Educational games for health professionals

Are serious games seriously good at preparing students for clinical practice?: A randomized controlled trial

PURPOSE

Serious games (SGs) have great potential for pediatric medical education. This study evaluated the efficacy of a SG in improving learner satisfaction, knowledge, and behavior.

MATERIALS AND METHODS

This was an investigator-blinded randomized controlled trial (RCT) comparing a SG against two controls: (i) adaptive tutorial (AT), and (ii) low-stimulus control (LSC). SG is a highly immersive role-playing game in a virtual hospital. AT delivers interactive web-based lessons. LSC is paper-based clinical practice guidelines. Metropolitan senior medical students at UNSW were eligible. A total of 154 enrolled and were block randomized to one intervention. Participants had access to one intervention for 8 weeks which taught pediatric acute asthma and seizure assessment and management. Satisfaction was assessed with Likert-scale responses to 5 statements and 2 free-text comments. Knowledge was assessed with 10 multiple-choice questions (MCQs). Clinical behavior was assessed during a 30-point simulated clinical management scenario (CMS). Primary analysis was performed on a modified intention-to-treat basis and compared: (1) SG vs. AT; and (2) SG vs. LSC.

RESULTS

A total of 118 participants were included in the primary analysis (modified intention-to-treat model). No significant differences in MCQ results between the SG and control groups. SG group outperformed the LSC group in the CMS, with a moderate effect (score out of 30: 20.8 (3.2) vs. 18.7 (3.2), respectively, d = 0.65 (0.2-1.1), p = 0.005). No statistically significant difference between SG and AT groups in the CMS (score: 20.8 (3.2) vs. 19.8 (3.1), respectively, d = 0.31 (-0.1 to 0.8), p = 0.18). A sensitivity analysis (per-protocol model) was performed with similar outcomes.

CONCLUSIONS

This is the first investigator-blinded RCT assessing the efficacy of a highly immersive SG on learner attitudes, knowledge acquisition, and performance in simulated pediatric clinical scenarios. The SG demonstrated improved translation of knowledge to a simulated clinical environment, particularly compared to LSC. SGs show promise in pediatric medical education.

Boardgames as an innovative approach to promote life skills and well-being among inmates: A scoping review protocol

Over the past few decades, a growing body of evidence has emerged regarding the positive impact of boardgames in promoting life skills and well-being in various settings including health, education, and military schooling. However, the use of boardgames with inmates for cultural and educational purposes is still an unexplored and fragmented area of research. Incorporating boardgames into correctional settings can be a complex challenge for correctional stakeholders who seek to identify innovative tools to enhance inmate education and promote integration into society after incarceration. This article outlines our scoping review protocol designed to map and evaluate published and grey literature on the motivational, psychological, and pedagogical considerations involved in the design and use of boardgames as an innovative approach to promoting life skills and well-being among inmates.

Assessment and evaluation of a serious game for teaching factual knowledge in dental education

OBJECTIVES

A serious game application was developed to train factual knowledge and for self-assessment. The aim of the present study was to compare the effects of a game application (intervention group) or paper scripts (control group) on knowledge acquisition and to evaluate the acceptance of the new application among dental students.

METHODS

The 4th semester students of the second preclinical prosthodontics course were randomly assigned to one of the two groups (n = 58/51) for two consecutive years. The study was conducted in two phases: First, all participants took a pretest, with the intervention group using the game application and the control group receiving the same set of questions in a paper script. In the second phase, all participants took a post-test. After the post-test, both groups had access to the application for another three weeks. After that, all participants completed standardized questionnaires and a scale to evaluate the usability of the system. Usage statistics were also tracked. Differences between groups were evaluated together and for both years separately in terms of pretest and posttest scores and learning success.

RESULTS

There was no significant difference between the groups with regard to the posttest and learning success. A significant improvement in knowledge between pretest and posttest (p < 0.05) was demonstrated in both groups. Each student played approximately 350 questions. Participants rated the application with the German school grade "good". Participants appreciated the application and rated it positively. They stated that the game motivated them to learn and that they spent more time with the learning content.

CONCLUSION

Due to the positive perception achieved through the game, this application is able to motivate students to learn. The learning effect achieved is similar to learning on paper.

Comparative satisfaction and effectiveness of virtual simulation and usual supervised work for postpartum hemorrhage management: a crossover randomized controlled trial

BACKGROUND

Because virtual simulation promotes learning and cognitive skill development, it may be useful for teaching students to manage postpartum hemorrhage (PPH) and its complex decision algorithm.

OBJECTIVE

This study aimed to compare the satisfaction and effectiveness of virtual simulation with usual supervised work in producing knowledge and satisfaction.

METHODS

This two-center two-stage crossover randomized controlled trial included student midwives. One group underwent the virtual simulation intervention in the first period (January 2018) and the usual supervised classroom work in the second (May 2018); the other group followed the reverse chronology. Satisfaction was the primary outcome. The secondary outcome was knowledge of the PPH management algorithm, assessed by responses to a case vignette after each intervention session.

RESULTS

The virtual simulation -supervised work (VS-SW) chronology was allocated to 48 students, and its inverse (SW-VS) to 47; Satisfaction was significantly higher for the virtual simulation for its overall grade (6.8 vs. 6.1, P = 0.009), engagingness (very good 82.1% vs. 24.3%, P < 0.001), and ease of use (very good 77.9% vs. 46.1%, P < 0.001). Knowledge did not differ between the two groups (respectively, 89.5% versus 83.5%, P = 0.3).

CONCLUSION

Satisfaction is higher with virtual simulation without lowering knowledge scores, which argues for the use of such innovative teaching strategies. This could lead to an increase in students' motivation to learn.

Benefits of gamification in medical education

Medical education is changing at a fast pace. Students attend medical school with a high degree of technological literacy and a desire for a diverse educational experience. As a result, a growing number of medical schools are incorporating technology-enhanced active learning and multimedia education tools into their curriculum. Gamified training platforms include educational games, mobile medical apps, and virtual patient scenarios. We provide a systematic review of what is meant by gamification in this era. Specific educational games, mobile apps, and virtual simulations that may be used for preclinical and clinical training have been discovered and classified. The available data were presented in terms of the recognized platforms for medical education's possible benefits. Virtual patient simulations have been shown to enhance learning results in general. Gamification could improve learning, engagement, and cooperation by allowing for real-world application. They may also help with promoting risk-free healthcare decision-making, remote learning, learning analytics, and quick feedback. We account for Preclinical training which included 5 electronic games and 4 mobile apps, while clinical training included 5 electronic games, 10 mobile applications, and 12 virtual patient simulation tools. There were additionally nine more gamified virtual environment training products that were not commercially accessible. Many of these studies have shown that utilizing gamified media in medical education may confer advantages. This collection of hyperlinked resources may be utilized by medical students, practitioners, and instructors at all levels.

Development of a board game to assist pharmacists learning the potentially inappropriate medications in older people

BACKGROUND AND PURPOSE

Pharmacists have been reported to have inadequate awareness about potentially inappropriate medications (PIMs) in older people. This warrants more efforts to enhance their familiarity and knowledge in this topic. A board game was developed based on the 2019 American Geriatrics Society (AGS) Beers Criteria to assist pharmacists learning the topic.

EDUCATIONAL ACTIVITY AND SETTING

The board game is played using dice and pawns and involved players encounter questions on various aspects of PIMs in older people. Questions used in the board game were reviewed by a panel of experts. The board game exposed pharmacists to drug-drug and drug-disease/syndrome interactions. The board game was pilot tested among 16 pharmacists and played by a group of 34 pharmacists. Close- and open-ended feedback regarding the board game were sought in both sessions using a self-developed questionnaire.

FINDINGS

All pharmacists in the pilot test (PT) and actual game (AG) sessions agreed that the board game is an innovative, useful, and interesting way to learn about PIMs in older people. All pharmacists in the PT session and a high majority of those in the AG session agreed that the board game increased their knowledge about PIMs in older people. The open-ended responses showed generally positive feedback.

SUMMARY

The board game can be useful as an educational tool to supplement traditional teaching methods to assist pharmacists learning the PIMs in older people. Periodic review and relevant modifications of the board game content can be done to ensure its efficiency and relevance.

Clinician adoption of Parent–Child Interaction Therapy: A systematic review of implementation interventions

Background

Parent–Child Interaction Therapy (PCIT) is a parent training intervention for childhood conduct problems, distinctive in its use of live clinician coaching of the parent–child dyad via a one-way mirror and discrete earpiece. However, despite a compelling evidence base, uptake of evidence-based parent training programmes such as PCIT by clinicians in routine care settings remains poor. This systematic review aimed to identify and synthesise implementation interventions that have sought to increase clinician adoption of PCIT in usual care settings.

Methods

We searched MEDLINE (Ovid), Embase (Ovid), PsycInfo (Ovid), CINAHL (EBSCO), Science Citation Index and Social Sciences Citation Index, and Web of Science Core Collection from inception to October 2020. Articles were included if they tested (by way of randomised controlled trials, controlled clinical trials, interrupted time series and controlled before and after trials) implementation interventions across any and all of the patient, clinician, clinic, system or policy domains. Two independent reviewers screened and selected studies, assessed risk of bias and extracted data – summarising implementation intervention components according to items from the Template for Intervention Description and Replication (TIDieR) checklist ( Hoffmann et al., 2014 ).

Results

Of the 769 articles identified once duplicates were removed, 13 papers relating to three studies met the inclusion criteria – all were quantitative or mixed-methods examinations of the effectiveness of different PCIT clinician training or training-related consultation methods. A narrative description of interventions was provided, as quantitative synthesis was not possible.

Conclusions

Research attention has to date been focussed on the establishment of an evidence-base for PCIT's effectiveness, with relatively little attention to the dissemination, implementation and sustainment of this treatment. Those studies that do exist have focused on training methods and training-related expert consultation. Research attention could usefully turn to both adoption and sustainment of this effective treatment in usual care settings.

Plain language summary

In this review, we aimed to summarise what is already known about how to implement PCIT in community settings after clinicians have received training in the approach. While research relating to the implementation of other parent training programmes is interesting and informative, implementation efforts are most effective when tailored to a specific programme in a specific context. As such, it was important to review published studies relating to PCIT specifically. We identified three relevant studies, one of which is yet to publish its main implementation findings. The three studies have focused on how best to train clinicians in PCIT, including how best to provide post-training support from expert trainers. We concluded that a fruitful line for future research would be to focus on the post-training period, particularly how best to support clinicians to adopt and sustain PCIT in their practice.

Systematic review registration

The study was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 01/10/2020 (CRD42020207118).

Development and implementation of a novel Web-based gaming application to enhance emergency medical technician knowledge in low- and middle-income countries

BACKGROUND

Increasing access to high-quality emergency and prehospital care is an important priority in low- and middle-income countries (LMICs). However, ensuring that emergency medical technicians (EMTs) maintain their clinical knowledge and proficiency with procedural skills is challenging, as continuing education requirements are still being introduced, and clinical instructional efforts need strengthening. We describe the development and implementation of an innovative asynchronous learning tool for EMTs in the form of a Web-based trivia game.

METHODS

Over 500 case-based multiple-choice questions (covering 10 essential prehospital content areas) were created by experts in prehospital education, piloted with EMT educators from LMICs, and delivered to EMTs through a Web-based quiz game platform over a 12-week period. We enrolled 252 participants from nine countries.

RESULTS

Thirty-two participants (12.7%) completed the entire 12-week game. Participants who completed the game were administered a survey with a 100% response rate. Ninety-three percent of participants used their mobile phone to access the game. Overall, participants reported that the interface was easy to use (93.8% agreed or strongly agreed), the game improved their knowledge (100% agreed or strongly agreed), and they felt better prepared for their jobs (100% agreed or strongly agreed). The primary motivators for participation were improving patient care (37.5%) and being recognized on the game's leaderboard (31.3%). All participants reported that they would engage in the game again (43.8% agreed and 56.3% strongly agreed) and would recommend the game to their colleagues (34.4% agreed and 65.6% strongly agreed).

CONCLUSIONS

In conclusion, a quiz game targeting EMT learners from LMICs was viewed as accessible and effective by participants. Future efforts should focus on increasing retention and trialing languages in addition to English.

Surgical Jeopardy: Play to Learn

BACKGROUND

General Surgery residencies use protected education time in various fashions in order to optimize content quality and yield for their learners. This knowledge is tested annually with the American Board for Surgery In-Training Examination (ABSITE) exam and is used to evaluate several aspects of a resident. We hypothesized that using a jeopardy game in educational conference would encourage residents to engage in self-learning and improve ABSITE scores at a single institution.

MATERIALS AND METHODS

At a single institution, during protected education conference, residents played an hour-long surgical jeopardy game every 7 wk to summarize high yield topics discussed during the previous 6 wk of didactic learning. A 5-point Likert survey was completed by general surgery residents to discern the utility of the game format for learning. The ABSITE category scores were also evaluated from the year before and the year after the game was implemented.

RESULTS

Twenty-four general surgery residents took the survey with >80% agreeing that the jeopardy format was either a fun or an effective way to learn general surgery topics. Additionally, over 80% of residents thought the game format helped with retention of knowledge. ABSITE categories that had a jeopardy session improved from 65.9% to 70.4% correct (P = 0.0003). ABSITE categories that did not have dedicated jeopardy had a non-significant increase in scores (67.7%-69.9%, P = 0.1).

CONCLUSIONS

Implementing surgical jeopardy as a component of educational conferences in general surgery resident training is correlated with improvement of ABSITE scores. Surgical jeopardy may be easily adopted and implemented to stimulate self-directed learning for residents.

GoDental! Enhancing flipped classroom experience with game-based learning

AIM

To investigate the use of game-based learning (GBL) to enhance students' experience of the flipped classroom (FC) in dental education.

MATERIALS AND METHODS

Students participated in three sessions organised as FC, implemented either as conventional FC or FC augmented with the GoDental! game. In the pre-class phase, sessions 1 and 2 were organised as instructor-made video lectures, plus a questionnaire. These activities were supplemented with the individual development of questions and answers for the game in session 3. In the in-class phase, group and plenary discussions were used during sessions 1 and 2 and were replaced by game activities in session 3. Perceptions of session 3 compared to that of sessions 1 and 2 were explored via a questionnaire with both open-ended and Likert-scale items.

RESULTS

Most students (29, 97%) perceived the FC session augmented with the GoDental! game as enjoyable. The game augmented session was perceived as more enjoyable compared to the conventional FC sessions. Students agreed that GBL augmented FC compared to conventional FC increased engagement (25, 83%), motivation (24, 83%), their integration in the social environment (23, 77%) and concentration (22, 73%), helped them learn more about the topic (24, 80%) and was a good learning method (25, 83%). There was a positive correlation between the degree of enjoyment and concentration and the feeling that the game helped them learn more about the topic.

CONCLUSION

Game-based learning augmented FC proved to enhance students' experience, resulting in increased enjoyment compared to the conventional FC setup. Future studies should explore whether the use of GBL in FC has the potential to increase examination performance.

Advantages of Kahoot! Game-based Formative Assessments along with Methods of Its Use and Application during the COVID-19 Pandemic in Various Live Learning Sessions

BACKGROUND

Technology has played important roles in education, thus the application of online Kahoot! Game-based technology as a learning tool particularly in formative assessments might improve learning and achieve promising education. It can be applied live, either face to face or virtual in distance learning as during the current situation of COVID-19 pandemic that resulted in total shift toward online learning.

METHODOLOGY

Kahoot! Game-based histology and cell biology lab formative assessments were prepared, equipped with light and electron microscopic photos, and applied for 2nd year undergraduate medical students. Students' engagement was evaluated by calculating number of engaged students in Kahoot! versus number of attended students in each lab. Students' satisfaction was evaluated according to students' feedback collected on Kahoot! platform and by an online questionnaire applied on Google Forms which included 5 items that were measured on a 5-point Likert scale, with 1 indicating strongly disagree and 5 indicating strongly agree, with overall satisfaction ranging between 5 (least satisfaction) and 25 (maximum satisfaction). YouTube videos were done to demonstrate and spread the idea of using Kahoot! platform in education particularly in the COVID-19 pandemic.

RESULTS

Kahoot! was successfully applied in Histology and Cell Biology lab sessions. Students' engagement for Kahoot! game-based formative assessments were 100% in most lab sessions. The mean overall students' fun assessment score for Kahoot! was 4.65 out of 5. Most students recommended the use of Kahoot! game-based formative assessments. The mean overall Kahoot! questionnaire satisfaction score was 24.25 (ranging between agree and strongly agree). YouTube videos were successfully published.

CONCLUSION

Kahoot! produces marked students' engagement and satisfaction in formative assessments enabling it to be applied live for any learning session either face to face or virtual for distance learning.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

Theory-based electronic learning intervention to support appropriate antibiotic prescribing by nurse and pharmacist independent prescribers: an acceptability and feasibility experimental study using mixed methods

OBJECTIVES

To assess the acceptability and feasibility of using a theory-based electronic learning intervention designed to support appropriate antibiotic prescribing by nurse and pharmacist independent prescribers for patients presenting with common, acute, uncomplicated self-limiting respiratory tract infections (RTIs).

DESIGN

Experimental with mixed methods; preintervention and postintervention online surveys and semistructured interviews.

SETTING

Primary care settings across the UK.

PARTICIPANTS

11 nurse and 4 pharmacist prescribers.

INTERVENTION

A theory-based brief interactive animation electronic learning activity comprised a consultation scenario by a prescriber with an adult presenting with a common, acute, uncomplicated self-limiting RTI to support a 'no antibiotic prescribing strategy'.

OUTCOME MEASURES

Recruitment, response and attrition rates were assessed. The overall usefulness of the intervention was assessed by analysing prescribers' self-reported confidence and knowledge in treating patients with RTIs before and after undertaking the intervention, and views on the relevance of the intervention to their work. Acceptability of the intervention was assessed in semistructured interviews. The feasibility of data collection methods was assessed by recording the number of study components completed by prescribers.

RESULTS

15 prescribers (maximum sample size) consented and completed all four stages of the study. Prescribers reported high to very high levels of confidence and knowledge preintervention and postintervention, with slight postintervention increases in communicating with patients and a slight reduction in building rapport. Qualitative findings supported quantitative findings; prescribers were reassured of their own practice which in turn increased their confidence and knowledge in consultations. The information in the intervention was not new to prescribers but was applicable and useful to consolidate learning and enable self-reflection. Completing the e-learning intervention was acceptable to prescribers.

CONCLUSIONS

It was feasible to conduct the study. The intervention was acceptable and useful to prescribers. Future work will add complex clinical content in the intervention before conducting a full trial.

Is virtual reality effective to teach prevention of surgical site infections in the operating room? study protocol for a randomised controlled multicentre trial entitled VIP Room study

INTRODUCTION

Some surgical site infections (SSI) could be prevented by following adequate infection prevention and control (IPC) measures. Poor compliance with IPC measures often occurs due to knowledge gaps and insufficient education of healthcare professionals. The education and training of SSI preventive measures does not usually take place in the operating room (OR), due to safety, and organisational and logistic issues. The proposed study aims to compare virtual reality (VR) as a tool for medical students to learn the SSI prevention measures and adequate behaviours (eg, limit movements…) in the OR, to conventional teaching.

METHODS AND ANALYSIS

This protocol describes a randomised controlled multicentre trial comparing an educational intervention based on VR simulation to routine education. This multicentre study will be performed in three universities: Grenoble Alpes University (France), Imperial College London (UK) and University of Heidelberg (Germany). Third-year medical students of each university will be randomised in two groups. The students randomised in the intervention group will follow VR teaching. The students randomised in the control group will follow a conventional education programme. Primary outcome will be the difference between scores obtained at the IPC exam at the end of the year between the two groups. The written exam will be the same in the three countries. Secondary outcomes will be satisfaction and students' progression for the VR group. The data will be analysed with intention-to-treat and per protocol.

ETHICS AND DISSEMINATION

This study has been approved by the Medical Education Ethics Committee of the London Imperial College (MEEC1920-172), by the Ethical Committee for the Research of Grenoble Alpes University (CER Grenoble Alpes-Avis-2019-099-24-2) and by the Ethics Committee of the Medical Faculty of Heidelberg University (S-765/2019). Results will be published in peer-reviewed medical journals, communicated to participants, general public and all relevant stakeholders.

Development and Evaluation of a New Serious Game for Continuing Medical Education of General Practitioners (Hygie): Double-Blinded Randomized Controlled Trial

Background

Continuing medical education is important but time-consuming for general practitioners (GPs). Current learning approaches are limited and lack the ability to engage some practitioners. Serious games are new learning approaches that use video games as engaging teaching material. They have significant advantages in terms of efficiency and dissemination.

Objective

The aim of this study was to create a serious game and to evaluate it in terms of effectiveness and satisfaction, comparing it with a traditional method of continuing education—article reading.

Methods

We produced a prototype video game called Hygie on the 5 most common reasons of consultation in general practice using 9 articles from independent evidence-based medicine journals (reviews from Prescrire and Minerva). We created 51 clinical cases. We then conducted a double-blinded randomized trial comparing the learning provided by a week of access to the game versus source articles. Participants were GPs involved as resident supervisors in 14 French university departments of family practice, recruited by email. Primary outcomes were (1) mean final knowledge score completed 3 to 5 weeks after the end of the intervention and (2) mean difference between knowledge pretest (before intervention) and posttest (3 to 5 weeks after intervention) scores, both scaled on 10 points. Secondary outcomes were transfer of knowledge learned to practice, satisfaction, and time spent playing.

Results

A total of 269 GPs agreed to participate in the study. Characteristics of participants were similar between learning groups. There was no difference between groups on the mean score of the final knowledge test, with scores of 4.9 (95% CI 4.6-5.2) in the Hygie group and 4.6 (95% CI 4.2-4.9) in the reading group (P=.21). There was a mean difference score between knowledge pre- and posttests, with significantly superior performance for Hygie (mean gain of 1.6 in the Hygie group and 0.9 in the reading group; P=.02), demonstrating a more efficient and persistent learning with Hygie. The rate of participants that reported to have used the knowledge they learned through the teaching material was significantly superior in the Hygie group: 77% (47/61) in the Hygie group and 53% (25/47) in the reading group; odds ratio 2.9, 95% CI 1.2-7.4. Moreover, 87% of the opinions were favorable, indicating that Hygie is of interest for updating medical knowledge. Qualitative data showed that learners enjoyed Hygie especially for its playful, interactive, and stimulating aspects.

Conclusions

We conclude that Hygie can diversify the offering for continuing education for GPs in an effective, pleasant, and evidence-based way.

Trial Registration

ClinicalTrials.gov NCT03486275; https://clinicaltrials.gov/ct2/show/NCT03486275

Impact of Using a 3D Visual Metaphor Serious Game to Teach History-Taking Content to Medical Students: Longitudinal Mixed Methods Pilot Study

BACKGROUND

History taking is a key component of clinical practice; however, this skill is often poorly performed by students and doctors.

OBJECTIVE

The study aimed to determine whether Metaphoria, a 3D serious game (SG), is superior to another electronic medium (PDF text file) in learning the history-taking content of a single organ system (cardiac).

METHODS

In 2015, a longitudinal mixed methods (quantitative and qualitative) pilot study was conducted over multiple sampling time points (10 weeks) on a group of undergraduate medical students at The University of Auckland Medical School, New Zealand. Assessors involved in the study were blinded to group allocation. From an initial sample of 83, a total of 46 medical students were recruited. Participants were assigned to either a PDF group (n=19) or a game group (n=27). In total, 1 participant left the PDF group after allocation was revealed and was excluded. A total of 24 students in the game group and 14 students in the PDF group completed follow-up 7 weeks later. Using an iterative design process for over a year, with input from a variety of clinical disciplines, a cardiac history-taking game and PDF file were designed and informed by Cognitive Load Theory. Each group completed its intervention in 40 min. A total of 3 levels of Kirkpatrick training evaluation model were examined using validated questionnaires: affective (perception and satisfaction), cognitive (knowledge gains and cognitive load), and behavioral attitudes (Objective Structured Clinical Exam) as well as qualitative assessment. A priori hypotheses were formulated before data collection.

RESULTS

Compared with baseline, both groups showed significant improvement in knowledge and self-efficacy longitudinally (P<.001). Apart from the game group having a statistically significant difference in terms of satisfaction (P<.001), there were no significant differences between groups in knowledge gain, self-efficacy, cognitive load, ease of use, acceptability, or objective structured clinical examination scores. However, qualitative findings indicated that the game was more engaging and enjoyable, and it served as a visual aid compared with the PDF file.

CONCLUSIONS

Students favored learning through utilization of an SG with regard to cardiac history taking. This may be relevant to other areas of medicine, and this highlights the importance of innovative methods of teaching the next generation of medical students.

Effectiveness of the spaced education pedagogy for clinicians' continuing professional development: a systematic review

CONTEXT

Ensuring clinical practice reflects current evidence is challenging given the rapid proliferation of new knowledge. Changing entrenched clinical behaviours and facilitating the adoption of best practice evidence requires a range of strategies, including affordable, scalable and effective continuing professional development (CPD). Yet, identifying the CPD delivery method most likely to effectively change and improve patient outcomes is difficult given the variability in the evidence for different learning approaches. Although there is moderate level evidence for outreach education, audit and feedback, and face-to-face or online learning, little is known about the capacity of spaced education to change ineffective clinical practice(s). Spaced education harnesses the power of spacing, repetition and testing learning content to increase topic-specific knowledge. Although spaced education is widely used in undergraduate and postgraduate medical programmes, its effectiveness as a CPD delivery method that improves patient outcomes is less certain.

AIM

To determine the effectiveness of the spaced education CPD programmes to change targeted clinical knowledge and practice(s) to improve patient outcomes.

METHOD

A systematic review, appraising the spaced education CPD evidence generated from searching six specialist medical and psychosocial databases. Studies published in English peer-reviewed journals from 1 January, 2000 to 31 August, 2018 were eligible for inclusion. A modified Kirkpatrick four levels of evaluation framework assisted with appraising the effect of spaced education CPD interventions on clinicians and patients.

RESULTS

Of the 2396 studies identified, 17 met the inclusion criteria, involving 2701 practising clinicians from multiple disciplines and specialties. Five randomised controlled trials generated level II evidence, with the remaining 12 studies generating lower levels of evidence. The majority of studies (n = 14) involved the delivery of online spaced education. All studies were evaluated using the modified Kirkpatrick four levels of evaluation framework with: 10 studies demonstrating significant increases in participants' knowledge; seven studies reporting significant changes in clinician behaviour; four studies showing significant increases in clinician confidence; and three studies identifying significant and sustained increases in participants' clinical skills. Only two studies reported positive improvements in patient outcomes.

CONCLUSION

Spaced education via an online platform offers a scalable CPD format that can increase clinical knowledge and change practice. However, further adequately powered randomised controlled trials are required to confirm that spaced education CPD can impact positively on patients' reported outcomes.

Feasibility of an augmented reality cardiopulmonary resuscitation training system for health care providers

AIM OF THE STUDY

Augmented reality (AR) has the potential to offer a novel approach to CPR training that supplements conventional training methods with gamification and a more interactive learning experience. This is done through computer-generated imagery superimposed on users' view of the real environment to simulate interactive training scenarios. We sought to test the feasibility of an AR CPR training system (CPReality) for health care providers (HCPs).

METHODS

In this feasibility trial, a CPR training manikin was integrated with a commercial AR device (Microsoft HoloLens) to provide participants with real-time audio-visual feedback via a holographic overlay of blood flow to vital organs dependent on CC quality. In this system, higher quality CC visually improved virtual blood circulation. HCPs performed a 2-minute cycle of hands-only CPR using only the AR system, and CC parameters were recorded. Descriptive data on participants' demographics, CC quality, and satisfaction with the training environment were reported using quantitative and qualitative analysis.

RESULTS

Between 10/2018-11/2018, we enrolled a convenience sample of 51 HCPs. The median age of participants was 31 years (IQR 27-41), 71% (36/51) were female, and 67% (34/51) were registered nurses. CC rates (mean 126 ± 12.9 cpm), depths (median 53 mm, IQR 46-58), and percent with complete recoil (median 80%, IQR 12-100) were consistent with guideline recommendations for good quality CPR. Participants were predominantly satisfied with the system, with 82% perceiving the experience as realistic, 98% recognizing the visualizations as helpful for training, and 94% willing to use the application in future CPR training.

CONCLUSIONS

As AR is increasingly applied in the healthcare setting, integration in CPR training offers a novel and promising educational approach. In this convenience sample of trained HCPs, high quality CC delivery was feasible using the AR CPR training system which was received favorably by most participants.

Health professions digital education on clinical practice guidelines: a systematic review by Digital Health Education collaboration

BACKGROUND

Clinical practice guidelines are an important source of information, designed to help clinicians integrate research evidence into their clinical practice. Digital education is increasingly used for clinical practice guideline dissemination and adoption. Our aim was to evaluate the effectiveness of digital education in improving the adoption of clinical practice guidelines.

METHODS

We performed a systematic review and searched seven electronic databases from January 1990 to September 2018. Two reviewers independently screened studies, extracted data and assessed risk of bias. We included studies in any language evaluating the effectiveness of digital education on clinical practice guidelines compared to other forms of education or no intervention in healthcare professionals. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to assess the quality of the body of evidence.

RESULTS

Seventeen trials involving 2382 participants were included. The included studies were diverse with a largely unclear or high risk of bias. They mostly focused on physicians, evaluated computer-based interventions with limited interactivity and measured participants' knowledge and behaviour. With regard to knowledge, studies comparing the effect of digital education with no intervention showed a moderate, statistically significant difference in favour of digital education intervention (SMD = 0.85, 95% CI 0.16, 1.54; I2 = 83%, n = 3, moderate quality of evidence). Studies comparing the effect of digital education with traditional learning on knowledge showed a small, statistically non-significant difference in favour of digital education (SMD = 0.23, 95% CI - 0.12, 0.59; I2 = 34%, n = 3, moderate quality of evidence). Three studies measured participants' skills and reported mixed results. Of four studies measuring satisfaction, three studies favoured digital education over traditional learning. Of nine studies evaluating healthcare professionals' behaviour change, only one study comparing email-delivered, spaced education intervention to no intervention reported improvement in the intervention group. Of three studies reporting patient outcomes, only one study comparing email-delivered, spaced education games to non-interactive online resources reported modest improvement in the intervention group. The quality of evidence for outcomes other than knowledge was mostly judged as low due to risk of bias, imprecision and/or inconsistency.

CONCLUSIONS

Health professions digital education on clinical practice guidelines is at least as effective as traditional learning and more effective than no intervention in terms of knowledge. Most studies report little or no difference in healthcare professionals' behaviours and patient outcomes. The only intervention shown to improve healthcare professionals' behaviour and modestly patient outcomes was email-delivered, spaced education. Future research should evaluate interactive, simulation-based and spaced forms of digital education and report on outcomes such as skills, behaviour, patient outcomes and cost.

Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review

OBJECTIVES

Our goal is to conceptualise a clinical governance framework for the effective management of chronic diseases in the primary care setting, which will facilitate a reorganisation of healthcare services that systematically improves their performance.

SETTING

Primary care.

PARTICIPANTS

Chronic Care Model by Wagner et aland Clinical Governance statement by Scally et alwere taken for reference. Each was reviewed, including their various components. We then conceptualised a new framework, merging the relevant aspects of both.

INTERVENTIONS

We conducted an umbrella review of all systematic reviews published by the Cochrane Effective Practice and Organisation of Care Group to identify organisational interventions in primary care with demonstrated evidence of efficacy.

RESULTS

All primary healthcare systems should be patient-centred. Interventions for patients and their families should focus on their values; on clinical, professional and institutional integration and finally on accountability to patients, peers and society at large. These interventions should be shaped by an approach to their clinical management that achieves the best clinical governance, which includes quality assurance, risk management, technology assessment, management of patient satisfaction and patient empowerment and engagement. This approach demands the implementation of a system of organisational, functional and professional management based on a population health needs assessment, resource management, evidence-based and patient-oriented research, professional education, team building and information and communication technologies that support the delivery system. All primary care should be embedded in and founded on an active partnership with the society it serves.

CONCLUSIONS

A framework for clinical governance will promote an integrated effort to bring together all related activities, melding environmental, administrative, support and clinical elements to ensure a coordinated and integrated approach that sustains the provision of better care for chronic conditions in primary care setting.

Improved empirical antibiotic treatment of sepsis after an educational intervention: the ABISS-Edusepsis study

BACKGROUND

Early appropriate antibiotic treatment is essential in sepsis. We aimed to evaluate the impact of a multifaceted educational intervention to improve antibiotic treatment. We hypothesized that the intervention would hasten and improve the appropriateness of empirical antibiotic administration, favor de-escalation, and decrease mortality.

METHODS

We prospectively studied all consecutive patients with sepsis/septic shock admitted to 72 intensive care units (ICUs) throughout Spain in two 4-month periods (before and immediately after the 3-month intervention). We compared process-of-care variables (resuscitation bundle and time-to-initiation, appropriateness, and de-escalation of empirical antibiotic treatment) and outcome variables between the two cohorts. The primary outcome was hospital mortality. We analyzed the intervention's long-term impact in a subset of 50 ICUs.

RESULTS

We included 2628 patients (age 64.1 ± 15.2 years; men 64.0%; Acute Physiology and Chronic Health Evaluation (APACHE) II, 22.0 ± 8.1): 1352 in the preintervention cohort and 1276 in the postintervention cohort. In the postintervention cohort, the mean (SD) time from sepsis onset to empirical antibiotic therapy was lower (2.0 (2.7) vs. 2.5 (3.6) h; p = 0.002), the proportion of inappropriate empirical treatments was lower (6.5% vs. 8.9%; p = 0.024), and the proportion of patients in whom antibiotic treatment was de-escalated was higher (20.1% vs. 16.3%; p = 0.004); the expected reduction in mortality did not reach statistical significance (29.4% in the postintervention cohort vs. 30.5% in the preintervention cohort; p = 0.544). Gains observed after the intervention were maintained in the long-term follow-up period.

CONCLUSIONS

Despite advances in sepsis treatment, educational interventions can still improve the delivery of care; further improvements might also improve outcomes.

An Evaluation on Iran International Public Health Summer School in Relation to its Efficacy Based on Participants' Experience and Opinions

Background

A serious challenge to educate health staff for public health is to appear encouraging enough to persuade them for learning issues on this field and implementing new educational methods and innovative ways. Iran International Public Health Summer School (IPHS) made an effort to provide medical sciences students with a fortune to get familiar with and involved in public health. This study intended to evaluate the efficacy of this event.

Materials and Methods

This cross-sectional study was performed in March-April 2015 by the help of an electronic self-administered questionnaire filled out by 49 Iranian participants 6 months after IPHS2014. The questionnaire assessed the main goals in seven main domains: Interest, activities, and general knowledge in the field of public health, general skills, educational methods, educational and executive schedules, and general satisfaction.

Results

Average scores of all domains were >3 (the mean), and all were statistically significant. The highest average score belonged to educational methods (3.92) and the lowest was calculated for the item regarding participants' activities on public health (3.5). No significant difference was found between positive answers of individuals who were interested or active in public health prior to the event and those who had no background.

Conclusions

We believe IPHS was a unique instance in Public Health Education in Iran. Considering the level of success of this program to reach its goals for both students' with or without any previous background on public health, it is recommended as a general model to be simulated in other developing countries.

Developing nurse medication safety training in a health partnership in Mozambique using behavioural science

Background

Globally, safe and effective medication administration relies on nurses being able to apply strong drug calculation skills in their real-life practice, in the face of stressors and distractions. These may be especially prevalent for nurses in low-income countries such as Mozambique and Continuing Professional Development post-registration may be important. This study aimed to 1) explore the initial impact of an international health partnership’s work to develop a drug calculation workshop for nurses in Beira, Mozambique and 2) reflect upon the role of health psychologists in helping educators apply behavioural science to the training content and evaluation.

Methods

In phase one, partners developed a training package, which was delivered to 87 Portuguese-speaking nurses. The partnership’s health psychologists coded the training’s behaviour change content and recommended enhancements to content and delivery. In phase two, the refined training, including an educational game, was delivered to 36 nurses in Mozambique and recoded by the health psychologists. Measures of participant confidence and intentions to make changes to healthcare practice were collected, as well as qualitative data through post-training questions and 12 short follow-up participant interviews.

Results

In phase one six BCTs were used during the didactic presentation. Most techniques targeted participants’ capability to calculate drug doses accurately; recommendations aimed to increase participants’ motivation and perceived opportunity, two other drivers of practice change. Phase two training included an extra seven BCTs, such as action planning and further skills practice. Participants reported high confidence before and after the training (p = 0.25); intentions to use calculators to check drug calculations significantly increased (p = 0.031). Qualitative data suggested the training was acceptable, enjoyable and led to practice changes, through improved capability, opportunity and motivation. Opportunity barriers to medication safety were highlighted.

Conclusions

Reporting and measuring medication errors and related outcomes is a complex challenge affecting global efforts to improve medication safety. Through strong partnership working, a multi-disciplinary team of health professionals including health psychologists developed, refined and begin to evaluate a locally-led drug calculation CPD workshop for nurses in a low-resource setting. Applying behavioural science helped to collect feasible evaluation data and hopefully improved impact and sustainability.

A systematic review of gamification in e-Health

Gamification is a relatively new trend that focuses on applying game mechanics to non-game contexts in order to engage audiences and to inject a little fun into mundane activities besides generating motivational and cognitive benefits. While many fields such as Business, Marketing and e-Learning have taken advantage of the potential of gamification, the digital healthcare domain has also started to exploit this emerging trend. This paper aims to summarize the current knowledge regarding gamified e-Health applications. A systematic literature review was therefore conducted to explore the various gamification strategies employed in e-Health and to address the benefits and the pitfalls of this emerging discipline. A total of 46 studies from multiple sources were then considered and thoroughly investigated. The results show that the majority of the papers selected reported gamification and serious gaming in health and wellness contexts related specifically to chronic disease rehabilitation, physical activity and mental health. Although gamification in e-Health has attracted a great deal of attention during the last few years, there is still a dearth of valid empirical evidence in this field. Moreover, most of the e-Health applications and serious games investigated have been proven to yield solely short-term engagement through extrinsic rewards. For gamification to reach its full potential, it is therefore necessary to build e-Health solutions on well-founded theories that exploit the core experience and psychological effects of game mechanics.

Tablet computer enhanced training improves internal medicine exam performance

Background

Traditional teaching concepts in medical education do not take full advantage of current information technology. We aimed to objectively determine the impact of Tablet PC enhanced training on learning experience and MKSAP^® (medical knowledge self-assessment program) exam performance.

Methods

In this single center, prospective, controlled study final year medical students and medical residents doing an inpatient service rotation were alternatingly assigned to either the active test (Tablet PC with custom multimedia education software package) or traditional education (control) group, respectively. All completed an extensive questionnaire to collect their socio-demographic data, evaluate educational status, computer affinity and skills, problem solving, eLearning knowledge and self-rated medical knowledge. Both groups were MKSAP^® tested at the beginning and the end of their rotation. The MKSAP^® score at the final exam was the primary endpoint.

Results

Data of 55 (tablet n = 24, controls n = 31) male 36.4%, median age 28 years, 65.5% students, were evaluable. The mean MKSAP^® score improved in the tablet PC (score Δ + 8 SD: 11), but not the control group (score Δ- 7, SD: 11), respectively. After adjustment for baseline score and confounders the Tablet PC group showed on average 11% better MKSAP^® test results compared to the control group (p<0.001). The most commonly used resources for medical problem solving were journal articles looked up on PubMed or Google^®, and books.

Conclusions

Our study provides evidence, that tablet computer based integrated training and clinical practice enhances medical education and exam performance. Larger, multicenter trials are required to independently validate our data. Residency and fellowship directors are encouraged to consider adding portable computer devices, multimedia content and introduce blended learning to their respective training programs.

InsuOnline, an Electronic Game for Medical Education on Insulin Therapy: A Randomized Controlled Trial With Primary Care Physicians

Background

Most patients with diabetes mellitus (DM) are followed by primary care physicians, who often lack knowledge or confidence to prescribe insulin properly. This contributes to clinical inertia and poor glycemic control. Effectiveness of traditional continuing medical education (CME) to solve that is limited, so new approaches are required. Electronic games are a good option, as they can be very effective and easily disseminated.

Objective

The objective of our study was to assess applicability, user acceptance, and educational effectiveness of InsuOnline, an electronic serious game for medical education on insulin therapy for DM, compared with a traditional CME activity.

Methods

Primary care physicians (PCPs) from South of Brazil were invited by phone or email to participate in an unblinded randomized controlled trial and randomly allocated to play the game InsuOnline, installed as an app in their own computers, at the time of their choice, with minimal or no external guidance, or to participate in a traditional CME session, composed by onsite lectures and cases discussion. Both interventions had the same content and duration (~4 h). Applicability was assessed by the number of subjects who completed the assigned intervention in each group. Insulin-prescribing competence (factual knowledge, problem-solving skills, and attitudes) was self-assessed through a questionnaire applied before, immediately after, and 3 months after the interventions. Acceptance of the intervention (satisfaction and perceived importance for clinical practice) was also assessed immediately after and 3 months after the interventions, respectively.

Results

Subjects’ characteristics were similar between groups (mean age 38, 51.4% [69/134] male). In the game group, 69 of 88 (78%) completed the intervention, compared with 65 of 73 (89%) in the control group, with no difference in applicability. Percentage of right answers in the competence subscale, which was 52% at the baseline in both groups, significantly improved immediately after both interventions to 92% in the game group and to 85% in control (P<.001). After 3 months, it remained significantly higher than that at the baseline in both groups (80% in game, and 76% in control; P<.001). Absolute increase in competence score was better with the game (40%) than with traditional CME (34%; P=.01). Insulin-related attitudes were improved both after the game (significant improvement in 4 of 9 items) and after control activity (3 of 9). Both interventions were very well accepted, with most subjects rating them as “fun or pleasant,” “useful,” and “practice-changing.”

Conclusions

The game InsuOnline was applicable, very well accepted, and highly effective for medical education on insulin therapy. In view of its flexibility and easy dissemination, it is a valid option for large-scale CME, potentially helping to reduce clinical inertia and to improve quality of care for DM patients.

Trial Registration

Clinicaltrials.gov NCT001759953; https://clinicaltrials.gov/ct2/show/NCT01759953 (Archived by WebCite at http://www.webcitation.org/6oeHoTrBf)

An educational board game for learning and teaching burn care: A preliminary evaluation

Timely and effective assessment, resuscitation and transfer of patients with severe burns has been demonstrated to improve outcome. A dedicated one-day course exists to equip all frontline emergency healthcare workers with the necessary knowledge and skills to manage severe burn injuries. More recently, a board game has been developed which aims to act as a learning and practice development tool for those managing burn injuries. We present the findings of our preliminary evaluation of this game. We played this game with a multidisciplinary group of staff including doctors, nurses and therapists. A proportion of these participants had previously completed the Emergency Management of Severe Burns (EMSB) course. We obtained subjective results from a questionnaire, using both Likert-type ratings and open-ended questions. The styling of the game and ease of instructions was rated from ‘average’ to ‘excellent’. The relevance of questions was rated from ‘good’ to ‘excellent’. The usefulness of the game to increase knowledge and stimulate discussion was rated between ‘good’ and ‘excellent’. All participants stated that they would recommend the game to other healthcare professionals. This is the only burns and plastic surgery-related educational game in the literature. Educational games adhere to principles of adult learning but there is insufficient evidence in the literature to either confirm or refute their utility. Our preliminary evaluation of this game has shown that it achieves its main aims, namely to increase knowledge in burn care and to stimulate discussion. Further work is required to assess the board game.

Staff who work in emergency areas should know how to assess, treat and transfer patients with severe burns. This improves the outcome for these patients. Board games have been used in other areas of teaching in medicine.

This article shows the way we used a board game to teach doctors, nurses and therapists about how to assess and treat burns. This board game has been made to increase knowledge and to help players talk about and share how they have managed these injuries in the past.

We asked staff to play the game and tell us what they thought about the design and the instructions. We also asked whether it helped them increase their knowledge and if it helped to start a discussion about treating burns. We asked if they thought other staff should use the game.

We found that the staff who played the game rated the style and instructions from ‘average’ to ‘excellent’. They rated the questions and if it helped to start a discussion as ‘good’ to ‘excellent’. All staff would recommend the game as a way of teaching about burns.

This is the only game which exists to help staff learn about treating burns. We feel it should be used with all staff who see and manage patients with burns. More work needs to be done to look at this game in more detail.

Development of an Educational Game to Set Up Surgical Instruments on the Mayo Stand or Back Table: Applied Research in Production Technology

Background

Existing research suggests that digital games can be used effectively for educational purposes at any level of training. Perioperative nursing educators can use games to complement curricula, in guidance and staff development programs, to foster team collaboration, and to give support to critical thinking in nursing practice because it is a complex environment.

Objective

To describe the process of developing an educational game to set up surgical instruments on the Mayo stand or back table as a resource to assist the instructor in surgical instrumentation training for students and nursing health professionals in continued education.

Methods

The study was characterized by applied research in production technology. It included the phases of analysis and design, development, and evaluation. The objectives of the educational game were developed through Bloom’s taxonomy. Parallel to the physical development of the educational game, a proposed model for the use of digital elements in educational game activities was applied to develop the game content.

Results

The development of the game called “Playing with Tweezers” was carried out in 3 phases and was evaluated by 15 participants, comprising students and professional experts in various areas of knowledge such as nursing, information technology, and education. An environment was created with an initial screen, menu buttons containing the rules of the game, and virtual tour modes for learning and assessment.

Conclusions

The “digital” nursing student needs engagement, stimulation, reality, and entertainment, not just readings. “Playing with Tweezers” is an example of educational gaming as an innovative teaching strategy in nursing that encourages the strategy of involving the use of educational games to support theoretical or practical classroom teaching. Thus, the teacher does not work with only 1 type of teaching methodology, but with a combination of different methodologies. In addition, we cannot forget that skill training in an educational game does not replace curricular practice, but helps.

Tools developed and disseminated by guideline producers to promote the uptake of their guidelines

BACKGROUND

The uptake of clinical practice guidelines (CPGs) is inconsistent, despite their potential to improve the quality of health care and patient outcomes. Some guideline producers have addressed this problem by developing tools to encourage faster adoption of new guidelines. This review focuses on the effectiveness of tools developed and disseminated by guideline producers to improve the uptake of their CPGs.

OBJECTIVES

To evaluate the effectiveness of implementation tools developed and disseminated by guideline producers, which accompany or follow the publication of a CPG, to promote uptake. A secondary objective is to determine which approaches to guideline implementation are most effective.

SEARCH METHODS

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL); NHS Economic Evaluation Database, HTA Database; MEDLINE and MEDLINE In-Process and other non-indexed citations; Embase; PsycINFO; CINAHL; Dissertations and Theses, ProQuest; Index to Theses; Science Citation Index Expanded, ISI Web of Knowledge; Conference Proceedings Citation Index - Science, ISI Web of Knowledge; Health Management Information Consortium (HMIC), and NHS Evidence up to February 2016. We also searched trials registers, reference lists of included studies and relevant websites.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs, controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies evaluating the effects of guideline implementation tools developed by recognised guideline producers to improve the uptake of their own guidelines. The guideline could target any clinical area.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane 'Risk of bias' criteria. We graded our confidence in the evidence using the approach recommended by the GRADE working group. The clinical conditions targeted and the implementation tools used were too heterogenous to combine data for meta-analysis. We report the median absolute risk difference (ARD) and interquartile range (IQR) for the main outcome of adherence to guidelines.

MAIN RESULTS

We included four cluster-RCTs that were conducted in the Netherlands, France, the USA and Canada. These studies evaluated the effects of tools developed by national guideline producers to implement their CPGs. The implementation tools evaluated targeted healthcare professionals; none targeted healthcare organisations or patients.One study used two short educational workshops tailored to barriers. In three studies the intervention consisted of the provision of paper-based educational materials, order forms or reminders, or both. The clinical condition, type of healthcare professional, and behaviour targeted by the CPG varied across studies.Two of the four included studies reported data on healthcare professionals' adherence to guidelines. A guideline tool developed by the producers of a guideline probably leads to increased adherence to the guidelines; median ARD (IQR) was 0.135 (0.115 and 0.159 for the two studies respectively) at an average four-week follow-up (moderate certainty evidence), which indicates a median 13.5% greater adherence to guidelines in the intervention group. Providing healthcare professionals with a tool to improve implementation of a guideline may lead to little or no difference in costs to the health service.

AUTHORS' CONCLUSIONS

Implementation tools developed by recognised guideline producers probably lead to improved healthcare professionals' adherence to guidelines in the management of non-specific low back pain and ordering thyroid-function tests. There are limited data on the relative costs of implementing these interventions.There are no studies evaluating the effectiveness of interventions targeting the organisation of care (e.g. benchmarking tools, costing templates, etc.), or for mass media interventions. We could not draw any conclusions about our second objective, the comparative effectiveness of implementation tools, due to the small number of studies, the heterogeneity between interventions, and the clinical conditions that were targeted.

[Development and validation of an instrument for evaluating the ludicity of games in health education]

OBJECTIVE

Developing and validating an instrument to evaluate the playfulness of games in health education contexts.

METHODOLOGY

A methodological, exploratory and descriptive research, developed in two stages: 1. Application of an open questionnaire to 50 graduate students, with content analysis of the answers and calculation of Kappa coefficient for defining items; 2. Procedures for construction of scales, with content validation by judges and analysis of the consensus estimate by Content Validity Index(CVI).

RESULTS

53 items regarding the restless character of the games in the dimensions of playfulness, the formative components of learning and the profiles of the players.

CONCLUSION

Ludicity can be assessed by validated items related to the degree of involvement, immersion and reinvention of the subjects in the game along with the dynamics and playability of the game.

Effectiveness of a strategy that uses educational games to implement clinical practice guidelines among Spanish residents of family and community medicine (e-EDUCAGUIA project): a clinical trial by clusters

Background

Clinical practice guidelines (CPGs) have been developed with the aim of helping health professionals, patients, and caregivers make decisions about their health care, using the best available evidence. In many cases, incorporation of these recommendations into clinical practice also implies a need for changes in routine clinical practice. Using educational games as a strategy for implementing recommendations among health professionals has been demonstrated to be effective in some studies; however, evidence is still scarce. The primary objective of this study is to assess the effectiveness of a teaching strategy for the implementation of CPGs using educational games (e-learning EDUCAGUIA) to improve knowledge and skills related to clinical decision-making by residents in family medicine. The primary objective will be evaluated at 1 and 6 months after the intervention. The secondary objectives are to identify barriers and facilitators for the use of guidelines by residents of family medicine and to describe the educational strategies used by Spanish teaching units of family and community medicine to encourage implementation of CPGs.

Methods/design

We propose a multicenter clinical trial with randomized allocation by clusters of family and community medicine teaching units in Spain. The sample size will be 394 residents (197 in each group), with the teaching units as the randomization unit and the residents comprising the analysis unit. For the intervention, both groups will receive an initial 1-h session on clinical practice guideline use and the usual dissemination strategy by e-mail. The intervention group (e-learning EDUCAGUIA) strategy will consist of educational games with hypothetical clinical scenarios in a virtual environment.

The primary outcome will be the score obtained by the residents on evaluation questionnaires for each clinical practice guideline. Other included variables will be the sociodemographic and training variables of the residents and the teaching unit characteristics. The statistical analysis will consist of a descriptive analysis of variables and a baseline comparison of both groups. For the primary outcome analysis, an average score comparison of hypothetical scenario questionnaires between the EDUCAGUIA intervention group and the control group will be performed at 1 and 6 months post-intervention, using 95 % confidence intervals. A linear multilevel regression will be used to adjust the model.

Discussion

The identification of effective teaching strategies will facilitate the incorporation of available knowledge into clinical practice that could eventually improve patient outcomes. The inclusion of information technologies as teaching tools permits greater learning autonomy and allows deeper instructor participation in the monitoring and supervision of residents. The long-term impact of this strategy is unknown; however, because it is aimed at professionals undergoing training and it addresses prevalent health problems, a small effect can be of great relevance.

Trial registration

ClinicalTrials.gov: NCT02210442.

Educational Tools: Thinking Outside the Box

The understanding, study, and use of educational tools and their application to the education of adults in professional fields are increasingly important. In this review, we have compiled a description of educational tools on the basis of the teaching and learning setting: the classroom, simulation center, hospital or clinic, and independent learning space. When available, examples of tools used in nephrology are provided. We emphasize that time should be taken to consider the goals of the educational activity and the type of learners and use the most appropriate tools needed to meet the goals. Constant reassessment of tools is important to discover innovation and reforms that improve teaching and learning.