University of Groningen
Improving delirium education: the role of experiential learning in a serious game
Buijs-Spanjers, Kiki
DOI:
10.33612/diss.126540538
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Buijs-Spanjers, K. (2020). Improving delirium education: the role of experiential learning in a serious game.
https://doi.org/10.33612/diss.126540538
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ISBN
978-94-034-2730-0 Design/lay-out
Promotie In Zicht (www.promotie-inzicht.nl) Print
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© K.R. Spanjers, 2020
All rights are reserved. No part of this book may be reproduced, distributed, stored in a retrieval system, or transmitted in any form or by any means, without prior written permission of the author.
PhD thesis
ter verkrijging van de graad van doctor aan de Rijksuniversiteit Groningen
op gezag van de
rector magnificus prof. dr. C. Wijmenga en volgens besluit van het College voor Promoties.
De openbare verdediging zal plaatsvinden op donderdag 11 juni 2020 om 11.00 uur
door
Kiki Rodinde Spanjers
geboren op 28 mei 1990 te Wageningen
Improving delirium education:
the role of experiential learning
Promotores
Prof. dr. S.E.J.A. de Rooij Prof. dr. A.D.C. Jaarsma
Copromotor
Dr. F. Cnossen
Beoordelingscommissie
Prof. dr. J.P.E.N. Pierie Prof. dr. B.C. van Munster Prof. dr. M.P. Schijven
Table of content
Chapter 1 General Introduction 7
Chapter 2 A Web-Based Serious Game on Delirium as an Educational Intervention for Medical Students: Randomized Controlled Trial
25
Chapter 3 The effect of a serious game on delirium on nursing students’ care advice and perceived self-efficacy: a before-after design
41
Chapter 4 Dark Play of Serious Games: Effectiveness and Features 53
Chapter 5 Normal Play or Dark Play in a Serious Game for Medical Students: Differences in Students Characteristics, Play Strategy, and Learning Experiences
67
Chapter 6 The influence of a serious game’s narrative on students’ attitudes and learning experiences regarding delirium: an interview study
83
Chapter 7 General Discussion 103
Chapter 8 Summary 125
Chapter 9 Nederlandse samenvatting 137
Biography 143
Dankwoord 145
General introduction
1
What I remember of last year, is that delirium is a bit of confusion with or without hallucinations.
– Medical student after four years of medical education before playing The Delirium Experience The way I look back now is that I don’t ever want an operation ever again. If I need an operation of any kind, I’ll tell them to just let me die instead. If I ever get another delirium I don’t think I’ll survive it. No, I know for sure I wouldn’t survive another one.
8 9
General Introduction
1
The first time I heard of delirium was when I wrote my MSc thesis that was part of a larger studyin a hospital. One of the exclusion criteria was delirium. As I had never heard of delirium, I asked a nurse what delirium is and why we couldn’t include patients with delirium. She explained to me that patients with delirium are somewhat confused and were therefore unable to answer the questionnaires or perform physical tests.
One year later, I started my PhD project on The Delirium Experience, a serious game to train and educate healthcare professionals about delirium. I was of course curious about the game, and started playing on a dark winter evening. My lack of a medical background or sufficient knowledge on delirium resulted in severe delirious episodes for the patient in The Delirium Experience. These delirious episodes were so frightening that I quit playing and decided to play this interesting but somewhat scary game during daytime! That evening, I became aware that there was an important misbalance between the nurse’s explanation of delirium and the patient’s experience I encountered in The Delirium Experience. I was however not aware yet, that this misbalance is one of the challenges in delirium education and would play a central role throughout my PhD project.
Delirium
Delirium is an acute neuropsychiatric syndrome due to a physical condition that affects patients’ attention and awareness.1 Patients experience reduced ability to direct, focus,
sustain and shift their attention, and orientation to the environment. This disturbance in attention and awareness usually develops within hours to a few days and the severity tends to fluctuate over the day. Furthermore, patients experience an additional disturbance in cognition such as memory deficit, language problems, visuospatial ability, or perception. It is a multifactorial condition, always triggered by medical causes, such as surgery, infection, pain, and/or drugs.1,2 Delirium develops from a complex interrelation between
patients’ vulnerability and the exposure to triggers, e.g. older hospitalized patients are more susceptible to develop delirium.3 It is associated with serious consequences such as
increased length of hospital stay, functional and cognitive decline, institutionalization, and mortality.1,2 For patients, experiencing delirious episodes is frightening and affects
their psychological and emotional well-being.4,5 Depending on the clinical setting the
incidence of delirium varies between 29 to 64% in medical and geriatric wards, up to 80% in Intensive Care Units, and is also present in about 40% of nursing home residents.2
Adequate recognition and management of delirium is important to reduce its incidence and severity,6,7 but unfortunately delirium often goes unrecognized.8,9 To treat and manage
delirium, healthcare professionals can use both pharmacological and non-pharmacological interventions. In past years, delirium was often treated with pharmacological interventions, recent studies show however that pharmacological interventions are not proven to be effective, both regarding effects on incidence and/or severity of delirium. Because
pharma-General Introduction
1
clinical importance and level of screening for delirium.21,22 Also, healthcare professionals
often have inadequate levels of knowledge and lack education on delirium.21–24 In
addition, the limited availability of time and staff to assess patients at increased risk of developing delirium, and their experienced discomfort with delirium assessment contribute to low delirium detection rates.21–23,25
Even when (an increased risk of) delirium is detected, preventive or therapeutic delirium management is often suboptimal. Many healthcare professionals state that they are unsatisfied with the organization of delirium management in their work environment.21,22,25,26 The factors that affect low delirium detection rates also play a role
in suboptimal delirium management. These factors include: inadequate knowledge and education,21,23,24,27,28 insufficient time, tools, and staff,23,27,28 and experiencing discomfort
with delirium management.25 But also a lack of effective collaboration between disciplines
resulting in suboptimal coordinated and integrated plans for treatment and follow-up seems to play a role as well.22,23,29 In addition, negative attitudes of healthcare professionals
towards delirium contribute to the suboptimal management of delirium and thereby care for delirious patients.28,30 Caring for delirious patients is often experienced as burdensome
and distressing and delirious patients are frequently stigmatized because of for example aggressive behavior and the complexity of providing them with medical care as they often remove intravenous lines and indwelling catheters.16,24,25,27,31–33 Furthermore,
healthcare professionals often lack an understanding of the patients’ experiences, emotions, and needs when patients endure delirious episodes, even though we know this understanding enhances delirium management and care and benefits a patient’s recovery.18,19,26,28,30
Delirium education
Current delirium education fails to educate healthcare professionals in such a way that they can overcome the barriers described above leading to suboptimal delirium detection and management.21,29,30,34–37 There is thus an urgent need for improvements in delirium
education to decrease the burden for all people involved. Delirium education that focuses solely on increasing knowledge and skills in recognition, without paying attention to attitudes, is not sufficient to improve delirium detection and management.34,35 Researchers emphasize
the need to design delirium education that enables changes in the focus as well as on the delivery methods of delirium education.24,30,36
On the one hand, delirium education should not only focus on specific disease-related knowledge, but should increase the patient-oriented focus by involving patients and their experiences.30,36 Issues that were identified as important to improve delirium care are the
negative attitudes of healthcare professionals towards delirium, lack of understanding the patients’ experience, and behavior and communication skills related to delirium care.30,36
Attitudes are learned evaluations of persons, places, or issues that affect feelings, beliefs, and behavior.38–40
cological interventions are also associated with adverse effects, it is recommended to only use pharmacological interventions if other interventions do not succeed in reducing the psychomotor symptoms of delirium.9–12 Clinicians are nowadays advised to implement
multicomponent non-pharmacological interventions to prevent, treat, and manage their patients with delirium. The interventions in delirium care focus for example on: treatment or prevention of possible precipitating medical conditions, re-orientation, early mobilization, avoidance of sensory deprivation, hydration, and involvement of family.11 They have found
to be effective, low-risk, and consistent with standards for quality care.11,13,14 It is estimated
that these multicomponent non-pharmacological interventions may reduce delirium incidence by 30 to 50%.9,11,14
The patient’s experience
Patients who experienced delirious episodes can frequently recall their experiences.15,16
They describe these experiences as distressing, frightening, or even terrifying.17–19 During
delirious episodes patients feel confused or disoriented and they can have hallucinations or delusions.17,19 Delirium and altered behavior due to delirium also made patients lose
their self-control and dignity.17–19 These feelings withhold some patients from sharing
information about their experiences with healthcare professionals. Sharing these experiences with healthcare professionals is even less if patients do not trust the healthcare professionals, this lack of trust may be a result of delirium.18,19 However, this information
may be of essential value to healthcare professionals to reduce the severity of delirium symptoms, and thereby also reduce the level of distress of patients who experienced delirium.4,15,16
Not only during or directly after the delirious episodes do patients describe remembering the feelings of distress or hallucinations, but also long after the episodes ceased, patients still experience consequences of delirium.4,5,17–19 The loss of self-control and dignity during
the delirious episodes may lead to feelings of embarrassment and feeling humiliated after the delirious episodes ceased.17–19 Patients often describe nightly struggles such as the
inability to fall asleep and sleeplessness as a result of delirium lasting for a long time.17
In addition patients may also describe an altered sense of self, doubt about perceptions, unresolved feeling of anxiety, and a reduced feeling of autonomy.17–19 About 30% of
patients who experienced delirious episodes even develop post-traumatic stress disorder4
or depression.5 Not only does delirium affect patients, but it also affects their spouses,
healthcare professionals and/or other caregivers experience severe distress.16,20 For
example, overt agitations and hallucinations cause worry and distress in spouses and caregivers of delirious patients.16,20
Barriers in delirium detection and management
Several factors play a role in why delirium or an increase risk often goes unrecognized. One factor is a lack of delirium awareness and a disconnection between the perceived
12 13
General Introduction
1
Experiential learning in delirium care
Experiential learning is not yet been used often as a foundation to teach delirium care.24,48,49 However, healthcare professionals describe they often rely on experiential
learning when providing care to delirious patients.24,32,48–50 They especially use principles
of experiential learning in cases where they report insufficient education or cannot rely on their own experience to provide good care to delirious patients.24,32,48 Experiential
learning in delirium care allows healthcare professionals to learn the acquired clinical and communication skills, and creates more understanding of the delirious patient’s case.24
Serious games
A medium suited to apply principles of experiential learning is a serious game.51 Serious
games are games that are active and entertaining learning environments.52,53 Serious
games focus on the main objective of educating the player, but also have many play characteristics of entertainment games.52 They provide environments in which players
can safely experiment,52,54,55 thereby connecting to one of the key aspects of experiential
learning. Serious games are applied for many different purposes such as cognitive training, health education or promotion, and to increase physical activity (e.g. exergames).56,57
Also in medical education, serious games are increasingly being used to educate and train medical students and other healthcare professionals in various medical fields such as surgery, obstetrics, radiology, or emergency care.58,59 However, to our knowledge this was
the first serious games to teach delirium care, we also found a serious game that was intended to screen hospitalized patients for delirium. Patients played this serious game, and the output of the game was used to screen for delirium.60
In recent years, several scientific reviews have been conducted on the use of serious games in the various fields of medical education.58,59,61,62 These reviews show that serious
games are found to be more effective in achieving learning goals compared to conventional educational interventions, often with higher learner satisfaction. However, these reviews also reveal that the quality of evidence is modest due to methodological issues and there are many unresolved questions on serious game development and evaluation to understand what makes a game useful.58,59,61,62
Current challenges in studying serious games
To draw more reliable conclusions on the effectiveness of serious games, there are a number of methodological issues that need to be addressed in future studies of serious games for medical education as well as other serious game domains.57–59,61–65 There is
first a need for (clustered) randomized controlled trials following a published detailed protocol with information about appropriate control groups, randomization of participants, and blinding of assessors instead of quasi-experimental study designs to On the other hand, there is increasing interest for educating delirium care with more
interactive methods that actively involve learners to address the issues raised above.24,41
Feedback on how learners are performing and the use of simulations contribute to this more interactive way of teaching.24,34,35,41,42 Furthermore, the involvement of patients and
patients’ experiences in delirium education is expected to address the negative attitudes towards delirium and improve delirium care.24,34,36 However, little is yet known about
which specific aspects of education affect learning about delirium care, and how this knowledge is translated into skills needed to improve daily practice.29,30,34
Content in delirium education should have a more patient-oriented and experience- based focus. It relies more on exploring new experiences than on factual knowledge or skills. Not only are the experiences of the patients important in delirium education, experiences of the learner also play an important role to improve learning outcomes.43–45
Acquiring clinical experience with delirium care is one way to address this, but it takes time to master this and it is often hard to expose all students to delirious patients without causing extra burden to these vulnerable patients.34,46 A suitable learning strategy in
delirium education to overcome these practical challenges may be experiential learning.
Experiential learning
Experiential learning considers how learners bring their own experiences gathered in reality into their learning process.44 Learning is therefore dependent on the context in
which it occurs.45 The principles of experiential learning describe how new knowledge is
created by interpreting and integrating an experience into what a learner already knows.44,45 This means that learners try or do something that will create an experience.
Reflection is in turn essential to make sense of the experience and helps to solidify the experience into the learner’s memory.44,47 The emotion the memory evokes helps to
integrate the experience into the learners knowledge.43 Also critical reflection about the
experience and how it may have been improved is important in experiential learning.44 In
this way, learners theorize on how they may improve the experience before they test their theories and try to improve the experience in reality. This leads to active experimentation with their theories and experiences, which helps learners with the interpretation of the experience.44 This can in turn contribute to a new experience that needs to be interpreted
and integrated to create new knowledge.44,45
In experiential learning a learner’s experience thus plays an important role in creating new knowledge. As explained above, intertwining the patient’s experience of delirium into the learners’ experiences is recommended to improve delirium education.30,36 The
principles of experiential learning may therefore serve as a lens to study the recommended improvements in delirium education.
General Introduction
1
determine what happens to the patient during the night; hence different choices interact with the course of the delirium symptoms. In this way, players should gain insight into what a patient endures in delirious episodes, and how the concrete actions as a healthcare professional can influence this.
study serious games.59,61,62,65 In addition, the use of standardized or validated measurement
instruments is recommended to enhance the quality of evidence and comparability of serious games.58,61,66 A plea was made to also investigate attitudes patient outcomes, and
clinician behavior as serious games outcomes in addition to knowledge, skills, and player satisfaction.61,62 And it was found important to broaden participant characteristics,54,61,62,64
and make sure studies on serious games are adequately powered.61,64,66 To enhance the
quality of evidence, researchers emphasize the need to implement and test serious games multiple times and in different settings.58 One other important recommendation is to evaluate
interventions that have a robust theoretical underpinning.61,67 This theoretical under -
pinning with educational or behavioral theories may increase the game’s effectiveness,67,68
however less than 40% of educational games includes a theoretical underpinning.64
In addition to the methodological issues contributing to more reliable conclusions, to develop more efficacious serious games, we need to know what makes a game effective in achieving its goals.56–59,61,62 However, current research often investigates
serious games as a whole artifact with a predefined outcome (e.g. knowledge) without distinguishing between individual game aspects.57–59,62 This contributes to evidence on
the effectiveness of a specific serious game, but does not provide us insight in the particular aspects of the serious game contributing to this effect. More research is therefore needed on game aspects that promote engagement, support learning, and connect to pedagogical principles.57–59,62
The Delirium Experience
The Delirium Experience is a serious game that was developed in 2015. It makes use of video simulation and was developed with the intention to address identified gaps in delirium education, as described above. It aims to teach players how to care for patients with (an increased risk of developing) delirium, provide them with insight in what patients endure during delirious episodes, and how the actions of a healthcare professional influence the patient’s experience.69 The game incorporates narratives of a patient
undergoing a hip surgery and a healthcare professional who has to provide care to this patient. After the surgery, the patient experiences delirious episodes which differ in severity depending on the care provided by the healthcare professional. The Delirium Experience was designed to make a contribution to interactive delirium education that actively involves learners and to have a more patient-oriented focus.
In the game the player plays four “days”, which take about twenty minutes playtime (https://www.youtube.com/watch?v=A-lLLP8Me0E). During daytime, the player has the perspective of a healthcare professional of a delirious patient and provides care for the patient (Figure 1). During the corresponding nights, the player receives the perspective of the delirious patient himself (Figure 2). The daytime actions of the healthcare professional
Figure 1. Examples of the nurse’s perspective in The Delirium Experience
16 17
General Introduction
1
players to practice behaviour and communication skills that are needed in delirium care.30,36
Both narratives were provided to the player in a first-person perspective because this facilitates better comprehension of the study material. The idea was that it also enhances the transfer of what players saw to their own performance.79
Rationale and outline of this thesis
From the introduction provided above it becomes clear that good quality delirium care is important because of the high burden on all people involved. To provide good quality delirium care, there are however important issues that need to be addressed in delirium education.29,30,36 The aim of this thesis therefore is to investigate whether a serious game
on delirium that uses principles of experiential learning is a suited strategy to improve delirium education. In addition, this thesis aims to identify aspects of a serious game that contribute to specific improvements in delirium education. This, to enhance the needed under- standing of effective aspects of both delirium education29,30,34 and serious games.56,58,61,62
Next to the outline of this thesis described below, an overview of this outline and how the corresponding chapters relate to the aims of this thesis is provided in Figure 3. In chapter 2 we describe a three-arm randomized controlled trial in which we investigate the effects of the serious game The Delirium Experience on medical students’ skills, learning outcomes and motivations, and attitude. We therefore compared the game to watching two videos on delirium and a patient’s experience on delirium, and to watching a video on healthy ageing.
To broaden our study population and setting, we investigated The Delirium Experience to teach delirium care to nursing students in chapter 3. We used a before-after design to evaluate the game’s effect on students’ quality of care advice for delirious patients and perceived self-efficacy in providing care to delirious patients.
Chapter 4 shows a two-arm randomized controlled trial to gain insight in the effect
of different play strategies in the serious game on its effectiveness. Furthermore, we used open-ended questions to explore the different game aspects of these play strategies and how these aspects contributed to improving delirium education. In this study we randomly assigned medical students to either play strategy.
We describe a study in which medical students were allowed to choose their preferred play strategy in chapter 5. We investigated differences in medical students’ characteristics, reasons to choose the play strategy, and learning experiences between the two play strategies. By answering open-ended questions students described their reasons to choose the play strategy and learning experiences.
Finally, we explore how the narrative and its aspects within The Delirium Experience affects students attitudes an learning experiences toward delirium in chapter 6. We conducted semi-structured interviews with both nursing and medical students.
Development
The Delirium Experience was developed together with professionals who have experience in developing serious games, designing education, training healthcare personnel, and providing care to delirious patients. The close collaboration of these professionals resulted in clearly defined transfer of concepts from the various involved fields into the game.70
To produce the game’s content, experiences of patients who experienced several delirious episodes and the national delirium guidelines from the United Kingdom (NICE guidelines)71 and
the Netherlands72 were used in addition to the input of the professionals involved in the
development process. An iterative process within the development team was used to develop and review prototypes of the game and its elements. After consensus was reached on the serious game within the team, a group of healthcare professionals played the game with a think-aloud protocol. This allowed the development team to identify final improvements in the games usability, playability, and functionality.70 Based on the
outcome of these play sessions, the final version of The Delirium Experience was made. The primary author of this thesis (Kiki Buijs-Spanjers) was not involved in the development of The Delirium Experience, neither were the second promoter (Debbie Jaarsma) and the two co-supervisors (Fokie Cnossen and Harianne Hegge). The first promoter (Sophia de Rooij) was the professional on providing care to delirious patients in the development of The Delirium Experience.
Goals and design principles
Within the design of The Delirium Experience, experiential learning was used as a lens. In addition, to achieve the serious game’s goals (teach players how to care for delirium, provide players insight in the patient’s experience and in how their actions influence this experience), several design principles were used.
The serious game provides players a safe environment to experiment and practice caring for a delirious patient without the risk of harming a patient.54,55,73,74 This encourages
players to actively experiment with the different care options incorporated in The Delirium Experience to create new experiences and knowledge.44,45,47
In The Delirium Experience, feedback is provided to players in multiple ways, because this is often preferred by learners.75,76 Players therefore receive written feedback after each
day in the game on how they could have improved taking care of a delirious patient. Furthermore, the responses of the patient to the actions of the player and progression of delirium symptoms also provide feedback to the player. At the end of the game all individual players’ choices considering caretaking within the game are also reconsidered and evaluated.
Another important aspect of the design was to incorporate the narrative of a patient experiencing delirious episodes which was implemented into The Delirium Experience with the intention to increase the patient-oriented focus in delirium education.30,36
A narrative supports players information processing and making sense of the experience.77,78
General Introduction
1
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Figure 3. Thesis outline
Is a serious game a suited strategy to improve delirium education?
CHAPTER 2
A web-based serious game on delirium as an educational intervention for medical students: a randomized controlled trial
CHAPTER 3
The effect of a serious game on delirium on nursing students’ care advice and perceived self-efficacy: a before-after design
CHAPTER 5
Normal play or dark play in a serious game for medical students: differences in students’ characteristics, reasons, and learning experiences.
CHAPTER 4
Dark play of serious games: effectiveness and features
CHAPTER 6
The influence of a serious game’s narrative on students’ attitudes and learning experiences regarding delirium: an interview study
Which aspects of a serious game on delirium contribute to improvements in delirium education?
20 21
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47. Sandars J. The use of reflection in medical education: AMEE Guide No. 44. Med Teach. 2009;31(8):685-695. doi:10.1080/01421590903050374
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with delirium symptoms: a qualitative study using critical incident technique. Int J Nurs Stud. 2014;51(10):1353-1365. doi:10.1016/j.ijnurstu.2014.02.005
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Biomedical Visualisation. Advances in Experimental Medicine and Biology. Springer, Cham; 2019:97-109.
doi:10.1007/978-3-030-19385-0_7
52. Wattanasoontorn V, Boada I, García R, Sbert M. Serious games for health. Entertain Comput. 2013;4(4):231-247. doi:10.1016/j.entcom.2013.09.002
53. Ritterfeld U, Cody MJ, Vorderer P. Serious Games: Mechanisms and Effects. New York: Routledge; 2009. 54. Cook DA, Hamstra SJ, Brydges R, et al. Comparative Effectiveness of Instructional Design Features in
Simula-tion-Based Education: Systematic Review and Meta-Analysis. Vol 35.; 2013. doi:10.3109/0142159X.2012.714886
55. Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for medical education and surgical skills training. Br J Surg. 2012;99(10):1322-1330. doi:10.1002/bjs.8819
56. Lu AS, Kharrazi H. A State-of-the-Art Systematic Content Analysis of Games for Health. Games Health J. 2018;7(1):1-15. doi:10.1089/g4h.2017.0095
57. Boyle EA, Hainey T, Connolly TM, et al. An update to the systematic literature review of empirical evidence of the impacts and outcomes of computer games and serious games. Comput Educ. 2016;94. doi:10.1016/j. compedu.2015.11.003
58. Gorbanev I, Agudelo-Londoño S, González RA, et al. A systematic review of serious games in medical education: quality of evidence and pedagogical strategy. Med Educ Online. 2018;23(1). doi:10.1080/10872981.2 018.1438718
59. Wang R, DeMaria S, Goldberg A, Katz D. A Systematic Review of Serious Games in Training Health Care Professionals. Simul Healthc J Soc Simul Healthc. 2016;11(1):41-51. doi:10.1097/SIH.0000000000000118
60. Lee JS, Tong T, Tierney MC, Kiss A, Chignell M. Predictive Ability of a Serious Game to Identify Emergency Patients With Unrecognized Delirium. J Am Geriatr Soc. 2019;67(11):2370-2375. doi:10.1111/jgs.16095
61. Gentry SV, Gauthier A, Ehrstrom BLE, et al. Serious gaming and gamification education in health professions: systematic review. J Med Internet Res. 2019;21(3). doi:10.2196/12994
62. Haoran G, Bazakidi E, Zary N. Serious Games in Health Professions Education: Review of Trends and Learning Efficacy. Yearb Med Inform. 2019;28(01):240-248. doi:10.1055/s-0039-1677904
63. Wouters P, van Nimwegen C, van Oostendorp H, van der Spek ED. A meta-analysis of the cognitive and motivational effects of serious games. J Educ Psychol. 2013;105(2):249-265. doi:10.1037/a0031311
64. Kharrazi H, Lu AS, Gharghabi F, Coleman W. A scoping review of health game research: Past, present, and future. Games Health J. 2012;1(2):153-164. doi:10.1089/g4h.2012.0011
65. Girard C, Ecalle J, Magnan A. Serious games as new educational tools: How effective are they? A meta-analysis of recent studies. J Comput Assist Learn. 2013;29(3):207-219. doi:10.1111/j.1365-2729.2012.00489.x
66. Hamari J, Koivisto J, Pakkanen T. Do Persuasive Technologies Persuade?-A Review of Empirical Studies. Persuas
Technol. 2014;8462:118-136. doi:10.1007/978-3-319-07127-5_11
67. Kato PM. Evaluating Efficacy and Validating Games for Health. Games Health J. 2012;1(1):74-76. doi:10.1089/ g4h.2012.1017
22. Trogrlić Z, Ista E, Ponssen HH, et al. Attitudes, knowledge and practices concerning delirium: A survey among intensive care unit professionals. Nurs Crit Care. 2016:1-8. doi:10.1111/nicc.12239
23. Nydahl P, Dewes M, Dubb R, et al. Survey among critical care nurses and physicians about delirium management. Nurs Crit Care. 2018;23(1):23-29. doi:10.1111/nicc.12299
24. Brooke J, Manneh C. Caring for a patient with delirium in an acute hospital: The lived experience of cardiology, elderly care, renal, and respiratory nurses. Int J Nurs Pract. March 2018:e12643. doi:10.1111/ijn.12643
25. Maximous R, Miller F, Tan C, et al. Pain, agitation and delirium assessment and management in a community medical-surgical ICU: results from a prospective observational study and nurse survey. BMJ Open Qual. 2018;7(4):e000413. doi:10.1136/bmjoq-2018-000413
26. Bélanger L, Ducharme F. Patients’ and nurses’ experiences of delirium: a review of qualitative studies. Nurs Crit
Care. 2011;16(6):303-315. doi:10.1111/j.1478-5153.2011.00454.x
27. Palacios-Ceña D, Cachón-Pérez JM, Martínez-Piedrola R, Gueita-Rodriguez J, Perez-De-Heredia M, Fernández-De-Las-Peñas C. How do doctors and nurses manage delirium in intensive care units? A qualitative study using focus groups. BMJ Open. 2016;6(1):1-11. doi:10.1136/bmjopen-2015-009678
28. Morandi A, Lucchi E, Turco R, et al. Delirium superimposed on dementia: A quantitative and qualitative evaluation of informal caregivers and health care staff experience. J Psychosom Res. 2015;79(4):272-280. doi:10.1016/j.jpsychores.2015.06.012
29. Morandi A, Pozzi C, Milisen K, et al. An interdisciplinary statement of scientific societies for the advancement of delirium care across Europe (EDA, EANS, EUGMS, COTEC, IPTOP/WCPT). BMC Geriatr. 2019;19(1):253. doi: 10.1186/s12877-019-1264-2
30. Teodorczuk A, Mukaetova-Ladinska E, Corbett S, Welfare M. Reconceptualizing models of delirium education: findings of a Grounded Theory study. Int Psychogeriatr. 2013;25(4):645-655. doi:10.1017/S1041610212002074 31. Mc Donnell S, Timmins F. A quantitative exploration of the subjective burden experienced by nurses when
caring for patients with delirium. J Clin Nurs. 2012;21(17-18):2488-2498. doi:10.1111/j.1365-2702.2012.04130.x 32. LeBlanc A, Bourbonnais FF, Harrison D, Tousignant K. The experience of intensive care nurses caring for
patients with delirium: A phenomenological study. Intensive Crit Care Nurs. 2018;44:92-98. doi:10.1016/j. iccn.2017.09.002
33. Mukaetova-Ladinska EB, Cosker G, Chan M, et al. Delirium Stigma Among Healthcare Staff. Geriatr (Basel,
Switzerland). 2018;4(1). doi:10.3390/geriatrics4010006
34. Fisher JM, Gordon AL, MacLullich AMJ, et al. Towards an understanding of why undergraduate teaching about delirium does not guarantee gold-standard practice--results from a UK national survey. Age Ageing. 2015;44(1):166-170. doi:10.1093/ageing/afu154
35. Yanamadala M, Wieland D, Heflin MT. Educational interventions to improve recognition of delirium: A systematic review. J Am Geriatr Soc. 2013;61(11). doi:10.1111/jgs.12522
36. Copeland C, Fisher J, Teodorczuk A. Development of an international undergraduate curriculum for delirium using a modified delphi process. Age Ageing. 2018;47:131-137. doi:10.1093/ageing/afx133
37. Fowler BM. Clinical education to decrease perceived barriers to delirium screening in adult intensive care units. Crit Care Nurs Q. 2019;42(1):41-43. doi:10.1097/CNQ.0000000000000235
38. Breckler SJ. Empirical validation of affect, behavior, and cognition as distinct components of attitude. J Pers Soc
Psychol. 1984;47(6):1191-1205. doi:10.1037/0022-3514.47.6.1191
39. Bagozzi RP, Tybout AM, Craig CS, Sternthal B. The Construct Validity of the Tripartite Classification of Attitudes.
J Mark Res. 1979;16(1):88. doi:10.2307/3150879
40. Perloff RM. The Dynamics of Persuasion: Communication and Attitudes in the 21st Century. 4th ed. New York: Routledge; 2010.
41. Coyle MA, Chang HC, Burns P, Traynor V. Impact of Interactive Education on Health Care Practitioners and Older Adults at Risk of Delirium: A Literature Review. J Gerontol Nurs. 2018;44(8):41-48. doi:10.3928/00989134-20180626-02
42. Robles MJ, Esperanza A, Pi-Figueras M, Riera M, Miralles R. Simulation of a clinical scenario with actresses in the classroom: A useful method of learning clinical delirium management. Eur Geriatr Med. 2017;8(5-6):474-479. doi:10.1016/j.eurger.2017.07.011
General Introduction
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68. Fleming TM, de Beurs D, Khazaal Y, et al. Maximizing the Impact of e-Therapy and Serious Gaming: Time for aParadigm Shift. Front Psychiatry. 2016;7(April):1-7. doi:10.3389/fpsyt.2016.00065
69. Effectieve Ouderen Zorg. Delirium Experience. http://www.deliriumexperience.nl/. Published 2017. Accessed May 26, 2017.
70. Olszewski AE, Wolbrink TA. Serious Gaming in Medical Education A Proposed Structured Framework for Game Development. Simul Healthc J Soc Simul Healthc. 2017;12(4):240-253. doi:10.1097/SIH.0000000000000212 71. National Clinical Guideline Centre for Acute and Chronic Conditions. Delirium: Diagnosis, Prevention and
Management. London: National Clinical Guideline Centre - Acute and Chronic Conditions,; 2010. https://www.
nice.org.uk/guidance/cg103.
72. Dautzenberg PLJ, Molag ML, van Munster BC, de Rooij SEJA, Luijendijk HJD, Leentjens AFG. Herziene richtlijn “Delier volwassenen en ouderen.” Ned Tijdschr voor Geneeskd. 2014;158.
73. Fisher JM, Walker RW. A new age approach to an age old problem: Using simulation to teach geriatric medicine to medical students. Age Ageing. 2014;43(3):424-428. doi:10.1093/ageing/aft200
74. Leigh GT. High-Fidelity Patient Simulation and Nursing Students ’ Self-Efficacy : A Review of the Literature.
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78. Koivisto J-M, Niemi H, Multisilta J, Eriksson E. Nursing students’ experiential learning processes using an online 3D simulation game. Educ Inf Technol. 2017;22(1):383-398. doi:10.1007/s10639-015-9453-x
79. Lindgren R. Generating a learning stance through perspective-taking in a virtual environment. Comput
A Web-Based Serious Game on
Delirium as an Educational Intervention
for Medical Students: Randomized
Controlled Trial
Kiki Buijs-Spanjers Harianne Hegge Carolien Jansen Evert Hoogendoorn Sophia de RooijPublished in JMIR Serious Games 2018; 6(4):e17
Single wrong actions can have a big impact on the course of delirium and on how the patient feels. I also learned that sometimes patients don’t seem to show how severe their confusion might be.
- Medical student after three years of medical education and playing The Delirium Experience
Delirium education for medical students
2
Introduction
Delirium is an acute neuropsychiatric syndrome often experienced by older hospitalized patients. It is characterized by altered attention, awareness, and cognition. Delirium has serious consequences such as increased length of hospital stay, functional decline, institutionalization, and mortality.1 Adequate delirium recognition and management are
important to reduce the incidence and severity of delirium.2,3 To improve delirium
recognition and management, training of medical staff and students is needed4 as timely
recognition is crucial.2 Lack of delirium awareness, knowledge, and education were the
most commonly reported barriers to improving the recognition of delirium (risk) and the hospital care for delirious patients.5 Current educational interventions focus merely on
increasing knowledge and skills in recognition of delirium but do not seem to be effective enough.6,7 It was suggested that educational interventions on delirium should have a
broader scope to target (1) the attitude of the medical staff and students toward delirious patients; (2) the understanding of patients’ needs; and (3) the translation of this knowledge into the practice of offering good health care to delirious patients.7,8 Future educational
interventions on delirium should not only have a broader scope addressing these 3 objectives but also focus on teaching methods with students actively involved and supportive technologies with sufficient feedback loops.6,7
Serious games may be an opportunity to meet this demand for new educational interventions. Serious games are games developed and intended to provide playful learning experiences, which can be transferable to or applicable in real-life settings.9 Serious games
are often more effective compared with regular health care educational interventions10
or assessments.11 However, there is a lack of effect studies12 and assessment13 of good
quality on serious games.
Delirium Experience is a recently designed serious game that uses video simulation,14
which is intended to train and educate medical students on how to take better care of delirious patients. As both serious games15 and simulation-based learning16,17 provide
learning spaces in which learners can safely practice, Delirium Experience might serve as a new educational intervention by addressing the need for a focus on caregiver attitude and the application of knowledge to the care of delirious patients.
In this study, we aimed to gain insight into whether Delirium Experience is suited as an educational intervention for medical students regarding skills in advising care for delirious patients, skills in screening and rating of delirium symptoms, and improving the attitude toward delirious patients. Additionally, we aimed to gain insight into the possible effects of Delirium Experience on learning motivation and engagement, as well as self- reported knowledge on delirium.
Abstract
Background: Adequate delirium recognition and management are important to reduce
the incidence and severity of delirium. To improve delirium recognition and management, training of medical staff and students is needed.
Objective: In this study, we aimed to gain insight into whether the serious game Delirium
Experience is suited as an educational intervention.
Methods: We conducted a 3-arm randomized controlled trial. We enrolled 156 students
in the third year of their Bachelor of Medical Sciences at the University Medical Centre Groningen. The Game Group of this study played Delirium Experience. The Control D Group watched a video with explanations on delirium and a patient’s experience of delirious episodes. The Control A Group watched a video on healthy aging. To investigate students’ skills, we used a video of a delirious patient for which students had to give care recommendations and complete the Delirium Observations Screening Scale and Delirium Rating Scale R-98. Furthermore, students completed the Delirium Attitude Scale, the Learning Motivation and Engagement Questionnaire, and self-reported knowledge on delirium.
Results: In total, 156 students participated in this study: Game Group, 51; Control D Group,
51; Control A Group, 55. The Game Group scored higher, median (interquartile range 25-75), 6 (4-8), on given recommendations and learning motivation and engagement compared with Control D, 1 (1-4), and A, 0 (0-3), Groups (P<.001). Furthermore, the Game Group, 7 (6-8), scored higher on self-reported knowledge compared with the Control A Group, 6 (5-6; P<.001). We did not find differences between the groups regarding delirium screening (P=.07) and rating (P=.45) skills or attitude toward delirious patients (P=.55).
Conclusion: The serious game Delirium Experience is suitable as an educational
intervention to teach delirium care to medical students and has added value in addition to a lecture.
28 29
Delirium education for medical students
2
game tries to achieve this by giving players insight into what a patient experiences during delirious episodes and how your actions as a caregiver influence the experience of the patient. Delirium Experience was based on the delirium guidelines used in the United Kingdom19 and the Netherlands20 and on stories of patients who suffered from delirious
episodes. The game was developed with personnel who were specialists in developing serious games, designing education, and treating delirium, all working closely together. Usability was tested by a group of care professionals during the development. Based on their suggestions and feedback, the final version of the game was made. Completing the game once takes approximately 20 minutes; in these 20 minutes, one experiences 4 days as a caregiver and the corresponding 4 nights as the patient. During the daytime, as a caregiver, the player has to take care of a delirious patient and can choose different actions. Depending on the actions one chooses, the delirious episodes of the patient differ in severity, and one gets different actions to choose from the next day. Hence, if one performs poorly as a caregiver, the severity of delirious episodes increases, and the next day, one has fewer actions to choose from compared with a caregiver who performed well. Players who perform poorly have their actions limited to only the most important actions to decrease the level of difficulty. Furthermore, players receive feedback every other day in the game on how they performed and how they could improve as a caregiver before they switch to the patient’s perspective.
We compared this Game Group with two other groups, one with and one without information about delirium. The first control group, Control D Group, watched a video on delirium, which explained delirium causes, symptoms, diagnosis, treatment, and pathology. Contrary to the serious game, the video did not ask active involvement of students; thus, students were not able to try different scenarios. Furthermore, this group watched a second video of a patient’s experience explaining his suffering from delirious episodes.
The second control group, Control A Group, watched a more general video on healthy aging. This video did not have any specific information on delirium and how to take care of delirious patients; each session took 20 minutes.
Outcome Measurements
At baseline, before the intervention started, all participants completed a form including questions on sex, age, experience with older and delirious patients, learning community, self-reported knowledge on delirium “Which mark (0-10) would you give your knowledge on
delirium?,” and attendance at the lecture. Primary and secondary outcome measures were
assessed directly after the intervention or control condition.
The primary outcome of this research was assessment of the skills acquired by students in advising care for delirious patients, in which students describe how they would manage delirium in practice. In this outcome, students could show their understanding of patients’ needs and be able to translate this knowledge into practice.7,8 To measure skills in advising
care, all participants observed an interview of a delirious patient and were asked to give
Methods
Design and Study Population
We conducted a 3-arm randomized controlled trial. The study population consisted of undergraduate medical students at the University Medical Centre Groningen (UMCG). To be included in this study, participants had to (1) be in their third year of preclinical education in December 2016; (2) sign up for the practical on delirium; and (3) sign the informed consent form. The UMCG offers an undergraduate program of 6 years—3 years of preclinical and 3 years of clinical education. Preclinical medical students at the UMCG select 1 of 4 different learning communities with different, in-depth focus during their medical education (global health, sustainable care, intramural care, and molecular medicine). At the moment, the UMCG third-year preclinical medical curriculum on delirium is based on lectures and literature. However, educators of the UMCG emphasize the need for a more practice-based education before students enter their clinical education.
Students started with the conventional lecture on delirium. Thereafter, students could voluntarily sign up for the practical on delirium, in which the study conditions took place. The practicals were given in three separate classrooms of the University of Groningen. Each study condition had a separate classroom. All students had the opportunity to join the practical on delirium, including students who did not wish to participate in the study. Students were informed about the study in the description of the practical. This practical description explained that the practical was divided over 3 different groups for research purposes but did not explain the different study conditions. Students were not aware that the serious game Delirium Experience was one of the study conditions, in order not to influence the motivation to sign up for the practical. All students were provided a license of Delirium Experience after the practical so they could play the serious game. Data were collected and analyzed anonymously.
We used SPSS 23.0 (IBM Inc) for stratified block randomization (block size of 6) to allocate participants into one of the three research groups.18 Learning communities represented
the 4 different strata used. All participants who signed up for the practical were randomly allocated to one of the groups. They subsequently received an email indicating the classroom in which they were expected. As our research subjects consisted of medical students that could voluntarily sign up for both the practical and the study, registration of the trial was not necessary in accordance with the ICMJE recommendations.
Intervention and Control Groups
We designed three different practicals on delirium, which represented the study conditions. Only the intervention group, the Game Group, played Delirium Experience.14
Delirium Experience is a serious game focusing on delirium both from a patient’s and a caregiver’s perspective (watch the trailer in Multimedia Appendix 1). The goal of Delirium Experience is to allow players to learn how to take better care of delirious patients. The
Delirium education for medical students
2
Results
In total, 176 of 387 students subscribed for the practical on delirium in December 2016. Of these 176 students, 156 signed the informed consent form and participated in the study (Figure 1). The 20 students who declined to sign the informed consent form still participated in the practical but were not included in the study. Students did not have to give a reason why they declined to sign the informed consent form. We compared playing a serious game (Game Group) to either watching a video on delirium in combination with a video of a patient’s experience (Control D Group) or watching a video on healthy aging (Control A Group). Data on students’ characteristics and outcome measures were not normally distributed. The median age (interquartile range [IQR] 25-75) of all participants was 20 (20-21) years, and 75% (117/156) participants were females. No differences were found between the research groups regarding baseline variables, as presented in Table 1. 3 written recommendations for the care of this patient. A predefined rubric-form was used
to assess all given recommendations as rubric-forms can enhance the reliability of assessors’ scoring.21 The rubric-form was based on the Dutch delirium guidelines.20 Recommendations
were assessed independently by two researchers, and a weighted kappa was calculated. To ensure blinding of the assessors, data on intervention and control groups were removed from the assessed recommendations. Each recommendation could receive 0 (incorrect or not mentioned), 1 (topic mentioned), 2 (nonspecific recommendation), or 3 (specific recommendation) points from the 10 different domains of the Dutch delirium guidelines (range, 0-9 points).
Subsequently, several secondary outcomes were measured. First, use of screening and rating instruments for delirium was measured. Participants completed the Delirium Observations Screening Scale (DOSS)22 and Delirium Rating Scale R-98 (DRS-R-98)23,24 for
the patient in the observed interview. Both scales are widely accepted and applied tests for the recognition and severity assessment of delirium. Second, attitude toward delirious patients was measured using the Delirium Attitude Scale. The Delirium Attitude Scale is based on the Dementia Attitude Scale.25 Items regarding creativeness, enjoyment of life,
and coping skills were replaced by items focusing on the experiences of delirium. This resulted in a 19-item 7-point Likert scale (range, 19-133 points). “I feel confident around
people with delirium” and “I would avoid an agitated person with delirium” are examples of
statements used in the Delirium Attitude Scale. Third, learning motivation and engagement were measured using the Motivation and Engagement Questionnaire to evaluate learning experiences,26 a 9-item 5-point Likert scale (range, 9-45 points). Examples of statements
used in this questionnaire are as follows: “It was challenging to perform well in this practical” and “I liked this way of learning.” Finally, participants were asked to self-report their knowledge on delirium (range, 0-10 points).
Statistical Methods
We checked data for normality by judging histograms, skewness, and kurtosis. We analyzed discrete variables using chi-square test. Furthermore, continuous variables were analyzed using one-way analysis of variance (ANOVA) in case of normal distribution and Kruskal- Wallis in case of a nonnormal distribution. P<.05 was considered statistically significant for the results of the chi-square and one-way ANOVA or Kruskal-Wallis tests. In case of significant results regarding outcome measurements, specific post hoc or Mann-Whitney U tests were performed to investigate differences between the (1) Game Group and Control D Group or (2) Game Group and Control A Group. Furthermore, a Bonferroni correction for two tests was used for the Mann-Whitney test; therefore, P<.025 was considered statistically significant for the results of the Mann-Whitney test.
Figure 1. Flowchart of approached students and participants
387 students approached
176 students subscribed for the
practical
Control D
Video on delirium & patient experience n = 59 Game Serious game Delirium Experience n = 58 Control A Video on healthy aging n = 59 n = 7 n = 9 n = 4 Included in Game Group n = 51 Included in Control D Group n = 50 Included in Control A Group n = 55 Students who wanted to participate in the practical but not in
the study Random allocation
32 33
Delirium education for medical students
2
had a median score of 1 (1-4), and Control A Group had a median score of 0 (0-3). With regard to learning motivation and engagement, participants in the Game Group had a median score of 36 (32-38) compared with a median score of 27 (24-30) for the Control D Group and 20 (15-25) for the Control A Group. The median mark on self-reported knowledge of the Game Group was a 7 (6-8) compared with a 6 (5-6) for the Control A Group.
Discussion
Principal Findings
In this study, we investigated the effects of a serious game, Delirium Experience, as a new educational intervention. We compared playing a serious game with watching a video with delirium explanation in combination with a patient experience video or a video on healthy aging. The results showed that the serious game had a positive effect on students’ skills in advising care for delirious patients, learning motivation and engagement, and self-reported knowledge on delirium. However, the serious game did not influence skills in screening and rating the severity of delirium. In addition, it did not affect the attitude toward delirious patients.
The primary outcome of this study, skills in advising care for delirious patients, was measured on the basis of the given care recommendations. The independently assessed recommendations, which were scored using the rubric-form, had a weighted kappa of .835. Disagreements were resolved through discussion.
Kruskal-Wallis tests showed differences between the three groups regarding given recommendations, H(2)=54.5, P<0.001, learning motivation and engagement, H(2)=91.5,
P<.001, and self-reported knowledge, H(2)=26.0, P<.001, as presented in Table 2. No
differences were found regarding delirium screening, H(2)=5.2, P=.07, and rating H(2)=1.6,
P=.45, scores or in attitude toward delirious patients, H(2)=5.8, P=.55.
Furthermore, Mann-Whitney test to compare the Game Group and the Control D Group showed differences regarding given recommendations (U=466.0, z=−5.58, P<.001) and learning motivation and engagement (U=302.5, z=−6.61, P<.001) but not for self-reported knowledge (U=967.5, z=−2.18, P=.03). The comparison of the Game Group with the Control A Group showed differences in given recommendations (U=363.0,
z=−6.77, P<.001), learning motivation and engagement (U=110.5, z=−8.18, P<.001), and
self-reported knowledge (U=651.0, z=−4.91, P<.001). Participants in the Game Group scored a median score (IQR 25-75) of 6 (4-8) on recommendations, whereas the Control D Group
Table 1. Baseline variables.
Characteristics Total participants (N=156) Gamea (n=51) Control D a (n=50) Control A a (n=55) Age in yearsb, median
(interquartile range 25-75)
20 (20-21) 21 (20-21) 20 (20-21) 21 (20-21) Femalec, n (%) 117 (75.0) 37 (72.5) 40 (80.0) 40 (72.7) Experience older patientsc, n (%) 118 (75.6) 36 (70.6) 38 (76.0) 44 (80.0) Experience delirious patientsc, n (%) 48 (30.8) 17 (33.3) 15 (30.0) 17 (30.9) Learning communityc, n (%) Global health 45 (28.8) 19 (37.3) 15 (30.0) 12 (21.8) Molecular medicine 39 (25.0) 11 (21.6) 14 (28.0) 14 (25.5) Sustainable care 31 (19.9) 11 (21.6) 7 (14.0) 11 (20.0) Intramural care 40 (25.6) 10 (19.6) 14 (28.0) 18 (32.7) Attended lecture, n (%) 129 (82.7) 44 (86.0) 43 (86.0) 43 (78.2) Self-reported knowledge on delirium (0-10)b, median (interquartile range 25-75) 5 (4-6) 5 (4-6) 5 (4-6) 5 (4-6)
a Game: Delirium Experience; Control D: video on delirium with a patient experience video;
Control A: video on healthy aging.
b Data compared using Kruskal-Wallis test, P>.05. c Data compared using chi-square test, P>.05.
Table 2. Kruskal-Wallis and Mann-Whitney tests for primary and secondary outcomes
for the Game (n=51), Control D (n=50), and Control A (n=55) Groups. Outcome Gamea Control Da Control Aa Pb value P value
(G-D)c P value (G-A)d
Recommendations 6 (4-8) 1 (1-4) 0 (0-3) <.001 <.001 <.001
DOSSe 10 (9-11) 9 (8-10) 9 (8-11) .07 N/Af N/A
DRS-R-98g 14 (12-16) 13 (12-15) 14 (11-16) .45 N/A N/A
Attitude 92 (88-96) 94 (90-100) 92 (85-96) .55 N/A N/A
Learning motivationh 36 (32-38) 27 (24-30) 20 (15-25) <.001 <.001 <.001 Delirium knowledgei 7 (6-8) 6 (6-7) 6 (5-6) <.001 .03 <.001 a Data are presented as median (interquartile range 25-75); Game: Delirium Experience; Control D: video on delirium
with patient experience video; Control A: video on healthy aging.
b Kruskall-Wallis test to compare the three groups.
c Mann-Whitney test to compare the Game Group and the Video Delirium Group
(P<.025 considered statistically significant).
d Mann-Whitney test to compare the Game Group and the Video Aging Group
(P<.025 considered statistically significant). e DOSS: Delirium Observation Screening Score.
f N/A: not applicable.
g DRS-R-98: Delirium Rating Scale R-98. h Learning motivation and engagement. i Self-reported knowledge on delirium.
