Development and validation of a video on bed baths*

Objective: develop and validate a video on bed bathing directed to nursing professionals and students. Method: the video was based on the literature and presents the definition of bed bath, indications for its performance, steps to perform it, and potential complications. Nursing professors and nurses validated it. They assessed the pertinence of content, clarity, and language of the video scenes. The Delphi Technique was used in this phase. After recording, three nursing professors, along with undergraduate nursing students from a public university, assessed the educational video. The professors first watched the video and suggested changes, and then the students watched the video after the changes were implemented. Results: six rounds were needed for experts to validate the video script using the Delphi Technique. After the video recording, undergraduate students considered the video of easy understanding. Conclusion: the video script was composed of four topics and was validated by experts after six rounds. The video was assessed by the professors and nursing undergraduate students, who considered the topics and the video as a whole as apprehensible. This study is expected to contribute to professional training and improvement of the knowledge and skills of nursing students.


Introduction
Bed bathing is one of the procedures most frequently performed in clinical practice, but because its execution presents various steps, students often face difficulties performing it (1) . Therefore, teaching tools that aid in the execution of this procedure are extremely important.
Universities currently seek other tools to use in the teaching-learning process with students, since teaching based only on theoretical classes does not facilitate the retention of knowledge (2) . Thus, various tools have been used, and videos are among them.
A video can be an effective tool to be used during classes because it has various advantages, such as the fact it is a practical method, with a good cost-benefit profile, and low investment when compared to the large number of people it reaches. It also facilitates understanding of information as people are allowed to watch the scenes multiple times, as many times as necessary, and is well-accepted in the educational field (3)(4) . This tool can be used in undergraduate teaching, as well as to improve the knowledge of patients and family members who are supposed to perform a given procedure (5)(6)(7)(8) . Video can be used in various teaching settings, such as classrooms, simulation centers, distance learning, and can aid students in acquiring new skills and improve their learning process.
Compared with written information, videos are more accessible in terms of language and communication and can be more cost-effective (9) . Video content allows for the demonstrations of clinical skills that undergraduate students are yet to experience, thus providing them an opportunity to enhance visual learning.
There are various methods to develop a video but in general three steps are implemented: preproduction (development of a script, considering the target population and filming strategies), production (video recording, considering appropriate lighting and positioning of cameras and microphone) and postproduction (video editing and inclusion of audio) (10) .
Another important step is assessing the video, which can be performed by experts and by the population who are supposed to use the video (3,11) . In this context, studies developing and validating videos addressing nursing procedures are essential both for teaching and care delivery.
One study, the objective of which was to develop and validate an educational video on the dressing of central venous catheters without cuff, shows that this tool can contribute to nurses' training and can be used to update human resources, even through distance learning, improving the quality of care delivery (12) .
Other studies (8,11,(13)(14) report the efficacy of using videos, such as reducing the need to repeat lectures, and allowing to review and improve teaching methods (11) ; increase knowledge at the short-term (8) ; and improve practical and theoretical knowledge and performance in assessment tests (13)(14) .
From this perspective, nurses can develop and incorporate validated teaching technologies, such as videos, to assist educational practices. However, no studies developing and validating a video on bed bathing were found in the literature. This procedure has several steps and can lead to complications when not performed appropriately. Therefore, a video can promote patient safety, as students are allowed to practice several times while watching the video before actually providing patient care.
In this sense, the following guiding question emerged: Do nurse specialists and undergraduate nursing students consider a literature-based video considered valid?
In order to answer this question, the objective was to develop and validate a video on bed bathing directed to nursing professionals and students.

Method
This methodological study was conducted from from five to nine specialists (3,11,15) .
The nurses assessed the pertinence of content, clarity, and language used by the characters of each of the video scenes (11) , as well as the order of dialogues and images. An instrument containing all the topics addressed in the video that included a three-  appropriate, and 1 totally inappropriate), used in previous studies, was adopted (11) and sent via e-mail along with the video script to be analyzed. If nurses considered the script to be partially appropriate or totally inappropriate, they were asked to suggest pertinent changes. In order to be considered valid, there should be a 100% agreement regarding the video script among the specialists and achieve a mean score equal to 3 (totally appropriate).
The Delphi Technique was used in this phase of validation. This technique has been used to validate instruments and video scripts (3,11,16) . It is a method to collect opinions and criteria from a group of experts on a given topic by successively applying questionnaires, while information from previous phases is used in each phase to reach consensus among the participants (17) .
Comments from one round are collected, analyzed, and integrated into the next round to collect opinions from the experts. The advantages of using the Delphi and used in a previous study (11) , was used for the students to assess understanding of the educational video as a whole and each of its parts. The minimum score was 1 (I did not understand anything), and the maximum was 5 (I understood it perfectly and have no doubts). In addition to the content, students were asked to assess the video for images and audio, the environment where it was filmed and the characters.
The Wilcoxon Test was used to verify agreement among the students' answers. Binomial distribution was used to calculate a 95% confidence interval for the proportion of maximum scores (equal to 5). The project was submitted to the Institutional Review Board, while data collection was initiated only after receiving approval (No. 1025890).

Results
The Regarding the topic "definition", three rounds were necessary to obtain a consensus among the experts. In round 1, the mean score of the content was 3.0; clarity was 2.71; order of dialogue was 3.00; and language was 2.29. In round 2, the mean score of content was 3.00; clarity was 3.00; and language was 2.57.
The changes suggested by the nurses regarding the content can be viewed on Figure 1. www.eerp.usp.br/rlae 4 Rev. Latino-Am. Enfermagem 2020;28:e3329.  No change was proposed.

Procedure
To include phrases related to patient safety (raise bed rails, remove the plastic covering venous access after the bath, and concomitantly clean the patient's bed and furniture with 70% alcohol solution).
To include phrase related to inform of the need to practice hygiene of the upper and lower limbs on the opposite side of the professional washing the patient and include a modified technique of the procedure for patients with reduced mobility and/or who are unconscious.
To include the justification of why not to apply comforting massage vigorously on bone prominences and where pressure injuries are starting to appear (stage I) and keep the call-light close to the patient after bathing. The text order was changed regarding the procedure for unconscious patients or patients with reduced mobility.
No change was proposed.
No change was proposed.

Complications
To include other bath-related complications (microbial translocation).
To include interventions to prevent complications such as changing the dressings affixing tubes and probes after bathing.
To include interventions to prevent complications such as covering the peripheral venous access to prevent infection.
To include information about keeping patients in severe condition under hemodynamic monitoring. The video was re-edited implement these changes and then the video was presented once more to the nurses; no further changes were suggested at that time.
Afterwards, the video was assessed by the nursing undergraduate students, who scored the level of comprehension for each topic and the video as a whole.
All scores were greater than 4 (Table 3) and the percentage of maximum scores was high, ranging from 77% to 95% (

Discussion
Various steps that can be taken to develop a video, but the most frequently used are: planning or pre-production, filming or production, editing or postproduction (10) . Planning is essential to ensuring the success of the subsequent steps, and this study presents the development and validation of a storyboard, which portrays (lines and images) exactly what is addressed in the video, in addition to guiding the filming and avoiding the need to re-editing (10,12) . The script was composed of four topics: definition, indication, procedure, and complications in order to address all the knowledge necessary to teach students and the population that will use this tool.
The Delphi Technique was used to validate the script. Even though it has seldom been used for this specific purpose, it has been used to validate instruments and manuals through expert consensus (11) . The experts were nursing professors from the Fundamental Nursing Program and professional nurses and the experience of judges on the topic was taken into account; both professionals had experience with this procedure (bed bath) in their professional routines (11) . The choice of 100% inter-judge agreement was intended to lend greater rigor to the planning phase, though a mean of 75% consensus is generally used (18) .
Six rounds were necessary to validate the script, a number larger than that reported in the literature (two to three rounds) (18) . We believe this result is due to the size of the script, which contained 18 pages, and the fact the experts did not communicate during the assessments, The objective of this information is to prevent and/or not worsen pressure injuries (20) . Another suggestion was to keep the call-light close to the patient after the bath, especially for the bedridden. One study emphasizes that not having devices to call the health staff is a risk factor for falls, which compromises the safety of patients (21) .  (1) . The nurse who played the role of a patient recorded scenes related to orientation provided by the health worker and scenes of the technique that did not involve body exposure. The use of professionals who experience the procedure in their practice substantiates the technique and facilitates recording (10,12) . The video's final version, i.e., after editing, was 21 minutes and 21 seconds long. Studies suggest that a video should not last more than 10 to 20 minutes (10) , in order to avoid hindering comprehension of content on the part of viewers and also due to the difficulty disseminating the material on the internet (10)(11) . In this case, however, parts of the video can be viewed separately, while the most extended topic is the description of the procedure, with 17 minutes and 24 seconds.
After the editing, the video was first watched by professors, who had participated in the script validation, so that they could identify potential gaps; a few adjustments were suggested and then implemented. The study's limitation is related to the size of the script, which may have hindered the experts' assessments.

Conclusion
A video addressing bed bathing was developed and validated. The video was composed of four topics addressing the definition of bed bathing, the indications for this type of bath, steps to execute this procedure, and related complications. This study is expected to contribute to professional training and improvement of the knowledge and skills of nursing students.