Many support the idea that learning should be fun and engaging (Conrad & Donaldson, 2004; Watkins, 2005). Gaming has been a formal learning strategy for more than 75 years and offers several advantages over traditional teaching methods because the gaming methods may touch emotion. Innovative games bridge the gap between theory and practice and provide practice opportunities for real-world experience in a safe and fun environment that is diversely rich with opportunity for immediate feedback (Henry, 1997). Application of pedagogical changes in nursing using gaming will require an understanding of the educator's view of gaming as well as the public's view as they critique the process (Bradshaw, 1998; Henry, 1997; Lean, Moizer, Towler, & Abbey, 2006). The next step is to see how this can be accomplished in distance learning. Not only will the educator need to consider the availability of resources and the preparation time needed for development of quality games (Blakely, Skirton, Cooper, Allum, & Nelmes, 2009; Lean et al., 2006), they will also need to see how it plays out using hypermedia strategies. Some newer technology with high definition (HD) cameras and large HD screens can provide a format for excellent interaction. One challenge is that everyone needs to be heard in the room, both locally and remotely, as students are being challenged by the educational game being used. There appears to be current technology to make this work; the question is, will it be used?

Regardless of these technological advances, students might experience stress and embarrassment when incorrect answers are given or if they view the gaming atmosphere as too competitive. Blakely, Skirton, Cooper, Allum, and Nelmes (2009) are also concerned with creating appropriate evaluation tools in order to assess the competencies of the students or the value of the exercise. It would also be of value to have a staff or faculty person monitor both settings in order to address any process issues.

Blakely et al. (2009) found that gaming strategies build learner confidence and meet varying learning styles beyond simply having fun while learning. They contend that “new attitudes toward experiential learning methods have contributed to the expansion of gaming as a [learning] strategy . . ., [and] the use of games generally enhances student enjoyment and may improve long-term retention of information” (p. 259). Will gaming change the look of nursing education, or are there sufficient gaming strategies already in place? For distance education or online learning environments, can we still have this much learning or enjoyment if students really do not know each other and are in different locations? It certainly could increase competition within the process.

The terms gaming and simulation in educational settings have been closely linked (Dipietro, Ferdig, Boyer, & Black, 2007; Sauvé, Renaud, Kaufman, & Marquis, 2007). It would be an easy step to look at a simulation experience as a game; the two are indistinguishable in many respects. However, gaming may provide a learning alternative that is lacking in what nursing views as a simulated learning experience. Sauvé, Renaud, Kaufman, and Marquis (2007) stress “the lack of consensus on the terminology used with regards to games and simulations results [has] contradictory findings about learning” (p. 247). Table 7.1 outlines research findings conducted by Sauvé et al. and identifies essential attributes that distinguish games from simulation. Distance educators would need to be able to address using highquality technology in order to make this palatable for students. This would include fast and nondelayed feeds to both sites, which is no easy feat. It would be very detrimental to misinterpret who is the first to answer the question because of such delays.

Table 7.1 essential distinguishing attributes of gaming and simulation

Gaming Simulation
• Player or players
• Conflict
• Rules
• Predetermined goal of the game
• Artificial nature
• Pedagogical nature of the game
• A model of reality defined as a system
• A dynamic model
• A simplified model
• A model that has fidelity, accuracy and validity
• Directly addresses the learning objectives

Source: Adapted from Sauvé et al. (2007).

Dipietro, Ferdig, Boyer, and Black's (2007) research identifies multidimensional aspects of gaming. Subsequently, a framework developed specifically for electronic gaming in education that includes five key elements: pedagogy, psychology, media effects, design, and genre, which includes style, form, and game content. Faculty wanting to integrate gaming in distance learning will want to address each of the five elements and include an assessment of the gaming's software/hardware capabilities.

Even though games can be viewed as a viable teaching strategy, literature provides conflicting views. Blakely et al. (2009) provide a list of potential positive outcomes from the use of games in nursing education (see Table 7.2). Royse and Newton (2007) contend that gaming is an innovative teaching strategy and improves nursing student learning outcomes, whereas Benner, Sutphen, Leonard, and Day (2010) state:

Although the students' attention is gained through games, the quality of their attentiveness may fall short of serious engagement with the practice of nursing. Whether the teacher intends it or not, games can reinforce the idea that guessing is acceptable and that memorization is the major learning goal in nursing education. (p. 74)

It would seem necessary for faculty to be concerned with what the exercise means to the student and their own self-awareness and learning. If there were guided reflection steps to look at what just occurred and what may be hidden to the student during the exercise, then the reflection might allow for a deeper sense of what was previously hidden to the student. We may rethink the value of putting gaming strategies into distance learning when it adds the component of heavy competition as well. Benner et al. (2010) warn educators there may be unintended consequences when we turn education into competition behaviors. For example, consider how competition could have negative impacts on learning. Yet, others list possible benefits.

Table 7.2 Advantages of gaming

• Reduces stress and anxiety
• Stimulates interaction
• Reduces monotonous lessons
• Promotes teamwork
• Creates a conductive environment for increased learning and retention of knowledge
• Enhances motivation
• Promotes a relaxed learning environment
• Adds entertainment

Source: Adapted from Henderson as cited in Blakely et al. (2009, p. 261).

Pardue, Tagliareni, and Valiga (2005) list several recommendations supporting innovation in nursing (including gaming) that include:

■ Explore new pedagogies to enhance nursing education, including gaming

■ Review current research supporting (or not supporting) gaming, to provide evidence and inform decisions regarding new pedagogies that bridge education and practice gaps

■ Engage in dialogue with peers, students, and nursing practice colleagues to design, incorporate, and evaluate gaming strategies that enhance student learning outcomes, meet students' needs, and prepare graduates for today's health care environment

■ Conduct pedagogical research to document the effectiveness and meaningfulness of gaming innovations that are occurring in nursing education (p. 2).

Table 7.3 outlines seven characteristics of nurses positively influenced by gaming.

It is clear that gaming in nursing education has strong support for and against its use and yet the issue may be a lack of method that allows for effective learning, affective literacy, and positive personal growth to occur. This subject does need additional research and reflection on the part of the instructors using it.

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