Construction and validation of a booklet of perioperative orientation and patient safety

Construcción y validación de un folleto para la orientación perioperatoria y la seguridad del paciente

ABSTRACT

Objective:

To describe the development and validation process of a booklet with perioperative guidelines for surgical patients.

Method:

This is a methodological, quantitative study, divided into three stages: narrative review, booklet preparation and validation with 23 judges, nurses specialized in patient safety/perioperative nursing, who answered the online Educational Content Validation Instrument. The booklet was considered valid when each item obtained a Content Validity Index equal to or greater than 0.8.

Results:

The elaborated material was divided into four items: surgical patient safety; preoperative guidelines; the surgical center; guidelines after surgery. The overall Content Validity Index in the validation with judges was 1.0, considered gold standard.

Conclusion:

The booklet was validated by experts regarding objectives, structure/presentation and relevance.

Keywords:
Perioperative nursing; Patient safety; Health education

RESUMEN

Objetivo:

Describir el proceso de elaboración y validación de un folleto con directrices perioperatorias para pacientes quirúrgicos.

Método:

Estudio metodológico, cuantitativo, dividido en tres etapas: revisión narrativa, elaboración del cuadernillo y validación con 23 jueces, enfermeros especializados en seguridad del paciente/enfermería perioperatoria, que respondieron al Instrumento de Validación del Contenido Educativo online. El cuadernillo se consideró válido cuando cada ítem obtuvo un Índice de Validez de Contenido igual o superior a 0,8.

Resultados:

El material elaborado se dividió en cuatro ítems: seguridad del paciente quirúrgico; pautas preoperatorias; el centro quirúrgico; pautas después de la cirugía. El Índice de Validez de Contenido global en la valoración con juicios fue de 1,0, considerado estándar de oro.

Conclusión:

El folleto fue validado por los expertos en cuanto a los objetivos, la estructura/presentación y la relevancia.

Palabras clave:
Enfermería perioperatoria; Seguridad del paciente; Educación en salud

RESUMO

Objetivo:

Descrever o processo de elaboração e validação de uma cartilha com orientações perioperatórias para os pacientes cirúrgicos.

Método:

Estudo metodológico, quantitativo, dividido em três etapas: revisão narrativa, elaboração da cartilha e validação com 23 juízes, enfermeiros especialistas em segurança do paciente/enfermagem perioperatória, que responderam ao Instrumento de Validação de Conteúdo Educacional via online. A cartilha foi considerada válida quando cada item obteve Índice de Validade de Conteúdo igual ou superior a 0,8.

Resultados:

O material elaborado foi dividido em quatro itens: segurança do paciente cirúrgico; orientações pré-operatórias; o centro cirúrgico; orientações após a cirurgia. O Índice de Validade de Conteúdo global na validação com juízes foi 1,0, considerado padrão-ouro.

Conclusão:

A cartilha foi validada pelos especialistas em relação aos objetivos, estrutura/apresentação e relevância.

Palavras-chave:
Enfermagem perioperatória; Segurança do paciente; Educação em saúde

INTRODUCTION

The surgical period impacts the patient’s life, changes their daily lives, generates family complications, fear, anxiety and insecurity, especially when they do not receive adequate orientations on the surgical intervention1. The patient’s anxiety regarding the surgical anesthetic act can generate physiological repercussions, such as altering the release of cortisol and anti-insulin hormone, raise blood pressure levels, heart rate and predisposing to arrhythmias in the intra and postoperative period, distorted perception of postoperative pain and reduce their level of satisfaction with the procedure2^,3.

The nursing visit, an integral part of the Systematization of Perioperative Nursing Care (SPNC), can be a way of attenuate the patient’s anxiety and expand their knowledge about the perioperative period and consists of a moment in which the nurse can guide and clarify the patient's doubts about the anesthetic-surgical act. Preoperative orientation is efficient in reducing anxiety, depression, hospital stay and postoperative complications1^,2.

In addition to specific surgical orientations, there is information related to patient safety that can enhance safer care and make the patient a protagonist in their care. The surgical center is a risk space for incidents, with higher rates of adverse events than other hospital units, which may be related to the complexity of the environment and the profile of the patient treated4. Patient safety is understood as a set of actions that allow reducing, to an acceptable minimum, the risk of damage to the patient during health care5.

A well-oriented patient can help to prevent several adverse events, such as surgical site infection, by understanding the process of hand hygiene, care with the preoperative bath, hair removal and the surgical wound. Or even, prevent the execution of wrong/inadequate procedures by knowing more about preoperative preparation related to fasting, medication use, laterality demarcation and/or surgical incision level. It is important for the patient to know what information is relevant for their surgical preparation, in order to transmit it to health professionals6.

To carry out preoperative orientation, nurses can have several pedagogical strategies, such as the use of instructional materials, such as booklets and leaflets, to carry out the orientations related to the surgical period and patient safety, that allow the recovery of the information orally transmitted by the nurse and the consultation in case of doubts, helping health professionals, patients and family members, in addition to constituting devices that facilitate the teaching-learning process, which can contribute to the improvement of the population’s living and health conditions7.

It is noteworthy that educational materials, in addition to undergoing a careful process of content selection, must also be evaluated before being used by the benefited population. Content validation is, therefore, an important step, as it evaluates the representativeness of the material produced and points out the need for adjustments and improvements8.

During the execution of the actions of an extension project aimed at the safety of surgical patient, it was identified the need to develop a booklet that would allow surgical patients to resume the information addressed during visits, reinforcing the patient’s understanding of their surgical trajectory and expand their knowledge about actions aimed at ensuring their safety, in order to make them a protagonist in ensuring their compliance.

Given the above, the present study aims to describe the process of elaboration and validation of an educational booklet with perioperative orientations for surgical patients.

METHOD

Methodological study, with a quantitative approach, based on the theoretical framework of Echer9, for the construction and validation of an educational booklet on perioperative orientations for surgical patients, conducted in three stages: narrative review of the literature; elaboration of an educational material in the form of a booklet; and validation of the booklet’s content by judges. The first and second stages took place between May and October 2020, and the third stage, between December 2020 and January 2021.

Stage 1 - Narrative review of the literature

A narrative review was performed in order to identify the general orientations necessary for surgical patients, in addition to patient safety strategies that may interfere with their surgical trajectory, published between 2005 and 2020. The delimitation period was after the publication of the first international challenge of patient safety.

The search was conducted in May and June 2020, using the descriptors “Patient Safety”, “Perioperative Period” and “Nursing Care”, combined with the Boolean operator AND. Articles and other publications available in full were included. The search in databases returned 116 publications, 111 in the Virtual Health Library (VHL), two in the Scientific Electronic Library Online (SciELO) and three in the Latin American and Caribbean Health Sciences Literature (LILACS). Searches were also carried out in books, manuals and patient safety protocols of the Ministry of Health and in the Guidelines for Practice in Surgical Nursing and Processing of Health Products of the Brazilian Society of Surgical Center Nurses and Material and Sterilization Center (Sociedade Brasileira de Enfermeiros de Centro Cirúrgico e Centro de Material e Esterilização - SOBECC)10.

After reading the material and discussion, the authors chose to analyze and extract the information for the construction of the booklet of the manuals and patient safety protocols of the Ministry of Health and the Guidelines for Practices in Surgical Nursing and Processing of Health Products of SOBECC. The material of the Ministry of Health5 is the guiding axis of the actions of orientations of the patient safety program in the country and the SOBECC guidelines gather and present the best evidence for the care of surgical patients10.

Stage 2 - Elaboration of the booklet

The booklet construction process was based on the three recommended aspects for the elaboration of educational materials printed in health: language, illustration and layout/design11^,12.

Stage 3 - Validation of the booklet

Nurses who met at least two requirements described by Jasper13, were included in the study, defined as characteristics: minimum professional experience of five years (clinical, teaching and/or research); with technical-scientific production in the areas of perioperative nursing and/or patient safety; and with an academic degree of specialist, master or doctor. Those who did not respond to the questionnaire within the time indicated in the invitation email address were excluded.

The sample calculation to determine the number of judges was obtained using the formula n=Za².P(-1-P)/e². The stipulated values were Za (confidence level) = 95%, P (proportion of judges’ agreement) = 85% e (accepted difference from what is expected) = 15%, which resulted in 22 judges14. Considering the possibility of sample loss, 55 nurses were invited, however, 23 responses were obtained within the stipulated period for evaluation and completion of the form.

The selection of judges was performed through a search and analysis of curricula on the Lattes Platform, with the insertion of the terms patient safety, surgical nursing and perioperative nursing. After evaluating the curricula and verifying compliance with the inclusion criteria, a random selection of 55 curricula was made. Then, the participants were invited by means of an electronic address (e-mail) to participate in the research. If they expressed their agreement through the Free and Informed Consent Form (FICF), they received the research instruments and booklet in PDF.

Data collection took place online, through the electronic tool Google Forms, including data related to the characterization of the judges (age, gender, qualification, state, training time, current occupation, experience and publication on the subject) and the Instrument Educational Content Validation Instrument (IVCES), built and validated by Brazilian researchers8, which has 18 items, distributed in three domains, namely: objectives (purposes, goals or purpose of the booklet), structure/presentation (organization, structure, language, coherence and text size) and relevance (significance, impact, motivation and interest in reading the booklet). Each item contained affirmative sentences and, after reading the material and analyzing the booklet, the judges could evaluate the item as totally agree, partially agree, or disagree. In addition, in each domain evaluated, the judges could make considerations if they deemed necessary.

Data organization and analysis

Data organization and analysis were performed using the Statistical Package for the Social Sciences-SPSS, version 19. To characterize the judges, a descriptive analysis of the data was performed, with the calculation of absolute and relative frequencies. To verify the content validity of the booklet, the Content Validity Index (CVI) was used: calculating the I-CVI (Item-Level Content Validity Index) for each item in the instrument and the overall CVI. The booklet was considered valid when each item had a CVI equal to or greater than 0.8⁽¹⁵⁾. To verify the agreement, statistically, equal to or greater than 0.80 of the judges, the binomial test was used. The significance level adopted in the study was 5%.

Ethical aspects

The study was approved by the Human Research Ethics Committee of the proposing institution, under Opinion 3,399,532 (CAAE 14113819.2.0000.5545). The entire research process and the use of data followed the terms of Resolution No. 466 of 2012 of the National Health Council, therefore, all participants agreed with the FICF.

RESULTS

The content was structured based on practical experience, scientific literature and concerns observed during the orientation of surgical patients, related to the trajectory within the institution, routines, family participation and discharge, and structured in topics in language accessible to the patient.

The material was worked by a graphic designer, hired by the researchers, to create the illustrations (custom characters) and textual layout of the booklet. A comic strip was created that illustrates the surgical care routine, which includes the patient’s arrival at the preoperative unit, reception in the operating room, monitoring, surgery occurrence, recovery in the Post-Anesthetic Recovery Unit (PACU) and discharge from the surgical center (SC).

Therefore, the educational material was didactically divided into the following items:

1) Surgical patient safety: which contains patient identification data (explains the function of the identification bracelet and how to use it); hand hygiene (about the importance of hand washing, the moments in which it should be performed and illustrates the correct steps of hygiene); fall prevention (addresses the risk of falling in the hospital environment and ways to avoid it); surgical safety checklist (explains and highlights the role of the safe surgery checklist, questions that professionals can ask throughout the perioperative period, and illustrates a possible checklist model).

2) Preoperative orientations: related to the preparation of the surgical patient, such as the need for fasting, preoperative hygiene, use of medication, bladder and bowel emptying, skin preparation, removal of prostheses and adornments, separation of laboratory tests, identification of signs and symptoms that, if they occur, must be communicated to the team before surgery, routines and guarantee of patient privacy.

3) The surgical center: which explains what happens to the patient from their arrival in this unit until their discharge. It addresses care in the preoperative unit, in the operating room, in addition to portraying the post-anesthetic recovery room.

4) Orientations after surgery: addresses important information that must be obtained by the patient together with the surgery team that assists him, such as the end of fasting, resumption of life activities, removal of stitches, care with the dressing and evaluation after discharge. Also highlighted in this topic were alarm signs and symptoms that should be reported to the health care team.

Finally, suggestions were listed that can allow the patient to be distracted during the perioperative period, a space for notes of doubts and the inclusion of games with the content worked during the booklet.

In Figure 1, some pages of the final version of the booklet are presented.

Figure 1-
Pages of the booklet “I want to know - Safe Surgery Booklet”. Divinópolis, Minas Gerais, Brazil, 2020

The content validation of the booklet was performed by 23 nurses, with a mean age of 42.4 years (SD=10.8) and professional training time of 18.7 years (SD=10.2), being most women (87%). The nurses participating in the study worked professionally in several regions of the country, such as São Paulo (43.5%), Minas Gerais (30.3%), Santa Catarina (8.7%), Rio de Janeiro (4.3%), Paraná (4.3%), Piauí (4.3%) and Pernambuco (4.3%). Regarding the qualification, 15 were doctors and eight were masters, working in teaching (60.9%), in care (26.1%), in research (8.7%) and one working in teaching and care, simultaneously (4.3%). Regarding experience in the booklet's theme, 95.7% reported working with teaching or care for surgical patients, and the same proportion (95.7%) had already published in the area of ​​perioperative nursing or patient safety.

Regarding the verification of the booklet’s content validity, Table 1 shows the evaluated items and respective values ​​of the agreement proportions and CVI per item (I-CVIs), as well as the p-value of the binomial test. There was an agreement of 100% among all the judges in relation to the 18 items evaluated, being considered statistically significant those with the value of p< 0.05 (Table 1).

Table 1 -
Judges’ agreement in relation to the items in the booklet, Minas Gerais, Brazil, 2020

Item	Totally Agree n (%)	Partially Agree n (%)	I-CVI*	p**
1. Contemplates the proposed theme	22 (95.7)	01 (4.3)	1	0.006
2. Appropriate for the teaching-learning process	21 (91.3)	02 (8.7)	1	0.006
3. Clarifies doubts about the theme addressed	22 (95.7)	01 (4.3)	1	0.006
4. Provides reflection on the theme	23 (100)	0 (0.0)	1	0.006
5. Encourages behavior change	21 (91.3)	02 (8.7)	1	0.006
6. Appropriate language for the target audience	20 (87.0)	03 (13.0)	1	0.006
7. Appropriate language for the educational material	22 (95.7)	01 (4.3)	1	0.006
8. Interactive language, allowing active involvement in the educational process	20 (87.0)	03 (13.0)	1	0.006
9. Correct information	20 (87.0)	03 (13.0)	1	0.006
10. Objective information	21 (91.3)	02 (8.7)	1	0.006
11. Clarifying information	20 (87.0)	03 (13.0)	1	0.006
12. Necessary information	20 (87.0)	03 (13.0)	1	0.006
13. Logical sequence of ideas	20 (87.0)	03 (13.0)	1	0.006
14. Current theme	23 (100)	0 (0.0)	1	0.006
15. Size of the appropriate theme	21 (91.3)	02 (8.7)	1	0.006
16. Stimulates learning	22 (95.7)	01 (4.3)	1	0.006
17. Contributes to knowledge in the area	20 (87.0)	03 (13.0)	1	0.006
18. Awakens interest in the theme	22 (95.7)	01 (4.3)	1	0.006

• Note: ^*Item-Level Content Validity Index; ^**Binomial Test.
• Source: the authors.

The overall CVI of all 18 items in the validation with judges was equal to 1.0, being considered gold standard. In view of these results and the minimal suggestions for modifications to the booklet, only one validation round was carried out with the judges. It is worth mentioning that the judges’ suggestions would not invalidate the material already evaluated and validated and that they were accepted with the aim of further improving the booklet. Among these suggestions, we highlight the changes to some sentences to better understanding of the patient, spelling corrections, inclusion of information on the theme of hand hygiene, preoperative orientations, and the description that the figure on the safe surgery checklist is illustrative.

DISCUSSION

The educational material presented in this manuscript can act as a tool to help patients understand their surgical trajectory and empower them with the safety protocols involved in the surgical process through objective and accessible information. In addition, it is suitable to be used by nurses during preoperative visits and has the potential to support the family of the patient who will undergo surgery.

The validation process demonstrated that the material produced may be able to clarify patients’ doubts, stimulate learning and contribute to the construction of the patient’s knowledge in the face of the challenges that will be faced during the perioperative experience. The validation process allows presenting to the target audience a material that has adequate, clear and understandable content16^).

Nursing professionals can assist in the validation processes of educational materials since they have health education as an inherent point in their work and training. In addition, the booklet is configured as support for educational activities, and can contribute to strengthening the capacity and autonomy of the other17.

Instruments, such as booklets, work as a tool for accessing information, accessible and easy to understand. In this sense, the use of educational technologies printed in the education of the surgical patient contributes to the reduction of anxiety and pain levels; for that, the material must be clear, appropriate for the target audience and subject to consultation during the perioperative period7.

Initiatives for patients to commit themselves to their care process have emerged around the world as a strategy to strengthen patient safety. It is recommended that the same be involved in security actions of the institutions by asking questions, providing information and reporting situations that may lead to a breach of security18.

Regarding the involvement of patients in their surgical trajectory, a study points out that there is a specific desire for information related to the surgical experience, perioperative period and postoperative care. It is evident that patient satisfaction was greater when there was an association of written and verbal information19.

Patients who received preoperative orientation report the use of technical terms by health professionals to explain and guide about procedures that make it difficult to understand. Therefore, it is emphasized that health professionals must precisely guide the patient, in addition to using educational materials that facilitate their understanding12.

It is up to perioperative nurses to provide pre- and post-operative education to patients, in order to welcome them in their physical and emotional aspects20. Therefore, despite being an important tool, the booklet is complementary to the preoperative nursing visit, in which the patient’s evaluation allows that, in addition to the general information contained in the educational instrument, personalized orientations are offered according to the patients clinical condition and surgery.

During the visit, the educational instrument can be adapted to the reality of the patient and the institution in which he will undergo surgery, paying special attention to patients with visual, cognitive, and cultural limitations. Patients are more satisfied with the surgical experience when they receive personalized information and instructions19.

The booklet on perioperative information and patient safety will possibly contribute to nursing practice, by enabling the patient to have access to knowledge about a surgical trajectory and about patient safety protocols, which can be used to their benefit. It is known that surgical patients commonly have doubts about the surgical trajectory, what they should do before the procedure, what information about their health status they should communicate to the team. They do not know about the recovery process, about resuming activities of daily living, performing exercises, sexual life6.

In this case, it is observed the importance of the booklet as an information tool, since this material can be offered as a complement to the verbal orientations provided by nursing. Surgical patients want to be offered a tool that helps them in the surgical preparation and to remember information that should be discussed with health professionals6. Having a material validated by experts can provide more reliability in offering the material to the patient.

It is noteworthy that the material elaborated can be used at different levels of health care for the preoperative preparation of patients. Furthermore, new studies can be developed from the application of the booklet, in different audiences, which will possibly allow new contributions to the perioperative nursing scenario.

However, the use of the booklet should not replace the preoperative visit, considering the individual needs of each patient and possible physical, cognitive and cultural limitations.

Finally, as limitations of the study, we consider the narrative type review used to classify the evidence that based the composition of the booklet and the fact that it was not possible to perform the validation with the target audience. This stage will be carried out when researchers are able to safely return to the hospital and when elective surgeries are normalized, in view of their interruption due to the COVID-19 pandemic.

CONCLUSION

The research promoted the construction and validation of the educational booklet with expert judges on the subject and it is believed that it can be used as a tool in the context of health education at different levels of health care. It is expected that the instrument constructed can assist in the autonomy and empowerment of the surgical patient, as well as support family members and professionals in the care of surgical patients in different scenarios.

New investigations can be conducted using the booklet presented here as an educational element, or even validating it in different populations.

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• Acknowledgment:

  To the Institutional Program for Academic Development in Affirmative Actions (Programa Institucional de Desenvolvimento Acadêmico nas Ações Afirmativas) - PIDAC-Af UFJS for the Scientific Initiation Scholarship.

Edited by

Associate editor:

Wiliam Wegner

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Publication Dates

• Publication in this collection
  26 Aug 2022
• Date of issue
  2022

History

• Received
  25 June 2021
• Accepted
  06 Dec 2021