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Teaching Tracheostomy Management Using VoiceThread: Reflection on the evolution of our blended coaching approach

Special Issue: Blended Learning Technologies in Healthcare

By Jennifer C. Benjamin, Weichao Chen, Satid Thammasitboon / February 2023

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The COVID-19 pandemic posed unprecedented challenges to teaching and learning, but it has also spurred creative adaptation and innovations in education. Like other educators around the globe, we experienced disruptions to our pediatric resident training in our 36-bed, progressive care unit at the Texas Children’s Hospital, one of the largest ACGME accredited pediatric training programs with 350 trainees. Pediatric residents are the first line caregivers of the medical team, caring for patients with medically fragile children. An artificial airway, like a tracheostomy, is associated with emergencies that pose a substantial risk to the patients and need swift intervention. Our residents do not routinely receive training to manage these airway emergencies, warranting the need for additional training to address this gap. Barriers to provide in-person training of these essential skills due to the pandemic prompted us to explore the innovative use of VoiceThread to teach these skills in a blended manner. In this paper, we report the evolution from VoiceThread-based completely asynchronous towards blended coaching, and we discuss the optimization of blended coaching into just-in-time coaching. Lessons learned and best practices from this implementation are also presented.

The Problem: Challenges with in-person coaching

Children with medical complexity, depending on technologies such as home ventilation, tube feedings, etc., for their daily living are considered medically fragile. Many are unable to breathe by themselves, requiring life sustaining home ventilation, and hence need an artificial airway, i.e., tracheostomy, that allows them to live a relatively normal life at home. Medical providers and caregivers alike need to be proficient in managing and troubleshooting issues for tracheostomy dependent children. The hands-on skills of tracheostomy change are challenging to teach on real patients given their fragile conditions. Therefore, medical simulations play a vital role in teaching airway management. Simulations are highly effective for training not only the technical skills of tracheostomy management but also non-technical skills, including assessing and dealing with complex situations and effective communication with other caregivers.

Unfortunately, the pandemic has posed enormous challenges for in-person simulations [1], only allowing for smaller learner groups and requiring innovative methods to continue training [2]. In addition to restrictions with accessing simulation facilities, the increased clinical care burdens on the trainees led to scheduling conflicts for training. Therefore, we identified VoiceThread to develop our interactive module to teach these skills. In this paper, we share the evolution of our evidence-based blended coaching approach and findings from our critical reflection. Our story can inform educators interested in leveraging the strengths of VoiceThread and different modes of coaching in the teaching of procedural skills. 

Original Conceptualization of Solution: VoiceThread-based asynchronous coaching

We designed our virtual module using the “educational design research” approach [3], which involves identification of desirable features of the online module based on needs assessment and literature review, iterative development of the module, refinement of instructional design principles, and ongoing reflection and program evaluation [4]. The aim of our intervention was to develop learners’ mastery of essential technical skills with tracheostomy change.

After researching and comparing between software options, we decided to use VoiceThread as our platform. VoiceThread is an online application that supports uploading, sharing, commenting of audios, videos, presentations, and other media files. Since VoiceThread is a cloud application, using VoiceThread requires no software installation. Users can easily access VoiceThread content from their web browsers or mobile apps, which is convenient for resident trainees with a busy schedule. As described below, using VoiceThread, we developed an interactive module that allowed trainees the opportunity to watch the expert and their peers performing/narrating the procedure, pose questions, post their videos and narration, and receive feedback from the instructor.

Our VoiceThread-based module implemented Peyton’s four-stage model [5] to engage learners in the deliberate practice [6]. The theory of deliberate practice emphasizes fostering learners’ skill acquisition through engaging them in deliberate and concentrated effort. To support learners’ deliberate practice, instructors need to set up appropriate instructional conditions, including providing clear, well-defined learning objectives, developing learner motivation, offering learners abundant opportunities for repeated practice and gradual refinement of skills, and implementing performance assessment with timely feedback [7, 8].

Peyton’s model requires instructors to break down the deliberate practice process into manageable steps, beginning with the learner observing expert demonstration and deconstruction of the process, towards developing a mental model about the procedure and eventually mastering the skills [5]. The effectiveness of Peyton’s stepwise approach in health professions’ procedural skill training has been supported in a recent meta-analysis [9].

Our VoiceThread-based online module allowed resident trainees to access expert demonstrations of tracheostomy change at their own convenience, on their personal devices whenever their schedules allowed. Trainees could watch the content repeatedly to develop mental representations of expert performance, adjusting the replay speed and pausing, fast-forwarding, and rewinding the video to clarify challenging and difficult portions. The commenting feature of VoiceThread enabled them to receive feedback from the instructor and learn from reviewing instructor feedback to their peers. Specifically, our VoiceThread-based asynchronous coaching of tracheostomy change implemented the following four steps according to Peyton’s model [5]:

  • Step 1, trainees watched a demonstration video in VoiceThread, with an expert performing the entire tracheostomy change procedure from start to finish without pauses.
  • Step 2, trainees watched a deconstruction video, which had close-up views and expert comments and narration to describe the procedure and highlight essential steps.
  • Step 3, trainees formulated their comprehension of the procedure through narrating the expert demonstration video in VoiceThread. Trainees could watch the procedure multiple times. Once they were certain of the steps, they could narrate the procedure. Subsequently, they received constructive feedback from the instructor in VoiceThread to rectify any deficiencies in knowledge (see Figure 1). Trainees were also encouraged to review the narration uploaded by their peers and the instructor feedback that their peers received.
  • Step 4, trainees uploaded a video of themselves performing the procedure in a simulation center onto VoiceThread using a mobile device.

[click to enlarge]

Figure 1. Implementation of just-in-time coaching via VoiceThread.

The Implemented and Improved Solution: A blended approach

Although we designed our VoiceThread-based module to be completely asynchronous in order to provide both trainees and the instructor the maximum amount of flexibility, our experience and critical reflection led us to recognize the value of adding in-person coaching. This led us to adopt and implement a blended learning approach by requiring trainees to attend an in-person session in a simulation center following completion of their virtual learning in VoiceThread.

Technology difficulties. Trainees encountered various challenges completing the last step in VoiceThread, i.e., recording a performance video in the simulation center. They often required assistance to tackle technical issues, including setting up recording and tracking devices and poor Wi-Fi connectivity for uploading videos. Further, tracheostomy change is usually performed with two people, with one person stabilizing the tracheostomy while the other changing the ties. To complete the video recording, residents had to perform the tracheostomy change just by themselves. This made tying the tracheostomy ties especially challenging, as they were expected to hold the tracheostomy with one hand and tighten the tracheostomy ties with the other hand.

Teaching and assessing skills that are beyond performing a procedure. While knowing how to perform routine tracheostomy change is essential, typical patient care often involves performing tracheostomy change as part of managing an airway emergency. The latter involves several management steps, such as identifying the size and type of tracheostomy cuffed or cuffless. For the procedure, residents need to identify an accurate size tube and the appropriate downsize tub in case they cannot get the normal size tube back in the patient. In addition, for a cuffed tracheostomy tube, they will need to fill the cuff with sterile water or air depending on the size of the tracheostomy tube. Prior to performing a tracheostomy change, they will need additional supplies such as lubricant and sterile water with a syringe to inflate the cuffed tracheostomy tube. They will need to ensure the tracheostomy ties are of the correct size. Another essential skill is determining the need for correct technique for suctioning, using the appropriate suction depth. Suctioning performed without referring to the accurate suction depth can harm a patient’s airway.

Trainees also need to manage the situation strategically, including anticipating complications, examining the tracheostomy site, and responding to trouble-shooting queries from parents and caregivers. Although our VoiceThread-based virtual module was effective in helping trainees acquire basic skills to perform a tracheostomy change, we could only assess their application of skills to manage a tracheostomy emergency through an in-person simulation scenario. Additionally, trainees attempting to handle the simulated challenge could benefit from immediate feedback and coaching from the instructor. Therefore, synchronous coaching plays an essential role in helping trainees solidify their critical thinking and management skills.

Value of immediate, in-person feedback. In-person coaching afforded the environment for instructors to provide immediate feedback. Although learners were able to develop a base knowledge on tracheostomy change through taking the asynchronous learning module, the virtual environment could not redirect them effectively if they deviated from the correct procedure. An in-person instructor could effectively cue learners when they began deviating from the expected course of action. During the synchronous session, instructors were able to coach beyond the scope of the tracheostomy management on chest compression techniques which is part of cardiopulmonary resuscitation (CPR) and fully address these nuances that arise during teaching procedural skills.

Peer learning opportunities. A synchronous session also enabled the trainee groups to learn from observing their peers performing, which supported further refinement of procedural skills. Observing peers similar to themselves successfully performing the procedure could also raise learners’ self-efficacy, i.e., their perceived capacities to learn or perform at a certain level [10, 11]. We also engaged our resident trainees  in the peer feedback activity, a powerful strategy to foster learning  through both giving and receiving feedback [12].

Further Enhanced Approach: Just-in-time coaching

We successfully implemented the blended instruction of tracheostomy management with 64 first-year residents in our pediatric intensive care unit. Our evaluation findings supported the effectiveness of this approach [4]. Trainee average usability rating of the VoiceThread-based online module (measured by the System Usability Scale) was 68.6, which was above the acceptable average of 68. Trainees’ perceived self-efficacy in listing and performing critical steps to change a tracheostomy increased statistically significantly following the blended instruction. Trainees also achieved satisfactory mastery of tracheostomy change skills, demonstrated by mean performance score of 10.4 (out of 12), as rated by two individual raters (inter-rater reliability = 88.1%).

Next, we use the framework of Just-in-time Teaching (JiTT) pedagogy to guide our critical reflection of lessons learned and best practices on optimizing our blended teaching toward “Just-in-time Coaching” (see Figure 2). JiTT features the use of warm-ups, web-based assignments for learners to complete before in-person sessions, seeking to create “feedback loops between teaching and learning and between in-class and out-of-class experiences” [13]. Specifically, instructors use the warm-ups to guide learners to prepare for the in-person meeting and to elicit and assess learners’ prior-knowledge and misconception about the main topics. The latter enables the instructors to adapt their in-person instruction just in time [14]. JiTT has been successfully adopted across disciplines to enhance student learning and motivation [15]. The essence of JiTT is the application of warm-ups to help learners maximize their learning prior to the in-person session and to provide instructors feedback to optimize students’ in-person learning. Although traditional applications of JiTT have mainly concentrated in the cognitive domain, such as teaching biology concepts, its major principles offer a useful lens for enhancing the synergy between asynchronous and synchronous learning of tracheostomy management.

[click to enlarge]

Figure 2. Demonstration of learner narration in the green bar and the instructor (J.B.) feedback in the text box on the left in VoiceThread.

Maximize learning prior to using in-person synchronous simulation. Our VoiceThread-based online module successfully engaged the resident trainees in the deliberate practice of tracheostomy change prior to attending the simulation session, which was beneficial for our trainees in busy clinical rotations. Clear instructional goals were provided to guide their virtual learning. Peyton’s four stage model effectively guided them to start from building basic conceptual understanding and eventually master the procedural skills. Setting clear deadlines for the completion of each step further supported their time management of asynchronous learning.

Provide a safe learning environment for deliberate practice in the simulation center. A safe environment ensured that trainees were not scared of failing but instead learning from their mistakes. In our project, trainees were encouraged to practice as much as they liked prior to the formal performance assessment in the simulation center. They were also assured that their performance outcome did not affect their rotation assessments. Instructor feedback was constructive and effectively supported trainees to rectify errors. If possible, allowing resident trainees to have protected time will allow them to learn these skills without distractions of patient care needs, which is especially pertinent in busy intensive care units.

Use learner performance in VoiceThread for Just-in-time adaptation of in-person instruction. Our VoiceThread module is equivalent to the warm-up in JiTT, which allowed the instructor to assess learner understanding and provide feedback to enhance the effectiveness of synchronous teaching in the simulation center. During our in-person sessions, if most learners in a group shared the same deficiency in their narrations, this was addressed prior to performing simulation. In the future, we can also adapt the difficulty of the management tasks based on trainee performance in the virtual module.

Maximize peer learning opportunities. Peer learning activities have proved to be highly useful to augment the effectiveness of implementing JiTT [14,16,17]. In our current implementation, we encouraged trainees to review peer's online feedback in VoiceThread, but most of them did not do so. A possible future approach is to pair them up as critical friends, i.e., assigning trainees to review and give each other feedback. During the in-person sessions, we were able to invite trainees to provide feedback to their peers, which they found helpful. To optimize the effectiveness of the peer feedback activity, one future idea is to adapt a procedure that has been successfully adopted in microteaching, training of teaching skills. Residents might be asked to go to a different room to watch the video of themselves performing tracheostomy change/management, while the instructor and their peers discussed the feedback to them. After watching their own video, the feedback recipients joined their peers and the instructor to discuss the feedback. In our experience adding this procedure into microteaching training, watching the video engaged feedback recipients in self-reflection and prepared them for getting feedback. The process of discussing and delivering feedback as a colleague could also enhance the feedback provider’s confidence in performance. 

The Silver Lining

In this paper, we shared the evolution of our evidence-based blended coaching approach, which was based on critical reflection and analysis. Although we initially began our journey as a response to the challenges posed by the pandemic, we were pleasantly surprised by the effectiveness of our approach, especially in maximizing trainees’ in-person learning in the simulation center. Even prior to pandemic, simulation-based learning has been considered resource-intensive [18]. Therefore, our discovery from developing and implementing this blended approach will continue to be of relevance in the post-pandemic world.


[1] Papapanou, M., Routsi, El., Tsamakis, K., Fotis, L., Marinos, G., Lidoriki, I., Karamanou, M., Papaioannou, T., Tsiptsios, D., Smyrnis, N., Rizos, E., and Schizas, D. Medical education challenges and innovations during COVID-19 pandemic. Postgraduate Medical Journal (2021).

[2] Wyres, M. and Taylor, N. Covid-19: Using simulation and technology-enhanced learning to negotiate and adapt to the ongoing challenges in UK healthcare education. BMJ Simulation and Technology Enhanced Learning 6, 6 (2020), 317–319.

[3] Chen, W. and Reeves, T. Twelve tips for conducting educational design research in medical education. Medical Teacher 42, 9 (2020), 980–986.

[4] Benjamin, J., Flores, S., Jain, P., Kumar, S., and Thammasitboon, S. Virtual deliberate practice module for tracheostomy change training: An application of educational design research. ATS Scholar (In press).

[5] Fiona, R., Hamdorf, L., and Hamdorf, J. Teaching on the run tips 5: Teaching a skill. The Medical Journal of Australia 181, 6 (2004), 327–328.

[6] Ericsson, K. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic Medicine 79 (2004), 10: S70.

[7] Ericsson, K. Deliberate practice and acquisition of expert performance: A general overview. Academic Emergency Medicine 15, 11 (2008), 988–994.

[8] Donoghue, A., Navarro, K., Diederich, E., Auerbach, M., and Cheng, A. Deliberate practice and mastery learning in resuscitation education: A scoping review. Resuscitation Plus 6 (2021), 100137.

[9] Giacomino, K., Caliesch, R., and Sattelmayer, K. The effectiveness of the Peyton’s 4-step teaching approach on skill acquisition of procedures in health professions education: A systematic review and meta-analysis with integrated meta-regression. PeerJ 8 (2020), e10129.

[10] Bandura, A. Self-Efficacy: The Exercise of Control. New York, Freeman, 1997.

[11] Schunk, D. and Pajares, F. Self-efficacy theory. In Handbook of Motivation at School. New York, Routledge/Taylor & Francis Group, 2009, 35–53.

[12] Chen, W. Knowledge convergence among pre-service mathematics teachers through online reciprocal peer feedback. Knowledge Management & E-Learning: An International Journal 9, 1 (2017), 1–18.

[13] Novak, G. Just-in-time teaching. New Directions for Teaching and Learning 2011, 128 (2011), 63–73.

[14] Schuller, M., DaRosa, D., and Crandall, M. Using just-in-time teaching and peer instruction in a residency program’s core curriculum: enhancing satisfaction, engagement, and retention. Academic Medicine: Journal of the Association of American Medical Colleges 90, 3 (2015), 384–391.

[15] Simkins, S. and Maier, M. Just-in-time Teaching: Across the Disciplines, Across the Academy. Stylus Publishing, 2010.

[16] Rowley, N. and Green, J. Just-in-time teaching and peer instruction in the flipped classroom to enhance student learning. Education in Practice 2, 1 (2015), 14–17.

[17] Watkins, J. and Mazur, E. Just-in-time teaching and peer instruction. In Just-in-time Teaching: Across the Disciplines, Across the Academy. Stylus Publishing, 2010, 39–62.

[18] Sawaya, R., Mrad, S., Rajha, E., Saleh, R., and Rice, J. Simulation-based curriculum development: lessons learnt in global health education. BMC Medical Education 21, 33 (2021).

About the Authors

Jennifer Benjamin M.D., M.S. is an associate professor in academic general pediatrics at Texas Children’s Hospital and in the Department of Education, Innovation and Technology (EIT) at Baylor College of Medicine.  She is the co-director for Faculty College at Texas Children’s Hospital. She serves as a director for technology for Center for Research Innovation and Scholarship for Health Professionals Education (CRIS). Her passion is for using technology in education and in applying theoretical frameworks for instruction. She developed the tracheostomy virtual deliberate practice module and contributed to this manuscript as the first author.

Weichao Chen holds a Ph.D. in information science and learning technologies from the University of Missouri at Columbia. Her professional interests include medical education, instructional design and technology, assessment, and evaluation, design-based research, concept mapping, knowledge construction, and faculty development. Dr. Chen contributed to this paper as the co-first author while serving as the assistant director of evaluation and assessment innovation and assistant professor at the Baylor College of Medicine.

Satid Thammasitboon M.D., MHPE is an associate professor in pediatric critical medicine at Texas Children’s Hospital, Baylor College of Medicine. He is the director of Center for Research, Innovation and Scholarship in Health Professions Education (CRIS). He co-directs the Best Evidence Medical Education and Health Professions Education International Collaborating Center (BICC) at Texas Children's Hospital and is the chair of the Resident Scholarship Program Executive Committee. His areas of research include clinical reasoning, assessment instrument development and psychometric validation, competency-based education, evidence-synthesis, game-based learning, and technology enhanced learning.

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