Development of a virtual simulation game on basic life support

To validate the content of a virtual learning object in the format of a Role Playing Game - educational simulation game about basic life support, aimed at academics and health professionals.

Method:

Methodological, construction and validation study with qualitative data approach on the content of a virtual learning object, conducted between August and September 2016.

Results:

The game was developed in 13 screens, of which nine presented contents of basic life support, and the others presented general guidelines for progress in the game. The five suggestions of the experts were accepted by the researchers, and were mostly related to organization, clarity and vocabulary. No item was considered inappropriate by the judges, and the game had a mean content validity index of 0.96 and a Kappa value of 0.92. In the Likert scale evaluation, the game was considered in all analyzes as an excellent content for a virtual learning object.

Conclusion:

This learning technology is expected to support teaching of basic life support techniques for academics and health professionals, and to stimulate the development of similar teaching strategies in other scenarios, in order to bring advancements to the design of health training processes.

DESCRIPTORS:
Cardiopulmonary Resuscitation; Educational Technology; Education, Distance; Simulation; Validation Studies

Item	Definition
1 − Evaluation of overall content	Analysis of the content as a whole.
2 - Organization	Presents a logical sequence of events.
3 - Presentation	Presents adequate visual content.
4 − Utility/Pertinence	The question is relevant and serves the purpose of the instrument.
5 - Consistency	The content presents sufficient depth for understanding.
6 - Clarity	The content was presented in a clear, simple and precise manner.
7 - Objectivity	Allows a precise response.
8 - Reliability	The information’s degree of reliability to the original.
9 - Feasibility	The content presented is feasible.
10 - Updated	The content follows the most current evidence-based practices.
11 - Vocabulary	Words are appropriate for the educational level to which the instrument is intended and does not present ambiguities.
12 - Instructional sequence of the items	Items are previously explained.
13 - Learning assessment	Identify if the screen questions evaluate the content under analysis.

Screen/Objectives	Components of the game script
Presentation screen/ − Presenting the problem situation	− Simulated scenario: João Pedro is a 40-year old nursing technician who was spending his vacation in Natal/RN. One fine morning, as he was taking a walk on the beach esplanade, he felt a pressure in his chest, followed by severe pain radiating to his left arm and back. An intense, cold sweating began to afflict Joao Pedro, who found a nearby bench and sat down. When he realized that his condition was getting worse, he asked people who were passing by for help. Then he lost consciousness and fainted.
Instructions screen/ − Presenting the objective of the VLO and the instructions for the student progress in the game	− Objective of the simulation and orientation regarding the contents necessary to save João Pedro’s (the victim) life;
	− Navigation instructions;
	− The student will play the role of rescuer in the simulation game.
1^st content screen/ − Contextualizing the position of the student (active subject in the game) in relation to the problem situation − Beginning the assistance to João Pedro	− Stopwatch on;
	− Animation shows the rescuer watching the victim collapse;
	− Four multiple choice alternatives with actions to be taken with the victim fainting and safe scene;
	− Wrong answer generates feedback “wrong choice, please try again”;
	− Right answer generates animation showing the rescuer testing responsiveness and with cellphone on speaker calling the Mobile Emergency Care Service (SAMU 192).
2^nd content screen/ − Evaluating pulse and breath	− Four multiple choice alternatives with options to check pulse;
	− Wrong answer generates feedback “wrong choice, please try again”;
	− Right answer generates animation: rescuer palpates carotid pulse, simultaneously observes chest and diagnoses CPR.
3^rd content screen/ − Beginning 30 chest compressions − Identifying the correct location of compressions in the victim’s chest	− Four multiple choice alternatives with actions to be taken after CRP diagnosis;
	− Wrong answer generates feedback “wrong choice, please try again”;
	− Right answer generates animation: rescuer opens the shirt and new options regarding the location to start compressions appear; wrong answer generates the option to try again, right answer generates next animation.
4^th content screen/ − Identifying the frequency (rhythm) of chest compressions	− Four multiple choice alternatives with compression frequencies;
	− Wrong answer generates feedback “wrong choice, please try again”;
	− Right answer generates animation: rescuer performing the compressions at the right frequency.
5^th content screen/ − Identifying the depth of chest compressions	− Ruler is shown;
	− Three options of blocks of centimeters are shown for the rescuers to select the correct option;
	− If the rescuer defined the wrong mark, he receives the feedback message: “Ineffective compression. Try again”. If the rescuer chose the correct mark, he receives the feedback message: “Compression was effective. Perform 30 chest compressions”.
6^th content screen/ − Opening airway	− The rescuer has one hand on the victim’s forehead and is asked about where to place the other hand to open the airway. Four alternatives appear;
	− Wrong answer generates feedback “wrong choice, please try again”;
	− Right answer generates animation: opening of the airway, through hyperextension of the head and elevation of the chin.
7^th content screen/ − Performing ventilations	− Four multiple choice alternatives with actions related to ventilation;
	− Wrong answer generates feedback “wrong choice, please try again”;
	− Right answer generates animation: rescuer gets a CPR pocket mask on the backpack and performs two ventilations lasting 1 second each. Now the rescuer takes an Automatic External Defibrillator (AED) out of the backpack.
8^th content screen/ − Operating the AED correctly	− Four multiple choice alternatives with actions related to the position of the AED electrodes;
	− Wrong answer generates feedback “wrong choice, please try again”;
	− Right answer generates animation: rescuer puts the paddles in the correct position and the sound indicates that the AED is analyzing the heart rate. Then the screen shows the rescuer following the commands of the device to defibrillate.
9^th content screen/ − Restarting chest compressions	− Four multiple choice alternatives with actions to be taken after shock;
	− Wrong answer generates feedback “wrong choice, please try again”;
	− Right answer generates animation: the rescuer performs chest compressions. Curious faces appear, looking at the work of the rescuer. João Pedro reacts and begins to move. The curious crowd begins to applaud.
Success in Cardiopulmonary Resuscitation (CPR) screen)/ − Congratulating for the success on BLS actions	− Message of congratulations on the fact that João Pedro regained spontaneous circulation thanks to the rescuer (player), and that he will now be transported by the SAMU team to a Hospital for post-resuscitation care.
Death screen/ − Evidencing that there were failures in the BLS	− Message saying that João Pedro did not resist due to failures in BLS actions or delay in the onset of chest compressions. This screen is shown after the rescuer (player) has lost all three chances of saving the victim due to inappropriate actions.

Evaluation requirements	CVI	Kappa
Evaluation of overall content	1.00	1.00
Organization	0.83	0.67
Presentation	1.00	1.00
Utility/Pertinence	1.00	1.00
Consistency	1.00	1.00
Clarity	0.83	0.67
Objectivity	1.00	1.00
Reliability	1.00	1.00
Feasibility	1.00	1.00
Updated	1.00	1.00
Vocabulary	0.83	0.67
Instructional sequence of the topics	1.00	1.00
Learning assessment	1.00	1.00
Mean CVI	0.96	0.92

Screen/Objective	Suggestions (n)	Alterations
2^nd content screen − Evaluating pulse and breath	− Assess time spent to verify pulse and breath (1)	− Second stopwatch is added;
		− Feedback on wrong action added: “you lost more than 10 seconds checking the pulse, João Pedro will have sequels”;
		− Right answer within 10 seconds generates animation: resuscitator palpates carotid pulse, simultaneously observes chest and diagnoses CPR
4^th content screen − Identifying the frequency (rhythm) of chest compressions	− Check how the song “Stayin’ Alive” by Bee Gees could appear to help memorizing the rhythm of the compressions (1)	− In the animation that follows the right answer, the script was rearranged, so that two scenes are shown. On the first scene the rescuer performs the compressions on the frequency of the song, and on the second scene the rescuer remembers a moment in the classroom, when he was listening to “Stayin’ Alive” by Bee Gees on his headphones and tapping his foot in the rhythm of the song.
5^th content screen − Identifying the depth of chest compressions	− Add the reasons for the ineffectiveness of the compressions in the wrong alternatives (1)	− Addition in the feedback. If the rescuer chooses the mark of 0 to 4 cm in the ruler, he receives the message: “Very superficial compression. It cannot be effective. Try again”; If the rescuer chooses the mark of 6 to 7 cm in the ruler, he receives the message: “Very deep compression. You are using excessive force. Risk of rib fractures. Try again”. And if the rescuer chooses the mark of 5 to 6 cm, he receives the message: “Compression was effective. Perform 30 chest compressions”.
7^th content screen − Performing ventilations	− It is weird that a rescuer in the middle of the street has an AED in the bag (1)	− The script of the animation was restructured. After the correct ventilation, a SAMU ambulance is seen in the background. The rescuer and the SAMU professional merge into a single person dressed as a SAMU professional and carrying an AED.
9^th content screen − Restarting chest compressions	− Reuse the Bee Gee’s song “Stayin’ Alive” (1);	− CPR process occurs to the sound of the song “Stayin’ Alive” by Bee Gees;
9^th content screen − Restarting chest compressions	− Grammatical corrections (1)	− Textual corrections were made.

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author: Rodrigo Assis Neves Dantas Rua Petra Kelly, 61, Geraldo Galvão Residencial, casa 48, Nova Parnamirim CEP 59152-330 - Parnamirim, RN, Brazil rodrigoenf@yahoo.com.br