EDUCATIONAL TECHNOLOGY FOR THE NURSING TEAM'S INITIAL CARE OF ADULT PATIENTS WITH SEVERE BURNSABSTRACT
Objective: to develop an educational technology for the nursing team's initial care of adult patients with severe burns.
Method: methodological study consisting of three stages: 1) literature review; 2) construction of the educational technology; and 3) validation by expert judges. Data was collected from June to December 2023. The validation process was carried out by experts and the target population (nurses) of the Regional University Hospital of Maringá (Paraná). For data analysis, the Content Validity Index was used, considering a concordance index of 80% or more. Study approved by the Ethics Committee.
Results: in the literature review, 14 articles were selected, whose main themes were condensed and transformed into eight domains that underpinned the development of educational technology. The material was validated by 17 experts in a single round of evaluation with a Content Validity Index of 0.97 and by three nurses, achieving a Content Validity Index of 0.98.
Conclusion: the technology was validated in terms of its content and appearance, with a high Content Validity Index, demonstrating that it is scientific and safe to use in clinical practice. It is hoped that its construction and validation will help clinical decision-making and critical thinking in the initial care provided by the nursing team to adults with severe burns.
DESCRIPTORS:
Burns; Nursing care; Validation study; Technology; Training
RESUMO
Objetivo: elaborar uma tecnologia educativa para o atendimento inicial da equipe de enfermagem ao paciente adulto grande queimado.
Método: estudo metodológico composto por três etapas: 1) revisão de literatura; 2) construção da tecnologia educativa; e 3) validação por juízes especialistas. A coleta de dados foi realizada no período de junho a dezembro de 2023. O processo de validação foi realizado por especialistas e pela população-alvo (enfermeiros) do Hospital Universitário Regional de Maringá (Paraná). Para a análise de dados, foi utilizado o Índice de Validade de Conteúdo, considerando um índice de concordância a partir de 80%. Estudo aprovado pelo Comitê de Ética.
Resultados: na revisão de literatura foram selecionados 14 artigos, cujos principais temas foram condensados e transformados em oito domínios que fundamentaram a elaboração da tecnologia educativa. O material foi validado por 17 especialistas em uma única rodada de avaliação com Índice de Validade de Conteúdo de 0,97 e por três enfermeiros, alcançando um Índice de Validade de Conteúdo 0,98.
Conclusão: a tecnologia construída foi validada em seu conteúdo e aparência com alto Índice de Validade de Conteúdo, demonstrando cientificidade e segurança para ser empregada na prática clínica. Espera-se que a partir de sua construção e validação, possa-se auxiliar a tomada de decisão clínica e o pensamento crítico para a assistência inicial da equipe de enfermagem ao indivíduo adulto grande queimado.
DESCRITORES:
Queimaduras; Cuidados de enfermagem; Estudo de validação; Tecnologia; Capacitação
RESUMEN
Objetivo: desarrollar una tecnología educativa para la atención inicial del equipo de enfermería al paciente adulto gran quemado.
Método: estudio metodológico que consta de tres etapas: 1) revisión de la literatura; 2) construcción de tecnología educativa; y 3) validación por jueces expertos. La recolección de datos se realizó de junio a diciembre de 2023. El proceso de validación fue realizado por expertos y la población objetivo (enfermeros) del Hospital Universitário Regional de Maringá (Paraná). Para el análisis de los datos se utilizó el Índice de Validez de Contenido, considerando una tasa de acuerdo igual o superior al 80%. Estudio aprobado por el Comité de Ética.
Resultados: en la revisión de la literatura se seleccionaron 14 artículos que, mediante la síntesis de sus temas principales, se transformaron en ocho dominios que sostuvieron el desarrollo de la tecnología educativa. El material fue validado por 17 expertos en una sola ronda de evaluación con un Índice de Validez de Contenido de 0,97 y por tres enfermeros, alcanzando un Índice de Validez de Contenido de 0,98.
Conclusión: la tecnología construida fue validada en su contenido y apariencia con un alto Índice de Validez de Contenido, lo que demuestra su cientificidad y seguridad para ser utilizada en la práctica clínica. Se espera que a partir de su construcción y validación sea posible contribuir en la toma de decisiones clínicas y el pensamiento crítico para la asistencia inicial del equipo de enfermería al paciente adulto gran quemado.
DESCRIPTORES:
Quemaduras; Cuidados de enfermería; Estudio de validación; Tecnología; Capacitación
INTRODUCTION
Burns are considered a global public health problem and are the fourth most common type of trauma1. According to global reports, around 11 million burn victims need specialized care every year, and the mean number of burn deaths worldwide is 265,000 per year2. In turn, the World Health Organization (WHO) states that the number of deaths associated with burns in a year is 180,000 worldwide3.
The majority of burn accidents occur in low- and middle-income countries, with women and children being the most affected, involving accidents with hot liquids in the home, associated with cooking. Among men, burns are caused by fires, chemical and/or electrical burns related to work activities3.
In Brazil, according to the Ministry of Health, there are around one million cases of burns every year, of which approximately 100,000 (10%) require hospitalization and 2,500 (2.5%) die from their injuries4.
A study based on data from the Unified Health System (Sistema Único de Saúde, SUS) between 2007 and 2018 found that burns were responsible for more than one million hospitalizations, with the South Region having the highest number of hospitalizations due to this condition, 288,691 (around 28%)5. The mean hospitalization time for burns in Brazil is approximately 20 days6.
In this context, the nursing team plays a fundamental role in the direct care of burn patients, requiring appropriate technical and scientific competence. When welcoming a burned person, the nurse must calm the victim, classify the type of burn and the causative agent, prioritize initial care, and investigate other traumas related to the injury7.
Despite their importance in the care process, it was found that nurses need continuous and up-to-date training in order to provide adequate care to burn victims8.
Nurses are challenged to find options to support the training of their teams. In this context, educational technologies are powerful allies in the process of continuing education. However, in order to use this tool, it needs to be developed and validated9.
Educational technologies are tools that facilitate the teaching-learning process. They can be printed as folders, leaflets, manuals and booklets and serve as a tool to raise awareness, stimulate new evidence-based practices and share knowledge, as well as allowing professionals easy access to the content in case of doubts, helping with day-to-day decision-making9.
The educational technology development is a strategy to support the nursing team in the initial care of burn patients, promoting practice based on scientific evidence and patient safety, reducing errors and non-standardized conduct in hospitals. Therefore, this study has the following question: Can the development and validation of an educational technology for the initial care of adult patients with severe burns help to guide the nursing team during care? The aim of this study was to develop an educational technology for the nursing team's initial care of adult patients with severe burns.
METHOD
This is a methodological study carried out in three phases: Literature review; Construction of the educational technology, and Validation of the material by specialists and final version by the target population, following the steps proposed by Polit and Beck10.
The educational technology developed by this study aims to provide support for the technical and scientific training of nursing professionals who care for burns patients in a public teaching hospital that is not a reference for this type of injury, for care up until the patients are assigned to a reference service.
For the initial stage, a literature review was carried out, based on the guidelines of the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-analyses)11. To collect the data, we used a combination of the following terms from the MeSH (Medical Subject Headings): burns, nursing care, first aid and emergency room, in the PUBMED, EMBASE, Web of Sciense and SCOPUS search strategies. The VHL (Virtual Health Library) used the DeCS (Health Sciences Descriptors): burns, nursing care, first aid and emergency room. It should be noted that only keywords were used for this collection, and synonyms were discarded. In order to obtain more articles, a cross-search between the keywords was operated using the Boolean connector AND, adopting the same combination in all search locations.
The inclusion criteria were: original articles, published in the last five years (between January 2018 and May 2023), available in full electronically, free of charge, with a focus on adults, without restricting the language, the place of origin of the productions and the method used. The exclusion criteria were: articles that distanced themselves from the subject proposed by the study, short communications, literature reviews/reflection, editorials, clinical trial projects, abstracts from annals, theses, dissertations, course completion work, epidemiological bulletins, management reports and books. After compiling the data obtained from the articles selected from the literature review, the selected material was read in its entirety, critically analyzed and the results interpreted.
In the literature review, a total of 138,992 studies were initially found. After applying the eligibility criteria, title and abstracts were read and then the full text, 14 articles12-25 were selected, which contemplated the scientific contribution of the material prepared (Figure 1).
Flowchart of the selection of articles that include the literature review. Maringá, PR, Brazil.
Of the works selected12-25, five (35.71%) mentioned care for electrical and chemical burns; four (28.57%) applied the principles of the ATLS (Primary Assessment, 9th Edition, chapter 1) for the initial assessment of the burned individual; six (42.85%) recommended the rule of nine to determine the extent of the injuries; three (21.42%) used the Parkland formula for volume replacement; nine (64.28%) recommended analgesia with opioids; four (28.57%) the importance of aseptic technique in dressings; five (35.71%) encouraged early physiotherapy on the affected limbs; six (42.85%) advised psychological support for the patient; two (14.28%) reinforced the use of Personal Protective Equipment (PPE); seven (50%) warned about the risk of hypothermia; five (35.71%) recommended checking the status of the tetanus vaccine; and three (21.42%) recommended continuous training for the teams.
In the second stage, educational technology was built based on the content that emerged from the review. In order to build the technology and validate its content, the steps proposed by Lynn (1986) were followed: identifying the domain, generating items and forming the instrument. The domains were identified from the integrative review, and the most relevant ones were listed to make up the educational technology: Identification of the major burn patient; Preparing the environment to receive the burn patient; Assessment: use of the ABCDE system, type of burn, depth, extent, secondary SAMPLE assessment (S: signs and symptoms, A: allergies, M: medication, P: past medical history, L: liquids ingested, E: environment); Diagnosis; Intervention; Fluid therapy; Nutritional assessment; Wound care; Maintaining mobility and functionality of affected limbs; Reassessment; and Criteria for transfer to a referral hospital26.
In building the technology, the aim was to provide information on initial care for major burns patients in urgent and emergency care in a chronological, attractive, easy-to-read and quick-to-access order to make it easier for the nursing team to find information during care. Due to the lack of space and in order to obtain a larger font size, it was necessary to prioritize objectivity in relation to the care of burn patients, while maintaining clarity and coherence.
After identifying the domains, eight large items were generated: 1) Definition of a major burn; 2) Assessment - type of burn, depth and extent; Interventions - general care, fluid therapy, Parkland formula; 3) Primary care; 4) Fluid therapy; 5) Preparing the environment; 6) Secondary care; 7) Maintaining mobility; and 8) Criteria for transfer to a specialized unit. Finally, as the last stage, the technology was built, so that the information was arranged in a logical and easy-to-understand order. To edit the material, we used the Canva® 2.0 website, free version 2019.
In the final stage, the material was subjected to content and appearance validation by a panel of experts. Content validity refers to the degree to which the content of an instrument is faithful to the subject being addressed, i.e. the instrument's ability to reflect the construct of interest. The validity of appearance, on the other hand, is about aesthetic representation27. The experts were selected following Lynn's recommendations, considering a minimum number of five experts26. For the validation process, experts were determined to be nurses with a high capacity for pattern recognition through a high degree of knowledge, skill and experience in a given area, being recognized as an expert by their peers28.
In addition, specialists should have a specialization, master's degree, doctorate or post-doctorate in one of the following areas: urgency and emergency, hospitalization, stomatherapist, burn patient care, tissue viability, wound care, construction and/or validation of instruments and health education. The experts were identified and contacted using information available on the Lattes Platform.
In order for the final version to be validated by the target population, we selected the nurses who worked in the Emergency Room of the Regional University Hospital of Maringá, which belongs to the 15th Health Region of the State of Paraná, a medium-sized institution that provides services exclusively through the Unified Health System. The nurses had to be over 18 years old and have been working in the sector for at least six months. Professionals who were on leave and/or away from work for any reason were excluded. Three nurses took part in this stage.
All participants were asked to sign the Informed Consent Form (ICF) in two copies of equal content. The rules of Resolutions No. 466/2012 and No. 510/2016 of the National Health Council were followed in order to ensure research ethics.
The invitation was sent to the experts and the target audience by sending an invitation letter via e-mail containing all the objectives of the research and their participation. After accepting the invitation, the experts received a copy of the educational technology in PDF format and the evaluation tool prepared in google forms, the same one used by the experts, whose data was then exported in a Microsoft Excel® compatible spreadsheet.
The questionnaire has a section for characterizing the specialists (gender, age, undergraduate degree, qualifications, area of expertise, time working in the area, teaching experience and their specialty) plus 27 questions, distributed among the following themes: Objective (n=4); Content (n=7); Language (n=4); Relevance (n=4); Layout (n=5); Motivation (n=2); and Adaptability (n=1). The evaluation was carried out using a likert-type scale with four degrees of evaluation: Inadequate (1), partially adequate (2), adequate (3) and fully adequate (4)10-11,26-28. Initially, they were given 15 days to respond to the questionnaire, but this took between one and 26 days (mean 16 days), making it necessary to send a second invitation e-mail.
For data analysis, the CVI (Content Validity Index) was used, considering a concordance index of 80% or more as a validity parameter9-11,26. The calculation was made by adding up the Adequate and Totally Adequate responses of each judge on each item of the evaluation questionnaire and dividing by the total number of responses (CVI: sum of agreement with the items / total number of responses to the items), the items that were rated partially adequate and inadequate were revised according to the evaluators' suggestions27.
To validate the final version by the target audience, the same questions sent to the experts were used, and items with a 75% agreement level were considered valid29. Finally, the educational technology was subjected to Portuguese proofreading by a specialized professional.
RESULTS
The educational technology was validated with the help of a panel of experts, sending out 30 invitations. Of the 17 respondents (56.66% adherence), five had postgraduate degrees, four were masters in nursing, six were doctors and two were post-doctors. The specialists declare experience in: adult health (n=1, 7.14%), urgency and emergency (n=5, 35.71%), Intensive Care (n=4, 28.57%), Wound Treatment (n=2, 14.28%), Tissue Healing (n=1, 7.14%), Surgical Center (n=1, 7.14%), Mental Health (n=1, 7.14%) and Management and Technology (n=1, 7.14%). The mean age of the specialists was 38 years (minimum 25 years and maximum 63 years), the majority were female (n=13, 92.85%) and the mean time working in the area was 15 years (minimum 2.5 years and maximum 42 years).
After the validation process, the following CVI results were obtained: the objective construct achieved a CVI of 1.00; content 0.94; language 0.97; relevance 0.95; layout 0.94; motivation 1.00; and adaptability 1.00. Thus, the instrument was considered validated in terms of its content and appearance, in all aspects judged by the experts, with an overall CVI of 0.97 in just one round of evaluation (Table 1).
The experts' suggestions for changes to improve educational technology focused on three constructs: content, language and layout (Chart 1). It should be noted that most of the suggestions were accepted. Those not applicable were justified.
The last stage of validation, the final stage, was carried out with the target audience, made up of three nurses who worked directly in the hospital's emergency room, the field for this research After the evaluation, with the same instrument used by the experts, a CVI of 0.98 was obtained and they did not suggest any other changes. The final version of the educational technology can be seen Supplementary material.
DISCUSSION
The urgent and emergency care of victims of major burns requires the nursing team to have technical and scientific competence, agility, precision and a holistic and humanized approach. Patients should be given the chance to return to their social and work activities with as few consequences as possible, whether physical, emotional or psychological.
Individuals who suffered burns developed acute complications such as infections (14%), amputations (13%), compartment syndrome and rhabdomyolysis. In the long term, patients developed insomnia (68%), anxiety (62%), post-traumatic stress disorder (33%) and major depressive disorder (25%), or were unable to return to work (19%)30. This reiterates the importance of broadening our view of the needs of individuals who have suffered burns, demands that were covered in the technology developed by addressing pain care, maintaining physical mobility and the need for psychological support.
In this context, the use of educational technologies as a tool to support care is an important strategy for improving care. For the health sciences, technology is defined as a procedure or group of methods that is organized in a specific field31. Technology for educational purposes can be digital or printed on materials such as banners or folders, so that it is easy to apply and allows the information to be well visualized and understood. By associating knowledge of a technology with practice, individuals develop decision-making skills and autonomy32.
The guidelines in the educational technology were based on national and international scientific evidence and can be used both in clinical practice and as a tool for continuing education for teams, since this study brings together the knowledge produced and provides resources for improving the quality of health care33.
Evidence-Based Nursing (EBN) is an important strategy for improving care. EBN consists of providing health care by integrating the best available scientific evidence, with the best cost-effectiveness, the experience of the professional and the specificities of each patient/family, for clinical decision-making related to health care33. In order to implement it in everyday clinical practice, it is necessary to use effective tools that raise the standard of care provided through EBN, in particular instruments built and validated by experts in the field34.
In this perspective, the results of this study may favor the consolidation of the EBN by building an instrument whose constructs were validated, receiving an overall CVI of 0.97, demonstrating high reliability, and can be used safely to support initial nursing care for the severely burned adult and in nursing education26. The majority of experts considered the items evaluated to be adequate or totally adequate, indicating that the proposals met the initial objective of the research.
The content of the first domain of the technology focuses on identifying the type of burn, calculating the burnt body surface area and depth. Assessing injuries and their impact on the patient's clinical condition makes it possible to identify possible life-threatening conditions early on by making a rapid nursing diagnosis in order to determine the necessary interventions22.
Based on the characteristics of the injury identified, primary care for the stabilization of the major burn patient is determined (domain 2), including protection of the airway, oxygen supply and obtaining venous access for the need for fluid therapy, delayed bladder catheterization to assess renal function and constant cardiac monitoring19.
In the third and fourth domains, care of the environment was highlighted to ensure the safety of the patient and the nursing team, especially to avoid hypothermia and infections that could worsen the patient's clinical condition. The chances of contamination of burn injuries are high, as the patient has lost the skin's protective barrier. The proper use of PPE and the use of aseptic techniques are essential to avoid cross-contamination19.
To avoid hypothermia, the room temperature should be kept at 28ºC and, if necessary, rewarming measures should be adopted, such as keeping the room closed, using a thermal blanket or heater and reducing the patient's body exposure, since hypothermia drastically reduces the chances of survival13.
In the fifth area of technology, the importance of maintaining mobility is reiterated, and it is essential to keep the affected limbs immobilized, especially in the first 24-48 hours, to avoid an increase in pain. However, physiotherapy is recommended for major burn victims to avoid sequelae resulting from long periods restricted to bed. The main complication to avoid is tissue contracture after healing35.
Finally, the technology addressed the relevant aspects of the clinical and psychological condition of adult burn victims that indicate the need for transfer to a specialized service, the parameters of which were based on the international recommendations of the American Burn Association36.
Limitations include the difficulty in finding specialists with experience in burns and willing to participate in the technology validation process, so that after the initial deadline for responses (15 days), it was necessary to send a second e-mail requesting participation in the study. There is also a shortage of up-to-date national material on the subject, which makes it difficult to adapt to the Brazilian reality.
However, it is hoped that the educational technology will help nursing teams in hospitals that are not a reference for the care of patients with severe burns to have technical and scientific support to provide qualified, humanized initial care that promotes patient safety and can help restore quality of life and the well-being of patients.
CONCLUSION
The objective of the study was met and the educational technology was validated with an overall CVI of 0.97. The material was printed on an A2 folder to make it quick and easy for the nursing team to access the information in the emergency room.
Technology can be used as a strategy to optimize clinical decision-making by the nursing team, and it is understood that knowing its applicability, as well as the opinion of the people who will actually use it, can be considered a promising study to be carried out in the future. It should be emphasized that the use of tools to help care for major burns patients, especially in institutions that are not a reference for such care, is extremely important considering the importance of ensuring patient safety. It should be noted that the material will not be effective on its own, making it necessary to train the nursing and multi-professional teams in this area.
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NOTES
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ORIGIN OF THE ARTICLE
Extracted from the Residency Conclusion Work - Construction and Validation of Educational Technology for initial care by the nursing team for adult burn patients, presented to the Multiprofessional Integrated Residency Program in Urgency and Emergency Care at the State University of Maringá, in 2024.
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FUNDING INFORMATION
Ministério da Educação (MEC), Bolsa de Residência Multiprofissional em Saúde e em Área Profissional da Saúde, process number 9029.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved in the Research Ethics Committee of the State University of Maringá, under opinion No. 6,199,283/2023, and Certificate of Presentation for Ethical Appraisal No. 69301923.5.0000.0104.
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TRANSLATED BY
Agência Latintrad - Leonardo Parachú.
SUPPLEMENTARY MATERIAL
The following online material is available for this article:
