This descriptive study was approved by the Research Ethics Committee of the Federal University of São Paulo (UNIFESP; São Paulo, Brazil; approval no. CAAE 79468017.7.0000.5505) and performed in accordance with the ethical standards of the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all participants prior to their inclusion in the study, and anonymity was ensured.
Literature search
Initially, a novelty search was performed on PubMed, Google Scholar, and the Scientific Electronic Library Online (SciELO), but no educational material similar to the guide proposed in this study was found.
The development of the illustrated guide was based on a literature review covering the period 2001 to 2017 and limited to publications in Portuguese, English, and Spanish. A literature search was carried out on the Cochrane Library, MEDLINE/PubMed, and SciELO databases, and on the Google Scholar search engine using the descriptors burns, occlusive dressings, epidemiology, patient care, dressings, and therapeutics.
Guide topics and images
The topics of the illustrated guide were selected. The content of the guide consisted of an informative text and sequences of photographs illustrating the techniques of dressing application in burn injuries.
The guide included Introduction and Reference sections and 10 chapters, categorized as follows: (1) wound dressing supplies; (2) positioning the patient on the bed; (3) gowning and gloving procedures; (4) dressing technique for the face, ears, and cervical region; (5) dressing technique for the upper limb (ie, upper arm, forearm, and axilla); (6) dressing technique for the hand; (7) dressing technique for the lower limb (ie, thigh, legs, and feet); (8) technique to prepare a vest-type garment dressing; (9) technique for placing the vest-type garment dressing in the trunk region; and (10) assessment of shoulder, elbow, wrist, knee, and ankle mobility and chest expansion.
The author created a draft of the guide and possible sequence of illustrations. Standardized photographs were taken using a manikin to illustrate the step-by-step procedures in a realistic setting. The most representative 86 photographs were used in the guide to illustrate the techniques of dressing application in burn injuries. Also, the authors chose colors that would make the figures and images most effective for communicating each technique. The layout of the illustrated guide followed the Brazilian Standard NBR-6029.17
Panel evaluation
A panel of burn specialists validated the content of the guide. Inclusion criteria for the health professionals on the panel were to have more than 3 years of experience in the field of burn care, be a nurse or a plastic surgeon, and agree to participate by providing written informed consent. Potential panelists who did not meet the inclusion criteria or did not return the completed questionnaire within 10 days of mailing were excluded.
Content validity of the illustrated guide was assessed by the expert panel through a questionnaire in the search for a consensus opinion among evaluators (Delphi technique).16,17 The Delphi technique may be applied as a qualitative, quantitative, or mixed-methods approach.16-21 There is no consensus in the literature as to the number of experts required to form a panel. The anonymity of the experts was ensured.18 Two to 3 rounds or cycles of consultation are usually necessary to reach a consensus among the experts, but more rounds may be needed.18 The experts were requested to return the completed questionnaire for each round of consultation within 10 days.
Questionnaire
The questionnaire evaluated 3 components of the illustrated guide: Objective (4 items), assessing the importance of the subject; Structure and Presentation (11 items), analyzing the overall organization, clarity of the text, number of images, educational content, and formatting; and Relevance (4 items), regarding the importance of the information provided on the different topics for the health care professional and whether the guide has the potential to be used as an educational tool. The questionnaire items had 5 alternative responses (ie, inadequate, partially adequate, adequate, very adequate, and not applicable [N/A]) and instructions for the experts to optionally express their personal opinion in the provided space.22,23
Content validation
The content validity index (CVI) was used to measure the proportion of experts who considered certain aspects of the illustrated guide as adequate or very adequate. First, the CVI was calculated for each item by dividing the number of responses adequate and very adequate by the total number of responses for that item (Formula 1). The CVI of an item should be greater than or equal to 0.78 (ie, an agreement of at least 78% among experts) for content validation of the item when the panel is composed of 6 or more experts.24
The overall CVI is given by the sum of the CVI values of all items divided by the number of items in the questionnaire (Formula 2). A minimum overall CVI of 0.90 (ie, an overall agreement of at least 90% among experts) is required for content validation of the instrument.24
Only items rated as adequate and very adequate were entered into the CVI calculation. Items rated as inadequate, partially adequate, and NA carefully were revised according to the experts’ comments and suggestions, and if necessary, the guide was sent for another round of consultation until at least 78% consensus was reached for every item.