Question Details

(solution) Healthcare 2014, 2, 272-281; doi:10.3390/healthcare2030272 OPEN

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


ISSN 2227-9032


Article The Patient?s Conceptions of Wound Treatment with Negative


Pressure Wound Therapy


Ann-Mari Fagerdahl


Department of Surgery, Department of Clinical Science and Education, Södersjukhuset, Karolinska


Institutet, SE-171 77 Stockholm, Sweden; E-Mail:; Tel.: +46-70089-1063;


Fax: +46-8616-2460


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


personnel?s competence.


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 [1]. 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 [2]. 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 [3].


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 [4].


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 [5]. 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 [6]. 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.


2. Methods


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 [7].


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


Wound type


Pressure ulcer


Traumatic wound


Open abdomen




NPWT pump type






Treatment time (days)


Median Number


























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 [9].


2.3. Data Analysis


Data analysis was conducted according to the phenomenographic method [8]. 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).


3. Results


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.


Description Category


Personal environment


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 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 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.


3.2. Adaptation


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 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?.


4. Discussion


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.


4.1. Stress


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 [16] 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 [17] 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 [4]; 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].


4.2. Adaptation


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 [18]. 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


other settings.


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 [9]. 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


with NPWT.


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.


These fi...


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