Play and Learn with Patients-Designing and Evaluating a Serious Game to Enhance Nurses' Inhaler Teaching Techniques: A Randomized Controlled Trial

Improving Knowledge Retention and Perceived Control Through Serious Games: A Study About Assisted Emergency Evacuation

Digital games for education and training, also called serious games (SGs), have shown beneficial effects on learning in several studies. In addition, some studies are suggesting that SGs could improve user's perceived control, which affects the likelihood that the learned content will be applied in the real world. However, most SG studies tend to focus on immediate effects, providing no indication on knowledge and perceived control over time, especially in contrast with nongame approaches. Moreover, SG research on perceived control has focused mainly on self-efficacy, disregarding the complementary construct of locus of control (LOC). This article advances both lines of research, assessing user's knowledge and LOC over time, with a SG as well as traditional printed materials that teach the same content. Results show that the SG was more effective than printed materials for knowledge retention over time, and a better retention outcome was found also for LOC. An additional contribution of the paper is the proposal of a novel SG that targets the inclusivity goal of safe evacuation for all, extending SG research to a domain not dealt with before, i.e., assisting persons with disabilities in emergencies.

Empirical Research on Technological Pedagogical Content Knowledge (TPACK) Framework in Health Professions Education: A Literature Review

In the context of twenty-first-century information and communication technologies, the Technological Pedagogical Content Knowledge (TPACK) framework is a new way of conceptualizing categories of knowledge required by teachers to achieve technology integration in educational practice. The main purpose of this review is to identify research on the TPACK framework in the field of health professions education. Journal empirical studies from 4 databases are included in this review. Of the 76 selected articles, nine met the selection criteria. The findings in the examined papers highlighted four themes: TPACK level measurement, TPACK relationship with other variables, TPACK application, and professional development. Research on the TPACK framework in the health professions education area is still lacking; however, the finding indicates that the TPACK as a theoretical foundation generated positive outcomes that can guide practitioners and researchers' future practice and investigations.

Deep Reinforcement Learning-Based iTrain Serious Game for Caregivers Dealing with Post-Stroke Patients

This paper describes a serious game based on a knowledge transfer model using deep reinforcement learning, with an aim to improve the caretakers’ knowledge and abilities in post-stroke care. The iTrain game was designed to improve caregiver knowledge and abilities by providing non-traditional training to formal and informal caregivers who deal with stroke survivors. The methodologies utilized professional medical experiences and real-life evidence data gathered during the duration of the iTrain project to create the scenarios for the game’s deep reinforcement caregiver behavior improvement model, as well as the design of game mechanics, game images and game characters, and gameplay implementation. Furthermore, the results of the game’s direct impact on caregivers (n = 25) and stroke survivors (n = 21) in Lithuania using the Geriatric Depression Scale (GDS) and user experience questionnaire (UEQ) are presented. Both surveys had favorable outcomes, showing the effectiveness of the approach. The GDS scale (score 10) revealed a low number of 28% of individuals depressed, and the UEQ received a very favorable grade of +0.8.

Digital serious games in developing nursing clinical competence: A systematic review and meta-analysis

OBJECTIVE

This review aimed to synthesise evidence from experimental studies of the application of digital serious games in developing nursing clinical competence.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Eight databases were searched for randomized controlled trials and quasi-experimental studies published in English from 2000 to 2021.

REVIEW METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were adopted in this review. Quality appraisal was conducted using Cochrane's Risk of Bias tool and the Joanna Brigg's Institute Critical Appraisal Tool for Quasi-Experimental Designs. A narrative synthesis of studies, and a meta-analysis and subgroup analysis, was performed on the study outcomes.

RESULTS

22 experimental studies including 13 randomized controlled trials and nine quasi-experimental studies were included. Of these, 19 studies examined nursing students and three examined qualified nurses. These studies applied serious games to develop nursing competencies in management of nursing care, clinical reasoning skills, procedural skills, legal practice and quality improvement. Compared with control groups, serious games improved knowledge (SMD = 1.30, 95% CI [0.75, 1.86]) and skills (SMD = 0.38, 95% CI [0.17, 0.60]). Subgroup analysis for both knowledge and skills outcomes demonstrated that serious games were more effective than control groups with either no intervention or other educational interventions. A large effect size (SMD = 1.13, 95% CI [0.91, 1.34]) was found in favour of serious games for improving knowledge scores in management of nursing care.

CONCLUSION

The reviewed studies identified a broad application of digital serious games for developing nursing competencies. The knowledge and skills performance outcomes supported the use of serious games, which were found to be superior to conventional educational interventions. More serious games are required to be incorporated into undergraduate and continuing nursing education for workplace training, with more rigorous studies examining the effect of serious games in improving the quality and safety of clinical nursing practice.

Educational interventions for health professionals managing chronic obstructive pulmonary disease in primary care

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable health condition. COPD is associated with substantial burden on morbidity, mortality and healthcare resources.

OBJECTIVES

To review existing evidence for educational interventions delivered to health professionals managing COPD in the primary care setting.

SEARCH METHODS

We searched the Cochrane Airways Trials Register from inception to May 2021. The Register includes records from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and PsycINFO. We also searched online trial registries and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs. Eligible studies tested educational interventions aimed at any health professionals involved in the management of COPD in primary care. Educational interventions were defined as interventions aimed at upskilling, improving or refreshing existing knowledge of health professionals in the diagnosis and management of COPD.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data and assessed the risk of bias of included studies. We conducted meta-analyses where possible and used random-effects models to yield summary estimates of effect (mean differences (MDs) with 95% confidence intervals (CIs)). We performed narrative synthesis when meta-analysis was not possible. We assessed the overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were: 1) proportion of COPD diagnoses confirmed with spirometry; 2) proportion of patients with COPD referred to, participating in or completing pulmonary rehabilitation; and 3) proportion of patients with COPD prescribed respiratory medication consistent with guideline recommendations.

MAIN RESULTS

We identified 38 studies(22 cluster-RCTs and 16 RCTs) involving 4936 health professionals (reported in 19/38 studies) and 71,085 patient participants (reported in 25/38 studies). Thirty-six included studies evaluated interventions versus usual care; seven studies also reported a comparison between two or more interventions as part of a three- to five-arm RCT design. A range of simple to complex interventions were used across the studies, with common intervention features including education provided to health professionals via training sessions, workshops or online modules (31 studies), provision of practice support tools, tool kits and/or algorithms (10 studies), provision of guidelines (nine studies) and training on spirometry (five studies). Health professionals targeted by the interventions were most commonly general practitioners alone (20 studies) or in combination with nurses or allied health professionals (eight studies), and the majority of studies were conducted in general practice clinics. We identified performance bias as high risk for 33 studies. We also noted risk of selection, detection, attrition and reporting biases, although to a varying extent across studies. The evidence of efficacy was equivocal for all the three primary endpoints evaluated: 1) proportion of COPD diagnoses confirmed with spirometry (of the four studies that reported this outcome, two supported the intervention); 2) proportion of patients with COPD who are referred to, participate in or complete pulmonary rehabilitation (of the four studies that reported this outcome, two supported the intervention); and 3) proportion of patients with COPD prescribed respiratory medications consistent with guideline recommendations (12 studies reported this outcome, the majority evaluated multiple drug classes and reported a mixed effect). Additionally, the low quality of evidence and potential risk of bias make the interpretation more difficult. Moderate-quality evidence (downgraded due to risk of bias concerns) suggests that educational interventions for health professionals probably improve the proportion of patients with COPD vaccinated against influenza (three studies) and probably have little impact on the proportion of patients vaccinated against pneumococcal infection (two studies). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on the frequency of COPD exacerbations (10 studies). There was a high degree of heterogeneity in the reporting of health-related quality of life (HRQoL). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on HRQoL overall, and when using the COPD-specific HRQoL instrument, the St George's Respiratory Questionnaire (at six months MD 0.87, 95% CI -2.51 to 4.26; 2 studies, 406 participants, and at 12 months MD -0.43, 95% CI -1.52 to 0.67, 4 studies, 1646 participants; reduction in score indicates better health). Moderate-quality evidence suggests that educational interventions for health professionals may improve patient satisfaction with care (one study). We identified no studies that reported adverse outcomes.

AUTHORS' CONCLUSIONS

The evidence of efficacy was equivocal for educational interventions for health professionals in primary care on the proportion of COPD diagnoses confirmed with spirometry, the proportion of patients with COPD who participate in pulmonary rehabilitation, and the proportion of patients prescribed guideline-recommended COPD respiratory medications. Educational interventions for health professionals may improve influenza vaccination rates among patients with COPD and patient satisfaction with care. The quality of evidence for most outcomes was low or very low due to heterogeneity and methodological limitations of the studies included in the review, which means that there is uncertainty about the benefits of any currently published educational interventions for healthcare professionals to improve COPD management in primary care. Further well-designed RCTs are needed to investigate the effects of educational interventions delivered to health professionals managing COPD in the primary care setting.

The Use of Puzzles in Inhaler Technique Training

Objective: Inhaled drugs are essential for the treatment of several chronic respiratory diseases. However, patient inhaler techniques are frequently suboptimal; here, educational games may enhance patients' understanding of educational interventions. In addition, patients may practice repetitively, learning in a more relaxed and fun environment. In this study we aimed to compare two methods of inhaler technique training: (1) face-to-face training only and (2) face-to-face training and a subsequent puzzle game.Methods: The participants in group 1 were provided only face-to-face training. In group 2, the participants were given a puzzle after receiving the face-to-face training. Subsequently, the inhaler technique scores of both groups were compared. The chi-squared (χ² ) test was used for categorical variables and the Mann-Whitney U test (non-parametric) or Student's t test (parametric) were employed to compare the numerical variables between the groups.Results: In total, 170 patients with asthma and their parents were included in the study. It was found that the median total scores for the inhaler technique (p < 0.001) and the number of correct users (p < 0.001) were higher in group 2, whereas the inhaler technique error rate in shaking the inhaler tube (p < 0.001) was higher in group 1.Conclusion: The present study revealed that the success rate of correct users and participants' total scores were higher in the puzzle game group. Therefore, a game may help patients to better remember and visualize the steps of the inhaler technique. Our study supports the use of puzzles as real-world applications to teach patients optimal inhaler technique.

Effectiveness of serious games in nurse education: A systematic review

OBJECTIVES

To systematically summarize research employing serious games in nurse education, to examine their effectiveness, to provide recommendations and implementation strategies, and to suggest future directions for the development and application of serious games in nurse education.

DESIGN

A systematic review.

DATA SOURCES

An online search of the CINAHL, Medline, PubMed, EMBASE, PsycINFO, SCOPUS, and Web of Science databases, and a manual search of the reference lists of selected studies or review articles published in English and Korean between 1990 and July 2020.

REVIEW METHODS

This systematic review was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Articles that employed a serious game approach in nurse education were included. Two authors independently screened and reviewed the articles and assessed the methodological quality using the Cochrane risk-of-bias tools.

RESULTS

A total of seven studies met the inclusion criteria: three randomized controlled trials and four quasi-experimental studies. Heterogeneity was found across all studies regarding the application of serious games, platforms, and gamification elements. Most of the studies evaluated the effectiveness of serious games using knowledge tests, while two studies evaluated skills performance. Two randomized controlled trials and two one group before and after studies reported that the use of serious games improved nursing students' and nurses' knowledge and performance.

CONCLUSIONS

This systematic review does not provide comprehensive insights into the effectiveness of serious games in nurse education. However, based on the evidence reviewed, we provide suggestions for developing and implementing serious games in nurse education to enhance students' knowledge and performance.

Involvement of End Users in the Development of Serious Games for Health Care Professions Education: Systematic Descriptive Review

BACKGROUND

On the basis of ethical and methodological arguments, numerous calls have been made to increase the involvement of end users in the development of serious games (SGs). Involving end users in the development process is considered a way to give them power and control over educational software that is designed for them. It can also help identify areas for improvement in the design of SGs and improve their efficacy in targeted learning outcomes. However, no recognized guidelines or frameworks exist to guide end users' involvement in SG development.

OBJECTIVE

The aim of this study is to describe how end users are involved in the development of SGs for health care professions education.

METHODS

We examined the literature presenting the development of 45 SGs that had reached the stage of efficacy evaluation in randomized trials. One author performed data extraction using an ad hoc form based on a design and development framework for SGs. Data were then coded and synthesized on the basis of similarities. The coding scheme was refined iteratively with the involvement of a second author. Results are presented using frequencies and percentages.

RESULTS

End users' involvement was mentioned in the development of 21 of 45 SGs. The number of end users involved ranged from 12 to 36. End users were often involved in answering specific concerns that arose during the SG design (n=6) or in testing a prototype (n=12). In many cases, researchers solicited input from end users regarding the goals to reach (n=10) or the functional esthetics of the SGs (n=7). Most researchers used self-reported questionnaires (n=7).

CONCLUSIONS

Researchers mentioned end users' involvement in the development of less than half of the identified SGs, and this involvement was also poorly described. These findings represent significant limitations to evaluating the impact of the involvement of end users on the efficacy of SGs and in making recommendations regarding their involvement.

Efficacy of Serious Games in Healthcare Professions Education: A Systematic Review and Meta-analysis

SUMMARY STATEMENT

Serious games (SGs) are interactive and entertaining software designed primarily with an educational purpose. This systematic review synthesizes evidence from experimental studies regarding the efficacy of SGs for supporting engagement and improving learning outcomes in healthcare professions education. Randomized controlled trials (RCTs) published between January 2005 and April 2019 were included. Reference selection and data extraction were performed in duplicate, independently. Thirty-seven RCTs were found and 29 were included in random-effect meta-analyses. Compared with other educational interventions, SGs did not lead to more time spent with the intervention {mean difference 23.21 minutes [95% confidence interval (CI) = -1.25 to 47.66]}, higher knowledge acquisition [standardized mean difference (SMD) = 0.16 (95% CI = -0.20 to 0.52)], cognitive [SMD 0.08 (95% CI = -0.73 to 0.89)], and procedural skills development [SMD 0.05 (95% CI = -0.78 to 0.87)], attitude change [SMD = -0.09 (95% CI = -0.38 to 0.20)], nor behavior change [SMD = 0.2 (95% CI = -0.11 to 0.51)]. Only a small SMD of 0.27 (95% CI = 0.01 to 0.53) was found in favor of SGs for improving confidence in skills.

Employing serious game for assessing knowledge of blood transfusion procedure among nurses: A qualitative evaluation and feedback improvement study

BACKGROUND

Employing serious game for assessing nurses' blood transfusion knowledge and skill competency has gained interest among nurse educators worldwide. However, its acceptance by nurses has not been fully explored.

AIM

To explore the registered nurses' experiences using serious game for nursing skills competency and gather feedback to improve the quality of learning using serious game.

SETTING

Acute tertiary hospital in Singapore.

PARTICIPANTS

Registered nurses in inpatient settings.

METHODS

This qualitative evaluation and feedback improvement study was conducted in an acute tertiary hospital in Singapore between September 2019 and November 2019. Registered nurses who had completed the blood transfusion knowledge and skills competency via the serious game platform were invited to participate in this study. Individual face-to-face interviews using a semi-structured questionnaire were conducted. All interviews were audio-recorded and transcribed verbatim. Data analysis was performed inductively using the Braun and Clarke's six-step of thematic analysis.

RESULTS

A total of 11 registered nurses were interviewed from a variety of clinical areas including medical and surgical wards, and intensive care units. The mean age of the participants was 28 years old. The majority of participants were females (81.8%), with their years of experience ranging from 1 to 13 years. Each interview took between 20 and 30 min. Three themes were identified: (1) novel learning experience; (2) varying levels of appreciation towards the serious game; and (3) navigating the interface and technical issues.

CONCLUSION

Employing serious game for nursing skills competency is considered acceptable by the nurses in this sample population. Compared to the traditional modes of competency assessment, the serious game is innovative and stimulates learning. Nevertheless, more rigorous efforts are needed to improve the interface and technical issues to enhance the user learning experience. Future versions of the serious game will need to be more accessible and intuitive for all levels of nursing staffs.

Design and evaluation of a 3D serious game for communication learning in nursing education

BACKGROUND

Communication is essential for nursing practice; such competence is not intuitive and must be taught. Serious games in 3D virtual reality can support the nursing teaching-learning process; students connected to the virtual world can apply what they have learned in their professional practice.

AIM

To describe the design and heuristic evaluation of a serious game in 3D immersive VR for the development of communication competence.

METHOD

A methodological study was conducted to develop and evaluate the serious game in a 3D immersive virtual environment using Oculus Rift®, called Comunica-Enf. The game consists of the user asking for authorization to the patient's avatar to perform a nursing procedure using communication abilities. Professors from six nursing courses and 30 students from two undergraduate nursing courses were recruited to evaluate the usability and appearance of the Comunica-Enf serious game. After using the game, the participants completed the Heuristic Evaluation of Digital Educational Games. A maximum of 25% of high or urgent priority problems in the whole game or heuristics is necessary to validate the game.

RESULT

The participants considered Comunica-Enf suitable for nursing education because none of the heuristics reached more than 25% of high or urgent priority problems. The participants made suggestions that were analyzed and incorporated into the Comunica-Enf when possible.

CONCLUSION

Comunica-Enf is an educational technology that uses Oculus Rift® and a 3D virtual reality perspective as an innovative resource. It had its appearance and usability validated for nursing students, providing a safe and pleasant environment for communication competence.

Confidence of nurses with inhaler device education and competency of device use in a specialised respiratory inpatient unit

We performed a cross-sectional study within a specialised respiratory inpatient unit assessing 25 nurses' [85% female, 8.0 ± 7.9 (mean ± SD) years' experience in nursing] confidence in providing inhaler device education using a self-reported questionnaire, and their competency (% correct steps) in using eight different inhaler devices. Sixteen percent of participants were 'not confident' providing inhaler education, while 84% were 'moderately' or 'extremely' confident. The mean (±SD)% correct steps for all devices was 47 ± 17%. There was no correlation between % correct steps and nursing years (r = 0.21, p = 0.31), or 'confidence' with providing inhaler education (r = 0.02, p = 0.91) but % correct steps strongly correlated with number of individual device prescriptions within the hospital in the preceding year (r = 0.78, p = 0.039). Most respiratory nurses felt confident in teaching inhaler technique but their overall demonstrated ability to correctly use inhalers was poor, especially for less frequently prescribed devices within our hospital. Regular assessment and ongoing education on correct inhaler technique for respiratory nurses is necessary to optimise all device usage by nurses, irrespective of experience or confidence.