Simulated scenario for promoting breastfeeding in primary health care

Natarelli, Taison Regis Penariol; Campbell, Suzanne Hetzel; Mello, Débora Falleiros de; Moreno, Ana Isabel Parro; Fonseca, Luciana Mara Monti

doi:10.37689/acta-ape/2025AO0002852

Abstract

Objective: To develop and validate a simulation scenario on breastfeeding as a health education strategy for pregnant women in primary health care.

Methods: This methodological study to construct and validate a simulation scenario on breastfeeding for clients was divided into four stages: (1) construction of the scenario, (2) content validation with 15 experts, (3) appearance validation with 6 experts and (4) testing of the scenario with a pregnant woman. The Content Validity Index and the Appearance Validity Index were used to validate and evaluate the scenario, as well as the Breastfeeding Self-Efficacy Scale (pre- and post-test) and the Learning Satisfaction and Self-Confidence Scale. The data was analyzed using descriptive statistics and presented as absolute and relative frequencies.

Results: The simulation scenario thus constructed obtained a Content Validity Index >0.90 for all items and a total Appearance Validity Index of 0.96. The scenario was tested in the home of the pregnant woman, who achieved high levels of satisfaction and self-confidence in learning. There was also an increase in breastfeeding self-efficacy after the simulation.

Conclusion: The simulated scenario to promote breastfeeding was built and validated by experts and tested with a pregnant woman, suggesting that it is an effective health education strategy due to its potential to increase self-efficacy in breastfeeding. The achievement of high levels of satisfaction and self-confidence in learning indicates its application in prenatal education actions in primary health care.

Resumo

Objetivo: Construir e validar um cenário de simulação sobre aleitamento materno como uma estratégia de educação em saúde para gestantes no âmbito da atenção primária à saúde.

Métodos: Este estudo metodológico para construir e validar um cenário de simulação sobre aleitamento materno voltado à clientela foi dividido em quatro etapas: (1) construção do cenário, (2) validação de conteúdo com 15 experts, (3) validação de aparência com 6 experts e (4) teste do cenário com uma gestante. Para validar e avaliar o cenário foram usados o Índice de Validade de Conteúdo e o Índice de Validade de Aparência, além da Escala de Autoeficácia para Amamentação (pré e pós-teste) e Escala de Satisfação e Autoconfiança com a Aprendizagem. Os dados foram analisados por estatística descritiva e apresentados como frequências absoluta e relativa.

Resultados: O cenário de simulação assim construído obteve Índice de Validade de Conteúdo >0.90 em todos itens e um Índice de Validade de Aparência total de 0.96. O cenário foi testado no domicílio da gestante, que alcançou níveis altos de satisfação e autoconfiança na aprendizagem. Foi também verificado um aumento na autoeficácia para amamentação após a simulação.

Conclusão: O cenário simulado para promover aleitamento materno foi construído e validado por experts e testado com uma gestante, sugerindo configurá-lo como estratégia de educação em saúde eficaz pelo potencial de aumentar a autoeficácia em amamentação. O alcance de altos níveis de satisfação e autoconfiança na aprendizagem indica sua aplicação em ações educativas no pré-natal na atenção primária à saúde.

Descritores
Aleitamento materno; Gestantes; Treinamento por simulação; Educação em saúde; Educação pré-natal; Atenção primária à saúde

Resumen

Objetivo: Elaborar y validar un escenario de simulación sobre lactancia materna como una estrategia de educación para la salud para mujeres embarazadas en el contexto de la atención primaria de salud.

Métodos: Estudio metodológico para elaborar y validar un escenario de simulación sobre lactancia materna orientado a la asistencia, dividido en cuatro etapas: (1) elaboración del escenario, (2) validación del contenido con 15 especialistas, (3) validación de la apariencia con 6 especialistas y (4) prueba del escenario con una mujer embarazada. Para validar y evaluar el escenario se utilizó el Índice de Validez de Contenido y el Índice de Validez de la Apariencia, además de la Escala de Autoeficacia para la Lactancia (pre y postest) y la Escala de Satisfacción y Autoconfianza del Aprendizaje. Los datos fueron analizados por medio de estadística descriptiva y presentados como frecuencia absoluta y relativa.

Resultados: El escenario de simulación elaborado obtuvo un Índice de Validez de Contenido de >0,90 en todos los ítems y un Índice de Validez de la Apariencia total de 0,96. Se realizó una prueba del escenario en el domicilio de la mujer embarazada, con niveles altos de satisfacción y autoconfianza del aprendizaje. También se verificó un aumento de la autoeficacia para la lactancia después de la simulación.

Conclusión: El escenario simulado para promover la lactancia materna fue elaborado por especialistas y se realizó una prueba con una mujer embarazada, lo que sugiere que puede ser configurado como una estrategia eficaz de educación para la salud por su potencial para aumentar la autoeficacia en la lactancia. Los altos niveles de satisfacción y autoconfianza del aprendizaje indican su aplicación en acciones educativas en los controles prenatales de la atención primaria de salud.

Descriptores
Lactancia materna; Mujeres embarazadas; Entrenamiento simulado; Educación prenatal; Atención primaria de salud

Introduction

The World Health Organization (WHO) recommends breastfeeding (BF) until two years of age or older, considering its numerous benefits to the health of children and women in the short and long term, as well as to the family and society. However, efforts are still needed to increase breastfeeding rates around the world.(¹,²) In Brazil, the prevalence of Exclusive Breastfeeding (EBF) in children under six months is estimated at 45.8%, below the WHO expectation of 50% by 2025.(¹,³) In turn, early weaning is a complex and multifactorial phenomenon that involves biological, psychological, social and cultural aspects, requiring a comprehensive and broad approach to understand and monitor it.(⁴)

During the prenatal period, breastfeeding education is seen as capable of increasing women’s level of knowledge on the subject, favoring the initiation, establishment and continuity of breastfeeding.(⁵) However, when health education actions are carried out during prenatal care, they are generally based on banking education, consisting of prescriptive and imposing guidelines, favoring the vertical and unidirectional transmission of knowledge.(⁶)

As an alternative to traditional pedagogy, health professionals who care for pregnant women can use active methodologies that encourage women’s autonomy and protagonism in the construction of their knowledge. Among the different active teaching techniques available, we highlight simulation as a method that seeks to replace real experiences by imitating reality in a safe and controlled environment. It is capable of contributing to learning, acquiring skills and attitudes, as well as stimulating critical thinking and increasing the safety of participants.(⁷)

In recent years, successful experiences have been described in the literature with the use of simulation in the teaching of BF to undergraduate students,(⁸,⁹) postgraduate(¹⁰,¹¹) and health professional.(¹²) On the other hand, the use of simulation is still little explored in health education and underreported in the scientific literature. When simulation is applied in the context of breastfeeding education for pregnant or postpartum women, these experiences are generally limited to demonstrating and/or training in the breastfeeding technique with the help of low-fidelity simulators (such as didactic breasts and infant mannequins). These experiences are already advances in breaking with traditional pedagogical practices, making educational actions more attractive, dynamic and participatory, although they are not considered properly structured and validated simulation scenarios.(¹³, ¹⁴, ¹⁵)

As simulation is a proven effective teaching technique, and considering that there is still a lack of studies on breastfeeding simulation, it is necessary to develop a rigorously structured and validated simulated scenario on breastfeeding for clients. Therefore, the aim of this study was to build and validate a simulation scenario on breastfeeding as a health education strategy for pregnant women in primary health care.

Methods

This was a methodological study to build and validate a simulated scenario on promoting breastfeeding for pregnant women and their families. It was divided into four stages: (1) scenario construction, (2) content validation, (3) appearance validation and (4) scenario testing.

The simulated scenario was built in accordance with the International Nursing Association for Clinical Simulation and Learning’s Standards for Good Practice in Health Simulation,(¹⁶) being complementarily guided by the conceptual components of the National League Nursing Jeffries Simulation Theory (NLN/JST) model.(¹⁷) The content of the scenario was selected and prepared by researching the scientific literature, looking for the best and most up-to-date evidence on AM.

The simulation scenario was designed to be applied in situ, i.e. in the homes of pregnant women through home visits. This scenario can be used by any senior health professional who works in the FHS and is familiar with the area of breastfeeding.

The scenario also includes the life saver strategy. The facilitator can call in a trained actor to take part in the scene if he or she deems it necessary. The actor will play a Community Health Worker on a home visit who should direct the participant in carrying out the actions expected for the scenario.

After construction, the simulation scenario was validated by experts in the field of clinical simulation and/or MA. In order to assess the quality and representativeness of the scenario’s content, content and appearance validation techniques were used, as well as the understanding and presentation of the simulation, so that the appropriate adjustments could be made before the scenario was put into practice.(¹⁸)

The experts were selected for convenience through a search on the Lattes Platform (National Council for Scientific and Technological Development, CNPq) according to criteria adapted from a classification system for selecting experts.(¹⁹)

The classification system has the following mandatory criteria: clinical experience of at least one year in one of the study’s areas of interest (4 points). Six scoring criteria were also considered: (1) experience of at least one year in teaching (1 point), (2) publication of articles (1 point), (3) participation of at least two years in a research group (1 point), (4) doctorate in nursing (2 points), (5) master’s degree in nursing (1 point) and (6) residency or specialization (1 point) in an area of interest to the study (breastfeeding or child health or women’s health or clinical simulation or health education and/or nursing). This system classifies candidates according to the following nomenclatures: expert junior (minimum: 5 points), expert master (6-20 points) or expert senior (>20 points).(¹⁹) The inclusion criteria were as follows: participants with a score equivalent to or higher than the title of junior expert (≥5 points). Tose who did not respond to the validation form within the established timeframe were excluded.

The Delphi technique was used to validate the scenario. This consists of carrying out rounds of validation to reach a consensus among the experts.(²⁰) The content and appearance validation stages were carried out separately with two diferent groups, to avoid exhausting the experts in the face of the possibility of new rounds of validation.

Firstly, the content validation was carried out from January 2021 to June 2022. 24 experts who met the inclusion criteria were invited to take part in the study. Of these, nine were excluded for not returning within 90 days as informed in the invitation, totaling a sample of 15 experts. The participants were invited to take part by e-mail and sent the following documents: Informed Consent Form (ICF), expert characterization form, simulation scenario script in pdf format and content validation tool,(²¹) and its items were adapted to the context of the simulation (Google Forms®). In all, three rounds of validation were necessary, taking into account the incorporation of suggestions from the experts and approval of the final version of the simulation script.

The appearance was validated between June and August 2022. At this stage, the simulation scenario was shot and filmed, making it possible to validate the look remotely to reach experts in other regions of the country. As the video should reflect the proposal of an in situ simulation to be applied in the community, filming took place in the Simulated House of the Nursing Practice Simulation Center (Ribeirão Preto Nursing School of the University of São Paulo, EERP/USP), representing the pregnant woman’s home.

The video of the simulation scenario was sent in MP4 format to another sample of experts using the Google Drive® application. Six experts were invited to take part in this stage. They were selected according to the classification system used to validate the content. In addition to the invitation sent by email, the following were also sent via Google Forms®: ICF, expert characterization form and appearance validation tool.(²²) with items adapted to the context of the simulation. All six experts contacted accepted the invitation and met the 30-day deadline set and informed to analyze the video and respond to the forms sent.

After validation, the simulated scenario was tested on a representative of the target audience. A pregnant woman registered at a Family Health Unit (FHU) in a city in the interior of São Paulo (primi-gravida; second gestational trimester) and her aunt (a relative indicated by the pregnant woman as a possible helper in caring for the child that was to be born) took part in the test. The invitation was made at a meeting of the pregnant women’s group organized by the FHU. After reading and signing the informed consent form, the simulation was applied, including a briefing, scenario and debriefing. To assess the scenario simulated by the pregnant woman, the Self-Efficacy for Breastfeeding scales were applied (pre- and post-test)(²³) and Satisfaction and Self-confidence with Learning.(²⁴)

The items on the validation forms were associated with a Likert scale (1-5 points), where (1): totally disagree, (2): partially disagree, (3): don’t know, (4): partially agree and (5): totally agree. To check the quality of the scenario items, the Content Validity Index (CVI) and Appearance Validity Index (AVI) were used, calculated from the equation: number of “4” and “5” answers / total number of answers, as well as Average CVI and Total AVI, which correspond respectively to the average of the values obtained in the CVI and AVI. The minimum acceptable values were CVI, Average CVI and Total VA T >0.90, as well as AVI >0.78.(²²,²⁵) The data was tabulated in a Microsoft Office Excel® spreadsheet, analyzed using descriptive statistics and presented as absolute and relative frequencies.

This study was approved by the Research Ethics Committee with Human Beings (REC) of EERP/ USP (Opinion: 4.324.588; Certificate of Submission for Ethical Appraisal: 32947720.0.0000.5393) in accordance with the National Health Council, Resolution 466/2012. All participants signed the ICF.

Results

Building the scenario

The simulation scenario was entitled “Breastfeeding the Newborn”. The script for the simulated scenario, including the Decision-Making Tree, validated and improved in line with the experts’ suggestions, is presented in annex 1. The data from the experts who took part in the content and appearance validation processes is shown in table 1.

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Table 1
Characterization of the experts who participated in the validation of the simulated scenario

Content validation

Regarding the experts’ assessment and agreement on the three proposed domains (objectives; structure and presentation; relevance), all items showed CVI >0.90, with a Mean CVI of ~1.00 (Table 2).

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Table 2
Content validation of the simulated scenario with experts

Although the minimum criterion of CVI >0.90 was met and validated in the first round, some of the experts’ suggestions were accepted and incorporated through minor adjustments to improve the scenario. The following suggestions were accepted: include the NB’s signs of hunger and satiety in the specific objectives; mention the participation of family members as a target audience; make other materials and/or devices available in the scenario (breast pump, intermediary) which are not indicated but are available on the market; include in the observation checklist the performance of the appropriate latch and the importance of the mother talking to the baby; include some difficulties in the clinical case, making it closer to the puerperal woman’s reality; make it clear to the participant when the scenario will start; include the debriefing contents necessary to theorize the learning developed in the scenario, as well as minor grammatical corrections. A second round of validation was then carried out with the experts to assess the changes made. The modified scenario was sent to the 15 experts who took part in the first round; however, only five experts responded within the 30-day deadline, achieving 100% agreement among the respondents. In the second round, only one suggestion was made. Initially, the use of the breast pump would be treated as a possible unwanted action, preventing the participant from moving on to the next scene. However, an expert questioned the fact that expressing milk with a pump can provide short-term relief, although it is contraindicated. Therefore, if the pregnant woman decides to use the breast pump during the scenario, the simulation should move on to the next scene, and the contraindication of the device should be addressed during the debriefing. Finally, the final version of the script was sent to the 15 experts for approval. Of these, only six responded within the 30-day deadline, with 100% agreement among the respondents.

Appearance validation

After being validated in content, the simulation scenario was shot and filmed in the Primary Care Laboratory (Simulated House) of the Nursing Practice Simulation Center (Ribeirão Preto Nursing School of the University of São Paulo, EERP/USP) with a volunteer nurse (Figure 1).

Figure 1
Reproduction of the simulation scenario in the appearance validation stage

Most of the components of the instrument to validate the appearance reached AVI >0.78, except for item 11 (about the materials and devices in the scenario), which had AVI= 0.66. On this item, some experts questioned the use of devices that are contraindicated for breastfeeding women, such as breast pumps. If the participant decides to use them, the provision of such devices is still justified by the need to address their contraindications during the debriefing, as they are present in the daily lives of nursing mothers. Therefore, there was no need to adjust this item. It was suggested that the actor sanitize their hands and wear gloves when helping the participant with the breastfeeding technique. The suggestion was accepted but, considering the costs of producing a new video, we opted to indicate in the script that the actor should sanitize their hands with 70% alcohol gel and wear procedure gloves when meeting the participant. The simulated scenario showed a Total AVI=0.96 (Table 3).

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Table 3
Validating the appearance of the simulated scenario with experts

Testing the scenario

The scenario test was carried out at the pregnant woman’s home. The participant was 19 years old, married, a technical student with completed high school and a family income of more than one minimum wage. As for her obstetric history and current pregnancy data, she was primiparous and in her second trimester of pregnancy (gestational age: 22 weeks and 1 day). She reported an unplanned but wanted pregnancy; she attended her prenatal appointments regularly but had not yet received advice on breastfeeding. In the pre-test, the pregnant participant had a breastfeeding self-efficacy equivalent to 51 points (medium effica-cy); in the post-test, she scored 60 points (high effi-cacy). Maximum scores were achieved in the dimensions of satisfaction (25) and self-confidence (40) in learning. The participant evaluated the scenario positively and suggested that other simulations should be developed during prenatal care with other topics (e.g. first aid for newborns).

Discussion

The simulation scenario developed in this study has Primary Health Care as its context, which is considered the gateway to the Unified Health System (SUS) and a privileged space for developing health education actions and promoting primary health care.(²⁶) It is therefore important to use strategies such as the teaching method proposed here. They ensure that women’s doubts are clarified and their insecurities reduced during the prenatal period.(²⁷)

The results obtained in the validation process of this scenario were considered satisfactory. In addition, all items had a CVI >0.90 as recommended(²⁵) and the scenario script obtained an average CVI with ~100% agreement (similar to a study that built and validated the content and appearance of a virtual simulation on breastfeeding).(²⁸)

In the scenario test, the pregnant woman obtained maximum scores in the subscales of satisfaction and self-confidence with learning. A study using scales of satisfaction and self-confidence in learning found positive results in the use of simulation.(²⁹)

In order to improve participants’ learning satisfaction and self-confidence in a simulation, it is essential to consider the design, the practice of the simulation and the educational factors involved.(³⁰) This underscores the importance of scenario development processes.

In the scenario test, the pregnant woman also showed an increase in breastfeeding self-efficacy scores compared to the results obtained before and after the simulation. Similarly, a quasi-experimental study examining the effects of an educational intervention on breastfeeding during prenatal care found an increase in the breastfeeding self-efficacy scores of women in the experimental group, as well as higher breastfeeding success rates in the postpartum period compared to the control group.(³¹)

Self-efficacy in breastfeeding is based on the mother’s confidence in her ability to breastfeed her child, positively influencing the establishment, maintenance and duration of breastfeeding.(³²)

The limitation of this study is that the simulation scenario that was built and validated was only tested on one representative of the target audience. As this is an active and individualized teaching strategy (simulation in situ at the pregnant woman’s home), it would be impossible to replicate the scenario as a test in a large number of home visits. We therefore considered it acceptable to test it with just one pregnant woman, as it is necessary to know the target audience’s perception and evaluation at this initial stage, before the simulation is implemented as a large-scale educational intervention. However, the data collected on this stage should be analyzed with caution as it corresponds to the experience of a single pregnant woman.

We stress that the option is an innovative strategy because it has developed an individualized scenario. It aims to cover the specificities of each pregnant woman, taking into account the uniqueness of each breastfeeding experience and each family context. In addition, the proposal also favors collective and collaborative learning, enabling the participation of the family member who will help the mother in caring for the child.

Conclusion

A simulation scenario for breastfeeding education for pregnant women was built and validated by experts in the context of primary health care. The scenario was also tested by a representative of the target audience, who pointed to the simulation developed as an effective health education strategy, with the potential to provide high levels of satisfaction, self-confidence in learning and self-efficacy in breastfeeding for pregnant women. This validated simulation scenario can be used by health professionals in the field of primary health care, in health education activities carried out during prenatal care. Future studies with representative samples and a control group could expand its effects as an educational intervention on breastfeeding self-efficacy and its impact on establishing and maintaining breastfeeding.

Acknowledgements

To the Academic Excellence Program (PROEX) of the Coordination for the Improvement of Higher Education Personnel (CAPES) and to the Postgraduate Program in Public Health Nursing of the Ribeirão Preto Nursing School of the University of São Paulo. This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel -Brazil (CAPES) - Funding Code 001 and also the National Council for Scientific and Technological Development (CNPq), CNPq Universal Notice 2021 - 409758/2021-3 and Productivity Grant in Scientific and Technological Development - DT. PROC. 305000/2021-7- Level 2.

References

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Edited by

Associate Editor
Kelly Pereira Coca, (https://orcid.org/0000-0002-3604-852X), Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Publication Dates

Publication in this collection
28 Mar 2025
Date of issue
2025

History

Received
09 Nov 2023
Accepted
14 Oct 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

[1] ¹ World Health Organization (WHO) & United Nations Children’s Fund (UNICEF). The Extension of the 2025 Maternal, Infant and Young Child Nutrition Targets to 2030. Geneva: WHO; 2021 [cited 2023 July 31]. Available from: https://data.unicef.org/resources/extension-of-2025-maternal-infant-young-child-nutrition-targets-2030/
» https://data.unicef.org/resources/extension-of-2025-maternal-infant-young-child-nutrition-targets-2030/

[2] ² Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475-90.

[3] ³ Universidade Federal do Rio de Janeiro (UFRJ). Aleitamento materno: prevalência e práticas entre crianças brasileiras menores de 2 anos (ENANI-2019). Rio de Janeiro: UFRJ; 2021 [citado 2023 Jul 31]. Disponível em: https://enani.nutricao.ufrj.br/index.php/relatorios/
» https://enani.nutricao.ufrj.br/index.php/relatorios/

[4] ⁴ Maviso MK, Ferguson B, Kaforau LM, Capper T. A qualitative descriptive inquiry into factors influencing early weaning and breastfeeding duration among first-time mothers in Papua New Guinea’s rural eastern highlands. Women Birth. 2022;35(1):e68-74.

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Variables	Content validation (n=15)	Appearance validation (n=6)
Sex
Female	14(93)	6(100)
Male	1(7)	0(0)
Age (years)
Mean (SD)	38.1(10.3)	38.2(4.4)
Median (min-max)	34(29-63)	39.5(31-44)
Country region
Northeast	0(0)	1(17)
Midwest	1(7)	0(0)
Southeast	14(93)	4(67)
South	0(0)	1(17)
Undergraduate degree
Nursing	15(100)	2(33)
Speech therapy	0(0)	1(17)
Nutrition	0(0)	1(17)
Psychology	0(0)	1(17)
Physiotherapy	0(0)	1(17)
Graduate degree
Specialization and/or Residency	8(53)	5(83)
Master’s Degree	15(100)	3(50)
Doctorate	6(40)	2(33)
Area of activity
Breastfeeding	1(7)	4(67)
Children’s health	4(27)	0(0)
Women’s health	2(13)	0(0)
Primary care	3(20)	1(17)
Clinical simulation	0(0)	1(17)
Health and/or nursing education	5(33)	0(0)
Length of experience (years)
Mean (SD)	14(10.7)	12.3(5.3)
Median (min-max)	10(3-41)	14(1-17)
Research experience
Publications in areas of interest	9(60)	3(50)
Participation in a research group	13(87)	3(50)
Expert rating
Expert Junior	0(0)	1(17)
Expert Master	9(60)	0(0)
Expert Senior	6(40)	5(83)

Itens	TD	PD	DN	PA	TA	AVI
1. The setting is suitable for the target audience	-	-	-	1	5	1.00
2. The lines are clear and easy to understand	-	-	-	2	4	1.00
3. The scenes are relevant to the target audience’s understanding of the content	-	-	-	2	4	1.00
4. The briefing is appropriate for the simulation	-	-	1	2	3	0.83
5. The debriefing is suitable for the simulation	-	-	-	2	4	1.00
6. The scenes portray the daily life of the target audience	-	-	-	2	4	1.00
7. The layout of the scenario elements is consistent with the content of the simulation	-	-	-	1	5	1.00
8. The case used explains the content of the simulation	-	-	-	1	5	1.00
9. The scenes help to explain the theme and are in a logical sequence	-	-	-	3	3	1.00
10. The simulators used are suitable for the simulation	-	-	-	2	4	1.00
11. The materials and devices used are suitable for the simulation	-	-	2	1	3	0.66
12. The scenario helps to change the behavior and attitudes of the target audience	-	-	-	2	4	1.00
AVI Total	0,96

Itens	TD	PD	DN	PA	TA	CVI
Objectives
The content is consistent with the needs and reality of nursing mothers	-	-	-	2	13	1.00
The content is important for promoting and protecting breastfeeding	-	-	-		15	1.00
The objective of the simulation scenario invites and/or instigates changes in the behavior and attitude of pregnant women towards breastfeeding	-	-	1	1	13	0.93
The simulation scenario can circulate in the scientific environment of the area	-	-	-	-	15	1.00
The objectives of the scenario are clear	-	-	-	1	14	1.00
The simulation scenario can be applied during prenatal care to promote breastfeeding	-	-	-		15	1.00
Structure and Presentation
The simulation scenario script is suitable for use by healthcare professionals	-	-	-	-	15	1.00
The information is presented clearly and objectively	-	-	-	2	13	1.00
The information is scientifically correct	-	-	-	-	15	1.00
The information is well structured	-	-	-	1	14	1.00
The scenario script has a logical sequence	-	-	-	2	13	1.00
The clinical case information is coherent	-	-	-	1	14	1.00
The facilitator’s speeches are appropriate to the socio-cultural level of the pregnant women	-	-	-	1	14	1.00
The way the scenario is presented facilitates learning	-	-	-	-	15	1.00
Importance
The themes portray key aspects that should be reinforced	-	-	-	1	14	1.00
The simulation scenario encourages knowledge building	-	-	-	-	15	1.00
The simulation scenario contributes to the pregnant woman’s learning of the breastfeeding technique	-	-	-	1	14	1.00
The simulation scenario covers the information mothers need to know	-	-	-	-	15	1.00
The scenario script allows learning to be transferred and generalized to different contexts (primary care)	-	-	-	-	15	1.00
The scenario script is suitable for use by any health professional	-	-	-	-	15	1.00
Average CVI						1.00