‘The Ward’: A simulation game for nursing students

Article Outline

• Abstract
• Introduction
• Literature review
• Background
  • ‘The Ward’ outlined
• Methods
  • Study design
    • Aims
    • Design and methodology
    • Data collection
    • Data analysis
    • Ethical approval and confidentiality
    • Withdrawal
    • Bias
• Data/Results
  • Questionnaires
  • Focus groups
  • Theme 1: Relevance to practice
  • Theme 2: Relevance to specific skills
  • Theme 3: What can be done better?
• Discussion
• Conclusion
• Recommendations
• References
• Copyright

Abstract 

Aim

To evaluate the effectiveness and suitability of ‘The Ward’ as a simulation game to promote and support students’ understanding of decision making, critical thinking and team work in clinical practice situations.

Background

Students commonly indicate that there is a ‘gap’ between the theory and practice aspects of their nursing education. Nursing is also a team-based profession requiring collaboration and cooperation that is rarely seem in educational programs. Attempts to address these issues resulted in the development and trial of the simulation game ‘The Ward’.

Methods

A qualitative study using a questionnaire (n = 76) and four focus groups.

Results

‘The Ward’ proved to be well received as a learning tool and was enjoyable and effective in addressing learning issues related to clinical skill practice, ward management, nursing practice knowledge, critical thinking, medication knowledge and leadership. It also offered valuable learning in the areas of team work and decision making.

Conclusion

‘The Ward’ was shown to be a very useful simulation exercise that has evaluated well and helped promote the pivotal role of team work for student nurses and bridge the gap between theory and clinical practice in a safe, non-threatening way.

Keywords: Gaming, Simulated learning, Critical thinking, Team work

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Introduction 

Teaching in relation to any topic requires considerable creativity and imagination in order to capture and retain the interest of students/learners (Layne, 2001, Rowe, 2004). Simply having to deal with large groups of nursing students can mitigate against learning opportunities that are lively, creative and enjoyable. Learning in ways that stimulate creativity and imagination in the student/learner will result in better quality and more in depth learning than more traditional approaches to learning (Reece and Walker, 1997, Knowles, 1998).

It is suggested that the content of some nursing programs may be unrelated to the realities of clinical practice, highlighting a theory–practice gap (Nolan and Grant, 1992, Lathlean and Vaughan, 1995, Wilson-Thomas, 1995; Harttick et al., 1999 and Landers, 2000) that has been the source of concern and attention in nurse education for some time. Breeching the theory–practice gap is essential if teaching is to be effective, relevant and applicable in the real world of practice. ‘The Ward’ has been developed in an attempt to bridge the ‘gap.’

Much of the work of nurses and health professional involves working in teams (Bishop, 2009), however a considerable proportion of a nurses’ educational experience may still require students to learn independently. This issue is compounded by the introduction of electronic learning support modalities such as Black Board and Web CT which may encourage students to remain further isolated from a collaborative study environment. Occasions arise when students are encouraged to establish small study groups or to engage in groupwork as with Problem Based Learning, or Enquiry Based Learning and seminar groups. Therefore learning to work in teams and understand the dynamics of teamwork is central to understanding how nurses function in many clinical environments. Team work takes time to develop and requires communication, respect and learning to learn from and with each other.

As such a simulation game, ‘The Ward’ was designed to allow student nurses to explore aspects of nursing theory and its relationship to practice in a safe and controlled environment. It prompts students to work in teams, with clear roles, but with all team members working toward the same goal. It also prompts and promotes the application of nursing knowledge to a range of scenarios and situations based on aspects of hospital ward life, that are often beyond the collective range of any one type of clinical environment or clinical placement. ‘The Ward’ engages students/learners attention, allowing them to immerse themselves in the simulation, while at the same time having fun.

Each ‘ward’ or team of students work to acquire points that measure their progress in the six key areas of: quality of patient care, clinical competence, efficient management of the ward budget, stable and suitable staff morale, professional development activities and leadership/team work. The game is used with final semester Bachelor of Nursing (Science) students at Curtin University and initial feedback supports its effectiveness as a positive teaching and learning tool.

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Literature review 

A search for literature was conducted using a number of search databases, including, CINAHL, Med Line and ProQuest. Key words used included, ‘simulated learning’, ‘simulation games (in nursing)’, ‘gaming as a teaching strategy’ and ‘innovative teaching strategies (in nursing)’. A number of references were located however, few (n = 5) reflected an empirical approach to the topics considered. This was reinforced by Corbett and Lee (1992) who indicate that while gaming as a teaching strategy has been present for centuries, its use in nursing education has been brief. Joos (1984) suggested gaming was under-utilised in nurse education because it was not thought of as a serious educational approach and Royse and Newton (2007) support this, indicating that empirical support for the advantages of gaming as a teaching strategy in nursing is ‘lacking.’ There is however a new take on the use of games in health care and health care education with Skiba (2008) from the Emerging Technologies Centre indicating that a new taxonomy of ‘serious gaming’ has been created that describes serious games as ‘games that are driven by educational goals, not entertainment’ (Skiba, 2008 p230). This taxonomy dismisses the myth that games cannot be used in serious ways to develop learning and promote health. The claim is reinforced with evidence of a surge in the use of games in physical therapy and rehabilitation. Games are increasingly used to promote physical activity (as seen in the use of video games such as Nintendo’s Wii to stimulate exercise) and educational simulations are used by corporations and in the health care industry (Skiba, 2008). Serious gaming is also evident in nursing education with a surge of interest and use of simulation and simulated learning for clinical skills and critical thinking education (Gaba, 2004, Issenberg and Scalese, 2005).

There are numerous general publications that suggest that using games as an educational tool for nursing education has a number of advantages (Henry, 1997; Metcalf and Yankou, 2003; Glendon and Ulrich, 2005; Tarnow, 2005; Royse and Newton, 2007; Skiba, 2008) and that the use of innovative teaching strategies, including games have been shown to be effective (Royse and Newton, 2007). A summary of the advantages identified is offered in Table 1. Of the five articles that reflected an empirical approach to assessing gaming in nursing education, Regan (2000) undertook a quasi-experimental study designed to evaluate the effects of a gaming episode on empathetic communication approaches employed by nursing students (n = 55). The result was that the game used had a short-term positive impact on the nursing students’ empathetic communication following their involvement with the game.

Table 1. Advantages of using games in nursing education.

Bays and Herman (1997), Ingram et al. (1998) and Cowen and Tesh (2002) both employed a type of randomised controlled trial to determine the impact of gaming on enhancing learning, when combined with and compared against a more traditional teaching format. In both later studies, the students who took part in the game did significantly better in their post gaming test results. Although in Bays and Herman’s (1997) study there was no significant test score difference between the game and control group. However with all three studies, the researchers commented that student interest, motivation and enthusiasm for the subject content were increased in the group using the game.

A study by Cassario (1987) sought to test if gaming could motivate students to learn content related to nursing models. As such, a board game was developed and evaluated against students who did not play the game. The game playing students were better able to retain knowledge than the students in the control group and again the game playing students reported the game to be motivating and enjoyable, supporting their ability to reinforce their learning (Cassario, 1987).

There is another set of publications that are more descriptive in nature. These relate experiences of using games or offer descriptions of the types of games used (Hanna, 1991; Henry, 1997; Glendon and Ulrich, 2005). They commonly offer an evaluation of the games’ impact or effectiveness on learning. Metcalf and Yankou (2003) provide another example describing a game set up to help nursing students understand decision making dilemmas when dealing with ethical issues. They conclude that games are a ‘fundamental part of our culture,’ ‘have some popularity in teaching,’ ‘can reinforce critical thinking,’ and ‘make learning fun for both students and tutors’ (Metcalf and Yankou, 2003 p215). These publications are useful in building a catalog of teaching resources, but neglect to offer empirical support for the benefits of game playing in the domain of nurse education.

Gaining empirical evidence is important because a number of educators remain sceptical about the usefulness or value of game play in nursing education. Therefore, gaining insights into the tangible benefits of using game play in education is valuable if sceptics are to be convinced of the serious benefits on offer (hence the list of advantages and disadvantages in Table 1, Table 2). While the advantages are significant the disadvantages for game playing need to be seriously considered before games can be effectively employed in nurse education (see Table 2).

Table 2. Disadvantages of using games in nursing education.

The literature located supports the concept of gaming being a valuable and innovative teaching strategy and while the research evidence remains scant, evidence does indicate that games are worthy teaching tools and can be effective in improving student learning outcomes. As well, games have been shown to enhance the retention of knowledge and problem solving abilities, provide a fun and motivating format for learning and encourage students to engage more with the subject matter. Educational games, it seems, have a valuable place to take in future nursing programs.

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Background 

The game ‘The Ward’ was first designed and trialled in a UK, undergraduate program in 2003–5. However, it was never formally evaluated. The updated and Australianised version was developed and first used in late 2008. The game was designed to be used with students approaching the conclusion for their nursing program.

‘The Ward’ outlined 

The aim of the ‘The Ward’ simulation game was to explore critical thinking skills through a range of simulated activities in the context of an in-class game. It was designed to allow a review of previous course content and support the students growing confidence prior to completing the course. It also aimed to facilitate teamwork so that the fictitious ward/units functioned in a safe, efficient and competent way to ensure the advancement of the ward/units. Success in the game was measured by the awarding or withdrawal of points for a range of key ward functional areas as mentioned above. Table 3, outlines the ‘The Ward’ game.

Table 3. Outline of ‘The Ward’.

The game required a considerable amount of preparation and equipment, but as all tutors associated with the unit took part it was easy to put into effect although it was labour intensive.

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Methods 

Study design 

The aim of the research was to evaluate the effectiveness and suitability of ‘The Ward’ as a simulation game to promote and support students’ understanding of decision-making, critical thinking and team work in clinical practice situations.

The game was designed by the author who was also responsible for teaching in the final semester units of a Bachelor of Science (Nursing) program, at Curtin University, in Perth, Western Australia. Participants in the research were final semester student nurses (n = 96). They were then offered an opportunity to answer a short questionnaire about the game and at a later date, take part in short focus group to further discuss the relevance of the game to their clinical practice. Four focus groups were facilitated by four tutors, each in separate locations.

The study employed a mixed method approach, with some purely statistical data (sought in the questionnaire) and a substantial amount of qualitative data gathered from both the questionnaire and focus groups.

Data was collected via a questionnaire (distributed immediately after the game) (76 (79.2%) of the students completed questionnaire) and notes made by the tutors at each of the focus group meetings. Audio recording were not made of the focus groups. The focus groups lasted between 25 and 30 min and while specific questions were used to prompt or start discussions, students were encouraged to offer comments freely.

The questionnaires were collected and assessed with the aid of an excel spreadsheet. Tutors took notes at each of the focus group meetings and these notes were collected and analysed for themes and sub-categories.

All the information provided was kept confidential. At no point were participants identified nor were names recorded (on either the questionnaires or at the focus groups). Only the Unit Coordinator/Research Supervisor had access to the questionnaires and focus group feedback. Tutors who recorded the summary statements from the focus groups were not required to record individual participant names or attribute specific comments to any individual in the group. This research was approved by the Curtin University Human Research Ethics Committee (Approval No. SON&M18-2008) and supported by the Deputy Vice Chancellor (as required with research involving university student participants at Curtin University) prior to the commencement of the study.

At any point participants could have withdrawn from either the questionnaire (by not completing it) of from the focus group (by being excused). It was explained in writing (through an information sheet) and verbally at the commencement of the focus group that participants could withdraw at any point and that it would not prejudice or hold any negative consequences for them. As such, 20.8% of students chose not to complete the questionnaires and two complete groups withdrew from the focus group discussion, leaving only two focus groups to offer feedback.

Although the data was collected by the same tutors and lecturing staff who taught the unit, seeking ethical approval before the study ensured that students could decline to take part in the study and would remain anonymous if they did take part.

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Data/Results 

Questionnaires 

The questionnaire was used to identify if the game had been set up and explained correctly and if it was considered to be relevant to the students practice. The first question asked was, “Was the game explained clearly?” To this 83% said that “it was”, 13.1% indicated that “it was not” and 3.9% said that they were “unsure”. Although these students also added that they came late so missed the explanation.

The game set out to simulate a number of specific activities essential for and common in nursing practice. These activities were specifically designed to be evident within the game. The second question asked the students if these activities were recognised as being evident in the game. The results are shown in Table 4.

Table 4. Which of the following issues did you recognise in the “activities” addressed ‘The Ward’?

It was hoped that while the game was clearly a simulation activity, it would closely reflect realistic scenarios from the real world of practice. The third question sought feedback about how effectively this goal had been reached. Students responded positively, with 93.4% believing all the simulated activities represented potentially realistic situations. Only 6.5% felt other than this and when asked to explain this further, only one respondent made a comment, indicating that, budgeting was inappropriate in one of the scenarios as it was not a nurses’ responsibility.

The games designer was also interested to discover if the game was enjoyable as well as educational and in this regard, 93.4% said that it was. With 5.2% feeling it was not and one person (1.3%) not being sure if they had enjoyed themselves or not. To draw this information out further, participants were asked to identify three points to support why they thought the game was enjoyable. This produced a plethora of responses, almost all of which were positive and with most supporting the following themes:

Producing an enjoyable learning activity was not the only point of the game and it was important to the researcher that the participants understood what the aim of the game was. Question five on the questionnaire sought to explore this. A variety of responses were offered. Many students identified that the aims related to addressing the key activities suggested in question 2 (decision making, clinical skills, ward management, nursing practice knowledge, critical thinking, medication knowledge and leadership). However, a large number of responses also indicated that they felt the game was used to “explore issues such as teamwork”, “motivate students prior to graduation”, “practice communication skills”, “promote learning and team work in a fun and engaging environment”, or “to make revision fun and exciting.” While the majority of the comments were positive two students suggested they ‘didn’t know” the point of the game.

These responses reassured the games developers that it was on target as a learning tool. However this specific question needed to be tested, and as such question 6 asked students to rate the game as a learning activity, on a scale of 0–10 (with 10 being the highest). The majority of responses were for scores above 7 (68.7%) with the mean response being 7.3 out of 10 (see Table 5).

Table 5. How would you rate the game as a learning activity?

Participants were then asked to describe if the game highlighted the value of a number of issues considered important for nursing activities. These were, team work, critical thinking, decision-making skills and ward management skills. Table 6 indicates the results.

Table 6. Relative values of activities identified in “The Game”.

Participants where then asked to indicate why they felt the game had highlighted these activities as valuable for successful nursing practice. Students again offered a wide range of responses. Most reflected the views offered in these few examples:

Participants were asked to suggest up to three ways in which ‘The Ward’ could be improved. A number indicated that the game was “perfect”. However, the majority of suggestions related to offering a more suitable environment (a lecture room had been used and it was suggested by a number of respondents that a flat surfaced room would be better in future). To make more use of Power Point for the scenario explanations, to offer a better prize to the winning ward, to make the game harder with even more practical scenarios, to “get different teams to mark each others score or get a tutor to add up the team points – some groups were cheating” and to “do the game earlier in the semester.”

Finally, participants were asked to add any other comments. Few though were offered and those that were reflected much that had been written before. Although significantly, a large number of responses said simply, “enjoyed it”, “it’s fun!” “I enjoyed it.” “I think we should have this activity in previous semesters”, “great job”, “enjoyable game” “met new friends in learning”, “great learning activity” and “really valuable teamwork experience.”

Focus groups 

Focus groups met two weeks after the game was played. Students in focus groups were asked a series of questions aimed at drawing out the relevance of the game to them, or to clinical practice. It was again explained to students that participation was not compulsory and that they could leave the discussion if they wanted. As such, two whole groups chose not to take part and focus group activity (as these groups were planned for the end of the day) and comments were made by only two groups of students (38 students in all).

Focus group results were analysed and resulted in the development of a three themes (which also had a number of sub-categories, see Table 7 below).

Table 7. Themes and sub-categories from the focus groups.

Theme 1: Relevance to practice 

Most students offered comments in the focus groups that indicated that they had reflected on the game and talked to other students and clinical staff about a number of the specific scenarios, often to gauge the responses or insights of clinical staff if dealing with the same scenarios. Students also commented that they thought the scenarios and activities used might be applicable to their nursing practice. This prompted significant discussion in each focus group with students indicating that the scenarios were relevant and practical and that they could apply them in terms of a range of skills including delegation, dealing with conflict and decision-making, this lead to the second theme.

Theme 2: Relevance to specific skills 

Students commented that they thought the game specifically focused their learning on the skills of ‘team work’, ‘critical thinking’ ‘delegation’ and ‘decision making.’ Most students agreed that these issues were well addressed throughout the game and that the game helped them learn about various roles in the health care team and the various management responsibilities staff have. Many comments indicated that that the game met its objectives of focusing on these areas and in a fun way.

Focus group participants were also asked to discuss what they thought were the main ideas they took away after playing the game. Most responded that they had thought more about management and leadership issues since playing the game and that they had a better understanding of what to “brush up on” before completing the course. Or that they had a better insight into the significance and value of decision-making and teamwork.

Theme 3: What can be done better? 

Finally students offered views about ways to improve or re-design the game to improve the reality factor or its learning effectiveness. Most of the comments made, supported those offered in response to the questionnaire.

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Discussion 

There is only limited empirical support for the use of games in nursing education (Royse and Newton, 2007). However, this study offers an example of a detailed research study that demonstrates that empirical evidence can be offered to support the value of using games in nurse education. ‘The Ward’ was found to be enjoyable by the vast majority of participants with 93% supporting Henry’s (1997) claim that games can be fun and exciting ways to learn. Further support for this is that almost 7 out of 10 respondents felt the game was a useful and relevant learning activity.

The game set out to address a number of nursing specific activities and in this regard achieved considerable success. Results showed that between 80% and 95% of respondents indicated that they recognised the activities of decision-making, clinical skills, ward management, practical nursing knowledge, critical thinking, medication knowledge and leadership as central elements of the game. As this was a key aim of the game it was satisfying to see that the results of the evaluation study strongly supported this achievement.

Setting the game up and facilitating it was reasonably time consuming activity. However, in terms of focusing students’ sights and skills on the key issues of teamwork, critical thinking, decision-making skills and ward management activities the game was a great success. It also allowed a great deal of clinical and theoretical information to be reviewed and discussed in a short time frame while at the same time allowing tutorial and lecturing staff to interact with a large group of students in a collegial and enjoyable way. It was relatively labour intensive but it is recognised that much of the effort used was in setting it up for the first time and that future attempts to run the game will require less set up time. However, running the game will remain relatively labour intensive. One student said the game was, “a really valuable learning experience” and while there were a few teething problems with the set up, once the game got underway students quickly engaged with it and embraced the simulated activities the game offered. The evaluation has prompted the continued use of ‘The Ward’ and further development in response to the recommendations below.

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Conclusion 

‘The Ward’ was developed as a way of revising a wide range of the topics and subjects covered in the Bachelor of Science (Nursing) curriculum, in a short time and in a way that was enjoyable for lecturers and students alike. In every regard ‘The Ward’ has proven to be a very useful simulation exercise that has evaluated well and helped bridge the gap between theory and practice.

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Recommendations 

There were a number of recommendations that will be implemented with future versions of ‘The Ward’.

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