INTRODUCTION

The integumentary system plays an extremely important role in the human body. Among its functions, it acts as a physical and chemical barrier, in which its integrity, hydration and maintenance of an acid pH are important. Changes in this system lead to skin infections and/or wounds¹.

Incontinence-associated dermatitis (IAD) is a skin inflammation, common in urinary or faecal incontinent patients. In its pathophysiology, we can highlight the moisture resulting from eliminations, associated with the action of skin and faecal bacteria and digestive enzymes, with a consequent alteration in the skin pH of the affected region^1)(2)(3.

The cutaneous areas affected by IAD and pressure injury (PI) can be similar and, thus, patients at risk of IAD without proper care, may develop PI. PI is a wound caused by unrelieved pressure on the skin and/or adjacent tissues, associated with friction and/or shear, common in areas of bony prominences and medical device exit sites. PI is generally considered prevenTable and in advanced stages, it is understood as a serious adverse event^{1)(2)(3)(4)(5}.

The best practice documents on these diseases emphasize the importance of instructing care professionals and students of Nursing courses on the differentiation of these wounds, since an IAD can be confused with PI and be treated inappropriately, as the treatments of these injuries are not similar⁴.

Educational actions in health institutions must be implemented in a dialogic manner, in line with the reality identified in patients. Therefore, the themes must emerge from practice, with the objective of improving the interventions carried out⁶.

For that matter, tools that identify the knowledge of professionals on a given subject can be important to guide educational activities⁷. However, the questionnaires used must be validated^8,9.

Evaluative tools, in the field of health, work by helping educational processes, aiming to identify the weaknesses and potentialities of care. These should not be used to make actions rigid or act as a control mechanism for participants^7,10.

The present instrument was elaborated with this purpose, to facilitate the implementation of educational activities on the injury in question, due to its relevance and specificities. Another study, carried out in Brazil, aimed to develop an instrument to assess knowledge about IAD, but in conjunction with the assessment of knowledge about PI. In this sense, this research was conducted considering recent advances in scientific research on skin lesions associated with moisture as well as recognizing IAD as distinct from others¹¹. Based on the above, the objective of this study was to build and validate an instrument to assess knowledge about incontinence-associated dermatitis among nursing professionals.

MATERIAL AND METHODS

Methodological study for building and content validation of an instrument to assess knowledge about IAD. Content validity is defined as the degree to which a test actually measures the construct it aims to assess¹².

The study was conducted in three stages, which were developed in two periods, in which firstly there was the elaboration of the instrument between July and October 2020 and then the content validation and pre-test between March and May 2021 ⁽⁹.

The study sample was non-probabilistic for convenience, composed of experts, professional nurses selected through a search in the Lattes Curriculum Platform, characterized according to adapted criteria and were chosen those who obtained a minimum score of 5 points. As selection criteria, the following were adopted: master's or doctorate in Nursing or related areas, with publications on IAD or wounds; specialization in Dermatological Nursing or Stomatherapy with a one-year minimum experience in the area, associated with publications on IAD^13).

During content validation, it is recommended that the instrument be analyzed by evaluators similar to the test's target audience. In this way, professionals from the institution linked to direct patient care were also part of the sample. Thus, the selection criteria were: nursing professionals working in the Surgical Clinic, Pediatrics and Adult ICU, present during the data collection period⁹.

Due to the possibility of losses, fourteen experts and six employees of the institution were invited to participate. Of this total, seven expert judges and six service professionals participated in the validation, totaling a sample composed of 13 evaluators of the instrument.

The elaboration of the instrument was based on guiding documents on IAD and on systematic reviews of the subject, as well as on the PI clinical practice guide, which presents guidelines on the management of IAD, due to the correlation between these lesions^{2)(3)(4)(5)(14).}

For content validation, it was based on the assumptions of the Delphi method, in which two or more rounds of analysis of the instrument by the committee of examiners are necessary. The purpose of adopting this technique is to obtain the maximum consensus in the evaluation of the items among the evaluators¹⁵.

The evaluators were contacted virtually, through email individually, with clarification of the research objectives and sending of the informed consent form. Subsequently, the link for analysis of the constructed test, prepared in the Google Forms tool, was sent. The domains and items of the instrument were analyzed globally regarding clarity, simplicity and relevance to the construct⁸. The belonging of the items to the domains was also evaluated. The evaluation return deadline was 15 days⁹.

In the content validation instrument, there was room for suggestions in each item. The components and domains were analyzed using a 5-point Likert type scale, with 1 = very bad item, 2 = bad item, 3 = regular item, 4 = good item and 5 = excellent item¹⁶.

Regarding the analysis of agreement, the Content Validity Index (CVI) was calculated. This index measures the agreement between evaluators regarding the representativeness of the items and/or domains to the construct, being calculated by dividing the number of evaluators who judged the item as adequate by the total number of judges in each category. On the other hand, for calculation of the general CVI of the instrument, the CVI values of the items were added separately, dividing by the number of items present in the instrument¹⁷. The item or domain that obtained an agreement equal to or greater than 83% in each round of analysis was considered valid¹⁸.

The pre-test was carried out, including twenty nursing professionals from the institution's Pediatrics Section. The recommended number of evaluators varies in the literature, however, due to the characteristics of the institution and in order to avoid further losses in the application of the test, this sample number was obtained¹⁹. The pre-test aimed to make final adjustments to the instrument.

Data were organized and tabulated in statistical software, analyzed using descriptive statistics, with statistical tests and analysis of variance (ANOVA) of the responses. After the first evaluation round, the results were analyzed quantitatively and qualitatively, the CVI of the items and domains was calculated and the evaluators' suggestions were identified. Therefore, the instrument was reformulated and sent back for assessment. After the evaluations of the second round were returned, the CVIs were recalculated, reaching a consensus among the examiners and, therefore, a new stage of analysis was not conducted.

Concomitantly with the quantitative analysis of the judges' and target audience's suggestions, at the end of the first evaluation round, a qualitative analysis of the recommendations was carried out.

The Mann-Whitney U test was used to compare the findings for independent samples. Tests were carried out with the following hypotheses: H₀ = there is no statistically significant difference in the experts' assessment, as well as between the target audience regarding the instrument; H₁ = there is a statistically significant difference in the assessment of experts and between the target audience regarding the instrument.

The study complied with ethical precepts and was approved by the Research Ethics Committee of the Federal University of Mato Grosso do Sul, with Opinion nº 4405128 and Certificate of Presentation for Ethical Consideration (CAAE) 36636620.4.0000.0021.

RESULTS

This study aimed to build and validate an instrument to assess knowledge about incontinence-associated dermatitis among nursing professionals. The study participants were the experts (specialists) and professional nurses of assistance at the University Hospital of the Federal University of Grande Dourados (target audience), totaling 13 evaluators. The experts were from several locations in Brazil, as they were contacted via email, three from the Midwest region, two from the South region of Brazil, one from the Northeast and one more expert from the Southeast region, all with publications or works master's and/or doctorate related to the topic. Among specialists, three of them were PhDs (42.9%), the highest academic title, other three were masters (42.9%) and one was a specialist (14.2%). In addition, in this group, there were six (85.8%) Stomatherapists or Dermatologist Nurses. As for professional practice, five (71.4%) worked as professors and specialists, one (14.3%) was an assistant nurse and another (14.3%) was in the teaching profession exclusively.

Regarding the target audience, three of them worked as nursing technicians and the other three as nurses. Among the technicians, two (66.6%) had a degree and specialization course and one (33.3%) had a Nursing Technician course. Out of the nurses, two had a Master's degree and one had a Specialization course.

As mentioned, the instrument was analyzed in two rounds by the examiners. The content validity indexes of the items and the instrument, in each evaluation round, are described in Table 1.

Table 1. Content Validity Indexes of the items of the instrument regarding clarity, simplicity and relevance. Dourados, MS, Brazil, 2021. 

Table 1 (cont.). Content Validity Indexes of the items of the instrument regarding clarity, simplicity and relevance. Dourados, MS, Brazil, 2021. 

Table 1 (cont.). Content Validity Indexes of the items of the instrument regarding clarity, simplicity and relevance. Dourados, MS, Brazil, 2021. 

Table 1 (cont.). Content Validity Indexes of the items of the instrument regarding clarity, simplicity and relevance. Dourados, MS, Brazil, 2021. 

^CVI1:Content Validity Indexes in the 1st evaluation round;

^CVI2:Content Validity Indexes in the 2nd evaluation round;

^CVI3:Content Validity Indexes for the target audience in the 1st evaluation round;

^CVI4:Content Validity Indexes for the target audience in the 2nd evaluation round;

NI: New item added by examiners suggestion.

Examiners were asked if the domains were correct, if they were relevant and if they represented the construct. In addition, the items were analyzed regarding the belonging and content of that domain. Regarding these questions, all domains and items obtained CVI values equal to 1.0, in both evaluation rounds.

The qualitative analysis performed concomitantly with the quantitative analysis, at the end of the first evaluation round, is shown in chart 1.

Chart 1. Synthesis of the qualitative analysis of the expert judges' and target audience's suggestions for changes to the instrument. Dourados, MS, Brazil, 2021. 

In the application of the Mann-Whitney U test for independent samples, to compare the answers, it was identified that there was no statistically significant difference between the different groups and intergroups in the two evaluation rounds (Sig. (p-value) = 1 .000¹, considering a significance level of 0.05%. After these tests it was sought to investigate whether there was a significant difference between the content validity indexes, using the ANOVA test, described in Table 2.

Table 2. Hypothesis Test (ANOVA) to analyze the difference between the examiners' answers. Dourados, MS, Brazil, 2021. 

At the end of the validation stage, the pre-test of the instrument was conducted. At this stage, two items were improved in terms of clarity, as recommended. Only after these adjustments was the instrument considered validated.

DISCUSSION

The present instrument was developed with the main objective of assisting actions of Continuing Education in Health, since, when applying a valid instrument to evaluate the professionals' knowledge, it can help in the survey of the educational needs of the team and thus make the processes carried out more efficient for everyone^6,20.

Skin lesions associated with moisture have received greater attention from researchers and specialists, mainly due to their role in worsening the quality of life of patients, the costs involved in care and the possibility of worsening the health condition of those affected^2,3.

Recognizing IAD as a specific and differentiated skin lesion requiring careful care for its management, prevalent in health institutions, as well as perceiving it as a type of skin lesion in which health professionals are still in the learning process in relation to appropriate care practices and, also, the scarcity of studies and national recommendations, were factors considered for the building of this instrument. In the light of recent scientific advances in terms of knowledge about this injury, it is clear that teaching about this condition must be conducted in a way that is not associated with other injuries^21)(22)(23).

The analysis of the evaluators' responses showed that the instrument developed represents the proposed construct, having obtained adequate content validity indexes, regarding the evaluated criteria of simplicity, clarity and relevance. The domains present in this instrument were built based on reference documents on the subject, such as best practice guides, guidelines and systematic reviews, and were envisioned taking into account the most relevant concepts for the practice of IAD.

Authors report that this initial stage of surveying the literature on the construct is paramount for the development of a valid instrument. The more detailed the instrument, the better it will be able to cover the construct in question^{9)(19)(24)(25}

During the validation, the responses of the judges and target audience were analyzed quantitatively and qualitatively, through the analysis of the examiners' recommendations. At the end of each evaluation round, statistical analysis of the responses was carried out, respecting the accuracy required in the content validation process, as well as seeking to obtain considerable improvements in the test. It should be noted that only after the pre-test stage was the instrument considered valid^8)(24)(26.

In the preliminary version, the instrument had 50 items, distributed in three domains. After validation, the questionnaire increased to 57 items, keeping the same number of domains. When applying this instrument, in order to consider the appropriate level of knowledge, the percentage of correct answers for items adopted was equal or higher than 90%, which was based on a similar test validated in Brazil to assess knowledge about PI²⁷.

Through the analysis of the findings, the criterion with more feedback was item clarity. This criterion is understood as the action of using short and simple sentences for the test items, making them easier for the respondents to understand. The examiners' recommendations were accepted, as well as the pre-test suggestions⁸.

It can be highlighted as strengths of this research the fact that the validation was conducted with two groups of examiners - experts and target audience. Therefore, the instrument was validated in terms of content and applicable in care practice^24,28.

Among the limitations of this study, it can be pointed out the fact that it is a validity assessment and, therefore, the psychometric properties of the instrument presented were not verified. However, in view of the results presented, the instrument can be considered valid for measuring the knowledge of nursing professionals regarding the assessment, characteristics, prevention and treatment of IAD.

CONCLUSION

The instrument for assessing knowledge about incontinence-associated dermatitis was built and validated in accordance with its content. The instrument presented excellent clarity, simplicity and relevance in the evaluation before expert judges and target audience, being applicable to the target population. In this way, the developed test can be applied within the institutions to guide the actions of continuing education in health.