Telesimulation about home visits and child care: facilitators, barriers and perception of Nursing students

Abstract Objective: to evaluate the facilitators, barriers and perceptions of Nursing students in learning about home visiting and child care through Telesimulation during the COVID-19 pandemic. Method: a qualitative study to evaluate Telesimulation via computers, grounded on Kolb’s theoretical model. A semi-structured questionnaire and the Student Satisfaction and Self-Confidence in Learning Scale were applied, with descriptive analysis and qualitative thematic analysis on the perceptions of 41 Nursing students. Results: the contextualized Telesimulation provided learning opportunities in dimensions of the pedagogical strategy, telesimulated scenario, communication and specificities of child care in home visits. It was considered a safe and dynamic activity that helped knowledge consolidation and reflective attitudes, proximity to reality, and develop interaction, observation and types of approaches. There were restrictions due to Internet connection failures. A large percentage of the students indicated good satisfaction and self-confidence level with learning in the scale applied. Conclusion: the real clinical situation with remote immersion allowed observation, decision-making, reflection and elaboration of conclusions, inherent to the experiential learning cycle. The set of elements of this Telesimulation created an environment that stimulated the interest of Nursing students for other learning stages, suggesting a space that strengthens knowledge and maintains dialogue with face-to-face practices.

experiences and draw conclusions or inductive systematic abstractions, in order to refine frameworks for the clinical practice and empirically test action plans (10) .

Study locus
A research study carried out in a virtual environment, using the Google Meet ® and Google Forms ® platforms, with undergraduate Nursing students from a public university located in Ribeirão Preto-SP, Brazil, focusing on a didactic activity of an undergraduate course in Nursing.

Period
The study was developed between May 26 th to October 27 th , 2021.

Selection criteria
Nursing students enrolled in the Bachelor's Degree

Participants
The initial population consisted in 53 students attending third year of the undergraduate course enrolled in the aforementioned academic discipline, of which seven did not participate in the activity. There was no refusal to participate in the research. During the remote activity, five students withdrew their participation and seven did not attend the discipline the date in which this activity was conducted. The convenience sample was, 41 participants at both moments in Google Meet ® and Google Forms ® .

Process to design the Telesimulation
The theme of HV, which makes up the syllabus of the aforementioned discipline, was chosen for its relevance to child care and to integrate the Nursing practices in the field of primary health care (12)(13) . With the suspension of faceto-face classes at the university, the simulated scenarios, originally planned, were reformulated and adapted to the new academic situation, via remote access and synchronous activities. Consequently, the topic proposed was organized in a Telesimulation process. Subsequently, at other moments of the academic discipline, the topic was also offered to the participating students as an in-person practice in health services.
The activity consisted of a single Telesimulation lasting two hours and thirty minutes, with one hour and ten minutes of prebriefing, twenty minutes of telesimulated scenario and one hour of debriefing. The same facilitator conducted all the activities proposed.
The process established a safe learning environment, grounded on recommended practices (14) and on the standards of simulation design best practices (15) . In addition to that, three attributes of the learning environment were preserved: ability to make mistakes without consequences, qualities of the facilitator and activity with guidance, preparation, objectives and expectation (16) .
The prebriefing included an online conference, conducted by a professor in the field of Child Health Nursing, prior to the telesimulated scenario activity, to offer content relevant to the topic, as well as an initial explanation of the activity.
The Telesimulation intervention was based on monitoring infant growth and development of a nine-monthold baby without special health needs. The setting was conducted with real data, based on the home a child and his reference parental caregiver. The approach was focused on specific aspects of child health, featuring a telesimulated home visit, centered on dialogue and observation, resolution of doubts and professional support regarding follow-up of the child's growth and development, including visualization of real data from the child's handbook and guidelines related to the COVID-19 pandemic context (protection measures, social distancing and vulnerable situations).
The Telesimulation involved the participation of two actors, the baby and the grandmother, two teachers with availability of an operative microphone and webcam during development of the clinical case, with a computer screen and, simultaneously, the students participating in the activity. Two of them interacted with the actors, and the other students watched and listened, as in a typical simulation session. There was also the participation of two female graduate students, assisting in visualization of the written messages, supporting the students and professors, and making the link to the form available.
After the telesimulated home visit, the debriefing was carried out, permeating the emotional phases (How did you feel doing this activity), descriptive (How do you describe the scenario experienced?), evaluative (What did you do properly? What points could be improved?), and conclusive (What will you take from this to add to The SCLS scale presents 13 items with five-point Likert-type answers, where one point is the lowest satisfaction level and five points represent the highest satisfaction level (17) . Validation of the scale for the Portuguese language has psychometric properties with good potential for using the instrument, although there are limiting factors, such as sample size and its specificity (17) .

Data collection
Data collection was performed remotely, where the first contact was made via email. After the Telesimulation activity, a link for online access via Google Forms ® was

Data analysis
In the descriptive statistics analysis, the relative frequency of the variables investigated related to the results of the SCLS scale was calculated. Reflexive thematic analysis was used to analyze the students' perceptions, with initial familiarization with the data, code generation, naming of topics and reporting (18) .

The SCLS scale presents 13 items with five-point
Likert-type answers, where one point is the lowest satisfaction level and five points represent the highest satisfaction level (17) , presented in Figure 1.
The procedures consisted of indexing information regarding the answers to open questions, whose codes capture an aspect and display a facet, and the thematic units add multiple facets and dimensions (18) . This process made it possible to highlight thematic units, which allowed analyzing opinions, attitudes, values and beliefs, avoiding a passive and decontextualized channel about the participants' answers (18)(19) . The participants were assigned names of gems as codenames. It is worth noting the absence of any authority relationship between students and professors.

Results
The mean age of the students was 23 years old,     These opportunities bring about positive points that denote interest in the content and approach, with openness to the diverse information worked on that configure immediate learning and generate prospective interest.
On the other hand, the limits of the remote activity The perspective adopted recorded a real context, representing an opportunity marked by proximity to reality: We got closer to reality, even if remotely, training for when we go to Regarding the SCLS levels, Figure 3 presents the results of the scale for undergraduate Nursing students. 4. The teaching materials used in this simulation were motivating and helped me to learn.
5. The way my professor taught through the simulation was suitable to the way I learn.
6. I am confident that I am mastering the content of the simulation activity that my professor presented to me.
7. I am confident that this simulation included the necessary content to master the curriculum of home visits in children's health.
8. I am confident that I am developing skills and obtaining the required knowledge from this simulation to perform the necessary procedures in a clinical setting.
9. My professor used helpful resources to teach the simulation. 10. It is my responsibility as a student to learn what I need to know through this simulation activity.
11. I know how to get help when I do not understand the concepts covered in the simulation.
12. I know how to use simulation activities to learn skills.
13. It is the professor's responsibility to tell me what I need to learn on the theme developed in the simulation during class time. It is noted that a large percentage of the students pointed out good levels (scores of four and five). There was a higher level of satisfaction regarding the methods and resources used, conduction of the Telesimulation, availability of motivating materials, obtaining the necessary knowledge from the Telesimulation, and the student's responsibility to learn and to seek help.
The aspects pointed out with the lowest level of satisfaction were related to confidence to master the child's health content and the professor's responsibility to say what the students need to learn in the theme developed during the telesimulated activity.

Discussion
The results of the current study present facilitators,  (20) .
The COVID-19 pandemic context has generated changes in the everyday life of teaching, with Telesimulation being an alternative aimed at continuing undergraduate education and creating robust remote educational experiences that maximize learning opportunities (1)(2)(3)(4)(21)(22) , similarly to that found in the current study. In Brazil, during the COVID-19 pandemic, not only did the education area undergo changes in its routine, the health area in turn issued programmatic guidelines for primary health care related to the reorganization of actions, for example, the routine vaccination service was postponed at times throughout the national territory and teleservices were introduced, as measures to reduce faceto-face contact. Based on documentary analysis, a study identified that longitudinality of the health actions was affected by the reduced access to child health promotion, during the COVID-19 pandemic (23) .
Regarding the perception about Telesimulation, most of the students indicated satisfaction, a result also identified in other studies, which found greater engagement and stimulus for critical thinking (1,23) , flexibility and facilitations in the discussion (24) , as well as to learn both by observing and actively engaging in the activity (25) .
In addition, several studies pointed out limitations of remote activities, due to gaps in audio quality (1) , distractions and limited Internet connection (3) , similarly to the current research. It is worth pointing out that the Nursing students' desire to learn more with in-person HVs is legitimate.
Telesimulation appears as a possibility to redesign a practice and offers a set of elements that are likely to converge pedagogically in the name of meaningful learning (27) . Thus, it is a practice that reveals aspects that can be worked on in advance, reinvigorates students' interest in learning and, as an active guide, opens up possibilities for other learning stages.
Elaboration of a situation tangent to reality to provide the apprehension of factual aspects was relevant in the current study and, from this influx, other perceptions were born, provided by the debriefing moment, for the construction of visions of the professional practice and health care. Debriefing is considered effective in providing experiences and opportunities for acquiring knowledge and has been used in simulation in Nursing education to improve clinical skills and learning outcomes (28) .
The experiences that Nursing students have with experiences and use of technologies during graduation Domingues AN, Hilário JSM, Mello DF, Moreno AIP, Fonseca LMM.
are seen as a possibility of training and proximity to Telehealth, which is growing in the clinical practice and linked to the increase in health care (29)(30) . The