced length of stay (LOS) or faster training completion times.
There are numerous strengths in this investigation, including the use of both objective data and subjective feedback. This provides a balanced assessment of the impact of training dolls both from the standpoint of LOS and the perspective of the caregiver. The inclusion of retrospective and prospective data, and a control group of caregivers makes the study’s conclusions more compelling. This comparative analysis allows us to separate the effect of the doll from other confounding variables. The study goes beyond assessing caregiver confidence alone by including the time to complete training. This multifaceted approach helps stakeholders understand not just whether the training dolls were appreciated but whether they made a meaningful difference in the clinical setting.
The greatest appeal of using training dolls to enhance caregiver trainer is the real-world applicability and focus on family-centered care. Direct relevance to real-life scenarios should be exploited at every opportunity. Caregivers often struggle with complex tasks such as tracheostomy care and routine tube changes. This study evaluated an additional tool that has the potential to make the transition from hospital to home safer and more manageable. The authors recognize the importance of caregiver training because caregivers are often the primary point of care once the patient is discharged and health care extends into the patient’s home.
Unfortunately, the study failed to show that the training doll had any statistically significant impact on crucial outcomes such as the LOS and the time needed to complete training. Many confounders may have impacted the LOS in this study. The control group used was from before the COVID-19 pandemic, whereas the study was conducted at the height of pandemic years, when multiple barriers to discharge, including hospital visitation policies, readiness of the home environment, and limited availability of home nursing, became more burdensome.21 Additional covariates, such as the caregiver’s previous medical background and/or training, the child’s overall health status, the family’s socioeconomic status, and the availability of extended support systems were not captured; these factors could influence the other outcomes although these effects may be hard to tease out with this sample size. Therefore, it is not surprising that an impact on the LOS or the time to complete training was not seen.
The lack of impact of the training doll on the time to complete training likely reflects the fact that training is complex and involves other skills that are not easily learned or practiced on a task trainer. However, the training doll still offers benefit and introduces little risk. Training dolls increase access to training for caregivers, giving them the opportunity to practice psychomotor skills and gain familiarity with equipment and materials used, but they do not provide feedback to caregivers about whether they are using appropriate techniques for the tasks being performed. Care of the patient with a tracheostomy is multifactorial and patient-specific. Although increased caregiver confidence is beneficial, the ultimate goal is to demonstrate improved patient outcomes and efficiency, which the study was not able to show. Some caregivers also felt that the training dolls lacked realism.
The survey had a decrease in the response rate with the second survey (56%) compared with the first survey (94%).20 This may have resulted in underreporting of negative feedback on the overall experience. A pitfall of survey-based research is the tendency to give socially desirable answers, not by fault of the researchers but by the inherent design of the study. It is possible that caregivers provided the answers they thought the study team wanted to hear. In addition, no survey was used to gain the perspective of the trainer on the perceived benefit that the training dolls provided each family.
Although the article discusses the utility of the training doll, it does not address financial aspects of producing, distributing, and integrating training dolls into a standardized training program. This information would be considered critical by policymakers and administrators. There may be benefit in incorporating technology into these training dolls to add more functionality in response to interventions (eg, chest rise in response to ventilation) or provide feedback to train learners in proper technique. Future studies with higher technology dolls would shed light on whether high-tech solutions significantly outperform simpler, less costly options, and help us to identify where to implement each type of learning platform. A comprehensive cost-benefit analysis to understand the long-term economic implications of using training dolls compared with other methods and whether any method has a superior correlation with faster time to discharge would be of interest.
Understanding key strengths and weaknesses of this study in greater detail provides a clearer picture of the contribution to the peer review and identifies a multitude of future avenues for research. First and foremost, longitudinal studies must be conducted to investigate the long-term impact of different caregiver training strategies. In our own institutional experience, we find that caregivers who are able to spend substantial time at the bedside to familiarize themselves with their child’s care and have the opportunity to see what it looks like not only when their child is doing well but also when their child is struggling, are the most successful.19 When they are present, the caregivers have an opportunity to be the “first responders” in a relatively protected environment with the in-patient clinical team there as support.
The focus of the current study was on impressions of caregivers as they completed their training in the hospital. It would be useful to follow up with caregivers to examine how the training might impact quality of care at home or whether confidence gained during training is sustainable over an extended time frame. Future studies should examine how caregivers apply the skills that they have learned in the home environment and how this affects the patient’s health and well-being. A study could be conducted to measure how realistic the training feels to caregivers, how well the skills learned through the training doll translate into effective care in real-life scenarios, and how many caregivers have had to deploy emergency skills in the home.
In-depth reviews of focus groups with caregivers could provide more nuanced insights into the emotional and psychological impact of using training dolls, which self-administered questionnaires may not capture. It is true that results of a single-site study will have inherent limitations in generalizability given that it reflects the demographics of that site’s study population and training practices. We should investigate caregiver training across various health-care settings and demographic groups to determine whether the training meets all caregiver needs.
We commend the authors for performing this socially meaningful quality-improvement research. Although not every study is able to produce statistically significant results, it is of utmost importance for caregivers to feel psychologically safe as they navigate the realities of learning to care for their medically complex child. Complex emotional and logistical burdens are often shouldered by caregivers, and helping them navigate by practicing trauma-informed care and respecting their unique, individual needs as a lay person learning life-sustaining and life-saving skills is paramount to the outcomes for children with tracheostomies. As medical technologies advance, we are discharging more children home who are dependent on respiratory technologies such as tracheostomies. As this patient population grows, so will the need to understand how best to train their caregivers.
Footnotes
Ms Nickel discloses relationships with Nihon Kohden and Actuated Medical, and is an editorial board member for Respiratory Care. The other authors have disclosed no conflicts of interest.
See the Original Study on Page 1631
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