Construction and Evaluation of an Educational Video: Nursing Assessment and Intervention of Patients’ Spiritual Needs

Spirituality is particularly important in health and illness transitions and is a fundamental dimension of healthcare. However, nurses often feel underprepared to provide spiritual care and the use of dynamic and interactive strategies, such as educational videos, can facilitate the development of this competency in undergraduate education. This study aimed to construct and evaluate an educational video lasting 10 min and 52 s for nursing students concerning the assessment of patients’ spiritual needs. The methodological study was based on the pre-production, production, and post-production phases of the video with an evaluation of the comprehension and comprehensiveness of the content. The results demonstrated the pre-production phase was considered appropriate by the judges and allowed the phase of production of the educational video, considered an educational resource by 100% the experts. Nursing students were enrolled in the evaluation and 75% considered the content and the learning experience useful for their future roles as nurses. So, the educational video was considered a tool that facilitated deepening knowledge about spirituality and motivated students to assess spirituality in clinical practice.


Introduction
Literature in healthcare often describes spirituality as one of the dimensions of the human being, which is particularly important in health and illness transition, and so, more attention is needed to this dimension (Hasanshahi and Mazaheri 2016). Scientific evidence underlines that spirituality is a fundamental aspect of healthcare (Timmins and Caldeira 2017). Additionally, spiritual care has been associated with health benefits, such as better recovery of different health indicators (Soroka et al. 2019).
Relying on the importance and contribution of spirituality in clinical practice, many healthcare professionals, especially nurses, have aroused deep interest on the topic internationally; but, at the same time, most feel unprepared and perceive a lack of training to deliver spiritual care (Espinha et al. 2013). The same happens with nursing students, who are willing to approach religious and spiritual aspects  (Fleming et al. 2009).

Pre-Production
The pre-production phase consisted of three stages: elaboration of the script, elaboration of the storyboard, and evaluation by experts (Fleming et al. 2009). The script was described based on the results from a literature review, through a search in electronic databases (SCIELO, LILACS, MEDLINE). The following search terms were used combined with the Boolean operators AND and OR: teaching, nursing, spirituality, religiosity, concept, and video/multimedia. After, the script was reviewed by two international experts, one of whom is proficient in Portuguese.
The description of the scenes (script) included foundational concepts defined according to literature; assessment of spiritual needs explored during patient-nurse interpersonal communication; and the use of the NURSE technique (Back et al. 2005), which helps to intervene in patients' emotions. This technique includes identifying the emotion, understanding what is a feeling, respecting the other person's feelings, verbal or non-verbal, offering support, stimulating ways to face the situation, and exploiting the emotion manifested (Back et al. 2005). The script also included the definition of spirituality and religiosity, some activities aiming to deepen clinical reasoning within spiritual care, particularly, identifying the nursing diagnoses and planning related nursing interventions.
With the purpose of guiding the design of the video, the revised script allowed the construction of the storyboard, in the form of a three-column table. In the first column, the content corresponding to each scene and the actors were described; in the second column, the audiovisual resources to be used were individually described (such as images, scenes, animations, texts, voice-over, and background sounds); and, in the third column, the legend and the description of the behaviors. The

Pre-Production
The pre-production phase consisted of three stages: elaboration of the script, elaboration of the storyboard, and evaluation by experts (Fleming et al. 2009). The script was described based on the results from a literature review, through a search in electronic databases (SCIELO, LILACS, MEDLINE). The following search terms were used combined with the Boolean operators AND and OR: teaching, nursing, spirituality, religiosity, concept, and video/multimedia. After, the script was reviewed by two international experts, one of whom is proficient in Portuguese.
The description of the scenes (script) included foundational concepts defined according to literature; assessment of spiritual needs explored during patient-nurse interpersonal communication; and the use of the NURSE technique (Back et al. 2005), which helps to intervene in patients' emotions. This technique includes identifying the emotion, understanding what is a feeling, respecting the other person's feelings, verbal or non-verbal, offering support, stimulating ways to face the situation, and exploiting the emotion manifested (Back et al. 2005). The script also included the definition of spirituality and religiosity, some activities aiming to deepen clinical reasoning within spiritual care, particularly, identifying the nursing diagnoses and planning related nursing interventions.
With the purpose of guiding the design of the video, the revised script allowed the construction of the storyboard, in the form of a three-column table. In the first column, the content corresponding to each scene and the actors were described; in the second column, the audiovisual resources to be used were individually described (such as images, scenes, animations, texts, voice-over, and background sounds); and, in the third column, the legend and the description of the behaviors. The storyboard of the video, composed of 48 scenes, was sent to three expert nurses with experience in the area of spirituality and communication requesting review. For this, an instrument adapted from Barbosa and Bezerra (2011) was used, comprising items related to content congruence, usability, verbal language and efficiency, duration of the video, and the number and characterization of all participants. Experts were also invited to share any comments by answering an open-ended question.

Production
The production phase consisted of implementing the storyboard (from the previous phase) in four stages: (1) rehearsing the scenes with the actors, (2) filming, (3) providing the voice-over, and (4) providing images and animations (Fleming et al. 2009). In this phase, a video technician from the university was involved. Participation also included a speaker for the voice-over and two nurses representing the nurse and the patient roles during the assessment of spiritual needs and spiritual care.
After the tests and technical adjustments for good technical quality, the video was recorded in a laboratory, representing a scenario of clinical practice, with a patient hospitalized in a surgical ward. At this stage, a technician with audiovisual resources was also involved for technical aspects.
The legislation regarding the copyright of use and reproduction of resources was observed in Law Nº 9.610 from 1998. In this way, the capture of third-party images took place through the Creative Commons website, a non-profit organization that allows the sharing and use of creativity and knowledge through free legal instruments (Creative Commons Brasil 2017). The other images and video animations were developed using Adobe Illustrator ® and Adobe Flash ® software.

Post-Production
Post-production included two steps: editing and evaluation of the video including experts and students, as the assessment of the comprehension and comprehensiveness of content should include potential users (Fleming et al. 2009). In the editing, adjustments were made in the recording of the scenes and the voice-over, with the inclusion of images, text, and animations in the video. Adobe Premiere ® and Adobe Audacity ® were used. After all editing, the content of the video (voice-over, images, animations, and footage) was transferred to DVD (digital versatile disc) format through the Avid Liquid Pro ® program, version seven. The evaluation was carried out by five experts with experience in spirituality and educational resources in health, and two participated before in the script generation. They evaluated the educational material, based on an instrument adapted from the criteria proposed by Landeros Lopez and de Carvalho (2006), which allowed for verification of the suitability of the video for lighting, color, visibility, and sound intensity, as well as physical movements, vocal expression, and tone of voice. The evaluation of the usefulness of the content of the video for learning, whether it would be worth recommending to a colleague, and the video's influence in future performance as a nurse, as well as the usefulness and the pleasantness of the assessment technique displayed in the video, was realized by a sample of fifteen nursing students. The inclusion criteria were to be enrolled in the institution where the study was conducted and been approved for the course in which the video was included as a resource. Sampling was based on the snowball technique (Polit and Beck 2013). The first student was chosen at random; after evaluating the eligibility criteria for participation in the study, the student watched and evaluated the video. The students in the study answered a short questionnaire for characterization, comprising sex, type of course, and academic semester they were attending. Each student was asked to recommend another student and so on, until the sample was composed. The evaluation regarding the acceptance and importance of the video was adapted from the studies of Carvalho (1985) and Iglesias-Parra et al. (2016).

Data Analysis
Data from expert volunteers and from students were analyzed by content analysis. Data about the characteristics of participants and about participants' answers (experts and students rate) were based on descriptive analysis (frequencies and percentages) using SPSS, version 20.0.

Ethical Aspects
This study was approved by the Research Ethics Committee involving human beings of the institution, under opinion nº 1,365,334. In addition, all actors playing characters (nurse and patients) signed the Term of Authorization of Image Use; the narrator, the Authorization Term for Voice Use; and the experts and the students, the respective Terms of Free and Informed Consent.

Pre-Production
The literature review provided valuable content for the educational video script, such as concepts/definitions and constructs about spirituality (Wheaters et al. 2016;Koenig 2012) and religiosity (Saad et al. 2001;Murakami and Campos 2012), and the difference between both (Saad et al. 2001;Murakami and Campos 2012); the definition of spiritual care (Ramezani et al. 2014); the communication technique for managing the patient's emotions when reporting spiritual needs (Back et al. 2005), as well as the role of the nurse (Lopes et al. 2015); and the clinical reasoning of the nursing professional in identifying the relevant data in the collection of data to define nursing diagnosis (Herdman and Kamitsuru 2015) and to plan the interventions that are necessary (Bulechek et al. 2016). The data obtained guided the design of the script for the interview to assess spiritual needs.
All experts who participated in the analysis phase of the storyboard were female, aged between 30 and 48 years, had nursing training between six and 25 years, and had an international publication on spirituality. Two experts had Ph.D. degrees, one had a master's degree, and all had experience in clinical practice. When answering about the congruence of the content of the storyboard the experts recognized an overall logical sequence. As for usability, all experts considered that the storyboard allowed students to understand how to conduct an interview. In this regard, two experts considered that the video was clear and responded to the goal; but one recommended the use of diagrams or flowcharts to represent the concepts of spirituality and religiosity to improve students' understanding. Concerning language, 66% considered the language adequate to the target audience and corresponding to daily practice; the disagreements referred to the fact that the dialogue was considered formal. However, 100% considered the language efficient and understandable. Regarding the duration of the video, this was considered adequate by all experts, as well as the number and the characterization of the participants. All suggestions were admitted: the dialogue on the video was changed, aiming to better represent daily practice and the diagrams and the flowcharts were also included, as suggested.

Production
All actors participated in a test run-through with a total duration of approximately five hours. The filming of the scenes and the voice-over of the video took place in three sessions: first, filming containing the voice-over; second, the authors met with the technical team and verified the need for adjustments in lighting and acoustics and the need for new filming and voice-over; finally, a final version was filmed.

Post-Production
In order to edit the video, meetings were held with the technical team to adapt the audio to the respective images, as well as to include the overlapping actors, the figures, or diagrams. After the editing, the final version of the video was submitted for evaluation by five experts. These were nurses with five to 25 years of experience and aged between 26 and 48 years old. Of these, two were experts in the area of spirituality, two were experts in communication, and one had training in both spirituality and communication. All five had a recognized publication profile and had a master's or Ph.D. degree.
The evaluation of the video happened in two sessions. In the first evaluation, aspects of lighting, color, and visibility were considered adequate by 100% of the experts; however, 80% of the experts suggested revision of the sound intensity of voice as well as some gestures and movements as used by nurses in daily practice. All experts considered that other aspects related to the content, environment, and actors were necessary and appropriately addressed to the target population. These aspects reinforced the need to re-record the corresponding scenes and adjust the sound. The second version of the video was presented to the judges and got 100% agreement for all the items listed on the content, environment, and actors in the video. At this stage, one expert suggested adding a video progress bar to help the students on returning to a specific scene when watching the video.
The final version of the video lasted 10 min and 52 s. The video starts with some diagrams related to theoretical aspects of spirituality and religiosity. For example, in Figure 2, the nurse states that the video aims at improving the understanding of undergraduate nursing students about spirituality, the relation between religion and religiosity, and how to assess spiritual needs. The video continues with the scenes reporting patient-nurse interaction. Then, another diagram ( Figure 3) requires students' participation by asking about five or six symptoms/clues in previous scenes. After these, the video moves forward and a nurse demonstrates the delivery of spiritual care interventions. After this, another diagram ( Figure 4) is on-screen and students are invited to discuss the scenes and to describe the interventions.
Religions 2020, 11, x FOR PEER REVIEW 6 of 11 in the area of spirituality, two were experts in communication, and one had training in both spirituality and communication. All five had a recognized publication profile and had a master's or Ph.D. degree. The evaluation of the video happened in two sessions. In the first evaluation, aspects of lighting, color, and visibility were considered adequate by 100% of the experts; however, 80% of the experts suggested revision of the sound intensity of voice as well as some gestures and movements as used by nurses in daily practice. All experts considered that other aspects related to the content, environment, and actors were necessary and appropriately addressed to the target population. These aspects reinforced the need to re-record the corresponding scenes and adjust the sound. The second version of the video was presented to the judges and got 100% agreement for all the items listed on the content, environment, and actors in the video. At this stage, one expert suggested adding a video progress bar to help the students on returning to a specific scene when watching the video.
The final version of the video lasted 10 min and 52 s. The video starts with some diagrams related to theoretical aspects of spirituality and religiosity. For example, in Figure 2, the nurse states that the video aims at improving the understanding of undergraduate nursing students about spirituality, the relation between religion and religiosity, and how to assess spiritual needs. The video continues with the scenes reporting patient-nurse interaction. Then, another diagram ( Figure 3) requires students' participation by asking about five or six symptoms/clues in previous scenes. After these, the video moves forward and a nurse demonstrates the delivery of spiritual care interventions. After this, another diagram ( Figure 4) is on-screen and students are invited to discuss the scenes and to describe the interventions.   Religions 2020, 11, x FOR PEER REVIEW 6 of 11 in the area of spirituality, two were experts in communication, and one had training in both spirituality and communication. All five had a recognized publication profile and had a master's or Ph.D. degree. The evaluation of the video happened in two sessions. In the first evaluation, aspects of lighting, color, and visibility were considered adequate by 100% of the experts; however, 80% of the experts suggested revision of the sound intensity of voice as well as some gestures and movements as used by nurses in daily practice. All experts considered that other aspects related to the content, environment, and actors were necessary and appropriately addressed to the target population. These aspects reinforced the need to re-record the corresponding scenes and adjust the sound. The second version of the video was presented to the judges and got 100% agreement for all the items listed on the content, environment, and actors in the video. At this stage, one expert suggested adding a video progress bar to help the students on returning to a specific scene when watching the video.
The final version of the video lasted 10 min and 52 s. The video starts with some diagrams related to theoretical aspects of spirituality and religiosity. For example, in Figure 2, the nurse states that the video aims at improving the understanding of undergraduate nursing students about spirituality, the relation between religion and religiosity, and how to assess spiritual needs. The video continues with the scenes reporting patient-nurse interaction. Then, another diagram ( Figure 3) requires students' participation by asking about five or six symptoms/clues in previous scenes. After these, the video moves forward and a nurse demonstrates the delivery of spiritual care interventions. After this, another diagram ( Figure 4) is on-screen and students are invited to discuss the scenes and to describe the interventions.     The video was also assessed for the usefulness of the content by nursing students. As such, fifteen students participated in this phase, and most were female (93.33%); 53.3% were final-year students and third-year students. With regard to the nursing assessment technique for spiritual needs and spiritual care as presented in the video, 75% of the students considered it "useful" and "interesting". Additionally, 75% considered it "very useful" and "pleasant" as a learning experience; 81.3% said they would recommend the video to a colleague; and 75% considered that the educational video could bring some assistance in their future performance as a nurse.

Discussion
The changes that have taken place within the scope of nursing undergraduate education came along within a global context of transformation, challenging educators to explore less traditional methods of teaching while acknowledging the need to utilize a variety of teaching and learning strategies (Corbally 2005;Wright and Charnock 2018). As such, the use of didactic resources contributes to student learning, and those are able to be used in the most diverse areas of knowledge and at any stage of academic education. This study presents an innovative video concerning the assessment of spiritual needs, which was considered a clear, objective, and adequate learning teaching strategy. In addition, this didactic and technological tool provides knowledge development and favors critical awareness (Moreira 2016).
In any type of teaching, the use of video should aim at enhancing learning and favoring the construction of knowledge. This implies that it is not enough to innovate with the introduction of communication media, it is also important to contextualize in the learning environments-virtual or not-and adapt to the pedagogical proposal in which they are inserted . Video can be used in a variety of ways, either (1) in the video-lesson mode that transmits information with video support to illustrate the content as a monoconcept program, focused on a specific concept or (2) as a motivating program that sensitizes the student to articulate the content ). The educational material proposed in this study can be used as video support, a monoconceptual and motivational program, presenting the objective of transmitting knowledge and stimulating the student to articulate his/her learning in relation to spirituality.
Even, as far as the teaching-learning process is concerned, pedagogical experiences have shown the relevance of the applicability of educational video by combining several elements, such as images, text, and sound in a single object of knowledge promotion (Gómez and Pérez 2013). The combination of these elements was planned in the pre-production phase of the video, through the detailed elaboration of the storyboard which helped to develop the production phase.
Each phase of the video design had specificities, however, the post-production was longer, as the experts suggested editing of some scenes concerning nurse-patient interaction when they did the first assessment. The evaluation of the video was important, adding credibility to this educational technology and a science-based approach (Galindo-Neto et al. 2019). The video was also assessed for the usefulness of the content by nursing students. As such, fifteen students participated in this phase, and most were female (93.33%); 53.3% were final-year students and third-year students. With regard to the nursing assessment technique for spiritual needs and spiritual care as presented in the video, 75% of the students considered it "useful" and "interesting". Additionally, 75% considered it "very useful" and "pleasant" as a learning experience; 81.3% said they would recommend the video to a colleague; and 75% considered that the educational video could bring some assistance in their future performance as a nurse.

Discussion
The changes that have taken place within the scope of nursing undergraduate education came along within a global context of transformation, challenging educators to explore less traditional methods of teaching while acknowledging the need to utilize a variety of teaching and learning strategies (Corbally 2005;Wright and Charnock 2018). As such, the use of didactic resources contributes to student learning, and those are able to be used in the most diverse areas of knowledge and at any stage of academic education. This study presents an innovative video concerning the assessment of spiritual needs, which was considered a clear, objective, and adequate learning teaching strategy. In addition, this didactic and technological tool provides knowledge development and favors critical awareness (Moreira 2016).
In any type of teaching, the use of video should aim at enhancing learning and favoring the construction of knowledge. This implies that it is not enough to innovate with the introduction of communication media, it is also important to contextualize in the learning environments-virtual or not-and adapt to the pedagogical proposal in which they are inserted . Video can be used in a variety of ways, either (1) in the video-lesson mode that transmits information with video support to illustrate the content as a monoconcept program, focused on a specific concept or (2) as a motivating program that sensitizes the student to articulate the content ). The educational material proposed in this study can be used as video support, a monoconceptual and motivational program, presenting the objective of transmitting knowledge and stimulating the student to articulate his/her learning in relation to spirituality.
Even, as far as the teaching-learning process is concerned, pedagogical experiences have shown the relevance of the applicability of educational video by combining several elements, such as images, text, and sound in a single object of knowledge promotion (Gómez and Pérez 2013). The combination of these elements was planned in the pre-production phase of the video, through the detailed elaboration of the storyboard which helped to develop the production phase.
Each phase of the video design had specificities, however, the post-production was longer, as the experts suggested editing of some scenes concerning nurse-patient interaction when they did the first assessment. The evaluation of the video was important, adding credibility to this educational technology and a science-based approach (Galindo-Neto et al. 2019).
The duration of the video was 10 min and 52 s, which is considered adequate for its educational objective, as this period facilitates students effectively keeping their attention on the content (Fleming et al. 2009).
The technologies in health and nursing are in ongoing development and aim for the improvement of the quality of patient care. However, the use of these technologies may also facilitate understanding of events and promote changes in patients' health (Krau 2015). In this sense, the video that resulted from this study is another tool for the training of nursing students in spiritual care, which is widely described as absent, but also needed towards reducing patients' suffering (Reginato et al. 2016).
Regarding the object of this study-the assessment of patients' spiritual needs-most participants still described the need for assistance in providing spiritual care. In fact, using a video for training may be an advantage in facilitating the approach to such an intimate topic and in preparing for the clinical practices. Interestingly, most students that participated were final year students. In fact, the nursing students and nurses should be prepared to assess and adequately intervene when identifying patients' spiritual needs, based on professional principles and ethical responsibility for providing holistic care within the healthcare team. As such, education and preparation along the undergraduate nursing education is foundational (Caldeira et al. 2016). The video was considered useful for nursing students but also for nurses who need training in this specific topic, as such, it may represent a good strategy to implement this content in nursing education.
Regardless of the positive feedback on the video, it is not available in the public domain, and this is a limitation of this study.

Conclusions
The methodological approach adopted was fundamental in the design of the educational video, concerning the assessment of patients' spiritual needs. The pre-production and production phases made possible the construction of the video and the post-production phase facilitated the experts' evaluation and potential users, in this case, undergraduate nursing students. The video was well accepted by nursing students; 75% considered it pleasant to watch the video and participate in the activities. Students described the video as a tool very useful for training competencies and knowledge about spirituality in practice. As such, video was considered a motivational resource to improve specific strategies in implementing spirituality in clinical practice.
Regardless of the importance of using videos to improve nursing students' learning, it is still necessary to encourage teachers to approach and discuss spirituality with students and to promote the transfer into practice.