RESEARCH ARTICLES

Educational intervention about wounds: impact on nursing technicians' knowledge

Oleci Pereira Frota^I; Jaqueline Goulart de Oliveira Constanci^II; Marisa Dias Rolan Loureiro^III; Adriano Menis Ferreira ^IV

^I Nurse. Master's from the Program of Health and Development in the Midwest Region, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil. E-mail: olecifrota@gmail.com
^II Nurse. Stomatherapy Specialist. Municipality of Três Lagoas. Três Lagoas, MS, Brazil. E-mail: jaque_gou@yahoo.com.br
^III Nurse. Ph.D. Professor of the Nursing Course at the Federal University of Mato Grosso do Sul. Campo Grande, MS, Brazil. E-mail: marisarolan@gmail.com
^IV Nurse. Master's and Doctoral Advisor, Program of Health and Development in the Midwest Region and Master's in Nursing, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil. E-mail: a.amr@ig.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.12097

ABSTRACT

This exploratory, comparative, descriptive study to evaluate the effect of an educational intervention on the nursing technicians' knowledge on aspects of wound care was conducted at 12 primary health care facilities in Mato Grosso do Sul State, Brazil, from August to November 2012. Using a test of knowledge, data were collected from 23 subjects before and after the educational activity. Overall, the activity improved the professionals' levels of knowledge (p=0.001). However, only the topics 'cleansing', 'necrotic tissue', 'assessing progress', and 'silver sulfadiazine ointment' were considered known by ≥90% of participants. There was no increase in the proportion of correct post-test answers on three topics: 'autolytic debridement' (p=0.179), 'granulation tissue' (p=0.067) and 'assessment of wound progress' (p=0.108). It was concluded that the educational intervention was not fully effective. Supporting strategies should be sought to provide the desired knowledge to the sample studied.

Keywords: Nursing education; evidence-based nursing/education; in-service training; dressings.

INTRODUCTION

Education is a continuous process having teaching and learning processes in the pursuit of knowledge building, using the free, critical and reflective thought. It contributes to justify a personal and professional commitment to enable and transform the lived reality. Health education, specifically, represents activities through educational programs, in order to guide professionals, following the institutional principles. It is designed to create opportunities for professionals expanding the quality of their abilities and skills, seeking to fulfill their responsibilities, and also ensure assistance with less probability of adverse events¹.

It is noteworthy that, the management of people in the health area is focused on professional training for developing human resources (HR) with cognitive and technology skills with a focus on reflective and participatory education, opposed to exclusively technical operating training aiming to increase the psychomotor skills. From this perspective, studying the learning process in the organizational environment can generate new discoveries and contribute to practice changes in the management and administration².

Nursing, since its emergence as a profession, has always been inserted in the role of primary caregiver of people with wounds. With technological advances in this area, new methods to evaluate, monitor and diagnose wounds and patients emerged and together new innovative products and therapies. This shows the need to seek qualifications, updates, psychomotor skills and cognitive-technology skills as well as technical and scientific knowledge to adequately meet the person with wounds^3,4.

However, today there is a paradox between the skills required to care for people suffering from wounds and what is being taught in technical courses and Undergraduate Nursing, considering that the knowledge offered – particularly for graduate courses – is not enough⁵. In addition, currently there seems to be consensus on what pedagogical discipline should be responsible for teaching the care of patients with wounds. As the lack of knowledge leads to inadequate practices, the current practice is influenced by local culture and ritualism opposed to the recommendations of evidence-based guidelines ⁴.

Considering the benefits that health education can provide to improve the quality of care, management and administration in nursing, the question is: What is the effect caused by the implementation of an educational intervention on patients with wounds, using as a strategy, a course in the level of knowledge of nursing professionals in the primary health care? To answer this question, it is proposed that this study aims to determine the effect of an educational intervention on knowledge of nursing professionals on the evaluation, management and topical treatment of wounds.

This study is justified because - in a research in the electronic databases of the Latin American and Caribbean Health Sciences (LILACS), Database in Nursing (BDENF), Medical Literature Analysis and Retrieval System on-Online (MEDLINE) and Scientific Electronic Library Online (SciELO) with the intersection of controlled descriptors (Descriptors in Health Sciences-DeCS) Training x Nursing Team x Wound Healing and Learning x Nursing Team x Wound Healing – there was not a research which reflect the effect of educational interventions on knowledge of primary care nursing team about wounds. There were only similar studies but in hospitals and exclusively addressing pressure ulcers^6-8.

LITERATURE REVIEW

In the health area, the work process had substantially notable health changes in recent decades, health policy and demands of the population, in addition to contextual changes resulting from scientific and technological progress on the world scenario. Forced to act in line with the new requirements – or even to anticipate them – the organizations, seeking competitive advantages making them different from their competitors, the HR has a strategic positioning. However, there will be demand tangible demonstration of the effectiveness of their actions. In this context, the main challenge currently imposed on HR priority is to make the management of human capital, equating it to any other essential resource for institutional development⁹.

The implementation of educational activities organized, systematic and focused on continuous training of health professionals and highlighting nursing, is the subject of debate in the current context of the Brazilian public policy health and, arguably, is a fundamental strategy to ensure and increase the quality of health care. Reflective critical analysis and consensus built around these discussions have resulted in the implementation of the National Policy of Permanent Health Education^10,11. This policy recommends that health professionals be trained and their skills are permanently extended according to regional health needs and the care and management model change processes from the perspective of completeness, multi and inter-professional practice and effectiveness of health care¹².

HR training and development can be understood as three coordinated subsystems: assessment of needs, planning and implementation and evaluation of training, where training provides systematic information on the training set and the others refer to the development of training². Therefore, before implementing any educational intervention, it is important the diagnosis of training needs involving the application of means, methods, and techniques aimed at identifying gaps in skills required for proper human performance at work¹³.

Given this reality, the organizations are investing in continued and permanent education: commissions and sectors are already present in various health institutions in Brazil. However, there it is necessary a more effective and action based on scientific principles. In most cases, educational activities are done blindly, that is, activities are offered without a proper prior careful study of the real needs of the target population and may result in time and financial resources expenditures. In addition, many training, courses, and capacitation are offered without an evaluation of their effectiveness and efficiency of impact at work¹⁴.

There is a debate on the application of advanced care in health, including the concern with the assessment, management and treatment of wounds. However, it is necessary to involve nursing professionals with specific knowledge and practices, in order to provide individualized, humanized and holistic care to understand the pathophysiological context in which the patient lies and appropriate therapy, however, worry about psychological factors, particular and social environmental of each individual¹⁵.

The relevance of an ability and continually seek of scientific knowledge to provide excellent care to patients with wounds is highlighted by several authors^4,6-8,15 since it is an area in which the practice is often based on myths, traditions and common senses. It has to be considered that the fast evolution of topical therapies and covers have changed assistance practices to patients with wounds and have created new professional recommendations⁴. These and other conditions are essential to assess the knowledge and practices of nursing professionals in different scenarios, identifying if there is a need for educational interventions and their implementation.

METHODOLOGY

It is a quantitative study with comparative descriptive and exploratory design, developed from August to November 2012 in eight health units of the Family Health strategies (ESF) and five community health agents strategies (EACS) in the state of Mato Grosso do Sul, Brazil. The study was approved by the Ethics Committee on Human Research under the Protocol 47780/2012.

Once the course was specific to the technical nursing staff, all professionals in sectors surveyed were invited to participate and obtained the informed consent form. Those who have been on sick leave or vacation during the period of data collection, which had experience in the area less than one year and those who did not participate in all educational activities proposed or not fully answered the pre and post-test were excluded. The population of the study was 40 professionals from the nursing technician staff during the study period. After application of the selection criteria, the sample consisted of 23 subjects.

To meet the objective of this research, a structured questionnaire was built with items related to sociodemographic data (independent variable) and a knowledge test (dependent variable). The knowledge test aimed to identify the level of knowledge of the participants on issues related to the assessment and treatment of wounds before and after the educational intervention. The said instrument was developed based on the current literature on the experiences of researchers and also considering the available therapeutic resources and practices carried out at such units to patients with wounds by the professionals.

It is noteworthy there was due care on the governance of issues that composed the assessment instrument of knowledge, with the concern not to list knowledge and practices inherent in the private exercise of nurses or other health professionals.

In order to verify the objectivity, relevance and clarity of the items, the data collection instrument was submitted to content validation by three judges with technical and scientific knowledge on the subject (two researchers and a clinical nurse of primary care). After suggested refinements, a pilot test was conducted with the questionnaire in 10 nursing technician in an ESF of another municipality to evaluate its usefulness, objectivity, and semantic understanding.

After notes and adjustments, the final version as the test component of knowledge consisted of 13 topics containing five to 12 statements each one. The subjects were asked to respond to the test, where each item has the option of True (V) when agreed with the statement and false (F) when they disagreed. Hits to V questions answered as true or F answered as false were considered. For a topic to be considered as known by the professional, 90% of their questions should be answered correctly^8,16.

The study was divided into three stages: application of the closed questionnaire (pre-test: to determine whether there was a need of education), in-service education and, finally, the reapplication of the closed questionnaire (post-test). As the pre-test results, the educational intervention was given and all participants were asked directly and indirectly (leaflets), to participate in a course with 40 hours entitled Update on nursing care to patients with wounds. There was a brief explanation of the course´s objectives, operation hours, curriculum, among others, as well as the importance of participation of professionals as volunteers.

It was organized an educational action as theoretical and practical workshops, developed in a weekly meeting, using different strategies such as dialogue-based lecture, group discussion about the current practice (considering the local situation), case studies, and supply to the subject of a printed guide (content and attachment issues). An implementation schedule was prepared and provided to participants. It is noteworthy that the discussed contents were based on reality and availability of inputs and local equipment. Each meeting lasted about 60 minutes and were conducted by a research nurse.

The first and the last meeting (first and third one) were allocated for the implementation of pre and post-test respectively. It should be noted that implementation of the post-test was performed 15 days after educational activities. The other meetings were for health actions (second phase), distributed as follows: the concept of wound; types of tissue repair; types of wound healing; factors that interfere with healing; brief assessment of wound carrier; chronic wounds: diabetic foot, pressure ulcers and venous; concepts of infection and colonization; acromion: Red, Yellow, Black (RYB); cleaning, debridement and measurement and coverage/treatment: Vaseline, neomycin, silver sulfadiazine, papain, collagenase, essential fatty acids (EFA), calcium alginate, hydrocolloid, hydrogel, activated carbon with silver.

Data were arranged in a database using Microsoft Office Excel version 2010. It was considered enough knowledge for each topic and global average when ≥ 90% of the professionals who answered correctly the pre and post-test. The statistical analysis included the pre and post-test hits rather than on isolated hits for each subject. To identify the existence of statistically significant difference between the two moments (pre and post-educational intervention), the Wilcoxon test was used with a significance level of 5% (p <0.05).

RESULTS AND DISCUSSION

There were 23 technician professionals of the nursing team participating, all female. The average age was 38.04 years old ± 9.68. As for vocational training, the average reached was 7.52 years ± 5.35 and for the time of experience, the average reached 5.01 ± 8.69 years.

The results for the pre and post-test on assessment, management and topical treatment of wounds are shown in Table 1.

TABLE 1: Professional hits indexes on questions about the care of people with wounds, in the educational intervention pre-test and post-test. Três Lagoas / MS, 2012

^(*) Wilcoxon Test

The percentage data of hits frequency of each the 13 topics were set into points from zero to 10 – that is, the percentage of hits on the topics is divided by 10 – and constructed in Figure 1. This shows the descriptive statistics values and dispersion relating to the points of participants according to the pre and post-training.

FIGURE 1: Box-plot of the points by the participants, according to the different times of the test application. Três Lagoas / MS, 2012. n = 23

The results show that the educational intervention provides a positive effect on global average hits of the questionnaire on care for patients with wounds. Most of the topics had a statistically significant increase in the proportion of global hits in the answers of the questionnaire in the post-test. Thus, it can be said that professionals tend to correctly answer the questions after the educational intervention. These findings suggest that the methods employed were conducive to learning, evidenced also by the interest and participation of professionals in the proposed activities.

However, it was not appropriate to consider only the value to ensure that such intervention is able to ensure that participants having enough theoretical knowledge to care for patients with wounds, nor practices. For the analysis of Table 1, it is seen that in just four topics (1, 2, 6 and 10) more than 90% of the professionals hit at least 90% of the questions after the intervention. Given the theoretical reference adopted^7,8, it was found that the knowledge gained after the intervention was not enough for a professional who recently completed a course on the subject. On the other hand, it must consider the subjectivity to assign a cut-off point to classify adequate knowledge or not on a subject of interest. It also has to consider that the contents may have been too complex.

The ability of educational programs, certification courses, participation in updates and searching the Internet to achieve knowledge about wounds was confirmed in a study that included 460 American nurses with different educational levels. In this study, nurses who have obtained certification for the care of wounds reached 89% accuracy in pressure ulcer on the knowledge test, against 76.5% of those who had no certification⁸.

Questions related to topics 4, 7 and 11, shown in Table 1, highlighted among those with the highest percentage of mistakes in the pre-test questionnaire, showing fragile prior knowledge about the care wound cavity, assessing response to instituted treatment and use of neomycin ointment. Also, it is observed that the same topics remain with the highest percentage of errors after the educational intervention, the participants showing greater difficulty in learning or accept/understand the importance of aspects related to the topics. These findings indicate that these topics should be better worked during educational activities. In addition, it is recommended that qualitative studies are conducted to better understand this phenomenon.

Generally, questions of the tests about new or unknown content are essential to evaluate the effect of an educational intervention on the acquisition of knowledge, as expected a lower level of hits in pre and greater hits in post-test². Although it is seen an increase in the level of knowledge in the post-test on questions about the topic 4, 7 and 11 (respectively wound cavity, response to instituted treatment and neomycin ointment), the last two were had a percentage of 70% correct answers and the first one was below this value. This can also mean a deficiency of educational intervention.

Topics on necrotic tissue and neomycin ointment were the ones that showed the best improvement compared to the level of knowledge after educational intervention: 40.2% and 39.2% of hits more than those found in the pre-test, indicating a significant improvement in the knowledge level. Topics 1, 7, 12 and 13 can also be highlighted increasing their hits in 31%, 35%, 30.4% and 30.4% respectively, that is there was also a significant increase understanding about methods for cleansing of wounds, response to instituted treatment, Petrolatum use and EFA in the treatment of wounds.

However, a rational explanation for these findings is unclear. It appears that certain topics are of greatest interest to professionals; representing the practice of the subjects or the way to present them to participants not being the most appropriate. Despite these speculations, studies with other designs are required to make a possible clarification of these points.

The evaluation of the evolution of the wound, topic 6, was highlighted for being the one that had the highest percentage of hits in the pre-test, showing a good background of the participants (87%) on the topic. It is noticed that in the post-test - although with 100% accuracy - this topic did not reach statistically significant p-value, this is due to the reduced difference between knowledge before and after the educational intervention: 13% only. Issues with high rates of successes, both pre and post-training, suggest four possible explanations: first, that the subjects already had information on the subject (most likely), positive aspect, because the strengthening of information known to help to determine the content and relate it to new information; second, there was an error in the assessment of need of educational intervention; third, that the participants were not the correct target audience; fourth, that the instructors did not know how to elaborate content as the need of the professionals².

The survey and evaluation of training needs are the first and one of the most important steps of planning an educational activity, involving the availability and preparation of professionals to recognize their limitations and capacity needs. This review is linked in part to the integration of the teams with the staff of continuing education services. Another way adopted for evaluation of training needs is the analysis of institutional quality indicators, such as rates of infection, phlebitis, and pressure ulcers².

The process of evaluation of training and development can be carried out in four levels of evaluation: reaction or satisfaction (participant´s opinion about the conditions for learning); learning (training effectiveness to acquisition or increase of knowledge); behavior (changes generated by training the behavior of participants); and results (change in work practice)¹². In this study, the assessment of learning was adopted given the difficulty of achieving the latter two, the patient care with wounds in primary care in the studied reality.

Given the need for identification and evaluation of new methods that foster the acquisition of knowledge and a possible change in the practice of the nursing technician staff on issues related to the nursing care of patients with wounds, it is important to investigate the impact of these education strategies in professionals´ attitudes.

This research has some limitations: the sample was small, it was not assessed whether the acquisition of knowledge increased changes in practice. The study needs to be replicated in a multicenter character, a representative sample including all members of the nursing team, despite the adaptations of the instrument to the population and investigated realities.

Despite these notes that limit the generalizability of the results, this study brings advances for nursing in different areas. In management, this is the first research that evaluated and demonstrated the positive impact of health education on knowledge about wounds of the primary care nursing technicians, strengthening lifelong learning policies; as important and equally scarce in health institutions for the care to individuals with wounds. In the survey, it subsidized knowledge and identified approaches for further research in the area, such as the assessment of the impact of the intervention in real practice of care situations. In education, it pointed out the topics of greatest difficulty understanding and the need to implement supporting strategies to enhance learning. In practice, as ideal knowledge is an essential part of good practice, it appears that participants have broadened the skills to holistic assistance.

CONCLUSION

It is concluded that educational intervention improves the level of knowledge of the study on assessment, management and topical treatment of wounds. However, it is necessary to look for supporting strategies, innovative or not, in order to provide a higher level of knowledge. Among the issues that require the further attention of the teaching-learning strategies, there are autolytic debridement, wound cavity and tissue with granulation, topics with a lower percentage of learning in this study. Qualitative research can be timely to understand the difficulties to learn, assimilate or accept the recommendations arising from these topics.

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