Nursing Students' Attitudes Toward Video Games and Related New ...

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Nursing Students’ Attitudes Toward Video Games and Related New Media Technologies Judith Lynch-Sauer, PhD, RN; Terry M. VandenBosch, PhD, RN, CIP, CCRP; Frederick Kron, MD; Craig Livingston Gjerde, PhD; Nora Arato, PhD; Ananda Sen, PhD; Michael D. Fetters, MD, MPH, MA;

Journal of Nursing Education Volume 50 · Issue 5: 1-11 DOI: 10.3928/01484834-20110531-04

ABSTRACT

ABSTRACT Little is known about Millennial nursing students’ attitudes toward computer games and new media in nursing education and whether these attitudes differ between undergraduates and graduates. This study elicited nursing students’ experience with computer games and new media, their attitudes toward various instructional styles and methods, and the role of computer games and new media technologies in nursing education. We e-mailed all nursing students enrolled in two universities to invite their participation in an anonymous cross-sectional online survey. The survey collected demographic data and participants’ experience with and attitudes toward video gaming and multiplayer online health care simulations. We used descriptive statistics and logistic regression to compare the differences between undergraduates and graduates. Two hundred eighteen nursing students participated. Many of the nursing students support using new media technologies in nursing education. Nurse educators should identify areas suitable for new media integration and further evaluate the effectiveness of these technologies. Dr. Lynch-Sauer is Clinical Assistant Professor, Division of Acute, Critical, and Long-Term Care, Dr. VandenBosch is Adjunct Associate Professor, University of Michigan School of Nursing; Dr. Arato is Data Manager, Department of Family Medicine, Dr. Sen is Biostatistician, Department of Family Medicine and Department of Statistics, and Dr. Fetters is Diplomate, American Board of Family Medicine, University of Michigan, Ann Arbor, Michigan. Dr. Kron is President and Founder, Medical Cyberworld, Inc., and Dr. Gjerde is Professor Emeritus, University of Wisconsin, Madison, Wisconsin. Dr. VandenBosch is also Senior Research Compliance Associate, Office of Human Research Compliance Review, University of Michigan, and Dr. Fetters is also Associate Professor and Director, Japanese Family Health Program, Ann Arbor, Michigan. At the time this article was written, Dr. Kron was Assistant Clinical Professor, Department of Family Medicine, University of Wisconsin-Madison, Madison, Wisconsin. This project was supported in part by an award from the National Cancer Institute (award number R43CA141987). Dr. Fetters’ participation in this research was also made possible in part by the generous support of the Jitsukoukai Foundation. The authors have no financial or proprietary interest in the materials presented herein. Address correspondence to Judith Lynch-Sauer, PhD, RN, Clinical Assistant Professor, Division of Acute, Critical, and Long-Term Care, University of Michigan School of Nursing, 400 North Ingalls, Room 2179, Ann Arbor, MI 48104-5482; e-mail: [email protected].

Received: June 15, 2010 Accepted: January 07, 2011 Publish Online: May 31, 2011

As early as 2000, futurist Charles P. Friedman recognized both the sweeping cultural and technological changes that were creating digitally savvy learners and the lack of movement by health educators to embrace the change ( Friedman, 2000). Much has happened since then. Scholarly interest in serious computer games has skyrocketed ( Foreman, 2004). Yee ( 2006) and Griffiths, Davies, and Chappell ( 2003) convincingly demonstrated that college students, CEOs, college professors, middle-aged homemakers, and retirees all play computer games. As predicted

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( Moore, 1998, 2005), microcomputing power has grown dramatically; the average desktop computer now has enough power to support highly sophisticated games and incorporate “virtual humans”—computer-generated characters that exhibit believable behaviors and characteristics that can be used as pedagogical agents ( Gratch & Marsella, 2005). Funding initiatives from the Robert Wood Johnson Foundation and the MacArthur Foundation demonstrate that well-respected foundations and agencies believe that serious games are compelling ( MacArthur Foundation, 2008; Robert Wood Johnson Foundation, 2008). There are many definitions of games in existence. A short definition provided by Juul ( 2005) will suffice for this article: A game is a rule-based system with various and quantifiable outcome, where different outcomes are assigned different values, the player exerts effort in order to influence the outcome, the player feels emotionally attached to the outcome, and the consequences of the activity are negotiable. Serious games are applications that use computer game-derived technologies and design strategies to achieve educational aims. They incorporate principles supported by learning and cognition theories ( Gee, 2003). Massive multiplayer online role-playing games can promote leadership capabilities ( Reeves, Malone, & O’Driscoll, 2008) and model economics ( Castronova, 2001, 2002). Serious games have the potential to teach high-level business skills ( McConnon, 2007), networking concepts ( Nymphadora, 2007), and conflict resolution ( Raybourn, 1997, 2007). They can also help learners reframe their identities and interests in relation to professional communities of practice ( Shaffer, 2005). In short, serious games can do more than entertain; they can provide deep, epistemic learning that traditional educational techniques may lack—precisely, important areas in nursing education. One of the most pressing goals of nursing education is to prepare the student to provide safe and high-quality patient care. A recent issue of Nursing Outlook was devoted entirely to this subject, with a specific focus on how nursing education must change to adequately prepare future practitioners ( Cronenwett et al., 2007). Nursing has adopted the Institute of Medicine’s ( 2003) competencies for nursing (patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics) that spell out the knowledge, skills, and attitudes necessary for practice competency ( Cronenwett et al., 2007). Although serious games can contribute substantively to these initiatives, there remains little work in this area. Current nursing literature indicates that the only new media venues into which nursing educators have ventured into are simulation, virtual environments, and gaming. Simulation, an “artificial representation of a real-world process to achieve educational goals via experiential learning” ( Flanagan, Nestel, & Joseph, 2004, p. 57), offers opportunities to practice psychomotor skills, primarily, without causing harm to patients ( Baxter, Akhtar-Danesh, Valaitis, Stanyon, & Sproul, 2009). It builds confidence through reinforcing basic techniques and providing immediate feedback in a safe environment ( Lapkin, Levett-Jones, Bellchambers, & Fernandex, 2010). Simulation runs from low-fidelity human-like manikins to high-fidelity sophisticated manikins with computer programs that mimic human patients and share some characteristics with gaming. Simulation has been studied primarily in undergraduate nursing education programs ( Lapkin et al., 2010; Tiffen & Corbridge, 2009). Research evidence for simulation use generally resides in single-site studies with small sample sizes. In undergraduate nursing education, high-fidelity simulation has improved knowledge acquisition and critical thinking and has enhanced student satisfaction with learning ( Lapkin et al., 2010). However, simulation has some drawbacks. It is faculty time intensive ( Jansen, Johnson, Larson, Berry, & Brenner, 2009), and high-fidelity simulation lacks evidence of effectiveness in acquisition of complex clinical reasoning skills ( Lapkin et al., 2010). In one study that evaluated current quality and assessment education in nursing schools, simulation was used less frequently than all other pedagogical strategies except return demonstrations ( Smith, Cronenwett, & Sherwood, 2007). New possibilities may emerge because the environment created with the use of high-fidelity simulation “poses new questions on implementation, evaluation, and incorporation of the technology into nursing curricula” ( Paige & Daley, 2009, p. e102).


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Four schools of nursing have described their experimentation into the virtual environment of Second Life ®. Duke University School of Nursing students across the United States can gather for lectures and discussions in classrooms in the physical School of Nursing building and in the virtual world of Second Life ( Duke University School of Nursing, 2009). Skiba ( 2009) reported on pioneering faculty at Tacoma Washington Community College, University of Kansas School of Nursing, and University of Wisconsin Oshkosh College of Nursing as examples of nurse educators who are actively using the virtual world of Second Life in their teaching. John Miller, an instructor at Tacoma Community College, Washington, has his students learn application of theory, as well as team decision making. Judith Warren and Julia Brixey use Second Life to teach graduate students informatics at University of Kansas School of Nursing, and a team of faculty at University of Wisconsin Oshkosh College of Nursing have created a virtual learning center to facilitate distance learning for its collaborative online bachelor’s degree program. In regard to the use of games in nursing education, two articles comment on their use in nursing education ( Cowen & Tesh, 2002; Royse & Newton, 2007). One point of interest, however, is that the games described in these articles are not presented to students using high technology, but rather are of the board or pencil-and-paper genre. Yet the educational outcomes of the games may be similar. Cowen and Tesh ( 2002), who looked at the effects of gaming on nursing student’s knowledge of pediatric cardiovascular dysfunction, found that not only did students who were taught with traditional methods plus gaming do better on posttest scores than those taught only by traditional means, but that the games were fun and enhanced their students’ “ability to retain knowledge” (p. 508). These authors found that gaming “stimulates student involvement…and promotes critical thinking” (p. 509). Royse and Newton ( 2007) reviewed the literature on how gaming is used in nursing education and found support for “enhancement of retention of knowledge; promotion of problem based learning; and motivation for nursing students to become more engaged in their learning” (p. 263). It can be expected that growing ranks of nursing students will be increasingly comfortable with computer-based and Internet-based forms of education. Born between 1982 and 2002, these Millennial generation ( Strauss & Howe, 2000) nursing students differ radically from the students of 15 or 20 years ago ( Elam, Stratton, & Gibson, 2007; Grunwald Associates, 2003; Oblinger, 2003; Oblinger & Oblinger, 2005). Millennial students grew up with computers and Internet connectivity and have a global outlook. More Millennials send text messages or e-mail messages than talk on the telephone. A recent National School Boards Association survey ( DeBoor & Halpem, 2007) revealed that 96% of student respondents with online access used social networking technologies, such as chatting, text messaging, and blogging, and visited online communities, such as Facebook and MySpace; 71% used social networking tools at least weekly. Almost 60% of the students using social networking discuss education-related topics, including college or college planning, learning outside of school, news, careers or jobs, politics, ideas, religion, morals, and schoolwork. A more recent study by Lenhart, Madden, and Hitlin ( 2005) found that 73% of American adolescents with Internet access now use social networking Web sites, a significant increase from previous surveys. More than half of online teens (55%) used social networking sites in November 2006, and 65% did so in February 2008 ( Lenhart, Purcell, Smith, & Zickhur, 2010). Millennials are simultaneously technologically adept with and shaped by technology. They actively experience and experiment with new technology. They read less frequently than their predecessors ( Sweeny, 2007) and are more comfortable in image-rich environments than with text. Millennials can readily weave images, text, and sound together and can instantaneously move between real and virtual worlds. They have fast response times and multitask with ease. They prefer the first-person, highly interactive, experiential learning present in new media technologies but absent in traditional lectures ( Lenhartet al., 2005). Using new media and serious games in nursing education fits well with the learning styles of today’s Millennial students.

Method Purpose


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Despite this relatively untapped potential for nursing education, the authors could find no published research on nursing students’ use of and views toward video games and related new media technology. Consequently, the purpose of this research was to (1) describe nursing students’ use of video games and related new media technology; (2) describe nursing students’ experience with computer games; (3) elicit nursing students’ attitudes toward various instructional styles and methods; and (4) better understand the role that video games and related new media technology play in nursing education. Design

The study employed an anonymous, 30-item, cross-sectional survey conducted via the World Wide Web that addressed demographics, video game play experience, and attitudes about using video game and related new media technology in nursing education. The survey was hosted by SurveyMonkey ( 2007), a commercial, Webbased survey delivery service. Population

We recruited study participants from students enrolled in baccalaureate and graduate nursing programs offered by two midwestern universities, university A and university B. Approximately 600 students were enrolled at university A and 820 at university B at the time of the study. University A exempted the study from institutional review board oversight, and university B obtained institutional review board approval. Survey Instrument

The survey instrument used on SurveyMonkey was designed by the investigators, research methodologists and experts on game playing. It contained 30 items that included: (1) questions on demographics and four major domains, namely game-play experience and attitudes about game-play; (2) attitudes about the use of new media technology; (3) beliefs about multiplayer online simulations for health care education; and (4) perceived importance of acquiring specific skills, knowledge, and behaviors during nursing school. Most of the items were created after consultation with experts in the area and were designed to extract general characteristics of the game-playing subpopulation of nursing professionals. Nursing students were asked to indicate their favorite types of games. From a list of game types (with example games provided on the survey instrument) students were asked to select all that apply. Choices given included: (a) I don’t play video games; (b) Strategy games; (c) Role-playing games; (d) Adventure games; (e) Sports games; (f) Arcade games; (g) Puzzle games; (h) Simulation games; (i) First-person shooter games; and (j) Other (participant could enter free text). The online survey included skip patterns for items not relevant to the participant based on individual responses. For example, participants who replied that they “did not play games” were not asked to answer which games they played. Scales measuring agreement with attitudinal items were written using the four-point Likert scale format ( strongly agree, agree, disagree, and strongly disagree. Recruitment

A study investigator at university A hosted a brown-bag luncheon to discuss student interest in video games and related new media technology to raise interest in the research and to help develop survey items. Later, study investigators sent an e-mail solicitation, including a link to the survey, to nursing students from her or his respective institution. After the initial e-mail, the site-specific investigator sent reminder messages 1 and 2 weeks later. Data collection began in April 2007 and continued into May 2007. Data Analysis

We downloaded survey data from SurveyMonkey into SPSS Complex Samples Module software and calculated


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frequency and summary statistics for all variables and results presented using valid percentages. We organized the data to address the major domains of inquiry. Responses closely linked (i.e., strongly agree or agree responses, and disagree or strongly disagree responses) were combined unless otherwise indicated. For advanced statistical analyses, we conducted chi-square tests to compare two independent proportions for dichotomous outcomes. Twosample t tests for comparing two means were applied to compare various characteristics between undergraduate and graduate nursing students. For proportion comparisons, Fisher’s exact test was used when observed proportion fell below 10% in any cell. Binary logistic regression was used to model the dichotomous outcomes with gender, institutional affiliation, familiarity level (basic/intermediate or advanced), and age as independent variables. Ordinal outcomes, such as frequency of playing, change in playing hours, and level of interest in multiplayer online health care simulations, were analyzed using ordinal logistic regression.

Results A total of 218 nursing students returned the survey ( Table ). Most respondents (75%) were from university B. University A nursing students represented approximately 42% of the sample receiving e-mails and comprised 25% of the respondents. As expected, undergraduates comprised 68.8% of the respondents and outnumbered graduates, who comprised 31.2%. A significantly higher proportion of undergraduates were from university A than from university B (80% versus 65%, respectively, p = 0.04). Student respondents were at various stages of completing their programs of study, but a slight majority (51%) was within the last 2 years of undergraduate study. Graduate nursing student respondents were significantly older than undergraduates ( p = 0.001). There was no difference in the distribution of academic level across gender, computer skills, or Internet access between institutions. More undergraduates than graduates owned an MP3 player (84% versus 56%, respectively, p = 0.001), whereas a significantly higher percentage of graduates than undergraduates owned USB flash drives (90% versus 69%, respectively, p = 0.001). Undergraduate students averaged more game playing time per game session (mean = 77 minutes) compared with graduate students (mean = 45 minutes). Graduate nursing students started playing video at a significantly later age ( p = 0.006) and spent a significantly smaller amount of time on playing per session ( p = 0.009). Experience with Games

Forty-one percent of undergraduate and 25% of graduate nursing student respondents reported playing games. Respondents were asked to select their favorite genres from a group of eight game genres. The three most reported were puzzle games (79%), arcade games (29%), and simulation games (29%). When asked about gaming frequency, 41% reported playing games from several times per month to daily. Most students (70%) agreed their game playing time had decreased significantly since starting professional school; for 17%, game playing time did not decrease. When we combined undergraduate and graduate responses, two reasons for playing games stood out: to “help me relax” and to “challenge me in problem solving.” At 57%, a high percentage also said that games enabled them to “avoid studying.” For a smaller, but substantial percentage (39%), game playing is seen as a “socializing activity.” Table presents the overall gaming experience for respondents who reported playing games. A statistically significant difference was obtained between the undergraduate and graduate nursing students, with respect to the frequency of game play ( p = 0.02); however, the significance went away when we adjusted for age in a logistic regression analysis because age is a confounding variable that is independently associated with level of education and game playing. Further, undergraduate nursing students do not differ from graduates with respect to game types, frequency of playing games, and changes in playtime since starting professional school. Game Play and Nursing Education

Overall, respondents (regardless of whether they identified themselves as game players) were positive about the potential role of video games and related new media technology in nursing education. An overwhelming majority


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(94%) liked the idea of using technology to enhance health care education, and 88% believed that nursing education should make better use of video games and related new media technology. A solid majority of students (89%) believed that real life is migrating online in many aspects, and 60% agreed that video games could have educational value. Indeed, 31% of the respondents reported that they would like to be part of the design team that would create multiplayer online health care simulations. A majority (80%) indicated that if a multiplayer online health care simulation helped accomplish a personal goal, they would be willing to use it, even on their own time. Most nursing students (89%) disagreed with the statement that when communicating with patients, being goodhearted and sincere are the only essential skills that health care professionals need. Table summarizes nursing student respondents’ attitudes about video games as a teaching tool. With the exception of the response to the item stating “When communicating with patients…,” no significant difference was found between undergraduates and graduate nursing students with regard to any of the attitude items. A significantly higher percentage of undergraduates (15%) agreed to the statement about being good-hearted and sincere in comparison with the graduates (3.3%), a difference deemed statistically significant ( p = 0.015) based on Fisher’s exact test for comparing two independent proportions. However, the significance is attenuated when adjusted for age, familiarity level, and institution in a logistic regression model ( p = 0.07). In general, a higher proportion of agreement was observed for older and more advanced students with respect to the attitude items. Multiplayer Online Health Care Simulation

Slightly more than half (52%) of the respondents were interested in using multiplayer online health care situations that would realistically replicate the experience of being in professional practice ( Table ). The participants indicated several factors that would interest them in a multiplayer online health care simulation. The simulation should (1) be fun, (2) be helpful for developing skills and comfort in patient interactions, (3) be helpful for creating firsthand, authentic experiences that shaped the views and values of professors they admire, and (4) include an in-person mentoring session with professors. There is no statistically significant difference between the distribution of undergraduates and graduates across the levels of interest in multiplayer online health care simulations, both in an unadjusted chi-square analysis and in an ordinal logistic regression adjusted for age, familiarity level, and institution. Furthermore, there is no difference among the undergraduates and graduates regarding the individual items describing reasons for multiplayer online health care simulations. Students with an advanced level of familiarity are generally more interested than their counterparts in multiplayer online health care simulations. When asked about the hypothetical situation of a student who kills a simulated patient in a nursing-themed game, almost all respondents (96%) agreed the person would likely find out what happened and learn from the mistake; 18% thought it would convince the student to stop playing the game; 4% thought it would cause the person to give up their health care career; and 2% thought it would encourage the player to kill real patients. No significant difference was obtained between the undergraduates and graduates with respect to their belief of the consequence of killing a simulated patient while playing a nursing-themed game. Approximately 93.5% of the undergraduates believed that the student would learn from their mistake, whereas all graduates surveyed believed the same. This difference was mildly significant based on Fisher’s exact test ( p = 0.06), but the significance disappeared in an adjusted analysis based on a logistic regression model. Sixty-nine percent of student respondents rated “clinical facts and critical thinking,” and “health professional-patient interpersonal skills” as equally important. There is no statistically significant difference between the distribution of undergraduates and graduates regarding their assessments of relative importance of clinical facts and critical thinking skills versus health professional-patient interpersonal skills.


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Nursing Student Ranking of the Relative Importance of Knowledge and Skills

Participants prioritized eight categories of specific skills, knowledge, and behaviors that a nurse might acquire in nursing school, from most to least critical. The eight categories were patient safety; patient-provider communication skills; coordination of care; fund of professional knowledge; health care team integration; skills in case management; preventing provider burnout; and organizational skills (e.g., how to run an office). The three items receiving the most votes as the number one priority were patient safety (41%), fund of professional knowledge (30%), and patientprovider communication skills (11%). We then calculated the percentages of the categories selected as one of the participants’ top three choices; the same three categories emerged. Approximately 79% of the participants ranked patient safety, 72% ranked patient-provider communication skills, and 66% ranked fund of professional knowledge as either first, second, or third most important. Not surprisingly, graduate nurses were more likely statistically to value “fund of professional knowledge” and skills in case management ( p < 0.01).

Discussion This study demonstrates that a substantive number of nursing students have positive attitudes toward video games and related new media technology. They can identify learning priorities for their education and recognize that video games and related new media technology could facilitate and strengthen nursing education. Of interest, nursing students reported playing and enjoying games, particularly puzzle, arcade, and simulation games. Puzzles help to develop critical thinking skills, a strong focus in nursing education. Knowing that nursing students play and enjoy commercial games of this genre can inform the design of serious games in educational curricula. Nurses also need to develop other skills to provide high-quality, safe care. Simulation in virtual environments could enable them to practice these skills without harming patients. The ability to design learning applications that include the elements that students identify as fun is a key determinant in whether players will choose to play, and hence learn, from serious games. As Edward Castronova, PhD, discovered when he tried to build a Shakespearean multiplayer online role-playing game called Arden, if the application is a yawn, it’s a failure ( Baker, 2008). Student respondents understood that being good-hearted and expressing sincerity are useful attributes when communicating with patients, but also that analyzing clinical facts, critical thinking, and interpersonal skills are equally important—these latter elements being skills that can be developed through serious games. Nursing Students View Games Positively

All students surveyed, whether they reported playing video games, had positive perceptions about the potential of game play in nursing education. They not only liked the idea of using video games and related new media technology to enhance nursing education and thought it was time for nursing to use this technology, but approximately one third of them were actually willing to help design multiplayer online health care simulations. Safety and Values in Nursing

Learning about patient safety and professionalism is a priority in nursing education ( Institute of Medicine, 2003). Although the excellent learning exercises for integrating quality and safety content into clinical teaching in the acute care setting ( Day & Smith, 2007) recognize the shift from an individual to a system focus, none employ serious game and related new media technology and most are conducted in the clinical environment. Complex, multiplayer games could enable nursing students to experience and analyze system influences on patient safety in a virtual environment much like the real world. Nursing student respondents supported the use of multiplayer online health care simulations, viewed them as a way to realistically replicate clinical experiences, and were willing to use such simulations on their own time. This can allow nursing education to proceed during off-peak hours and not directly compete with lecture, laboratory, and classroom-based curricula, thereby freeing up physical resources. Factors deemed to make these simulations interesting include simulation that is fun, provides for skill development, explicates economics of different health care systems, and provides experiences reflecting views and values of admired professors.


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Violence in Video Games

Counterbalancing the positive role that games already play in undergraduate education, military training, business, and patient care ( Beale, Kato, Marin-Bowling, Guthrie, & Cole, 2007) is apprehension about games as a negative, even dangerous influence. This criticism needs to be addressed. With current technology, characters in games become increasingly realistic, the experience more immersive and the violence more graphic. Resurrecting a character requires little more than pushing the restart button and the patience for the microprocessor to reload the game. Consequently, concerns have been raised that chronic, violent video game play may desensitize users to real-world violence, increasing aggression by blunting aversive reactions to violence and removing normal inhibitions against aggression ( Anderson & Bushman, 2001; Barthlow, Bushman, & Sestir, 2006; Funk, Baldacci, Pasold, & Baumgardner, 2004). Six of 201 participants in this study thought that a student killing a patient in a simulated game would encourage the student to actually kill patients in the future. Although a very small number, the potential implications merit consideration. Some researchers believe that violent video games can cause imitative behavior that carries forward into real life ( Gentile & Anderson, 2003). Some go so far as to call modern entertainment media an “effective systematic violence desensitization tool” ( Carmagey, Anderson, & Bushman, 2007, p. 495). Although there are undoubtedly negative effects from chronic violent media exposure, others question whether highly realistic video games that involve violence can cause, in and of themselves, players to engage in violent real-world behavior. Ivory and Kalyanaraman ( 2007) recently examined the interplay of technological advancement and violence in video games. They found that technological advancement increased players’ sense of presence, feelings of involvement, and arousal, but did not significantly affect aggressive thoughts or feelings. They also refuted the hypothesis that violent content would increase accessibility of aggressive thoughts in players and would heighten players’ real-world aggression. The fact that technologically advanced video games produce a more immersive, involving, exciting player experience without necessarily causing aggression and imitation is promising to those who see the educational potential of video games. Pushing Limits in Game Design

An issue in the medical simulation community that mirrors the video game violence debate is the extent to which students should be allowed to push the limits of simulator or game design (M. Scerbo, personal communication, December 14, 2008). One group argues for using constrained, guided instruction that prevents the user from doing anything inappropriate; in this way, they hope to avoid any possibility of breeding imitable behaviors that are negative. The other group argues that a less restrained design encourages exploratory behaviors, which they view as the authentic foundation of education. They point out that many other high-risk professions use simulators that allow users to safely play out “what-if” scenarios that could result in catastrophic consequences, like crashing an airplane or bankrupting a business. A potential solution that respects both points of view is that human mentorship, feedback, assessment, and reflection should ideally be part of every educational simulation or game offered. Not only is this method key to the integration of new knowledge and skills in general ( Biswas, Schwartz, Bransford, & The Teachable Agent Group at Vanderbilt, 2001), but it also provides the opportunity for both peers and instructors to identify outliers, explore their motivations in making certain choices, and offer remediation as appropriate ( Raybourn, 2007).

Limitations Caution should be exercised in extrapolating these results to all nursing students because only a minority of eligible participants in both nursing schools opted to take the survey. We believe the low response rate is due in part to timing of the survey given that it was conducted near the end of the academic year and many students were too busy to participate or had left for the summer. Beyond conjecture about why the response rate was low, a discourse about representativeness of the sample is prerequisite. The respondent profile was similar to the national student


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nurse profile in regard to gender and age ( Fang, Tracy, & Bednash, 2009). Moreover, their favorable opinions about video games and related new media technology in nursing education are consistent with the literature on how Millennial students would be expected to respond to new media. Still, there is potential selection bias given that the two study sites are strongly research-focused universities that might attract nursing students more interested in research and academics. In addition, because individuals will adopt innovations at different rates, or belong to multiple innovativeness categories ( Rogers, 1995), ranging from innovators, early adopters, early majority, late majority, to laggards, it is possible that a preponderance of survey responders were early adopters and few were late majority and laggards. Should this be the case, this group would be representative of the leading edge and would suggest that there will be growing acceptance of this technology among nursing students. Conjecture about representativeness of the sample aside, the respondents unequivocally represent themselves, and approximately 20% of the nursing school student body of both institutions (university A and university B) participated. Consequently, it is reasonable to conclude that at least 20% of students support greater applications of digital media in nursing education. The near Absence of New Media in Nursing Education

The literature suggests that nursing education has only begun the foray into new media through simulation applications ( Skiba, 2009; Smith et al., 2007) and use of virtual learning environments ( Duke University School of Nursing, 2009). Although the literature does not necessarily reflect the spectrum of movement into new media applications (e.g., leaders in one of our own institutions are also venturing into a Second Life hospital for educational purposes), it appears nursing education has merely scratched the surface of the potential for serious gaming and new media applications for nursing education. We believe that enthusiasm among Millennial students will grow as the use of technology becomes more creative and better enables the learning of competencies that the students themselves, as suggested by our data, consider most important. What Nursing Education Needs and How Video Games and Related New Media Technology Can Contribute

Academic leadership has called for innovation to enhance how nursing students learn the concepts fundamental to professional development ( Kanter, 2008). The discussion of promoting interprofessional education for nursing students ( Barnsteiner, Disch, Hall, Mayer, & Moore, 2007) speaks to the specific need to purposefully teach teamwork and collaborative skills. Video games and related new media technologies could help educators meet this critical mandate. These technologies can assist learners’ development of greater clinical skill proficiency by fostering an awareness of and ability to manage complex care issues with the goal of safe outcomes. Serious games offer opportunities for first-person, experiential learning and reflection. This method has powerful epistemic value; it can help beginning students to understand the nursing world and develop their professional identities. Given the positive experience with serious games and new media in other fields ( Nymphadora, 2007; Raybourn, 1997, 2007; Reeves et al., 2008; Shaffer, 2005), it is safe to say that video games and related new media technologies also have the potential to foster multicultural understanding, teach conflict resolution, and permit nursing students to practice nurse-patient communication skills in interactions with virtual patients. Current Nursing Students into the Future

In the twenty-first century, digital technology has changed many traditional approaches and provided greater opportunities for educators and students alike. The currently matriculating nursing students have been immersed in technology since birth, and their generation embraces these changes. They are comfortable using new media for both personal enjoyment and professional development. Nursing education must be poised to move into the virtual world to improve students’ acquisition of necessary patient-care skills. Applications that foster reflection and provide embodied experience while removing any danger of harm to real patients provide ideal learning vehicles. To meet society’s growing need for prepared nurses, nurse educators must adopt novel ways of teaching greater numbers of students, despite increasingly space-limited universities and real clinical settings. Video games and related new


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media technologies are a highly promising means by which to handle this explosion in nursing enrollment, given that the distributed virtual worlds they enable can both eliminate geographic boundaries and provide unlimited space for students to learn and for faculty to teach. Nursing students’ interest in and their facile use of technology, as well as their desire to play a role in designing multiplayer online health care simulations, can help move nursing education into the twenty-first century. Providing institutional support to this group of students will not only help train today’s learners, but also will cultivate a new generation of educators. Conclusion and Future Implications

This study demonstrates that a critical mass of today’s nursing students are comfortable with technology and welcome the possibility of using interactive media in an educational setting. Further exploring and funding the design of new media programs offers great promise for developing effective tools for teaching critical nursing skills to this and future generations. We believe nursing faculty need to embrace new media technologies and develop nursing education applications to meet the needs of Millennial students and to enhance nursing education.

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Total ( N = 218), n (%)

Undergraduate ( n = 150), n (%)

Graduate ( n = 68), n (%)

P

University A

55 (25)

44 (29)

11 (16)

–

University B

163 (75)

106 (71)

57 (84)

0.038

Freshman

19 (9)

19 (13)

–

NA

Sophomore

21 (10)

21 (14)

–

NA

Junior

45 (20)

45 (30)

–

NA

Senior

65 (30)

65 (43)

–

NA

Graduate year 1

21 (10)

–

21 (31)

NA

Graduate year 2

22 (10)

–

22 (32)

NA

Graduate year 3+

25 (11)

–

25 (37)

NA

Affiliation

Year of study

Gender


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Demographics

Total ( N = 218), n (%)



P

17 (8)

10 (7)

7 (10)

NS

201 (92)

140 (93)

61 (90)

–

15 (7)

10 (7)

5 (7)

NS

189 (87)

131 (87)

58 (86)

NS

14 (6)

9 (6)

5 (7)

NS

209 (96)

143 (95)

66 (97)

NS

9 (4)

7 (5)

2 (3)

–

MP3

164 (75)

126 (84)

38 (56)

< 0.001

USB flash drive

164 (75)

103 (69)

61 (90)

0.001

PDA

87 (40)

60 (40)

27 (40)

NS

Handheld game

28 (13)

19 (13)

9 (13)

NS

Sony Playstation 2 or 3

21 (10)

15 (10)

6 (9)

NS

Microsoft X Box

18 (8)

12 (8)

6 (9)

NS

Hybrid device

14 (6)

7 (5)

7 (10)

NS

Age and Experience

Mean ( SD)

Mean ( SD)

Mean ( SD)

P

Age (years)

29.5 (11.1)

24.8 (8.03)

39.9 (9.9)

< 0.01

Age at onset of gaming (years)

11.7 (8.3)

10.4 (7.1)

19.4 (9.6)

0.006

Time in one session of video gameplay (minutes)

70.9 (60.8)

77.7 (65.3)

45.9 (30.5)

0.009

Male Female Computer skills a Basic Intermediate Advanced Internet access Broadband Dial-up Devices owned

a

Table 2 Experience with Gaming Among Respondents Who Reported Playing Video Games ( N = 79) Variable

Favorite game types for students who reported a favorite game a

Total ( N = 79) (%)

Undergraduate ( n = 62) (%)

Graduate ( n = 17) (%)

P

79

Puzzle games

62 (79)

48 (77)

14 (82)

NS

Arcade

23(29)

20 (32)

3 (18)

NS

Simulation games

23 (29)

20 (32)

3 (18)

NS

Role-playing games

14 (18)

13 (21)

1 (6)

NS

Adventure games

18 (23)

14 (23)

4 (24)

NS

Sports games

13 (17)

11 (18)

2 (12)

NS

Strategy games

19 (24)

17 (27)

2 (12)

NS


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Variable

Total ( N = 79) (%)

Undergraduate ( n = 62) (%)

Graduate ( n = 17) (%)

P

9 (11)

8 (13)

1 (6)

NS

First-person shooter games Frequency of playing videogames

72

NS

Rarely

42 (58)

33 (58)

9 (60)

Several times per month

19 (26)

13 (23)

6 (40)

Several times per week

8 (11)

8 (14)

0 (0)

Daily/almost daily

3 (4)

3 (5)

0 (0)

Changes in video game play time since starting professional school

73

NS

Decreased

51 (70)

40 (69)

11 (73)

Not decreased

12 (17)

18 (31)

4 (27)

Reasons why nursing students enjoy video games a

74

Challenge me in problem solving

56 (76)

45 (76)

11 (73)

NS

Help me relax

57 (77)

44 (75)

13 (87)

NS

Allow me to avoid studying

41 (57)

34 (58)

7 (47)

NS

Fun way to spend time with existing friends

28 (39)

25 (42)

3 (20)

NS

Make me feel less lonely when friends not available

25 (34)

23 (39)

2 (13)

0.032

Like competitive aspects

25 (34)

21 (36)

4 (27)

NS

Like exploring new worlds

25 (34)

20 (34)

5 (33)

NS

Help release hostility

9 (12)

8 (14)

1 (7)

NS

Learn a lot from playing games

7 (10)

7 (12)

0 (0)

NS

Make new friends

7 (10)

7 (12)

0 (0)

NS

Table 3 Nursing Students’ Attitudes About Video Games Statement

Agree

Disagree

P

Undergraduate, Graduate, Total, Undergraduate, Graduate, Total, n (%) n (%) N (%) n (%) n (%) N (%) I think real life is migrating online for many millions of people, in its personal, social, economic, educational and even political aspects (undergraduate, n = 144; graduate, n = 66)

131 (91)

56 (85)

187 (89)

13 (9) 10 (15)

23 (11)

NS

I think that education should make better use of new media technologies

123 (85)

61 (92)

184 (88)

21 (15)

5 (8)

26 (13)


NS

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Statement

Agree

Disagree

P

Undergraduate, Graduate, Total, Undergraduate, Graduate, Total, n (%) n (%) N (%) n (%) n (%) N (%) (undergraduate, n = 144; graduate, n = 66) I can clearly envision what my professional life will be like once I finish my training (undergraduate, n = 144; graduate, n = 66)

102 (71)

47 (71)

149 (71)

42 (29)

19 (29)

61 (29)

NS

I feel that video games can have educational value (undergraduate, n = 144; graduate, n = 66)

82 (57)

45 (68)

127 (61)

62 (43)

21 (31)

83 (40)

NS

I like the idea of using technology to enhance the current health care education experience (undergraduate, n = 139; graduate, n = 63)

129 (93)

60 (95)

189 (94)

10 (7)

3 (5)

13 (6)

NS

If multiplayer online health care simulation helped to accomplish a goal that was important to me, I would use it even if I had to do that with my own time (undergraduate, n = 139; graduate, n = 63)

108 (78)

54 (86)

162 (80)

31 (22)

9 (14)

NS

0.185

I would like to be part of the design team that creates a multiplayer online health care simulation (undergraduate, n = 139; graduate, n = 63)

39 (28)

25 (40)

64 (32)

100 (72)

37 (59)

137 (68)

NS

When communicating with patients, being goodhearted and sincere are the only essential skills that health care professionals need (undergraduate, n = 134; graduate, n = 61)

20 (15)

2 (3)

22 (11)

114 (85)

59 (97)

173 (89)

0.07 (0.017)

Table 4 Nursing Students’ Attitudes and Beliefs About Multiplayer Online Health Care Simulations by Undergraduate and Graduate Program


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Survey Question

Total ( N = 201), n (%)



P

Very interested

66 (33)

47 (34)

19 (30)

NS

Somewhat interested

106 (53)

71 (51)

35 (56)

Not at all interested

29 (14)

20 (15)

9 (14)

It was fun

184 (92)

129 (94)

55 (87)

NS

It helped me to develop skill and comfort in patient interactions

180 (90)

127 (92)

53 (84)

NS

It let me experience firsthand the authentic experiences that shaped the views and values of professors I admire

164 (82)

117 (85)

47 (75)

NS

As a course, it included in-person mentoring sessions with professors

160 (80)

109 (79)

51 (81)

NS

It was part of for-credit course

156 (78)

108 (78)

48 (76)

NS

It was visually crafted and strategically designed to equal the best of entertainment properties

151 (75)

105 (76)

46 (73)

NS

It allowed me to meet interesting people in other healthrelated fields

153 (76)

103 (75)

50 (79)

NS

It modeled politics (e.g., letting people set health policy) in a realistic way

151 (75)

88 (64)

47 (75)

NS

It let me overcome challenges in a group with my friends

128 (64)

91 (66)

37 (59)

NS

It modeled economics of different health care systems (e.g., single-payer insurance, socialized medicine) in a realistic way

151 (75)

101 (73)

50 (79)

NS

They would likely find out why that happened and learn from their mistakes

193 (96)

130 (94)

63 (100)

0.039

It would likely convince them to stop playing the game

36 (18)

24 (17)

12 (19)

NS

It would likely convince them to give up their health care career

7 (4)

4 (3)

3 (5)

NS

It would likely encourage them to really kill patients

3 (2)

3 (2)

0 (0)

NS

135 (69) b

87 (63) c

48 (76) d

NS

How interested are you in multiplayer online health care simulations that realistically replicate the experience of what it is like to be in professional practice (choose one)?

Multiplayer online health care simulations would be interesting to me if: a

What do you believe would happen to a student if he/she was playing a health care themed game and killed a simulated patient? a

Regarding the relative value of clinical facts and critical thinking skills versus health professional-patient interpersonal skills (choose one) : Clinical facts and critical thinking, and health


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Survey Question

Total ( N = 201), n (%)



Clinical facts and critical thinking are slightly more important

28 (15) b

20 (15) c

8 (13) d

Clinical facts and critical thinking are much more important

16 (8) b

14 (10) c

2 (3) d

Health professional-patient interpersonal skills are slightly more important

14 (7) b

12 (9) c

2 (3) d

Health professional-patient interpersonal skills are much more important

2 (1)

1 (1) c

1 (2) d

P

professional-patient interpersonal skills are equally important


b

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