Computer and laboratory simulation in the teaching of neonatal nursing: innovation and impact on learning 1

ABSTRACT Objectives: to evaluate the cognitive learning of nursing students in neonatal clinical evaluation from a blended course with the use of computer and laboratory simulation; to compare the cognitive learning of students in a control and experimental group testing the laboratory simulation; and to assess the extracurricular blended course offered on the clinical assessment of preterm infants, according to the students. Method: a quasi-experimental study with 14 Portuguese students, containing pretest, midterm test and post-test. The technologies offered in the course were serious game e-Baby, instructional software of semiology and semiotechnique, and laboratory simulation. Data collection tools developed for this study were used for the course evaluation and characterization of the students. Nonparametric statistics were used: Mann-Whitney and Wilcoxon. Results: the use of validated digital technologies and laboratory simulation demonstrated a statistically significant difference (p = 0.001) in the learning of the participants. The course was evaluated as very satisfactory for them. The laboratory simulation alone did not represent a significant difference in the learning. Conclusions: the cognitive learning of participants increased significantly. The use of technology can be partly responsible for the course success, showing it to be an important teaching tool for innovation and motivation of learning in healthcare.


Introduction
Among the strategies and tools applied to nursing education, realistic simulations conducted in laboratories, navigation software organized into specific content, and serious games (educational games) are important.

Serious
games are characterized as a complementary tool, whose main purpose is to provide experience and emotion by means of a simulated virtual environment transformed into meaningful learning (1) providing support for education with solid concepts based on critical thinking, problem solving, planning, flexibility and adaptability (2) .
In addition to the digital tools for education in healthcare, the simulated practice used in education, presents advantages indicated in the literature, with an emphasis on: Patient safety, as the student will have his first practical experience with a real patient; Ethics in the care performed by students in the healthcare area, because they will be better prepared for real situations after the previous simulation and Learning opportunity, considering that not all health intervention situations can be performed by students -such as emergency situations, for example (3)(4) .
This study was developed to understand the impact of a serious game, with computer simulation, associated with the laboratory simulation in a blended course on clinical evaluation of preterm infant.

Objectives
The objectives of this study were: to evaluate the cognitive learning of nursing students regarding neonatal clinical assessment from a blended course using computer and laboratory simulation; to compare the cognitive learning of the students in the control and experimental group when testing the laboratory simulation; and to evaluate the extracurricular blended courses offered on clinical assessment of preterm infants, according to students.

Methods
This was a quasi-experimental research study with 14 Portuguese students whose intervention was composed of the stages of the Clinical assessment of preterm infant course, which included an active pedagogical strategy, understood in this study as educational activities in which the student is encouraged to be an active member in the teaching-learning process, by means of challenges and questions.
Interactive tools were used, such as the serious game e-baby (5) (which virtually simulates the clinical assessment of a preterm infant with respiratory problems maintained in the incubator), instructional software semiology and semiotechnique of the preterm newborn (SSRNPT) (6) , and laboratory simulation.

Data collection
The blended course was offered in an extracurricular certificate program, by the School of Nursing of Coimbra For analysis of the laboratory simulation as intervention research, and so that the proposed methodological model could be used, all students in the sample (n=14) separately participated in this laboratory activity, considering the aim of this study (Figure 1), immediately before the midterm test (experimental group n=7/50%) and after the midterm test (control group n =7/50%).
Thus, Figure 1 represents the study flowchart for a better understanding of the method applied and the chronology of the study procedures. For the test of learning, the range of scores was a minimum of 0 and a maximum of 100. The desirable score was greater than or equal to 70.
Performance, established as the difference between scores achieved by students in a subsequent test and a previous test, the, difference between the post-test and pretest scores, and from the midterm test and the pretest score (8) .
The instrument for the course evaluation by students was composed of 23 items using a Likert scale, which used the scoring of: "insufficient", "sufficient", "good", "very good" and "excellent." A free text space and one for the course evaluation.
The characterization included issues related to personal data, such as sex and age, as well as to identify the technologies used routinely by the students.
The learning performance was evaluated by means of a questionnaire composed of 20 objective questions, exclusively designed for this study (with multimedia), used for all the tests, but in a randomized order of appearance of the questions and its alternatives, ensuring the same level of difficulty. The questions were designed to measure cognitive learning (conceptual knowledge hierarchically organized according to the degree of abstraction and generalization, which were related to each other) (7) . teaching tools that supported the course, in the same way as the general evaluation for organization and relevance.

Data analysis
The general description of the data relating to the characterization of the students was presented by use of descriptive statistics (mean, standard deviation, median and semi-quartile range).
The statistical analysis tests were performed using the Statistical Package for the Social Sciences (SPSS), non-parametric analysis method, according the nature of the main variable of interest which was poorly understood, and the limited sample size.
The intra-group comparison was performed using the non-parametric Wilcoxon test, while the comparison between control and experimental group was analyzed using the Mann-Whitney test, both of which considered a significance level of p < 0.05 and 95% of confidence interval.

Ethical aspects
This study was submitted to the Ethics Committee

Opinion of the students on the course
Among the 14 participants, only one student did not respond to course evaluation instrument, alleging forgetfulness. The results were mostly positive, ranging between "very good" and "excellent" in all the variables evaluated. There was a negative assessment characterized by "insufficient" only in the item: " time reserved for simulation laboratory practice" by three students, -corresponding to 21.5% of the study sample.

Digital educational technology
More situations in e-Baby could be introduced (Student B).

Course in general
The course is very well organized.

Many studies show a significant increase in students'
knowledge when using the simulation associated with other teaching strategies, (9) and that the digital technology is a valuable resource in the acquisition of information. However, its use alone may not be reflected in the acquisition of knowledge (10) . This information is supported by the results of this study, in which a course based on active learning methodology and associated tools was offered (digital material, virtual learning environment including chats and forums, laboratory and virtual simulation).
All educational intervention results improved learning, however, the relevance of the improvement comparing this process with "praxis", in the context of the working process and the quality demands of the health system (11) .
The improvement of the processes that includes the complex task of teaching and learning is the target of investigations throughout human history, studied since antiquity (12) . Increasingly, the teaching-learning process has been emphasized in the healthcare, due to the need to develop more creative professionals, engaged in problem-solving and guided by scientific evidence and ethics.
Studies attribute positive and successful characteristics to different strategies and tools used in this research, including: laboratory simulation, such as stimulating critical thinking (13) , virtual simulation as motivating and interactive with great potential as a pedagogical approach (14) , chats and forums as tools for online communication and collaboration (15) .
The results showed that the laboratory simulation, when analyzed as an isolated intervention, did not represent a significant difference between the control and experimental groups. However, at the end of the course, and after the several activities, the students from both groups achieved a significant improvement in learning without difference in their performance. The association of different educational tools is advantageous and they should not be used singly (16) . In addition, one should make use of innovative and creative strategies for the teaching-learning process, according to some researchers who evaluated the relevance of teaching technologies articulated to active learning methods (17) .
Despite satisfaction not necessarily being reflected in a good clinical performance (20) , it is a good indicator of quality education, as it is related to motivation and interest of students in learning, in addition to the versatility in simulating the clinical practice (21)(22) . of learning outcomes (23) . However, it is necessary to evaluate the developed educational tools, so that the cost-benefit question with each innovation can be analyzed, with basis on their impact and service to the development proposal. In addition to the validations of computer-user interface and scientific content, there is the evaluation by the target population for evaluation of satisfaction as to the results obtained with its use (25) .

Considering that the E-
The teaching tools must be evaluated and improved by students and teachers, who are the end users. Thus, their use in education can be significant, again. The results presented in this study reflect the Portuguese students' satisfaction with the course, from its organization and composition through to the execution.
We further suggest that the evaluation process of nursing courses is encouraged, includes self-evaluation, teacher evaluation by the students, and formative evaluation, just as was used by the researchers (26) , when analyzing and discussing the education of health professionals with a focus on problematization . Formative evaluation, among these, is a current challenge whose objective is monitoring the students' performance throughout the courses and not just at the end, allowing the educational reinforcement of the identified weaknesses.

Conclusion
According to the results, the cognitive learning of participants increased significantly from the beginning until the end of the extracurricular course, with gradual increase in scores on the tests (pre-test, midterm test and post-test). We believe that the teaching tools used as a support for physical classes and online activities had a satisfactory impact on the results. www.eerp.usp.br/rlae