Worldwide, patient safety has been a widely discussed topic, and has currently become one of the greatest challenges for health institutions. It is understood as the decrease, to an acceptable minimum, of the risk of unnecessary harm associated with health care, and although there are recommendations and progress in international literature, scientific knowledge must become incorporated into care practice [1].

The National Patient Safety Program, aligned with the objectives of the World Alliance for Patient Safety of the World Health Organization launched 6 patient safety protocols focusing on the most problematic areas of patient safety, among them improving safety in the prescription, use, and administration of medicines [2].

The concern with patient safety is heightened when referring to children, since they are a vulnerable part of society [3]. The quality of care related to patient safety in nursing is connected to the entire care process, thus, the use of intelligent technologies and the use of standardization can provide greater safety for patients [4].

Communication between professionals, parents, and patients is a factor in pediatric hospitalization, and the consequences of communication failures can generate significant damage to patients and decrease the effectiveness and quality of the care provided. Thus, in pediatric patient care, the prevention of errors, the analysis of the factors that led to an error, aims to implement measures, and improvements contribute to patient safety [5].

It was assumed that the development of a virtual learning environment on medication administration in neonatology and pediatrics would contribute to the knowledge gain of nursing students, and it was postulated that the use of a virtual learning environment is an adequate educational strategy to promote knowledge about pediatric medication administration, encouraging active and motivating learning.

Design-based research involves a new interventionist methodology that seeks to incorporate theoretical aspects of education research with educational practice and offers a promising approach to advance theoretical understanding; although theory alone will not solve all the problems encountered in practice, it can help explain how and why problems can be solved and can help students get better results [6].

Thus, based on the principles of design-based research, to contribute to continued professional education and student learning and to complement the principles of sustainability and patient safety, we developed, validated, and evaluated a virtual learning environment.

We used descriptive research, methodological development with a quantitative and qualitative approach, and the stages of design-based research as methodological strategies [7]. The phases of the research are described in Figure 1.

For the selection of the themes used in the virtual learning environment, main themes suggested by professionals in a previously conducted study [8] were taken into account, and 5 main themes were then selected: rights of medication administration, medication administration steps, medication administration routes, medication calculation, and nonpharmacological actions for pain relief.

After the construction of the virtual learning environment, 2 groups of participants, with different profiles and purposes, were included: experts in the field of pediatrics and neonatology (teachers and researchers) and final users (undergraduate students of nursing). After construction of the virtual environment, the content was validated by the experts and then evaluated by the students.

Students regularly enrolled in nursing at a public university were considered (convenience sample) and 112 students were invited; 26 students completed the evaluation by answering all the requested instruments corresponding to the final sample.

Data collection with students was carried out from June 2019 to August 2019. Participants were contacted by email and in person. Nursing students, through a questionnaire on Google Forms, filled out a 24-item Likert scale developed in a previous study [9] and adapted for this research. The students judged the virtual environment in terms of interaction and stimulus (6 items); interest and motivation to learn (3 items); dedication, discipline and time management (3 items); communication tools (3 items); didactic material (7 items); and the student's role in the learning process (2 items). Space was reserved for suggestions and additional comments. Quantitative data were calculated using mean and standard deviation using SPSS (version 20; IBM Corp). The percentage of agreement was also calculated, individually and by categories—80% agreement among users was considered as a positive evaluation.

The validation of the virtual learning environment was executed by a committee of specialists with evident knowledge in pediatrics or knowledge of active technologies and with the ability to evaluate the content of the virtual environment. A total of 59 specialists were invited, and 13 completed all the steps and answered all the requested instruments, corresponding to the final sample. To define the specialists, the Fehring Validation Model [10] was used, which consists of criteria used to classify the expertise of professionals in matters covered in educational technology. Nurses with specialized knowledge in pediatrics, neonatology, or active methodologies were included.

The experts answered a structured questionnaire focusing on the nature of the objectives, content, relevance, and environment. In the last section of the questionnaire, a blank space was reserved for the experts to add suggestions and comments (they were able to make qualitative collaborations and contribute to the improvement of the virtual learning environment). The content validity index was used, which measures and evaluates whether the proportion or percentage of experts are in agreement on certain aspects of the instrument and its items (each item individually and then the instrument as a whole). The questionnaire used a Likert-type scale with a score of 1 to 4 [11]. The content validity index of each item was calculated, and the content validity index of each category was calculated. Finally, the mean general content validity index of the virtual learning environment was calculated. For this study, a content validity index of 0.90 was considered as the experts judging the questions to be valid, based on Polit and Beck [12] who establish this value as standard to guarantee the excellence of a scale.

To measure the gain of knowledge, Worral [13] proposed the application of a pretest before the educational intervention, to identify the preacquired knowledge and a posttest to identify the gain of knowledge (retention capacity and memory) as an educational proposal. For the pretest, it was decided to carry out a questionnaire with 13 questions referring to the contents of the virtual environment, and those same questions were asked again in the posttest. The questionnaire contained true or false questions and underwent validation with 3 pediatric specialists, before being made available in the virtual environment. The students' responses to this questionnaire generated data on knowledge gain. With the Wilcoxon statistical test, we compared the outcome of the scores (pretest and posttest).

The research project was approved by the research Ethics Committee of the University of Brasília - Faculdade de Ceilândia, obtaining an opinion favorable to its realization under the protocol no. 3,203,397 and CAAE no. 08880519.3. 0000.8093.

The virtual learning environment for medication administration in pediatrics and neonatology was made available online with free access. The platform used to host the site was Heroku, a cloud computing service, and the reason for choosing this environment was the possibility of inserting images and videos created exclusively for a virtual learning environment.

The environment consisted of approximately 77 pages (HTML language), one of which was the main menu, and 8 were considered submenus of the themes of the modules. After registering, the user received an email, automatically generated by the platform as soon as the administrator approved participation. When accessing the virtual learning environment with login and password, the user was automatically redirected to the pretest page.

After answering the pretest questions, the user clicked on the save answers button and was directed to the main menu (Figure 2). This screen contained a button on the right side that accessed the 5 modules (Table 1), a button to check performance, an indication of the content already viewed, and a button for tutorial and credits. On the access screen for each module, it was possible to observe different interactions. Each circle generated a clickable link that opened a text box. Modules contained complementary material along with the reference used to write the content of that module. The links of the complementary material, when clicked, were directed to the publications.

At the end of the fifth module, the user was automatically redirected to the posttest page to answer the same 13 questions. After saving the answers, the user was directed to the home page and with the check performance button, could review which questions had been correct and which questions had been wrong. For the incorrect questions, a template showing correction and justification appeared.