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Nurse Education in Practice 13 (2013) 96e100

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Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

Active-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 States

a r t i c l e i n f o

Article history:Accepted 29 July 2012

Keywords:Nursing educationGamesActive learning

* Tel.: þ1 256 824 2435.E-mail address: lmb0006@uah.edu.

1471-5953/$ e see front matter � 2012 Elsevier Ltd.http://dx.doi.org/10.1016/j.nepr.2012.07.010

a 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

Today’s 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 have

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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 ¼ strongly disagree,5 ¼ 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 of‘Nursopardy’.

Background

“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 1980’s. 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 must

possess 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 platforms”as 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 student’s ability toproblem-solve and generate hypotheses. One group was taughtusing traditional didactic methods and the other group playeda game called “Let’s 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.

4.6

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) 96e10098

as 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 (Royseand Newton, 2007). Time constraints and large class sizes are alsofactors that can be seen as negatives when using games (Allumet al., 2010).

Methods

Aims

The aim of this case study was to evaluate the effectiveness andsuitability of ‘Nursopardy’ as a game to review material learned inFundamentals of Nursing, as measured by student perceptions andfaculty observation.

Study design

The students selected to play the game were from 5 clinicalgroups, consisting of 40 total students. The learning styles of thestudents were analyzed, using a standardized admission assess-ment, HESI A2 (Health Education Systems Incorporated AdmissionAssessment Exam), taken at the beginning of the semester. Allstudents are in their first semester of nursing classes and enrolledin NUR 310, a Fundamentals of Nursing course. The learning styleassessment showed all students’ top two learning styles. The toplearning styles for students were kinesthetic 67.5%, auditory 15%,cognitive 10% and visual 7.5%; the second learning style for studentsshowed that 70% are global and 30% analytical. This informationwas factored in while designing the game. The game containedvisual elements, questions on PowerPoint projected on a largescreen so that students could read them. Questions were also readaloud by the facilitator. The game is an active, kinesthetic, activityand emphasizes the global concept of group communication.Evaluation was completed with a survey using a Likert scale and

students could also write comments about their experience playing‘Nursopardy’.

Game design

The game was created with a Jeopardy template found onlinethat looks exactly like the television version, at: http://jc-schools.net/tutorials/PPT-games/; it has 5 categories and 26 questions,see Supplementary material. The categories were based on theNLCEX-RN Detailed Test Plan (2010) and included management ofcare, reduction of risk, safety and infection control, physiologicadaptation and basic care. The game covered material learned inthe first semester of nursing classes and had sound, theme music,pictures and applause. The game used PowerPoint and thestudents could see categories and number amounts. They decidedas a team what category and ‘dollar’ amount they wanted to pick.Each category had questions with values of $100, $200, $300,$400, $500. When the category and amount was clicked on, thequestion appeared, students worked as a team to choose thecorrect answer.

Topics in game questions included: therapeutic communication,contact precautions, prioritization of care, education of clients,catheter care, stoma care, basic assessment of patients and dressingchanges; see Table 2. These were all topics covered in their firstsemester of nursing courses; emphasis was placed on safety andinfection control, which are both concepts that are a large part ofthe current NCLEX-RN Test Plan (Kenny et al., 2010).

Implementation of game

A total of thirty-nine students played and evaluated the gameover two days, near the end of the semester in Fall 2011. The firstday two clinical groups played the game,16 students in all. The nextday 3 clinical groups played the game, equaling 23 students, onestudent was absent. Students were divided into teams, 2 the firstday, 3 the second, with their clinical groups and were able toalternate choosing a category and amount. The students discussedquestions as a group and then selected an answer. Students weregiven points for answering a question correctly and lost points forincorrect answers. There was a final round after all questions wereanswered, where students, as a team, could wager as much of theirtotal as they wished on one question, just as in the final Jeopardyround on television. During the game, there was time to discuss thecorrect answer/rationale with the instructor after a team chose theanswer they deemed correct. The game provided lively debatebetween students, when choosing an answer as a group. Questionswere all multiple choice except for one which required putting thesteps to a procedure in the correct order.

Table 2Examples of ‘Nursopardy’ questions.

Category management of care1. You are making assignment for clients in your unit. Which of the following is

appropriate for the CNA to perform?

A. Admission assessment on a new patient.B. Evaluating a client’s tolerance to activity while ambulating with

a walker.C. Documenting intake and output on the chart.D. Feeding a client with a history of dysphagia and aspiration

pneumonia.

Category safety and infection control2. A client with left-sided weakness is going home with a cane. Priority

discharge instructions include:A. Get client a bedside toilet and handrails for their shower.B. Order walker to help client from sitting to standing.C. Remove clutter from floors, including throw rugs.D. Have family stay with patient.

Category reduction of risk3. Which client should you see first?

A. A client with increasing confusion and a temperature of 103� .B. A diabetic client with a blood sugar of 165 at 7 am.C. An incontinent 90 y.o. client.D. A client with dehydration, who has a normal saline bolus infusing

through their I.V.

Correct answers are given in bold.

L. Boctor / Nurse Education in Practice 13 (2013) 96e100 99

Results

The students (n ¼ 39) filled out an anonymous survey after thegame to assess how they enjoyed the game andwhether or not theyfound that it was beneficial to learning. The survey used a 5-pointLikert scale (1 ¼ strongly disagree, 5 ¼ strongly agree) The results,see Table 1, demonstrate that overall students did find the activityto be beneficial, as a reinforcement of material learned (4.7), andincreased student confidence about answering test questions in thefuture (4.7). Students also reported that the game helped themreview Fundamentals of Nursing information (4.6), and helpedthem to learn new information (4.6).

Comments by students included: “it was fun” and “very helpful”.Other students noted: “I feel better about taking the final now”,“loved it”, “great learning activity” and “it helped me to look atthings in a different way.” There were no negative comments onthis survey.

Additional results

The following semester, Spring 2012, a convenience sample of 28students was surveyed about their preferred learning styles for lab/clinical content covered in their first semester of nursing classes.The survey was anonymous and administered via the Internet. Itwas given the week before final exams, so all students had experi-enced a variety of teaching methods, including playing ‘Nurso-pardy’. The results showed a preference in using a game to reviewclinical material, over lecture or videos. This survey was scoredusing a five-point Likert Scale.When asked if games are beneficial tolearning clinical/nursing material, the score was 4.25. Lecturescored 3.60 andwatching videos of skills 3.57. These results supportthat games can be a useful way to reinforce nursing concepts.

Discussion

This study supports the fact that students would like to see anincreased use of games in nursing education, as was found by Bays

and Hermann (1997). Playing ‘Nursopardy’ required students tothink critically, work together and analyze other students’ contri-bution as noted in educational games’ research by Royse andNewton (2007). The game was successfully used to review keyconcepts covered in Fundamentals of Nursing and students re-ported an increase in confidence for taking standardized exams.

While there is little empirical evidence supporting games innursing education (Stanley and Latimer, 2011), a substantialnumber of studies have shown that active-learning approaches canlead to improved student attitudes and increased learning(Armbruster et al., 2009). The results of this case study show thatthe vast majority of students found reviewing Fundamentals ofNursing material with the use of ‘Nursopardy’ was a positivelearning experience. The environment during the game was lightand fun, even though many students took the competition aspectseriously, adding to their engagement and participation in thegame.

Creating ‘Nursopardy’ was a time-consuming process, but oncecreated it was easy to implement. The game can now be used insubsequent semesters to review clinical concepts learned inFundamentals of Nursing. If needed, the game can easily beaugmented, and new questions added. There was no monetary costfor this game; the only equipment required was a computer,projector and screen.

Recommendations for future implementation

This version of Nursopardy was presented to students in Fall2011 and Spring 2012. Students played in teams of 8 in the fall andteams of about 10 in the spring. It was found that the more studentsare on a team the more likely it is that some students will not speakup and debate the answers with their teams. One way to fix thisissue could be to alternate a team leader who chooses the questionand final answer, after debate with the team. Smaller teams couldalso increase the likelihood of all students actively engaging in thegame. The game takes about 1 hour to play; this allows time todiscuss rationales for correct answer, an integral part of thelearning process for this activity. It is recommended to not play‘Nursopardy’ or similar gameswithout allowing time for debriefing.It is recommended that the game is used with each group of firstsemester nursing students, as it was an innovative approach toreinforcing the material learned throughout the semester and waswell received by students.

Limitations

This study had limitations including a small sample size, and it isrecommended that the use of games with a large group of studentsis examined. Another limitation was the lack of a comparisongroup. There is a lack of empirical evidence in the nursing literatureregarding the outcomes of active-learning strategies. More studiesare suggested to look at how active-learning strategies, such asgames, affect learning outcomes, including exam scores for nursingstudents.

Conclusion

‘Nursopardy’ was created to review topics covered in Funda-mentals of Nursing prior to students taking a standardized finalexam. The game was a useful teaching strategy that studentsevaluated positively. The combination of visual, sound, teamworkand competitionworked well to hold student attention and engagethem in the learning process. The game was successful in allowinga large volume of material to be covered with one activity.

L. Boctor / Nurse Education in Practice 13 (2013) 96e100100

Acknowledgments

I would like to thank Alex Boctor for his support during thewriting process. I would also like to thank Mrs. Courtney Ratliff forher support and cooperation with the implementation of the gameused in this study.

Appendix A. Supplementary material

Supplementary material associated with this article can befound, in the online version, at http://dx.doi.org/10.1016/j.nepr.2012.07.010.

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