Blended learning program for the development of skills in the aspiration of artificial airways

Objective: to develop and validate a blended learning program, of the inverted classroom type, on the aspiration of artificial airways. Method: applied and methodological research that involved technological production for teaching a Nursing Intervention, based on Vygotsky’s theoretical frameworks and on the Nursing Process. For elaboration and validation, a classic instructional design model was followed. The general and pedagogical requirements were validated, as well as those for videos and interface. For the analysis, the Content Validity Index and the First-order agreement coefficient were used. Results: 34 experts participated, 27 of whom were nurses and seven were professionals in Information Technology. In the nurses’ opinion, the general and pedagogical requirements obtained a Content Validity Index of 0.99 and 0.98 was obtained for the videos and for the interface. The interface for the IT professionals was 0.94. All requirements showed almost perfect agreement. Conclusion: the teaching program was elaborated and validated by experts and constitutes an innovative proposal to train nurses. The mediation of teaching by means of duly validated technologies can favor learning and reaching positive results in the development of skills in the practice of aspiration of artificial airways.


Introduction
The centrality of Nursing is care for the individual, family or human community and the Nursing Process (NP) is the way to give it scientific rationality capable of enhancing knowledge and the professional practice (1) . The NP consists of the attitude of scientific doing in Nursing.
As the nurses learn more about this way of doing Nursing, they note that the care provided has particularities and is materialized by resolute actions, based on the most innovative care practices.
The NP has five stages: research, nursing diagnosis, planning, implementation and evaluation. Such stages are capable of providing subsidies for the nurse's clinical reasoning. In the planning stage, after making a diagnostic decision, the nurse needs to select the best interventions, always considering obtaining positive results (2) .
The "aspiration of artificial airways" Nursing Intervention (NI) is an expanded approach that consists of removing secretions from the lower respiratory tract through a device with a negative pressure system, with aseptic technique and with the purpose of maintaining pervious airways (3) . In order to accurately detect the clinical signs that determine treatment with aspiration of artificial airways and perform it free of harms, it is necessary to continuously train Nursing professionals to effectively carry out this intervention (4) .
In 2017, the Federal Nursing Council (Conselho Federal de Enfermagem, COFEN) published resolution 557/2017 (5) , which standardized the role of Nursing in airway aspiration, demanding from nurses a proactive attitude in view of the obligation to investigate and correctly identify the need for this intervention, in addition to implementing it safely and developing a practice based on ethical and human precepts, supported by the best scientific evidence, with results monitoring.
The availability of evidence on artificial airway aspiration (AAA) still presents challenges for the professionals who perform it. In addition, the guidelines available in the scientific literature are not yet implemented in the clinical practice (6) .
To guarantee the quality of the teaching-learning process and personalized Nursing care for patients with specific needs, it is necessary to structure forms of education based on the results of clinical and educational scientific investigations (7) .
The teaching and learning process mediated by Information and Communication Technologies (ICT) seeks an innovative educational landscape employing changes in the way teachers teach courses and disciplines. In this sense, the blended learning modality -in-person and mediated by digital technology-stands out, with emphasis on the inverted classroom, which has been evidenced as an approach capable of improving student performance, as well as the perceptions of the learning experience (8)(9) .
Blended learning emerges as a promising approach to education in Nursing. In this conception, students have a variety of possibilities in the use of technology and countless communication practicalities about knowledge, making them motivated, involved in the learning process, committed and dedicated in their studies (10) .

Method
This is an applied and methodological research study, which involved technological production for teaching a NI, based on the Vygotsky's theoretical frameworks (11) and on the NP. The guidelines of the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) were adopted, as it is a study to improve quality of care, through the proposal of a teaching program.
For the elaboration and validation of the teaching program proposed in this study, the classic instructional design model ADDIE was used, which is an acronym for analyze, design, develop, implement and evaluate. These stages form a dynamic, flexible, effective and efficient guide (12) .
Instructional design analysis seeks to understand the educational problem and its possible solution (12) .
This phase consisted of conducting a literature review, which sought to broaden the understanding of AAA and subsidize the elaboration of the teaching plan, of Learning Objects (LO) -digital resources that can be used, reused or referenced during the technology-supported learning (12) and of assessment tools.
The main findings of the literature review were the clinical signs that indicate the need for AAA, the recommendations for execution and its main complications.
Based on these findings, the teaching plan was elaborated, covering research, diagnostic and therapeutic reasoning and the assessment of AAA through LO, which included videos and infographics.
The design referred to the planning moment in which the target audience, the necessary workload for the educational action, the learning objectives, the available resources and the evaluation of learning and of the references were defined. In the ADDIE instructional design, the implementation is subdivided into two phases: publication and execution (12) .
The first consists of making the learning units available to the experts and the second is the moment when the students carry out the activities proposed by the teaching program (12) .
In this study, it was chosen to host this teaching

Implementation (publication)
Hosting of the learning objects and assessment instruments in Moodle: "Extension Courses of the University of São Paulo"

Assessment
Validation by experts The criteria proposed by a scholar (13) for the selection of Nursing experts were adopted, considering a minimum score of five points to be included in the study. For the IT area, the following inclusion criteria were chosen: experience with technical support, programming or networking. Those participants who did not return the instrument within 12 days were excluded.
The search for experts took place through the Lattes Platform from the National Research Council (CNPQ) of Brazil, in research groups related to the theme of this study. Invitations were sent via e-mail, setting out the objectives, to 35 Nursing professionals and ten IT professionals in January 2020. The number of invitations sent to each professional category was motivated due to the requirements to be validated for the teaching program.
The IT professionals only participated in interface validation, while the Nursing professionals validated all requirements.
Those who agreed to participate were sent, at the end of the invitation, a link that directed them to a Google Gwet's First-order Agreement Coefficient (AC1) was used to verify the reliability of the agreement between the experts.
The program used for the agreement analyses was R, version 3.6.2, from the irrCAC library. The preference for using Gwet's AC1 over Cohen's kappa coefficient was due to the fact that the first is a more stable reliability coefficient than the second, that is, less affected by substantially unbalanced marginal totals (15) . For the classification of considerable, between 0.61 and 0.80; and almost perfect, between 0.81 and 1.00 (16) . The CVI considered acceptable was at least 0.80 and, preferably, greater than 0.90 (17) .
The project followed the legal procedures determined  Table 2 shows the characterization of the IT experts.  Table 3 presents the validations of the pedagogical requirements and specific requirements for videos and interfaces, performed by the Nursing experts. Table 4 presents the interface validation by the IT experts.

Discussion
The blended learning program was elaborated and its theoretical content was organized into six short topics that covered the stages of the EP through infographics and videos considered attractive LO (18) . The success of blended programs depends, not only on their validation and pedagogical quality, but also on how much the students are prepared to learn through this technology-mediated teaching (27) .
It is also necessary that the educators are prepared and take ownership of the ICT, with an emphasis on social networks. They must also develop skills with the VLE, especially Moodle and, finally, seek greater understanding of the human-computer interface and usability. It is essential to know the possibilities and limitations of the interface: the entire interaction of the student with the content, resources and LO takes place through it (12) . In this study, the interface requirements were validated by both Nursing and IT professionals, aiming at greater adequacy and success in the interaction between human and computer.
When there is a possibility of transition from a traditional program to the blended modality, the institution must offer support to the professors who have never taught online, with guidance from instructional designers and multimedia personnel, benefiting the leaders in their conceptions and design of innovative teaching programs (26) . In the past, a whiteboard and brush were the protagonists of this process. Nowadays, and in an irreversible way, it is the ICT that increasingly gain space and credibility (9,(25)(26) .
Direct instruction, with strict class schedules, is being replaced by videos and other attractive LOs, allowing the classroom experience to be better used in skills training activities and clinical simulations that contribute to the practice of students and nurses in the transition of virtual environments for assisting patients in a real environment (28-29) .
As limitations of this study, the absence of the usability evaluation of this teaching program from the student's perspective is mentioned. It is suggested that future studies may evaluate its usability and its impacts on the teaching and learning process of AAA.
As for the benefits and advances in knowledge, a teaching program on AAA is available, which can be used both for the training of future nurses and for permanent education in health institutions. The mediation by technological devices of a digital culture for teaching and learning corroborates Vygotsky's ideas (11) and constitutes an innovative proposal.

Conclusion
The blended learning program for aspiration of