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Development of an Educational Game to Set Up Surgical Instruments on the Mayo Stand or Back Table: Applied Research in Production Technology

Development of an Educational Game to Set Up Surgical Instruments on the Mayo Stand or Back... Background: Existing research suggests that digital games can be used effectively for educational purposes at any level of training. Perioperative nursing educators can use games to complement curricula, in guidance and staff development programs, to foster team collaboration, and to give support to critical thinking in nursing practice because it is a complex environment. Objective: To describe the process of developing an educational game to set up surgical instruments on the Mayo stand or back table as a resource to assist the instructor in surgical instrumentation training for students and nursing health professionals in continued education. Methods: The study was characterized by applied research in production technology. It included the phases of analysis and design, development, and evaluation. The objectives of the educational game were developed through Bloom’s taxonomy. Parallel to the physical development of the educational game, a proposed model for the use of digital elements in educational game activities was applied to develop the game content. Results: The development of the game called “Playing with Tweezers” was carried out in 3 phases and was evaluated by 15 participants, comprising students and professional experts in various areas of knowledge such as nursing, information technology, and education. An environment was created with an initial screen, menu buttons containing the rules of the game, and virtual tour modes for learning and assessment. Conclusions: The “digital” nursing student needs engagement, stimulation, reality, and entertainment, not just readings. “Playing with Tweezers” is an example of educational gaming as an innovative teaching strategy in nursing that encourages the strategy of involving the use of educational games to support theoretical or practical classroom teaching. Thus, the teacher does not work with only 1 type of teaching methodology, but with a combination of different methodologies. In addition, we cannot forget that skill training in an educational game does not replace curricular practice, but helps. (JMIR Serious Games 2017;5(1):e1) doi: 10.2196/games.6048 KEYWORDS nursing education research; educational technology; perioperative nursing Current research suggests that digital games can be used Introduction effectively for educational purposes at any level of training [1,2]. Education, in an enlarged view, covers the formative processes that occur at work in school learning and human coexistence. http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier In 2015, the Horizon Report identified game-based learning as Jeopardy-style game called “Nursopardy” is used to reinforce an area likely to have major impact on learning in the next 2 the fundamentals of nursing material, aiding in students’ years. The discovery of this report is indicative of the growing preparation for a standardized final exam [15]. Still under interest in the use of digital games technology with effective development is an in-home and community care settings game projection in education [3]. [16]. The e-Baby Serious Game was built to feature the simulated environment of an incubator, in which the user An educational game is defined as an instructional method, performs a clinical evaluation of the respiratory process in a which requires that the learner participates in a competitive virtual preterm infant [17]. LISSA is another serious game that activity with preset rules [4]. With educational games, learners considers all the steps of the cardiopulmonary resuscitation have an opportunity to experiment with decision-making and (CPR) flowchart [18]. problem-solving in a risk-free active learning environment [5]. Therefore, educational games are considered experiential Thus, the aim of the study was to describe the process of learning methods that may contribute positively to students’ developing an educational game to set up surgical instruments learning. on the Mayo stand and back table as a resource to assist the instructor in training nursing students and health professionals Generally, educators use active learning approaches to keep up in continued education. with new interesting data, promote information retention, and stimulate critical thinking. This is especially important when Methods the subject is complex or tedious [6]. Study Design Surgical centers are considered high risk scenarios extremely susceptible to errors dominated by pressure and stress [7,8] It . The study was based on applied research in technology is well known that students from different fields of medical production [19], which was adopted because it dealt with the science are exposed to several stress factors throughout clinical process of developing or creating a new product, activity or education processes inside the operating room [9-11]. The level service, namely, a learning management system in nursing where of anxiety can increase when some factors are associated [12], the theme was to develop an educational game. such as interpersonal communication, humiliating experiences, This study was approved by the Research and Ethics Committee educational environment, clinical experiences, and unpleasant of the Institute of Cardiology of Rio Grande do Sul state. emotions [10]. The Galvis Panqueva methodology was used to create an Perioperative nursing has a serious agenda with significant educational game [20] because of its clarity and cohesion, content that can be adapted to the game environment for making the process more objective. This methodology teaching, improving proficiency and self-development, and comprised 3 phases: analysis and design, development, and conducting outcomes of research for best practices and evaluation. improvement initiatives. The prospect of using serious games creates an exciting—and maybe for some, a frightening—future A constructivist learning theory was employed to achieve the for those who face this oncoming technology [13]. objectives of the educational game in development. This requires that learners use various tools to access content information, Perioperative nursing educators can use games to complement derive meaning, and develop knowledge of how to work through curricula in guidance and staff development programs, foster a scenario and solve given problems. Guiding this construction team collaboration, and give support to critical thinking in of knowledge, Bloom’s taxonomy offers 6 levels of nursing practice because it is a complex environment [6]. competencies to acquire knowledge about a topic moving from If a serious game could help nurses overcome fear of new simple to complex levels: knowledge, comprehension, procedures, learn changes in the sequencing of events, reduce application, analysis, synthesis, and evaluation [21]. the stress of a situation, or help prevent errors, then the patient Parallel to the physical development of the educational game, will be the ultimate winner [13]. a proposed model for the use of digital elements for educational In this context, the search for quality education of health game activities was used for the development of game content professionals and their services is based on guidelines. As an [22]. example, we mention the Safe Surgery Saves Lives campaign, The Phases whose main objective is to improve the safety of surgical care around the world by defining a core set of safety standards that Phase 1: Analysis and Design can be applied in all countries and settings. The protocol The target audience, choice of subject, educational goals, includes the prevention of infection in surgical sites, safe outlining of the content, and technological infrastructure were anesthesia, safe surgical teams, and surgical care indicators [14]. defined in the analysis phase. The idea is that the educational game can help in this search process for excellence in teaching in the care of surgical patients. The target audience chosen was surgical instrumentation students and nursing health professionals in continued education. An example in international literature in the surgical nursing area is the QuizBowl game that was presented at the Annual The choice of subject was the setup of surgical instruments on Congress of the Association of Perioperative Registered Nurses the Mayo stand and the back table with basic instruments. 2003 to 2010 [6]. Moreover, in the general nursing area, a http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier Thus, the educational goals for the cognitive domain were learning mode, the player can use the “hint” as many times as established by considering that at the end of the game, the needed, showing the location where the instruments should be student was able to set up surgical instruments on the table and placed. In either way, the student assessment will not provide understand the organizational sequence when applying it to the any help. setup of the Mayo stand and back table. Additionally, the student Items or bonus: For each surgical time that is completed with would be able to analyze organization of the operating table, the instruments of the game, the player is awarded a star as a synthesize organization of the operating table in accordance bonus; 6 stars being the maximum. with the procedure and types of instruments needed, and finally evaluate the acquisition of knowledge with increasing score. The game was developed in HTML 5 using the an computer program, which can be used on Windows, Linux, and Mac In order to approach the subject, the content of basic types of platform. The instrumental images were photos from the surgical instruments and surgical time were considered researcher’s personnel file and modeled in blendere changed important, and for the technological infrastructure, the support in gimp. The game designers built the image of the avatar in of a team of game designers. surgical nursing. In the game design phase, the proposal was to create an The game will be hosted on the financial institution's website environment with instruments on a basic tray used in general and a password will be provided to the user. surgery, for example, hernioplasty and postectomy, in which the student had to arrange them according to the model. Phase 3: Evaluation During the stage of the evaluation, students from the surgical The company hired to produce the game planned the navigation instrumentation course and expert professionals in various fields structure, navigation map design, learning environment, and of knowledge related to nursing, information technology, and the interface design. As for the system tools, the need for help education were invited to evaluate the learning environment. buttons to facilitate solving doubts was stipulated. The evaluators comprised a nonprobabilistic convenience sample Phase 2: Development for which selection was performed using nonrandom, intentional The development stage in the construction consisted of an methods [19]. educational game developed by the researchers and 3 game A specific form based on 3 thematic areas according to the designers. Its construction comprised the months of April 2015 Ergolist Project was used for data collection, distinct for the to February 2016. different areas of professionals [23], using a Likert scale, in According to the proposed model for the use of gamification which the user had to mark one of the choices: “totally elements, we cite elements pertaining to this game in the disagree,” “partially disagree,” “indifferent,” “partially agree,” following points: and “totally agree.” Mission: To set surgical instruments on the Mayo stand or back Health education and nursing experts, along with the students table according to the model in virtual tour mode while evaluated the following thematic areas:(1)   Educational aspects considering the 6 surgical times: cutting, grasping, hemostatic, (if the central theme is significant, if there is coherence of retractors, special, and suture. objectives, if theoretical directions are understandable, if exercises and activities are easy to understand, if valuation Plot: In the game, the player assumes the role of a surgical nurse method is applicable, if autonomy is provided to the user, and in the operating room. In the learning mode, the player has no if didactic resources helped in solving problems); (2) specific time to finalize the setup table, but in assessment mode Environment interface (if navigability, accessibility, is given 7 minutes, with a basic instrumental tray used in general environment design, and didactic resources are easy to view); surgery (hernioplasty and postectomy). The player has to and (3) Interactivity of the system (if it is easy to use and recreate a model setup of surgical instruments proposed in the navigate on the screen). virtual tour. However, the specific form for information technology Character: A character called Metzenbaum was created to professionals contemplated Response time (referring to represent a surgical nurse. navigability, accessibility, and system feedback to the user);  Challenges: Increase the score with each attempt, until one Interface quality (design, colors, menu, and buttons); and   Tools reaches the appropriate level of 70% of correct positions. After and resources (form, presentation, and working operating placing the instruments in each step, the player has to click the system). correct button, which results in the following warnings: “Try again,” “Congratulations, you have reached 70% or more,” Results “Great you hit 100%.” Delivery of the first release of the game was in version 1.0 where Specific objectives: Place the instruments in the location set for there were discussions on some topics regarding the layout and each surgical time. background color, the slogan of the institution, use of visual and auditory feedback, and background music. This release Resources, collaboration, or help: In the virtual tour mode, the featured the home screen, which allowed visualization of the player can view the setup of the surgical table, which includes game design with the slogan of the funding institution and a scientific and popular names and classes of instruments. In http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier menu with 4 topics: virtual tour, learning, assessment, and experience in surgical instrumentation, a professor from the credits. The topic of learning highlighted the surgical surgical instrumentation course, and 2 IT professionals. instruments of a Mayo stand at the center and a scroll bar system We identified that the entire sample of health professionals and on the underside with the instrumentals. students agreed totally or partially with the educational aspects, On delivery of the second release in version 1.1, we included showing no difference to the pilot group. With regard to the the virtual tour screen with images of the instruments, the interface, there was improved acceptance with 77% (10/13) that learning screen with the scroll bar system, instruments, and agreed totally or partially to navigability, 85% (11/13) to signalization of hits and fails on the screen. We required accessibility, and 77% (10/13) to design. Regarding system adjustments in relation to the position of the instruments (closed interactivity, 100% of the sample agreed that the game screen and front position) and defined the pilot project (1st testing) is easy to navigate and use. with surgical instrumentation students. The suggestions given were to start the game with a total score The pilot group consisted of 6 surgical instrumentation students. and subtract points as mistakes were made. Others included: to We identified that the sample agreed 100% (6/6) totally or use a stop button, increase the range of adjustment, improve the partially with the educational aspects. Therefore, we concluded viewing tip of the instruments, provide a score below the scroll that the central theme is significant, there is consistency of bar, use as criterion the calculation of points for accuracy and objectives, the theoretical directions are understandable, the time, delete the fail sound, improve color of the screen with an evaluation method is applicable, exercises and activities are updated design, adjust the resolution of the instruments, divide easy to understand, it offers autonomy and educational support, the table and highlight the phases, and enable musical and assists in resolution. With regard to the interface, most of background sound. the sample totally or partially disagreed as follows: 83% (5/6) The IT group rated the response time, interface quality, tools, compared with navigability and 67% (4/6) with accessibility and resources. Responses showed no particularity, emphasizing and design. Regarding the interactivity of the system, 50% (3/6) that the environment was appropriate for a teaching proposal. of the sample agreed that the game screen was easy to navigate and easy to use, but the other half disagreed with this view. The Use of the Galvis Panqueva methodology, in association with suggestions given were in improving the system, use of sound educational objectives and digital gaming elements, created for to signal the hit and fail, time to score, streamlined speed of the educational game “Playing with Tweezers,” a virtual response commands, to highlight the display of instruments, environment that teaches instrumentalization in an active and increase the amount of tweezers. participatory fun way. The game offers a learning and evaluation platform facilitating the teaching-learning process. After the study, the requests were addressed, such as sound differentiating on hits and fails, positioning and addition of An environment with an initial screen containing menu buttons instruments, time recorded on the learning screen, the sum of with rules of the game and the virtual tour modes, learning, and the points on the evaluation screen, use of 3D image, and buttons assessment was created. We used a character feature (avatar) to move the instrumental. to represent the surgical nurses. At the end of the game, if the score was above 70%, a buzzer goes off and the avatar of the The third release in version 1.2 was tested with surgical surgical nurse signals, raising its hands with a happy expression. instrumentation students and professional experts from various In the situation of being below a 70% score, you hear a new fields of knowledge related to nursing, information technology, sound, and the avatar with hands on its face, obscures the and education. There were 15 participants, which included 8 appearance of sadly crying, highlighting the need for greater surgical instrumentation students, 4 professionals with attention. The screens of the final version of the game are shown in Figures 1-5. http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier Figure 1. Initial screen. Figure 2. Virtual tour mode for learning. http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier Figure 3. Instrumental in 3D. Figure 4. Virtual tour mode for assessment. http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier Figure 5. Final screen of the game. analyzed the effect of using LISSA after the introduction of Discussion theory and before laboratory practice. The results obtained showed that students who practiced with LISSA performed Principal Findings better in the laboratory sessions than students that only read The literature on the use of educational games has repeatedly theoretical material. Therefore, from the results we can conclude shown that they have a positive effect on leaners [2,6,15,24-27]. that the use of LISSA improves students’ knowledge and skills Although this study only describes and assesses an educational on CPR. In addition, students feel that LISSA helps them to game to set up surgical instruments on the Mayo stand and back learn [18]. table, the evaluation data of the study suggests there is some Another study created a 3D serious game for scenario-based level of interest from those within the study population toward retraining and proved to be effective in advanced life support the use of a digital game to teach perioperative nursing. This and supported retention of acquired knowledge and skills in 3 preliminary finding appears to support the existing research in months. The serious game, called EMSAVE, also positively the area and has the potential to add data to an area of research engaged and motivated participants [25]. that is underexplored. In the perioperative nursing area, 1 study describes the creation, Perioperative nursing consists in meaningful content that can implementation, and evaluation of a game called “Nursopardy.” be tailored to the targeted teaching game environment, Nursopardy was used with first semester students in nursing improving proficiency and self-development, and the results classes to prepare them for the final exams. The game consisted that conduct research for best practices and improvement of 5 categories with a total of 26 questions, involving care initiatives. management issues, risk reduction, safety and infection control, Changes in our health care system are demanding that nurses physiological adaptation, and basic care. Research involved a have to develop new skills and competencies. Having the small sample of 39 students, but concluded that the game is a opportunity to “test-out” various clinical reasoning pathways useful teaching strategy and the students had positive allows the practitioner to become more aware of how reason is evaluations. The combination of visual, sound, teamwork, and reached and recognize the consequences of this reasoning in competition worked well to increase the teaching-learning action [16]. process [15]. This educational game works with the objective to improve critical thinking and decision-making, and proves In the context of medical education, there has been significant that there is still a gap in the literature in relation to developing research interest in the use of digital games in clinical training, skills in perioperative nursing. such as for surgical skills training [24]. There is also a small amount of research in the use of digital games for continued The data obtained in the evaluation of students, specialists in education, including studies in their usability for retraining of nursing and computer areas, were extremely rewarding and fully resuscitation skills [18,25]. validated the objectives of this study. “Playing with Tweezers” proved to be an intuitive virtual environment, visually pleasant, For example, an article evaluated the use of LISSA, a serious with good navigability and accessibility. It has virtual drive game that considers all the steps of the CPR flowchart. We http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier modes, learning, and assessment that facilitate the test than the ones in the script group. The mean score was 28.6 teaching-learning process. for the game group and 26.0 for the script group. Attitudes toward the recent learning experience were significantly more Limitations positive with the game group. Students reported having more Some limitations of the study were observed in relation to the fun while learning with the game compared with the script-based handling of this new technology as well as the use of information approach [2]. technology in a small sample size. The gaming platform “They Know” is a strategy game based Our future work will be centered on the design of new scenarios on team participation designed for use in a variety of educational and the introduction of new characters into the game and will curricula. In the context of this study, the platform will be used assess the effect of educational gaming for the improvement of to develop a game for medical students to study anatomy and knowledge and skills. histology. The goal is to work in cooperation with teammates in order to take control of a home base opposing team across Comparison With Prior Work the map. To cross the map, players must answer multiple-choice There are numerous examples of educational games that can be questions on each node they pass, related to its specific category used in health care specialties, including jeopardy style, of learning. During the game, players will be observed by a concentration, quiz bowls, puzzle formats, crossword puzzles, study coordinator and will be filmed for the research team to card games, board games, electronic games, slideshows, and review how the players interact with their teammates. The multimedia formats. Regardless of the type of game used, it is research team will also be working with the study participants important to carry out an assessment of knowledge consolidation to explore the ways in which their knowledge was structured [1,5]. There is limited information about the impact of these as a result of playing the educational video game [1]. strategies on learner engagement and outcomes [26]. Further Nursing faculty at a mid-Atlantic historical black college and research in this area would be of benefit to both learners and university introduced “serious gaming” technology to a educators alike [1]. community health nursing course by using 2 Web-based game A Cochrane review evaluated the effect of educational games simulations (1) Outbreak at WatersEdge: A public health on health professionals’ performance, knowledge, skills, attitude, discovery game, and (2) EnviroRisk. This innovation proved and satisfaction as well as on patient outcomes. Just 2 to be effective in reinforcing learning and improving student randomized controlled trials, in which the effect knowledge was learning outcomes [27]. not statistically different between the 2 groups, were included. It is necessary to determine whether learning is taking place The findings of the systematic review did not confirm nor refute and what are the game elements that support learning. More the use of games as a teaching strategy for health professionals. studies are suggested to observe how active-learning strategies, More and better evidence is needed to make practice such as games, affect learning outcomes, including exam scores recommendations. However, those designing and implementing for nursing students. educational games should carefully consider their advantages and disadvantages [5]. Conclusions A randomized controlled trial was conducted with 145 medical The “digital” nursing student needs engagement, stimulation, students to compare the effectiveness on the learning outcome realism, and entertainment and not just more reading. “Playing of a game-based e-learning instruction with conventional with Tweezers” is 1 example of educational gaming as an script-based instruction in the teaching of phase contrast innovative teaching strategy in nursing, as it encourages the microscopy urinalysis under routine training conditions of strategy of involving the use of educational games to support undergraduate medical students. Of the total, 82 subjects where the theoretical or practical classroom teaching. The teacher does allocated for training with an educational adventure-game and not work with only 1 type of teaching methodology, but with a 69 subjects for conventional training with a written script-based combination of methodologies. In addition, we cannot forget approach (script group). The students in the game group that skill training in educational games does not replace the achieved significantly better results in the cognitive knowledge curricular practice, but helps. Acknowledgments The authors would like to thank the Institute of Cardiology of Rio Grande do Sul for their ongoing support of this study. Conflicts of Interest None declared. References 1. Janssen A, Shaw T, Goodyear P. Using video games to enhance motivation states in online education: protocol for a team-based digital game. JMIR Res Protoc 2015;4(3):e114. [doi: 10.2196/resprot.4016] [Medline: 26416522] http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier 2. Boeker M, Andel P, Vach W, Frankenschmidt A. 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[Medline: 26665503] http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier Abbreviations CPR: Cardiopulmonary Resuscitation Edited by G Eysenbach; submitted 30.05.16; peer-reviewed by I Boada, M Hendrix; comments to author 18.07.16; revised version received 02.09.16; accepted 19.09.16; published 10.01.17 Please cite as: Paim CPP, Goldmeier S Development of an Educational Game to Set Up Surgical Instruments on the Mayo Stand or Back Table: Applied Research in Production Technology JMIR Serious Games 2017;5(1):e1 URL: http://games.jmir.org/2017/1/e1/ doi: 10.2196/games.6048 PMID: 28073736 ©Crislaine Pires Padilha Paim, Silvia Goldmeier. Originally published in JMIR Serious Games (http://games.jmir.org), 10.01.2017. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 10 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Development of an Educational Game to Set Up Surgical Instruments on the Mayo Stand or Back Table: Applied Research in Production Technology

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JMIR Publications
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Copyright © The Author(s). Licensed under Creative Commons Attribution cc-by 4.0
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2291-9279
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10.2196/games.6048
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Abstract

Background: Existing research suggests that digital games can be used effectively for educational purposes at any level of training. Perioperative nursing educators can use games to complement curricula, in guidance and staff development programs, to foster team collaboration, and to give support to critical thinking in nursing practice because it is a complex environment. Objective: To describe the process of developing an educational game to set up surgical instruments on the Mayo stand or back table as a resource to assist the instructor in surgical instrumentation training for students and nursing health professionals in continued education. Methods: The study was characterized by applied research in production technology. It included the phases of analysis and design, development, and evaluation. The objectives of the educational game were developed through Bloom’s taxonomy. Parallel to the physical development of the educational game, a proposed model for the use of digital elements in educational game activities was applied to develop the game content. Results: The development of the game called “Playing with Tweezers” was carried out in 3 phases and was evaluated by 15 participants, comprising students and professional experts in various areas of knowledge such as nursing, information technology, and education. An environment was created with an initial screen, menu buttons containing the rules of the game, and virtual tour modes for learning and assessment. Conclusions: The “digital” nursing student needs engagement, stimulation, reality, and entertainment, not just readings. “Playing with Tweezers” is an example of educational gaming as an innovative teaching strategy in nursing that encourages the strategy of involving the use of educational games to support theoretical or practical classroom teaching. Thus, the teacher does not work with only 1 type of teaching methodology, but with a combination of different methodologies. In addition, we cannot forget that skill training in an educational game does not replace curricular practice, but helps. (JMIR Serious Games 2017;5(1):e1) doi: 10.2196/games.6048 KEYWORDS nursing education research; educational technology; perioperative nursing Current research suggests that digital games can be used Introduction effectively for educational purposes at any level of training [1,2]. Education, in an enlarged view, covers the formative processes that occur at work in school learning and human coexistence. http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier In 2015, the Horizon Report identified game-based learning as Jeopardy-style game called “Nursopardy” is used to reinforce an area likely to have major impact on learning in the next 2 the fundamentals of nursing material, aiding in students’ years. The discovery of this report is indicative of the growing preparation for a standardized final exam [15]. Still under interest in the use of digital games technology with effective development is an in-home and community care settings game projection in education [3]. [16]. The e-Baby Serious Game was built to feature the simulated environment of an incubator, in which the user An educational game is defined as an instructional method, performs a clinical evaluation of the respiratory process in a which requires that the learner participates in a competitive virtual preterm infant [17]. LISSA is another serious game that activity with preset rules [4]. With educational games, learners considers all the steps of the cardiopulmonary resuscitation have an opportunity to experiment with decision-making and (CPR) flowchart [18]. problem-solving in a risk-free active learning environment [5]. Therefore, educational games are considered experiential Thus, the aim of the study was to describe the process of learning methods that may contribute positively to students’ developing an educational game to set up surgical instruments learning. on the Mayo stand and back table as a resource to assist the instructor in training nursing students and health professionals Generally, educators use active learning approaches to keep up in continued education. with new interesting data, promote information retention, and stimulate critical thinking. This is especially important when Methods the subject is complex or tedious [6]. Study Design Surgical centers are considered high risk scenarios extremely susceptible to errors dominated by pressure and stress [7,8] It . The study was based on applied research in technology is well known that students from different fields of medical production [19], which was adopted because it dealt with the science are exposed to several stress factors throughout clinical process of developing or creating a new product, activity or education processes inside the operating room [9-11]. The level service, namely, a learning management system in nursing where of anxiety can increase when some factors are associated [12], the theme was to develop an educational game. such as interpersonal communication, humiliating experiences, This study was approved by the Research and Ethics Committee educational environment, clinical experiences, and unpleasant of the Institute of Cardiology of Rio Grande do Sul state. emotions [10]. The Galvis Panqueva methodology was used to create an Perioperative nursing has a serious agenda with significant educational game [20] because of its clarity and cohesion, content that can be adapted to the game environment for making the process more objective. This methodology teaching, improving proficiency and self-development, and comprised 3 phases: analysis and design, development, and conducting outcomes of research for best practices and evaluation. improvement initiatives. The prospect of using serious games creates an exciting—and maybe for some, a frightening—future A constructivist learning theory was employed to achieve the for those who face this oncoming technology [13]. objectives of the educational game in development. This requires that learners use various tools to access content information, Perioperative nursing educators can use games to complement derive meaning, and develop knowledge of how to work through curricula in guidance and staff development programs, foster a scenario and solve given problems. Guiding this construction team collaboration, and give support to critical thinking in of knowledge, Bloom’s taxonomy offers 6 levels of nursing practice because it is a complex environment [6]. competencies to acquire knowledge about a topic moving from If a serious game could help nurses overcome fear of new simple to complex levels: knowledge, comprehension, procedures, learn changes in the sequencing of events, reduce application, analysis, synthesis, and evaluation [21]. the stress of a situation, or help prevent errors, then the patient Parallel to the physical development of the educational game, will be the ultimate winner [13]. a proposed model for the use of digital elements for educational In this context, the search for quality education of health game activities was used for the development of game content professionals and their services is based on guidelines. As an [22]. example, we mention the Safe Surgery Saves Lives campaign, The Phases whose main objective is to improve the safety of surgical care around the world by defining a core set of safety standards that Phase 1: Analysis and Design can be applied in all countries and settings. The protocol The target audience, choice of subject, educational goals, includes the prevention of infection in surgical sites, safe outlining of the content, and technological infrastructure were anesthesia, safe surgical teams, and surgical care indicators [14]. defined in the analysis phase. The idea is that the educational game can help in this search process for excellence in teaching in the care of surgical patients. The target audience chosen was surgical instrumentation students and nursing health professionals in continued education. An example in international literature in the surgical nursing area is the QuizBowl game that was presented at the Annual The choice of subject was the setup of surgical instruments on Congress of the Association of Perioperative Registered Nurses the Mayo stand and the back table with basic instruments. 2003 to 2010 [6]. Moreover, in the general nursing area, a http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier Thus, the educational goals for the cognitive domain were learning mode, the player can use the “hint” as many times as established by considering that at the end of the game, the needed, showing the location where the instruments should be student was able to set up surgical instruments on the table and placed. In either way, the student assessment will not provide understand the organizational sequence when applying it to the any help. setup of the Mayo stand and back table. Additionally, the student Items or bonus: For each surgical time that is completed with would be able to analyze organization of the operating table, the instruments of the game, the player is awarded a star as a synthesize organization of the operating table in accordance bonus; 6 stars being the maximum. with the procedure and types of instruments needed, and finally evaluate the acquisition of knowledge with increasing score. The game was developed in HTML 5 using the an computer program, which can be used on Windows, Linux, and Mac In order to approach the subject, the content of basic types of platform. The instrumental images were photos from the surgical instruments and surgical time were considered researcher’s personnel file and modeled in blendere changed important, and for the technological infrastructure, the support in gimp. The game designers built the image of the avatar in of a team of game designers. surgical nursing. In the game design phase, the proposal was to create an The game will be hosted on the financial institution's website environment with instruments on a basic tray used in general and a password will be provided to the user. surgery, for example, hernioplasty and postectomy, in which the student had to arrange them according to the model. Phase 3: Evaluation During the stage of the evaluation, students from the surgical The company hired to produce the game planned the navigation instrumentation course and expert professionals in various fields structure, navigation map design, learning environment, and of knowledge related to nursing, information technology, and the interface design. As for the system tools, the need for help education were invited to evaluate the learning environment. buttons to facilitate solving doubts was stipulated. The evaluators comprised a nonprobabilistic convenience sample Phase 2: Development for which selection was performed using nonrandom, intentional The development stage in the construction consisted of an methods [19]. educational game developed by the researchers and 3 game A specific form based on 3 thematic areas according to the designers. Its construction comprised the months of April 2015 Ergolist Project was used for data collection, distinct for the to February 2016. different areas of professionals [23], using a Likert scale, in According to the proposed model for the use of gamification which the user had to mark one of the choices: “totally elements, we cite elements pertaining to this game in the disagree,” “partially disagree,” “indifferent,” “partially agree,” following points: and “totally agree.” Mission: To set surgical instruments on the Mayo stand or back Health education and nursing experts, along with the students table according to the model in virtual tour mode while evaluated the following thematic areas:(1)   Educational aspects considering the 6 surgical times: cutting, grasping, hemostatic, (if the central theme is significant, if there is coherence of retractors, special, and suture. objectives, if theoretical directions are understandable, if exercises and activities are easy to understand, if valuation Plot: In the game, the player assumes the role of a surgical nurse method is applicable, if autonomy is provided to the user, and in the operating room. In the learning mode, the player has no if didactic resources helped in solving problems); (2) specific time to finalize the setup table, but in assessment mode Environment interface (if navigability, accessibility, is given 7 minutes, with a basic instrumental tray used in general environment design, and didactic resources are easy to view); surgery (hernioplasty and postectomy). The player has to and (3) Interactivity of the system (if it is easy to use and recreate a model setup of surgical instruments proposed in the navigate on the screen). virtual tour. However, the specific form for information technology Character: A character called Metzenbaum was created to professionals contemplated Response time (referring to represent a surgical nurse. navigability, accessibility, and system feedback to the user);  Challenges: Increase the score with each attempt, until one Interface quality (design, colors, menu, and buttons); and   Tools reaches the appropriate level of 70% of correct positions. After and resources (form, presentation, and working operating placing the instruments in each step, the player has to click the system). correct button, which results in the following warnings: “Try again,” “Congratulations, you have reached 70% or more,” Results “Great you hit 100%.” Delivery of the first release of the game was in version 1.0 where Specific objectives: Place the instruments in the location set for there were discussions on some topics regarding the layout and each surgical time. background color, the slogan of the institution, use of visual and auditory feedback, and background music. This release Resources, collaboration, or help: In the virtual tour mode, the featured the home screen, which allowed visualization of the player can view the setup of the surgical table, which includes game design with the slogan of the funding institution and a scientific and popular names and classes of instruments. In http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier menu with 4 topics: virtual tour, learning, assessment, and experience in surgical instrumentation, a professor from the credits. The topic of learning highlighted the surgical surgical instrumentation course, and 2 IT professionals. instruments of a Mayo stand at the center and a scroll bar system We identified that the entire sample of health professionals and on the underside with the instrumentals. students agreed totally or partially with the educational aspects, On delivery of the second release in version 1.1, we included showing no difference to the pilot group. With regard to the the virtual tour screen with images of the instruments, the interface, there was improved acceptance with 77% (10/13) that learning screen with the scroll bar system, instruments, and agreed totally or partially to navigability, 85% (11/13) to signalization of hits and fails on the screen. We required accessibility, and 77% (10/13) to design. Regarding system adjustments in relation to the position of the instruments (closed interactivity, 100% of the sample agreed that the game screen and front position) and defined the pilot project (1st testing) is easy to navigate and use. with surgical instrumentation students. The suggestions given were to start the game with a total score The pilot group consisted of 6 surgical instrumentation students. and subtract points as mistakes were made. Others included: to We identified that the sample agreed 100% (6/6) totally or use a stop button, increase the range of adjustment, improve the partially with the educational aspects. Therefore, we concluded viewing tip of the instruments, provide a score below the scroll that the central theme is significant, there is consistency of bar, use as criterion the calculation of points for accuracy and objectives, the theoretical directions are understandable, the time, delete the fail sound, improve color of the screen with an evaluation method is applicable, exercises and activities are updated design, adjust the resolution of the instruments, divide easy to understand, it offers autonomy and educational support, the table and highlight the phases, and enable musical and assists in resolution. With regard to the interface, most of background sound. the sample totally or partially disagreed as follows: 83% (5/6) The IT group rated the response time, interface quality, tools, compared with navigability and 67% (4/6) with accessibility and resources. Responses showed no particularity, emphasizing and design. Regarding the interactivity of the system, 50% (3/6) that the environment was appropriate for a teaching proposal. of the sample agreed that the game screen was easy to navigate and easy to use, but the other half disagreed with this view. The Use of the Galvis Panqueva methodology, in association with suggestions given were in improving the system, use of sound educational objectives and digital gaming elements, created for to signal the hit and fail, time to score, streamlined speed of the educational game “Playing with Tweezers,” a virtual response commands, to highlight the display of instruments, environment that teaches instrumentalization in an active and increase the amount of tweezers. participatory fun way. The game offers a learning and evaluation platform facilitating the teaching-learning process. After the study, the requests were addressed, such as sound differentiating on hits and fails, positioning and addition of An environment with an initial screen containing menu buttons instruments, time recorded on the learning screen, the sum of with rules of the game and the virtual tour modes, learning, and the points on the evaluation screen, use of 3D image, and buttons assessment was created. We used a character feature (avatar) to move the instrumental. to represent the surgical nurses. At the end of the game, if the score was above 70%, a buzzer goes off and the avatar of the The third release in version 1.2 was tested with surgical surgical nurse signals, raising its hands with a happy expression. instrumentation students and professional experts from various In the situation of being below a 70% score, you hear a new fields of knowledge related to nursing, information technology, sound, and the avatar with hands on its face, obscures the and education. There were 15 participants, which included 8 appearance of sadly crying, highlighting the need for greater surgical instrumentation students, 4 professionals with attention. The screens of the final version of the game are shown in Figures 1-5. http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier Figure 1. Initial screen. Figure 2. Virtual tour mode for learning. http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier Figure 3. Instrumental in 3D. Figure 4. Virtual tour mode for assessment. http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier Figure 5. Final screen of the game. analyzed the effect of using LISSA after the introduction of Discussion theory and before laboratory practice. The results obtained showed that students who practiced with LISSA performed Principal Findings better in the laboratory sessions than students that only read The literature on the use of educational games has repeatedly theoretical material. Therefore, from the results we can conclude shown that they have a positive effect on leaners [2,6,15,24-27]. that the use of LISSA improves students’ knowledge and skills Although this study only describes and assesses an educational on CPR. In addition, students feel that LISSA helps them to game to set up surgical instruments on the Mayo stand and back learn [18]. table, the evaluation data of the study suggests there is some Another study created a 3D serious game for scenario-based level of interest from those within the study population toward retraining and proved to be effective in advanced life support the use of a digital game to teach perioperative nursing. This and supported retention of acquired knowledge and skills in 3 preliminary finding appears to support the existing research in months. The serious game, called EMSAVE, also positively the area and has the potential to add data to an area of research engaged and motivated participants [25]. that is underexplored. In the perioperative nursing area, 1 study describes the creation, Perioperative nursing consists in meaningful content that can implementation, and evaluation of a game called “Nursopardy.” be tailored to the targeted teaching game environment, Nursopardy was used with first semester students in nursing improving proficiency and self-development, and the results classes to prepare them for the final exams. The game consisted that conduct research for best practices and improvement of 5 categories with a total of 26 questions, involving care initiatives. management issues, risk reduction, safety and infection control, Changes in our health care system are demanding that nurses physiological adaptation, and basic care. Research involved a have to develop new skills and competencies. Having the small sample of 39 students, but concluded that the game is a opportunity to “test-out” various clinical reasoning pathways useful teaching strategy and the students had positive allows the practitioner to become more aware of how reason is evaluations. The combination of visual, sound, teamwork, and reached and recognize the consequences of this reasoning in competition worked well to increase the teaching-learning action [16]. process [15]. This educational game works with the objective to improve critical thinking and decision-making, and proves In the context of medical education, there has been significant that there is still a gap in the literature in relation to developing research interest in the use of digital games in clinical training, skills in perioperative nursing. such as for surgical skills training [24]. There is also a small amount of research in the use of digital games for continued The data obtained in the evaluation of students, specialists in education, including studies in their usability for retraining of nursing and computer areas, were extremely rewarding and fully resuscitation skills [18,25]. validated the objectives of this study. “Playing with Tweezers” proved to be an intuitive virtual environment, visually pleasant, For example, an article evaluated the use of LISSA, a serious with good navigability and accessibility. It has virtual drive game that considers all the steps of the CPR flowchart. We http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier modes, learning, and assessment that facilitate the test than the ones in the script group. The mean score was 28.6 teaching-learning process. for the game group and 26.0 for the script group. Attitudes toward the recent learning experience were significantly more Limitations positive with the game group. Students reported having more Some limitations of the study were observed in relation to the fun while learning with the game compared with the script-based handling of this new technology as well as the use of information approach [2]. technology in a small sample size. The gaming platform “They Know” is a strategy game based Our future work will be centered on the design of new scenarios on team participation designed for use in a variety of educational and the introduction of new characters into the game and will curricula. In the context of this study, the platform will be used assess the effect of educational gaming for the improvement of to develop a game for medical students to study anatomy and knowledge and skills. histology. The goal is to work in cooperation with teammates in order to take control of a home base opposing team across Comparison With Prior Work the map. To cross the map, players must answer multiple-choice There are numerous examples of educational games that can be questions on each node they pass, related to its specific category used in health care specialties, including jeopardy style, of learning. During the game, players will be observed by a concentration, quiz bowls, puzzle formats, crossword puzzles, study coordinator and will be filmed for the research team to card games, board games, electronic games, slideshows, and review how the players interact with their teammates. The multimedia formats. Regardless of the type of game used, it is research team will also be working with the study participants important to carry out an assessment of knowledge consolidation to explore the ways in which their knowledge was structured [1,5]. There is limited information about the impact of these as a result of playing the educational video game [1]. strategies on learner engagement and outcomes [26]. Further Nursing faculty at a mid-Atlantic historical black college and research in this area would be of benefit to both learners and university introduced “serious gaming” technology to a educators alike [1]. community health nursing course by using 2 Web-based game A Cochrane review evaluated the effect of educational games simulations (1) Outbreak at WatersEdge: A public health on health professionals’ performance, knowledge, skills, attitude, discovery game, and (2) EnviroRisk. This innovation proved and satisfaction as well as on patient outcomes. Just 2 to be effective in reinforcing learning and improving student randomized controlled trials, in which the effect knowledge was learning outcomes [27]. not statistically different between the 2 groups, were included. It is necessary to determine whether learning is taking place The findings of the systematic review did not confirm nor refute and what are the game elements that support learning. More the use of games as a teaching strategy for health professionals. studies are suggested to observe how active-learning strategies, More and better evidence is needed to make practice such as games, affect learning outcomes, including exam scores recommendations. However, those designing and implementing for nursing students. educational games should carefully consider their advantages and disadvantages [5]. Conclusions A randomized controlled trial was conducted with 145 medical The “digital” nursing student needs engagement, stimulation, students to compare the effectiveness on the learning outcome realism, and entertainment and not just more reading. “Playing of a game-based e-learning instruction with conventional with Tweezers” is 1 example of educational gaming as an script-based instruction in the teaching of phase contrast innovative teaching strategy in nursing, as it encourages the microscopy urinalysis under routine training conditions of strategy of involving the use of educational games to support undergraduate medical students. Of the total, 82 subjects where the theoretical or practical classroom teaching. The teacher does allocated for training with an educational adventure-game and not work with only 1 type of teaching methodology, but with a 69 subjects for conventional training with a written script-based combination of methodologies. In addition, we cannot forget approach (script group). The students in the game group that skill training in educational games does not replace the achieved significantly better results in the cognitive knowledge curricular practice, but helps. Acknowledgments The authors would like to thank the Institute of Cardiology of Rio Grande do Sul for their ongoing support of this study. Conflicts of Interest None declared. References 1. Janssen A, Shaw T, Goodyear P. Using video games to enhance motivation states in online education: protocol for a team-based digital game. JMIR Res Protoc 2015;4(3):e114. [doi: 10.2196/resprot.4016] [Medline: 26416522] http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier 2. Boeker M, Andel P, Vach W, Frankenschmidt A. 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[Medline: 26665503] http://games.jmir.org/2017/1/e1/ JMIR Serious Games 2017 | vol. 5 | iss. 1 | e1 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Paim & Goldmeier Abbreviations CPR: Cardiopulmonary Resuscitation Edited by G Eysenbach; submitted 30.05.16; peer-reviewed by I Boada, M Hendrix; comments to author 18.07.16; revised version received 02.09.16; accepted 19.09.16; published 10.01.17 Please cite as: Paim CPP, Goldmeier S Development of an Educational Game to Set Up Surgical Instruments on the Mayo Stand or Back Table: Applied Research in Production Technology JMIR Serious Games 2017;5(1):e1 URL: http://games.jmir.org/2017/1/e1/ doi: 10.2196/games.6048 PMID: 28073736 ©Crislaine Pires Padilha Paim, Silvia Goldmeier. Originally published in JMIR Serious Games (http://games.jmir.org), 10.01.2017. 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JMIR Serious Games – JMIR Publications

Published: Jan 10, 2017

Keywords: nursing education research; educational technology; perioperative nursing

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