Assessment of the quality of a software application for the prevention of skin lesions in newborns*

Objective: to assess the technical quality of a mobile application to support the nurse’s decision to prevent skin lesions in hospitalized newborns, according to the Product Quality Model. Method: a methodological study for technological assessment. The 20 evaluators, divided into two groups, 10 nurses and 10 information technology professionals, used the software, conducted tests based on two case studies, and evaluated six features and 23 sub-features of quality. The assessment was conducted by means of an online form. Data was analyzed through a specific formula and the items that obtained a concordance percentage over 70% were considered adequate. Results: the concordance percentages of the features in the groups of nurses and of information technology specialists were the following: functional adequacy (100%-98.9%), reliability (90%-100%), usability (93.2-85%), performance efficiency (100%-100%), compatibility (97.5-90%), and safety (94%-91%). In the assessment of the sub-features, only accessibility presented a percentage value below the desired one (70%-60%). Conclusion: the software has excellent technical quality to meet the needs of nurses in planning the care for the prevention of skin lesions of hospitalized newborns, brings important advances to neonatal care, contributes to the work process, expands knowledge, and promotes the professional’s clinical reasoning.


Introduction
Technological advances have made the survival of ever smaller and more premature newborns (NBs) possible, evidencing the problems with skin integrity in the Neonatal Unit (NU), largely caused by the anatomical and physiological specificities of the neonate and by the need to use devices, indispensable for the care of these patients. This scenario has been responsible for concerns of the neonatal nurses regarding skin care for NBs (1) .
In an NU, there are few interventions that do not present risks, and nurses need to know how to identify products and procedures that can be useful, as well as the unintended negative consequences that an intervention can cause (2) .
In view of the structural specificities of the newborn's skin, the potential for lesions is high (3) . The lower the gestational age (GA), the higher the risk (4) .
These lesions can increase the chances of infections, main cause of neonatal morbimortality, in addition to provoking definite scars and functional alterations (5)(6) .
They also contribute to longer hospital stays and to increased costs of hospitalization (7) . Therefore, although it is an area of clinical practice that still needs to be improved, the prevention of skin lesions is fundamental in the care of NBs (8)(9)(10) .
The integrity of the integument should be used as a metric to leverage the quality of neonatal care (1) and, with regard to the performance of their praxis, nurses must acquire the necessary knowledge in order to improve the care provided to the NB. For this, they can use technologies that offer adequate information and that assist in the decision-making process.
The use of technologies in the health field has grown considerably and collaborates with the monitoring of the health of individuals in an effective and personalized way (11) . Clinical decision support systems (CDSSs) allow adopting prevention and early diagnosis strategies, thus improving the quality of patient care (12) .
In order to combine technology and care in the neonatal area and contribute to support the decision in the prevention of skin lesions in newborns, Neonatal Skin Safe  was developed, an application for mobile devices developed by nurses. The development of this technology is justified by not knowing about the existence of any software for mobile devices that can be used by the neonatal nurse at the bedside and that has the function of targeting the skin care of the hospitalized NB, considering the anatomical, physiological, and care conditions. In this sense, this study brings important contributions to improve the care and safety of neonatal patients.
The content of Neonatal Skin Safe  presents evidence-based recommendations, which have also been validated by the experts on the theme in question (13) . However, to ensure that the software presents the necessary requirements to meet the needs of the users, its quality needs to be assessed. The quality of software ensures that the product presents the features, functions, and content that the user wants, offering agility in carrying out the processes for which it was developed (14) .
In this sense, evaluating the quality of Quality in Use identifies the following as quality requirements: efficacy, efficiency, satisfaction, risk-free operation, and context coverage. The "satisfaction" feature presents the following sub-features: usefulness, confidence, pleasure, and comfort. "Risk-free operation" has the following sub-features: reduction of the economic risk, reduction of the health and safety risk, and reduction of the environmental risk. Finally, "context coverage" has integrality of context and flexibility as sub-features (15) .
As regards the evaluation requirements of   to the intended user group (19) . The inclusion criteria used to select the experts were adapted from a scoring system for validation studies (20) .
Titles, the participant's experience in the study area, and the scientific production were considered. Each specialist should obtain a minimum score of five points, according to their area/specialty, as shown in Figure 2.

Inclusion Criteria Score
Graduated in Nursing for at least 2 years or Bachelor of Computer Science for at least two years 2 Experience in teaching or neonatal care for at least 2 years or experience in the development of software for at least two years 3 Master's degree in Nursing with a dissertation in the field of neonatal nursing and/or Specialist in Stomatherapy with emphasis on neonatal/pediatric care or Master's degree in Computer Sciences, with a dissertation on software development 2 PhD in Nursing with a thesis on the skin theme or PhD in Computer Sciences with a thesis on software development 3 Research studies published with an emphasis on the skin theme or research studies published on software development 2 Participating in a research laboratory in the field of neonatal nursing and/or stomatherapy or teaching experience in the area of software development 1 The evaluation was carried out using two forms from Google Forms  , one for the group of nurses and another for the group of IT specialists, containing the features and specific questions for the quality subfeatures. They were adapted from a previous study (21) ; thus, the data collection instruments were already validated, minimizing the chances of bias in this study.

Data collection was conducted from
December 2018 to January 2019. The participants were given seven days to complete the evaluation form, and it was necessary to extend the period for another five days, in order to ensure that the evaluators finished the process. During this period, the researcher was available to answer questions and help the participants via email, phone, and WhatsApp.
To specify the assessment, the quality metrics, scoring levels, and criteria for judging the software were defined (16) . Each evaluator attributed a score level to each of the assessed sub-features. The score levels were defined as follows: (A) Agree; (D) Disagree; (NA) Not Applicable; Comments (22) . The specialists' comments, especially when accompanied by a level D For analyzing the results, the items that obtained a percentage of agreement greater than 70% were considered adequate, according to the rating scale for sub-features (21)(22) , where 25% (weak); 50% (regular); 75% (good); and 100% (excellent).   As for the inclusion criteria, the score varied between five and 11 points in the two groups, with the teaching professionals having the highest score.
In each group, the participants evaluated 36 key questions. These were distributed in the 23 Sub-features and six Features of Quality. Only the key question of the "capacity" sub-feature, which is part of the "performance efficiency" feature and relates to the capacity of the software's database, was modified in the group of nurses in order to facilitate the understanding of the evaluators.
In the assessment of the "functional adequacy" feature by the IT specialists, all the key questions obtained a concordance percentage over 70%. In the group of nurses, all the key questions of this feature presented 100% concordance.
Of the questions evaluated in the "reliability" feature, both in the IT group and in the nurses group, "fault tolerance" and "recoverability" received a concordance percentage below 70%; however, these were evaluated as "not applicable".
In the assessment of the "usability" feature by the nurses and by the IT specialists, only the "accessibility" sub-feature presented a percentage value below 70%.
When the IT group assessed the "performance efficiency" feature, only the "capacity" sub-feature received 80% of "Not applicable" answers. In the group of nurses, all the questions obtained 100% concordance.
In the IT group, the "compatibility" feature presented two questions with a concordance percentage below 70%.
The highest percentage of answers was related to the "Not applicable" option. In the assessment by the nurses, all the questions obtained percentage values over 70%.
In the assessment of the "safety" feature in the IT group, the questions related to integrity and nonrejection were assessed with less than 70%. However, they received the "Not applicable" answer. In the assessment by the nurses, all the questions obtained percentage values over 70%.
In the evaluation of the features from the set of subfeatures, excluding the "Not applicable" answers, both in the group of IT specialists and in the group of nurses, it is observed that only the "accessibility" sub-feature did not reach the appropriate percentage (> 70%) to be considered of good quality. These data are presented in Table 1. Computerized decision support systems offer specific recommendations and guidance to the professionals for meeting the needs and improving the patients' health. These systems assist in solving clinical practice problems, reduce error rates, improve the accessibility of the professionals to evidencebased knowledge, and help to increase the quality and efficiency of the care provided (25) . It is also added that computerized processes are tools that optimize and simplify the actions of nurses, whether in the field of management, care or teaching, thus being related to the work process of these professionals (26) .
The evaluation process had the participation of professionals with knowledge in neonatal nursing and in IT, allowing the software to be analyzed from different To use an instrument in different regions, it must be adapted to the local specificities of culture, language, and work of the professionals who will use it (27) .
In view of the current technological scenario, mobile devices are presented as strategies that can leverage the promotion of health education (28) . The assessment of these technologies is important, as they seek to promote improvements in safety and in the quality of care provided to patients (29)(30) , the professionals who use them need to be sure of their quality conditions and requirements.
Being developed for mobile applications, the software is easy to access and use, allowing evaluation of the patient at the bedside. This feature guarantees greater reliability of the data collected during the evaluation process. Corroborating this issue, the use of smartphones allows for mobility breakdown, presenting the user with faster and easier access to information (31) . conditions of the skin of the newborns with GA less than 32 weeks and weight less than 1,500 grams (32) .
In the evaluation of the "functional adequacy" feature, the difficulty of evaluation by the IT group is justified by the lack of knowledge of the evaluators, since the questions evaluated presented specificities of nursing care to the newborn, requiring mastery on this theme. However, an error was found in the inclusion and exclusion of interventions by one of the evaluators.
Based on the nurses' assessment, it is observed that the software meets the proposed objectives, promoting benefits to the care process.
The use of devices for therapy, life maintenance, and monitoring are considered the major causes of pressure injuries in neonatal patients (3,(33)(34) . Proper use, correct fixation, and skin protection contribute to reducing the risk of lesions (35) . In this sense, the software suggests nursing interventions, presents photographs and step- In assessing the "compatibility" feature, although the software presents the possibility to access the journal online for accessing the article from the list of references, and to present the resource for sharing the care plan generated at the end of the newborn's assessment via email or network printing, some participants claimed that they were unable to assess these requirements. This denotes that the evaluators did not use all the resources available in the software, which may have led to a lower result than expected in the evaluation of this feature.
When analyzing the data obtained in the "safety" feature, it is observed that there were disagreements in the answers of the IT specialists for some subfeatures, demonstrating that, despite having been asked to carefully observe the functioning of the software, the participants did not know how to assess these questions.
In the nurses' evaluation, one of the evaluators had difficulties in recovering the access password; for this reason, she suggested including a register of electronic address for user and password recovery in case of forgetfulness.
In the individual assessment of the sub-features, both in the group of nurses and in the IT group, only accessibility did not reach the adequate percentage.
Based on the analysis of the set of sub-features, it is observed that the results were homogeneous and all characteristics obtained a percentage above 80%, although the groups of evaluators had different experience and professional training, demonstrating that the application has excellent technical quality.
It is important to note that a software application is considered of good quality when it meets the user's needs regarding the functions, resources, and content offered (14) . The learning process through mobile devices is instantaneous, occurs in an interactive way, and presents itself as a potential source of transformation of the methods of offering education and training (37) .
Although developed to support decision making, the software can also be useful in the educational process of the professional. In addition to the initial screen, which contains information on anatomy, physiology, and possible risks for the development of skin lesions, all the nursing interventions have justifications based on the literature, allowing the user's knowledge to be expanded.
In this perspective, the software can foster the critical sense of nurses, targeting actions, supporting care, reducing risks related to health care, and providing a better quality of life and safety for neonatal patients.
As limitations in carrying out this study, the following stand out: the scarcity of software that contemplate skin care of the hospitalized NB, as well as of technological evaluation studies that could serve as a model in carrying out this research. Also noteworthy is the lack of resources to contemplate a server for data storage.
It is highlighted that all the suggestions made by the evaluators will be considered to improve the software, in order to make it even more appealing, safe, practical, and accessible for the users. It is reiterated that this action will be constant, given the accelerated process of information updates, both in terms of technological development, as well as in health care.
As a suggestion for future research studies, it is recommended that Neonatal Skin Safe  be evaluated in the daily practice of nurses who care for the NBs in the NU and also by nursing students, in order to verify its effectiveness for lesion prevention, work organization, and health education.
It is expected that this study will encourage research studies on the development and evaluation of care technologies aimed at nursing and health care, collaborating with the technical scientific knowledge and with the instrumentalization of the professionals to develop their daily practice with quality and safety.
The study can be replicated in other scenarios whose theme is the evaluation of the quality of software in health care.

Conclusion
Neonatal Skin Safe  is a technological innovation in health which allows the nurse to assess the risks, identify the diagnoses, and plan care actions for the prevention of skin lesions in the hospitalized NB, based on updated content, supported by the literature, and evaluated by subject matter experts. It contributes to the nurse's work process, expands knowledge, and allows for the professional's clinical reasoning.
This study showed that all the quality features of Neonatal Skin Safe  were considered as excellent, denoting that the software has the necessary technical quality to meet the needs of the nurses in addressing care actions for the prevention of skin lesions in NBs.