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PERMANENT HEALTH EDUCATION IN NURSING AND EDUCATIONAL

TECHNOLOGIES FOR IMPROVING HOSPITAL CARE

Lana Nicole dos Santos Batista Almeida1

Pedro Daniel dos Santos Nunes2

Abstract: This study examined barriers to permanent health education in nursing and contributions

of educational technologies in hospitals. An integrative review used a targeted PubMed search and

veriﬁ cation of a previous bibliography, covering publications from 2020 to 2025. Of 86 records

identiﬁ ed, 23 full texts were assessed and 16 studies entered a descriptive and thematic synthesis.

Findings addressed participation conditions, educational strategies, and measured outcomes.

Workload, lack of time, funding constraints, and digital access restricted participation. Simulation

and learning platforms showed favorable ﬁ ndings for knowledge, conﬁ dence, or implementation,

with methodological limitations. In one Brazilian study, simulation and interactive lectures

improved theoretical performance without a signiﬁ cant difference between methods. Perceptions and

educational indicators predominated and did not establish reduced adverse events. Improving care

requires alignment between service needs, staff participation, managerial support, and assessment of

learning transfer. R estricted coverage, screening without independent duplication, and unretrieved

texts limit the conclusions.

Keywords: permanent health education; nursing; educational technology; hospital care; patient safety.

1 Bacharel em Enfermagem, Santa Cruz Centro Universitário

2 Bacharel em Enfermagem, Santa Cruz Centro Universitário

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INTRODUCTION

Learning on the job integrates the challenges of hospital nursing, whose performance

involves updating knowledge and decisions in complex clinical situations. Continuing Education in

Health (PHE) places everyday problems as a starting point for analyzing and transforming practices.

In Brazil, Ordinance No. 1,996/2007 guides the articulation between training, service needs and

development of workers in the Uniﬁ ed Health System (Brasil, 2007). This perspective requires

understanding how hospital organization allows teams to identify problems, discuss alternatives and

monitor changes in care.

The provision of training, however, does not ensure participation or application of learning.

In hospitals, professionals report difﬁ culties in reconciling educational activities, care demands, and

personal responsibilities. The existence of available content also does not eliminate barriers to internet

access, availability of equipment, or time to study (Yu; Huang; Liu, 2022; Hamukoto et al., 2025).

Such conditions help explain why initiatives valued by the teams may remain punctual or poorly

integrated into the service.

Simulations and digital environments expand the possibilities of teaching, but their results

need to be examined according to the outcomes effectively measured. Gains in tests of knowledge,

satisfaction, and trust do not in themselves equate to a reduction in harm to the patient. This distinction

is relevant to guide the choice of educational resources and to avoid attributing to a technology effects

that the study did not demonstrate (Nazário et al., 2025; Lee et al., 2025).

The guiding question was: what barriers and contributions of educational technologies

are described in continuing education and in the professional development of the nursing team in

hospitals? The objective was to analyze these barriers and contributions, identifying conditions of

implementation, strategies used and limits of evidence for the qualiﬁ cation of hospital care. The study

brings together Brazilian and international production, preserving the differences between their

conceptual references.

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CONTINUING EDUCATION AND LEARNING ON THE JOB

PEH is based on the collective analysis of work and health needs, seeking to modify practices

and institutional relations. Continuing Education (CE), in turn, usually organizes the updating of

knowledge and skills through courses, training and other delimited activities. Although they can

complement each other, periodic training is not enough to characterize PEH: it is necessary to relate

learning to the problems of the service and to the participation of workers in the production of changes

(Ceccim, 2005; Brasil, 2007).

In the international literature, continuing professional development (CPD) designates

professional development processes throughout the career, which may involve formal education,

informal learning, and requirements to maintain professional registration. The metasynthesis of

Mlambo, Silén, and McGrath (2021) highlights the relevance of organizational conditions for this

development. In this article, CPD is a concept related to professional learning, without automatic

equivalence with Brazilian PHE. International ﬁ ndings allow us to compare barriers and resources,

but do not necessarily demonstrate collective processes of work transformation.

Educational technologies also need to be examined from their pedagogical purpose. A

platform can facilitate the distribution of content; simulation can organize situations of practice and

discussion. Its insertion in a PHE proposal depends on how the problems are chosen, who participates

in the planning and subsequent follow-up. The articulation between education, safety and quality

requires spaces for interaction between care and management, as evidenced by Koerich, Erdmann

and Lanzoni (2020).

RESEARCH METHODOLOGY

An integrative review was carried out with descriptive and thematic synthesis, guided by the

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six stages of Mendes, Silveira and Galvão (2008): deﬁ nition of the problem; search and selection; data

extraction; evaluation of studies; interpretation; and presentation of the synthesis. The directed search

was conducted in September 2026, with a publication cut from 2020 to 2025, corresponding to six full

years. When there was a divergence between early publication and ﬁ nal edition, the year of the ﬁ nal

edition was considered for eligibility.

Empirical articles in Portuguese or English on in-service education, professional development

or its conditions of implementation, involving nursing workers in hospitals, were included.

Multiprofessional studies were admitted when they included nursing and dealt with hospital programs

or institutional conditions. In samples with students or other levels of care, the possibility of separating

the pertinent results was required. Descriptive evaluations of programs with systematized data were

admitted. Reviews, protocols, opinion texts, reports without structured empirical evaluation, and

studies in which education appeared only as a recommendation, without analysis of the educational

process or its conditions, were excluded.

The main query was performed in PubMed, a platform that gathers bibliographic records

from different sources, with the expression: (“permanent education”[Title/Abstract] OR “permanent

health education”[Title/Abstract] OR “continuing professional development”[Title/Abstract]) AND

nurs*[Title/Abstract] AND hospital*[Title/Abstract] AND (2020:2025[dp]). A total of 74 records

were retrieved. The complementary query with controlled terms was: “Education, Nursing,

Continuing”[MeSH Terms] AND “Educational Technology”[MeSH Terms] AND hospital*[Title/

Abstract] AND (2020:2025[dp]), with no records retrieved. The counts correspond to these ﬁ nal

strategies, without incorporating exploratory queries.

The search was complemented by the veriﬁ cation of 12 articles from 2020 to 2025 present in

the bibliography gathered in the preparatory stage. Conceptual and methodological references were

treated separately from the sample. Title, authorship, and DOI were checked to identify duplicates.

The screening of titles and abstracts preceded the full reading of those eligible; unretrieved texts were

recorded as such, without using their abstracts to compose results. The selection was not carried out

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by independent reviewers in duplicate.

The extraction matrix included authorship, year, country, setting, participants, design,

educational strategy, results, and limitations. The critical assessment was descriptive, examining

sample selection, clarity of procedures, nature of the instruments, presence of comparison, follow-

up, and compatibility between results and conclusions. No standardized risk of bias scale or global

quality score was applied. The ﬁ ndings were compared and grouped by recurrence in conditions of

participation, educational strategies, and achievement of outcomes. No meta-analysis was performed

due to the heterogeneity of the designs, measures, and interventions. The selection ﬂ ow was organized

based on the presentation structure of PRISMA 2020, without equating this reporting resource to the

integrative review method (PRISMA, n.d.).

RESULTS

The selection gathered 86 records, with no duplicates identiﬁ ed. After screening, 46 were

excluded and 40 texts were searched. Seventeen were not retrieved from the sources accessed. Of the 23

texts evaluated in full, seven were excluded: six presented hospital and non-hospital scenarios without

sufﬁ cient separation of the results; one aggregated students and professionals without discriminating

the ﬁ ndings. The ﬁ nal synthesis comprised 16 studies, 12 of which came from PubMed and four from

the previous bibliography (Figure 1).

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Figure 1 – Flow of identiﬁ cation and selection of studies

Main search: 74; complementary search with MeSH: 0.

Exploratory stages are not part of these counts.

Source: prepared by the authors (2026)

The studies included twelve countries, with four Brazilian publications. Qualitative

investigations predominated; cross-sectional studies, mixed approach, program evaluation, and

educational interventions were also identiﬁ ed. Chart 1 distinguishes the observed results from the

limits of interpretation, without adding participants from different designs and populations.

Chart 1 – Characterization of the studies and critical appraisal

Study Design and context Main result Limit of evidence

Koerich, Erdmann

and Lanzoni

(2020)

Brazil; qualitative; 27

participants, 22 nurses,

in hospital and state

management.

Integration between HPS, safety

and quality depends on leadership,

communication and managerial

support.

Predominance of the

managers’ perspective; it

does not measure clinical

effect.

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Emmanuel et al.

(2020)

England; cross-sectional;

2,959 respondents analyzed,

in 48 hospitals.

Shifts ≥12 h were associated with

lower educational opportunities:

OR 0.58; 95%CI 0.44–0.76.

Self-report and data from

2009–2010; association

without causation.

Maluwa, Mwalabu

and Msiska (2021)

Malawi; qualitative; 73

participants from four

hospitals.

Ethics education and supervision

were described as supporting

ethical competence.

Perceptions and intentional

selection; does not assess

change after intervention.

Melariri, Kalinda

and Chimbari

(2021)

South Africa; cross-

sectional; 495 professionals

in the total sample;

analyzable hospital strata.

The tertiary stratum presented

gaps in the provision of training for

health promotion.

Separate hospital outcomes;

self-report and variable

denominators were used.

Rahmah, Hariyati

and Sahar (2021)

Indonesia; qualitative; six

nurses.

Professional development,

accreditation and management

support were related to the

maintenance of competencies.

Small and non-probabilistic

sample; no effect on

patients.

Yu, Huang and Liu

(2022)

China; qualitative; 14

tertiary hospital nurses.

Needs vary with professional

trajectory; work and family make

participation difﬁ cult.

Single center and

perceptions; limited

contextual transference.

Gomes and Ribeiro

(2023)

Brazil; qualitative; 35

professionals from two adult

ICUs.

Recognition of the relevance of PEH

coexisted with speciﬁ c educational

practices and difﬁ culties in

participation.

44 refusals among 79

guests; daytime sample

only.

Wehabe,

Gebretensaye and

Bizuwork (2024)

Ethiopia; mixed method;

262 responses and nine

informants.

90 of 262 nurses reported

participation in CPD; time,

funding, and information barriers.

Temporal deﬁ nition of

participation is not uniform;

self-report.

Munyaneza et al.

(2024)

Rwanda; qualitative; 35

hospital professionals, with

nurses.

Availability did not guarantee

access; relevance of the themes,

mentoring and participation in

planning were demands.

Multiprofessional results;

not attributable only to

nursing.

Mukamana et al.

(2024)

Rwanda; transversal; 140

professionals, including 88

nurses.

Digital platforms were used, but

internet connectivity and cost

made access difﬁ cult.

Convenience; low

consistency in two

subscales; no measured

clinical effect.

Gaus, Conway and

Herrera (2024)

Ecuador; descriptive

evaluation of the program;

two hospitals; 108

participants in the nursing

category.

Modules on the Chamilo platform

had full participation and approval

after up to two attempts.

Obligation linked to salary;

without transfer control or

evaluation.

Hamukoto et al.

(2025)

Namibia; qualitative; 15

nurses from a reference

hospital.

Lack of staff, time, digital

resources, funding and trainers

restricted participation.

Single hospital; perceptions

without statistical

generalization.

Karikari et al.

(2025)

Ghana; transversal; 406

nurses from 11 district

hospitals.

Refresher training was associated

with an additional 3.3 percentage

points in the knowledge test.

Intentional sampling in

the day shift; association

without causal inference.

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Lee et al. (2025) South Korea; multi-method

intervention; 90 participants,

of which 60 nurses were

analyzed separately.

Risk simulation showed gains

in dimensions of perceived

competence and conﬁ dence.

No unexposed control;

mostly self-reported

measures and two-week

follow-up.

Nazario et al.

(2025)

Brazil; quasi-experimental;

41 professionals; two

inpatient units.

Simulation and dialogue classes

improved knowledge; there was

no signiﬁ cant difference between

methods.

Only two units; participant

losses and theoretical

outcome.

Weissenberg et al.

(2025)

Brazil; qualitative; 41

professionals, 18 nurses and

23 technicians.

Simulation was perceived as an

opportunity for technical learning,

communication and teamwork.

Immediate and perceptual

assessment; it does not

demonstrate a reduction in

adverse events.

Source: prepared by the authors based on the included studies (2026). ICU: intensive care unit; OR:

odds ratio; 95%CI: 95% conﬁ dence interval. Total samples are indicated when the results of interest

could be separated.

Conditions of participation and organization of work

The lack of time and team coverage during educational activities appeared recurrently.

Hamukoto et al. (2025) identiﬁ ed, in the interviews, restrictions on personnel, funding, digital access,

and availability of trainers. Yu, Huang, and Liu (2022) described conﬂ icts between training, work, and

family life. In Gomes and Ribeiro (2023), the recognition of the relevance of PEH did not translate into

its continuous implementation. Brazilian studies also highlighted the distance between management

and care as an obstacle to the articulation of education with safety and quality (Koerich; Erdmann;

Lanzoni, 2020).

The quantitative results reinforced the presence of barriers, without demonstrating causality.

Emmanuel et al. (2020) found a lower chance of reporting professional development opportunities

among nurses in shifts of at least 12 hours, compared to those of up to eight hours. In Ethiopia,

90 of the 262 respondents reported participation in PCD, but the article varied in the deﬁ nition of

the reference period; the data should be understood as frequency reported in that sample (Wehabe;

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Gebretensaye; Bizuwork, 2024).

Educational strategies and outcomes evaluated

Strategies included simulation of clinical situations, risk identiﬁ cation, dialogued classes,

and digital modules. Nazário et al. (2025) observed an increase in knowledge about patient safety

in both methods compared, with no statistical superiority of simulation. Lee et al. (2025) presented

separate results for beginner and experienced nurses, allowing these groups to be considered without

incorporating students into the professional synthesis. Weissenberg et al. (2025) identiﬁ ed favorable

perceptions of simulation learning, but did not assess the frequency of adverse events after the activity.

In the program described by Gaus, Conway, and Herrera (2024), the nursing category

brought together 108 participants. Full adherence to the modules cannot be interpreted as spontaneous

motivation, as participation was linked to salary payment. Mukamana et al. (2024) identiﬁ ed

connectivity difﬁ culties in a multiprofessional sample, while Munyaneza et al. (2024) recorded

demands for greater relevance of the contents and participation in planning. These ﬁ ndings describe

implementation conditions, not demonstrated clinical effects.

Critical assessment of the body of evidence

The literature gathered experiences consistent with the need for institutional support, but

with uneven reach. Qualitative studies deepened perceptions in speciﬁ c contexts; cross-sectional

studies investigated associations, subject to confounding and memory. Karikari et al. (2025) used

a knowledge test, offering a different measure of simple self-conﬁ dence, but without prospective

comparison before and after training. In Mukamana et al. (2024), two subscales showed low internal

consistency, which reduces the security of interpretations about these domains. In the interventions,

small samples, absence of unexposed control, or restriction to two units limited inferences of efﬁ cacy.

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None of these results, in isolation, supports a reduction in care harm.

DISCUSSION

Studies indicate that the performance of educational activities depends on both pedagogical

choices and concrete working conditions. The association between long working hours and less

opportunity for training, observed by Emmanuel et al. (2020), converges with reports of scarcity of

time and personnel. However, convergence does not eliminate differences between contexts nor does

it authorize the conclusion that the duration of the shift alone explains adherence. Planning training

requires considering care coverage, opportunities for different shifts, and available resources, without

attributing non-participation exclusively to individual availability.

The distinction between PHE and CPD modiﬁ es the interpretation of the results. A

requirement for credits or completion of modules may produce formal participation, but it does not

evidence collective reﬂ ection on the problems of the service. The Ecuadorian case shows this tension:

the platform enabled a learning routine, while the link to the salary conditioned the behavior of the

participants (Gaus; Conway; Herrera, 2024). In the light of Ceccim (2005), the approach to PHE

also requires discussing labor relations, autonomy, and participation in the deﬁ nition of educational

priorities.

Brazilian studies offer elements for this articulation. Gomes and Ribeiro (2023) highlight the

distance between recognizing the importance of PEH and incorporating it into the routine. Koerich,

Erdmann, and Lanzoni (2020) situate professional interaction and management support as components

of safety-oriented education. In the studies by Maluwa, Mwalabu and Msiska (2021) and Rahmah,

Hariyati and Sahar (2021), supervision and development support also appear as important resources.

These results support the interpretation that learning is not sustained only by the provision of material

or by individual mastery of techniques.

Technologies should therefore be chosen according to the objectives and conditions of the

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service. Simulation allows exploring situations and discussing decisions, but the result of Nazário

et al. (2025) advises against assuming its superiority over a dialogued class. Likewise, access to

platforms does not automatically solve connectivity and cost problems (Mukamana et al., 2024). In

Melariri, Kalinda, and Chimbari (2021), the results separated from the tertiary hospital level point

to gaps in training for health promotion, reinforcing that the content also needs to correspond to the

needs of action.

For hospital practice, the synthesis suggests relating the diagnosis of needs to problems

identiﬁ ed by the team and monitoring what happens after the activity. Attendance and approval in

modules can inform reach; tests can assess knowledge; observation of practice and care indicators,

when properly deﬁ ned, can investigate transfer and care outcomes. This sequence is an implication of

the analysis, not an effect proven by all studies. The available data support educational beneﬁ ts and

participation conditions with greater certainty than conclusions about patient outcomes.

The review has limitations. The directed search on a single platform and the complementation

by previous bibliography restrict coverage and may favor already known studies. The main expression

favors certain denominations of professional education, while the consultation with MeSH did not

retrieve records; the absence of results in this consultation does not mean the absence of evidence on

technologies. Seventeen texts that were not retrieved introduce possible availability bias. Added to

this are the selection without double independent review, the non-standardized critical appraisal, the

restriction of languages, and the conceptual heterogeneity between PHE, CS, and CPD. The results

do not constitute an exhaustive estimate of efﬁ cacy, nor do they allow for the hierarchization of

technologies for all hospitals.

FINAL CONSIDERATIONS

The review identiﬁ ed barriers related to time, personnel, resources, digital access, and

managerial support. Simulations, dialogued classes, and platforms presented contributions to learning

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or to the organization of educational activities, with limited evidence on transfer to care and patient

outcomes. The incorporation of these resources into PHE requires a link with service problems, worker

participation, and post-training evaluation. The objective was achieved by identifying the conditions

for implementation and differentiating between observed educational beneﬁ ts and care effects not yet

demonstrated. Research with follow-up, appropriate comparators, and practice indicators are needed

to clarify the sustainability of changes in the hospital context.

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