The Journal of Continuing Education in Nursing

Original Article 

Gamification in Nursing Education: An Integrative Literature Review

Angela Malicki, MEd, MISD; Franz Henryk Vergara, PhD, DNP, RN, ONC, CCM; Barbara Van de Castle, DNP, RN-BC, APRN-CNS, OCN; Paola Goyeneche, MS; Stefanie Mann, MS, RN; Margo Preston Scott, MSN, RN-BC; Julie Seiler, MS, RN; Marjone Zapanta Meneses, MSN, RN; Madeleine Whalen, MSN/MPH, RN, CEN

Abstract

The objective of this literature review and evaluation project was to determine what evidence exists on the use of interactive digital learning and gamification for adult learners in nursing, for the purpose of guiding a redesign of our organization's online clinical education courses. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used in the literature search, with the critical analysis and leveling of evidence. After determining the search terms, four electronic databases (PubMed, CINAHL, ERIC, and Cochrane) were searched with the guidance of a medical librarian. Eight reviewers participated, and an evidence-based practice specialist served as auditor. Twenty-three articles were included in the review, which revealed overall support for the gamification process with specific findings about optimizing the process. The review further suggested that interactive digital learning in the form of games, gamification, or scenario-based learning has a positive effect on learner engagement and satisfaction; however, none of the studies were able to quantify objective data about knowledge retention. Further research is needed to test different modalities that improve both learner engagement and knowledge retention. [J Contin Educ Nurs. 2020;51(11):509–515.]

Abstract

The objective of this literature review and evaluation project was to determine what evidence exists on the use of interactive digital learning and gamification for adult learners in nursing, for the purpose of guiding a redesign of our organization's online clinical education courses. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used in the literature search, with the critical analysis and leveling of evidence. After determining the search terms, four electronic databases (PubMed, CINAHL, ERIC, and Cochrane) were searched with the guidance of a medical librarian. Eight reviewers participated, and an evidence-based practice specialist served as auditor. Twenty-three articles were included in the review, which revealed overall support for the gamification process with specific findings about optimizing the process. The review further suggested that interactive digital learning in the form of games, gamification, or scenario-based learning has a positive effect on learner engagement and satisfaction; however, none of the studies were able to quantify objective data about knowledge retention. Further research is needed to test different modalities that improve both learner engagement and knowledge retention. [J Contin Educ Nurs. 2020;51(11):509–515.]

Clinical educators and educational course developers strive to improve learner engagement in academic and hospital settings. At a large academic medical institution, a multidisciplinary committee of cross-functional educators and learning designers was established to review current evidence of the effects of digital delivery of learning on learners' engagement and knowledge retention. Adult learners in health care systems have unique needs, as they need to stay informed on evolving standards of practice, staff education requirements, and evidence-based practice (EBP). Traditional educational methods including PowerPoint® presentations, lectures, and didactic online modules are commonly used to deliver educational content for professional nurses (Brull et al., 2017). These static, traditional approaches offer limited learner interaction engagement and may compromise content retention (Brull et al., 2017). Identified practice gaps and links to learner outcomes should drive nurse educators to use EBP approaches that promote learner engagement (Moyer & Graebe, 2018). Evaluating differing educational strategies that provide the best outcomes is a challenge for nurse educators. In our organization, our course evaluations highlighted the need to leverage new technologies to optimize learners' experiences.

The development of high-quality nursing education learning activities can be costly. In the current state with limited health care dollars, strategies to optimize the delivery of learning activities and improve outcomes are global concerns. Nurses are indispensable members of health care teams, especially when implementing best practices to deliver high-quality care. However, in many settings, these evolving responsibilities have outpaced the ability of nurse educators to deliver robust and engaging educational activities (Institute of Medicine, 2010). Learner-centric education is essential to significantly increase the effectiveness of nursing care while achieving learner satisfaction in a multigenerational workforce (Pilcher & Graebe, 2018). Recent solutions to these problems include leveraging digital content to create engaging, relevant education with individualized delivery in the form of interactive gamification (Pront et al., 2018). As technology permeates all aspects of health care delivery, it should be explored for methods to educate the providers of health care.

With the purpose of redesigning a mandatory online course for all members of our nursing staff, we explored the concept of digital gamification. We first sought to evaluate the state of the literature to answer the question, what evidence exists on the use of interactive digital learning and gamification for adult learners in health care education?

Method

Design

The project team conducted an integrative review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model by Dang and Dearholt (2018). The team comprised nurse educators, instructional design and multimedia experts, and an EBP specialist. The study members had expertise in the delivery of education across the health continuum. In collaboration with a medical librarian, the team developed a literature search strategy to identify the relevant articles. A literature search was conducted across four electronic databases, PubMed®, CINAHL®, ERIC™, and Cochrane (Table 1).

Search Terms Used

Table 1:

Search Terms Used

Inclusion and Exclusion Criteria

The Question Development Tool from the JHNEBP model was used to identify the Population, Phenomenon of Interest or Intervention, Context or Comparison, and Outcomes in the form of a PICO question (Dang & Dearholt, 2018). Our population of interest included prelicensure and postlicensure nursing students and professionals. The phenomenon of interest or interventions were gamification, scenario based, and digital learning. The context was academia and hospital or health systems settings. Initially, studies included in the review were published between January 2007 and January 2018; however, we later narrowed the search to January 2013 to January 2018 to reflect the most current evidence. Articles written in English with either a prelicensure or postlicensure element that answered the practice question were included. Items that did not answer the question, did not have an online or digital gamification component, or did not have any nursing involvement were excluded.

Study Selection

Screening eligibility based on title or abstract and the removal of duplicate articles were independently completed by two reviewers. Eight reviewers were assigned to critique the selected articles; each article was independently screened and appraised by at least two reviewers.

Data Extraction

A standard data extraction form, based on the JHNEBP appraisal tool, was developed and consistently used for the review process. Relevant information, including the sources of evidence, the year of publication, and information gathered from each source to answer the EBP question, was summarized. This information was collated to facilitate the analysis of the quantity, consistency, and applicability of evidence to the EBP question. Specific characteristics of each article were independently recorded by reviewers. These characteristics included evidence type, country and year of publication, sample size and setting, findings that answer the EBP question, measurable outcomes, limitations, evidence level and quality, licensure status of participants, type of gamified content, and, if applicable, reason for exclusion (Table A; available in the online version of this article). The JHNEBP guidelines were used to determine the quality and level of evidence for each study. Group meetings were held to resolve inconsistent appraisals, with the EBP specialist serving as auditor and third reviewer of appraised articles. The final analysis of the evidence was also completed in group meetings to establish consensus about the level, quality, and applicability to the EBP question.

Synthesis of the LiteratureSynthesis of the LiteratureSynthesis of the LiteratureSynthesis of the LiteratureSynthesis of the LiteratureSynthesis of the LiteratureSynthesis of the LiteratureSynthesis of the LiteratureSynthesis of the Literature

Table A:

Synthesis of the Literature

Appraisal of Methodological Quality

Eight reviewers and the EBP coordinator participated in the appraisal of methodological quality of selected articles using the JHNEBP appraisal tool (Dang & Dearholt, 2018).

The appraisal form consisted of focused questions that guided reviewers in the determination of the bias, strengths, and weaknesses of each study. All reviewers received training by a health system EBP specialist to ensure consistency in the critique, appraisal, evaluation, and synthesis of articles.

Definition of Terms

This study used the following definitions:

  • Game: A system in which players engage in an abstract challenge, defined by rules, interactivity, and feedback, that results in a quantifiable outcome often eliciting an emotional reaction (Kapp 2012).
  • Gamification: The use of gaming principles (i.e., challenges, feedback, interactivity) in nongame contexts, including scenario-based learning (Arieli-Attali & Cayton-Hodges, 2014; Werbach & Hunter, 2012).
  • Interactivity: Gamification or scenario-based learning that requires the learner to engage with the content (Kapp, 2017).
  • Prelicensure nurse: A student enrolled in a prelicensure nursing program that is specifically designed for students who do not currently hold a state nursing license and have no prior nursing experience or education (Dang & Dearholt, 2018).
  • Postlicensure nurse: A licensed RN whose license was granted by state board of nursing licensure and who has authority to perform nursing acts and procedures not permitted by persons without an RN license (Dang & Dearholt, 2018).
  • Serious gaming: Using entertainment quality for training, education, health, public policy, and strategic objectives (Wouters et al., 2013).
  • Dynamic education: Learning that takes place organically, growing and evolving through more unconventional means, with the learner collaborating, creating, and communicating to demonstrate progress and mastery (Bell, 2018).
  • Static education: An overall lack of movement, growth, and action. It is learning that happens in short bursts and is most often demonstrated by the learner completing one-and-done activities, short-term assignments, and stand-alone worksheets, all confined within the bounds of the traditional school day (Bell, 2018).

Results

Initial results (N = 653) from the electronic data base search underwent a title screening, and a total of 118 duplicate articles were removed and 442 articles were excluded for failure to meet the inclusion criteria. Overall, 93 abstracts were screened, leading to a full-text reading of 55 articles. A thorough review of the full-text articles led to additional exclusions, as two articles did not answer the identified practice question, 18 articles did not have an interactive/online digital component, eight articles did not have a nursing component, two were protocol descriptions, and two were duplicates, leaving a total of 23 assessed articles (Figure 1).

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Study Characteristics

The 23 studies were conducted in 10 countries between the years of 2013 and 2018: United States (n = 6), Canada (n = 4), Australia (n = 2), Finland (n = 2), Norway (n = 2), Portugal (n = 2), Spain (n = 2), Singapore (n = 1), South Korea (n = 1), and United Kingdom (n = 1). This integrative review included randomized controlled studies (n = 5), quasi-experimental study (n = 1), mixed-methods study (n = 1), quality improvement projects (n = 2), qualitative studies (n = 4), design-based research/feasibility studies (n = 7), and literature reviews (n = 3). Samples in primary reports ranged from 11 to 933 participants; however, one study did not provide the number of participants. The literature review articles that were chosen for this integrative review included 12 to 18 studies in the synthesis.

Of the 23 journal articles that met the specified inclusion criteria (Table A), 20 articles included content on primary reports of nursing students (n = 12), professional nurses (n = 7), and a combination of these two groups (n = 1). Of these articles, 16 supported gamification for a variety of reasons, whereas four studies did not show conclusive support for this approach. Eight games involved teaching content relevant to the provision of nursing clinical practice or skills, and the remaining 12 presented information on nursing theory. Thirteen articles reported on providing education in a static model, and seven studies used a dynamic approach. The project's methods of content delivery and the types of content are displayed in Table 2 and are sorted by demonstrated support or no support for the project. Ten studies reported primary results (five randomized control trials, two quality improvement project, one quasi-experimental study, two qualitative studies), and ten described the process or reception of the game design itself.

Characteristics of Type and Delivery Method of Educational Content Stratified by Results

Table 2:

Characteristics of Type and Delivery Method of Educational Content Stratified by Results

The three remaining articles were in the form of literature reviews with nursing students (n = 2) and both nursing student and professional nurse (n = 1) populations. These reviews endorsed overall support for the gamification process, with more specific findings related to optimizing the process and offering immediate feedback. The levels of research evidence and quality of the evidence are displayed in Table A. The types of immediate feedback varied; however, four immediate feedback delivery methods were recurrent:

  • Video immersion: First-person video game and/or Second Life®, where learner is immersed in a virtual reality and synchronously interacts with learning content within that reality synchronously.
  • Scenario-based and/or virtual video: Video or live demonstrations of clinical scenarios followed by decision points, where learner must apply clinical knowledge.
  • Web-based games: Testing of clinical knowledge using various gaming techniques, badges, competition, and leveling degrees of difficulty.
  • Self-pace scored testing: Questions immediately following learning and asynchronously scored for accuracy asynchronously.

Discussion

Synthesis

This review demonstrated overall support for the gamification process. The most support (n = 16) was in games of theory content in a static manner (56%; n = 9) versus not supported (n = 4) in skill-based education following a dynamic model (50%; n = 2). Overall support for gamification was higher in theory content (69%), compared with skill content (31%). This trend was reflected in studies in which the majority of content was related to theory taught in a static manner (45%), whereas dynamic approach for skills (20%), theory (15%) and static skills (20%) were seen in the remainder of the studies.

Leveraging game design principles to optimize learner experiences was evident in most articles with good- to high-quality evidence. These included providing immediate feedback and ensuring authenticity in a user-friendly, self-paced environment (Boada et al., 2015; Darragh et al., 2016; Davidson & Candy, 2016; De Gagne et al., 2013; Fonseca et al., 2015; Johnsen et al., 2016; Koivisto et al., 2016; Koivisto et al., 2017; Koivisto et al., 2018; Popil & Dillard-Thompson, 2015; Pront et al., 2018; Tan et al., 2017; Verkuyl et al., 2016). Competitions, points, quests, challenges, and other reward systems were commonly used (Davidson & Candy, 2016; Gallegos et al., 2017; Lacey et al., 2016; Lemermeyer & Sadesky, 2016; Orwoll et al., 2018; Popil & Dillard-Thompson, 2015). The learners' experiences varied based on population, educational content, and teaching methodologies.

One of the most prevalent themes was the advantage of providing the learner immediate feedback during the gaming and learning process (Boada et al., 2015; Cant & Cooper, 2014; Darragh et al., 2016; De Gagne et al., 2013; Del Blanco et al., 2017; Davidson & Candy, 2016; Fonseca et al., 2015; Foss et al., 2014; Lacey et al., 2016; Lemermeyer & Sadesky, 2016; Koivisto et al., 2016; Koivisto et al., 2017; Koivisto et al., 2018; Popil & Dillard-Thompson, 2015; Pront et al., 2018; Verkuyl et al., 2016; Verkuyl et al., 2017). This overwhelming positivity was further highlighted in two articles that cited that lack of immediate feedback was seen as a deficit to learners (Brull et al., 2017; Tan et al., 2017). The opportunity for learners to receive repeated and speedy responses reinforces learning and encourages engagement in the gaming process. The feedback mechanism was cited by many learners as a great satisfier. These principles are consistent with educational theory and represent a unique benefit to game-based teaching (Aliakbari et al., 2015).

Additionally, learner feedback reinforced the desire for games to be as true to life scenarios as possible (Darragh et al., 2016; Koivisto et al., 2017; Koivisto et al., 2018; Pront et al., 2018; Verkuyl et al., 2016; Verkuyl et al., 2017). Realistic scenarios allow users to make decisions and experiment without facing real-life risks (Cant & Cooper, 2014; Koivisto et al., 2017; Pront et al., 2018; Verkuyl et al., 2016; Verkuyl et al., 2017). Regardless of these attributes, ease of use was largely associated with overall learner satisfaction. Those studies that had usability issues reported decreased learner satisfaction. It can be concluded that if the learner has difficulty with the desirability or usability, which is related to the game design, technology, or mechanics, then the learner's performance and satisfaction are adversely affected. Usability is essential for on-boarding learners into a new platform, yet it was a barrier cited in many of the studies (Brull et al., 2017; Davidson & Candy, 2016; Gallegos et al., 2017; Johnsen et al., 2016; Lemermeyer & Sadesky, 2016; Popil & Dillard-Thompson, 2015; Verkuyl et al., 2016).

Although results vary on the benefits of gamification in learning, many of the articles that reported support for gamification did so within the gaming environment and did not translate these gains into real-world benefits. Of the 10 articles that reported positive results, only four assessed learners to determine whether results went beyond the virtual environment, three in support of gamification (Boada et al., 2015; Del Blanco et al., 2017; Orwoll et al., 2018) and one without concrete support (Lau et al., 2017). Although this is almost half of the articles on primary learner outcomes, the gains in the gaming environment of the six other studies should be taken in that specific context and will need further investigation. The acknowledgment of gamification as one methodology among many is supported by several studies and highlights gamification as an addition, not replacement for traditional teaching methods (Boada et al., 2015; Cant & Cooper, 2014; Fonseca et al., 2015; Lau et al., 2017; Tan et al., 2017).

Limitations

There were several limitations in this integrative review. First, the higher level articles reported on static approaches to learning delivery (Table 2) and most of the literature included varying definitions of interactivity. For the purposes of our review, the definition of interactivity was narrowed to gamification or scenario-based learning that required the learner to engage with the content. Because of this definition, other potential articles could have been excluded. Second, there was a lack of consistency in terminology to describe gamification methodologies. For the purpose of our review, we narrowed the definition to learning content delivery that incorporated two or more game ingredients, such as rewards, challenges, competition, learning enjoyment, and scoring. Third, many of the articles had nursing student populations. The generalizability of this group may be limited as it relates to our goal to modernize online learning delivery based on the research of best practices for delivering online, interactive learning for licensed professional nurses. Fourth, although many of the articles revealed a positive outcome with gamification and participant satisfaction and engagement, few did so within the clinical environment, and none examined knowledge retention. Finally, small sample sizes of some of the studies may have limited the generalizability of the findings.

Recommendation for Future Implementation and Translation

To address our clinical question of what evidence exists on the use of interactive digital learning and gamification for adult learners in health care education with the goal to redesign our hospital's education modules, we found the evidence to be inconclusive and therefore cannot recommend changing them. With this in mind, there is some evidence about specific advantages of gamification, such as self-pacing, immediate feedback, competitive nature, motivation, and risk-free environment; there is no evidence that this approach is harmful to participants' learning and satisfaction. As online teaching modules are updated to reflect best practices, the benefits of gamification can be targeted to increase learners' engagement. Due to the lack of conclusive support, any use of gamification and its related learning outcomes should be closely monitored. Robust data collection, both within and outside the virtual environment, should guide future changes.

Conclusion

The findings of this integrative literature review suggest that although the use of interactive digital learning in the form of games, gamification, and scenario-based learning has a positive effect on learner engagement and satisfaction, no study was able to quantify any objective data on knowledge retained over time. We recommend conducting further research by testing the newest technology and interventions that may improve learners' knowledge retention through gamification. There is also a need to develop a reliable and valid tool to objectively measure licensed health care professionals' knowledge retention. The development of educational content, satisfaction of learners, and cost of cutting-edge educational tools must be considered in this time of increased costs of education for health care providers. Further studies are needed to quantify objective data on the effects of gamification on clinical knowledge retention among adult learners in health care professions.

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Search Terms Used

Term
“gamification” OR “scenario based” OR “gamify” OR “game based” OR “gaming” OR “video game” OR “video games” OR videogame* or “digital learning” or “digital education” or “digital game” or “digital games” or “digital gaming” AND “nursing staff, hospital” [mesh] OR nurse* OR physician* OR resident* OR “clinical staff” OR “clinical personnel” OR “doctor” OR “doctors” AND “education” OR “learning” OR “teaching” OR “educational”

Characteristics of Type and Delivery Method of Educational Content Stratified by Results

Type of Educational ContentDelivery Method of Education

DynamicStatic
Results demonstrate support to gamification (n = 16)
  Nursing practice/clinical skill23
  Nursing theory29
Results do not demonstrate support to gamification (n = 4)
  Nursing practice/clinical skill21
  Nursing theory10

Synthesis of the Literature

Level and QualityAuthorsYearCountryAimDesignPopulationKey FindingsMeasuresContent Taught via GamificationGaming Intervention
Randomized Control Trials
Level 1 BBlanco Á, Torrente, J., Fernández-Manjón, B., Ruiz, P., & Giner, M.2017SpainTo determine if a game-like simulation improves perceptions and performance of novices in the surgical theaterRandomized Control Trial (control group n = 62, intervention group n = 70)132 2 nd and 3rd year nursing and medical studentsParticipants who engaged in the gamification intervention showed statistically significant improvements in feelings, emotions and attitudes related to first time operating theater experiencesMann-Whitney U tests on fear to make mistakes, perceived knowledge, perceived errors committed, adequate attitudeProper behavior and interactions while in the operating theaterA first-person video game with pictures and short videos in the operating theater (dynamic)
Level 1 BBoada, I., Rodriguez-Benitez, A., Garcia-Gonzalez, J. M., Olivet, J., Carreras, V., & Sbert, M2015SpainTo evaluate the differences between student nurses learning CPR via a serious game compared to classic teaching methodologyRandomized Control Trial109 nursing studentsStudents with partial or full exposure to LISSA showed statistically significant improvements in performancePaired t-tests to compare coded 15 item CPR protocol and student evaluations on 5-point Likert scale and two open ended questionsCPRLISSA, a serious game to complement CPR teaching with a 3D virtual environment
Level 1 BFoss, B., Lokken, A., Leland, A., Stordalen, J., Mordt, P., & Oftedal, B. F2014NorwayTo determine if nursing students who play the Medication Game improve on examinations compared to traditional lecturesRandomized Control Trial (control group n = 100, intervention group n = 101)201 nursing studentsUse of the medication game did not lead to statistically significant improvement in test scorest test to compare pass/fail ratesDosage calculationsTraining, self-testing and examination sections with timed and scored testing
Level 1 ALau, B. D., Shaffer, D. L., Hobson, D. B., Yenokyan, G., Wang, J., Sugar, E. A., Haut, E. R.2017United StatesTo evaluate the effectiveness of nurse education on medication administration practiceRandomized Control Trial (control group n = 396, intervention group n = 405)933 professional nursesUse of dynamic gamified content did not statistically significantly reduce odds ratios when compared to non-gamified content, but learner satisfaction was higherOdds ratio to determine non-administrat ion between static and dynamic educational armsHeparin administrationWeb-based learner-centric dynamic scenario-based education
Level 1 BTan, A. J. Q., Lee, C. C. S., Lin, P. Y., Cooper, S., Lau, L. S. T., Chua, W. L., & Liaw, S. Y.2017SingaporeTo describe the development and evaluation of a serious game to improve nursing students' knowledge, confidence and performance in blood transfusionsRandomized Control Trial control group n = 46, intervention group n = 57)103 2nd year nursing studentsUse of the gamified content had no statistically significant difference in knowledge, confidence, performancePaired t-test to compare knowledge, confidence, perception and performanceBlood transfusion administration3D virtual hospital ward with mini challenges
Quasi-experimental and Mixed Method
Level 2 BDavidson, S. J., & Candy, L2016CanadaTo develop, implement and evaluate a game-based teaching strategyPilot study22 student nursesHigh levels of satisfaction from students and facultySatisfaction scoresEvidence-based Practice3D game lab to earn badges and awards through quests
Level 3 BBrull, S., Finlayson, S., Kostelec, T., MacDonald, R., & Krenzischec k, D2017United StatesTo explore the effectiveness of 3 different teaching methods, didactic, online modules and gamification during nursing orientationQuasi-experimental115 professional nurses (didactic group n = 31, online group n = 32, gamification group n = 52)The gamification group had statistically significant higher knowledge scores than comparison groups. Participants had overall positive feedback on the gaming experienceKnowledge Mean scores with ANOVA and qualitative responsesWound management, pain management, fall preventionAvatar led game with education followed by knowledge challenges and ability to earn badges
Qualitative
Level 3 AKoivisto, J., Multisilta, J., Niemi, H., Katajisto, J., & Eriksson, E.2016FinlandTo investigate nursing students' experiences of learning clinical reasoning process by playing a 3D simulation gameCross-sectional, descriptive166 nursing studentsGamification can help build the clinical reasoning process, identify problems and apply theoretical knowledge but is less useful in establishing goals and evaluating effectiveness of an interventionMeans and learning phases measured using5 point Likert scale on participant self-reported learning of clinical reasoning, nursing knowledge, and a 4-point Likert scale to measure explorationClinical reasoning3D patient scenarios with interactive patient and equipment with immediate feedback
Level 3 BMonti Fonseca, L. M., Del'Angelo Aredes, N., Vilela Dias, D. M., Silvan Scochi, C. G., Amado Martins, J. C., & Alves Rodrigues, M.2015PortugalTo evaluate students opinion regarding e-baby educational technologyExploratory descriptive14 nursing studentsThe game was found to be easy to use and motivational and students enjoyed self-paced nature with appropriate interactivityLikert scale and open-ended questionsPreterm infant careA serious game with a virtual baby with a provided history and tools for clinical assessment
Level 3 BGallegos, C., Tesar, A. J., Connor, K., & Martz, K2017United StatesTo describe nursing student's reflection on a game-based learning platformQualitative, descriptive57 nursing studentsStudents had negative perceptions of the gamified content's navigation, usability ability to motivate, education and age appropriateness, ability to increase knowledge,Thematic analysis of open-ended questionnaireNursing research3D GameLab with readings, videos and learning activities to earn badges and awards
Level 3 BVerkuyl, M., Hughes, M., Tsui, J., Betts, L., St-Amant, O., & Lapum, J. L.2017CanadaTo examine student experiences of a virtual gaming simulationQualitative cross sectional20 nursing studentsThe game promoted experiential and reflective learning, self-assessment and reflection, self-efficacy and knowledgeThematic analysisMental health and interpersonal violence assessmentFilm clips with standardized patients followed by decision making points
Design-Based Research Design (feasibility, usability)
Level 3 BKoivisto, J., Niemi, H., Multisilta, J., & Eriksson, E.2017FinlandTo investigate nursing students' experimental learning processes during a 3D simulation game and determine which game characteristics support experimental learningDesign-based research8 nursing studentsAudiovisual authenticity, authenticity of patient scenarios and interactivity were key elements for game success. Gaming supports independent learning and opportunity to experiment in safe environment. Feedback to learner triggers self-reflectionQualitative, open-ended feedback with thematic analysisClinical reasoning3D first person game with patient scenarios around specific medical problems and learner feedback
Level 3 BLemermeyer, G., & Sadesky, G.2016CanadaTo explore potential for combining principles of online gaming with sound education and assessmentA pilot with iterative development69 professional nursesThe module demonstrated psychometric defensibility with positive perceptions of participants regarding ability to learn the content and enjoy- ability of the game.Cronbach alpha of game content and survey with Likert scale and open ended questionsJurisprudenceNine scenes with a guide and images with associated activities and awards
Level 3 CPopil, I., & Thompson, D. D2015United StatesTo evaluate learning outcomes, level of engagement and satisfaction with an educational gameEvaluation/feasibility study15 professional home health nurses60% of participants found the game to be effective. Knowledge tests increased from 78% correct to 89% correctPre/post survey on knowledge and focus group discussionsPatient assessment for home health nursesAn online game with computer-generated questions with immediate feedback
Level 5 BKoivisto, J., Haavisto, E., Niemi, H., Haho, P., Nylund, S., & Multisilta, J2018PortugalTo describe the development process and generate principles for the design of educational simulation gamesDesign-based researchNursing students, number not providedKey elements to successful game design involve authenticity, end-users and educators should be involved in design process,Feedback regarding game designClinical reasoningVirtual, scenarios with real-life clinical situations. Prototype 1 was a birds-eye-view, Prototype 2 used 3D environment with 1st person point of view
Level 3 BVerkuyl, M., Atack, L., Mastrilli, P., & Romaniuk, D2016CanadaTo assess the usability of a virtual game-based simulation to address a clinical gap for nursing studentsUsability studyUser testing conducted with 6 nursing students and 5 professional nursesThe game demonstrated ease of use, utility and engagement of participants with overall satisfactionThematic analysis of monologue collected during the game and 5-point Likert scale measuring ease of use and usefulnessPost-op pediatric patient care17 short video vignettes with standardized patient and patient's mother followed by decision-making points
Level 5 BDarragh, A. R., Lavender, S., Polivka, B., Sommerich, C. M., Wills, C. E., Hittle, B. A., Stredney, D. L2016United StatesTo describe the process used for developing and evaluating an interactive virtual simulation training system used to education home healthcare professionalsMixed methods with participatory design methodology68 home health providers (nurses n = 21)Participatory design methods can yield training packages for home health professionalPre-survey (Modified Home Healthcare Worker Questionna ire, focus group, individual interviews and usefulness, usability and desirability assessmentHealth and safety hazards in the home3D home environment with multiple hazards to be identified to score points
Level 5 BJohnsen, H. M., Fossum, M., Vivekanand a-Schmidt, P., Fruhling, A., & Slettebø, Å2016NorwayTo describe the design, development and usability of video based serious game for nursing students caring for patients with COPDPilot to determine usability6 nursing studentsUsers found the game to be relevant, useful and satisfying with some usability issuesThematic analysis using TURF framework (task, users, representati on, function)Care of patients with COPDVideo-based simulation scenarios with tasks and questions
Literature Reviews
Level 5 BDe Gagne, J. C., Oh, J., Kang, J., Vorderstrass e, A. A., & Johnson, C. M2013South KoreaTo identify the current evidence on the use of virtual worlds in the education of nursing and other health professional students and to describe emerging themes surrounding this phenomenon.Literature synthesis504 health-related disciplines, 12 articlesStudent-centered learning, improved clinical reasoning are advantages to gamification. Proper design is essential to realize these advantagesn/aTrauma training, patient transfers and safety, community nursing, pediatric nursing, diabetesThe majority of the studies used second life
Level 5 BPront, L., Muller, A., Koschade, A., & Hutton, A.2018AustraliaTo investigate videogame-based learning in nursing education and establish how videogames are currently employed and how they link to the development of decision-making, motivation and other benefitsLiterature search14 articlesOverall positive results related to usability and effectiveness with benefits related to decision-making, motivation, repeated exposure, logistical and financial valuen/aMedication administration, medical vocabulary researchn/a
Level 5 BCant, R. P., & Cooper, S. J.2014AustraliaTo review the literature on utilization and place of web-based simulation in nursing educationIntegrative review18 programs for nursing educationWeb-based simulation is highly acceptable and appears to provide learning benefits and augments face-to-face teaching.Types of programs and student feedbackVarious depending on studyVarious depending on study
Quality Improvement
Level 5 BOrwoll, B., Diane, S., Henry, D., Tsang, L., Chu, K., Meer, C., Roy-Burman, A2018United StatesTo determine if a digital self-assessment application, bundling line care best practices with social gamification and micro learning can engage nurses in CLABSI preventionPre/post Quality improvementProfessional nurses caring for patients with central lines on 3 high-risk unitsUse of gamified content and app statistically significantly decreased CLABSI rates in pre/post analysisChi square to determine CLABSI rate changes pre/post gaming interventionCLABSI preventionCLABSI app with self-assessment checklist and CVC tracking with competition between groups
Level 5 B/CLacey, G., Corr, M., Morrow, H., McQueen, A., Cameron, F., & Connolly, C.2016United KingdomTo describe a hand hygiene improvement campaignQuality improvement419 unique usersCompliance with proper hand hygiene techniques improved over timeNumber of interactions with Sure Wash station and pass rate of hand hygiene techniqueProper hand hygieneKiosk E-Learning system with a camera to provide real time feedback with quizzes
Authors

Ms. Malicki is Program Manager, Multimedia and Learning, Office of Nursing Professional Practice, Dr. Vergara is Nurse Abstractor, Johns Hopkins Intrastaff, Ms. Goyeneche is Learning Systems Specialist, Multimedia and Learning Technology, Ms. Mann is Nurse Educator, Unlicensed Assistive Personnel Program, Ms. Preston Scott is Program Manager, Unlicensed Assistive Personnel Program, Ms. Meneses is Nurse Educator, Nurse Residency Program, Ms. Seiler is Nurse Educator, ICU Nurse Residency, Ms. Whalen is Evidence-Based Practice Program Coordinator, and Dr. Van de Castle is Nurse Educator, The Johns Hopkins Hospital, Baltimore, Maryland. Dr. Van de Castle is also Assistant Professor, University of Maryland, Baltimore, Maryland.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the Department of Nursing Education, specifically Deborah Dang, who encourages lifelong learning for nurses and staff at The Johns Hopkins Hospital. The authors also thank Carrie Price from the Welch Medical Library, and the Evidence-Based Practice and Institute of Johns Hopkins Nursing teams for their guidance and support.

Address correspondence to Angela Malicki, MEd, MISD, Program Manager, Multimedia and Learning, Office of Nursing Professional Practice, The Johns Hopkins Hospital, 901 N. Broadway, Baltimore, MD 21205; email: amalick1@jhmi.edu.

Received: November 14, 2019
Accepted: May 20, 2020

10.3928/00220124-20201014-07

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