The contribution of distance learning to the knowledge of nursing lecturers regarding assessment of chronic wounds1

OBJECTIVE: to identify the contribution made by a refresher course on the assessment of chronic wounds, offered through the Moodle virtual learning environment (VLE), to the knowledge relating to this issue of nursing lecturers and nurses linked to higher education. METHOD: a prospective, quasi-experimental study, with data collection before and after the educational intervention. The study was undertaken in three stages using the Moodle VLE. The sample was made up of 28 participants who answered the pre-test on the knowledge, devised in accordance with international guidelines on chronic wounds. Afterwards, the refresher course was offered (intervention) and was accessed in accordance with individuals' schedules, during the established time period. At the end of the course, 26 participants answered the post-test. Those who did not participate in the post-tests were excluded from the study, as it is pairwise analysis of the sample. RESULT: the participants obtained, on average, 55.5% of correct answers in the pre-test on their knowledge, and 73.4% in the post-test, this difference being statistically significant. There was a negative correlation between the time of experience in lecturing and the performance in the test on their knowledge. CONCLUSION: the participation in the online refresher course contributed to improving the lecturers' performance in the test on their knowledge, in relation to the recommendations for assessing chronic wounds, based in scientific evidence.


Introduction
The chronic wounds (CW), in particular pressure ulcers (PU), venous ulcers (VU) and neuropathic ulcers (NU) stand out as chronic health conditions, with great epidemiological relevance. These occurrences generate a negative impact on peoples' quality of life, and can result in prolonged episodes of inpatient treatment, an increase in morbidity and mortality, and in high social and economic costs -which constitute them as a serious public health problem (1)(2)(3)(4) .
The nursing care for people with CW, based on recommendations with the best scientific evidence, requires the systematic assessment of the wound and its characteristics. This stage is the basis for decisionmaking and structuring the therapeutic plan, and makes it possible to monitor and document the results of the interventions, as well as the healing process (2)(3)(4)(5) .
The anatomical location of the wound, the extent of the area with tissue compromise, the size of the wound, the exudative pattern, the characteristics of the tissues present in the wound bed, wound edges and adjacent skin, the bacterial load, odor and local pain constitute the aspects to be considered in assessing the wound.
Studies have revealed gaps in nurses' knowledge regarding this issue, which needs standardization and a foundation in scientifically-based guidelines (5)(6)(7) .
Moreover, studies involving student nurses have demonstrated that the knowledge acquired during the undergraduate course was insufficient for the future nurses to be prepared for assessing wounds and prescribing nursing interventions as part of the care actions for the person with a chronic wound (8)(9)(10) .
Lecturers on undergraduate courses in nursing have responsibilities in training the future nurses, which presupposes convergence between the best practices and the legal directives. This requires the explaining of the shortcomings in the teaching, and the adoption of strategies for overcoming these through constant updating and through the improvement and development of scientific knowledge (10) .
The flexibility of distance learning (DL) through virtual learning environments (VLE) is one alternative for the updating and training of professionals, which makes good use of time, and can be adjusted to the individual's routine; and has been demonstrated to be effective in improving knowledge regarding the prevention and treatment of chronic wounds (11) .
In Brazil, as in other countries of the world, the Moodle VLE has been widely used for DL. This VLE encompasses various asynchronous and synchronous resources, including chat rooms, discussion forums, blogs, glossaries, Wikipedia, an assignment submission area, files with support materials and questionnaires, among others (12) .
In the perception of nursing lecturers, undergraduate students and nurses, the Moodle VLE allows the exchanging of experiences and active discussion regarding the use of nursing practices in clinical situations, both in their formal aspects and in the aspects related to the feelings of the people involved in the care process; it is also useful as a tool for continuing education (13) . The inclusion criteria for participating in the study were to be a nurse and to work in lecturing in higher education in theoretical and/or practical courses. The exclusion criteria were to not have access to the Internet and not to undertake the post-test, as it was a pairwise analysis of the sample.
The educational intervention, the independent variable of this study, was offered as a Distance Learning refresher course, titled "Assessment of chronic wounds in nursing care", which was produced and validated (15) in accordance with the WOCN (Wound, Ostomy and Continence Nurses Society), for caring for people with pressure ulcers, venous ulcers, and neuropathic ulcers (2)(3)(4) , and was adapted for the present study's population. In order to ascertain if there was a significant difference in the number of correct answers among the lecturers/nurses who participated in events related to the issue, information was exchanged regarding the issue among peers both in-and outside the HEI, and they sought to update their knowledge using the Internet, and the non-paired two-tailed Student t-test was administered to those who stated that they did not.

Results
The mean age among the study participants was  There was a statistically significant improvement in the participants' performance after the intervention, both for the group of participants who stated that they undertook activities associated with "chronic wounds", in the practice of teaching (p=0.00001) and used some strategy for seeking information on the issue -Internet the mean percentage of correct answers was lower in the pre-test (51.1%), although in the post-test, the mean obtained was identical to that of the first group.
The group which stated that it did not adopt strategies for updating knowledge, in comparison with the group which stated that it did so, obtained a greater increase in the level of knowledge from the pre-to the post-test, that is, the internal gain was greater. The comparison between the differences was statistically significant (p=0.048) only for the strategy of "seeking information among peers from the same HEI".  (16)(17)(18) .

Discussion
In their current work, in relation to the knowledge regarding the classification of the PU in "stage I -nonblanching hyperemia", the participants presented poor performance both before and after the educational intervention. A similar result was observed in an experimental study held in order to identify the knowledge of nurses and student nurses regarding the classification of PU, in which stage I of the PU was erroneously classified as "blanching erythema" by the majority of the participants (19) .
Not knowing the correct definition and characteristics of stage I of the PU results in late intervention against the worsening of the PU, although this stage can indicate lower severity without underlying tissue damage, and can be reversed (19) . The lecturer needs to direct the practice of teaching, emphasizing the commitment which the nurse has in relation to patient safety and that, for this, the nurse needs to be prepared to provide up-to-date knowledge.
Also observed was poor performance in the test on knowledge in relation to the etiology of chronic wounds.
The literature emphasizes that restricting the care provided to the person with a chronic wound to topical therapy and failing to take into account the etiological factors makes the therapeutic plan inefficacious and impedes the complete healing of the wound (2)(3)(4) .
The refresher course entitled "Assessment of chronic wounds in the nursing care" had a positive impact on the participants' performance, with a significant increase in the correct answers following the educational intervention. This finding was similar to that of another work (20) , critical colonization, and infection (2)(3)(4) .
This work found a negative correlation between the time of experience in lecturing and the performance in the test of knowledge. Similar results have been found in other works (6,21) . In recent decades, the practices and knowledge (6,10).
Nevertheless, the experience in lecturing should promote the improvement of the practicing of teaching, given that it provides opportunities both for the process of learning knowledge and for developing teaching skills (10) .
This study made it possible to infer that seeking information on "chronic wounds", through other strategies, was associated with participants' better performance in the test of their knowledge, before the educational intervention. Brazilian and international works are relevant to the findings of the present study, as the search for updating is essential for maintaining knowledge, whether through updating through the scientific knowledge available in media for the diffusion of knowledge, such as the reading of scientific articles, the use of the Internet and/or library, participation in scientific events and others, or through specialized professional qualification (6,22) .
Based on the presupposition that updating is fundamental and that the lecturer on undergraduate courses in Nursing has responsibilities in the training of future professionals, it is essential to consider the gaps in the professors' training as a problem which generates reflections and gives rise to initiatives with efforts to close them (17) .
The attitude of the nursing lecturer needs to be aligned with public health policies, which require critical, reflexive and active professionals who are committed to the quality of the care provided. To this end, the practice of higher education requires a constant search for the development of critical and scientific knowledge, and encompassing reflection on this knowledge's contribution in the construction of society (10) .
The literature has indicated the intensification of the workload of nursing lecturers in higher education, which exceeds the workday and extends into the domestic environment, with requirements for complying with productivity goals, which has resulted in work overload and dissatisfaction, and has been implicated in illness (23) .
These conditions can compromise the lecturers' participation in activities of updating knowledge which require time.
In this perspective, distance learning is configured as a strategy for updating knowledge which makes good use of time, due to the flexibility which it allows people, as they choose when and where to access it.
The dynamic architecture of the VLE makes it possible to rapidly access new information, which contributes to nurses' knowledge not becoming out of date. Besides this, the virtual environment makes it possible to compile massive quantities of information, and provides access to a variety of scientific documents (11) .
Nevertheless, it is important to consider that continuing education is necessary, although it may be insufficient for causing changes in the practice. The literature indicates that in addition to acquiring scientific knowledge, other factors, such as a context which is favorable to consolidating evidence-based practice (EBP), and the professional's perception regarding the importance of adopting scientific evidence in order to qualify the care, can also influence the decision to abolish the use of practices which are not evidence-based (17,24) .

Conclusion
Knowledge grounded in the best scientific evidence