Massive Open Online Courses for continuing education for nursing professionals in Peru

Objective: to determine the global offer of Massive Open Online Courses (MOOCs) in health and nursing, and to know the characteristics of its content, for continuing education in nursing professionals in Peru. Method: exploratory study was carried out on the websites: Coursera, edX, FutureLearn, XuetangX and Udacity, Class Central and MOOC List. The courses were classified according to the five nursing areas recognized by the Peruvian College of Nurses (Colegio de Enfermeros del Perú, CEP). From each course, data was collected on institution and country of origin, hours per week and total duration in weeks, audio and subtitle language. Results: a total of 654 courses in this modality are offered in health were found, covering the five areas contemplated by the Peruvian College of Nurses. Fourteen courses were specifically developed for nursing with an average duration of five weeks (3.2 hours per week of activities). Eleven came from Anglo-Saxon institutions, with content in English. Only two courses were offered in Spanish and one in Turkish. Conclusion: Massive Open Online Courses would be a useful tool for the continuing education of the Peruvian nurse given the wide offer, including some specifically for nurses, in the different areas of nursing. The content of the course is mostly in English. Expanding the range of languages or subtitles would facilitate the participation of a larger audience.


Introduction
Health professionals require constant training and the acquisition of new knowledge and skills for their job performance that allows them to respond to the health needs of the population during their work activities (1)(2) .
Nursing is one of the professions that, historically and with the greatest boom in recent decades, has shown interest in developing programs that provide constant professional training (3) . Worldwide, despite the availability of in person courses, mostly provided by academic institutions for continuing education in nursing, professionals increasingly find it difficult to take in person courses to continue their training due to various factors, including economic, family and availability ones (1,4) . This scenario has generated an increase in the number of participants in part-time courses or courses available on the Internet (5)(6) , which also facilitate the dissemination of knowledge with greater accessibility and reducing costs, the latter being desirable characteristics for professionals in low and middle income countries (7) .
The continuous certification and reaching higher academic degrees by nursing professionals is associated with an improvement in the clinical outcomes of patients during their professional practice and in their professional performance (8)(9) . The dizzying emergence including the area of health (10) . The attainment of a MOOC course, against payment or not (depending on the course), can generate the student a certificate of completion of the course useful to verify knowledge or learning (10) .
In Peru, in 2002 Law No 27669 -"Law on the Work of the Nurse" was issued. This document indicates that continuing education, training, and permanent improvement are inherent to the work of the nursing professional in Peru, also pointing out that professionals who provide services in less developed areas should receive training according to the needs of their community (11) . In this way, the need for continuous training for the nursing health professional is recognized.
In addition, the aforementioned law states that, within Comprehensive Nursing Care, made up of five areas, the teaching area has to include the training of nurses and continuing education in nursing (11) .
Although online education, including MOOCs, is recognized as an alternative to continuing education for health professionals (10,(12)(13) , the offer and content of MOOCs in health have not been explored, nor specifically for the continuing education of nursing professionals, having only described isolated experiences on the development of nursing MOOCs in the world (14)(15) .
Therefore, the objective of this study was to determine the global offer of MOOCs in health and specifically for nursing professionals and to know the characteristics of its content, for continuing education in nursing professionals in Peru. It is hoped that the rise of MOOCs can be useful as a tool for continuing education in nursing professionals in Peru.  (16) , which were the terms included in the search tools available in the learning platforms. These platforms were used to search for MOOCs in health or nursing since their websites include the widest range of MOOCs and have the largest number of registered users (17) , in addition to having been used by previous studies on health MOOCs (10,(18)(19) . Additionally, a manual This work did not require approval by the ethics committee as it was a study of secondary data in the public domain.

Results
A total of 654 MOOCs in health were found with content related to the five areas covered by the CEP.
The area with the highest number of MOOCs in health was Public, Family and Community Health with 35.8% of courses followed by the Professional Care area (26.6%).
The professional development area was the one where the least offer of MOOCs courses was found, being only 12 (1.8%) ( Table 1). The other institutions offered one MOOC each (Table 2).  (Table 2).
Regarding the language, eleven of the courses were offered in English, two in Spanish and one in Turkish with their respective transcripts of the audiovisual material in the same languages. The nursing MOOCs found did not have available subtitles of their content in other languages ( Table 2).

Discussion
In this work, we sought to determine the global such as mental health (18) , training on current global health topics such as emerging infectious diseases (19) , and medical education (20) . Having found MOOCs in all areas of nursing, according to the CEP classification, with courses specifically developed for the nursing professional, would indicate that MOOCs would be a useful tool in the field of nursing.
One of the goals of continuing education for health professionals is to improve professional performance. In this regard, a higher educational level and experience has been described related to lower mortality and better clinical response of patients in the acute area (21) .
In addition, MOOCS as an alternative available to anyone with Internet access may be an option for groups suffering from professional isolation, such as professionals working in rural and remote areas (22) . The offer of online courses would allow nurses to continue their training in a cost-effective way, in a professional setting in which it is increasingly difficult to attend traditionally taught courses (development courses that require physical presence of the student and educational facilitator). In this regard, it has been described that increasingly, nursing professionals take online courses to continue their training and obtain training (23)(24)(25) . In Most of the MOOCs in health and nursing are provided in the English language, elaborated mostly by recognized academic institutions from Anglo-Saxon countries (10) . This result is in accordance with the general panorama on MOOCs, where 75% of courses on MOOC platforms are offered in that language (26) . making it necessary to promote courses that address topics of regional interest (28) . to undergraduate studies in Peru (29) . Given that the number of people, including professionals, who have an adequate level of English to be able to take academic courses is still low in Peru (30) , up to six times that evidenced in classroom courses (31) .
In this way, a lower hourly load could facilitate the participant to be able to comply with the entire program There are various methodologies to communicate knowledge in an area. The development of online courses must consider the peculiarities of each area of study or the target audience for which it is developed (34) .
In the case of nursing and health sciences in general, most MOOCs in health or specifically nursing-oriented are focused on the application of knowledge to this field of study or towards research or education in it, such as It can be seen in the courses found. Nursing is a profession that urgently involves problem solving, which means that the courses developed for this area must provide the student with the highest degree of knowledge and facilitate the development of skills that allow them to develop problems such as those they will face in the daily practice, hence the need for courses, in person or online, to evaluate the best strategies to provide this training to the nursing professional, and that it be in accordance with the required training standards (23,34) .
This study sought to know the current state of