University of Ghana http://ugspace.ug.edu.gh
SCHOOL OF NURSING 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA 
LEGON 
 
 
 
LIFE AFTER TRACHEOSTOMY: THE EXPERIENCES OF ADULTS IN THE 
KUMASI METROPOLIS, GHANA 
 
 
 
BY 
BISMARCK ASARE 
10508598 
 
 
 
THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN 
PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL 
NURSING DEGREE.  
 
 
JULY 2016 
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
DECLARATION 
I (Bismarck Asare) declare that this thesis is my work produced from research done under 
the supervision of Dr. Lydia Aziato, School of Nursing, University of Ghana and Dr. 
Issahalq Duah Mohammed, ENT Department, KATH Kumasi. This thesis has not been 
submitted in any form for any degree or diploma at any university or other institution of 
tertiary education. Authors and publishers whose works I have used in this study have been 
duly acknowledged in the text and list of references.  
 
 
…………………………………   …….………………………… 
Bismarck Asare      Date 
(Student)        
 
 
…………………………………   ….………………………… 
Dr. Lydia Aziato      Date 
(1st Supervisor)        
 
 
…………………………………   …….……………………… 
Dr. Issahalq Duah Mohammed    Date 
(2nd Supervisor)        
  
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
DEDICATION 
I dedicate this work to the memory of my late parents Mr. Yaw Asare and Mad. Margaret 
Adutwumwaa for teaching me to be independent all the time. This work is also dedicated 
to my senior colleague, Alhaji Abdul R. Shaban for his support and encouragement; to my 
uncle Mr. Boakye Ansah Duah for his continuous prayers on my behalf. Finally, this thesis 
is dedicated to all adults living with a tracheostomy tube (ALTT) in the Kumasi Metropolis.  
  
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
ACKNOWLEDGEMENT 
First of all, my utmost gratitude goes to God Almighty, for His love, wisdom, mercies 
guidance and protection in my life and during this work. 
My heartfelt gratitude goes to my supervisors; Dr. Lydia Aziato and Dr. Issahalq Duah 
Mohammed for the enormous contributions and directions they gave without which this 
work would not have been possible. I equally extend my thanks to the Dean and all the 
faculty members of the School of Nursing, the University of Ghana for adding so much to 
my life during my graduate studies. 
My deepest gratitude goes to all the tracheostomised adults who availed themselves to be a 
part of this study. Without their cooperation, this work would not have seen the light of day. 
I am highly indebted to Ms. Belinda Osei-Akoto for making time to proof-read all the 
chapters of this study.  
My thanks go to the Head and staff of the ENT Department, KATH for support and 
cooperation. 
I also acknowledge all the authors of the textbooks and the articles used for this study.  
Lastly, to all my course mates and anyone who has contributed in any way to my life till 
now, I am so grateful.     
  
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
TABLE OF CONTENT 
DECLARATION .................................................................................................................. i 
DEDICATION ..................................................................................................................... ii 
ACKNOWLEDGEMENT .................................................................................................. iii 
TABLE OF CONTENT ...................................................................................................... iv 
LIST OF TABLES ............................................................................................................ viii 
LIST OF FIGURES ............................................................................................................ ix 
LIST OF ABBREVIATIONS .............................................................................................. x 
ABSTRACT........................................................................................................................ xi 
CHAPTER ONE .................................................................................................................. 1 
BACKGROUND ................................................................................................................. 1 
1.1 Introduction ........................................................................................................... 1 
1.2 Statement of Problem ............................................................................................ 5 
1.3 The Purpose of the Study ...................................................................................... 7 
1.4 Objectives of the Study ......................................................................................... 7 
1.5 Research Questions ............................................................................................... 7 
1.6 Significance of the Study ...................................................................................... 8 
1.7 Operational Definitions ......................................................................................... 8 
CHAPTER TWO ............................................................................................................... 10 
LITERATURE REVIEW .................................................................................................. 10 
2.1 Introduction ......................................................................................................... 10 
2.2 Guiding Thematic Concepts of reference for the study ...................................... 11 
2.3 The physical experiences of living with a tracheostomy .................................... 14 
2.3.1 Pain in tracheostomy .................................................................................... 14 
2.3.2 Activities of daily living and tracheostomy ................................................. 16 
2.4 The Physiological Experiences of living with a tracheostomy ........................... 17 
2.4.1 Difficulty in breathing ................................................................................. 18 
2.4.2 Dysphagia .................................................................................................... 19 
2.4.3 Reduced sense of smell and taste ................................................................. 20 
2.5 The psychosocial experiences of living with a tracheostomy ............................. 21 
2.5.1 Altered body image ...................................................................................... 22 
2.5.2 Social Anxiety and Social Isolation ............................................................. 23 
2.5.3 Sexuality ...................................................................................................... 25 
2.5.4 Anxiety, Depression, Distress, Aggression and Suicidal Ideations ............. 26 
2.6 The Economic experiences of living with a tracheostomy ................................. 27 
2.7 The communication experiences of living with a tracheostomy ......................... 28 
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2.8 Patients’ coping strategies of living with a tracheostomy ................................... 29 
2.9 Summary of literature review.............................................................................. 31 
CHAPTER THREE ........................................................................................................... 32 
METHODS ........................................................................................................................ 32 
3.1 Introduction ......................................................................................................... 32 
3.2 Research Design .................................................................................................. 32 
3.3 Research Setting .................................................................................................. 33 
3.4 Target Population ................................................................................................ 34 
3.4.1 Inclusion Criteria ......................................................................................... 34 
3.4.2 Exclusion Criteria ........................................................................................ 35 
3.5 Sample size and sampling technique .................................................................. 35 
3.6 Pre-testing of Data Collection Tool .................................................................... 36 
3.7 Data Collection Tool and Procedure ................................................................... 36 
3.8 Data Management ............................................................................................... 37 
3.9 Data Analysis ...................................................................................................... 38 
3.10 Methodological Rigour (Trustworthiness) .......................................................... 39 
3.11 Ethical considerations ......................................................................................... 41 
CHAPTER FOUR.............................................................................................................. 43 
FINDINGS ......................................................................................................................... 43 
4.1 Introduction ......................................................................................................... 43 
4.2 Description of the study population .................................................................... 43 
4.3 Organisation of themes and Thematic Concepts ................................................. 44 
Table 1: Summary of Themes ............................................................................. 45 
4.4 Physical Experiences of living with a tracheostomy .......................................... 46 
4.4.1 Painful Experiences ..................................................................................... 46 
4.4.2 Impaired activities of daily living ................................................................ 48 
4.5 Physiological experiences of living with a tracheostomy ................................... 50 
4.5.1 Difficulty in breathing ................................................................................. 51 
4.5.2 Dysphagia .................................................................................................... 52 
4.5.3 Reduced sense of smell ................................................................................ 53 
4.6 Social experiences of living with a tracheostomy ............................................... 54 
4.6.1 Altered Body Image ..................................................................................... 55 
4.6.2 Social Isolation ............................................................................................ 55 
4.6.3 Altered Sexuality ......................................................................................... 56 
4.7 Psychological experiences of living with a tracheostomy .................................. 58 
4.7.1 Fear and Anxiety .......................................................................................... 58 
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4.7.2 Depression ................................................................................................... 59 
4.7.3 Suicidal Ideations ......................................................................................... 60 
4.8 Economic experiences of tracheostomy .............................................................. 60 
4.8.1 Work Challenges.......................................................................................... 61 
4.8.2 Reduced income ........................................................................................... 63 
4.9 Patients’ communication experiences on living with a tracheostomy ................ 64 
4.9.1 Mode of communication .............................................................................. 65 
4.9.2 Challenges with verbalization ...................................................................... 66 
4.10 Patients’ coping mechanisms while living with a tracheostomy tube................. 67 
4.10.1 Acceptance of situation ................................................................................ 68 
4.10.2 Resilience ..................................................................................................... 69 
4.10.3 Spirituality ................................................................................................... 69 
4.11 Support while living with a tracheostomy tube................................................... 70 
4.11.1 Family support ............................................................................................. 70 
4.11.2 Friends’ support ........................................................................................... 72 
4.12 Summary ............................................................................................................. 72 
CHAPTER FIVE ............................................................................................................... 74 
DISCUSSION .................................................................................................................... 74 
5.1 Introduction ......................................................................................................... 74 
5.2 Physical experiences of living with a tracheostomy ........................................... 74 
5.3 Physiological experiences of living with a tracheostomy ................................... 79 
5.4 Social experiences of living with a tracheostomy ............................................... 82 
5.5 Psychological experiences of living with a tracheostomy .................................. 86 
5.6 Economic experiences of living with a tracheostomy ........................................ 88 
5.7 Patients’ communication experiences of living with a tracheostomy ................. 89 
5.8 Patients’ coping mechanisms of living with a tracheostomy .............................. 92 
5.9 Discussion of the Guiding Thematic Concepts ................................................... 94 
CHAPTER SIX .................................................................................................................. 96 
SUMMARY AND CONCLUSION .................................................................................. 96 
6.1 Introduction ......................................................................................................... 96 
6.2 Summary ............................................................................................................. 96 
6.3 Implications for Clinical Nursing Practice .......................................................... 97 
6.4 Implications for Nursing Education .................................................................... 98 
6.5 Implications for Policy ........................................................................................ 99 
6.6 Avenues for Future Research ............................................................................ 100 
6.7 Field Experiences/Reflections ........................................................................... 101 
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6.8 Limitations of the Study .................................................................................... 102 
6.9 Conclusion ........................................................................................................ 103 
6.10 Recommendations ............................................................................................. 104 
6.10.1 Recommendation to Nurses and other Health Professionals ..................... 104 
6.10.2 Recommendation to the ENT Department/Komfo Anokye Teaching 
Hospital ...................................................................................................... 105 
6.10.3 Recommendation to the Ministry of Health/Ghana Health Service .......... 105 
REFERENCES ................................................................................................................ 106 
APPENDICES ................................................................................................................. 141 
Appendix A: Background information of Participants ................................................ 141 
Appendix B: Interview Guide ...................................................................................... 142 
Appendix C: Consent Form ......................................................................................... 144 
Appendix D: Introductory Letter ................................................................................. 148 
Appendix E: Ethical Clearance ................................................................................... 149 
 
  
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LIST OF TABLES 
Table 1: Summary of Themes...................................................................................... 45 
  
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LIST OF FIGURES 
Figure 1: Guiding Thematic Concepts (Foster, 2010)................................................. 11 
 
 
  
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
LIST OF ABBREVIATIONS 
KATH: Komfo Anokye Teaching Hospital 
ENT:  Ear, Nose, and Throat  
VAS-A: Visual Analog Scale – Anxiety 
ICU:  Intensive Care Unit 
US:  United States of America 
UK:  United Kingdom 
WHO:  World Health Organization 
NHIS:  National Health Insurance Scheme 
HNC:  Head and Neck Cancer 
HRQOL: Health Related Quality Of Life 
ALTT: Adults living with a tracheostomy tube 
PLTT:      People/persons living with a tracheostomy tube 
  
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
ABSTRACT 
The use of a tracheostomy tube affects physical and psychosocial life resulting in reduced 
quality of life. The purpose of the study was to explore the lived experiences of adults with 
a tracheostomy tube in the Kumasi Metropolis, Ghana. The study used a qualitative 
exploratory, descriptive design. A purposive sampling method was used, and the data 
saturation was reached on the ninth participant. The data was analysed using thematic 
content analysis. Anonymity and confidentiality were ensured. The Thematic Concepts by 
Foster (2010) was used as a guide for the study. Eight major themes emerged: physical 
impact, physiological changes, social experiences, psychological experiences, economic 
constraints, communication dynamics, coping strategies, and support. All the participants 
experienced pain and impaired functions to carry out their activities of daily living after the 
surgery. There was difficulty in breathing, dysphagia and altered sense of smell. The adults 
had altered body image which altered their sexuality and affected their social participation. 
There were reports of fear and anxiety, depression and suicidal ideations. The participants 
had challenges with employment due to reduced strength and difficulties with 
communication. The participants used “speaking valve” or the “finger occlusion method” 
to communicate and coped with challenges using strategies such as acceptance, resilience 
and relying on God. They also had physical, financial and social support from family and 
friends. The possible areas for future investigations identified included an exploration of 
the support systems for adults with a tracheostomy tube and the attitude of the public 
towards people living with a tracheostomy tube. It was recommended that the Ministry of 
Health should extend National Health Insurance Scheme to cover all the healthcare needs 
of these adults and provide a speaking valve for them at a subsidised cost. There should be 
counselling and rehabilitation for patients. 
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
CHAPTER ONE 
BACKGROUND 
1.1 Introduction 
According to Hamick (2014) and Serra (2000), the trachea is an extension of the 
larynx, which measures between 10 and 13cm long in adults. Tracheostomy is a surgical 
procedure which involves creating an opening into the trachea through the skin of the 
anterior part of the neck to facilitate breathing (Cheung & Napolitano, 2014; Dawson, 
2014). The opening is mostly created at the level of the second and third cartilaginous rings 
and kept patent by the insertion of a tracheostomy tube. It may be a planned or emergency 
surgery. It can either be temporary or permanent (Pratt, Ferlito, & Rinaldo, 2008; 
"Tracheostomy," 2014; Woodrow, 2002). A tracheostomy bypasses the upper airway; this 
prevents the warming, humidification, and filtration of inhaled air (Barnett, 2012).  
Historically, tracheostomy is the first surgical procedure recorded as far back as the 
first century BC. However, the most popular reference is the description of how Alexander 
the Great, in the 4th century BC, used his sword to cut open the trachea of a soldier when 
he was getting choked from a bone lodged in his throat. Aretaeus (2nd century AD) and 
Galen (2nd to 3rd century AD) wrote that Greek physician Asclepiades of Bithynia 
performed elective tracheostomy around the 100 BC (Pahor, 1992; Pierson, 2005; Pratt et 
al., 2008; Walts, Murthy, & DeCamp, 2003). 
The indications for tracheostomy include acute respiratory failure with an 
anticipation of the need for prolonged mechanical ventilation and failure to wean from 
mechanical ventilation. It is also to maintain the airway in upper airway obstruction, to 
reduce the risk of aspiration in the airway due to the absence of laryngeal reflexes or ability 
to swallow. Tracheostomy also provides access to clean the secretions from the 
tracheobronchial tree (Amusa, Akinpelu, Fadiora, & Agbakwuru, 2004; De Leyn et al., 
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
2007; Durbin, 2010; Serra, 2000). The reason for the majority of tracheostomy surgeries 
are a severe respiratory failure; the need for continued mechanical ventilation (the reason 
for the majority of tracheostomy surgeries) and traumatic or severe neurologic illness 
requiring airway, or mechanical aeration or both. Upper airway obstruction is a less 
common indication for tracheostomy (Cheung & Napolitano, 2014).  
Tracheostomy is a life-saving surgical operation performed in the Intensive Care Unit 
(ICU) as part of a routine management of critically ill patients. It has a high morbidity rate 
of about 10% of all intubated patients and patients requiring long-term ventilation 
(Cardone & Lepe, 2010; Durbin, 2010; Freeman et al., 2013; Haspel, Coviello, & Stevens, 
2012). However, there is a low mortality rate in both adults and children when performed 
with the right indication and surgical technique (Freeman et al., 2013; İlçe et al., 2002; 
Zenk et al., 2009). Comparatively, the incidence of tracheostomy is higher in adults than 
in children (Wallis, Paton, Beaton, & Jardine, 2011; Zenk et al., 2009). Despite this, 
tracheostomy in the paediatric age group has been better reported than in adults. The 
explanation is that the procedure is more challenging and technically more demanding in 
paediatric patients  (Adoga & Ma'an, 2010). It also carries a higher degree of morbidity 
and mortality in paediatric patients than in the adult population (Adoga & Ma'an, 2010; 
Daudia & Gibbin, 2006) with a higher morbidity among males than in females because 
males have increased susceptibility to congenital and acquired disorders (Adoga & Ma'an, 
2010). 
The procedure represents a significant medical advancement readily available to 
contemporary physicians (Cardone & Lepe, 2010). There are several benefits associated 
with tracheostomies. These include less airway dead space and lower airway resistance 
which potentially reduce the work of breathing and further decrease analgesic and sedative 
requirements (Durbin, 2010). It also facilitates the prevention of oropharyngeal and 
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
laryngeal lesions, making oral feeding possible and contributes to providing easier and 
safer nursing care to patients and reduces intensive care and hospital stay (Durbin, 2010; 
King & Moores, 2008; Shan, Hao, Xu, & Chen, 2013).  Tracheostomy is an invasive 
surgical procedure with numerous possible complications such as bleeding, subcutaneous 
emphysema, pneumothorax, stoma infection, and sometimes death due to rupture of the 
innominate artery (King & Moores, 2008; Mallick & Bodenham, 2010; Shah et al., 2012). 
Tracheal granuloma, tracheomalacia, and tracheal stenosis are also well documented as 
other complications (Pawar & Suri, 2011; Soudon, Steens, & Toussaint, 2008).  
Dawson (2014) posits that tracheostomy operation and for that matter, the use of the 
tube has a high impact on patients. There is a drastic adverse effect on life satisfaction and 
body-image perceptions due to the prominent disfigurement in the anterior neck (Gilony 
et al., 2005). Psychological distress and physical indisposition continue to be a major 
challenge for people who have undergone tracheostomy even months to years after 
hospitalization (Adhikari et al., 2011; Myhren, Ekeberg, Tøien, Karlsson, & Stokland, 
2010; Ringdal, Plos, Ortenwall, & Bergbom, 2010). The issue of self-concept, personal 
identity, and social integration or social isolation associated with living with the tube, 
either temporary or permanent can be disturbing and disheartening for any patient and their 
family (Gilony et al., 2005). There are considerable changes in respiration, nutrition, and 
communication in people living with a tracheostomy tube (PLTT). There is also a 
significant reduction in their sense of smell, physical discomfort as well as economic 
problems which affect their quality of life (Gilony et al., 2005; Gul & Karadag, 2010; 
Huffman, Emam, & Stevens, 2014). Aside from the fear and panic that accompany 
dyspnoea and weaning, people give an account of anxiety owing to inaccurate perceptions 
and delusional memories of living with the tracheostomy tube (Engström, Nyström, 
Sundelin, & Rattray, 2013). 
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
While individuals with a tracheostomy tube suffer considerable challenges in the 
aspect of their physical, emotional, and social functioning. It is essential to explore their 
coping mechanisms for these difficulties. People usually under-report their experience of 
distress which could result in greater psychological indisposition (Moore, Chamberlain, & 
Khuri, 2004). Gelinas, O'Connor, and Miller (1998) argue that, most importantly, patients 
and their caregivers should accept the new life with tracheostomy and not look back to the 
past life. The reality is that living with a tracheostomy tube brings about a radical change 
in physical, personal, and social life circumstances and it requires fundamental alterations 
in self-concept and self-image, social relations, and interactions. Hassanein, Musgrove, 
and Bradbury (2005) state that clinicians need to assess the way these individuals are 
coping with the numerous psychosocial effects of tracheostomy because poor coping 
mechanisms often result in depression. Aarstad, Aarstad, and Olofsson (2008) indicate that 
neuroticism and an abstention mode of coping lead to a reduced quality of life. Instead, 
persons who display active coping strategies like creating fun with the problem at hand or 
engaging in relaxing activities reduce the stress. In addition, individuals who find 
emotional support from family members or friends (Derks, Leeuw, Hordijk, & Winnubst, 
2005) and keep a fighting spirit suffer less depression and have improved quality of life 
(Hassanein et al., 2005). According to Gelinas et al. (1998), people can cope better when 
there exist a robust and healthy bond between them and the caregiver and whether there is 
a good support system available. 
There are several studies within nursing and allied healthcare on the physical 
problems associated with the tracheostomy tube insertion; however, there is a poor 
description of the lived experiences of adults with a tracheostomy (Foster, 2010). There is 
a paucity of literature in our local setting regarding the subject (Gilyoma, Balumuka, & 
Chalya, 2011). Most studies done in this area have concentrated on the surgical technique 
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itself, trying to identify which technique is best and has fewer complications while few 
studies have explored the experiences of people who live with a tracheostomy tube (Akram 
& Khosrow, 2009). In fact, Gul and Karadag (2010) state that most studies that looked at 
the experiences of people living with a stoma concentrated on those with gastrointestinal 
system and urinary system stoma to the neglect of tracheostomy stoma. They continue that, 
both their observations and nursing literature have demonstrated that the experiences in a 
tracheostomy, which is also a stoma, have not been studied adequately by nurses. It also 
seems there are no published studies on the experiences of adults living with a 
tracheostomy tube (ALTT) in Ghana. Cook, Meade, and Perry (2001) indicate that if 
clinicians understand the lived experiences of PLTT, they can better appreciate the needs 
of patients which will enhance their care during the adaptation and rehabilitation processes. 
Qualitative methods are uniquely designed to access an emic perspective, to 
understanding the experience from the viewpoint of those experiencing it (Spiers, 2000). 
The use of the explorative descriptive method facilitated the study of the experiences of 
ALTT. 
 
1.2 Statement of Problem  
The incidence of tracheostomy has significantly increased in recent times (Mehta, Syeda, 
Bajpayee, et al., 2015; Mehta, Syeda, Wiener, & Walkey, 2015) across countries 
(Needham et al., 2005; Vargas et al., 2015). This increase in numbers is due to the presence 
of complications from prolonged endotracheal intubation which influence the decision to 
opt for tracheostomy over continued endotracheal intubation (Mehta, Syeda, Bajpayee, et 
al., 2015; Mehta, Syeda, Wiener, et al., 2015). Other findings that contributed to the 
increase in the use of tracheostomy included the improvement of care of people who were 
mechanically ventilated with a tracheostomy. This improvement of care included seduction 
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requirements, mobility, and oral feeding (Mehta, Syeda, Bajpayee, et al., 2015; Mehta, 
Syeda, Wiener, et al., 2015; Vargas et al., 2015). The National Confidential Enquiry into 
Patient Outcome and Death quotes the number of tracheostomies done in the United 
Kingdom (UK) during 2012 to be about 12000, of which 2546 were adults aged 16 years 
and above (Wilkinson, Freeth, & Martin, 2015). On average, more than 100,000 
tracheostomy operations are done in the United States (US) annually (Yu, 2010). 
Tracheostomy forms about 9.3% of all Ear, Nose and Throat (ENT) surgeries and 13.4% 
of all emergency cases at the ENT Department of Komfo Anokye Teaching Hospital 
(KATH) for the period 2008 and 2013 (KATH Records, 2014). 
PLTT experience a drastic reduction in both physical and emotional functioning 
which leads to worsening self-esteem (Hashmi, Ransom, Nardone, Redding, & Mirza, 
2010). The lived experiences of these people are poorly described (Foster, 2010) and 
unexplored to give any scientific statement. Clinical experience of the researcher, an ENT 
Nurse at the ENT Nursing School, Kumasi indicates that adults who are living with a 
tracheostomy tube present with physical, psychological and social problems such as 
reduced life gratification and body-image.  
In addition, literature so far shows that the impact of a tracheostomy on the lived 
experiences of ALTT seems unexplored in Ghana. These are the reasons that made the 
researcher conduct a qualitative study with the aim of exploring the experiences of ALTT 
in the Kumasi Metropolis. There is the belief that the results of this study will add to the 
literature and inform the care, training and the rehabilitation programmes for PLTT and 
health care policy related to services for this population.    
 
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
1.3 The Purpose of the Study 
This qualitative study purposed to explore the experiences of adults living with a 
tracheostomy tube in the Kumasi Metropolis. 
 
1.4 Objectives of the Study 
a. To find the physical experiences of adults living with a tracheostomy tube. 
b. To examine the physiological experiences of adults living with a 
tracheostomy.  
c. To explore the psychosocial experiences of adults living with a tracheostomy 
tube. 
d. To study the economic experiences of adults living with a tracheostomy tube.  
e. To investigate how adults living with a tracheostomy tube communicate. 
f. To identify the coping strategies of adults living with a tracheostomy tube.  
 
1.5 Research Questions 
a. What are the physical experiences of adults living with a tracheostomy tube? 
b. What are the physiological experiences of adults living with a tracheostomy 
tube? 
c. What are the psychosocial experiences of adults living with a tracheostomy 
tube? 
d. What are the economic experiences of adults living with a tracheostomy tube? 
e. How do adults living with a tracheostomy tube communicate? 
f. What are the coping strategies of adults living with a tracheostomy tube?  
 
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
1.6 Significance of the Study 
The knowledge gained from the experiences of adults living with a tracheostomy 
tube (ALTT) will enhance better understanding among nurses and other health 
professionals in providing quality care to meet the needs of ALTT. The reason is that 
ALTT has different needs other than those limited to the care of the tube and stoma. 
Findings can assist the development of better rehabilitation programmes to improve their 
quality of life. It is hoped that the results of the study will serve as resource materials for 
ALTT to assist them to cope with their new way of life. The study has also assisted in 
unearthing the need for future investigations in areas such as; the coping strategies of adults 
with a tracheostomy tube; the attitude of the public towards people living with a 
tracheostomy tube; the needs assessment of people living with a tracheostomy tube towards 
the planning of rehabilitation programmes; the clinical viability of the “finger occlusion 
method” of speaking among people living with a tracheostomy tube. Ultimately, findings 
of the study will add knowledge to the field of tracheostomy experiences. 
 
1.7 Operational Definitions 
Adults: Males and females aged 18 years and above 
Experience: What a person living with a tracheostomy goes through. 
Tracheostomy: An operation to make an opening into the trachea for breathing (Cheung 
& Napolitano, 2014; Dawson, 2014). 
Thyroiditis: Inflammation of the thyroid gland (Dictionary, 2012). 
Thyroidectomy: A surgical procedure to remove all or part of a thyroid gland 
(Dictionary, 2012). 
Family: Parents, spouse, children, siblings and uncles 
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Polite Yawning: Fast, downward movement of the lower jaw and tongue, while keeping 
the lips closed, to create a subtle vacuum, drawing air into the nasal passages (Hilgers et 
al., 2000). 
Finger Occlusion Method: Using any of the fingers to close the tracheostomy tube to 
enable sound production. 
  
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
CHAPTER TWO 
LITERATURE REVIEW 
2.1 Introduction 
This chapter discusses the thematic concepts used as the framework of reference for 
the study as well as the review of relevant literature on the experiences of adults living 
with a tracheostomy tube (ALTT). A search for literature was conducted to explore what 
was available on the lived experiences of ALTT regarding physical experiences, 
physiological experiences, psychosocial experiences, economic experiences, mode of 
communication and the coping strategies of life with a tracheostomy. The electronic 
databases used to perform the search included: ‘CINAHL’, ‘MEDLINE’, 
‘SCIENCEDIRECT’, ‘PUBMED’, ‘GOOGLE SCHOLAR’ and ‘SCOPUS’. The search 
included keywords and phrases like ‘tracheostomy’, ‘living with’, ‘tube’, ‘life after 
tracheostomy’. These words were used together with ‘adult lived experience’, ‘physical’, 
‘physiological’, ‘psychological’, ‘social’, ‘economic’, ‘communication’, ‘support’, 
‘coping’, ‘self-identity’, ‘stigma’. Moreover, qualitative either individually or in 
combination was also added to get relevant studies on the lived experiences of ALTT. 
The search identified several studies on tracheostomy. However, the majority of these 
studies focused on the surgical procedure, thus trying to determine the technique most 
appropriate with fewer complications (Lissauer, 2013; Walts et al., 2003) and suctioning 
technique (Khimani, Ali, Rattani, & Awan, 2015; Moore, 2003). The other studies also 
concentrated on how to care for the stoma regarding controlling infection, humidification 
and ensuring that the tubes are clean (Griggs, 1998; Randall, 2014; Woodrow, 2002). 
Nonetheless, a few studies saw the need to add psychosocial concerns such as altered body 
image (Adhikari et al., 2011; Myhren et al., 2010), anxiety and depression (Breckenridge, 
Chlan, & Savik, 2014; Gilony et al., 2005). Communication difficulties were also 
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
identified (Flinterud & Andershed, 2015; Khalaila et al., 2011; Madan, Stadler, Uhrich, 
Reilly, & Drake, 2011). These findings have generated guidelines on how to care for a 
person with a tracheostomy tube. However, they lacked the perspectives of the person 
experiencing the phenomena of living with a tracheostomy tube. 
   
2.2 Guiding Thematic Concepts of reference for the study 
The study adopted the thematic concepts (figure 1), developed by Foster (2010) as a 
guide. 
Foster developed this thematic concept from the data analysis of a study conducted at a 
hospital in the UK to provide a graphical description of how tracheostomy has a physical 
and psychosocial impact from the acute phase of illness through to recovery (Foster, 2010). 
Living with a tracheostomy tube alters body image, affects verbal communication and 
impairs swallowing and breathing, impacting negatively on life (Dawson, 2014). Therefore 
selecting this thematic concept to guide the research questions and analysis was appropriate 
because it was consistent to a larger extent with the objectives of the study. It also offered 
a wide scope to explore the study area.  
 
 
 
 
 
 
 
Figure 1: Guiding Thematic Concepts (Foster, 2010) 
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
The thematic concepts have the following major concepts; 
a. Necessity for communication 
b. Retaining normality 
c. Psychosocial discomfort 
d. Painful procedures 
e. Fear of the unknown   
f. Relationships with staff 
 
a. Necessity for communication 
Foster (2010) identifies this theme as core among the experiences of PLTT. He states 
that verbal communication is a very vital component of our day to day interaction with 
people around us. The findings by Donnelly and Wiechula (2006) support this 
phenomenon as they state that, the ability to speak is a basic functionality of every human 
being. Verbal communication allows us to be clear, well understood as well as to be seen 
and recognised as people. Individuals who lose their ability to communicate verbally lose 
their identity as a person (Ford & Martin-Harris, 2016; Foster, 2010). 
b. Retaining normality 
This theme refers to the feelings related to deviations in normal activities such as 
communication, coughing, swallowing and diet (Foster, 2010). Additionally, Johnson, St 
John, and Moyle (2006) describe this theme as a situation where people report of living in 
an unknown body that does not do its normal functions. The loss of normal body functions 
whether temporarily or not has a long-term impact on the individual even when the 
physical discomfort no longer exists (Foster, 2010).  According to Johnson (2004), it 
demands a lot of efforts for PLTT to regain normality. This normality, however, is not 
equal to the normal life they lived before having the tracheostomy tube, but rather 
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
becoming used to and having control over the most important things in their lives while 
living with the tracheotomy tube. 
c. Psychosocial discomfort 
Foster (2010) states this concept as the impact of a tracheostomy tube on patients’ 
daily lives. He states that the stoma at the anterior neck of PLTT and the difficulty in 
communication associated with having a tracheostomy tube among other challenges, limits 
tracheostomised persons in their social interactions with other people. These limitations 
make them withdraw from most social gatherings resulting in social isolation and other 
psychosocial challenges. 
d. Painful procedures 
This concept relates to the physical sensation of pain which PLTT experience. The 
dressing of the tracheostomy stoma, suctioning of mucus which accumulates in the tubes 
and coughing elicit pains (Al Sutari, Abdalrahim, Hamdan-Mansour, & Ayasrah, 2014). 
e. Fear of the unknown  
According to Foster (2010), this concept relates to the fear and anxiety associated 
with living with a tracheostomy tube as a new experience. Hafsteindóttir (1996) relates this 
fear to having a hole in the neck and unable to communicate. To be uncertain about 
regaining normality without using the tube, and whether or not living with the tube is going 
to be a temporary phenomenon makes patients have a fear of the unknown (Magnus & 
Turkington, 2006).  
f. Relationships with Staff 
Relationship with staff describes both the positive and negative experiences PLTT 
have with employees which are related to the care they received rather than the 
tracheostomy tube specifically (Foster, 2010). 
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This study applied some of the concepts since the study focused on people who were 
living at home with a tracheostomy tube. The present study applied the following concepts; 
Painful procedures, Psychosocial discomfort, Necessity for communication, Fear of the 
unknown and retaining normality. 
In the examination of the related publications, the focus was on a description of the 
physical experiences, physiological experiences, psychosocial experiences, economic 
experiences, communication and the coping strategies of ALTT. 
 
2.3 The physical experiences of living with a tracheostomy 
The review of studies on the physical experiences of living with a tracheostomy tube 
on adults’ quality of life identified several challenges. These challenges included pain 
sensations (Arroyo-Novoa et al., 2008; Khimani et al., 2015; Stotts et al., 2007), reduced 
strength to undertake daily activities such as bending, walking and lifting (Gilony et al., 
2005; Hashmi et al., 2010).  
 
2.3.1 Pain in tracheostomy 
The issue of pain is related to the physical presence of pains experienced by 
tracheostomised persons (Al Sutari et al., 2014; Foster, 2010). It is the commonest 
experience among people living with a tracheostomy which has an adverse impact on their 
lives (Ahlers et al., 2008; Li & Puntillo, 2006; Pandharipande, Patel, & Barr, 2014). Studies 
have shown that the procedure is painful and there is also pain during some nursing 
procedures such as breathing and coughing exercises (Al Sutari et al., 2014; Pasero, 2003; 
Siffleet, Young, Nikoletti, & Shaw, 2007). Repositioning (Siffleet et al., 2007; Stotts et al., 
2007), as well as tracheal suctioning and stoma dressing (Arroyo-Novoa et al., 2008; 
Khimani et al., 2015; Moore, 2003) cause pain. 
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Using a 0 - 10 numeric rating scale, a behavioural tool, and a revised McGill Pain 
Questionnaire-Short Form, Arroyo-Novoa et al. (2008) measured the link between tracheal 
suctioning and the experience of pain by conveniently selecting 755 patients who had 
tracheal suctioning done on them in the intensive care units. The results showed that the 
intensity of pain was greater during tracheal suctioning (M = 3.96, S.D. = 3.3) than before 
(M = 2.14, S.D. = 2.8) or after (M = 1.98, S.D. = 2.7) the tracheal suctioning. Although the 
mean pain intensity during tracheal suctioning was mild, almost half of the patients 
reported moderate-to-severe pain.  
Similarly, Stotts et al. (2007) state that 30% of ICU patients find tracheal suctioning 
to be an uncomfortable procedure. Applying a scale of 0 - 10, the pain intensity during 
suctioning of the tracheostomy tube was seven or more. This pain intensity was greater in 
tracheal suctioning than in other procedures such as wound care, wound drain removal, 
turning, femoral sheath removal and central line insertion among younger and older adults 
in Critical and Acute Care Units in acute care hospitals (Stotts et al., 2007). These are great 
revelations on tracheal suctioning and the associated pain. However, the use of the 
quantitative method in both studies limited participants in responding to predetermined 
questions and answers which could be different from their actual experiences of pain 
during tracheal suctioning. The participants were selected by convenience sampling 
method which is a non-probability method and thus, the patients who could not participate 
could have different pain responses and perceptions to suctioning.    
To further understand the concept of pain in tracheal suctioning from the patients’ 
perspective,  Foster (2010) used a qualitative phenomenology method to investigate the 
lived experiences of three tracheostomised patients at the NHS Trust Hospital in the United 
Kingdom (UK). Two of his participants lived on a tracheostomy tube for 14 and 36 days 
while the remaining participant was permanent. Findings from the study indicated that 
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
people living with a tracheostomy tube experience painful sensations especially during 
procedures such suctioning and dressing of the stoma and while coughing. Although the 
study offers rich information on the physical effects of adults with a tracheostomy tube, 
the use of participants who have lived with the tube for only 14 and 36 days gives an 
experience while in the acute care setting. This finding leaves a gap on people’s 
experiences in the home/community setting. It is also hard to understand whether the 
author reached data saturation on the various themes using only three participants. 
Although there is an association between pain and suctioning of the tracheostomy 
tube, Karlsson, Lindahl, and Bergbom (2012) and Moore (2003), identify suctioning as an 
essential nursing intervention. Suctioning assists to get rid of secretions in the airway and 
to maintain proper ventilation and oxygenation in patients with a tracheostomy. Hence it 
is better to have such pains while being suctioned than to suffocate from secretions in the 
airway (Karlsson, Lindahl, et al., 2012). Sherlock, Wilson, and Exley (2009) state that 
suctioning should be reserved for patients who are not able to get rid of their secretions 
because the suction catheter and suction pressure can lead to tracheal damage and most 
patients find it distressing. Khimani et al. (2015) posit that with adequate knowledge on 
the pain experiences as well as other challenges associated with tracheal suctioning, health 
care professionals would be in a better position to enhance the safety of patients with a 
tracheostomy tube. 
 
2.3.2 Activities of daily living and tracheostomy 
According to Isaksson, Wilms, Laurell, Fransson, and Ehrsson (2015) living with a 
tracheostomy tube decreases strength and the power to work. There is a reduction in a 
person’s ability to undertake activities of daily living (Gilony et al., 2005; Hashmi et al., 
2010) which leads to a decreased quality of life (Gul & Karadag, 2010; Hutzel, 2014). 
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According to Björklund, Sarvimäki, and Berg (2010) and Molassiotis and Rogers (2012), 
tracheostomised individuals are unable to undertake everyday functions and activities of 
daily living. They add that caregivers also express lots of frustration, resentment, and 
unhappiness. 
Gilony et al. (2005) used the Karnofsky Performance Scale (KPS) to measure the 
influence of a tracheostomy on the quality of life and body image. The authors put 63 
participants into three groups: A, 24 cannulated patients; B, 19 patients who have had 
successful Decannulation and C, 20 non-cannulated patients who were on admission for 
planned surgeries with no obvious body defects. On the level of physical activities among 
these three groups of participants, both cannulated and decannulated participants had 
reduced performance of activities of daily living. These findings widely support other 
studies that looked at the impact a tracheostomy has on activities of daily living (Gul & 
Karadag, 2010; Hashmi et al., 2010) of PLTT. However, these were quantitative studies 
which did not allow participants to provide in-depth explanations to their experiences. 
Moreover, participants responded to questions based on their experiences in the acute 
setting but not their lived experiences in the home setting. 
Gul and Karadag (2010) identified that a tracheostomy influences activities of daily 
living which include sports, swimming, shopping, and bending thereby having a profound 
negative impact on quality of life.  
 
2.4 The Physiological Experiences of living with a tracheostomy 
Several physiological functions happen in the human body. These physiological 
functions keep the body in its normal state. Any deviation in the standard anatomy of the 
human body affects the human physiology (List & Bilir, 2004). There are structural 
changes in PLTT (List & Bilir, 2004; Russell, 2005). These structural changes affect 
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normal bodily functions such as breathing (Karlsson, Bergbom, & Forsberg, 2012), sense 
of smell (Gul & Karadag, 2010; Huffman et al., 2014) and verbal communication 
(Flinterud & Andershed, 2015; Madan et al., 2011). It also leads to difficulty in swallowing 
(dysphagia) (Ceriana et al., 2015; Sharma et al., 2007). 
 
2.4.1 Difficulty in breathing 
Studies have shown that breathing is a major concern for PLTT (Gul & Karadag, 
2010; Huffman et al., 2014; Karlsson, Bergbom, et al., 2012). According to Karlsson, 
Bergbom, et al. (2012), the worst experiences of tracheostomised individuals is their 
inability to breath. Changes in the anatomy of people with a tracheostomy cause a drastic 
decrease in the normal warming and humidification of inhaled air (Russell, 2005). A 
reduced humidification of the inhaled air may result in retention of secretions, impairment 
of mucociliary clearance, a decrease in cough reflex and also a reduction in the function of 
the lungs (Clarke, 1995; Conlan & Kopec, 2000; Woodrow, 2002). 
Karlsson, Bergbom, et al. (2012) studied the lived experiences of adult intensive care 
patients who were conscious during mechanical ventilation in the ICU of the Swedish 
County hospital using a qualitative phenomenological hermeneutic design. The 
participants reported challenges such as the inability to breath, being voiceless and 
helpless. These findings impact negatively on the quality of life of patients with mechanical 
ventilation. Although the study provides rich information on the physical experiences of 
mechanically ventilated patients which include patients with a tracheostomy, the use of 
only participants who understand and speak Swedish (Karlsson, Bergbom, et al., 2012) 
makes it difficult to generalise the findings to other geographical areas.  
Difficulty in breathing affects the quality of life of tracheostomised persons (Akram 
& Khosrow, 2009). It also makes these individuals weak, making them not able to perform 
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activities that demand much physical strength in addition to activities that would earn them 
income (Mehnert, de Boer, & Feuerstein, 2013). 
  
2.4.2 Dysphagia  
Structural changes in a tracheostomy operation also lead to difficulty in swallowing 
(Sharma et al., 2007). There is a decrease in elevation of the larynx, oesophageal 
compression, reduced closure time of the glottis and an obstruction from the cuff of the 
tracheostomy (Daudia & Gibbin, 2006; De Leyn et al., 2007). These increase the difficulty 
in swallowing in PLTT (Ceriana et al., 2015; Sherlock et al., 2009).  
Sherlock et al. (2009) did a pilot study on the experiences of tracheostomy patients 
and their opinions on the flow of information at the hospital. The study involved eight 
patients who had been on a tracheostomy within 12 weeks. Six out of the seven participants 
who were on oral intake during the period of the interview had dysphagia. Participants had 
difficulties swallowing food and drink. This finding confirms that PLTT experience 
dysphagia; however, 12 weeks experience on a tracheostomy is a short time to tell the 
impact dysphagia will have on the quality of life. 
There have been conflicting findings on the association between living with a 
tracheostomy tube and experiencing aspiration. Some earlier findings identified a link 
between a tracheostomy and aspiration (Elpern, Scott, Petro, & Ries, 1994; Pannunzio, 
1996). However, some new discoveries identified no such association between a 
tracheostomy and aspiration (Brady, Wesling, & Donzelli, 2009; Leder & Ross, 2010). 
There is the need to assess the swallowing status as well the airway of these people by 
speech-language pathologists for appropriate interventions (McGrath & Wallace, 2014; 
Starmer et al., 2014). The reason is that dysphagia in tracheostomised persons could result 
in loss of appetite and possible hypoglycaemia (Ganzer, Rothpletz-Puglia, Byham-Gray, 
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Murphy, & Touger-Decker, 2015; Tsang & Carey, 2015). Knowing the swallowing 
abilities of these individuals will facilitate the provision of their needed dietary needs the 
best way possible (Serra, 2000). 
 
2.4.3 Reduced sense of smell and taste 
A tracheostomy limits the nasal airflow, leading to an altered sense of smell (Hilgers 
et al., 2000; Hong, Holbrook, Leopold, & Hummel, 2012; Risberg-Berlin, Rydén, Möller, 
& Finizia, 2009). The human sense of smell influences well-being and performance and it 
is directly linked to the quality of life (Huffman et al., 2014; Kennedy, Lewis, Stow, & 
Sobol, 2016; Tsikoudas, Barnes, & White, 2011). For example, the ability to smell 
enhances appetite and food choices (Croy, Nordin, & Hummel, 2014; Hays & Roberts, 
2006; Mennella, Jagnow, & Beauchamp, 2001). When there is reduced ability to smell, 
there could be reduced appetite which may later result in loss of weight (Huffman et al., 
2014). 
A person’s ability to smell means that person is in a good position to perceive 
possible hazards in the environment. Smelling affects our relationships with others 
(Doucet, Soussignan, Sagot, & Schaal, 2009; Jacob, Garcia, Hayreh, & McClintock, 2002; 
Jacob, McClintock, Zelano, & Ober, 2002; Neuland, Bitter, Marschner, Gudziol, & 
Guntinas‐Lichius, 2011). To live with a reduced sense of smell means there will be 
difficulty in detecting possible hazards in the environment, which is a threat to the person’s 
safety (Miwa et al., 2001). This feeling of insecurity could lead to anxiety and depression 
(Croy, Negoias, Novakova, Landis, & Hummel, 2012; Tsikoudas et al., 2011).   
Kennedy et al. (2016) did a cross-sectional survey on the ability to smell among 18 
paediatric patients living with a long-term tracheostomy (cannulated), persons who had 
been decannulated after a long-term tracheostomy and individuals who were healthy and 
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could match the age and sex as controls. The participants of the study had no nasal 
abnormalities or any other challenge that could destruct the test. The results of the survey 
suggested that tracheostomy affects the smelling functions of people who are still living 
with a tracheostomy or have been decannulated. The study provides rich information to 
affirm the association of a tracheostomy with a reduced sense of smell. However, the use 
of only paediatric patients presents a need for further studies among adults to enhance a 
full understanding of the smell phenomenon among a tracheostomy patients. 
 
2.5. The psychosocial experiences of living with a tracheostomy 
There are several studies on psychosocial experiences of a tracheostomy. 
Conclusions from these studies suggest that people living with a tracheostomy have a 
drastic reduction in psychosocial functioning. This decrease in functioning alters body 
image, life gratification, and self-esteem (Adhikari et al., 2011; Fingeret, Teo, & Goettsch, 
2015). It further impacts greatly on their quality of life (Dawson, 2014; Hashmi et al., 
2010). Such psychosocial challenges can be attributed to the prominent disfigurement at 
the anterior neck (Gilony et al., 2005; Katz, Irish, Devins, Rodin, & Gullane, 2000). 
Moreover, the inability to communicate properly to enhance successful interpersonal 
relationships and social interactions is also a setback (Flinterud & Andershed, 2015; 
Madan et al., 2011). 
The obvious psychosocial impact of a tracheostomy that people experience includes; 
embarrassment and shame (Buhlmann & Wilhelm, 2004; Conroy et al., 2008; Fuchs, 
2002). There is also social isolation (Akenroye & Osukoya, 2013; Bessell, Dures, Semple, 
& Jackson, 2012; Flynn, Carter, Bray, & Donne, 2013) and emotional distress (Adhikari 
et al., 2011; Ringdal et al., 2010). People experience anxiety and depression (Breckenridge 
et al., 2014; Engström et al., 2013) as well as suicidal ideations (Cougle, Keough, Riccardi, 
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& Sachs-Ericsson, 2009; Phillips & Menard, 2006). Besides, self-concept and sexuality 
are also affected (Fobair et al., 2006; Gallo-Silver, 2011; Olsson, Berglund, Larsson, & 
Athlin, 2012). 
 
2.5.1 Altered body image 
The term ‘body image’ has been used to conceptualize the psychosocial impact of 
people’s perception of their bodies. Body image is described as the perception people have 
of their physical self and most importantly, the perception they believe other people have 
of them (Grogan, 2007; Phillip & de Man, 2010). These include the perceptions of, and the 
reactions to how they look, beauty, the state of health, functionality, and sexuality. The 
concept also incorporates a person’s sense of how their body influences interactions (e.g. 
how they feel about themselves and other people’s reactions to them), making it a major 
factor in social and interpersonal relationships (Grogan, 2007; Lubkin & Larsen, 2006; 
Muth & Cash, 1997).  
Altered body image, however, is a state of personal distress, defined by the patient, 
which indicates that the body no longer supports self-esteem; it is dysfunctional to 
individuals, limiting their social engagement with others (Fingeret et al., 2015). Altered 
body image exists when coping strategies are overwhelmed by injury, disease or social 
stigma (Price, 1995). According to Pelusi (2006), it is not only the changes in physical 
appearance which makes the patient experience altered body image; a mental image of our 
appearance does not necessarily match actual body structure, but a change in body image 
implies that a patient feels changed, physically or psychologically. 
Zając et al. (2008) identified a relation between altered body image and low quality 
of life and relates it to the physical disfigurement (stoma). The face and neck play a major 
role in an individual’s perception of self (Callahan, 2005). It is in a visually prominent area 
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of the anatomy, reflecting animation and emotion and serving as a means of 
communication with others. As a result, Fingeret et al. (2015) state that the presence of a 
hole in the neck that is kept open by a tube, and through which sputum come out, is likely 
to reduce the quality of life. Altered body image also leads to high levels of embarrassment 
and shame (Buhlmann & Wilhelm, 2004; Conroy et al., 2008; Fuchs, 2002). The reason is 
that the mere realisation of an altered body image makes a person feel shameful and 
embarrassed in the midst of other people. Most people do not feel comfortable in their 
current situation, they feel awkward within themselves and would not want to be seen in 
public because they feel embarrassed by their appearance (Buhlmann et al., 2010). 
 
2.5.2 Social Anxiety and Social Isolation 
Facial disfigurement profoundly affects self-concept, social interaction, and 
emotional well-being (Katz, Irish, Devins, Rodin, & Gullane, 2003). These often result in 
people feeling isolated and restricted in their social activities (Newell, Ziegler, Stafford, & 
Lewin, 2004). Studies have shown that people with a tracheostomy exhibit strong signs of 
social anxiety and social isolation (Aderka et al., 2014; Akenroye & Osukoya, 2013; 
Bessell et al., 2012; Fingeret et al., 2015; Flynn et al., 2013).  
Akenroye and Osukoya (2013) evaluated the social impact of permanent 
tracheostomy and their management in the Ondo State, Southwest Nigeria. They 
purposively selected four participants who were all females with ages 65, 50, 43 and 40 
years who had lived with a tracheostomy for over 11 years for the study. The authors 
identified that people living with a tracheostomy had a common challenge of social 
integration as was indicated by all four participants in the study. The presence of a 
tracheostomy tube on the neck of people encourages social stigma which prevents them 
from socially interacting with others. Akenroye and Osukoya (2013) identified that the 
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families of individuals with a tracheostomy tube were reluctant to accept them home, three 
(75%) of the four participants stated. The findings by Akenroye and Osukoya (2013) 
provide significant evidence of the social impact of a tracheostomy. However, the use of 
only female participants makes it gender bias as the inclusion of males in the study would 
have made the results richer and generalisable, because the findings as they stand now, 
may only apply to an all-female population.  
Flynn et al. (2013) reviewed reported experiences and views of parents’ whose 
children has had a tracheostomy tube. Using critical appraisal of qualitative studies guided 
by the seven criteria outlined in Carter and Goodacre, 10 publications met the inclusion 
criteria for the study of which six were qualitative and four quantitative. The ages of the 
children in all the studies were between 2 and 18 years. The authors identified social 
isolation as a major issue for people living with a tracheostomy. According to the 
respondents, social isolation can be caused by several factors which include the stigma 
attached to having a tracheostomy. For a person with a tracheostomy tube to fully partake 
in any social interaction meant that the people involved understand and accept living with 
a tracheostomy tube. When this acceptance is absent, the best thing people with a 
tracheostomy do is to limit their participation in social activities by staying isolated or 
socialise with few friends and relatives who understand and accept them (Myhren et al., 
2010). 
People who are socially anxious usually show signs of intense fear most especially 
when they are going to be exposed to the public (American Psychiatric Association, 2013; 
Ballenger et al., 1998). According to Bögels et al. (2010), these people mostly exhibit 
physical and motor symptoms such as blushing, trembling and sweating due to the fear that 
others are observing their altered body. According to Rumsey, Clarke, White, Wyn-
Williams, and Garlick (2004), these symptoms worsen when there are public staring, 
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name-calling, and unwanted interrogations. These experiences result in appearance-related 
distress, and make them feel they are not complete, and lead to creating a negative mindset 
on what they understand about attractiveness (Bessell, Clarke, Harcourt, Moss, & Rumsey, 
2010). Individuals with these difficulties may also be socially timid and appear withdrawn 
or shy (Akenroye & Osukoya, 2013). In some instances, they put up camouflaging 
behaviours such as wearing clothes with a long neck or hanging extra materials around 
their neck to cover the tracheostomy tube in order to conceal their defects (Bessell et al., 
2012; Flynn et al., 2013).  
 
2.5.3 Sexuality 
Sexuality has a close association with body image (Salter, 1992). Even though the 
desire for sexual activity exists in the midst of a significant degree of disability (Schonhofer 
et al., 2001), many people who live with stomas worry about sexual issues (Nugent, 
Daniels, Stewart, Patankar, & Johnson, 1999; Persson & Hellström, 2002). Cantlay (2015) 
indicates that the existence of a tracheostomy tube in addition to difficulty in breathing and 
an altered voice and appearance may particularly affect sexuality. There is also the loss of 
the desire for sexual activities such as becoming conscious of the stoma and thinking that 
one’s partner finds it unattractive (Gallo-Silver, 2011). Many people with physical 
anomalies and their sexual partners are mostly aware of the contradictions of the body and 
its exposure in intimate acts when the body and its imperfections are exposed (Olsson et 
al., 2012). An absence of a body part and various bodily dysfunctions complicate 
individuals’ social and sexual lives (Fobair et al., 2006). 
 
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2.5.4 Anxiety, Depression, Distress, Aggression and Suicidal Ideations  
Sharpe, Patel, and Clarke (2011) state that body image disturbance is essential 
because of its relationship with anxiety, depression, and distress. Breckenridge et al. (2014) 
studied the influence of a tracheostomy on anxiety in mechanically ventilated adults ICU 
patients using a secondary analysis of existing data from a large parent study. The study 
was conducted in the Minneapolis and St. Paul, Minnesota Urban area. Subjects used were 
from 12 ICUs, between September 2006 and March 2011. The inclusion criteria were; 
patients aged 18 years and above, alert and participating in their care, able to read and write 
in English, had an adequate corrected hearing and vision as determined by the ICU nurses’ 
assessment. A total of 116 patients were used to detect a difference of 13% in the Visual 
Analog Scale-Anxiety (VAS-A) scores after a tracheostomy placement, with the power of 
80% and alpha set at .05. The VAS-A was used to measure patients’ anxiety each day. The 
findings of the study showed that the daily mean anxiety scores were quite variable among 
patients with a tracheostomy. Although these results enhance the existing evidence on the 
association between a tracheostomy and anxiety, the use of patients in the ICU continues 
to leave a gap on the experiences of people with a tracheostomy in the home. 
Chiou et al. (2013) evaluated the link between the level of emotions and health-
related quality of life (HRQOL) in well head and neck cancer (HNC) patients post 
treatment and to explore their predictive factors using a cross-sectional design between 
2008 and 2010 in Taiwan. The authors recruited 73 HNC patients post-treatment, at least 
one year to complete three survey tools. These tools were; the European Organization for 
Research and Treatment of Cancer Quality of Life Questionnaire version 3.0 (EORTC 
QLQ-C30 v.3), the EORTC Head and Neck Cancer Module (EORTC QLQ-H&N35), and 
the Beck Depression Inventory-II (BDI-II). The results of the study showed that depression 
is a major problem in patients with Head and Neck Cancer. Depressed Head and Neck 
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Cancer patients had a significantly poor global health-related quality of life in almost all 
functioning symptoms.  
Björklund et al. (2010) state that people living with a tracheostomy become anxious 
and depressed mostly because of a reduced ability to fully undertake activities of daily 
living which are usually used to measure the quality of life of a healthy person. Yanhui et 
al. (2010) posit that people pay attention to how they look and how they appeal to others. 
The authors add that this phenomenon is more common in individuals with altered body 
image than those with no appearance concerns, which usually result in higher levels of 
depressive symptoms. Buhlmann et al. (2010) provide further evidence that altered body 
image leads to significant morbidity such as depression. In most instances, these feelings 
lead people to have negative thoughts such as suicidal ideation and suicide attempts 
(Cougle et al., 2009). People are unable to live with the stigmatisations attached to altered 
body image. Some individuals may appear defensive and be dismissive of their appearance 
which can manifest as aggression usually borne out of the negative response they have 
received from others (Bessell et al., 2010). 
 
2.6. The Economic experiences of living with a tracheostomy 
Studies have shown that the presence of a tracheostomy tube reduces strength and 
the power to work (Isaksson et al., 2015). According to Mehnert et al. (2013), a PLTT is 
likely to experience challenges such as reduced strength to work, stopping work, 
compulsory retirement, and change in job description. In some situations, PLTT changes 
their routine daily activities both at home and at work (Björklund et al., 2010; Griffiths, 
Humphris, Skirrow, & Rogers, 2008). This change of activities enables them to meet the 
demands of everyday life in the midst of the physical inactiveness of living with a 
tracheostomy tube (Molassiotis & Rogers, 2012; Röing, Hirsch, & Holmström, 2007; 
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Semple & McCance, 2010). The change in activities also affects their employment because 
they are unable to do jobs that need physical strength, resulting in reduced income (Steiner, 
Cavender, Main, & Bradley, 2004). 
 
2.7. The communication experiences of living with a tracheostomy  
Communication and specifically verbal communication forms the core aspect of our 
day to day interactions. The ability to communicate verbally is a fundamental need for 
every individual (Donnelly & Wiechula, 2006). Speaking enables us to express ourselves, 
our feelings, and it also allows people to recognize us as humans (Donnelly & Wiechula, 
2006). However, studies have shown that a tracheostomy greatly affects the ability to 
communicate verbally (Flinterud & Andershed, 2015; Guttormson, Bremer, & Jones, 
2015; Khalaila et al., 2011). More than 50% of tracheostomised individuals report of 
reduced ability to verbally communicate (Samuelson, Lundberg, & Fridlund, 2007). 
Reduced verbal communication is one of the biggest challenges of people living with a 
tracheostomy (Lewarski, 2005; Sherlock et al., 2009). This reason is that the tracheostomy 
tube goes below the vocal cords, thus reduce the ability to produce sound. Therefore the 
act of speaking is inhibited (Woodrow, 2002). 
Mostly, the inability to speak leads to psychological discomfort (Karlsson, Bergbom, 
et al., 2012; Khalaila et al., 2011; Patak et al., 2006). Usually, they exhibit signs of 
frustration (Flinterud & Andershed, 2015; Johnson et al., 2006) and fear (Khalaila et al., 
2011). There is also anxiety, depression, and distress (Engström et al., 2013; Hashmi et al., 
2010; Myhren et al., 2010).  
Flinterud and Andershed (2015) used a descriptive qualitative design to explain how 
tracheostomised patients in intensive care communicate and to get a better understanding 
of their experiences in the perspective of the transitions theory. The sample size was 11 
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adults who were 18 years or older and could speak the Norwegian language. Findings from 
the study indicated that PLTT goes through different kinds of psychological experiences 
trying to communicate. They feel powerless, have upsetting emotions and lose control. 
Tembo, Higgins, and Parker (2014) posit that being voiceless feels like being imprisoned 
or being trapped. According to Guttormson et al. (2015) and Laakso, Markström, and 
Hartelius (2009), inability to communicate verbally affect a person’s well-being, safety, 
and comfort which affects the quality of life. 
Studies have shown that tracheostomised persons adapt the use of a non-verbal form 
of communication (Barnett, 2012; Flinterud & Andershed, 2015; Grossbach, Stranberg, & 
Chlan, 2010; Hurtig & Downey, 2008). Usually, they resort to the use of pen and paper, 
picture and alphabet boards, and techniques such as nodding or shaking their heads as well 
as eye blink to communicate initially (Barnett, 2012; Grossbach et al., 2010; Hurtig & 
Downey, 2008). Nonetheless, as indicated by Flinterud and Andershed (2015)’s, study, 
their ability to verbally communicate improves with time. Techniques such as lip-reading, 
facial expressions, and more recently, the use of “speaking valves” assist them to achieve 
successful communication (Barnett, 2012; Flinterud & Andershed, 2015). However, these 
methods of communication are not all the time effective; speaking valve are costly and 
usually prone to breakages, usually leading to stress and frustration (Hashmi et al., 2010; 
Patak et al., 2006). 
 
2.8. Patients’ coping strategies of living with a tracheostomy  
 List et al. (2002), define coping as the ability to develop adaptive behaviours or 
strategies to minimise the experience of stress. Tracheostomised patients experience far-
reaching emotional reactions while they find ways to cope with the change in their 
appearance and present themselves to others. Some individuals can cope well with their 
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situation, while others become isolated and depressed (Wood & Bisson, 2004). Aarstad et 
al. (2008) indicate that the inability to develop a good coping mechanism reduces one’s 
quality of life. However, individuals who show proper coping mechanisms, find emotional 
support from family members or friends (Derks et al., 2005), and are resilient undergo less 
depression and have improved quality of life (Hassanein et al., 2005).  
In line with the conclusions drawn by Semple and McCance (2010) and Bessell and 
Moss (2007), people living with a tracheostomy receive psychosocial and everyday support 
from family and friends. Spirituality alongside the support they get from church gives them 
a sense of direction, peace, and meaning to life (Semple & McCance, 2010; Spratling, 
Minick, & Carmon, 2012). Furthermore, emotional support from employers and employees 
(formal counselling) and working colleagues promotes proper coping (Semple & 
McCance, 2010). Richardson, Morton, and Broadbent (2015) indicate that tracheostomised 
persons can cope better when there exists a robust and healthy bond between the patient 
and the caregiver and whether there is a good support system available. Health care 
providers are also major players in ensuring that patients with a tracheostomy tube can live 
a normal life despite their challenges, providing informational, practical, and emotional 
support to enable them to develop effective coping skills and increasing confidence in 
social settings (Bessell & Moss, 2007). 
A more recent form of coping mechanism identified by Madan et al. (2011) is social 
media platforms such as Facebook, Twitter, WhatsApp, which have the potential to reduce 
social isolation and improve peer interaction and communication. It also augments social 
supports. 
 
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2.9. Summary of literature review  
The literature reviewed showed that living with a tracheostomy tube comes with 
physical, physiological, psychosocial, and economic as well as communication stress of 
which these individuals used different strategies and supports to cope. Most of these 
findings focused on the patients’ experiences in the acute care setting which make the lived 
experiences of ALTT in the community/home setting understudied. In addition, most of 
these findings were from quantitative studies which did not allow participants to provide 
in-depth explanations to their experiences. These are findings from studies conducted in 
developed countries. There is a paucity of knowledge on people’s lived experiences after 
a tracheostomy in the Ghanaian context. In the current study, information about the lived 
experiences of ALTT was provided. The difficulties associated with Ghanaian adults living 
with a tracheostomy were explored and described. The belief is that findings from the study 
will enhance the delivery of nursing care, assist the development of better rehabilitation 
programmes and add to knowledge in the field of a tracheostomy experiences. In the 
ensuing chapter, detailed descriptions of the methodology used in the study are shown.  
  
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CHAPTER THREE 
METHODS 
3.1 Introduction  
This chapter describes the methods which were used to conduct the study. These 
include the research design, the study setting, target population, the sampling method and 
how the data was collected and analyzed. The chapter also discusses the methods that were 
used to ensure trustworthiness (methodological rigour) as well as ethical considerations. 
  
3.2 Research Design 
The study employed qualitative research design. Qualitative research involves an 
interpretive, naturalistic approach which studies human experiences in their natural 
environment. Thus, the manner in which people make meaning of the world and the 
experiences they have in the world (Borbasi & Jackson, 2012; Denzin & Lincoln, 2005; 
Gergen, Josselson, & Freeman, 2015; Merriam, 2009). The goal of qualitative research is 
to generate an understanding of a phenomenon from the perspective of the person 
experiencing the said phenomenon (Spiers, 2000). Specifically, an exploratory descriptive 
design was employed to explore and describe the experiences of adults living with a 
tracheostomy (Mayan, 2009). According to Brink and Wood (1997), exploratory, 
descriptive design explores people in their natural settings, it provides a minimum control 
of variables, and the end-product of the data collected either aid in theory development or 
assist in explaining a subject from the people studied. 
Therefore this design was desirable to offer rich, comprehensive information from 
the perspective of people living with a tracheostomy about how adults live with a 
tracheostomy (Webb, 2011), given the researcher’s clinical experience gained through 
practice as an Ear, Nose, and Throat (ENT) Nurse. 
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3.3 Research Setting 
The study took place in Kumasi, the capital city of the Ashanti Region and the second 
biggest city in Ghana. Kumasi is sited in the transitional forest zone and has a distance of 
about 255.6km from the National Capital, Accra. There are 209 communities in Kumasi, 
and the metropolis has a population of about 1,975,628. The people in Kumasi are mostly 
Ashantis. Their primary occupation is trading and farming. “Twi” (Ghanaian local 
language) is the local dialect shared by almost all people. Kumasi is cosmopolitan in nature 
and has drawn migrants from all over the country and from abroad. There is a mixed culture 
in Kumasi; aside from the Ashantis, other ethnic groups have also settled in the city. These 
include Fantes, Dangomba, Frafra, Hausa, Ewe, Ga-Adangbe, and Krobo. 
There are many public and private schools in the metropolis. It also contains one of 
the nation‘s biggest universities (Kwame Nkrumah University of Science and 
Technology). Both public and private hospital offer health services in the Metropolis. 
These hospitals include: 
 10 Government Hospitals (1 Teaching Hospital - Komfo Anokye Hospital).  
 160 Private Hospitals/Clinics.  
 3 Quasi-Governments Hospitals.  
 2 Christian Health Associations of Ghana (CHAG) Institutions.  
 18 Private Laboratories.  
 676 Pharmacies.  
 514 Chemical Shops.  
 
The Ear, Nose, and Throat Department at Komfo Anokye Teaching Hospital was the 
outlet for the recruitment of the participants. The unit is the second largest ENT 
Department in the country apart from the ENT Department at Korle-Bu Teaching Hospital. 
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The Komfo Anokye Teaching Hospital (KATH) in Bantama was built in 1940 and became 
a Teaching Hospital in 1975. The geographical location of the 1000 – bed Komfo Anokye 
Teaching Hospital, the road network and the business nature of Kumasi make the hospital 
reachable to all the areas that share boundaries with Ashanti Region and others that are 
farther away. Referrals come from the three Northern Regions namely, Northern, Upper 
East, and Upper West Region; Brong Ahafo, Central, Western, Eastern and some parts of 
the Volta Region. The ENT Department of the hospital came into being in 1963. The 
Department attends to clients with all kinds of ENT health problems including patients 
with conditions that call for a tracheostomy. The Department performs close to 78 
tracheostomy surgeries annually. The Department also accepts referred cases from 
neighbouring countries such as Cote d'Ivoire, Togo, Nigeria and other African countries. 
 
3.4 Target Population 
The target population for this study was Ghanaian adults living with a tracheostomy in 
the Kumasi metropolis. 
 
3.4.1 Inclusion Criteria 
The inclusion criteria for the study were both males and females who:  
a. Were aged 18 years and above or older, because the study was targeted at adults. 
b. Had lived with a tracheostomy for at least one year. People with less than one 
post tracheostomy experience were likely to focus on their intensive care 
experience and immediate post-operative recovery, which was not the focus of 
this study.  
c. Could speak “Twi” (local language) or English (these were languages the 
researcher could speak fluently)  
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d. Gave an informed consent to be participants in the study. 
 
3.4.2 Exclusion Criteria 
a. Persons who had extreme difficulty in speaking 
b. Individuals with the obvious psychiatric deficit.  
 
3.5 Sample size and sampling technique 
The sample size of the study depended on data saturation when successive 
participants gave similar responses, and no new themes and subthemes emerged (Bernard, 
2011; Schensul & LeCompte, 2010). The data reached saturation by the ninth interview. 
The participants of the study were recruited using purposive sampling method. This 
approach enabled the selection of individuals who had specific knowledge and experience 
in the phenomenon under study (Marshall & Rossman, 2014). The sampling technique also 
allowed only participants who met the inclusion criteria to be recruited to provide the rich 
information on their experiences on living with a tracheostomy. The ENT Department at 
the Komfo Anokye Teaching Hospital was the outlet for recruitment. Adults who have 
lived with a tracheostomy for at least one year and accessed care at the ENT Department 
were recruited. 
A formal permission was sought from the head of the ENT Department with an 
introductory letter from the School of Nursing, University of Ghana, which stated the 
purpose of the study. The researcher used multiple strategies to identify and recruit 
participants with the support of two ENT Nurses and the nurse-in-charge of the department. 
The researcher had an interaction with these three staff to brief them on the purpose of the 
study as well as the inclusion and exclusion criteria and gave them the information sheet 
which contained the complete information about the study. The contact number of the 
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researcher was made available to the nurses for notification of potential participants. The 
researcher reached such potential participants on the phone, explained the study to them, 
answered all questions bothering them and subsequently screened them for eligibility. The 
researcher then met the potential participants who showed interest at a mutually convenient 
time and place, completed consent form and conducted the interview.  
 
3.6 Pre-testing of Data Collection Tool 
The semi-structured interview guide was pre-tested with two adults who met the 
inclusion criteria in the Accra Metropolis using Korle-Bu Teaching Hospital as the point 
of recruitment. The goal was to determine if the guiding questions and wording were 
appropriate and comprehensible and to practice explaining the study, and completing 
informed consent procedures. The practice interview also enabled the researcher to 
improve his interviewing skills. 
 
3.7 Data Collection Tool and Procedure 
The data collection was from January to April 2016. The researcher used individual 
interviews as the primary data collection tool. These in-depth interviews employed a semi-
structured interview guide with open-ended questions (Appendix B) to solicit information 
from each participant. During and after completion of informed consent (Appendix C), the 
researcher established rapport with the participants and also gained their cooperation which 
allowed them to share their lived experiences freely on a tracheostomy tube. This rapport 
building occurred while completing a basic demographic profile (Appendix A) which 
assisted in reducing participants' anxiety through answering easy questions about 
themselves. 
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The researcher started the interview with a grand tour question “Tell me about your 
experiences on living with a tracheostomy”. Grand tour questions opened up discussions 
and allowed participants to choose a convenient way to begin (Mayan, 2009). Furthermore, 
any unclear responses from the participants were also be clarified when necessary while 
asking for follow-up information during the interview  (Leedy & Ormrod, 2001; Mayan, 
2001, 2009). Following this question, the researcher used probes to explore their 
experiences and perceptions about changes and adaptations after a tracheostomy. 
During the interview, the researcher wrote brief notes to keep track of ideas for later 
exploration; he observed verbal and nonverbal behaviours as observation included some 
degree of interaction between the researcher and the environment or the people being 
observed (Dewalt & Dewalt, 2011). The interviews were audio-taped and transcribed 
verbatim (Mayan, 2009). The in-depth interviews were conducted at participants’ places 
of choice, i.e., their home or workplace to certify that they were comfortable during the 
process. The researcher did all the interviews in Twi (local dialect). The interviews lasted 
between 45 to 70 minutes.  
As data collection and analysis progressed, and as the researcher learned more about 
the participants’ experiences of living with a tracheostomy, interview questions evolved 
and focused on issues and concepts important to the participants’ experience rather than 
the concepts that he identified as essential before the start of the study (Mayan, 2009).  
 
3.8 Data Management  
Interviews were audio-taped and the observations made on participants formed part 
of the field notes which were taken to complement the audio-recording. Participants were 
assigned letters in a chronological manner (A to Z) according to the order of the interview. 
Researcher transcribed verbatim each recorded interview immediately after the interview. 
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A replay of the audiotape was done to ensure accurate transcription and to reduce error and 
omissions as much as possible. During the transcription, pseudonyms were used to replace 
the letters. Each transcription was saved as a different file and put in a folder with special 
identification. The researcher kept the hard copies of the interviews under lock and key in 
the office. Additionally, participants’ demographic characteristics were separated from the 
hard copies. Electronic copies of the transcriptions were kept in a folder on a password 
protected computer hard drive to ensure that data was secure and safe.  
 
3.9 Data Analysis 
Data analysis was done simultaneously with data collection using thematic content 
analysis technique to identify important themes and patterns in the data. The process of 
data analysis in this study involved identifying, coding and categorizing the primary 
patterns in a data. It involved organising and integrating narrative qualitative information 
according to the emerging themes and concepts (Mayan, 2001; Miles & Huberman, 1994). 
The researcher spaced out individual interview sessions to enable simultaneous data 
collection and analysis, to follow the tenets of inductive inquiry. The researcher booked no 
interview until the recorded interviews were transcribed and coded. 
The researcher familiarized himself with the data by listening and reading and re-
reading the transcripts several times, noting down initial ideas after each interview. The 
researcher then generated the preliminary coding by noting interesting ideas, words or 
concepts. This open-coding included labelling section of text that were important to the 
research questions. The researcher used in vivo coding which involved labelling 
participants own words with labels to remain close to the data and to preserve the vitality 
of the meaning. Categories were formed by merging similar codes and using encompassing 
labels. Comparison of categories continued and the researcher examined the relationships 
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between categories. The researcher identified themes, which were underlying ideas that 
seemed related to all data. The researcher discussed the coding and data analysis with a 
supervisor to have a better data analysis. 
 
3.10 Methodological Rigour (Trustworthiness)  
Rigour is a critical component of a qualitative study. (Speziale, Streubert, & 
Carpenter, 2011). According to Aroni et al. (1999), rigour is the process of showing 
reliability and proficiency in a qualitative study and a demonstration of the validity of the 
research procedure. Morse, Barrett, Mayan, Olson, and Spiers (2002) posit that a 
qualitative study which lacks rigour is not credible and would not impact knowledge. It is, 
therefore, essential that reliability and validity be adequately employed when conducting 
research. Consequently, trustworthiness, composing of credibility, transferability, 
dependability, and confirmability has been chosen as the criteria which are equal to 
reliability and validity to ensure rigour in a qualitative study (Guba & Lincoln, 1981, 1982; 
Lincoln & Guba, 1985). Situated in these are other methodological strategies such as audit 
trail, member checks when coding, categorizing or confirming results with participants, 
peer debriefing, and negative case analysis to ensure rigour in qualitative studies (Guba & 
Lincoln, 1982). The researcher applied the criteria above to ensure trustworthiness in the 
study. 
Credibility, according to Merriam (1998) and Guba and Lincoln (1981) tells how 
reliable the findings of the study are to reality. According to Lincoln and Guba (1985) 
ensuring credibility is one of the most vital components in ensuring trustworthiness. The 
researcher purposefully recruited participants who met the inclusion criteria and were able 
to provide in-depth information on their experiences after the tracheostomy to achieve 
credibility. The researcher also employed iterative questioning skills and probes to elicit 
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detailed data from participants. Member checks were also carried out in the form of 
iterative verification to verify the accuracy of the data and by continuing analysis (Morse 
et al., 2002) at the end of the interview session. The researcher also ensured that each 
interview was transcribed and analysed (coded) before the next interview was conducted. 
Researcher again ensured that a second person experienced in qualitative research did 
independent coding. The two codings were compared to reduce disparities and also to 
present participants realities as much as possible. 
Transferability describes how applicable the findings of a study are in other settings 
(Guba & Lincoln, 1981; Merriam, 1998). The researcher gave a thick description of the 
setting, the design of the study as well as the sample size and the method of data collection. 
The inclusion and exclusion criteria of the study, as well as the number and length of data 
collection sessions and the period used to collect the data, were described. 
Dependability describes the replicability of the study by another researcher (Guba & 
Lincoln, 1981). To ensure dependability, the researcher wrote in detail the research process 
which included the design and its implementation, data gathering as well as evaluation of 
the success of the research methodology for future replication by another researcher 
(Shenton, 2004). This procedure assisted in establishing the proper application of the 
research process. 
Confirmability in the qualitative study shows how objective the researcher is. It is 
the process of ensuring that the findings are the specific experiences and ideas expressed 
by the participants and not the preferences of the researcher (Patton, 1999). The researcher 
made sure that the results of the study reflected the participants’ experiences and 
perspectives, and not the researcher’s preferences by keeping a reflective journal of the 
researcher’s biases and assumptions. The researcher also kept an audit trail which showed 
how the data was collected, analysed and processed to get the findings of the study. 
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3.11 Ethical considerations 
The researcher obtained ethical approval from the Institutional Review Board at the 
Noguchi Memorial Institute for Medical Research, University of Ghana. A permission was 
sought from the ENT Department of the Komfo Anokye Teaching Hospital, Kumasi with 
an introductory letter from the School of Nursing, University of Ghana and a copy of the 
ethical approval. Participants were given the information sheet which outlined the purpose 
and objectives of the study. Any potential benefits and risks were explained to participants 
in Twi (local dialect). The researcher then did a follow-up to get their intention either to 
participate in the study or not. Potential participants who accepted to take part in the study 
were given a consent form to sign. For participants who had challenges reading and 
writing, the researcher translated the consent form into Twi for them in the presence of a 
witness after which both the witness and the participant were made to sign or thumbprint 
the consent form. Researcher informed the participants that they had the option of not 
answering a question if it was sensitive, to pause or stop the interview or to withdraw from 
the study even after signing the consent form without any consequences. The researcher 
assured participants of the safekeeping of the data. 
The researcher ensured confidentiality by assigning letters to participants in a 
chronological manner (A to Z) according to the order of the recruitment. Pseudonyms were 
used to replace the letters when quoting participants in the findings chapter or any 
publications. Participants were made aware that all the data and documents including the 
audiotapes, consent form would be kept under lock and key in researcher’s office for at 
least five years of the study. Additionally, participants’ demographic characteristics were 
separated from these documents. The soft copies of the transcriptions were kept in a folder 
with a password on researcher’s hard drive to ensure that data was secure and safe. 
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The researcher anticipated minimal risks; however, participants’ reflections on their 
experiences could at times be distressing. The researcher arranged for an ENT 
counsellor/social worker to provide counselling services for participants when necessary. 
No participant was referred to the counsellor since participants were able to control their 
emotions while sharing their experiences. The participants were assured of anonymity 
during publications of aspects of this study. 
Participants did not have any direct benefits, however, their experiences shared 
would assist to enhance the delivery of quality nursing care to people living with a 
tracheostomy tube. 
  
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CHAPTER FOUR 
FINDINGS 
4.1 Introduction 
This chapter gives a description of the results of the data gathered from the various 
participants of the study on their experiences of living with a tracheostomy tube. Both 
common and unique experiences of all the participants are presented. Using thematic 
content analysis, eight themes were identified. They are physical experiences, 
physiological experiences, social experiences, psychological experiences, economic 
experiences, communication experiences, coping mechanisms and support.  The main 
themes and their sub-themes are presented with verbatim quotations from the participants 
using pseudonyms. The Thematic Concepts and the objectives of the study were used to 
analyse the data. The descriptions of the background of the participants as well as the 
thematic findings of the study are also presented in the following sections. 
 
4.2 Description of the study population  
The study population was nine adults, of which eight were females and one, male, 
aged between 42 and 57 years. One was in his early forties, three in their late forties, 
another three in their early fifties and two in their late fifties. The average age of the 
participants was 50 years. Regarding their educational background, three of the 
participants had no formal education, four were middle school leavers, and the other two 
had tertiary education. Regarding their employment statuses, four of the participants were 
not working during the time of the interview. Out of these four, one was a trader, one, a 
farmer and the remaining two were secretaries before they had the tracheostomy tube. The 
remaining five participants were still working at the time of the interview. One was a 
farmer, another one was a teacher, and one a cleaner with the remaining two being traders. 
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Six of the participants were married, two were widows, and one was not married. Only one 
of the participants had no child, the remaining eight had children with ages ranging from 
1 to 5 years. One participant had eight children, but only four were alive. Eight of the 
participants were Christians with one, a Muslim. 
The participants spoke several languages such as Twi, Dagomba, Frafra, Grusi, 
Hausa, Fante, Ga, and English. All the participants spoke Twi aside their native languages. 
The participants’ years of experience in living with a tracheostomy tube ranged between 
one year four months and 32 years. All the participants were living permanently on the 
tracheostomy tube. Seven of the participants had their tracheostomy tube as a result of 
post-thyroidectomy complications (cut of recurrent laryngeal nerve), and the remaining 
two had upper airway obstruction. Two of the nine participants had their tracheostomy 
surgeries planned while the remaining seven were operated as emergency cases. The 
residential locations of participants were in and around the Kumasi Metropolis. All the 
participants accessed healthcare at the Komfo Anokye Teaching Hospital.  
 
4.3 Organisation of themes and Thematic Concepts 
Thematic Concepts (Foster, 2010) was used as a guide this study. There are six major 
constructs in the thematic concepts which provide a graphical description of how 
tracheostomy has a physical and psychosocial impact from the acute phase of illness 
through to recovery; necessity for communication, retaining normality, psychosocial 
discomfort, painful procedures, fear of the unknown, relationships with staff. This study, 
however, applied five of the constructs in the thematic concepts since the focus of the study 
was people who were living with a tracheostomy in the community. The findings of the 
study were organised according to the constructs of the thematic concepts together with 
the objectives of the study as; physical experiences, physiological experiences, 
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psychosocial experiences, economic experiences, communication experiences and coping 
strategies. 
Table 1: Summary of Themes  
THEMES SUB-THEMES 
Physical experiences Painful experience  
 Impaired activities of daily living 
Physiological experiences Difficulty in Breathing 
Dysphagia 
Reduced sense of smell 
Social experiences Altered body image 
Social isolation  
Altered sexuality 
Psychological experiences Fear and anxiety 
Depression  
Suicidal ideation 
Economic experiences   Work Challenges 
 Reduced income  
Communicate experiences  Mode of communication 
Challenges with verbalisation   
Coping mechanisms Acceptance of situation 
Resilience,  
Spiritual 
Support Family,  
Friends support 
 
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In the quest to answer the first research question: “What are the physical experiences of 
adults living with a tracheostomy tube,” one theme emerged; “physical experiences of a 
tracheostomy tube” with corresponding sub-themes. These are presented in the following 
paragraphs. 
 
4.4 Physical Experiences of living with a tracheostomy  
This theme describes the physical effects associated with living with a tracheostomy 
tube. It was realised that living with a tracheostomy tube was physically discomforting 
with a particularly painful experience immediately after the surgery. The pains emanated 
from the surgery itself, during bending, while coughing and when swallowing. Usually, 
the pains were treated with medications especially when it resulted from infections. 
However, some were allowed to resolve on their own as participants did not know which 
drug to take to address the problem. Living with a tracheostomy tube led to reduced 
strength leading to difficulty in performing activities of daily living such as cooking, 
washing and sweeping as well as challenges in mobility like bending, climbing and lifting 
items. The sub-themes identified for the physical impacts were painful experiences and 
impaired activities of daily living. These are described with verbatim quotations. 
 
4.4.1 Painful Experiences 
One of the major physical experiences of a tracheostomy tube among participants 
was pain that made it difficult to do anything. Participants indicated that the pain was 
severe in the initial stages after the surgery, and it usually subsided later in life.  
“So when I was fully conscious, I saw that my neck and throat had 
become heavy, and I felt so much pain, but what could I do?” (Aba); 
 
“I felt some pains and heaviness in my throat and on my neck. I wanted 
to lift my head, but the pains were so much. The nurses told me to relax 
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and not to raise my head. I felt so much pain; the pains were unbearable 
that I even cried” (Mansa). 
“Right now there is no pain, but when it was freshly done, it was painful” 
(Aba); “When I came home, actually, I did not feel the pains” (Becky); 
“It was painful at first, but it is not painful now” (Sussy). 
 
Participants indicated that the causes of the pain included the surgery itself (site of the 
operation), swallowing, piercing of the tube especially when they bent. 
“It pained me, the location of the operation (pointed to the right lateral 
side of neck) pained me very much mostly on swallowing” (Nsiah). 
 
“Oooh sometimes the tube chokes me, and I try to straighten it. It pierces 
and hurt when I bend down, and that makes it very painful” (Aba). 
 
There were also chest pains from excessive coughing and pains when the stoma became 
infected.  
“Whenever I cough, I have chest pains. When the inner tube become 
blocked, and I remove it, it was painful initially. I had to remove it 
gradually, yet I was able to wash it frequently. Coughing causes many 
pains” (Becky). 
 
“….again when there is an infection, it is painful, but when the infection 
resolves, there is no pain” (Sussy). 
 
However, most of the participants stated that suctioning or cleaning of the tube was 
not painful 
“Suctioning was not painful. It was rather walking around that was 
difficult” (Becky); “Usually suctioning was not painful” (Aba). 
 
Some participants used medications to treat the infections and resolve the pains.  
“I go for a check-up, and I am given some medications for the infections 
and pains. The doctor told me to report anytime I have any infection” 
(Sussy). 
 
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One of the participants did not report to the hospital or take any drugs. She endured the 
pains till it subsided on its own because she did not know which drug to take to relieve the 
pains.  
“I did not do anything. I did not take any drugs because I did not know 
which drug I had to take to resolve the pain. So I could have the pain for 
2 or 3 days, but I would not do anything. I always endured the pain till it 
subsided” (Akua). 
 
4.4.2 Impaired activities of daily living 
Participants indicated that the tube had reduced their strength, they easily got tired making 
them unable to performance activities of daily living. 
“Now I am not fit, you may think I am fit when you see me, but when I 
am at home, I am unable to do anything” (Nsiah); 
“I do not have enough strength now, my brother. The least activity I do, 
I get tired, and it is as if I am short of breath” (Mansa); “I am unable to 
do things quickly if I do it quickly, I have difficulty in breathing unless I 
rest for a while. So I usually don’t rush when I am doing something” 
(Akua). 
 
All the participants indicated difficulties in doing routine activities such as bending, 
talking, sweeping, carrying or lifting items, climbing hills or stairs, walking briskly or 
exercising.  
“I am unable to do any other thing like sweeping. I cannot bend down 
and sweep. As the tube is in, it is like a pen….. So anytime I bend, it hurts 
my throat” (Nsiah). 
“I am unable to talk for a longer period. I usually get exhausted when I 
talk for a longer time. I do not have enough strength now” (Sussy). 
 
“I was not having any such difficulties before I did the surgery. These 
days if I want to lift something, like a bucket with water to go and bath, 
I have to seize breathing for a while before I am able to lift the bucket. 
Because of the tube, I am unable to do this (tries to bend down)” (Adiza). 
 
“You see, now my strength has reduced, I am not as strong as I was 
initially. The work I doing at first, I cannot do it now because I do not 
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have the strength to work. You see this hill, (pointed to a small hill in 
front of her house) I almost die anytime I climb it. This little hill, it is not 
this one alone oooh, any hill at all, I cannot climb with ease. Unless I 
stop and rest severally, I cannot’ continue climbing” (Akua). 
 
Some participants indicated their difficulty in undertaking household chores like washing 
their dirty clothes. This was because most of the participants felt dizzy and or had waist 
pains in their attempt to stand to do these activities. 
“I am unable to wash. I do not know, but I get so tired of washing just a 
single cloth. The strength has reduced. I am unable to wash the clothes 
of my children. If I wash one cloth, I sweat profusely; it will surprise 
you” (Akua). 
 
“I cannot even stand to do anything. As soon as I stand, I get waist pains. 
It was not like that at first before the surgery. I cannot stand to do 
anything, for instance, standing to wash, I cannot do it. I get dizzy 
anytime I stand, and I always feel like I am falling” (Nsiah). 
 
Some participants also indicated cooking as a major challenge for them especially the 
females. This was due to weakness and difficulty in getting closer to fire. Usually, it led 
them into difficulty in breathing which made them felt uncomfortable.  
“I find it tough to go near the fire, so cooking for my husband and 
children has become a burden for me. Thankfully, my husband has been 
very supportive. Most of the time he does the cooking and the children 
also assist” (Mansa). 
 
“Even my cooking at home is a problem. Usually, I sit in one place and 
order for the items to cook” (Akua). 
   
  
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                              Life after tracheostomy: Experiences of adults in the Kumasi Metropolis, Ghana 
In the quest to answer the second research question: “What are the physiological 
experiences associated with adults living with a tracheostomy tube,” one theme emerged; 
“physiological experiences of a tracheostomy tube” with corresponding sub-themes. These 
are presented in the following paragraphs. 
 
4.5 Physiological experiences of living with a tracheostomy 
Living with the tracheostomy tube affected some physiological functions of the 
participants. It was identified that most of the participants were given the tracheostomy 
tube because of difficulty in breathing that emanated from complications of thyroidectomy. 
Participants, therefore, became relieved initially of difficulty in breathing after they 
were given the tube. However, most of the participants reiterated that their exposure to dust 
and high scented substances resulted in difficulty in breathing. Participants were also afraid 
of getting aspirated from eating and drinking. Eating dried, roasted, fried and hard foods, 
as well as drinking soups, were major concerns for most participants. There were 
difficulties in controlling where these foods would pass, and most participants had the 
difficult task of creating a “support base” in the throat with their tongues to prevent 
aspirating the foods eaten. The ability to smell also reduced among several of the 
participants especially when the cover of the tube was taken off. Odour from the tube was 
sometimes not perceived unless participants were prompted. The sub-themes found 
included difficulty in breathing, dysphagia and a reduced sense of smell. These are 
described with verbatim quotations. 
 
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4.5.1 Difficulty in breathing 
Breathing was a major concern to all the participants. Most of the participants had 
difficulty in breathing from post thyroidectomy complications which necessitated the 
tracheostomy operation.  
“(Wiped tears from her eyes, occluded the tube and started to talk) I had 
a goitre, and I was operated; afterwards, I had difficulty in breathing 
because there was a problem with a nerve in my neck, so I was given the 
tube to aid me breath” (Mansa). 
 
Given this, most of the participants indicated they were relieved of difficulty in breathing 
after they were given the tube although some were told the tube was going to be inserted 
temporarily.  
“Yes I felt relieved because I was able to breathe well when the tube was 
inserted” (Becky); 
 
“I was suffering initially with breathing, so I was not surprised when I 
woke up to see the tube. The doctor informed me that he was going to 
give me the tube for the time being and later he will remove it, so I felt it 
was a good thing for me because I was able to breathe afterwards” 
(Aba); 
 
“My breathing is better than after the thyroidectomy when the tube was 
not there. The tube has again reduced the noisy breathing” (Sussy). 
 
All the participants still had problems with their breathing while living with the 
tracheostomy tube.  
“Awww, since I was given the inner tube, my breathing is not like how it 
was before, (takes in air and covers the tube) before I was given the inner 
tube, my breathing was better than how it is now” (Aba); 
“There is difficulty in breathing. As you already know, this is not your 
natural breathing that God gave you, it is now artificial, and so your 
breathing will not be normal”(Adiza);  
“The breathing is not as good as before I was given the tube” (Sussy). 
 
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Factors that contributed to the difficulty in breathing with the tube included intolerance to 
dust and high scented items. The exposure to dust made participants cough extensively and 
even coughed out blood and had difficulty in breathing.  
“Sometimes I have difficulty in breathing especially when I come in 
contact with high scented items. Anytime I came in touch with great 
scented perfumes; I become breathless. If it happens while I am in traffic, 
I have to sit close to the window so that I can get enough air or else I will 
have problems with breathing” (Nsiah). 
 
“Now that I have the inner tube in my throat if I am doing something, it 
does not like dust, so if dust gets into me, I suffer a lot. I suffer, and it 
makes me cough, cough severely and you will see that I even cough out 
blood” (Kwasi). 
 
Accumulation of mucus in the tubes also resulted in difficulty in breathing.  
Now too, with the inner tube, if I make the least mistake, and it blocks 
because I did not wash it, it becomes difficult for me to breath. Someone 
who does not know me may think I am asthmatic. Meanwhile, I do not 
have asthma” (Aba). 
 
4.5.2 Dysphagia 
Difficulty in swallowing was another major challenge for the participants. Most 
participants were afraid of getting choked whenever they ate. There were times 
participants had to take out the inner tube before they could eat. 
“Yes there is a problem with swallowing, you have to be very careful else 
you will get choked. The food will pass through where food is not 
supposed to pass. That is how I see it, and it is same when you are 
drinking soup. So you have to get a “support base” in your throat. At 
times when I put soup in my mouth, I have to block my throat with my 
tongue else when it enters where it is not supposed to pass, I am in 
trouble” (Becky); 
 
“Yes, the surgery has affected me in many ways. Even if I wanted to 
eat, I had to take out the inner tube” (Nsiah). 
 
  
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Participants’ biggest challenge was eating dried, roasted, fried and hard foods. 
“Eating too dried foods could choke you, you always have to be careful, 
or when you are drinking soup, and you do not take your time, you can 
aspirate it; you will cough. So you have to take your time anytime you 
are eating” (Adiza). 
 
“In the beginning, I was told not to eat hard foods, as it is dry and can 
choke me. So I was taking liquid diets and light soup” (Adoma). 
 
“….for instance, roasted or fried yam, if there is not enough water in it, 
you have to take your time and chew till it gets very soft before you can 
swallow it well else it will choke you when swallowing. Even during 
chewing, I do not know if there is a hole there or not; if you do not use 
your tongue to support it, you can get choked” (Kwasi). 
 
 
4.5.3 Reduced sense of smell 
Some of the participants complained of reduced ability to smell. Detecting odour on 
themselves was a challenge unless someone prompted them. 
“My sense of smell has reduced, it is not like before I was given the inner 
tube. Sometimes someone has even to tell me I have a bad odour on me 
because I am unable to smell it myself” (Aba). 
 
“Yes, the presence of the tube has reduced my sense of smell. If you are 
not careful, you cannot detect the scent of anything; for instance the bad 
smell of something. Even now I used perfumes with caution else my nose 
will be blocked. There are a lot of issues ooh” (Akua). 
 
“Sometimes you are unable to smell anything, and I do not know why. 
Even when you get an infection, there is a bad odour around you. There 
are times that I do not even perceive it myself. Usually, my husband is 
the one that tells I smell unpleasant. So I can say the way I smell has also 
been affected” (Mansa). 
 
  
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However, one of the participants did not have any problem with her sense of smell. She 
was able to detect any scent including good and bad ones. 
“My sense of smelling has not changed in any way; it is my vocal cords 
that have a problem. I can smell everything. I am even able to smell when 
there is an odour in the tube” (Adoma). 
 
 
In answering the third research question: “What are the psychosocial experiences of adults 
living with a tracheostomy tube?” two major themes emerged; social experiences and 
psychological experiences. These are presented in the following paragraphs: 
 
4.6 Social experiences of living with a tracheostomy 
The physical presence of the tube on the neck altered participants’ body image 
and made them “look different” and “incomplete”. The tube was very obvious in the 
neck. The position of the tube changed the way participants wore clothes. They were 
restricted in the kind of dresses they put on especially when they had to go for social 
gatherings. This prevented most participants from taking part in social activities either 
at church or home because they could not withstand how much people stared at them. 
Additionally, the odour from the tube also prevented participants from going into public 
gatherings. In situations where participants had to attend these programmes, other 
clothing materials were used to “cover the neck” to reduce being stared at. Usually, 
participants preferred to stay indoors. The sexual life of the participants was also 
affected. Participants felt “unfit” and “unattractive” to engage in sexual activities. The 
participants who were not married bemoaned that, most suitors got interested in them, 
but they got scared when they saw the tube. They lost hope in marrying. It was identified 
that both the married and unmarried participants had sex once in a while. The sub-
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themes identified are altered body image, Social Isolation, and Altered Sexuality. These 
are described with verbatim quotations. 
 
4.6.1 Altered Body Image 
All the participants indicated that the physical presence of the tube altered their appearance 
and body image. They looked different, incomplete and felt bad. 
“You see, when you have this (points to the tube) on your neck, it makes 
you look different… I feel sorry; I feel terrible. It is like you are not even 
a human being. You feel incomplete, and you feel weird as well. My 
brother, it is not easy for me at all” (Mansa). 
 
Most participants indicated that the tube had changed their mode of dressing. The position 
of the tube restricted them in wearing certain kinds of dresses and putting on ornaments.  
“It has changed the way I dress. I would have put on a necklace if I dress 
up, but with this, on my neck, I cannot put the necklace on” (Akua); 
“It has affected my dressing and how I see myself severely. Even now if 
you are going to sew a dress, you are careful of the style; there are some 
dresses that you cannot wear now. You cannot wear dresses that can 
have contact with the tube” (Adoma). 
 
4.6.2 Social Isolation  
All the participants reiterated that the tube was very obvious on their neck, and people 
stared at them anytime they went out.  
“The tube is very visible; it is very obvious to others that I have a 
problem going out with it” (Mansa). 
 
“Eii! In the beginning, I was so disheartened. Someone could look at me 
till he hits an object before he would stop staring at me. Everywhere I 
went, people looked at me; at church, market everywhere, people stared 
at me” (Aba). 
 
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Most of the participants indicated that they socially isolated themselves from most public 
activities because of the odour from the tube.  
“For me, ever since I had the tube, I have seized to patronize any public 
events. Truthfully I do not go to public places or gathering; I am truthful. 
(Chuckled, chuckled again) Usually, I do not feel right; you would not 
feel fine in yourself” (Sussy). 
 
“Sometimes I am unable to go into the public, especially when there is 
an odour in the tube. My guilty conscience will even make me move from 
the crowd or isolate myself from the public” (Becky). 
 
In situations where participants had to go, they covered their neck with other clothing 
materials to prevent the embarrassment from staring. 
“All the time I covered my neck with the “hijab.” It is embarrassing 
going into the public with this tube because people will ask: “Why, what 
is wrong with her, what’s that in her neck.” Hmmm, it is pathetic” 
(Akua). 
 
“I mostly wear shirts these days because those are the ones that can 
cover the tube a bit. Whenever I put on a shirt, I have to button to the 
neck, so it covers the tube a bit; either than that, I had to cover it with 
something, else people will look at you” (Kwasi). 
 
4.6.3 Altered Sexuality  
All the nine participants both married and unmarried complained of diminished interest 
in sexual activities.  
“Honestly, since I was given the tube, I have lost interest in having sex, 
because it is tiring; but you cannot also stay unconcerned about your 
husband” (Becky); 
 
“Ahh my sexual relationship with my husband - that one has diminished 
tremendously” (Nsiah); 
 
  
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Participants indicated they were unfit to engage in sexual activities. Hence they engaged 
in sexual activities once in a while. 
“You do not have strength, so you cannot be having sex often. Your 
strength is low” (Akua); “…Ooh that one, once in a while I have sex” 
(Aba). 
“Once in a while then, we make love. However, like to be doing it 
continuously, no! I cannot because there is not enough strength” 
(Kwasi). 
 
Most of the participants echoed that the presence of the tube made them look unattractive. 
The participants who were not married had lost hope of marrying because they felt 
unattractive to suitors. Most suitors were scared of the tube so they could not approach 
them to talk about marriage.  
“I have not married again. After my husband’s death, I have not 
remarried, but even with this tube in my neck, who will be interested in 
marrying me? If someone sees me with this tube in my neck and having 
difficulty breathing and talking, he will not even be interested in me. So 
now I do not have a husband, I am not married and since my husband’s 
death about 5 years now, I have never had sex” (Sussy). 
 
“Ooh men are interested when they see me, but because of the tube, they 
are afraid. As I have been operated on with the inner tube in my neck, 
they get scared, so it is part of the reason why I am not married” (Aba). 
 
However, participants who were married indicated that their partners understood their 
situation and empathised with them. The partners did not worry them with sexual 
activities often. 
“Mmmmm, it is ok, (chuckles), it is not regular, but it is ok. My husband 
is fine with it because he knows the situation I am in” (Becky);  
 
“My wife copes with it. That is why I said she has been very supportive 
and cooperative. You know, it is not every woman that will understand 
you like that, but she takes it like that. She has never complained. She 
knows I will give out my best if I had the strength” (Kwasi). 
 
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4.7 Psychological experiences of living with a tracheostomy 
Most participants became anxious and depressed in their current state. Some 
participants were given the tracheostomy tube temporarily. However, unsuccessful 
weaning from the tube made participants live on the tube permanently. They had therefore 
lost hope in becoming normal again. Most of the participants were afraid of not knowing 
what was going to happen while they lived with the tube. There were also fears of dying 
and leaving children behind. Participants were disturbed going through these challenges 
and out of frustrations entertained the idea of committing suicide. The sub-themes 
identified are fear and anxiety, depression and suicidal tendencies. These are described 
with verbatim quotations. 
 
4.7.1 Fear and Anxiety  
Some of the participants initially thought they were going to live with the tube temporarily, 
but they had to live with it permanently due to unsuccessful weaning process. This made 
them sad. 
“Oooh, I was there. I stayed at the ward for some time; I stayed for 
almost one month. Initially, I was told by the doctors that the tube would 
be removed after some time. However, here I am, six years now, and I 
am still living with it” (Mansa); “They tried, the doctors tried to remove 
it when I was in the ward. Initially, they covered it, but anytime it was 
covered; I had the difficulty in breathing. So they could not remove it, 
and I had to live with it” (Adiza). 
 
The majority of the participants were anxious and had lost hope of becoming normal again. 
Participants had a fear of not knowing what will happen to them next while living with the 
tube. 
“…since then no one had attempted to remove the tube because I 
suffered when the tube was removed. So I do not know whether the nerve 
will get to its normal state or not, I do not know” (Akua). 
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“The Doctor told me I was only going to live with it for 6months when 
it was 6months, he did not say anything, one year time he did not 
mention anything. So in the second year when we went there, he stated 
that with this operation, when the nerves are cut, it cannot be repaired 
in Ghana unless outside. Who will send me outside the country for it to 
be repaired”? (Becky). 
 
Some participants were even afraid they were going to die to leave their children behind. 
They were disturbed going through such challenges. 
“Eiii, my brother, you have this thing in your throat (points to the tube) 
you would be afraid. Whether you are going to live, whether you are 
going to die, you do not know. Meanwhile, my kids are very young, and 
I do not know what will happen to me, so that is what makes me 
sad…Eii!, (shook her head severally and continued to talk) it is not easy, 
(shook the head again) it is not easy (wiped tears from her eyes with her 
cloth and continued to talk) when you wake up in the morning, you 
become sorrowful” (Akua). 
 
“It is very disturbing. Some people can stare at me till they run into an 
object before they stop watching me. When it happens like that, I get 
morose. Everywhere I go, people look at me; at church, market, 
everywhere, people stare at me” (Aba). 
 
4.7.2 Depression 
Participants bemoaned that it was depressing and disturbing having numerous challenges 
ranging from difficulty in verbal communication, difficulty in breathing, change in 
appearance and eating as well as reduced strength while living with the tube. 
“It is sad and disturbing... (Wiped her tears with a tissue and continued 
to talk). Everything about me has changed now. I am living an almost 
new life full of challenges; A new life where eating is even a problem 
because you are afraid you will aspirate the food. I am unable to express 
my feelings when something disturbs me. You are always indoors 
because you are shy to go out... It disturbs” (Becky). 
 
“Now, I am unable to talk much; there is difficulty breathing, even my 
appearance has changed, and I do not have enough strength because I 
get tired easily for doing the least activity. It worries me a lot, (looked 
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saddened), it is as if you are not even a human being.....it makes me cry 
sometimes” (Sussy). 
 
“There are times I want to add my voice to something but my situation 
does not allow me. It is very depressing at times” (Mansa). 
 
4.7.3 Suicidal Ideations 
Participants were disturbed going through these challenges and out of frustrations 
entertained the idea of committing suicide. 
“Sometimes you feel like crying; you become so frustrated and so 
worried. You get sad and feel so lonely that if you are not careful, you 
will commit suicide” (Mansa).  
 
In answering the fourth research question: “What are the economic experiences of a 
tracheostomy on adults living with a tracheostomy,” one main theme emerged; economic 
constraints. This is presented in the following paragraphs. 
 
4.8 Economic experiences of tracheostomy  
Living with the tracheostomy tube brought economic hardships to most of the 
participants. The tube reduced participants’ strength and made them unfit to work. Most of 
the participants changed their jobs; some lost their jobs while others did not get employed 
because employers saw them as unfit for the jobs. Most of the participants especially those 
who were unemployed had little hope of gaining employment. Participants who were 
engaged in trading lost customers because of their difficulties in verbally communicating. 
These led to much financial hardship as participants could not take care of themselves and 
their families. They also had financial difficulties assessing health care. The sub-themes 
included work challenges and reduced income. These are described with verbatim 
quotations. 
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4.8.1 Work Challenges 
Most of the participants complained the tube had reduced their strength to work. Four of 
the participants had to stop their jobs because of reduced strength. 
“Oooh, after the surgery truly job has been a big problem for me. I was 
a government worker. I was working at Ghana Pioneer Aluminium 
Factory, so the money I had from that work is what I used for the 
surgery. However, after the surgery, if I tell you I have been working, I 
will be lying to you, I do not work” (Aba); 
 
“I started work after the first surgery. I was going to work at Kuntenase. 
When I got to the station, I had to take “dropping” because I could not 
walk. So my boss told me to take rest on days I felt I could not come. I 
used to work thrice every week, but now I do not go anymore. I have 
stopped the work” (Nsiah). 
“Mmmmm, that is what I have been saying. Unlike initially when I could 
go to the farm and work, now I am unable to go. For two years now, I 
have not gone to farm. I am always at home. I am unable to do anything, 
anything I do, no matter how small it is, I become exhausted”(Sussy).  
 
Some participants indicated they felt dizzy walking in the sun. Due to this, they could not 
do the normal trading they used to do. 
“Oooh now I am home ooh, I am even unable to go to the store. The 
reason is if I walk under the sun, I get dizzy, and I am unable to see 
anything... I do not like heat, so I am unable to do any work or job” 
(Adiza). 
 
Getting a new job was also a challenge for participants who were either not employed or 
stopped the work they were doing before the tube was inserted because employers felt they 
were unfit to work. 
“I searched and searched, but I did not get any job to do. If I get a job, 
I will be very glad, but I do not know whether it is because of the tube I 
have in my neck or what. When I told employers I needed a job, they 
usually stared at me for a long time and afterwards said to me, there 
was no job. Sometimes when I got back home from the unfruitful job 
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search, I asked myself “is it because of the tube in my neck that is why 
I do not get a job to do?” So that is what I sometimes think” (Aba). 
 
Some participants changed their jobs and others had to reduce the number of employment 
they had because of the tube.  
“The thing is, I had been a professional teacher for almost 17years until 
I had the tube in my throat but now I cannot teach (started tearing, 
wiped the tears with her cloth and began to talk again). Initially, I was 
given a different task to be doing. I was asked to be recording marks 
and writing reports. Later, I was sent to our district education office to 
be doing documentations, and that is where I work now” (Mansa). 
 
“This is the same work I was doing (Chemical selling), but I was doing 
some others aside. Initially, I was working with the Health Insurance; 
but after being given the tube, I was unable to do that work again 
because of tiredness. So when it happened like that, (chuckles), I went 
there and told them I could not do the job anymore because it was very 
tiring” (Becky). 
 
“It has reduced the way I used to work. I was a trader, and I still am a 
merchant, but I am unable to work as before. Now there is no strength; 
there is not enough force. I used to go far for trading, but now I am 
unable to do so” (Akua). 
 
Some participants especially those who were engaged in trading lost most of their 
customers as well as revenue because they were unable to communicate well verbally with 
the customers. 
“…when someone comes to buy something because he or she fail to hear 
you, that person will even leave. Usually, they tell you “I am coming, or 
I am unable to hear you.” Even now, some people have difficulty 
hearing what I say, so they will tell you “I am coming” but they leave 
and never returned. So it affects you, your finances” (Becky). 
 
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4.8.2 Reduced income 
Participants indicated they were faced with many challenges getting money to take care of 
themselves and their families.  
“No money comes from anywhere because I am not working (hehehe, 
she laughed)” (Nsiah). 
 
“(Remained silent, sobbed and cleaned the tears, continued to talk). As 
I sit here now, if you ask me even GH¢5, I cannot get it for you, GH¢5, 
I cannot get it for you (remains silent for a while, wipes her tears) I do 
not have it. There are times I go hungry the whole day without food; it 
is as if I am fasting” (Aba). 
 
“My husband who was taking care of me is dead. Moreover, even this 
my son (points to her son), I was working and taking care of him in 
school, but now there is no money. He has even completed Senior High 
school, but he owes the school, so we have not been able to go for his 
results” (Sussy). 
 
Attending reviews and taking care of the tube was a challenge for most of the participants.  
“So as I live now, it is hard for me. Even taking care of the tube, buying 
gauze and tape all the time is an issue for me. Money is also needed to 
visit the hospital for review monthly. So life is difficult for me” (Sussy). 
 
“Additionally, I have to take care of myself and the tube, change the 
dressings and buy drugs among others. So your finances will go down. 
For my salary, I still get it but it is not enough for me, and I cannot do 
any other job unless the one that will allow me to sit only at one place” 
(Mansa). 
 
“Your finances will go down (smiled, spoke with some difficulty, took in 
some air, then continued) because you cannot do any other work. I 
usually went to work late and had to close early. This reduced the 
amount of money I made in a day” (Becky). 
 
All the participants wished the tube would be removed to enable them to work to 
take care of themselves and their families. 
“If they do not remove this tube, how will I survive, I am unable to work, 
what will I do, how will I be able to buy these items? (Remained silent, 
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wiped her face and continued to talk)I do not have any money to take 
care of my son. Had it not been this sickness, I would have been able to 
do some small work to at least to take care of him. With this tube on my 
neck, I cannot farm to get money to take care of him and myself” (Sussy). 
 
“So if it can be taken off, I will be euphoric. I want to regain my strength 
and do things the way I used to do them” (Mansa). 
 
In answering the fifth research question: “How do adults living with a tracheostomy tube 
communicate?” one major theme emerged; Communication experiences. This is presented 
in the following paragraphs. 
 
4.9 Patients’ communication experiences on living with a tracheostomy  
Communication was a major challenge for all participants. Most of the participants 
had difficulty verbally communicating with the tube. Participants indicated production of 
speech was not possible at the initial stages of the tube insertion. However, they gradually 
regained their voice usually about a month or two later. It was identified that during 
hospitalization, participants used sign language and wrote on papers to communicate when 
they could not produce speech. Participants who were not educated had many difficulties 
writing to express their needs to the health personnel on the ward. 
Some participants used “speaking valve” when they regained their voice before their 
voice could be heard. Participants who could not afford the speaking valve used their finger 
to occlude the tube to talk. However, talking without putting the finger on the tube left 
participants with rib pains.  
There were other challenges associated with verbal communication. Participants 
were unable to speak for a longer period; they got exhausted whenever they talked for a 
long time. The spiritual life of some participants was also affected. Participants who had 
certain responsibilities at church before the tube insertion were unable to do so again. 
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Things such as reading the Bible at church, and singing at church were all affected, and 
participants indicated it had an adverse impact on their spirituality. The sub-themes 
included mode of communication and challenges with verbalization. These sub-themes 
have been described with verbatim quotations from participants. 
 
4.9.1 Mode of communication 
Most of the participants indicated that when the tubes were freshly inserted, they could not 
have verbal communication.  
“After the operation, I became “dumb.” I was not talking (Aba); 
“Immediately after the operation, I was unable to talk” (Sussy). 
 
They resorted to the use of non-verbal cues like sign language and writing on papers with 
a pen to communicate.  
“…so initially, after the surgery when I was in the Ward, whenever I 
needed something I will do a sign to get me understood. Whenever a 
nurse or a doctor asked me a question, there were pens and papers that 
I used to write my “broken English” to them, and they understood me” 
(Aba).  
 
“The voice to talk was not coming at all. I was using signs; sometimes I 
wrote to communicate (Becky). 
 
“Oooh, I was using signs to communicate. When the tube is inserted 
freshly you will not be able to talk so the only way out is to use sign 
language” (Adiza).  
 
However, participants bemoaned that it was difficult using nonverbal cues to communicate 
because some of them could not even read and write and it was not everyone who could 
read what they wrote.  
“I could not do anything, whatever I wanted to do, I had to write it, and 
it was not everyone that could read what I wrote. So it was not easy 
(chuckles)” (Becky). 
 
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“Life was difficult for me when I had not regained my voice. There were 
times I went somewhere, and because I could not talk, I had to do signs 
or write on paper. Meanwhile, I could not write well what I wanted to 
say so it was not good, not good. When it happens like that, you do not 
feel like going where you want to go” (Adoma). 
 
Participants gradually regained their voices within a week or two after the surgery.  
“Yes, I initially struggled to speak, but the speech became better 
gradually. So it was like that till about 2weeks after the surgery when I 
realised I was gradually regaining my voice until I was discharged and 
now by God’s grace, I can speak”(Aba). 
 
“As you get better than, your voice also gets better. The doctor told me 
they did not cut anything in my throat” (Adiza). 
 
Participants indicated that when they regained their voice, they still had to either use 
“speaking valves” or their fingers to occlude the tube anytime they were talking. They 
stated that anytime the tube was not occluded while talking, only air came out instead of 
voice and they got rib pain when they did that. 
“I use a “speaking valve,” so if I put it on the tube, I can talk well but if 
the valve is off, I am unable to talk” (Adiza). 
 
“The doctor told me to be putting my finger on the tube when I am 
speaking. So anytime I put my finger on the tube, my talking is fine, but 
if I take off my hand, it is only air that comes out” (Sussy). 
 
“By God’s grace, I can speak now. However, if I need to talk, I have to 
put my finger on the hole of the inner tube (she directs her left index 
finger to show me how she covers the inner tube).However, if I do not 
put my finger there, I find it difficult to talk and anytime I do so, I get 
pains in my ribs” (Aba). 
 
4.9.2 Challenges with verbalization 
Most of the participants indicated that there were challenges associated with the regained 
verbal communication. The majority of the participants stated that they could not talk for 
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a longer period. They could not engage in long conversations, anytime they did that, they 
got exhausted and had to pant for breath because they had to cover the tube to talk.  
“There is tiredness all the time. When you speak for a while, you get 
tired, and you are unable to breathe, but when you take off your hand 
from the tube to take in some air too, you cannot talk” (Becky).  
 
“The thing is, you get tired easily for talking for a long time. You are 
unable to engage in long conversation” (Mansa). 
 
“Now I do not have problems with speech when I put my hand on it. It is 
only that when I talk for a while, I get tired” (Sussy). 
 
Some participants revealed that their spiritual life was also affected, particularly the 
performance of activities such as Bible reading and singing at church. 
“My inability to communicate has affected me very much. At first, before 
the insertion of the tube, I was a Bible reader at church, now I cannot do 
it anymore, I was a chorister, I cannot sing again. All these affect me 
spiritually. I am someone who loves singing, but now I cannot sing 
anymore. When it happens like that (chuckles) it gets me 
worried….sometimes I try to sing but the voice does not come” (Becky). 
 
“Yea, I was a singer, but now I cannot sing, and it worries me so 
much…usually, I get worried a lot looking at myself as I cannot sing like 
I used to. When I go to church, I do not have any voice to sing, so I just 
sit and look on” (Sussy). 
 
In answering the sixth research question: “what are the coping strategies of adults living 
with a tracheostomy tube? Two major themes emerged: coping mechanisms and support. 
These are presented in the following paragraphs. 
 
4.10 Patients’ coping mechanisms while living with a tracheostomy tube 
Participants of the study reiterated how they coped with the challenges they 
encountered while living with the tracheostomy tube. Most of the participants indicated 
that they accepted the fact that they were going to live permanently with the tube because 
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they knew before the surgery was done that, it was either they had the tube or died. Some 
also indicated that once they were not dead and were still alive, it meant that they had to 
be content because some other people did the operation and died. Given these, they were 
not shy of their situation. They developed the strong mentality and strong will to live. Other 
participants also indicated that they were encouraged when they saw other PLTT who were 
also doing very well anytime they came to the hospital. The majority of the participants 
also indicated that they depended on spiritual support to survive. The prayed to God and 
He supplied them with their needs through people. The sub-themes identified are 
Acceptance of the situation, resilience, and spirituality. These are described with verbatim 
quotations. 
4.10.1 Acceptance of situation 
Most of the participants knew and accepted their situation even before the tube was 
inserted. They were therefore not surprised to see the tube in their neck. 
“I was not surprised. I knew I was going to have something in my neck, 
and I knew that was the only way for me to survive. When I became 
conscious, I used my hand to feel the tube in my throat, and I realised I 
was able to breathe, so I was ok with it” (Becky). 
 
Some of the participants also indicated that they have realised nothing would change, so 
they have accepted the situation. 
“Yes! Initially, I was disturbed that someone like me who was very active 
and able to talk my mind on anything as long as I wanted, couldn’t do it 
now. However, now I have realised that is how it is going to be, so I have 
taken it like that” (Sussy). 
 
Some participants indicated they were not shy of their situation anymore because people 
around them knew they were normal. They were in that state because of sickness.  
“I am not shy. Anyone who knew me knows that this was not how God 
created me. This is because of illness, so I am not shy” (Nsiah). 
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4.10.2 Resilience 
Most of the participants indicated that they no longer paid attention to what people said 
about their current situation but rather concentrated on whatever they did.  
 
“In the beginning, I was so discouraged…however, later I realised I was 
making a mistake, so I decided that I not be going to pay attention to 
anyone. I saw that people looked at me, but I did not pay attention to 
them” (Aba). 
 
“Eii!.....They stared at me seriously. However, in all these, I did not care 
because I came to worship God” (Kwasi) 
 
 
Some participants felt there was no need to worry because other people had the same 
operation but died, so they had to be grateful to be alive. 
“Ooh me, I feel I am ok. Someone did it once but did not talk and died. 
So if I am living, then it is grace. I do not listen to what people say” 
(Nsiah). 
 
Some of the participants developed the strong mentality and a strong will to live when they 
saw other people who were on tracheostomy doing very well anytime they came to the 
hospital for review. 
“…So when I come to the hospital, and I meet other people who have the 
tube and are doing well, it encourages me that all is well. My people 
have not seen it before, so they pity me” (Sussy). 
 
4.10.3 Spirituality 
All the nine participants indicated that they also got inspiration from God. They relied on 
and prayed to God to assist them in all things. They believed God answered their prayers 
and provided their needs through people. 
“It is all God’s doing. Honestly, when I get lorry fare, I go for prayers. 
Sometimes I give GH¢1 offering but it is from my heart, and God knows 
I do not have much money. So if I get something small, then I go, I go for 
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prayers. So had it not been prayers, it would have been tough (still 
sobbing)” (Aba). 
 
“God is God because He gives me hope to live all the time. With my kids 
and the finances unstable, God gives me food to eat because He is God. 
God will do it, and He is faithful to His words, God has done it” (Akua). 
 
“It is God who is taking care of me. Usually, I pray to God for His Grace 
and He has never disappointed me” (Sussy). 
 
 
4.11 Support while living with a tracheostomy tube  
Living with a tracheostomy tube posed lots of challenges. Mostly people living with 
the tube needed support to survive. All the participants in the study indicated that they got 
various forms of support from spouses, family, friends, and children in undertaking some 
of these activities. It was realised that most of the participants depended on their spouses 
and relatives for financial and emotional support as well as support in undertaking activities 
of daily living. Nonetheless, some of the participants indicated that some forms of support 
waned with time. Additionally, not all the participants were lucky to get these supports. 
The sub-themes are family, friends, and spiritual supports. These are described with 
verbatim quotations in the following paragraphs. 
 
4.11.1 Family support 
Most of the participants stated that their family (spouses, children, mothers, fathers, uncles) 
lent their support in undertaking most of these household chores. 
“Oooh, it is ok; my family supports me. They do not allow me to do 
anything at home; like washing and others, they do it. Whenever we went 
somewhere, like the village, for instance, we used to go to the farm 
together; but now, they do not allow me even to go when I ask to go with 
them. They tell me to stay at home” (Becky). 
 
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However, some of the participants indicated they did not get any assistance to 
undertake some of the household chores; they rather hired people to do those activities 
for them. 
“I always hire someone to wash them for me” (Akua). 
Some of the participants were also supported financially by their family members. 
“I sometimes get financial assistance from family especially my mother. 
My daughter too is not working but she is married, so when she gets some 
money, she sends some to me” (Sussy). 
 
“It is only my mother who supports me. I have children, so my mother 
sells the shear butter and gives me the proceeds to take care of myself 
and my kids. So she supports me” (Akua). 
 
Some of the participants lamented that the financial supports from family members had 
decreased over time. Life, therefore, had become unbearable for them and their families.  
“Ooh at first, my uncle was supporting me, but he is out of a job now, so 
if I say I have anyone who supports me, then I am lying…as I sit here 
now if you asked me even GH¢5, I cannot get it for you, (Remained silent 
for a while, wiped her tears) I do not have. It is a generous person who 
gives me money to prepare some meal so that we will all eat; that is all. 
It has been like that till you came to meet me” (Aba). 
 
“When I got sick, my father died. You know when it gets so difficult 
initially they will support, but now that it seems I am a bit strong, who 
will support? If someone will support you, it is just like giving you GH¢2 
to buy something like bread. If I am going to the hospital, I cannot go 
and ask my relatives for assistance. They will say they do not have any 
money” (Sussy). 
 
Participants also indicated they got emotional support from their families especially 
their husbands and children. 
“My husband has been very supportive. He supports me a lot. He is my 
main source of support and inspiration. He does most of the things for 
me” (Mansa). 
 
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“Now my children have seen how it is, so it is not surprising to them 
anymore. So if I am unable to do something I used to do before the tube 
was inserted, they do not get surprised because they know my situation 
now. So they have taken it to be normal, and they encourage me a lot” 
(Becky). 
 
4.11.2 Friends’ support 
Some of the participants also indicated that their friends sometimes also gave them 
emotional and financial assistance. 
“My friends at church also sympathise with me. They sometimes pay me 
visits and give me some encouragement” (Nsiah). 
“I have friends who also come around to visit. Whenever they come 
around, they give me some money. Usually, I use it for transportation 
to the hospital for review and other expenses” (Sussy). 
“Sometimes my friends also come around. They usually come on 
weekends to see me” (Mansa). 
 
4.12 Summary 
The findings above were based on the data collected from adults who are living with 
a tracheostomy tube in the Kumasi metropolis. The findings indicate that ALTT have 
different kinds of experiences ranging from physical, physiological, psychosocial and 
economic, communication to coping. They experienced pain from the operation itself when 
they bend and cough as well as during stoma infection. Majority sought for medical 
treatment for the pain they experienced while others did not seek for any treatment because 
they could not afford the cost of health care. 
The majority of the participants had reduced strength which made them unfit to do 
any job to earn income. However, some had to change jobs or stop the work they were 
doing because the tube made them incapable of doing the job they were doing before they 
had the tube resulting in lots of financial constraints. 
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Participants had a problem with swallowing, breathing and smelling which 
compromised their quality of life. The majority of the participants felt different because 
the tube made them look incomplete and reduced their self-image. They preferred to stay 
indoors and isolate themselves from most social activities because of how people looked 
at them. These made them anxious, depressed and at times they entertained suicide ideas. 
Additionally, most of the participants used nonverbal cues like sign language and 
writing on papers to communicate when the tube was freshly inserted because they had no 
voice in the initial stages after the surgery, however, those who could not read and write to 
express themselves became frustrated and lived in apathy. As they gained their voices, they 
either used ‘speak valves’ or occluded the tube with their finger to talk. Most of them had 
problems doing some kinds of activities like singing and reading the Bible at church, 
reducing their spirituality. 
Participants received support from their family members in undertaking some 
activities of daily living like washing, cooking. Others received financial assistance from 
family members, friends and generous individuals for survival. Participants used various 
kinds of coping strategies to survive. These included; acceptance, resilience and relying on 
God to cope.  
Most of these findings were in line with the constructs in the thematic concepts used 
as a guide for this study. However, since this study was done among ALTT in the 
community rather than patients in the ICU, some of the findings such as economic 
constraint and support emerged as new discoveries. These results are discussed in detail in 
the next chapter. 
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CHAPTER FIVE 
DISCUSSION 
5.1 Introduction 
The study aimed at exploring the experiences of adults living with a tracheostomy in 
the Kumasi Metropolis. The study explored different kinds of experiences after in-depth 
interviewing of nine adults with tracheostomy tubes. The study had the following 
objectives:  
a. to describe the physical impact of adults living with a tracheostomy tube 
b. to examine the physiological changes associated with adults living with a 
tracheostomy tube 
c. to explore the psychosocial experiences of adults living with a tracheostomy tube 
d. to study the economic impact of tracheostomy on adults living with a 
tracheostomy tube 
e. to investigate how adults living with a tracheostomy communicate 
f. to identify the coping strategies of adults living with a tracheostomy tube.  
Eight main themes emerged from the analysis of the experiences of adults living with a 
tracheostomy in the Kumasi Metropolis based on the thematic concepts by Foster (2010) 
and the objectives: physical experiences, physiological experiences, social experiences, 
psychological experiences, economic experiences, communication experiences, coping 
mechanisms and support. These key findings are discussed in relation to existing studies 
subsequently.  
5.2 Physical experiences of living with a tracheostomy 
The physical experiences among adults living with a tracheostomy tube (ALTT) 
identified in this study included painful experiences and impaired activities of daily living. 
Pain is a subjective and an unpleasant sensory and emotional experience arising from an 
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actual or potential tissue destruction or described regarding such damage (Breivik, 2002; 
Leeson, Gulabivala, & Ng, 2014). In the present study, the experience of pain was due to 
sensory and actual tissue damage arising from the surgical procedure itself and the 
discomfort from the tube in the performance of certain activities. All the participants in the 
study complained of the pain they experienced at the site of the surgery as well as on 
swallowing when they became conscious after the surgery. This is consistent with several 
studies which also identified the association of tracheostomy surgery and pain (Al Sutari 
et al. (2014). According to Al Sutari et al. (2014), the experience of pain from the 
tracheostomy surgery and the physical presence of the tracheostomy tube are well-known 
among tracheostomised individuals. Freeman (2011) also identified in her study that 
people who have undergone a tracheostomy surgery usually have pains on swallowing 
mostly at the initial stages after the surgery which reduces their nutritional requirements. 
Considering that there is difficulty in speaking in the early stages after the tracheostomy 
surgery (Flinterud & Andershed, 2015; Madan et al., 2011), the ability to express the pain 
experienced is hindered (Foster, 2010). ALTT, therefore, become exasperated, and they 
express it in anger (Magnus & Turkington, 2006). The only option left for them is to be 
quiet and endure the pains they experience (Karlsson, Bergbom, et al., 2012). The 
reduction in nutritional requirement can lead to hypoglycaemia since they may not be able 
to meet their nutritional requirement. Therefore, nurses need to assess the nutritional 
demands of such individuals and meet the requirements through other means like taking of 
light diet and intravenous fluids since those may be tolerable; hence the prevention of 
possible hypoglycaemia (Ganzer et al., 2015). 
In the current study, the pain subsided later, especially when the incisional wound 
healed. However, participants had pains whenever they coughed. This is consistent with 
studies by Al Sutari et al. (2014) and Siffleet et al. (2007) which indicated that breathing 
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and coughing exercises cause pain in people living with a tracheostomy. Additionally, 
stoma infection and movement of the tube on bending were identified to be other factors 
which caused pain among the adults living with a tracheostomy in the Kumasi Metropolis. 
This finding is also in line with the findings by McCormick et al. (2015) that, stoma 
infection and the dressing of the stoma cause pain in tracheostomized adults.  
Contrary to the study by Arroyo-Novoa et al. (2008) who described suctioning of the 
tracheostomy tube to be painful, the findings of the current study showed that suctioning 
was not painful. This difference may have resulted from the fact that participants might 
have forgotten their experiences while they were in the intensive care unit since this present 
study used tracheostomised adults who were at home and did no suctioning. The 
commonest way of cleaning the tube is to take the inner tube off, clean and reinsert, hence 
suctioning is not practised amongst them (Barnett, 2012; Russell, 2005).  
The efficient management of postoperative pain is inadequate in most continents and 
even in the United States and Europe, studies have shown that there is the need for 
improvement (Apfelbaum, Chen, Mehta, & Gan, 2003; Benhamou et al., 2008; Francis & 
Fitzpatrick, 2013). Studies have also shown that nurses worldwide lack the requisite 
knowledge in postoperative pain management (Abdalrahim, Majali, Stomberg, & 
Bergbom, 2011; Francis & Fitzpatrick, 2013; Wang & Tsai, 2010; Yava et al., 2013). This 
situation is similar to the Ghanaian nurses’ (Aziato & Adejumo, 2014), although there is 
the belief that nurses have their subjective understanding of pain and see pain as a 
distasteful sensation (Aziato, Akorfa, Dedey, & Clegg-Lamptey, 2016).  
The most significant activity in improving postoperative pain management is to 
administer nonopioid analgesics such as NSAIDs, acetaminophen (White, 2005). These 
analgesics contribute to improving sleep, reducing delirium and agitation (Gélinas, 2007), 
as well as reducing the high rate of post-traumatic stress disorders that are associated with 
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the experience of pain (Granja et al., 2008). It will also assist to achieve quick resumption 
of normal activities of daily living (Eng, 2011; White et al., 2007) which will assist to 
improve patients’ quality of life. Therefore adults undergoing a tracheostomy surgery 
should be given adequate preoperative education on the experience of pain on awakening 
from the anaesthesia. Potent analgesia should be provided and administered to facilitate 
the pain management (Abdalrahim et al., 2011). Proper education during discharge with 
emphasis on how assuming certain body positions could reduce tube movements (which 
cause pain) should be a priority.   
Impaired performance of activities of daily living was one of the physical experiences 
of ALTT in the Kumasi Metropolis. Impaired activities of everyday life is a situation where 
a person is unable to perform all their daily activities due to reduced strength, 
immobilisation, restrictions in movement, lack of motivation and pain (Chiang, Wang, Wu, 
Wu, & Wu, 2006; Elvir-Lazo & White, 2010). In the current study, all the participants 
complained of reduced strength and easy fatigability which made it difficult for them to 
undertake activities of daily living. Consistent with these findings, other studies have 
reported that PLTT have reduced capacity to participate in activities of daily living (Foster, 
2010; Hashmi et al., 2010).  
Among the activities identified in the current study which participants were unable 
to do included bending, talking, sweeping, carrying or lifting items, climbing hills, walking 
briskly or exercising. Cooking and washing were also affected. Participants felt dizzy and 
had waist pains when they stood to wash or cook. This is consistent with the findings by 
Gul and Karadag (2010), which indicated that living with a tracheostomy tube affects one's 
performance of activities such as swimming, bending, climbing, talking as well as any 
other activity that needs physical strength; this greatly affects their quality of life. These 
findings indicate that adults living with a tracheostomy have a lot of functional limitations. 
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Hence, the need to provide support in undertaking some of these functions to assist improve 
their quality of life and to reduce possible frustrations and depressions (Björklund et al., 
2010; Lang, France, Williams, Humphris, & Wells, 2013). As Howren, Christensen, 
Karnell, and Funk (2013) suggests, the provision of social support, especially from family 
members and friends, will positively influence the quality of life of individuals with a 
tracheostomy.  
In the current study, the impaired performance of activities of daily living from 
reduced strength impacted on the economic status of the participants. Consistent with this 
finding, Isaksson et al., (2015) reported on the central concern of a reduction in work power 
in the literature. At times, tracheostomised adults changed their normal daily activities both 
at home and at work (Björklund et al., 2010; Griffiths et al., 2008). This change of activities 
is to enable them to meet the physical impairments that result from living with a 
tracheostomy tube (Molassiotis & Rogers, 2012; Röing et al., 2007; Semple & McCance, 
2010). This change in activities leads to reduced income because most of these adults are 
unable to undertake jobs requiring physical strength (Steiner et al., 2004). Coupled with 
the high cost of living and tube care (Hyde et al., 2015), these individuals need financial 
support. They also need retraining in less difficult jobs to earn a living (Björklund et al., 
2010; Steiner et al., 2004; Verdonck-de Leeuw, van Bleek, Leemans, & de Bree, 2010).    
From the findings on the physical challenges of the tracheostomy tube in the current 
study, it can be concluded that ALTT have physical challenges. The experience of pain 
from the surgery itself, when swallowing, during breathing and coughing, piercing of the 
tube on bending as well as during stoma infections is stressful enough for these adults. 
Reduction in strength to perform activities of daily living impact on their quality of life. 
Their inability to perform strenuous activities including working to earn an income is very 
frustrating taking into account the rising cost of living and health care. 
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5.3 Physiological experiences of living with a tracheostomy 
This aspect discusses the defects of bodily functions of the ALTT in the Kumasi 
Metropolis in Ghana. The human body performs different physiological functions which 
assist in keeping the body in an active state. Any artificial change in the human structure 
is likely to affect the physiology of the body. The tracheostomy surgery interrupts vital 
bodily physiology (List & Bilir, 2004) such as, disruption in the ability to breath, swallow, 
speak, and taste which cause tremendous discomfort (Björklund et al., 2010; Funk, Karnell, 
& Christensen, 2012). The physiological changes of the ALTT were: difficulty in 
breathing, dysphagia and a reduced sense of smell. 
The structural changes that occur in tracheostomised individuals result in a reduction 
of the natural warming and humidification of inhaled air (Russell, 2005). The decrease in 
the humidification leads to retention of secretions, impairment of mucociliary clearance, 
decrease cough reflex and reduction in lung function (Conlan & Kopec, 2000; Woodrow, 
2002) resulting in difficulty in breathing (Gul & Karadag, 2010; Huffman et al., 2014). In 
the current study, difficulty in breathing was a major challenge for all the participants.  
The findings of the present study further revealed that difficulty in breathing from 
post thyroidectomy complication was the common indication for the tracheostomy surgery 
for most of the participants. This finding affirms the study by Cheung and Napolitano 
(2014) which identified the most common indications for a tracheostomy to include acute 
respiratory failure, the need for prolonged mechanical ventilation and trauma to the throat 
requiring mechanical ventilation. These adults were therefore relieved when the tube was 
inserted (Durbin, 2010; Haspel et al., 2012). However, accumulation of mucus in the tube, 
intolerance to dust and high scented items resulted in excessive coughs and difficulty in 
breathing which reduced their quality of life. Akram and Khosrow (2009) state that 
difficulty in breathing is a major challenge for tracheostomised adults and this 
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physiological dysfunction affects their quality of life. Additionally, the difficulty in 
breathing made most people weak rendering them incapable of undertaking any strenuous 
activities including those that could earn them a living (Mehnert et al., 2013). Therefore, 
adequate education before discharge on the tube care and the avoidance of high scented 
items and dust will assist to reduce an excessive cough and the resultant difficulty in 
breathing. 
The act of swallowing involves the passage of food and drink that has been chewed 
or broken into smaller pieces in the mouth through the throat into the stomach. Interruption 
at any stage of the process or a disruption in the structure of the throat can lead to difficulty 
in swallowing (dysphagia) (Sharma et al., 2007). In tracheostomised adults, a reduction in 
laryngeal elevation, oesophageal compression, reduced glottis closing time, and 
obstruction from the cuff of the tracheostomy tube cause difficulty in swallowing (Daudia 
& Gibbin, 2006; De Leyn et al., 2007; Russell, 2005; Serra, 2000). Findings from the 
present study showed that adults living with a tracheostomy tube had difficulty in 
swallowing (dysphagia). In line with this finding, other surveys have also reported of the 
difficulty in swallowing as a common phenomenon among tracheostomised adults 
(Ceriana et al., 2015; Foster, 2010; Serra, 2000; Sherlock et al., 2009).  
Further findings from the current study indicate that there is the feeling of aspiration 
and the sensation of getting choked while swallowing especially soup, dried, roasted, fried 
and hard foods. However, there are conflicting findings in the literature on the impact of 
the tracheostomy tube and aspiration. While earlier findings suggest a link between a 
tracheostomy tube and aspiration (Elpern et al., 1994; Pannunzio, 1996), some recent 
findings disapprove of this linkage (Brady et al., 2009; Leder & Ross, 2010). To confirm 
the non-association of the tracheostomy tube and aspiration, Leder and Ross (2010) 
identified no significant change in aspiration between pre and post tracheostomy situations. 
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However, it was identified that people who need tracheostomy are likely to experience 
swallowing disorders after the surgery (Sherlock et al., 2009). Therefore there is the need 
for more collaborative work to include the speech-language pathologist to assess the 
swallowing function and the airway of people who are tracheostomized before discharge 
(McGrath & Wallace, 2014; Starmer et al., 2014) to verify these individuals’ ability to 
swallow without getting aspirated.  
Dysphagia in tracheostomy may certainly lead to loss of appetite, possible 
hypoglycaemia, and a resulting weight loss. The reason is that food serves as a fundamental 
and physiological need, providing energy and nutrients for the body to enhance growth and 
vitality (Ganzer et al., 2015; Tsang & Carey, 2015). The inability to eat as a result of 
dysphagia will derail the sustenance of life (Klinke, Hafsteinsdóttir, Thorsteinsson, & 
Jónsdóttir, 2014). Hence, ALTT should be educated and encouraged to follow proper 
dietary requirements (Serra, 2000). 
Another physiological challenge that compounded the lives of ALTT was the 
reduced sense of smell. The smelling process relies so much on the flow of air through the 
nasal cavity as well as odorant binding and stimulation of an associated chemosensory 
receptor (Kaupp, 2010; Patel & Pinto, 2014). Both conductive and sensorineural defects 
can alter the process of smelling (Hong et al., 2012). Studies have shown that surgical 
procedures such as laryngectomy and tracheostomy lead to a conductive dysfunction of the 
nose by limiting nasal airflow, hence causes a reduction in the sense of smell (Hilgers et 
al., 2000; Hong et al., 2012; Risberg-Berlin et al., 2009). It was evident in the current study 
that the ALTT had reduced the sense of smell. This finding confirms other studies that, 
living with a tracheostomy tube impact negatively on the ability to smell (Huffman et al., 
2014; Kennedy et al., 2016; Tsikoudas et al., 2011).  
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Furthermore, in the present study, participants had difficulty detecting odour on 
themselves unless someone prompted them. The ability to smell has a significant influence 
on our health and behaviour. Reduced sense of smell is detrimental to the quality of life of 
adults living with a tracheostomy (Hummel & Nordin, 2005; Neuland et al., 2011; Nordin, 
Blomqvist, Olsson, Stjärne, & Ehnhage, 2011). For instance, studies have shown that the 
ability to smell influences eating lifestyles and improve nutritional intake by enhancing 
appetite and food choices (Croy et al., 2014; Hays & Roberts, 2006; Mennella et al., 
2001). Therefore, interruption in the sense of smell could reduce appetite and further lead 
to loss of weight (Huffman et al., 2014). Smelling also facilitates the detection of possible 
hazards in our surroundings and as well influences interpersonal relationships (Doucet et 
al., 2009; Jacob, Garcia, et al., 2002; Jacob, McClintock, et al., 2002; Neuland et al., 2011). 
The reduced ability to smell implies that the safety of ALTT is at stake (Miwa et al., 2001). 
These individuals are susceptible to developing anxiety and depression (Croy et al., 2012; 
Tsikoudas et al., 2011).  
Therefore, preoperative education for patients who are undergoing a tracheostomy 
surgery should include education on the physiological changes (Tsikoudas et al., 2011). 
There is also the need for proper evaluation of the olfactory status of tracheostomised 
persons post-surgery for counselling, and where needed, rehabilitated with the “polite 
yawning” technique (Hilgers et al., 2000; Hong et al., 2012). 
 
5.4 Social experiences of living with a tracheostomy 
In this study, ALTT had different social implications which included: altered body 
image, social isolation, and altered sexuality. The human face and neck are critical in an 
individual’s self-identification (Bradbury, 2012; Callahan, 2005) because it is the most 
prominent part of the human structure serving as a channel of interaction with others. 
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Therefore any changes in this nomenclature alter the body image of the individual resulting 
in reduced self-esteem (Caravati-Jouvenceaux et al., 2011; Krouse et al., 2009). The reason 
is that body image as explained by Phillip and de Man (2010) is the impression people 
make of their physical appearance and the impression they trust others have of them. These 
include how they see themselves and how others see them regarding their look, attraction, 
their health as well as how their bodies aid them to interact with people (Grogan, 2007; 
Lubkin & Larsen, 2006). In the current study, the physical presence of the tube altered the 
appearance and body image of ALTT making them look different and incomplete. This 
finding is congruent with numerous studies of the change in body image of 
tracheostomised adults (Callahan, 2005; Fingeret et al., 2015; Rhoten, Murphy, & Ridner, 
2013; Sherlock et al., 2009; Teo et al., 2016). In related studies, Dawson (2014) and Katz 
et al. (2003) affirm that living with a tracheostomy tube results in high incidence of altered 
body image as a consequence of the noticeable mutilation at the anterior part of the neck. 
According to Callahan (2005), the human face enhances an individual’s self-identity and 
as well serve as a means of interaction since it is the most visually prominent part of the 
human body. Therefore, the presence of a visible hole at the anterior part of the neck which 
is kept patent with a tube, through which mucus passes will likely alter the body image and 
quality of life (Fingeret et al., 2015; Zając et al., 2008). 
Findings of the study identified that the position of the tube restricted these adults in 
wearing certain kinds of dresses and putting on ornaments. This finding is similar to the 
results of  Bodenham et al. (2014) which stipulates that living with a tracheostomy tube 
comes with numerous restrictions ranging from a change in physical appearance, change 
in dressing to change in daily activities. These limitations reduce people’s self-esteem and 
quality of life (Howren, Christensen, Karnell, & Funk, 2013; Pereira da Silva, Feliciano, 
Vaz Freitas, Esteves, & Almeida e Sousa, 2015; Wells et al., 2015). These limitations lead 
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to numerous psychosocial challenges (Brown & Randle, 2005; Paul, 2010). Adequate 
counselling and close monitoring in addition to social support will support to improve the 
lives of these individuals and contribute to reducing possible psychosocial challenges 
(Howren, Christensen, Karnell, Van Liew, & Funk, 2013). These will assist because 
dissatisfaction in the body image of people living with a tracheostomy increase with time 
with no evidence of adjustment (Sharpe et al., 2011). 
One of the social impacts of living with a tracheostomy tube that emanated from 
altered body image was social isolation. Studies show that there is a close link between 
altered body image and social isolation (Aderka et al., 2014; Coles et al., 2006; Kelly, 
Walters, & Phillips, 2010; Pinto & Phillips, 2005). This link often limits individuals with 
altered body image in playing active roles in social activities (Newell et al., 2004). 
Consistent with what literature reports, ALTT reported the tube was very prominent on 
their neck and made people stare at them anytime they went out. They added that they 
socially isolated themselves from public activities because of the odour they had from the 
tube which increased the staring from the public. This finding confirms previous studies 
which reported that people living with altered body image especially from facial 
disfigurement suffer social isolation (American Psychiatric Association, 2013; Katz et al., 
2003) from the fear of being looked at by others (Bögels et al., 2010). These experiences 
result in the feeling of incomplete, and the creation of negative impression about 
themselves (Bessell et al., 2010)  further leading to more psychological distress (Sharpe et 
al., 2011). 
It was also identified that participants covered their neck with other clothing 
materials to hide the tube and reduce public embarrassment when it became necessary they 
had to attend gatherings. Studies have shown that PLTT find ways to disguise themselves. 
They wear clothes with necks or hang extra materials around their neck to cover the tube, 
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feeling comfortable in public (Akenroye & Osukoya, 2013; Bessell et al., 2012; Flynn et 
al., 2013).  
The participants of the study had an alteration in their sexuality. They experienced 
diminished sexual activities because they felt unfit to engage in frequent sexual activities. 
In addition, participants stated that the tube made them look sexually unattractive. Studies 
have shown that living with a tracheostomy affects sexuality (Batıoğlu-Karaaltın, Binbay, 
Yiğit, & Dönmez, 2016; Schonhofer et al., 2001). The presence of the tube, with the 
associated difficulty in breathing and loss of voice as well as a change in appearance, 
reduce the desire for sexual activities (Cantlay, 2015; Coelho-Marques, Wagner, De 
Figueiredo, & d'Avila, 2006; Persson & Hellström, 2002).  
Participants who were not married or had lost their partners felt they looked 
unattractive to win the attention of suitors. Those who were married indicated their partners 
understood they were unfit to engage in sexual activities. According to Gallo-Silver (2011), 
people become aware of their altered appearance and accept that their partners find them 
sexually unattractive which further reduce their desire for sexual activities. Sexual 
gratification is considered to be an integral part of life fulfilment; lacking it will most likely 
lead to psychosocial problems such as low self-esteem, depression, and anxiety and lessen 
the quality of life (Batıoğlu-Karaaltın et al., 2016; Hoole, Kanatas, & Mitchell, 2015). It 
is, therefore, important to provide psychosocial support and also involve partners of people 
who are to undergo a tracheostomy surgery during preoperative preparation and follow-up 
care (Batıoğlu-Karaaltın et al., 2016; Offerman, Pruyn, de Boer, Busschbach, & 
Baatenburg de Jong, 2015). Specific programmes on sexual counselling will also be useful 
(Öztürk & Mollaoğlu, 2013). 
 
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5.5 Psychological experiences of living with a tracheostomy  
This aspect describes the psychological experience of ALTT. These were fear and 
anxiety, depression and suicidal tendencies. The current findings showed most of the 
participants initially thought they were going to live temporarily on the tube but had to live 
with it permanently due to unsuccessful weaning process. They were anxious and had lost 
hope of regaining normality. There was also the fear of not knowing what could happen to 
them next while living with the tube. Studies have shown that tracheostomised individuals 
experience fear and anxiety (Howren, Christensen, Karnell, & Funk, 2013; Molassiotis & 
Rogers, 2012).  
For instance, majority of Magnus and Turkington (2006) participants recounted being 
unsure how long they were going to live on the tracheostomy tube, clearly depicting their 
fear of the unknown. Living with the tracheostomy tube was a new experience for all the 
participants. This new experience came with its fear of the unknown. Additionally, 
participants were anxious living with a new appearance, having difficulty in breathing and 
speaking. These were enough to have them entertain the fear of the unknown and anxiety 
about the uncertainty of regaining normality. However, Breckenridge et al. (2014) state 
that healthcare professionals should not believe they can best detect the existence and 
severity of patients’ anxiety. They should not assume that psychological challenges like 
anxiety reduce after the tracheostomy placement. Hence, there is the need for healthcare 
professionals to employ evidenced-based strategies such as communication methods, 
supportive measures, preventive care and other complementary treatments to ease patients’ 
anxiety in both pre and post tracheostomy stages.  
Another psychological impact identified in the current study was depression. 
Participants were depressed because they encountered several challenges. They indicated 
that the tube had affected almost every aspect of their lives so much so that, they no longer 
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lived like normal human beings. These make them depressed. The numerous challenges 
associated with having a tracheostomy tube result in depression and distress (Sharpe et al., 
2011). About 15 to 50% of PLTT experience depression in their disease trajectory.  
In a related study, Chiou et al. (2013) established that living with a tracheostomy tube 
with the associated change in appearance, speech and breathing results in depression. 
According to Buhlmann et al. (2010) and Yanhui et al. (2010), depression is more 
prominent among people with alteration in body image than those with no appearance 
challenge. Flinterud and Andershed (2015) and Karlsson, Forsberg, and Bergbom (2012) 
indicate that being voiceless after a tracheostomy is very depressive, considering the 
inability to communicate even the feeling of pain for immediate remedy. They added that 
most people only have the option of enduring the pain and hoping that, their facial 
expression of the discomfort would be recognised by health professionals as soon as 
possible. In most situations, the feeling of depression leads to suicidal ideations (Cougle et 
al., 2009). 
In the current study, suicidal ideations were one of the psychological experiences on 
ALTT tube in the Kumasi Metropolis. Most of the participants became frustrated from the 
countless challenges they encountered from having the tracheostomy surgery. These 
frustrations made them entertain the idea of committing suicide. Suicidal ideation is the 
deliberate idea people have of ending their lives, which include either planning in detail or 
having the slightest thought of killing oneself rather than killing oneself (Phillips & 
Menard, 2006). This is congruent with other studies which show that persons with chronic 
depression are more likely to commit suicide (Haisfield-Wolfe, McGuire, Soeken, Geiger-
Brown, & De Forge, 2009). Furthermore, Cougle et al. (2009) indicate that having a 
tracheostomy tube with the associated physical and psychosocial challenges lead to 
suicidal ideations. In a related study, Kam et al. (2015) identified that patients with health 
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problems related to the head and neck are three times likely to commit suicide in the whole 
US population. It is not surprising that adults with a tracheostomy tube had suicide 
ideations because they experienced physical symptoms such as pain and impaired activities 
of daily living and psychosocial challenges including; altered body image, social isolation, 
altered sexuality, fear and anxiety, and depression. All these predicaments in which 
participants fond themselves could lead to suicidal ideations. It is, therefore, necessary that 
these adults be given the needed social support through strict monitoring and counselling 
(Howren, Christensen, Karnell, Van Liew, et al., 2013).  
 
5.6 Economic experiences of living with a tracheostomy  
The present study identified economic constraints among adults with a tracheostomy 
which included work challenges and reduced income. According to Mehnert et al. (2013), 
living with a tracheostomy tube facilitates economic challenges such as reduction in work 
power, the cost of health care, leaving a job, compulsory retirement and change in 
employment structure. Results of the current study showed that adults with a tracheostomy 
had challenges with verbal communication and reduced strength to work, hence some 
stopped working, and others changed their jobs while some reduced the number of 
employment they had. There was a challenge of getting new jobs for participants who were 
either not working before the tracheostomy or stopped their work after the tracheostomy. 
Meanwhile, studies have shown that good economic status of an individual reduces 
physical disability, reduces psychosocial distress, and improves health-related quality of 
life (Gul & Karadag, 2010; Mehnert, 2011). 
Also, the current study identified that tracheostomised adults had the arduous task of 
getting money to take care of themselves and their families. In some instances, attending 
the review and taking care of the tube served as a huge challenge for them. Most of the 
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participants wished the tube would be removed to enable them work. This finding affirms 
findings in other studies that poor economic status of people living with a tracheostomy 
tube affects their health seeking behaviour and their health standing and reduce their 
quality of life (Mehnert, 2011; Öztürk & Mollaoğlu, 2013; Steiner et al., 2004; Verdonck-
de Leeuw et al., 2010). However, it was identified in the current study that the participants 
had support from family members and friends. In line with this finding, studies have shown 
that the provision of support from caregivers have positive influence on patients recovery 
and life thereof (Howren, Christensen, Karnell, Van Liew, et al., 2013)  
 
5.7 Patients’ communication experiences of living with a tracheostomy 
This section talks about the issues related to communication among ALTT. These 
were; mode of communication and challenges with verbalization. Verbal communication 
is a basic human physiology and a fundamental need for every individual. It plays a major 
role in our daily interactions, supporting us to express ourselves and our feelings as humans 
(Donnelly & Wiechula, 2006). However, living with a tracheostomy tube affects this 
fundamental physiology tremendously (Flinterud & Andershed, 2015; Guttormson et al., 
2015). In the current study, most participants complained of difficulty in speaking at the 
initial stages of the tube insertion. This finding is consistent with numerous studies on the 
reduction in verbal communication after a tracheostomy (Flinterud & Andershed, 2015; 
Karlsson, Forsberg, et al., 2012; Khalaila et al., 2011; Sutt, Cornwell, Dunster, Spooner, 
& Fraser, 2014). For instance, Samuelson et al. (2007) posit that more than 50% of people 
who undergo a tracheostomy have reduced ability to communicate verbally within the 
initial stages after the surgery. Related studies have also shown that verbal communication 
is one of the biggest challenges of people who live with a tracheostomy tube (McCormick 
et al., 2015; Schindler et al., 2012; Sherlock et al., 2009).  
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However, participants in the current study resorted to the use of non-verbal cues 
specifically sign language and writing on papers to communicate. Findings from other 
related studies indicate that tracheostomised persons adopt a non-verbal form of 
communication such as the use of pen and paper, picture, and alphabet boards, nodding or 
shaking of heads and eye blinking to communicate (Barnett, 2012; Grossbach et al., 2010; 
Hurtig & Downey, 2008). 
The participants in this study lamented that the use of these non-verbal methods of 
communication was very frustrating due to weakness and inability to read and write. In 
line with this finding, Foster (2010) indicates that the use of non-verbal methods of 
communication is also frustrating due to inability to write, either because of poor 
coordination or physical weakness. In a much same way, Johnson et al. (2006) state that 
weakness impairs patients’ non-verbal communication. Most tracheostomised patients quit 
trying to communicate and become apathetic when these non-verbal methods of 
communication are not effective (Kraaijenga et al., 2016; Schindler et al., 2012). 
Therefore, there is the need for other alternative and efficient means of communication 
between health professionals and tracheostomised patients who are voiceless; because 
when there is ineffective communication between a nurse and a non-vocal patient due to 
poor understanding, lack of clarity and uncertainty occur (Carroll, 2007).  
In the current study, participants regained their voice. However, they still had to 
either use “speaking valve” or their finger to occlude the tube when talking. They stated 
that anytime the tube was not occluded while talking, only air came out instead of voice, 
and they get pain in their ribs. This finding is congruent with the findings by Flinterud and 
Andershed (2015) that, tracheostomised persons gradually regain their ability to 
communicate verbally with time. Furthermore, related findings also indicate the use of 
“speaking valves” assist adults with a tracheostomy tube to have successful verbal 
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communication (Barnett, 2012; Chandrasekhar et al., 2013; Hess, 2005; Pandian et al., 
2014). However, studies have shown that this method of communication is not very 
reliable, it is costly and usually prone to breakages leading to stress and frustration for 
people with a tracheostomy tube (Hashmi et al., 2010; Patak et al., 2006). The use of the 
finger to occlude the tube while talking was not identified in the literature; probably, it is 
not a clinically accepted method of verbal communication for tracheostomised persons. 
Further research could be done to assess its potential usage and benefits; it may be a better 
alternative especially for those patients who cannot afford the cost of the speaking valve. 
In the current study, the participant had challenges when they regained their voice. 
They got exhausted and had to gasp for breath whenever they talked for a longer period. 
They could not engage in longer conversations. This finding confirms findings in other 
studies that people who live on tracheostomy are unable to speak for longer periods due to 
reduced strength and exhaustion (Björklund et al., 2010; Molassiotis & Rogers, 2012). 
Participants in the current study had difficulty in undertaking some activities like reading 
of the Bible and singing at church, impacting on their spiritual life. Various studies have 
identified the impact of living with a tracheostomy on all aspects of life including 
spirituality (Cantlay, 2015; Fingeret et al., 2015; Flinterud & Andershed, 2015; Isaksson 
et al., 2015) including spirituality (Allmon, Tallman, & Altmaier, 2013; Falsetti, Resick, 
& Davis, 2003). However, Cole, Hopkins, Tisak, Steel, and Carr (2008) noted that spiritual 
decline impacts negatively on coping, hence the need to encourage tracheostomised people 
on spiritual growth to enhance their coping. 
The current study identified that inability to have effective verbal communication 
resulted in lots of psychosocial discomforts expressed in the form of apathy, anxiety, 
depression and social isolation. Some participants even had to change their jobs due to a 
disruption in verbal communication. Studies have shown that inability to speak leads to 
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psychosocial distress. Usually, there is frustration and fear (Johnson et al., 2006; Khalaila 
et al., 2011), anxiety, depression, and distress (Engström et al., 2013; Myhren et al., 2010). 
There is also interruption with work  (Björklund et al., 2010; Griffiths et al., 2008; 
Molassiotis & Rogers, 2012; Röing et al., 2007) and social isolation (Aderka et al., 2014; 
Kelly et al., 2010). These affect the quality of life of ALTT (Batıoğlu-Karaaltın et al., 2016; 
Hutzel, 2014). 
 
5.8 Patients’ coping mechanisms of living with a tracheostomy 
The mechanism of coping refers to the adaptation of strategies to minimise the 
experience of stress (List et al., 2002). It is normal for individuals who experience stressful 
situations such as living with a tracheostomy tube to learn ways to cope with their new life 
(Wood & Bisson, 2004). According to Derks et al. (2005). People living with a 
tracheostomy tube use strategies to cope with the stress associated with the tube. In the 
current study, most of the adults living with a tracheostomy accepted their situation. Most 
of the participants knew and accepted their situation even before the tube insertion because 
they knew tracheostomy was their last resort for survival. Although they were not 
comfortable with their current situation, they realised nothing would change, so they 
accepted the situation. Other studies have also identified the use of acceptance to cope with 
stressful situations (Birkeland & Natvig, 2009; Thumala Dockendorff, 2014). For instance 
Lang et al. (2013) state that individuals identify successful coping by accepting the current 
situation and seeing the new life as better rather than worse. In the end, they learn to be 
positive and have a healthy life rather than be in the state of chronic denial and get worse. 
Another coping strategy adopted by the adults living with a tracheostomy in this 
study was being resilient. Participants no longer paid attention to what people said about 
their current situation. They developed the strong mentality and strong will to live when 
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they saw other tracheostomised individuals doing better in life. In line with this finding, 
Aarstad et al. (2008) report that people who develop positive attitudes towards their 
situations have better coping than those who think negative of themselves. In other words, 
the individuals who develop active coping strategies (Derks et al., 2005) and have strong 
mentality cope well, are less depressed and live improved lives (Hassanein et al., 2005; 
Sherman, Simonton, Adams, Vural, & Hanna, 2000). 
The current study also identified spirituality as another coping strategy for 
tracheostomised adults. All the participants stated that they got inspiration from God. They 
relied on and prayed to God to support in all things. According to de Guzman et al. (2012), 
this method of coping is called religious coping. Studies have shown that people use 
religious coping mostly in critical situations where there seems to be no hope (Bagheri-
Nesami, Rafii, & H. Oskouie, 2010; de Guzman et al., 2012; Semple & McCance, 2010; 
Sturz & Zografos, 2014). In confirmation of these studies, the literature states that religious 
coping improves psychological well-being (de Guzman et al., 2012). Moreover, instead of 
grieving over a normal life that lost forever, it is better to believe in God for his support to 
cope with the new life (Sherman et al., 2000; Spratling et al., 2012). Participants found 
solace in God through faith and prayers that in the midst of the difficulties, they believed 
they served a living God, who came to their rescue anytime they needed His assistance. 
People living with a tracheostomy receive different kinds of social supports from 
various sources (Bessell & Moss, 2007; Semple & McCance, 2010). In the current study, 
participants received most of their social supports from their family members (spouses, 
children, mothers, and siblings) and their friends. The kinds of support they received 
ranged from emotional, financial to physical. Participants had support from spouses and 
children in undertaking most of the physical activities they could not do: washing, cooking 
and lifting items. They received emotional support as well as financial assistance from their 
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spouses and children for their health care needs. This finding is congruent with the study 
by Richardson et al. (2015) that, the presence of family and friends to provide social 
support is useful to PLTT. The availability of social support has also been linked with 
general and disease-specific quality of life in people living with a tracheostomy tube and 
thus, assist to decrease the feeling of distress (Howren, Christensen, Karnell, Van Liew, et 
al., 2013; Zarzycka, Kobos, Czarnecka, & Imiela, 2015). Furthermore, social network sites 
such as Facebook could assist to reduce social isolation and enhance peer interaction. In 
addition, the creation of an online community for people living with a tracheostomy could 
augment their social welfare (Madan et al., 2011). Social support has numerous advantages 
to individuals living with a tracheostomy tube, hence the need to encourage its use. 
 
5.9 Discussion of the Guiding Thematic Concepts 
Finally, findings of this study to some extent support the Thematic Concepts by 
(Foster, 2010), which sought to give some knowledge of how the various aspects of 
tracheotomised patients’ experience interconnect and make meaning with each other. The 
different themes in the framework link to each other, and although they are grouped into 
principal components, reflecting various aspects of the tracheostomy experience (Dawson, 
2014), they still do not stand as independent components. This study found the 
interconnections to be relevant because living with a tracheostomy tube impact on the 
whole life of the individual, not just an aspect of it. For example, living with the tube leads 
to difficulty in breathing and speaking as well as a change in appearance (Flinterud & 
Andershed, 2015; Huffman et al., 2014; Teo et al., 2016). Difficulty in breathing results in 
weakness and incapacitation in undertaking strenuous activities which include those that 
can bring income (Isaksson et al., 2015; Mehnert et al., 2013). The change in appearance 
together with challenges with speech results in other psychosocial problems like social 
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isolation, anxiety, and depression (Chiou et al., 2013). Speech problems also affect 
employment and reduction in income (Isaksson et al., 2015; Mehnert et al., 2013). 
Therefore, the experiences people get while living with a tracheostomy tube do not stand 
alone, but they relate to each other to make up their whole lived experience.  
However, there are still some aspects of the experience that are missing from the 
themes mentioned by Foster (2010). For instance, the impact of a tracheostomy on 
employment, the support people get and the strategies they use to cope with these 
challenges of living with a tracheostomy which this study highlighted, are missing in 
Foster’s work. These additional findings could partly be due to the differences in the study 
settings. The current study’s setting (home setting) explores more into the tracheostomised 
persons’ lived experiences because these experiences do not end in the ICU but transcend 
into the home setting. However, this study found the constructs of the Guiding Thematic 
Concepts as very useful in exploring the experiences of adults living with a tracheostomy. 
  
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CHAPTER SIX 
SUMMARY AND CONCLUSION 
6.1 Introduction 
This chapter provides the summary and conclusion of the study. It highlights the 
implications for nursing practice, education, research, and policy. The researcher also 
presents the experience acquired in the study together with recommendations.  
 
6.2 Summary  
This qualitative study explored the lived experiences of ALTT in the Kumasi 
Metropolis, Ghana. The study has largely proven that living with a tracheostomy tube 
presented with lots of physical, physiological, psychosocial and economic challenges. 
There was pain from the surgery, during coughing and on swallowing which these adults 
could not report due to their inability to produce speech freshly after the surgery. This 
situation they found themselves in mostly resulted in anger and frustration. The reduced 
ability to talk, difficulty in breathing, and dysphagia impaired the performance of activities 
of daily living with a direct effect on employment. Some of the participants were not 
employed; others had changed jobs, and some had reduced the number of employment due 
to the tracheostomy tube. Participants complained of a change in appearance and body 
image, reduced self-esteem and altered sexuality. Due to this new look, participants 
socially isolated themselves from most social activities or had to put up a camouflage 
behaviour (cover the tube with extra clothing) to be a part of these social events. 
Participants lived in fear and anxiety wondering if the tube will ever be taken off. Owing 
to these challenges of life with a tracheostomy tube, they became depressed, even to the 
point of harbouring suicidal ideation.  
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This study identified that a few ALTT used “speaking valve” to speak. However, the 
majority of the participants used “the finger occlusion method” to talk because they could 
not afford the cost of the speaking valve. In the midst of all these difficulties, participants 
employed strategies such as acceptance, resilience, and reliance on God to cope with them. 
They also gained physical, financial and emotional support from friends and family 
members. 
 
6.3 Implications for Clinical Nursing Practice  
Findings of the current study bring to the fore issues that must be addressed to 
improve the quality of life of ALTT. These results have implications for nursing practice. 
Understanding the lived experiences of adults with a tracheostomy tube can support 
nursing, and medical practitioners provide efficient care to meet the health needs of these 
individuals. Results of the study indicated that living with a tracheostomy tube has an effect 
on all aspects of the person’s life: physical, physiological, psychosocial, and economic and 
communication. Most of these challenges are new experiences to adults living with a 
tracheostomy and worsen their plight. Therefore, nurses should intensify the preoperative 
preparations and education, emphasis on the many problems associated with living with 
the tube such as pain, reduced strength, difficulty in breathing and speaking, change in 
appearance and the associated emotional challenges. Knowing about these problems before 
the surgery will assist these adults to have a better transition into their new life with the 
tracheostomy. 
Patients have difficulty in speaking in the initial stages of the surgery. In most 
situations, these patients are unable to utilize the call systems provided to them for 
communication. Therefore, nurses should assess the communication needs such as the 
ability to read and write before the surgery and provide non-verbal communication tools 
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that will be suitable for the patient. This requirement assessment will assist to reduce the 
frustrations patients go through when they are unable to communicate their complaints to 
the health staff. To lessen the incidence of possible hypoglycaemia from painful and 
difficulty in swallowing, nurses ought to assess the nutritional needs of the patients after 
the surgery and provide adequate nutrition through other means such as giving light diets 
and IV fluids. Nurses should also critically observe patients after the surgery for the 
possible experience of pain and institute proper pain management for these adults; since 
most of them are unable to communicate verbally. Moreover, care of the tube and 
suctioning should be done tactfully to reduce pain and prevent infection.  
The challenges of living with the tube at home far outweigh those experienced while 
at the hospital. Therefore, nurses should ensure proper counselling and education on tube 
care, the need for review, avoidance of high scented items and dust to reduce coughing and 
difficulty in breathing as well as activities that are likely to cause pain before discharge. 
The relatives and partners of these patients should be involved in the preparation before 
discharge on the need to provide adequate physical, emotional, financial and social 
support. There should be close monitoring of these adults in their homes. There is the need 
to watch for the effect of a tracheostomy tube on their job and income and possible 
challenges such as depression, and suicidal tendencies. 
Finally, nurses should ensure that there are proper rehabilitation programmes for 
these adults to support improve their quality of life.    
 
6.4 Implications for Nursing Education 
Nursing education is core in enhancing the knowledge of nurses in providing quality 
care to adults who have to undergo or have undergone a tracheostomy surgery. Nurses play 
a major role in the preoperative preparation, inter and intraoperative treatment as well as 
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post-operative care. Nurse link up with other members of the health team in the provision 
of all the needed support for these patients and spend more time with them than other 
members of the health team. Therefore, nurses’ understanding of what constitute quality 
nursing care in achieving the quality of life for these patients should be a priority.  
Although there is an established ENT Nursing School in Ghana that train specialist 
ENT nurses to render this needed care, the capacity of this institution should be built 
regarding infrastructure and equipment to enhance the training of these specialist nurses. 
Additionally, the aspect of the curriculum for training general nurses at the core level which 
deals with courses or topics on ENT should be given the needed attention. Tracheostomy 
care should be taught by ENT nurse specialists who have adequate knowledge in the care 
of patients with ENT health problems. General Nurses will get a better understanding of 
caring for patients with a tracheostomy since general nurses are the cadre of nurses who 
mostly care for these patients in the wards. 
In the interim, training on continuous professional development (CPD) for nurses 
should include aspects of ENT nursing care; specifically, care of tracheostomised persons 
so that it will equip all groups of nurses on at least the basic health needs of these 
individuals living with a tracheostomy tube. 
 
6.5 Implications for Policy 
The results of this study suggest the formation of a National Association of 
Tracheostomised Persons. With this association formed, the large number of active persons 
who have been rendered inactive and mostly dependent on their family members will be 
identified and given the needed rehabilitation so that their individual knowledge, 
professional skills, and productivity will not go waste but rather, make them resourceful to 
the nation.  
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The government should support in providing a speaking valve which is always in 
short supply. Also, there should be a waiver on the cost of the speaking valve since most 
of these individuals have been rendered jobless due to living with a tracheostomy tube. 
Hence their inability to afford the high cost of these speaking valves has made them resort 
to the non-clinically approved “finger occlusion” method as identified in this study. 
Additionally, the various policies such as Livelihood Empowerment Against Poverty 
(LEAP), which support people within the poverty bracket should be extended to people 
living with a tracheostomy since they are also a suffering but unrecognised group of 
individuals who depend on the benevolence of philanthropists and family members. 
The policy on the National Health Insurance Scheme should be planned to cover all 
the treatments that PLTT receive. If possible, they should be registered free of charge on 
the scheme since most of them are unable to attend reviews to care for the tube because of 
lack of finances which further reduces their quality of life.  
 
6.6 Avenues for Future Research 
From the results of this study, many prospective studies could be conducted. For 
example, the main themes that emerged out of this study can be further studied to gain a 
thorough understanding of their experiences. More studies can be done in the following 
areas: 
a. The physical impact of adults living with a tracheostomy tube. 
b. The physiological challenges of adults living with a tracheostomy tube. 
c. The Psychological experiences of adults living with a tracheostomy tube. 
d. The Social experiences of adults living with a tracheostomy tube. 
e. The economic constraints of tracheostomy on adults living with a tracheostomy 
tube.  
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f. The communication dynamics of adults living with a tracheostomy tube. 
g. Coping strategies of adults living with a tracheostomy tube.  
h. The lived experiences of adolescents with a tracheostomy tube. 
i. The attitude of the public towards people living with a tracheostomy tube.  
j. Needs assessment of people living with a tracheostomy tube towards the planning 
of rehabilitation programmes. 
k.  The clinical viability of the “finger occlusion method” of speaking among people 
living with a tracheostomy tube. 
 
6.7 Field Experiences/Reflections 
The experiences gained during this study can be described as rich and revealing. The 
researcher made new friends during the research. This study allowed the researcher to see 
the realities of living with a tracheostomy tube in the home setting. The study additionally 
gave the researcher the chance to learn what adults living with tracheostomy endure and 
their everyday needs at home. The emotional state of the researcher in those moments of 
the study was that of empathy. The physical and psychosocial miseries shared by these 
adults, and the financial constraints which were very obvious from their physical 
appearance, rendered the researcher very emotional. The researcher had to shed some tears 
at a point during the interview and even had to give some financial support to some 
participants as they had not eaten the whole afternoon.  
The general attentiveness of the researcher, the encouraging responses, and the 
emotional facial expressions made the participants open up to share more of their 
experiences. The researcher felt participants’ pain and suffering from their voices and  
although they had challenges with speaking for long, these participants were still ready to 
share their experiences, because they felt it was an opportunity for people to hear how they 
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were suffering since it was their first time of going through such interview after their 
tracheostomy surgery.  
The study was touching. Both researcher and participants depicted several emotional 
responses during the study. The researcher was surprised at the kind of revelations 
participants were making on their lives with the tracheostomy tube. It was realised that the 
study gave adults living with a tracheostomy tube the opportunity to share their experiences 
on living with a tracheostomy tube. The researcher observed that participants looked 
relieved and happy after sharing their story. It seemed they were glad they had the chance 
to tell their story. An indication to them that someone cared about them.  
The study has brought a drastic change of the researcher’s attitude towards people 
living with a tracheostomy tube.  The researcher has developed a more empathetic feeling 
for people living with a tracheostomy tube. The researcher before the study, saw people 
living with a tracheostomy tube as individuals who only had a physical challenge due to 
the presence of the tube on their neck. It was identified that, although these individuals 
with a tracheostomy tube look well and happy on the outside, inwardly, they go through a 
lot of challenges which they hardly get people to share with.    
 
6.8 Limitations of the Study 
This study contributed to the understanding of the experiences of adults living with 
a tracheostomy in the Kumasi Metropolis. However, it has some limitations. Only adults 
were used for this study; there is the possibility that people in different age groups may 
have different experiences. One other constraint of the study was identifying the correct 
locations of the participants. Most of the addresses of the participants were difficult to 
locate. The researcher had to drive around trying to locate participants’ residences leading 
to increased cost of transportation and communication. The interviews that were conducted 
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at participants’ homes were interrupted by family members. Those that were done at 
participants’ workplaces were also interrupted by customers. These interruptions affected 
the flow of the stories. Despite all these limitations, the findings should be seen as a support 
to an ongoing effort to fill the gap in the non-existing literature on the experiences of adults 
in Ghana living with a tracheostomy tube. 
 
6.9. Conclusion 
This study can conclude that living with a tracheostomy tube had a physical impact 
in areas of painful experience and impaired activities of daily living in the lives of adults 
living with the tracheostomy tube. Physiologically, there were challenges with breathing, 
swallowing and the sense of smell. Living with a tracheostomy also had psychosocial 
challenges: there was an alteration in body image which altered these adults’ sexuality and 
further got them socially isolating themselves from public activities. Participants, 
therefore, became anxious, depressed and even had suicidal ideations. 
Living with a tracheostomy also affected the economic status of these adults. The 
change in appearance, the difficulty in breathing and speaking either made these adults 
stop the work they were doing, change their work schedule or reduce their workload. This 
dwindled their income and contributed to financial hardship in the midst of high cost of 
living and healthcare. The communication aspect of these adults was also affected. At the 
initial stage, these adults relied on non-verbal cues but later resorted to using either 
speaking valve or “finger occlusion” method before they could speak. However, they could 
not partake in some activities like singing and reading of the Bible which they were doing 
before the tracheostomy tube insertion.  
Despite all these challenges, acceptance of the situation, being resilient and relying 
on God, as well as available support from family and friends, assisted them to cope with 
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life. In all, the Guiding Thematic Concept by Foster used as a guide to this study was useful 
in identifying the interrelatedness of the various aspects of the experiences of living with 
a tracheostomy tube. Even though some aspect of the experiences were lacking taking into 
consideration the experiences of people with a tracheostomy residing in a community, it 
was a useful guide. 
   
6.10 Recommendations 
Based on the results of the study, the ensuing recommendations were made:  
 
6.10.1 Recommendation to Nurses and other Health Professionals 
a. Nurses should collaborate with other health professionals and patients’ relatives to 
enhance proper preoperative counselling and education before the surgery. 
b. Nurses should ensure proper pain assessment and management during the 
immediate post-surgery stage since patients have difficulty communicating their 
pain. 
c. Nurses should assess the nutritional needs of the patient with tracheostomy and 
encourage them to follow proper dietary requirements.   
d. Nurses should provide high-quality nursing care to prevent stoma infection. 
e. Nurses should prepare patients and relatives adequately on tube care and the 
provision of social support while at home. 
f. Nurses should ensure that patients have access to the needed care during follow-up 
visits. 
  
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6.10.2 Recommendation to the ENT Department/Komfo Anokye Teaching Hospital 
a. The heads of the ENT Department should liaise with the hospital management to 
provide adequate speaking valves and at a subsidised price for tracheostomised 
persons. 
b. There should be a collaborative work which will bring on board all needed 
specialists such as the nutritionist and speech-language pathologist to assess the 
patient before discharge.  
c. The leadership at the ENT Department together with the hospital management 
should establish proper rehabilitation and counselling programmes for people 
living with a tracheostomy. 
d. The hospital management in collaboration with the ENT department and other 
agencies should conduct further studies to assess the clinical viability of the “finger 
occlusion method” of speaking and as well promote its usage among people living 
with a tracheostomy tube. 
 
6.10.3 Recommendation to the Ministry of Health/Ghana Health Service 
a. Health facilities should make it a policy that, there should be proper airway 
assessment for all patients who are to undergo thyroidectomy surgery. 
b. There should be a collaboration with agencies to ensure an adequate supply of 
speaking valves at a subsidised price. 
c. National Health Insurance package should be extended to cover all medical 
treatments of people living with a tracheostomy tube and possibly, free registration 
for them.  
  
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APPENDICES 
Appendix A: Background information of Participants 
       Number    No of years 
Pseudony Age Type Of Sex Edu. Occupation Marital of   Languages of 
ms Surgery Background status children Nationality Religion spoken experience 
Madam            
Nsiah 001 50yrs Planned F Tertiary Unemployed Married 3 Ghanaian Christian Twi, English 3years 
Madam      Not    Fante, Ga,  
Aba 002 48yrs Emergency F Middle Sch. Unemployed married 0 Ghanaian Christian Twi 23years 
Madam            
Becky 003 57yrs Emergency F Middle Sch. Trading Married 4 Ghanaian Christian Twi, English 9years 
Madam          Twi, Hausa,  
Akua 004 47yrs Emergency F None Trading Married 3 Ghanaian Muslim Dagomba 9years 
Madam            
Sussy 005 50yrs Emergency F Middle Sch. Unemployed Widow 2 Ghanaian Christian Twi 3years 
Madam            
Mansa 006 48yrs Emergency F Tertiary Teaching Married 3 Ghanaian Christian Twi, English  6years 
Madam            
Adiza 007 57yrs Planned F Middle Sch.  Unemployed  Married 5 Ghanaian Christian Twi, English  2years 
Madam       4A; 4D   Twi, Frafra, 1year, 
Adoma 008 54 Emergency F None Farming Widow Ghanaian Christian Grusi 4months 
Mr. Kwasi            
009 42 Emergency M None Cleaning Married 4 Ghanaian Christian Twi, English 32 
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Appendix B: Interview Guide 
 
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Appendix C: Consent Form 
 
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Appendix D: Introductory Letter 
 
  
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Appendix E: Ethical Clearance  
 
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