Facilitators and barriers to the early implementation of speaking valves in intensive care: a qualitative study using normalisation process theory

The utilization of tracheostomy in conjunction with mechanical ventilation significantly impacts various physiological functions, particularly the ability to communicate verbally. Speaking valves, integrated into the ventilator circuit, restore phonation and are recognised internationally as best practice, yet remain underused in Swedish intensive care units (ICUs). Beyond enabling verbal communication, the early use of speaking valves has been associated with improved swallowing, secretion management, and reduced duration of mechanical ventilation. The TRACH INSPIRE project aims to promote their implementation in Swedish ICUs. This study explored facilitators and barriers to the early interprofessional implementation of speaking valves in tracheostomised, mechanically ventilated ICU patients.

This qualitative study design analysed 19 semi-structured interview data, pre-implementation, with ICU professionals (intensivists, nurses, physiotherapists, and speech-language pathologists) from two participating ICUs in the TRACH INSPIRE project conducted in January-February 2025. Inclusion criteria were that the participants must have participated in the interprofessional competency training for the TRACH INSPIRE project. No formal exclusion criteria were defined. The Data were analysed using deductive content analysis guided by the Normalisation Process Theory (NPT), which examines how new practices are embedded into routine care.

Twelve subcategories were identified that were organized according to the NPT. Facilitators included a shared understanding of the intervention's value, strong professional commitment, structured implementation processes, managerial support, clearly defined roles, effective interprofessional collaboration, targeted training, and open communication. Barriers centred on organisational constraints such as limited resources, low patient volumes, lack of a comprehensive implementation strategy, and documentation-related challenges.

Early implementation of speaking valves in mechanically ventilated, tracheostomised ICU patients is supported by high interprofessional engagement, shared recognition of benefits, and structured training. However, operational limitations, small eligible patient populations, and documentation burdens present notable challenges. Inclusive team strategies, maintaining competencies, and streamlined processes may promote sustainable integration into routine ICU practice.