Improving delirium education: the role of experiential learning in a serious game
Buijs-Spanjers, Kiki
DOI:
10.33612/diss.126540538
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Publication date:
2020
Link to publication in University of Groningen/UMCG research database
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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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Awesome! I found it really interesting. Especially because of the headphones, your laptop, and I was hyper focused on what I saw and heard!
I wasn’t distracted by my surrounding at al. It was interesting to really experience it from another perspective, that was really cool.
- Nursing student after 1 year of nursing education and playing The Delirium Experience
The influence of a serious game’s
narrative on students’ attitudes and
learning experiences regarding delirium:
an interview study
Kiki Buijs-Spanjers Anne Harmsen Harianne Hegge Jorinde Spook Sophia de Rooij Debbie Jaarsma Submitted6
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Background
Delirium
In recent years, researchers have identified persistent gaps in delirium education for health care professionals, which result in suboptimal delirium care.1–7 Delirium is an acute neuro-psychiatric syndrome characterized by altered attention, awareness, and cognition, and is associated with serious consequences such as increased length of hospital stay, functional decline, and mortality.8 Depending on the clinical setting, the incidence of delirium varies from 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.9 For patients, experiencing delirium and having flashbacks of delirious episodes is frightening and affecting their psychological and emotional well-being.10–12 Providing appropriate care to delirious patients also entails a great burden for healthcare professionals because of for example difficult behaviors of patients and the overlapping symptoms with dementia.13,14 Although early detection of delirium or timely recognition of patients at increased risk of delirium is highly important to prevent incidence or severity of delirium, it frequently goes unrecognized.15 Low detection rates of delirium are often related to low delirium awareness, inadequate knowledge and education, lack of time, feeling uncomfortable with delirium assessment, and missing co- operation between professions. However, if delirium and/or its increased risk are detected, these barriers, together with negative attitudes towards delirium, are also related to suboptimal delirium management.2,13,16–18
Researchers emphasize the need for different and more effective delirium education to overcome unnecessary barriers influencing delirium detection and management.4,6 On the one hand a change is needed in content of delirium education to address negative attitudes of healthcare professionals towards delirium, the lack of understanding how frightening delirium is, and behavior and communication skills in delirium care.4,6 On the other hand, there is a call for educating delirium care with methods that incorporate interaction and active involvement of learners, sufficient feedback loops, and simulations.3,6,13,19,20 Delirium education should not only focus on specific disease related knowledge, but have a more patient-oriented focus.4 To accomplish more patient-oriented education it is important to involve patients and family members in the delivery of delirium education and increase clinical experiences.3,6,21 However, this may increase the burden on patients in real life.3,21 Serious games provide an environment in which players can safely practice before entering real-life settings, thereby allowing players to gain experiences without increasing the burden on patients.22
Serious games
Serious games are developed for other purposes than conclusive entertainment and aim to provide playful learning experiences.22,23 In medical education, serious games are often more effective in achieving their goals compared to conventional education.24–26
Abstract
Background: Delirium is a neuropsychiatric syndrome that affects patients’ attention and
awareness as a result of a physical condition. Persistent gaps in delirium education have been identified, which result in suboptimal delirium care. Still little is known about which aspects play a role in effective delirium education. Serious games are games that are both entertaining and an active learning environment, providing safe environments in which players can safely experiment to create new knowledge. They hold the potential to contribute to improvements for delirium education. This study aims to explore aspects potentially playing a role in students’ learning experiences and attitudes regarding delirium by making use of a serious games’ narrative.
Methods: We interviewed seven vocational nursing students and nine students from the
Master of Medical Sciences on their attitudes and learning experiences after playing the serious game using a semi-structured interview guide.
Results: We identified that the patient’s and nurse’s perspective, interactivity to
experiment, realistic views on care options, and feedback on care actions were important aspects for students attitudes and learning experiences toward delirium. These aspects contributed to students being actively involved and experimenting with the study material, which in turn contributed to enhanced reflection on their caring for delirious patients and learning to do so. In addition, our findings emphasized the importance of incorporating a patient-oriented focus in delirium education to drive attitudinal change. Emotional responses were provoked by these aspects which enhanced students’ learning experienced and created better understanding of the patient’s experience
Conclusions: A patient-oriented narrative within a serious game provides a clinical
relevant experience to students on which they reflect. In addition, it is a medium for active experimentation to create better understanding of how healthcare professionals influence the patient’s experience of delirium.
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This type of learning is used in many different fields in the education of healthcareprofessionals.47,48 Healthcare professionals describe they often rely on experiential learning when providing delirium care in cases where they lack education or experience to provide good quality care.13,33,49 However, experiential learning is not often explicitly incorporated in delirium education.13,34,49
Aim
In this study, we aim to explore aspects of a serious game’s narrative potentially playing a role in students’ learning experiences and attitudes regarding delirium by making use of a serious games’ narrative.
Methods
Study design
This study explores which aspects from the serious game’s narrative influence students’ attitudes and learning experiences regarding delirium. We therefore needed to engage in interpretations of participants’ experiences after playing the serious game. To do so, we used semi-structured interviews as these allowed us to engage in these interpretations and probe for responses and clarify ambiguities.50,51
Game and narrative description
The Delirium Experience is a serious game that makes use of video simulation. It aims to teach players how to improve their caring for delirious patients, provide them with insight in what patients endure during delirious episodes, and how the actions of the healthcare professional influence the patient’s experience.52 The game incorporates the delirium guidelines from the United Kingdom,53 and from the Netherlands.54 The scenes are based on experiences of real patients who experienced delirious episodes.
The game incorporated the narratives of an older 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 of the healthcare professional. In the game, players play four days from the perspective of the healthcare professional. Within this perspective, players provide care to the patient and have to choose which care actions they would like to perform, and as such manipulate the narrative. During the corresponding nights, players receive the perspective of the patient. The features in this perspective differ depending on the actions of the player taken during daytime. Players receive tailored feedback after each play day in the game on how they could have improved caring for a delirious patient. Furthermore, the responses of the patient to the care actions of the player and the consequences on the delirium symptoms also provide feedback to the player. At the end of the game all players’ care In previous research, we showed that the serious game ‘The Delirium Experience’ is suited
to teach delirium care .27 However, still little is known about which aspects affect learning delirium care,1,3,4 and also about which aspects of serious games contribute to players’ learning experiences and outcomes.28–30 The narrative is an element of serious games that can be of value in addressing the issues in delirium education as this supports players in information processing and making sense of the experience.31,32 Also experiential learning seems to be important because healthcare professionals often rely on experiential learning when providing care for delirious patients with insufficient knowledge or experience.13,33,34
Narratives
Narratives can be defined as stories with a beginning, middle and end, and they provide information on scenes, characters, and conflict.35 Thereby they raise questions or unresolved conflicts and present a solution.35 Narratives often increase involvement with the learning material and create empathy for the characters through narrative characteristics (i.e., characters and interactivity) and engaging elements of the narrative (i.e., identification, transportation, and perceived realism).36–39 For medical students, narratives are also relevant in promoting the more humanistic aspects of medicine.40
When learners get immersed into the narrative, the narrative can influence the learner’s attitude 35. Attitudes are learned evaluations of persons, places or issues that affect thoughts and behaviour 41, and are composed of affective (feelings and emotions), behavioural and cognitive (knowledge and beliefs) components.42,43 A narrative that involves patients, families, and carers involved in delirium care may stimulate the attitudinal change by learning from the patient’s experience, which is essential to improve delirium care.6,44 A first-person perspective in a narrative facilitates better comprehension of the study material by enabling the transfer of what players saw to their own performance.45 A first-person perspective of people involved in delirium care therefore holds the potential to increase players understanding of the patient’s experience and behaviour and communication skills in delirium care.
Experiential learning
Learning within a serious game can often be considered to be experiential learning. Experiential learning considers how learners take experiences they gather in the outside world into their learning process.46 Experiential learning is an active form of learning in which the experience a learner gains must be interpreted and integrated into what the learner already knows to create new knowledge. Reflection is therefore essential in experiential learning to make sense of the experience.46,47 Another important aspect of experiential learning is experimentation with what they have learned via the experience and interpretation of this experience.46
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In total, sixteen respondents participated in the study. The sample consisted of sevennursing students and nine medical students, of which two were males and fourteen females in the age of 16 till 27 years. The interviews took between thirteen and 46 minutes. Table 1 shows an overview of the participants.
Research team and reflexivity
The team was composed of two junior (KBS and AH) and four senior researchers (HH, JS, SR, DJ). KBS has a background in communication sciences and nutrition, and she was a PhD-candidate at the time of the interviews. AH is a nurse and has a background in communication sciences, and she was a Master of Science student at the time of the interviews. HH is an internist and clinical educator. JS is an experienced researcher in serious game research. SR is a professor of medicine, trained in geriatrics and internal medicine. And DJ is a professor in health professions education. The diversity of this research team enabled us to interpret the results with insights from the different aspects of this narrative: medical, educational, and as a serious game.
To prevent recall bias, interviews were conducted within one week after playing the game. Furthermore, interviews were conducted at quiet locations that suited the options taken within the four days of the game are evaluated in the game as written
feedback. It takes twenty minutes to complete the game once.
Participants
The Delirium Experience is intended for a broad audience, varying in background, experience and education. Researchers have emphasized the need for educating delirium care to healthcare professionals in an early stage.6 We were therefore specifically interested in studying the influence of the narrative in both Vocational Nursing students and Master of Medical Sciences students. With these two target groups, we were able to gather a heterogenic sample consisting Dutch students at either a Vocational Nursing school or University Medical Center in the Netherlands.
Ethical approval or registration was not necessary in accordance with the International Committee of Medical Journal Editors (ICMJE) guidelines as our participants were medical and nursing students who could voluntarily sign up for the study. All participants provided written informed consent.
Procedure and setting
Purposive and snowball sampling was used to recruit participants varying in background, experience, and education.50 For the purposive sample, we used practical sessions that were part of the regular delirium education. Furthermore, we used snowball sampling to reach medical students via contacts at our Geriatric Department.
The practical on delirium for nursing students took place in June 2018, for medical students in July 2018. One week before the practical on delirium started, 20 nursing and 20 medical students received an e-mail with the information letter on the study. In this information letter, we explained the aim of this study and asked students if they wanted to participate. If students were interested in participating they could schedule an appointment with the second author (AH) via e-mail. A reminder was send two days before the practical started. At the beginning of the practical, the study was once more orally explained by the second author (AH). Students could still schedule an appointment during the practical. Out of these 40 students approached, eleven were willing to participate. Although students did not have to provide a reason for non-participation, students who voluntary did gave a reason said they did not want to participate due to time-constraints. In January and February 2019, we asked our colleagues within the Geriatric Department to invite also some additional medical students from their network to participate in this study. We did so to reach out to more students we could include in our study because new themes emerged from the previous conducted interviews. Students who were interested in participating in this study received the e-mail with information letter and could contact the first author (KBS) for additional information or schedule an appointment for the interview. We included five additional medical students until data saturation was reached and no new themes emerged from the interviews.
Table 1. Characteristics of participants and interviews
Participant Education
type Years of education Experience with delirium Age(in years) Interview duration(in minutes)
P1 Nursing 1 Some 17 16 P2 Nursing 1 Some 17 13 P3 Nursing 1 No 18 21 P4 Nursing 1 No 18 26 P5 Nursing 1 No 16 26 P6 Nursing 1 No 20 35 P7 Nursing 1 No 17 22 P8 Medical 4 Yes 22 32 P9 Medical 4 Some 22 25 P10 Medical 4 Yes 23 23 P11 Medical 4 Some 23 16 P12 Medical 6 Yes 25 40 P13 Medical 4 No 23 41 P14 Medical 6 Yes 24 37 P15 Medical 5 Yes 23 46 P16 Medical 6 Some 27 36
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Results
We could distinguish four different aspects affecting learning experiences and attitudes regarding delirium: (1) perspectives of the characters, (2) interactivity, (3) realism, and (4) feedback.
Perspectives of the characters
The perspectives of the characters made participants more involved into the narrative. Seeing the same scene in the game from two different perspectives was highly valued by participants, because the responses of the patient made more sense to them now; as explained by a participant: First, you just see the teabags from his [the patient] perspective.
Then from the nurse’s perspective, you see him muddle with his hands … you think the patient is just acting weird, but when you also see how it is for the patient, it makes sense that you tidy out if you see teabags. [P12] Participants also stated the two perspectives made them aware
of the consequences of their actions as a healthcare professional, as one participant explains: When I played the second time, I played dark play, and I thought ‘if you act incorrect,
the things people see are really more frightening’. This made me realize in a certain way you are responsible for how intense delirious episodes become. [P11]
Patient
The patient’s perspective was highly valued by participants. It enabled them to create an idea of what delirious patients see and endure when experiencing delirious episodes. A participant explains this by comparing it to reading learning material: If you’re reading,
you have to imagine what it is like … and in The Delirium Experience, you can see what a patient sees, how it looks like and what happens … it makes it easier to create an image of how it would be for a patient. [P13] Because of this, participants mentioned having more empathy for
delirious patients. It also made participants realize experiencing delirious episodes is more intense and frightening than they expected. Explained by these two participants: What we
learned was that, just in general, a delirious patient can be a little confused, but it is more than confusion, for the patient it is really severe. [P5] and When you leave during the night, you don’t see delirium anymore, but for the patient it is the most intense at that moment. That is something I forget because you are working with other people at that moment again. [P14]
The patient’s perspective created better understanding of the responses and actions of patients during delirious episodes. Participants stated they often had the notion that delirious patients were acting weird, but they could make more sense to these responses due to the patient’s perspective in The Delirium Experience. Furthermore, a participant explained she could understand why patients do not respond when you enter their room:
Something I also didn’t realize yet, was when he wakes up with all the little creatures crawling around, the nurse enters but even I almost didn’t notice her because you are so focused on what is happening around you. [P15]
participant without the presence of other people to make sure participants felt at ease and not distracted during the interview. We also explained to participants that the researchers (KBS and AH) conducting the interviews were not involved in the development of The Delirium Experience to prevent interviewer bias leading to socially desired answers. To ensure students did not feel obliged to participate, students were allowed to play The Delirium Experience without participating in the study. Furthermore, the researchers were not involved in the education of the participants nor did they know the participants on forehand. All participants signed an informed consent form stating they were willing to participate and allowed anonymously audio-recordings of the interview.
Data collection
The interviews were conducted by the first and second author, AH conducted nine interviews, KBS conducted the remaining seven. Interviews were conducted using a semi-structured interview guide, which was developed on the basis of literature and discussions with members of the team (KBS, AH, JS, DJ). The interview guide specifically included questions on participants’ attitudes and behavior towards delirious patients, and knowledge and learning experiences on delirium.4 We used narrative characteristics (i.e., characters) and engaging elements (i.e., realism) of a narrative as prompts to provoke more in-depth answers.37,38 We conducted two pilot interviews to refine the interview guide. Before the interview started, participants answered demographic questions on age, gender, education level and year, and experience with providing care to delirious patients. All interviews were audio-recorded, transcribed verbatim, and summarized.
Data analysis
Data collection and analysis occurred concurrently. Data was analyzed by making use of inductive content analysis with constant comparison to find similarities or differences within and across interviews.50,55 Two researchers (KBS and AH) thoroughly read all the transcripts to get familiar with the data. Thereafter, codes were applied to describe the aspects of the content. Codes were repeatedly evaluated with four researchers (KBS, AH, JS, DJ). In case new codes emerged from the dataset, they were applied inductively. Overarching themes were defined and named. Team meetings were used to discuss the process and interpretations of the data. We used Atlas.ti software, version 8 (ATLAS.ti Scientific Software Development GmbH, Berlin) for the coding process. Three transcripts were coded by two researchers (KBS and AH). Disagreements on assigned codes were solved through discussion. Five transcripts were coded by only the first author, eight by only the second author. Summaries of all transcripts were discussed by two researchers (KBS and HH) to clarify the themes.
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delirious patients without doing something wrong at a real patient. The choices are of coursesomewhat limited, so that doesn’t resemble how you would act in real life, but it makes you think about what you should do. [P9] Reflecting on what they would do in real life was even
enhanced since the interactivity was related to providing care to patients in real life, as in real life the wellbeing of the patient is also depending on their choices. The interactivity also made participants more involved because they had a feeling of control over the course of the narrative. Participants stated they valued the possibility to make choices within The Delirium Experience because it allowed them to make mistakes and learn from these mistakes without harming a patient. Finally, the interactivity made participants curious to explore other options and wanting to play the game multiple times.
Realism
Participants evaluated The Delirium Experience as realistic and stated this was important for them. Firstly, because it created better understanding of how patients experience delirious episodes and how this influences the patient’s behavior. This understanding was even enhanced due to the audible thoughts of the patient when experiencing delirious episodes.
Secondly, participants stated that the realism in The Delirium Experience makes it easier to transfer what they learned to real life later on. On the one hand because they could easier translate the examples on how to provide care for, or communicate with a delirious patient to real life. On the other hand, the limited amount of time available to provide care to the patient resembles real professional life and made participants reflect on what care choices would be most important for the patient’s wellbeing. A participant explained: Because of the limited amount of time available you can’t do everything you would
like … Because of that you start thinking about what you find the most important to do for a delirious patient … But when I could have done everything I would have clicked on everything and just see what would have happened. [P14]
Thirdly, participants stated they were more involved with the study material because it looked realistic to them. One the hand they were more involved because the realistic responses of the patient interested them. On the other hand, this realism also created better involvement because the choices they made in the game were more considered. Explained by a participant: I like it [the realism], because you get more involved in the narrative,
and it is not just an icon, but a real person … that is nice because it creates more empathy and because of that you make more considered choices instead of just clicking at something. [P3]
Feedback
In general, participants stated that the feedback in The Delirium Experience gave them more knowledge what actions to perform when providing care to delirious patients. This was mainly a result of the written feedback at the end of each day in the game. However, participants also stated they were in need of more specific written feedback providing Participants mentioned the patient’s perspective showed them important aspects of
providing care to delirious patients because they could experience what the effect was on the patient; explained by a participant: I think the patient’s perspective is really important in
realizing why it is frustrating not to talk to somebody. You can read that you should first communicate with the patient … but when you hear doctors speak from his perspective, you realize you also don’t like people speaking across you and you can’t hear them. That strengthens why you should do something and also makes it more likely you remember that experience, because you did not only read it, but you experienced it. [P14]
Experiencing the patient’s perspective also made participants reflect on their actions as a healthcare professional. Participants mentioned they would now act differently when they would encounter delirious patients; explained by this quote: I learned a lot, and for
that I would now pay more attention to a delirious patient. It is something really intense, and something small can already have a big impact on a patient. So, I think now I’ve seen this, I’ll take delirium more seriously. [P7]
Before playing The Delirium Experience, participants stated they sometimes felt helpless when caring for delirious patients as they felt they could not do enough for the patient. After playing the game, participants mentioned delirious episodes were much more intense than they expected.
Nurse
The nurse’s perspective mainly showed participants examples on how to provide good quality care to delirious patients. This made participants more aware of which behaviors they could execute when providing care to delirious patients, but also how to communicate with patients suffering from delirium; as a participant explained what she learned from the nurse’s perspective: Anyway, I learned how I should approach these patients. [P2] It also made participants who felt helpless because they had the feeling they could not do enough for delirious patients, feel less helpless because they now knew better what they could do for a patient experiencing delirious episodes. Furthermore, participants stated the nurse’s perspective was important to improve collaboration between nurses and doctors when providing care to delirious patients.
Interactivity
The interactive element of the narrative within the serious game allows participants to change the course of the narrative. Participants stated they obtained knowledge on how to provide care to delirious patients because of the interactivity in The Delirium Experience. This was mainly since the interactivity made participants actively involved with the study material and they thereby reflected on their actions within the game, and what the consequences of these actions were for the patient. They mentioned this made them reflect on what to do when they would have to provide care for delirious patients in real life as this participant answered: It looked realistic and in this way you encounter caring for
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interactivity of the narrative appeared to influence the behavioral component. Theseaspects contribute to students’ awareness on how to behave towards delirious patients. The patient’s perspective made them aware on how a patient experiences the behavior of the healthcare professional, the interactivity supported them in seeing the consequences of their behavior, and the nurse’s perspective showed how students could execute these behaviors. Students often mentioned the communication with a delirious patient as a behavior they would change due to these aspects, which is one of the important topics that need to be addressed in delirium education.4
The cognitive component consists of students’ knowledge and beliefs on delirium.42,43 Aspects of The Delirium Experience’s narrative, important for the cognitive component, were the patient’s perspective, interactivity, and feedback. These aspects changed the beliefs students had on how their actions as a healthcare professional made a difference for the patient’s experience of delirious episodes, thereby holding the potential to change students’ attitudes.56 Secondly, these aspects also increased students’ knowledge on how patients experience delirium and how to provide care to delirious patients.
For all three components of attitude, the patient’s perspective played an important role. We therefore emphasize the need to incorporate the patient’s experiences and perspective in delirium education to contribute to more patient-oriented delirium education. Our results thereby confirm the importance of incorporating a patient-oriented focus in delirium education to drive attitudinal change.4,6,7
The aspects influencing students’ attitudes towards delirium also contributed to higher involvement in The Delirium Experience. Previous research in domains outside medical education, already showed that the use of multiple perspectives, interactivity, and realistic settings can enhance the involvement of players.39,57,58 To enable attitudinal change, this higher involvement is important because it motivates students to evaluate and reflect upon the messages incorporated in The Delirium Experience’s narrative. These evaluations and reflections are related to attitudes that are more persistent over time and a better predictor of their behavior when providing care to patients with delirium.59,60 Learning experiences
Also with regard to students’ learning experience the perspectives, interactivity, and realism were found to be important for students’ active involvement with the learning material. These aspects created involvement because it made students see the value of what they could learn from the game’s narrative. This is an important finding as there is a growing demand for educating delirium care with more interactive methods that actively involve learners,3,5,13,19 because active involvement increases learning experiences and outcomes.61,62 Our results suggest that to enhance active involvement in delirium education incorporate the perspectives of people involved in delirium care and a close connection with the reality of caring for a patient should be incorporated.
information on why certain choices were incorrect and how they could improve even more. However, the lack of this feedback also triggered participants to experiment with different options and made them reflect on their choices as one participant answered: At
the end, I didn’t know what I did wrong. I think it was the order of actions, but what the correct order was, I don’t know. … this didn’t work, so I’ll try something else, or just think what the correct order would be. But I missed that you didn’t see the correct choices because you can learn from that. But because of that I started thinking about the choices I made like ‘this happened then, what would happen if I do this, would that be the correct choice or should I…’ So actually, it made me think about the choices. [P6]
In contrast, there were also participants who mentioned the response of the patient and progression of the delirious episodes triggered them to reflect on what they did and how this influenced the patient and narrative. Thereby they used the feedback from the patient’s response to actively search for answers on why something was wrong or how to improve themselves; as explained by a participant: So I think the way the patient reacts and
how his story continues, that’s more important. Because of that you see what effect your choices have on the patient himself. And then you can think of what you should or shouldn’t do. [P13]
Discussion
In this study, we aimed to explore the aspects potentially playing a role in students’ learning experiences and attitudes regarding delirium by making use of a serious games’ narrative. We identified four important aspects at play when learning to provide care to delirious patients: (1) perspectives of people involved in delirium care, (2) interactivity to experiment, (3) realistic views and care options, and (4) feedback on care actions.
Principal findings
Attitude
We found several aspects of the serious game’s narrative that played a role in addressing students’ attitudes towards delirium in terms of affective, behavioral, and cognitive components of attitude. The affective component of attitude resonated with feelings and emotions towards delirium.42,43 Aspects from The Delirium Experience that influenced students’ feelings and emotions were: the patient’s perspective, the nurse’s perspective, and the realism of the delirious episodes. These aspects made students feel less helpless when providing care to a delirious patient, and created better understanding of what a delirious patient encounters and how this explains their behavior. This is an important finding as understanding of how frightening delirium is, is often lacking,4 and healthcare professionals often experience discomfort when caring for delirious patients.16,18
The behavioral component of attitude refers to a person’s tendency to behave in a certain way towards delirium.42,43.The patient’s perspective, nurse’s perspective and
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All the aspects we found in this study, were always presented to the participants incombination with other aspects of The Delirium Experience. However, this study provides insight aspects of importance for both delirium education as well as serious games that may enhance future development or in the development phase to distinguish between aspects.70
Further recommendations
Current delirium education often fails to address co-operation between the different professions involved in delirium care.1,17 Our results indicate that taking another person’s perspective may enhance co-operation between healthcare professionals because medical students stated collaboration with nurses would be easier because they gained insight in their activities. We therefore propose to investigate the use of perspective- taking to improve co-operation between the different professions in delirium care.
In this study we were interested in the use of a narrative for learning delirium care of undergraduate students, as researchers emphasized the need to teach delirium care early on in education.6 There are however also similar issues that need to be addressed in delirium care for healthcare professionals already graduated and working with delirious patients. We would therefore recommend to repeat this study with a broader sample of healthcare professionals.
Conclusion
In learning delirium care a narrative contributes to students’ learning experiences by the perspectives of people involved in the care process, interactivity to experiment, realistic views and care options, and feedback on care actions. This creates greater understanding of the experience of a delirious patient and addresses attitudes towards delirious patient, but also contributes to knowledge on care behaviors and how to communicate with delirious patients. A patient-oriented narrative within a serious game provides an experience to students on which they reflect and a medium for active experimentation to create better understanding of how they influence the patient’s experience of delirium. Many aspects of The Delirium Experience’s narratives triggered emotional responses
in students. For example, the frightening episodes of delirium from the patient’s perspective or the unexpected influence on the delirious episodes due to the interactivity. These emotional responses are important to enhance learning experiences, and provide learners with better understanding of the patient’s experience.46,48,63,64 In delirium care, healthcare professionals’ understanding of the patient’s experience is often missing,3 these emotional responses are therefore of essential value in delirium education. The patient’s perspective also contributes to a more patient-oriented education, which is suggested to be an important improve in delirium education.3,6,21 Our findings indicate that the patient’s perspective evokes emotional responses in students that eventually may contribute to better delirium care by enhancing the transfer of knowledge to student’s practical performance45
Integrating feedback into a narrative in different ways seems to provoke reflection and active experimentation, which are important for learning.46 Although feedback is most effective when the messages are specific and clear ,65,66 our results suggest that some students may achieve learning goals in a different way if feedback is less specific. Providing general written information on the student’s progression in the narrative, triggered some students use active experimentation with the narrative to find the feedback they needed. Active experimentation plays an important role in learning knowledge transfer in delirium care.13,46 Students also reflected on their actions within the narrative to find the answers on unresolved questions in the written feedback. These reflections may contribute to the transfer of obtained knowledge into practice, because the development of professional practice includes constant reflection on action and the exploration of multiple perspectives.47 However, for students who were not triggered to find the explanation in a different way, the amount of written feedback was too limited to fulfill their learning needs. It seems that these students were unable to decode the feedback incorporated in the patient’s narrative.67
Strengths and limitations
An important strength of this study is that it resonates with the call to gain more insight in which aspects contribute to achieving goals in both delirium education as well as serious games.1,3,4,24–26,68,69 The findings of this study are therefore of use for future development of delirium education and serious games.
However, this study also has a number of limitations. First this study aimed to investigate the aspects of a serious game’s narrative at play in improving delirium education. Although we explained this to our participants, we noticed that it was hard for participants to distinguish between aspects of the narrative and serious game. Our findings may therefore not be generalizable to narratives that are applied via other mediums than serious games. Second, we used the complete version of The Delirium Experience in our study. We were therefore unable to isolate specific aspects to investigate their individual influence.
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