Distance continuing education on prevention of pressure ulcer


Ana Karine da Costa MonteiroI, Ana Karoline da Costa MonteiroII, Elaine Maria Leite Rangel AndradeIII, Maria Helena Barros Araújo LuzIV, Patrícia de Azevedo Lemos CavalcantiV

I Nurse. Nursing Department. Universidade Federal do Piauí. Teresina, Brazil. E-mail: karinemonteiro2006@hotmail.com
II RN. Nursing Department. Universidade Federal do Piauí. Teresina, Brazil. E-mail: karolmonteiro2006@hotmail.com
III RN. Ph.D. Adjunct Professor, Nursing Department. Universidade Federal do Piauí. Teresina, Brazil. E-mail: elairgel@gmail.com
IV RN. Ph.D. Associate Professor, Nursing Department. Universidade Federal do Piauí. Teresina, Brazil. E-mail: mhelenal@yahoo.com.br
V RN. M.Sc. Manager, Hospital de Terapia Intensiva de Teresina. Piauí, Brazil. E-mail: patriciaazevedo@yahoo.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.5733




Objective: to develop and evaluate a distance continuing professional development (CPD) program on prevention of pressure ulcers. Method: this is an applied study. Data were collected from August to October 2011. The program, hosted in a Moodle virtual learning environment, was developed and evaluated in the following stages: educational design, computational modeling, environment implementation, and ergonomic and pedagogical evaluation. Results: ergonomic and pedagogical assessments by specialists in IT (n=10) and pressure ulcers (n=11) showed satisfactory results; items needing adjustment were reviewed. Conclusion: distance education resources made it possible to develop a CPD program that can be accessed anywhere and at any time, and will contribute to nurses' training in preventing pressure ulcers.

Keywords: Distance education; pressure ulcer; nursing; educational technology.




Continuing education (CE) is learning at work, in which learning and teaching are incorporated into the organizations' daily reality and into work1. Professional education in the care context presupposes coping with physical dislocation difficulties, lack of space for classes within an in-class education concept, lack of motivation to assume new activities beyond the work hours and insufficient remuneration, entailing multiple employment bonds2. To cope with these difficulties, different continuing education strategies have been used in health organizations, including distance education.

The growth of CE programs through distance education is due to the popularization of internet access and the fact that distance education grants advantages to professionals. Among these, the study of class contents anytime and anywhere can be highlighted3, as well as collaborative learning through synchronous and asynchronous activities 4 and the possibility for the teacher to present the content to the students in multiple formats, text, sound and image.

On the other hand, in most cases, in-class teaching uses passive methods, generally lectures, to transmit information to the students, who are treated as a group in time, space and educational material5. Although frequently used, this type of teaching does not favor the nurses' critical thinking and decision making, which requires competences and skills to assess, systemize and decide on the most appropriate and evidence-based conducts6,7.

Pressure ulcer (PU), the theme of the CE program in this study, can extend the patient's hospitalization period, pain and discomfort8. In addition, treating these lesions is costly, making prevention more important. Nevertheless, the nurses will be unable to successfully treat PU if this clinical condition is managed without the systematic assessment of the patient risk, planning and implementation of appropriate prevention measures and assessment of the expected results9, and if the nurses' knowledge on the prevention measures recommended in the guidelines is insufficient, as the results of some studies have shown10-12. Therefore, CE programs have been developed to increase the nurses' knowledge on the ulcer and disseminate the prevention guidelines 13,14. In that context, distance education has resources at its disposal that make PU learning more concrete, interactive and favorable, without professionals having to leave the workplace or spending their own time and resources15,16.

Knowledge on PU prevention needs to be disseminated in accordance with evidence-based practice guidelines17. A Brazilian study undertaken at a public general hospital in Teresina, Piauí, showed that, on average, the nurses who participated in the research gave 72.3% (SD 10.21) of correct answers on the items of a PU knowledge test, when 90% or more of correct answers are expected. In addition, many measures not recommended in the PU prevention guidelines were detected, such as to the use of water or air cushions, massaging of bony prominences and use of water or air gloves 18. Based on these arguments, the objectives in this study were to construct and assess a CE program on PU prevention.



In distance education, multimedia and synchronous and asynchronous interaction tools mediate learning.

The first generation of distance education started in 1880 through instruction courses by mail19. The second emerged as from 1970 through the use of radio technologies, developed during the first world, and through television for transmitting educational programs. In the third generation, in the 1990's, two new technologies were available: the internet and the computer20. Today, the fourth generation uses computers linked to the internet, permitting synchronous interaction between students and tutors19.

In Brazil, the enactment of the Basic National Education Law No. 9.394/199621 stimulated the development and transmission of distance education programs at all levels and in all educational modalities.

In that context, nursing has explored distance education as a continuing education strategy on PU and other chronic wounds to facilitate the dissemination of knowledge on this theme among its professionals.

In Brazil, researchers have developed, applied and assessed a distance education program on wound treatment, using the virtual learning environment (VLE) TelEduc and comparing the pre and post-tests, showing a better result on the post-test (p<0.0001)22.

In another study in the interior of São Paulo State, after an educational intervention, it was verified that nurses gave more correct answers on questions about PU prevention, classification and assessment measures23.

Researchers have used the advantages of DE to build an online proposal on PU and expand the knowledge of nursing students and professionals about PU15.

In São Carlos, researchers have elaborated and assessed educational contents on PU for distance education. The educational intervention was well assessed in terms of scientific rigor and updated knowledge24.

In Ribeirão Preto, an educative module on topical chronic wound therapy disseminated guidelines for evidence-based practice and contributed to nursing students' education at a public uniersity7.

Abroad, an educational program on PU was applied at a hospital in New Zealand, observing improvements in the nurses' knowledge after the intervention25.

In New York, researchers found that computer-based instruction is an option for distance education on PU, as it grants the educators greater flexibility to plan and present the program and provides the nurses with an alternative knowledge gaining method13.

In view of the above, these study result appoint that distance education is a feasible strategy for continuing education of nursing professionals on PU.



Applied, descriptive and quantitative research developed between August and October 2011, after approval from the Research Ethics Committee of Universidade Federal do Piauí, under opinion 45/11 (CAAE 0137.0.045.000-11).

To construct and assess the distance continuing education program on PU prevention, five phases were used, adopted from the construction method of a VLE through the world wide web (web), previously used in another study 26,27.

In the construction, phase 1, entitled educational design, comprised the identification of the target public, definition of the objectives and the content. In phase 2, computer modeling, the programming language Hyper Text Markup Language (HTML) and the text and image media were defined. In phase 3, the environment was implemented in the VLE in Moodle.

In phases 4 and 5, concerning the ergonomic and pedagogical assessments, ten informatics experts and 11 PU specialists participated, affiliated with higher education institutions (HEI) in the Southeast and Northeast of Brazil, selected through the Lattes platform, who complied with the following inclusion criteria: the PU specialists should agree to participate in the research by signing the Informed Consent Form, hold at least an M.Sc. and have developed the theme in their research related to PU. The informatics experts should agree to participate in the research by signing the Informed Consent Form and hold at least an undergraduate degree in informatics.

To contact the evaluators, the following procedures were adopted: inviting the expert to participate as evaluator by e-mail or telephone. If the evaluator accepted, the Informed Consent Form was sent. After receiving the signed document, the expert was registered in the virtual learning environment (VLE) in Moodle and a password and login was forwarded by e-mail, as well as the assessment tools, which were completed and returned to the researchers by e-mail.

The informatics and PU experts performed the ergonomic assessment, while only the PU specialists undertook the pedagogical assessment, considering that they mastered theoretical knowledge on the theme. For the assessments, tools adapted from the literature28, 29 were used. The ergonomic assessment tool consisted of 23 items: 12 related to navigation, six to readability, four to media and one to printing. The pedagogical assessment tool consisted of 19 items: 17 related to content and two to the objectives. For each of the items, the evaluator was expected to select an answer on the following scale: (1) I completely disagree, (2) I disagree, (3) I agree, (4) I completely agree. For scores (1) and (2), a justification should be provided.

Phase 6, the usability assessment, was not carried out in this study but was focused on in another research, when the distance continuing education program on PU prevention was implemented among nurses from a hospital in Teresina.

The data from the assessments were coded to elaborate a data dictionary and later transcribed using double data entry, using Microsoft Excel worksheets. After correcting any errors, the data were exported and analyzed in SPSS (Statistical Package for Social Science) version 18.0. Descriptive statistics with frequencies, percentages, averages and standard deviations were calculated and the results were presented through tables.



The continuing education program on PU prevention

The target public of the program consisted of nurses from a public hospital in Teresina.

The objective was to develop knowledge on PU. The content was divided in four classes and, for each, specific objectives were established. In the introductory class, the anatomy and physiology of the skin and scarring were explored. In the first class, the etiology and risk factors for PU were discussed. In the second class, the PU classification was addressed, and the third class was focused on the guidelines for PU prevention.

The program was made available on the electronic address: http://treinamento.ufpi.br/ and was available to the PU and informatics experts through a login and password they had received by e-mail.

The interaction between the program tutors and the PU and Informatics experts was possible in the VLE on Moodle through the tool Messages, which permitted the exchange of e-mails.

The VLE used to host the program was Moodle, which permitted posting the class contents in text and image formats and the interaction between tutors and evaluators. This may have facilitated the learning, the flexibility of time and the communication. The VLE is a scenario that promotes collaborative work, social networks and interaction. In the scenario, the individuals meet, discuss and interact to learn. In addition, for nursing, the VLE can be an opportunity to ratify the teaching of clinical skills and clinical reasoning4.

The construction of the program required dedication, from the elaboration of the contents to the definition of the objectives and the implementation in Moodle. In addition, the researchers needed training to use the environment, as well as the cooperation of informatics experts for its construction.

Assessment of distance CE program on PU prevention

Twenty-one experts participated in the assessment, ten in informatics and 11 in PU. Most evaluators, 11 (52.4%), were experts in PU. The numbers of M.Sc. and Ph.D. graduates were equivalent, 10 (47.6%), and all of them were lecturers, 21 (100%).

The results of the PU and Informatics experts' ergonomic assessment are presented in Tables 1 and 2.

TABLE 1: Answers concerning navigation. Teresina, 2012.

i=Mean ii= Standard deviation

TABLE 2: Answers on readability, media and printing. Teresina, 2012.

i=Mean ii = Standard deviation

Concerning the navigation, three items the informatics experts assessed scored below the average there is a navigation map, 2.90 (s=0.74), the buttons are well defined and easy to identify 2.90 (s =0.99) and there is a feedback mechanism like e-mail, telephone contact, Twitter or MSN, 2.50 (s= 0.85). It was observed that, for this assessment, the PU experts answered with a score of 3.00 or higher. The question on the "functioning of the links" obtained the highest average, 3.91, among these experts (s=0.30).

Concerning the readability, all items obtained averages of 3.00 or higher from the PU and informatics specialists.

With regard to the media, the items related to uses multimedia resources, animation, graphs and figures in the interface and there is integration among them obtained the lowest averages 2.60 (s=0.84) and 2.67 (s=1.00), respectively, from the informatics experts. The remaining items received positive assessments from both experts.

What the printing is concerned, the informatics experts' scores was lower than the average – 2.70 (s=1.16).

Overall, the informatics and PU experts assessed the ergonomic evaluation items well.

Concerning the navigation, the ease and freedom to navigate, the functioning of the links and accessibility stood out. The user's ease to navigate in the VLE is fundamental to reduce dropout rates from the distance education course29. The links should be well defined and integrated to make navigation easier. If they do not exist or do not function properly, this can discourage the user30. Accessibility should be possible for any computer linked to the internet 31.

Also regarding the navigation, the items related to the existence of a navigation map and a feedback mechanism like e-mail, telephone contact, Twitter or MSN scored below the average among the informatics experts. Regarding the existence of a navigation map, a VLE does not contain a tool to visualize this map. Therefore, a tutorial with all information on how to navigate in the environment was available to solve possible difficulties. What the feedback mechanism is concerned, incoherence was found in the informatics experts' assessment of what was asked, considering that, in the justifications, they agreed with the presence of the item in the application, but questioned its easy use. In addition, the e-mail tool was available in each user's profile to interact.

A satisfactory result was found for the item readability in the nursing and informatics experts' assessment, with good acceptance of the colors, source and interface used. The colors should strengthen the educational proposal. Caution is due so as not to distract the user. In addition, no background colors should be used which reduce the readability of the text and the font chosen should facilitate the view and reading32.

The interface can be considered a means to grant the user access to the system. When creating an interface, it should attract and maintain the users in the application, as any difficulty found can make them stop using it. Therefore, it is important to demonstrate the entire content of the software, using icons and menus, its functions, besides improving the resources available in the application33.

The buttons and graphs should be easy to recognize in the graphical interface. Through these devices, one can advance through the pages, reproduce sound and move a text in the VLE30.

As regards the media, the informatics evaluators did not agree with the items on the use and integration of these resources. This fact can be explained by the high cost to produce educative material and the lack of funding for the research. Another study reported that these factors limit the development of distance courses for nursing34.

The item printing received a score below average and the incoherence in the answer or the lack of understanding of the item assessed was clear in the experts' justifications when they affirmed that this device existed in the VLE.

The results of the PU specialists' pedagogical assessment are displayed in Table 3.

TABLE 3: Answers about content and goals. Teresina, 2012.

i=Mean ii = Standard deviation

The PU specialists agreed on most of the items assessed in the content. Only one item, related to if the abbreviations are defined the first time they are cited in the text obtained the lowest average, 2.91 (s=1.22). Nevertheless, the items is the sequence in accordance with the proposed objectives?, are the authors competent to discuss the content? and is there a list of bibliographic references? obtained the highest average 4.00 (s =0.00).

Concerning the objectives, the two items assessed obtained averages of 3.7 or higher.

The items in the pedagogical assessment were considered appropriate, which demonstrates that the content was reliable and in accordance with the objectives proposed. The content of the educative material should be reliable, ethical and scientific35. The educative material should permit reflection, autonomy and knowledge construction, besides enhancing interactivity among the participants36.

The evaluators also agreed that the content is up to date. Knowledge is not static. Therefore, it is important to constantly update the content 29.

Another positive point was related to the length of the paragraphs. To facilitate the reading, the text should be divided into small blocks and short lines, as long lines can make the text tiresome32.

One item was appointed though that needs modification: the abbreviations are defined upon their first mention in the text. Although the evaluators did not provide any justification, the item will be reassessed.

The objectives were coherent with the target public. The objectives elaborated for the VLE should guarantee that the information provided promotes knowledge acquisition based on the understanding and content offered31.

The language was also in accordance with the target public. The language was expected to demonstrated clarity, objectivity and accessibility, besides being adapted to each course29.



The distance education resources permitted the construction of the continuing education program, which can be accessed anytime and anywhere, without negatively affecting the nurses' work and their application can enhance these professionals' knowledge on PU prevention.

The ergonomic and pedagogical assessments appointed satisfactory results, consolidating the continuing education program as a tool for the further qualification of nurses on PU.

What the limitations are concerned, in this study, the high cost of producing the educative material and the lack of funding to develop the research stand out. This problem intimidates creation initiatives in nursing.

And, finally, the implementation of the CE program is important for the qualification of nurses on PU prevention and the dissemination of distance education among clinical nurses in Teresina.



1.Ministério da Saúde (Br). Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação em Saúde. Política Nacional de Educação Permanente em Saúde. Brasília (DF): Ministério da Saúde; 2006.

2.Mendes IAC, Godoy S, Silva EC, Seixas CA, Nogueira MS, Trevizan MA. Educação permanente para profissionais de saúde: a mediação tecnológica e a emergência de valores e questões éticas. Enfermería Global. 2007; 10: 1-8.

3. Bigony L. Can you go the distance? Attending the virtual classroom. OrthopNurs.2010; 6:390-392.

4. Phillips B, Shaw RJ, Sullivan DT, Johnson C. Using Virtual Environments to Enhance Nursing Distance Education. Creative Nursing.2010; 16: 132-5.

5. Bastable SB. Nurse as educator: principles of teaching and learning. London: Jones and Barlett Publishers International; 1997.

6. Conselho Nacional de Educação. Resolução CNE/CES nº 3, de 7 de nov. 2001. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Enfermagem. Brasília (DF): Câmara de Educação Superior, 2001.

7.Rabeh SAN, Gonçalves MBB, Caliri MHL, Nogueira PC, Miyazaki MY. Construção e validação de um módulo educativo virtual para terapia tópica em feridas crônicas. Rev enferm UERJ. 2012;20:603-8.

8. Souza TS, Maciel OB, Méier MJ, Danski MTR, Lacerda MR. Estudos clínicos sobre úlcera por pressão. Rev Bras Enferm. 2010; 63:470-6.

9. Magnan MA, Maklebust J. The nursing process and pressure ulcer prevention: making the connection. Adv Skin Wound Care. 2009; 22:83-92.

10. Chianca TC, Rezende JF, Borges EL, Nogueira VL, Caliri MH. Pressure Ulcer Knowledge Among Nurses in a Brazilian University Hospital. Ostomy Wound Management. 2010;56: 58–64.

11.Iranmanesh S, Rafiei H,Foroogh A G. Critical care nurses' knowledge about pressure ulcer in southeast of Iran. Int Wound J. 2011; 8: 459–64.

12. Claudia G, Diane M, Daphney SG, Danièle D. Prevention and treatment of pressure in a university hospital centre:A correlational study examining nurses' knowledge and best practice.International Journal of Nursing Practice. 2010;16:183-7.

13.Cox JR,Wynen S, CoxEVJ, Roche S,Wynen EV. The effects of various instructional methods on retention of knowledge about pressure ulcer among critical care and medical-surgical nurses.The journal of continuing education in nursing. 2011; 42: 71-8.

14.Jones ML. E-learning in wound care: developing pressure ulcer preventioneducation. Br J Nurs. 2007; 16: 26-31.

15.Costa JB, Peres HHC, Rogenski NMB; Baptista CMC. Proposta educacional online sobre úlcera por pressão para alunos e profissionais de enfermagem. Acta Paul Enferm. 2009; 22: 607-611.

16. Godoy CBG. Guimarães EMP. Assis DSS. Avaliação da capacitação dos enfermeiros em unidades básicas de saúde por meio da Telenfermagem. Esc Anna Nery. 2014;18(1):148-55.

17. European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Ulcer Advisory Panel (NPUAP). Prevention and treatment of pressure ulcers: quick reference guide. Washington (DC): National Pressure Ulcer Advisory Panel; 2009.

18.Rabêlo CBM. Conhecimento de enfermeiros sobre a prevenção de úlcera por pessão [Dissertação de Mestrado]. Teresina: Universidade Federal do Piauí; 2011.

19.Moore MG, Kearsley G. Educação a distância: uma visão integrada. Tradução Roberto Galman. São Paulo: Thomson Learning; 2007.

20.Mcisaac MS, Gunawardena CN. Distance Education. New York: Simon & Schuster Macmillan, 2000.

21.Senado Federal(Br). Lei n. 9.394, de 20 de dezembro de 1996. Estabelece as diretrizes e bases da educação nacional. Diário Oficial da União. Brasília (DF) Gráfica do Senado:1996.

22.Ribeiro MAS, Lopes MHBM. Desenvolvimento, aplicação e avaliação de um curso à distância sobre tratamento de feridas. Rev Latino-am Enfermagem. 2006; 2006; 14:77-84.

23.Fernandes LM, Caliri MHL, Haas VJ. Efeito de Intervenções Educativas no conhecimento dos profissionais de enfermagem sobre prevenção de úlceras por pressão.Acta Paulista de Enfermagem. 2008; 21:305-11.

24.Casaburi PR, Westin UM, Zem-Mascarenhas SH. Elaboração e avaliação de conteúdo educacional sobre úlceras por pressão. J Health Inform. 2012; 4:120-4.

25.Tweed C, Tweed M. Intensive care nurse´s knowledge of pressure ulcers: development of an assessment toll and effect of an educational program. Am J CritCare. 2008; 17:338-346.

26.Andrade AF, Franciosi B, Beiler A, Wagner PR. Caracterização da modelagem de ambientes de aprendizagem a distância[Internet].In: Anais do Congresso Internacional de Educação a distância; 2001; Porto Alegre, Brasil. Porto Alegre (RS): Pontifícia Universidade Católica do Rio Grande do Sul. 2001. [cited on 2012, May 12]. Available from: http://www.inf.ufes.br/~cvnascimento/artigos/Webnet_ModelagemComputacional_port.pdf

27.Barbosa SFF, Marin HF. Simulação baseada na web: uma ferramenta para o ensino de enfermagem em terapia intensiva. Rev Latino-Am Enfermagem. 2009;17: 7-13.

28.Whitten P,Holtz B, Cornacchione J, Wirth C. An evaluation of telehealth websites for design, literacy, information and content. Journal of Telemedicine and Telecare.2011; 171: 31-35.

29.Freitas AA, Loyolla W, Prates,M. Linguagem e arquitetura de conteúdos em educação a distância mediado por computador. [Internet]. São Paulo; 2002. [cited on 2012, May 05]. Available from: http://www.abed.org.br

30. Mori S, Whitaker IY, Marin HF. Avaliação do website educacional em Primeiros Socorros. Revista da Escola de Enfermagem da USP. Rev Esc Enferm USP. 2013; 47:950-957.

31.Aguiar RV. Desenvolvimento, Implementação e Avaliação de um ambiente virtual de aprendizagem em um curso profissionalizante de enfermagem. [tese de doutorado] [Internet]. São Paulo: Universidade de São Paulo; 2006. [cited on 2012, Nov 16]. Available from: http://www.teses.usp.br/teses/disponiveis/83/83131/tde-03052006-183016/pt-br.php

32.Nascimento CA. Princípios de design na elaboração de material multimídia para a Web [Internet]. São Paulo; 2006. [cited on 2012, May 01]. Available from: http://www.nead.unisal.br/

33.Salles JAG, Costa CAC, Cardoso RCC. Necessidades para o desenvolvimento de uma interface adequadas para resultados de ensino-aprendizagem bem sucedidos [Internet]. In: Anais do 4° seminário Nacional de educação a distância; 2006. São Paulo: Brasil.São Paulo (SP): ABED; 2006. [cited on 2012, May 12]. Available from: http://www.abed.org.br/seminario2006/pdf/tc047.pdf

34. Grossi MG, Kobayashi RM. A construção de um ambiente virtual de aprendizagem para educação a distância: uma estratégia educativa em serviço. Rev Esc Enferm USP. 2013; 47(3):756-60.

35.Xelegati R, Évora YDM. Desenvolvimento de ambiente virtual de aprendizagem em ventos adversos, em enfermagem. Rev Latino-Am Enfermagem. 2011;19: 1181-7.

36.Lins TH,Veríssimo RCSS, Marin HF. Concepção dos enfermeiros sobre o conteúdo do website sala de recuperação pós-anestésica. RevBras Enferm. 2010; 63: 22-5.

36.Soares SSKP, Filho MPS, Reich STS. Estudo para produção de material didático para educação médica continuada, elaborados de acordo com referenciais da Ead [Internet]. São Paulo; 2011. [cited on 2012, May 23]. Available from: http://www.abed.org.br/congresso2011/cd/223.pdf