Nursing Practice
Innovation
Education
Keywords: Education/Board games/
Pressure ulcer prevention/Harm-free
care/Pressure ulcers/Patient safety
●This article has been double-blind
peer reviewed
Board games are raising staff awareness of pressure ulcer prevention and other patient
safety issues as part of a wider regional education and improvement programme
How board games can be
used to improve safety
In this article...
he value of educational games in staff education
T
How games raise awareness of pressure ulcer prevention
Wider applications and why games are gaining popularity
Authors Authors Lyn McIntyre is deputy
nurse director – patient experience, NHS
England (Midlands and East); Andy
Yeoman is director, Focus Active Learning,
Glasgow.
Abstract McIntyre L et al (2015), How
board games can be used to improve
safety. Nursing Times 111: 25, 14-17.
Games can be used in healthcare as a fun
way to engage staff and patients, and
deliver information to them more
effectively. This article explores the
increasing popularity of “serious” or
educational games, and how one health
region is using them as a part of its
regional educational and improvement
programme. It explains how board games
are raising staff awareness of pressure
ulcer reduction, as part of a wider
programme to help eliminate avoidable
new ulcers.
S
taff education is vital to the
delivery of safe patient care.
Many patient harms are
avoidable (Vincent et al, 2008)
and often the safety improvements needed
are simple and do not require any
new technology or complex support
(Department of Health, 2013). Persuading
staff to make small improvements in the
way they deliver care can do much to
reduce patient harm.
How do we persuade NHS staff to
do their jobs differently in such a
large organisation and with increasing
pressure on resources? The challenge is
magnified because many staff members do
not have sufficient protected learning
time. This calls for new and innovative
ways of educating staff to deliver key staff
and training.
The growth of serious games
One definition of serious games is “games
that do not have entertainment, enjoyment or fun as their primary purpose”
(Michael and Chen, 2005). Such games harness the enjoyable aspects of playing to
deliver information more effectively.
Using games for non-entertainment
purposes is not a new idea: the Prussian
army developed sophisticated table-top
war games, or “kriegsspiele”, as early as
1812. The use of serious games was further
developed and widely introduced in the
20th century by teachers searching for new
ways to engage and motivate their pupils.
In the 21st century, serious gaming, or
games-based learning, was introduced to
wider audiences in diverse sectors
including healthcare, science, politics,
defence, aviation and management. When
used in this context, serious games can
help create a relaxed learning environment, where learning is fun and sociable
while still being mature and professional
(Connolly et al, 2012).
There is growing evidence for the
efficacy of games in healthcare education
(Tanaka et al, 2010), rehabilitation (Burke
et al, 2009) and behavioural change (Kato
et al, 2008). However, their use in healthcare is growing rapidly, it is still relatively
new and many games are not validated for
their use as a tool to improve outcomes.
The few research studies that do exist are
often poorly designed, and their conclusions cannot be considered valid evidence
to support or refute efficacy (Kato, 2012).
Board games are increasingly being
used to engage and educate frontline staff,
patients and carers. Apparently simple
table-top games can deliver a multi-faceted experience to the players (Box 1).
14 Nursing Times 17.06.15 / Vol 111 No 25 / www.nursingtimes.net
5 key
points
1
Games can be
used in
healthcare as a fun
way to engage
staff and patients
and deliver
information more
effectively
Board games
are helping
raise staff
awareness of
pressure ulcer
prevention as part
of a wider
education and
improvement
programme
Wider
applications
include games on
nutrition, hydration
and harm-free care
This style of
learning
appeals to frontline
clinicians as it is
delivered in teams
in the clinical
setting
Developing
online versions
of these games can
extend their reach
and impact,
especially among
younger audiences
2
3
4
5
Nursing
Times.net
For more articles on pressure ulcers, go
tonursingtimes.net/pressureulcers
would be popular with frontline clinical
staff and could be effective in a wider
communication, awareness-raising and
teaching programme.
A project group was set up to develop
a Stop the Pressure board game, with a
remit to:
» Define learning objectives;
» Understand target audiences;
» M
ap practical obstacles and challenges
faced by frontline clinicians.
Once the above was decided, the group
worked intensively to identify the knowledge and practical skills needed by staff
and patients to make pressure ulcer prevention a reality. Prototypes of the game
were developed and tested extensively in
different clinical settings. The game was
launched in November 2012 as a part of
World Pressure Ulcer Day and copies sent
to all trusts in the Midlands and East
region and to selected care homes (Fig 1).
FIG 1. Pressure ulcer game
How the game works
A carefully designed game built around
relevant clinical content can deliver a vast
amount of information to between two
and 14 players in a 45-minute-to-an-hour
session. These games can be used as standalone learning resources, or as adjuncts
to more traditional training and education
delivery, and often allow levels of competence to be assessed.
The potential of serious video games to
help increase the effectiveness of training
and learning is also much debated (Connolly et al, 2012). Some studies suggest it
can increase motivation and accelerate
learning (DeFreitas and Oliver, 2006). This
is coupled with a generational acceptance
of games as a significant part of everyday
life (Gee, 2007).
Games in pressure ulcer prevention
In October 2011, Midlands and East
Strategic Health Authority set itself five
ambitions for improving the patient
experience of care through a legacy of
initiatives that would be continued and
sustained in the new NHS (McIntyre et al,
2012). Among these was a plan to eliminate
avoidable new grade two, three and four
pressure ulcers. Ten work streams were
developed to support this ambition, one of
which was education and training
(McIntyre, 2014).
The authority commissioned social
marketing research to inform the work
(Thurman et al, 2012), which showed the
need for an effective communication and
engagement campaign that would motivate frontline staff. The target audience
of nursing and support staff was large,
diverse and geographically widespread, so
the region’s response was an integrated
engagement campaign called Stop
the Pressure (Fig 1) (www.stopthe
pressure.com), aimed at frontline staff in
acute, mental health and community settings. This was used to motivate frontline
staff to prevent pressure ulcers and as a
portal for education and communication
resources.
As part of this work, serious games
were identified as an innovative and
effective engagement and learning
mechanism that would complement other
models of training. It was thought games
Box 1. What serious
board games deliver
● Motivation: games are fun and
people want to play
● Feedback: players are encouraged to
share new ideas and collaborate
● Team building: enables team
members to learn together
● Practice: board games facilitate
active learning of real and virtual skills
● Positive emotions: fun, competition
and collaboration make the learning
memorable
● Intensity: players are completely
focused on the game and the
discussions they are having
● Choices and decisions: Games
encourage active engagement with
information and ideas
The game takes between 45-60 minutes to
play and can be used in any care setting. All
it requires is people, a table and some
chairs. The rules are simple and it is easy to
run a game without the need for a trained
specialist facilitator. It can be used as an
educational tool at team meetings, study
days, workshops and events.
Participants are asked questions developed by expert tissue viability nurses
relating to all areas of pressure ulcer care.
Some only need simple answers, while
others require group discussion to
generate ideas.
The game gives staff the opportunity to
share experiences, analyse critical
incidents, reflect on new information and
review
their
performance,
while
reinforcing key messages to support
pressure ulcer reduction. It also allows
them to discuss, share and reflect on their
own personal experiences in a safe and
supportive environment.
The board game has also been used by
ward staff to educate patients about
pressure ulcer management. Patients can
take the board game home to play and give
feedback on their experience to staff. Also,
by taking the game to conferences, where
it can be played with delegates, issues,
concerns and misunderstandings can be
discussed and shared.
Putting the game into practice
So far more than 800 games have been
distributed across the region and
nationally. The game has been tested by
managers, staff and patients, who
described it as an enjoyable and effective
www.nursingtimes.net / Vol 111 No 25 / Nursing Times 17.06.15 15
Nursing Practice
Innovation
learning tool. Feedback from staff suggests
it is an innovative way to enhance learning
and stimulate discussion among teams
and across complex boundaries of care and
patient pathways.
For example, one acute organisation
used the Stop the Pressure board game
during its annual link nurse study day. At
registration, each of the 60 attendees was
allocated to one of six teams. Three games
(with two teams playing against each
other) were set up, managed by the tissue
viability nurse and requiring only “light
touch” facilitation.
The sessions were lively and competitive. Staff said the game was fun, tested
their knowledge and made them think
about what is involved in ensuring tissue
viability.
An online version has now been
developed to extend the reach and impact
of the game, especially among younger
audiences. It has also proved popular with
patients and carers as information can be
accessed easily and when time allows.
Extending the programme
Following the success of the Stop the
Pressure board game, a second game has
been developed on nutrition and hydration
(Fig 2). The Nutrition Game was launched
in 2013 and won Nutritional Resource of
the Year at the Nutrition and Health Live
awards that year.
A more complex board game, the Harm
Free Game, has also been designed with
Derbyshire Community Health Services
NHS Trust and NHS Innovations to help
staff understand their role and responsibilities in reducing avoidable patient
harm. The game encourages staff to
communicate and share experiences by
working through realistic scenarios that
could occur in their day-to-day work. Specifically, it focuses on how staff can influence the prevention of four key harms:
» Falls;
» Catheter-associated urinary tract
infections;
» Pressure ulcers;
» Venous thromboembolism.
The game also highlights other related
areas of harm such as medication, nutrition and hydration. Results from one acute
trust –after 3,000 of its staff had played the
game once, with no other interactive educational intervention – showed an
improvement of around 10% in patient’s
“harm-free scores” (from 81.6% in April
2012 to 90.32% in March 2013).
Further games have been produced,
including one on dysphagia and another
on complaints, developed as a joint
FIG 2. The nutrition game
initiative with the Patients Association.
Both are available for staff, patients
and carers.
Practice implications
Educational board games are an alternative
and portable solution to training, and may
be developed as part of a suite of teaching
materials. They can be fun, stimulating
and an opportunity for staff to discuss
emotive issues in a non-threatening way.
They explore all aspects of care delivery and
encourage communication, interaction,
teamwork and reflective practice.
The fact that they are fun enables participants to learn effortlessly and effectively. This style of learning appeals to
frontline clinicians because it can be delivered in the clinical setting and lets them do
some of their mandatory training in
teams, in a way that stimulates discussion
and helps strengthen and build team relationships. There is also an opportunity to
assess levels of competency following the
core training, through scenario-based
questioning and team review.
Accompanying these board games with
online versions, accessible on smartphones, tablets and PCs, extends their
reach to a wider audience and ensures
games appeal to all age groups.
Conclusion
Overall, the Midlands and East regional
initiative has achieved a nearly 50% reduction in new grade 2, 3 and 4 pressure ulcers
across the region. It is not possible to say
how much of this is due to the use of board
games, but staff feedback suggests serious
games provide a fun and informative
method of training and education, as a
valuable addition to education and
improvement programmes. NT
16 Nursing Times 17.06.15 / Vol 111 No 25 / www.nursingtimes.net
References
Burke JW et al (2009) Serious games for upper
limb rehabilitation following stroke. IEEE
International Conference in Games and Virtual
Worlds for Serious Applications.
Connolly T et al (2012) A systematic literature
review of empirical evidence on computer games
and serious games. Computers & Education; 59: 2,
661-686.
De Freitas S, Oliver M (2006) How can exploratory
learning with games and simulations within the
curriculum be most effectively evaluated?
Computers and Education; 46: 3, 249-264.
Department of Health (2013) The Mandate: a
Mandate from the Government to the NHS
Commissioning Board April 1013 to March 2015.
Bit.ly/DHMandate
Gee J (2007) What video games have to teach us
about learning and literacy. Basingstoke: Palgrave
Macmillan.
Kato PM et al (2008) A Video Game Improves
Behavioral Outcomes in Adolescents and Young
Adults with Cancer: a Randomized Trial. Pediatrics;
122: 2, e305-e317.
Kato PM (2012) Evaluating efficacy and validating
games for health. Games for Health Journal; 1: 1,
74-76.
Michael D R, Chen S L (2005) Serious games:
Games that Educate, Train, and Inform. Boston MA:
Cengage Learning
McIntyre L (2014) Implementing a regional
strategy to reduce avoidable pressure ulcers.
Wounds UK; 10: 2, supplement 1.
McIntyre L et al (2012) A strategy to reduce
avoidable pressure ulcers. Nursing Times;
108: 29, 14–17.
Murphy et al (2011) Creating flow, motivation and
fun in learning games.The Design of Learning
Games. Springer-Verlag. Bit.ly/CreatingFlow
Tanaka J et al (2010) Using computerized games
to teach face recognition skills to children with
autism spectrum disorder: the Let’s Face It!
program. Journal of Child Psychology and
Psychiatry; 51: 8, 944–952.
Thurman M, Robinson M (2012) NHS Midlands
and East. Preventing Pressure Ulcers Research.
Research Report: Phase 1. Eventure, Bradford.
Vincent C et al (2008) Is health care getting safer?
British Medical Journal; 337: a2426.
For more on this topic go online...
A communication project to
prevent pressure ulcers
B
it.ly/NTPUPrevention