INTRODUCTION

Serious games are used to train and expand knowledge, discuss soluti= ons, simulate situations in different contexts and raise awareness of children a= nd adults in health education⁽¹⁾. The player must decide in critical situations that are electronically reproduced, based on the reality experienced in everyday life, whose objective is to verify if the player recognizes the problem and knows how t= o suggest solutions⁽²⁾.

The use of mobile devices works as a complement to traditional learn= ing methods, helping to minimize the gap between theory and practice, allowing access to information according to each individual’s needs^{(3-4)<=
/sup>.}

A study conducted in Sweden, based on the use of a serious game aime= d at cardiopulmonary resuscitation, showed that in the training, the level of me= ntal tension was low to moderate, as the students said that the game caused a decrease in stress due to its fictitious virtual games feature, opposed to = the important apprehension experienced in a real situation of cardiac arrest(5).

In an integrative review on the development and validation of the serious game in Brazil, games were found that explored pathologies aimed at health promotion, prevention, treatment, and rehabilitation, directed at bo= th undergraduate students, health professionals and the general population(6).

In this context, a serious game, called Reanima= bebê, was developed, which had as its principle cardiopulmonary resuscitation in babies younger than one-year-old. The choice of theme occurred due to a dem= and of the referred service and emerged through a focus group held with the team before the development of the game.

It is believed that the use of the game within the health service can help to reduce the gap between theory and practice, besides working as a dynamic strategy for continuing education. It becomes an innovative and pioneering strategy in improving the quality of care. Therefore, it was established as an objective, to validate the usability and applicabilit= y of a serious game for assistance to infants under one year old under cardiac arrest, from the perspective of nursing professionals of an emergency care service.

METHODS

This is a methodological study, using Participatory Design (PD)⁽⁷⁾, aimed = at proposing ways for the individual to effectively participate in the project= ’s design and development cycle, enabling the perspectives and needs of the software to be suggested, developed and evaluated by those who will effecti= vely use it⁽⁸⁾. For the creation of the software, the study had as its starting point the learning needs of the nursing team concerning emergencie= s with children, following the principles of the PD⁽⁹⁾.

In the Reanimabebê, the game’s scenario and narr= ative take place in an emergency room of an Emergency Care for Children located i= n an Emergency Room. The content was created based on the standards of care established in the literature: Pediatric Advanced Life Support (PALS) of the American Heart Association (AHA)⁽¹⁰⁾.

The subjects were nursing professionals from different shifts, intentionally selected, considering the objectives established for the research, based on the following inclusion criteria: having a mobile device with Internet access, having basic computer knowledge and be working in the= children’s health unit for at least six months, considering this time as a minimum requirement for the professional to be familiar with the service routine; a= dded to the researcher’s knowledge about this population⁽¹¹⁾.

The emerg= ency service provides clinical care to children from the age zero to 13 years, 11 months and 29 days, seeking to stabilize the patient, and begin the diagnos= tic investigation, defining the need for referral to more complex services. Data collection took place in February 2019, through a focus group conducted by = the researcher with the help of an observer who took notes in a field diary, at= the institution, at a scheduled time with the team and lasted about 1h30m. A recorder was used to ensure the accurate and complete recording of the spee= ches for later transcription.

The focus group discussion started from the following triggering question: How = did you evaluate the experience of using digital technology as a way/tool for learning about the cardiopulmonary arr= est (CPA) in infants under one year of age? A theme guide created by the researcher was used, consisting of items based on the player’s experi= ence regarding performance, manipulation, design, dynamics, knowledge improvemen= t, difficulties, and facilities in the game. In the second part of the meeting, the subjects used an instrument to assess the game, called EGameFlow⁽¹²⁾.

The instrument was translated, adapted and applied originally by the Learning Objects Laboratory of the Federal University of São Carlos^{(13)<=
/sup>
and, later, through a study carried out at the same University, in which the
authors assessed a serious game about healthy eating and physical exercise =
for
health promotion and help to fight childhood obesity⁽¹⁴⁾. Based =
on a
scale of user satisfaction with the virtual game, it helps the team that
created the game to recognize the strengths and weaknesses in the player=
217;s
point of view⁽¹²⁾. The EGameFlow ena=
bles
the identification of relevant problems in the game, showing that it is a
simplified and effective method for the detailed analysis of aspects relate=
d to
entertaining and to learning ⁽¹⁵⁾.}

The evaluator assigns to each item, of the eight existing= dimensions (Concentration, Challenges, Autonomy, Clarity of objectives, Feedback, Immersion, Social Interaction and Knowledge Improvement), a score consistent with their experience when interacting with the educational game. In Reanimabebê, the “social interacti= on” category, from the original version was eliminated, as it does not have such characteristics. The scores range from 1 to 7, with 1 for “weak” and 7, “strong”; these are then analyzed to determine the score= for each dimension. The final grade of each dimension is obtained from the aver= age of the grades of the items that compose it⁽¹²⁾. Items with a fin= al average equal to or below six were considered as items to be reconsidered to improve the final version of the game.

The final score given to each dimension is an average of the ratings= of the related items, considering the final grades given by the evaluators. If= any item was considered irrelevant to the application or not existing in the ga= me, or when the evaluator did not feel qualified to judge one of these variable= s, he had the option of excluding the item’s evaluation, marked as “Not Applicable” (NA).

Data from the focus groups were transcribed, analyzed and categorized according to the content analysis technique⁽¹⁶⁾. Data from the <= span class=3DSpellE>EGameFlow questionnaire were quantitatively analyzed = using simple descriptive statistics and organized in a table. Participants were identified with the letter N, referring to the first letter of the word Nur= sing and Arabic numbers.

The research was approved by the institutional Research Ethics Committee, under opinion no. 2.424.019/2018 and Certificate of Presentation for Ethical Appraisal no 79615917.6.0000= .0104. The subjects were approached for participation upon consent and accordingly signed an Informed Consent Form.

RESULTS

Nine subjects participated in the research, three nurses and six nur= sing technicians. Eight were women and one man, aged between 28 and 42 years (me= an 34.5 years); seven were married and two were single.

Five subj= ects had a higher degree in nursing, and four people had a graduate degree. The = time since graduation ranged from two to 20 years (average of 7.7 years), with experience in pediatrics from one to six years (mean of three years) and working time at the institution between one and three years (mean of 2.4 years). Regarding the shift, five people worked in the morning and four in = the afternoon.

Only two people reported having no experience, despite working for a year in the service. All professionals said having particip= ated in training. When asked about the last class or training they attended, thr= ee reported that it was five months before, three said three months before, one more than a year ago, and three people did not remember the date or time of= the last training. Regarding the theme, two referred to the care of pati= ents in cardiac arrest, one about breastfeeding and six about basic life support= . One of the participants mentioned not remembering the theme.<= /p>

About the game, the scenario is presented to the player, who chooses between two emer= gencies to start the game. These two situations are stories narrated by the game and that the player must use objects in the scenario, actions, and interactions with other characters to advance through the stages, besides correctly answering the questions that arise.

The results are presented based on the validation of the game by the professionals, through the application of the= EGameFlow instrument. Moreover, the data analysis of = the focus group, these were consolidated into two thematic categories: <= span lang=3DEN-US style=3D'font-family:"Times New Roman",serif;mso-fareast-font-= family: "Times New Roman";color:black;mso-ansi-language:EN-US;mso-fareast-language: PT-BR;mso-bidi-font-weight:bold'>1) Difficulties experienced by the team wh= ile using Reanimabebê; 2) Reanimabebê: technological innovation and reality as strategies for permanent education.=

Health team assessment using the Egameflow instrument

The validation of the game by professionals was implemented using th= e EGameFlow instrument. The average scores of the dimen= sions are shown in table 1.

&nbs= p;

Table 1 – M= ean of evaluations of the Reanimabebê EGameFlow instrument. Maring&aac= ute;, PR, Brazil, 2019

Assessment	Mean
Concentration
C1 – Does the game catches my attention?=	6.4
C2 – Does it have content that stimulate= s my attention?	7.0
C3 – Are most activities related to the learning task?	7.0
C4 – No distractions from the task are highlighted??	6.4
C5 – Overall, do I stay focused on the g= ame?	6.8
C6 – Am I not distracted from tasks I sh= ould be concentrating on?	6.0
C7 – Am I not overwhelmed with tasks that seem unimportant?	6.0
C8 – Is the game workload adequate?	6.6
Final Mean<= /p>	6.5
Challenges
H1 – Do I enjoy the game without getting bored or anxious?	6.5
H2 – Level of difficulty is adequate?	6.3
H3 – Are there “tips” that h= elp with the task?	6.5
H4 – Does it provide online support that helps with the task?	5.5
H5 – Does it provide video or audio to h= elp with the task?	6.6
H6 – Do my skills increase as the game progresses?	6.7
H7 – I’m motivated by improving my skills?	6.7
H8 – Do challenges increase as my skills increase?	6.0
H9 – Does it provide new challenges at an appropriate pace?	6.1
H10 – Does it provide different levels of challenges that suit different players?	6.1
Final Mean<= /p>	6.3
Authonomy
A1 – Do I feel in control of the menu?	6.3
A2 – Do I feel in control over features = and objects?	6.3
A3 – Do I have a sense of control over interactions between functions and objects?	6.2
A4 – Is it possible to make mistakes that stop the game from progressing?	6.6
A5 – Can I go back in any mistakes made?=	6.4
A6 – Do I feel I can use any strategies?=	5.7
A7 – Do I have a sense of control and im= pact on the game?	6.0
A8 – Do I know the next step in the game= ?	6.0
A9 – Do I feel in control over the game?=	5.6
Final Mean<= /p>	6.1
Clarity of objectives
G1 – General objectives presented at the beginning of the game?	6.7
G2 – General objectives clearly presente= d?	6.7
G3 – Intermediate goals presented in the appropriate place?	6.6
G4 – Are the intermediate goals clearly presented?	6.6
G5 – Do I understand the learning object= ives through the game?	6.8
Final Mean<= /p>	6.6
Feedback	<= /i>
F1 – Do I get feedback on my game progre= ss?	6.6
F2 – Do I get immediate feedback on my actions?	6.8
F3 – Am I reported of new tasks immediat= ely?	6.7
F4 – Am I reported of new events immediately?	6.6
F5 – Do I receive information about the success or failure of intermediate goals immediately?	6.7
F6 – Do I get information about my statu= s, such as level or score?	6.5
Final Mean<= /p>	6.6
Immersion
I1 – Do I forget about time while I play= ?	6.3
I2 – Do I forget things around me while I play?	6.4
I3 – Do I forget about everyday problems= while I play?	5.8
I4 – Do I feel an altered sense of time?=	6.0
I5 – Can I get involved with the game?	6.8
I6 – Do I feel emotionally involved with= the game?	6.6
I7 – Do I feel deeply involved in the ga= me?	6.4
Final Mean<= /p>	6.3
Knowledge improvement<= o:p>
K1 – Does the game improve my knowledge?=	7.0
K2 – Do I get the basic ideas of the con= tent presented?	6.8
K3 – Do I try to apply knowledge in the game?	6.8
K4 – Does the game motivate the player to integrate the content presented?	7.0
K5 – Do I want to know more about the content presented?	7.0
Final Mean<= /p>	6.9

S= ource: The authors, 2019.

= &nb= sp; =

Regarding= the “Concentration” domain, the team scored a mean score of 6.5, su= ggesting a story with a coherent and pleasant/motivating sequence.=

The “Challenge” domain had a final mean score of 6.3, indicating the existence of a challenging situation, capable of motivating the player to s= tay in the game. The item that received the lowest score was related to online support, as the game did not provide such support.

Regarding “Autonomy”, the subjects considered having autonomy over the ga= me, with a final grade of 6.1. When questioned while filling out this part of t= he instrument, they reported that there were questions about what was to be do= ne in certain scenes. Some questions were about accessing the “menu̶= 1; or recovering from mistakes made during the game. As this is an Alpha versi= on, errors and/or suggestions can later be readjusted in the game.

The score assigned to the “Clarity of Objectives” domain was 6.6. Although the existence of a performance/score scale for each player was not predicte= d, the category “Feedback” had a score of 6.6, demonstrating that = the game had immediate returns (positive and negative feedbacks) after the play= er’s actions through automatic warnings describing whether the course taken was correct or not.

The subje= cts scored the “Immersion” domain with 6.3, suggesting that the game promo= tes the individual’s involvement, sometimes leading him/her to disconnect from the surrounding environment while playing, ensuring his/her full immer= sion and concentration. The category “Social interaction” could not = be evaluated, as the game does not provide support for this item. <= /span>

Finally, = regarding the domain “Knowledge Improvement”, the final average score was 6.9, indicating the participants’ perception of knowledge acquisition= . In general, there was a positive evaluation of the game, especially based on i= ts innovative, playful, and adequate character in terms of its technical-scientific relevance and regarding its fidelity to the context/ca= re setting portrayed.

Difficulties experienced by the team in using the Reanimabebê=

Complementing the validation by the EGameFlow instrument, the subjects mentioned two main difficulties while using the Reanimabebê game. As reported by four people, t= he dynamics of the game did not make it clear how the baby would be ventilated. This is because it was a stage of the game in which the player remained still, whic= h, in the opinion of the participants, could lead to giving up on the game.

Until then, the scene was monitored by a stopwatch or timer and the player was asked to ventilate the baby with a valve-mask bag. Due to this negative evaluation of the professionals, the researcher, in partnership wi= th the responsible informatics team, chose to reformulate this stage of the ga= me, with the incorporation of a clearer instruction about what the player should do:

I got stuck in the ventilation part, I didn’t get the right time between one and the other ‘ventilation’ with ambu<= /span> (valve-mask bag) (n8).

About medication during the arrest, three subjects reported difficul= ty in preparing and administering intravenous adrenaline. This finding was evidenced in the speeches of the technical level subjects:

I struggled a = lot with the medication. Like it or not, the nurse is responsible for this part= . I thought it was really cool because it stimulates the person’s curiosi= ty (n6).

Although the subject has raised discussions, the professionals themselves recognized the need for shared knowledge as a necessity for optimizing collaborative and interprofessional work in the situation of car= ing for babies in cardiac arrest:

It is also important to know about medication (n1). We need to know everything that is going = on, the whole team working together to provide better care for the baby (n3).

Amid the reflections in the focus group, some suggestions arose from= the group, such as the elaboration of more cases/phases; inclusion of scores or performance scale in the game and the possibility of viewing the scores of other players. The issue of scoring/competitiveness was identified based on= the justification that this would promote an incentive/stimulation among player= s:

Even if everyone is in their own house... it could show who is playing in real-time or even a score scale, you know? (n2). Seeing the scores of co-workers makes us wish: No, my baby will live, wait a minute, I’ll do everything right = (n9).

More outcomes were proposed to make the game even more real, such as= the development of new situations to be solved by the player:=

I think there should be more phases. Although ther= e is already an outcome, there could be more than one, for example, the child progressing to death when we don’t get it right. Everyone would have a different experience (n8). I felt like this: Wow, I really wanted it to keep going. Because there are many possibilities to happen (n10= ).

An issue very discussed was concerning new game ideas for the genera= l people. Some participants suggested the creation of a serious game with the theme &= #8220;First Aid” to be made available to the population:

Even for our children it would be great! Maybe, if= it was something about first aid, basic things, because they’re interest= ed in the game, it catches their attention (n6). I think you should create more cases in this game and other= themes in other apps, not only for healthcare professionals but also for lay peopl= e. It’s very didactic! (n10). <= /o:p>

=

Reanimabebê: technological innovation and reality as strategies for permanent education<= o:p>

=

The creation of game scenarios based on the realities and care conte= xts they target provides levels of reality that enable the immersion of subject= s in the game, increasing involvement and optimizing the results of the educatio= nal action:

We drew the emergency scenario in that other meeti= ng. I found the images to be very similar to our reality. Even the place where = the monitor is located was illustrated (e1).

The critically ill condition of the child brought to the emergency r= oom was evaluated as very similar to the reality experienced. Additionally, the subjects reported that there is a logical sequence of steps to assist the b= aby in cardiac arrest, making the game very adequate and didactic:

O The Reanimabebê has a sequential logic of events (n8). For example, in intubation, the child who has already been intubated does not appear, the tube appears, the electrodes being placed, it was very good! (n4).

= Besides the educational feature, the game was also described as an innovative, practical, original strategy, and an entertainment component to the teaching-learning process:

The idea is incredible. Practical. Very good (e4). This way of learning is very didactic and innovative (e2). Despite its educational nature, it instig= ated me as fun (e7).

DISCUSSION

The findings show that the use of technological approaches within he= alth services can bring positive results to practice, to dynamically empower hea= lth professionals. A study conducted in France, in which students were trained = with a serious game aimed at obstetric emergencies, showed that active learning = was possible, as the subject was immersed in an environment that recreated the obstetric scenario close to reality, enabling to face emergencies which demanded quick decision-making based on effective knowledge⁽¹⁷⁾.=

Research conducted at the Federal University of Pernambuco, develope= d a serious game aimed at adolescents to promote reflections on sexual and reproductive health. After validating the game with the target audience and with professionals in the respective area, it was concluded that immersion = in the game was possible because it approximated the game with the daily lives= of teenagers, by characters using a specific language, bringing the game close= r to reality⁽¹⁸⁾.

In this study, we sought to include the subjects in the development = of the game to make learning closer to the local reality and, thus, very simil= ar to the context of the action of the target audience. Besides being an innovati= ve, didactic, and easy-to-handle tool, the game features easy decision-making, = as it is a very realistic simulation, but in a stress-free environment. This conclusion confirms several studies in the national and international field= ^(17,19-20).

Some subjects reported problems at the stage in which it was necessa= ry to be aware of the preparation and administration of adrenaline. Initially, this was justified by the fact that this is an exclusive nurse’s task, however, after group discussion, there was the acknowledgment of the import= ance that everyone in the team sharing knowledge about the complete management of the baby in cardiac arrest, regardless of the professional category.

It is noteworthy that the nursing team is one of the first to recogn= ize that something is not right with the baby, so keeping the environment and adequate materials, as well as knowing how to handle them correctly and man= age the necessary medications, is crucial for decisions taken in emergency care= are well performed and include the participation of all, so that the objective = is always to re-establish the patient’s health, especially the pediatric population⁽²¹⁾.

Another important thing highlighted by the group mentioned the baby&= #8217;s ventilation. According to the subjects, this moment was not clear, as they lacked game command details about what to do at the time to continue the ga= me. We chose to improve this step, as the team that will use the device must te= st it and expose suggestions and implications concerning its reality so that t= he primary scope (providing learning) is established⁽⁸⁾.=

Regarding= the assessment of the subjects, using the EGameFlow= instrument, it can be inferred that all domains (concentration, challenge, autonomy, clarity of objectives, feedback, immersion, and knowledge improvement) presented appropriate scores, indicating the potential for using the game. = The limitations of the study are related to not carrying out comparative assessments of the professionals’ learning, before and after using the game, besides the limited number of professionals who participated in the s= tudy due to the small number of human resources in that location and refusals. I= t is suggested, therefore, the development of new studies that proceed with the application and evaluation of this tool in other realities.

FINAL CONSIDERATIONS

It is concluded that the serious game Reanimabebê showed good acce= ptance by the target audience, as the subjects emphatically reported this finding, showing itself to be applicable in an emergency room. It is also noteworthy that it is an innovative, didactic tool that is very close to the reality experienced. The subjects reported that the tool is effective for learning = and recommend its use for other populations and care contexts.

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Corresponding author

Roberta Tognollo Borotta Uema. Rua Antonio Valdir Zanuto<= /span>, número 53. Jardim Novo Horizonte, Maringá, PR. CEP: 87010-100. E-mail: robertaborotta@hotmail.com

Submission: 2021-08-04

Approval: 2021-10-11