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Evaluating patient satisfaction in the care of ulcerating metastatic skin lesions Upright, Cheryl Ann 1990

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EVALUATING PATIENT SATISFACTION IN THE CARE OF ULCERATING METASTATIC SKIN LESIONS by CHERYL ANN UPRIGHT B . S . N . , The U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1983 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES S c h o o l o f N u r s i n g We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA September, 1990 (5) C h e r y l Ann U p r i g h t , 1990 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT The purpose o f t h i s t h e s i s was t w o - f o l d : f i r s t , t o d e v e l o p a P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e which r e f l e c t s p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g s used i n t h e c a r e of u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s ; and second, t o e v a l u a t e p a t i e n t s a t i s f a c t i o n and p a t i e n t p r e f e r e n c e w i t h two t y p e s of d r e s s i n g s : M e s a l t d r e s s i n g s and c o n t i n u o u s wet s a l i n e d r e s s i n g s . The P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e was d e v e l o p e d t o measure p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g p e r f o r m a n c e . P a t i e n t s w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s were asked t o i d e n t i f y i m p o r t a n t c h a r a c t e r i s t i c s f o r e v a l u a t i n g p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g s . These q u e s t i o n s were v a l i d a t e d and r e v i e w e d f o r c l a r i t y by t h e p a t i e n t s . A v i s u a l analogue s c a l e was used as t h e r e s p o n s e s c a l e . T e s t i n g f o r r e l i a b i l i t y was l i m i t e d . M e s a l t d r e s s i n g s were compared t o c o n t i n u o u s wet s a l i n e d r e s s i n g s by e v a l u a t i n g p a t i e n t s a t i s f a c t i o n w i t h p r e - d e f i n e d c r i t e r i a . The c r i t e r i a f o r e v a l u a t i o n i n c l u d e d ease o f a p p l i c a t i o n and r e m o v a l , d i s c o m f o r t d u r i n g and between d r e s s i n g changes, c o n t r o l o f odor , and p a t i e n t p r e f e r e n c e . The s t u d y used a c r o s s - o v e r d e s i g n i n which each p a t i e n t used one d r e s s i n g f o r a month and t h e o t h e r d r e s s i n g f o r t h e next month. A l t h o u g h 14 p a t i e n t s were i n v o l v e d i n t h e s t u d y , o n l y 10 were s t a t i s t i c a l l y a n a l y z e d . The r e m a i n i n g f o u r p a t i e n t s were e x c l u d e d because t h e y were u n a b l e t o complete a p o r t i o n o f each t r e a t m e n t . Two major f i n d i n g s were i d e n t i f i e d . F i r s t , r e g a r d i n g t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e , p a t i e n t s w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s had numerous i d e a s about what s h o u l d be asked t o e v a l u a t e p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g s . They c o n s i d e r e d t h e q u e s t i o n n a i r e t o be an a p p r o p r i a t e format and t h e q u e s t i o n s g e n e r a t e d by t h e i n v e s t i g a t o r t o be b o t h i m p o r t a n t and u n d e r s t a n d a b l e . Second, t h e f i n d i n g s o f t h e s t u d y i n d i c a t e d t h a t t h e M e s a l t d r e s s i n g s r e c e i v e d s i g n i f i c a n t l y more p o s i t i v e r a t i n g s when compared w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s f o r ease o f a p p l i c a t i o n and odor c o n t r o l . M e s a l t d r e s s i n g s were a l s o s i g n i f i c a n t l y p r e f e r r e d t o c o n t i n u o u s wet s a l i n e d r e s s i n g s . The knowledge g a i n e d t h r o u g h t h i s s t u d y i s u s e f u l when h e l p i n g p a t i e n t s d e c i d e which d r e s s i n g s t o use i n t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . The M e s a l t d r e s s i n g appears t o be a f a v o r a b l e c h o i c e , p a r t i c u l a r l y when ease o f a p p l i c a t i o n and odor c o n t r o l i s i m p o r t a n t . TABLE OF CONTENTS Page ABSTRACT i i TABLE OF CONTENTS i v LIST OF TABLES v i i L I S T OF FIGURES v i i i ACKNOWLEDGEMENTS i x CHAPTER 1. INTRODUCTION Background o f t h e Study 1 C o n c e p t u a l Framework, 1 Statement o f t h e Problem and Purpose 3 Hypotheses . 5 D e f i n i t i o n o f Terms 6 P a t i e n t , 6 U l c e r a t i n g m e t a s t a t i c s k i n l e s i o n , 6 S a t i s f a c t i o n , 6 P r e f e r e n c e , 7 Assumptions and L i m i t a t i o n s 7 A s s u m p t i o n s , 7 L i m i t a t i o n s , 8 Summary. 8 2. REVIEW OF RELEVANT LITERATURE I n t r o d u c t i o n 9 I n c i d e n c e o f U l c e r a t i n g M e t a s t a t i c S k i n L e s i o n s 9 M e d i c a l Treatment o f U l c e r a t i n g M e t a s t a t i c S k i n L e s i o n s 10 Care of U l c e r a t i n g M e t a s t a t i c S k i n L e s i o n s 11 C l e a n s i n g , 11 B l e e d i n g , 14 C l i n i c a l I n f e c t i o n , 15 Odor, 15 D r a i n a g e , 17 C o n t i n u o u s Wet S a l i n e D r e s s i n g s 18 M e s a l t D r e s s i n g s . 18 P a t i e n t S a t i s f a c t i o n 22 Summary 26 i v Page 3. METHODOLOGY Introduction 27 Development of the Patient S a t i s f a c t i o n Questionnaire 28 Sample for Patient S a t i s f a c t i o n Questionnaire, 28 Procedure f o r Questionnaire Development, 29 Content I d e n t i f i c a t i o n , 29 Content V a l i d i t y V e r i f i c a t i o n , 29 R e l i a b i l i t y Testing, 30 Study Methodology 31 Study Design, 31 Study Group, 32 Study Procedure, 33 Accrual, 33 Procedure, 33 Evaluation Tools, 35 S t a t i s t i c a l Analysis, 36 Sample Size, 36 S t a t i s t i c a l Procedures, 36 Withdrawals, 39 Ethics, 39 Summary 39 4. PRESENTATION AND DISCUSSION OF FINDINGS Introduction 41 Patient S a t i s f a c t i o n Questionnaire 41 Content I d e n t i f i c a t i o n , 41 Characteristics of the Sample, 41 Results of the Interviews, 42 Development of the Preliminary Questionnaire, 44 Content V a l i d i t y V e r i f i c a t i o n , 45 Characteristics of the Sample, 46 Results of the Testing, 47 Development of the P i l o t Questionnaire, 48 R e l i a b i l i t y Testing, 48 Characteristics of the Sample, 49 Results of the Testing, 49 The Patient S a t i s f a c t i o n Questionnaire, 52 Discussion of the Findings, 53 v Page Study F i n d i n g s 55 C h a r a c t e r i s t i c s of t h e Sample, 55 Study Completeness , 57 O v e r a l l E v a l u a t i o n S c a l e , 58 Comments about t h e A n a l y s i s , 60 Comments about t h e O v e r a l l E v a l u a t i o n S c a l e , 61 D i s c u s s i o n o f F i n d i n g s , 62 P r e f e r e n c e S c a l e , 64 Comments about t h e A n a l y s i s , 65 R e v i s i o n s t o t h e P r e f e r e n c e S c a l e , 65 A n a l y s i s of t h e Open-Ended Q u e s t i o n , 66 Comments about t h e P r e f e r e n c e S c a l e , 67 D i s c u s s i o n of t h e F i n d i n g s , 67 G e n e r a l Comments about t h e S tudy , 69 Comments about t h e Study D e s i g n , 69 Comments about t h e P a t i e n t s , 70 P a t i e n t s ' Comments and P o s t - S t u d y C o n s u l t a t i o n , 74 Summary 75 5. CONCLUSION AND RECOMMENDATIONS I n t r o d u c t i o n 76 Major C o n c l u s i o n s D e r i v e d from t h e R e s u l t s 76 I m p l i c a t i o n s f o r N u r s i n g 77 Recommendations f o r F u r t h e r Study 80 Summary 81 REFERENCES 83 APPENDIXES A. P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e 90 B. I n t e r v i e w G u i d e 95 C. P r e l i m i n a r y Q u e s t i o n n a i r e 97 D. L e t t e r o f I n t r o d u c t i o n 103 E . P i l o t Q u e s t i o n n a i r e 105 F . M e d i c a l H i s t o r y 112 G. P r o t o c o l f o r Wound Care ! 114 H. O v e r a l l E v a l u a t i o n S c a l e 116 I. P r e f e r e n c e S c a l e 118 J . P r e f e r e n c e S c a l e ( R e v i s e d ) • • • • 120 K. P a t i e n t I n f o r m a t i o n and Consent Form 122 L . Content I d e n t i f i c a t i o n Summary . . 125 v i LIST OF TABLES Table Page 1. Patient Randomisation to F i r s t Dressing 58 2. Frequency D i s t r i b u t i o n of Patient Preferences... 64 v i i LIST OF FIGURES Figure Page 1. Histogram depicting the average differences between the 1st and 2nd t e s t f o r the 25 questions on the P i l o t Questionnaire 50 v i i i ACKNOWLEDGEMENTS I would l i k e t o t h a n k t h e p a t i e n t s w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s who have p r o v i d e d t h e energy and i n s p i r a t i o n f o r t h i s t h e s i s . In a d d i t i o n , I would l i k e t o express my a p p r e c i a t i o n t o t h e s t a f f a t t h e B r i t i s h Columbia Cancer Agency (BCCA) who have been v e r y h e l p f u l i n e n s u r i n g p a t i e n t s were a c c r u e d t o t h e s t u d y . A l s o a p p r e c i a t e d i s t h e encouragement from t h e c o - i n v e s t i g a t o r s o f t h e BCCA s t u d y : C h r i s S a l t o n , D r . M i c h e l e Deschamps, Joan Murphy, Maureen Maher, and D r . F r e d R o b e r t s . O t h e r p e o p l e who have s u p p o r t e d my r e s e a r c h i n c l u d e : L e s l i e B r a d l e y , A s s i s t a n t D i r e c t o r o f N u r s i n g (BCCA); and Sharon B r i d g e r and Penny B i c k e r t o n , wound c a r e s p e c i a l i s t s . The a u t h o r i s g r a t e f u l f o r t h e g u i d a n c e r e c e i v e d f rom t h e t h e s i s committee members: C a r o l J i l l i n g s and Judy Mogan. F i n a l l y , I acknowledge my f a m i l y , whose p a t i e n c e and s u p p o r t were i n v a l u a b l e . i x CHAPTER 1 I n t r o d u c t i o n Background o f t h e Study L i v i n g w i t h c a n c e r i s a phenomenon t h a t has become more s i g n i f i c a n t as t e c h n o l o g i c a l advances i n c r e a s e t h e l i f e e x p e c t a n c y o f c a n c e r p a t i e n t s (Rosenbaum, 1982). In a d d i t i o n t o d e v e l o p i n g new c o p i n g s k i l l s f o r l i v i n g w i t h c a n c e r , some i n d i v i d u a l s and t h e i r f a m i l i e s have t h e added s t r e s s e s o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . As t h e s e l e s i o n s may p r o d u c e " g r o s s d e f o r m i t i e s , u n s i g h t l y s o r e s , o r i n t o l e r a b l e o d o r s , and may p l a g u e t h e p a t i e n t w i t h d r a i n a g e and b l e e d i n g " ( B i l l i n g s , 1985, p . 103), t h e y a r e among t h e most d i f f i c u l t m a n i f e s t a t i o n s o f advanced c a n c e r f o r t h e p a t i e n t , f a m i l y and h e a l t h c a r e p r o v i d e r s . Compounding t h e s e d i f f i c u l t i e s a re t h e needs t o r e g u l a r l y c l e a n s e t h e l e s i o n and change t h e d r e s s i n g . A l t h o u g h o c c u r r e n c e i s uncommon, t h e s e l e s i o n s may be p r e s e n t f o r months or i n some cases even y e a r s (Andreev, 1978). C o n s e q u e n t l y , a t t e n t i o n needs t o be p a i d t o t h e t y p e s of d r e s s i n g s chosen and t h e i r a f f e c t on p a t i e n t c o m f o r t . C o n c e p t u a l Framework S a t i s f a c t i o n w i t h h e a l t h c a r e i s an i m p o r t a n t component o f s a t i s f a c t i o n w i t h l i f e or q u a l i t y o f l i f e , e s p e c i a l l y i n c h r o n i c , l o n g - t e r m c a r e s i t u a t i o n s ( M c M i l l a n , 1987). S a t i s f a c t i o n i s a p o s i t i v e judgment of a p r o d u c t or s e r v i c e , compared t o o n e ' s own e x p e c t a t i o n s ( M c M i l l a n ) . Because 1 p a t i e n t s a re consumers o f h e a l t h c a r e , consumer s a t i s f a c t i o n w i l l be r e f e r r e d t o as p a t i e n t s a t i s f a c t i o n . E f f o r t s t o e v a l u a t e p a t i e n t s a t i s f a c t i o n i n h e a l t h c a r e a r e b e i n g emphasized as an i m p o r t a n t a s p e c t o f q u a l i t y -a s s u r a n c e programs ( B l a c k , 1985). A l t h o u g h q u a l i t y o f c a r e and p a t i e n t s a t i s f a c t i o n are o f t e n r e l a t e d , t h e p r e s e n c e o f q u a l i t y c a r e does n o t n e c e s s a r i l y mean t h e p a t i e n t i s s a t i s f i e d ( O b e r s t , 1984). T h e r e f o r e , e v a l u a t i n g h e a l t h s e r v i c e s u s i n g c l i n i c a l and economic c r i t e r i a i s i n a d e q u a t e w i t h o u t i n p u t from t h e p a t i e n t ( L o c k e r 8s Dunt, 1978). P a t i e n t s a t i s f a c t i o n has been g a i n i n g impor tance i n r e c e n t y e a r s f o r a v a r i e t y of r e a s o n s . Not o n l y i s i t e t h i c a l l y i m p o r t a n t t o s a t i s f y t h e p a t i e n t , but i n some c o u n t r i e s such as t h e U n i t e d S t a t e s , i t i s a l s o a f i n a n c i a l r e q u i r e m e n t f o r t h e i n s t i t u t i o n ' s s u c c e s s ( M c M i l l a n , 1987). E m p h a s i z i n g t h e a c c o u n t a b i l i t y o f h e a l t h c a r e p r o f e s s i o n a l s t o p r o v i d e e f f e c t i v e p a t i e n t c a r e a l s o n e c e s s i t a t e s e v a l u a t i n g p a t i e n t s a t i s f a c t i o n ( B l a c k , 1985; M c M i l l a n ) . Concern about t h e e f f e c t s of p a t i e n t d i s s a t i s f a c t i o n on c o m p l i a n c e w i t h recommended h e a l t h c a r e regimens has a l s o i n c r e a s e d t h e i m p o r t a n c e of e v a l u a t i n g p a t i e n t s a t i s f a c t i o n ( L a r s e n & Rootman, 1976). The consumer movement has c o n t r i b u t e d t o t h e s i g n i f i c a n c e o f p a t i e n t s a t i s f a c t i o n . Canadians have d e c l a r e d t h e consumer ' s r i g h t t o " p a r t i c i p a t e i n d e c i s i o n making a f f e c t i n g h i s h e a l t h , w i t h t h e h e a l t h p r o f e s s i o n a l s and p e r s o n n e l i n v o l v e d i n h i s d i r e c t h e a l t h c a r e " (Consumers ' A s s o c i a t i o n of 2 Canada, 1974 p. 1) . A s t u d y of c a n c e r p a t i e n t s r e v e a l e d t h a t 51% t o 87% p r e f e r r e d t o p a r t i c i p a t e i n making d e c i s i o n s about t h e i r t r e a t m e n t ( C a s s i l e t h , Z u p k i s , S u t t o n - S m i t h & March, 1980). The need f o r p a t i e n t i n p u t i s n o t o n l y a g o a l ; i t i s a c e r t a i n t y as p r o c l a i m e d by t h e H o n o r a b l e Jake Epp, M i n i s t e r o f N a t i o n a l H e a l t h and W e l f a r e (1986). C a n a d a ' s h e a l t h c a r e system i s c h a n g i n g t o a system where consumers have a g r e a t e r r e s p o n s i b i l i t y f o r p a r t i c i p a t i n g and making d e c i s i o n s about t h e i r h e a l t h c a r e . A t t h e p r e s e n t t i m e , knowledge about p a t i e n t s ' e x p e c t a t i o n s and s a t i s f a c t i o n w i t h d r e s s i n g s i n t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s i s l i m i t e d t o i n d i v i d u a l c o n t a c t s w i t h h e a l t h c a r e p r o f e s s i o n a l s . No s p e c i f i c i n f o r m a t i o n i s a v a i l a b l e about p a t i e n t s a t i s f a c t i o n and p r e f e r e n c e s r e l a t e d t o d r e s s i n g s . Statement o f t h e Problem and Purpose The d r e s s i n g c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s i s n o t w e l l e s t a b l i s h e d ( I v e t i c & Lyne , 1990). The a v a i l a b l e l i t e r a t u r e i s l i m i t e d and t h e recommended c a r e i s based m a i n l y on p e r s o n a l e x p e r i e n c e s . The e v a l u a t i o n of d r e s s i n g s i s a l s o l i m i t e d . To d a t e , no t o o l s which e v a l u a t e d r e s s i n g s have been r e p o r t e d i n t h e l i t e r a t u r e , n o r have any been d e v e l o p e d s p e c i f i c a l l y t o e v a l u a t e d r e s s i n g s i n u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . P a t i e n t s a t i s f a c t i o n i n t h e e v a l u a t i o n o f d r e s s i n g s a l s o has not been c o n s i d e r e d . Most p a t i e n t s a t i s f a c t i o n t o o l s e v a l u a t e s a t i s f a c t i o n w i t h c a r e o n l y from a 3 b r o a d p e r s p e c t i v e . No known s t u d i e s have f o r m a l l y e v a l u a t e d d r e s s i n g s used i n t h e c a r e of u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s , or examined t h e p a t i e n t ' s p e r s p e c t i v e s on t h e c o m f o r t o f t h e d r e s s i n g s . A B r i t i s h C o l u m b i a Cancer Agency (BCCA) s u r v e y o f major c a n c e r c e n t e r s a c r o s s Canada r e v e a l s t h a t o f t h e v a r i o u s d r e s s i n g s u s e d , wet s a l i n e d r e s s i n g s were t h e most common ( C h r i s S a l t o n , p e r s o n a l communicat ion, November 14, 1988). C o n t i n u o u s wet s a l i n e d r e s s i n g s can be u n c o m f o r t a b l e and may cause bed l i n e n a n d / o r c l o t h i n g t o become wet. I f t h e d r e s s i n g s do not m a i n t a i n t h e i r m o i s t u r e , t h e y can cause problems w i t h p a i n and b l e e d i n g . However, t h e f r e q u e n t d r e s s i n g changes r e q u i r e d t o m a i n t a i n m o i s t n e s s a r e not always a f e a s i b l e o p t i o n , e s p e c i a l l y i n t h e community s e t t i n g where a d d i t i o n a l d r e s s i n g changes r e q u i r e more f r e q u e n t v i s i t s by t h e Home Care N u r s e s . The M e s a l t d r e s s i n g i s a d r y , s a l i n e - i m p r e g n a t e d gauze which i s u s e f u l i n t h e c a r e o f l e g and d e c u b i t u s u l c e r s ( G a l l a n t & S i b b a l d , 1986; G r o s s & G e r n e r , 1982; R u t h , 1979) and i n open, i n f e c t e d l e s i o n s (Jagelman & Spencer , 1986). As d r y d r e s s i n g s , M e s a l t d r e s s i n g s a r e easy t o a p p l y and r e q u i r e fewer d r e s s i n g changes . M e s a l t d r e s s i n g s a r e removed when t h e y a re m o i s t and t h e r e f o r e r e s i s t s t i c k i n g t o t h e wound. One a n e c d o t a l r e p o r t found t h a t M e s a l t d r e s s i n g s c o n s i d e r a b l y d e c r e a s e d t h e odor of an u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n r e s u l t i n g from b r e a s t c a n c e r (Spencer , 1988). One purpose o f t h i s t h e s i s , c o n s e q u e n t l y , was t o d e v e l o p an e v a l u a t i o n t o o l w h i c h , based on p a t i e n t i n p u t , measures t h e 4 p a t i e n t ' s s a t i s f a c t i o n w i t h d r e s s i n g s i n t h e c a r e of u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . A n o t h e r purpose was t o e v a l u a t e t h e p a t i e n t s a t i s f a c t i o n and p a t i e n t p r e f e r e n c e components of a l a r g e r s t u d y conducted by t h e BCCA i n Vancouver , B . C . The s t u d y compared M e s a l t d r e s s i n g s w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s i n u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s by e v a l u a t i n g p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g p e r f o r m a n c e , p a t i e n t and n u r s e p r e f e r e n c e , o c c u r r e n c e of i n f e c t i o n , number o f d r e s s i n g changes, t i m e s p e n t f o r c a r e o f t h e l e s i o n , and c o s t o f d r e s s i n g m a t e r i a l s . Two p r e - d e v e l o p e d t o o l s were used t o measure p a t i e n t s a t i s f a c t i o n and p a t i e n t p r e f e r e n c e . The O v e r a l l E v a l u a t i o n S c a l e was used t o e v a l u a t e p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g p e r f o r m a n c e , i n c l u d i n g ease of a p p l i c a t i o n and removal o f t h e d r e s s i n g s , d i s c o m f o r t d u r i n g and between d r e s s i n g changes, and c o n t r o l o f odor . The P r e f e r e n c e S c a l e was used t o e v a l u a t e p a t i e n t p r e f e r e n c e . I t was hoped t h a t t h e p a t i e n t s a t i s f a c t i o n t o o l d e v e l o p e d f o r t h i s t h e s i s would a l s o be used as p a r t o f t h e s t u d y . However, due b o t h t o low numbers o f p a t i e n t s w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s and t o t i m e c o n s t r a i n t s , t h e t o o l was d e v e l o p e d but not u s e d . Hypotheses The hypotheses a r e : 1. M e s a l t d r e s s i n g s w i l l r e c e i v e a more p o s i t i v e r a t i n g t h a n c o n t i n u o u s wet s a l i n e d r e s s i n g s w i t h r e s p e c t t o p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g p e r f o r m a n c e . 5 2. M e s a l t d r e s s i n g s w i l l be p r e f e r r e d by p a t i e n t s t o c o n t i n u o u s wet s a l i n e d r e s s i n g s . D e f i n i t i o n of Terms F o r t h e p u r p o s e s o f t h i s s t u d y , t h e terms " p a t i e n t , " " u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n , " " s a t i s f a c t i o n " and " p r e f e r e n c e " a re d e f i n e d . " S a t i s f a c t i o n " and " p r e f e r e n c e " a re o p e r a t i o n a l l y d e f i n e d so as t o more a c c u r a t e l y r e f l e c t t h e i r use w i t h i n t h e s t u d y . P a t i e n t The p a t i e n t i s an i n d i v i d u a l 18 y e a r s o r o l d e r , w i t h a c o n f i r m e d d i a g n o s i s of c a n c e r , r e g i s t e r e d w i t h t h e BCCA, and r e q u i r i n g d r e s s i n g s f o r an u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n . U l c e r a t i n g m e t a s t a t i c s k i n l e s i o n An u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n i s an open and d r a i n i n g cancerous l e s i o n w i t h i n t h e dermis o f t h e s k i n . T h i s l e s i o n may r e s u l t f rom a m e t a s t a s i s t o t h e s k i n f rom a l o c a l tumor or from a tumor i n a d i s t a n t s i t e (Rosenberg , 1977). S a t i s f a c t i o n S a t i s f a c t i o n i s t h e p a t i e n t ' s judgment o f a p r o d u c t or s e r v i c e , compared t o h i s / h e r own e x p e c t a t i o n s ( M c M i l l a n , 1987). I t i s a s u b j e c t i v e , e v a l u a t i v e r a t i n g on a cont inuum which cannot be d i r e c t l y o b s e r v e d by o t h e r s . S a t i s f a c t i o n v a r i e s f rom a v e r y n e g a t i v e judgment t o a v e r y p o s i t i v e judgment. Measures o f s a t i s f a c t i o n were i n c o r p o r a t e d i n t o t h e 6 P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e d e v e l o p e d i n t h i s t h e s i s . P a t i e n t s i d e n t i f i e d f a c t o r s which t h e y e x p e c t e d t o f i n d i n d r e s s i n g s , and t h e r e s p o n s e s c a l e a l l o w e d t h e p a t i e n t s t o r a t e t h e d r e s s i n g s on a cont inuum. S a t i s f a c t i o n was a l s o measured u s i n g t h e O v e r a l l E v a l u a t i o n S c a l e as p a r t o f t h e e v a l u a t i o n o f M e s a l t d r e s s i n g s and c o n t i n u o u s wet s a l i n e d r e s s i n g s . The p a t i e n t s were asked t o e v a l u a t e t h e d r e s s i n g s i n terms o f ease o f a p p l i c a t i o n and r e m o v a l , d i s c o m f o r t d u r i n g and between d r e s s i n g changes, and c o n t r o l of odor . P r e f e r e n c e P r e f e r e n c e i s d e t e r m i n e d when t h e p a t i e n t s u b j e c t i v e l y chooses a p a r t i c u l a r d r e s s i n g which h e / s h e f a v o r s o v e r t h e o t h e r d r e s s i n g ( A v i s , D r y s d a l e , Gregg , N e u f e l d t , & S c a r g i l l , 1983). P r e f e r e n c e i s a g e n e r a l e v a l u a t i o n o f s a t i s f a c t i o n . P a t i e n t s were asked t o i n d i c a t e a p r e f e r e n c e as p a r t o f t h e e v a l u a t i o n o f M e s a l t d r e s s i n g s and c o n t i n u o u s wet s a l i n e d r e s s i n g s . Assumptions and L i m i t a t i o n s Assumptions There are t h r e e major assumptions i n t h i s s t u d y : 1. P a t i e n t s r e c e i v i n g c a r e f o r t h e i r u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s have an i n t e r e s t i n d e c i s i o n - m a k i n g r e g a r d i n g t h e d r e s s i n g s b e i n g u s e d . 2. P a t i e n t s a re a b l e t o e v a l u a t e t h e performance of 7 d r e s s i n g s and make d e c i s i o n s r e g a r d i n g p r e f e r e n c e . 3. Changes i n t h e c l i n i c a l wound c o n d i t i o n d u r i n g t h e s t u d y a r e p r i m a r i l y a r e s u l t o f t h e d r e s s i n g b e i n g u s e d . Limitations There are two major l i m i t a t i o n s i n t h i s s t u d y : 1. The P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e d e v e l o p e d d u r i n g t h e s t u d y has had l i m i t e d t e s t i n g f o r r e l i a b i l i t y and v a l i d i t y . 2. The O v e r a l l E v a l u a t i o n S c a l e measures t h e p a t i e n t s ' s a t i s f a c t i o n w i t h p r e - d e t e r m i n e d c r i t e r i a , t h u s l i m i t i n g t h e e v a l u a t i o n t o t h o s e p a r t i c u l a r c r i t e r i a . The c r i t e r i a were i d e n t i f i e d f rom p r e v i o u s c o n t a c t s w i t h p a t i e n t s c a r i n g f o r u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . However, t h i s i n p u t was n o t f o r m a l l y o b t a i n e d f o r t h e p u r p o s e s of t o o l development . Summary In t h i s c h a p t e r , t h e background o f t h e s t u d y , i n c l u d i n g t h e c o n c e p t u a l framework, has been p r e s e n t e d ; and t h e p r o b l e m and p u r p o s e of t h e s t u d y have been i n t r o d u c e d . The hypotheses have been i d e n t i f i e d , terms d e f i n e d , and assumptions and l i m i t a t i o n s r e c o g n i s e d . The n e x t c h a p t e r p r e s e n t s t h e l i t e r a t u r e r e l e v a n t t o t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s and t h e e v a l u a t i o n o f p a t i e n t s a t i s f a c t i o n . Subsequent c h a p t e r s i n c l u d e t h e methodology, p r e s e n t a t i o n and d i s c u s s i o n of f i n d i n g s , and c o n c l u s i o n and recommendations. 8 CHAPTER 2 Review o f R e l e v a n t L i t e r a t u r e I n t r o d u c t i o n P r e s e n t e d i n t h i s c h a p t e r a r e a r e v i e w o f t h e l i t e r a t u r e on t h e i n c i d e n c e , m e d i c a l t r e a t m e n t , and c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . C o n t i n u o u s wet s a l i n e d r e s s i n g s and M e s a l t d r e s s i n g s a re d i s c u s s e d i n more d e t a i l , and t h e c o n c e p t u a l framework o f p a t i e n t s a t i s f a c t i o n i s expanded. I n c i d e n c e o f U l c e r a t i n g M e t a s t a t i c S k i n L e s i o n s The o c c u r r e n c e o f s k i n metas tases w i t h o u t u l c e r a t i o n i s r e l a t i v e l y uncommon. L i t t l e d o c u m e n t a t i o n t o d e t e r m i n e t h e exac t f r e q u e n c y o f t h i s p r o b l e m i s a v a i l a b l e (Rosen, 1980). Even l e s s d o c u m e n t a t i o n about t h e o c c u r r e n c e o f u l c e r a t e d metas tases e x i s t s . Andreev (1978) e s t i m a t e s t h a t s k i n metas tases account f o r a p p r o x i m a t e l y 2.7% o f a l l m e t a s t a t i c l e s i o n s . I t i s g e n e r a l l y agreed t h a t s k i n metas tases a r e most commonly a s s o c i a t e d w i t h b r e a s t c a n c e r and, a c c o r d i n g t o Andreev , o c c u r i n 7.3 - 31.9% o f a l l p a t i e n t s w i t h b r e a s t c a n c e r . S k i n metastases can a l s o o c c u r i n m a l i g n a n t lymphoma; o r c a r c i n o m a o f t h e stomach, l u n g , u t e r u s , k i d n e y , o v a r y , c o l o n , b l a d d e r , head, or neck (Rosenberg, 1977; Watson, Sweeney, McGregor , & S l e i g h , 1986). A m a l i g n a n t growth o c c u r s from a l o c a l i n f i l t r a t i o n of a tumor, or a m e t a s t a t i c p r o c e s s o f e m b o l i z a t i o n t h r o u g h l y m p h a t i c s and b l o o d v e s s e l s (Rosenberg) . S k i n u l c e r a t i o n r e s u l t s when p r o l i f e r a t i n g and 9 i n f i l t r a t i n g m a l i g n a n t c a n c e r c e l l s d e s t r o y t i s s u e ( A n d r e e v ) . The u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n may t a k e t h e form o f a c a v i t y , an open a r e a on t h e s u r f a c e of t h e s k i n , s k i n n o d u l e s , or a n o d u l a r growth e x t e n d i n g f rom t h e s u r f a c e o f t h e s k i n (Andreev ; Rosen, 1980). The f r e q u e n c y o f t h e s e l e s i o n s i n p a t i e n t s was d e t e r m i n e d by t h e i n v e s t i g a t o r t h r o u g h i d e n t i f i c a t i o n o f p a t i e n t s by BCCA s t a f f and c h a r t r e v i e w s . D u r i n g t h e p e r i o d J a n u a r y 1988 -December 1989, 87 p a t i e n t s were i d e n t i f i e d w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s which d i d n o t r e s p o n d e a s i l y t o a g g r e s s i v e m e d i c a l t r e a t m e n t . At t h e end o f December 1989, 21 o f t h e 87 l e s i o n s had e v e n t u a l l y h e a l e d w i t h m e d i c a l t r e a t m e n t . The 66 r e m a i n i n g l e s i o n s e i t h e r were s t i l l p r e s e n t a t t h e end o f December 1989, o r were p r e s e n t a t t h e t i m e o f t h e p a t i e n t ' s d e a t h . Of t h e 66 l e s i o n s , t h e average d u r a t i o n o f p r e s e n c e was 9 .3 months, w i t h a range o f 1 week t o 60.5 months. The median d u r a t i o n was 6.5 months. M e d i c a l Treatment o f U l c e r a t i n g M e t a s t a t i c Skin Lesions M e d i c a l t r e a t m e n t f o c u s e s on d e s t r o y i n g or removing t h e m a l i g n a n t c e l l s , o r s t a b i l i z i n g t h e i r growth w i t h t h e i n t e n t i o n o f h e a l i n g t h e u l c e r a t i o n o r a t l e a s t c o n t r o l l i n g i t s c o m p l i c a t i o n s ( B i l l i n g s , 1985; B o r g , R u b i n , & DeWys, 1983) C o n t r o v e r s y e x i s t s , however, as t o t h e degree t o which t h e m a l i g n a n c y e f f e c t s t h e h e a l i n g p o t e n t i a l o f t h e l e s i o n ( I r v i n , 1981). M e d i c a l t r e a t m e n t s f o r l o c a l i z e d 10 u l c e r a t i o n s may i n c l u d e r a d i a t i o n t h e r a p y , s u r g i c a l d e b r i d e m e n t , e x c i s i o n ( B i l l i n g s ) , or more r e c e n t l y i n some b r e a s t l e s i o n s , chemomasteetomy ( G o n c a l v e s , 1987). S y s t e m i c t r e a t m e n t s such as chemotherapy or hormonal t h e r a p y may be i n v o l v e d i n a d d i t i o n t o , or i n s t e a d o f , l o c a l t h e r a p y ( P e t r e k , G l e n n , & Cramer, 1983; Wood, 1980). U n f o r t u n a t e l y , when t h e s e m o d a l i t i e s a re i n a p p r o p r i a t e or no l o n g e r e f f e c t i v e , p a l l i a t i v e c a r e o f t h e l e s i o n f o c u s e s on m i n i m i s i n g r e l a t e d p r o b l e m s . Care o f U l c e r a t i n g M e t a s t a t i c S k i n L e s i o n s The c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s i s not w e l l e s t a b l i s h e d , and few s t u d i e s have s y s t e m a t i c a l l y i n v e s t i g a t e d t h e e f f i c a c y o f d i f f e r e n t t r e a t m e n t s . L i t e r a t u r e r e l a t i n g t o t h e wound c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s o f t e n i n c l u d e s i n f o r m a t i o n about c l e a n s i n g t h e l e s i o n , c o n t r o l l i n g and p r e v e n t i n g b l e e d i n g , p r e v e n t i n g and managing c l i n i c a l i n f e c t i o n , c o n t r o l l i n g and p r e v e n t i n g odor , c o n t a i n i n g d r a i n a g e , and p r o m o t i n g h e a l i n g where p o s s i b l e ( F o l t a , 1980; Sims & F i t s g e r a l d ' , 1987). The p r o m o t i o n o f p a t i e n t c o m f o r t may be t h e p r i m a r y o b j e c t i v e where t h e l e s i o n has l i t t l e or no p o t e n t i a l f o r h e a l i n g . C l e a n s i n g T r a d i t i o n a l l y , many s o l u t i o n s have been recommended i n t h e c l e a n s i n g p r o c e s s : normal s a l i n e s o l u t i o n , hydrogen p e r o x i d e , p o v i d o n e i o d i n e , and h e x a - c h l o r o p h e n e ( F o l t a , 1980; Sims & F i t z g e r a l d , 1987). Recent s t u d i e s , however, i n d i c a t e t h a t t h e t r a d i t i o n a l use o f a n t i s e p t i c s i n wound c a r e i s no l o n g e r a p p r o p r i a t e as t h e y are d e t r i m e n t a l t o t h e wound and i n t e r f e r e w i t h wound h e a l i n g ( A l v a r e s , R o s i n t , & Wiseman, 1988; Rodeheaver , 1988). E x c e p t f o r t h e normal s a l i n e s o l u t i o n and t h e s o l u t i o n "Shur C l e n s " (Rodeheaver ) , most o t h e r commonly used a n t i s e p t i c s have t o x i c e f f e c t s on e i t h e r t h e wound t i s s u e or t h e c e l l s t h a t e l i m i n a t e b a c t e r i a a n d / o r o r c h e s t r a t e h e a l i n g ( A l v a r e s e t a l . ; R o d e h e a v e r ) . These a n t i s e p t i c s i n c l u d e sodium h y p o c h l o r i t e ( D a k i n ' s s o l u t i o n ) , hydrogen p e r o x i d e , a c e t i c a c i d , and p o v i d o n e i o d i n e (Brennan & L e a p e r , 1985; L ineaweaver e t a l . , 1985; Van den Broek, Buys, & Van F u r t h , 1982). P o v i d o n e i o d i n e i n c o n c e n t r a t i o n s o f 10% ( f u l l - s t r e n g t h ) and 5% has been found not o n l y t o damage t h e wound, b u t a l s o t o i n c r e a s e t h e o c c u r r e n c e o f i n f e c t i o n (Becker , 1986; V i l j a n t o , 1980). F u r t h e r , t h e r e i s s p e c u l a t i o n about t h e b a c t e r i c i d a l e f f e c t i v e n e s s of a n t i s e p t i c s such as p o v i d o n e i o d i n e and hydrogen p e r o x i d e i n d i l u t e d , n o n - t o x i c c o n c e n t r a t i o n s (Lineaweaver e t a l . ; Rodeheaver e t a l . , 1982). The l i t e r a t u r e has a l s o recommended debr idement t o m a i n t a i n t h e c l e a n l i n e s s o f t h e wound ( F o l t s , 1980). In g e n e r a l , debr idement o f dead t i s s u e i s c o n s i d e r e d v i t a l i n p r o m o t i n g wound h e a l i n g ( S t o t t s , 1990). F o l t s s u g g e s t s t h a t debr idement i n v o l v e t h e use of w e t - t o - d r y s a l i n e d r e s s i n g s , a n d / o r e n s y m a t i c o r o x i d i s i n g agents such as D a k i n ' s s o l u t i o n . A c t i v e d e b r i d e m e n t , however, may be q u e s t i o n a b l e i n wounds w i t h l i t t l e p o t e n t i a l for. h e a l i n g s i n c e i t may i n f a c t e x a c e r b a t e problems w i t h b l e e d i n g and d r a i n a g e . W e t - t o - d r y 12 s a l i n e d r e s s i n g s s t i c k t o t h e wound and o f t e n cause b l e e d i n g o f t h e u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n when removed. A l s o , a r e c e n t s t u d y d i s c o u r a g e s u s i n g w e t - t o - d r y d r e s s i n g s because removing t h e d r e s s i n g d i s t u r b s t h e c r u s t s a t t a c h e d t o t h e wound bed, t h e r e b y i n t e r f e r i n g i n wound h e a l i n g ( A l v a r e z & E a g l s t e i n , 1984). A l t h o u g h D a k i n ' s s o l u t i o n has been used e x t e n s i v e l y , a r e c e n t s t u d y i n d i c a t e s t h a t as t h e r e a r e no " s a f e " c o n c e n t r a t i o n l e v e l s , i t s use s h o u l d be d i s c o n t i n u e d ( K o z o l , G i l l i e s , Salwa, & E l g e b a l y , 1988). D a k i n ' s s o l u t i o n a l s o c o n t a i n s a n t i c o a g u l a n t p r o p e r t i e s (American M e d i c a l A s s o c i a t i o n , 1986) which may p o t e n t i a t e problems i n a m e t a s t a t i c l e s i o n a l r e a d y prone t o b l e e d i n g . P r o d u c t s such as E l a s e , T r a v a s e , M e z i n c , as w e l l as papaya, have been used f o r d e b r i d e m e n t . No l i t e r a t u r e was f o u n d , however, r e g a r d i n g t h e s e a g e n t s ' use i n m e t a s t a t i c wounds. A l e s s a g g r e s s i v e and more uncommon method o f removing dead t i s s u e i n wounds i n v o l v e s t h e p r o c e s s o f a u t o l y s i s ( A l v a r e z e t a l . , 1988). T h i s method causes t h e wound t o d e b r i d e i t s e l f t h r o u g h a s l o w e r but l e s s h a r m f u l p r o c e s s . T h i s may be a c h i e v e d by u s i n g o c c l u s i v e d r e s s i n g s such as DuoDerm (Friedman & Su, 1984) or M e z i n c , a l l o f which p r o v i d e a m o i s t , warm envi ronment . I m p o r t a n t l y , however, o c c l u s i v e d r e s s i n g s s h o u l d n o t be used i n a c l i n i c a l l y i n f e c t e d wound where t h e d r e s s i n g c o m p l e t e l y o c c l u d e s t h e wound ( A l v a r e z e t a l . ) . A s t i l l a c c e p t a b l e method o f removing s l o u g h i n g t i s s u e w i t h o u t c a u s i n g g r e a t harm t o t h e wound i s t h r o u g h m e c h a n i c a l means; u s i n g c o n t i n u o u s wet s a l i n e d r e s s i n g s . 13 B l e e d i n g B l e e d i n g can be c o n t r o l l e d by t h e a p p l i c a t i o n o f a t o p i c a l h e m o s t a t i c p r o d u c t such as K a l t o s t a t or an a b s o r b a b l e g e l a t i n sponge such as G e l f o a m ( F o l t z , 1980). A p p l i e d t o f o c a l b l e e d i n g p o i n t s , t h e s e p r o d u c t s a re l e f t i n p l a c e u n t i l a b s o r b e d . D r e s s i n g s which s t i c k t o t h e wound n o t o n l y promote i r r i t a t i o n and b l e e d i n g , but a l s o i n t e r f e r e i n wound h e a l i n g . D e s i g n e d t o p r e v e n t s t i c k i n g are t h e f o l l o w i n g : n o n - a d h e r e n t d r y d r e s s i n g s ( e . g . ETE d r e s s i n g ) ; impregnated gauze d r e s s i n g s between t h e wound and t h e a b s o r b e n t d r e s s i n g ( e . g . A d a p t i c , o r J e l o n e t ) ; c r e a m s / o i n t m e n t s which a c t as b a r r i e r s ( e . g . s i l v e r s u l f a d i a z i n e ( F l a m a z i n e ) ) ; o r d r e s s i n g s which promote m o i s t u r e as a b a r r i e r ( e . g . c o n t i n u o u s wet s a l i n e d r e s s i n g s , or h y d r o c o l l o i d d r e s s i n g s such as DuoDerm). D e s p i t e t h e i r n o n - a d h e r e n t i n t e n t i o n s , some d r e s s i n g s n e v e r t h e l e s s do s t i c k t o t h e wound. There i s a l a c k o f i n f o r m a t i o n about f a c t o r s which may cause a d r e s s i n g t o s t i c k , such as t h e amount, c o n s i s t e n c y , or t y p e o f d r a i n a g e . D r e s s i n g s a l s o d e l a y wound h e a l i n g i f t h e y p r e v e n t organisms which s u p p o r t h e a l i n g from moving a c r o s s t h e wound ( A l v a r e z e t a l . , 1988; May & S t i l l , 1985). L i t t l e i s known about t h e e f f e c t s on t h e wound h e a l i n g p r o c e s s o f gauze d r e s s i n g s impregnated w i t h p a r a f f i n or an o i l e m u l s i o n . D r e s s i n g s which c o m p l e t e l y o c c l u d e t h e wound, such as h y d r o c o l l o i d d r e s s i n g s , a r e viewed as t h e s a f e s t d r e s s i n g s t o p r e v e n t s t i c k i n g t o t h e wound and t o promote wound h e a l i n g . 14 C l i n i c a l I n f e c t i o n A c l i n i c a l i n f e c t i o n may i n v o l v e a l o c a l a n d / o r s y s t e m i c i n f e c t i o n . A l o c a l wound i n f e c t i o n i n c l u d e s s i g n s such as p u r u l e n t d r a i n a g e , r e d n e s s and s w e l l i n g , and i n c r e a s e d t e n d e r n e s s (Westaby & White , 1985). A s y s t e m i c i n f e c t i o n i n c l u d e s s i g n s o f a f e v e r and a h i g h w h i t e b l o o d c e l l count ( e . g . > 10 ,000) . Managing e i t h e r a l o c a l or a s y s t e m i c i n f e c t i o n r e q u i r e s i n v o l v i n g a p h y s i c i a n . Both l o c a l and s y s t e m i c i n f e c t i o n s may r e q u i r e a n t i b i o t i c t h e r a p y , w i t h p o s s i b l e h o s p i t a l i z a t i o n f o r wound management a n d / o r i n t r a v e n o u s a n t i b i o t i c t h e r a p y . The t y p e s o f d r e s s i n g s used d u r i n g a c l i n i c a l i n f e c t i o n are s i m i l a r t o t h o s e d e s c r i b e d i n t h e upcoming s e c t i o n on odor . Wound c u l t u r e s t a k e n f rom u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s a lmost always demonstra te a c o l o n i z a t i o n o f b a c t e r i a . However, w i t h o u t t h e s i g n s o f a c l i n i c a l i n f e c t i o n , t h e wound i s not c o n s i d e r e d t o be i n f e c t e d and t h e r e f o r e does n o t r e q u i r e any f u r t h e r a t t e n t i o n u n l e s s i t i s c a u s i n g odor p r o b l e m s . P r e v e n t i n g c l i n i c a l i n f e c t i o n i n v o l v e s p r o v i d i n g an environment which promotes c l e a n l i n e s s , t h u s d e c r e a s i n g t h e r i s k o f wound c o n t a m i n a t i o n . Odor U l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s a r e o f t e n malodorous , due m o s t l y t o t h e p r e s e n c e of anaerobes or as a r e s u l t o f t h e n e c r o s i s o f t i s s u e c e l l s ( A s h f o r d , P l a n t , & Maher, 1984; Sparrow, M i n t o n , Rubens, Simmons, & Aubrey , 1980). 15 T r a d i t i o n a l l y , b a c t e r i c i d a l s o l u t i o n s have been used t o d e c r e a s e b a c t e r i a ( E l l e r h o r s t - R y a n , 1987; F o l t z , 1980). However, b o t h t h e i n j u r y t o t h e wound bed and i n t e r f e r e n c e i n wound h e a l i n g a re c a u s i n g r e e v a l u a t i o n o f t h i s p r a c t i c e . Gauze impregnated w i t h a n t i m i c r o b i a l agents c o n s i d e r e d t o be t o x i c t o t h e wound may a l s o have a d e t r i m e n t a l e f f e c t on t h e wound ( A l v a r e z e t a l . , 1988; Geronemus, M e r t z , & E a g l s t e i n , 1979; May & S t i l l , 1985). T o p i c a l a n t i m i c r o b i a l c r e a m s / o i n t m e n t s may be used t o t r e a t a l o c a l i n f e c t i o n as w e l l as t o p r o v i d e a b a r r i e r which p r e v e n t s t h e a b s o r b e n t d r e s s i n g from s t i c k i n g . R e s e a r c h has shown t h a t some a n t i m i c r o b i a l c r e a m s / o i n t m e n t s such as F l a m a z i n e , P o l y s p o r i n , and N e o s p o r i n a r e not o n l y s a f e t o use i n wounds, but a l s o promote h e a l i n g ( A l v a r e z e t a l . ; Geronemus e t a l . , 1979). The i n d i c a t i o n s f o r u s i n g a n t i m i c r o b i a l c r e a m s / o i n t m e n t s i n g e n e r a l wound c a r e a r e n o t e n t i r e l y c l e a r as t h e r e i s c o n t r o v e r s y about t h e i r e f f e c t i v e n e s s and t h e development o f r e s i s t a n c e . M e t r o n i d a z o l e ( F l a g y l ) t a k e n o r a l l y was found t o be e f f e c t i v e i n c o n t r o l l i n g b o t h i n f e c t i o n and odor i n a v a r i e t y o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s ( A s h f o r d , e t a l . , 1984; Sparrow, e t a l . , 1980). F o r odor c o n t r o l , t r a d i t i o n a l d e o d o r a n t p r o d u c t s l i k e N i l o d o r , Hexon, and B a n i s h have been a p p l i e d t o t h e o u t s i d e o f d r e s s i n g s and a r e s t i l l used e f f e c t i v e l y ( F o l t z , 1980). I n c r e a s i n g t h e f r e q u e n c y o f d r e s s i n g changes may a l s o d e c r e a s e t h e exposure t o d r e s s i n g s s a t u r a t e d w i t h odorous d r a i n a g e . H y d r o c o l l o i d d r e s s i n g s such 16 as DuoDerm may d e c r e a s e t h e number of d r e s s i n g changes n e c e s s a r y , t h e r e b y d e c r e a s i n g t h e p a t i e n t ' s exposure t o odor . A l t h o u g h c h a r c o a l d r e s s i n g s have a l s o been used t o c o n t r o l odor ( B e c k e t t , Coombs, F r o s t , M c L e i s h , & Thompson, 1980), t h e y a r e e x p e n s i v e and t h e r e f o r e d i f f i c u l t f o r p a t i e n t s t o o b t a i n and h o s p i t a l s t o j u s t i f y . D r a i n a g e A f t e r c l e a n s i n g t h e l e s i o n and c o n s i d e r i n g what i s needed t o manage b l e e d i n g , i n f e c t i o n , and odor , t h e d r a i n a g e needs t o be c o n t a i n e d . The i n n e r d r e s s i n g s chosen a r e t h o s e which are i n d i r e c t c o n t a c t w i t h the. wound ( e . g . A d a p t i c , F l a m a a i n e cream, or c o n t i n u o u s wet s a l i n e d r e s s i n g s ) . The o u t e r d r e s s i n g , c o v e r i n g t h e i n n e r d r e s s i n g , i s u s u a l l y a d r y d r e s s i n g . The s i a e o f t h e o u t e r d r e s s i n g depends on t h e amount o f d r a i n a g e . I f t h e r e i s m i n i m a l d r a i n a g e and no c l i n i c a l i n f e c t i o n , a h y d r o c o l l o i d d r e s s i n g such as DuoDerm may be used i n p l a c e o f an i n n e r d r e s s i n g . H y d r o c o l l o i d d r e s s i n g s r e q u i r e fewer d r e s s i n g changes t h a n do most of t h e o t h e r d r e s s i n g t y p e s . However, t h e y o f t e n cannot adapt t o t h e many u n u s u a l shapes and s i a e s of t h e u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . In some cases where d r y gause d r e s s i n g s do not s t i c k , t h e y are a l l t h a t i s r e q u i r e d . In cases where d r a i n a g e i s c o n s i d e r a b l e , a wound d r a i n a g e c o l l e c t o r such as an ostomy pouch may be u s e f u l . Tape, n e t t i n g or c l o t h i n g may be used t o s e c u r e t h e o u t e r d r e s s i n g s . 17 C o n t i n u o u s Wet S a l i n e D r e s s i n g s Wet s a l i n e d r e s s i n g s are d r y gauze d r e s s i n g s soaked i n an i s o t o n i c "normal s a l i n e " s o l u t i o n (0.9% sodium c h l o r i d e i n water) and are o f t e n recommended i n t h e t r e a t m e n t of u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s ( S t a i r , 1986). C o n t i n u o u s wet s a l i n e d r e s s i n g s d i l u t e v i s c o u s exudate and keep t h e wound c o n s t a n t l y m o i s t , thus p r e v e n t i n g adherence t o t h e l e s i o n and d e c r e a s i n g problems w i t h p a i n and b l e e d i n g ( C u s a e l l , 1985). They p r o v i d e an a p p r o p r i a t e d r e s s i n g f o r u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s because a d h e s i o n t o t h e l e s i o n i s n o t recommended (Greenberg , 1978). U n f o r t u n a t e l y , c o n t i n u o u s wet s a l i n e d r e s s i n g s o f t e n r e q u i r e f r e q u e n t d r e s s i n g changes t o keep t h e d r e s s i n g m o i s t , or t o remove d r a i n a g e t h a t has s a t u r a t e d t h r o u g h . As mentioned p r e v i o u s l y , t h i s i n c r e a s e d f r e q u e n c y o f d r e s s i n g changes i s e c o n o m i c a l l y u n d e s i r a b l e i n t h e Home N u r s i n g c a r e s i t u a t i o n , as w e l l as more bothersome f o r t h e p a t i e n t c h a n g i n g h i s / h e r own d r e s s i n g s . A second c o n s i d e r a t i o n i s t h a t c o n t i n u o u s wet d r e s s i n g s may r e s u l t i n m a c e r a t i o n o f v i a b l e t i s s u e and may i n c r e a s e b a c t e r i a l p r o l i f e r a t i o n ( C u s z e l l , 1985). T h i r d , c o n t i n u o u s wet d r e s s i n g s can be u n c o m f o r t a b l e , and may cause bed l i n e n a n d / o r c l o t h i n g t o become wet. M e s a l t D r e s s i n g s M e s a l t d r e s s i n g s a re made o f b l e a c h e d 100% c o t t o n gauze impregnated w i t h c r y s t a l l i n e sodium c h l o r i d e ( S a n c e l l a , 18 p a m p h l e t ) . They are f r e q u e n t l y used i n b o t h community and h o s p i t a l s e t t i n g s . When M e s a l t d r e s s i n g s a re a p p l i e d , a h y p e r t o n i c environment i s c r e a t e d , s t i m u l a t i n g wound c l e a n s i n g and removing excess f l u i d , thus d e c r e a s i n g i n t e r s t i t i a l edema ( S a n c e l l a , p a m p h l e t ) . A p p l i e d d r y , M e s a l t d r e s s i n g s a re l e f t i n p l a c e t o become mois tened by d r a i n a g e . To be e f f e c t i v e , M e s a l t d r e s s i n g s must be i n c o n t a c t w i t h a m o i s t u l c e r base which has a moderate t o l a r g e amount o f d r a i n a g e . M e s a l t d r e s s i n g s a r e removed when t h e y a r e m o i s t , t h e r e b y d e c r e a s i n g t h e i r p o t e n t i a l f o r s t i c k i n g t o t h e wound. A l s o s u g g e s t e d i s t h a t t h e h y p e r t o n i c environment d e c r e a s e s t h e p o t e n t i a l f o r b a c t e r i a l growth ( S a n c e l l a , b o o k l e t ) . However, no r e s e a r c h i n t h e c l i n i c a l s e t t i n g s u b s t a n t i a t e s t h i s e f f e c t . As p r e v i o u s l y n o t e d , M e s a l t d r e s s i n g s c o n s i d e r a b l y d e c r e a s e d odor i n one case i n v o l v i n g an u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n r e s u l t i n g from b r e a s t c a n c e r (Spencer , 1988). A d d i t i o n a l l y , s i n c e M e s a l t d r e s s i n g s a re d r y , t h e problems of wet c l o t h i n g / b e d l i n e n a s s o c i a t e d w i t h wet d r e s s i n g s a re m i n i m i s e d . To d a t e f o u r s t u d i e s , a l l o f them d e a l i n g w i t h n o n - c a n c e r o u s s k i n l e s i o n s , have e v a l u a t e d M e s a l t d r e s s i n g s . A l l o f t h e s e s t u d i e s used a d e s c r i p t i v e d e s i g n w i t h l i m i t e d i n f o r m a t i o n about t h e s p e c i f i c methods o f c o l l e c t i n g d a t a and t h e measurement t o o l s u s e d . Of t h e two s t u d i e s p u b l i s h e d , however, o n l y one has been t r a n s l a t e d i n t o E n g l i s h . The f i r s t s t u d y e v a l u a t e d M e s a l t d r e s s i n g s i n 17 p a t i e n t s w i t h a r t e r i a l wounds, p r e s s u r e wounds, an i n f e c t e d venous wound, and a l a r g e amputa t ion wound (Ruth, 1979). R e s u l t s 19 showed t h a t M e s a l t d r e s s i n g s , comparable t o t r a d i t i o n a l wet s a l i n e d r e s s i n g s , were t h e most e f f e c t i v e w i t h d e c u b i t u s u l c e r s . M e s a l t d r e s s i n g s , though, were f a v o r e d over wet s a l i n e d r e s s i n g s because t h e y d e c r e a s e d t h e r e q u i r e d f r e q u e n c y o f d r e s s i n g changes, were e a s i e r t o h a n d l e and d i d n o t cause m a c e r a t i o n a t t h e wound edges. The second s t u d y e v a l u a t e d M e s a l t d r e s s i n g s among 21 p a r a p l e g i c p a t i e n t s w i t h d e c u b i t u s u l c e r s (Gross & G e r n e r , 1982, 1985). M e s a l t d r e s s i n g s were b e n e f i c i a l i n p r o m o t i n g c l e a n l i n e s s o f t h e wound, g r a n u l a t i o n and h e a l i n g . These d r e s s i n g s r e q u i r e d fewer changes t h a n d i d wet s a l i n e d r e s s i n g s . As w e l l , M e s a l t d r e s s i n g s were easy t o a p p l y , r e d u c i n g d r e s s i n g change t i m e . The t h i r d s t u d y e v a l u a t e d M e s a l t d r e s s i n g s w i t h 16 p a t i e n t s h a v i n g l e g u l c e r s s e c o n d a r y t o p e r i p h e r a l venous d e f i c i e n c y , t h r e e o f them h a v i n g l e s i o n s s u i t a b l e f o r p a i r e d comparisons ( G a l l a n t & S i b b a l d , 1986). Of t h e p a i r e d c o m p a r i s o n s , one o f t h e u l c e r s was t r e a t e d w i t h M e s a l t d r e s s i n g s , t h e o t h e r w i t h b e n z o y l p e r o x i d e a n d / o r B a r d g e l . R e s u l t s i n d i c a t e d t h a t 10 o f t h e 14 u l c e r s t r e a t e d o n l y w i t h M e s a l t d r e s s i n g s , h e a l e d c o m p l e t e l y w i t h i n 2 t o 14 weeks. In t h e p a i r e d c o m p a r i s o n s , two p a t i e n t s e x p e r i e n c e d improvement o f b o t h u l c e r s , and i n t h e t h i r d p a t i e n t t h e r e was a f a i l u r e t o show any s i g n i f i c a n t r e s p o n s e . The a u t h o r s c o n c l u d e d t h a t 1) t h e h e a l i n g p r o p e r t i e s of M e s a l t d r e s s i n g s were comparable t o t h o s e o f o t h e r e s t a b l i s h e d m o d a l i t i e s and 2) t h a t M e s a l t d r e s s i n g s were s i g n i f i c a n t l y l e s s e x p e n s i v e 20 t h a n most o t h e r t h e r a p i e s used i n t h e i r c l i n i c . N u r s i n g s t a f f p r e f e r r e d M e s a l t d r e s s i n g s t o o t h e r d r e s s i n g s because t h e y were s i m p l e and r e q u i r e d l e s s t i m e t o change. The l a s t s t u d y e v a l u a t e d M e s a l t d r e s s i n g s i n 27 p a t i e n t s w i t h open i n f e c t e d l e s i o n s (Jagelman & Spencer , 1986). E v a l u a t i o n i n c l u d e d t h e o v e r a l l per formance o f M e s a l t d r e s s i n g s f o r ease o f a p p l i c a t i o n and r e m o v a l , a b i l i t y t o c l e a n s e and d e b r i d e t h e l e s i o n , and e f f e c t on t h e s u r r o u n d i n g s k i n . A l l p a t i e n t s were p a r t of a s t r u c t u r e d c a r e p l a n i n c l u d i n g a v a r i e t y of o t h e r t r e a t m e n t m o d a l i t i e s . " R e p r e s e n t a t i v e c a s e s " were d e s c r i b e d w i t h r e s p e c t t o t r e a t m e n t p r o t o c o l s , size o f t h e l e s i o n p r i o r t o and d u r i n g t h e t r e a t m e n t , and f r e q u e n c y o f M e s a l t d r e s s i n g changes . The a u t h o r s c o n c l u d e d t h a t M e s a l t d r e s s i n g s appeared t o h a s t e n and s t i m u l a t e wound h e a l i n g , reduce wound edema, and i n c r e a s e t h e r a t e o f g r a n u l a t i o n t i s s u e f o r m a t i o n , w h i l e n o t a d v e r s e l y a f f e c t i n g t h e s u r r o u n d i n g s k i n . In a d d i t i o n , M e s a l t d r e s s i n g s were c o n v e n i e n t t o a p p l y , t h e p a t i e n t s appeared more c o m f o r t a b l e d u r i n g t h e d r e s s i n g changes, and t h e f r e q u e n c y o f d r e s s i n g changes d e c r e a s e d . Thus, t h e c o s t r e l a t e d t o m a t e r i a l and n u r s i n g s t a f f was m i n i m i s e d . In g e n e r a l , t h e s e r e s u l t s i n d i c a t e t h a t t h e M e s a l t d r e s s i n g i s a p r o m i s i n g d r e s s i n g which c o u l d be used i n t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . However, t h e s e c o n c l u s i o n s must be c o n s i d e r e d w i t h c a u t i o n because o f t h e m e t h o d o l o g i c a l l i m i t a t i o n s o f t h e s t u d i e s , and i n p a r t i c u l a r , t h e absence o f a p r o p e r c o n t r o l g r o u p . 21 Pat ient , g a t i s f a c t i o n P a t i e n t s a t i s f a c t i o n i s i n f r e q u e n t l y or u n c l e a r l y d e f i n e d i n t h e l i t e r a t u r e ( O b e r s t , 1 9 8 4 ) . O f t e n t h e r e s u l t s o f a s t u d y are p r e s e n t e d and a n a l y z e d w i t h o u t d e f i n i n g p a t i e n t s a t i s f a c t i o n or d e s c r i b i n g t h e c r i t e r i a used t o measure i t . S a t i s f a c t i o n i s a s u b j e c t i v e r a t i n g on a cont inuum t h a t i n c l u d e s an e v a l u a t i v e component which cannot be d i r e c t l y o b s e r v e d by o t h e r s (Ware, 1 9 8 1 ) . S a t i s f a c t i o n can be viewed as t h e p a t i e n t ' s judgment of t h e a c t u a l c a r e r e c e i v e d , compared t o h i s / h e r own e x p e c t a t i o n s or s t a n d a r d s ( M c M i l l a n , 1987 ; O b e r s t ; Ware). D i s s a t i s f a c t i o n o c c u r s when t h e p r o d u c t o r s e r v i c e i s p e r c e i v e d t o be lower i n performance t h a n e x p e c t e d ( M c M i l l a n ) . Numerous p a t i e n t s a t i s f a c t i o n s t u d i e s have examined m e d i c a l s e r v i c e s such as t h o s e o f t h e g e n e r a l p r a c t i t i o n e r , i n - p a t i e n t and o u t - p a t i e n t h o s p i t a l s e r v i c e s , and t h e i n f l u e n c e o f v a r i o u s p e r s o n a l and i n s t i t u t i o n a l c h a r a c t e r i s t i c s (Lemke, 1987 ; L o c k e r & Dunt, 1 9 7 8 ) . S a t i s f a c t i o n w i t h t h e d e l i v e r y o f n u r s i n g c a r e has a l s o been s t u d i e d ( D e r d i a r i a n , 1990 ; Hinshaw & Atwood, 1982 ; R i s s e r , 1975 ; V e n t u r a , Fox, C o r l e y , 8s M e r c u i r o , 1 9 8 2 ) . O n l y a few s t u d i e s have e v a l u a t e d s p e c i f i c t r e a t m e n t s or p r o d u c t s . These s t u d i e s i n c l u d e t h e e v a l u a t i o n of a t r e a t m e n t f o r impotence ( S i d i , Reddy, 8s Chen, 1988) and t h e i m p l a n t a t i o n o f a d e n t a l b r i d g e ( H o o g s t r a t e n 8s Lamers, 1 9 8 7 ) . A l t h o u g h t h e r e i s no g e n e r a l l y a c c e p t e d method f o r measur ing p a t i e n t s a t i s f a c t i o n ( M c M i l l a n , 1 9 8 7 ) , t h e most 22 commonly used t o o l i s t h e q u e s t i o n n a i r e (Ware, 1981). Most h o s p i t a l s t u d i e s e i t h e r have d e v e l o p e d t h e i r own q u e s t i o n n a i r e or have used a q u e s t i o n n a i r e p r e v i o u s l y d e v e l o p e d (Abramowits, Cote , & B e r r y , 1987). The q u e s t i o n n a i r e was e i t h e r m a i l e d out t o d i s c h a r g e d p a t i e n t s , d e l i v e r e d t o t h e s t i l l - h o s p i t a l i s e d p a t i e n t , o r used as format f o r an i n t e r v i e w (Abramowits e t a l . ).. As m a i l i n g s o f t e n r e s u l t i n low r e t u r n r a t e s , d i r e c t c o n t a c t w i t h p a t i e n t s t h r o u g h i n t e r v i e w s i s p r e f e r r e d ( F r e n c h , 1981). W h i l e most q u e s t i o n n a i r e s use o n l y s t r u c t u r e d q u e s t i o n s , some combine s t r u c t u r e d and u n s t r u c t u r e d q u e s t i o n s ( L o c k e r & Dunt , 1978). G e n e r a l l y , t h e q u e s t i o n n a i r e has two p a r t s : 1) t h e items t o be e v a l u a t e d and 2) t h e r e s p o n s e s c a l e s (Ware, 1981). Numerous problems e x i s t r e g a r d i n g t h e methodology used t o e v a l u a t e p a t i e n t s a t i s f a c t i o n ( F r e n c h , 1981; L o c k e r & Dunt, 1978; O b e r s t , 1984; Ware, D a v i e s , & Stewar t , 1978). V a l i d i t y o f t h e measurement t o o l i s a major c o n c e r n ( O b e r s t ; Ware e t a l . , 1978). Many s t u d i e s measure s a t i s f a c t i o n f rom a b r o a d p e r s p e c t i v e , sometimes as a s i n g l e q u e s t i o n . P a t i e n t s may be asked how s a t i s f i e d t h e y a r e i n g e n e r a l , and t h e r e s u l t s t e n d t o be i n s e n s i t i v e t o d i f f e r e n c e s i n s p e c i f i c a s p e c t s o f t h e c a r e r e c e i v e d ( L o c k e r & D u n t ) . F u r t h e r , t h e r e s u l t s do not i n d i c a t e how c a r e may be changed t o improve s a t i s f a c t i o n ( L o c k e r & D u n t ) . H e n l e y and D a v i s (1967) s u g g e s t t h a t consumer s a t i s f a c t i o n be e v a l u a t e d u s i n g two t o o l s : f i r s t , a s a t i s f a c t i o n measure f o r each a s p e c t o f t h e i n d i v i d u a l ' s c a r e ; 23 and second, a g e n e r a l e v a l u a t i o n o f t h e c a r e r e c e i v e d . Not c l e a r l y d e f i n i n g what i s b e i n g measured i s a major p r o b l e m i n e v a l u a t i n g p a t i e n t s a t i s f a c t i o n . Two a s p e c t s o f t h i s p r o b l e m e x i s t . F i r s t , some q u e s t i o n n a i r e s have been d e v e l o p e d f o r use i n h o s p i t a l environments w i t h t h e i n t e n t i o n o f b e i n g more u n i v e r s a l l y u s e d . These i n c l u d e t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e by Ware, Snyder , & Wright (Ware, 1981) and t h e P a t i e n t S a t i s f a c t i o n Instrument by R i s s e r (1975). However, as b o t h o f t h e s e q u e s t i o n n a i r e s measure o n l y g e n e r a l c a r e r e c e i v e d , t h e y a re n o t s e n s i t i v e t o p a r t i c u l a r a s p e c t s o f t h e c a r e ( O b e r s t , 1984). Second, t h e r e i s a p r o b l e m w i t h t h e development o f t h e q u e s t i o n n a i r e i t s e l f . R e s e a r c h e r s o f t e n measure s a t i s f a c t i o n based on p r e - d e t e r m i n e d t o p i c s . The q u e s t i o n s o f t e n r e l a t e t o what t h e r e s e a r c h e r s want t h e p a t i e n t t o e v a l u a t e or what t h e y assume i s i m p o r t a n t f o r e v a l u a t i n g p a t i e n t s a t i s f a c t i o n ( O b e r s t ) . W i t h o u t p a t i e n t i n v o l v e m e n t i n t o o l development , t h e v a l i d i t y o f t h e measurements o b t a i n e d i s q u e s t i o n a b l e ( O b e r s t ) . The l a c k of v a l i d i t y i s a major c o n c e r n because t h e m a j o r i t y o f p a t i e n t s a t i s f a c t i o n s t u d i e s do n o t i n d i c a t e p a t i e n t i n v o l v e m e n t i n t o o l development . O t h e r problems i n v o l v e t h e format o f t h e q u e s t i o n s , whether used i n an i n t e r v i e w or a q u e s t i o n n a i r e . Some a r e r e n d e r e d u s e l e s s as t h e y a r e ambiguous, b a d l y worded, or f a i l t o i d e n t i f y or m i s r e p r e s e n t p a t i e n t s ' a t t i t u d e s ( F r e n c h , 1981). A common p r o b l e m i n measur ing consumer s a t i s f a c t i o n i s 24 t h a t s a t i s f a c t i o n r a t i n g s a re f r e q u e n t l y h i g h ( O b e r s t , 1984). T h i s may be a r e s u l t o f t h e i n s e n s i t i v i t y of t h e t o o l used t o measure s a t i s f a c t i o n . O b e r s t recommends u s i n g a v i s u a l analogue s c a l e t o i n c r e a s e t h e s e n s i t i v i t y o f t h e r e s p o n s e s . A v i s u a l analogue s c a l e (VAS) c o n s i s t s o f a s i n g l e h o r i z o n t a l l i n e ( c o n v e n t i o n a l l y 10 c e n t i m e t e r s i n l e n g t h ) w i t h anchor words a t each end o f t h e l i n e (Reading , 1980). Each of t h e words i n d i c a t e p o l a r o p p o s i t e s w i t h r e s p e c t t o meaning ( e . g . n o t u n c o m f o r t a b l e a t a l l , v e r y u n c o m f o r t a b l e ) . The r e s p o n d e n t p l a c e s a mark, a p o i n t on t h e l i n e which c o r r e s p o n d s t o h i s / h e r f e e l i n g s on t h e cont inuum r e l a t i v e t o t h e two extremes ( O b e r s t , 1984). The d i s t a n c e from t h e f i r s t anchor word t o t h e mark i s measured and a s c o r e i n m i l l i m e t e r s i s o b t a i n e d . The VAS i s s h o r t , and easy t o a d m i n i s t e r and s c o r e ( Jensen, K a r o l y , & B r a v e r , 1986). Used e x t e n s i v e l y i n p a i n s t u d i e s , i t has been shown t o be r e l i a b l e and s e n s i t i v e t o v a r i a t i o n s (Seymour, 1982). In a d d i t i o n , VAS i s a r a t i o s c a l e ( P r i c e , McGrath , R a f i i , & Buckingham, 1983). T h i s i m p o r t a n t c h a r a c t e r i s t i c e n a b l e s t h e q u a n t i t a t i v e e x p r e s s i o n on i n t e n s i t y l e v e l s . A p o t e n t i a l l i m i t a t i o n o f t h i s s c a l e i s t h a t some s u b j e c t s have d i f f i c u l t y u n d e r s t a n d i n g t h e t a s k (S tewar t , 1977). T h i s may be overcome by e n s u r i n g t h a t t h e p a t i e n t c l e a r l y u n d e r s t a n d s t h e t a s k p r i o r t o u s i n g t h e s c a l e . The few s t u d i e s t h a t have e v a l u a t e d a p a r t i c u l a r t r e a t m e n t do not appear t o have i n v o l v e d t h e p a t i e n t i n d e v e l o p i n g t h e q u e s t i o n n a i r e , and t h e e v a l u a t i o n s o f p a t i e n t 25 s a t i s f a c t i o n v a r y from s p e c i f i c r e s p o n s e s t o an o v e r a l l r a t i n g ( H o o g s t r a t e n & Lamers, 1987; S i d i , Reddy, & Chen, 1988). No q u e s t i o n n a i r e i s a v a i l a b l e t o measure p a t i e n t s a t i s f a c t i o n w i t h r e s p e c t t o t h e t y p e of d r e s s i n g s used i n t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s , n o r i s t h e r e one which i n c l u d e s t h e development p r i n c i p l e s O b e r s t sugges ted (1984). Summary In summary, t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s i s n e i t h e r w e l l e s t a b l i s h e d i n t h e l i t e r a t u r e nor r e s e a r c h e d . Though c o n t i n u o u s wet s a l i n e d r e s s i n g s a r e commonly u s e d , some i n c o n v e n i e n c e s and p a t i e n t d i s c o m f o r t do not make them i d e a l c h o i c e s . M e s a l t d r e s s i n g s may p r o v i d e a good a l t e r n a t i v e . They a r e d r y , and s t u d i e s have shown them t o be c o n v e n i e n t and r e q u i r e fewer d r e s s i n g changes ; t h u s , t h e y d e c r e a s e t h e n u r s e ' s w o r k l o a d and i n c r e a s e p a t i e n t c o m f o r t . U s i n g p a t i e n t s a t i s f a c t i o n t o s p e c i f i c a l l y e v a l u a t e d r e s s i n g s i s u n i q u e s i n c e most p a t i e n t s a t i s f a c t i o n t o o l s have a b r o a d f o c u s . Most p a t i e n t s a t i s f a c t i o n t o o l s seem t o be d e v e l o p e d w i t h o u t p a t i e n t i n v o l v e m e n t . No e v a l u a t i o n t o o l s have been d e v e l o p e d f o r e v a l u a t i n g d r e s s i n g s , and s p e c i f i c a l l y not f o r u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . The next c h a p t e r d i s c u s s e s t h e methods used t o d e v e l o p t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e , and t o compare M e s a l t d r e s s i n g s w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s , u s i n g p a t i e n t s a t i s f a c t i o n as an i n d i c a t o r . 2 6 CHAPTER 3 Methodology Introduction The r e s e a r c h f o r t h i s t h e s i s i s p a r t o f a l a r g e r s t u d y conducted by t h e BCCA, comparing M e s a l t d r e s s i n g s w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s i n t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . The l a r g e r s t u d y e v a l u a t e d : p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g performance , p a t i e n t and n u r s e p r e f e r e n c e , o c c u r r e n c e of i n f e c t i o n , number o f d r e s s i n g changes, c a r e o f t h e l e s i o n , and c o s t o f d r e s s i n g m a t e r i a l s . T h i s t h e s i s f o c u s e d on t h e p a r t e v a l u a t i n g p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g performance and p a t i e n t p r e f e r e n c e . The f o c u s on t h e p a t i e n t was c o n s i d e r e d t o be i m p o r t a n t because many p a t i e n t s change t h e i r own d r e s s i n g s and o f t e n have t h e l e s i o n f o r a c o n s i d e r a b l e p e r i o d of t i m e . T h e r e f o r e , t h e purposes o f t h i s t h e s i s were t w o - f o l d : f i r s t , t o d e v e l o p a P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e which r e f l e c t s p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g s used i n t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s ; and second, t o compare M e s a l t d r e s s i n g s w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s . U n f o r t u n a t e l y , due t o t i m e c o n s t r a i n t s and t h e low numbers o f p a t i e n t s a c c r u e d t o t h e s t u d y , t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e was not used d u r i n g t h e s t u d y . I n s t e a d p a t i e n t s a t i s f a c t i o n d a t a were o b t a i n e d u s i n g two p r e - d e v e l o p e d BCCA i n s t r u m e n t s . F o r c l a r i t y i n d i s c u s s i n g t h e methodology and 27 s t u d y f i n d i n g s , " s t u d y " w i l l r e f e r o n l y t o t h e t h e s i s component o f t h e l a r g e r BCCA s t u d y . Two hypotheses were t e s t e d : f i r s t , M e s a l t d r e s s i n g s w i l l r e c e i v e a more p o s i t i v e r a t i n g t h a n c o n t i n u o u s wet s a l i n e d r e s s i n g s w i t h r e s p e c t t o p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g p e r f o r m a n c e ; and second, M e s a l t d r e s s i n g s w i l l be p r e f e r r e d by p a t i e n t s t o c o n t i n u o u s wet s a l i n e d r e s s i n g s . T h i s c h a p t e r r e v i e w s t h e methodology and a n a l y s i s used b o t h f o r d e v e l o p i n g t h e t o o l and e v a l u a t i n g t h e d r e s s i n g s d u r i n g t h e s t u d y . Development o f t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e The P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e was d e v e l o p e d t o measure s a t i s f a c t i o n w i t h d r e s s i n g performance (Appendix A ) . The q u e s t i o n n a i r e has two p a r t s : 1) t h e items t o be e v a l u a t e d and 2) t h e r e s p o n s e s c a l e s . Items t o be e v a l u a t e d were d e v e l o p e d from i n p u t by p a t i e n t s as w e l l as s u p p o r t f rom t h e l i t e r a t u r e . The VAS was used as t h e r e s p o n s e s c a l e . Sample f o r P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e P a t i e n t s w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s who were seen i n t h e Ambulatory Care U n i t o f t h e BCCA Vancouver C l i n i c formed t h e m a j o r i t y o f t h e sample used t o d e v e l o p t h e q u e s t i o n n a i r e . A few p a t i e n t s were seen as i n - p a t i e n t s a t t h e BCCA Vancouver C l i n i c . S u b j e c t s were r e q u i r e d t o u n d e r s t a n d , speak and read E n g l i s h . A l l t h o s e p a t i e n t s who f i t t h e c r i t e r i a were approached and t h o s e who consented were i n c l u d e d i n t h e sample. 28 P r o c e d u r e f o r Q u e s t i o n n a i r e Development The q u e s t i o n n a i r e was d e v e l o p e d t h r o u g h a p r o c e s s o f c o n t e n t i d e n t i f i c a t i o n , c o n t e n t v a l i d i t y v e r i f i c a t i o n , and r e l i a b i l i t y t e s t i n g . C o n t e n t I d e n t i f i c a t i o n . C o n t e n t f o r t h e q u e s t i o n n a i r e was i d e n t i f i e d t h r o u g h a c o m b i n a t i o n o f p a t i e n t i n t e r v i e w s , r e v i e w o f t h e l i t e r a t u r e , and p e r s o n a l e x p e r i e n c e s . A t o t a l o f e i g h t p a t i e n t s w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s were i n t e r v i e w e d by t h e i n v e s t i g a t o r who used an i n t e r v i e w g u i d e (Appendix B) t o d e t e r m i n e t h o s e f a c t o r s t o be c o n s i d e r e d when e v a l u a t i n g p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g s . The d a t a o b t a i n e d was used t o d e v e l o p t h e P r e l i m i n a r y Q u e s t i o n n a i r e (Appendix C ) . A l e t t e r o f i n t r o d u c t i o n was w r i t t e n t o e x p l a i n t h e purpose o f t h e q u e s t i o n n a i r e and g i v e an example q u e s t i o n and r e s p o n s e (Appendix D ) . C o n t e n t V a l i d i t y V e r i f i c a t i o n . C o n t e n t v a l i d i t y i s t h e e x t e n t t o which t h e i tems i n c l u d e d i n t h e s c a l e a r e r e l e v a n t and complete ( N u n n a l l y , 1978). The i n v e s t i g a t o r a d m i n i s t e r e d t h e p r e l i m i n a r y q u e s t i o n n a i r e t o e i g h t p a t i e n t s (not p r e v i o u s l y i n v o l v e d i n t h e f i r s t s t e p ) w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s t o d e t e r m i n e t h e r e l e v a n c e and completeness o f t h e q u e s t i o n n a i r e , and t h e c l a r i t y and importance o f each of t h e items i d e n t i f i e d . O n l y t h e r e s p o n s e s of f i v e p a t i e n t s were used t o r e f i n e t h e q u e s t i o n n a i r e . The o t h e r t h r e e p a t i e n t s had t o be e l i m i n a t e d f r o m t h e s t u d y because t h e y appeared s l i g h t l y d i s o r i e n t e d and 29 o f t e n were u n a b l e t o complete t h e q u e s t i o n n a i r e w i t h o u t a g r e a t d e a l o f a s s i s t a n c e . Comments about t h e wording and meaning o f t h e q u e s t i o n s were c o n s i d e r e d and u s e d f o r r e v i s i n g t h e q u e s t i o n n a i r e . F o r each i tem, t h e average importance was c a l c u l a t e d . Items w i t h an average r a t i n g of 50% or g r e a t e r were k e p t , w h i l e t h o s e w i t h an average r a t i n g o f l e s s t h a n 50% were d e l e t e d . These r e s u l t s were used t o d e v e l o p t h e P i l o t Q u e s t i o n n a i r e (Appendix E ) . R e l i a b i l i t y T e s t i n g . The P i l o t Q u e s t i o n n a i r e was t e s t e d f o r r e l i a b i l i t y u s i n g t h e t e s t / r e - t e s t method. The q u e s t i o n n a i r e was a d m i n i s t e r e d t o f o u r p a t i e n t s w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s (who were n o t p r e v i o u s l y i n v o l v e d i n t h e f i r s t two s t e p s ) . One week l a t e r i t was r e - a d m i n i s t e r e d t o t h r e e o f t h e f o u r p a t i e n t s . However, one p a t i e n t was n o t f e e l i n g w e l l enough t o complete t h e second p a r t o f t h e t e s t i n g . The average d i f f e r e n c e s between t h e f i r s t t e s t and t h e second t e s t were d e p i c t e d i n t h e form o f a h i s t o g r a m . The P e a r s o n c o r r e l a t i o n c o e f f i c i e n t was d e t e r m i n e d by t h e i n v e s t i g a t o r , r e c o g n i s i n g t h e l i m i t a t i o n s o f such a s m a l l sample . The a n a l y s i s i n v o l v e d c o r r e l a t i n g 1) t h e sum o f t h e average r e s p o n s e s t o each q u e s t i o n o f t h e f i r s t t e s t , w i t h 2) t h e sum o f t h e average r e s p o n s e s t o each q u e s t i o n f o r t h e second t e s t . The r e s u l t s were f u r t h e r t e s t e d f o r i n t e r n a l c o n s i s t e n c y . Homogeneity o f t h e q u e s t i o n s was a s s e s s e d u s i n g t h e s p l i t - h a l f method: d i v i d i n g t h e q u e s t i o n s i n t o two groups by a l t e r n a t i n g q u e s t i o n s . The two groups were t h e n 30 r e - t e s t e d u s i n g t h e P e a r s o n c o r r e l a t i o n c o e f f i c i e n t . The f i n a l outcome o f t h e t o o l development was t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e which was made a v a i l a b l e f o r use i n t h e s t u d y . U n f o r t u n a t e l y , t h e r e was a l a c k o f o p p o r t u n i t y t o a d m i n i s t e r t h i s q u e s t i o n n a i r e w i t h p a t i e n t s s t i l l i n t h e s t u d y , due t o t i m e c o n s t r a i n t s and t h e low numbers o f p a t i e n t s i n v o l v e d . Study Methodology Study D e s i g n The s t u d y used a c r o s s - o v e r d e s i g n t o compare M e s a l t d r e s s i n g s w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s . The c r o s s - o v e r d e s i g n i s a " w i t h i n - p a t i e n t " s t u d y i n which each p a t i e n t r e c e i v e s two t r e a t m e n t s , one f o l l o w i n g a n o t h e r , w i t h t h e o r d e r o f t r e a t m e n t s b e i n g d e c i d e d randomly (Pocock, 1983). T h i s t y p e o f d e s i g n i s a p p r o p r i a t e f o r use i n comparing i n d i v i d u a l p a t i e n t p r e f e r e n c e s f o r two t r e a t m e n t s ( P o c o c k ) . I t i s b e s t s u i t e d where a p a t i e n t sample i s r e l a t i v e l y s t a b l e i n terms o f d i s e a s e s t a t e , and t h e t r e a t m e n t i s r e l a t i v e l y s h o r t - t e r m ( P o c o c k ) . The d u r a t i o n o f t r e a t m e n t i n t h i s s t u d y was 2 months f o r each s u b j e c t : 1 month f o r t h e f i r s t arm o f t r e a t m e n t and 1 month f o r t h e second. P a t i e n t s were randomly a s s i g n e d t o t h e i r f i r s t t r e a t m e n t u s i n g a r a n d o m i s a t i o n t a b l e d e v e l o p e d by t h e D i v i s i o n o f E p i d e m i o l o g y , B i o m e t r y and O c c u p a t i o n a l O n c o l o g y , BCCA. 31 Study Group F o u r t e e n p a t i e n t s were a c c r u e d t o t h e s t u d y d u r i n g t h e t i m e p e r i o d c o v e r e d by t h i s t h e s i s . They were s e l e c t e d from r e g i s t e r e d BCCA p a t i e n t s : o u t p a t i e n t s , i n p a t i e n t s , and homecare p a t i e n t s . P a t i e n t s were e x c l u d e d i f t h e y were u n d e r g o i n g r a d i a t i o n or chemotherapy a f f e c t i n g t h e c o n d i t i o n o f t h e l e s i o n . To be e l i g i b l e f o r t h e s t u d y , p a t i e n t s had t o s a t i s f y t h e f o l l o w i n g c r i t e r i a : 1. BCCA r e g i s t e r e d p a t i e n t , 18 y e a r s or o v e r , w i t h no upper l i m i t . 2. R e s i d e n t of t h e G r e a t e r Vancouver Lower M a i n l a n d a r e a . 3. U l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s e c o n d a r y t o a c o n f i r m e d c a n c e r . 4. U l c e r a t i n g m e t a s t a t i c s k i n l e s i o n w i t h d i s c h a r g e r e q u i r i n g a t l e a s t two d r e s s i n g changes p e r 24 h o u r s . 5. F r e e o f c l i n i c a l and m i c r o b i o l o g i c a l e v i d e n c e of i n f e c t i o n . 6. S u r v i v a l e x p e c t a n c y g r e a t e r t h a n 3 months. 7. S t a b l e d i s e a s e one month p r i o r t o s t u d y e n t r y . 8. Competent t o answer q u e s t i o n s and w i l l i n g t o be c o m p l i a n t w i t h t h e t h e r a p e u t i c p r o t o c o l . 9. C o n s e n t i n g t o p a r t i c i p a t i n g i n t h e s t u d y and h a v i n g s i g n e d t h e c o n s e n t form. The sample used f o r t h i s s t u d y was a sample o f c o n v e n i e n c e . Many o f t h e p a t i e n t s were n o t e l i g i b l e f o r t h e s t u d y as t h e y were f rom o u t s i d e t h e G r e a t e r Vancouver Lower M a i n l a n d , were r e c e i v i n g chemotherapy or r a d i a t i o n t h e r a p y 32 which was e f f e c t i n g t h e i r l e s i o n , were i n t h e t e r m i n a l s t a g e s o f t h e i r d i s e a s e , or had t o o l i t t l e d r a i n a g e . In a number o f i n s t a n c e s , i t was not f e a s i b l e f o r t h e Home Care Nurses t o i n c r e a s e t h e i r v i s i t s t o accomodate s t u d y p a t i e n t s who were on t h e t r e a t m e n t arm u s i n g t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s . I t was t h u s d i f f i c u l t t o a c c r u e p a t i e n t s who were c o m p l e t e l y * dependent on t h e Home N u r s i n g c a r e program f o r t h e i r d r e s s i n g changes . D u r i n g t h e s t u d y p e r i o d , f i v e p a t i e n t s d e c i d e d not t o p a r t i c i p a t e i n t h e s t u d y , m o s t l y due t o t h e i n c o n v e n i e n c e o f t h e v i s i t s and t h e need t o f o l l o w a p r o t o c o l . S t u d y P r o c e d u r e A c c r u a l . Nurses and p h y s i c i a n s a t t h e BCCA, and n u r s e s i n t h e community, i d e n t i f i e d p o t e n t i a l s t u d y p a t i e n t s and c o n t a c t e d t h e i n v e s t i g a t o r t o d e t e r m i n e e l i g i b i l i t y . I f t h e p a t i e n t was e l i g i b l e , t h e n u r s e or p h y s i c i a n b r i e f l y e x p l a i n e d t h e s t u d y t o them. I f t h e p a t i e n t was i n t e r e s t e d i n p a r t i c i p a t i n g i n t h e s t u d y , t h e i n v e s t i g a t o r was c o n t a c t e d t o f u r t h e r e x p l a i n t h e s t u d y t o t h e p a t i e n t i n more d e t a i l . I f t h e p a t i e n t was n o t a c t i v e l y b e i n g seen a t t h e BCCA, t h e p a t i e n t ' s BCCA p h y s i c i a n was asked t o c o n t a c t t h e p a t i e n t r e g a r d i n g h i s o r h e r p a r t i c i p a t i o n i n t h e s t u d y . L a t e r i n t h e s t u d y , a l l o f t h e h o s p i t a l s i n t h e G r e a t e r Vancouver Lower M a i n l a n d were c o n t a c t e d i n an at tempt t o promote a c c r u a l . However, t h i s d i d n o t r e s u l t i n t h e a c c r u a l o f any p a t i e n t s t o t h e s t u d y . P r o c e d u r e . I f t h e p a t i e n t co nsented t o t h e s t u d y , 33 t h e i n v e s t i g a t o r t o o k a m e d i c a l h i s t o r y (Appendix F) p r i o r t o s t u d y . The f a m i l y p h y s i c i a n s o f a l l t h e p a t i e n t s i n v o l v e d i n t h e s t u d y were i n f o r m e d a t t h e b e g i n n i n g and end o f t h e s t u d y . O n l y one p a t i e n t had c l i n i c a l and m i c r o b i o l o g i c a l e v i d e n c e o f i n f e c t i o n , and e n t e r e d t h e s t u d y a f t e r r e s o l u t i o n of t h e i n f e c t i o n . The l e s i o n was c a r e d f o r a c c o r d i n g t o a s t a n d a r d p r o t o c o l (Appendix G ) . Most o f t h e p a t i e n t s were independent i n t h e c a r e o f t h e i r l e s i o n s , b u t i n some cases Home Care Nurse i n t h e community or t h e S t a f f Nurse i n t h e h o s p i t a l changed t h e d r e s s i n g s . P r i o r t o e n t e r i n g t h e s t u d y , t h e . i n v e s t i g a t o r o r i e n t e d t h e p a t i e n t t o t h e wound c a r e p r o t o c o l . The program o f c a r e was t h e same f o r b o t h t y p e s of t r e a t m e n t s . The i n v e s t i g a t o r m o n i t o r e d t h e p r o t o c o l c o m p l i a n c e on a weekly b a s i s . The s t u d y t o o k p l a c e p r i m a r i l y i n t h e p a t i e n t s ' homes. However, t h r e e p a t i e n t s were v i s i t e d once or t w i c e w h i l e a t t h e BCCA t o see a p h y s i c i a n ; f o u r p a t i e n t s were v i s i t e d once or more i n a h o s p i t a l s e t t i n g w h i l e t h e y were r e c e i v i n g t r e a t m e n t f o r c o m p l i c a t i o n s n o t i n v o l v i n g t h e i r wound. Home Care Nurses r e g u l a r l y v i s i t e d seven o f t h e s t u d y p a t i e n t s . The O v e r a l l E v a l u a t i o n S c a l e was a d m i n i s t e r e d a t t h e end o f t h e f i r s t t r e a t m e n t arm and t h e end o f t h e second t r e a t m e n t arm. The P r e f e r e n c e S c a l e was a d m i n i s t e r e d a t t h e end o f t h e second t r e a t m e n t arm. 34 Study a s s e s s m e n t s : B e g i n n i n g of Study Weekly End o f f i r s t t r e a t m e n t arm End of second t r e a t m e n t arm M e d i c a l H i s t o r y X Assessment o f C o m p l i a n c e X O v e r a l l E v a l u a t i o n X X S c a l e P r e f e r e n c e S c a l e X E v a l u a t i o n T o o l s The s t u d y used two measurement t o o l s p r e v i o u s l y d e v e l o p e d f o r t h e BCCA s t u d y . The f i r s t t o o l , t h e " O v e r a l l E v a l u a t i o n S c a l e , " used a q u e s t i o n n a i r e format (Appendix H ) . The p a t i e n t was asked f i v e q u e s t i o n s , and each q u e s t i o n was f o l l o w e d by a r e s p o n s e s c a l e i n t h e v i s u a l analogue f o r m a t . Each q u e s t i o n i d e n t i f i e d was a r e s u l t o f p r e v i o u s c o n t a c t s w i t h p a t i e n t s who were u s i n g d r e s s i n g s i n t h e c a r e o f t h e i r u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n . However, t h e q u e s t i o n s d i d n o t undergo any t e s t i n g f o r v a l i d i t y or r e l i a b i l i t y p r i o r t o use i n t h e s t u d y . The second t o o l , t h e " P r e f e r e n c e S c a l e , " asked t h e p a t i e n t t o i n d i c a t e a p r e f e r e n c e f o r t h e " f i r s t d r e s s i n g " , t h e " s e c o n d d r e s s i n g " or "no p r e f e r e n c e " (Appendix I ) . An open-ended q u e s t i o n asked "Why?" As p a r t o f t h i s t h e s i s , a VAS was added t o t h i s t o o l t o measure t h e degree o f p r e f e r e n c e 35 f o r a d r e s s i n g . The q u e s t i o n used was " I f you d i d have a p r e f e r e n c e i n d i c a t e d above, how s t r o n g was y o u r p r e f e r e n c e ? " The two e n d p o i n t s used were "Not v e r y s t r o n g " and " V e r y s t r o n g . As a r e s u l t o f t h i s q u e s t i o n , t h e "Why?" q u e s t i o n was expanded t o " I f you d i d have a p r e f e r e n c e ( i n d i c a t e d above) , why d i d you p r e f e r t h e d r e s s i n g ? " The r e v i s e d s c a l e i s i n A p p e n d i x J . S t a t i s t i c a l A n a l y s i s Sample S i z e . P r e v i o u s s t u d i e s u s i n g M e s a l t d r e s s i n g s were m o s t l y c o n c e r n e d w i t h d e s c r i b i n g i t s h e a l i n g p r o p e r t i e s , and c o n s e q u e n t l y no d a t a were a v a i l a b l e t o c a l c u l a t e sample s i z e . T h e r e f o r e , t h e c a l c u l a t i o n o f sample s i z e f o r t h i s s t u d y was based on t h e number needed t o e v a l u a t e p a t i e n t p r e f e r e n c e . A sample o f 26 p a t i e n t s was r e q u i r e d t o d e t e r m i n e a 75% p r e f e r e n c e f o r t h e M e s a l t d r e s s i n g compared t o p r e f e r e n c e f o r n e i t h e r d r e s s i n g w i t h C X = .05 and 1 - ft = .80 . The sample s i z e was based on b i n o m i a l p r o b a b i l i t y ( F l e i s s , 1981) and was c a l c u l a t e d by t h e BCCA D i v i s i o n o f E p i d e m i o l o g y , B i o m e t r y , and O c c u p a t i o n a l O n c o l o g y . U n f o r t u n a t e l y , a t t h e t i m e t h a t t h i s t h e s i s was c o m p l e t e d , o n l y f o u r t e e n p a t i e n t s had been a c c r u e d t o t h e s t u d y . T h e r e f o r e , t h e a n a l y s i s o f t h e r e s u l t s has some l i m i t a t i o n s . S t a t i s t i c a l P r o c e d u r e s . 1. O v e r a l l E v a l u a t i o n S c a l e The h y p o t h e s i s t e s t e d was " M e s a l t d r e s s i n g s 36 w i l l r e c e i v e a more p o s i t i v e r a t i n g t h a n c o n t i n u o u s wet s a l i n e d r e s s i n g s . " The responses t o each o f t h e f i v e q u e s t i o n s were t e s t e d u s i n g t h e W i l c o x o n s i g n e d - r a n k t e s t u s i n g a o n e - t a i l e d t e s t w i t h an O C = -05. (Neave & W o r t h i n g t o n , 1988). Ho: There i s no d i f f e r e n c e i n t h e average r a t i n g s ( f o r each q u e s t i o n ) f o r M e s a l t d r e s s i n g s and f o r c o n t i n u o u s wet s a l i n e d r e s s i n g s . H i : M e s a l t d r e s s i n g s w i l l r e c e i v e a more p o s i t i v e average r a t i n g ( f o r each q u e s t i o n ) t h a n c o n t i n u o u s wet s a l i n e d r e s s i n g s . L e t "+" i n d i c a t e a p o s i t i v e d i f f e r e n c e i n f a v o r o f t h e t h e M e s a l t d r e s s i n g s and " - " i n d i c a t e a n e g a t i v e d i f f e r e n c e i n f a v o r o f t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s . I f t h e Ho ( n u l l h y p o t h e s i s ) i s t r u e , t h e average (median) o f d i f f e r e n c e s w i l l be s e r o . I f t h e H i ( a l t e r n a t e h y p o t h e s i s ) i s t r u e , t h e t r u e average d i f f e r e n c e w i l l be p o s i t i v e . The d i f f e r e n c e was o b t a i n e d by s u b t r a c t i n g t h e s c o r e o b t a i n e d w i t h t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s f rom t h e s c o r e o b t a i n e d w i t h t h e M e s a l t d r e s s i n g s . The d i f f e r e n c e s were ranked , and t h e n e g a t i v e s c o r e s t o t a l l e d . F o r t h i s t e s t , " T " was d e f i n e d as t h e sum o f ranks o f n e g a t i v e d i f f e r e n c e s , as T would be expec ted t o be s m a l l e r i f H i were t r u e . D e c i s i o n r u l e : I f T i T c r i t i c a l , H i i s s u p p o r t e d . 37 U s i n g t h e s t a t i s t i c a l t a b l e s f o r t h i s t e s t (Neave & W o r t h i n g t o n , 1988), t h e T c r i t i c a l was d e t e r m i n e d and a d e c i s i o n made. 2. P r e f e r e n c e S c a l e The h y p o t h e s i s t e s t e d was " M e s a l t d r e s s i n g s w i l l be p r e f e r r e d by p a t i e n t s t o c o n t i n u o u s wet s a l i n e d r e s s i n g s . " T h i s h y p o t h e s i s was t e s t e d u s i n g t h e s i g n t e s t ( o n e - t a i l e d ) w i t h a c r i t i c a l l e v e l CxS = .05 (Neave & W o r t h i n g t o n , 1988). Ho: P r e f e r e n c e i s e q u a l between M e s a l t d r e s s i n g s and c o n t i n u o u s wet s a l i n e d r e s s i n g s . H i : M e s a l t d r e s s i n g s a r e p r e f e r r e d more t h a n c o n t i n u o u s wet s a l i n e d r e s s i n g s . L e t "+" i n d i c a t e t h e number o f p r e f e r e n c e s f o r M e s a l t d r e s s i n g s and " - " i n d i c a t e t h e number of p r e f e r e n c e s f o r c o n t i n u o u s wet s a l i n e d r e s s i n g s . I f Ho ( n u l l h y p o t h e s i s ) i s t r u e , t h e number o f "+" and " - " s i g n s would be r o u g h l y e q u a l . Whereas, i f H i ( the a l t e r n a t e h y p o t h e s i s ) i s t r u e , t h e r e would be a r e l a t i v e l y l a r g e number o f "+" s i g n s and c o r r e s p o n d i n g l y few number o f " - " s i g n s . No p r e f e r e n c e s were o m i t t e d from t h e a n a l y s i s . S i n c e i t was expec ted t h a t t h e r e would be s m a l l e r numbers o f t h e " - " s i g n s , t h e t e s t s t a t i s t i c " S " was d e f i n e d as t h e number o f " - " s i g n s . D e c i s i o n r u l e : H i t e n a b l e i f S _ S c r i t i c a l 38 U s i n g t h e s t a t i s t i c a l t a b l e s f o r t h i s t e s t (Weave & W o r t h i n g t o n , 1988), t h e S c r i t i c a l was d e t e r m i n e d and a d e c i s i on made. The open-ended q u e s t i o n r e s u l t s were examined u s i n g a theme a n a l y s i s a p p r o a c h . The VAS r e s u l t s f r o m t h e r e v i s e d P r e f e r e n c e S c a l e r e f l e c t i n g s t r e n g t h o f p r e f e r e n c e were a l s o e v a l u a t e d . W i t h d r a w a l s . P a t i e n t s who d i d n o t complete a t l e a s t one week o f b o t h s t u d y arms were o m i t t e d from t h e s t a t i s t i c a l a n a l y s i s . The r e s u l t s o f t h e r e m a i n i n g p a t i e n t s were a n a l y z e d by s u b - g r o u p s d e p e n d i n g on t h e l e n g t h o f t i m e t h e y were i n t h e s t u d y . E t h i c s . P a t i e n t s were i n f o r m e d o f t h e p u r p o s e and p r o c e d u r e s o f t h e s t u d y as w e l l as t h e p o t e n t i a l b e n e f i t s and i n c o n v e n i e n c e t h a t c o u l d o c c u r d u r i n g t h e s t u d y . P a t i e n t s were a l s o i n f o r m e d t h a t t h e i r p a r t i c i p a t i o n was v o l u n t a r y and t h e i r r e f u s a l or w i t h d r a w a l f rom t h e s t u d y would not compromise t h e i r t r e a t m e n t and c a r e a t t h e BCCA. P a t i e n t s s i g n e d a c o n s e n t f o r m b e f o r e e n t e r i n g t h e s t u d y (Appendix K ) . A u n i q u e s t u d y number was a s s i g n e d t o each p a r t i c i p a n t . No name was w r i t t e n on t h e d a t a and c o d i n g forms, except f o r t h e c o n s e n t form. A l l t h e forms used i n t h e s t u d y were kept under s e c u r e c o n d i t i o n s i n t h e D i v i s i o n o f N u r s i n g , BCCA. Summary T h i s c h a p t e r has p r e s e n t e d t h e methodology and a n a l y s i s used t o d e v e l o p t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e as w e l l 39 as t o compare M e s a l t d r e s s i n g s w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s as p a r t o f a l a r g e r s t u d y . The r e s u l t s a r e p r e s e n t e d and d i s c u s s e d i n t h e next c h a p t e r , f o l l o w e d by a c h a p t e r d e s c r i b i n g t h e c o n c l u s i o n s and recommendations. 40 CHAPTER 4 P r e s e n t a t i o n and D i s c u s s i o n o f F i n d i n g s I n t r o d u c t i o n The f i n d i n g s a r e p r e s e n t e d i n two s e c t i o n s i n t h i s c h a p t e r . The development o f t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e i s d e s c r i b e d i n t h e f i r s t s e c t i o n . F i n d i n g s r e l a t e d t o t h e two s t u d y hypotheses a r e p r e s e n t e d i n t h e second s e c t i o n . W i t h i n each s e c t i o n , t h e c h a r a c t e r i s t i c s o f t h e sample a r e d e s c r i b e d . The f i n d i n g s a r e d i s c u s s e d a t t h e end o f each s e c t i o n . P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e The q u e s t i o n n a i r e development i n v o l v e d t h r e e s t e p s : c o n t e n t i d e n t i f i c a t i o n , c o n t e n t v a l i d i t y v e r i f i c a t i o n , and r e l i a b i l i t y t e s t i n g . The c h a r a c t e r i s t i c s of t h e sample a r e d e s c r i b e d and t h e r e s u l t s g i v e n . C o n t e n t I d e n t i f i c a t i o n E i g h t p a t i e n t s were i n t e r v i e w e d t o i d e n t i f y c o n t e n t f o r t h e P r e l i m i n a r y Q u e s t i o n n a i r e . A d d i t i o n a l c o n t e n t was i d e n t i f i e d t h r o u g h a r e v i e w o f t h e l i t e r a t u r e and p e r s o n a l e x p e r i e n c e s . C h a r a c t e r i s t i c s o f t h e Sample. Of t h e e i g h t p a t i e n t s , s i x were females and two were males . T h e i r ages ranged f rom 35 t o 78 y e a r s , w i t h an average 61.1 y e a r s , and a median o f 63 y e a r s . The l e n g t h of t i m e t h a t t h e y had t h e i r 41 l e s i o n s ranged from 1 week t o 33.5 months, w i t h an average o f 11.3 months and a median o f 7 months. Seven l e s i o n s were a r e s u l t o f b r e a s t c a n c e r and t h e e i g h t h l e s i o n was due t o melanoma. The l e s i o n s i n v o l v e d t h e b r e a s t or c h e s t w a l l i n seven i n s t a n c e s , and t h e l e g i n one i n s t a n c e . R e s u l t s o f t h e I n t e r v i e w s . The f i r s t s t e p i n t h e q u e s t i o n n a i r e development was t o i n t e r v i e w e i g h t p a t i e n t s w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s t o d e t e r m i n e f a c t o r s t o be c o n s i d e r e d when e v a l u a t i n g p a t i e n t s a t i s f a c t i o n . The i n t e r v i e w g u i d e was w e l l r e c e i v e d , a l t h o u g h some p a t i e n t s had d i f f i c u l t y a r t i c u l a t i n g t h e i r l i k e s and d i s l i k e s about d r e s s i n g s . The p a t i e n t s who had used d r e s s i n g s f o r some t i m e or had used a v a r i e t y of d r e s s i n g s found t h e q u e s t i o n s e a s i e r t o answer t h a n d i d t h o s e w i t h l i m i t e d e x p e r i e n c e w i t h d r e s s i n g s . A l s o , t h o s e p a t i e n t s who changed t h e i r own d r e s s i n g s seemed t o be more i n t e r e s t e d i n t h e q u e s t i o n s t h a n t h o s e who had t h e i r d r e s s i n g s changed by a n o t h e r p e r s o n such as t h e Home Care N u r s e . The f i r s t q u e s t i o n asked was "What t y p e s o f d r e s s i n g s have you used i n t h e c a r e o f y o u r open wound?" The r e s p o n s e s i n c l u d e d T e l f a , J e l o n e t , S o f r a t u l l e , U n i t u l l e , wet s a l i n e d r e s s i n g , p a r a f f i n d r e s s i n g , M e s a l t d r e s s i n g , V a s e l i n e o i n t m e n t and d r y gause, and a v a r i e t y o f p l a i n d r y gause d r e s s i n g s . The second q u e s t i o n asked was "What d i d you l i k e about each d r e s s i n g ? " Four p a t i e n t s responded t h a t t h e y l i k e d t h e f a c t t h a t t h e d r e s s i n g d i d n o t s t i c k . One p a t i e n t c l a r i f i e d 42 t h a t i f i t d i d n o t s t i c k , t h e n i t d i d n o t cause b l e e d i n g . A n o t h e r r e s p o n s e was t h a t t h e d r e s s i n g d r i e d t h e l e s i o n f a s t e r , e v i d e n c e t o t h e p a t i e n t t h a t t h e l e s i o n was h e a l i n g . In a d d i t i o n , one p a t i e n t c o n s i d e r e d i t i m p o r t a n t t h a t t h e d r e s s i n g was easy t o use . The t h i r d q u e s t i o n asked was "What d i d you d i s l i k e about each d r e s s i n g ? " D r e s s i n g s t h a t s t u c k t o t h e wound were a major d i s l i k e . I f t h e d r e s s i n g s t u c k , i t was u n c o m f o r t a b l e t o remove and c o u l d make t h e l e s i o n b l e e d . U s i n g a c l e a n s e r which d i d n o t s t i n g was i d e n t i f i e d as b e i n g i m p o r t a n t . One d r e s s i n g was found t o be t o o s t i c k y and "gummy," and caused a " s t r a n g e " odor . A n o t h e r d r e s s i n g caused t h e wetness t o go o u t s i d e t h e d r e s s i n g and was a " b o t h e r " a t n i g h t . One. p a t i e n t d i s l i k e d one o f t h e d r e s s i n g s as i t made t h e tumor w e t t e r . She t h o u g h t t h i s would cause t h e tumor t o b r e a k down and t a k e l o n g e r t o heal ' . The f o u r t h q u e s t i o n asked was "What do you want t h e d r e s s i n g t o d o ? " or "What c h a r a c t e r i s t i c s o f t h e d r e s s i n g would you c o n s i d e r i m p o r t a n t i n c h o o s i n g a d r e s s i n g ? " T h i s was a d i f f i c u l t q u e s t i o n f o r many o f t h e p a t i e n t s . Some p a t i e n t s p r e f e r r e d t o l e a v e t h i s q u e s t i o n and answer t h e f i f t h q u e s t i o n i n s t e a d . Those who d i d respond t h o u g h t a major c h a r a c t e r i s t i c s h o u l d be t h a t i t d i d not s t i c k . O t h e r c h a r a c t e r i s t i c s i d e n t i f i e d were t h a t i t s h o u l d be easy t o t a k e o f f , a b s o r b e n t , u s a b l e w i t h o u t t a p e , n o n - a b r a s i v e , and w i t h o u t l i n t . I t s h o u l d be a l s o f i t t e d so i t does not s l i p , i t s h o u l d promote h e a l i n g and i t s h o u l d n o t a l l o w t h e d r a i n a g e t o pass 43 t h r o u g h . The f i n a l q u e s t i o n asked was "What f a c t o r s would i n f l u e n c e y o u r s a t i s f a c t i o n w i t h t h e d r e s s i n g ? " o r "Can you d e s c r i b e t h e ' p e r f e c t ' d r e s s i n g ? " L i k e t h e f o u r t h q u e s t i o n , many p a t i e n t s had d i f f i c u l t y answer ing t h i s q u e s t i o n . Those who answered t h e f o u r t h q u e s t i o n u s u a l l y d i d n o t answer t h i s q u e s t i o n . Those who d i d r e s p o n d s u g g e s t e d d r e s s i n g s which would be s o f t , easy t o a p p l y and remove, n o t s t i c k y , and a b s o r b e n t but n o t b u l k y ; and which would not adhere t o t h e wound. Some of t h e s u g g e s t i o n s f o c u s e d on t h e shape o f t h e bandage, t h e d e s i r a b i l i t y o f h a v i n g i t come i n d i f f e r e n t s i z e s c o n t o u r e d t o adapt t o shape, and f i t t e d such as a s p r a y foam which p e e l s o f f . One p a t i e n t s u g g e s t e d h a v i n g a d r e s s i n g where you p u t on one t h i n g - " j u s t open i t up and p u t i t on l i k e a B a n d - A i d . " Development o f t h e P r e l i m i n a r y Q u e s t i o n n a i r e . C o n s i d e r i n g t h e c h a r a c t e r i s t i c s i d e n t i f i e d i n t h e p r e v i o u s s t e p (summarised i n A p p e n d i x L ) , t h e P r e l i m i n a r y Q u e s t i o n n a i r e was d e v e l o p e d (Appendix C ) . The wording and format o f t h e q u e s t i o n n a i r e was i n f l u e n c e d by t h e comments f r o m a l a r g e number o f n o n - h e a l t h c a r e workers and a few p a t i e n t s . A t o t a l o f 28 q u e s t i o n s were i d e n t i f i e d . The r e s p o n s e s c a l e used f o r each i t e m t o be e v a l u a t e d was t h e V i s u a l Analogue S c a l e (VAS) . T h i s s c a l e c o n s i s t e d o f a s i n g l e 10 cm h o r i z o n t a l l i n e w i t h anchor words a t each end o f t h e l i n e . Each anchor word r e p r e s e n t e d an extreme w i t h r e s p e c t t o meaning ( e . g . a g r e a t d e a l , n o t a t a l l ) . The p a t i e n t s were 44 asked t o " p l a c e a mark t h r o u g h t h e l i n e , between t h e two extremes t o i n d i c a t e t h e degree o f y o u r r e s p o n s e . " The second p a r t o f each o f t h e q u e s t i o n s asked about t h e importance of t h e q u e s t i o n . I t was worded "Is t h e s u b j e c t o f t h e q u e s t i o n i m p o r t a n t t o y o u ? " I n i t i a l l y a VAS was c o n s i d e r e d f o r r a t i n g t h e importance o f each q u e s t i o n . However, t h e f e e d b a c k r e c e i v e d was t h a t t h e VAS was somewhat d i f f i c u l t and t i m e consuming, e s p e c i a l l y f o r t h e number o f q u e s t i o n s b e i n g a s k e d . S i n c e t h e i n i t i a l q u e s t i o n a l r e a d y used t h e VAS, t h e i s s u e was compounded. As i t was p r e - d e t e r m i n e d t h a t o n l y q u e s t i o n s which averaged g r e a t e r t h a n a 50% r a t i n g would be i n c l u d e d , i t was e a s i e r o v e r a l l t o use a " y e s " or " n o " t y p e r e s p o n s e . The wording o f t h e q u e s t i o n r e g a r d i n g impor tance was d i f f i c u l t as i t a t tempted t o i d e n t i f y o n l y t h o s e q u e s t i o n s which were i m p o r t a n t t o t h e p a t i e n t by t h e i r own e x p e r i e n c e and omit q u e s t i o n s which t h e p a t i e n t p e r c e i v e d as " g e n e r a l l y i m p o r t a n t . " An i n t r o d u c t o r y l e t t e r was d e v e l o p e d (Appendix D) t o d e s c r i b e t h e q u e s t i o n n a i r e ' s p u r p o s e , g i v e an example, and r e i n f o r c e t h a t t h e q u e s t i o n about impor tance r e l a t e d t o t h e i r own p e r s o n a l e x p e r i e n c e s . The l e t t e r o f i n t r o d u c t i o n was a l s o used t o remind p a t i e n t s t h a t t h e q u e s t i o n s were r e l a t e d o n l y t o t h e d r e s s i n g and n o t t o t a p e or o t h e r d e v i c e s used t o h o l d t h e d r e s s i n g i n p l a c e . C o n t e n t V a l i d i t y V e r i f i c a t i o n To d e t e r m i n e t h e v a l i d i t y of t h e c o n t e n t , t h e P r e l i m i n a r y 45 Q u e s t i o n n a i r e was t e s t e d t o d e t e r m i n e i f t h e q u e s t i o n s were u n d e r s t a n d a b l e and i m p o r t a n t , and i f t h e q u e s t i o n n a i r e was easy t o f i l l out . The i n v e s t i g a t o r a d m i n i s t e r e d t h e q u e s t i o n n a i r e t o e i g h t p a t i e n t s , r e m a i n i n g i n a t t e n d a n c e w h i l e t h e p a t i e n t s f i l l e d them out . U n f o r t u n a t e l y , t h r e e o f t h e e i g h t p a t i e n t s were u n a b l e t o complete t h e q u e s t i o n n a i r e as t h e y were not f e e l i n g w e l l enough. F o r t h e s e t h r e e t h e q u e s t i o n n a i r e was f i l l e d out m o s t l y by t h e i n v e s t i g a t o r , u s i n g t h e i r v e r b a l r e s p o n s e s . D u r i n g t h e d i s c u s s i o n s w i t h t h e i n v e s t i g a t o r , t h e t h r e e p a t i e n t s o f t e n responded v a g u e l y and somewhat i n a p p r o p r i a t e l y t o q u e s t i o n s u n r e l a t e d t o t h e q u e s t i o n n a i r e , and t h e i r a t t e n t i o n span was p o o r . T h e r e f o r e , o n l y f i v e o f t h e p a t i e n t s were used as t h e sample. Some o f t h e comments f r o m t h e t h r e e p a t i e n t s e x c l u d e d from t h e sample were u s e f u l and were i n c o r p o r a t e d i n t o t h e r e v i s i o n s . C h a r a c t e r i s t i c s o f t h e Sample. The f i v e p a t i e n t s i n c l u d e d f o u r females and one male . T h e i r ages ranged f rom 64 t o 73 y e a r s , w i t h an average o f 68.6 y e a r s , and a median o f 63 y e a r s . The l e n g t h o f t i m e t h a t t h e y had t h e i r l e s i o n s ranged from 3 weeks t o 19.5 months, w i t h an average o f 8.5 months, and a median o f 1.5 months. F o u r o f t h e p a t i e n t s had l e s i o n s due t o b r e a s t c a n c e r and t h e f i f t h was due t o e n d o m e t r i a l c a n c e r . The l e s i o n s i t e s i n c l u d e d f o u r o f t h e b r e a s t or c h e s t w a l l and one of t h e abdomen. The t y p e s o f d r e s s i n g s p r e v i o u s l y used by t h e p a t i e n t s i n c l u d e d F l a g y l o intment and ETE d r e s s i n g , F l a m a z i n e cream and d r y gauze, M e s a l t d r e s s i n g , 46 J e l o n e t and d r y gauze , wet s a l i n e gauze, P o l y s p o r i n o intment and d r y gauze, an unknown a n t i b i o t i c o intment and d r y gauze, and p l a i n d r y gauze . One o f t h e f i v e p a r t i c i p a n t s had a l e s i o n which had h e a l e d one month p r i o r t o b e i n g g i v e n t h e q u e s t i o n n a i r e . T h i s p a r t i c i p a n t had c o n s i d e r a b l e e x p e r i e n c e w i t h d r e s s i n g s s i n c e t h e wound had been p r e s e n t f o r a l o n g t i m e . Because she c o u l d e a s i l y r e c a l l i m p o r t a n t c h a r a c t e r i s t i c s o f t h e d r e s s i n g s she had u s e d , she was not o m i t t e d from t h e sample. R e s u l t s of t h e T e s t i n g . Most of t h e q u e s t i o n s were e a s i l y u n d e r s t o o d and o n l y a few s u g g e s t i o n s were made. Those p a t i e n t s u s i n g t a p e t o h o l d t h e d r e s s i n g i n p l a c e needed t o be reminded t h a t t h e q u e s t i o n s were r e l a t e d o n l y t o t h e d r e s s i n g . A t t i m e s , one o f t h e p a r t i c i p a n t s wanted t o respond t o t h e f r e q u e n c y o f t h e p r o b l e m : f o r example, "Do you e x p e r i e n c e p a i n f r o m t h e d r e s s i n g w h i l e i t i s on?" G i v e n t h e two extremes as "a g r e a t d e a l " and " n o t a t a l l , " she wanted t o answer " s o m e t i m e s . " However, h e r f i n a l d e c i s i o n was t o p l a c e a mark which r e f l e c t e d t h e average o c c u r r e n c e . In 27 o f 28 i t e m s , 3 or more o f t h e p a r t i c i p a n t s found t h e s u b j e c t of t h e q u e s t i o n s i m p o r t a n t t o them. The s u b j e c t o f t h e q u e s t i o n was i m p o r t a n t t o a l l 5 p a r t i c i p a n t s i n 21 o f 28 q u e s t i o n s ; t o 4 o f t h e 5 p a r t i c i p a n t s i n 6 o f 28 q u e s t i o n s ; and t o 2 o f t h e 5 p a r t i c i p a n t s i n 1 o f 28 q u e s t i o n s . O v e r a l l , t h e y f o u n d t h e q u e s t i o n n a i r e easy t o f i l l out once t h e y u n d e r s t o o d t h e p r o c e s s . The examples g i v e n i n t h e l e t t e r o f i n t r o d u c t i o n p r o v e d t o be u s e f u l f o r e x p l a i n i n g t h e s c a l e . 47 Development o f t h e P i l o t Q u e s t i o n n a i r e . The f o l l o w i n g r e v i s i o n s were made a f t e r r e v i e w i n g t h e r e s p o n s e s t o t h e P r e l i m i n a r y Q u e s t i o n n a i r e : From: Is t h e r e d i s c o m f o r t d u r i n g t h e d r e s s i n g change? T o : Do you e x p e r i e n c e d i s c o m f o r t when t h e d r e s s i n g i s removed? From: Do you e x p e r i e n c e p a i n when t h e d r e s s i n g i s changed? T o : Do you e x p e r i e n c e p a i n when t h e d r e s s i n g i s removed? From: Does t h e d r e s s i n g s t i c k t o t h e wound? T o : Does t h e d r e s s i n g s t i c k t o t h e wound when i t i s b e i n g removed? From: Is d r e s s i n g f i b r e l e f t i n t h e wound when d r e s s i n g i s removed? T o : A r e t h e r e d r e s s i n g f i b r e s l e f t i n t h e wound when t h e d r e s s i n g i s removed? From: Does t h e d r e s s i n g rub r o u g h l y a g a i n s t t h e wound? T o : Does t h e d r e s s i n g rub r o u g h l y a g a i n s t t h e wound w h i l e i t i s on? From: Can you use t h e d r e s s i n g w i t h o u t t a p e o r o t h e r d e v i c e s which h o l d t h e d r e s s i n g i n p l a c e ? T o : Can you use t h e d r e s s i n g WITHOUT t a p e , n e t t i n g o r o t h e r d e v i c e s which h o l d t h e d r e s s i n g i n p l a c e ? D e l e t e : Does t h e d r e s s i n g cause t h e wound t o e n l a r g e ? Does t h e d r e s s i n g cause a "gummy" f e e l i n g ? Does t h e d r e s s i n g cause i t c h i n e s s t o t h e s k i n s u r r o u n d i n g t h e wound? G i v e n t h e above r e v i s i o n s and q u e s t i o n d e l e t i o n s , t h e q u e s t i o n n a i r e was r e v i s e d t o i n c l u d e 25 q u e s t i o n s . The g e n e r a l format was t h e same as t h e P r e l i m i n a r y Q u e s t i o n n a i r e . T h i s t h e n became t h e P i l o t Q u e s t i o n n a i r e (Appendix E ) . R e l i a b i l i t y T e s t i n g The P i l o t Q u e s t i o n n a i r e was t e s t e d u s i n g t h e t e s t / r e - t e s t method. The q u e s t i o n n a i r e was a d m i n i s t e r e d t o f o u r p a t i e n t s ; 48 and r e - a d m i n i s t e r e d one week l a t e r t o t h r e e of t h e f o u r p a t i e n t s . One p a t i e n t was n o t f e e l i n g w e l l enough t o complete t h e second p a r t o f t h e t e s t i n g . C h a r a c t e r i s t i c s o f t h e Sample. The t h r e e p a t i e n t s i n c l u d e d two females and one male. T h e i r ages ranged from 50 t o 57 y e a r s , w i t h an average of 53 y e a r s , and a median of 53 y e a r s . The l e n g t h o f t i m e t h a t t h e y had t h e i r l e s i o n s ranged from 4 t o 11.5 months, w i t h an average o f 6.8 months, and a median o f 5 months. Two l e s i o n s were a r e s u l t o f b r e a s t c a n c e r and one was a r e s u l t o f a neck c a n c e r . The t h r e e l e s i o n s i t e s i n c l u d e d t h e c h e s t w a l l , t h e neck, and t h e arm. The t y p e s o f d r e s s i n g s used i n c l u d e d wet s a l i n e , M e s a l t , T e l f a , F l a m a z i n e cream and d r y gauze, and p l a i n d r y gauze . One p a t i e n t who p a r t i c i p a t e d was n o t u s i n g a d r e s s i n g a t t h e t i m e o f t h e t e s t i n g as she was u n d e r g o i n g r a d i a t i o n t r e a t m e n t . When c o m p l e t i n g b o t h q u e s t i o n n a i r e s , she t h e r e f o r e r e f e r r e d t o t h e d r e s s i n g she had r e c e n t l y been u s i n g . R e s u l t s o f t h e T e s t i n g . D u r i n g t h e one week p e r i o d , t h e l e s i o n s o f each o f t h e t h r e e p a t i e n t s remained s t a b l e . The p a t i e n t s c o n t i n u e d t o use t h e same d r e s s i n g , or i n t h e i n s t a n c e o f one p a t i e n t , c o n t i n u e d t o r e f e r t o t h e same d r e s s i n g w h i l e c o m p l e t i n g b o t h q u e s t i o n n a i r e s . The average d i f f e r e n c e between t h e f i r s t and second t e s t f o r t h e 25 q u e s t i o n s have been d e p i c t e d i n t h e f o r m o f a h i s t o g r a m ( F i g u r e 1) . The marks made by t h e p a t i e n t s on t h e 10 cm VAS were measured t o t h e n e a r e s t t e n t h o f a c e n t i m e t e r . The second t e s t r e s u l t was s u b t r a c t e d from t h e f i r s t t e s t 49 6-r Frequency of 3 Quest ions A v e r a g e Dif ferences b e t w e e n 1st a n d 2nd test ( i n cen t imet res ) F i g u r e 1. H i s t o g r a m d e p i c t i n g t h e average d i f f e r e n c e s between t h e 1st and 2nd t e s t f o r t h e 25 q u e s t i o n s on t h e P i l o t Q u e s t i o n n a i r e . 50 r e s u l t f o r each p a t i e n t . The d i f f e r e n c e s o b t a i n e d f o r t h e t h r e e p a t i e n t s were t h e n averaged f o r each q u e s t i o n . The average d i f f e r e n c e s f o r each q u e s t i o n ranged from a n e g a t i v e 2 .0 cm t o a p o s i t i v e 2.5 cm. There were one t o s i x q u e s t i o n s f o r each 0.5 cm d i f f e r e n c e . A g r e a t e r number o f q u e s t i o n s tended t o be r a t e d more p o s i t i v e l y on t h e f i r s t t e s t t h a n on t h e s e c o n d . U s i n g t h e P e a r s o n c o r r e l a t i o n c o e f f i c i e n t , t h e c o r r e l a t i o n o f r e s u l t s between t h e f i r s t and second a d m i n i s t r a t i o n of t h e P i l o t Q u e s t i o n n a i r e was c a l c u l a t e d t o be q u i t e s t r o n g a t .75 . U s i n g t h e s p l i t - h a l f method f o r t e s t i n g i n t e r n a l c o n s i s t e n c y , t h e two s u b s e t s were a n a l y z e d . The f i r s t group r e v e a l e d a c o r r e l a t i o n of .63, and t h e second group r e v e a l e d a c o r r e l a t i o n o f .75 . R e g a r d i n g t h e q u e s t i o n s ' i m p o r t a n c e , some p a t i e n t s t h o u g h t one o f t h e q u e s t i o n s was i m p o r t a n t one week and n o t t h e o t h e r . T h i s o c c u r r e d w i t h one p a t i e n t f o r t h e q u e s t i o n "Does t h e d r e s s i n g cause t h e wound t o b l e e d when i t i s removed?" T h i s a l s o o c c u r r e d i n two q u e s t i o n s w i t h a n o t h e r p a t i e n t f o r t h e q u e s t i o n s "Do you e x p e r i e n c e p a i n f rom t h e d r e s s i n g w h i l e i t i s on?" and "Does t h e d r e s s i n g adapt t o t h e shape of t h e wound?" One p a t i e n t d i d n o t f i n d t h e q u e s t i o n "Does t h e d r e s s i n g cause a s t i n g i n g s e n s a t i o n ? " i m p o r t a n t e i t h e r t i m e . The same p a t i e n t d i d n o t f i n d t h e q u e s t i o n "Does t h e d r e s s i n g cause a ' s t r a n g e ' o d o r ? " i m p o r t a n t e i t h e r t i m e , and a n o t h e r p a t i e n t f o u n d t h i s q u e s t i o n i m p o r t a n t one t i m e and n o t i m p o r t a n t t h e o t h e r t i m e . In t h e s i t u a t i o n where t h e p a t i e n t had t h e same r e s p o n s e each t i m e , i t may be i n t e r p r e t e d t h a t h i s o p i n i o n i s s t r o n g enough t o be m a i n t a i n e d over a one week p e r i o d . Where p a t i e n t s were n o t c o n s i s t e n t i n t h e i r o p i n i o n , i t may be i n t e r p r e t e d t h a t t h e i r o p i n i o n s were weaker because t h e y were u n a b l e t o c a r r y them over a one week p e r i o d . O v e r a l l , 19 of 25 q u e s t i o n s were t h o u g h t by a l l t h r e e p a t i e n t s t o be i m p o r t a n t b o t h t i m e s . Each p a t i e n t changed h i s / h e r mind about t h e importance of one q u e s t i o n - a l l o f t h e q u e s t i o n s b e i n g d i f f e r e n t . One p a t i e n t f e l t two q u e s t i o n s were n o t i m p o r t a n t t o him and m a i n t a i n e d t h i s o p i n i o n over t h e one week p e r i o d . The P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e . The P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e was t h e f i n a l r e s u l t o f t h e p r e v i o u s s t e p s of d e v e l o p i n g t h e c o n t e n t and t e s t i n g t h e r e l i a b i l i t y . A f t e r c o n s i d e r i n g t h e r e s p o n s e s o f t h e p a t i e n t s , i t was d e t e r m i n e d t h a t t h e comment about t h e q u e s t i o n "Do you e x p e r i e n c e p a i n f rom t h e d r e s s i n g w h i l e i t i s on?" was a v a l i d remark. I t was o f t e n d i f f i c u l t f o r t h e p a t i e n t t o d e t e r m i n e i f i t was t h e d r e s s i n g or t h e wound which was c a u s i n g t h e p a i n . A l s o , s i n c e t h e r e were q u e s t i o n s which r e l a t e d t o t h e d r e s s i n g c a u s i n g a " s t i n g i n g " or " b u r n i n g " s e n s a t i o n , t h e t o p i c was i n d i r e c t l y c o v e r e d i n t h e q u e s t i o n n a i r e . T h e r e f o r e , t h i s q u e s t i o n was d e l e t e d w h i l e t h e r e m a i n i n g 24 q u e s t i o n s remained unchanged, f o r m i n g t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e . 52 D i s c u s s i o n o f t h e F i n d i n g s D u r i n g t h e development o f t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e , many c h a r a c t e r i s t i c s were i d e n t i f i e d as b e i n g i m p o r t a n t when e v a l u a t i n g s a t i s f a c t i o n w i t h a d r e s s i n g . Many i n d i v i d u a l s r e p e a t e d t h e s e c h a r a c t e r i s t i c s . T h e i r importance was r e i n f o r c e d d u r i n g t h e t e s t i n g f o r c o n t e n t v a l i d i t y and r e l i a b i l i t y . F o r some c h a r a c t e r i s t i c s , p a t i e n t s found i t d i f f i c u l t t o d e c i d e i f t h e u n d e s i r a b l e c h a r a c t e r i s t i c was b e i n g caused by t h e d r e s s i n g o r t h e wound i t s e l f . F o r t h i s r e a s o n , some q u e s t i o n s were d e l e t e d . Most p a t i e n t s were not f a m i l i a r w i t h t h e VAS as a r e s p o n s e s c a l e . Some p a t i e n t s had d i f f i c u l t y w i t h i t a t f i r s t and r e q u i r e d some e x p l a n a t i o n . T h i s d i f f i c u l t y had a l s o been e x p e r i e n c e d by o t h e r s when u s i n g t h e VAS ( G i f t , 1989; S tewar t , 1977). A f t e r c o m p l e t i n g a few q u e s t i o n s , p a t i e n t s found t h e VAS e a s i e r t o u s e . However, a few p a t i e n t s i n d i c a t e d t h a t t h e y p r e f e r r e d t o have boxes t o check i n s t e a d o f a l i n e t o mark. A s t u d y comparing L i k e r t and v i s u a l analogue s c a l e s a l s o found t h a t t h e L i k e r t s c a l e was e a s i e r f o r t h e p a t i e n t s t o u n d e r s t a n d , making i t e a s i e r t o a d m i n i s t e r ( G u y a t t , Townsend, Berman, & K e l l e r , 1987). The i n t r o d u c t o r y l e t t e r was u s e f u l i n t h a t i t h e l p e d p a t i e n t s u n d e r s t a n d t h e q u e s t i o n n a i r e ' s p u r p o s e and gave them an example o f u s i n g t h e VAS. P r e - q u e s t i o n n a i r e t e a c h i n g , a l t h o u g h t i m e consuming, was u s e f u l i n a p r e v i o u s s t u d y (Guyat t e t a l . ) , and t h e d e t a i l e d i n s t r u c t i o n s i n an example form was p r e v i o u s l y r e c o g n i z e d as b e i n g e f f e c t i v e ( L o r i g , 1984). F o r t h i s t h e s i s , i n s t r u c t i o n s 53 were p l a c e d a t t h e t o p o f each page o f t h e q u e s t i o n n a i r e . I t was f e l t t h a t due t o t h e d i f f i c u l t y p a t i e n t s had i n c o m p l e t i n g t h e VAS, e i t h e r p r e - q u e s t i o n n a i r e t e a c h i n g or an e x p l a n a t o r y l e t t e r w i t h an example was needed, a d d i t i o n a l t o t h e b r i e f i n s t r u c t i o n s a t t h e t o p o f each page. Two d i f f i c u l t i e s i n r e s p o n d i n g t o t h e q u e s t i o n s o c c u r r e d . The f i r s t one was w i t h r e g a r d t o t h o s e q u e s t i o n s which p a t i e n t s wanted t o answer w i t h " s o m e t i m e s . " In t h o s e cases t h e y needed encouragement t o f i l l i t i n as "an a v e r a g e . " The second d i f f i c u l t y was w i t h q u e s t i o n s where t h e p e r s o n had not e x p e r i e n c e d t h e s e n s a t i o n asked about . P a t i e n t s i n t h i s s i t u a t i o n wanted t o r e s p o n d "no, " an o p t i o n n o t a v a i l a b l e u s i n g t h e VAS. T h e r e f o r e , t h e y responded c l o s e t o t h e "not a t a l l " anchor word, but r a r e l y a t t h e v e r y end o f t h e l i n e . The r e l i a b i l i t y t e s t i n g u s i n g t h e t e s t / r e - t e s t method r e v e a l e d r e s u l t s which have l i m i t e d i n t e r p r e t a t i o n s i n c e o n l y t h r e e p a t i e n t s were i n v o l v e d . The average d i f f e r e n c e s f o r t h e q u e s t i o n s were d e p i c t e d w i t h a h i s t o g r a m and showed t h a t p a t i e n t s tended t o respond more p o s i t i v e l y on t h e f i r s t t e s t t h a n on t h e second. The P e a r s o n c o r r e l a t i o n c o e f f i c i e n t r e s u l t s showed a f a i r l y s t r o n g c o r r e l a t i o n of .75 between t h e f i r s t and t h e second t e s t . The t e s t i n g f o r homogeneity o f q u e s t i o n s a l s o s u g g e s t e d t h a t t h e q u e s t i o n n a i r e had f a i r l y good i n t e r n a l c o n s i s t e n c y . O v e r a l l , t h e p a t i e n t s l i k e d t h e q u e s t i o n n a i r e ' s format and found t h e q u e s t i o n s t o be b o t h u n d e r s t a n d a b l e and i m p o r t a n t . 54 Study F i n d i n g s The r e s u l t s of t h e h y p o t h e s i s t e s t i n g are d e s c r i b e d i n t h i s s e c t i o n . F o u r t e e n p a t i e n t s were i n v o l v e d i n t h e s t u d y . The c h a r a c t e r i s t i c s o f t h e sample, t h e r e s u l t s o f t h e O v e r a l l E v a l u a t i o n S c a l e (Appendix H ) , and t h e P r e f e r e n c e S c a l e (Appendix I) a re p r e s e n t e d and d i s c u s s e d . Because some o f t h e p a t i e n t s d i s c o n t i n u e d t h e s t u d y e a r l i e r t h a n p l a n n e d , much o f t h e d a t a was s t a t i s t i c a l l y a n a l y s e d i n t h r e e subgroups . The f i n d i n g s o f t h e a n a l y s i s a r e d i s c u s s e d and g e n e r a l comments about t h e s t u d y a r e made. C h a r a c t e r i s t i c s o f t h e Sample Of t h e 14 p a t i e n t s who p a r t i c i p a t e d i n t h e s t u d y , 13 were female and 1 was male . T h e i r ages ranged f rom 45 t o 85 y e a r s , w i t h an average o f 65.6 y e a r s , and a median o f 67 y e a r s . The l e n g t h o f t i m e t h e y had t h e i r l e s i o n s ranged from 3 t o 33.5 months, w i t h an average o f 11.8 months, and a median of 10.25 months. The l e s i o n r e s u l t e d from b r e a s t c a n c e r i n 11 p a t i e n t s , t h e neck i n 2 p a t i e n t s , and t h e o v a r y i n 1 p a t i e n t . The l e s i o n s i n v o l v e d t h e b r e a s t or c h e s t w a l l i n 10 i n s t a n c e s , t h e neck i n 2 i n s t a n c e s , t h e g r o i n i n 1 i n s t a n c e , and t h e s c a l p i n t h e r e m a i n i n g i n s t a n c e . Of t h e 14 p a t i e n t s a c c r u e d t o t h e s t u d y , 7 p a t i e n t s were e q u a l l y randomised i n t o each d r e s s i n g arm. A l l p a t i e n t s were l i v i n g i n t h e G r e a t e r Vancouver Lower M a i n l a n d , and were l i v i n g a t home a t t h e s t a r t o f t h e s t u d y . D u r i n g t h e s t u d y , two o f t h e p a t i e n t s were a d m i t t e d t o t h e 55 h o s p i t a l due t o d i s e a s e c o m p l i c a t i o n s , u n r e l a t e d t o t h e i r wounds. Many t y p e s o f d r e s s i n g s were b e i n g used p r i o r t o e n t r y i n t o t h e s t u d y . They i n c l u d e d S o f r a t u l l e and d r y gauze, F l a m a z i n e and d r y gauze, c o n t i n u o u s wet s a l i n e d r e s s i n g s , V a s e l i n e o i n t m e n t and d r y gauze, an unknown a n t i b i o t i c o intment and d r y gauze, C i c a t r i n powder & T e l f a , H y g e o l (sodium h y p o c h l o r i t e ) s o l u t i o n and gause, ETE d r e s s i n g , J e l o n e t & d r y gause , and p l a i n d r y gause. With t h e e x c e p t i o n o f J e l o n e t used by t h r e e p a t i e n t s , a l l o t h e r d r e s s i n g s were used by each of t h e r e m a i n i n g p a t i e n t s . One p a t i e n t was u s i n g K l e e n e x t o absorb t h e d r a i n a g e , w h i l e a n o t h e r was u s i n g d i a p e r s . No p a t i e n t had p r e v i o u s l y used M e s a l t d r e s s i n g s and o n l y one o f t h e p a t i e n t s had used c o n t i n u o u s wet s a l i n e d r e s s i n g s . Of t h e s o l u t i o n s used t o c l e a n s e t h e wounds, s i x used normal s a l i n e s o l u t i o n , f i v e used water , and one used H y g e o l . Two p a t i e n t s d i d n o t c l e a n s e t h e i r wounds. Seven o f t h e p a t i e n t s had s c a n t or a s m a l l amount o f b l e e d i n g p r i o r t o e n t e r i n g t h e s t u d y , and two o t h e r s had b l e e d i n g which r e q u i r e d c o n t r o l t h r o u g h t h e o c c a s i o n a l use o f G e l f o a m . E i g h t p a t i e n t s e x p e r i e n c e d some degree o f odor , and f o u r were t a k i n g F l a g y l p i l l s f o r odor c o n t r o l , p r i o r t o e n t r y i n t o t h e s t u d y . S i x p a t i e n t s had no odor . Seven p a t i e n t s were r e c e i v i n g m e d i c a l t r e a t m e n t a t t h e s t a r t o f t h e s t u d y . S i x were on hormones and one was u n d e r g o i n g chemotherapy. None o f t h e t r e a t m e n t s were 56 a f f e c t i n g t h e c o n d i t i o n o f t h e l e s i o n . One p a t i e n t d i d n o t e n t e r t h e s t u d y u n t i l t h e c l i n i c a l i n f e c t i o n o f h e r wound was r e s o l v e d . S tudy Completeness Not a l l o f t h e p a t i e n t s completed t h e e n t i r e s t u d y . T h e r e f o r e , b o t h t h e O v e r a l l E v a l u a t i o n S c a l e and t h e P r e f e r e n c e S c a l e have been s t a t i s t i c a l l y a n a l y z e d by g r o u p i n g s o f 6, 8, and 10 p a t i e n t s , d e p e n d i n g on t h e e x t e n t o f s t u d y c o m p l e t i o n . The f i r s t a n a l y s i s i n c l u d e d t h e s i x p a t i e n t s who completed b o t h arms o f t h e s t u d y ; t h e s e p a t i e n t s a r e i d e n t i f i e d as subgroup A. The second a n a l y s i s added two p a t i e n t s : one p a t i e n t who completed two weeks o f each s t u d y arm, and one p a t i e n t who completed f o u r weeks of one s t u d y arm and two weeks o f t h e other;- t h e s e p a t i e n t s a r e i d e n t i f i e d as subgroup B. The t h i r d a n a l y s i s added two more p a t i e n t s t o t h o s e a l r e a d y a n a l y z e d . These p a t i e n t s completed f o u r weeks o f one arm and one week o f t h e second arm; t h e s e p a t i e n t s a re i d e n t i f i e d as subgroup C. F o u r o f t h e o r i g i n a l f o u r t e e n p a t i e n t s were o m i t t e d from t h e a n a l y s i s . Two d i s c o n t i n u e d t h e f i r s t arm w i t h i n one week o r l e s s and d i d n o t w i s h t o change t o t h e second arm. The t h i r d p a t i e n t d i s c o n t i n u e d t h e f i r s t arm w i t h i n one week and was on t h e second arm f o r o n l y one week. The f o u r t h p a t i e n t completed t h e f i r s t arm, but due t o t h e d i s e a s e p r o g r e s s i o n d i d n o t s w i t c h t o t h e second arm. F o r t h e p a t i e n t s i n c l u d e d 57 i n t h e a n a l y s i s , t h e r a n d o m i z a t i o n t o t h e f i r s t d r e s s i n g i s i n d i c a t e d i n T a b l e 1. T a b l e . 1 P a t i e n t R a n d o m i z a t i o n t o F i r s t D r e s s i n g Subgroups o f P a t i e n t s P a t i e n t ' s F i r s t D r e s s i n g A B C M e s a l t d r e s s i n g s 4 4 5 C o n t i n u o u s wet s a l i n e d r e s s i n g s 2 4 5 O v e r a l l E v a l u a t i o n S c a l e The f i r s t h y p o t h e s i s t e s t e d was t h a t M e s a l t d r e s s i n g s would r e c e i v e a more p o s i t i v e r a t i n g t h a n c o n t i n u o u s wet s a l i n e d r e s s i n g s w i t h r e s p e c t t o p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g p e r f o r m a n c e . T h i s h y p o t h e s i s was t e s t e d by a s k i n g t h e f i v e q u e s t i o n s i n t h e O v e r a l l E v a l u a t i o n S c a l e (Appendix H) and a n a l y s i n g t h e r e s u l t s u s i n g t h e W i l c o x o n s i g n e d - r a n k t e s t (Neave 8s W o r t h i n g t o n , 1988). The f i r s t q u e s t i o n asked was "How i s t h e a p p l i c a t i o n o f t h e d r e s s i n g ? " From subgroup A, f i v e r e s p o n s e s were a n a l y z e d . With n = 5, T = 2 and T c r i t i c a l = 0, t h e n u l l h y p o t h e s i s was s u p p o r t e d and no d i f f e r e n c e between d r e s s i n g s was f o u n d . From subgroup B, s i x r e s p o n s e s were a n a l y s e d . With n = 6, T = 2 and T c r i t i c a l = 2, t h e n u l l h y p o t h e s i s was r e j e c t e d and t h e r e was s u p p o r t f o r M e s a l t d r e s s i n g s h a v i n g a more p o s i t i v e r a t i n g 58 u s i n g a o n e - t a i l e d t e s t and an O x £ = .05 . From subgroup C, e i g h t r e s p o n s e s were a n a l y s e d . With n = 8, T = 3 and T c r i t i c a l = 5, t h e n u l l h y p o t h e s i s was r e j e c t e d and t h e r e was s t r o n g s u p p o r t f o r M e s a l t d r e s s i n g s h a v i n g a more p o s i t i v e r a t i n g u s i n g a o n e - t a i l e d t e s t and an 0 < £ = .05 . The second q u e s t i o n asked was "How i s t h e removal o f t h e d r e s s i n g ? " From subgroup A, f o u r r e s p o n s e s were o b t a i n e d which were i n a d e q u a t e f o r a n a l y s i s . From subgroup B, f i v e r e s p o n s e s were a n a l y s e d . With n = 5, T = 10.5 and T c r i t i c a l = 0, t h e n u l l h y p o t h e s i s was s u p p o r t e d and no d i f f e r e n c e between d r e s s i n g s was f o u n d . From subgroup C, e i g h t r e s p o n s e s were a n a l y s e d . With n = 8, T = 10.5 and T c r i t i c a l = 3, t h e n u l l h y p o t h e s i s was s u p p o r t e d and no d i f f e r e n c e between d r e s s i n g s was f o u n d . The t h i r d q u e s t i o n asked was "How much d i s c o m f o r t do you e x p e r i e n c e when t h e d r e s s i n g i s removed?" From subgroup A, f o u r r e s p o n s e s were o b t a i n e d which were i n a d e q u a t e f o r a n a l y s i s . From subgroup B, s i x r e s p o n s e s were a n a l y s e d . With n = 6, T = 13 and T c r i t i c a l = 2, t h e n u l l h y p o t h e s i s was s u p p o r t e d and no d i f f e r e n c e between d r e s s i n g s was f o u n d . From subgroup C, e i g h t r e s p o n s e s were a n a l y s e d . With n = 8, T = 17 and T c r i t i c a l = 5, t h e n u l l h y p o t h e s i s was s u p p o r t e d and no d i f f e r e n c e between d r e s s i n g s was f o u n d . The f o u r t h q u e s t i o n asked was "How c o m f o r t a b l e i s t h e d r e s s i n g between d r e s s i n g changes?" From subgroup A, f i v e r e s p o n s e s were a n a l y s e d . With n = 5, T = 1 and T c r i t i c a l = 0, t h e n u l l h y p o t h e s i s was s u p p o r t e d and no d i f f e r e n c e between 59 d r e s s i n g s was f o u n d . From subgroup B, seven r e s p o n s e s were a n a l y z e d . With n = 7, T = 6 and T c r i t i c a l = 3, t h e n u l l h y p o t h e s i s was s u p p o r t e d and no d i f f e r e n c e between d r e s s i n g s was f o u n d . From subgroup C, e i g h t r e s p o n s e s were a n a l y z e d . With n = 8, T = 6 and T c r i t i c a l = 5, t h e n u l l h y p o t h e s i s was s u p p o r t e d and no d i f f e r e n c e between d r e s s i n g s was f o u n d . D e s p i t e t h e absence o f s i g n i f i c a n t r e s u l t s t h e r a t i n g s were a lmost more p o s i t i v e w i t h t h e M e s a l t d r e s s i n g s . The f i f t h q u e s t i o n asked was "How e f f e c t i v e i s t h e d r e s s i n g i n c o n t r o l l i n g o d o r ? " O n l y t h r e e r e s p o n s e s were o b t a i n e d f o r b o t h subgroups A and B, and p r o v i d e d i n a d e q u a t e numbers f o r a n a l y s i s . From subgroup C, f i v e r e s p o n s e s were a n a l y z e d . With n = 5, T = 0 and T c r i t i c a l = 0, t h e n u l l h y p o t h e s i s was r e j e c t e d and t h e r e was s u p p o r t f o r M e s a l t d r e s s i n g s h a v i n g a more p o s i t i v e r a t i n g u s i n g a o n e - t a i l e d t e s t and an CxC = .05 . Comments about t h e A n a l y s i s . In some c a s e s , p a t i e n t s i n v o l v e d w i t h t h e s t u d y were u n a b l e t o complete t h e e n t i r e O v e r a l l E v a l u a t i o n S c a l e . In two c a s e s , t h e p a t i e n t s were h o s p i t a l i z e d . As t h e y were not i n v o l v e d i n d o i n g t h e i r d r e s s i n g changes, t h e y d i d n o t complete t h e q u e s t i o n s r e l a t i n g t o ease o f a p p l i c a t i o n and ease o f r e m o v a l . In one case , t h e p a t i e n t became t e r m i n a l l y i l l . A l t h o u g h she was a b l e t o r e s p o n d v e r b a l l y , she was u n a b l e t o complete t h e q u e s t i o n n a i r e u s i n g t h e VAS. The a n a l y s i s o f t h e a l r e a d y s m a l l numbers of r e s p o n s e s was a l s o a f f e c t e d by t h e d e l e t i o n o f one d i f f e r e n c e i n each o f q u e s t i o n s , two, t h r e e , f o u r and f i v e , as t h e 60 d i f f e r e n c e was e q u a l t o 0. Because some p a t i e n t s e x p e r i e n c e d no odor d u r i n g t h e e n t i r e s t u d y , t h e y d i d not respond t o t h e q u e s t i o n about odor . The a n a l y s i s o f t h i s q u e s t i o n i n c l u d e d two p a t i e n t s who had used M e s a l t d r e s s i n g s f o r a p e r i o d o f o n l y one week but n o t i c e d a d i f f e r e n c e i n c o n t r o l o f odor . One p a t i e n t was u n a b l e t o complete t h e q u e s t i o n about odor as she was u n a b l e t o s m e l l . Both t h e Home Care Nurse and t h e i n v e s t i g a t o r n o t e d t h a t t h e r e d i d not seem t o be any d i f f e r e n c e between t h e two d r e s s i n g s f o r t h i s p a t i e n t . The p a t i e n t s were randomised e q u a l l y i n t o subgroups B and C. Subgroup A was u n b a l a n c e d s i n c e f o u r were f i r s t randomised t o t h e M e s a l t d r e s s i n g s and t h e o t h e r two t o t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s . Due t o t h e a l r e a d y low numbers o f r e s p o n s e s o f t h e group subgroup A, o n l y q u e s t i o n s one and f o u r were a f f e c t e d ; and i n b o t h i n s t a n c e s t h e a n a l y s i s showed no d i f f e r e n c e between t h e d r e s s i n g s . Comments about t h e O v e r a l l E v a l u a t i o n S c a l e . The p a t i e n t sometimes found i t d i f f i c u l t t o u n d e r s t a n d t h e p r o c e d u r e f o r u s i n g t h e VAS. E x p l a n a t i o n s were made and an example was g i v e n . The i n v e s t i g a t o r was i n a t t e n d a n c e d u r i n g t h e c o m p l e t i o n o f a l l e v a l u a t i o n s c a l e s . I t was d i f f i c u l t f o r p a t i e n t s t o mark t h e VAS w i t h an " X . " The i n s t r u c t i o n s were t h e r e f o r e m o d i f i e d f rom " . . . p u t a X on t h e l i n e . . . " t o " . . . p u t a / on t h e l i n e . In one i n s t a n c e , t h e i n v e s t i g a t o r was n o t s u r e t h a t t h e r e s p o n s e g i v e n t r u l y r e f l e c t e d t h e p a t i e n t ' s f e e l i n g s . F o r 61 example, one p a t i e n t i n d i c a t e d t h a t she had q u i t e a l o t o f d i s c o m f o r t when answer ing t h e q u e s t i o n about d i s c o m f o r t d u r i n g d r e s s i n g r e m o v a l . As t h i s c o n f l i c t e d w i t h t h e o b s e r v a t i o n s made by t h e i n v e s t i g a t o r , t h e p a t i e n t was q u e s t i o n e d f u r t h e r . The p a t i e n t c l a r i f i e d t h a t h e r r e s p o n s e r e f l e c t e d h e r d i s c o m f o r t w i t h a l l d r e s s i n g changes and not p a r t i c u l a r l y about t h e r e m o v a l . She m a i n t a i n e d t h a t h e r r e s p o n s e was a p p r o p r i a t e even when i t was emphasised t h a t t h e q u e s t i o n r e l a t e d t o t h e d r e s s i n g " r e m o v a l . " A f t e r u s i n g t h e o t h e r d r e s s i n g f o r f o u r weeks, she i n d i c a t e d t h a t t h e d i s c o m f o r t d u r i n g t h e d r e s s i n g removal was n o t t o o bad. In comparing t h e M e s a l t d r e s s i n g s t o t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s , she f e l t t h a t b o t h d r e s s i n g s were about t h e same w i t h r e g a r d t o d i s c o m f o r t d u r i n g d r e s s i n g r e m o v a l . When t h i s r e s p o n s e was d e l e t e d from t h e a n a l y s i s , t h e r e s u l t s f o r t h a t q u e s t i o n remained unchanged. D i s c u s s i o n o f F i n d i n g s . E x c e p t f o r t h e u n c e r t a i n t y o f one p a t i e n t ' s r e s p o n s e , each o f t h e o t h e r p a t i e n t s ' r e s p o n s e s were g e n e r a l l y e x p e c t e d . There i s agreement between what t h e i n v e s t i g a t o r o b s e r v e d d u r i n g t h e s t u d y and t h e f i n d i n g s o f t h e a n a l y s i s . The f i n d i n g t h a t M e s a l t d r e s s i n g s a r e easy t o a p p l y i s s u p p o r t e d by p r e v i o u s r e s e a r c h ( G a l l a n t & S i b b a l d , 1986; G r o s s & G e r n e r , 1982, 1985; Jagelman & Spencer , 1986; R u t h , 1979). The r e s u l t s i n d i c a t i n g g r e a t e r odor c o n t r o l w i t h M e s a l t d r e s s i n g s s u b s t a n t i a t e t h e e a r l i e r f i n d i n g by Spencer (1988). L i t t l e d i f f e r e n c e was n o t e d between t h e two d r e s s i n g s w i t h r e g a r d t o ease of d r e s s i n g removal and 62 d i s c o m f o r t d u r i n g t h e d r e s s i n g change. Some p a t i e n t s f e l t t h a t t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s were q u i t e u n c o m f o r t a b l e t o wear, and f u r t h e r r e s e a r c h may r e v e a l more s i g n i f i c a n t f i n d i n g s r e g a r d i n g d i s c o m f o r t of t h e s e d r e s s i n g s between d r e s s i n g changes . Of i n t e r e s t i s t h e compar ison o f q u e s t i o n s asked on t h e O v e r a l l E v a l u a t i o n S c a l e and t h o s e i d e n t i f i e d f o r t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e . The f i v e q u e s t i o n s f rom t h e O v e r a l l E v a l u a t i o n S c a l e a r e s i m i l a r t o f i v e o f t h e q u e s t i o n s p a t i e n t s i d e n t i f i e d f o r t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e . A l t h o u g h t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e i n c l u d e s many o t h e r q u e s t i o n s , t h e f i v e q u e s t i o n s are r e c o g n i z e d as b e i n g p e r t i n e n t f o r e v a l u a t i n g p a t i e n t s a t i s f a c t i o n . The e v a l u a t i o n o f t h e second d r e s s i n g was made w i t h o u t r e f e r r i n g t o t h e r e s p o n s e s g i v e n f o r t h e f i r s t d r e s s i n g . Some i n v e s t i g a t o r s recommend t h a t t h e p r e v i o u s r e s u l t s s h o u l d be shown t o t h e p a t i e n t , w h i l e o t h e r s do not ( G i f t , 1989). I t i s d i f f i c u l t t o know whether or not t h i s would have had any e f f e c t i n t h i s s t u d y . However, t h e one i n s t a n c e r e g a r d i n g d i s c o m f o r t d u r i n g t h e d r e s s i n g change would p r o b a b l y n o t have o c c u r r e d i f t h i s method was i n p l a c e . A n o t h e r approach would be t o have t h e p a t i e n t s r a t e b o t h d r e s s i n g s a t t h e same t i m e . In summary, t h e M e s a l t d r e s s i n g s were found t o be s i g n i f i c a n t l y e a s i e r t o a p p l y and s i g n i f i c a n t l y more e f f e c t i v e i n c o n t r o l l i n g odor compared w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s . There appeared t o be no s i g n i f i c a n t 63 d i f f e r e n c e between t h e two d r e s s i n g s w i t h r e g a r d t o ease o f removal and d i s c o m f o r t d u r i n g and between d r e s s i n g changes . The c h a r a c t e r i s t i c s e v a l u a t e d i n t h e s t u d y were r e c o g n i s e d as i m p o r t a n t t o measure when e v a l u a t i n g p a t i e n t s a t i s f a c t i o n i n t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . P r e f e r e n c e S c a l e The second h y p o t h e s i s t e s t e d was t h a t " M e s a l t d r e s s i n g s would be p r e f e r r e d by p a t i e n t s t o c o n t i n u o u s wet s a l i n e d r e s s i n g s . " T h i s h y p o t h e s i s was t e s t e d by use o f t h e P r e f e r e n c e S c a l e . P a t i e n t s were asked t o choose a p r e f e r e n c e between t h e " f i r s t d r e s s i n g , " t h e "second d r e s s i n g , " o r a l t e r n a t i v e l y , "no p r e f e r e n c e . " The r e s u l t s were a n a l y z e d u s i n g t h e s i g n t e s t (Neave & W o r t h i n g t o n , 1988). A l l p a t i e n t s responded t o t h i s q u e s t i o n , two d o i n g so v e r b a l l y . The f r e q u e n c y d i s t r i b u t i o n o f p r e f e r e n c e s are d i v i d e d i n t o t h e t h r e e subgroups i n T a b l e 2. T a b l e 2 F r e q u e n c y D i s t r i b u t i o n o f P a t i e n t P r e f e r e n c e s Subgroups o f P a t i e n t s P a t i e n t P r e f e r e n c e s A B C M e s a l t d r e s s i n g s 5 6 7 C o n t i n u o u s wet s a l i n e d r e s s i n g s 1 No p r e f e r e n c e 1 2 2 64 Of subgroup A, f i v e p r e f e r r e d M e s a l t d r e s s i n g s and one had no p r e f e r e n c e . With n = 5, S = 0 and S c r i t i c a l = 0; t h e n u l l h y p o t h e s i s was r e j e c t e d , and t h e r e was s u p p o r t f o r t h e c o n c l u s i o n t h a t M e s a l t d r e s s i n g s were p r e f e r r e d t o c o n t i n u o u s wet s a l i n e d r e s s i n g s u s i n g a o n e - t a i l e d t e s t and an 0<^ = .05 Of subgroup B, s i x p r e f e r r e d M e s a l t d r e s s i n g s and two had no p r e f e r e n c e . With n = 6, S = 0 and S c r i t i c a l = 0, t h e n u l l h y p o t h e s i s was r e j e c t e d , and t h e r e was s u p p o r t f o r t h e c o n c l u s i o n t h a t M e s a l t d r e s s i n g s were p r e f e r r e d t o c o n t i n u o u s wet s a l i n e d r e s s i n g s u s i n g a o n e - t a i l e d t e s t , w i t h an Q * ^ = .05 . Of subgroup C, seven p r e f e r r e d M e s a l t d r e s s i n g s , two had no p r e f e r e n c e and one p r e f e r r e d c o n t i n u o u s wet s a l i n e d r e s s i n g s . With n = 8, S = 1 and S c r i t i c a l = 1, t h e n u l l h y p o t h e s i s was r e j e c t e d , and t h e r e was s u p p o r t f o r t h e c o n c l u s i o n t h a t M e s a l t d r e s s i n g s were p r e f e r r e d t o c o n t i n u o u s wet s a l i n e d r e s s i n g s u s i n g a o n e - t a i l e d t e s t w i t h an -.05 . Comments about t h e A n a l y s i s . The r a n d o m i z a t i o n t o t h e f i r s t d r e s s i n g was e q u a l f o r subgroups B and C, and was u n b a l a n c e d i n f a v o r o f t h e M e s a l t d r e s s i n g s f o r t h e subgroup A. I t was d i f f i c u l t t o d e t e r m i n e i f t h e r a n d o m i z a t i o n of t h e group o f s i x a f f e c t e d t h e r e s u l t s o b t a i n e d . However, t h e p r e f e r e n c e f o r M e s a l t d r e s s i n g s i n subgroup A appears c o n s i s t e n t w i t h t h e a n a l y s i s o f t h e o t h e r two g r o u p s . R e v i s i o n s t o t h e P r e f e r e n c e S c a l e . The P r e f e r e n c e 65 S c a l e was r e v i s e d u s i n g a VAS i n an at tempt t o measure how s t r o n g t h e p r e f e r e n c e was, s i n c e t h e r e was no method f o r t h e p a t i e n t t o i n d i c a t e t h e magnitude o f t h e i r r e s p o n s e (Appendix K ) . The anchor words were chosen w i t h i n p u t from a number of n o n - h e a l t h c a r e w o r k e r s . However, a f t e r t h e r e v i s i o n was made, o n l y two p a t i e n t s were i n v o l v e d i n c o m p l e t i n g t h e q u e s t i o n . T h e r e f o r e , t h e r e was an i n a d e q u a t e number o f r e s p o n s e s f o r a n a l y s i s . A n a l y s i s o f t h e Open-Ended Q u e s t i o n . The open-ended q u e s t i o n asked "Why?" w i t h r e g a r d t o t h e p a t i e n t ' s , p r e f e r e n c e , i f a p r e f e r e n c e was i n d i c a t e d . D u r i n g t h e s t u d y t h e q u e s t i o n was m o d i f i e d t o " I f you d i d have a p r e f e r e n c e ( i n d i c a t e d above) , why d i d you p r e f e r t h e d r e s s i n g ? " T h i s m o d i f i c a t i o n o c c u r r e d a t t h e same t i m e t h e VAS was added t o d e t e r m i n e p r e f e r e n c e s t r e n g t h . The m o d i f i c a t i o n d i d n o t seem t o have any a f f e c t on t h e t y p e o f responses r e c e i v e d . A t t e m p t i n g t o a n a l y s e t h e r e s u l t s u s i n g a theme approach was d i f f i c u l t . No one common theme appeared due t o t h e s m a l l number o f p a t i e n t s i n v o l v e d . T h e r e f o r e , each r e s p o n s e was c o n s i d e r e d i n d i v i d u a l l y . The r e s p o n s e r e c e i v e d t o t h e open-ended q u e s t i o n h e l p e d t o c l a r i f y t h e p a t i e n t ' s c h o i c e and sometimes added i n f o r m a t i o n t h a t was n o t e v a l u a t e d on t h e O v e r a l l E v a l u a t i o n S c a l e . In t h e group o f 6, t h e r e s p o n s e s from t h e 5 p a t i e n t s p r e f e r r i n g M e s a l t d r e s s i n g s i n c l u d e d t h e comments t h a t t h e d r e s s i n g s were e a s i e r t o a p p l y and manage, and t h a t t h e f l u i d d i d n o t d r a i n t h r o u g h so q u i c k l y . In one case t h e d r a i n a g e 66 was l e s s , t h e wound was c l e a n e r , and t h e d r e s s i n g was p e r c e i v e d t o be v e r y e f f e c t i v e because i t d e c r e a s e d t h e m o i s t u r e i n t h e wound. One p a t i e n t p r e f e r r e d M e s a l t d r e s s i n g s because t h e y were q u i c k e r t o a p p l y , t h e p r o c e s s was not as messy, and t h e r e was m i n i m a l odor . T h i s p a t i e n t d i d not l i k e t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s because t h e y always f e l t wet and caused i r r i t a t i o n a t t i m e s . There was no comment from t h e p a t i e n t who d i d n o t have a p r e f e r e n c e . Of t h e a d d i t i o n a l 2 p a t i e n t s i n t h e group o f 8, t h e i n d i v i d u a l w i t h no p r e f e r e n c e had no comment. The r e s p o n s e from t h e p a t i e n t who p r e f e r r e d M e s a l t d r e s s i n g s i n d i c a t e d t h a t t h e M e s a l t d r e s s i n g caused l e s s scab f o r m a t i o n on t h e u l c e r and caused i t t o be d r i e r . Of t h e f i n a l 3 p a t i e n t s i n t h e group o f 10, one p a t i e n t had no p r e f e r e n c e and no comment. The p a t i e n t who p r e f e r r e d t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s d i d so because she found t h e M e s a l t d r e s s i n g " v e r y d i s t r e s s i n g f o r my p a r t i c u l a r c a s e . " The p a t i e n t who p r e f e r r e d t h e M e s a l t d r e s s i n g s f o u n d t h a t a f t e r a c o u p l e o f d a y s , t h e d r e s s i n g was q u i t e c o m f o r t a b l e and t h e odor was g r e a t l y d e c r e a s e d . In a d d i t i o n , t h e d r e s s i n g s seemed t o " d r y t h e wound q u i t e a b i t . " Comments about t h e P r e f e r e n c e S c a l e . P a t i e n t s seemed t o have no d i f f i c u l t y c o m p l e t i n g t h e q u e s t i o n about p r e f e r e n c e . The a d d i t i o n o f t h e VAS t o d e t e r m i n e s t r e n g t h of p r e f e r e n c e r e q u i r e d a d d i t i o n a l e x p l a n a t i o n w i t h an example, i n o r d e r t o be e a s i l y c o m p l e t e d . D i s c u s s i o n o f F i n d i n g s . The a n a l y s i s r e v e a l e d t h a t 67 t h e r e were s t a t i s t i c a l l y s i g n i f i c a n t r e s u l t s which s u p p o r t M e s a l t d r e s s i n g s b e i n g p r e f e r r e d t o c o n t i n u o u s wet s a l i n e d r e s s i n g s . The p r e f e r e n c e s g i v e n were s u p p o r t e d by t h e p a t i e n t s ' comments d u r i n g t h e s t u d y . Where t h e two p a t i e n t s d i d not have a p r e f e r e n c e , t h e r e s p o n s e s were u n e x p e c t e d . D u r i n g t h e s t u d y , b o t h o f t h e s e p a t i e n t s made more f a v o r a b l e comments about t h e M e s a l t d r e s s i n g s . One p a t i e n t had been a d m i t t e d t o t h e h o s p i t a l c o n c u r r e n t t o e n t e r i n g t h e M e s a l t d r e s s i n g arm o f t h e s t u d y . As a r e s u l t , she was n o t i n v o l v e d i n c h a n g i n g h e r own d r e s s i n g s . I t i s d i f f i c u l t t o know what h e r r e s p o n s e would have been i f she had been c h a n g i n g h e r own d r e s s i n g s . The second p a t i e n t f o u n d M e s a l t d r e s s i n g s d e c r e a s e d t h e odor q u i t e a b i t . She found t h a t t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s were u n c o m f o r t a b l e between d r e s s i n g changes and t h a t t h e y caused a g r e a t d e a l o f s l o u g h i n g of dead t i s s u e , r e s u l t i n g i n i n c r e a s e d odor . Thus , she had t o spend much more t i m e c l e a n i n g t h e wound. However, by t h e end o f f o u r weeks, she f e l t t h a t t h e c l e a n l i n e s s o f t h e wound was an i m p o r t a n t c h a r a c t e r i s t i c and t h a t t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s had caused h e r t o c l e a n more. U n f o r t u n a t e l y , t h e v i g o r o u s n e s s o f t h i s c l e a n i n g caused i n c r e a s e d b l e e d i n g . Because t h e p a t i e n t d i d n o t v iew t h i s as a p r o b l e m , i n h e r o v e r a l l e v a l u a t i o n o f t h e d r e s s i n g s she d i d not p r e f e r one d r e s s i n g over t h e o t h e r . The open-ended q u e s t i o n s r e v e a l e d more s p e c i f i c i n f o r m a t i o n r e g a r d i n g t h e r a t i o n a l e f o r p r e f e r r i n g t h e d r e s s i n g . Some o f t h e comments were not r e f l e c t e d i n t h e 68 O v e r a l l E v a l u a t i o n S c a l e . T h i s i n d i c a t e d t h a t t h e p a t i e n t ' s s a t i s f a c t i o n w i t h d r e s s i n g s was not t o t a l l y e v a l u a t e d u s i n g o n l y t h e q u e s t i o n s i n t h e O v e r a l l E v a l u a t i o n S c a l e . Of i n t e r e s t , most o f t h e r e s p o n s e s t o t h e open-ended q u e s t i o n were i n c l u d e d i n t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e . In summary, t h e r e s u l t s o b t a i n e d showed a s i g n i f i c a n t p r e f e r e n c e f o r t h e M e s a l t d r e s s i n g s when compared w i t h t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s , even w i t h t h e s m a l l sample e v a l u a t e d . Answers t o t h e open-ended q u e s t i o n s added more s p e c i f i c i n f o r m a t i o n about p a t i e n t s ' reasons f o r p r e f e r r i n g t h e d r e s s i n g s . G e n e r a l Comments about t h e Study Comments About t h e S t u d y D e s i g n . The c r o s s - o v e r d e s i g n was an a p p r o p r i a t e method f o r comparing t h e two d r e s s i n g s . F o r t h o s e p a t i e n t s who used each d r e s s i n g f o r f o u r weeks, no c a r r y - o v e r or r e s i d u a l e f f e c t s were a p p a r e n t when t h e d r e s s i n g s were e v a l u a t e d . The p o s s i b i l i t y o f c a r r y - o v e r e f f e c t s was m i n i m i z e d by t h e r a n d o m i z a t i o n t o t h e f i r s t d r e s s i n g . In g e n e r a l , t h e wounds remained s t a b l e t h r o u g h o u t t h e s t u d y , a d e s i r a b l e s i t u a t i o n f o r u s i n g t h e c r o s s - o v e r d e s i g n (Beck, 1989; Pocock, 1983). The c o n c e r n about p a t i e n t s d r o p p i n g out o f t h e c r o s s - o v e r d e s i g n (Beck, 1989) was a r e a l i s t i c p r o b l e m i n t h i s s t u d y because many p a t i e n t s were u n a b l e t o f u l l y complete b o t h s t u d y arms. The p a t i e n t s who d i s c o n t i n u e d t h e s t u d y a f t e r b e i n g on t h e second d r e s s i n g f o r o n l y one week found t h e one week 69 p e r i o d adequate enough t o e v a l u a t e a l l of t h e v a r i a b l e s . The p a t i e n t who used b o t h d r e s s i n g s f o r two weeks a l s o f e l t t h a t he d i d not need t o use t h e d r e s s i n g s f o r f o u r weeks i n o r d e r t o e v a l u a t e them. The d i f f i c u l t y a r o s e i n t h e d e c i s i o n o f t ime needed f o r adjustment t o t h e d r e s s i n g s . Some p a t i e n t s were a b l e t o f u l l y a d j u s t t o t h e d r e s s i n g s q u i c k l y , w h i l e o t h e r s t o o k more t i m e . The l e n g t h o f t i m e t h a t a d r e s s i n g s h o u l d be used f o r t h i s t y p e o f s t u d y depends on t h e v a r i a b l e s b e i n g e v a l u a t e d . The ease o f a p p l i c a t i o n and removal o f t h e d r e s s i n g seemed t o r e q u i r e l e s s t i m e t o d e t e r m i n e t h a n d i d t h e c o n t r o l o f odor and t h e c o m f o r t between d r e s s i n g s . Some p a t i e n t s n o t i c e d a g r e a t d i f f e r e n c e w i t h i n a few days of u s i n g t h e d r e s s i n g . In some cases t h e d i f f e r e n c e was so i n t o l e r a b l e t h a t t h e y d i s c o n t i n u e d t h e use o f t h e d r e s s i n g or d i s c o n t i n u e d p a r t i c i p a t i o n i n t h e s t u d y i t s e l f . A n o t h e r p r o b l e m was w i t h t h e f o u r - w e e k t i m e p e r i o d f o r each s t u d y arm. I t was a l o n g p e r i o d o f t i m e f o r some p a t i e n t s t o remember what t h e d r e s s i n g s were l i k e f o r t h e p u r p o s e s o f c o m p a r i s o n . The d i f f i c u l t y i n remembering has a l s o been r e c o g n i z e d i n a p r e v i o u s s t u d y ( C a r l s s o n , 1983). However, t h e p r e f e r e n c e s i n d i c a t e d by t h e p a t i e n t s were g e n e r a l l y s u p p o r t e d by t h e i r comments d u r i n g t h e s t u d y . Comments About t h e P a t i e n t s . Most o f t h e p a t i e n t s were a b l e t o t o l e r a t e t h e s t u d y . C l i n i c a l l y , t h e r e were m i n i m a l changes i n t h e p a t i e n t s ' l e s i o n s . None o f t h e p a t i e n t s d e v e l o p e d a c l i n i c a l i n f e c t i o n w h i l e on t h e s t u d y . Many p a t i e n t s had a s c a n t or s m a l l amount o f b l e e d i n g p r i o r t o 70 t h e s t u d y , and t h i s d i d n o t change g r e a t l y . A s l i g h t i n c r e a s e i n b l e e d i n g was n o t e d i n some s i t u a t i o n s u s i n g t h e M e s a l t d r e s s i n g s , but t h i s a l s o o c c u r r e d w i t h t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s . D e s p i t e t h e m o i s t n e s s o f t h e d r e s s i n g s , i n some cases t h e M e s a l t d r e s s i n g s and c o n t i n u o u s wet s a l i n e d r e s s i n g s s t u c k t o t h e wound s l i g h t l y . Why t h i s o c c u r r e d i s not w e l l u n d e r s t o o d . A number o f Home Care Nurses a t t h e s t a r t of t h e s t u d y i d e n t i f i e d s t i n g i n g from t h e M e s a l t d r e s s i n g as a c o n c e r n . Out o f t h e 13 p a t i e n t s on t h e s t u d y who u s e d M e s a l t d r e s s i n g s , 10 d i d n o t e x p e r i e n c e any s t i n g i n g . Three d i d e x p e r i e n c e some s t i n g i n g , and i n one o f t h e s e cases t h e s t i n g i n g d i m i n i s h e d w i t h i n two weeks. One p a t i e n t d i d not use t h e M e s a l t d r e s s i n g as she d i d n o t s w i t c h t o t h e M e s a l t d r e s s i n g t r e a t m e n t arm. Of i n t e r e s t , t h e d r a i n a g e d e c r e a s e d i n o n l y t h r e e cases w h i l e u s i n g t h e M e s a l t d r e s s i n g s . In one case t h e M e s a l t d r e s s i n g s somewhat i n c r e a s e d t h e d r a i n a g e . In f i v e cases t h e M e s a l t d r e s s i n g s caused t h e wound t o d r y out or s h r i n k . A l l o f t h e p a t i e n t s f e l t t h a t t h i s was b e n e f i c i a l . In one case t h e wound c o m p l e t e l y d r i e d and d i d n o t r e q u i r e d r e s s i n g changes f o r f i v e months. However, i n most cases t h e d r a i n a g e remained unchanged f o r t h e e n t i r e s t u d y p e r i o d . Most o f t h e p a t i e n t s on m e d i c a l t r e a t m e n t a t t h e s t a r t o f t h e s t u d y were on t h e t r e a t m e n t f o r t h e s t u d y d u r a t i o n . One p a t i e n t s t a r t e d chemotherapy d u r i n g t h e s t u d y . None o f t h e t r e a t m e n t s appeared t o have a f f e c t e d t h e c o n d i t i o n o f t h e l e s i o n s . 71 F o r t h e p a t i e n t s who f u l l y completed b o t h arras o f t h e s t u d y no d i f f i c u l t y o c c u r r e d i n t o l e r a t i n g t h e wound c a r e p r o t o c o l . In one case , however, t h e p a t i e n t was asked t o remain on one d r e s s i n g f o r f i v e weeks i n s t e a d o f f o u r . T h i s o c c u r r e d a f t e r t h e p h y s i c i a n r e c e i v e d t h e swab r e s u l t f o r c u l t u r e and s e n s i t i v i t y , and o r d e r e d o r a l a n t i b i o t i c s f o r t h e p a t i e n t . The p a t i e n t had f o r g o t t e n t h a t she was n o t t o t a k e any m e d i c a t i o n s t h a t might i n t e r f e r e w i t h odor , and t h e p h y s i c i a n had f o r g o t t e n t h a t t h e p a t i e n t was on t h e s t u d y . In t h i s s i t u a t i o n , t h e p a t i e n t n e i t h e r had a c l i n i c a l i n f e c t i o n n o r n o t i c e d any change i n t h e o d o r . T h i s i n c r e a s e d l e n g t h o f t i m e on t h e s t u d y d i d n o t appear t o a f f e c t any o f t h e p a t i e n t ' s r e s p o n s e s about s a t i s f a c t i o n or p r e f e r e n c e . The reasons f o r d i s c o n t i n u i n g t h e s t u d y e a r l y v a r i e d f o r each p a t i e n t . One p a t i e n t d i s c o n t i n u e d t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s e a r l y as t h e p h y s i c i a n was p l a n n i n g t o do some wound d e b r i d e m e n t . The p a t i e n t f e l t he had used t h e d r e s s i n g l o n g enough t o a s s e s s i t and wanted t o t r y t h e M e s a l t d r e s s i n g s . He d i s c o n t i n u e d t h e s e a f t e r two weeks when t h e wound was d e b r i d e d . One p a t i e n t d i s c o n t i n u e d t h e M e s a l t d r e s s i n g s e a r l y because t h e wound d r i e d up. A n o t h e r p a t i e n t who f o u n d M e s a l t d r e s s i n g s " t o o i r r i t a t i n g " t o c o n t i n u e w i t h had g r e a t d i f f i c u l t y d e s c r i b i n g t h e e x a c t f e e l i n g . In c o n t r a s t , one o t h e r p a t i e n t who used c o n t i n u o u s wet s a l i n e d r e s s i n g s f o u n d them t o o u n c o m f o r t a b l e t o c o n t i n u e . The f o u r p a t i e n t s e x c l u d e d from t h e a n a l y s i s d i s c o n t i n u e d t h e s t u d y f o r v a r i o u s r e a s o n s . F o r one p a t i e n t , s e v e r a l 72 f a c t o r s c o n t r i b u t e d t o t h e w i t h d r a w a l : a g r a v e l y d e t e r i o r a t e d c o n d i t i o n ; t h e Home Care N u r s e s ' i n a b i l i t y t o i n c r e a s e t h e i r v i s i t s f o r t h e c o n t i n u o u s wet s a l i n e d r e s s i n g arm o f t h e s t u d y ; and t h e Home Care N u r s e s ' r e l u c t a n c e t o i n v o l v e t h e f a m i l y w i t h c o m p l i c a t e d d r e s s i n g changes. Two o t h e r p a t i e n t s d i s c o n t i n u e d t h e s t u d y a f t e r u s i n g o n l y one o f t h e d r e s s i n g s f o r one week or l e s s . One p a t i e n t e x p e r i e n c e d s t i n g i n g w i t h t h e M e s a l t d r e s s i n g ; and t h e o t h e r p a t i e n t , f i n d i n g t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s u n c o m f o r t a b l e , d i d not w i s h t o have them changed more t h a n once p e r day. The f o u r t h p a t i e n t t r i e d b o t h d r e s s i n g s but was more c o m f o r t a b l e w i t h a d r e s s i n g she had used p r e v i o u s l y . A n o t h e r d i f f i c u l t y e n c o u n t e r e d i n t h e s t u d y was w i t h r e g a r d t o m a i n t a i n i n g p r o t o c o l c o m p l i a n c e . T h i s o c c u r r e d w i t h t h o s e p a t i e n t s who were a d m i t t e d t o h o s p i t a l . C o n s i d e r a b l e e f f o r t was needed t o ensure t h a t t h e p r o t o c o l was f o l l o w e d . The s t a f f i n b o t h h o s p i t a l s i n v o l v e d , however, were v e r y s u p p o r t i v e . I t was a l s o d i f f i c u l t t o m a i n t a i n p r o t o c o l c o m p l i a n c e w i t h p a t i e n t s who were c o m p l e t e l y dependent on Home N u r s i n g c a r e f o r t h e i r d r e s s i n g changes. The d r e s s i n g changes depended more on t h e a v a i l a b i l i t y of t h e Home Care Nurse r a t h e r t h a n t h e p a t i e n t ' s need t o have i t changed. T h i s was a major c o n c e r n w i t h t h e c o n t i n u o u s wet s a l i n e d r e s s i n g s as t h e y r e q u i r e d d r e s s i n g changes on a r e g u l a r b a s i s t o m a i n t a i n m o i s t n e s s and p r e v e n t s t i c k i n g t o t h e wound. 73 P a t i e n t s * Comments and P o s t - S t u d y C o n s u l t a t i o n In g e n e r a l t h e p a t i e n t s had p o s i t i v e f e e l i n g s about b e i n g i n v o l v e d i n t h e s t u d y . They a p p r e c i a t e d r e c e i v i n g feedback about how t h e y were c a r i n g f o r t h e i r wounds and welcomed t h e weekly v i s i t s . One p a t i e n t n e v e r t h e l e s s became d i s c o u r a g e d when he f o u n d a d r e s s i n g he l i k e d w h i l e on t h e s t u d y which was d i f f i c u l t t o a f f o r d a f t e r t h e s t u d y was c o m p l e t e d . A l l p a t i e n t s were o f f e r e d two boxes (50 gause) o f t h e M e s a l t d r e s s i n g s a t t h e end o f t h e s t u d y . C o n s u l t a t i o n about t h e c a r e o f t h e l e s i o n was o f f e r e d a f t e r t h e s t u d y was c o m p l e t e d . T h i s i n v o l v e d d i s c u s s i n g c l e a n s i n g t h e l e s i o n , c o n t r o l l i n g and p r e v e n t i n g b l e e d i n g , p r e v e n t i n g and managing c l i n i c a l i n f e c t i o n , c o n t r o l l i n g and p r e v e n t i n g odor and c o n t a i n i n g d r a i n a g e . V a r i o u s d r e s s i n g o p t i o n s were d i s c u s s e d , as were f a c t o r s such as c o s t , p l a c e s t o o b t a i n t h e d r e s s i n g s , and comments r e c e i v e d p r e v i o u s l y from p a t i e n t s r e g a r d i n g c o m f o r t o f d r e s s i n g s . P a t i e n t s were a l s o s t r o n g l y encouraged t o become i n v o l v e d w i t h t h e l o c a l Home N u r s i n g c a r e program t o m o n i t o r t h e i r own c a r e o f t h e l e s i o n . One p a t i e n t f o u n d t h e s t u d y v i s i t s so h e l p f u l t h a t she wanted them t o c o n t i n u e a f t e r t h e s t u d y was c o m p l e t e d . She d i d n o t , however, w i s h t o be i n v o l v e d i n t h e Home N u r s i n g c a r e program. Those p a t i e n t s who a p p r e c i a t e d t h e s t u d y v i s i t s t h e most were t h o s e q u i t e a b l e t o do t h e i r own d r e s s i n g s and who d i d n o t w i s h t o be i n v o l v e d w i t h Home N u r s i n g c a r e . Those p a t i e n t s who were n o t r e c e i v i n g Home N u r s i n g c a r e had p r e v i o u s l y e n c o u n t e r e d many d i f f i c u l t i e s . These d i f f i c u l t i e s i n c l u d e d 74 d e c i d i n g on d r e s s i n g s and knowing where t o p u r c h a s e them. F u r t h e r m o r e , t h e s e p a t i e n t s d i d n o t f i n d t h a t t h e i r p h y s i c i a n p r o v i d e d t h e i n f o r m a t i o n and r e a s s u r a n c e t h a t t h e y r e q u i r e d . Summary The r e s u l t s of b o t h t h e development of t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e , and t h e e v a l u a t i o n o f p a t i e n t s a t i s f a c t i o n w i t h M e s a l t d r e s s i n g s compared w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s , have been p r e s e n t e d and d i s c u s s e d . P a t i e n t s w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s l i k e d t h e q u e s t i o n n a i r e ' s format and found t h e q u e s t i o n s t o be b o t h u n d e r s t a n d a b l e and i m p o r t a n t . Though t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e s o l i c i t e d i n p u t f rom p a t i e n t s i n i t s development , i t has had l i m i t e d t e s t i n g f o r v a l i d i t y and r e l i a b i l i t y . In t h e s t u d y , however, M e s a l t d r e s s i n g s r e c e i v e d s i g n i f i c a n t l y more p o s i t i v e r a t i n g s i n a group of 10 p a t i e n t s when compared w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s w i t h r e g a r d t o ease of a p p l i c a t i o n and odor c o n t r o l . The q u e s t i o n s u s e d t o e v a l u a t e p a t i e n t s a t i s f a c t i o n i n t h e s t u d y were c o n s i d e r e d a p p r o p r i a t e s i n c e t h e y were s i m i l a r t o t h o s e i d e n t i f i e d f o r t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e . N o t a b l y , p a t i e n t s w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s s i g n i f i c a n t l y p r e f e r r e d M e s a l t d r e s s i n g s t o c o n t i n u o u s wet s a l i n e d r e s s i n g s . 75 CHAPTER 5 C o n c l u s i o n and Recommendations I n t r o d u c t i o n The l i m i t e d knowledge r e l a t e d t o t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s i s a d d r e s s e d i n t h i s t h e s i s . A P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e was d e v e l o p e d , w i t h p a t i e n t i n p u t , t o e v a l u a t e d r e s s i n g s used i n t h e c a r e o f t h e s e l e s i o n s . A l s o , an e v a l u a t i o n o f p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g performance comparing M e s a l t d r e s s i n g s w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s i n t h e same t y p e s o f l e s i o n s was c o m p l e t e d . Major c o n c l u s i o n s , i m p l i c a t i o n s f o r n u r s i n g and recommendations f o r f u r t h e r s t u d y are p r e s e n t e d i n t h i s c h a p t e r . Ma.ior C o n c l u s i o n s D e r i v e d f rom t h e R e s u l t s T o o l development i n v o l v e d c o n s i d e r a b l e i n p u t from p a t i e n t s w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . Many p a t i e n t s * h a v i n g used d r e s s i n g s f o r l o n g p e r i o d s , had numerous i d e a s about what s h o u l d be asked t o e v a l u a t e p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g s used i n t h e c a r e o f t h e i r l e s i o n s . The q u e s t i o n n a i r e i n c o r p o r a t e d t h e i r i d e a s i n t o a form which many p a t i e n t s f e l t was u n d e r s t a n d a b l e and i m p o r t a n t . Though some t e s t i n g f o r v a l i d i t y and r e l i a b i l i t y was done, i t was l i m i t e d . The s t u d y e v a l u a t e d p a t i e n t s a t i s f a c t i o n w i t h M e s a l t d r e s s i n g s as compared w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s i n 76 t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . The s t u d y had a l i m i t e d a c c r u a l o f 14 p a t i e n t s . Because n o t a l l t h e p a t i e n t s completed t h e s t u d y , t h e r e s u l t s were a n a l y z e d by g r o u p i n g s o f 6, 8, and 10 p a t i e n t s , d e p e n d i n g on t h e e x t e n t o f s t u d y c o m p l e t i o n . The r e s u l t s of s t u d y s t u d y were s t a t i s t i c a l l y a n a l y z e d w i t h an = .05 . The major c o n c l u s i o n s were: 1. In t h e group o f 10 p a t i e n t s , M e s a l t d r e s s i n g s r e c e i v e d a more s i g n i f i c a n t l y p o s i t i v e r a t i n g t h a n c o n t i n u o u s wet s a l i n e d r e s s i n g s w i t h r e s p e c t t o ease o f a p p l i c a t i o n and odor c o n t r o l . 2. In t h e s m a l l e r group o f e i g h t p a t i e n t s , M e s a l t d r e s s i n g s r e c e i v e d a more p o s i t i v e r a t i n g f o r ease o f a p p l i c a t i o n . 3. No s i g n i f i c a n t d i f f e r e n c e s were f o u n d between M e s a l t d r e s s i n g s and c o n t i n u o u s wet s a l i n e d r e s s i n g s w i t h r e s p e c t t o ease o f removal and d i s c o m f o r t d u r i n g and between d r e s s i n g changes . A l t h o u g h not s i g n i f i c a n t l y p o s i t i v e , t h e r a t i n g s were h i g h i n f a v o r o f M e s a l t d r e s s i n g s w i t h r e g a r d t o c o m f o r t between d r e s s i n g changes. 4. A s i g n i f i c a n t o v e r a l l p r e f e r e n c e f o r M e s a l t d r e s s i n g s was i d e n t i f i e d i n compar ison w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s t h r o u g h o u t t h e a n a l y s e s . I m p l i c a t i o n s f o r N u r s i n g The i n f o r m a t i o n o b t a i n e d r e g a r d i n g p a t i e n t s a t i s f a c t i o n can be u s e d i n v a r i o u s ways. The P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e i s t h e f i r s t known q u e s t i o n n a i r e which at tempts 77 t o e v a l u a t e d r e s s i n g s used i n c a r i n g f o r u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s , and i n p a r t i c u l a r , i n c o r p o r a t e s t h e e v a l u a t i o n o f p a t i e n t s a t i s f a c t i o n from t h e p a t i e n t ' s p e r s p e c t i v e . D i r e c t l y a s k i n g p a t i e n t s what was i m p o r t a n t t o e v a l u a t e p r o v e d an e f f e c t i v e a p p r o a c h , r a t h e r t h a n l i m i t i n g t h e p a t i e n t s ' i n p u t t o t h e e v a l u a t i o n o f p r e - d e t e r m i n e d c r i t e r i a . The t o o l i s now a v a i l a b l e f o r f u r t h e r r e s e a r c h i n t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . The method used f o r d e v e l o p i n g t h i s t o o l may o u t l i n e an i n i t i a l p r o c e s s f o r d e v e l o p i n g a t o o l t o e v a l u a t e d r e s s i n g s u s e d i n t h e c a r e of n o n - m a l i g n a n t wounds. Nurses can use t h e c h a r a c t e r i s t i c s i d e n t i f i e d i n t h e q u e s t i o n n a i r e as t o p i c s f o r d i s c u s s i o n t o h e l p p a t i e n t s choose d r e s s i n g s . The q u e s t i o n n a i r e may f u r t h e r h e l p n u r s e s i d e n t i f y t h o s e c h a r a c t e r i s t i c s which p a t i e n t s f e e l s h o u l d be i n c l u d e d i n new d r e s s i n g p r o d u c t s . T h i s was t h e f i r s t known s t u d y t o f o r m a l l y e v a l u a t e d r e s s i n g s used i n t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . The e v a l u a t i o n o f M e s a l t d r e s s i n g s and c o n t i n u o u s wet s a l i n e d r e s s i n g s has p r o v i d e d b o t h p a t i e n t s and h e a l t h c a r e p r o f e s s i o n a l s w i t h u s e f u l i n f o r m a t i o n about p a t i e n t s a t i s f a c t i o n w i t h d r e s s i n g s . C o n t i n u o u s wet s a l i n e d r e s s i n g s a r e commonly used and t h e i r performance was r a t e d s a t i s f a c t o r y i n many c a s e s . The use o f M e s a l t d r e s s i n g s i n u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s was a new a p p l i c a t i o n o f a f r e q u e n t l y u s e d t y p e o f d r e s s i n g . The M e s a l t d r e s s i n g appears t o be a p o s i t i v e c h o i c e where ease o f a p p l i c a t i o n and c o n t r o l o f odor are i m p o r t a n t . A p p l i c a t i o n ease may be p a r t i c u l a r l y i m p o r t a n t 78 i f t h e p a t i e n t i s h a v i n g d i f f i c u l t y c h a n g i n g h i s / h e r own d r e s s i n g s . Odor c o n t r o l may be an added i m p o r t a n t r e a s o n f o r c h o o s i n g M e s a l t d r e s s i n g s , s i n c e odor can become e x t r e m e l y o f f e n s i v e and o n l y a few o p t i o n s f o r i t s management are a v a i l a b l e . M e s a l t d r e s s i n g s were a l s o found t o d r y out or s h r i n k some wounds, something which may be important , i f t h e p a t i e n t i s more c o m f o r t a b l e w i t h a d r i e r wound. In one case where t h e M e s a l t d r e s s i n g s d r i e d t h e wound c o m p l e t e l y , t h e p a t i e n t d i d not r e q u i r e d r e s s i n g changes f o r some t i m e . What was n o t a d d r e s s e d d u r i n g t h e s t u d y was t h e h i g h e r c o s t o f M e s a l t d r e s s i n g s , a f a c t o r which may d e t e r some p a t i e n t s f rom u s i n g them. O v e r a l l , because t h e M e s a l t d r e s s i n g s were s i g n i f i c a n t l y p r e f e r r e d t o c o n t i n u o u s wet s a l i n e d r e s s i n g s , t h e y a r e a r e a s o n a b l e o p t i o n t o c o n s i d e r when c h o o s i n g d r e s s i n g s f o r t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s . F i n a l l y , t h e p a t i e n t s o f t e n commented t h a t many h e a l t h c a r e p r o f e s s i o n a l s , m o s t l y p h y s i c i a n s and n u r s e s , had l i t t l e knowledge or e x p e r i e n c e i n managing t h e i r l e s i o n s . A l t h o u g h many p a t i e n t s who i n d e p e n d e n t l y c a r e d f o r t h e i r l e s i o n s d i d not want t o be i n v o l v e d i n t h e Home N u r s i n g c a r e program, t h e y f e l t t h e y would a p p r e c i a t e r e g u l a r l y c o n s u l t i n g a n u r s e who has s p e c i a l i z e d knowledge o f t h e c a r e r e q u i r e d f o r t h e i r t y p e o f l e s i o n . These p a t i e n t s o f t e n d i d not have r e g u l a r f o l l o w - u p w i t h any h e a l t h c a r e p r o f e s s i o n a l ; n o r d i d t h e y have much knowledge about t h e d r e s s i n g s a v a i l a b l e t o them, t h e c o s t o f t h e d r e s s i n g s and p l a c e s t o p u r c h a s e them. Many recommended d r e s s i n g s are q u i t e e x p e n s i v e and no i n s u r a n c e 79 p l a n c o v e r s t h e c o s t s . P a t i e n t s a re o f t e n f r u s t r a t e d by t h i s as t h e l e s s c o s t l y d r e s s i n g s t h e y must use , a r e not n e c e s s a r i l y t h e most a p p r o p r i a t e ones. I t i s t h e r e f o r e recommended t h a t a n u r s e who has a s p e c i a l i z e d knowledge o f t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s be a v a i l a b l e t o c o n s u l t w i t h p a t i e n t s and t o f o l l o w - u p on t h e c a r e o f t h e i r l e s i o n s . In a d d i t i o n , f i n a n c i a l a s s i s t a n c e s h o u l d be a v a i l a b l e t o t h e s e p a t i e n t s i n o r d e r t h a t t h e y be a b l e t o o b t a i n t h e most a p p r o p r i a t e d r e s s i n g f o r t h e c a r e o f t h e i r l e s i o n s . Recommendations f o r F u r t h e r S tudy Recommendations i n c l u d e f u r t h e r t e s t i n g o f t h e P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e d e v e l o p e d f o r t h i s t h e s i s . I t would a l s o be o f i n t e r e s t t o have p a t i e n t s rank t h e impor tance o f each o f t h e q u e s t i o n s . The e v a l u a t i o n o f M e s a l t d r e s s i n g s and c o n t i n u o u s wet s a l i n e ; d r e s s i n g s i n t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s has g r e a t l y i n c r e a s e d t h e a v a i l a b l e knowledge about p a t i e n t s a t i s f a c t i o n w i t h t h e d r e s s i n g s . F u r t h e r e v a l u a t i o n o f a l l d r e s s i n g s a v a i l a b l e t o p a t i e n t s needs t o be c o m p l e t e d . A s y s t e m a t i c approach t o e v a l u a t i o n i s c r u c i a l s i n c e t h e r e are o n l y a few p a t i e n t s w i t h u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s , and s i n c e most h e a l t h c a r e p r o f e s s i o n a l s have l i m i t e d e x p e r i e n c e managing t h e c a r e o f t h e l e s i o n s . I t i s recommended t h a t t h e e v a l u a t i o n o f t h e d r e s s i n g s c o n t i n u e , c o o r d i n a t e d by a l i m i t e d group o f n u r s e s , i n o r d e r t o p r o v i d e 80 c o n s i s t e n c y . An i n d i v i d u a l e v a l u a t i o n o f a d r e s s i n g p a t i e n t s ' used may p r o v i d e h e l p f u l i n f o r m a t i o n . However, a more s t r u c t u r e d comparison o f two d r e s s i n g s would o f f e r more i n f o r m a t i o n and a more s y s t e m a t i c e v a l u a t i o n o f t h e d r e s s i n g s . G i v e n t h e remarks from t h e p a t i e n t s , a two-week t r i a l seems t o be an adequate l e n g t h of t i m e t o a d j u s t t o t h e d r e s s i n g and e v a l u a t e i t . However, when s p e c i f i c a l l y comparing e f f e c t i v e n e s s on c o n t r o l o f odor , t h e t i m e l i m i t may need t o be ex tended. The s t u d y p a r t i c i p a n t s o f t e n emphasized t h e impor tance of u s i n g a d r e s s i n g t h a t d i d n o t s t i c k when removed. A l s o e v i d e n t was t h a t some d r e s s i n g s s t u c k t o one p a t i e n t ' s wound but d i d n o t t o t h o s e o f o t h e r s . T h i s phenomenon d i d not seem s i m p l y t o r e f l e c t t h e amount o f d r a i n a g e n o r t h e c o n s i s t e n c y o f t h e d r a i n a g e . F u r t h e r r e s e a r c h t h e r e f o r e i s needed i n t h i s a r e a . Summary The P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e was d e v e l o p e d as a t o o l t o e v a l u a t e d r e s s i n g s used i n c a r i n g f o r u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s , and i s now a v a i l a b l e f o r f u r t h e r t e s t i n g . Because r e s e a r c h r e l a t e d t o t h e c a r e o f u l c e r a t i n g m e t a s t a t i c s k i n l e s i o n s i s l i m i t e d , t h i s s t u d y has e v a l u a t e d two d r e s s i n g s : M e s a l t d r e s s i n g s and c o n t i n u o u s wet s a l i n e d r e s s i n g s . M e s a l t d r e s s i n g s s c o r e d a more p o s i t i v e r a t i n g f o r ease o f a p p l i c a t i o n and odor c o n t r o l i n a group o f 10 p a t i e n t s . S i g n i f i c a n t numbers o f p a t i e n t s i n v o l v e d i n t h e 81 s t u d y p r e f e r r e d M e s a l t d r e s s i n g s o v e r c o n t i n u o u s wet s a l i n e d r e s s i n g s . 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J o u r n a l of the American M e d i c a l Association, 244, 820-822. 89 APPENDIX A P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e 90 PATIENT SATISFACTION QUESTIONNAIRE LETTER OF INTRODUCTION Dear P a r t i c i p a n t , P l e a s e f i n d e n c l o s e d a P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e which which e v a l u a t e s d r e s s i n g s used i n t h e c a r e o f cancerous wounds. Each q u e s t i o n r e f e r s o n l y t o t h e d r e s s i n g and does n o t i n c l u d e t a p e or o t h e r d e v i c e s which h o l d t h e d r e s s i n g i n p l a c e . When you answer t h e q u e s t i o n s " P l e a s e p l a c e a mark t h r o u g h t h e l i n e , between t h e two extremes t o i n d i c a t e t h e degree o f y o u r r e s p o n s e . " An example i s g i v e n below: Does t h e weather e f f e c t y o u r mood? A g r e a t d e a l _ / Not a t a l l Thank you f o r y o u r c o o o p e r a t i o n . 91 V PATIENT SATISFACTION QUESTIONNAIRE PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE ID# TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE: 1. Is t h e d r e s s i n g easy t o a p p l y ? Not v e r y easy V e r y easy 2. Is t h e d r e s s i n g easy t o remove? Not v e r y easy ; V e r y easy 3. How l o n g does i t t a k e t o change y o u r d r e s s i n g ? Not A l o n g t ime v e r y l o n g 4. Do you e x p e r i e n c e d i s c o m f o r t when t h e d r e s s i n g i s removed? A g r e a t d e a l Not a t a l l 5. Do you e x p e r i e n c e p a i n when t h e d r e s s i n g i s removed? A g r e a t d e a l Not a t a l l 6. Does t h e d r e s s i n g s t i c k t o t h e wound when i t i s b e i n g removed? A g r e a t d e a l Not a t a l l 7. Does t h e d r e s s i n g cause t h e wound t o b l e e d when i t i s removed? A g r e a t d e a l Not a t a l l 8. A r e t h e r e d r e s s i n g f i b r e s l e f t i n t h e wound when t h e d r e s s i n g i s removed? Q u i t e a few None at a l l 92 PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE ID# TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE: 9. Does t h e d r e s s i n g cause t h e wound t o d r y up? A g r e a t d e a l Not a t a l l 10. Does t h e d r e s s i n g keep t h e wound c l e a n ? Not v e r y w e l l V e r y w e l l 11. Is t h e d r e s s i n g s o f t a g a i n s t y o u r s k i n ? Not v e r y s o f t V e r y s o f t 12. Is t h e d r e s s i n g c o m f o r t a b l e w h i l e i t i s on? Not v e r y V e r y c o m f o r t a b l e c o m f o r t a b l e 13. Does t h e d r e s s i n g cause a " s t i n g i n g " s e n s a t i o n ? A g r e a t d e a l Not a t a l l 14. Does t h e d r e s s i n g cause a " b u r n i n g " s e n s a t i o n ? A g r e a t d e a l • Not a t a l l 15. Does t h e d r e s s i n g cause a "clammy" f e e l i n g ? A g r e a t d e a l Not a t a l l 16. Does t h e d r e s s i n g rub r o u g h l y a g a i n s t t h e wound w h i l e i t i s on? A g r e a t d e a l Not a t a l l 93 PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE ID# TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE: 17. Does t h e d r e s s i n g d e c r e a s e t h e odor ( i f t h e r e i s any) f rom t h e wound? A g r e a t d e a l Not a t a l l 18. Does t h e d r e s s i n g cause a " s t r a n g e " odor? A g r e a t d e a l Not a t a l l 19. Does t h e d r e s s i n g absorb a l l o f t h e d r a i n a g e ? Not v e r y w e l l V e r y w e l l 20. Does t h e d r e s s i n g p r e v e n t d r a i n a g e from p a s s i n g t h r o u g h t o t h e o u t s i d e o f t h e d r e s s i n g ? Not v e r y w e l l V e r y w e l l 21. Does t h e d r e s s i n g adapt t o t h e shape o f t h e wound? Not v e r y w e l l V e r y w e l l 22. Does t h e d r e s s i n g have more b u l k t h a n i s needed? A g r e a t d e a l Not a t a l l 23. Can you use t h e d r e s s i n g WITHOUT t a p e , n e t t i n g or o t h e r d e v i c e s which h o l d t h e d r e s s i n g i n p l a c e ? Not v e r y w e l l V e r y w e l l 24. Does t h e d r e s s i n g cause i r r i t a t i o n t o t h e s k i n s u r r o u n d i n g t h e wound? A g r e a t d e a l Not a t a l l 94 APPENDIX B I n t e r v i e w G u i d e 95 INTERVIEW GUIDE 1. What t y p e s o f d r e s s i n g s have you used i n t h e c a r e of y o u r open wound? 2. What d i d you l i k e about each d r e s s i n g ? 3. What d i d you d i s l i k e about each d r e s s i n g ? 4. What do you want t h e d r e s s i n g t o do? or What c h a r a c t e r i s t i c s o f t h e d r e s s i n g would you c o n s i d e r i m p o r t a n t i n c h o o s i n g a d r e s s i n g ? 5. What f a c t o r s would i n f l u e n c e y o u r s a t i s f a c t i o n w i t h t h e d r e s s i n g ? or Can you d e s c r i b e t h e " p e r f e c t " d r e s s i n g ? 96 APPENDIX C P r e l i m i n a r y Q u e s t i o n n a i r e 97 PLEASE PLACE A MARK THROUGH THE LINE, BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE: ID#_ Is t h e d r e s s i n g easy t o a p p l y ? Not v e r y easy V e r y easy Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Is t h e d r e s s i n g easy t o remove? Not v e r y easy V e r y easy Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No How l o n g does i t t a k e t o change y o u r d r e s s i n g ? A l o n g t i m e Not v e r y long Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Is t h e r e d i s c o m f o r t d u r i n g t h e d r e s s i n g change? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Do you e x p e r i e n c e p a i n when t h e d r e s s i n g i s changed? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g s t i c k t o t h e wound? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No 98 PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE ID# TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE? Does t h e d r e s s i n g cause t h e wound t o b l e e d when i t i s removed? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Is d r e s s i n g f i b r e l e f t i n t h e wound when t h e d r e s s i n g i s removed? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause t h e wound t o e n l a r g e ? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause t h e wound t o d r y up? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g keep t h e wound c l e a n ? Not v e r y w e l l . V e r y w e l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Is t h e d r e s s i n g s o f t a g a i n s t y o u r s k i n ? Not v e r y s o f t V e r y s o f t Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No 99 PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE: Is t h e d r e s s i n g c o m f o r t a b l e w h i l e i t i s on? Not v e r y V e r y c o m f o r t a b l e c o m f o r t a b l e Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Do you e x p e r i e n c e p a i n from t h e d r e s s i n g w h i l e i t i s on? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause a " s t i n g i n g " s e n s a t i o n ? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause a " b u r n i n g " s e n s a t i o n ? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause a "gummy" f e e l i n g ? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause a "clammy" f e e l i n g ? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No 100 PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE: im. Does t h e d r e s s i n g rub r o u g h l y a g a i n s t t h e wound? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g d e c r e a s e t h e odor ( i f t h e r e i s any) from t h e wound? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause a " s t r a n g e " odor? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g absorb a l l o f t h e d r a i n a g e ? Not v e r y w e l l , V e r y w e l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g p r e v e n t d r a i n a g e from p a s s i n g t h r o u g h t o t h e o u t s i d e o f t h e d r e s s i n g ? Not v e r y w e l l V e r y w e l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g adapt t o t h e shape o f t h e wound? Not v e r y w e l l V e r y w e l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No 101 PLEASE PLACE A MARK THROUGH THE LINE, BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE? ID#. Does t h e d r e s s i n g have more b u l k t h a n i s needed? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Can you use t h e d r e s s i n g w i t h o u t t a p e or o t h e r d e v i c e s which h o l d t h e d r e s s i n g i n p l a c e ? Not v e r y w e l l V e r y w e l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause i r r i t a t i o n t o t h e s k i n s u r r o u n d i n g t h e wound? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause i t c h i n e s s t o t h e s k i n s u r r o u n d i n g t h e wound? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No 102 \ APPENDIX D L e t t e r o f I n t r o d u c t i o n 103 APPENDIX E P i l o t Q u e s t i o n n a i r e 105 PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE: im Is t h e d r e s s i n g easy t o a p p l y ? Not v e r y easy ; V e r y easy Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Is t h e d r e s s i n g easy t o remove? Not v e r y easy V e r y easy Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No How l o n g does i t t a k e t o change y o u r d r e s s i n g ? A l o n g t i m e . Not v e r y long Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Do you e x p e r i e n c e d i s c o m f o r t when t h e d r e s s i n g i s removed? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Do you e x p e r i e n c e p a i n when t h e d r e s s i n g i s removed? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g s t i c k t o t h e wound when i t i s b e i n g removed? A g r e a t d e a l : Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No 107 PLEASE PLACE A MARK THROUGH THE LINE, BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE? Does t h e d r e s s i n g cause t h e wound t o b l e e d when i t i s removed? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Are t h e r e d r e s s i n g f i b r e s l e f t i n t h e wound when t h e d r e s s i n g i s removed? Q u i t e a few None a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause t h e wound t o d r y up? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g keep t h e wound c l e a n ? Not v e r y w e l l V e r y w e l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Is t h e d r e s s i n g s o f t a g a i n s t y o u r s k i n ? Not v e r y s o f t V e r y s o f t Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Is t h e d r e s s i n g c o m f o r t a b l e w h i l e i t i s on? Not v e r y V e r y c o m f o r t a b l e c o m f o r t a b l e Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No 108 PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE ID#. TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE: Do you e x p e r i e n c e p a i n from t h e d r e s s i n g w h i l e i t i s on? A g r e a t d e a l • Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause a " s t i n g i n g " s e n s a t i o n ? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause a " b u r n i n g " s e n s a t i o n ? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g cause a "clammy" f e e l i n g ? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g rub r o u g h l y a g a i n s t t h e wound w h i l e i t i s on? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g d e c r e a s e t h e odor ( i f t h e r e i s any) f rom t h e wound? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No 109 PLEASE PLACE A MARK THROUGH THE LINE, BETWEEN THE ID#_ TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE: Does t h e d r e s s i n g cause a " s t r a n g e " odor? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g absorb a l l o f t h e d r a i n a g e ? Not v e r y w e l l V e r y w e l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g p r e v e n t d r a i n a g e from p a s s i n g t h r o u g h t o t h e o u t s i d e o f t h e d r e s s i n g ? Not v e r y w e l l V e r y w e l l Is t h e s u b j e c t of t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g adapt t o t h e shape o f t h e wound? Not v e r y w e l l V e r y w e l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Does t h e d r e s s i n g have more b u l k t h a n i s needed? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No Can you use t h e d r e s s i n g WITHOUT t a p e , n e t t i n g or o t h e r d e v i c e s which h o l d t h e d r e s s i n g i n p l a c e ? Not v e r y w e l l V e r y w e l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No 110 PLEASE PLACE A MARK THROUGH THE LINE, BETWEEN THE ID# TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE? Does t h e d r e s s i n g cause i r r i t a t i o n t o t h e s k i n s u r r o u n d i n g t h e wound? A g r e a t d e a l Not a t a l l Is t h e s u b j e c t o f t h i s q u e s t i o n i m p o r t a n t t o you? Yes No 111 APPENDIX F M e d i c a l H i s t o r y 112 MEDICAL HISTORY DATE: ID# Day/Month/Year DIAGNOSIS: DATE OF DIAGNOSIS: H i s t o r y o f the L e s i o n Date at Appearance: Day/Month/Year Ulceration: • No • Yes Date: Bleeding: • No • Yes Date: Infection: • No • Yes Date: Day/Month/Year Day/Month/Year Day/Month/Year CURRENT TREATMENT Hormonal therapy • Yes -> When started Type I I No Specify CURRENT LESION CARE A. When Started: Month/Year B. Dressings typeONS •Dakins QDry •Adaptic •Other_ #dressings: #dressing changes/24 hours: C. Cleansing solution: QYes -ONS • H202 QOther I I No Specify D. Bleeding Control: • Yes ->QGelfoam • • Kalostat •Other • No Spec E. Odor Control: OYes ->• Flagyl • Other • No Specify F. Infection Control: OYes ->• Antibiotic: • No Specify 113 APPENDIX G P r o t o c o l f o r Wound Care 114 PROTOCOL FOR WOUND CARE 1. CLEANSING OF WOUND Solution: Cleanse wound with Normal Saline (N/S) solution 0.9%. Following consultation with the Research Nurse, may use 1/2 strength Hydrogen Peroxide and rinse with N/S i f indicated by the presence of crusting or dead tissue. Method: Cleanse wound using gauze soaked with solutions described above. May also use other methods i f gauze is inappropriate eg. cotton-tipped swabs, spray bottle, soft shower, squeeze from sponge over wound etc. *Use a gentle rubbing action unless tissue is friable, then NO rubbing. 2. FREQUENCY OF CLEANING/DRESSING CHANGES To be determined by the Research Nurse depending on amount of drainage. Drainage which extends beyond the outer dressing (dry gauze dressing) indicates need for increase in dressing changes. Wet normal saline dressings will be changed every 4 to 6 hours depending on the dryness of the dressing. Mesalt will be changed when the area over the wound is saturated with drainage. 3. CONTROL OF BLEEDING Apply Gelfoam or Kalostat to source of bleeding as required. 4. DRESSING APPLICATION INNER DRESSINGS (1st layer - applied directly to wound) - Mesalt or N/S soaked gauze (depending on study randomization) - Apply dressing by laying gauze over top of wound - For N/S soaked gauze, soak gauze in N/S solution so it is moderately soaked. OUTER DRESSINGS 2nd layer - Dry gauze over Mesalt or N/S soaked gauze 3rd layer - (optional) Abdominal padding SECUREMENT OF DRESSINGS Secure dressing with any of the following: - tape - Mefix - netting eg. fastonet - clothing eg. tube tops, camisoles, etc. For the purposes of the study, do not use: - creams, ointments, solutions, dressing materials, other than those specified - anything that effects bacterial growth or odor. 115 APPENDIX H O v e r a l l E v a l u a t i o n S c a l e 116 OVERALL EVALUATION SCALE ( p a t i e n t ) ID#_ Please put an X on the line to indicate: 1. How is the application of the dressing? Very Difficult Very easy to apply to apply 2. How is the removal of the dressing? Very difficult . " Very easy to remove to remove 3. How much discomfort do you experience when the dressing is removed? A lot of discomfort No discomfort 4. How comfortable is the dressing between dressing changes? Very Very comfortable uncomfortable 5. How effective is the dressing in controlling odor? Not effective Very effective at all 117 APPENDIX I P r e f e r e n c e S c a l e 118 PREFERENCE SCALE ( p a t i e n t ) ID# Which dressing did you prefer? Q T h e first dressing Q T h e second dressing | j No preference Why? 119 APPENDIX J P r e f e r e n c e S c a l e ( R e v i s e d ) 120 PREFERENCE SCALE ( p a t i e n t ) ID# Which dressing did you prefer? I I The first dressing | 1 The second dressing [Zl No preference If i you did have a preference (indicated above), how strong was your preference? (Please place a mark through the line, between the two extremes to indicate the degree of your response) Not very strong Very strong If you did have a preference (indicated above), why did you prefer the dressing? 121 APPENDIX K P a t i e n t I n f o r m a t i o n and Consent Form 122 CCA BC Cancer Control Agency of British Columbia 600 West 10th Avenue Vancouver, B.C., Canada V5Z 4E6 (604) 877-6000 Telex 04-507648 Fax (604) 872-4596 EVALUATION OF DRY VS WET NORMAL SALINE DRESSINGS IN WOUND CARE PATIENT INFORMATION AND CONSENT FORM The purpose of this study is to compare two types of dressings used in the care of open wounds related to cancer. The main focus of the study is to determine the convenience of both dressings. The study also examines the effects of the dressing on odor control and infection. Both types of dressings have been previously used in the care of open wounds and to date, there has been no evidence of side effects from either type of dressing. At the beginning of the study, the Research Nurse (a Registered Nurse assigned to the study) will see you either at the Cancer Control Agency of British Columbia or in your home. She will ask you questions about your wound and how you presently care for i t . She will then examine you for any signs of infection and use a cotton swab to take a specimen of the drainage from your wound. To compare these dressings, you will be randomly assigned to use one of the dressings for the first four weeks. This means that you will have an equal chance of being assigned to use either of the two dresssings. Then for the last four weeks you will use the other dressing. The study will therefore involve a total of eight weeks. The Research Nurse will instruct you about how to use each of these dressings. While you are on the study, the Research Nurse will visit you once a week in your home to collect information about your wound and how you are managing with the dressings. During the time you are on the study, you will be asked not to use any ointments or solutions upon the wound other than those specified by the Research Nurse. Specimens of the drainage from your wound, using a cotton swab will be taken before switching to the second dressing, and again at the end of the study. If you are involved in changing the dressing you will be asked to record the number of dressing changes required per day and the time it takes you to do the dressing. The study will require about 15 minutes per week of your time for the Research Nurse's visit and 5-10 minutes for recording information about the dressing changes. Although there may be no direct benefit to you by participating in this study, the knowledge 123 APPENDIX L C o n t e n t I d e n t i f i c a t i o n Summary 125 CONTENT IDENTIFICATION SUMMARY C h a r a c t e r i s t i c s of i d e a l d r e s s i n g s from i n t e r v i e w s : - not u n c o m f o r t a b l e - no s t r a n g e odor - not s t i c k i n g t o wound - d o e s n ' t cause b l e e d i n g - a b s o r b e n t - d r a i n a g e d o e s n ' t pass t h r o u g h - s o f t - easy t o u s e / a p p l y - c o n t o u r s t o wound; d o e s n ' t s l i p - a d a p t a b l e - a p p r o p r i a t e s i z e , not b u l k y - not g u m m y / s t i c k y - n o t a b r a s i v e - no l i n t - d r i e s up wound - d o e s n ' t cause wound t o b r e a k down - can use w i t h o u t t a p e - easy t o remove - h e a l s wound - n o t a b o t h e r - d o e s n ' t s t i n g A d d i t i o n a l c h a r a c t e r i s t i c s f rom l i t e r a t u r e : - c o n t r o l o f odor - c o n t r o l s d r a i n a g e - c o n t r o l s b l e e d i n g - p r e v e n t s i n f e c t i o n - c l e a n s wound - d r i e s wound - no p r u r i t i s o f s u r r o u n d i n g t i s s u e - no p a i n - wound - no d i s c o m f o r t - wound - c o m f o r t a b l e - d e c r e a s e s s i a e o f l e s i o n ( s h r i n k s ) A d d i t i o n a l c h a r a c t e r i s t i c s f rom own e x p e r i e n c e : - not i r r i t a t i n g / s t i n g i n g - wound - s u r r o u n d i n g t i s s u e - easy t o do d r e s s i n g - q u i c k t o change d r e s s i n g - keeps wound c l e a n - d o e s n ' t promote i n f e c t i o n - c o m f o r t " d u r i n g " d r e s s i n g change - n o t "clammy" - d e c r e a s e s odor 126 

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