Knowledge of the care of wounded patients: evidence of validity of an instrument

Macedo, Eurides Araújo Bezerra de; Freitas, Camylla Cavalcante Soares de; Dionisio, Alessandra Justino; Torres, Gilson de Vasconcelos

doi:10.1590/0034-7167-2018-0643

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Revista Brasileira de Enfermagem

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ORIGINAL ARTICLE • Rev. Bras. Enferm. 72 (6) • Nov-Dec 2019 • https://doi.org/10.1590/0034-7167-2018-0643 copy

Knowledge of the care of wounded patients: evidence of validity of an instrument

Conocimiento acerca del cuidado de la persona com heridas: evidencias de validez del instrumento

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

to present evidence of validity of an instrument aimed at evaluating the knowledge of nursing students about the care of the wounded patient, according to the difficulty and discrimination indexes of the items.

Method:

methodological study conducted in a nursing higher education institution with 117 undergraduate students and 38 professionals from a research group with experience in the area of wounds. For data collection, a questionnaire with 10 multiple choice questions was applied before and after classes on wounds.

Results:

most of the questions presented low level of difficulty and inefficient discrimination index, requiring a revision of the instrument. After two review stages, the difficulty and discrimination indexes of the instruments improved.

Conclusion:

an instrument with better evidence of validity was obtained. However, it still requires refinement for later revalidation in the same population.

Descriptors:
Nursing Assessment; Nursing Care; Validation Studies; Wounds and Injuries; Knowledge

Knowledge questionnaire Domains/Questions	Before knowledge Classes 1 and 2		After knowledge Classes 1 and 2		Sign test			p value
Knowledge questionnaire Domains/Questions	DIFI	DI	DIFI	DI	N	E	P	p value
Wound assessment
Q1	0.69 (M)	0.57 (S)	0.94 (B)	0.10 (I)	02	54	21	< 0.001
Q2	0.81 (B)	0.38 (A)	1.00 (B)	0.00 (I)	00	62	15	< 0.001
Q3	0.79(B)	0.43 (S)	0.92 (B)	0.19 (I)	03	61	15	< 0.001
Choice of dressing
Q4	0.75 (M)	0.62 (S)	0.88 (B)	0.24 (R)	04	59	14	0.031
Q7	0.90 (B)	0.29 (R)	0.95 (B)	0.14 (I)	03	67	07	0.344
Q8	0.17 (AT)	0.10 (I)	0.64 (M)	0.67 (S)	03	35	39	< 0.001
Dressing technique
Q5	0.57 (M)	0.62 (S)	0.83 (B)	0.29 (R)	07	43	27	< 0.001
Q6	0.81 (B)	0.48 (S)	0.87 (B)	0.38 (A)	03	66	08	0.227
Recording and orientation
Q9	0.90 (B)	0.33 (A)	0.94 (B)	0.24 (R)	03	68	06	0.508
Q10	0.87 (B)	0.38 (A)	0.94 (B)	0.14 (I)	03	66	08	0.227
Total	0.72 (M)	0.42 (S)	0.89 (B)	0.24 (R)	06	17	54	< 0.001
Cronbach's Alpha	0.515		0.040		-

2^nd application - After theoretical and practical classes Domains/Questions Index (DIFI ;DI)	Changes made to the questionnaire⁽¹⁸18 Costa RKS, Torres GV, Salvetti MG, Azevedo IC, Costa MAT. Validity of instruments used in nursing care for people with skin lesions. Acta Paul Enferm. 2014;27(5):447-57. doi: 10.1590/1982-0194201400074 https://doi.org/10.1590/1982-01942014000... ⁾
Wound assessment	The answer "all alternatives are correct" was replaced⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q1 (0.95L; 0.009I)
Q2 (1.00L;0.00I)	The answer "all alternatives are correct" was replaced ⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q3 (0.95L;0.18I)	Distractors were improved to be similar to the correct alternative⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Choice of dressing	The answer "all alternatives are correct" was replaced⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q4 (0.88L;0.18I)
Q7 (0.95L;0.09I)	It was renamed as Q5 so that questions about the same domain are in sequence in the instrument⁽²²22 Coluci MZO, Alexandre NMC, Milani D. Construção de instrumentos de medida na área da saúde. Ciênc Saúde Colet. 2015;20(3):925-36. doi: 10.1590/1413-81232015203.04332013 https://doi.org/10.1590/1413-81232015203... ⁾. The answer "all alternatives are correct" was replaced⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾, the terms "any" and "only" were removed from the alternatives⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾and the distractors were improved to be similar to the correct alternative⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q8 (0.55M;0.91S)	It was renamed as Q6 so that questions about the same domain are in sequence in the instrument⁽²²22 Coluci MZO, Alexandre NMC, Milani D. Construção de instrumentos de medida na área da saúde. Ciênc Saúde Colet. 2015;20(3):925-36. doi: 10.1590/1413-81232015203.04332013 https://doi.org/10.1590/1413-81232015203... ⁾. The correct alternative and one of the distractors were altered so that all alternatives are similar⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Dressing technique	It was renamed as Q7 so that questions about the same domain are in sequence in the instrument⁽²²22 Coluci MZO, Alexandre NMC, Milani D. Construção de instrumentos de medida na área da saúde. Ciênc Saúde Colet. 2015;20(3):925-36. doi: 10.1590/1413-81232015203.04332013 https://doi.org/10.1590/1413-81232015203... ⁾. Distractors were improved to be similar to the correct alternative⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q5 (0.90L; 0.18I)
Q6 (0.79L; 0.64S)	It was renamed as Q6 so that questions about the same domain are in sequence in the instrument⁽²²22 Coluci MZO, Alexandre NMC, Milani D. Construção de instrumentos de medida na área da saúde. Ciênc Saúde Colet. 2015;20(3):925-36. doi: 10.1590/1413-81232015203.04332013 https://doi.org/10.1590/1413-81232015203... ⁾. Distractors were improved to be similar to the correct alternative⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Recording and orientation	The option that considered all the alternatives as correct was replaced⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q9 (0.98L; 0.00I)
Q10 (0.98L; 0.00I)	Distractors were improved⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Total (0.89L; 0.23R)	The content of the instrument was not modified, but all the questions were reviewed.

Knowledge questionnaire Questions/Domains	3^rd application Class 2
Knowledge questionnaire Questions/Domains	DIFI	DI
Wound assessment
Q1	0.40(M)	0.73(S)
Q2	0.95(B)	0.18(I)
Q3	0.88(B)	0.18(I)
Choice of dressing
Q4	0.76(B)	0.45(S)
Q7	0.26(M)	0.64(S)
Q8	0.67(M)	0.55(S)
Dressing technique
Q5	0.62(M)	0.73(S)
Q6	0.79(B)	0.18(I)
Recording and orientation
Q9	0.83(B)	0.18(I)
Q10	0.86(B)	0.00(I)
Total	0.70(M)	0.38(A)

Knowledge questionnaire Questions/Domains	Research Group
Knowledge questionnaire Questions/Domains	DIFI	DI
Wound assessment
Q1	0.39 (M)	0.20(R)
Q2	1.00(B)	0.00 (I)
Q3	0.84(B)	0.30(A)
Choice of dressing
Q4	0.68(M)	0.50(S)
Q7	0.29(M)	0.60(S)
Q8	0.92(B)	0.00(I)
Dressing technique
Q5	0.47(M)	0.90(S)
Q6	0.92(B)	0.10 (I)
Recording and orientation
Q9	0.74(M)	0.20 (R)
Q10	0.68(M)	0.70 (S)
Total	0.69(M)	0.35 (A)

Question	Suggestion from professionals (n)	Procedure adopted/Justification
Q1	Remove "No" from question (3).	Removed/Requesting a wrong answer results in lack of clarity⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q1	Clearer alternatives with a single correct alternative (8).	Terms were added to the alternatives, providing greater clarity and a single correct answer⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q2	Remove "No" from question(7).	Removed/ Requesting a wrong answer results in lack of clarity⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q2	Improve clarity and specificity in the question and in the alternatives(3).	The term "skin wound" was replaced by "skin wound bed", making the question more clear and specific.
Q3	Standardize the number of signs/symptoms in the alternatives (1).	Done, making the alternatives more similar⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q3	Specify the type of exudate in all alternatives (2).	Done/The type of necrosis was also specified, making the alternatives more clear, complete and similar ⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q4	Remove the term "except" (3).	Removed/Requesting a wrong answer results in lack of clarity ⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q4	Clearer alternatives with a single correct alternative (3).	Terms were added to the alternatives, providing greater clarity and a single correct answer ⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q5	Remove the initial verbs from the alternatives (3).	Removed. It allows grammatical agreement and agreement of meaning between the question and the alternatives, avoiding the excess of verbs⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q5	Review the alternatives so that there is only one correct alternative(2).	Two alternatives that were correct were altered, providing a single true alternative ⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q6	Specify the type of debridement(2).	Not done, as this was not the purpose of the question.
Q6	Put all the debriders into a single alternative (3).	One more debrider was added in each alternative so that all are similar⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾. All of them were not put into a single alternative to increase the difficulty of the question.
Q7	Replace the term curative with dressing when referring to the product used in the wound bed (1).	Replaced. The term curative is broad, referring not only the product/dressing, but to the set of care given to a wound⁽²³23 Brasil. Ministério da Saúde, Secretaria de Políticas de Saúde, Departamento de Atenção Básica. Manual de condutas para úlceras neurotróficas e traumáticas [Internet]. Brasília; 2002 [cited 2018 Aug 4]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/manual_feridas_final.pdf http://bvsms.saude.gov.br/bvs/publicacoe... ⁾.
	Use technical terms such as "perilesional tissue" and "lesional", instead of terms such as "toward the inside of the wound" (5).	Used. The use of the different terms in nursing records makes it difficult to retrieve information, impairing the measurement of results in nursing practice, as well as the possibility of constructing evidence ⁽²⁴24 Gomes DC, Cubas MR, Pleis LE, Shmeil MAH, Peluci APVD. Terms used by nurses in the documentation of patient progress. Rev Gaúcha Enferm. 2016;37(1):e53927. doi: 10.1590/1983-1447.2016.01.53927 https://doi.org/10.1590/1983-1447.2016.0... ⁾.
	Use the term "preferably" when indicating the use of saline to clean the lesion (1).	Used. Several studies recommend different cleaning solutions; however, saline solution (0.9%) is the preferred solution for wound cleaning and it can be used safely⁽²⁵25 Santos E, Queirós P, Cardoso D, Cunha M, Apóstolo J. A eficácia das soluções de limpeza para o tratamento de feridas: uma revisão sistemática. Rev Enf Ref. 2016;IV(9):133-44. doi: 10.12707/RIV16011 https://doi.org/10.12707/RIV16011... ⁾.
Q8	Remove the term "independent"(2).	Removed, because it can induce the right answer⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q8	Use term "exudate" instead of "secretion" (3).	Used. The use of the different terms in nursing records makes it difficult to retrieve information, impairing the measurement of results in nursing practice, as well as the possibility of constructing evidence ⁽²⁴24 Gomes DC, Cubas MR, Pleis LE, Shmeil MAH, Peluci APVD. Terms used by nurses in the documentation of patient progress. Rev Gaúcha Enferm. 2016;37(1):e53927. doi: 10.1590/1983-1447.2016.01.53927 https://doi.org/10.1590/1983-1447.2016.0... ⁾.
Q9	Review the alternatives so that there is only one correct alternative(4).	All alternatives were altered, providing greater clarity and a single correct answer⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.
Q10	Review the alternatives so that there is only one correct alternative (4).	Terms were added to the alternatives so that only one can be considered correct⁽²¹21 Haladyna TM, Downing SM, Rodriguez MC. A review of multiple choice item writing guidelines for classroom assessment. Appl Meas Educ. 2002;15(3):309-34. doi: 10.1207/S15324818AME1503_5 https://doi.org/10.1207/S15324818AME1503... ⁾.

Knowledge questionnaire Domains/Questions	Before knowledge Class 3		After knowledge Class 3		Sign test			p value
Knowledge questionnaire Domains/Questions	DIFI	DI	DIFI	DI	N	E	P	p value
Wound assessment
Q1	0.58 (M)	0.64 (S)	0.93 (B)	0.09 (I)	00	26	14	< 0.001
Q2	0.15 (AT)	0.45 (S)	0.63 (M)	0.36 (A)	01	19	20	< 0.001
Q3	0.50 (M)	0.55 (S)	0.70 (M)	0.64 (S)	03	26	11	0.057
Choice of dressing
Q4	0.78 (B)	0.45 (S)	0.93 (B)	0.18 (I)	02	30	08	0.109
Q7	0.73 (M)	0.18 (I)	0.95 (B)	0.09 (I)	01	29	10	0.012
Q8	0.28 (M)	0.73 (S)	0.65 (M)	0.64 (S)	05	15	20	0.004
Dressing technique
Q5	0.33 (M)	0.27 (R)	0.48 (M)	1.00 (S)	04	26	10	0.180
Q6	0.10 (AT)	0.18 (I)	0.50 (M)	0.82 (S)	01	22	17	< 0.001
Recording and orientation
Q9	0.80 (B)	0.27 (R)	0.93 (B)	0.18 (I)	01	33	06	0.125
Q10	0.95 (B)	0.18 (I)	1.00 (B)	0.00 (I)	00	38	02	0.500
Total	0.52 (M)	0.39 (A)	0.77 (B)	0.40 (S)	01	04	35	< 0.001
Cronbach's alpha	0.405		0.517		-

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[1] Corresponding Author: Eurides Araújo Bezerra de Macedo. E-mail: eurides.araujo@hotmail.com