As health care is continuously changing, it is important to advance evidence-based practice and innovation by nurses who are continually learning and integrating new knowledge. Although nurses are motivated to increase competence and supplement knowledge gaps (Pool et al., 2016), there are competing demands on nursing time and the nature of shift work in acute care hospital settings that make attendance at traditional continuing education challenging. eLearning has gained prominence to gain information and enhance learning within time and space constraints (Govranos & Newton, 2014). In this article we discuss the use of innovative technology for continuing education with acute care nurses.
Nurses want continuing education to be accessible, integrated into their work, and easily available (Govranos & Newton, 2014). Participation in traditional methods of continuing education requires time, nurses' willingness to participate (Brown et al., 2009), and support from employers (Bahn, 2007; Dahlke et al., 2016; Leonard, 1994; Melnyk et al., 2012). Nurses are more likely to participate in education occurring at their place of work when they are paid to attend (Bahn, 2007) and within a context where there are supportive leaders and unit cultures (Brown et al., 2009; Dahlke et al., 2016; Leonard, 1994; Melnyk et al., 2012).
Tight staffing levels and the nature of shift work create challenges to traditional didactic methods of delivering education in acute care hospitals and has led many employers and clinical educators to explore eLearning systems (Chang et al., 2011). eLearning can be defined as education that is delivered on a digital device (Fontaine et al., 2017). Conventional eLearning uses words either spoken or written, and illustrations, animations, or videos. Content is often presented linearly, much like reading a book. Findings from a systematic review of the literature by Cook et al. (2010) to examine the effectiveness of eLearning suggest that it is an effective strategy to improve health professionals' knowledge, competence, and behaviors. They also suggest that interactivity, practice exercises, repetition, and feedback are associated with improved learning outcomes.
eLearning in Continuing Education for Acute Care Nurses
Engagement and motivation are two long-standing issues with traditional approaches of nursing professional development (Kapp, 2012). Although the literature is replete with studies suggesting that eLearning can be used effectively in nursing continuing education in acute hospital settings, the majority of such studies report on more traditional types of learning, such as providing content about a topic on an ePlatform, similar to using a didactic approach in face-to-face learning. Although this type of education is not particularly innovative, success in using this type of eLearning for acute care nurses has been reported. Some examples include supporting an understanding of the types of information needed for an effective handoff at shift change (Usher et al., 2018); improving nurses' knowledge of delirium (Detroyer et al., 2018; McCrow et al., 2014); enhancing face-to-face education related to skin tears (McTigue et al., 2009); teaching novice nurses how to access Port-A catheters (Tsai et al., 2008); and increasing emergency nurses' confidence in their ability to identify victims of human trafficking (Donahue et al., 2019). Nurses' satisfaction with eLearning continuing education is influenced by the system, information, and service quality of the eLearning (Chang et al., 2011). In what follows, we discuss published research of eLearning and innovation in continuing education with acute care nurses.
Moving Beyond the Traditional: Innovations in eLearning for Acute Care Nurses
To further inform our interest in innovative approaches to continuing education for nurses in acute care settings, we used the integrative review process outlined by Whittemore and Knafl (2005) to examine the evidence related to using innovative methods via an ePlatform in continuing education with acute care nurses. We were particularly interested in gamification because this type of innovative education method has gained interest in the past 5 years and its use has increased among our nursing faculty. We wondered if the same interest would be evident with continuing education for acute care nurses. With the guidance of a medical librarian, search terms using truncations of terms related to acute care, nurses, gamification, and education were tailored to each of nine databases (Table A; available in the online version of this article). Three of the authors reviewed all the titles of the 1,605 articles from this review and agreed on 200 articles. After reading the abstracts of these articles, 100 articles were selected to read in full. The first two authors read 77 articles, but 23 were unable to be retrieved, as they were from international journals that did not support electronic searching. At the end of this review process, only one article related to examining gamification and acute care nurses was retrieved. The study used quantitative methods and was conducted in the United States (Brull et al., 2017). Of note, these authors indicated that they had been unable to find any studies that had used gamification with acute care nurses' education. During our exploration of the literature, we identified four studies that used innovative eLearning methods to deliver education to acute care nurses. We defined innovation as integration of techniques such as gamification, virtual reality and/or simulation, or practice in a virtual world that moves the activity beyond linear presentation of information in an eLearning format. When you add an ePlatform to innovative learning methods, there are opportunities for experiential learning through interaction and immersion in environments that seem real and thus improve the contextualization of learning (Brown et al., 2012).
Databases and Search Terms
The Growth of Gamification
The concept of using games with the term gamification has become more popular since 2010 to describe the use of game-based features in nongame settings (Faiella & Ricciardi, 2015). Gamification uses “game-based mechanics, aesthetics, and game thinking to engage people, motivate action, promote learning, and solve problems” (Kapp, 2012, p. 10). Games have been used widely in K-12 education for decades and have been taken up in higher education settings and for professional development and continuing competency in many industries more recently (Kapp, 2012). Lee and Hammer (2010) theorized that well-designed games motivate learners because they impact cognitive, emotional and social aspects of learning through mastery, reframing failure as part of learning, and taking on new roles as a part of in-game decision making and problem solving. Research suggests that gamification increases intrinsic motivation when boring tasks are made more interesting (Brull & Finlayson, 2016; Hanus & Fox, 2015). Game-based elements and mechanics such as the use of levels, badges, point systems, time constraints, interactivity, and feedback serve to improve motivation for learning (Kapp, 2012). Game aesthetics such as storytelling, cooperation, competition, and exploration promote learner engagement. Extrinsic motivation such as social elements of competition works for some learners, but not all (Dominguez et al., 2013).
The following descriptions of the five studies that examined innovation in continuing education with acute care nurses provides suggestions for future innovation (Brull et al., 2017; Dubovsky et al., 2017; Liaw et al., 2016; Liaw et al., 2017; Mallette et al., 2011).
Acute Care Learning Activities
Brull et al. (2017) used a quasi-experimental design and convenience sampling to recruit nursing orientation participants into one of three groups of orientation learning styles: didactic face-to-face (n = 31); online PowerPoint® presentations (n = 32) and gamification (n = 52). The online PowerPoint presentation was an eLearning linear style of delivery and gamification was delivered via ePlatform. Clinical knowledge scales for nursing orientation were assessed for knowledge pre- and postintervention. Mean scores were measured using analysis of variance. Although nurses from all three methods had significantly higher average test scores postintervention, the gamification orientation group had the highest scores for all measures when compared with the didactic and online module groups. Participants reported that the gamification method was engaging, interactive, and stimulating. The authors did not explain the method they used to assign participants to the groups, and the groups were not of equal size. Clinical experts in the areas of wound management, pain management, and fall prevention management developed the clinical knowledge scales. The mean scores and effect size of each type of knowledge scale for each group was reported.
The study by Dubovsky et al. (2017) used a quasi-experimental design with 10 emergency triage nurses and a virtual reality model of 10 patient triage scenarios. They examined attitudes toward the simulation, perceived workload, and patient prioritization according to severity and importance of the task. Nurses regarded the scenarios as realistic to their real-world experiences and reported being moderately comfortable with the simulation. Paired t tests showed no significant differences from nurses' equivalent subjective workload during a regular workday, suggesting that the simulation was a realistic learning experience.
Liaw et al. (2017) used a randomized controlled trial study and a pre- and posttest design to compare the use of video animation, multimedia instructional material, and virtual patient simulation learning activities to improve enrolled nurses' recognition and management of deteriorating patients. They reported no significant statistical differences in the knowledge pretest scores between the experimental and control groups. Posteducation statistical improvements in knowledge were found in the experimental group but no statistical increase in knowledge was found in the control group.
In another study, Liaw et al. (2016) reported on a pre- and posttest design about RNs' and enrolled nurses' motivational reaction, knowledge, and perceived transfer of learning after participating in an animated video learning activity, a web-based study guide, and virtual simulation designed to improve their recognition and management of deteriorating patients. Nurses' recognition of deteriorating patients on a general medical ward increased significantly from pre- to postintervention, and nurses reported positively on the transfer of learning from the web-based simulation to clinical practice.
Finally, Mallette et al. (2011) used a pre- and posttest design with a control group in a horizontal violence educational program. RNs and registered practical nurses were assigned to one of five groups: (1) complete a workbook; (2) complete a self-directed linear eLearning module; (3) participate in role-play, practice, and feedback within the virtual world; (4) completed self-directed eLearning module followed by role-play, practice, and feedback within the virtual world; or (5) participated in no educational intervention. Self-efficacy and knowledge scales were used pre- and posteducation, and learner satisfaction scales were completed posteducational intervention. There was some increase in knowledge following the completion in three of the four educational interventions. There was no change in mean knowledge test scores for the group engaged in only the virtual-world experiential learning. The authors concluded that learning through a self-directed eLearning module followed with practice in a virtual world was the most effective way of acquiring knowledge, skills, and abilities to address horizontal violence.
Taken together, these five studies suggest that gamification, simulation, and web-based virtual worlds hold promise in improving knowledge transfer and satisfaction of education method in continuing education for acute care nurses. Use of innovative approaches via ePlatform are creative approaches that could increase nurses' motivation and satisfaction because it shifts learning to learners' time and motivation, to engage in an active form of learning, with the educator acting as a facilitator of learning (Dominguez et al., 2013). This contrasts with more traditional forms of in-service education where the educator must attempt to engage and motivate nurses within a limited, prescribed time period. Given the paucity of research reported related to the use these types of innovation with acute care nurses, we suggest that use of and evaluation of innovative methods in continuing education using ePlatforms for this population are not well developed. This is an area of potential growth in both providing continuing education and evaluating the use of these innovative educational strategies. Educators could partner with researchers to develop and evaluate these types of innovative continuing educational strategies using ePlatforms for acute care nurses. They have the potential to meet nurses' desires for flexible education at their workplace that is meaningful to their work.