Gaming as an Instructional Strategy

Gaming as an Instructional Strategy to Enhance Baccalaureate Nursing Students' Learning

Nurse educators play a key role in preparing a future workforce of nurses to provide quality care that meets the health care needs of the population (the National League of Nursing [NLN], 2002). Nurse educators are responsible for facilitating student learning and evaluating outcomes. In 2003, the NLN stated that nursing curricula needed to be evidence-based, receptive to the needs of students, flexible, and incorporate current technology. To better meet the needs of today's students, an educator must become familiar with the characteristics and ways of preferred learning of today's learner. Recently, the NLN (2006) identified 72.1% of baccalaureate nursing students being comprised of the millennial or net generation. The millennial student was born between roughly 1980 and 1994 (Carlson, 2005). According to Tapscott (1998), educators must design a new method of how to deliver instruction to the millennial generation. The following eight shifts of learning were outlined by Tapscott that differentiated the millennial student from the previous generation's way of learning:

1. From linear to hypermedia learning

2. From instruction to construction and discovery

3. From teacher-centered to learner-centered

4. From absorbing material to learning how to learn

5. From school to lifelong learning

6. From one-size-fits all to customized learning

7. From learning as torture to learning as fun

8. From teacher as transmitter to teacher as facilitator.

The millennial student's are smart, impatient, expect immediate results, like to take control of their learning, and prefer active learning as opposed to passive learning (Carlson, 2005). Millennial student's enjoy working independently or collaboratively in groups, like creativity and structure, prefer professors that engage them in the learning process, and enjoy multitasking (Oblinger, 2003; Tucker, 2006). Because of its fun, active, and adaptive nature, gaming might be one instructional strategy that meets the needs of the millennial student.

In nursing education currently, content is increasing in quantity and complexity. With lectures, because of its mostly one-way communication medium, holding the attention of millennial students for an entire hour or longer to teach complex content is nearly impossible (Foreman, 2003). Lack of student attention inhibits immediate knowledge and retention of important content. Educators must confidently deliver nursing content which utilizes a research-based instructional strategy that enhances student's immediate knowledge and retention of knowledge (Mertig, 2003). Games have a way of engaging the learner and maintaining their attention (Foreman). Therefore, gaming may be an effective strategy to convey the increase in nursing education's complex content. A review of the educational and nursing literature identified gaming as one instructional strategy that may facilitate students' immediate knowledge and retention of knowledge.

Purposes of the Study

The primary purpose of this research study is to compare the effectiveness of two teaching strategies, lecture only and lecture with gaming, in baccalaureate nursing students' immediate knowledge and knowledge retention, using the concepts of arterial blood gases as the teaching exemplar. The secondary purpose of the study is to explore students' attitudes towards gaming as an instructional strategy in nursing education.

Statement of the Problem

Typically, baccalaureate nursing students are taught nursing content utilizing lecture as the main instructional strategy (Young & Diekelmann, 2002). With this instructional strategy, information is passively received by the nursing student and one's involvement in the teaching-learning process is limited (Eggen & Kauchak, 2001). Instructional strategies that encourage active student involvement in the learning of nursing content may be more effective in promoting student learning than lecture alone. According to Freeman (2003), active learning enhances critical thinking and improves student's skills. In addition, active learning increases student's interest thereby aiding in reinforcing content learned and retention of knowledge. Caruson (2005) stated "The use of active learning strategies can involve students with course material in ways that the traditional lecture can not." Active learning increases student motivation to learn, enhances student learning attitude, and improves on the student's responsibility for learning. When students are engaged actively in learning, they are more likely to bring about the higher cognitive skills of analysis, synthesis, and evaluation of learning (Sarason & Banbury, 2004).

Gaming is one instructional strategy that promotes active learning in nursing education (Henderson, 2005). Literature suggests that gaming is an effective instructional strategy to enhance knowledge (Henderson); however, there is limited empirical evidence concerning its use in nursing education and in particular, teaching baccalaureate nursing students' the content of arterial blood gases.

Research Questions

The following research questions will be addressed in this study:

Is there an immediate difference in baccalaureate nursing students' knowledge of arterial blood gases when taught by an equivalent combination of lecture and gaming or by lecture only?

Is there a difference in baccalaureate nursing students' retention of knowledge of arterial blood gases after four weeks when taught through an equivalent combination of lecture and gaming as compared to lecture only?

What are baccalaureate nursing students' attitudes toward gaming after its use to enhance learning of arterial blood gas content?

Statement of Hypotheses

Baccalaureate nursing students who are taught about blood gases through the equivalent combination of lecture and gaming will demonstrate greater immediate knowledge of the content than students taught through lecture only.

Baccalaureate nursing students who are taught about blood gases through the equivalent combination of lecture and gaming will demonstrate greater retention of knowledge of arterial blood gases after four weeks than students taught through lecture only.

At least 75% of baccalaureate nursing students who participate in gaming method of instruction will have a positive attitude toward gaming as a teaching-learning strategy of arterial blood gas content.

Theoretical Framework

Malcolm Knowles Adult Learning Theory (1980) provides a framework for examining gaming as an instructional strategy to enhance student learning and knowledge retention. Knowles defines an adult as one who is performing adult-like roles such as a worker, a voting citizen, a spouse or parent. Adults also view themselves as responsible for their own life and take responsibility for making decisions (Knowles, Holton, & Swanson, 2005). Millennial undergraduate nursing students meet Knowles criteria of an adult learner. Individuals become adults at various rates as they move through various activities of childhood and adolescence, participate in organizations that foster responsibilities, and by attending college.

According to Knowles, the adult learner is in need of non-traditional ways to approach learning. In contrast to pedagogy which relates to how children learn, andragogy, the art and science of helping adults learn, is a term that grew in recognition in the 1960s and 1970s when Knowles popularized its use in the United States (Knowles, 1980). In Knowles' book, Self-Directed Learning: A Guide for Learners and Teachers (1975), the author defined self-directed learning as a process in which individual learners, without the help of others, construct their own learning activity. In particular, these adult learners are able to identify their own learning objectives, find learning resources, implement learning strategies, and determine their own learning outcomes (Leonard, 2002). Likewise, self-directed learning is an important aspect of Knowles' andragogy, in which the adult learner is self-motivated to learn on his or her own in order to provide improvements in knowledge and skills related to work enhancement and job promotion. Characteristics describe the adult learner as increasingly independent, self-directed, and an active learner with various life experiences that may impact problem-solving and decision-making (Cyr, 1999).

Knowles's (2005) theory of adult learning incorporates six assumptions or principles which support the use of gaming with adult learners. First, Knowles stated that adult learners have a need to know. Adult learners have a need to know because they are approaching new job roles or careers. In this study, undergraduate nursing students are broaching on a new career. Adults prefer to know why they need to learn something before learning it. As in classroom lecture, in educational gaming, learning objectives are stated either by the instructor or provided in written form with the gaming instruction. Objectives help to identify the purpose of the game. Objectives also provide adult learners with a sense of progress toward meeting the learning objectives during the game.

Second, Knowles (2005) stated that adults are independent and self-directed beings. According to Knowles, students enrolled in higher education see themselves as fundamentally self-directed and they identify with the adult role. Gaming allows the student, rather than the instructor, active control of learning and promotes independence. Learners participate actively by answering questions or problem-solving during a game. Gaming allows the learner to be self-directed and submit to learning. Learners who perceive a lack of self-directedness may react with resentment and resistance towards learning. Utilizing lecture only in the classroom may lead to learners resenting the instructor for imposing their will on them. In addition, when learners sense a lack of self-directedness, they regress back to their dependent "teach me" nature.

Third, adult learners incorporate new knowledge based on an existing foundation which has been previously developed through experience (Knowles, 2005). As an individual matures, experiences accumulate and a base to relate new learning to is formed. Active learning techniques, such as gaming, tap into learners' experiences and engage them in utilizing those experiences. Knowles stated "The richest resources for learning reside in the adult learners themselves" (p. 66). An instructional strategy like gaming may help to facilitate tapping into the adult learner's experience. Through collaboration during the play of a game, learners may discuss prior experiences to aid in discovery of the correct answer. Gaming activities also permit peer feedback to be given to students based on their previous experiences. The millennial student desires immediate feedback and integrates their experiences into their learning (Tapscott, 1998). Again, through group discussion and collaboration, learners share previous experiences with others to confirm or not the correct answer.

By not tapping into the experience of adult learners, negative effects may result (Knowles, 2005). The adult learner identifies their experiences as who they are. In other words, their experiences help to define them as a person. Adult learners, who perceive their experiences as being ignored or devalued, perceive the instructor as rejecting them as persons (Knowles). By devaluing or ignoring the millennial learner's experiences, the mutual respect they desire with the instructor is hampered because they are no longer seen as adults (Aviles, Phillips, Rosenblatt, & Vargas, 2005).

Fourth, the adult learner's readiness to learn is dependent on one's evolving social roles (Knowles, 2005). Knowles stated adult learners become ready to learn in order to effectively cope with their real-life or upcoming situations. Baccalaureate nursing students become ready to learn when they become aware of potential real-life or upcoming events they will be facing as a nurse. Interaction that occurs when learners participate in gaming may promote social role development and readiness to learn (Knowles, 2005).

Fifth, adult learning orientation shifts from subject-centered to problem-centered (Knowles, 2005). Adults learn best if new material is presented in a problem format in which the learner can immediately apply what is being learned. According to Knowles, the adult learner seeks to apply tomorrow what they learned today. In this regard, gaming activities allow students to immediately apply their knowledge from classroom lecture to situations that promote application. Oblinger and Oblinger (2005) state the millennial learner thrives on immediate gratification through application of new knowledge. Through immediate application of content learned, the link between nursing theory and practice is strengthened (Henderson, 2005).

Lastly, Knowles's theory (2005) stated that adults are both internally and externally motivated to learn. The most powerful motivators are internal factors such as a desire, a perceived need, or a wanting to learn. "Adults are motivated to learn to the extent that they perceive that learning will help them perform tasks or deal with problems that they confront in their life situations" (p. 67).

Given the explosive growth in the number of adult learners in recent years, it is not surprising that the methods developed by Knowles and others have received an increasing amount of attention, particularly as they relate to what actually helps motivate adult learners to learn. In this regard, Griffin and his associates report that, "Malcolm Knowles' theory of andragogy originated the contract idea. Experiential learning also lies at the heart of much current theory and practice, and this too involves a degree of self-directed learning. As a result, self-directed learning and learning contracts are increasingly used for purposes of assessment and accreditation both in higher education and in professional continuing education and development" (p. 90). These trends have been fueled by some external forces as well that make the identification of what motivates adults to learn effectively all the more pressing and an extensive body of literature on the subject of self-directed learning has developed, reflecting research, adult learning theory and practice (Griffin et al., 2003), and these issues are discussed further below.

Application of Adult Learning Theory

There has been a profusion of new educational strategies in adult education in recent years that have provided educators with some viable alternatives to conventional teaching methods (Braithwaite & Westbrook, 2001), and one such approach is used in this study. The card game entitled "ABG Go Fish" will be played by undergraduate baccalaureate nursing students (Appendix a). Students seeking a career in nursing have a need to know about arterial blood gas content. "ABG Go Fish" seeks to reinforce arterial blood gas parameters, analysis, and clinical manifestations of respiratory and metabolic acidosis or alkalosis. The game will provide participants with a sense of progress towards identifying and interpreting normal and abnormal arterial blood gas parameters, and recognizing abnormal clinical manifestations of acid-base imbalances.

Gaming also allows the adult learner to have active control of learning and promotes independence. The "ABG Go Fish" card game allows students to participate actively by interpreting and analyzing arterial blood gas parameters and clinical manifestations. The card game also allows the student to have active control of learning at their own pace.

The "ABG Go Fish" game allows learners the ability to apply existing knowledge of acid-base imbalances. The card game engages the learner and permits peer feedback of previous experiences with acid-base imbalances.

Gaming can promote an adult learner's readiness to learn and social role development. Interaction between players during the "ABG Go Fish" card game permits social development and promotes a readiness to learn. Nursing students become ready to learn arterial blood gas content when they are aware of this need to know in order to cope effectively in patient care.

According to Knowles (1998), adults are problem-centered in their route to learning. Therefore, the "ABG Go Fish" card game supports this principle of learning. The card game presents arterial blood gas information in a hands-on, problem format which allows immediate application of content. Gaming makes learning more effective when presented in the context of application (Knowles, 1998). In fact, there is a profound motivation among adult students to learn (Knowles, 1998). Consequently, it is reasonable to suggest that adult students, in particular adult nursing students, will be motivated when they recognize learning will help them perform the responsibilities necessary to deal with the problems they will confront when performing patient care (Knowles, 1998). The "ABG Go Fish" card game motivates nursing student's learning of arterial blood gas content.

Definition of Terms

Gaming is an instructional strategy, directed by rules and levels of chance, which uses an established format to involve one or more players who compete (with self, one another, or a computer) in an effort to achieve an outcome (De Tornyay & Thompson, 1987). In this study, the card game "ABG Go Fish" is the format used amongst teams consisting of two players who compete to correctly interpret and analyze arterial blood gas parameters and clinical manifestations cards.

Knowledge is an understanding of information gained by experience (Merriam-Webster, 1999).

Immediate knowledge is knowledge gained at once after content to be learned is presented. Immediate knowledge will be measured by a difference in a 15-item multiple choice pretest and posttest score (Appendix B, C).

Knowledge retention is information that is retained or held onto. In this study, knowledge retention will be measured by a difference between the immediate posttest score and a 15-item multiple choice posttest score in four weeks (Appendix D).

Lecture is a passive form of instructive talk in which students passively receive verbal information, facts, or ideas by teachers (DeYoung, 2003). In this study, lecture will include a 30-minute presentation/discussion by the researcher on arterial blood gas components and analysis of lab results.

Nursing student includes any male or female, 18 years of age or older, an academically passing junior or senior level baccalaureate, enrolled part-time or full-time, in a National League of Nursing Accredited Commission (NLNAC) or Commission of Collegiate Nursing Education (CCNE) accredited university or college. Nursing student also includes only those who can read and write English.

Attitude towards Gaming is the opinion that nursing students have about gaming as a teaching method. In this study, attitude towards gaming will be measured by the total score on the Attitude Toward Gaming Semantic Differential Instrument (ATG-SDI) (Appendix E).

Assumptions of the Study

This study is based on the following assumptions:

1. Baccalaureate nursing students' meet Knowles principles of adult learning.

2. Baccalaureate nursing students' in the experimental group will actively participate in the proposed game intervention in good faith.

3. Baccalaureate nursing students' in both groups will answer the research questionnaires honestly and in good faith.

Significance of the Study

Nursing Research

The significance of this study in nursing education, science, and research, is noteworthy for several reasons. Currently, there is a limited amount of research available on the evaluation of gaming in adult education and in particular, nursing education (Jarvis, 2004). A review of the literature revealed that much has been written supporting the value of gaming in nursing education; however, most of the literature consisted only of opinion. A minimal amount of empirical evidence exists that demonstrates gaming to be more effective than traditional instructional strategies, such as lecture, for enhancing students' knowledge in nursing education. In addition, little empirical research exists in assessing a game's impact on knowledge retention. Using an instructional strategy like gaming may facilitate students' immediate learning and retention of information better than a traditional method of instruction. In order to validate a game's use and outcomes, research is needed. This study will begin to fill the current void existing in research-based evidence that supports the use of gaming in nursing education to enhance knowledge. Research is an essential component in the evaluation of instructional teaching strategies.

Nursing Education

This study is vital because it will add to the empirical knowledge base of gaming strategies for nursing education. The study will compare the effectiveness of a lecture and gaming vs. lecture only on enhancement of arterial blood gases by baccalaureate nursing students. The NLN (2003) stated that nursing curricula needs to be evidence-based and this study will serve to support this endeavor.

Additionally, this study may encourage nurse educators to incorporate a new instructional strategy. The NLN's position statement on nursing education clearly states that nurse educators are central resources in preparing future nurses to provide quality care (2002). In order to graduate academically sound students, knowledge of nursing concepts must be retained. Educators are challenged with finding ways to enhance learning. If the use of gaming as an instructional learning strategy is found to be effective, nurse educators might feel more comfortable with incorporating it into the classroom.

Gaming is used to make learning a pleasant and enjoyable experience, in addition to promoting learning (Cessario, 1987). This study will serve to aid in the understanding of student's attitude towards gaming as an instructional strategy. If students perceive gaming as a positive experience that enhances and promotes learning, then nurse educators may embrace and encourage its use.

Nursing Science

This research study will add to the body of knowledge of nursing science by identifying information about gaming use in teaching blood gases in nursing education. This study will compare the effectiveness of gaming and lecture vs. lecture only on the achievement and retention of blood gas concepts by baccalaureate nursing students. It will also help to predict student outcomes of blood gas knowledge and retention when gaming is utilized in the classroom.

Summary

This chapter identifies the reason for exploring gaming as an instructional method to promote and enhance student learning. The primary purpose of this research study is to compare the effectiveness of two teaching strategies, lecture only and lecture with gaming, in baccalaureate nursing students' retention of knowledge of arterial blood gases. Another purpose of the student is to explore students' perceptions of gaming as a teaching-learning strategy. Three research questions were derived and introduced. Malcolm Knowles adult theory of learning was explained as a theoretical framework for the study. Conceptual definitions of the study variables were presented. The assumptions and significance of the study concluded the chapter.

CHAPTER 2

REVIEW of the LITERATURE

This chapter reviews published research, anecdotal, descriptive, and theoretical literature regarding the use of gaming in education and in particular, nursing education. Additionally, a review of the theoretical framework regarding Malcolm Knowles' Theory of Adult Learning will be presented.

The databases searched for the foundation of this literature review included Chronicle of Higher Education, PubMed, Ovid, Educational Resources Information Center (ERIC), and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The data base searches covered the time span from 1980 to 2005. The search included a 25-year period due to the reported increased interest in gaming amongst educators within that earlier time frame. The following keywords were used: 'gaming,' 'teaching strategy,' 'higher education,' 'nursing education,' 'adult education, 'adult learning,' 'knowledge retention,' and 'Malcolm Knowles.' Abstracts for citations were read for appropriateness and bibliographies of all retrieved articles were scrutinized for additional studies. The review of literature located seven studies comparing lecture and other strategies to gaming and its usefulness in nursing education. These studies will be reviewed in-depth in this chapter. In addition, relevant research studies related to adult learning and knowledge retention will be critically evaluated in this review.

Theoretical Framework

Gaming enhances learning by addressing the special needs of the adult learner. Therefore, it is imperative for nurse educators to develop a good understanding of Adult Learning Theory in order to enhance the development of future nurses. Therefore, it is reasonable to posit that Knowles' Adult Learning Theory is a useful framework for using gaming strategies to help adults learn.

As mentioned in the previous chapter, Knowles's (1998) Adult Learning Theory incorporated six assumptions which support the use of gaming with adult learners. The number of assumptions Knowles developed has grown from four to six since originally presented in 1975 (Knowles, Holton, Swanson, 2005). Knowles stated that adults are independent and self-directed. Adults strive on being accountable for their own decision-making and have a need to be regarded by others as being competent of self-direction. To this end, Knowles formulated the classic distinction between andragogy and pedagogy, but was later compelled to refine it somewhat.

According to Cunningham and his colleagues, "Modern andragogical approaches are drawn predominantly from the work of Malcolm Knowles, and his work is frequently referred to where debate is framed around the adult/child binary" (p. 47). Although adult education did not assume the form of a unified movement with national organizations in the United States until progressive elements were introduced during the period between 1924 and 1961, Knowles reported as early as the 1960s that adult education has longstanding historical roots and predicted that the adult education movement might be the educational vanguard of the latter 20th century. In 1961, Knowles predicted that the following trends would significantly influence the future of adult education:

The size of the student body of adult education will continue to expand.

The educational level of the student body of adult education will continue to rise.

The resources and facilities for the education of adults will gradually expand. An increasing number of private institutions, including industry, will be perceived as having an educational responsibility toward their employees and clients, and will construct facilities and employ specialists for the fulfillment of this responsibility.

The curriculum and methodology of adult education will become increasingly differentiated from those designed for children and youth.

There will be a rapid expansion in the body of knowledge about the education of adults

The role of the adult educator will become increasingly differentiated from other roles and training for this role will become increasingly specialized.

Should it come to pass that education is redefined as a lifelong process, adult education would then become the largest and most significant dimension of our national educational enterprise (pp. 269-76).

A few years later, Knowles (1977) revised his earlier predictions and reported that the trends that began in the preceding era had continued to accelerate during the intervening period with the following results:

Business and industry had indeed become major adult education institutions.

There had been a massive infusion of funds into the higher adult education system by the federal government.

There had been explosive growth in the number of community colleges across the country.

There had been increasing pressures from a variety of sources to make higher education more accessible to more people-especially part-time working adult students, a trend that has produced a flood of nontraditional and external degree programs.

New delivery systems for reaching large numbers of people spread over extensive geographic areas had been and were being developed.

New ways of financing higher continuing education were being explored and developed.

Graduate programs for training professional adult education workers had expanded.

According to Griffin, Holford and Jarvis (2003), "[Knowles] wrote that originally his distinction was as follows: 'andragogy [is] the art and science of helping adults learn, in contrast to pedagogy [which is] the art and science of teaching children" (1980, p. 43 cited in Griffin et al. At p. 71). This fundamental distinction between adult and young learners received a great deal of criticism from educators and policymakers alike, but Knowles' primarily concern at the time, though, was that the precepts of andragogy provided adults learners with the freedom they needed to use their own experience and learn from the situations within which they found themselves. By sharp contrast, pedagogy, in Knowles' view, involved making learners learn what they were being taught by their teachers, although he eventually acknowledged that young learners are taught by student-centered methods in some cases and that adult learners were taught by teacher-centered methods (Griffin et al., 2003). In this regard, these authors add that, "When Malcolm Knowles introduced his concept of 'andragogy,' he wanted to develop a theory of learning and teaching appropriate to adults. Andragogy, he said, was the 'art and science of helping adults learn'" (Griffin et al., 2003, p. 77). Therefore, using this approach, the role of the teacher in adult education is to assist the adult learner in making the critical transition from a dependent to a self-governed or self-directed learner.

The majority of adult learners seek out new learning opportunities for specific reasons; these reasons may be based on internally experienced or externally created needs. In this regard, Mezirow's (1981) seminal work on adult education reinforces the concept that adults determine why they enter educational programs based on what they think they need to learn. According to Mezirow (1991), "What we [society or leaders], have perfected is instrumental learning, the capacity to solve specific discrete technical problems in the world through the application of the scientific method of analysis and implementation. What we have devalued and ignored are the capacities implied by communicative learning, the domain in which we learn to discover and develop values, find ways to resolve conflicts and manage complexity" (p. 37). Furthermore, in his book, Transformative Dimensions of Adult Learning, Mezirow describes the emancipatory learning framework as being a domain where adult learners can experience the discovery of perception and action.

According to Williams (1996), "The freedom in the discovery is based on the extent of communicative learning possibilities. Our process of knowing or learning is often based on different strategies that allow approaching one another to explore new thoughts, new issues, and new beliefs" (p. 101). This author suggests that adult learning studies in the future should be informed by feedback from all of the participants involved, rather than just those who have been consulted concerning adult curriculum development in the past. For example, Williams suggests that, "Technical resolution is a compartmentalized resolution. Communicative learning and emancipatory learning become the methods for a comprehensive resolution strategy for business decision making and ultimate business action. This process is called transformative learning" (p. 101).

The term transformative learning, then, indicates that there are actually some profound changes taking place both within the adult learner as well as the framework in which learning takes place, and there are a wide range of factors involved that might not be readily apparent to the casual observer. According to Williams (1996), "Transformation is the restructuring or altering of beliefs and values based on a reevaluation of the underlying assumptions that guide thought, action, and being.... because the underlying assumptions surrounding personhood, culture, socialization (and society), and learning were challenged. The old paradigms have restricted creation, and the old paradigms have caused dysfunctions that block growth and development" (p. 102).

The growing body of literature concerning transformation as being an important goal of adult learning initiatives is an extension of the philosophy of continuing personal growth throughout an individual's life, as well as facilitating the adult learner's ability for self-direction in learning (Mezirow, 1981, p. 21). According to this author, "Perspective transformation is the process of becoming critically aware of how and why our presuppositions have come to constrain the way we perceive, understand and feel about our world; of reformulating these as to permit a more inclusive discriminating, permeable and integrative perspective; and making decisions or otherwise acting on these new understandings" (Mezirow, 1981, p. 14). Clearly, most adult learners are able to recognize their desire or survival need to improve their quality of life and the realization that particular skills are needed for such improvement, otherwise no one would achieve any advancement in their careers and industry would stagnant entirely.

As a result, it is reasonable to posit that when adult learners begin to investigate educational programs they feel may be appropriate and relevant for their own unique purposes; their expectations of these programs will naturally influence how they motivationally respond to what they are taught in powerful ways. Furthermore, adult learners who are truly motivated to learn generally have a higher degree of success in accomplishing their goals than do their counterparts who are not motivated (Mezirow 1991).

Initially, adult learners, like their younger counterparts, may be dependent when learning a new subject matter or facing a new situation, but they quickly become self-governed once the initial groundwork has started. Gaming aids in the transition of the learner and enforces the adult need to make decisions. By participating in a game, the adult learner assumes responsibility for their learning (Wolf & Duffy, 1979). Games help guide adult learners in becoming more autonomous (Wolf & Duffy). With gaming, the adult learner gains knowledge through self-discovery (Sprengel, 1994).

Previous experience and knowledge also affect the learning needs of adults. Knowles, Holton, and Swanson (2005) stated, "Adults come into an educational activity with both a greater volume and a different quality of experience from that of youths" (p. 65).

Therefore, through discussion, projects, simulations, and gaming, adults can contribute their reservoir of knowledge gained through experience to each learning opportunity. Experience, then, becomes a rich resource for nursing students. Besides personal and family healthcare history, nursing students also gain experience through practice in a clinical setting. Students grow and develop their reservoir of experience with each clinical assignment and gaming can be utilized to enhance the knowledge that students gained in a clinical setting.

In this regard, Knowles stated (1980, p.44), "People attach more meaning to learnings they gain from experience than those they acquire passively." Gaming encourages the recall of previous experience and knowledge and promotes the integration with newly learned knowledge. When new knowledge is integrated with previous knowledge, retention of knowledge is enhanced (Ward & O'Brien, 2005). Likewise, according to Schwartzman (1997), "The concept of gaming offers an accurate and appropriate description of the educational process. Furthermore, placing education within a gaming framework encourages cooperation, emphasizes excellence, and fosters values that a business-driven view of education omits or downplays" (emphasis added) (p. 9).

In addition, Knowles (1998) stated that adults have a strong desire to know why they need to learn something prior to beginning the learning experience. Learning objectives help to fulfill the adult's need to know prior to learning. Objectives will also help educators identify whether or not gaming is an appropriate instructional strategy to use in order to meet the desired outcomes (Ballantine, 2003).

Overview of Gaming

Although gaming can be traced back to 3,500 B.C. with a game similar to chess, gaming as a formal teaching strategy was introduced in the classroom over 75 years ago (Henry, 1997). The use of games in educational settings is also highly congruent with the national consciousness. For example, according to Yablon (1994), "Americans are great lovers of games. We love to play them, to watch them, to argue about them, and to bet money on them. We use the term "game" to denote not only trivial and unimportant pastimes, but some of the most significant events in our personal and professional lives" (p. 227).

Games in general, though, do not have fixed and definite meanings, but can refer to anything from "a ball bouncing against a wall to multimillion dollar corporate takeovers to the most intimate of human relationships" (Yablon, 1994, p. 227). Indeed, some types of games are firmly entrenched in American culture and psychology. For example, while many Americans do not understand the enormous popularity of the game of soccer as it is played by the rest of the world (some Americans wonder what all of the fuss is about as well), football is a different story. According to Yablon (1994), American football is likewise not understood or appreciated by much of the rest of the world, but the game has acquired a.".. quasi-religious significance in the United States as the ritual through which we observe some of our most important national holidays" (p. 227).

Innovations in technology and computer-based gaming applications have also experienced explosive growth in recent years. In this regard, Pillay (2002) reports that, increasingly, games are being incorporated into educational settings to take advantage of the skills and cognitive abilities that students bring to the classroom:

The use of information technology (it) and multimedia in education will significantly change the way we learn and carry out our everyday business. Individuals will require new and different types of schemas, which may be similar to schemas necessary for playing many recreational computer games. For instance, information will be presented on a screen with little face-to-face instruction. Access to hard copies or concrete objects may no longer be available. There will be an increasing need for skills to generate alternative paths and navigate successfully through unfamiliar situations. There will be extensive use of simulation and other abstract means to deliver instruction. These issues are equally applicable to recreational computer games. (p. 336)

Not surprisingly, then, within the last 20 years, interest in gaming has increased rapidly amongst educators. Henry stated that a new mind-set toward experiential learning is one explanation for the explosion of gaming. Another rationale offered is that gaming was perceived as fun and enjoyable (Cowen & Tesh, 2002; Ingram et al., 1998). With the arrival of the computer and its use in the classroom, the interest in gaming also increased. Today, educators are developing computer-based applications that are specifically designed to simulate various aspects of the healthcare system including, for instance, the management of a day surgery clinic and the use of the application, "IThink!," that is used for modeling hospital organizational complexity (Braithwaite & Westbrook, 2001). According to these authors, "More broadly, there is widespread use of simulations, role-plays, software packages, interactive multimedia, and Web-based learning tools in an attempt to deepen and broaden the learning experience. No academic discipline appears to be untouched, with recent reports of applications in fields as diverse as, for example, accounting, strategic management, business administration, economics and welfare work" (Braithwaite & Westbrook, 2001, p. 89).

Likewise, educational games, Jarvis (2002) notes, are designed to help people learn something and gaming in general is, "An educational method in which the students participate in games in order to explore issues of social concern, personal growth, and development. Gaming is one method of motivating reluctant participants in the learning process" (p. 77). While much of the research on educational games has been directed at younger learners, it is clear from the growing body of evidence that has accumulated to date that adult learners appreciate the opportunity to incorporate fun into the learning process. In this regard, Huttly, Sweet and Taylor (2003) report that, "Education should be as enjoyable as possible. Creating a non-threatening and supportive educational environment for the students can enhance enjoyment experienced, with time protected for critical learning individual and group activities, which can include games (for example, discipline-based crossword puzzles)" (p. 152). These types of initiatives are becoming increasingly commonplace across a wide range of disciplines as well. According to Goldstein, Buckingham and Brougere (2004):

Toys, games, and media are merging inexorably into a seamless blend of entertainment, information, education, and play. Although traditional toys and play have not lost their appeal, technology is increasingly applied to the pursuit of pleasure. And pleasure in the form of computer-mediated activities and games is increasingly applied in the pursuit of more purposeful goals such as education in the form of "edutainment" or, more directly, as educational toys and computer games. (p. 1).

Not surprisingly, then, a vast array of online and computer-based instructional gaming techniques are being increasingly regarded as representing viable instructional strategies at all levels of education (Cameron & Dwyer, 2005). According to these authors, "The field of instructional technology has experienced dramatic growth in the research and development of multimedia learning environments. This growth has been especially pronounced in computer based and web-based learning environments" (p. 243). An instructional game can be defined as any training format that involves competition and is rule-guided (Jones, 1987).

Any type of educational game, though, has some fundamental requirements to ensure successful outcomes. For example, Cameron and Dwyer (2005) point out that educational games must develop confidence in the learners by generating positive expectancies. The growing body of research into educational gaming has provided researchers with evidence that these types of games are able to promote retention and the ability to transfer knowledge to new domains. In this regard, these authors conclude that, "Instructional games are attractive to learners because they offer a simple and creative means of providing high-level motivation, clear and consistent goals, and sustained interactivity" (Cameron & Dwyer, 2005, p. 244). Clearly, then, these attributes suggest that educational gaming represents a highly effective technique for communicating even complex information students in a wide range of disciplines, including nursing and these issues are discussed further below.

Gaming in Nursing Education

The review of literature revealed many positive outcomes to utilizing gaming in nursing education. In analyzing the findings, four categories of outcomes, cognitive, environmental, psychosocial, and personality outcomes, prevailed and are displayed in a game board format (see Appendix F).

Cognitive Outcomes

Cognitive outcomes to gaming will be the first category presented. Cognitive outcomes identified gaming as a way to enhance, promote, stimulate, reinforce, and clarify learning (Bays & Hermann, 1997; Ballantine, 2003; Cowen & Tesh, 2002; Fetro & Hey, 2000; Gordon & Brown, 1995; Hayes, 2000; Kuhn, 1995; Lewis et al., 1989; McDougal, 1992; Metcalf & Yankou, 2003; Morton & Tarvin, 2001; Pennington & Hawley, 1995; Phillips, 1994; Poston, 1998; Robinson et al., 1988; Sisson & Becker, 1988; Speers, 1993; Tankel, 2001; Wargo, 2000). According to Cameron and Dwyer (2005), educational gaming can be understood as being a method by which the rehearsal of information can facilitate the organization and retention of relevant educational content (Cameron & Dwyer, 2005). According to these authors, "The theory of intrinsic motivation is by far the dominant source of support for instructional gaming. Research has provided evidence that instructional gaming has the intrinsic ability to develop the learners' confidence in determining their own destiny. Additional research has shown that as the learner's self-concept improves, cognitive learning also increases" (Cameron & Dwyer, 2005, p. 244).

One of the primary attributes of educational gaming and its ability to enhance cognitive awareness among students is the competition that it engenders among participants, but there is a basic requirement to ensure that educators also provide appropriate feedback to the gamers to help convey the relevance of the game to the learner (Cameron & Dwyer, 2005). Furthermore, some educators have found that competitiveness in educational gaming tends to detract from its overall effectiveness as a learning tool. According to Hark (1999), "The gaming model for education can usefully be adapted to deal with several learning outcomes which require different gaming strategies. In teaming up against ignorance, educational gaming applies to the process of discovery and problem-solving. This could be seen as analogous to a game of charades or twenty-questions" (p. 6).

This type of cooperative educational game playing by using teams would seem to be most effective in accomplishing educational tasks that establish a basic foundation for an evaluation of student learning and performance, but do not already contain this evaluative component (Hark, 1999). Furthermore, educational material that might otherwise be communicated through instructor lecture, assigned reading, or any other outside source of information can also be produced and disseminated through group projects wherein the whole class discovers the answers for themselves through working together (Hark, 1999).

This author concludes that, "Experimental science or solving complex mathematical problems are obvious analogues, but similar gaming strategies can produce team translations of documents in a foreign language or explication of difficult literary texts. In such circumstances competitive instincts can usually be quelled, as long as the group exercise is viewed as a process of discovery, and no grades are assigned to the completed product" (Hark, 1999, p. 6). This point is also made by Schwartzman (1997), who reports that, "Gaming can provide a reassuring context for implementing specific treatment measures such as systematic desensitization, cognitive restructuring, and visualization. If the communicator recognizes that self-worth is not at stake, then fear of punishment (i.e., rejection or retribution) can be transformed into the less threatening concept of penalties on performance" (p. 9). According to Tholander (2005), the research on the relationship between cognitive gains, problem solving, programming, and the understanding of science is inexorably related to the controversy concerning how to understand the notion of information transfer:

The view on transfer taken in this analysis is in line with the socio-cultural viewpoint that although research rarely succeeds in demonstrating the existence of transfer, it is clear that learners draw heavily on prior experience and knowledge when acting in new situations. However, learners do not always utilize the knowledge or the experiences that the researchers expect or wish. Thus, the consequences of the failure of transfer studies is not that transfer does not exist, but rather that we need to conceptualize and study transfer in new ways. (p. 51)

Taken together, the foregoing issues and trends suggest that intrinsic motivation in an instructional gaming context is comprised of an optimal relationship between fantasy, challenge, curiosity, and control; other studies have indicated that educational games serve to provide additional opportunities for repeated responses to specific information that improves delayed retention by focusing attention and facilitating the encoding of information into long-term memory (Cameron & Dwyer, 2005).

In a game developed by Pennington and Hawley, content related to two nursing theorists was presented to a class of graduate nursing students. The teaching objectives included presenting major theorist concepts, facilitating scholarly discussion, clarifying material previously presented, and facilitating analysis of major theoretical concepts. Pennington and Hawley developed the game, 'Theoretical Jeopardy' in order to "fulfill the teaching-learning objectives in an innovative way."

The game consisted of four categories asking a total of 13 questions related to nursing theorist concepts of person, health, and environment, application of concepts to nursing practice, and recall of specific information presented in class. Prior to the game, students were randomly divided into groups. Each group then became a team. The rules of the game awarded points to the team with the correct answer and also points to any team member who added to the group discussion. After completion of the game in an hour of play, Pennington and Hawley concluded that their 'Theoretical Jeopardy' game reinforced learning of nursing theory. Students commented on how the game helped to clarify what they knew. During the game, students could be seen actively participating, laughing, and the authors noted a sense of a relaxed atmosphere that seemed to enhance student learning of information presented in class.

Metcalf and Yankou's (2003) used gaming to reinforce and clarify nursing student's learning about ethical decision-making model. One week prior to the playing the game, the students were introduced to the concepts of ethics, an ethical decision-making model, and their relationship to clinical settings. The following week, students were divided into pairs prior to playing the game. Each student pair was given an ethical dilemma or conflict formulated by the researchers. The dilemma was read aloud and a coin toss decided which side of the argument a student would present to the class using the ethical decision-making model. After both sides of the dilemma were presented, the class would then vote for the student who made the strongest argument. Each student who argued the dilemma would receive one point from every student who voted for them. In addition, all students who voted for the winning argument would receive a point. The student with the most points at the end of the game was declared the winner. Although no statistical data was presented in the article, student feedback related to playing the game was presented. According to the students, the game was fun, provided an opportunity to evaluate and clarify material already learned, and provided a "newfound confidence in using an ethical decision-making model."

Another game that demonstrated cognitive outcome gains was McDougal's (1992) 'Ionic Exchange Game.' According to McDougal, the game was developed to increase student involvement, understanding of electrolyte imbalances, and outcomes of interventions. To play the game, students are divided into groups representing intracellular and extracellular components, the cell membrane, mobile ions, and water molecules. Scenarios are presented and the students physically move across the cell membrane accordingly based on their knowledge of fluid and electrolyte exchange. A debriefing occurred after each scenario by the teacher which included a summary of key components. Advantages to the game included increased active student involvement, reinforcement of learning, and enhancement of group problem-solving skills.

Crossword puzzles are another gaming format used in nursing education to enhance cognitive outcomes. Speers (1993) found that the use of crossword puzzles in critical care education stimulated learning and enhanced improvement in understanding basic subject material. Speers stated that much of critical care nursing content has been presented didactically in the past. In order to avoid long lectures, Speers created a crossword puzzle to reinforce concepts and previous material presented by lecture. 'The Inner Sea' was designed to enhance student's knowledge of fluid and electrolytes and renal concepts. The puzzle was distributed to education and content specialists for validation and piloted for clue clarification and expansion. After final revision, the puzzle was presented to students in a critical care class. According to Speers, the puzzle was well received by the learners. Learners stated the puzzle helped them in preparation for exam and clarified class content.

An analysis of the cognitive abilities that students typically employ in playing educational games is recapitulated in Table 1 below.

Cognitive Process

Description

Cited Examples from Students

General search

Players engage in a trial- search and-error process to explore game features. The search is not driven by any specific intention to seek the solution of given tasks.

Find out what things do." "Have a look around."

Goal-directed search.

The players have a purpose, they go to specific sites and icons they believe will help in finding a solution -- they click to see what happens. Often this is triggered by previous game experiences. Sometimes the search may be directed to simple subgoals of the overall task, which may be limiting; nevertheless, it is directed toward a specific outcome, which helps the player progress toward achieving a solution.

The inventory bar usually has tools that I can use to open the power generator. I will try them."

Anticipatory Thinking

Game players anticipate future situations and thus take necessary precautions. This is more than metacognition, as it not only monitors one's thinking but also tries to extend it beyond the given information.

I think I might get the guards to spread out just in case I do get attacked, to protect the tower."

Working Backward

Game players have identified subgoals that may lead to a solution and work backward from the subgoals to the previous stage by seeking possible connections to confirm the right path. This is often referred to as a means-end analysis strategy. It works well in the absence of sufficient domain knowledge.

If I can get the ball to the point where it ignites the fuse I will be able to solve the problem."