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.
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
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.
Glenda Agra glenda.agra@ufcg.edu.br
