Abstract
Background
Obstetric care demands clinical reasoning, technical skills and timely decisions. Persistent training gaps highlight the need for strategies that integrate theory and practice. Educational technologies, especially virtual clinical simulation, offer safe, realistic environments for skill development. Thus, this study aimed to validate a virtual simulation prototype for teaching natural childbirth care.
Method
This methodological study, conducted between May 2021 and June 2022, involved three stages: construction of the storyboard of a virtual simulation prototype including two clinical scenarios (normal labor and postpartum hemorrhage); content validation by 26 experts who assessed the scenarios and storyboard interfaces using the Suitability Assessment of Materials (SAM), analysis based on the Agreement Index (AI); and appearance validation by 16 obstetric nursing residents using the Instrument for Validation of the Appearance of Educational Technologies in Health (IVAETH). Ethical approval was obtained, and all participants provided informed consent.
Results
The design and storyboard of the simulator demonstrated adequacy for its intended educational purpose. The sample, composed of 26 nurse specialists with experience in technology validation, positively validated all screens of the constructed storyboard, with an agreement index greater than 0.90 in the six evaluation domains (Content; Language appropriate for the population; Graphic illustrations, lists, tables; Layout and typography; Learning and motivation; and Cultural adaptation). Sixteen obstetric nursing residents, predominantly at the State University of Ceará, participated in this study. The evaluation of the domains for appearance validation yielded an average agreement index greater than 0.80 among residents.
Conclusion
The storyboard developed for virtual reality simulation scenarios in childbirth care demonstrated high levels of agreement in both content and appearance validation, indicating its adequacy as an educational tool for obstetric nursing training. The validated structure provides a foundation for the future development of the Birth Now virtual simulator to support clinical decision-making in childbirth care.
Keywords: Obstetric nursing, Childbirth, Labor, Simulation, Technology, Teaching, Nursing assistance
Background
Skilled obstetric care is essential to ensure maternal and fetal safety, since early recognition of complications and the adoption of evidence-based practices reduce adverse outcomes during labor and delivery [1]. However, despite advances in obstetric care, gaps still exist in clinical training related to decision-making during labor, as well as in the management of prolonged and complicated labor scenarios [2].
In prolonged labor scenarios, clinical management requires interpreting the results of maternal and fetal clinical conditions, assessing labor progression, and making timely decisions about interventions such as oxytocin administration or cesarean Sect. [3]. These decisions require not only technical knowledge but also clinical reasoning and adherence to evidence-based protocols. Therefore, it is understood that the processes involved in decision-making require repeated practice in safe and structured environments, which is not always feasible in real-world clinical settings.
It is clear that various techniques, practices, and care behaviors in women’s health care during childbirth have been developed and improved over time, aiming to recover good practices and humanize the moment of labor and delivery. However, the incorporation of humanized practices requires structured educational strategies that prepare students and professionals to integrate technical competence with woman-centered care. Accordingly, teaching methods require adjustments that promote a closer connection with clinical practice, in order to make the training process more applied and contextualized to the reality of health care [2].
Regarding the difficulties that students and professionals in the field of obstetrics may face in their clinical practice, a study conducted with obstetric nurses further highlights the need for validation of technical competence before the health team at the time of childbirth assistance [4]. This scenario reinforces the importance of pedagogical strategies that strengthen clinical judgment and confidence in decision-making.
From this perspective, educational technology should be understood as a tool grounded in scientific knowledge, focused on the production of educational materials that enhance the teaching-learning process. Moreover, it involves digital and non-digital devices that aim to encourage teachers and students to participate in an innovative and proactive way in pedagogical practices [5]. Clinical simulation, in turn, stands out as a nursing teaching strategy that can promote the improvement of clinical reasoning and the performance of care skills, in addition to being well accepted by students in terms of pedagogical relevance and usability [6].
However, traditional simulation methods can be limited by high operational costs, restricted access, and dependence on physical infrastructure, which hinders their scalability in obstetric education. In this context, the use of Virtual Reality (VR) - based simulations is a promising alternative, offering a safe and effective environment for the practice of clinical skills, favoring more interactive and immersive learning experiences [7].
VR technology aims to promote experiences close to reality and has the relevant attribute of breaking down geographical barriers, allowing remote access and expanding opportunities for qualified training for academics and professionals [8]. By enabling repeated exposure to complex labor scenarios, VR can help fill gaps in experiential learning, especially in contexts with limited access to supervised obstetric practice.
However, simulation does not replace real contact with patients and should be considered a preparatory step that makes clinical practice safer for both professionals and patients. For students, simulation strategies promote an experience close to clinical reality, enhance practical training, improve communication, and enable the identification and correction of errors in the training process [9].
By strengthening clinical reasoning and decision-making in simulated environments, such tools may contribute to safer obstetric practices, indirectly supporting efforts to reduce preventable maternal morbidity and mortality.
Given the identified educational gaps in decision-making during labor, the limitations of traditional training environments, and the potential of immersive simulation technologies, this study aimed to validate a virtual simulator prototype for teaching natural childbirth care.
Methods
This methodological study, based on the assumptions of Polit and Beck [10], was developed between May 2021 and June 2022, in three stages: construction of the simulator prototype project, validation of the content of the clinical simulation scenario and validation of the appearance of the clinical simulation scenario project.
It is worth noting that an electronic form was created for data collection, using the Google Forms® tool, and sent by email to the research participants after initial contact. This form consisted of: an invitation letter, an Informed Consent Form, a Responsibility and Confidentiality Agreement, a form containing the scenario’s characterization and script, and content and appearance validation forms. Furthermore, all participants were informed about the objectives and procedures of the study and provided free and informed electronic consent before participating. Confidentiality and anonymity were ensured throughout the data collection and analysis.
In the first stage, the design of the simulator prototype, called Birth Now, was constructed. The virtual simulation environment used as a methodological basis the model proposed by Jeffries et al. (2016), which guided the definition of learning objectives, participant roles, scenario structure, and expected results [11]. In this stage, scenarios were designed based on two cases, resulting in 62 simulator screens, developed from the perspective of the player/student, who is presented within a simulated hospital environment similar to the real one. In addition, situations such as normal (eutopic) labor and more complex situations were considered, including decision-making in obstetric cases such as Postpartum Hemorrhage (PPH).
From this, the prototype was built through a 2D drawing with the formulation of a storyboard in Portuguese, with a total of 65 images, which provides a graphic visualization of the relevant images in sequence, as if it were a comic strip. The storyboards involved two realistic simulation scenarios based on clinical cases: the management of uncomplicated vaginal delivery and the management of vaginal delivery with postpartum hemorrhage (PPH), these scenarios being selected due to their educational relevance and their representation of obstetric decision-making situations, both routine and high-risk.
Through this, it was possible to get an idea of the physical characterization of the characters in the story, as well as the scenarios, colors, actions, and emotions present. The storyboards for the first scenario to be simulated included the presentation of the maternity ward facade, reception, obstetric risk classification room (Fig. 1); the first care in the obstetric reception office; procedures in the doctor’s office involving the referral and admission of the parturient to the normal delivery center; admission to the delivery room, guidelines and non-pharmacological methods; feeding, environment and procedure; sensations and support; end of the dilation phase, auscultation of fetal heartbeats and beginning of the expulsion phase (Fig. 2); fetal expulsion phase; The encounter between mother and newborn, skin-to-skin contact, timely clamping of the umbilical cord and administration of oxytocin (Fig. 3); and the birth of the child until the expulsion of the placenta and membranes (Fig. 4).
Fig. 1.
BirthNow Storyboard: maternity facade, reception, obstetric risk classification office
Fig. 2.
BirthNow Storyboard: end of the dilation phase and auscultation of the fetal heartbeat
Fig. 3.
BirthNow Storyboard: skin-to-skin contact, timely clamping of the umbilical cord and administration of oxytocin
Fig. 4.
BirthNow Storyboard: deliverance
The realistic simulation scenario for managing vaginal delivery with postpartum hemorrhage encompasses the moment the nurse assesses the first signs of PPH until the decision-making process. This scenario involved the fourth stage of labor and the beginning of the recognition of PPH signs; assessment of vaginal bleeding and initiation of the PPH protocol (Fig. 5); assessment of vital signs, initiation of medication administration and ventilatory support; support and assistance to the postpartum woman, assessment of the shock index and Trendelenburg positioning (Fig. 6); performance of bimanual massage and administration of medication; and response to treatment, control of PPH and rigorous monitoring (Fig. 7).
Fig. 5.
BirthNow Storyboard: Assessment of vaginal bleeding at the beginning of the PPH protocol
Fig. 6.
BirthNow Storyboard: Support for postpartum women, assessment of the shock index, and Trendelenburg positioning
Fig. 7.
BirthNow Storyboard: Response to treatment, PPH control, and strict monitoring
After defining the simulation scenarios and building the interfaces in the Storyboard, the second stage of the study began with the objective of validating the content of the BirthNow clinical simulation scenario through evaluation by expert judges.
The experts were identified through an advanced search on the Lattes Platform of the National Council for Scientific and Technological Development. Convenience sampling was adopted, considering the need to select professionals with expertise in obstetric nursing, women’s health, and validation of educational technologies. To ensure the qualification of the judges, objective eligibility criteria were established, adapted from the Fehring model [12], used in content validation studies.
The criteria proposed by Fehring were adapted in order to encompass competencies related to obstetric nursing and the validation of educational technologies. In this sense, the adapted scoring system considered the following criteria: master’s degree in women’s health, obstetrics, or clinical simulation (3 points); doctoral thesis in obstetrics and/or technology, technology validation (2 points); Publication of an article in a peer-reviewed journal in the areas of obstetrics or women’s health (2 points); at least one year of clinical practice or teaching in obstetrics or women’s health (3 points); specialization certificate in obstetrics or women’s health (2 points); participation in scientific events in these areas (1 point); and a minimum of one year of experience in validating educational instruments or materials (2 points). The maximum possible score was 15 points.
Experts who scored five points or higher were considered eligible. It should be noted that this score was defined to ensure basic knowledge of the subject matter, while also allowing the inclusion of professionals with relevant clinical experience, even without a doctoral degree. Professionals who did not fully complete the electronic evaluation form were excluded from the study.
The number of experts required was calculated using the formula: n = Z² × P × (1 − P) / e² where Z corresponds to a confidence level of 95%, P represents the expected proportion of agreement among experts (85%) and corresponds to the acceptable margin of error (15%). The expected proportion of agreement was defined based on previous validation studies in educational technology that reported high levels of consensus among experts [13]. Using these parameters, a minimum of 22 experts was established.
Therefore, 26 selected experts participated in this stage. The judges had access to the scripts for scenarios 1 and 2 and the corresponding screens of the virtual environment, organized in storyboard format containing the complete sequence of the scenario screens for analysis.
To evaluate the content of the clinical simulation scenario screens, the Suitability Assessment of Materials (SAM) instrument was used. The instrument assesses the suitability of educational materials based on six domains: Content; Language appropriate for the population; Graphic illustrations, lists and tables; Layout and typography; Learning and motivation; and Cultural appropriateness. SAM was advocated by Doak, Doak and Root (1996) and later translated and adapted into Portuguese by Sousa et al. [14].
SAM consists of a checklist with 22 items, with a scoring scale from zero to two. Each item was classified as superior, adequate or inadequate, according to the objective criteria included in the instrument. At the end of the evaluation of each domain, the experts were able to record comments, suggestions or criticisms, with the aim of contributing to the improvement of the simulation scenario and the design of the interfaces. For the content validation analysis of the Birth Now clinical simulation scenario, the Agreement Index (AI) was used. The AI was calculated from the ratio between the number of evaluations classified as “superior” or “adequate” and the total number of responses for each item. Items with an AI ≥ 0.80 were considered validated and maintained in the design of the final virtual environment. This threshold was defined based on values adopted in validation studies in the area of educational technologies [15].
The third phase of the study aimed to validate the appearance of the design/storyboard of the simulation prototype scenarios. Sixteen nurses linked to Residency Programs in Obstetric Nursing participated in this stage. As inclusion criteria, residents from the Regional University of Cariri, Federal University of São Paulo, Ceará School of Public Health, Federal University of Ceará, and State University of Ceará were considered. These institutions were selected because they are recognized for their clinical training in the area and for incorporating clinical simulation as a pedagogical resource for the development of professional skills.
As an exclusion criterion, nurses with less than six months of residency were considered. This initial period is usually related to the resident’s adaptation to the new practice scenario in obstetrics. In addition, it is understood that the professional maturity necessary to participate in the validation process of the proposed educational technology is still developing at this stage, since the transition from training to autonomous clinical practice in obstetric nursing usually extends beyond the initial months of residency. Studies on the development of clinical competence in nursing indicate that the acquisition of professional autonomy and clinical judgment occurs progressively throughout practical experience and structured transition-to-practice programs, often lasting up to a year or more [16].
Appearance validation was performed using the Instrument for Validation of the Appearance of Educational Technologies in Health (IVAETH), which analyzes the harmonization of specific elements of educational technology in health, as well as the forms, cores, images, text, quantity, and sizes of figures, which can provide greater efficiency of the technology. Unlike SAM, which assesses the adequacy of the content and educational comprehensibility, IVAETH focuses on visual elements, clarity of presentation, organization, legibility, and overall coherence of the interface.
IVAETH consists of 12 items evaluated on a five-point Likert scale (1 = Strongly Disagree, 2 = Disagree, 3 = Partially disagree, 4 = Agree, and 5 = Strongly Agree) [17]. The calculation of responses for the Concordance Index analysis was done by summing the number of “agree” (4) and “strongly agree” (5) responses, dividing the sum by the total number of expert responses.
After analyzing the data, they were systematized and presented through the construction of graphs and tables and analyzed in accordance with the relevant literature on the subject.
This study was approved by the Research Ethics Committee of the State University of Ceará (Opinion No. 5,036,318) and conducted in accordance with national and international ethical guidelines for research involving human beings [18].
Although the present study focused on the development and validation of the storyboard as a preliminary phase, this structure was designed to guide the future implementation of the virtual simulation. In this subsequent stage, the validated storyboard will serve as the conceptual design for the development of an immersive virtual reality environment representing an obstetric care scenario. The sequential narrative, decision points, and educational interactions defined in the storyboard will be translated into a three-dimensional virtual environment, allowing users to navigate clinical situations, observe patient conditions, and make evidence-based decisions within a simulated labor and delivery scenario.
Results
The prototype content of the simulation scenarios was evaluated by 26 experts, who accessed the set of screens through a Google Forms document in which the sequence of the scenarios was presented through the storyboard referring to scenarios 1 and 2.
Regarding the demographic characteristics of the experts, the majority were female (24; 92.3%). The participants were from different cities in Brazil: 19 (73.077%) from Fortaleza, two (7.693%) from São Paulo and one (3.846%) each from Brasília, Goiânia, Itajubá, Macapá, and Sobral. In relation to academic background, four specialists (15.4%) held a specialist degree, 16 (61.5%) had a master’s degree, and six (23.1%) had a doctorate. No participant reported having completed postdoctoral studies.
Concerning the previous experience with simulation, six experts (23.1%) reported having participated in some type of virtual reality simulation activity. Additionally, 12 experts (46.2%) reported methodological experience related to the development or validation of studies involving educational technologies and/or women’s health and obstetrics.
Among the experts, 12 (46.5%) reported working as faculty members in higher education institutions, primarily public universities, with more than ten years of professional experience in the field. All professionals participating in this phase achieved the minimum score required according to the predefined expert selection criteria based on the adapted Fehring model, confirming their eligibility to participate in the validation process.
Evaluation of the six domains of the SAM (instrument-content, literacy demand, graphics, layout and typography, learning stimulation and motivation, and cultural adaptation) showed a mean agreement index of 0.98 across the 22 evaluated items.
All six domains individually demonstrated high levels of agreement among experts, with values above 0.96. Domains content, learning stimulation and motivation, and cultural adaptation reached the maximum agreement index (1.0).
Table 1 presents the distribution of expert responses for each domain, including the AI calculated for each evaluated item and the overall index for each domain.
Table 1.
Descriptive distribution of expert responses (n = 26) in the analysis domains. Fortaleza, Ceará, Brazil, 2022
| EVALUATION ITEM | 2 SCORE (Superior) |
1 SCORE (Adequate) |
0 SCORE (Inadequate) |
AI* | |||||
|---|---|---|---|---|---|---|---|---|---|
| Content Domain | |||||||||
| The purpose is evident | 13 | 13 | - | 1.0 | |||||
| Content addresses behavior | 12 | 14 | - | 1.0 | |||||
| Content is focused on purpose | 15 | 11 | - | 1.0 | |||||
| Content highlights key points | 11 | 15 | - | 1.0 | |||||
| AI mean | 1.0 | ||||||||
| Domain Language appropriate for the population | |||||||||
| Reading level | 12 | 14 | - | 1.0 | |||||
| Active voice style | 14 | 11 | 1 | 0.96 | |||||
| Vocabulary uses common words | 16 | 9 | 1 | 0.96 | |||||
| Context comes before new information | 12 | 13 | 1 | 0.96 | |||||
| Advanced signal-mediated learning | 13 | 13 | - | 1.0 | |||||
| Average AI* | 0.97 | ||||||||
| Domain Graphic illustrations, lists and tables | |||||||||
| The purpose of the illustration referring to the text is clear | 12 | 12 | 2 | 0.92 | |||||
| Type of illustrations | 13 | 12 | 1 | 0.96 | |||||
| The figures/illustrations are relevant | 12 | 14 | - | 1.0 | |||||
| Lists, tables, graphs and shapes | 10 | 14 | 2 | 0.92 | |||||
| Subtitles are used | 13 | 13 | - | 1.0 | |||||
| Average AI* | 0.96 | ||||||||
| Domain Layout and Typography | |||||||||
| Layout feature | 14 | 12 | - | 1.0 | |||||
| Typography | 11 | 14 | 1 | 0.96 | |||||
| Subtitles are used | 11 | 13 | 2 | 0.92 | |||||
| Average AI* | 0.96 | ||||||||
| Domain Stimulation for learning and motivation | |||||||||
| Interaction is included in the figures | 12 | 14 | - | 1.0 | |||||
| Desired behavior patterns are modeled or shown in specific terms | 12 | 14 | - | 1.0 | |||||
| Motivation/effectiveness | 13 | 13 | - | 1.0 | |||||
| Average AI* | 1.0 | ||||||||
| Domain Cultural adaptation | |||||||||
| Logo cultural-logic, language and experience (LLE) | 13 | 13 | - | 1.0 | |||||
| Cultural image and examples | 12 | 13 | - | 1.0 | |||||
| Average AI* | 1.0 | ||||||||
*Agreement index
Source: Prepared by the author
The evaluation of the SAM instrument domains indicated high levels of agreement among the experts. The domains Content, Stimulation of learning and motivation, and Cultural adaptation obtained the maximum agreement index (1.0).
The other domains of Language appropriate for the population; Graphic illustrations, lists and tables; and Layout and typography presented average agreement indices between 0.96 and 0.97, values considered high and above the cutoff point established for validation. In general, results indicate that all evaluated domains were considered adequate and validated by the experts.
Regarding the comments and suggestions proposed by experts with experience in the obstetric area, it is worth highlighting that all recommendations were read and analyzed by the researcher and the team that developed the storyboard. Among the expert judges’ main suggestions were language adjustments for clarity, the inclusion of figures representing different pregnant women, and the reorganization of some clinical workflows to better align with care protocols.
Following the content validation phase, the storyboard underwent appearance validation with obstetrics nursing residents.
A total of 16 residents participated in this phase, most of whom were residents from the Universidade Estadual do Ceará. Among the participants, 14 (87.5%) were female. Most residents were older than 25 years and were enrolled in the second year of residency training (R2).
Table 2 below presents the characteristics related to the use of digital technologies by residents.
Table 2.
Data regarding the use of technologies by residents participating in the Birth Now Storyboard evaluation (N = 16). Fortaleza, Ceará, Brazil 2022
| Data regarding the use of technologies (computer and internet) | n | % |
|---|---|---|
| Do you have a computer (yes) | 16 | 100 |
| Has a computer course | 08 | 50 |
| Do you have Internet access via mobile device? (smartphones, tablets, etc.) | 16 | 100 |
| Frequency with which you access the internet via mobile device | 16 | 100 |
| Have you ever used any type of virtual reality simulator? | 09 | 52.9 |
| The experience was satisfactory | 09 | 52.9 |
| Do you think the implementation of this type of technology is effective in promoting improvements in labor and birth education? | 15 | 93.7 |
All participants (100%) reported owning a personal computer, having internet access at home, and frequently accessing the internet through mobile devices. Regarding experience with virtual reality simulation, 9 residents (52.94%) reported having used some type of VR simulator during their academic training. Most participants also considered the use of this type of technology effective for improving education related to labor and birth care.
The face validation process used the IVAETH. Residents evaluated the storyboard using a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The agreement index was calculated for each item based on the responses.
Table 3 shows the distribution of responses obtained from the residents.
Table 3.
Descriptive distribution of residents’ responses to the Instrument for Validation of the Appearance of Educational Technologies in Health (IVAETH) (n = 16). Fortaleza, Ceará, Brazil, 2022
| Item | 1 (SD) |
2 (D) |
3 (PD) |
4 (A) |
5 (SA) |
AI* |
|---|---|---|---|---|---|---|
| 1. The illustrations are suitable for the target audience. | - | - | - | 5 | 11 | 1.0 |
| 2. The illustrations are clear and easy to understand. | - | - | - | 4 | 12 | 1.0 |
| 3. Illustrations are relevant for understanding the content by the target audience. | - | - | - | 4 | 12 | 1.0 |
| 4. The colors of the illustrations are appropriate for the type of material. | - | - | - | 3 | 13 | 1.0 |
| 5. The shapes of the illustrations are appropriate for the type of material. | - | - | - | 6 | 10 | 1.0 |
| 6. The illustrations portray the daily lives of the target audience of the intervention. | - | - | 3 | 5 | 8 | 0.81 |
| 7. The arrangement of the figures is in harmony with the text. | - | - | 1 | 8 | 7 | 0.93 |
| 8. The figures used elucidate the content of the educational material. | - | - | - | 5 | 11 | 1.0 |
| 9. The illustrations help to explain the theme and are in a logical sequence. | - | - | - | 9 | 7 | 1.0 |
| 10. The illustrations are in adequate quantity in the educational material. | - | - | 1 | 7 | 8 | 0.93 |
| 11. The illustrations are in appropriate sizes in the educational material. | - | - | - | 6 | 10 | 1.0 |
| 12. Illustrations help change behaviors and attitudes among the target audience. | - | 1 | - | 5 | 10 | 0.96 |
| Average AI* | 0.96 |
TD – Totally disagree; D – Disagree; PD – Partially disagree; A- I agree; TA– I totally agree
*Agreement Index
Source: Prepared by the author
The evaluation of the IVAETH domains resulted in a mean agreement index of 0.96 among residents. Eight of the twelve evaluated items achieved an agreement index of 1.0, indicating full agreement among participants. Three items presented agreement values above 0.90 (0.93), while one item—related to whether the illustrations represented the daily reality of the target audience—obtained an agreement index of 0.81.
Despite this lower value, the agreement remained above the predefined validation threshold, and suggestions related to improving the contextual representation of clinical situations were incorporated into the storyboard during the revision process. Overall, residents considered the structure and visual presentation of the storyboard satisfactory for educational purposes.
Residents suggested improvements to the visual layout of interactive elements and the logical sequence of the birth stages. All modifications were incorporated before the final validation stage, resulting in a more functional prototype that closely reflects clinical reality.
Discussion
The integration of simulation technologies into nursing education has been increasingly recognized as an effective strategy for developing clinical competencies and improving decision-making skills. In addition, content considered difficult to teach can be selectively rehearsed and repeatedly produced through simulators, obtaining skills through deliberate and repeated practices [19].
In obstetric care, where clinical situations may evolve rapidly and require timely interventions, simulation-based learning provides a safe and controlled environment in which students and professionals can practice complex clinical scenarios without compromising patient safety. In this sense, the application of simulations and computational resources in nursing education has been associated with improved quality of care. Thus, it is an effective clinical teaching strategy, even without face-to-face practice [20].
In the present study, the storyboard designed to guide the development of a virtual reality simulator for childbirth care demonstrated high levels of agreement in both phases of validation. The expert panel confirmed the adequacy of the content across all domains evaluated by the Suitability Assessment of Materials (SAM), while the obstetric nursing residents reported high levels of agreement regarding the appearance and usability of the storyboard evaluated through the IVAETH. These findings suggest that the educational structure and visual organization of the proposed simulation scenario are considered appropriate for use in obstetric training contexts.
Given this, simulation-based education has been consistently associated with improvements in clinical reasoning, communication, and decision-making skills among nursing students. By recreating clinical situations in a controlled setting, simulation allows learners to practice decision-making, learn from errors, and engage in reflective practice without compromising patient safety. Studies have also reported increased learner satisfaction and self-confidence when simulation and virtual patients are incorporated into training programs, reinforcing the value of this strategy in nursing education [21, 22].
Simulation approaches based on emerging immersive technologies, such as extended reality (XR) and virtual reality, have been increasingly explored as educational tools in the training of healthcare professionals. Recent evidence reports that these technologies can increase student engagement, reduce anxiety, and enhance satisfaction with the learning process, particularly in complex clinical areas such as obstetrics [23].
In this context, the findings of the present study reinforce the relevance of simulation-based strategies in obstetric training, demonstrating that the validated scenarios were considered appropriate and pedagogically adequate by experts. These results support research on the educational potential of simulation in obstetric care and contribute by providing validated instructional material designed to support teaching and training in this field.
In this regard, a recent study that proposed a technology acceptance model for virtual clinical simulation identified factors influencing its acceptance and use by nursing students, highlighting its potential to stimulate intrinsic motivation, promote active learning, and support the development of professional skills. These findings corroborate previous studies on the educational benefits of simulation-based strategies in nursing education [24].
Regarding the results obtained in the content validation, the high agreement observed among the experts in the SAM assessment, with an average index of 0.96 across all domains, may reflect both the clarity of the educational objectives and the relative homogeneity of the expert panel in terms of professional experience in obstetrics and educational technology.
These results are aligned with recent evidence on the effectiveness of nurse training through clinical simulations in the initial management of postpartum hemorrhage. In a study that assessed performance skills, the instrument presented a Cronbach’s alpha of 0.915, indicating high reliability. The authors also observed better performance among nurses who participated in Simulation-Based Training (SBT) compared to those who did not participate [25]. Thus, the validated simulation scenarios of the present study can contribute to the development of clinical competencies of nurses in obstetric care.
The suggestions provided by the experts indicate that the evaluation process contributed to the improvement of aspects such as the clarity of language, the representation of patient diversity, and the organization of clinical workflows within the storyboard. These contributions not only favored the alignment of the simulated scenarios with the objectives proposed for the development of the simulator, but also reinforce the importance of combining quantitative indicators of agreement with qualitative feedback in the validation process of educational technologies.
Considering the validation of appearance, the participation of residents in this phase contributed to broadening the evaluation of educational technology from the target audience’s perspective. Overall, participants considered the storyboard visually clear and pedagogically appropriate. All items on the IVAETH were evaluated satisfactorily, with a concordance index of 0.96, indicating a high degree of consensus among the residents. The comments provided by the participants also suggested adjustments aimed at improving contextual realism, which were incorporated into the revised version of the storyboard.
The involvement of learners in the validation process is considered an important step in the development of educational technologies. Their perceptions regarding usability, educational value, and practical applicability help ensure that the resulting tool aligns with the needs and expectations of the intended users. Studies have demonstrated that students who participate in simulation scenarios with prior theoretical knowledge are better able to integrate, organize, and retain new clinical information [26, 27].
Similar results were reported by Lima et al., who developed and validated a clinical simulation scenario for the management of postpartum hemorrhage intended for healthcare professionals, demonstrating the suitability of the instrument used to validate the proposed clinical scenario and the effectiveness of the validation process. In this study, psychometric measures such as the Intraclass Correlation Coefficient (ICC) and Cronbach’s alpha coefficient were used. Among the participating healthcare professionals, the ICC was 0.844 and Cronbach’s alpha was 0.841, indicating adequate levels of reliability between raters and internal consistency of the instrument. In addition, agreement greater than 0.85 was observed for all items evaluated, demonstrating consensus among the experts regarding the content and appearance of the simulation scenario [28].
It is clarified that in the field of validation of educational and psychometric instruments, different statistics are used to assess the reliability and quality of the instruments, such as Cronbach’s alpha coefficient, the Agreement Index (AI), the Content Validity Index (CVI), and the Intraclass Correlation Coefficient (ICC). These measures generally range from 0 to 1, with values closer to 1 indicating adequate levels of consistency or quality of the instrument being evaluated [29].
The development of validated simulation scenarios represents an important step in the creation of immersive educational environments. In this study, the validated storyboard provides the conceptual structure necessary for the future implementation of a virtual reality simulator for childbirth care. By organizing the clinical narrative, decision points, and pedagogical objectives, the storyboard serves as a blueprint for the development of an immersive simulation capable of supporting obstetric training for both students and professionals.
Regarding the implications for practice and education, the Birth Now simulator may support the teaching-learning process in obstetrics in a constructivist manner. Thus, based on the storyboard validated in this study, the simulator can be integrated into both undergraduate nursing courses and postgraduate obstetric nursing programs. In undergraduate courses, the simulator can be integrated into subjects related to women’s health or maternal care, allowing students to practice clinical decision-making in labor and delivery simulations before entering real clinical settings. In postgraduate studies and medical residency, the technology can support the development of advanced skills through repeated exposure to complex obstetric situations in a safe and structured learning environment.
It is worth highlighting that the next stage of this research will involve the development of the Birth Now virtual simulator, its implementation, and the evaluation of its effectiveness in improving clinical skills in obstetric care.
Limitations
This study has some limitations that should be acknowledged. First, the number of experts and residents involved in the validation process was relatively small, although consistent with methodological recommendations for validation studies.
Second, participants were recruited predominantly from institutions in one region of Brazil, which may limit transferability of the findings to other educational contexts. Future studies should include broader and more diverse samples to strengthen the external validity of the results.
Conclusions
This study developed and validated a storyboard for virtual reality simulation scenarios focused on nursing care during labor and childbirth, including situations of normal labor and postpartum hemorrhage. High levels of agreement in content and appearance validation support the adequacy of the storyboard as a pedagogically structured basis for the development of a virtual simulation tool for obstetric education. These findings indicate that the storyboard represents a pedagogically consistent structure to support the development of immersive simulation technologies for obstetric education.
The validated storyboard provides a conceptual framework for the future development of the Birth Now virtual simulator, which may contribute to strengthening clinical reasoning and decision-making skills among nursing students and professionals involved in childbirth care.
Future stages of this research will focus on the technological development of the simulator based on the validated storyboard, followed by usability testing and evaluation of its educational effectiveness in nursing training contexts.
Abbreviations
- AI
Agreement Index
- CVI
Content Validity Index
- ICC
Intraclass Correlation Coefficient
- IVAETH
Instrument for Validate of the Appearance of Educational Technologies in Health
- PPH
Postpartum Hemorrhage
- SAM
Suitability Assessment of Materials
- SBT
Simulation-Based Training
- VR
Virtual Reality
Author contributions
DCAS: Conceptualization, methodology, data analysis and interpretation, discussion of results, and writing - original draft. SJSB: Conceptualization, validation, writing - review and editing, and supervision. KMCM and ARFJ: Validation and writing - review and editing. DPR: Conceptualization, methodology, validation, and writing - review and editing. REFLC: Conceptualization, methodology, validation, writing - review and editing, and supervision. All authors read and approved the final manuscript.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data availability
The datasets generated and/or analysed during the current study are not publicly available because they contain information that could compromise participant privacy, but are available from the corresponding author on reasonable request.
Declarations
Ethical approval and consent to participate
This research received approval from the Research Ethics Committee of the State University of Ceará (Certificate of Presentation of Ethical Appreciation: 47849821.6.0000.5534) under opinion Nº 5.036.318. It was carried out respecting the ethical and legal principles of National Health Council Resolution No. 466/2012. Participation in the research was voluntary, and informed consent was obtained from all participants. Participants were assured that the data collected would remain strictly confidential and that they had the option to withdraw from participation at any time.
Declaration of consent for publishing images
There is no need to declare consent for publishing images containing human faces. The design of all graphic materials involved in the project was carried out with drawing and creation of images and textures through a great creative process and composition of visual concepts. From this, the storyboard was formulated and was developed based on the scripts presented with images, which provide a graphic visualization of the relevant images that were recorded in sequence, as if it were a comic book. Through it, it was possible to get an idea of the physical characterization of the characters in the story, settings, colors, actions and emotions present.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analysed during the current study are not publicly available because they contain information that could compromise participant privacy, but are available from the corresponding author on reasonable request.