Critique of a selective qualitative article.
Your assignment should contain all of the following elements:
45 Marks = 15%
1.Provide a brief overview of the paper and discuss how the various sections fit making the paper a good one or not.
2.Identify and discuss the problem statement and research question(s) - significance and consistent with philosophical bases.
3.Identify the research design that was used and discuss its appropriateness, congruence and reason it was used for this study
4.Discuss the sample and sampling processes that were used - were the details of the setting and sample, recruitment adequately described
5.Discuss appropriateness of procedures for the protection of the rights of the participants.
6.Discuss the appropriateness of the method used for the data collection. Were appropriate procedures used to assess the reliability and validity of the study?
7.Discuss the relevance and sufficiency of the data analysis procedures used.
8.Identify and discuss the adequacy of the key findings - effective summarization; adequacy of the themes; Logical connection of themes to form a convincing whole? Appropriateness of figures and maps used?
9.Identify and discuss any questions you were left with and any limitations you noted after reviewing the article.
10.Include a discussion of the relevance/ appropriateness of the findings to nursing practice.
11.Include a discussion of any considerations for future research.
·You are expected to choose One article from the 3 articles provided in the list.
·You are expected to complete this assignment independently of other students.
·The paper should be in APA format - Double Spaced, and 1" margins on letter-size paper.
·The assignment should be NO MORE THAN 6 pages in length excluding the title and reference pages.
Healthcare 2014, 2, 272-281; doi:10.3390/healthcare2030272
OPEN ACCESS healthcare
Article The Patient?s Conceptions of Wound Treatment with Negative
Pressure Wound Therapy
Department of Surgery, Department of Clinical Science and Education, Södersjukhuset, Karolinska
Institutet, SE-171 77 Stockholm, Sweden; E-Mail: firstname.lastname@example.org; Tel.: +46-70089-1063;
Received: 31 March 2014; in revised form: 10 June 2014 / Accepted: 2 July 2014 /
Published: 21 July 2014 Abstract: During the last two decades, additional methods have been developed in wound
care where traditional treatments have been insufficient. Negative pressure wound therapy
(NPWT) is one such method. This method has been described in multiple studies, but still,
many pieces of the puzzle are missing to get a complete picture of NPWT?s impact on the
patient?s health-related quality of life and how the patient experiences the treatment. The
purpose of this study was to describe the patient?s conceptions of wound treatment with
NPWT. The study was inspired by phenomenography, and eight interviews were
conducted with patients treated with NPWT. The results of the study were grouped into
two main categories: stress and adaptation. Three descriptive categories were presented
under stress: personal environment, competence of the nursing staff and organization and
continuity of the dressing changes. Two descriptive categories were presented under
adaptation: knowledge and creativity and confidence with the healthcare. Patients were
affected by the treatment, and at times, the stress meant that they had difficulty coping. The
most common source of stress observed in this study was the care environment,
particularly the organization of the dressing changes and deficiencies in the healthcare
Keywords: negative pressure wound therapy; NPWT; wound treatment; patient?s conceptions 1. Introduction
Throughout history, wounds and, particularly, slow-healing wounds have been a cause of suffering
and great distress to unfortunate victims. During the last two decades, additional methods have been Healthcare 2014, 2 273 developed in areas where traditional wound treatment has been insufficient. Negative pressure wound
therapy (NPWT) is one such method. This method has been explored in multiple studies, and it has
been shown that NPWT may be stressful to the patient. However, there are still many pieces of the
puzzle missing to get a complete picture of the impact on the patient?s health-related quality of life
(HRQoL) and how the patient experiences this treatment.
The NPWT method consists of a device that creates a vacuum in the wound using a wound filler of
polyurethane foam, polyvinyl alcohol foam dressing or gauze. The foam, or gauze, is adapted exactly
after the size of the wound, and then, the wound filler and the entire wound are covered with
a transparent adhesive drape. A hole is cut in the drape and a suction tube adapted. The tube is
connected to the vacuum machine, and a subatmospheric pressure is applied.
NPWT has been in clinical use for wound management since 1995, and the first scientific
documentation originates from 1997 with the work of Argenta and Morykwas . Since then,
thousands of articles have been published, but only a small fraction of the literature focuses on the
patient?s conceptions and experiences of the treatment.
The impact on the HRQoL during NPWT has been explored qualitatively in only a few studies.
Abbotts showed that the treatment with NPWT was experienced as stressful, especially regarding the
impact on daily life and the organization of dressing changes . An interview study by Bolas and
Holloway confirms these findings, but also emphasizes the technical aspect of NPWT and describes
the feelings of distress associated with its use .
Upton, Stephens and Andrew described that the NPWT system can cause patients to feel anxious,
due to both the patient and the health professional being unfamiliar with this form of treatment.
Furthermore, they described that the treatment can also restrict the patient?s daily care and wider social
life, which may result in a negative self-image and low self-esteem. They also emphasize the need for
more knowledge, particularly exploring the patient?s experience throughout the treatment process in
order to minimize the negative effects of NPWT .
The World Union of Wound Healing Societies (WUWHS) consensus document on NPWT states
that NPWT can have a positive impact on a patient?s HRQoL . However, Ousey, Cook and Milne
conclude in their review of the impact of NPWT on the patient?s HRQoL that it is not possible to
determine whether the impact is positive, neutral or negative based on existing research . Since the
amount of research focusing on the patient?s experiences and that the existing literature presents
varying results with both negative and positive impact on the patient?s HRQoL, it is necessary to
conduct more qualitative research on the effects of NPWT. The aim of this study was to describe the
patient?s conceptions of wound treatment with NPWT.
In this study, a phenomenographic approach was used. Phenomenography is a research method that
explores the qualitatively different ways in which people perceive a specific phenomenon.
Fundamental in phenomenography is to find the variation of people?s conceptions of this phenomenon .
In this study, the phenomenon is wound treatment with NPWT. Healthcare 2014, 2 274 2.1. Participants
The participants were purposefully selected to ensure variation with respect to gender, age, wound type,
type of NPWT device and treatment time, in accordance with the phenomenographic methodology [7,8].
Nineteen patients treated with NPWT during 2006 were asked to participate in the study, and in total,
eight patients agreed (Table 1).
Table 1. Demographic and medical data of the participants (n = 8). NPWT, negative
pressure wound therapy.
Post-operative wound infection
Diabetic foot ulcer
NPWT pump type
Treatment time (days)
17 The NPWT system used was, in four cases, a portable vacuum-assisted closure (VAC) device
(ActiV.A.C., KCI Inc, San Antonio, TX, USA) and in four cases, a larger stationary pump
(InfoV.A.C., KCI Inc, San Antonio, TX, USA). The dressings were changed twice weekly.
The dressing changes were performed as an inpatient treatment for patients with the stationary pumps
and at the outpatient clinic for patients with portable machines. The healthcare personnel performing
the wound treatment were physicians of different specialties, registered nurses and nurse?s aides at a
large emergency city hospital. The hospital had no formal requirement that the personnel should have
received specialized education in wound care, so knowledge and competence varied and was dependent
on the individual?s experience and own interest.
2.2. Data Collection
Interviews were conducted in the period of June?November, 2006. A non-structured interview
procedure was used, developing new questions following earlier answers, until no further information
was received. All interviews began with one open question, where the participants were asked to talk
freely about their conceptions of NPWT in general. The interview was expanded by follow-up
questions regarding the injury, the wound healing process and the experience of being treated with
NPWT. Six of the interviews were conducted at the hospital and two were telephone interviews.
All interviews were conducted by the same researcher and lasted from seven to 43 min. The interviews
were tape-recorded and transcribed verbatim. Healthcare 2014, 2 275 Initially, six interviews were conducted and analyzed. Then, two more additional interviews were
conducted, and after analysis, no new data was received, indicating a satisfying saturation of the material .
2.3. Data Analysis
Data analysis was conducted according to the phenomenographic method . In all phases of the
analysis, discussions took place between the researcher and co-workers, until consensus was reached.
The transcribed interviews were initially read several times to get familiar with the content and to
obtain a sense of the whole. When a deeper understanding of the content was reached, distinct
statements of conception were compared. Statements with similar content were grouped together and
categorized into five labelled descriptive categories. These categories were thoroughly examined and
discussed to ensure that they were distinctly separated from each other. In the next phase, the
underlying meaning on an abstract level of the descriptive categories was analyzed, discussed and
formulated into two main categories. Finally, the whole material was analyzed again to confirm the
correlation between the statements of conception, descriptive categories and the main categories with
the original text of the transcribed interviews.
2.4. Ethical Considerations
All participants were given written and verbal information, and their informed consent was
obtained. Confidentiality was assured by decoding the interviews and all research data were kept in
locked cabinets. Ethical approval was obtained by the local Ethics Committee (2006/571-31/2).
The findings in this study show that being treated with NPWT was perceived by the participants as
stressful, and at times, the stress meant that they had difficulty coping. The ability to adapt to the
prevailing circumstances had a major effect on their conceptions and experiences of the wound
treatment process. The descriptive categories presented in the result comprise the participants?
conceptions as identified in their responses (Table 2).
Table 2. Patients? conceptions of being treated with NPWT: main categories and description categories.
Competence of the nursing staff
Organization and continuity of the dressing changes
Knowledge and creativity
Confidence with the healthcare Main Category
Adaptation 3.1. Stress
The majority of the participants perceived treatment with NPWT as being stressful, but worth
the inconvenience. Healthcare 2014, 2 276 3.1.1. Personal Environment
The participants? personal environment was affected by the treatment in physical, mental, social and
spiritual aspects. The participants particularly perceived physical discomfort during the treatment.
Some of the participants described the treatment as being painful, especially during the dressing
changes, but the majority did not perceive the treatment as painful at all. One participant even
expressed himself so well that the staff was surprised by the fact that he did not have any pain:
?...about the abdomen...I don?t feel that I...I never had any pain...in the abdomen...all
doctors asked but do you not have any pain there...??
The most frequently described problem when being treated with NPWT was the inconvenience of
being attached to a machine all the time. This was particularly disturbing to the participants treated
with the larger stationary pump. The participants with the smaller portable pump, however, described
an inconvenience when carrying it for a longer time, even when it felt light at first. The machine also
affected some issues of daily life, like getting dressed and undressed and taking a shower. One man
described frustration in the prolonged time required for performing everyday tasks:
?Most difficult this period was taking a shower?with a plastic bag?or thinking that the
tube enters somewhere?and there will leak in water?if it gets soaked it must be replaced.
So I put on two socks and then a plastic bag?oh, it was the greatest project?and what I
have missed most of all?is not to sleep but to stand on two naked feet in the shower??
3.1.2. Competence of the Nursing Staff
The participant perceived the competence and knowledge of the treatment as being rather varying
and that there were major differences within the personnel who fully mastered the treatment compared
to those that did not. Several participants described this as feeling like guinea pigs:
?It is not so many that feels...you know of the staff that knows this inside out yet, so they
are experimenting a bit?
??the staff?they said they did not know much?so they were also curious to know more
about the machine??
The competence of the staff was perceived by the majority of the participants as being inadequate,
and they described this as very troublesome. The participants, however, also described being tolerant
and understanding regarding the deficiencies in the competence of the staff, since they were aware of
that the treatment was new, some even expressed an interest in being part of the staff?s education.
??it was a bit?fascinating. Yes, there were several people in the OR and they were invited
to watch the dressing changes?on some occasions there was a flow of visitors asking if
they could take a look?well, it can be fun with a little public but finally only four persons
at a time were allowed to watch the dressing changes as it became crowded I suppose?? Healthcare 2014, 2 277 3.1.3. Organization and Continuity of the Dressing Changes
All of the participants described the continuity of the dressing changes as troublesome, particularly
since there were so many people involved in their care and no one with the full responsibility.
The participants who had their dressing changes performed in the operation room (OR) ward
described the waiting as most stressful in the process of dressing changes. The procedure was planned
in the so-called emergency list at the OR and prioritized together with all other emergency cases in
need of surgery. All of the participants experienced being given lower priority to have to wait for
a long time for each dressing change. They all expressed this not being a great problem when being
treated once or twice, but for longer treatment periods with many dressing changes, it became a major
concern. Particularly problematic was when being forced to fast all day and the dressing change was
postponed until the next day:
So that a?well?that part was an inconvenience, to have to wait not knowing if the change
of dressing could be done that day?all of a sudden it could not be done and then you did
not know when next a change could be performed?well you must get a scheduled time for
the change of dressing.
Despite the stressful impact the treatment had on the participants, the majority perceived the
treatment as being positive and that they were able to adapt and to manage the stress.
3.2.1. Knowledge and Creativity
Several of the participants described the importance of knowledge, both the knowledge within the
staff, but also their own knowledge of the NPWT technique and their understanding of their own
wound treatment. The participants received information regarding the treatment several times, however
of varied content, and it is difficult to understand. The healthcare personnel who was informing also
showed clear shortcomings in knowledge. One participant perceived that the staff was taking much for
granted and did not understand that the patients had difficulties comprehending the information.
Furthermore, the reduced health condition that several of the participants had was considered a reason
for the perceived lack of information given and the understanding of that information.
The participants talked about several problems with daily living during treatment, but also how
they, in a creative way, went about to solve these problems. They showed great creativity when trying
to adapt to the situation and make everyday life as manageable as possible, both on their own, but also
together with the healthcare personnel. Some participants treated with the larger stationary pump had
different ways of making the pump more mobile:
?...then I went and experimented a bit on the ward so it resulted in that we took this
vacuum pump and put on one of those IV-poles and then it went after all...it was...I was
able to walk around and it up and...?
??but I learnt to put the bed there (closer to the shower room, authors? comments). I put
the wire under the door so I could take a shower on my own.? Healthcare 2014, 2 278 3.2.2. Confidence with the Healthcare
The participants said that, from the very beginning, they had had great confidence in the treatment
and in the healthcare staff, and when the wound started to heal, they felt faith in the future.
One participant had had the wound for a long time and was willing to try just about anything to see
an improvement. Particularly, participants treated with open abdominal wounds described the
treatment and trust in healthcare as giving them hope for recovery. One participant said that he, before
treatment with NPWT, had been lying with an open abdomen and experienced how the intestines
virtually fell out when he moved. With NPWT, he got the feeling that his body was whole again and
with that, the agony he felt disappeared and the hope of recovery was lit:
No, it was that feeling?those first days?that everything leaks out of you?it was literally
speaking only the peritoneum which held the intestines in place, and it leaked and
smelled?you felt this is not going to work?almost a sort of deadly anxiety, I must say.
I thought I wouldn?t survive?despite everyone saying to the contrary?When they applied
this VAC dressing it felt more like it was a part of my body, somehow?The body felt
whole again. This increased my well-being psychologically?from thinking ?This is the
end? to suddenly feeling ?This is not so bad?.
The results of this study show that the participants treated with NPWT perceived the treatment as
positive and effective, despite stress in the form of physical strain and the inconvenience of being
connected to the unit around the clock. These strains were managed by the participants? feeling of the
fundamental belief in the treatment and healthcare and that they had trust that their wounds would heal.
Moreover, they perceived knowledge of the treatment method as important and contributing to their
ability to creatively solve problems that arose during the treatment. The participants perceived the
inadequate and varied skills of the healthcare staff and the organization and continuity of the dressing
changes as being the most troublesome aspect.
The participants stated that treatment with NPWT was stressful to them, which is in accordance
with other research focusing on patients? experiences of traditional wound treatment [10?12].
The most troublesome for the participants during treatment was the organization of the dressing
changes, particularly when performed in the OR ward. This problem has also been described by Abbott
and by Bolas and Holloway [2,3]. It is important to facilitate the care of these patients and to minimize
stress. By planning the dressing changes as elective operations in the surgical planning schedule, the
risk of being postponed can be reduced. This could give the patients a better ability for themselves to
prepare for the dressing change, which could result in a greater sense of control.
Another issue contributing to stress during treatment was the inadequate and varying competence
of the healthcare personnel. This is also a well-described problem with NPWT treatment in the
literature [3,13]. It is a major concern when apparently insufficiently-educated personnel handle
advanced treatment, such as NPWT. Unfortunately, problems with the staff?s lack of skills are not Healthcare 2014, 2 279 unique to NPWT, but also occur in other wound treatment methods, as confirmed by previous
research [14,15]. Graham  pinpoints the importance of sufficient education before applying the
therapy, especially since incorrect use could seriously harm the patient. Graham suggests an
educational program according to the theories by Patricia Benner  with different knowledge levels,
from novice to expert. According to the ethical principle of non-maleficence, embodied by the phrase
?first, do no harm?, it is essential for healthcare to ensure that the personnel has adequate knowledge of
the equipment and method used, to avoid the risk of harming the patient.
The participants? description of pain during treatment and, particularly, the absence of pain are
worth mentioning. Procedural pain during dressing changes when treated with NPWT was earlier
described in the literature ; however, studies of pain during the entire wound treatment process have
shown varying results, and some studies even indicate that NPWT as a treatment may, in fact, ease the
wound pain rather than enhance it [4,13].
The participants had to adapt to the current situation to manage the stress involved in the treatment
to maintain a balance and the conception of health. The first step towards adaptation for the patients
was receiving sufficient knowledge and information regarding the treatment. Edward, Moffat and
Franks point out the importance of adequate information for the experience and management of the
strain that wound treatment may have on the patient . They also emphasize the varying quality of
information provided. In their study, only one fifth of the patients had received some form of written
information. The participants in this study expressed that poor general status of health during treatment
was one explanation of difficulties to comprehend received information. Having the possibility of
written information in addition to verbal could facilitate the patients? understanding and allow them to
process the information in a longer time span.
When feeling confident in managing the treatment, the participants became inventive and creative
in dealing with different obstacles that arose in everyday life. Knowledge and confidence were key
factors for managing and coping in a positive way with stressful issues during treatment, which is in
concordance with other studies of NPWT [4,13] and in wound management, in general [11,12,19].
4.3. Methodological Considerations
Why is it important to know the patient?s conceptions of NPWT? There is an old saying: ?The cure
is worse than the disease?. This means that the treatment itself can be effective, but at the same time,
so incredibly stressful to the individual patient that it is just not worth it. It is only the patient who is
an expert of his/her own body and own conceptions, and therefore, research must be based on
a patient?s perspective. Thus, using phenomenography as a research method and purposive sampling is
appropriate, particularly since it is possible to identify a variation of conceptions, which is the main
objective of phenomenography as a research method [7,8]. To ensure clinical credibility, the whole
process of analysis was performed in close collaboration with co-workers and other wound experts,
and the process has been thoroughly described in the Methods section.
Regarding the transferability of the result, it should only be seen as an awareness-raising of the
knowledge of wound patients and not as a representative experience of all patients treated with NPWT. Healthcare 2014, 2 280 However, since the participants in this study were selected with a large variation concerning age, gender,
different wound types, different treatment times and different types of NPWT machines, the result
describes a wide range of conceptions, which may be transferred to patients treated with NPWT in
One limitation of qualitative research may be that it is the interviewer who is the main instrument in
the acquisition of knowledge. It is important that the researcher is aware of his/her role in order to
obtain scientific knowledge, also adhering to ethical considerations, during the research interview. By
recording and transcribing the interviews verbatim, the credibility of collected material may be
enhanced. To ensure a sufficient amount of material, two additional interviews were performed.
These interviews did not change the findings, so that the feeling of saturation of the material was
achieved . Another limitation of this study may be the rather short interviews, often due to the poor
health status among several of the participants. However, the objective with this study was not to
perform in-depth interviews, only to describe a variation of conceptions among patients treated
5. Conclusions and Relevance for Practice
The findings in this study show that patients were negatively affected by treatment with NPWT and,
at times, the stress meant that they had difficulty coping. The largest source of stress observed in this
study was the clinical setting, particularly the organization of the dressing changes and deficiencies in
healthcare personnel?s competence.
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