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ORIGINAL ARTICLE
Acute surgical wound-dressing procedure: Description of the
steps involved in the development and validation of an
observational metric
Josephine Hegarty
1
| Victoria Howson
1
| Teresa Wills
1
| Sile A. Creedon
1
| Pat Mc Cluskey
2
|
Aoife Lane
1
| Aine Connolly
2
| Nuala Walshe
1
| Brendan Noonan
1
| Fiona Guidera
3
|
Anthony G Gallagher
4
| Siobhan Murphy
1
1
Catherine McAuley School of Nursing and
Midwifery, University College Cork, Ireland
2
Nursing Division, Cork University Hospital
Group, Ireland
3
Nursing Division, Mercy University Hospital,
Cork, Ireland
4
Application of Science to Simulation based
Education and Research on Training Centre,
College of Medicine and Health, University
College Cork, Cork, Ireland & Faculty of Life and
Health Sciences, Ulster University, Magee
Campus, Northland Rd, Londonderry BT48 7JL,
United Kingdom
Correspondence
Josephine Hegarty, Catherine McAuley School of
Nursing and Midwifery, Brookfield Health
Sciences Complex, University College Cork, Cork,
T12 AK54, Ireland.
Email: j.hegarty@ucc.ie
Funding information
School of Nursing and Midwifery, University
College Cork, Ireland, Grant/Award Number:
SON&M/ASSERT- ANTT pilot project;
University College Cork
The aim of this study was to develop an observational metric that could be used to
assess the performance of a practitioner in completing an acute surgical wound-
dressing procedure using aseptic non-touch technique (ANTT). A team of clini-
cians, academics, and researchers came together to develop an observational metric
using an iterative six-stage process, culminating in a Delphi panel meeting. A scop-
ing review of the literature provided a background empirical perspective relating to
wound-dressing procedure performance. Video recordings of acute surgical
wound-dressing procedures performed by nurses in clinical (n = 11) and simulated
(n = 3) settings were viewed repeatedly and were iteratively deconstructed by the
metric development group. This facilitated the identification of the discrete compo-
nent steps, potential errors, and sentinel (serious) errors, which characterise a
wound dressing procedure and formed part of the observational metric. The ANTT
wound-dressing observational metric was stress tested for clarity, the ability to be
scored, and interrater reliability, calculated during a further phase of video analysis.
The metric was then subjected to a process of cyclical evaluation by a Delphi panel
(n = 21) to obtain face and content validity of the metric. The Delphi panel delib-
eration verified the face and content validity of the metric. The final metric has
three phases, 31 individual steps, 18 errors, and 27 sentinel errors. The metric is a
tool that identifies the standard to be attained in the performance of acute surgical
wound dressings. It can be used as both an adjunct to an educational programme
and as a tool to assess a practitioner's performance of a wound-dressing procedure
in both simulated and clinical practice contexts.
KEYWORDS
aseptic non-touch technique (ANTT), metric development, proficiency-based
progression training, surgical wound-dressing procedure
1|INTRODUCTION
Every day, approximately 81 000 people acquire a health
care-associated infection (HCAI) in hospitals across
Europe.
1
Surgical site infections (SSIs) are one of the
most common types of HCAI, representing up to 20% of
this patient group. Health care professionals caring for
patients with surgical wounds need specialist expertise,
knowledge, and skills to ensure optimum evidence-based
wound care.
2
However, standardised education for health
Received: 20 August 2018 Revised: 27 December 2018 Accepted: 28 December 2018
DOI: 10.1111/iwj.13072
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2019 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.
Int Wound J. 2019;1–8. wileyonlinelibrary.com/journal/iwj 1
care professionals performing surgical wound dressings is
lacking.
3
The association between microorganisms in the clinical
environment and HCAIs is well accepted.
4
A substantial
number of surgical site infections are caused by microorgan-
ism contamination during and after invasive clinical proce-
dures through surgically initiated breaks in the skin.
5
It is
estimated that nearly 50% of surgical site infections are pre-
ventable by following evidence-based guidelines.
6,7
SSIs are
burdensome on individuals, their families, and on the health
services.
8–10.
Each SSI is associated with approximately 7 to
11 additional postoperative hospital days, and patients with
SSI have a 2 to 11 times higher risk of death compared with
operative patients without an SSI.
11
Given that SSIs are acutely problematic and preventable,
it is important that health care professionals caring for
wounds exercise strict asepsis in order to minimise their inci-
dence.
2
Indeed, the use of aseptic technique for changing or
removing wound dressings is one of the most important
components of wound management given that a break in
aseptic non-touch technique (ANTT) potentially causes the
introduction of exogenous microbes, thereby contaminating
the wound.
12
1.1 |Aseptic non-touch technique
“Aseptic non-touch technique”is a term applied to a set of
specific practices used to ensure asepsis and prevent the
transfer of potential pathogens to a susceptible site on the
body (eg, an open wound or insertion site for an invasive
medical device) or to sterile equipment/devices.
13
Non-touch
(of key parts and key sites) is an integral component of
ANTT and is the cornerstone of recommended best practices
during surgical procedures.
12
The National Institute Clinical
Effectiveness (NICE) recommends the use of ANTT for
changing or removing surgical wound dressings and the use
of sterile saline for wound cleansing up to 48 hours after sur-
gery. The National evidence-based wound management
guidelines, 2009 recommend using an aseptic wound tech-
nique when the individual is immuno-compromised or if the
wound is located in a sterile body cavity, for example,
nephrostomy or central venous line,
14
whilst the Australian
National Safety and Quality Health Service Standards rec-
ommend that health care professionals be trained in ANTT,
that compliance with ANTT is audited, and that actions are
taken to increase compliance with ANTT.
15
Practical
evidence-based recommendations published to assist acute
care hospitals in preventing SSIs include the recommenda-
tion to “evaluate wound care practices”.
11
In relation to the
type of dressings used, a Cochrane review found no clear
evidence that one dressing type was better than any other or
that covering wounds with any dressing at all reduced the
risk of SSIs.
16
However, the review authors noted that the
number of studies was very small and that the level of evi-
dence was low or very low and recommended that decisions
relating to wound dressings be based on patient and clinician
preferences and dressing costs.
Despite substantial focus being placed on the importance
of the correct performance of aseptic technique,
5,12
it
appears that achieving the correct technique is problematic
in clinical practice.
5,17
Lack of provision of feedback to
health care professionals regarding HCAI prevention strate-
gies, such as ANTT, may be a contributory factor.
3
It may
be that the procedural elements of ANTT are unclear and
would benefit from closer analysis and examination to
ensure that health care professionals are cognisant of the
exact steps to be taken in the use of the non-touch technique.
Optimal performance of the aseptic technique relies on
effective staff training in infection control, safe environ-
ments, and equipment that is fit for purpose.
18
Given that
ANTT is used in the performance of most acute surgical
wound dressings in hospital wards, more research is required
to develop a valid metric, which can be used to train practi-
tioners to become proficient in performing ANTT and to
audit their practice.
1.2 |Proficiency-based progression training
There have been public concerns in recent years regarding
the skills of some health care professionals, with many high-
profile cases linked to the suboptimal performance of practi-
tioners.
19,20
In addition, there has been public discourse
around the fact that trainees in some disciplines are graduat-
ing with considerably less clinical experience than might
have been the case historically. This has prompted a change
in the pedagogical approach taken to the teaching of high-
volume and high-risk technical and non-technical skills. It
appears that providing trainees with precise feedback on
their performance and with specific recommendations for
improvement proximate to their performance is the optimal
training style.
21,22
This approach to training is referred to as
proficiency-based progression training (PBPT).
23
It recom-
mends that trainees be provided with a quantitative
Key Messages
•it is estimated that up to 60% of surgical site infections are
preventable by following evidence-based guidelines
•health care professionals responsible for patients with wounds
require a level of expertise and education to ensure optimum
wound care
•an observational metric for acute surgical wound-dressing pro-
cedures using aseptic non-touch technique (ANTT) was
developed
•the final metric had: three phases, 31 individual steps,
18 errors, and 27 sentinel errors and provides a standard of
measurement that can be used to objectively assess
performance
2HEGARTY ET AL.
performance benchmark to work towards, and this bench-
mark should be a valid representation of the procedure.
22
PBPT requires learners to practice until a performance
benchmark is unambiguously demonstrated. Feedback using
metrics that clearly define performance criteria and delineate
deviation from optimal performance is a key element of
PBPT. This approach relies on a comprehensive and quanti-
tative characterisation of a skill to be learned for a certain
procedure. In the present study, the procedure is acute surgi-
cal wound dressings. The performance characteristics, or
“metrics”, and their “operational definitions”offer very spe-
cific goals and guidance, which can be used as part of a
training curriculum for trainee health care professionals.
Many health care professionals perform aseptic tech-
niques, but, with time, their actions may become automated,
and it is difficult for trainees to pick up the level of intricate
detail needed to become “proficient”in their performance. It
is challenging to identify the key features that characterise
optimum performance given that health care professionals
rarely think about performing the aseptic technique in micro
detail. The units of performance that constitute a skill can be
quantified with a “task analysis”or breakdown of the key
steps and actions imperative for the procedure. The steps
then need to be operationally defined and not simply
described. The definition or “metric”for a specific procedure
provides a standard of measurement that can be used to
objectively assess performance. Thus, this study set about
objectively developing such a metric for ANTT wound-
dressing procedures.
The primary aim of the present study was to develop an
observational metric to assess the performance of a practi-
tioner in completing an acute surgical wound-dressing pro-
cedure using ANTT. The secondary aim was to validate the
appropriateness of the metric steps, errors, and sentinel
errors identified within the metric.
2|MATERIALS AND METHODS
2.1 |Study Design
A team of clinicians, academics, and researchers came
together to develop an observational metric using an iterative
six-stage process, culminating in a Delphi panel meeting.
The developmental process was underpinned by PBPT prin-
ciples (Figure 1).
2.2 |Scoping review of literature
EBSCO (CINAHL with full text and Medline) and Cochrane
were searched using a combination of search terms divided
into two main concepts: Aseptic non-touch technique (asep-
tic, “aseptic technique”,“aseptic non-touch technique,”
ANTT, dressing, “clean technique”,“sterile technique”, ster-
ile) AND wound (wound, “wound care”,“wound infection”,
“wound management”,“surgical wound infection”,“surgical
site infection”,“surgical wound care”, incision, drain, suture,
staple). The search was extended to include literature per-
taining to central venous catheters as well (“venous cathe-
ter”,“central line”,“peripherally inserted central catheter”,
PICC, Hickman). Each concept was searched as a group and
then as a combination with the Boolean terms “OR”and
“AND”, respectively. Reference lists of included papers
were reviewed.
Inclusion criteria were papers that: were published within
the timeframe of January 2006 to January 2017, were written
in English, and presented primary empirical data or were
structured reviews. Papers were included if they presented
an analysis that (a) focused on the processes for preventing
contamination of wounds during a wound-dressing proce-
dure in adult patients in the acute care setting, (b) examined
the clinical effectiveness (harm/benefit) of ANTT,
(c) evaluated the effectiveness of an ANTT educational
FIGURE 1 The study followed a number of distinct stages as outlined in this graphic
HEGARTY ET AL.3
programme in the context of dressing a wound or central
line, and (d) empirically derived the steps involved in per-
forming an acute surgical wound dressing. The team also
reviewed manufacturer guidelines for various wound-
dressing products.
Retrieved search hits from EBSCO (n = 5993) and from
Cochrane (n = 82) were exported to EndNote (version 7)
where duplicates (n = 1893) were identified and removed.
All remaining papers from both searches (n = 4182) were
uploaded to “Covidence Online.”Title and abstract screen-
ing identified 442 papers for full-text screening, with
7 papers being deemed eligible for inclusion. Selected
papers underwent a full-text assessment (JH, DD, VH), and
eligibility issues were resolved with a third author (SC).
2.3 |Procedure for obtaining videos of wound
dressings being performed
Nurses working in areas where they routinely performed
wound dressings self-selected to partake in the study. A
GoPro camera was mounted on the forehead of nurses
while performing an acute surgical wound-dressing proce-
dure. The nurses were given directions to start the proce-
dure from the very beginning, progressing through the
procedure to the disposal of waste and performance of hand
hygiene as per their normal nursing daily routine. The
nurses were not interrupted or guided during the procedure.
Video recordings were stored on a secure university server
that was only accessible to select members of the research
team (n = 3). A further three Additional recordings were
attained using mannequins in the simulated context from
three experienced nurses with specialist expertise in per-
forming wound dressings. Attaining recordings from nurses
with a variety of experiences in performing wound dress-
ings ensured variation in the level of experience of those
performing the procedures and enhanced the researchers’
understanding of the nuanced variation in the performance
of the procedure.
2.4 |Task analysis and interrater reliability
Key terms associated with the development of the metric are
identified in Table 1. Video recordings of acute surgical
wound-dressing procedures performed by nurses in clinical
(n = 11) and simulated (n = 3) settings were viewed repeat-
edly and iteratively. Team members conducted a “task anal-
ysis”, deconstructing the procedure into a series of
procedural “steps.”Procedural potential “errors”and “senti-
nel errors”were also identified. During the process of itera-
tive reviewing of the videos, each metric step was identified,
and the step was defined to include both a beginning and
endpoint. Such a precise definition of each step allowed for
unambiguous scoring of the step as having either occurred
or not occurred, with a high degree of reliability. The obser-
vational metric included both the specific operative steps
and the general order in which the steps should be accom-
plished. Procedural phases were specified for groups of
related steps. The task analysis and initial stress testing of
the developed metric (stages 3 and 4 [Figure 1)] took
2.5 days for the team to complete (20 hours). After the
primary members of the metric development group were
satisfied that the entirety of the procedure had been charac-
terised, the metric was then stress tested so that inter-rater
reliability of the metric could be scored. Two members of
the team watched videos in silence a maximum of three
times before calculating the level of agreement between
raters when scoring a nurse's performance when doing a
wound dressing procedure. The process of independent
viewing, scoring, and revising the step and error metrics was
continued until the metrics group was satisfied that the
TABLE 1 Metric definitions
22,36
Glossary Definition
Step (S) A component task or defined unit of behaviour,
the series aggregate of which constitutes the
completion of a specific procedure
Error (E) A deviation from optimal performance
SE Is an event or occurrence involving a serious
deviation from optimal performance defined
by events that, by themselves, could lead to
any of the following: contamination of the
wound; surgical site infection; risk of health
care professional exposure to bodily fluid, or
broader risk for hospital acquired infection
Wound The wound in this context is the surgical wound.
The wound boundaries are defined as the area
encompassing the staple or suture insertion
points, incision line of wound and/or perimeter
of wound drain
Aim of aseptic
technique
Asepsis: is the prevention of the transfer of
pathogenic microorganisms to the wound. In
the context of the wound dressing this is the
set of procedures performed which seek to stop
the direct transfer of microorganisms to the
wound through contact with other surfaces,
equipment or persons (health care worker or
patient).
Aseptic field A designated aseptic working area that contains
the equipment needed for the procedure and
the external surface of the sterile gloves
Violation of aseptic
non-touch technique
The asepsis of “key-parts”and “key-sites”were
not fully protected during the wound dressing
as they were contaminated through clear and
explicit contact with contaminated surface(s),
equipment or persons (patient or health care
professional). Non-touch technique also
involves the avoidance of touching key parts
and key sites with gloved hand
Key site Is the wound incision/site
Key part Are the surfaces that come in direct contact with
the wound
Violation of aseptic
dressing field
That is a clear and explicit contamination of
either the
upward facing surface of the opened dressing
pack or
external surface of sterile gloves or forceps if
used to touch a key part or key site
Contamination Occurs by contact with other contaminated
surfaces, equipment or persons (patient or
health care professional)
4HEGARTY ET AL.
metric accurately characterised the procedural steps of an
acute surgical wound-dressing procedure with a consistent
inter-rater reliability ≥0.85. Once the team was satisfied with
the metric, it was brought to a Delphi panel meeting (Stage
6, Figure 1).
2.5 |Delphi panel meeting
The development of the Delphi method has been attributed
to Dalkey and Helmer,
24
although the conceptual roots can
be traced further back in time.
25
The pivotal components of
this type of research are the identification of a panel of
experts and use of a multi-stage iterative approach, with each
stage building on the results of the previous, coming closer
to the desired result as the number of iterations increase.
22,25
In the case of the ANTT wound-dressing observational met-
ric, the desired result was consensus on the appropriateness
of the metric in its definition of steps, errors, and sentinel
errors. This consensus was acquired by means of repeated
cycles of questioning; deliberation; modification of the met-
ric; and ultimate voting on the definitions, steps, and errors.
Twenty-one members of the Delphi panel attended the for-
mal meeting. The meeting began with a presentation that
introduced the Delphi panel to the metric and the objectives
and goals of the meeting and an overview of ANTT, acute
surgical wound-dressing procedures, PBPT, and any other
definitions and components important to understanding the
metric (Table 1).
An affirmative vote by a Delphi panel member indicated
that the metric steps presented were accurate and acceptable
as written but not necessarily that it was the manner in which
that particular panellist might have chosen to complete the
steps. This was in recognition that slightly different
approaches to acute surgical wound-dressing procedures are
taken in different settings. “Consensus”meant that all Del-
phi panel members agreed with the definition of phases,
steps, and that they were “not wrong”(pg.1434)
21
while
recognising that individuals may have personal preferences
for the sequencing of particular steps.
Each of the phases were broken down into their steps
and errors and evaluated individually by the panel. The
panel had a copy of the metric and were facilitated to read
through each step as it was discussed. If consensus could not
be reached or there was disagreement, the metric was modi-
fied according to feedback using an onscreen version of the
metric, and a new vote on the acceptability of the modified
metric was carried out. This meant that, throughout the pre-
sentation of the steps, any modifications that were suggested
could be altered immediately, and so, the final modifications
could be seen, saved, and then voted on by all attendees.
This process was repeated until each phase had been
voted on.
2.6 |Ethics
Ethical approval was received from the local Clinical
Research Ethics Committee, and approval was given to enter
the hospitals. Potential participants were given full informa-
tion about the study and assured of anonymity. Written con-
sent was obtained from both nurses and patients in the case
of clinically based observations.
2.7 |Statistical analysis
The inter-rater reliability was expressed by Cohen's Kappa
(κ) for each item (step, error, and sentinel error) separately.
26
Reliability κscores ≥0.85 were considered appropriate for
this study.
The developed metric was scored for (a) number of steps
observed/total number of steps, (b) number of errors obser-
ved/total number of potential errors, and (c) number of errors
observed/total number of potential sentinel errors.
3|RESULTS
3.1 |Review of literature
A number of relevant papers were sourced (n = 13).
3,27–38
The team also reviewed manufacturer guidelines (n = 3) for
various wound-dressing products and the Royal Marsden
Procedural Manuel.
18
This information described how the
development process should begin and what areas of the pro-
cedure the metric should focus on but did not supply the
team with a tool that could be adapted.
The papers provided background perspectives on the
potential effectiveness of ANTT in the provision of care to
surgical patients. However, there was a lack of high-quality
empirical evidence on the actual measured benefits or harms
of using ANTT generally or in the performance of acute surgi-
cal wound-dressing procedures (ie, in reducing mortality, hos-
pital acquired infection rates, and surgical site infections) in
the reviewed literature. The papers reviewed shared a common
theme, which is the lack of empirically derived and tested edu-
cation and training initiatives surrounding the implementation
of ANTT for acute surgical wound-dressing procedures in the
clinical settings. In addition, the wound-dressing requirements
for acute surgical wounds were not differentiated according to
patient risk categories, types of surgery (elective, emergency),
operative time, size of wound, presence/absence of drains, or
surgery type involving entry to larger body cavities (eg,
abdominal and thoracic cavities). The focus within the
reviewed papers was predominantly on the uncomplicated
clean surgical wound healing by primary intention.
3.2 |Task analysis and inter-rater reliability
The videos of nurses performing wound dressings were
reviewed iteratively. The majority of the video recordings
HEGARTY ET AL.5
showed dressing changes of wounds that were relatively
large (>13 cm), often included a port entry for a drain, and
involved the care of patients with complex comorbidities.
A group of experts from academic (n = 8) and clinical
(n = 4) fields reviewed past literature, the evidence pertain-
ing to the steps involved in and performance of an acute sur-
gical wound dressing procedure, and the videos of
practitioners performing the wound dressings.
The created metric was broken down into three phases,
and each phase contained a series of related, explicitly
defined, and observable steps. Each step had a clearly
marked beginning point and endpoint. All steps, errors, and
sentinel errors that occur throughout the metric are outlined
in Tables 2 and 3.
3.3 |Delphi panel meeting
During the modified Delphi panel, all phases of the procedure
were accepted. The alterations that occurred during the panel
meeting were documented and applied to the metric. Changes
included: replacement of the word “clean”trolley with “disin-
fect”trolley surfaces; clarifications regarding the term “critical
aseptic field”; the application of the WHO five moments for
hand hygiene;
39
and the sequence of removing an apron, gloves
at the bed side. After the Delphi panel meeting, consensus was
reached for three phases, 31 steps, 18 errors (13 unique errors),
and 27 sentinel errors (7 unique sentinel errors) within the
observational metric. Some errors could be observed repeatedly,
for example, incorrect hand hygiene technique (Table 2 and 3).
Notably, other procedural requirements relating to the
preparation of the patient, consent, health care professional,
environment and assessment of a wound, and matching the
wound requirements with appropriate dressings are part of a
broader educational programme and are difficult to observe
objectively within an observational metric.
4|DISCUSSION
The aim of this study was to develop an observational metric
to assess the performance of a practitioner in completing an
TABLE 2 Three phases of acute surgical wound dressing and abridged
summary of the steps within the procedure post-Delphi process
Phase I
1. Disinfect top shelf of dressing trolley with alcohol wipe(s)
2. Disinfect bottom shelf of dressing trolley with alcohol wipe(s)
3. Disinfect all the legs of trolley in turn with alcohol wipe(s)
4. Dispose of all used alcohol wipe(s)
5. Gather basic equipment/products for wound dressing
6. Check expiry dates of solutions
7. Performs hand hygiene (before touching patient)
Phase II
8. Don apron (before exposure of wound)
9. Expose dressing area
10. Performs hand hygiene (before clean aseptic procedure)
11. Open the dressing pack and lay it flat to create a critical aseptic field
on the top shelf of trolley
12. Pick up non-clinical waste bag
13. Pick up clinical waste bag
14. Pour pertinent solutions into liquid compartments of dressing tray
15. Open equipment items using non-touch technique and place items of
equipment needed for dressing on critical aseptic field
16. Remove the soiled dressing
17. Place soiled dressing in clinical waste bag
18. Performs hand hygiene (after body fluid exposure risk and before
dressing procedure)
19. Don sterile gloves using non-touch technique
20. Dispose of sterile glove wrapper
21. Place sterile drape adjacent to/under wound
22. Clean wound (if required)
23. Dispose of each used swab into the clinical waste bag
24. Apply new sterile dressing
Phase III
25. Remove gloves at the bedside and dispose
26. Perform hand hygiene immediately after removing gloves
27. Remove apron and dispose in waste bag
27. Dispose of non-clinical waste
29. Dispose of clinical waste
30. Perform hand hygiene (after touching patient/patient surroundings
and exposure to bodily fluid)
31. Decontaminate and clean trolley
TABLE 3 Summary of metric errors (E) and sentinel errors (SE)
1. Failure to use stainless steel trolley with two shelves. (E)
2. Failure to use visibly clean trolley. (E)
3. Did not gather equipment in advance of procedure (E)
4. Failure to perform hand hygiene. (SE)
5. Incorrect hand hygiene. (E)
6. Apron not put on. (E)
7. Violation of aseptic non-touch technique. (SE)
8. Violation of aseptic dressing field. (E)
9. Used bare hands to remove dressing. (SE)
10. Failure to remain within the boundaries of the wound when cleaning
wound. (SE)
11. Swab used for more than one cleaning wipe/motion. (SE)
12. If cleaning peri-wound area, violation of aseptic non-touch technique
observed. (SE)
13. Crossed over the critical aseptic field whilst holding a used swab. (E)
14. Failure to drop the used swab into the clinical waste bag. (E)
15. At any point during phase II of the procedure the practitioner leaves
the patient. (E)
16. Wound is exposed for any period (over and above procedural
requirements) prior to the application a new dressing (e.g. ward
round facilitated during dressing procedure, awaiting review by
another health care professional, equipment not available). (E)
17. Failure to remove the gloves at the bedside. (E)
18. Failure to remove the apron at the bedside. (E)
19. Steps (glove removal, hand hygiene, apron removal) to be completed
in the order stipulated. (E)
20. Failure to dispose of non-clinical waste materials into a non-clinical
waste bag. (E)
21. Failure to place contaminated materials in the clinical waste bag at
bedside. (SE)
6HEGARTY ET AL.
acute surgical wound-dressing procedure using ANTT and
to validate the appropriateness of the metric steps, errors,
and sentinel errors identified within the metric.
Results showed that an acute surgical wound dressing
can be deconstructed into the essential procedural phases
and steps; the potential errors related to the procedure can be
identified and characterised; and face and content validity
for the resulting step and error metrics can be obtained
through use of the modified Delphi panel technique.
Clare and Rowley
40
demonstrated that standardising asep-
tic technique for invasive IV procedures using the ANTT—
Clinical Practice Framework (CPF), increased staff mean
compliance with hand hygiene, glove use, key-part protection,
use of a non-touch technique, key-part cleaning, and aseptic
field management (P≤0.001).
40
Thus, having validated met-
rics are essential in defining optimum standards of perfor-
mance.
41
The methodology used in this study provides a
framework for the development of such metrics and stan-
dards.
22
Metrics, thus, not only define how training should be
characterised and procedures performed by the student or
practitioner but also afford the opportunity for meaningful
assessment of performance and progress.
41
The metric provides a step-by-step guide underpinning
the procedure of an acute surgical wound dressing whether
carried out by a novice or expert. The metric is a tool that:
reflects the standard to be attained in the performance of acute
surgical wound dressings; supports future educational pro-
grammes relating to wound-dressing procedures; assesses the
impact of educational programmes relating to wound-dressing
procedures; and can be used to audit procedure performance
in clinical practice. However, there is a need for training in
the use of a metric to ensure consistency in its application.
Key challenges encountered while doing this research
included: technical difficulties with the Go Pro camera and
keeping the camera charged while in use. There were many
variations in the performance of acute surgical wound dressings
observed relating to the use/non-use of non-sterile gloves, use
of a clean and dirty hand technique, and double gloving. Some
variations in clinical practice were attributable to local prefer-
ences for dressings after different types of surgeries, differences
in the content, and arrangement of dressing packs. Challenges
encountered by practitioners while performing wound dressings
included: patients touching wounds, limited space while doing
dressings, concurrent cleaning of the environment, and interrup-
tions (eg, consultant rounds, attendance to other clinical needs).
Notably, wound-dressing procedural recommendations
originating from the empirical literature has been structured
around standard non-complicated wounds and day care
patients, whereas the reality of patients in a hospital context
is much different.
4.1 |Strengths and limitations of the study
The use of videos for guiding the development of the metric
and a Delphi panel process lends credibility to the use of this
metric for future educational programmes. This study
focused on acute surgical wound healing by primary inten-
tion, post-major surgeries, as these represented the patients
staying in hospital for longer periods. The research was con-
ducted in only one region in Ireland. Further testing of the
metric in the clinical context would further enhance the
validity of the metric.
5|CONCLUSION AND
RECOMMENDATIONS
The development of robust tools, such as this ANTT wound-
dressing observational metric, helps remove some of the
subjectivity involved in the learning and assessment of these
procedures. When existing wound-dressing metrics were
studied by the team, they lacked indicative detail to make
objective observations a practical reality. We believe that
these metrics can be used for the assessment of the perfor-
mance of wound dressings and to assist learners to self-
assess their own or a peer's performance.
A rigorous process underpinned the development of this
ANTT wound-dressing observational metric, following the
steps involved in PBPT. Routine performance of practices,
such as wound dressings, can benefit from closer and per-
haps even microscopic analysis so that we truly understand
optimum performance and can benchmark what is needed to
deem a health care professional proficient in this procedure.
ACKNOWLEDGEMENTS
This research was funded by the School of Nursing and Mid-
wifery, University College Cork, Ireland. The authors thank
all those who assisted with this project, particularly the
nurses, patients, and Delphi panel members who gave of
their time to be part of this study. We thank Diane Duarte,
Tony Archer, Cathal Brennan, and Jennifer Walshe for their
assistance.
CONFLICTS OF INTEREST
All the authors declare that they have no conflicts of interest
.
ORCID
Josephine Hegarty https://orcid.org/0000-0002-
1663-4820
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How to cite this article: Hegarty J, Howson V,
Wills T, et al. Acute surgical wound-dressing proce-
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ment and validation of an observational metric. Int
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