https://doi.org/10.15218/ejnm.2023.14 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2023 Original Article Effect of Tracheostomy Care Training on Nurse’s Performance at Critical Care Units in Erbil City ABSTRACT Background and objectives: Tracheostomy is one of the oldest known surgical proce- dures. Tracheostomy patients are at high risk for airway obstruction, impaired ventila- tion, and infection as well as other lethal complications. Skilled bedside nursing care can prevent these complications. Therefore, this study aimed to evaluate the effect of pro- gressive tracheostomy care practice on nurses and physiotherapists in the ICU and RCU in Erbil City-Iraq. Methods: A quasi-experimental study was conducted at four Intensive Care Units (ICU) and Respiratory Care Unit (RCU) Hospitals (Hawler Teaching Hospital, East Emergency Hospital, West Emergency Hospital, and Lalav RCU Hospital) in Erbil City/Iraqi Kurdistan Region. Nurses and physiotherapists from hospitals were selected as the control group, and study group respectively. Nurses and physiotherapists were evaluated through the demographic data questionnaire and tracheostomy care (preparatory phase, perfor- mance phase, and follow-up phase) scale. Results: A total of 90 nurses and physiotherapists (40 nurses and 5 physiotherapists from the interventional group and 38 nurses and 7 physiotherapists from the control group) participated. At the end of the study, there were significant improvements in tra- cheostomy care practice (P-value was 0.001). Conclusion: Nurses and physiotherapists had incompetent practice regarding tracheost- omy care (TC) in the ICU, and RCU and the nurses and physiotherapists who received progressive tracheostomy care procedure training had more knowledge and practice than those who did not attend this program. Attempts should focus on improving tra- cheostomy care in ICUs and RCUs and establish management guidelines. Keywords: Effect; Nurses; Practice; Tracheostomy. Yousif Bakr Omar; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: yousif.omar@hmu.edu.krd) Abdullah Faqiyazdin Ahmed; KBMS and College of Medicine, Hawler Medical University, Erbil, Iraq. 125 Received: 15/07/2022 Accepted: 29/09/2022 Published: 30/11/2023 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:yousif.omar@hmu.edu.krd)?subject=yousif.omar@hmu.edu.krd) mailto:yousif.omar@hmu.edu.krd)?subject=yousif.omar@hmu.edu.krd) mailto:yousif.omar@hmu.edu.krd?subject=yousif.omar@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2023 Original Article Tracheostomy is one of the oldest and most famous surgical procedures. Trache- ostomy is a rescuing procedure done for emergency open-airway inpatients with upper respiratory tract obstruction. Needs to be opened in the trachea or stoma, and then a tube is inflicted through the gate to the passage of air and remove respiratory or other secretions through the tracheosto- my. According to some authors, tracheost- omy is more permanent opining when de- scribed in this terms [1].Airway obstruction is a life-threating and medical emergency that needs artificial airway support, such as the use of tracheostomy. A capable nurse is required to educate the patient or their relatives, to help in the supply of care, and to finance the obviousness of the airways [2]. A greater number on third of patients in RCUs and ICUs will need tracheostomy tube for long-period ventilation. Recently, there have been an estimated 6.5 million people in the United States living with tra- cheostomy despite of its increasing preva- lence, care of the stoma is a’’ high-risk, low -incidence skill’’ that is in many cases edu- cated as described interesting knowledge from one provider to another [3]. This term (tracheostomy) is increasingly carried out in ICUs and RCUs by adults for upper air- way protection or maintenance, airway ob- struction, bronchial cleaning, lengthening mechanical ventilation, and promoting weaning. The tracheostomy causes physi- cal changes in the person, such as body im- age, airway clearance, communication, breathing, smell, and swelling. These often cause social and psychological outcomes. These changes can also self-esteem, and the sense of self-efficacy and often reduce interpersonal and social relationship activi- ty [4]. Nurses are a frontline caregiver and first react in an airway emergency. As much, need to be provided to replay ap- propriately to prevent unnecessary mortality and morbidity, being sufficient knowledgeable of the respiratory system, anatomical tracheostomy, and underline physiology are necessary aspects of a nurse’s ability to sufficiently assess and care for patients both knowledge and practice essential main component in exactly identifying potential problems and acting immediately to prevent serious complications. Complications associated with nurses who are absent the essential skills and training are mucus plugging, accidental decannulation, bleeding, tube displacing inappropriate or inadequate tracheostomy suctioning, or complications during tracheostomy change [5].An important surgery called a tracheostomy is used to help patients with respiratory distress secure their airways so that they can receive adequate care and avoid situations that could lead to death. The practice problem is that, as seen during yearly competency evaluations, staff nurses have shown poor knowledge, abilities, and confidence in the delivery of care to patients living with a tracheostomy. For instance, despite evidence that the practice is unsafe; nurses are continuing to caring for patients with tracheostomies by installing a standard saline bullet into the ostomy to break up mucus. Additionally, the nurses are not adhering to the advised practice when making judgments about tracheostomy care on an individual basis. Additionally, they are not keeping the necessary supplies in patient rooms to act quickly if a tracheostomy tube comes loose.The objective of this study is to evaluate the effect of progressive tracheostomy care on nurses and physiotherapists in ICUs and RCUs in Erbil City-Iraq. 126 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2023 Original Article and the remaining 90 were recruited). Par- ticipants were randomly assigned to con- trol or intervention groups using a num- bered list of names (the odd names re- cruited into the control group and the even names recruited into the intervention group) with proper matching of the two groups in factors such as age, sex, academ- ic qualification, marital status, years of ex- perience, and attending training course. After the exclusion of the 40 nurses for a variety of reasons, including (the limitation of their time and having second jobs), an interview was performed for 45 partici- pants (40 nurses and 5 physiotherapists) in the intervention group and 45 participants (38 nurses and 7 physiotherapists) in the control group (Figure 1). Control and interventional groups of nurses and physiotherapists were recruited as per the quasi-experimental study design from the Intensive Care Unit (ICU) and Respirato- ry Care Unit (RCU) of four hospitals (Hawler Teaching Hospital, East Emergency Hospital, West Emergency Hospital and Lalav RCU Hospital) in Erbil City/Iraqi Kurdistan Region. Inclusion criteria: Include nurses and physio- therapists who provided tracheostomy care for patients admitted to RCU and ICU, both genders, who had experience at least one year, and also who have graduated from [Hawler Medical Institute (Nursing institute which also includes physiotherapy depart- ment and/ or Nursing College)]. After an in- terview with 130 nurses and physiothera- pists (40 nurses and physiotherapists re- fused to enroll in the study 127 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. METHODS Assessed for eligibility (n= 130) Assessment for eligibility of nurses in intervention group (n= 47) Not meeting inclusion criteria=1 Enrolment Assessment for eligibility of nurses in control group (n=83) Not meeting inclusion criteria=38 Intervention group (n=46) Dropouts for variety reasons (n=1) Allocation Control group (n=45) No dropouts for variety reasons Follow up Figure 1. Flow Diagram of control and interventional group of tracheostomy care. Assessment after three months (n=45) Assessment after three months (n=45) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2023 Original Article In a 20-minutes direct interview with par- ticipants (face to face), the questionnaire and check lists were filled out; five minutes for sociodemographic data, and 15 minutes for observing participants during practices by the researcher in pre and post- educational programs two times per week. The program was developed from the Fun- damental of Nursing, Lippincott Manual of Nursing Practice and Tracheostomy Care Program [6,7,8]and validated by expert recommendations The study questionnaire consisted of socio demographic character- istics including (age, sex, academic qualifi- cation, marital status, years of experience, and attending training courses) and the practice (6 items included for suctioning the trachea during tracheostomy care and 27 activities to be done). The practice was prepared for three tracheostomy care as- pects (preparatory phase, performance phase, and follow-up phase). Each of the aspects of tracheostomy scores on a 2- point scale (0: not achieved and 1 achieved). Thus, scores on each subscale range from 0 to 33. Good scores indicate good performance of the practice; the cat- egories of pre and post-practice are inter- preted as poor (below 16), fair (16-24), and good (25-33).At the beginning of the study, the two groups were interviewed and the data were taken (a questionnaire was filled out and checklist completed), then the tra- cheostomy care practice level of partici- pants in both groups was evaluated (pre- test), and then the intervention group un- derwent the tracheostomy care practice training ( 4 hours per week for two succes- sive weeks). All the participants carried on their official duties at the ICUs and RCUs of their hospitals. Three months later, partici- pants from both groups were interviewed again and evaluated for their levels of tra- cheostomy care practice (post-test). Ethical consideration was the main principle in da- ta collection. Permission is taken from nurses before starting the interview by signing the informed consent prepared by the researcher. The researcher is fully aware of research ethics; therefore, nurses dignity, values, and protection from im- pacts that could happen during data collec- tion. Before data collection, the researcher explained the objectives of this study for nurses and the request for participation in this study. The answers and information raised from the study were kept confiden- tial and used for this study only. In addi- tion, the researcher provided opportuni- ties for participants to ask questions or ex- press concerns at any point. Moreover, the local ethical approval was obtained from the Ethical Committee of Hawler Medical University at the College of Nursing to con- duct the study. The date was October 25, 2020, and the code number was 129. Data were analyzed through the SPSS (Version23) application for statistical data analysis based on the objective by using descriptive and inferential statistics. [Frequency, Percentage, Mean, and stand- ard deviation] and t-test. Table1 shows that the number of partici- pants (nurses and physiotherapist) was 45 per each of the control groups and the in- tervention. Participants were grouped into 3 age categories, where the category of 20 -31 years scored the highest percentage among both groups of participants (44.4%). The gender distribution was 66.7% and 71.1% female in the control and intervention groups, respectively. The qualifications of participants were 57.8% Diploma graduates from Hawler Medical Technical Institute (nursing and physio- therapist) in the control group and 53.3% in the intervention group. According to the marital status 57.8% and 60% were mar- ried in intervention and control groups, 128 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULT https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2023 Original Article 129 There were no significant differences be- tween the socio demographic character- istics of the nurses and physiotherapists in intervention and control groups (p. val- ue ≥ 0.05). follow-up phase) in the pre-test, while a very high significant difference result was observed in the post-tests after three months in the study group (P- value=0.001). respectively; Most of participants at both control and interventional groups had 1-4 years of work experience in critical care units (73.3%). The majority of the partici- pants had not attended any previous train- ing on tracheostomy care (91.1% of the control group and 95.6% of the interven- tional group). Table 2 reveals that there is no statistically significant difference between the control and intervention groups regarding doing tracheostomy care (preparatory phase, performance with suctioning phase, and Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 1 : Socio-demographic characteristic of nurses Items Control group (n=45) Intervention group (n=45) P. value F (%) F (%) 0.170 Age group/Years 20-31 29 (64.4) 30 (66.7) 32-43 12 (26.7) 13 (28.9) 44-55 4 (8.9) 2 (4.4) Sex Male 15 (33.3) 13 (28.9) 0.160 Female 30 (66.7) 32 (71.1) Qualification Institute 26 (57.8) 24 (53.3) 0.160 College 19 (42.2) 21 (46.7) Marital Single 19 (42.2) 18 (40.0) 0.323 Married 26 (57.8) 27 (60.0) Work experience in critical department (RCUs & ICUs)/years 1-4 33 (73.3) 33 (73.3) 0.209 5-8 8 (17.8) 8 (17.8) 9-12 4 (8.9) 4 (8.9) Tracheostomy Care Training Yes 4 (8.9) 2 (4.4) 0.160 No 41 (91.1) 43 (95.6) Table 2 Tracheotomy care practice mean score in pre and post tests TC Control group Mean Intervention group Mean t-test P-value C.N Pre-tests 10.7333 10.8000 0.404 NS Posttest (after 3 months) 10.4667 27.7111 0.000 VHS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2023 Original Article a control group in both pre and post-test 95.6%, while in the intervention group the performance was poor level in the pre-test 97.8 % and good level at the post-test 91.1 %. result of the present study shows that the highest percentage of the study sample was married and this result was supported by Nwakaego (2016) [16]. The intensive care facilities are lacking in Erbil and the nurses and physiotherapists usually rotate among governmental hospitals depart- ments according to MOH rules. This affect- ed on years of work of participants (majority of study sample were within 1-4 year work group, a finding of this study similar to the study by Pritchett etal (2019) and Khanum, et.al. (2021) [17,18]. In re- gard to the training program for nurses and physiotherapists in critical care units in Erbil city, the results indicated that the ma- jority of the study sample did not attend any training courses in chest physiothera- py, possibly because of a lack of interest in attending and a lack of encouragement and training programs by their institution; on the other hand, there may be limited time to attend such trainings because of long duties at ICUs and RCUs , this result agreed with the results of the studies con- ducted by Alnemare (2020) and Qalawa 130 Table3 shows the performance of trache- ostomy care practices in pre and post- procedures (preparatory phase, perfor- mance with tracheostomy suctioning phase, and follow-up phase), where apoor level of performance was observed in In this study, the ages of the participants in the control group (20-31) (64.4%) and intervention group (20-31) (66.7%) were consistent with the results of Thomas and Dhudum (2021), and Babiker and Yousif (2016) [9, 10].The majority of the study samples were females; this finding is sup- ported by Padma et al. (2016) [11] study and Mwakanyanga etal (2018) with Ab- dulrahman, and Hamed (2015) study. [12,13], possibly because of a cultural be- lief in the Kurdistan region that females can better manage nursing duties and hence more encouraged to attend such carriers. For decades, the only teaching institution for nursing and physiotherapist in Hawler (Erbil) was Hawler Medical Insti- tute which used to provide Diploma cer- tificates, and it is just recently that more institutions and nursing and physiothera- pist colleges established, that is why the majority of participants were Diploma graduates, which means fewer years of study and training, this result agreed with the result conducted by Ochoki etal. (2021) Mungan, etal. (2019) [14, 15]. The Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 3 : Overall tracheostomy care practices level in pre and post test. TC Practice level Control group Intervention group Pre test Post test Pre test Post test F (%) F (%) F (%) F (%) Poor 43 (95.6) 43 (95.6) 44 (97.8) 0 (0) Fair 2 (4.4) 2 (4.4) 1 (2.2) 4 (8.9) Good 0 (0) 0 (0.0) 0 (0) 41 (91.1) DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2023 Original Article We are thankful to the nurses and physio- therapists for giving their time to interview with us and providing reliable practice. Ethical consideration was the main princi- ple in data collection. Permission is ob- tained from nurses and physiotherapists before starting the interview by signing the informed consent prepared by the re- searcher. The researcher is fully aware of research ethics; therefore, nurses and physiotherapists dignity, values, and pro- tection from impacts that could happen during data collection. Before data collec- tion, the researcher explained the objec- tives of this study for nurses, and physio- therapists, and the request for participa- tion in this study. The answers and infor- mation raised from the study were kept confidential and used for this study only. In addition, the researcher provided opportu- nities for participants to ask questions or express concerns at any point. Finally, the results of the study were given to all the participants of the study. Moreover, the local ethical approval was obtained from the Ethical Committee of Hawler Medical University, at College of Nursing to con- duct the study. The authors declare that they have no competing interests. etal (2017) [19,20].The present study showed that three months after CPT train- ing, the performance of participants in the intervention group improved statistically very significantly (P- value < 0.000) as com- pared to control group. The performance difference between the two groups was not significant at baseline evaluation (pre- test P- value = 0.632); The Mehta etal (2019) [21] and other studies [22,23,24,25,26,27,28] did not show the difference in performance between inter- vention and control group in pre-test but showed a significant difference in the tra- cheostomy care program at the post-test. Furthermore, the findings of the present study found that the majority of both the intervention and control groups had poor level scores regarding the performance of chest physiotherapy in the pre-test. After three months of training, the score changed just in intervention group from poor to good performance in the post test. This result was in concordance with the study done by Frota, et.al. (2013) [29] and other studies [30,31]. Studied nurses and physiotherapists had incompetent practice regarding tracheost- omy care in intensive care units and res- piratory care units in Erbil hospitals, while those who underwent training for three months improved in their practice of three phases (preparatory phase, performance phase, and follow-up phase) of tracheosto- my care. Attempts should focus on im- proving tracheostomy care among nurses and physiotherapists at ICUs and RCUs and establish protocols to be developed ac- cording to guidelines. 131 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. CONCLUSION ACKNOWLEDGEMENTS Ethics approval and informed consent to participate CONFLICT OF INTEREST https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2023 Original Article (2021); Vol. 25, Issue 3, Pages. 7193 – 7203. Available from:https://www.annalsofrscb.ro/ index.php/journal/article/view/2249 [Accessed: 14th Jan 2022]. [10] Babiker MA, and Yousif YM., Assessment of Nurses Knowledge and Practice Regarding Tracheostomy Care in Almak Nimer Universi- ty Hospital. Shendi University faculty of postgraduate studies and scientific research. (2016). Available from:http:// repository.ush.sd:8080/xmlui/ handle/123456789/418 [Accessed: 21th Jun 2022]. [11] Padma K, Arundathi S, Latha A, Dr. Indira S, and Sreelakshmi T. A study to assess the knowledge regarding tracheostomy care among staff nurses and nursing students in narayana medical college and hospital, Nel- lore. International Journal of Advanced Sci- entific Research. (2016); 1 (3): 05-08. Availa- ble from: http:// www.allscientificjournal.com/ archives/2016/vol1/issue3/1-3-14 [Accessed: 18th Jun 2022]. [12] Mwakanyanga ET, Masika GM, and Tarimo EA. Intensive care nurses’ knowledge and practice on endotracheal suctioning of the intubated patient: A quantitative cross- sectional observational study. PLoS ONE journal. (2018); 13(8): e0201743. Available from: https://doi.org/10.1371/ journal.pone.0201743 [Accessed: 29th Nov. 2021]. [13] Abdulrahman,and Hamed EE. Effect of an Educational Training Program in Tracheosto- my Care on Nurses’ Knowledge and Skills at Sennar Teaching Hospital. University of Khartoum. (2015). Available from: http:// khartoumspace.uofk.edu/items/4b12024b- 98d7-40a7-9c44-2521c0520f42 [Accessed: 2th Dec. 2021]. [14] Ochoki NO, Kyalo MA, and Githinji ME. Health System Factors Associated with Ad- herence to Tracheostomy Care Guidelines among Critical Care Nurses at a National Referral Hospital in Kenya. International Journal of Nursing Science. (2021); 11(2): 36 -40 11(2): 36-40 Available from: http:// arti- cle.sapub.org/10.5923.j.nursing.20211102.0 2.html [Accessed: 30th Nov. 2021]. [15] Mungan I, Kazancı D , Bektaş Ş, Sarı S, Çavuş M, and Turan S. The evaluation of nurses’ knowledge related to tracheostomy [1] Rajesh O, and Meher R. Historical Review Of Tracheostomy. The Internet Journal of Otorhinolaryngology.(2013); 4 (2). Available from:http://ispub.com/ IJORL/4/2/7498 [Accessed: 31th Dec 2021]. [2] Gaterega T, Mwiseneza J, and Chironda G. Nurses knowledge and practices regarding tracheostomy care at a selected referral hospital in Rwanda – A descriptive cross- sectional study. International Journal of Afri- ca Nursing Sciences. (2021); 15(2):100350. Available from: https://doi.org/10.1016/ j.ijans.2021.100350 [Accessed: 18th Jun 2022]. [3] McDonough K, Crimlisk J, Nicholas P, Cabral H , QuinnEK, and Jalisi S. Standardizing nurse training strategies to improve knowledge and self-efficacy with tracheostomy and laryngectomy care. Applied Nursing Re- search. (2016); 32: 212-216. Available from: https://www.sciencedirect.com/science/ article/pii/S0897189716301215 [Accessed: 22th Jun 2022].. [4] Queirós SMM, Pinto IEM, de Brito MAC, and de Brito Santos CSV., (2021). Nursing inter- ventions for the promotion of tracheostomy selfcare: A scoping review. Journal of Clini- cal Nursing . (2021); 30(21-22):3055- 3071.00:1–17. Available from: https:// onlinelibrary.wiley.com/doi/abs/10.1111/ jocn.15823[Accessed: 15th Jan 2022]. [5] Onuoha J. Developing an Educational Pro- gram for Tracheostomy Care. Walden University. (2019). Available from: https://scholarworks.waldenu.edu/ dissertations/6934/ [Accessed: 22th Jun 2022]. [6] Perry A, Potter P, and Ostendorf W. Clinical Nursing Skills & Techniques. 8th ed. Cana- da. Elsevier Mosby publishing; (2014). [7] Potter P, Perry A, Stockert P, and Hall A, Fundamentals of nursing. Nineth editions. United States of America. 9th ed. Elsevier publishing; (2017). [8] Nettina SM., Lippincott Manual of Nursing Practice. 11th ed. China. Wolters Kluwer publishing; (2019). [9] Thomas LB, and Dhudum B., A Study to As- sess the Knowledge and Practices for Endo- Tracheal Care among Staff Nurses Working in Selected Hospitals of Pune. Annals of the Romanian Society for Cell Biology journal. 132 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. REFERENCES https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2023 Original Article PMC6684148/ [Accessed: 16th jun. 2022]. [22] Qadir MB. A study to assess the impact of structured teaching programme on knowledge regarding tracheostomy care among staff nurses working in selected hos- pital of Kashmir. International Journal of Nursing Research (IJNR). (2018); 4 (1): 29-35. Available from: innovationalpublishers.com/ journal/ijnr [Accessed: 16th jun. 2022]. [23] Yelverton JC, Nguyen JH, Wan W, Kenerson MC, and Schuman TA. Effectiveness of a Standardized Education Process for Trache- ostomy Care. The American Laryngological, Rhinological and Otological Society, Inc. (2015);125(2): 342-347. Available from: https://onlinelibrary.wiley.com/doi/ abs/10.1002/lary.24821[Accessed: 18th jun. 2022]. [24] Agarwal A, Marks N, Wessel V, Willis D, Bai S, Tang X, Ward WL, Schellhase DE, and Carroll JL. Improving Knowledge, Technical Skills, and Confidence Among Pediatric Health Care Providers in the Management of Chronic Tracheostomy Using a Simulation Model. Pediatric Pulmonology. (2016) 51 (7): 659-766. Available from: https:// onlinelibrary.wiley.com/doi/abs/10.1002/ ppul.23355[Accessed: 16th jun. 2022].. [25] Sodhi K, Shrivastava A, and Singla M. Impli- cations of dedicated tracheostomy care nurse program on outcomes. Japanese Soci- ety of Anesthesiologists. (2014); 28(3):374- 80. Available from: https:// pubmed.ncbi.nlm.nih.gov/24097169/ [Accessed: 16th jun. 2022]. [26] Bayram SB, and Caliskan N. Effect of a Game- Based Virtual Reality Phone Application on Tracheostomy Care Education for Nursing Students: A Randomised Controlled Trial. Nurse Education Today. (2019); 79: 25-31. Available from: https:// www.sciencedirect.com/science/article/abs/ pii/S0260691718305240?via%3Dihub [Accessed: 24th jun. 2022]. [27] Prickett K, Deshpande A, Paschal H, Simon D,and HebbarKB. Simulation-based educa- tion to improve emergency management skills in caregivers of tracheostomy patients. International Journal of Pediatric Otorhino- laryngology. (2019); 120: 157-161. Available from: https://www.sciencedirect.com/ science/article/abs/pii/ S016558761930031X?via%3Dihub. [Accessed: 24th jun. 2022]. care in tertiary intensive care units. Interna- tional Medicine. (2019); 1(6): 313-318. Avail- able from: mno=54258 [Accessed: 16th Jun. 2022]. [16] Nwakaego O. Knowledge and Practice of Tracheostomy Care: A Case of Federal Medi- cal Centre, Umuahia South East of Nigeria. Texila International Journal of Nursing. (2016); 2 (2). Available from: https:// www.texilajournal.com/nursing/article/599- knowledge-and-practice [Accessed: 18th Jun. 2022]. [17] Pritchett CV, Rietz MF, Ray A , Brenner MJ, and Brown D. Inpatient Nursing and Paren- tal Comfort in Managing Pediatric Trache- ostomy Care and Emergencies . JAMA Oto- laryngol Head Neck Surg. (2016); 142 (2):132 -137. Available from: http:// archotol.jamanetwork.com/. [Accessed: 5th Jul. 2022]. [18] Khanum T, Zia S, Khan T, Kamal S, Khoso MN, Alvi J, and Ali A. Assessment of knowledge regarding tracheostomy care and management of early complications among healthcare professionals. Brazilian Journal of Otorhinolaryngology. (2021); 88 (2):251-256 Available from: https:// pubmed.ncbi.nlm.nih.gov/34419386/. [Accessed: 5th Jul. 2022]. [19] Alnemare AK. Nurses Training and onϐ dence in Management of Tracheostomy Patients in a Community Hospital in Saudi Arabia. Jour- nal of Research in Medical and Dental Sci- ence. (2020); 8 (5): 110-118. Available from: https://www.jrmds.in/articles/nurses- training-and-confidence-in-management-of- tracheostomy-patients-in-a-community- hospital-in-saudi-arabia-authors.pdf [Accessed: 17th Jun. 2022]. [20] Qalawa SA, Diab AE, Gazzar SE, and El- Gawab HM. Quality of nursing care on pa- tient with tracheostomy. Port Said scientific Journal of Nursing. (2017); 4 (1):202-215. Available from: https:// pssjn.journals.ekb.egartcle_33096_95fe012f 99bf64e02fee24b1493773b9.pdf [Accessed: 18th Oct. 2021]. [21] Mehta K, Schwartz M, Falcone TE, and Ka- vanagh KR. Tracheostomy Care Education for the Nonsurgical First Responder: A Need Based Assessment and Quality Improve- ment Initiative. American academy of oto- larengology- head and neck surgery, OTO open. (2019); 3(2):1-6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ 133 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 Erbil j. nurs. midwifery, Vol. 5, No. (2), Nov 2023 Original Article [28] Kaur K. A Pre-Experimental Study to Assess the Effectiveness of Structured Teaching Programme on Knowledge and Practice re- garding Tracheostomy Care among Staff Nurses at Selected Hospitals of Punjab. In- ternational Journal of Science and Research (IJSR). (2019); 8 (3): 593 – 598. Available from: https://www.ijsr.net/ get_abstract.php?paper_id=ART20196062 [Accessed: 17th Dec. 2021]. [29] Frota OP, Rolan Loureiro MD, and Ferreira AM., (2013). Knowledge about endotracheal suctioning on the part of intensive care nursing professionals: a descriptive study. Online Brazilian Journal of Nursing. (2013); 12 (3): 546-554. Available from: https:// www.redalyc.org/ pdf/3614/361433917013.pdf [Accessed: 18th Dec. 2021]. [30] Singh R , and Raghavendran M.A Study To Assess The Effectiveness Of Video Assisted Teaching Module On Knowledge Regarding Tracheostomy Care Among B.Sc. Nursing Students In Selected Colleges In Kanpur. IOSR Journal of Nursing and Health Science. (2020); 9 (6): 40-44. Available from: https:// www.iosrjournals.org/iosr-jnhs/papers/vol9 -issue6/Series-1/F0906014044.pdf [Accessed: 17th July 2022]. [31] Varshney S, Sharma SK, and Jelly P. Trache- ostomy suctioning: Exploration of Knowledge and Practices of Nurses Working in Selected Tertiary Care Hospitals in Utta- rakhand State. Nursing and midwifery Re- search Journal. (2017); 13 (2). Available from: https://journals.sagepub.com/doi/ abs/10.1177/0974150X20170203 [Accessed: 16th Jun 2022]. 134 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/