Use of a therapeutic communication application in the Nursing undergraduate program: randomized clinical trial*

Objective: to analyze the effect on the knowledge of therapeutic communication by Nursing students through the use of applications. Method: a randomized and controlled clinical trial conducted with 60 nursing students. In the topic Groups and therapeutic communication techniques, the intervention-IG group (n=30) used the application and the control-CG group (n=30) was submitted to the traditional class. The pre- (Zero Test -0) and post-test knowledge (immediate-Test 1 and after 30 day-Test 2) of those involved were evaluated. Results: Test 1, performed immediately after the intervention, showed a mean of 11 hits in the control group and 13 in the intervention, with statistical significance (p=0.036). Test 2 showed a decrease in hits in both groups (IG=10.87 and CG=9.3), but maintained the difference between IG and CG in the post-test (p<0.01). Conclusion: the use of the application on therapeutic communication favored the knowledge of the students, when compared to the traditional teaching method. REBEC RBR-4TF6MR Registration.


Introduction
The Nursing undergraduate courses aim to accompany changes in the health needs of society, the training process and health work. Integrated disciplines, active and student-centered methods have been a relevant challenge, instigating students and teachers to overcome the traditional method of teaching-learning (1)(2) . A study predicts that soon nurses will experience their practice permeated with technology, requiring curricular adaptation (3)(4)(5)(6) that favors the early use of media resources in the undergraduate course and in care, as in the case of mobile devices or applications (APPs) (7)(8)(9) .
Although there is no guideline or legislation on the use of applications for teaching, the Brazilian Ministry of Education created the International Bank of Educational Objects, which provides virtual tools produced by teachers in free format, with multiple platform and language. But this bank has received few registrations, raising the need to increase its production (10) .
In this sense, review studies (11)(12) denote the adoption of multiple Learning Objects (OAs), such as blogs, chats, wikis and virtual simulations, in the increase of knowledge and autonomy of students, especially in the health area, suggesting their testing in clinical trials for the production of scientific evidence (12) .
When considering the complexity of nursing care, which requires the nurse, polysemy and completeness of content (13) , communication is the basic instrument of care, allowing centralization in the user and in their singularities (14) . Communication, whether verbal, nonverbal or para-verbal, is strongly present in the practice of the nurse, constituting action, including therapeutic, as the actions of nursing care provided to pregnant women, deaf people, mother-child binomial, critical patients, among others (15)(16)(17)(18) .
The theoretical reference of communication adopted in this study was that of Maguida Costa Stefanelli, who considers the communication in Nursing as an integrator between assistance, teaching and research, being fundamental in the care, educational practice and health care (19)(20) . Thus, the objective of this study was to analyze the effect on the knowledge of therapeutic The intervention took place on a school day of the discipline "Psychological Basis for the Care Process", in the class on "therapeutic communication". In the curricular matrix of the course, this subject is taught in the third semester. The population of the study was 146 students enrolled in the discipline and the sample was 121 of these who were present in class during the data collection. The subject was taught in different shifts, minimizing the contact between participants.
Grouped randomization via www.random.org was used and the classes of the three shifts had the same chance to participate in the IG and the CG (21) , because the computerized algorithm defined which group would receive the intervention and which would be the control.  of the APP. The same researcher, who taught the class at IG and CG, applied the data collection questionnaire in all three stages. Blinding in educational interventions is complex and needs to minimize possible co-interventions and blind, minimally, the responsible for the evaluation and adjudication of the outcomes, diminishing biases of the principal researcher in a differentiated look to the IG (21) .
The IG and CG classes began with the conceptual presentation of human communication, its forms and functions, therapeutic relationship, groupings (expression, clarification and validation) (19) and  (19) .
The CG class was taught in the morning group and held exposition with the PowerPoint feature and duration of one hour and 47 minutes. In the night group (IG), following the POP, in the topic Groups and therapeutic communication strategies, the APP "Therapeutic Communication" was used. For this, students were guided to download the APP in temporary link using a specific login and password. The APP resources were handled, which also contained an interactive video about the practice of content. This class lasted one hour and 52 minutes. They were told to feel free to explore the APP, watch and interact with the video and that they could dialogue through the teacher's exposure and the content of the APP. After the class, students' access to APP was cancelled to prevent other students from accessing it. It should be noted that APP was produced and validated for this essay, and this methodological study is under evaluation in a journal for later publication.

Results
Of the 121 students invited, 104 met the inclusion criteria and accepted to participate in the study, 50 were assigned to IG and 54 to CG. During the research, the IG had 11 losses for absence in the M1 and another nine for absence in the M2, ending with 30 students. In the CG, there were ten losses for absence at the M1 and 14 more for absence at M2, ending also with 30 participants  Even with more students decreasing their grades in M2, still the students in IG showed higher values than those in CG, with statistical significance (p=0.028) and greater homogeneity of values ( Table 3). The study was finalized after data collection from M2.  The ANOVA test showed the effect of the intervention on learning by students from IG (p < 0.001) and CG (p < 0.001). Sidak's post-hoc showed a significant difference between all moments in both groups (intragroup).

M1-M2) of the Control Group (CG)
The following Figure 2 compares the averages of hits of the two groups at the three moments, associated with the trend lines.

Discussion
At first, it should be considered that in experimental research, sampling bias is a significant problem. Thus, getting homogeneous samples, even unrepresentative ones, is one of the ways to minimize this issue (21) . The similarity in the study groups with the two groups is a way to ensure that they have the same characteristics, configuring the intervention as the only different variable to permeate the study (22) .
The on-screen study reveals that the average grades  (24) . At Washington State University, research on the use of APP in teaching-learning was conducted and it was proven that the use of APP by students contributes to learning (p=0.01) (25) . A Peruvian clinical trial measured the knowledge acquired by nursing students after using APP to teach tracheostomy tube aspiration and pointed out that the knowledge of students who used APP was superior and of statistical significance (p=0.003) to the traditional one, recommending the adoption of such a device (29) .
A meta-analysis of 11 clinical trials showed the increase in learning via APP for nurses and students, stating that there is good support and positive influence on Nursing education (30) . However, using smartphones during the lesson can also be a distraction (31) , which can make it difficult to reach the intended goal.