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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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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I really liked it, because you learn something and normally you are just listening and are they telling you everything about delirium. Now you really see it, and you are really doing something with it! Because of that you learn more from it, and I just like it. - Nursing student after one year of nursing education and playing The Delirium Experience
The effect of a serious game on
delirium on nursing students’ care
advice and perceived self-efficacy:
a before-after design
Kiki Buijs-Spanjers Harianne Hegge Fokie Cnossen Sophia de Rooij Submitted3
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Delirium education for nursing students
3
Introduction
Delirium is an acute neuropsychiatric syndrome characterized by altered awareness, attention and cognition, and is often experienced by older and hospitalized patients. For patients, experiencing delirium is often frightening and distressing, not only during delirious episodes but also afterwards.1–3 Delirium is associated with functional decline, longer hospital stay, institutionalization, and mortality.4 However, severity, incidence, and consequences of delirium can be reduced with adequate and timely delirium recognition management, but delirium often goes unrecognized.5,6
Due to ageing of society and higher susceptibility of older patients to delirium, increasing numbers of hospitalized patients suffer from delirium, and therefore nurses have to provide more demanding care for an increasing number of delirious patients. In comparison to other health care professionals in the hospital, nurses have most direct contact with delirious patients and therefore play an important role in improving adequate delirium care.7 Commonly reported barriers to take adequately care of (the risk of) delirium are lack of delirium awareness, knowledge, education, and the overlapping symptoms with dementia.8,9 Nurses are often unaware of how to respond to delirious patients to decrease the intensity of delirium.10 Providing care for delirious patients is often challenging and entails a great burden for nurses.9,11 This has resulted in a call for more and better training of nurses.8,9
So far, most previous educational interventions on delirium have focussed on increasing knowledge and skills in recognition of symptoms of delirium.12,13 To improve delirium care, it is necessary that educational interventions not only focus on knowledge and skills in recognising delirium, but also in translating this knowledge into good clinical practice.9,14 It has been suggested that these educational interventions should actively involve learners and provide feedback.7,9,12,13
Furthermore, to improve clinical performance of nurses and nursing students, perceived self-efficacy plays an important role.15,16 Perceived self-efficacy is the confidence a person has in succesfully executing a particular behaviour or action. To enhance self-efficacy it is important to gain experiences in executing that specific behaviour.17 However, as exposure to delirious patients during nursing education is not always possible, gaining actual experience can be difficult. Caring for delirious patients entails a great burden for nurses as patients with delirium can show difficult behavior such as aggression or incivility.9 Self-efficacy of nurses had been shown to play a protective role against incivility at the workplace.18 The question thus arrises whether educational interventions to improve this experience may enhance perceived self-efficacy in nursing students towards taking care of delirious patients.
Serious games and simulation-based learning provide environments in which users can safely practice and gain experience.16,19–21 Because serious games and simulation are promising educational methods to improve nursing student education,22–24 we developed
Abstract
Delirium is often not recognized early enough. Commonly reported barriers are lack of awareness, knowledge, and education. Nurses are often unaware of how to respond to delirious patients while caring for these patients entails a great burden for them. We therefore developed a serious game, The Delirium Experience, on how to provide care for delirious patients. In a before-after design we investigated whether The Delirium Experience enhanced nursing students’ care advice for delirious patients and increased perceived self-efficacy in delirium care. We were also interested whether the game stimulated students’ learning motivation and engagement. 128 Second-year applied university nursing students participated in this study. To measure the quality of care advice for delirious patients, participants were asked before and after playing The Delirium Experience to write three specific recommendations for caring for delirious patients. We also measured perceived self-efficacy in caring for delirious patients, and learning motivation and engagement through validated questionnaires. The results showed that playing The Delirium Experience improved the quality of nursing students’ delirium care advice and perceived self-efficacy in providing care for delirious patient. Playing the game was also associated with a high learning motivation and engagement. We conclude that The Delirium Experience is a practical, useful, and effective educational tool for nursing students to improve delirium training.
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professional determine what happens to the patient during the night; hence differentchoices interact with the course of the delirium symptoms. In this way, players should gain insight into what a patient endures during delirious episodes, and how the concrete actions as a healthcare professional can influence this.
Players receive feedback after each 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 progression of delirium symptoms also provide feedback to the player. At the end of the game all players’ choices within the game are also evaluated. The game incorporates the delirium guidelines from the United Kingdom,26 and from the Netherlands27 and the scenes are based on experiences of real patients who experienced delirious episodes.
Measures
The primary outcome of this experiment was the quality of care advice for delirious patients. To measure this, participants were asked to write down three specific recom-mendations for the care for delirious patients. A pre-defined scoring rubric-form (as described in previous research 28) was used to assess the recommendations given. Rec-ommendations were scored from 0 to 3 points: 0 incorrect or not mentioned, 1 topic mentioned, 2 nonspecific recommendation or 3 specific recommendation; the total score thus ranged from 0 to 9 points. Hence, more specific care advices result in a higher score. Subsequently, two secondary outcomes were measured: perceived self-efficacy in providing care for delirious patients, and learning motivation and engagement.
General self-efficacy can differ from self-efficacy in completing a specific task.29 We therefore developed the more specific Perceived Self-Efficacy Scale in Providing Care for Delirious Patients, as a representative scale was not available. Based on the Dutch delirium guidelines27 and according to the principles of Bandura on how to construct a self-efficacy scale,29 we developed a 12-item scale (range 0 to 1200). All items on this scale referred to tasks recommended for nurses to perform when providing care for delirious patients. For each item, respondents were asked to rate how certain they felt that they would be able to perform that task on a scale from 0 (cannot do at all) via 50 (moderately certain can do) to 100 (highly certain can do). The scale has an internal consistency of =.958 (Crohnbach’s Alpha) and a test-retest reliability .924 (Pearson Correlation).1
To evaluate learning experiences of playing a serious game, we used the Motivation and Engagement Questionnaire, a validated 9-item 5-point Likert scale (range 9-45 points). This scale has previously been applied in Dutch medical students.30
1 Face validity was tested with two advanced nursing practitioners geriatrics and a geriatrician. Thereafter, we tested the scale with 37 nursing students that did not participate in this study. The scale of self-efficacy in providing care for delirious patients had a high internal consistency (Crohnbach’s Alpha .958, p=.000), and test-retest reliability (Pearson Correlation .924, p=.000).
The Delirium Experience to train and educate both students and healthcare professionals on how to provide care for delirious patients.25 The Delirium Experience is a serious game that makes use of interactive video simulation. It is a serious game showing delirium both from the patient’s and healthcare professional’s perspective. Players gain insight into what a patient endures during delirious episodes, and how the actions of a healthcare professional influence this. Furthermore, several scenarios include responses of a healthcare professional, providing players a role model on how they can approach delirious patients.
The aim of this study was therefore to investigate whether The Delirium Experience enhances nursing students’ care advises for delirious patients and perceived self-efficacy, and is also able to stimulate their learning motivation and engagement. We performed a single-arm experiment with before-after-test measurements.
Methods
Study population
In February 2018, we asked second-year nursing students at the Hanze University of Applied Sciences in Groningen to voluntarily participate in this study in addition to a practical on delirium. Students were provided with information on the study both written and verbally before the practical started. At the start of the practical, the first author (KBS) verbally explained the study, thereafter students were again provided with written information on the study. All 128 students agreed to participate in the study and gave informed consent.
Procedure and design
In the practical on delirium all students individually play The Delirium Experience twice, the first time to get familiar with the game, the second time to apply their newly obtained knowledge. Before playing, participants answered background questions on age, gender, experience with caring for an older patient (scale from 0 (no experience at all) to 100 (a lot of experience), experience with caring for delirious patients (scale from 0 (no experience at all) to 100 (a lot of experience), and internship experience. Before and after playing the game, they were asked to give care advice for delirious patients, and fill out two questionnaires: one on self-efficacy and learning motivation and engagement.
Intervention
In the game the player plays four “days”, which take about twenty minutes playtime (for a trailer https://www.youtube.com/watch?v=A-lLLP8Me0E). During daytime, the player receives the perspective as a healthcare professional of a delirious patient and has to provide care for the patient. During the corresponding nights, the player receives the perspective of the delirious patient himself. The daytime actions of the healthcare
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Perceived self-efficacy in providing care for delirious patients (range 0 to 1200) differed significantly after playing the game from before (t(127)=-11; p=.000). Participants’ mean score (SD) before playing the game was 462 (211) points compared to 638 (207) points after playing the game (Figure 3). This indicates that participants felt more confident in providing care to a delirious patient after playing the game.
Statistical analysis
Data was analyzed using IBM SPSS statistics version 23.0. We used descriptive statistics to describe baseline variables and learning motivation and engagement. To test whether quality of care advice and perceived self-efficacy increased after playing The Delirium Experience, we used a paired sample t-test (p-values < 0.05 were considered significant).
Results
In total, 128 students participated in this study. Participants’ median age (Inter quartile range (IQR)) was 19 (1) years; 116 (91%) were female. On a scale from 0 (no experience at all) to 100 (a lot of experience), participants’ mean scores (SD) was 51 (26) points on experience with caring for older patients, and 22 (24) points on experience with caring for delirious patients. Ninety (70%) participants had done their internship before the practical, while 38 (30%) participants were starting their internship after the practical. We did not find any statistically significant effects of internship experience on the primary and secondary outcome measurements; therefore, we collapsed results over all participants.
Scores on quality of care advice (range 0 to 9) before and after playing the game were significantly different (t(127)=-5.7; p=.000). Participants’ mean score (SD) before playing the game was 3.4 (2.0) points compared to 4.6 (1.9) points after playing the game (Figure ). Figure provides an overview of the assigned points (0, 1, 2, 3) to the care advices given by participants before and after playing the game, showing that after playing The Delirium Experience participants gave more specific care advice.
Figure 1. Mean care advice scores and SD before and after playing The Delirium
Experience (range 0 to 9)
Figure 3. Perceived self-efficacy scores and SD before and after playing The Delirium
Experience (range 0 to 1200)
Figure 2. Percentage of care advice in each point category before and after playing;
the higher the points the more specific the advice
0 1 2 3 4 5 6 7 8 9 Before After M ean 0 200 400 600 800 1000 1200 Before After M ean 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Before After Care a dvi ce in e ac h p oin t ca te go ry 3 points 2 points 1 points 0 points
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learning motivation. We already showed in a previous study that playing The DeliriumExperience increased learning motivation and engagement compared to other educational interventions in medical students.28 Therefore, we can safely assume that The Delirium Experience also increases learning motivation in nursing students. As high learning motivation and enhanced self-efficacy are important for nursing education,34 this is an important finding.
We emphasize the importance of a first-person’s perspective of a delirious patient in nurses’ education on delirium. Delirious patients are often stigmatized, and exposure to patients with delirium reduces stigma,35 and perspective-taking can also reduce stigmatization.36 Although nurses often have to care for delirious patients, most students are not sufficiently exposed to delirious patients during their education.7,37 It may be hard to expose all nursing students to delirious patients during their training without causing extra burden to patients. Therefore, it is important to embed the perspective of a delirious patient into nursing education. This also resonates the call for more patient-oriented instead of disease oriented training.14,37,38 We believe The Delirium Experience may be very useful in this context.
In the set-up of the present study, we did not include a debriefing after playing the game. However, debriefing after simulation exercises may enhance the effectiveness of the exercise. Students seem to prefer real life debriefing after simulation exercises.16,39 So we suggest to study the effect of a debriefing after playing The Delirium Experience to further examine whether debriefings are needed in nursing education and may further enhance the effect of the game.
Conclusion
This study shows that the serious game The Delirium Experience enhances nursing students’ ability to give specific delirium care advice and increases perceived self-efficacy in providing care for delirious patient. We believe The Delirium Experience is a practical, useful, and effective educational tool for nursing students to improve delirium care. On average, participants scored 33.7 points (SD=8.2) for learning motivation and
engagement (range 9-45), indicating that, in general participants were motivated to learn with The Delirium Experience.
Discussion
Our main findings were that The Delirium Experience enhanced nursing students’ quality of care advices for delirious patients, increased their perceived self-efficacy in caring for delirious patients with a high level of learning motivation and engagement.
After playing The Delirium Experience, the average score on quality of care advice increased from 3.4 to 4.6 (max score = 9). The initial score of 3.4 indicates that students already had some general knowledge of delirium care, but that after playing the game, recommendations became more specific. For example, before playing, a participant would involve family in the caring process, an advice that became more specific by using rooming-in (inviting family to stay the night). We can therefore conclude that students obtained more knowledge on specific behaviors of taking care of these patients, which was our main research question. This is an important finding as nurses often are unaware of how to respond to delirious patients.10 There are several features in The Delirium Experience that may support students in obtaining more knowledge on behaviors related to providing care to delirious patients. Firstly, as serious games and simulation-based learning provide safe environments in which users can safely practice,16,19,20,31 in the game students are empowered to practice their skills in a safe environment and thereby gain more practical knowledge on how to provide care to delirious patients. Secondly, a first-person perspective facilitates better comprehension of the study material. This also enhances transfer of what players saw to their own performance.32 The perspective of the healthcare professional in the game may therefore have contributed to their increased knowledge on specific behaviors in providing care for delirious patients.
Playing The Delirium Experience increased nursing students’ perceived self-efficacy from 462 to 638 points (range 0 to 1200 points), indicating that students felt more confident in providing care to delirious patients. This study therefore confirms that perceived self-efficacy can be improved by simulation-based education, including serious games, as was already suggested in previous research.16 This increase in perceived self-efficacy after playing the game may be explained by several features of the game. Firstly, exposure to effective role models is related to improved relational occupational coping self-efficacy of nurses.18 In the game students are exposed to a role model of a healthcare professional on how to approach and provide care to delirious patients. Secondly, the game creates a safe environment to practice, and practicing increases perceived self-efficacy.17,33 Thirdly, increased learning motivation is related to improved self-efficacy of nursing students.34 In our study, the game was associated with high
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