Virtual Learning Object for the Simulated Evaluation of Acute Pain in Nursing Students

This study aimed to evaluate the results of the application of a virtual learning object for the simulated evaluation of acute pain in the learning of undergraduate nursing students and to verify the opinions of the students regarding the quality of the technology. This was a quasi-experimental, non-randomized, before and after study performed with 14 students in the seventh phase of the undergraduate nursing course of the Federal University of Santa Catarina. The pre (8.84) and post-test (9.31) means revealed significant differences in learning after the intervention (p=0.03). In the qualitative evaluation the flexibility of access, access independent of time/place, freedom to decide the best learning route and the similarity with reality were highlighted. It constitutes a promising educational tool, an interactive experience, similar to reality, dynamic and constructive learning. The application of the technology has brought positive results for learning about pain evaluation, contributing to fill the gap in the teaching of the thematic.


Introduction
Pain is a universal experience, uniquely experienced by the individual, considered a public health problem.
In Brazil, as in other countries, the prevalence of pain affects 45% to 80% of patients during the period of hospitalization (1)(2) .This situation may be related to inadequate training of health professionals in the area of pain, evidenced by the absence of the theme in the pedagogic projects of undergraduate courses, which contributes significantly to the difficulties encountered in the professional practice (3) .Considering that the teaching-learning process is based on the practice of nursing care and that nurses play an important role in pain management, it is understood that they need to know how to evaluate it adequately in order to provide the necessary care to patients.www.eerp.usp.br/rlaeAlvarez AG, Dal Sasso GTM Studies conducted in developed countries, where basic and specialized education regarding pain is advanced, also highlight weaknesses in the learning of issues related to the evaluation and management of pain, with this situation in developing countries possibly being even more pronounced (4)(5) .Concerned with this situation, major organizations such as the International Association for the Study of Pain and the Brazilian Association for the Study of Pain have stimulated the development of new educational strategies in the area of pain, due to the relevance of the theme from the perspective of care.
Faced with the need for changes in the current teachinglearning process, it is observed that communication and information technologies impel even more changes in the most diverse areas of knowledge, causing significant impact in the teaching-learning process, and also representing new opportunities and challenges for educators and students (6) .In this context, virtual learning objects (VLO) are highlighted, characterized by flexible learning environments compatible with active learning methodologies, which valorize the autonomy of the students (7) .
From the conceptual point of view a VLO can be defined as a small unit that comprises a determined educational context.It represents an active and constructive teaching-learning strategy which constitutes the center of a new paradigm of instructional design for web-based learning, due to its support for various file types and also due to its characteristic of reuse (8)(9) .Thus, the creation and evaluation of the simulated virtual learning object for the evaluation of acute pain in adults (OVADOR) was developed by the authors from the fundamentals of Problem Based Learning (PBL) (10)(11)(12) , one of the most promising methodologies in the area of health education, and also from Evidence Based Learning (EBL).In this context, the application of the educational intervention mediated by the OVADOR seeks to offer undergraduate nursing students an innovative experience, based on an active teaching-learning strategy and also conforms to the ethical issues involved, since, through the simulation, learning that occurs during the real experience of the pain of the patients is avoided.
The study aimed to evaluate the results of the application of a virtual learning object for the simulated evaluation of acute pain in the learning of undergraduate nursing students and to verify the opinions of the students regarding the quality of the technology.

Materials and Method
This was a quasi-experimental, non-randomized,   When evaluating a patient with a wound in his left leg with a numeric visual scale, an intensity = 6 was identified.How can this pain and its severity be classified, considering that the evaluation was conducted with a numerical scale from 0 to 10?

Results
The analysis of the personal data of the students (n=14) revealed a young sample with a mean age of 24 years and predominantly female (84.2%When comparing the variables of time necessary to evaluate each virtual patient in the OVADOR and the post-test evaluation results, it was found that the means of the students were above 8, which did not allow the relationship between the variables to be established (Figures 3, 4).Regarding the freedom to decide the best route for the learning process, the premise of active learning methodologies, the following reports are highlighted: The level of anxiety reported by the students during the evaluation of the virtual patients in the OVADOR reached levels between 6 and 9 in 57.14% of the students and the evaluation of overall student satisfaction in relation to the technology obtained scores between 8 and 10.

Discussion
The average hours per week of students accessing the web for educational purposes and the use of various Alvarez AG, Dal Sasso GTM These findings are similar to other studies which show a growing interest of students in such technologies (12)(13) .
Analyzing the means and standard deviation obtained in the pre and post-tests of the students it was observed that the overall mean in the post-test was higher than in the pre-test (p=0.03).It can then be considered that the educational intervention provided significant results in the learning of the students.By identifying these results, it can be inferred that education mediated by a VLO in an online environment can result in improvements in the nursing teaching-learning process, with similar results encountered in other studies (13)(14)(15)(16)(17)(18)(19)(20)(21) .
The OVADOR provided the students with a learning opportunity through an active and collaborative association/relationship, allowing access independent of time or place, thus meeting the needs of the individual students.The technology also provided the freedom to decide on the learning route, corresponding to the premise of the methodology of PBL (11) , the method used in previous studies (7,(10)(11)14,17) . The reognition is highlighted of a simulated environment with real situations experienced in the health field, approaching those of the practice, an aspect highly valued by the students which can also further motivate them to study the thematic (18,(20)(21) .
Some of the suggestions for improvements recommended by the students, such as the elaboration of other simulated environments in different care contexts, were also observed in other studies (13,17) .This finding demonstrates the acceptability of the technology among students, reinforcing the idea that it could be applied especially valorizing the freedom to construct their own learning route (12) , as shown in Figure 5: Rev. Latino-Am.Enfermagem 2011 Mar-Apr;19(2):229-37.
It can be observed from the findings or this study, that the association of such learning methodologies coupled to computer resources can provide positive experiences for learning in nursing, in that it enables the student to make a critical analysis of situations and to search for resolution strategies for determined problems (10)(11)(12)17) .

Conclusion
The results of this study showed that the OVADOR

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before and after study, approved by the Research Ethics Committee of the UFSC (No. 171/2008), and conducted from September to October 2009.The intentional non-probabilistic sample of subjects was composed of 14 students from the seventh phase of the undergraduate program in nursing of the Federal University of Santa Catarina (UFSC).The study included the students who signed the Terms of Free Prior Informed Consent (TFPIC), with the availability to participate in study during extra-curricular time, who accessed the proposed content and completed the questionnaires for data collection.The educational intervention consisted of the following steps: 1 -Recognition of the OVADOR and signature of the TFPIC (in-person meeting), 2 -Access to the video and welcome, syllabus, expectations questionnaire, glossary and completion of the pre-test questionnaire, 3 -Access to the theoretical content for the deepening of knowledge (slides, texts, crosswords, articles for download in PDF, links to websites), Use of the OVADOR simulated environment and 5 -Completion of post-test questionnaire and qualitative evaluation of the technology.Steps 2 to 5 were carried out entirely online through the Moodle ® Virtual Learning Environment.Regarding the simulated environment (OVADOR), students were presented with two cases of virtual adult patients, one in a medical surgical ward and the other in an intensive care unit.The following tools for the evaluation of pain were available (Figure 1): 1 -Consult the Medical Records; 2 -Evaluate the Patient; 3 -Determine Diagnosis; and 4 -Prescribe Intervention.The tool "To Evaluate the Patient" had the options: 1 -To Talk to the Patient; 2 -To Apply a Pain Scale (Numeric Visual and Critical-Care Pain Observation Tool); 3 -To Evaluate Behavioral Aspects; and 4 -To Evaluate Physiological Aspects.Rev. Latino-Am.Enfermagem 2011 Mar-Apr;19(2):229-37.

Figure 1 -
Figure 1 -Tools for the evaluation of virtual patients in the OVADOR.Florianópolis, Brazil, 2009.Data collection was performed using four instruments: 1 -Socio-demographic data questionnaire, 2 -Questionnaire (pre and post-test) on the evaluation of acute pain (Figure 2), 3 -Qualitative evaluation of

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Explain in your own words why pain is considered the 5th vital sign:2.Regarding its duration, pain can be classified as:( ) Acute or neuropathic ( ) Acute or chronic ( ) Chronic or neuropathic ( ) Neuropathic or visceral3.Nociceptive pain results from stimulation of nerve endings by nociceptive (algogenic) substances, such as the substances resulting from the inflammatory process ( ) True ( ) False4.Acute persistent pain can lead to diverse alterations in the human organism.Indicate the answer that does not belong to the group of alterations resulting from acute pain:

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Figure 2 -Questionnaire on acute pain evaluation applied during the educational intervention.Florianópolis, 2009.The socio-demographic data questionnaire consisted of open questions that included the variables: age, gender, use of information technology, number of hours of internet access per week for educational purposes, and experience of the students with VLEs.The qualitative evaluation included the identification of difficulties during the study, description of positive and less positive aspects related to the use of the technology, perception about the contributions to learning, suggestions for improvements, level of anxiety during the simulation (scale of 0 to 10) and general satisfaction of the students with the OVADOR (scale of 0 to 10).The results obtained were collected and analyzed in spreadsheets using the software Excel ® 2007 and the analysis occurred through

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Figure 3 -Results at post-test compared to the time of evaluation of the surgical patient.Florianópolis, Brazil, 2009.

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Figure 4 -Results at post-test compared to the time of evaluation of the intensive care patient.Florianópolis, Brazil, 2009.The results of the qualitative evaluation of the OVADOR highlighted the flexibility of access offered by computer technology, especially the valorization of the aspects of access independent of time and place, according to personal need: (...) adaptation of our time availability because it could be done according to the availability of each person (Student 9); (...) practicality and ease of access, providing the opportunity of learning for all, regardless of workload, domestic commitments (...) (Student 14).

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...) presents different ways of learning, since the mode of evaluation does not remain the same all the time (Student 9); (...) encourages the participant to seek related issues (...) (Student 13).The perception of the students regarding the proximity of the simulation to the reality experienced in the care practice can also be identified: (...) in an almost practical way it shows us how the evaluation of the pain of a patient should be carried out (Student 1); (...) seeing the situation it becomes clearer to assimilate what has been studied (Student 4); (...) when caring for a patient today I think immediately about the pain.I'm more attentive, especially "to see" the pain through the signs and symptoms when it is not visible, (Student 13); The simulated environment tries to approach the practice and makes us feel in the same learning place (Student 14).In relation to the less positive aspects, the students mainly cited problems related to technical matters, such as: The biggest difficulty was that several times I tried to start the study and the page did not load, even using Firefox (Student 4), I think the biggest difficulty was the delay in opening the page (...) (Student 14).Specifically regarding the OVADOR, some difficulties were mentioned related to the signs of pain presented by the virtual patients: In the case of the boy with the broken arm, I was in some doubt regarding whether his color change was related to the pain or not (Student 12); (...) the difficulty I encountered was to evaluate the sedated patient of the simulated environment, as the presented signs were unclear (...) (Student 13).Students also suggested improvements in order to facilitate the teaching-learning process mediated by this type of educational technology in undergraduate nursing courses.A total of 13.3% indicated a need for improvements in the signs of pain presented by the virtual intensive care patient and 46.7% suggested the inclusion of new clinical cases related to different contexts (collective health, emergency, fundamentals of nursing).
more frequently in educational institutions, benefiting the teaching-learning process of future nurses.The high levels of anxiety (6 to 9) reported by 57.14% of the students during the simulation indicates their immersion in the environment, to the point of feeling anxious at the moment of evaluation of the virtual patients, as might occur during a real experience.The general satisfaction of students in relation to the OVADOR, reaching scores of 8 to 10, must be highlighted, demonstrating once again the acceptability of the technology for educational purposes.During the educational intervention mediated by the OVADOR the relationship between the steps of PBL and EBL in the student learning was observed, delivered an interactive educational experience to the undergraduate students in nursing, similar to real situations experienced in healthcare.It was concluded that the OVADOR is a dynamic, constructive, innovative method which is appealing for the learning of the students, in the teaching of simulated acute pain evaluation to nursing students.Analysis of the pre and post-test means allowed the observation of the influence of the OVADOR in the learning of the study participant students after the educational intervention.Concerning the qualitative evaluation, the flexibility of access, valorization of access independent of time/place, freedom to decide on the best learning route, and the similarity of the simulation with the real situations experienced in the care practice were highlighted.Based on these, it was concluded that, despite the limited sample of students, the OVADOR reached the objectives proposed by the study, i.e. identified positive outcomes for the learning of future nurses.It should also be considered that teaching mediated by the concept of VLO still constitutes a challenge for developers, researchers, educational institutions, teachers and students, due to the increasing insertion in the area of nursing, as well as the need for familiarization with web-based technologies.The development of other studies in different care contexts is recommended, as well as the analysis of the various aspects related to the teaching-learning process mediated by the concept of VLO and its impact on patient care, in order to contribute to scientific knowledge in the area of nursing and the training process of future nurses.