Development and usability evaluation of training equipment for syringe-based wound irrigation education

Abstract

Background

Wound irrigation is the process by which an irrigating solution is delivered to a wound site at constant pressure to remove bacteria, necrotic tissue, and foreign materials. Maintaining an appropriate pressure according to wound characteristics is essential for effective wound irrigation. The purpose of this study was to develop training equipment to help maintain appropriate wound irrigation pressure during syringe-based wound irrigation, and to evaluate its usability by experts for educational applications.

Methods

This study developed training equipment for effective syringe-based wound irrigation education and conducted a usability evaluation with an expert group. Training equipment was developed according to the five stages of the instructional design model. The developed equipment was evaluated by nine clinical nurses and nine nursing professors using the System Usability Scale (SUS) to assess system usability. Additional expert feedback regarding areas of improvement was also collected.

Results

The training equipment developed in this study consisted of an irrigation space, a pressure measurement component located beneath the irrigation space, and a monitor that allowed learners to check the average and maximum pressures applied during wound irrigation in real time. A mean SUS score of 85 from 18 experts was achieved for the training equipment aimed at maintaining an appropriate wound irrigation pressure. In contrast, the mean score given by the nursing professors responsible for education was 88. The experts indicated that, although the training equipment demonstrated high educational usefulness and strong applicability to evidence-based practice, improvements in the hardware components, enhanced user convenience, and further development of the educational content to better reflect clinical practice are desired.

Conclusions

This study developed training equipment designed to maintain appropriate wound irrigation pressure for syringe-based wound irrigation education, and confirmed its applicability in both clinical and educational settings through expert evaluation. By visualizing and sensorially concretizing the abstract concept of wound irrigation pressure for education purposes, this study increased awareness of the need for systematic education to support evidence-based practice.

Background

Wound infection is a major complication that seriously affects patient outcomes worldwide, leading to prolonged hospitalization, increased medical costs, and a decline in patients’ quality of life [1]. Wound irrigation is essential for preventing infection and achieving effective wound treatment [2]. Beyond its simple cleansing function, wound irrigation plays an important role in inhibiting biofilm formation and reducing the bacterial load. Additionally, it is a wound management strategy that helps prevent progression to chronic wounds [3]. For effective wound irrigation, it is important to select an appropriate solution and maintain adequate irrigation pressure [4]. If the wound irrigation pressure is too low, contaminants cannot be sufficiently removed. However, if the pressure is excessively high, it may damage healthy tissues or cause pain [4, 5].

The Agency for Healthcare Research and Quality recommend a wound irrigation pressure of 5–15 psi to prevent infection and tissue damage [4]. In clinical practice, various irrigation devices have been developed and applied to maintain appropriate pressure. However, their use is limited because of the financial burden on patients and the complexity of equipment management in hospitals. Consequently, syringe-and-needle-based irrigation methods are most commonly used in clinical settings because of their low cost and ease of use [6].

Syringe-based wound irrigation is highly dependent on the operator’s skill level and subjective experience, resulting in persistent variability in wound irrigation pressure. Previous studies [7] reported that even irrigation devices designed to maintain constant pressure have difficulty sustaining the recommended pressure range of 8–15 psi. Although syringe-based wound irrigation can achieve the recommended pressure, it exhibits substantial variability depending on the operator and timing of the procedure. These findings highlight the need for strategies that compensate for this limitation [2]. Such pressure variability can ultimately compromise patient outcomes due to inadequate removal of contaminants or healthy tissue damage.

Global aging populations and the elevating prevalence of diabetes have led to an associated increase in wounds, including pressure injuries, skin tears, and venous leg ulcers, which have major implications for nurse education [8]. The global wound management cost burden is rising, and to provide comprehensive wound care in inpatient and outpatient health services, it is crucial for nurses to have evidence-based knowledge of the prevention, assessment, and care of wounds [9]. Notably, experienced and newly graduated nurses alike have expressed concerns regarding the inadequate wound care skills graduates possess when entering the profession. Disconnections between transfer theory and clinical practice have been observed [10]. In nursing education, the development of clinical competence requires repeated practice of technical skills in a safe and structured learning environment [11, 12]. However, the opportunities for nursing students to practice syringe-based wound irrigation in controlled educational settings remain limited [13]. Insufficient hands-on experience with wound irrigation may hinder the development of the practical skills and confidence required for safe wound care practice after graduation [11, 13].

To bridge the gap between theory and practice, and enhance skill proficiency within a controlled environment, the use of simulators or advanced training devices has recently emerged as an essential pedagogical strategy in nursing education [14]. This shift in the learning environment aligns with the competency-based education (CBE) paradigm, which enables nursing students and clinical nurses to engage in repetitive training without the risk of patient harm, ultimately allowing them to achieve standardized clinical competencies [15]. To ensure that precise technical skills, such as wound irrigation, are performed safely in clinical settings, it is crucial to objectively measure learners’ actual performance capabilities [13]. To reliably assess the accuracy and proficiency of wound irrigation, it is necessary to move beyond mere knowledge assessment and establish a learning environment and educational equipment that provide realistic physical sensations and feedback [16]. While educational models and simulators have been developed for various nursing skills, such as intravenous therapy and airway management, and prior studies have demonstrated the educational efficacy of these training devices [13], education regarding syringe-based wound irrigation pressure currently relies solely on the practitioner’s subjective sensations, with some guidance from clinical practice guidelines.

Educational programs relating to syringe-based wound irrigation have generally been conducted in wound care-related fields, such as nursing, emergency medicine, and surgery, using mannequins or models. However, these approaches are limited in their ability to accurately simulate or quantitatively evaluate the pressure applied to patients. Although the International Wound Infection Institute [17] provides comprehensive evidence-based guidelines for wound infection management, including wound irrigation, detailed guidance specific to syringe-based wound irrigation is not included. Furthermore, previous studies have indicated that nurses’ wound care interventions are still largely based on experiential and non-scientific practices, underscoring the lack of structured educational systems in both academic and clinical settings, and emphasizing the need for systematic education to support evidence-based practice [18]. Although maintaining consistent pressure during wound irrigation requires a high level of skill, objective evaluation criteria and training equipment to teach and practice this skill are yet to be developed.

Accordingly, the present study aimed to develop training equipment that enables repetitive practice to maintain appropriate wound irrigation pressure for effective syringe-based wound irrigation and to examine the usability evaluation results obtained from a group of experts. Through this process, this study seeks to contribute to the systematization and standardization of wound care education, and ultimately to improve the quality of wound management and enhance patient safety in clinical practice.

Methods

Study design

This study was conducted by an expert group. The study aimed to develop training equipment for effective syringe-based wound irrigation education and evaluate its usability.

Study process

This study was conducted according to the five stages of the analysis, design, development, implementation, and evaluation (ADDIE) model. The ADDIE model is an instructional design framework that comprises five phases: analysis, design, development, implementation, and evaluation. The analysis phase involved a data collection process aimed at identifying available and required resources. During the design phase, educational objectives are established, and evaluation tools are devised based on the data collected in the preceding phase. The development phase generates the educational program content and conducts a pilot test to identify areas for improvement. The developed program is delivered to the target audience during the implementation phase. During the evaluation phase, all aspects of education before and after its application are assessed [19].

Analysis stage

A literature review was conducted during the analysis stage to obtain the foundational data required for developing the wound irrigation training equipment. The elements necessary for repetitive training of wound irrigation while maintaining appropriate pressure during syringe-based wound irrigation were identified. These elements included the type of irrigating solution, type of syringe and needle, wound irrigation pressure, height between the wound and syringe, and the irrigation angle. Based on this process, the foundational data for equipment development was established.

Design stage

In the design stage, the content and learning objectives were defined by analyzing the foundational data for equipment development. Based on these, the display features and functional components of the equipment were designed.

Development stage

In the development stage, the structure, display, and functions of the training equipment were defined and manufactured based on the results derived from the analysis and design stages. The training equipment consisted of an irrigation space that allowed actual syringe-based wound irrigation to be performed, and a load cell located beneath the irrigation space to measure pressure and transmit signals that enabled learners to monitor the pressure applied during wound irrigation. A load cell is a sensor or transducer that measures mechanical force (e.g., tension, compression, pressure, or torque) and converts it into an electrical signal. The monitor was configured to display a pressure graph, the average pressure, and the maximum pressure, allowing learners to check the wound irrigation pressure in real time (Fig. 1).

Fig. 1.

Overview of the training equipment structure for syringe-based wound irrigation education

Implementation stage

In the implementation stage, a pilot study was conducted to assess the operational performance and accuracy of the developed training equipment. The pilot study involved two nurses with more than ten years of clinical experience and one nursing student. In the ADDIE model, a preliminary study was conducted prior to the main study to establish the direction of the educational program and gain an in-depth understanding of any necessary supplements or modifications. This process is typically performed by using a small group of five or fewer individuals [20]. In this same context, the present study conducted a preliminary investigation involving an expert panel of two individuals, and the process of finalizing the training equipment based on their feedback. Based on the results of the pilot study, issues related to the implementation of the monitor display functions were identified and subsequently revised and refined.

Evaluation stage

An expert group conducted the evaluations. The criteria for expert selection were as follows: (1) nurses currently working in clinical settings who had completed wound care education or held related certifications and had experience with wound irrigation, including syringe-based wound irrigation; and (2) nursing professors in related fields. Regarding the number of experts required for the usability evaluation, Jakob Nielsen, co-founder of the Nielsen Norman Group, suggested that testing with approximately five users can identify approximately 85% of usability problems, whereas testing with nine or more users can identify nearly 100% of the usability issues [21]. Based on this rationale, 18 experts were recruited, including nine clinical nurses and nine nursing professors. After receiving an explanation of the training equipment, the experts performed wound irrigation using a 35-cc syringe, a 19-gauge needle, and 0.9% normal saline, as recommended in the clinical practice guidelines. Subsequently, a usability evaluation was conducted to assess the usefulness of the training equipment developed in this study (Fig. 2). The usability was evaluated using the System Usability Scale (SUS), developed by Brooke [22]. The SUS consists of ten items that measure system convenience, complexity, stability, and overall usability. Odd-numbered items are positively worded, whereas even-numbered items are negatively worded. Responses were rated on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). The SUS score is calculated as follows: X = (sum of scores for all odd-numbered items) − 5; Y = 25 − (sum of scores for all even-numbered items); the total SUS score is then calculated as (X + Y) × 2.5, yielding a score ranging from 0 to 100. A score of 68 or higher indicates acceptable system usability. In Brooke’s original study [22], Cronbach’s α was 0.95, and in the present study, it was 0.70. Additionally, an open-ended question was included to collect expert opinions regarding the applicability of the training equipment in clinical and educational settings. In this study, the reliability of the SUS scale achieved a Cronbach’s α of 0.70. According to established psychometric guidelines by Nunnally [23] and Hair et al. [24], a Cronbach’s α of 0.70 or higher is deemed acceptable, particularly in early-stage or exploratory research.

Fig. 2.

Usability evaluation of training equipment

Data collection

Eighteen experts participated in the study, including nine clinical nurses and nine nursing faculty members. Data was collected from clinical nurses at two university hospitals in Seoul. Nurses who were informed about the purpose of the study, recommended as appropriate experts, and agreed to participate were included. Nursing professors were recruited from universities in Seoul and Gyeonggi and were required to have clinical experience in wound care. The purpose of the study was to explain to all potential participants and those who provided informed consent were included.

Data analysis

The collected quantitative data were analyzed using the R statistical software (version 4.3.2; R Core Team, 2023). Descriptive statistics were used to summarize the sociodemographic characteristics and SUS scores. This study was conducted as a formative evaluation to develop a wound irrigation training device, assess its practical applicability, and identify any system defects and areas for improvement. Consequently, although the mean usability scores across the expert groups were calculated, statistical differences between the groups were not included. Furthermore, responses to the open-ended questions regarding applicability in clinical and educational settings were analyzed using content analysis to identify key themes, implications, and areas for improvement. The rigor of this study was ensured based on the truth value, applicability, consistency, and neutrality criteria proposed by Guba and Lincoln [25]. To enhance the truth value, qualitative data were analyzed strictly based on the participants’ raw data, and two researchers conducted independent coding before reaching a consensus through mutual discussion. To ensure applicability, an expert group with diverse clinical experience was purposively sampled, allowing the findings on the device’s usability to be applied to various clinical and educational settings. To establish consistency, two researchers continuously cross-checked and discussed the results during the data analysis process to derive categories and themes. Finally, to ensure neutrality, the researchers took precautions to prevent personal bias or preconceptions from intervening during the data interpretation process, striving to derive results based entirely on participants’ statements. Two researchers independently reviewed and coded the qualitative responses. Discrepancies were discussed until a consensus was reached to ensure the rigor of the analysis.

Results

General characteristics of the expert group

Eighteen participants, including nine clinical nurses and nine nursing professors, were included in this study. Sixteen participants were female (88.9%) and two were male (11.1%). The mean age of participants was 41.7 years. Clinical experience was distributed as follows: three participants (16.7%) had one to less than 5 years of clinical experience, eight participants (44.4%) had five to less than 10 years, and seven participants (38.9%) had 10 years or more. In terms of educational attainment, five participants (27.8%) held a bachelor’s degree, three (16.7%) held a master’s degree, and 10 (55.5%) held a doctoral degree.

Usability evaluation of the wound irrigation training equipment by the expert group

The mean SUS score for the syringe-based wound irrigation training equipment evaluated by the 18 experts was 85. This score meets Brooke’s criterion that a score of 68 or higher indicates an acceptable level of usability. Furthermore, a score of 80 or higher corresponds to the “excellent” category, which was also achieved. Notably, the mean SUS score given by the nursing professors responsible for education was 88 (Fig. 3). Additionally, within Brooke’s SUS, items 4 and 10 constitute the learnability subscale, whereas items 1, 2, 3, 5, 6, 7, 8, and 9 fall under the usability subscale. The results indicate an average score of 6.9 (unweighted) for learnability and 37.1 (unweighted) for usability.

Fig. 3.

Expert-based usability evaluation of the wound irrigation training equipment. SUS score = System Usability Scale score; C = clinical nurse; E = educator (nursing faculty); Tave = mean score of the entire expert group; Cave = mean score of the clinical nurses; Eave = mean score of the nursing faculty; red line = cutoff score (68 points)

Analysis of qualitative feedback from the expert group

Educational usefulness and applicability to evidence-based practice

Participants reported that the equipment developed in this study provided intuitive feedback to learners by visualizing abstract concepts related to wound irrigation pressure. They noted that directly experiencing appropriate wound irrigation pressure, rather than learning about it solely through written clinical practice guidelines, could enhance the practitioners’ confidence in applying this technique in clinical settings.

“Although understanding appropriate pressure during wound irrigation is not possible through written text alone, performing the procedure allowed me to perceive the appropriate pressure, which I think would be very helpful in clinical practice” (Expert 2).

“Because the pressure can be adjusted while being visually monitored rather than relying on subjective sensation, the equipment allows users to experience actual hand pressure, making it a very efficient tool for nursing students and newly graduated nurses” (Expert 17).

Improvement of hardware components and enhancement of user convenience

The participants suggested several improvements for the components of the irrigation equipment. Moreover, these improvements aim to support sustained and practical use. These included adjusting the weight and size of the training equipment, incorporating a component for the safe handling, and disposing used items, such as syringes and needles.

“If the equipment were slightly smaller in size, it would be more efficient, and safety issues during practice (e.g., syringe separation) should also be considered” (Expert 13).

“It would also be useful to include guidance for the height and angle of irrigation during the procedure” (Expert 14).

Expansion of education to reflect clinical realism

The participants expressed that the equipment developed in this study should be expanded beyond simple pressure-measuring training equipment. Additionally, it would be desirable to incorporate systems or scenario-based structures that better reflect the tactile properties of actual wound tissues and the complex conditions of clinical practice. Specifically, they emphasized the importance of simulating factors, such as wound depth and patient pain responses, to enhance educational realism.

“It would be good if the training equipment itself were designed like a human body model and upgraded to a high-fidelity simulation level” (Expert 18).

“It would be beneficial if the reactions that real patients experience were also taken into consideration” (Expert 13).

Discussion

This study aimed to develop training equipment for effective syringe-based wound irrigation education and to examine its applicability to wound care education in clinical and academic settings through expert-based usability evaluation. The discussion is organized based on these objectives.

First, this study developed equipment that enabled operators to receive real-time feedback on wound irrigation pressure during wound irrigation by applying five stages of the ADDIE model. To date, wound irrigation education has generally relied on mannequins or models, and such approaches have limitations in accurately simulating or quantitatively evaluating the pressure applied to patients. The wound irrigation equipment developed in this study allows healthcare professionals, after preparing for wound irrigation while considering various clinical scenarios, to determine the pressure applied to the wound surface based on the force exerted on the syringe plunger, that is, the flow rate of the irrigating solution being expelled. In this respect, the equipment can be regarded as a training tool that supports safe wound irrigation while maintaining the appropriate pressure in a manner applicable to real patients. In particular, the equipment developed in this study represents an innovative approach to addressing the persistent problems identified in previous studies [2, 7], namely that syringe-based wound irrigation relies heavily on the operator’s skill level and subjective experience, resulting in substantial variability in wound irrigation pressure.

Second, through a usability evaluation conducted by an expert group, this study confirmed the applicability of the developed training equipment to wound-care education in both clinical and academic settings. The syringe-based wound irrigation training equipment received high usability ratings from an expert group comprising clinical nurses and nursing professors. Specifically, the mean SUS score evaluated by the experts was 85, which far exceeds the usability threshold of 68 proposed by Brooke [22], but also corresponds to an “excellent” rating. When these quantitative evaluation results are comprehensively interpreted alongside the three themes derived from the experts’ qualitative feedback, they not only corroborate the excellence of the device, but also suggest directions for future improvement. Specifically, highly positive responses regarding ease of use and learnability in the SUS evaluation were consistent with the first theme derived from the qualitative analysis. However, despite the high usability scores, the experts proposed specific requirements for improvement aimed at future educational enhancement. Through the second theme, qualitative feedback, the necessity for practical hardware modifications was raised, such as optimizing the size and weight of the device and preventing syringe detachment. The third theme emphasizes the importance of ensuring clinical realism through the implementation of human body modeling or introduction of a patient response system. Moreover, the participants in this study represented a highly specialized group with extensive average clinical experience in relevant fields and more than half held doctoral degrees. The fact that this expert group rated the intuitiveness and convenience of the equipment highly suggests that when introduced into actual nursing education settings, it can be effectively utilized by learners without imposing significant technical barriers. One of the most notable findings of the analysis of the experts’ subjective feedback was that the equipment concretized the abstract concept of “wound irrigation pressure” in a visual and sensory manner. Conventional nursing education has largely conveyed appropriate wound irrigation pressure only through textbook-based descriptions, which limits the learners’ ability to translate this knowledge into practice. This enables nursing students and newly graduated nurses to move beyond rote memorization and immediately adjust their actions based on real-time feedback regarding the physical impact of their behavior.

Limitations

Although this study is significant for developing training equipment and evaluating its usability for enhancing the safety and effectiveness of wound irrigation nursing, several limitations should be acknowledged. First, as indicated by the expert group’s feedback, improvements in the physical aspects of the hardware, such as the size and weight of the equipment, are necessary to ensure sustainable use. Second, further studies are required to examine the educational effects of the equipment on the users’ knowledge, skills, and performance in clinical practice. Third, the evaluation was conducted only with expert participants, including clinical nurses and faculty members. Therefore, future studies involving nursing students or clinical trainees are needed to further examine the applicability and effectiveness of training equipment in real educational settings. In addition, the study was based on a small purposively selected sample, which may limit the generalizability of the findings. The participants were recruited from specific geographic regions, which may have restricted the broader applicability of the results. Furthermore, this study focused on usability evaluation without assessing educational outcomes. Finally, additional psychometric validation of the training equipment was not conducted, which should be addressed in future studies.

Conclusion

This study developed training equipment for syringe-based wound irrigation education and evaluated its usability by an expert group. The findings demonstrated that the equipment had a high level of usability, as assessed by clinical nurses and nursing professors. However, this study did not evaluate educational effectiveness. Therefore, future experimental studies are required to examine their impact on learning outcomes and clinical performance. Further research should explore the development of pressure-responsive models that accurately reflect diverse wound types encountered in clinical practice.

Abbreviations

ADDIE

Analysis, Design, Development, Implement, Evaluation

SUS

System Usability Scale

Authors' contributions

Jeongwon Han designed the study and analyzed the data. Jeongwon Han, Boeun Yang and Kyeongeun Lee drafted the manuscript. All authors have critically reviewed and approved the final version of this manuscript.

Funding

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean Government (MSIT) (RS-2025-00563647).

Data availability

The datasets used and analyzed in the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki. This study was approved by the Institutional Review Board (IRB) of Kyung Hee University, where the principal investigator was affiliated with KHSIRB-25-439(EA). Informed consent was obtained from all the participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.