Interdisciplinary simulation scenario in nursing education: Humanized childbirth and birth

Objective: to develop and validate with a panel of experts a scenario of maternal-child clinical simulation, related to humanized childbirth and birth. Method: methodological study based on the Jeffries framework and standardized guides of the International Nursing Association for Clinical Simulation in Learning, which used analysis with descriptive statistics for general aspects of adherence to the aforementioned guide and inferential statistics for validating the checklist of actions through the Intraclass Correlation Coefficient (ICC). Results: the scenario contains learning objectives, necessary resources, prebriefing and debriefing of guidelines, description of the simulated situation, participants and roles, and checklist of expected actions. The validation obtained an agreement level above 80% in all aspects evaluated by 31 experts, highlighting realism of the environment and setting, vital sign parameters, alignment with scientific literature and encouragement of critical thinking and problem solving. In addition, the checklist of actions was validated with 0.899 agreement among experts, statistically analyzed by the ICC and Cronbach’s alpha 0.908 (95% confidence interval). Conclusion: the simulated scenario on humanized childbirth and birth can strengthen the articulation between women’s and children’s health disciplines, and was validated by experts.


Introduction
The complexity of the health situations that nursing professionals face in their daily lives requires a set of knowledge, skills and attitudes that must be mobilized in an articulated manner to address the health needs of the population (1) .
The National Curricular Guidelines for Nursing determine that learning is centered on the student as an active subject in this process, with the teacher having the role of facilitator and mediator (2) . This document directed curricular changes in the pedagogical projects of courses across the country, and its new preliminary version -approved by the National Health Commission in 2018 -shows elements that are compatible with this aspect, highlighting it even more.
However, for these guidelines to be translated into improvements in the teaching-learning process, it is necessary to invest in training based on active methodologies, which enable meaningful learning (3) .
In this context, clinical simulation stands out as a strategy aligned with the active pedagogy model, providing the student with the opportunity to develop complex learning by experiencing realistic situations in a safe and risk-free environment (3) . Through simulated practices, the student health professional can improve technical, communication and also behavioral skills, develop critical observation, learn to work in a team, exercise clinical reasoning and decision-making (1) .
Clinical or realistic simulation has an important educational attribute in improving the performance of students in practice settings, as it allows the execution of possible to make mistakes without harming themselves and others, reflecting about the error and define new strategies with a view to success before being subjected to care practice (4)(5) .
Another important advantage of simulation, which in particular motivated the realization of this work, is the possibility of an interface between contents and themes that are generally fragmented in different disciplines. As it allows the articulation of contents in an interdisciplinary perspective, simulation is highlighted in competence education and in the exercise of clinical reasoning with a view to comprehensive health care.
Thus, the objective of this research was to develop and validate a simulation scenario in the maternal and child area related to humanized birth and birth.

Method
Methodological research for the development of a clinical simulation scenario in an interdisciplinary perspective and validation with experts on the topic of women's and children's health, held in the first quarter of 2019.
For the development of the simulation scenario, we adopted the framework proposed by Jeffries (6) which consists of the following elements: Theme identification, simulation objectives, participants, scenario and debriefing process, in addition to the elaboration guides standardized by the International Nursing Association for Clinical Simulation in Learning (INACSL) (7) .  (13) and, to meet the purpose proposed in the study, the absolute agreement analysis was used, in order to measure whether the different experts would attribute similar scores using the proposed instrument.
The cut-off points of the ICC analysis generally vary depending on the reference, but always with values between 0 and 1, indicating a high correlation the closer to 1 and a low correlation the closer to 0. In this study, we adopted the framework that defines: ICC <0.4 as weak; 0.59> ICC> 0.4 as regular; 0.74>ICC>0.59 as good and 1.0> ICC> 0.74 as excellent (14) .
In addition, the descriptive analysis evaluated the simulation scenario regarding the contained information that guides the student in solving the problem situation, alignment with scientific evidence, realism, resources used, level of difficulty and debriefing.

Results
As a result of the first objective of this study, that of developing the simulation scenario, it was called "Humanized childbirth and birth" and had the following Rev. Latino-Am. Enfermagem 2020;28:e3286.
Still in the perspective of environmental support, it is worth noting the importance of a physical medical record with data on the parturient, partogram, a form with the variables of the Apgar evaluation and for recording the delivery data, which must be prepared by the teachers in advance.
To perform the simulation, the first moment was the prebriefing, which includes prior preparation for what will be experienced in the scenario based on the theme. Thus, the participants previously received scientific references for the study of childbirth and birth with a focus on the humanization of care. At the time of the simulated activity with the participants, at the Simulation Center, the prebriefing followed the following steps: Agreement of the rules, the roles to be played, mutual respect and confidentiality. Thus, in the prebriefing, in addition to these items, we identified the experiences of the participants in previous simulations and in childbirth and birth, we clarified that the general objective of the scenario would be assistance in this context, we inform that the estimated scene time would be ten minutes and we present the environment and the functioning of equipment and mannequins. A moment was offered for the participants to familiarize themselves with the scenario. The prebriefing lasted five minutes.
Before the volunteer participant on the scene acted properly in the problematic situation, he participated in the shift by a colleague from the health unit who presented the data contained in Figure 1.

SHIFTING PASS
Simone, a 15-year-old primigravid parturient, with 8 cm dilation, is accompanied by her sister in the delivery room. She mentions that she is experiencing severe pain during the contractions, but is confident about the vaginal delivery route decided in the prenatal period, which by the way followed all the steps and recommendations of the Ministry of Health. BP = 128x80 mmHg, HR = 98 bpm, oxygen saturation = 97%. Without analgesia, without serum.   Objectives displayed in the prebriefing; Simulator and environment parameters; Debriefing as for the questions, reflection and analysis proposed and carried out, as to the synthesis constructed and about the feedback from teachers to students; and adherence to the scientific evidences.
Stimulation to critical thinking; the resolution of problems with autonomy, the ability to prioritize evaluations and actions inherent to the nurse's performance; materials and equipment available for the resolution of the scenario.

Initiatives like this have been encouraged by
documents regulating nursing courses in the country (1) and simulation, in general, draws attention as a strategy to strengthen integrated, critical and resolutive learning (17)(18) .
In addition to the articulation of women's health and children's health content in nursing, the scenario has potential for interprofessional use, expanding the concept of interdisciplinarity to other professional categories in the health field that work with the common goal of promoting safe and comprehensive care to the patients and their families (19) .

Inter-professional teaching in courses promoted by
HEIs is encouraged by the World Health Organization itself, so that it makes possible the realization of a collaborative practice and with an important advance in communication (20) .
Although admittedly necessary, both interdisciplinarity and interprofessionality, it is still challenging to break the barriers of fragmented teaching in HEIs.
On the other hand, advances have been made with the reformulation of pedagogical projects for courses and from the commitment of students and teachers in the use of active methods and strategies, such as the mapping of competences (21) , the curricula integrated with activities of interface of the basic area with the specific area (22) and curricula that incorporate the simulation (18) .
The results of the validation were quite positive and the experts' suggestions added greater quality to the scenario, strengthening its realism and providing more specific information related to humanized childbirth -a topic that is very important in the current context of the country, in which it seeks to improve the quality of care to women throughout the pregnancy-puerperal cycle, in order to reduce the maternal mortality rate, which is currently 60 deaths per 100,000 live births (23) .
Therefore, it is necessary to advance in aspects of universal access to quality health services that are effective and safe, and that offer reliable guidance to women, favoring their autonomy for informed decisionmaking during care during this period, so that they have their rights respected by health professionals (24) .
Still in the national epidemiological context, infant mortality was reduced during the analysis of the millennium goals, reaching around 15 deaths per 1000 live births in 2015 (25) .
Despite national and global advances, it is important to note that 45.1% of infant deaths occur in the neonatal period worldwide (26) . Another study developed in situ with teachers of kindergarten and elementary school I showed that the simulation contributed to increase the self-confidence of these participants to manage health problems in schools, reinforcing the relevance of using this strategy even outside simulation centers (31) .
Thus, for HEIs that do not have a high fidelity environment, conducting the simulation in health units -when available for this purpose -can be an interesting proposal.
Or, even in a laboratory with little equipment or without a high-fidelity simulator, it is possible to implement the strategy with a portable simulator that has significantly lower cost and also presents favorable results in the teaching-learning process (28) .
Even from the simulation that mixes simulated anatomical parts and an actor or actress representing the patient, it is possible to strengthen the aspect of interpersonal communication (28) , impaired in the nonverbal aspect when the student must communicate with a mannequin (32) .
Clinical simulation allows the student to experience the stresses of participating in the health team during childbirth and being responsible for assessing health needs and acting quickly, efficiently and in accordance with what is recommended.
The experts who took part in this study, suggested to include in the list of expected actions the late clamping of the cord, however this was not incorporated due to the validation process being underway and because the clamping, in a realistic way, would be under the responsibility of the professional interpreted by an actor and not by the student on the scene.
In the prebriefing, which displays guidelines and information on the theme through videos, texts and other sources immediately before the simulated scene, participants should be guided to the next steps of the activity.
The prebriefing displays a review of the objectives of the scenario, guides on the use of equipment, mannequins, the roles to be developed by each person in the scene, the time of execution of the scenario and the situation to be experienced (7,33) , recommendations that were followed in this study.
The purpose of the prebriefing is to establish a psychologically safe environment for the simulation participants, with the establishment of a work "contract" for the activities (7) .
After the prebriefing and the simulated scene, the debriefing took place, an important moment of reflection and discussion to consolidate learning, which contributes to improving the performance of students apprentices in the real practice of health care (34) .
The debriefing was structured according to the emotional, behavioral and cognitive stages and was mediated by the facilitator, who initially sought the verbal expression of the participants who were on the scene and, subsequently, the expression of the other members of the group (35) .
For operationalization purposes, we can divide the debriefing in the following phases: We emphasize that the debriefing is necessary and can be carried out in different ways, from different references, but we suggest the format we implemented in this study, considering the positive evaluation by the participants.
Although a duration forecast is provided for each phase (35) , the time used for the debriefing depends on This investigation contributes to the scientific advancement of research on nursing simulation, through the methodological rigor adopted. This is because the study presents not only the theme of a case that does not involve urgency and emergency (most contingent of simulated scenarios created in nursing), but a new look at a situation that often happens, unfortunately, in hospitals and maternity hospitals and that nurses' decision-making is required to change reality.
In addition, the study presents the steps for the development and validation of interdisciplinary scenarios, strongly recommended by the World Health Organization.

Conclusion
Simulation is a teaching-learning strategy with a strong potential for interdisciplinarity and benefits