Application of the educational method of realistic simulation in the treatment of pressure injuries*

Objective: to evaluate the use of realistic simulation as a strategy to promote teaching about pressure injuries. Method: This is a quasi-experimental study. A modified and translated version of the Pieper Pressure Ulcer knowledge test was applied. Kappa statistical analysis was used to assess the professionals’ knowledge in the realistic simulation using the SPSS software. A p-value <0.05 was considered significant. Results: Seventy-seven nursing professionals participated in the realistic simulation, the majority (72.7%) being nursing technicians. Regarding the knowledge of primary and secondary coverage techniques, the Kappa index went from 0.56 (p=0.002) in the pre-test to 0.87 (p=0.001) in the post-test. As for the sterile dressing technique, there was a variation from 0.55 (p=0.002) in the pre-test to 0.91 (p=0.001) in the post-test. Regarding the cleaning of pressure injuries, there was a variation from 0.81 (CI: 0.62-0.84) in the pre-test to 0.91 (0.85-0.97) in the post-test. The knowledge about the use of a sterile spatula to distribute the dressing in the wound increased from an agreement index from regular to good. Conclusion: The introduction of the realistic simulation in the clinical practice has created quality assessment indicators for the prevention and treatment of pressure injuries.

In view of the above, the following is asked: The inclusion criteria were the following: being a professional working in one of the hospitalization clinics (medical, surgical, neurological, and health insurance). Nursing professionals who worked in the emergency room, intensive care unit, and hemodialysis were excluded from the study. In addition, professionals who were on vacation or on leave were excluded from the study.
The recruitment and selection of research participants took place through the monthly service schedule, made available by the technician responsible for Nursing. The professionals were divided into teams, two during the day and two at night, so as not to compromise the work routine and patient care.
A random probabilistic sample was used, and the sample size was calculated using the Epidat software,  To implement data collection, four phases were followed: Phase I: pre-intervention period (a): prior to the simulation, the researcher presented the implementation of the new active methodology in the health institution, not only for the theme related to the PIs, but also for all the themes associated with the patient's clinic.
The principles and objectives of the realistic clinical simulation were explained so that the professionals were comfortable when the activity started.
To evaluate the knowledge of the professionals about wounds, a semi-structured questionnaire was applied, pre-test, from the Pieper/Pressure Ulcer Knowledge Test (PUKT) (8,(23)(24) . The adapted and validated version for Brazil was used (25) . This phase of applying the pre-test lasted two months.
The original instrument contained 47 items that measured knowledge of prevention, risk, stage, and description of the wound. The test included true and false questions. Correct answers received 1 point and incorrect answers received no points. International studies verified the effectiveness of PUKT in educational programs for Nursing and showed to be effective (8,24) .
Although the PUKT questionnaire evaluates the specific knowledge of the nurse, for this study, the variables were adapted to a simple and easy language so that the content involved the basic theoretical knowledge, important for the care of the PIs both for students and the entire nursing team. The adapted questionnaire aimed to develop critical and reflective aspects with the entire team involved with the prevention and care of PIs in the daily practice, regardless of specific knowledge in each category; therefore, we emphasize that it did not involve educational actions for Nursing technicians to learn private actions of nurses, such as the prescription of dressings. In the intervention of this study, the purpose of four dressings specifically used in the institution stood out, such as hydrogel, hydrogel with alginate, calcium alginate and collagenase, which often generated doubts among the entire team, regarding the appropriate cleaning techniques of the wound bed, and specific care of the dressing after its closure. In addition, four images of PIs containing the following tissues were presented in the questionnaire: "epithelium", "granulation", "slough", and "necrotic tissue". The participants wrote in full what types of tissues were presented in the images.
In order to assess the knowledge of the teaching methodology, there was the following question in the pre-test: "Do you know the teaching methodology of realistic simulation?" It was categorized descriptively as "yes" or "no".
Phase II: pre-intervention period (b): clinical cases were applied to the professionals and the problematization of the PIs related to prevention, care, and treatment was discussed. The second phase lasted five hours with each team of participants for the day and happened during a period of three months.
It was held in a private room, provided by the study site. The participants were asked not to share the experience of the clinical cases with other groups that had not yet participated in this phase of the study.
Each team was composed of five professionals, chosen at random, and there was a total of three meetings, that is, three days of discussion, so Rev. Latino-Am. Enfermagem 2020;28:e3357.
cases. The first professional started the initial simulation session of 20 minutes. After the first session, a 7-minute interrogation session was conducted by two members of this research, both are registered nurses with a clinic experience of more than 5 years, including PI care. The simulation sessions were alternated so that each of the five participants in the group, chosen at random, could be an actor in the simulation. Overall, the simulation scenario lasted 80 minutes, so that there was time to exchange experiences and discuss the cases presented.
The following materials were used for the scenario: kidney dishes, sterile dressing kit, gauze, gloves, 0.9% saline solution, bandage, adhesive tape, dressings, and artificial blood.

2) What would you do differently on another occasion?
At this moment, a "diagnosis" of the action performed was promoted together with the participants, that is, everything that was done was analyzed and discussed. The researcher assumed the position of facilitator of the group discussion, by working on the feelings experienced by the participants who performed the simulations, identifying the successes and opportunities for improvement, as well as promoting diagnostic/therapeutic reasoning, critical thinking, and judgment.
Phase V: After completing the realistic simulation experiment, the same questionnaire from Phase I was applied. In addition, in the post-test, there was one more question regarding the self-assessment of the professional performance in relation to dressing before using the realistic simulation as a learning method. It was categorized descriptively as "bad", "regular", "good", and "excellent".
The collected data were categorized and
With regard to the participants' prior knowledge in relation to the realistic simulation teaching methodology, 68 (88.31%) answered that they did not know this teaching strategy and 9 (11.69%) that they already knew it. Table 2      Rev. Latino-Am. Enfermagem 2020;28:e3357.

Discussion
This study proposed a new teaching methodology that was reproducible and effective not only for the study institution, but also for other health care establishments as a model for teaching and training.
In view of the results obtained, it was verified that the level of knowledge of the nursing professionals and students, associated with the Kappa concordance index, was mostly very good, after performing the realistic simulation with values greater than 90. Such agreement value represents the acquisition of an adequate level of knowledge for the institution (4,8,24) .
Regarding the other statement in the questionnaire, The realistic simulation method was the subject of a study that demonstrated the importance of this method in nursing teaching and learning through a narrative literature review (21) . The mentioned study verified debriefing (18)(19) . The authors verified that the use of the A meta-analysis study carried out in Iran analyzed several European and Australian surveys that used PUKT to assess Nursing knowledge in relation to PIs (22) . It was verified that the total percentage of knowledge in relation to the prevention of PIs was 53.1% (95% CI: 47.5-58.8), which would be acceptable but not desirable (22) .  (8) . The authors observed that, of the Nursing professionals eligible for the study, obtained values below 60% of the correct answers (8) .
The study concluded that the Nursing knowledge was insufficient and that there would be a risk in the quality of the care plan for the prevention of PIs. As in Brazil, the high incidence of PIs made the government support effective actions for its prevention and treatment (8,26) .
Assessing the knowledge and attitudes of the professionals in their practice contributes to determining educational priorities and to the development of specific interventions within health institutions (24,27) .
A cross-sectional study carried out in Belgium assessed the knowledge of nurses and Nursing technicians about the care with PIs through the PUKT test (11) . The mean number of correct answers regarding issues of care and prevention of PIs was 50.7% (11) .
The theoretical knowledge of the Nursing team was considered inadequate (11) .
In addition, participants who were present in training on PIs had a higher percentage of correct answers when compared to those who did not participate in the training (61.0% versus 50.2%, p=0.004) (11) .
These results corroborate with the data of the present study, since higher values of agreement of the Kappa index were observed in the post-test of the professionals after participating in the realistic simulation. Through an active teaching dynamics, even pathophysiological concepts can be established, as verified in this study through the identification of different types of tissues (Table 3). These concepts are essential for determining an effective preventive measure and for preventing recurrent treatments of PIs.
One of the limitations of this research was that, although the study covered a period of nine months, the post-test questionnaire was applied immediately after the realistic simulation, which may have influenced the improvement in the knowledge of the professionals.
However, the period between Phases II and IV lasted three months, so that the professionals could study and become familiar with the clinical cases and with the problematization of the themes. Future exploratory studies could be carried out with the entire multidisciplinary team to compare the knowledge of PIs among the different professional categories.

Conclusion
The educational strategy of realistic simulation used in this study proved to be effective for improving the knowledge of PIs and changing the behavior of the professionals in the Nursing practice, especially as it is a marker of quality of care in which nurses play a fundamental role. The results of this study came from a modified version of PUKT and indicated significant gaps in knowledge about the prevention and treatment of PIs.