Nurse educators today are faced with increasing pressure to produce competent and safe graduate nurses who can function in an ever increasingly complex and diverse health care system. Due to limited experiences during clinical rotations for nursing students to practice the full scope of nursing care, many new nurses do not have the necessary clinical practice skills when they begin their first job. The majority of employers of newly graduated nurses are not satisfied with the entry-level clinical decision-making skills of new graduate nurses (Saintsing et al., 2011). To quantify this “preparation to practice gap,” a study by Kavanagh and Szweda (2017) found that only 23% of new nurses were functioning in a safe manner. Clearly, a change in teaching pedagogy is needed that can help increase the practice readiness of new nurses. Game-based learning has the potential to improve this problem by supporting nursing students' development of problem solving skills, risk-taking, and team communication practices. Game-based learning can increase student motivation by keeping the classroom interactive and enjoyable, and it also can promote active and self-directed learning for contextual application of learning.
Nurse educators have been slow to adopt new teaching methods, with the most widely used teaching method in nursing still being the traditional lecture (Lee et al., 2019). Today's millennial and Generation Z college students are “digital natives” who prefer digital communication and expect technological learning activities over lecture (Williams, 2019). Research indicates that 70% of college students report playing video, computer, or online games, a trend that has led to an increase in the use of teaching methods that use gaming (Bauman, 2013; Jones, 2003). According to Bauman (2013), the digital shift that is happening in nursing education is due to digital gaming's ability to “engage learners through interaction based on narrative, decision making, and consequence” (p. 10).
Games can be defined as any activity that follows a precise set of rules, and players must compete using knowledge and skills in attempts to reach a specified goal (Rowles, 2012). Simulations—which involve mimicking an event, scenario, or environment as close as possible to real life—have been well researched in nursing education. Although simulations share many characteristics with games, simulations often lack a game's sense of play. Bauman (2013) noted a lack of consensus regarding the definitions of and meanings for both games and simulations in nursing education. Serious games are defined as learning games in virtual environments with educational purposes. Johnston et al. (2013) defined serious games as games that have a purpose beyond entertainment, often in an immersive, video, or virtual environment with an engaging storyline that attempts to tackle problems in a specific discipline.
These games have the potential to help nursing students with clinical reasoning and decision making in a risk-free environment. Such clinical reasoning and decision making can help nursing students distinguish irrelevant data from important clinical data that could pose real risk for their patients. More research is needed to determine how the use of serious games can be integrated with teaching methodologies in nursing education. Both games and simulations can provide context-rich, well-designed educational experiences that help nursing students achieve the intended learning outcomes and move one step closer to competent clinical practice.
Studies on gaming in education have focused on comparing gaming activities with traditional didactic methods by examining student satisfaction, knowledge retention, achievement, motivation to learn, and skill performance for students who participated in educational games with those who did not. Gaming uses principles of andragogy, which support adult learning theory by requiring users to be self-directed and learn through problem solving experiences. Empirical research in the health professions for educational gaming is in its infancy, and gaming in nursing education has not been well studied (Kinder & Kurz, 2018).
A review of educational gaming in the health sciences by Blakely et al. (2009) found 16 empirical studies that compared gaming with didactic methods of teaching. The authors concluded the limited evidence showed that gaming in health science education may increase knowledge and skills but was not clearly more beneficial over didactic learning. It also was noted that games may support the learning styles of some students more than others (Blakely et al., 2009). Abdulmajed et al. (2015) performed a systematic review of educational games for the health professions and found only two experimental pretest/posttest studies, along with three observational studies. Positive outcomes were noted overall for improving students' knowledge, awareness, and satisfaction (Abdulmajed et al., 2015).
Breytenbach et al. (2017) performed an integrative literature review on evidence-based teaching strategies specifically for nurse educators. They found 16 studies that discussed and compared the effectiveness of innovative teaching methods, such as e-learning, concept mapping, internet-based learning, web-based learning, gaming, problem-based learning, case studies, and evidence-based learning. Although gaming was examined, only concept mapping, internet-based learning, and evidence-based learning showed significant effects on knowledge (Breytenbach et al., 2017). Although educational gaming may increase student enjoyment, educators should not assume that all students find games enjoyable. Effective games must be well-designed and linked to learning objectives with meaningful goals, well-ordered problem solving, space for possibility, feedback, and empowerment/reward (Bauman, 2013).
Faculty face barriers to implementing new technologies, such as gaming, into their classrooms. Barriers include lack of time, lack of financial support for software, and lack of training, all of which can impact the implementation of games in the classroom (Gibson & Douglas, 2013). Blakely et al. (2010) surveyed the reasons that faculty in the United Kingdom did not use games; the top reasons teachers provided were the potential negative reaction of students (43.8%) and time constraints (27.4%). Some students may not like the pressure of competition or may prefer to take a more passive role in their education. Although some students thrive on competition, others may “be discouraged, stressed, or frustrated by failure to win recognition and thus may be distracted from the content of the course” (White & Shellenbarger, 2018, p. 81). It is clear that further research is needed on gaming using more rigorous methods to enable educators to use gaming productively in the classroom.
The purpose of this literature review was to systematically explore the current state of the science of gaming in nursing education and to answer the following research questions:
What learning outcomes have been linked to games in nursing education?
What does research indicate are potential gaps in the field's knowledge regarding games in nursing education?
A literature search was completed using CINAHL® and Google™ Scholar databases to identify all relevant articles from 2009 to 2019 using the keywords “gaming in nursing education” and “games in nursing education.” Although basic games have been used by nurse educators for many years, a focus on the past 10 years was an appropriate search starting point as the intent of this article was to explore more recent trends and technological changes in nursing education games. The initial search identified 49 articles. Search inclusion criteria included articles discussing games in the education of undergraduate nursing students in various nursing specialties but excluded research specifically focused on simulations. Specifically, articles were excluded if they focused on simulation-based learning, virtual simulation, or high- or low-fidelity simulator manikins. Because much has already been written on simulations in nursing, the focus of this literature search was narrowed to educational games in the classroom. Although care was taken to include international articles, only peer-reviewed journals written in English that were empirical in nature were included. Because the purpose of the literature review was to determine what research-based evidence exists for gaming in nursing education, only empirical articles that tested interventions were included. Fifteen articles met the search criteria and were included in this literature review.
A limited number of empirical studies were found that tested the outcomes of games in nursing education, which is consistent with previous similar literature reviews (Abdulmajed et al., 2015; Blakely et al., 2009; White & Shellenbarger, 2018). Of the 15 articles reviewed, the majority were descriptive in nature and examined student perceptions of gaming in the classroom. Five studies were experimental or quasi-experimental, four studies used a control group, and only two studies were randomized (Table 1). Specific nursing curricula that used games included fundamentals of nursing, nursing of adults, evidence-based practice/nursing research, pharmacology, geriatrics, home health, community nursing, and nursing management/ethics.
Overview of Empirical Articles on Gaming in Nursing Education
Sample sizes ranged from 30 to 218 participants, with the average sample comprising 94.7 students (standard deviation, 50 students); many of these studies were convenience samples (Table 1). Fourteen of the fifteen articles reported beneficial learning outcomes with games, such as increased knowledge, higher test scores, and positive student comments. Only one article indicated particularly negative student responses, due to technical difficulties and students feeling overwhelmed with the game platform used (Gallegos et al., 2017).
In analyzing the 15 articles, several learning outcomes and themes emerged, including diverse game genres, creation of a “safe space” for learning, and the use of games to prepare for simulation. The types of games were diverse and included a competitive team game, Jeopardy-style gaming, an escape room, a card game, Kahoot interactive quiz gaming, 3D Gamelab, and virtual learning games for nursing education. Jeopardy, card, and board games have been used in nursing education for decades, but the recent trend is the rise of virtual “serious games,” due to their ability to provide an immersive visual space to practice decision-making and problem-solving skills. Hogan et al. (2011) described their development of a new serious game for community nursing education and stated that in “contrast to traditional teaching environments wherein the teacher normally controls the learning (e.g., teacher centered), serious games offer a more learner-centered approach to education as the player controls the learning through interactivity” (p. 7). Several articles described the development of serious games in nursing education but were only descriptive in nature and therefore were not included in Table 1 (Hogan et al., 2011; Petit dit Dariel et al., 2013). As serious games increase in nursing education, the profession needs such games to be empirically tested and added to the growing research base of gaming for nurse education.
A quasi-experimental study by Brull et al. (2017) used the “World of Salus” game with avatars, points, quests, and challenges to present nursing content on wound, pain, and fall management. The gaming group was compared with a traditional didactic group and a group that used online modules. The gamification group had the highest scores on posttests, indicating a greater knowledge retention (Brull et al., 2017). Another experimental study by Tan et al. (2017) tested a serious game for safe blood administration using a randomized controlled trial in Singapore. The authors found that the posttest knowledge and student confidence levels were significantly higher (p < .001) for students who participated in the gaming. However, they did not find a significant change in the performance of the skill between the two groups (Tan et al., 2017). These results lead to the question of whether virtual environments are the best place for physical skills since they often do not provide haptic (touch) feedback to learners. This is a needed area for future research in gaming for nursing education.
Additional gaming genres discussed included Kahoot, a multiple-choice interactive quiz game platform, and a large team competitive game called “The Race for Nursing Student Success,” both of which were reported to have increased test scores and knowledge associated with each game (Kinder & Kurz, 2018; Strickland & Kaylor, 2016). Aljezawi and Albashtawy (2015) performed a randomized controlled trial and found that Jeopardy-style gaming in the classroom increased long-term knowledge retention (after 10 weeks) in students compared with traditional lecture format. This finding suggests gaming can help students retain information better when used appropriately by educators in the right contexts. Even simple, low-cost games can be effective in supplementing didactic methods, and nurse educators should use and share existing resources when available to decrease barriers to usage (Johnsen et al., 2018; Kaylor, 2016).
Chen et al. (2015) reported an increase in students' empathy toward older adults after students participated in a geriatric game that required students to “walk in the shoes” of an older adult with disabilities who was attempting to navigate a complex health system. Increased student (self-reported) confidence and increased student motivation also were reported in several studies with the use of games (Boctor, 2013; Davidson & Candy, 2016; Day-Black et al., 2015; Johnsen et al., 2018; Kaylor, 2016). Gomez-Urquiza et al. (2019) used an escape room game to teach various nursing concepts and skills in Spain and found students were highly satisfied with their learning and agreed similar games should be used for future nursing students. The escape room gaming format can assist students in the development of teamwork and communication skills, which are essential nursing skills for 21st century health care.
Two studies examined the use of 3D GameLab, a quest-based learning platform, in a nursing education course and reported conflicting results. Davidson and Candy (2016) studied 3D GameLab in an evidence-based practice nursing course and evaluated student satisfaction and engagement. They reported high levels of student satisfaction, specifically with the self-paced nature of the quests. In their study, students earned course points for completing the gaming quests, and the majority of students were engaged and earned a letter grade of “A” in the course (Davidson & Candy, 2016). Gallegos et al. (2017) also used 3D GameLab for a similar course but found students had a negative reaction. Students reported technical errors and stated the digital badges felt “juvenile” and unmotivating to them since it did not affect their course grades (Gallegos et al., 2017). Such results advocate for additional research into how nurse educators should reward gaming success and whether gaming should impact course grades. This is another area for potential future research with gaming in nursing education, as well as whether certain curricular subject matter lends itself better to gaming than others.
The creation of a “safe space,” in which students have a chance to experiment with new knowledge and skills, is one of the benefits of well-designed games in nursing education. Nursing students often are under high pressure and high stress to perform in clinical and need a low-stakes environment to practice and improve skills and decision making without the risk of serious consequences to patients if they fail. It is unethical to allow students to practice on real patients in crisis; thus, games should seek to mimic authentic nursing practices and support nursing students to develop expertise—especially with high-risk situations that students may not often encounter in clinical rotations.
Chia (2013) examined the perceptions of second-year nursing students after using a virtual game on a patient with chronic obstructive pulmonary disease (COPD) before participating in a practical simulation on COPD. Ninety-eight percent of the students indicated the game helped prepare them for the simulation. Johnsen et al. (2018) studied a video-based serious game, also on a COPD patient, and reported positive student feedback; specifically, students found the game highly usable and beneficial. With high levels of student anxiety reported in the literature surrounding nursing simulation and clinical rotations, the use of a low-stakes game can help prepare students for high-fidelity or standardized patient simulation, thus easing their anxiety and building self-efficacy. Future research should examine whether games that involve “playing in a safe space” could reduce anxiety and improve performance in simulation and clinical practice.
Although nurse educators may be slow to adopt gaming technologies in their classrooms due to a variety of barriers such as cost, time, and technical support, students desire more fun and interactive ways of learning (Lynch-Sauer et al., 2011). The vast majority of students in the 15 articles reviewed reported positive attitudes regarding new media technologies and games for nursing education. Such results are consistent with other articles that note gaming is enjoyable and the preferred method for most students (Blakely et al., 2009; Boctor, 2013). Ninety-four percent of students surveyed indicated they liked using technology to enhance their education, and 88% believed educators should make better use of video games for nursing education (Lynch-Sauer et. al (2011). Johnsen et al. (2018) found 78% of students agreed that serious games should be developed for other patient conditions to be used in nursing education. One third of students reported they were interested in helping to design multiplayer online games for nursing education (Lynch-Sauer et al., 2011). Clearly, students are ready to increase gaming in the classroom, but are educators?
Analysis of Research Questions
Research Question 1. What learning outcomes have been linked to games in nursing education? From the present review, gaming may have positive effects on short- and long-term knowledge retention, student enjoyment, student confidence levels, student empathy, student motivation and engagement, as well as students' perceptions of being better prepared for simulation.
Research Question 2. What does research indicate are potential gaps in the field's knowledge regarding games in nursing education? From digital badges to course grades, students are given a variety of types of reinforcements or rewards for their gaming participation. One gap identified by this literature review is how educators should choose appropriate rewards for classroom games that can best promote students' intrinsic motivation toward learning. Another gap is whether the use of virtual games is effective in teaching physical nursing skills since the virtual environment used in nursing often is lacking in haptic (touch) feedback. Because some nursing subjects may lend themselves more easily to gaming format, research also is needed to identify what types of nursing curriculum lend best to gaming as an educational strategy.
Contemporary nursing education pedagogy must change to provide students with more meaningful, experiential learning activities that can promote deeper learning to enhance new nurses' practice readiness. Planning and designing quality games for nurses is time consuming for educators. Future research should examine ways to reduce faculty barriers for implementation of new games and technologies in the classroom, including collaboration and ways to share effective games that are developed between institutions. The use of virtual and serious games to assist students in preparing for simulation and safe clinical practice will require future research to verify its effectiveness, specifically its effect on students' clinical decision-making skills.
Several methodological weaknesses were noted in the articles reviewed for this literature review, including small sample sizes, convenience samples, lack of randomization or control groups, and few experimental studies. Nurse educators involved in gaming in the classroom should design more rigorous research studies to test and evaluate their games so that the body of evidence in this area can become more robust and conclusive. Research variables for future studies should go beyond student satisfaction and perception of their experiences, and use evidence-based and validated tools to measure additional outcomes, such as gaming effects on self-efficacy, teamwork performance, and clinical judgment.
A shift in nursing education is occurring from a heavy-content to rich-context curriculum that is coinciding with the digital age. As games are becoming recognized as legitimate pedagogical tools, it is important for educators to recognize how and when to best use games to engage students in the classroom. Games have the potential to increase active learning for students by using the concepts of story-narrative, play, and consequence in a risk-free environment. Although nursing education programs are struggling in preparing students for the clinical decision-making skills required for professional practice, there is a growing body of research evidence supporting the use of games for learning (National Research Council, 2011). More research on gaming in education is needed with more rigorous methodologies to support this growing area in nursing education.
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Overview of Empirical Articles on Gaming in Nursing Education
|Authors||Research Design||Sample||Variables Measured||Results|
|Aljezawi & Albashtawy (2015)||Randomized controlled trial compared Jeopardy-style game format vs. didactic lecture||n = 66 fourth-year students in nursing management/ethics course in Jordan||Satisfaction and knowledge retention||Game group had significantly higher knowledge retention scores immediately postintervention and 10 weeks postcourse (p < .001) indicating long-term knowledge retention; statistically significant difference in satisfaction scores that gaming format was more pleasurable and satisfying for learning|
|Boctor (2013)||Case study on use of a Jeopardy-style game, “Nursopardy”||n = 39 convenience sample of first-semester nursing students||Student and faculty perceptions using 5-point Likert scale||Students found the activity beneficial as a reinforcement of material learned (4.7), increased students' confidence in answering test questions (4.7), and helped students learn new information (4.6)|
|Brull et al. (2017)||Quasi-experimental study explored 3 different teaching methods: didactic, online modules, and gamification||n = 115 convenience sample of nurses in orientation at an urban community hospital||Clinical knowledge tested pre- and postintervention, and qualitative comments collected with a postintervention questionnaire||Gamification group had highest mean scores postorientation compared with didactic and online module groups; gamification participants found the game engaging, interactive, and stimulating|
|Chen et al. (2015)||Quasi-experimental, pretest-posttest design using a game that simulated disabilities and challenges for older adults||n = 58 sophomore baccalaureate nursing students, convenience sample||Empathy and attitudes toward older adults||Statistically significant increase in empathy after completing the game; students reported more understanding in the health care challenges faced by older adults|
|Chia (2013)||Descriptive study of virtual game to enhance simulation-based learning in nursing education||n = 161 second-year diploma nursing students in Singapore||Students' perceptions and experiences of using a virtual game on COPD prior to a related simulation activity||98.6% of students indicated the game had prepared them well for the simulation learning activity that followed|
|Davidson & Candy (2016)||Descriptive study of 3D Gamelab quest-based learning in an online EBP course||n = 30 undergraduate nursing students||Satisfaction, level of engagement, and overall achievement of learning outcomes||High levels of satisfaction due to self-paced nature of course, choice in selection of learning quests, and prompt feedback; 26 of 30 students continued questing after they had accumulated enough “experience points” to earn a grade of A|
|Day-Black et al. (2015)||Descriptive study of a gamification teaching strategy in a community health nursing course||N = 42 undergraduate and RN-BSN students||Student examination scores and end-of-course student evaluations||No results clearly listed but authors concluded serious gaming increased overall student motivation to learn|
|Gallegos et al. (2017)||Descriptive, qualitative research study using 3D GameLab platform||n = 57 convenience sample of junior-level nursing students in a research course||Student experiences using a survey to identify themes||Overall response to 3D GameLab was negative; students found it difficult to use, experienced errors with the platform, and were not motivated by digital badges that did not affect their grades; students stated it felt juvenile|
|Gomez et al. (2019)||Cross-sectional descriptive study on an escape room game for examination preparation||n = 89 second-year nursing students in adult nursing course in Spain||Student opinions and experiences on the escape room game||On a 5-point Likert scale, mean scores were high (4.8) for students strongly agreeing that the escape room game helped them learn and that more games should be used in nursing education|
|Johnsen et al. (2018)||Descriptive pilot study to evaluate a prototype SG for home health and medical-surgical nursing that focused on clinical decision making for a COPD patient||n = 120 second-year nursing students in Norway||Student perceptions via a Likert scale to test face, content, and construct validity of SG||Participants from both home health and medical-surgical viewed SG as highly usable and beneficial to their learning; 78% of students agreed this type of learning resource should be developed for other patient conditions|
|Kaylor (2016)||Descriptive study of using card game in pharmacology course||n = 112 junior-level pharmacology students||Student perceptions||Student end-of-course evaluations and comments were generally positive|
|Kinder & Kurz (2018)||Quasi-experimental design of Kahoot gaming in the classroom||n = 98 senior nursing students (control group = 51, intervention group = 47)||Final examination scores||Independent t tests showed gaming group had higher test scores (t = 2.90, p = .005) than control group|
|Lynch-Sauer et al. (2011)||Cross-sectional descriptive study||n = 218 nursing students from two universities; students' experiences and attitudes with computer games and new media in nursing education||Three most reported favorite types of games were puzzle games, arcade games, and simulation games||Reasons for playing games included “help me with problem solving” (76%), “help me relax” (77%), and “avoid studying” (57%); majority (94%) liked using technology to enhance health care education, and 88% believed nursing education should make better use of video games|
|Strickland & Kaylor (2016)||Descriptive study on a large group competitive team game used for final examination review called “The Race for Nursing Student Success”||n = 112 junior-level undergraduate nursing students||Faculty and students' perceptions; final examination item analysis||Overall feedback from students and faculty were positive; game helped to promote a learner-centered competitive environment with 10 stations with various puzzles and activities to complete; examination item analysis compared with previous year showed an increase of 15% in mastery of the content|
|Tan et al. (2017)||Randomized controlled trial on use of an SG for the nursing skill of safely checking and administering blood||n = 103 second-year undergraduate nursing students in Singapore||Student knowledge and confidence compared between groups, as well as clinical performance and surveys of the students who participated in the game||Posttest knowledge and confidence of students in the experimental group who participated in SG was significant (p < .001); no significant variance was found in skill performance between the two groups|