EDUCATIONAL TECHNOLOGY IN THE SURGICAL CONTEXT: VALIDITY OF A SERIOUS GAME FOR PRE-OPERATIVE GUIDANCEABSTRACT
Objective: To validate the content and appearance, and assess the usability of a serious game for guiding surgical patients in preoperative preparation.
Method: This is a methodological, technological production, and quantitative study conducted between August 2024 and September 2025 in Florianópolis, Santa Catarina, Brazil. Data collection was carried out in three stages: (1) prototype conception and development; (2) serious game content and appearance validity by perioperative nursing specialists; and (3) usability assessment performed by nursing students in an academic context using the System Usability Scale. The analysis considered descriptive statistics, Content Validity Index, and mean usability score.
Results: The serious game was validated by 13 specialist nurses, obtaining a mean Content Validity Index of 0.9. In the usability assessment, 24 nursing students participated, and the mean score obtained was 75.2 points on the System Usability Scale, classified as “good”. Visual and textual adjustments were suggested to facilitate use by patients with less familiarity with written language.
Conclusion: The validated serious game demonstrates potential for use as an accessible strategy for guiding patients in preoperative preparation, contributing to the promotion of safety and expanding the possibilities for the use of educational technologies in perioperative nursing.
DESCRIPTORS:
Perioperative Nursing; Patient Safety; Educational Technology; Gamification; Health Education; Preoperative Care; Nursing
RESUMO
Objetivo: validar o conteúdo e a aparência, e avaliar a usabilidade de um jogo sério para orientação de pacientes cirúrgicos no preparo pré-operatório.
Método: estudo metodológico, de produção tecnológica e natureza quantitativa, realizado entre agosto de 2024 e setembro de 2025, em Florianópolis, Santa Catarina, Brasil. A coleta de dados foi conduzida em três etapas: (1) concepção e desenvolvimento do protótipo, (2) validação de conteúdo e aparência do jogo sério por especialistas em enfermagem perioperatória e (3) avaliação da usabilidade realizada por estudantes de enfermagem, em contexto acadêmico, por meio da System Usability Scale. A análise considerou estatística descritiva, índice de validade de conteúdo e escore médio de usabilidade.
Resultados: O jogo sério foi validado por 13 enfermeiros especialistas obtendo índice de validade de conteúdo médio de 0,9. Na avaliação da usabilidade, participaram 24 estudantes de enfermagem, e o escore médio obtido foi de 75,2 pontos na System Usability Scale, classificado como ‘bom’. Foram sugeridos ajustes visuais e textuais para facilitar o uso por pacientes com menor familiaridade com a linguagem escrita.
Conclusão: O jogo sério validado demonstra potencial de uso como estratégia acessível para a orientação de pacientes no preparo pré-operatório, contribuindo para a promoção da segurança e ampliando as possibilidades de uso de tecnologias educacionais no contexto da enfermagem perioperatória.
DESCRITORES:
Enfermagem perioperatória; Segurança do paciente; Tecnologia educacional; Gamificação; Educação em saúde; Cuidados Pré-Operatórios; Enfermagem
RESUMEN
Objetivo: Validar el contenido y la apariencia, y evaluar la usabilidad de un juego serio para guiar a pacientes quirúrgicos en la preparación preoperatoria.
Método: Estudio metodológico, de producción tecnológica y naturaleza cuantitativa, realizado entre agosto de 2024 y septiembre de 2025 en Florianópolis, Santa Catarina, Brasil. La recolección de datos se llevó a cabo en tres etapas: (1) concepción y desarrollo del prototipo; (2) validación del contenido y la apariencia del juego serio por especialistas en enfermería perioperatoria; y (3) evaluación de la usabilidad realizada por estudiantes de enfermería, en un contexto académico, utilizando la System Usability Scale. El análisis consideró estadística descriptiva, Índice de Validez de Contenido y puntuación promedio de usabilidad.
Resultados: El juego serio fue validado por 13 enfermeras especialistas, obteniendo un Índice de Validez de Contenido promedio de 0,9. En la evaluación de usabilidad participaron 24 estudiantes de enfermería, y la puntuación promedio obtenida fue de 75,2 puntos en la System Usability Scale, clasificada como “buena”. Se sugirieron ajustes visuales y textuales para facilitar su uso a pacientes con menor familiaridad con el lenguaje escrito.
Conclusión: El juego serio validado demuestra potencial como estrategia accesible para guiar a los pacientes en la preparación preoperatoria, contribuyendo a la promoción de la seguridad y ampliando las posibilidades de uso de tecnologías educativas en el contexto de la enfermería perioperatoria.
DESCRIPTORES:
Enfermería Perioperatoria; Seguridad del Paciente; Tecnología Educacional; Gamificación; Educación en Salud; Cuidados Preoperatorios; Enfermería
INTRODUCTION
Preoperative preparation is a fundamental aspect of ensuring patient safety during the perioperative period. Various physical, emotional, and informational factors can impact a patient’s experience at this time, making a careful and individualized approach essential1. Among these factors, anxiety stands out, a common human reaction that can be identified in the face of surgical procedures, regardless of their complexity, causing fear and nervousness in patients1. In this scenario, clear, accessible, and understandable guidelines are essential to minimize risks, reduce anxiety, and promote a safer surgical experience.
Weak instructions or a lack of opportunities to clarify doubts can compromise patient preparation, which can sometimes worsen their emotional state and directly impact surgical outcomes2. Well-informed patients tend to experience less anxiety, greater autonomy, and faster recovery2. It is the responsibility of the healthcare team to ensure that patients and their families fully understand the pre-operative stages, such as fasting, personal hygiene, medication use, type of anesthesia, possible complications in the post-operative period, among other aspects1,3.
Therefore, it is understood to be fundamental to clarify possible complications and limitations during and after surgery, such as the use of catheters, cardiac monitoring, the presence of pain, and recovery processes in the post-anesthesia recovery room and during surgical hospitalization1. Given this scenario, the nurses’ role involves not only conveying information, but also encouraging patients’ active participation, prioritizing safety and autonomy in the care process4. Joint participation promotes understanding of procedures, risk management, and commitment to the guidelines provided2.
Given the complexity of the surgical process, educational technologies are configured as complementary resources to verbal instructions, offering patients additional means of consultation and reinforcement of information through the technological mediation of knowledge5. These tools, when accessible, have the potential to influence behaviors related to health promotion, contributing to the internalization of practices and strengthening the bond with healthcare professionals5.
The use of printed, audiovisual, or digital educational materials in the context of surgical preparation enables multiple forms of pedagogical mediation while promoting the development of skills related to patient autonomy and co-responsibility6. These educational resources also support the planning of nursing actions, promoting care qualification and care management improvement.7 Among the available resources, educational games stand out, such as low-cost serious games, which present themselves as interactive strategies for engaging patients in the educational process. These games bring the content closer to users’ lived reality, contribute to knowledge retention, and offer continued support throughout the surgical journey5. Its adoption also addresses the need for methodological diversification, catering to different learning profiles and expanding the repertoire of educational technologies applied to health.
The relevance of this study lies in the need to improve the preoperative guidance process through validated educational technology. Strengthening educational strategies for surgical preparation guidance not only promotes patient safety but can also positively impact their overall experience. The structured delivery of preoperative guidance creates a basis for clearer communication between patients and healthcare professionals, strengthening collaborative and patient-centered care. Therefore, this study aimed to validate the content and appearance, and assess the usability of a serious game for guiding surgical patients in preoperative preparation.
METHOD
This methodological and quantitative study was conducted between August 2024 and September 2025, focusing on the assessment of an educational technology in the form of a serious game for preoperative guidance of surgical patients. The study was conducted in three stages: (1) game prototype conception and development; (2) content and appearance validity by health experts; and (3) usability assessment by undergraduate nursing students.
The game prototype development was based on a narrative literature review of nursing recommendations in surgical preparation. The search included national and international studies indexed in the PubMed, Scopus, Web of Science, and Virtual Health Library databases, as well as institutional guidelines and technical documents in the field of perioperative nursing. The selected content informed the definition of the topics addressed in the game and the educational guidelines incorporated into it. Technology development followed the Hexa-Tau model, which includes the phases for defining objectives, game type, mechanics, application, construction, and testing8.
The serious game (Figure 1) was designed in a board game format, with 17 spaces and visual and textual language, covering topics such as fasting, skin preparation, medication use, and other pre-operative instructions. Planned for printing on A4 paper, it includes the back of the game, with space for customization with patient and surgical procedure information. This personalization allows patients to review the instructions at any time. Moreover, a manual was developed with instructions on the game’s structure and guidelines for its use by nurses in pre-operative guidance. The game’s graphic prototype was created on the Canva® online design platform. The serious game was titled “Preparação Pré-operatória” in its first version, alluding to the stages of preparing a surgical patient. The full content of Figure 1 (the game prototype used in the validity process) can be viewed at: https://canva.link/validacao-jogo-do-preparo-cirurgico.
Front and back views of a serious game for preoperative guidance of surgical patients, version used in the validity process.
Content validity was conducted online with healthcare professionals working in surgical services and faculty from different regions of Brazil. Nurses working in surgical center care or teaching, holding a master’s and/or doctoral degree, with studies in the field and a minimum of one year of experience in surgical care, who responded to the invitation within 15 days, were included. Professionals who did not return the instrument within the established deadline were excluded. Specialist identification was carried out through a search on the Lattes Platform, based on previously defined inclusion criteria. The first participant selected from this search was invited via institutional email. The snowball sampling technique was used to identify and include the remaining specialists, configuring a non-probabilistic, accessible, and network-based sampling. It was estimated that 10 to 20 experts would participate, considering Pasquali’s precepts for content validity studies9. Sixty-eight experts were invited, of whom 13 responded to the data collection form, comprising the final sample for the study.
Validity data were obtained through a self-developed structured electronic questionnaire, administered individually via Google Forms®. The instrument included participant characterization (gender, age, years of experience) and 32 evaluative items distributed across six dimensions: objectivity; organization and rules; content; images and layout; relevance; and writing accuracy. A five-point Likert scale was used, and participants who assigned scores from 1 to 3 were instructed to provide suggestions. The serious game was made available for preview within the form itself. The estimated time for completion was 20 minutes.
Usability assessment was conducted in person with undergraduate nursing students from a public university in southern Brazil. The study included undergraduate nursing students over 18 years of age who had already completed a course related to surgical care. Students who dropped out during the study or completed less than 50% of the questionnaire were excluded. The sampling was non-probabilistic, based on convenience. The participation of approximately 30 students was estimated, a number recommended for the initial usability phases10. In total, 62 students were invited, of whom 24 completed the usability test.
The serious game was implemented in person, in a university setting, by prior appointment. Participants were organized into pairs and carried out the activity under the supervision of one of the researchers. At the end of the activity, participants answered an instrument composed of the System Usability Scale (SUS), adapted for Portuguese,11 with ten items, in addition to five open-ended questions about strengths, suggestions for improvements, and general perception of the technology. The activity lasted approximately 40 minutes.
Data were organized in a Microsoft Excel® spreadsheet and statistically analyzed. Sociodemographic variables were described by absolute frequency (n) and percentage (%). For validity, the Content Validity Index (CVI) was calculated, which expresses the proportion of agreement among expert judges regarding the adequacy of the analyzed items. The Individual-Item Content Validity Index (I-CVI) was obtained using the formula: CVI = number of responses 4 and 5 / total number of responses. Then, the mean of I-CVIs was calculated to obtain the Scale-Level Content Validity Index based on the Average Method (S-CVI/Ave). Items with a CVI ≥ 0.80 were considered valid, corresponding to a consensus of at least 80% among evaluators. Items with lower values were reviewed and re-assessed12.
Usability was assessed using the SUS scoring system. To calculate the score, one value was subtracted from the odd-numbered items, and five was subtracted from the values of the even-numbered items. The sum of scores was multiplied by 2.5, resulting in scores between 0 and 100. The scores were classified into mean SUS values associated with qualitative adjectives: 12.5 (Worst Imaginable), 20.3 (Terrible), 35.7 (Poor), 50.9 (Regular), 71.4 (Good), 85.5 (Excellent), and 90.9 (Best Imaginable)11. The responses to the open-ended questions were analyzed descriptively, through the identification of recurring suggestions, and were used exclusively as a basis for visual and textual adjustments to the material.
This research followed the guidelines of Resolutions 466/2012 and 510/2016 of the Brazilian National Health Council, and was approved by the Universidade Federal de Santa Catarina Research Ethics Committee. Data collection began after obtaining the consent of participants through the Informed Consent Form (ICF), in accordance with current ethical principles. During the preparation of this article, the authors used the ChatGPT tool (OpenAI), model GPT-5.1, only to support linguistic revision and improve textual clarity. All scientific information, analyses, and interpretations were produced by the authors, who fully reviewed the content and take full responsibility for the final version of the manuscript.
RESULTS
Thirteen nurses participated in the validity, of whom ten (76.9%) were female and three (23.1%) were male. The mean length of experience in nursing was 22 years, and in the surgical area, 13 years, encompassing both teaching and clinical practice. Regarding their area of practice, ten (76.9%) were surgical area instructors and three (23.1%) were operating room nurses. In terms of academic qualifications, two (15.4%) had a specialization, one (7.7%) had a master’s degree, and ten (76.9%) had a doctorate. Five participants (38.5%) worked in southern Brazil and eight (61.5%) in southeastern Brazil, covering the states of Minas Gerais, Rio de Janeiro, São Paulo, Paraná, Rio Grande do Sul, and Santa Catarina. The scores obtained during the validation of the serious game are presented in Table 1.
I-CVI indicated that most items achieved maximum validity, especially in the categories of objectivity and game content. Items related to game duration and wording accuracy (font size and text) presented an CVI = 0.8, highlighting the need for adjustments in textual clarity. Experts’ suggestions, recorded in the instrument’s descriptive fields, supported material reformulation, resulting in adjustments to the textual content, especially in font size and wording clarity of the teaching resource.
Following the validity phase, the gameplay assessment involved 24 nursing students, of whom 19 (78.3%) were female and five (21.7%) were male. Only two participants (8.3%) reported having no prior experience with educational games. The scores obtained in the usability assessment are presented in Table 2 and illustrated in Figure 2.
Table 2 reveals that the overall SUS score was 75.2, a value classified as “good” according to the reference adjective scale. Individual SUS scores (Figure 2) ranged from 42.5 to 95, indicating a heterogeneous perception among students regarding the technology’s usability. The lowest score was assigned to the statement “I think you need help from someone with technical knowledge to use this game”, while “I found this game complicated to use” obtained the highest score, suggesting the need for improvements in ease of use.
The serious game underwent adjustments aimed at improving visual presentation and textual clarity. Increased font size and the inclusion of personalized information on the identification form, such as arrival time and photo ID, were implemented, making it more accessible and intuitive. The title was reformulated to “Percurso Cirúrgico: sua jornada pré-operatória”, and the instructions in the guidance track were adjusted for greater clarity, with direct messages such as “You have been called to the operating room”, in addition to the visual reorganization of the stages. These modifications aimed to make the information clearer and facilitate understanding of the serious game. The final version of the material can be accessed via QR code (Figure 3), which directs to the interactive digital viewing, or directly via the link: https://canva.link/jogo-preparo-cirurgico2025-versao-final-artigo.
Final version of the serious game “Percurso Cirúrgico: sua jornada pré-operatória”, with QR code for access to the digital version.
DISCUSSION
“Percurso Cirúrgico: sua jornada pré-operatória” content validity demonstrates that properly planned educational technologies can become strategic tools to improve the preoperative guidance process. Structured and evidence-based educational resources promote patient understanding and help reduce uncertainties about surgical preparation13-14. Clarity in instructions and organization of information are important aspects for patients to understand the instructions, especially in healthcare practices, where a lack of understanding can lead to adverse consequences5. In this regard, objective structure and logically arranged content are central elements in the development of materials that seek to promote patient safety and autonomy.
Conversely, aspects related to visual design and graphic presentation proved to be areas for improvement. Analog educational technologies often have limitations in this respect, especially regarding the legibility of fonts and the arrangement of elements, which can impact user experience15-16. In this context, the need for adjustments to the serious game’s layout highlights the relevance of aesthetic and functional refinements throughout the prototyping and validity process, in order to enhance the tool’s clarity and attractiveness.
The development and validity of educational technologies in healthcare have advanced in different contexts. A national study showed a validity rate of over 90% in materials developed for preoperative guidance, highlighting the importance of expert participation in the process17. Similarly, the development of structured checklists and pre-surgical guidelines has proven essential in minimizing communication failures and increasing patient safety18. This study engages with this evidence by proposing a playful resource that combines scientific rigor with language accessible to the target audience.
The validity of this game reinforces the importance of systematic processes that ensure the consistency and relevance of the presented content, as well as the importance of the participation of professionals with expertise in the subject matter. In a validity study of a serious game focused on surgical site infection prevention, the adoption of structured assessment stages by specialists using CVI demonstrated methodological rigor and satisfactory validity indices, providing methodological clarity to the development process19.
Additionally, the serious game aimed at promoting patient safety achieved content validity scores higher than 0.80 in all assessed items, after applying two rounds of the Delphi technique20. Expert review allows for precise adjustments in the balance between scientific basis and suitability for the target audience21. Hence, the validity conducted in this study, by including experienced judges in the perioperative area and employing standardized metrics, reinforces the reliability of the developed technology and supports its potential application in clinical contexts.
Regarding usability, although the game received a positive rating according to the SUS, comparison with other initiatives reveals opportunities for improvement. Recent research has recorded higher scores for similar technologies, suggesting that aspects such as interaction and ease of use are crucial in user perception22-23. Participants’ familiarity with educational environments may have favored the acceptance of the resource, while at the same time it may have limited the identification of difficulties that would be more evident in patients in real-life care situations. Studies indicate that the sample composition influences the assessment of the applicability of health technologies15,24. The inclusion of nursing students as participants proved adequate for an initial validity phase, but limits the generalizability of results to surgical patients, who present specific conditions of vulnerability and anxiety. This consideration reinforces the need for future research with larger and more representative samples, including end users of the material.
Another point to highlight refers to the adjustment process carried out based on the material assessment. In games aimed at pediatric surgical preparation, it is observed that continuous assessment of gameplay guides successive adjustments24. Similarly, the final version of the serious game incorporated modifications suggested by reviewers, such as increasing the font size and reorganizing the stages, highlighting the importance of cyclical review and validity processes.
From an innovation perspective, serious games offer advantages by incorporating playful elements in an accessible, low-cost, and easily reproducible format. These characteristics favor their implementation in different hospital settings, including those with less access to digital technologies. This difference positions the game as a viable alternative for less complex contexts, in contrast to virtual reality resources, whose application requires greater infrastructure25.
In terms of applicability, the game validated in this study is configured as a complementary resource to the verbal guidance provided by the nursing team, expanding the strategies available for health education. Its adaptability to individual needs promotes inclusion and contributes to interventions more aligned with patients’ particularities, in line with contemporary guidelines for promoting patient-centered care, respecting their uniqueness and expanding their autonomy17,26.
In a healthcare setting, serious game can be integrated at different points in the perioperative flow, such as during preoperative nursing consultations, hospital admission prior to surgery, or as an educational reinforcement tool after admission to the surgical unit. It can also be used in outpatient settings as a preparatory strategy before the procedure, facilitating guidance, clarifying doubts, and reducing patient anxiety.
The use of games as an educational tool in the preoperative period has implications especially related to promoting patient autonomy27. Interactivity and the possibility of reviewing instructions individually make the educational experience more engaging, contributing to an understanding of the surgical process and the expectations involved. However, it is necessary to broaden the tool’s accessibility, considering patients with lower health literacy or who prefer traditional methods of information.
The study has limitations that should be considered, such as the small sample size composed only of nursing students, which may not reflect the experience in the real context of perioperative care. Although adequate for an initial testing phase, this choice may have influenced usability perception, since students have greater familiarity with educational environments and lower levels of anxiety when compared to surgical patients. Furthermore, the lack of longitudinal follow-up limits the measurement of the game’s impact on effectively reducing anxiety and adhering to perioperative guidelines. These gaps indicate the need for controlled clinical trials and multicenter studies that assess the technology’s performance in different population profiles.
CONCLUSION
This study validated the content and assessed the usability of a serious game aimed at the preoperative preparation of surgical patients. The validity results indicated high reliability, with a mean CVI of 0.9, confirming the technology’s relevance and suitability for the proposed objective. The usability assessment, using the SUS, obtained a score of 75.2, demonstrating good acceptance among participants and pointing out aspects to be improved, especially regarding interactivity and ease of use.
It is concluded that serious gaming presents potential as a complementary resource to support preoperative preparation, highlighting its applicability and pedagogical suitability, as validated by specialists and students. The combination of educational technology and patient-centered care can improve patient experience and contribute to better surgical outcomes.
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NOTES
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ORIGIN OF THE ARTICLE
It was extracted from the research project “Tecnologias educacionais para o ensino em saúde no contexto cirúrgico”, approved by the Universidade Federal de Santa Catarina Research Ethics Committee.
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FUNDING INFORMATION
This study was financed through the Institutional Program for Scientific and Technological Initiation - PIBIC 2024/2025 of the Universidade Federal de Santa Catarina, according to PROPESQ Notice 03/2024.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Universidade Federal de Santa Catarina, under Opinion 6,422,116 and Certificate of Presentation for Ethical Consideration (CAAE) 70760323.7.0000.0121.
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TRANSLATED BY
Letícia Belasco.
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DATA AVAILABILITY
The dataset that supports the results of this study is not publicly available.
Edited by
The dataset that supports the results of this study is not publicly available.
