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Nurse Education in Practice 11 (2011) 20e25

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Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

‘The Ward’: A simulation game for nursing students

David Stanley*, Karen LatimerC/o Curtin University of Technology, GPO Box U1987, Perth, Western Australia 8645, Australia

a r t i c l e i n f o

Article history:Accepted 8 May 2010

Keywords:GamingSimulated learningCritical thinkingTeam work

* Corresponding author. Tel.: þ61 08 92662212.E-mail address: D.Stanley@curtin.edu.au (D. Stanle

1471-5953/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.nepr.2010.05.010

a b s t r a c t

Aim: To evaluate the effectiveness and suitability of ‘The Ward’ as a simulation game to promote andsupport students’ understanding of decision making, critical thinking and team work in clinical practicesituations.Background: Students commonly indicate that there is a ‘gap’ between the theory and practice aspects oftheir nursing education. Nursing is also a team-based profession requiring collaboration and cooperationthat is rarely seem in educational programs. Attempts to address these issues resulted in the develop-ment and trial of the simulation game ‘The Ward’.Methods: A qualitative study using a questionnaire (n ¼ 76) and four focus groups.Results: ‘The Ward’ proved to be well received as a learning tool and was enjoyable and effective inaddressing learning issues related to clinical skill practice, ward management, nursing practice knowl-edge, critical thinking, medication knowledge and leadership. It also offered valuable learning in theareas of team work and decision making.Conclusion: ‘The Ward’ was shown to be a very useful simulation exercise that has evaluated well andhelped promote the pivotal role of teamwork for student nurses and bridge the gap between theory andclinical practice in a safe, non-threatening way.

� 2010 Elsevier Ltd. All rights reserved.

Introduction

Teaching in relation to any topic requires considerable creativityand imagination inorder to captureandretain the interestof students/learners (Layne, 2001; Rowe, 2004). Simply having to deal with largegroupsofnursing students canmitigateagainst learningopportunitiesthat are lively, creative and enjoyable. Learning inways that stimulatecreativity and imagination in the student/learner will result in betterquality andmore in depth learning than more traditional approachesto learning (Reece andWalker, 1997; Knowles, 1998).

It is suggested that the content of some nursing programsmay beunrelated to the realities of clinical practice, highlighting a theor-yepractice gap (Nolan and Grant,1992; Lathlean and Vaughan,1995;Wilson-Thomas, 1995; Harttick et al., 1999 and Landers, 2000) thathas been the source of concern and attention in nurse education forsome time. Breeching the theoryepractice gap is essential if teachingis to be effective, relevant and applicable in the real world of practice.‘The Ward’ has been developed in an attempt to bridge the ‘gap.’

Much of the work of nurses and health professional involvesworking in teams (Bishop, 2009), however a considerable propor-tion of a nurses’ educational experience may still require students

y).

All rights reserved.

to learn independently. This issue is compounded by the intro-duction of electronic learning support modalities such as BlackBoard and Web CT which may encourage students to remainfurther isolated from a collaborative study environment. Occasionsarisewhen students are encouraged to establish small study groupsor to engage in groupwork as with Problem Based Learning, orEnquiry Based Learning and seminar groups. Therefore learning towork in teams and understand the dynamics of teamwork is centralto understanding how nurses function in many clinical environ-ments. Team work takes time to develop and requires communi-cation, respect and learning to learn from and with each other.

As such a simulation game, ‘The Ward’ was designed to allowstudent nurses to explore aspects of nursing theory and its rela-tionship to practice in a safe and controlled environment. Itprompts students to work in teams, with clear roles, but with allteam members working toward the same goal. It also prompts andpromotes the application of nursing knowledge to a range ofscenarios and situations based on aspects of hospital ward life, thatare often beyond the collective range of any one type of clinicalenvironment or clinical placement. ‘The Ward’ engages students/learners attention, allowing them to immerse themselves in thesimulation, while at the same time having fun.

Each ‘ward’ or team of students work to acquire points thatmeasure their progress in the six key areas of: quality of patient

Table 1Advantages of using games in nursing education.

� Decrease fear and increased confidence with decision making (Henry, 1997;Metcalf and Yankou, 2003)

� Games can be fun and exciting (Henry, 1997)� Decisions made are often in tandem or enhanced by evaluation, reflection and

application (Thatcher, 1990)

D. Stanley, K. Latimer / Nurse Education in Practice 11 (2011) 20e25 21

care, clinical competence, efficient management of the wardbudget, stable and suitable staff morale, professional developmentactivities and leadership/team work. The game is used with finalsemester Bachelor of Nursing (Science) students at Curtin Univer-sity and initial feedback supports its effectiveness as a positiveteaching and learning tool.

� Stimulate/facilitate learning, motivation and interest (Henry, 1997)� Offer new information in new ways� Offer an opportunity to review course/unit content� Reinforce and apply theory (Hanna, 1991)� Immediate application of theory (Sisson and Becker, 1988)� Learning and engagement in games is more appealing (to adults) than lectures

(Schmitz et al., 1991)� Create community among students and faculty (Glendon and Ulrich, 2005)� Promote interaction between learners (Corbett and Lee, 1992)� Enhances students critical thinking abilities (Glendon and Ulrich, 2005; Royse

and Newton, 2007)� Promote active student-centred learning� Connect theory closely to real life situations (Istre, 1993; Schmitz et al., 1991)� Effective way to deal with topics thought to be mandated, repetitive, highly

technical or boring (Bradbury-Golas and Carson, 1994; Deck and Silva, 1990)� Promotes active learning (Sisson and Becker, 1988; Phillips, 2005)� Add motivation, diversity and an opportunity for immediate feedback (Henry,

1997)� Learning occurs without risk to actual patients/people (Henry, 1997)

Table 2Disadvantages of using games in nursing education.

� Length of time it takes to set up or design a game based activity (Hanna, 1991;Henry, 1997)

� Not all students will find gaming a style of learning they appreciate orrelate to

� Difficulties with using competition as a motivator. Some students whodo poorly may be de-motivated or become upset (Hanna, 1991;Corbett and Lee, 1992)

� High cost in developing or purchasing games (Gruending et al., 1991)� Issues of evaluating learning� Motivating tutors to be involved if they don’t recognise the value of gaming

as an effective learning tool� Keeping the game relevant to modern practice. Especially if clinical scenariosare used. These need to be updated and relevant

Managing large groups of people in scenario based games can at time becomenoisy or disruptive (Hanna, 1991; Corbett and Lee, 1992)

Literature review

A search for literature was conducted using a number of searchdatabases, including, CINAHL, Med Line and ProQuest. Key wordsused included, ‘simulated learning’, ‘simulation games (in nursing)’,‘gaming as a teaching strategy’ and ‘innovative teaching strategies(in nursing)’. A number of references were located however, few(n ¼ 5) reflected an empirical approach to the topics considered.This was reinforced by Corbett and Lee (1992) who indicate thatwhile gaming as a teaching strategy has been present for centuries,its use in nursing education has been brief. Joos (1984) suggestedgaming was under-utilised in nurse education because it was notthought of as a serious educational approach and Royse andNewton (2007) support this, indicating that empirical support forthe advantages of gaming as a teaching strategy in nursing is‘lacking.’ There is however a new take on the use of games in healthcare and health care education with Skiba (2008) from theEmerging Technologies Centre indicating that a new taxonomy of‘serious gaming’ has been created that describes serious games as‘games that are driven by educational goals, not entertainment’(Skiba, 2008 p230). This taxonomy dismisses the myth that gamescannot be used in serious ways to develop learning and promotehealth. The claim is reinforced with evidence of a surge in the use ofgames in physical therapy and rehabilitation. Games are increas-ingly used to promote physical activity (as seen in the use of videogames such as Nintendo’s Wii to stimulate exercise) and educa-tional simulations are used by corporations and in the health careindustry (Skiba, 2008). Serious gaming is also evident in nursingeducation with a surge of interest and use of simulation andsimulated learning for clinical skills and critical thinking education(Gaba, 2004; Issenberg and Scalese 2005).

There are numerous general publications that suggest that usinggames as an educational tool for nursing education has a number ofadvantages (Henry, 1997; Metcalf and Yankou, 2003; Glendon andUlrich, 2005; Tarnow, 2005; Royse and Newton, 2007; Skiba,2008) and that the use of innovative teaching strategies,including games have been shown to be effective (Royse andNewton, 2007). A summary of the advantages identified is offeredin Table 1. Of the five articles that reflected an empirical approach toassessing gaming in nursing education, Regan (2000) undertooka quasi-experimental study designed to evaluate the effects ofa gaming episode on empathetic communication approachesemployed by nursing students (n ¼ 55). The result was that thegame used had a short-term positive impact on the nursingstudents’ empathetic communication following their involvementwith the game.

Bays and Herman (1997), Ingram et al. (1998) and Cowen andTesh (2002) both employed a type of randomised controlled trialto determine the impact of gaming on enhancing learning, whencombined with and compared against a more traditional teachingformat. In both later studies, the students who took part in thegame did significantly better in their post gaming test results.Although in Bays and Herman’s (1997) study there was no signifi-cant test score difference between the game and control group.However with all three studies, the researchers commented thatstudent interest, motivation and enthusiasm for the subject contentwere increased in the group using the game.

A study by Cassario (1987) sought to test if gaming couldmotivatestudents to learn content related to nursing models. As such, a boardgamewasdevelopedandevaluatedagainst studentswhodidnotplaythe game. The game playing students were better able to retainknowledge than the students in the control groupand again thegameplaying students reported the game to be motivating and enjoyable,supporting their ability to reinforce their learning (Cassario, 1987).

There is another set of publications that are more descriptive innature. These relate experiences of using games or offer descrip-tions of the types of games used (Hanna, 1991; Henry, 1997;Glendon and Ulrich, 2005). They commonly offer an evaluation ofthe games’ impact or effectiveness on learning. Metcalf and Yankou(2003) provide another example describing a game set up to helpnursing students understand decision making dilemmas whendealing with ethical issues. They conclude that games area ‘fundamental part of our culture,’ ‘have some popularity inteaching,’ ‘can reinforce critical thinking,’ and ‘make learning funfor both students and tutors’ (Metcalf and Yankou, 2003 p215).These publications are useful in building a catalog of teachingresources, but neglect to offer empirical support for the benefits ofgame playing in the domain of nurse education.

Gaining empirical evidence is important because a number ofeducators remain sceptical about the usefulness or value of gameplay in nursing education. Therefore, gaining insights into thetangible benefits of using game play in education is valuable if

D. Stanley, K. Latimer / Nurse Education in Practice 11 (2011) 20e2522

sceptics are to be convinced of the serious benefits on offer (hencethe list of advantages and disadvantages in Tables 1 and 2). Whilethe advantages are significant the disadvantages for game playingneed to be seriously considered before games can be effectivelyemployed in nurse education (see Table 2).

The literature located supports the concept of gaming beinga valuable and innovative teaching strategy and while the researchevidence remains scant, evidence does indicate that games areworthy teaching tools and can be effective in improving studentlearning outcomes. As well, games have been shown to enhance theretention of knowledge and problem solving abilities, provide a funand motivating format for learning and encourage students toengage more with the subject matter. Educational games, it seems,have a valuable place to take in future nursing programs.

Background

The game ‘The Ward’ was first designed and trialled in a UK,undergraduate program in 2003e5. However, it was neverformally evaluated. The updated and Australianised version wasdeveloped and first used in late 2008. The game was designed tobe used with students approaching the conclusion for theirnursing program.

‘The Ward’ outlined

The aim of the ‘The Ward’ simulation game was to explorecritical thinking skills through a range of simulated activities inthe context of an in-class game. It was designed to allow a reviewof previous course content and support the students growingconfidence prior to completing the course. It also aimed tofacilitate teamwork so that the fictitious ward/units functioned ina safe, efficient and competent way to ensure the advancement ofthe ward/units. Success in the game was measured by theawarding or withdrawal of points for a range of key ward func-tional areas as mentioned above. Table 3, outlines the ‘The Ward’game.

The game required a considerable amount of preparation andequipment, but as all tutors associated with the unit took part itwas easy to put into effect although it was labour intensive.

Table 3Outline of ‘The Ward’.

1 Set up of the game: Students were encouraged to arrange themselv(with 96 students in the group, ten teams competed in playing thkey areas was dependent on the choices and decisions they made

2 Once all the students were in groups they were given a score sheedecide upon a ward/unit name (e.g. Doe ward etc.) and write thisthe list provided. Teams then provided their name to the game umof Nursing (a tutor) managed the game. There was also a ‘score kesheet projected on a Power Point screen.

3 Teams then had to consider appropriate roles for each member ofWho collected task and other cards, who came to see the ‘Directoguidance about the likely roles, useful in the game. Name-tags we

4 Starting of the game: The game began with a series of ‘activity rouThe first round was called “It is 07:30 on a Monday Morning” andPoints were allocated for the teams who completed the task safelywith a clinical activity ensured the game began with a high-energ

5 The second activity was called “Ward Management Challenge” anby the shift coordinator for a junior member of each team to be se“Anatomy Challenge”, a number of clinical scenarios including deastaff morale problems, considering a request by a dying patient fobudget allocation, bullying, and the application of a bandage. In eato deal with each activity safely and correctly. Each scenario had snext activity and before the allocation of points. The game concludScores were then tallied and the winner announced.

Methods

Study design

AimsThe aim of the research was to evaluate the effectiveness and

suitability of ‘The Ward’ as a simulation game to promote andsupport students’ understanding of decision-making, criticalthinking and team work in clinical practice situations.

Design and methodologyThe game was designed by the author who was also responsible

for teaching in the final semester units of a Bachelor of Science(Nursing) program, at Curtin University, in Perth,Western Australia.Participants in the research were final semester student nurses(n ¼ 96). They were then offered an opportunity to answer a shortquestionnaire about the game and at a later date, take part in shortfocus group to further discuss the relevance of the game to theirclinical practice. Four focus groups were facilitated by four tutors,each in separate locations.

The study employed a mixed method approach, with somepurely statistical data (sought in the questionnaire) and a substan-tial amount of qualitative data gathered from both the question-naire and focus groups.

Data collectionData was collected via a questionnaire (distributed immediately

after the game) (76 (79.2%) of the students completed question-naire) and notes made by the tutors at each of the focus groupmeetings. Audio recording were not made of the focus groups. Thefocus groups lasted between 25 and 30 min and while specificquestions were used to prompt or start discussions, students wereencouraged to offer comments freely.

Data analysisThe questionnaires were collected and assessed with the aid of

an excel spreadsheet. Tutors took notes at each of the focus groupmeetings and these notes were collected and analysed for themesand sub-categories.

Ethical approval and confidentialityAll the information provided was kept confidential. At no point

were participants identified nor were names recorded (on either

es into self-selected teams of up to 10 memberse game). Each team represented a ward/unit who’s success in the six(and a little luck) throughout the game.t, ward list, roles sheet and name-tags. They were instructed toon the score sheet. They then selected a specialty/ward type frompire, know throughout the game as ‘The Director of Nursing’. The Directoreper’ (another tutor) who kept the team scores on a master tally

the ward/unit team (e.g. who made the decisions, was this done as a group?r of Nursing’ and a range of other tasks). A role sheet was issued to offerre distributed and used for role identification.nds.’ Points were awarded depending on how well each team performed.offered a clinical challenge related to drawing up the correct dose of insulin., in the shortest time and with the correct dose drawn up. Starting the gamey activity.d asked each team to respond with a written response to a requestnt to another ward due to staff shortages. Other activities included anling with aggressive clients and administering medications. Dealing withr their dog “Fang” to visit them before they die, dealing with issues of wardch case teams were assessed for their competence, speed and their abilityet answers and these were discussed with all the teams before moving on to theed with a Bonus Challenge, made up of a set of nursing specific questions.

Table 5How would you rate the game as a learning activity?

0 1 2 3 4 5 6 7 8 9 10 Total

1 1 e e 1 11 5 12 30 7 8 No ¼ 761.3 1.3 e e 1.3 14.4 6.5 15.7 39.4 9.2 10.5

D. Stanley, K. Latimer / Nurse Education in Practice 11 (2011) 20e25 23

the questionnaires or at the focus groups). Only the Unit Coordi-nator/Research Supervisor had access to the questionnaires andfocus group feedback. Tutors who recorded the summary state-ments from the focus groups were not required to record individualparticipant names or attribute specific comments to any individualin the group. This research was approved by the Curtin UniversityHuman Research Ethics Committee (Approval No. SON&M18-2008)and supported by the Deputy Vice Chancellor (as required withresearch involving university student participants at CurtinUniversity) prior to the commencement of the study.

WithdrawalAt any point participants could have withdrawn from either the

questionnaire (by not completing it) of from the focus group (bybeing excused). It was explained inwriting (through an informationsheet) and verbally at the commencement of the focus group thatparticipants could withdraw at any point and that it would notprejudice or hold any negative consequences for them. As such,20.8% of students chose not to complete the questionnaires and twocomplete groups withdrew from the focus group discussion,leaving only two focus groups to offer feedback.

BiasAlthough the data was collected by the same tutors and

lecturing staff who taught the unit, seeking ethical approval beforethe study ensured that students could decline to take part in thestudy and would remain anonymous if they did take part.

Data/Results

Questionnaires

The questionnaire was used to identify if the game had been setup and explained correctly and if it was considered to be relevant tothe students practice. The first question asked was, “Was the gameexplained clearly?”To this 83% said that “itwas”,13.1% indicated that“it was not” and 3.9% said that they were “unsure”. Although thesestudents also added that they came late so missed the explanation.

The game set out to simulate a number of specific activitiesessential for and common in nursing practice. These activities werespecifically designed to be evident within the game. The secondquestion asked the students if these activities were recognised asbeing evident in the game. The results are shown in Table 4.

It was hoped that while the game was clearly a simulationactivity, it would closely reflect realistic scenarios from the realworld of practice. The third question sought feedback about howeffectively this goal had been reached. Students responded posi-tively, with 93.4% believing all the simulated activities representedpotentially realistic situations. Only 6.5% felt other than this andwhen asked to explain this further, only one respondent madea comment, indicating that, budgeting was inappropriate in one ofthe scenarios as it was not a nurses’ responsibility.

Table 4Which of the following issues did you recognise in the “activities” addressed ‘TheWard’?

Activity Yes(%)

No(%)

Not Sure(%)

Decision making 94.75 3.9 1.3Clinical skills 86.8 11.8 1.3Ward management 86.8 11.8 1.3Nursing practice knowledge 86.8 10.5 2.6Critical thinking 86.8 10.5 2.6Medication knowledge 78.9 19.7 1.3Leadership 88.1 9.2 2.6

The games designer was also interested to discover if the gamewas enjoyable as well as educational and in this regard, 93.4% saidthat it was. With 5.2% feeling it was not and one person (1.3%) notbeing sure if they had enjoyed themselves or not. To draw thisinformation out further, participants were asked to identify threepoints to support why they thought the game was enjoyable. Thisproduced a plethora of responses, almost all of which were positiveand with most supporting the following themes:

Opportunities to work together:� “The game promoted opportunities for me to work in andunderstand teams”, and “I worked with people I haven’t before”

It was simply a fun, engaging activity:� “It was simply fun and interactive” and “making learning fun”

Effective learning:� “Mind stimulating”, “absorb more knowledge” “entertaining aswell as educational”

Better than other forms of learning:� “Better than a tute”, “something different” and “more fun thana lecture”

Realistic scenarios� “Let us show our knowledge and skills”, “realistic scenarios”and “helps with decision making and skills development.”

Producing an enjoyable learning activity was not the only pointof the game and it was important to the researcher that theparticipants understood what the aim of the game was. Questionfive on the questionnaire sought to explore this. A variety ofresponses were offered. Many students identified that the aimsrelated to addressing the key activities suggested in question 2(decision making, clinical skills, ward management, nursing prac-tice knowledge, critical thinking, medication knowledge andleadership). However, a large number of responses also indicatedthat they felt the game was used to “explore issues such as team-work”, “motivate students prior to graduation”, “practice communi-cation skills”, “promote learning and team work in a fun and engagingenvironment”, or “to make revision fun and exciting.” While themajority of the comments were positive two students suggestedthey ‘didn’t know” the point of the game.

These responses reassured the games developers that it was ontarget as a learning tool. However this specific question needed tobe tested, and as such question 6 asked students to rate the game asa learning activity, on a scale of 0e10 (with 10 being the highest).The majority of responses were for scores above 7 (68.7%) with themean response being 7.3 out of 10 (see Table 5).

Participants were then asked to describe if the game highlightedthe value of a number of issues considered important for nursingactivities. These were, team work, critical thinking, decision-

Table 6Relative values of activities identified in “The Game”.

Activity Yes(%)

No(%)

Not sure(%)

Total

Team work 94.8 5.2 0 76Critical thinking 88.2 11.8 0 76Decision making skills 94.8 5.2 0 76Ward management skills 80.2 19.8 0 76

Table 7Themes and sub-categories from the focus groups.

Themes Sub-categories

Relevance to practice Taking with colleagues about the gameTalking with clinical staff about the gameDiscussing scenarios with clinical staffApplicability of the scenarios to practice

Relevance to specific skills Team working skillsCritical thinking skillsDecision making skillsSkills in delegationConflict management skills

What can be done better? Better environment for the game to be playedUse Power Point with questionsOffer a grander prizeAdd even more practical scenariosHave a better scoring systemNothing e “good as is”

D. Stanley, K. Latimer / Nurse Education in Practice 11 (2011) 20e2524

making skills and ward management skills. Table 6 indicates theresults.

Participants where then asked to indicate why they felt thegame had highlighted these activities as valuable for successfulnursing practice. Students again offered a wide range of responses.Most reflected the views offered in these few examples:

� “The set up enabled team work which included critical thinking,decision making and ward management.”

� “All were necessary to do well in the game.”� “Scenario activities directly addressed the above criteria.”� “There was a good range of questions and activities that allowedus to actively implement each skill.”

� “It showed the importance of team work.”� “Because critical thinking is needed (in practice).”� “Because each are equally important in increasing quality nursingand a positive working environment.”

� “It was stimulating and we were given tasks to perform andmaking decisions that actually are happening in the real clinicalscenario.”

� “Incorporated all these aspects in the game by allocating eachperson as a particular role.”

� “All these skills are important.”� “Need the above skills to deliver safe and efficient care.”

Participants were asked to suggest up to three ways in which‘The Ward’ could be improved. A number indicated that the gamewas “perfect”. However, the majority of suggestions related tooffering a more suitable environment (a lecture room had beenused and it was suggested by a number of respondents that a flatsurfaced room would be better in future). To make more use ofPower Point for the scenario explanations, to offer a better prize tothe winning ward, to make the game harder with even morepractical scenarios, to “get different teams to mark each others scoreor get a tutor to add up the team points e some groups were cheating”and to “do the game earlier in the semester.”

Finally, participants were asked to add any other comments. Fewthough were offered and those that were reflected much that hadbeen written before. Although significantly, a large number ofresponses said simply, “enjoyed it”, “it’s fun!” “I enjoyed it.” “I thinkwe should have this activity in previous semesters”, “great job”,“enjoyable game” “met new friends in learning”, “great learningactivity” and “really valuable teamwork experience.”

Focus groups

Focus groups met two weeks after the game was played.Students in focus groups were asked a series of questions aimed atdrawing out the relevance of the game to them, or to clinicalpractice. It was again explained to students that participation wasnot compulsory and that they could leave the discussion if theywanted. As such, twowhole groups chose not to take part and focusgroup activity (as these groups were planned for the end of the day)and comments were made by only two groups of students (38students in all).

Focus group results were analysed and resulted in the devel-opment of a three themes (which also had a number of sub-cate-gories, see Table 7 below).

Theme 1: Relevance to practice

Most students offered comments in the focus groups that indi-cated that they had reflected on the game and talked to otherstudents and clinical staff about a number of the specific scenarios,often to gauge the responses or insights of clinical staff if dealing

with the same scenarios. Students also commented that theythought the scenarios and activities used might be applicable totheir nursing practice. This prompted significant discussion in eachfocus group with students indicating that the scenarios wererelevant and practical and that they could apply them in terms ofa range of skills including delegation, dealing with conflict anddecision-making, this lead to the second theme.

Theme 2: Relevance to specific skills

Students commented that they thought the game specificallyfocused their learning on the skills of ‘teamwork’, ‘critical thinking’‘delegation’ and ‘decision making.’Most students agreed that theseissues werewell addressed throughout the game and that the gamehelped them learn about various roles in the health care team andthe various management responsibilities staff have. Manycomments indicated that that the game met its objectives offocusing on these areas and in a fun way.

Focus group participants were also asked to discuss what theythought were the main ideas they took away after playing thegame. Most responded that they had thought more aboutmanagement and leadership issues since playing the game and thatthey had a better understanding of what to “brush up on” beforecompleting the course. Or that they had a better insight into thesignificance and value of decision-making and teamwork.

Theme 3: What can be done better?

Finally students offered views about ways to improve or re-design the game to improve the reality factor or its learningeffectiveness. Most of the commentsmade, supported those offeredin response to the questionnaire.

Discussion

There is only limited empirical support for the use of games innursing education (Royse and Newton, 2007). However, this studyoffers an example of a detailed research study that demonstratesthat empirical evidence can be offered to support the value of usinggames in nurse education. ‘The Ward’was found to be enjoyable bythe vast majority of participants with 93% supporting Henry’s(1997) claim that games can be fun and exciting ways to learn.Further support for this is that almost 7 out of 10 respondents feltthe game was a useful and relevant learning activity.

The game set out to address a number of nursing specificactivities and in this regard achieved considerable success. Resultsshowed that between 80% and 95% of respondents indicated thatthey recognised the activities of decision-making, clinical skills,

D. Stanley, K. Latimer / Nurse Education in Practice 11 (2011) 20e25 25

ward management, practical nursing knowledge, critical thinking,medication knowledge and leadership as central elements of thegame. As this was a key aim of the game it was satisfying to see thatthe results of the evaluation study strongly supported thisachievement.

Setting the game up and facilitating it was reasonably timeconsuming activity. However, in terms of focusing students’ sightsand skills on the key issues of teamwork, critical thinking, decision-making skills and ward management activities the game wasa great success. It also allowed a great deal of clinical and theo-retical information to be reviewed and discussed in a short timeframewhile at the same time allowing tutorial and lecturing staff tointeract with a large group of students in a collegial and enjoyableway. It was relatively labour intensive but it is recognised thatmuchof the effort used was in setting it up for the first time and thatfuture attempts to run the game will require less set up time.However, running the game will remain relatively labour intensive.One student said the game was, “a really valuable learning expe-rience” and while there were a few teething problems with the setup, once the game got underway students quickly engaged with itand embraced the simulated activities the game offered. Theevaluation has prompted the continued use of ‘The Ward’ andfurther development in response to the recommendations below.

Conclusion

‘The Ward’ was developed as a way of revising a wide range ofthe topics and subjects covered in the Bachelor of Science (Nursing)curriculum, in a short time and in a way that was enjoyable forlecturers and students alike. In every regard ‘The Ward’ has provento be a very useful simulation exercise that has evaluated well andhelped bridge the gap between theory and practice.

Recommendations

There were a number of recommendations that will be imple-mented with future versions of ‘The Ward’.

1. Streamline the instructions to participants at the start of thegame. This will be achieved by allocating students into teams asthey enter the room and provide each team with all the set upequipment in an envelope at the start of the game.

2. Transfer all the scenarios (and answers) on to Power Pointslides.

3. Find a more suitable (flat floored) environment.4. Continue to review and improve the scenarios used.5. Use the game with each final semester group, but sooner in the

semester.

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