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Revista Latino-Americana de Enfermagem

On-line version ISSN 1518-8345

Rev. Latino-Am. Enfermagem vol.21 no.spe Ribeirão Preto Jan./Feb. 2013 



Individualized teaching programming for a virtual learning environment: development of content concerning nursing records


Programación de enseñanza individualizada para ambiente virtual de aprendizaje: elaboración del contenido registro de enfermería



Patrícia de Carvalho NagliateI; Elyrose Sousa Brito RochaII; Simone de GodoyIII; Alessandra MazzoIII; Maria Auxiliadora TrevizanIV; Isabel Amélia Costa MendesIV

IDoctoral Student, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Brazil
IIPhD, Adjunct Professor, Universidade Estadual do Piauí, Brazil
IIIPhD, Professor, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Brazil
IVPhD, Full Professor, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Brazil

Corresponding Author




OBJECTIVE: Describe the planning of contents on nursing records for use in a virtual learning environment, based on Individualized Teaching Programming, a didactic resource that uses basic principles of behavioral analysis.
METHOD: Final objectives were specified, after defining the intermediary components to achieve each final objective, as well as the preliminary requirements for each intermediary component. At the end of this process, teaching activities were planned and organized in steps the students need to develop.
RESULTS: By breaking up the contents into behaviors, seven action categories emerged: impartiality, organization, honesty, objectiveness, coherence, readability and discernment.
CONCLUSION: the use of Individualized Teaching Programming as a didactic resource to plan contents on nursing records is feasible to identify the units and modules for the development of a course in a virtual learning environment for nursing professionals.

Descriptors: Education, Nursing; Nursing; Nursing Education Research; Nursing Records; Educational Technology.


OBJETIVO: Describir la planificación de contenido sobre registro de enfermería, para utilización en ambiente virtual de aprendizaje, con base en la Programación de Enseñanza Individualizada, un recurso didáctico que utiliza principios básicos del análisis del comportamiento.
MÉTODO: fueron especificados objetivos finales, definidos los componentes intermediarios para alcanzar cada objetivo terminal, así como requisitos antecedentes para cada componente intermediario. Al final de ese proceso, fueron planeadas y organizadas las actividades de enseñanza en pasos que serán desarrollados por los aprendices.
RESULTADOS: Al desmembrar el contenido en comportamientos, siete categorías de acciones emergieron: imparcialidad, organización, honestidad, objetividad, coherencia, legibilidad y discernimiento.
CONCLUSIÓN: la utilización de la Programación de Enseñanza Individualizada como recurso didáctico para la planificación de contenido sobre registro de enfermería se mostró viable para el desarrollo del curso en ambiente virtual de aprendizaje para profesionales de enfermería.

Descriptores: Educación en Enfermería; Enfermería; Investigación en Educación de Enfermería; Registros de Enfermería; Tecnología Educacional.




Nursing records, which are used as one of the main means of communication among healthcare professionals, are flawed in that they are subject to written errors. These errors can lead to adverse events that directly influence patient safety(1-2).

The medical staff observes and understands patient needs through both verbal and nonverbal communication. As there are many professionals involved in any particular patient's care, clear and effective communication is critical to ensure the quality and continuity of care(3-4).

Clinical environments are often dynamic and complex and, as such, present many challenges for effective communication between health professionals. Under such conditions, adverse events can occur(5).  Poor communication is the most common cause of these events in health care environments and can result in problems ranging from delays in treatment to surgical and medication errors(6-7).

The notes recorded in patient records are a form of ongoing communication between members of a healthcare team. They help health professionals to plan efficient, high-quality medical interventions to restore a patient's health(8-9).

The information contained in the nursing notes reflects the care and treatment provided to patients throughout their period of hospitalization. They should explain all relevant events clearly, since these records form part of the legal responsibilities of the profession(7,10-11). As such, the records can be used for a range of purposes e.g. surveys, audits, lawsuits, strategic planning etc.(11-12).

Despite the legal importance of nursing records, in many cases we found that written communication has been overlooked by health professionals. Their failure to record information in an accurate and timely fashion, as well as the difficulty in accessing vital information contained in the medical records, significantly increase the risk of harming the patient, which could lead to disastrous consequences for their care(5).  Moreover, various initiatives indicate that it is possible to prevent adverse events such as surgical site infections by implementing protocols and ensuring comprehensive record keeping(13).

The relationship between the presence and quality of information provided in the records of hospitalized patients and the occurrence of adverse events is weak, suggesting that the components of the records are less valued when related to such events. In contrast, the quality of information concerning the patient was found to be deficient and had a high correlation with adverse events(2).

Moreover, in a recent study the quality of nursing records at a university hospital was audited and, of the 424 patient records analyzed, (26.7%) were classified as poor, (64.6%) as regular and only (8.7%) as good. This clearly demonstrates the need for investment in improvement in this area(10).

The literature provides us with many studies that highlight the errors often made by nurses in recording their activities(2,14-15).  Reflecting on this and the urgent need to implement measures to rectify the situation, we can see a clear need to adopt educational strategies to help nurses to develop and improve their record-keeping skills. We believe that implementing such teaching activities could have a positive impact on the current situation, especially as ICT-based training can encourage the interplay of practical knowledge and up-to-date scientific theory and thus encourage professionals to adopt new practices.

This concept of education (e-learning) has been identified by researchers as being in tune with the changing context of education today. Although this entails the reorganization of the training process, e-learning has been shown to be revolutionary in providing broad, comprehensive and permanent access to education(16).

In any case, we should always keep in mind that innovative projects of continuing professional development in nursing should be harmonized with criteria that favor the understanding of individuals in their professional context in the improvement process, enabling reflective and creative ways of thinking and doing, aiming the personal, social, and professional development of the citizen-worker(16).

In choosing a methodology to plan and develop the content of such training, we took into account the fact that nurses are required to constantly update their knowledge and skills in a range of professional practices, as well as the requirement that training be adjusted to the dynamic conditions of the profession. We were also concerned with offering training which was targeted but at the same time provided the necessary depth to be appropriate for continuing professional development training for nurses to access through online distance learning in virtual learning environments.

Taking all of these factors into consideration, we decided to use the Personalized System of Instruction (PSI) to plan and develop the content of training on nursing records.

In PSI the student is placed at the center of the learning process, in that they progress in a series of small steps that adapt according to an individual's performance. PSI differs from traditional teaching in five key aspects, offering: individualized pace, division of disciplinary content into small steps, classes and demonstrations for motivational purposes only, an emphasis on written material that can be accessed by the student at their convenience and finally, the importance of a monitor / mentor to provide immediate feedback(17-18).

According to the literature, PSI and distance learning are closely related in several aspects: both are instructional, use the written word (virtual or printed) and require careful preparation of teaching materials and content(19), since the methodology allows participants to access all course content whenever necessary or convenient (18,20).

In this context, we believe that the best strategy for continuing professional development on record-keeping is to use distance learning tools, particularly those available in virtual learning environments, in conjunction with PSI. This should make the training convenient, accessible and compatible with the time-constraints and realities of the nursing profession.

Thus, in this study we aim to describe how we planned the course content for e-training on nursing records based on PSI.



This is a descriptive study of the planning of PSI-based course content for training on nursing records to be provided online in a virtual learning environment. The course was developed between January 2012 and July 2012.

The PSI process consists of the following fifteen steps: 1) choose the theme or topic; 2) describe the problem to be solved; 3) specify the overall behavioral goals; 4) propose the behavioral goals; 5) justify the relevance of the goals in relation to the participants; 6) analyze the goals in terms of the intermediate components/objectives necessary to achieve them; 7) organize the intermediate outcome objectives which result from this analysis into a teaching sequence; 8) plan learning activities to enable participants to achieve each intermediate outcome objective in the sequence; 9) organize these activities into units or steps to be performed by the participant; 10) plan the procedure for evaluating the effectiveness of the teaching program; 11) organize the material be used by learners in different units within the program; 12) write instructions for each work unit; 13) plan procedures to assess the participant's performance; 14) draft a presentation of the teaching program including goals, resources, procedures and evaluation system; 15) communicate and examine the teaching program in terms of behavior(21).

We began this study by establishing an overall goal with reference to the question: what is best practice for completing nursing records? Then, we identified specific behavioral goals and analyzed the intermediate steps needed to achieve each of these goals. From this, we defined the prerequisites for each intermediate step and finally planned and organized the sequence of educational activities to be performed by participants.

Our starting point was to decide what results we wanted to see and how we expected participants to behave when faced with similar situations in the real world. We went on to determine what must be taught to the learner so that these results can be achieved. Finally, we broke the intermediate components (behavior outcome objectives) down into simpler sub-behaviors.

An intermediate component is so-called as it is a smaller, simpler behavioral objective than that expressed by the overall goal.  They are necessary for the learner to be able to accomplish the final goal of the training.

We identified and described all of the intermediate components, which were relevant to the behavioral goals. Based on these intermediate components, we proposed teaching activities in which the participant will be able to practice, master and display each of these behavioral objectives.

We planned training exercises for each intermediate component and then organized these activities into units or steps to be followed by learners. This was done taking into account the appropriate tools for each proposed activity available in a virtual learning environment.

In this study, we followed nine of the fifteen steps recommended in the literature. The six remaining steps were not addressed because they are related to the development, implementation and evaluation of PSI content.



One of the starting points for planning a teaching activity is to identify the issue or question to be addressed by the training. The fundamental question for this education program was thus: what is best practice for completing nursing records?

With this in mind, we present a description of the both the general and specific behavior classes that enabled us to identify seven goals. These were based on the dominant functions needed for best practice in nursing records: organization, fairness, honesty, consistency, objectivity, legitimacy and knowledge (Figure 1).

Teaching activities were planned based on each specific component. Below, we present the behavior that participants must display whilst completing the units, along with the prerequisite skills, which facilitate the mastery of each objective (Figure 2).

After describing the skills to be mastered by the participants, we organized activities into units or steps to be followed. We chose to give instructions on how to complete nursing records, followed by practical exercises. To enable the participants to master the skills or display the desired behavior classes in each unit, we included texts, descriptions of best practice, examples and videos.

We developed three modules and shown below is the work plan related to each, with descriptions of units, steps, objectives and suggested activities. The content of the introduction and communication units is shown in Figure 3, whilst the units on the textual aspects of record-keeping are shown in Figures 4 and 5.



With the goal of ensuring best practice in completing nursing records in mind, we identified specific behavior classes, which should be encouraged during training in order that students are able to meet the prerequisites and master each behavioral outcome objective. Thus, the unit descriptions and intermediate steps were established depending on the prerequisites needed to achieve a desirable outcome.

Breaking these requirements down into intermediate steps helped us to identify what behaviors the learner needed to develop in order to reach the final goal of best practice. It was necessary to check the student's initial level of performance and understanding, since it is only by observing this starting point that we can decide to what level of complexity the outcome objectives need to be broken down into. When the level of complexity of the intermediate steps is consistent with the student's initial level, there is no need to further break down the behavior into smaller components. In doing so, a training program should help to diminish the errors that participants make, as making mistakes generally has an adverse effect of a student's learning. The most effective way to keep the student motivated and allow them to effectively learn the target behavior is by eliminating or minimizing such mistakes(22).

Experts highlight the fact that when using PSI, the course content is carefully divided into small units and that student can only progress from one unit to the next when they have demonstrated mastery of the previous unit. This reduces the likelihood of a student experiencing difficulties in learning the new content due to the fact that they didn't understand some previous related content(20).

Based on this method, each student will undergo their training step by step at their own pace and will be closely monitored by the tutor, who gives individual feedback. If the student does not meet the learning criterion of a particular unit, he may revise the content and try again. This is a stark contrast to traditional methods, in which participants are forced to move along to the next unit at the pace of his colleagues or the program schedule.

The description of what the learner should be able to do at the end of the learning experience takes the form of a statement about the way in which they should go on to behave in real-world situations(21).

Assessment of each unit can take various forms within PSI, e.g. multiple choice questions, gap-fills, short written responses, practical demonstrations of a particular skill, oral tests etc.(20)

The training program breaks the topic down into units to be offered in small steps and in doing so provides a clear and objective overview of what should be learnt throughout the course. Furthermore, we believe that making the content available in a virtual learning environment allows for greater interaction between the tutor and the student in that positive feedback is required throughout the course.

During the planning and development of this course, our decision-making was always informed by the aim to offer an efficient and personalized course. These characteristics allow the professional to undergo training at their own pace and whenever it is convenient to their everyday lives. Moreover, the tasks are organized into steps, meaning that the learner can only progress to the next step when they have mastered the previous unit. Throughout this process, they receive mentoring and constant feedback.

An important consideration regarding the use of PSI for ongoing professional development for nurses is that the student completes each module relatively quickly during this type of training. In this it differs from other methods of training that require the student to dedicate all of their time to completing the course content. PSI methodology also allows participants enrolled in the same course to work on different units, depending on their rate of progress. Unlike traditional training methods, a self-study program recognizes and responds to individual participants and does not penalize participants who need more time to learn(19).

Breaking down best practice for nursing records into units was very time consuming. However, we believe that this detailed scrutiny of "nursing records", or indeed any other topic, is of fundamental importance if we wish to plan comprehensive, detailed training. This procedure demands that the programmer think critically about the content of each unit and ensures that no salient points are missed out. Good planning also requires that we establish clear outcomes and goals, i.e. that we know how to clearly specify the behaviors that we wish to observe in our participants at the end of the process, as well as provide the most appropriate conditions for these behaviors to be acquired and maintained. Effective training of this type is particularly crucial as health providers are increasing concerned with providing ongoing professional development to their staff(23).



We found using a personalized education program to plan and develop course content for training on nursing records a viable option. It helped us in identifying the units and modules we needed to develop for nursing professionals within a virtual learning environment. Using PIS allowed us to develop organized, objective, clear, detailed and rich topic content on the issue addressed.

However, one possible drawback of this method is that it is very time-consuming in terms of planning and requires a lot of preparation and dedication on the part of the programmer.

We hope that when this content is used for training purposes it will facilitate the learning process, since it was conceived in a series of steps in order to respect the pace and time constraints of each online participant.



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Corresponding Author:
Isabel Amélia Costa Mendes
Universidade de São Paulo. Escola de Enfermagem de Ribeirão Preto
Av. dos Bandeirantes, 3900
Bairro Monte Alegre
CEP: 14040-902, Ribeirão Preto, SP, Brasil

Received: July 30th 2012
Accepted: Nov. 6th 2012

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