Active-learning strategies: The use of a game to reinforce learning in nursing education. A case study

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    Nurse Education in Practice 13 (2013) 96e100Contents lists availableNurse Education in Practice

    journal homepage: www.elsevier .com/neprActive-learning strategies: The use of a game to reinforce learning in nursingeducation. A case study

    Lisa Boctor*

    University of Alabama in Huntsville, Nursing, 301 Sparkman Drive, Huntsville, AL 35899, United Statesa r t i c l e i n f o

    Article history:Accepted 29 July 2012

    Keywords:Nursing educationGamesActive learning* Tel.: 1 256 824 2435.E-mail address:

    1471-5953/$ e see front matter 2012 Elsevier Ltd. b s t r a c t

    The majority of nursing students are kinesthetic learners, preferring a hands-on, active approach toeducation. Research shows that active-learning strategies can increase student learning and satisfaction.This study looks at the use of one active-learning strategy, a Jeopardy-style game, Nursopardy, toreinforce Fundamentals of Nursing material, aiding in students preparation for a standardized finalexam. The game was created keeping students varied learning styles and the NCLEX blueprint in mind.The blueprint was used to create 5 categories, with 26 total questions. Student survey results, usinga five-point Likert scale showed that they did find this learning method enjoyable and beneficial tolearning. More research is recommended regarding learning outcomes, when using active-learningstrategies, such as games.

    2012 Elsevier Ltd. All rights reserved.Introduction

    Todays students are accustomed to living in a highly techno-logical world (Baid and Lambert, 2010). Millennials, students bornin or after 1982, are included in this group of students, who havedifferent learning preferences than their predecessors. Nursingfaculty often favor teaching methods that clash with these learningpreferences (Oblinger, 2003). Recognizing and providing innovativeteaching strategies to address students generational diversity isimportant for maximizing student retention and progress. Millen-nials expect instantaneous responses and multi-task with ease butoften have difficulty in focusing on one activity. Active, engaginglearning activities are preferred over lecture or other teacher-centric approaches. This generation of students provides chal-lenges to teachers including the need to review curriculum andincorporate video, graphics, sound and kinesthetic learningopportunities into teaching (Pardue and Morgan, 2008). Themajority of current baccalaureate undergraduate students fall intothe Millennial category (McCurry and Martins, 2010).

    Nurse educators are challenged to use teaching techniques thatmaintain students motivation to learn. Games are one techniquethat can be utilized to obtain students attention and bring deeprather than surface level, passive learning. Quiz-style games canbenefit instructors as a formative assessment to see if students haveAll rights reserved.met the desired learning outcomes or need more teaching in anarea (Baid and Lambert, 2010).

    This case study looks at the creation, implementation andevaluation of Nursopardy, a Jeopardy-inspired nursing game, usedto reinforce and review Fundamentals of Nursing material. Jeop-ardy is a popular American television game show that has been insyndication since 1984. The game features trivia and has been seenby millions of viewers worldwide (Alex Trebek: Host, 2012). Thetrivia for Nursopardy was based on material learned in the firstsemester of nursing classes, guided by the NCLEX blueprint. Eval-uation was completed with a Likert scale (1 strongly disagree,5 strongly agree) to examine students perception of the game,including whether they found it to be beneficial to learning.Qualitative informationwas also gathered; students were given theopportunity to write their own feedback about the use ofNursopardy.


    An educational game is an activity presided over by preciserules that involve varying degrees of chance, in which, playerscompete through the use of knowledge or skill in attempts to reachspecified goals (Peddle, 2011, p. 647). Educational games arecompetitive in nature, differentiating them from other active-learning strategies such as simulation and role play (Horsley, 2010).

    The use of games has been noted in nursing education since theearly 1980s. Early criticism stemmed from the fact that games wereseen to be more for entertainment value than a learning modality

  • L. Boctor / Nurse Education in Practice 13 (2013) 96e100 97(Royse and Newton, 2007). Nursing education has traditionallyrelied on didactic methods of delivery. The current rise of experi-ential learning, challenges the traditional, didactic, modes ofdelivery, increasing the call to use more active-learning strategiessuch as gaming (Peddle, 2011). Despite the increase in status ofexperiential strategies, many instructors in higher education stillprefer a conventional style of deliveringmaterial. Didactic lecture isconsidered efficient in the delivery of material in a relatively shorttime span, but the inhibition of inductive reasoning is considereda disadvantage (Royse and Newton, 2007).

    Educational games promote learning and enhance collaborationamong students. They keep learning active and student-centered,in a non-threatening environment. A game can be used topromote critical thinking and reasoning. One advantage of usinggames, as a teaching strategy, is that students have the opportunityfor immediate feedback, through the discussion of correct answersand their rationales (Glendon and Ulrich, 2005). This attributemakes games appealing to Millennial students, who value imme-diate feedback (McCurry and Martins, 2010). Another advantage ofgames is the opportunity for instructors to facilitate discussion andclarify misconceptions (Glendon and Ulrich, 2005).

    Games and learning styles

    According to Dale (1969) people learn 10% of what they read,20% of what they hear, 30% of what is demonstrated, but 90% whenwhat is said and done is combined (Kennedy, 2006, p. 46).Students are diverse and have different learning style preferences,by providing multiple approaches different learning styles ofstudents can be accommodated. Games can benefit many learningstyles with the use of visual and auditory stimuli, while encour-aging group discussion and participation.

    Teachers are challenged to use multiple teaching strategies toappeal to the different learning styles of their students. Auditorylearners prefer hearing material out loud via verbal instruction.Visual learners enjoy methods of learning including pictures,flashcards, video and observation (Dicarlo and Lujan, 2006).Cognitive learners like to give information personal meaning,putting it in their own words; while, global learners seek discus-sions and working with others (Pitts, 2009). Kinesthetic learnersprefer a hands-on approach to learning (Meehan-Andrews, 2008).

    This study looked at the different learning styles of the studentsinvolved and found that the majority are kinesthetic learners.Studies have shown that this learning modality is preferred by themajority of nursing students. Research by Meehan-Andrews(2008), found that students who are kinesthetic learners take ininformation best through practical sessions, case-studies orcomputer simulations as opposed to lecture-only. Lectures werefound to be better for initial presentation of information, whileactive-learning methods were best at reinforcing material.

    The Department of Health in London has emphasized fora number of years the need for nurses to engage in evidence-basedpractice and life-long learning (Kedge and Appleby, 2009). Theimportance of evidence-based practice is summed up in thefollowing definition: evidence-based practice helps nurses toprovide high-quality patient care based on research and knowledgerather than because this is the way we have always done it, orbased on traditions, myths, hunches, advice of colleagues, oroutdated textbooks (Beyea and Slattery, 2006, p. 11). Kedge andAppleby (2009) noted that curiosity is essential for nurses toengage in lifelong learning and that teaching must be relevant tothe student. They believe that the basis for curiosity is cognitive andthat promotion of curiosity is the responsibility of educators inhigher education and clinical practice. The cognitive approach toeducation can use an information gap perspective; students mustpossess some knowledge about the subject while being madeaware of gaps in their knowledge. The gaps in knowledge must beseen as manageable or could be overwhelming to the student.Educators must present differing views about an issue, presentingonly one view will not promote curiosity (Kedge and Appleby,2009).

    Nursopardy allowed time for students to debate answers intheir teams and with the facilitator of the game. There was time tolook at the rationale for why an answer was or was not correct. Thegame allowed students and faculty to explore what students haveseen in their real-life experiences at the hospital vs. what isevidence-based practice; thus, the game was an opportunity forstudents to develop curiosity about evidence-based practice.

    Knowles et al. (2005) noted that adult learners bring life expe-riences and prior knowledge to the classroom; thus, the teacher ismore a facilitator of learning than the one with all knowledge. Thissuggests that the teacher should empower students during thelearning process, and not expect them to take a passive role(Horsley, 2010). This concept is supported by research of Millenniallearners. Their learning preferences include teamwork, excitement,entertainment and technology. Successful teaching strategies forthis group include interactive and group focused experientialactivities (McCurry and Martins, 2010); Nursopardy fills thisrequirement as it is played in teams, providing an active, groupfocus.

    Games and nursing education

    The 2008 Horizon Report lists games as pedagogical platformsas a metatrend in higher education. The report looked at howgames can be used for learning and not simply as entertainment;stating that they must be immersive, require frequent importantdecisions, clear goals, involve a social network and adapt to theindividual player. The summit also underscored how games andsimulations could be used to instruct in the following areas: higherorder thinking, complex decisions, practical skills, team buildingand developing expertise (Skiba, 2008).

    Games should be carefully planned in a way that achievesspecific learning outcomes and includes time for debriefing (Baidand Lambert, 2010). As discussed later, allowing adequate time isessential for the learning process with Nursopardy.

    A study in the UK assessed nurse educators perspectives ofeducational games, using 97 online participants. The study foundthe main benefit of using games as: enhancement of studentlearning, enjoyment and interest, 62.3%; interaction and partici-pation among students, 44.2%. The factors that discouragedinstructors from using games, included: potential negative reactionof students, 43.8%; and time constraints, 27.4%. The study showeda limited use of games despite evidence that educators generallyfind the use of games to be beneficial (Allum et al., 2010).

    In a study by Cowen and Tesh (2002), students in a PediatricNursing Course were divided into a control and comparison group;with the control group learning material with traditional methods.The comparison group learned material using the same methods,but the students in this group were also expected to play a game,reviewing material learned. A pretest of the students showed nostatistically significant difference between the pre-knowledge ofthe two groups. A posttest did show a significant difference inknowledge with the comparison group scoring 94% correct asopposed to the control group that averaged 85%.

    Another study assessed if gaming enhanced a students ability toproblem-solve and generate hypotheses. One group was taughtusing traditional didactic methods and the other group playeda game called Lets Hypothesize. A posttest given to students thenext semester showed that those in the gaming group scored 85%

  • Table 1Study design.

    Statement Score

    1. I felt this learning activity was beneficial. 4.72. I enjoyed playing this game. 4.63. I feel this activity will help me to

    answer test questions better.4.7

    4. I learned new information related to nursing. 4.65. In the future, I want to use games like this to

    review material learned in class.4.5

    6. This game helped me review Fundamentalsof Nursing information.


    7. I did not enjoy this game. 1.38. I did not find this game beneficial to learning. 1.2

    Likert Scale: 1. Strongly disagree; 2. Disagree; 3. Neither agree nor disagree;4. Agree; 5. Strongly agree.

    L. Boctor / Nurse Education in Practice 13 (2013) 96e10098as opposed to the 74% accuracy rate of the traditional learninggroup (Ingram et al., 1998).

    While many studies suggest that the use of games is an effective,innovative teaching strategy for nursing education; there is littleempirical evidence to support this (Stanley and Latimer, 2011). Theimpact of gaming on nursing education was investigated ina Cochrane review. Only one study was selected because of thestrict inclusion criteria required by the review. The includedresearch found that students taught using an educational gamefared better than students who were taught using traditionalmethods. Students in the gaming group averaged six more pointsthan the control students on psychiatric nursing test questionsfollowing the game. The Cochrane review noted limited evidenceregarding games and nursing education (Bhoopathi and Sheoran,2006).

    The use of games in nursing education can require criticalthinking and encourage students to work in teams to make a deci-sion, while possibly necessitating that they analyze the contribu-tion of others when reaching a final decision (Royse and Newton,2007). Bays and Hermann (1997) reported that nursing studentswould prefer that games were used more frequently in theireducation and that they perceived educational games as an excel-lent way to learn, retain and transmit information. Games havebeen shown to be an effective way to reinforce knowledge previ-ously learned and can help students to revise their knowledge. Insome studies, games were shown to enhance the retention ofknowledge (Skirton and Blakely, 2009).

    Critics of gaming as a teaching strategy cite a lack of research tovalidate learning outcomes. As with any teaching strategy there aredisadvantages, including the fact that writing good game questionsis seen as being just as demanding as writing questions for a test.Some students may find competition threatening or intimidating,while others may prefer a more passive role in their learning...


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