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Introduction
Malignant tumor wounds are skin infiltrates of cancer cells that develop as a result of the growth of a primary skin tumor or metastases from any malignant tumor 1. The prevalence of these lesions is not well documented, but it is estimated from international studies that from 5 % to 15 % of people with cancer develop malignant wounds 2-4.
Cutaneous malignant tumor wounds are a serious problem in the life of the person with cancer, as they progressively disfigure the body, becoming friable, painful, exudative and fetid. Still, they have psychological and social effects that can interfere in interpersonal relationships, given that the person has feelings of rejection, social isolation, anxiety, sadness, and loneliness 1-2. In addition, these wounds give people a constant visible reminder of their incurable illness, poor prognosis, and, most often, the inevitable condition of approaching death; this last feeling perceived in their speech during the relational environment of the treatment. Faced with this situation, the individuals need palliative care to control the signs and symptoms of these injuries.
The health care of people with this type of wound requires systematized palliative care, provided by the multidisciplinary team and guided by care protocols, availability of material resources and pharmacological products, articulation among levels of care complexity, as well as effective participation of the person with the wound, relatives, and caregivers 1-3.
Treatment of cutaneous malignant tumor wounds is complex, given that it requires evaluation of the cancer etiology, the lesion, the person’s biopsychosocial and spiritual dimensions, the family’s economic condition, control of signs and symptoms, as well as planning and guidance of the care to be performed by the person and the family at home, when curing the disease and wound healing are no longer possible 1-4. Nurses are the members of the health staff that evaluate and handle the clinical management of wounds and place dressings, so it is up to them to develop skills and abilities that allow them to know and identify individual and/or social characteristics of people with tumor wounds, besides implementing actions specific to the needs identified. In this sense, placing functional, aesthetic, and comfortable dressings is a challenge for professionals, who can contribute, from the care provided, to a more acceptable presentation of the person in relation to their social image. Therefore, it is important to validate measuring instruments based on real situations that reproduce the routine activities of nurses in professional life, based on scientific studies and which contemplate the systematization of care to homogenize and ensure efficient behaviors in teaching, research, and clinical practice 5. In this perspective, it is worth mentioning a validation study conducted with 78 primary-care nurses in the city of João Pessoa, Paraíba, Brazil, whose results not only contributed to explain how the theoretical and practical knowledge applied to care for people with wounds, based on health education and management, as well as ensuring the theoretical-empirical organization in the proposal of a measure capable of assessing the nurse’s knowledge and practice in relation to the person with venous ulcer 6.
Given this scenario, this study sought to present the construction and validation process of an instrument directed to palliative care for people with cutaneous malignant tumor wound.
Materials and Methods
This was a methodological study of the construction and content validity and agreement of a two-stage data collection instrument, carried out from January to July 2017. Data collection began in March 2017, at the beginning of the first Delphi evaluation, after approval by the Research Ethics Committee at Universidade Federal da Paraíba, Protocol 031/2017, and the issuance of the Certificate of Presentation for Ethical Appreciation (CAAE, for the term in Portuguese) 64122116.1.0000.5188, and continued until July 2017, at the time of the conclusion of the second Delphi evaluation, according to the norms of Resolution 466/2012 of the National Health Council of the Brazilian Ministry of Health for research involving human beings.
First stage - construction of the instrument
The theoretical procedure of the instrument development process involved a search for representative items of the construct under investigation, through a revision of the Manual of the National Cancer Institute for Treatment and Control of Tumor Wound and Advanced Cancer Pressure Ulcers 7 and the construction of an integrative literature review in scientific articles 8.
From this literature review process, an instrument with 112 items was constructed to evaluate nurses’ knowledge and practice in palliative care for people with cutaneous malignant tumor wound. The instrument is composed of five categories: 1) assessment of the lesion and needs of the person with cutaneous malignant tumor wound; 2) basic care performed with the cutaneous malignant tumor wound; 3) specific care performed with the cutaneous malignant tumor wound (this category is subdivided into eight subcategories, related with the control of the signs and symptoms: a) pain control, b) exudates, c) itching, d) necrosis, e) fistula, f) bleeding, g) odor, and h) myasis infestation); 4) records of Nursing actions, and 5) guidelines for hospital discharge.
Second stage - validation of the instrument’s content
Selection of validation technique
The Delphi technique is a methodological strategy that seeks to achieve maximum consensus from a group of experts on a particular topic, when unanimous opinion does not exist due to lack of scientific evidence or when there is conflicting information 9. The technique has some advantages: economic viability, possibility to gather the opinion of qualified professionals, participation of judges from different geographic locations, elimination of bias inherent to face-to-face meetings 10. For said reasons, it has been widely used in health research 5,10.
Selection of judges
Content validation assumes a subjective judgment on whether a measure makes sense intuitively and refers to the degree to which an instrument represents a domain or the relevance of its items. The number of judges recommended is from 6 to 20 subjects 11. To select the judges, the snowball-type convenience sampling was used, which allows defining people with characteristics common to the research interest. The first-sample members were asked to nominate others who meet the criteria to compose the survey sample 12.
Fifty-seven professionals were invited, based on their fulfilling the following inclusion criteria: nurses with Brazilian nationality; doctors and masters with expertise in teaching and research, and specialists in dermatology/stomatherapy, with practical experience.
The nurses selected were contacted via e-mail and invited to participate as research judges, through an invitation letter, which contained the objectives and methodology of the study, the instrument to be validated and the Informed Consent Form, which had a 30-day limit to return it.
Regarding the sample calculation, the G*Power 3.1 statistical package was used to verify the significance of the sample for the intended study. This software is intended to calculate statistical power, based on verifying not only the “n” required for the type of research, but also the type of calculation to be performed 13. Thus, a probability of 95 % (p <0.05), magnitude of the sampling effect (r ≥0.25) and hypothetical power pattern (π ≥ 0.80) were considered. Generating the sample calculation based on these criteria, the sample of 30 subjects was sufficient for what was sought, with indicators: r ≥ 1.98; π ≥ 0.98; p < 0.05.
With respect to sample normality, the Shapiro-Wilk (S-W) calculation was performed, which is appropriate when the sample size is smaller than 50 subjects, and does not require the distribution parameters to be specified 14-15.
The form sent to the judges consisted of two parts: the first directed to the characterization of the study participants, with questions about gender, age, professional qualification, area of work, and place of work; the second part referred to the presentation of the structured instrument with 112 items and the instructions for its completion.
Concordance analysis
The judges were asked to evaluate the adequacy regarding the clarity and relevance of the items, which were arranged in tables, followed by two columns: one highlighted the clarity of the items presented; the other, their pertinence. Judges had to indicate, by means of a binomial response to each of the questions, how much they agreed on the category, subcategories, and item specificity. In case of inadequacies in the items, space was reserved for comments, justifications, and suggestions that the judges deemed pertinent.
The suggestions were also considered, which resulted in changes made by the authors, later justified. Agreement of at least 80 % among the judges can serve as decision criterion on the pertinence and/or acceptance of the item referred to theoretically 13. Due to this, a minimum 80 % concordance was considered to validate the instrument.
The second assessment by the judges
A form was sent containing both the original and modified versions of the instrument. In this phase, the judges had to evaluate the original and modified instrument according to their suggestions and analytical treatment, assigning the quality of assessment among the instruments related to palliative care for the person with cutaneous malignant tumor wound.
After evaluating the instrument, the following calculations were applied: Lambda 2 Guttmann as best estimation of reliability of instruments that form categories and which are answered by a sample equal to or less than 30 subjects; Kuder-Richardson’s Ρ, which seeks to verify the reliability of the degree of agreement between evaluators in a dichotomous measure; the Kappa coefficient, and the CVI to verify the level of concordance of the judges in relation with the items assessed.
Results
Thirty nurses (assistants, teachers and researchers) participated as judges, 28 women and 2 men, aged 29 to 58 years (mean = 39.82 years; SD = 8.17). Considering the Shapiro-Wilk (S-W) calculation, sample normality was observed (S-W = 0.96, p > 0.27) 14-15.
On the characterization of the sample, as to titration, 11 were specialists in dermatology/stomatherapy, nine were masters, and 10 were doctors; as for the area of expertise, 15 worked in hospital care and, of these, nine performed care activities directly with people with malignant cutaneous tumor wounds; 11 were teachers and four were technical advisors. Regarding the workplace, 12 worked in public hospitals, eight in public universities, four were self-employed, two worked in outpatient services for wound treatment linked to municipal health departments, two in private wound care clinics, and one in private hospital and one in private faculty.
Table 1 highlights the instrument (first and second versions) and some statistical indicators (Lambda 2 Guttmann and Kappa Index) about palliative care for people with cutaneous malignant tumor wounds and their five domains and eight sub-domains.
Table 1 Palliative care for people cutaneous malignant tumor wounds. João Pessoa-PB, 2017
| First version | Clarity | Pertinence | Second version | ||||
| Yes | No | Kappa | Yes | No | Kappa | ||
| Category 1. Evaluation of the lesion and needs of the person with cutaneous malignant tumor wound | |||||||
| 1. Location | 87 % | 13 % | 0.74 | 97 % | 3 % | 0.94 | 1. Anatomic location of the lesion |
| 2. Size | 80 % | 20 % | 0.60 | 93 % | 7 % | 0.86 | 2. Size - measurement of the lesion (height, length, depth, or bulging) |
| 3. Staging | 80 % | 20% | 0.60 | 97 % | 3 % | 0.94 | 3. Staging (1, 1N, 2, 3 and 4) |
| 4. Area of involvement | 43 % | 57 % | 0.14 | 50 % | 50 % | 0 | 4. Excluded |
| 5. Coloration | 80 % | 20 % | 0.60 | 73 % | 27 % | 0.46 | 5. Excluded |
| 6. Extension | 57 % | 43 % | 0.14 | 73 % | 27 % | 0.46 | 6. Excluded |
| 7. Odor (classification) | 97 % | 3 % | 0.94 | 100 % | 0 | 1.00 | 7. Intensity of odor (grade I, II, and III) |
| 8. Exudates (type, color, and consistency) | 93 % | 7 % | 0.86 | 100 % | 0 | 1.00 | 8. Exudates (type and quantity) |
| 9. Bleeding (classification) | 83 % | 17 % | 0.66 | 100 % | 0 | 1.00 | 9. Intensity of bleeding (light, moderate, and intense) |
| 10. Pain (intensity) | 97 % | 3 % | 0.94 | 100 % | 0 | 1.00 | 10. Intensity of pain of the wound (light, moderate, intense, excruciating), using the Analogue Visual Scale or the Numerical Visual Scale |
| 11. Itching | 100 % | 0 | 1.00 | 97 % | 3 % | 0.94 | 11. There was no change |
| 12. Peeling | 90 % | 10 % | 0.80 | 80 % | 20 % | 0.60 | 12. Border and peri-lesion area |
| 13. Signs of infection | 93 % | 7 % | 0.86 | 90 % | 10 % | 0.80 | 13. Signs of local infection (heat, redness, edema, and pain) |
| 14. Type of tissue (cicatrization, granulation, liquefaction, coagulation) | 83 % | 17 % | 0.66 | 90 % | 10 % | 0.80 | 14. Type of tissue (necrosis of coagulation, necrosis of liquefaction, granulation, epithelization) |
| 15. Presence of myasis | 100 % | 0 | 1.00 | 97 % | 3 % | 0.94 | 15. There was no change |
| 16. Fistulas | 97 % | 3 % | 0.94 | 93 % | 7 % | 0.86 | 16. Presence of fistulas and quantity drained |
| 17. Sinus | 87 % | 13 % | 0.74 | 83 % | 17 % | 0.66 | 17. Sinus (tunnels) |
| 18. Cavity | 93 % | 7 % | 0.86 | 93 % | 7 % | 0.86 | 18. Morphological classification of the lesion (nodular, cavitary and vegetative) |
| 19. Commitment or invasion of organs or systems | 87 % | 13 % | 0.74 | 93 % | 7 % | 0.86 | 19. There was no change |
| 20. Evaluation of the social, psychological, spiritual aspects | 87 % | 13 % | 0.74 | 93 % | 7 % | 0.86 | 20. Evaluation of the social, psychological, spiritual, and economic aspects |
| 21. Progression or change of the wound | 83 % | 17 % | 0.66 | 90 % | 10 % | 0.80 | 21. There was no change |
| 22. Necessary/appropriate products for the wound | 75 % | 15 % | 0.60 | 80 % | 20 % | 0.60 | 22. Excluded |
| 23. Identification of the educational needs of the person or the caregiver regarding wound care after discharge | 98 % | 2 % | 0.96 | 97 % | 3 % | 0.94 | 23. There was no change |
| Category 2. Basic care performed with the cutaneous malignant tumor wound | |||||||
| 24. Wear sterile gloves to proceed with the dressing | 90 % | 10 % | 0.80 | 73 % | 27 % | 0.46 | 23. Excluded |
| 25. Remove previous gauzes with abundant irrigation by using saline solution | 97 % | 3 % | 0.94 | 87 % | 13 % | 0.74 | 25. Remove gauze adhered to the lesion bed with abundant irrigation using saline solution |
| 26. Irrigate the wound bed with saline solution in jet with 20 mL syringe and 40 x 12 cm needle | 97 % | 3 % | 0.94 | 90 % | 10 % | 0.80 | 26. Irrigate the wound bed with saline solution |
| 27. Wash the wound with antiseptic soap (chlorhexidine or PHMB) | 93 % | 7 % | 0.86 | 83 % | 17 % | 0.74 | 27. Wash the wound with antiseptic (degenerating chlorhexidine or PHMB soap) to remove surface bacteria and debris |
| 28. Clean wound to remove surface bacteria and debris | 93 % | 7 % | 0.86 | 83 % | 17 % | 0.74 | 28. Excluded and directed to item 27 |
| 29. Employ aseptic technique | 97 % | 3 % | 0.94 | 87 % | 13 % | 0.74 | 29. There was no change |
| 30. Contain/absorb the exudates | 87 % | 17 % | 0.74 | 90 % | 10 % | 0.80 | 30. Use absorbent coatings |
| 31. Maintain wound bed moist | 100 % | 0 | 1.00 | 90 % | 10 % | 0.80 | 31. Maintain wound bed moist to avoid adherence of gauzes |
| 32. Eliminate dead space (fill it with bandages) | 97 % | 3 % | 0.94 | 93 % | 7 % | 0.86 | 32. There was no change |
| 33. Promote symmetrical dressings with the patient’s appearance | 100 % | 0 | 1.00 | 100 % | 0 | 1.00 | 33. Promote contoured area coatings to provide comfort to the person |
| 34. Protect the bandage with a plastic bag during the shower and open it only to change it (which avoids dispersion of the exudates and micro-organisms into the environment) | 100 % | 0 | 1.00 | 90 % | 10 % | 0.80 | 34. Protect the bandage with a plastic bag or transparent film during the shower and open it only to change it (which avoids dispersion of the exudates and micro-organisms into the environment) |
| Category 3. Specific care performed on the cutaneous malignant tumor wound | |||||||
| Subcategory 1. Specific care performed on the cutaneous malignant tumor wound to control pain | |||||||
| 35. Monitor the level of pain through the Analogue Visual Scale | 100 % | 0 | 1.00 | 100 % | 0 | 1.00 | 35. Monitor the level of intensity of pain through the Analogue Visual Scale or Numerical Visual Scale |
| 36. Consider using gel and analgesic medication, according to medical prescription | 80 % | 20 % | 0.60 | 80 % | 20 % | 0.60 | 36. Excluded |
| 37. Start dressings after 30 min of oral analgesia; 5 min of subcutaneous or intravenous analgesia and immediate start for topical path, according to medical prescription | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 37. There was no change |
| 38. Remove adhesives carefully | 100 % | 0 | 1.00 | 93 % | 7 % | 0.94 | 38. Remove adhesives carefully using removing solution (saline solution or Vaseline or mineral oil). Directed to Domain 2 |
| 39. Adjust schedules to change dressings after the patient is already medicated | 100 % | 0 | 1.00 | 93 % | 7 % | 0.94 | 39. Adjust schedules to change dressings after the person is already medicated, respecting the interval according to the type of analgesic |
| 40. Assess the need for topical analgesia with 2 % lidocaine gel | 93 % | 7 % | 0.94 | 87 % | 13 % | 0.84 | 40. Assess the need for topical analgesia with 2 % lidocaine gel, according to medical prescription |
| 41. Avoid forcefully rubbing the wound bed | 97 % | 3 % | 0.94 | 83 % | 17 % | 0.66 | 41. Do not forcefully rub the wound bed |
| 42. Irrigate the wound bed with saline solution | 100 % | 0 | 1.00 | 80 % | 20 % | 0.60 | 42. Excluded. Already contemplated in Domain 2 |
| 43. Use non-stick coatings (rayon gauze, petrolatum-impregnated gauze, mineral oil or Vaseline-soaked gauze) | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 43. Use non-stick coatings. Directed to Domain 2 |
| 44. Consider ibuprofen-based coatings | 90 % | 10 % | 0.80 | 73 % | 27 % | 0.46 | 44. Excluded |
| 45. Consider applying on the wound morphine tablets (10 or 30 mg) macerated and mixed with hydro-gel (15 g) | 83 % | 17 % | 0.66 | 60 % | 40 % | 0,20 | 45. Excluded |
| 46. Consider using hydro-gel if the wound is dry or with low exudation | 93 % | 7 % | 0.94 | 80 % | 20 % | 0.60 | 46. Excluded |
| 47. Apply zinc oxide ointment at the edges and around the wound | 90 % | 10 % | 0.80 | 67 % | 33 % | 0,30 | 47. Excluded |
| 48. Observe the need for analgesia after placing the dressing | 100 % | 0 | 1.00 | 100 % | 0 | 1.00 | 48. There was no change |
| 49. Consider reduction of frequent dressing changes using surgical pads, disposable geriatric tampons or disposable infant diapers | 93 % | 7 % | 0.94 | 83 % | 17 % | 0.66 | 49. Excluded and directed to Domain 2 |
| 50. Verify the need to change the prescribed analgesic scheme | 100 % | 0 | 1.00 | 87 % | 13 % | 0.74 | 50. Reassess, together with the medical staff, the need to change the analgesic scheme prescribed |
| 51. Consider, together with the medical staff, the need for anti-inflammatory drugs, anti-allergic radiotherapy, or surgery | 100 % | 0 | 1.00 | 97 % | 3 % | 0.94 | 51. There was no change |
| 52. Record the assessment of pain through the Analogue Visual Scale and analgesia before and after dressings | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 52. Record the evaluation of pain intensity through the Analogue Visual Scale or Numerical Visual Scale and analgesia before and after dressings |
| 53. Report to the medical staff cases of pain that are beyond the control of the recommended conduct | 90 % | 10 % | 0.80 | 93 % | 7 % | 0.94 | 53. There was no change |
| Subcategory 2. Specific care performed on the cutaneous malignant tumor wound to control the exudates | |||||||
| 54. Collect material for culture (aspirated or swab) | 90 % | 10 % | 0.80 | 93 % | 7 % | 0.94 | 54. Collect material for culture (aspirated/swab via Levine’s technique) with previous lesion cleaning |
| 55. Use activated carbon/calcium alginate/starch copolymer/ foam with or without silver/hydrofiber and compresses/gauze as secondary coating. | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 55. Use activated carbon/calcium alginate/starch copolymer/foam with or without silver/hydrofiber as primary coating and compresses/gauze as secondary coatings |
| 56. Use zinc oxide, hydrocolloid, barrier cream on macerated skin and wound edges prior to using antiseptics. | 77 % | 23 % | 0.54 | 53 % | 47 % | 0.06 | 56. Excluded |
| Subcategory 3. Specific care performed on the cutaneous malignant tumor wound to control itching | |||||||
| 57. Investigate the cause of itching | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 57. There was no change |
| 58. Perform cryotherapy (ice use) to block nerve stimulation | 87 % | 13 % | 0.74 | 80 % | 20 % | 0.60 | 58. Excluded |
| 59. Consider using hypoallergenic adhesives (micro-pore) | 100 % | 0 | 1.00 | 97 % | 3 % | 0.94 | 59. Use hypoallergenic adhesives |
| 60. Use dexamethasone cream 0.1 % in the itchy areas, according to medical prescription | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 60. There was no change |
| 61. Investigate presence of fungal infections | 93 % | 7 % | 0.86 | 100 % | 0 | 1.00 | 61. There was no change |
| 62. Use Nystatin or 1 % silver sulfadiazine with or without cerium, according to medical prescription for cutaneous Candidiasis in the areas of hyperemia around the whitish-stained wound | 93 % | 7 % | 0.86 | 93 % | 7 % | 0.86 | 62. Use Nystatin or 1 % silver sulfadiazine with or without cerium nitrate, according to medical prescription for cutaneous Candidiasis in the areas of hyperemia around the whitish-stained wound |
| 63. Consider reducing the interval of dressings to prevent this symptom | 83 % | 17 % | 0.66 | 93 % | 7 % | 0.86 | 63. Consider reducing the interval of dressings to prevent this symptom and investigate allergic reaction to the coating used |
| 64. In case itching persists, consider, together with the medical staff, the introduction of systemic therapy | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 64. There was no change |
| 65.Consider desonide-based creams for cases of allergy to topical corticosteroids, according to medical prescription | 97 % | 3 % | 0.94 | 87 % | 13 % | 0.74 | 65. Use desonide-based creams for cases of allergy, according to medical prescription |
| Subcategory 4. Specific care performed on the cutaneous malignant tumor wound to control necrosis | |||||||
| 66. Assess debridement needs, according to the patient’s capacity | 90 % | 10 % | 0.80 | 87 % | 13 % | 0.74 | 66. Assess debridement needs, according to the person’s clinical condition and the characteristics of the lesion (for example, friable) |
| 67. Select debridement form (autolytic, chemical, mechanical, and conservative instrumental) | 97 % | 3 % | 0.94 | 93 % | 7 % | 0.94 | 67. There was no change |
| 68. Consider autolytic debridement autolytic using hydro-gel or alginate | 93 % | 7 % | 0.86 | 83 % | 17 % | 0.66 | 68. Consider, as priority, autolytic debridement |
| Sub-domain 5. Specific care performed on the cutaneous malignant tumor wound to control the fistula | |||||||
| 69. Apply zinc oxide/hydrocolloid/barrier cream/polymeric solution on the skin around the fistula | 93 % | 7 % | 0.86 | 93 % | 7 % | 0.86 | 69. There was no change |
| 70. Adapt, whenever possible, use collecting bags on high-drainage fistulas, with hydrocolloid plates around the skin | 90 % | 10 % | 0.80 | 100 % | 0 | 1.00 | 70. Adapt, when possible, collecting pouches to high-drainage fistulas and to protect the peri-fistula area |
| 71. Place absorptive dressing with activated carbon and/or calcium alginate with compresses/gauze as secondary coating | 90 % | 10 % | 0.80 | 77 % | 23 % | 0.54 | 71. Excluded |
| Subcategory 6. Specific care performed on the cutaneous malignant tumor wound to control bleeding | |||||||
| 72. Apply pressure directly on the bleeding vessels with the protection of gauze, swabs or towels | 93 % | 7 % | 0.86 | 93 % | 7 % | 0.86 | 72. Apply pressure directly on the bleeding vessels with the protection of gauze, swabs or dark-colored towels for 10 to 15 min |
| 73. Consider applying cold saline solution through cold gauze or compresses or manual compression for 10 to 15 min | 93 % | 7 % | 0.86 | 100 % | 0 | 1.00 | 73. Consider applying cold saline solution using gauze and / or compresses |
| 74. Consider applying silver nitrate for small bleedings | 87 % | 13 % | 0.74 | 77 % | 23 % | 0.54 | 74. Excluded |
| 75. Consider applying aluminum solution for small to moderate bleedings | 87 % | 13 % | 0.74 | 77 % | 23 % | 0.54 | 75. Excluded |
| 76. Consider applying macerated tablets or 1 % sucralfate solution (tablet diluted with 5 mL aqueous gel or distilled water or speckled over the lesion), according to medical prescription) | 80 % | 20 % | 0.60 | 77 % | 23 % | 0.54 | 76. Excluded |
| 77. Consider porcine gelatin haemostatic dressing (Gelfoam) | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 77. There was no change |
| 78. Consider calcium alginate | 100 % | 0 | 1.00 | 90 % | 10 % | 0.80 | 78. Apply calcium alginate |
| 79. Consider applying oxidized cellulose dressing | 93 % | 7 % | 0.94 | 73 % | 27 % | 0.46 | 79. Excluded |
| 80. Consider adrenaline (injection solution) topically over bleeding points 1:1000, according to medical prescription | 93 % | 7 % | 0.86 | 90 % | 10 % | 0.80 | 80. There was no change |
| 81. Keep the environment moist to prevent gauze sticking to the wound site | 100 % | 0 | 1.00 | 97 % | 3 % | 0.94 | 81. Excluded. Already contemplated in Domain 2 |
| 82. Verify, together with the medical staff, the possibility of treatment with systemic coagulant, like aminocaproic acid (tablets or in injection solution) or tranexamic acid (tablets or in injection solution) | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 82. There was no change |
| 83. Consider using non-stick coatings (rayon gauze or gauze impregnated with petrolatum, mineral oil, Vaseline) | 93 % | 7 % | 0.86 | 87 % | 13 % | 0.74 | 83. Excluded. Already contemplated in Domain 3 |
| 84. Consider reduction of frequent dressing changes using surgical compresses, disposable geriatric tampons, disposable infant diapers | 97 % | 3 % | 0.94 | 90 % | 10 % | 0.80 | 84. Excluded. Already contemplated in Domain 3 |
| 85. Verify, together with the medical staff, the possibility of treatment with surgical intervention | 93 % | 7 % | 0.86 | 93 % | 7 % | 0.86 | 85. Verify, together with the medical staff, the possibility of treatment with surgical intervention in persistent bleedings or resistant to conventional therapies |
| 86. Verify, together with the medical staff, the possibility of treatment with anti-hemorrhagic radiotherapy | 93 % | 7 % | 0.86 | 90 % | 10 % | 0.80 | 86. There was no change |
| 87. Verify, together with the medical staff, the possibility of treatment with palliative sedation for cases of heavy bleeding accompanied by the individual’s agitation, despair, and anguish | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 87. There was no change |
| 88. In cases of the patient’s agitation and anguish due to intense bleeding, consider using dark colored towels to contain the hemorrhage | 83 % | 17 % | 0.66 | 83 % | 17 % | 0.66 | 88. In cases of the individual’s agitation and anguish due to intense bleeding, consider using dark colored towels to contain the hemorrhage |
| Subcategory 7. Specific care performed on the cutaneous malignant tumor wound to control odor | |||||||
| 89. Clean with saline solution and antisepsis with degenerating chlorhexidine or PHMB (polyhexamethylene biguanide) | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 89. Consider applying PHMB solution |
| 90. Remove antiseptic with saline solution Jet and maintain gauzes soaked in aluminum hydroxide on the wound bed | 97 % | 3 % | 0.94 | 87 % | 13 % | 0.74 | 90. Consider using gauzes soaked in aluminum hydroxide on the wound bed for grade I odor |
| 91. Use silver sulfadiazine in gauze and occlude with gauze soaked in liquid Vaseline | 78 % | 22 % | 0.56 | 70 % | 30 % | 0.40 | 91. Excluded |
| 92. Use activated carbon in gauze soaked with saline solution. | 93 % | 7 % | 0.94 | 90 % | 10 % | 0.80 | 92. Consider using activated carbon |
| 93. Apply metronidazole gel 0.8 %, according to medical prescription, in gauze soaked in Vaseline and apply on the wound bed | 90 % | 10 % | 0.80 | 83 % | 17 % | 0.66 | 93. Apply gel or metronidazole 0.8 % solution for grade II odor, according to medical prescription |
| 94. If necessary, perform necrotic tissue escharotomy and proceed to applying metronidazole gel | 87 % | 13 % | 0.74 | 77 % | 23 % | 0.54 | 94. Excluded |
| 95. Consider, together with the medical staff, the possibility of associating systemic metronidazole (intravenous or oral) with topical use | 93 % | 7 % | 0.86 | 93 % | 7 % | 0.86 | 95. Consider, together with the medical staff, the possibility of associating systemic (intravenous or oral) metronidazole with topical use for grade III odor |
| 96. Consider bandage impregnated with sodium chloride | 97 % | 3 % | 0.94 | 67 % | 33 % | 0,34 | 96. Excluded |
| 97. Consider using starch copolymer | 83 % | 17 % | 0.74 | 67 % | 33 % | 0,34 | 97. Excluded |
| 98. Consider using cadexomer iodine | 83 % | 17 % | 0.74 | 67 % | 33 % | 0,34 | 98. Excluded |
| Subcategory 8. Specific care performed on the cutaneous malignant tumor wound to control myasis infestation | |||||||
| 99. Consider applying topical lidocaine to reduce pain during manual larvae removal | 93 % | 7 % | 0.86 | 90 % | 10 % | 0.80 | 99. Consider applying topical lidocaine, according to medical prescription, to reduce pain during manual larvae removal |
| 100. Apply liquid Vaseline to suffocate the larvae and facilitate their removal | 100 % | 0 | 1.00 | 87 % | 13 % | 0.74 | 100. Apply liquid Vaseline to prevent the larvae from breathing, which facilitates their removal |
| 101. Perform manual larvae removal (with tongs) | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 101. There was no change |
| 102. Administer systemic Ivermectin, according to medical prescription | 100 % | 0 | 1.00 | 90 % | 10 % | 0.80 | 102. There was no change |
| Category 4. Record of Nursing actions | |||||||
| 103. Document the evaluation of the wound and of the patient | 97 % | 3 % | 0.94 | 97 % | 3 % | 0.94 | 103. Document the evaluation of the wound and the person’s needs |
| 104. Document all the interventions performed | 100 % | 0 | 1.00 | 97 % | 3 % | 0.94 | 104. Document all the interventions performed with the wound and with the person |
| 105. Document the education carried out with the patient and/or the family, indicating points where difficulty was noted in understanding and skills | 97 % | 3 % | 0.94 | 93 % | 7 % | 0.86 | 105. Document the education carried out with the person and/or the family, indicating points where difficulty was noted in understanding and skills |
| 106. Document the results obtained | 97 % | 3 % | 0.94 | 93 % | 7 % | 0.86 | 106. There was no change |
| 107. Carry out photograph record of the wounds | 97 % | 3 % | 0.94 | 93 % | 7 % | 0.86 | 107. Consider photographic record of wounds after authorization by the person and/or relative |
| Category 5. Guidelines for hospital discharge | |||||||
| 108. Identify and contact the principal caregiver to train in placing dressings at home | 97 % | 3 % | 0.94 | 100 % | 0 | 1.00 | 108. There was no change |
| 109. Identify, with the family, the public care network that can be accessed for partnership in wound care | 97 % | 3 % | 0.94 | 100 % | 0 | 1.00 | 109. Identify and contact, with the family, the public care network that can be accessed for partnership in wound care and to train said professionals, if necessary |
| 110. Carry out a summary Nursing report regarding hospital discharge and wound care | 100 % | 0 | 1.00 | 97 % | 3 % | 0.94 | 110. Conduct a summary Nursing report regarding hospital discharge and wound care, the products used, the results obtained and expected, and the family education process |
| 111. Clothing guide: more comfortable and tailored clothing for better wound access to change dressings | 97 % | 3 % | 0.94 | 100 % | 0 | 1.00 | 111. There was no change |
| 112. Guide with better sleeping conditions, consider using cushions and other devices to improve positioning | 97 % | 3 % | 0.94 | 100 % | 0 | 1.00 | 112. There was no change |
Source: research data, 2017.
Discussion
Considering the instrument in question, it was observed that most of the items had a percentile equal to or above 80 % regarding the degree of concordance in clarity, as well as in pertinence 16; for this reason, they remained on the proposed measurement scale; however, items 4, 5, 6, 22, 24, 44, 45, 46, 47, 56, 58, 71, 74, 75, 76, 79, 91, 94, 96, 97, and 98 did not present desired percentages, which were excluded from the respective categories. It is worth mentioning that some of these results are related to the lack of knowledge by the judges about the products and coatings highlighted in these items, whereas the evaluators themselves made it explicit in the space for suggestions and comments; for this reason, it was decided to exclude them.
Also, all items with a percentage equal to or greater than 80 % were significant with p <0.001. The intention in using Guttmann’s Lambda 2 (λ) calculation is because some studies 17-18 found that using Lambda is the best reliability estimate when the instrument assessed is composed of few items that form categories or by a sample equal to or less than 30 subjects 19-21.
Guttmann’s Lambda 2 (λ) in this study revealed (for the set of items on the assessment of clarity and relevance λ2 = 0.84 and 0.81, respectively) higher score than required by the statistical literature 19-22, which is 0.80, intended for low-participation assessments, as well as instruments that require instructional comments. Thus, the higher the statistically required λ, the better the test is able to differentiate from actual results and measurement errors. Considering these results, the Lambdas presented mean the percentage of the real variation of the measurement, that is, the Lambdas explain values > 80 %.
The appropriateness as to the degree of clarity and relevance of the items of the instrument in question indicated by the judges can be used for their assessment of the phenomenon “the knowledge and practice of nurses in palliative care for people with cutaneous malignant tumor wounds”.
In addition, the analysis generated a version with changes in the instrument content, based on the judges’ comments and suggestions, namely: item 28 was excluded, but the sentence was directed to item 27, once the judges understood that the information contained in these items complemented each other; items 38, 43, and 49 were directed from Category 3 to 2, once the judges understood that they would be better articulated in basic care; items 42, 81, 83, and 84 were excluded from Categories 3 and 8, because the judges realized that the information was repeated and understood that they should remain only in the basic care performed with the lesion.
Kuder-Richardson’s ρ, which is intended to verify the reliability of the degree of agreement between raters in a dichotomous measure, should have a score above 0.70 22, presented the following results for the condition of instrument clarity: category 1, ρ = 0.80; category 2, ρ = 0.73; category 3 (total, ρ = 0.71) was subdivided into eight subcategories: subcategory 1, ρ = 0.71; subcategory 2, ρ = 0.72; subcategory 3, ρ = 0.73; subcategory 4, ρ = 0.78; subcategory 5, ρ = 0.78; subcategory 6, ρ = 0.76; subcategory 7, ρ = 0.75; and subcategory 8, ρ = 0.77; category 4, ρ = 0.73 and category 5, ρ = 0.75.
The Kappa (K) index, which measures inter-observer agreement and degree of agreement and consistency of the judges regarding the permanence or not of the instrument’s items, taking into account the indications of “inadequate” for them, ranges from “minus 1” to “plus 1”; thus, the closer to 1, the better the level of agreement between the observers. As an acceptance criterion, agreement was established ≥ 0.61 among the judges, which presents a good level 23.
The instrument subjected to the first evaluation by the judges contemplated aspects related with palliative care expected for execution by the palliative-care nurse on the person with malignant tumor wound; however, the procedures involved in the care process did not include a detailed description of the technique. This initial configuration influenced the Kappa values and subsidized the instrument reformulations for the second evaluation of the instruments (original and modified); however, some were maintained, given that they are palliative care considered essential and supported by the relevant literature, namely: items 2, 3, and 12, regarding clarity 7-8.
Finally, apparent validity was verified (such considered the theoretical definition of a variable that, in fact, seems to measure the item proposed). Specifically, it refers to what the item, by the type of questions or situations presented, seems to evaluate; for this, the CVI was performed 12,16) related to the quality of agreement and content of the items in the judges’ conception for clarity and importance, and noting that this indicator ranged from 0.91 to 1.00.
Although items 2, 3, and 12 did not have an acceptable Kappa value, they were chosen to remain because in item 2, size refers to the measurement of the lesion, i.e., it is an assessment parameter that confers the evolution of the wound. It is recommended to measure length and width and, if possible, to measure depth and/or bulging, given that malignant tumor wounds also have a vegetative aspect 1,7-8. Regarding the permanence of item 3, it should be highlighted that staging is another evaluation method for tumor wounds and it is a classification proposed by the manual of the Brazilian Ministry of Health 7 and by the relevant literature 1-3,8, whose purpose is to classify the wound according to the degree of tissue compromise and predominant signs and symptoms. Item 12, related to the assessment of the border and the periphery skin, was also maintained because the border and the peri-lesion area presented, besides peeling, a common problem found in tumor wounds, maceration, excoriation, fragility, and hyperkeratosis. These damages cause pain and discomfort in people, as well as affecting negatively their quality of life 24. Items 36 and 58 were excluded because they did not have an acceptable Kappa percentage, although they are supported by the relevant literature 1-3,7-8.
All comments and suggestions from the judges were accepted and the items were reformulated to serve them in their entirety. To leave no doubt, a second evaluation by the judges was requested; for this, the original and modified instruments were sent so that they could analyze and attribute the evaluation quality between the versions. Of the 30 judges who participated in the first instrument evaluation, over 50 % 17 responded to the second version entirely and accepted it. It should be highlighted that loss of participants is expected with each Delphi evaluation, but it is not a limiting factor to analyze the research data 25.
Overall, although these results guarantee the initial quality of the instrument, further studies are important to determine its reliability, either in the more classical or the most complex psychometric perspective, which aims at the quality of the intended theoretical construct, a condition that will permit determining the degree of coherence with which the instrument measures the theoretical attribute under study. Given the aforementioned, the definitive instrument, which follows the compliance by the judges and agrees with the analytical treatment, remained with five categories and 84 items, as seen in Table 2.
Table 2 Definitive instrument to assess the knowledge and practice of nurses in palliative care for people with cutaneous malignant tumor wound. João Pessoa-PB, 2017
| Category 1. Evaluation of the lesion and needs of the person with cutaneous malignant tumor wound |
| 1. Anatomic location of the lesion. |
| 2. Size - measurement of the lesion (height, length, depth or bulging). |
| 3. Staging (1, 1N, 2, 3, 4). |
| 4. Intensity of odor (degree I, II, III). |
| 5. Exudates (type and quantity). |
| 6. Intensity of bleeding (light, moderate, and intense). |
| 7. Intensity of pain in the wound (light, moderate, intense, and excruciating), using the Analogue Visual Scale or Numerical Visual Scale. |
| 8. Itching. |
| 9. Border and peri-lesion skin. |
| 10. Signs of local infection (heat, redness, edema, pain). |
| 11. Type of tissue (necrosis of coagulation, necrosis of liquefaction, granulation, epithelialization). |
| 12. Presence of myasis. |
| 13. Fistulas and quantity drained. |
| 14. Sinus (tunnels). |
| 15. Morphological classification of the lesion (nodular, cavitary, vegetating). |
| 16. Target organ involvement or invasion. |
| 17. Evaluation of social, psychological, spiritual, and economic aspects. |
| 18. Progression or change of the shape of the wound. |
| 19. Identification of the educational needs of the person or of the caregiver regarding wound care after discharge. |
| Category 2. Basic care performed in the cutaneous malignant tumor wound |
| 20. Remove adhesives carefully using removing solution (saline solution or Vaseline or mineral oil). |
| 21. Remove gauze adhered to the lesion bed with abundant irrigation using saline solution. |
| 22. Irrigate the wound bed with saline solution. |
| 23. Wash the wound with antiseptic (degenerating chlorhexidine or PHMB soap), to remove surface bacteria and debris. |
| 24. Employ aseptic technique. |
| 25. Keep the wound bed moist to keep gauze from sticking. |
| 26. Eliminate dead space (fill it with bandages) before selected coatings. |
| 27. Use absorbent coatings. |
| 28. Consider using nonstick coatings. |
| 29. Consider reduction of frequent dressing changes using surgical dressings as primary coatings and disposable geriatric tampons or disposable infant diapers as secondary coatings. |
| 30. Promote coatings that conform to area contours to provide comfort to the person. |
| 31. Protect the bandage with a plastic bag or transparent film during the shower and open it only to change it (which prevents dispersion of exudates and microorganisms into the environment). |
| Category 3. Specific care performed on the cutaneous malignant tumor wound |
| Subcategory 1. Specific care performed on the cutaneous malignant tumor wound to control pain |
| 32. Monitor the level of intensity of pain through the Analogue Visual Scale or Numerical Visual Scale. |
| 33. Start dressings after 30 minutes of oral analgesia; 5 minutes of subcutaneous or intravenous analgesia; and immediate start to the topical pathway, according to medical prescription. |
| 34. Adjust schedules to change dressings after the person is already medicated, respecting the interval according to the type of analgesic. |
| 35. Assess the need for topical analgesia with 2 % lidocaine gel, according to medical prescription. |
| 36. Do not forcefully rub the wound bed. |
| 37. Verify the need to change the prescribed analgesic scheme. |
| 38. Consider, together with the medical staff, the need for anti-inflammatory drugs, anti-allergic radiotherapy, or surgery. |
| 39. Record the assessment of pain through the Analogue Visual Scale or Numerical Visual Scale and analgesia before and after dressings. |
| 40. Report to the medical staff cases of pain that are beyond the control of the recommended conduct. |
| Subcategory 2. Specific care performed on the cutaneous malignant tumor wound to control exudates |
| 41. Collect material for culture (aspirated/swab via Levine’s technique) with previous lesion cleaning. |
| 42. Use activated carbon/calcium alginate/starch copolymer/foam with or without silver/hydrofiber as primary coating and compresses/gauze as secondary coatings. |
| Subcategory 3. Specific care performed on the cutaneous malignant tumor wound to control itching |
| 43. Investigate the cause of itching. |
| 44. Use hypoallergenic adhesives. |
| 45. Use dexamethasone cream 0.1 % in the itchy areas, according to medical prescription. |
| 46. Investigate presence of fungal infections. |
| 47. Use Nystatin or silver sulfadiazine 1 % with or without cerium nitrate for cutaneous Candidiasis in areas of hyperemia around the whitish-stained wound, according to medical prescription. |
| 48. Consider reducing the interval of dressings, to avoid this symptom and to investigate allergic reaction to the coatings used. |
| 49. In case itching persists, consider, together with the medical staff, the introduction of systemic therapy. |
| 50. Use desonide-based creams for cases of allergy, according to medical prescription. |
| Subcategory 4. Specific care performed on the cutaneous malignant tumor wound to control necrosis |
| 51. Assess debridement needs, according to the person’s clinical condition and the characteristics of the lesion (for example, friable). |
| 52. Select the form of debridement (autolytic, chemical, mechanical, and conservative instrumental). |
| 53. Consider, as a priority, autolytic debridement. |
| Subcategory 5. Specific care performed on the cutaneous malignant tumor wound to control the fistula |
| 54. Apply zinc oxide/hydrocolloid/barrier cream/polymeric solution on the skin around the fistula. |
| 55. Adapt, when possible, collecting pouches to high-drainage fistulas and to protect the peri-fistula area. |
| Subcategory 6. Specific care performed on the cutaneous malignant tumor wound to control bleeding |
| 56. Apply pressure directly on the bleeding vessels with using gauze for 10 to 15 minutes. |
| 57. Consider applying cold saline solution using gauze and / or compresses. |
| 58. Consider using porcine gelatin haemostatic dressing (Surgifoam). |
| 59. Apply calcium alginate. |
| 60. Consider using adrenaline (injection solution) topically over bleeding points 1:1000, according to medical prescription. |
| 61. Verify, together with the medical staff, the possibility of treatment with systemic coagulant, like aminocaproic acid (tablets or in injection solution) or tranexamic acid (tablets or in injection solution). |
| 62. Verify, together with the medical staff, the possibility of treatment with surgical intervention in persistent bleedings or resistant to conventional therapies. |
| 63. Verify, together with the medical staff, the possibility of treatment with anti-hemorrhagic radiotherapy. |
| 64. Verify, together with the medical staff, the possibility of treatment with palliative sedation for cases of heavy bleeding accompanied by the individual’s agitation, despair, and anguish. |
| 65. In cases of the individual’s agitation and anguish due to intense bleeding, consider using dark colored towels to contain the hemorrhage. |
| Subcategory 7. Specific care performed on the cutaneous malignant tumor wound to control odor |
| 66. Consider applying polyhexamethylene biguanide (PHMB) solution. |
| 67. Consider using gauzes soaked in aluminum hydroxide on the wound bed for grade I odor. |
| 68. Consider using activated carbon. |
| 69. Apply gel or metronidazole 0.8 % solution for grade II odor, according to medical prescription. |
| 70. Consider, together with the medical staff, the possibility of associating systemic (intravenous or oral) metronidazole with topical use for grade III odor. |
| Subcategory 8. Specific care performed on the cutaneous malignant tumor wound to control myasis infestation |
| 71. Consider applying topical lidocaine to reduce pain during manual removal of larvae, according to medical prescription. |
| 72. Apply liquid Vaseline to prevent the larvae from breathing, which facilitates their removal. |
| 73. Perform manual larvae removal (with tongs). |
| 74. Administer systemic Ivermectin, according to medical prescription. |
| Category 4. Record of Nursing actions |
| 75. Document the evaluation of the wound and the person’s needs. |
| 76. Document all the interventions performed with the wound and with the person. |
| 77. Document the education carried out with the person and/or the family, indicating points where difficulty was noted in understanding and skills. |
| 78. Document the results obtained. |
| 79. Consider photographic record of wounds after authorization by the person and/or relative. |
| Category 5. Guidelines for hospital discharge |
| 80. Identify and contact the principal caregiver to train in placing the dressings at home. |
| 81. Identify and contact, with the family, the public care network that can be accessed for partnership in wound care and to train said professionals, if necessary. |
| 82. Conduct a summary nursing report regarding hospital discharge and wound care, the products used, the results obtained and expected, and the family education process. |
| 83. Clothing guide: more comfortable and tailored clothing for better wound access to change dressings. |
| 84. Guide with better sleeping conditions, consider using cushions and other devices to improve positioning. |
Source: research data, 2018.
Conclusions
In general, this study sought to describe the validation process of a measure that contributes to the evaluation of palliative care for people with cutaneous malignant tumor wound, performed in clinical oncology and palliative care units. From the results observed, it is possible to state that, in this first stage of the analysis of the measure, the instrument proved adequate for what it was intended to measure, given that the statistical indicators revealed percentages equal to or higher than those required by the literature, as well as categories and subcategories related to palliative care.
In this sense, it is believed that the construction of instruments with such theoretical and practical perspective is valid for the health area and, specifically, for Nursing; this condition probably contributes to assessing the quality of care and, thus, directing necessary changes in the process of caring for the Nursing staff, whose main objective is to expand the quality of care and care in the context of the local reality.
Thus, in practice, reduced data loss, refined opinions, and the consensus of judges regarding palliative care for people with cutaneous malignant tumor wound aimed at standardizing the measure and clearer interventionist attitudes, based on “place” in which respondents pointed out the degree of importance of items and categories in the area of nursing, which indicated that the instrument in question is applicable.
