This collaborative project involving researchers from George Brown College, Centennial College and Ryerson University has resulted in a learning resource intended for students as well as practitioners in nursing and other healthcare professions. The combination of the learning modules and virtual interactive game has the potential to improve the user's retention of knowledge and promote active learning, problem-solving and critical thinking skills.
We have created three online, self-study learning modules, designed to augment the teaching of foundational therapeutic communication and mental health assessment skills. The three modules provide content on assessment techniques and principles and can be incorporated as learning objects in nursing courses at various levels or used for self-study. This is followed by a simulation game, which allows learners to apply the principles from the three content modules in a virtual clinical situation.
By replicating a real-life situation in a virtual simulation, nursing students have the opportunity to practice their skills in an environment that is realistic and allows them to make clinical choices within a safe environment. The simulation game was developed using a series of videos, with actors following a script to portray a client and nurse in a home visit scenario.
During usability testing, participants commented on how engaging the videos were for delivering content and how these helped them to learn more effectively. In their own words, participants described the game as immersive, innovative, interesting, fun and engaging.
The learning modules and simulation game were designed to meet specific learning objectives, by providing a unique opportunity for practicing communication and assessment skills using a serious game approach. The target learners for this resource are those in nursing or other healthcare professions who wish to develop their knowledge and skills in a safe and interactive environment.
The modules present current, evidence-based content to develop knowledge and skills in therapeutic communication and mental health assessment. The learning outcomes align with competencies that are set out as the standard for practicing nurses, however these competencies can also be generalized to other healthcare practitioners.
The game provides the safety of a simulation to allow learners to use their knowledge and skills in a realistic situation.
The key learning objectives in the modules are summarized as follows:
Module 1: Therapeutic Relationships and Communication Techniques
1. Identify principles of the therapeutic nurse-client relationship.
2. Demonstrate the use of effective therapeutic communication techniques.
Module 2: Mental Status Assessment, Depression and Suicide Risk
1. Discuss screening recommendations for depression and assess a client for depression.
2. Differentiate between the risk factors and the protective factors for a client at risk of suicide.
Module 3: Interpersonal Violence
1. Describe how to assess an adult client for interpersonal violence.
2. Identify the responsibilities for a nurse who is concerned that a child may be suffering from abuse or neglect.
3. Describe the steps to take when a nurse discovers that an older adult client may be the victim of financial, emotional, physical or sexual abuse.
4. Describe communication strategies for use with suspected victims and perpetrators of abuse and neglect.
The development of this resource takes into account the needs of today’s learners, the value of simulation and virtual worlds for nursing education, and the potential for serious gaming to provide a unique and valuable learning experience. Today’s learners have grown up using technology, and as result their brains have adjusted to use different pathways, chemicals and neurons (Yoder & Terhorst, 2012). These adjustments have made them more likely to be graphically-oriented, visual-kinesthetic learners, used to a world of multimedia in which they have the option to try something multiple times until they are successful. These learners respond well when given immediate feedback; they want to look for answers to problems, and they learn by making mistakes.
Subject Matter Experts and E-learning strategists developed modes for delivering the content in these three modules in ways which would engage learners while meeting the learning objectives. Examples include: short video presentations from experts, development of skills videos, and learning objects such as test your knowledge quizzes and matching exercises.
The modules are followed by a game where learners apply the principles from the three modules in a computer-based, non-immersive virtual gaming clinical simulation (NIVGCS).
In the case of mental health assessment for depression and domestic violence, simulation within a virtual world can provide learners with the ability to practice skills, work through new concepts, replay scenarios and make mistakes in a safe environment.
Furthermore, the NIVGCS replaces the need for traditional live clinical simulation, which is expensive, since it involves laboratory space, specialized equipment and other resources. The high fidelity in the simulation and use of actors to play out scenarios, provide a more realistic experience compared to the use of animated avatars.
Please refer to attached bibliography for a list of articles that informed the basis of this project.
A key focus of this project was to optimize user-experience (UX) for the target audience. Two rounds of usability testing were conducted, one in the middle of the design development process and one at the end, to validate design decisions and to gauge user feedback. As part of the iterative design approach, changes were incorporated and then retested in the second round of usability testing. The iterative design approach involves sketching, prototyping, design discussions and collecting feedback from the whole team including stakeholders. In addition, it considers user-centred design (UCD) which requires input from key stakeholders (the nursing team) and end users (nursing students and practitioners). The project went through a few iterations to refine the requirements and design interface.
In the simulation, the learner assumes the role of a community health nurse assigned to complete a home visit with the mother of a client. The video clips depict various scenarios which provide learners with a realistic image of domestic violence and suicide risk, and expose them to a series of decision points as they complete the client assessment. The video simulations allow learners to imagine themselves in situations where they may find themselves empathizing with a client; it enables real world practice. Usability testing participants commented that the video was like a real movie with high production quality.
“Love the first person view! It was good, acting was good.”
“Overall...game would be helpful, ...Learn how you can interact with a client and the other people in the house.”
Ideally the modules would be studied first and then the learner would apply their knowledge by playing the game. However, the game is standalone and can be played first and then reset and played over for learners to keep practicing their skills.
The learning modules can be incorporated as learning objects in nursing courses at various levels. They can also be used as self-study learning objects by nursing students who are preparing to write the registered nurse (NCLEX) or registered practical nurse (CPRNE) exams with the College of Nurses of Ontario. No plug-ins, downloads or advanced computer skills are required; the learner can access the link and get started, even on their mobile device. It is an effective way to learn as it can be accessed on the go, for example on mobile devices, such as an iPad. Instructors do not need to prepare a class, or book a lab. Instead, the link can be sent to learners to practice their skills immediately.
Learners benefit from playing the game as it replicates a real-life situation and puts them in the action where they can safely practice their decision-making and problem-solving skills, which are critical for practice.
Usability testing participants provided feedback that they were more engaged when interacting with a visual presentation vs. reading a scenario.
Participants stated the game was Interactive, Informative, Immersive, Engaging, Fun, Interesting, Realistic.
Participants stated their experience playing the game was Enjoyable, Useful, Motivational, Engaging, Relevant.
Though the content is serious, participants described the game as fun and an enjoyable experience.
“Good tool, having done a lot of courses at home anything you can do to change up the learning is good.”
“Another venue, everyone learns differently, watching the video allows you to transport into that situation.”
“interesting and fun.... feel like you’re in the game. “
“I think it’s an excellent tool, the video, the graphics... the actors did a really good job portraying the story line...the suspense.”
The team deployed a survey to users of the resource to collect feedback. We will be compiling and reviewing the results and assess any updates or improvements to the resource.
The next step, the proposed study, is to conduct a randomized control study to compare the NIVGCS (non-immersive virtual gaming clinical simulation) to traditional laboratory simulation with respect to student knowledge gains, self-efficacy and satisfaction with the learning experience.
Our intention is to develop other serious games in a similar format as learners have expressed interest in gaining skills and knowledge through this medium.