Achieving Excellence in Tracheostomy Care: Qualitative Insights from a Multicenter Implementation Study

Introduction

Tracheostomies are artificial airway devices inserted into the front of the neck, predominantly for airway management and to facilitate invasive ventilation. Approximately 17 000 tracheostomy procedures are performed annually among adults and children in the United Kingdom (UK) for intensive care and surgical management.¹ Although it is a common procedure, tracheostomy insertion and subsequent management are associated with risks. The 4^th National Audit Project revealed that half of all airway-related deaths and brain injuries in intensive care units (ICUs) were due to complications involving tracheostomies, despite these cases representing a relatively small proportion of the total 2.9 million airway management episodes assessed across the National Health Service (NHS) annually.² Research indicates that many adverse events associated with tracheostomies are potentially preventable through the implementation of appropriate institutional and clinical safeguards.³

Tracheostomy care is inherently complex, requiring the coordinated input and management from a multidisciplinary team (MDT) that includes physicians, nurses, physiotherapists, and speech and language therapists (SLTs).^4,5 Implementing and sustaining improvements in such complex health care systems poses significant challenges. The Improving Tracheostomy Care (ITC) program addressed these challenges by implementing 18 targeted interventions (see Table 1) across 20 NHS hospitals in the UK between 2016 and 2019.⁶ The program demonstrated notable success, with reduced frequency and severity of adverse incidents, shorter ICU and hospital stays, and improved patient-centered outcomes. Success included a marked reduction in the time required for patients with new tracheostomies to regain vocalization and a significant decrease in patient anxiety and depression levels. An independent economic evaluation reported substantial cost savings of £33 251 per patient, primarily attributable to reduced length of stay, translating to a potential annual saving of £275 million across the UK.⁷

This analysis explores the barriers and enablers to achieving excellence in tracheostomy care, as perceived by the multidisciplinary staff directly involved in the management of these patients. Health care professionals, with their frontline experience and practical expertise, offer invaluable insights into the complexities and challenges of delivering high-quality care in diverse clinical settings. By drawing on their perspectives, we sought to deepen understanding of the organizational, clinical, and safety factors influencing tracheostomy care.

Aims

1. To explore the perspectives of multidisciplinary health care professionals on the barriers and enablers to achieve high-quality tracheostomy care within the framework of the Improving Tracheostomy Care program.

2. To evaluate the impact of the Improving Tracheostomy Care program interventions on organizational efficiency, patient-centered care, and safety from the viewpoint of staff involved in tracheostomy management.

Methods

The ITC program implemented 18 targeted interventions derived from the Global Tracheostomy (Quality Improvement) Collaborative (Table 1). To evaluate the impact of these interventions, a survey was conducted to collect data from staff participants. Ethical approval for the program was obtained from the National Research Ethics Committee (IRAS Project ID 206955; REC Ref 16/LO/1196), and the initiative was subsequently adopted onto the National Institute for Health Research Portfolio (CPMS ID 31544).

Staff participants from a range of health care backgrounds, including physicians, nurses, physiotherapists, and SLTs involved in tracheostomy care, were recruited by trained local research leads at each participating site. Recruitment procedures were intentionally flexible to accommodate differing organizational structures, but leads were to approach staff directly involved in tracheostomy management across relevant clinical areas.

Sites commonly used a combination of methods to invite participation, including announcements during morning handovers, in-person approaches during clinical shifts, and drop-in sessions held in wards. Some sites supplemented these with email circulation via local distribution lists or notices placed in staff areas. Although formal purposive sampling was not undertaken, local leads were encouraged to engage staff from a range of professional groups, levels of experience, and clinical environments (eg, medical and surgical wards, emergency departments, and ICUs) to ensure representation across the breadth of tracheostomy care.

Participants were invited to complete surveys in paper or electronic format. These were administered through convenience sampling as snapshot surveys during the following 3 phases of the project: baseline (months 0–10), implementation (months 11–22), and evaluation (months 23–30).

The surveys were developed using an appreciative inquiry framework, chosen to foreground strengths within existing tracheostomy care practices and to encourage staff to reflect on what worked well, rather than focusing solely on deficits.⁸ Appreciative inquiry was considered particularly appropriate for this quality-improvement context, as it facilitates engagement, supports positive cultural change, and helps identify locally generated solutions.⁹ The survey tool was piloted during a smaller quality improvement project.¹⁰ The final version was co-developed in a series of workshops with multidisciplinary staff, experts in change management, and patient representatives during the 6-month setup phase of the program.

Within this framework, the surveys incorporated open-ended free-text questions designed to elicit constructive reflections, highlight examples of effective practice, and capture a broad range of experiences and perspectives across clinical settings. The analytical approach aligned with this orientation by examining not only the challenges but also the conditions that enabled good care, thereby informing the development and refinement of implementation strategies. Figure 1 provides the questions included in the staff survey.

An appreciative inquiry framework was selected, as it is well-suited to qualitative work embedded within quality improvement initiatives, emphasizing the identification of existing strengths, effective practices, and enabling conditions within complex health care systems. This strengths-based approach supports staff engagement, aligns with the collaborative and iterative ethos of quality improvement, and facilitates the generation of actionable insights while minimizing participant defensiveness. The use of an appreciative inquiry-informed survey methodology enabled the inclusion of a large and diverse multidisciplinary sample, capturing perspectives from staff across multiple clinical areas and sites. Compared with face-to-face qualitative methods, this approach facilitated broader participation, reduced logistical barriers, and allowed a greater range of staff voices to be represented.

Study team members acknowledge that our professional backgrounds and involvement in tracheostomy care may have influenced our analysis processes. The multidisciplinary composition of the research team, comprising intensivists, anesthetists, nurses, and quality improvement experts, provided a range of perspectives that enriched our interpretation of the findings. However, we also recognize the potential for researcher bias, particularly in prioritizing themes that align with our clinical experiences and professional expertise. To mitigate this, we used strategies such as reflexive discussions, triangulation of findings, and adherence to established qualitative methodologies, including an inductive thematic analysis process.¹¹ In addition, the use of appreciative inquiry as a strengths-based framework helped to foreground participants’ perspectives and minimize undue influence from researchers’ preconceived notions. By reflecting on our positionality, we aim to present findings that authentically represent the voices of health care professionals engaged in tracheostomy care.

An inductive thematic analysis was conducted to analyze qualitative data from all survey phases, following the approach described by Braun and Clarke.¹² The process involved systematic familiarization with the dataset, generating initial codes through open coding, refining and organizing these codes, and distilling them into overarching themes. Data analysis was conducted using NVivo software (v11.0, Lumivero, Melbourne, Australia). Iterative discussions among the research team were held to resolve discrepancies and validate the thematic framework.

Reflexivity was maintained throughout the analysis to minimize the influence of researcher bias, and triangulation was applied by incorporating diverse perspectives from the multidisciplinary research team to enhance the credibility and trustworthiness of the findings.

Researcher Characteristics and Reflexivity

Data coding and analysis were conducted by two researchers. One was an anesthetic registrar at the time of the study, undertaking a clinical research master’s degree in the UK and holding a primary medical qualification. The second was an advanced nurse practitioner with experience in intensive care and involvement in clinical research. Both researchers were male and were clinically active health care professionals during the study period.

No prior relationship was established between the researchers and participants, as data were collected via anonymous, self-completed written surveys. Participants were aware that the study formed part of a quality improvement program focused on tracheostomy care but did not have direct interaction with the researchers.

Both researchers have professional experience in intensive care and regular clinical exposure to patients with tracheostomies. This background informed their interest in the research topic and may have shaped their perspectives during data interpretation. To mitigate potential bias arising from shared clinical experience, reflexive discussions were undertaken throughout the analytical process, and interpretations were reviewed within a multidisciplinary research team to support balanced and credible analysis.

Results

The survey received a total of 477 valid responses, representing a wide range of MDT members involved in tracheostomy care. Nursing staff made up the largest proportion of respondents (65%), followed by physiotherapists (11%), anesthetists (10%), physicians (5%), SLTs (4%), and surgeons (3%). Responses were obtained from all 20 participating hospital sites. In terms of survey phase, 204 responses were collected during the baseline period, 130 during implementation, and 143 during evaluation.

Thematic analysis identified the following 3 core themes for understanding tracheostomy care from the staff perspective: education and training, standardized daily care, and organizational efficiency. Each theme is detailed in the following sections, including key subthemes that provide further insight into the challenges and opportunities for ITC.

Theme 1: Education and Training

Education and training emerged as the most prominent theme from the analysis. Feedback from staff overwhelmingly highlighted significant deficiencies in education. Many respondents expressed that the absence of formal training increased anxiety and stress, particularly among nursing staff who felt ill-prepared to manage the needs of patients with tracheostomy. One respondent summarized this sentiment:

“There is no system in place to ensure staff are trained. This has huge knock-on effects to patient and staff, staff feel stressed if multiple [tracheostomy] patients on the ward and patients may feel neglected-new junior members of staff are nervous [to look after such patients]” – Physician, 1–2 years’ experience

Barriers to effective education and training were predominantly linked to the lack of protected time for attending sessions and insufficient staffing levels to allow participation. Respondents who had concerns about training consistently emphasized the need for it to be a mandatory component of clinical education. They advocated for guaranteed, regular opportunities to attend training and updates. Cancelled sessions further compounded the problem, leaving educators feeling disheartened by low attendance and less motivated to organize future events. This was reflected in comments such as:

“It is not deemed as mandatory training, therefore many of the ward nurses are unable to find time to be released for training.” – Nurse, 3–5 years’ experience

“Success has been limited due to unavailability of staff to attend: lack of proper study time given and lack of insight into importance.” – Nurse 6–10 years’ experience

By the evaluation phase, feedback demonstrated a noticeable shift toward positive experiences. Respondents praised the introduction of regular simulation sessions, national training days, and annual refresher courses. The institutional mandate for ongoing education was particularly appreciated, with guaranteed time for learning activities and opportunities for interdisciplinary collaboration cited as key enablers. Centers with specialist nurses coordinating training programs and protocols for maintaining proficiency were frequently highlighted as examples of best practice. This was confirmed by 1 respondent who stated:

“It is our speciality in our ward area and is embedded in practice. We have in-house training/coaching with specialist nurse using dummy. We have regular training.” – Nurse, >15 years’ experience

Theme 2: Standardized Daily Care

Standardized daily care emerged as the second prominent theme in this survey. Standardized care included daily care bundles, MDT involvement, appropriate staffing levels (considered “safe” by respondents), medical oversight, and provision of adequate and appropriate equipment.

Daily care bundles

Well-formulated tracheostomy daily care bundles emerged as a key factor in enhancing overall tracheostomy care. Staff valued bedhead signs that detailed critical patient and tracheostomy information, considering them vital for effective handovers and emergency management. These signs typically recorded essential details such as the type of tracheostomy tube, insertion date, insertion method, and any airway concerns or specific instructions for airway management (eg, whether the patient had a tracheostomy or laryngectomy). The inclusion of an emergency algorithm, often printed on the reverse of the bedhead sign, was particularly appreciated for its utility in emergent situations. High-quality nursing care was consistently regarded by respondents as a fundamental component of tracheostomy management. However, disparities in daily care standards were noted, with inconsistent practices around inner tube changes and suctioning frequently highlighted as areas of concern by nursing colleagues.

During the baseline phase, feedback often underscored the lack of standardization in care practices, contributing to variability in patient outcomes. This variability was reflected in comments such as the following:

“(Care) can be inconsistent depending on nursing staff, training, confidence, and experience.” – Nurse, 6–10 years’ experience

“Lack of uniformity in delivery of the tracheostomy care in three ITU units.” – Nurse, 6–10 years’ experience

The absence of clearly defined care bundles was identified as a contributing factor to these inconsistencies. In contrast, by the evaluation phase, the introduction of comprehensive and standardized daily care bundles was associated with noticeable improvements. Bedhead signs became integral to effective handovers and emergency preparedness, enhancing the overall consistency and quality of care. Respondents highlighted the following positive changes:

“The frequency of (incidence) reports has fallen; standardization of tracheostomy care across the whole trust.” – Nurse, 1–2 years’ experience

“We monitor trachy site every hour. Daily dressing. Monitor cuff pressure. Utilize the protocol on care of tracheostomy.” – Nurse, 11–15 years’ experience

These findings highlight the role of standardized care protocols and visual aids in promoting consistent, high-quality tracheostomy care across different settings.

Multidisciplinary (MDT) involvement

The involvement of the MDT was identified as a crucial component of effective tracheostomy care. Specialist input was often integrated into daily care, with MDT members participating in ward rounds that served as opportunities to discuss care objectives and discharge planning. Typical MDT composition included nursing and medical staff, SLTs, physiotherapists, and head and neck surgical specialists. Respondents noted that participation in the ITC project facilitated the establishment of tracheostomy steering committees and advanced local standards of care. Facilities with active MDTs or steering groups demonstrated positive correlations with various aspects of care, such as improvements in education and training, staff support, equipment availability, and adherence to standardized guidelines.

At the baseline phase, respondents highlighted significant challenges in establishing effective MDTs. These included the absence of protected time in job plans and inadequate organizational support, which hindered the development of structured multidisciplinary collaboration. This was reflected in comments such as the following:

“No organization-level ownership for planning of cross-cutting care, MDT support ie, job plans etc.” – Physician, 6–10 years’ experience

“Poor MDT input causes poor weaning/speech/swallow/cuff down.” – Physiotherapist, 3–5 years’ experience

By the evaluation phase, positive changes were observed with the strengthening of MDT involvement, leading to improvements in training, staff support, and the availability of essential equipment. The formation of tracheostomy steering committees played a pivotal role in driving local advancements in care. These developments were illustrated by the following examples:

“Increasing collaboration between multidisciplinary members to improve the quality of care of tracheostomy patients and also increasing awareness of quality improvement interventions.” – Physiotherapist, 3–5 years’ experience

“MDT, now doing ward rounds on all tracheostomy patients. Would not have been able to do this without ITC.” – Anesthetist, 3–5 years’ experience

Despite these improvements, persistent difficulties in establishing effective MDTs were noted. These included the lack of designated time in job plans, the unavailability of medical staff during sessions, the absence of specialist services within some hospital trusts, and insufficient organizational support. Respondents frequently recognized the impact of these barriers on patient care processes, particularly in areas such as weaning, decannulation, and discharge planning.

Staffing levels

Concerns about staffing levels were particularly noticeable in noncritical care environments, where the use of external temporary workers was reported to be more prevalent. Ward staff expressed unease about their inability to provide adequate care for patients with tracheostomy alongside their existing workloads. These daily staffing challenges were further exacerbated by staff illness and high turnover rates, leading to concerns among senior nurses about the overall quality of care they could deliver.

Although some improvements were noted in the evaluation phase, issues related to staff turnover and sickness persisted, presenting ongoing barriers to care. Respondents frequently acknowledged that stable and sufficient staffing was essential for ensuring the success of other interventions and maintaining high standards of care. These sentiments were encapsulated in several responses as follows:

“Limited ability to look after tracheostomies on the ward. Ward nurses too busy looking after too many patients to observe/monitor tracheostomy patients.” – Nurse, 1–2 years’ experience

“We have training courses for ward nurses, but unfortunately, with the fast turnover of staff, skills are lost very quickly.” – Nurse, 3–5 years’ experience

“Complex tracheostomy care with low staff levels. Care not standardized can vary ward to ward, though they receive the same training.” – Nurse, 1–2 years’ experience

The findings highlight the need for constant staffing levels to support tracheostomy care, ensuring sufficient time and resources are available for consistent, high-quality care delivery. Without addressing these challenges, the effectiveness of other quality improvement measures may be limited.

Medical oversight

A proportion of feedback called for greater involvement of medical staff in the day-to-day management of patients with tracheostomy, highlighting a significant gap in medical ownership and follow-up care. This issue was particularly pronounced on non-specialist medical wards, where respondents reported that no single medical team consistently assumed responsibility for patients with tracheostomy. Analysis from the baseline phase revealed a lack of consistent medical oversight and accountability, as captured in the following comments:

“No one seems to want to take responsibility for tracheostomy patients, and it is never straightforward where to provide care for them.” – Nurse, >15 years’ experience

“No medical group takes ownership for tracheostomy patients on medical wards.” – Nurse, 3–5 years’ experience

By the evaluation phase, some improvements in medical involvement were reported. However, gaps in follow-up care responsibilities remained a persistent issue. Respondents consistently emphasized the need for stronger and more consistent medical oversight to ensure comprehensive patient care. Notably, sites with active tracheostomy steering groups and well-functioning multidisciplinary teams did not report these issues, suggesting the positive impact of structured governance and collaborative care models.

The findings underscore the importance of establishing clear pathways for medical ownership and follow-up care for patients with tracheostomy, particularly in noncritical care environments. Strengthening medical involvement in these settings may improve continuity of care and overall patient outcomes.

Equipment

Staff expressed a strong desire for frequent familiarization sessions with tracheostomy equipment, advocating for these to be integrated into mandatory education and training programs. Barriers to effective equipment management included the limited availability of appropriate devices, particularly when patients had unique tube types or were managed in areas with less frequent exposure to patients with tracheostomy. Respondents highlighted concerns regarding variability in the range of available equipment, which often led to unfamiliarity, competence issues, and increased anxiety among staff. These challenges were captured in the following comments:

“Inappropriate stock levels for tracheostomy equipment ie, suction catheters.” – Nurse, 3–5 years’ experience

“Shortage of stock eg cuff manometer, heated humidifiers.” – Nurse, 1–2 years’ experience

During the evaluation phase, respondents noted improvements in equipment training sessions. However, concerns about the variety and consistent availability of tracheostomy equipment persisted. Regular familiarization sessions were identified as crucial for maintaining staff competence and confidence in managing patients with tracheostomy. Despite ongoing challenges, some centers demonstrated progress by standardizing equipment and establishing centralized storage systems, which facilitated better organization and accessibility. These improvements were reflected in comments such as the following:

“Having equipment lists for bedside equipment and emergency boxes has been beneficial to organization of equipment.” – Nurse, 3–5 years’ experience

“A central tracheostomy store has increased the number of tubes available and assisted with tube changes within the outpatient area and provided options for inpatients if a different type required.” – Nurse, 3–5 years’ experience

The findings underscore the importance of standardized equipment availability and regular training to reduce variability, improve staff confidence, and enhance the quality of tracheostomy care.

Theme 3: Organizational Efficiency

Job planned time

An underlying theme across responses was the need for job-planned, protected time dedicated to caring for patients with tracheostomies. This was especially evident for specialist nursing roles and critical care outreach services. Respondents expressed a desire for protected time to provide clinical support to colleagues and deliver regular education and training. However, the lack of support from hospital management to allocate time for these roles was a recurring concern. Feedback during the baseline phase highlighted that the absence of protected time hindered the ability of staff to provide optimal care. This sentiment was reflected in the following comments:

“Lack of support in the area for the patient and staff. For a long time, I have advocated for a tracheostomy specialist team to be put in place to support. Critical care and Macmillan nurses do well, but they have other responsibilities.” – Nurse, > 15 years’ experience

“Leadership fractured and compartmentalized as we do not have a tracheostomy nurse, so interventions, quality innovations, and quality initiatives [are] pushed through by a few key interested individuals.” – Nurse, <1 years’ experience

Despite these challenges, some centers demonstrated good management support, which enabled improved care and better outcomes. This was captured in comments such as:

“We have easy access to head and neck specialist nurses, senior ENT physicians, and outreach nurses that allow us to quickly troubleshoot and resolve any tracheostomy issues that we may have.” – Nurse, 6–10 years’ experience

By the evaluation phase, there was increased recognition of the importance of job-planned time for tracheostomy care roles. However, challenges related to management and budgetary constraints persisted, highlighting the need for stronger organizational commitment to support these initiatives.

Cohorting of patients

Cohorting refers to the practice of colocating patients with similar care needs into dedicated wards or areas. Respondents frequently described cohort wards as a protective mechanism for delivering high-quality care. These designated locations were seen as optimal environments for patients with tracheostomy, as they centralized staff, equipment, and infrastructure, which in turn facilitated training, support, resource availability, and appropriate governance. Staff highlighted the importance of maintaining a minimum volume of patients with tracheostomy in these areas to preserve skills and competencies.

However, limiting the number of locations within an organization that were deemed safe to manage patients with tracheostomy posed challenges. Respondents expressed concerns about the impact of this approach on patient flow, particularly the inability to step patients down from critical care or specialist environments. This was often compounded by a perceived de-skilling of staff in noncohort wards and concerns about their ability to manage patients with multiple comorbidities and a tracheostomy. These concerns were reflected in comments such as the following:

“Bed block on ICU. Ward care not good.” – Nurse, 1–2 years’ experience

“Patient flow, delayed critical care patients, blocked beds.” – Nurse, >15 years’ experience

At the baseline phase, the absence of dedicated wards for patients with tracheostomy was a significant concern, affecting the ability to provide specialized care. This was illustrated by comments such as the following:

“Patients get different care depending on where they are managed within the organization.” – Nurse, 11–15 years’ experience

“Within critical care, the standard of tracheostomy care is reasonable. Outside critical care, it is nonexistent.” Physiotherapist, >15 years’ experience

By the evaluation phase, the establishment of dedicated cohort areas improved care by concentrating staff, equipment, and infrastructure. However, challenges remained regarding maintaining skills in noncohort wards and ensuring they could manage patients with complex needs and multiple comorbidities. These findings highlight the need for a balanced approach that leverages the benefits of cohorting while addressing its impact on care delivery outside dedicated areas.

Discussion

Interpretation of Key Findings

This study identified the following 3 overarching themes for achieving high-quality tracheostomy care: education and training, standardized daily care, and organizational efficiency. Each theme reflects core areas that staff considered important for improving patient outcomes and addressing the inherent complexities of tracheostomy management. The findings illustrate not only the barriers to optimal care but also the potential for systematic improvements when targeted interventions are implemented.

The study highlights that insufficient formal training and a lack of protected time for education were significant barriers during the baseline phase. Staff described increased anxiety and reduced confidence in managing patients with tracheostomy, particularly among nurses. However, the implementation of regular simulation sessions, national training days, and refresher courses led to notable improvements in confidence and competence by the evaluation phase. These findings underscore the necessity of integrating mandatory, structured training programs to ensure consistent skill levels across all staff members.

The introduction of daily care bundles, including tools such as bedhead signs and emergency algorithms, was identified as a key facilitator for improving care consistency. At baseline, respondents frequently reported inconsistencies in care practices, which were attributed to variable staffing levels, equipment availability, and training gaps. By the evaluation phase, the standardization of protocols had resulted in reduced adverse events and improved communication during handovers. These findings emphasize the importance of implementing standardized care protocols to address variability and enhance patient safety.

Organizational inefficiencies, particularly a lack of job-planned time and inconsistent medical oversight, were highlighted as barriers to achieving high-quality care. Respondents described how the absence of dedicated tracheostomy teams or steering committees hindered progress. By the evaluation phase, centers with active steering groups and improved resource allocation reported more positive outcomes, including better staff support and patient flow. This highlights the critical role of organizational commitment in creating sustainable improvements and ensuring the success of interventions.

Overall, the dynamic changes observed over the course of the program demonstrate the value of a systematic and collaborative approach. The findings suggest that tailored interventions addressing education, standardization, and organizational support can significantly reduce barriers to tracheostomy care, improve staff confidence, and enhance patient outcomes. These results contribute valuable insights into how health care systems can operationalize quality improvement programs to address complex, multidisciplinary challenges.

Contextualization Within Literature

The findings of this study align with existing literature that emphasizes the role of comprehensive education, training, and multidisciplinary collaboration in improving tracheostomy care outcomes. Previous research has consistently demonstrated that structured education and training programs are fundamental to enhancing staff competence and confidence, particularly in caring for patients with tracheostomies. Studies by McDonough et al.¹³ and Ebling and Roberson¹⁴ similarly highlighted that deficiencies in education and preparation contribute to increased staff anxiety and variability in care delivery. Our findings reinforce these conclusions, demonstrating that regular simulation training, refresher courses, and institutional mandates for ongoing professional development are effective strategies to address these gaps.

The importance of multidisciplinary teamwork, as identified in this study, has been well-documented in tracheostomy care research. The National Patient Safety Improvement Programme has highlighted the need for coordinated multidisciplinary input to improve care pathways, particularly in areas requiring complex interventions.¹⁵ Similar to our findings, studies have found that active MDTs improve communication, facilitate care planning, and enhance patient-centered outcomes by pooling expertise from diverse health care professionals, including nursing staff, SLTs, physiotherapists, and surgeons.

Our study also underscores the necessity of implementing standardized care protocols to reduce variability and promote consistency in practice, findings that are supported by prior work from National Confidential Enquiry into Patient Outcome and Death,¹⁶ McGrath and Thomas.¹⁷ Standardized care bundles, including bedhead signs and emergency algorithms, have been shown to enhance communication during handovers and reduce the frequency of adverse incidents. For example, the Global Tracheostomy Collaborative has advocated for standardization as a cornerstone of improving patient safety, and our findings align with their evidence-based recommendations.¹⁸

Despite these similarities, our study uniquely contributes to the literature by capturing dynamic changes in staff perceptions and experiences over the course of a dedicated, sustained quality improvement program. Unlike retrospective reviews of patient safety incidents, this research provides real-time insights into how targeted interventions, such as the formation of tracheostomy steering committees and cohorting of patients, influence staff confidence, care consistency, and organizational efficiency. This longitudinal perspective builds on existing findings by demonstrating the tangible, cumulative benefits of implementing systematic and collaborative quality improvement programs.

Situating Findings Within Implementation Science Frameworks

The barriers and enablers identified in this study can be meaningfully situated within the Consolidated Framework for Implementation Research (CFIR), which offers a comprehensive, multilevel approach to understanding implementation within complex health care systems.¹⁹ Although this study adopted an inductive qualitative design, mapping the findings to CFIR domains provides a useful interpretive lens to enhance theoretical grounding and transferability.

The theme of education and training aligns closely with the CFIR domain Characteristics of Individuals, particularly constructs relating to knowledge, beliefs about the intervention, and self-efficacy. At baseline, staff reported anxiety and lack of confidence when caring for patients with tracheostomies, reflecting limited readiness for implementation. Improvements observed following structured education, simulation training, and mandatory refresher programs illustrate how targeted interventions can enhance individual capability and engagement, supporting successful implementation.

Standardized daily care, including the introduction of care bundles, bedhead signage, and emergency algorithms, maps to the Intervention Characteristics domain. Staff perceptions highlighted the importance of intervention design quality, clarity, and usability in reducing variability and improving safety. The perceived effectiveness of these tools suggests that interventions that are simple, visible, and easily integrated into daily workflows are more likely to be adopted and sustained across diverse clinical environments.

The theme of organizational efficiency aligns predominantly with the inner setting domain of CFIR. Barriers such as lack of job-planned time, inconsistent leadership engagement, variable MDT structures, and staffing constraints reflect challenges in implementation climate and available resources. In contrast, sites with active tracheostomy steering groups, designated coordinators, and organizational support demonstrated stronger readiness for implementation and more consistent improvements in care delivery.

Framing these findings within CFIR highlights that successful tracheostomy care improvement requires alignment across individual, intervention, and organizational levels. This framework helps explain variation in implementation success across sites and underscores the importance of leadership engagement, resourcing, and multidisciplinary collaboration in sustaining system-wide quality improvement initiatives. Situating the findings within CFIR, therefore, strengthens their relevance to wider implementation and quality improvement efforts in complex, multidisciplinary health care settings (Table 2).

Study Strengths

A major strength of this study is its longitudinal design, which involved data collection across 20 diverse UK hospitals over the course of a dedicated quality improvement program. This design allowed for the observation of dynamic changes in staff perceptions and practices over time, providing robust insights into the impact of the interventions. The multicenter approach enhances the transferability of the findings, making them applicable to a wide range of health care environments and settings.

The use of qualitative methods is another strength, as it enabled the collection of in-depth insights into the experiences and perceptions of health care professionals directly involved in tracheostomy care. These professionals are uniquely positioned to identify current challenges and propose actionable solutions for improving care. This rich, detailed understanding of barriers and enablers to high-quality care offers invaluable guidance for the design of future interventions and health care policies.

A novel aspect of this study is the use of appreciative inquiry as a qualitative research technique, which has seen limited application in health care to date.²⁰ Appreciative inquiry is a strengths-based approach to facilitating change. Instead of focusing on identifying problems and finding solutions, appreciative inquiry emphasizes exploring what is already working well and building upon those successes. This involves a process of positive questioning, which helps to uncover the strengths and successful practices within an organization, fostering a more optimistic and proactive environment for change.²¹ By using forms to collect qualitative data from a larger group of participants, this study mitigated the drawbacks of traditional semistructured interviews, which typically limit the number of participants because of time and resource constraints. This approach allowed for the gathering of diverse perspectives and a more comprehensive understanding of tracheostomy care practices across multiple health care settings. The positive focus of appreciative inquiry helped to identify effective interventions and innovative solutions, while also empowering staff by recognizing and valuing their contributions.

Study Limitations

This study has several limitations that should be considered when interpreting the findings. One notable limitation is response bias, as survey participation was voluntary. This may have attracted responses from highly engaged individuals with strong opinions or experiences in tracheostomy care, potentially skewing the results. In addition, the reliance on self-reported data introduces the possibility of recall bias or social desirability bias, where participants may underreport or overreport certain aspects of their experiences.

Although the qualitative nature of the study provides detailed insights, it lacks the quantifiable precision of quantitative methods, which can make it challenging to measure the exact impact of specific interventions. For example, while thematic analysis allowed for the identification of key barriers and enablers, it does not provide numerical estimates of their prevalence or impact, limiting the ability to generalize findings at a statistical level.

The study’s scope was also constrained by ethical permissions, which limited the collection of qualitative data to health care staff perspectives; therefore, the study team was unable to collect qualitative appreciative inquiry data from patients. This prevented a deeper exploration of how patient experiences evolved over time, which could have provided a more comprehensive understanding of the program’s impact.

Furthermore, the implementation of interventions varied across the participating hospitals. Differences in local resources, levels of staff engagement, and organizational support may have influenced the consistency of outcomes. Such variability highlights the importance of contextual factors in the success of quality improvement initiatives and suggests that some findings may not be directly transferable to all health care settings.

Finally, although this study applied appreciative inquiry as a novel and strengths-based approach to capturing staff experiences, this method may have its own limitations. The focus on identifying and building upon existing strengths could inadvertently underemphasize critical systemic weaknesses or failures, potentially overlooking important areas for improvement.

Despite these limitations, the study provides valuable insights into the barriers and enablers of tracheostomy care, offering a foundation for further exploration and the development of targeted interventions to enhance both staff and patient outcomes.

Future Directions

Future research should examine the long-term impact of educational interventions on patient-centered outcomes, including complication rates, time to decannulation, length of stay, and sustainability of observed practice improvements. Further work could evaluate advanced and scalable training approaches, such as high-fidelity simulation and virtual reality, using defined metrics including team communication scores, procedural competency assessments, and response times to tracheostomy emergencies.²² Interprofessional education strategies that bring together medical, nursing, and allied health professionals should be explored to improve coordination and shared decision-making in tracheostomy care. In parallel, digital innovations such as remote physiological and secretion monitoring to support decannulation readiness, as well as artificial intelligence-enabled dashboards to visualize quality improvement metrics, identify safety signals, and track adherence to care bundles, may offer opportunities to enhance the delivery, oversight, and consistency of tracheostomy care at scale. Finally, incorporating patient and family experiences would provide a more comprehensive understanding of care quality and unmet needs.

Take Home Message

This study underscores the pivotal role of education and training, standardized care practices, and organizational support in driving excellence in tracheostomy care. By addressing the barriers identified and capitalizing on the enablers highlighted by frontline health care professionals, significant improvements in patient outcomes can be achieved. As tracheostomy care evolves, the value of insights from multidisciplinary teams cannot be overstated. These findings reinforce the necessity of a coordinated approach, where education is prioritized, care protocols are standardized, and organizational frameworks are strengthened to sustain high-quality practices. Continuous professional development and institutional commitment will be critical in ensuring the long-term success of these interventions, ultimately enhancing both patient safety and staff confidence in managing this complex area of care.

Ethical and Reporting Statement

Ethical approval for the Improving Tracheostomy Care program was obtained from the National Research Ethics Committee (IRAS Project ID 206955; REC Ref 16/LO/1196). The initiative was subsequently adopted by the National Institute for Health Research Portfolio (CPMS ID 31544). Data were collected through anonymous, self-completed staff surveys. No identifiable patient data or case reports are included in this manuscript; therefore, individual patient consent was not applicable. The authors have reported this qualitative study in accordance with relevant qualitative reporting principles, including attention to study design, participant recruitment, reflexivity, data analysis, and trustworthiness.

Conflicts of Interest

The authors declare no conflicts of interest related to this manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Corresponding Author Information

Samuel Owen BM BS, BSc, FRCA
Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
Medical Education, Lancaster University, Lancaster, UK
Anaesthesia, North West School of Anaesthesia UK, Manchester, UK
sam.sowens@gmail.com