USABILITY OF A VIRTUAL LEARNING ENVIRONMENT ON DIABETES-RELATED FOOT ULCERS FOR NURSESABSTRACT
Objective: To evaluate the usability of the Virtual Learning Environment on the prevention and treatment of foot ulcers associated with diabetes mellitus complications according to Primary Health Care nurses.
Method: This analytical cross-sectional study was conducted with 131 primary healthcare nurses in the city of Teresina, Piauí, Brazil. Data collection was carried out using a form for sociodemographic, academic, and occupational characterization and application of the System Usability Scale. Inferential analysis was performed using the Chi-square and Fisher's exact tests.
Results: A total of 61.8% of nurses strongly agreed that they would like to use this system frequently, 48.8% strongly agreed that they found the system easy to use, and 46.6% strongly agreed that they felt very confident using the system. The average usability score was 81 points. Most rated usability as the best imaginable. Age, sex, monthly income, years since graduation, and academic degree did not show a statistically significant association with usability.
Conclusion: The usability of the Virtual Learning Environment Pediabetico.net was rated as excellent, reinforcing that this educational technology met the usability requirements and can be a useful tool for training primary healthcare nurses to improve care for people with diabetes mellitus. Moreover, the participants’ sociodemographic and academic variables did not have a statistically significant association with the usability of the Virtual Learning Environment.
DESCRIPTORS:
Diabetes Mellitus; Foot ulcer; Educational technology; Internet-based intervention; Primary Health Care
RESUMO
Objetivo: avaliar a usabilidade do Ambiente Virtual de Aprendizagem sobre prevenção e tratamento da úlcera do pé associada às complicações do diabetes mellitus segundo enfermeiros da Atenção Primária à Saúde.
Método: estudo transversal analítico realizado com 131 enfermeiros da Atenção Primária À Saúde, da cidade de Teresina, Piauí, Brasil. A coleta de dados foi realizada por meio de formulário para caracterização sociodemográfica, acadêmica e ocupacional e aplicação da System Usability Scale. A análise inferencial ocorreu por meio dos testes Qui quadrado e Exato de Fisher.
Resultados: 61,8% dos enfermeiros concordaram fortemente que gostariam de usar esse sistema frequentemente, 48,8% concordaram fortemente que acharam o sistema fácil para usar e 46,6% concordaram fortemente que se sentiram muito confiantes usando o sistema. A média de usabilidade foi 81 pontos. A maior parte avaliou a usabilidade como melhor imaginável. A idade, o sexo, a renda mensal, o tempo de formado e a titulação não apresentaram associação estatisticamente significativa com a usabilidade.
Conclusão: a usabilidade do Ambiente Virtual de Aprendizagem Pediabetico.net foi avaliada como excelente, reforçando que essa tecnologia educacional cumpriu as exigências de usabilidade, podendo ser uma ferramenta útil para capacitação de enfermeiros da Atenção Primária à Saúde para melhorar a assistências às pessoas com diabetes mellitus. Além disso, as variáveis sociodemográficas e acadêmicas dos participantes não tiveram associação estatisticamente significativa com a usabilidade do Ambiente Virtual de Aprendizagem.
DESCRITORES:
Diabetes Mellitus; Úlcera do pé; Tecnologia educacional; Intervenção baseada em internet; Atenção primária à saúde
RESUMEN
Objetivo: Evaluar la usabilidad del Entorno Virtual de Aprendizaje sobre la prevención y tratamiento de las úlceras del pie asociadas a complicaciones de la diabetes mellitus según enfermeros de Atención Primaria de Salud.
Método: Se trata de un estudio transversal analítico realizado con 131 enfermeros de atención primaria de salud de la ciudad de Teresina, Piauí, Brasil. La recolección de datos se realizó mediante un formulario de caracterización sociodemográfica, académica y ocupacional y aplicación de la System Usability Scale. El análisis inferencial se realizó mediante las pruebas de Chi-cuadrado y exacta de Fisher.
Resultados: El 61,8% de los enfermeros estuvo totalmente de acuerdo en que les gustaría utilizar este sistema con frecuencia, el 48,8% estuvo totalmente de acuerdo en que les resulta fácil de utilizar y el 46,6% estuvo totalmente de acuerdo en que se sienten muy seguros al utilizar el sistema. La puntuación media de usabilidad fue de 81 puntos. La mayoría calificó la usabilidad como la mejor imaginable. La edad, el sexo, los ingresos mensuales, los años de graduación y el título académico no mostraron una asociación estadísticamente significativa con la usabilidad.
Conclusión: La usabilidad del Entorno Virtual de Aprendizaje Pediabetico.net fue calificada como excelente, lo que refuerza que esta tecnología educativa cumple con los requisitos de usabilidad y puede ser una herramienta útil para la capacitación de enfermeros de atención primaria de salud para mejorar la atención a las personas con diabetes mellitus. Además, las variables sociodemográficas y académicas de los participantes no tuvieron asociación estadísticamente significativa con la usabilidad del Entorno Virtual de Aprendizaje.
DESCRIPTORES:
Diabetes Mellitus; Úlcera del pie; Tecnología educativa; Intervención basada en Internet; Atención primaria de salud
INTRODUCTION
Foot ulcer associated with diabetes mellitus complications is a syndrome characterized by the presence of infection, ulceration, and/or destruction of deep tissues associated with neurological abnormalities and peripheral vascular disease. This preventable complication accounts for a high number of hospitalizations, lower limb amputations, and physical disabilities, contributing to a reduction in the quality of life of people with diabetes mellitus1.
Worldwide, amputations resulting from foot ulcers associated with diabetes mellitus complications are a significant number of non-traumatic lower limb amputations. In Brazil, lower limb ulcers are highly prevalent in the diabetic population, being the main cause for the development of foot ulcers. In 2020, it was estimated that 9.3% of adults between the ages of 20 and 79 were living with diabetes mellitus. The prevalence of foot ulcers due to complications of diabetes mellitus in Brazil is high and, if not treated properly, can lead to microvascular damage and the development of diabetic neuropathy2.
Foot ulcer is a serious and prevalent complication, with a lifetime incidence of 19% to 34% in patients with diabetes mellitus, contributing significantly to lower limb amputations and raising healthcare costs worldwide3,4.
Given this scenario, the continuous professional development of nurses is crucial, as they play a strategic role in the prevention, risk assessment, and management of foot care for people with diabetes mellitus4. A study indicates that nurses’ inadequate knowledge about the management of foot ulcers resulting from diabetes mellitus complications is a real barrier, making the implementation of effective educational strategies essential5. Training and qualification in advanced wound care prevention and treatment are fundamental to clinical success and improved patient health outcomes3,6.
Virtual Learning Environments (VLEs), such as the platform Moodle or programs of asynchronous e-learning emerge as a promising tool for continuing education and training of nurses on a global scale4,7. Distance learning offers flexibility, allowing healthcare professionals to update their knowledge and practices in rapidly evolving technical and scientific areas, such as risk assessment and treatment of foot ulcers resulting from diabetes mellitus complications8. Research shows that online educational interventions have been effective in increasing wound care specialists' knowledge of ulcer prevention, underscoring the potential of digital learning modules, which incorporate videos, discussion forums, self-assessment questionnaires, and material based on international guidelines3,7.
Thus, the usability and feasibility of VLEs have been widely confirmed, with nurses reporting positive attitudes towards the use of tele-education for the care of foot ulcers resulting from diabetes mellitus complications9. This approach, through nurses extensive training, can lead to a significant improvement in knowledge about diabetes mellitus, as well as in relation to foot self-care and early interventions for the prevention of foot ulcers, directly contributing to the reduction of serious complications and, consequently, to the reduction of amputation rates, as suggested by systematic reviews on nurse-led digital health interventions6,9.
Therefore, the VLE is a tool that can facilitate Primary Health Care (PHC) nurses training and continuing education regarding the prevention and treatment of foot ulcers associated with diabetes mellitus complications, as it is available in the online format and allows collaborative and flexible learning. Thus, studies evaluating the usability of VLEs are important to contribute to the expansion and improvement of the use of this technology in continuing education in the nursing field.
In view of the foregoing, this study aims at evaluating the usability of the VLE on the prevention and treatment of foot ulcers associated with diabetes mellitus complications, according to nurses in PHC.
METHOD
This is an analytical cross-sectional study conducted in PHCs in the urban area of Teresina, Piauí, Brazil, which has 75 PHC Units (UBS), encompassing 241 Family Health Strategy teams10. PHC was chosen because it is the entry point for care for people with diabetes mellitus. In addition, it is the service that should routinely perform foot ulcer screening.
The study population consisted of 241 PHC nurses from the urban area. The inclusion criterion was having a minimum of six months of experience in the Family Health Strategy. Nurses who were absent from work during the data collection period were excluded. Nurses who did not respond to all data collection instruments were listed under the discontinuation criteria. After applying the eligibility and discontinuation criteria, 131 nurses participated in the study.
All eligible nurses were invited to participate, directly at the UBSs, via email or messaging app WhatsApp, with only one sender and one recipient. The contact information for the professionals was requested from the Municipal Health Foundation of Teresina. Thus, the participants were informed about the objective of the research and the ethical aspects, and then the Free Informed Consent Form was presented and signed.
The nurses responded to the consent form in the Free and Informed Consent Form, which was previously presented in the email or WhatsApp and a link provided to Google Forms with the following response options: “I have read the Free Informed Consent Form and agree to participate in the research” and “I do not agree to participate in the research”.
After acceptance, participants were informed by e-mail or WhatsApp about the steps in the data collection process and the date of the in-person phase, and were registered on the VLE Pediabetico.net, with the login and cited password made available through the same means. The VLE Pediabetico.net was built and validated, being organized into five modules: 1) Epidemiological aspects of foot ulcers associated with diabetes mellitus complications, anatomy and biomechanics of the feet; 2) Pathophysiology of foot ulcers associated with complications of diabetes mellitus; 3) Clinical examination of the feet in people with diabetes and classification of ulceration risk; 4) Health education for foot self-care in people with diabetes mellitus and appropriate types of footwear; and 5) Treatment of foot ulcers associated with diabetes mellitus complications11.
Data collection was carried out in two stages. The first one was conducted in person at the Municipal Health Foundation, where the VLE Pediabetico.net was presented and the form on sociodemographic, academic, and occupational characteristics was applied, via Google Forms, to PHC nurses, who had cited to this form through a QR Code designed with a Datashow feature after the VLE Pediabetico.net presentation. During presentation, handling instructions were given, such as login, course cited, course presentation, module layout, cited to video lessons, reading material, quizzes and forums. The theoretical and practical video lessons totaled 3 hours, 12 minutes, and 10 seconds. The second stage of data collection was carried out online, after participants completed the training course on prevention and treatment of foot ulcers associated with diabetes mellitus complications. Thus, in the second stage, the nurses responded, by e-mail or WhatsApp, the Google Forms with regard to the instrument System Usability Scale (SUS), translated into Portuguese, to evaluate the usability of the VLE Pediabetico.net12.
This scale has 10 questions graded on a Likert-type scale, with values from one to five, classified respectively as: “strongly disagree”, “disagree”, “neither agree nor disagree”, “agree” and “strongly agree”. Only the last question, regarding comments and/or suggestions, was an optional open question. After completing the SUS scale, the total score was calculated, generating a single number. To calculate the score, the scores for each contributing item were first added together on a scale of 1 to 5. For items 1, 3, 5, 7, and 9, the individual score consisted of the grade received minus 1. For items 2, 4, 6, 8, and 10, the contribution was 5 minus the grade received. Subsequently, the sum of all scores was multiplied by 2.5, thus obtaining the total score on the SUS scale. After scoring and calculating the score, it was possible to classify the evaluated system as follows: 20.5 (worst imaginable); 21 to 38.5 (poor); 39 to 52.5 (average); 53 to 73.5 (good); 74 to 85.5 (excellent); and 86 to 100 (best imaginable)13,14,15. The choice to use the SUS scale was due to it being an internationally known and validated tool, in addition to evaluating different dimensions of usability, such as ease of use, perceived complexity, need for support, consistency, and confidence in using the system. Data collection took place between December 2023 and January 2024.
Thus, the independent variables were the PHC nurses’ sociodemographic, academic, and occupational characteristics. The outcome variable was usability, which, for the association tests, was categorized dichotomously: “average and good” and “excellent and best imaginable”.
Data were tabulated in Excel 2019, with double typing for error correction and database cleanup, and processed in Statistical Package for Social Science (SPSS) version 22.0. The analyses were performed using descriptive and inferential statistics. In descriptive statistics, for numerical variables, the mean, median, standard deviation, minimum value, and maximum value were calculated. For categorical variables, absolute and percentage frequencies were used. In inferential statistics, the Chi-square and Fisher's Exact Test were used, considering a statistically significant p-value <0.05.
This study adhered to the ethical precepts of resolutions No. 466 of 2012 and No. 510 of 2016 of the National Health Council, and to the guidelines for research procedures with any stage in a virtual environment from the National Research Ethics Committee, and was approved by the Research Ethics Committee of the Universidade Federal do Piauí. All participants signed the Free and Informed Consent Form. It should be noted that no Artificial Intelligence tools were used in the production of this study.
RESULTS
Regarding sociodemographic, academic, and occupational aspects, 35.1% of nurses were between 31 and 40 years old; 67.2% had a partner; 92.4% were women; 60.3% had a monthly income equal to or greater than seven minimum wages; 89.3% had nine years or more of professional experience; 93.9% did not have a specialization in wound care; 63.4% were specialists; and 79.4% did not have training on foot ulcers associated with diabetes mellitus complications; 55.7% did not participate in a scientific event in the past three years; 38.9% stated that they had published an article in scientific journals in their field of work; and 62.6% reported having two jobs, as shown in Table 1.
Sociodemographic, academic, and occupational characterization of Primary Health Care nurses. Teresina, PI, Brazil, 2023. (n=131)
Regarding the usability of the VLE Pediabetico.net, 61.8% of nurses strongly agreed that they would like to use this system frequently; 51.9% disagreed that the system was unnecessarily complex; 48.8% strongly agreed that they found the system easy to use; 40.5% strongly disagreed that they would need technical support to use the system; 48.9% strongly agreed that they found the various functions in the system well integrated; 51.9% strongly disagreed that there was too much inconsistency in the system; 52.7% strongly agreed that most people would learn to use the system quickly; 48.8% disagreed that the system was too cumbersome to use; 46.6% strongly agreed that they felt very confident using the system; and 38.9% strongly disagreed that they needed to learn a number of things before they could continue using the system, according to Table 2.
Evaluation of the usability of the Pediabetico.net Virtual Learning Environment by primary health care nurses. Teresina, PI, Brazil, 2024. (n=131)
The average overall usability score for the VLE was 81 points, classified as excellent, with 40 being the lowest score and 100 the highest score assigned in the evaluation. Regarding the usability rating, most primary healthcare nurses rated the usability of the VLE Pediabetico.net as the best imaginable, as shown in Table 3.
Age, sex, monthly income, years since graduation, academic degree, participation in any scientific event in the past three years, and having published scientific articles in scientific journals in the field of expertise did not show a statistically significant association with the usability of the VLE Pediabetico.net (p>0.05), according to Table 4.
DISCUSSION
The usability of a software or other technology consists of evaluating the effort required to use it, as well as judging its usability. Therefore, usability evaluation allows us to infer whether a given technology can be used by specific users with determined levels of effectiveness, efficiency, and satisfaction16. Thus, it is emphasized that the VLE Pediabetico.net met the usability requirements, as the majority of nurses strongly agreed that they would like to use this system.
VLEs have been widely used without replacing traditional methodology, presenting themselves as a form of increasing and complementary education. This format has gained significant ground, as exemplified by the use of the VLE by the Universidade do Estado do Amazonas, which implemented a hybrid methodology in undergraduate and postgraduate education, demonstrating promising results17. From this perspective, the VLE Pediabetico.net, being an online learning tool with excellent usability, can facilitate cited and training for PHC nurses, and can be a useful technology for training and continuing education in health, since a large proportion of nurses strongly agreed that they felt very confident using the system.
The use of VLEs has had significant adoption and approval in recent years, and became an even more widely used and sought-after tool by educational institutions. Research conducted in 2021 in the Northwest of São Paulo state, with nursing students, showed that the use of the VLE, proposed by a university project, resulted in almost 90% satisfaction in the following aspects: easy navigation, content organized in a clear and intuitive way, and user-friendly graphic design/layout, confirming that the VLE is a well-evaluated learning tool18.
In usability evaluation, the characteristics to be measured consist of suitability, comprehensibility, error protection, operability, user interface aesthetics, and citedibility16. Consequently, the usability characteristics of the VLE Pediabetico.net were well evaluated by the study participants, as a large proportion strongly agreed that they found the various functions of the system well integrated, and most strongly disagreed that they needed to learn a series of things before they could continue using the system.
The mean usability score for the VLE Pediabetico.net was 81 points, classified as excellent. This result corroborates a study that evaluated the usability of the Website Diabetes News, using the SUS scale, which found that the overall usability rating was 87.7, considered the best imaginable19. It is worth noting that, in the VLE Pediabetico.net, most of the experts' suggestions were accepted, which may have contributed to improving the usability of the technology.
Thus, a study on a mobile phone application with citedible communication identified that this technology presented high usability, showing an excellent user satisfaction index, with an average of 89.5 points, and the capacity to promote communicative citedibility20. This corroborates the results evidenced in the VLE Pediabetico.net evaluation, as 52.7% of participants agreed that most people would learn to use this system quickly.
Most nurses rated the usability of the VLE Pediabetico.net as the best imaginable. This positive usability assessment can be explained by the fact that the validation of this technology involved experts from both the nursing and computer science fields, which allowed the correction of several errors and flaws in the system, optimizing the VLE functionality for the target audience. From this perspective, a study evaluating the functional performance and technical quality of educational software also emphasized the importance of expert participation in the validation process, particularly from the field of information technology, as these professionals master the characteristics inherent to usability, thus ensuring greater quality and acceptance of the technology by the target audience21.
This study, which aimed to validate an interactive digital educational material in e-book format and analyze its usability, highlighted the relevance of clinical validation with the target population to identify the needs of this audience and provide material that is easy to understand, safe, and effective22. Regarding ease of use, which is one of the essential characteristics for usability, most nurses agreed that the VLE Pediabetico.net is an easy-to-use system, which may generate greater interest among the target audience.
The usability of the VLE Pediabetico.net was evaluated using the instrument System Usability Scale, showing variation in usability scores from median to the best imaginable among the participants. Similar results were found in a study that evaluated the usability of a chatbot for people with hypertension and diabetes mellitus whose overall average usability score was 72.3%, rated as good, with 77% of participants stating that they would like to use the technology frequently and 72.7% finding the prototype easy to use, highlighting that this innovation can be incorporated into VLEs to promote collaborative learning, by encouraging interactive and collaborative engagement among peers23.
Educational technologies are expanding learning tools in the field of nursing, with high levels of approval regarding usability. A study that developed and validated a course on the pillars of foot care management for people with diabetes mellitus using the VLE Moodle, which was structured with teaching materials, videos, forums, and questionnaires to assess participant learning, was considered a modern, dynamic, viable, effective, and strategic alternative, with a significant impact on improving knowledge management and the quality of care for people with diabetes mellitus, emphasizing that the combination of various user-friendly Virtual Learning Objects contributes to improving learning, as well as enhancing the usability of educational technology, making it an important tool for training healthcare professionals24.
Furthermore, another factor that can ensure the usability of a technology is the content it develops. Based on this, a study was conducted on the usability of a mobile application for self-care of foot ulcers associated with diabetes mellitus complications. The product was developed in accordance with clinical practices and with a focus on the users’ needs and requirements25. It is emphasized that the content of the VLE Pediabetico.net was highly praised by nurses in the comments and/or suggestions section of the tool System Usability Scale, which certainly contributed positively to the evaluation of this technology usability.
The participants’ sociodemographic and academic variables did not have a statistically significant association with the usability of the VLE Pediabetico.net, showing that theses aspects did not influence the Virtual Learning Environment handling. Thus, the lack of statistical difference regarding sociodemographic and academic aspects and usability in this research can be explained by the homogeneity of the participants' profile.
This study contributes to the validation of a virtual learning environment about foot ulcers associated with diabetes mellitus complications, demonstrating its usability and acceptance by PHC nurses, which reinforces its potential as a tool to support continuing health education. By training professionals for proper and preventative care, the tool can positively impact the early detection and reduction of complications related to foot ulcers. Furthermore, the research encourages the incorporation of digital technologies into nursing practice and provides support for continuous improvements in the virtual environment, promoting more citedible, interactive teaching aligned with the users’ needs. One limitation is the impossibility of guaranteeing that all participants have answered the instrument faithfully and with the utmost attention when responding to each of the questions.
CONCLUSION
The overall mean usability rating of the VLE Pediabetico.net was excellent, with most primary healthcare nurses rating the usability of this technology as the best imaginable. Moreover, it was shown that participants’ sociodemographic and academic variables did not have a statistically significant association with the VLE usability.
In the usability assessment, the majority of nurses strongly agreed that they would like to use this system frequently, disagreed that the system was unnecessarily complex, and strongly agreed that most people would learn to use this system quickly. This reinforces that this educational technology met the usability requirements, ensuring effectiveness, efficiency, and user satisfaction, and can be a useful tool for training primary healthcare nurses in the prevention and treatment of foot ulcers associated with diabetes mellitus complications.
ACKNOWLEDGMENT
Universidade Federal do Piauí, Postgraduate Program in Nursing.
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NOTES
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ORIGIN OF THE ARTICLE
Extracted from the final course work - Evaluation of a virtual learning environment on diabetic foot care by PHC nurses, presented to the Nursing Course, Universidade Federal do Piauí, in 2023.
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FUNDING INFORMATION
National Council for Scientific and Technological Development. Beneficiary's Case Number: 138681/2022-8.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Universidade Federal do Piauí, opinion no. 5.179.989/2021. CAAE number: 52612021.8.0000.5214.
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TRANSLATED BY
Denise Costa Rodrigues.
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DATA AVAILABILITY
All the data supporting the results of this study were published in the article itself.
Edited by
All the data supporting the results of this study were published in the article itself.
