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Games in education could lead to more confident nurses

Using games in education could make nursing students more prepared for real situations. That is the conclusion of Hege Mari Johnsen’s PhD work.

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Fire studenter ser på en iPad
Nursing students explore the game "Jeg får ikke puste" which is developed as a part of Hege Mari Johnsens PhD work. Photo: Hildegunn Mellesmo Aslaksen.

A nurse’s job is demanding. Not only do they have to deal with many different patients each day, they also have to make decisions which in a worst-case scenario could mean the difference between life and death.

This June, Hege Mari Johnsen defended her doctoral thesis “Being-in-the-world – Teaching clinical reasoning skills to nursing students through a serious game” at the University of Agder (UiA). Johnsenhas 15 years of experience as an intensive care nurse in Arendal and is now an associate professor at the Department of Health and Nursing Science at UiA.

She believes that using so-called “serious games” can result in more confident nurses. As a part of her PhD work, she has developed a web-based game for use in education called “Jeg får ikke puste" (I cannot breathe). The work has been done in cooperation with students and employees from different academic and expert environments at UiA, Grimstad municipality and the Hospital of Southern Norway.

"It will not replace practical work experience or simulations in the laboratory, but it is a nice addition. The game challenges students with questions, and the situation-based learning makes them remember more each time the play. They can also play it anywhere and as many times they want," Johnsen says.

The results from the PhD work shows that the students who play the game are better prepared and get to use theory from the education in practical situations. Nursing students who were starting their work practice in home healthcare were especially pleased since the simulations during education have been largely used for preparation for work practice at hospitals’ medical and surgical wards.

Hege Mari Johnsen

Hege Mari Johnsen has 15 years of experience as an intensive care nurse. She is now an associate professor at the Department of Health and Nursing Science at UiA.

Video-based game

At UiA, a simulation laboratory is already used to provide nurses with a place to practice on advanced dolls in a hospital environment. The dolls are controlled by teachers in another room where they can control blood pressure, pulse and the dolls’ voices.

"Simulations are very important for the nursing study programme. Nursing students have a limited amount of time for practical work experience, and they will not encounter every type of patients or critical situations,” Johnsen says.

One the challenges regarding simulations is that they require a lot of resources, especially when 150 students are going to use the laboratory. That is why games can be a good addition.

In the videos of "Jeg får ikke puste", students meet an elderly man suffering from chronic obstructive pulmonary disease (COPD) and a nurse. The students have access to measurements done by the nurse on screen and must answer quiz-based questions before the nurse in the game provides the correct answers.

"One of the challenges regarding nursing is that there is rarely a simple answer. It can be a long list actions that could be performed in each instance, but I want the students to figure out what is correct through logic and based on the individual patient and situation. The game emphasises using knowledge correctly," Johnsen says.

From home healthcare to hospitals

Serious games combine learning with traditional game mechanics. A classic example is Microsoft Flight Simulator which has given prospective pilots realistic experiences since 1982.

Such games are also often used in public healthcare services where situations from reality teach student about the consequences of correct and incorrect decisions. An important part of the game "Jeg får ikke puste" is following the patient through the whole process of the illness from home healthcare to hospital since different aspects are emphasised during different situations.

For the first study, Johnsen joined newly graduated nurses as they met patients with chronical illnesses to listen to the nurses thinking out loud.

"I wanted to investigate among the nurses what parts of the education could potentially be lacking. For examples, I saw how easy it was for the nurses to simply ask the patient how they were doing instead of doing specific observations," Johnsen says.

Some of the nurses said that they had not met patients with COPD during their education nor practical work experience period, and therefore did not feel completely prepared.

Videokamera som filmer pasient sammen med helsepersonell

Arnulf Torp plays the part of the patient. He actually suffers from COPD and is the former head of National Association for Heart and Lung Disease, Grimstad branch. Photo: Christina Therese Lien.

A part of the education

The game itself has been made in cooperation with bachelor’s students from the Faculty of Engineering and Science at UiA. Limitations in the software that was used meant that the game could not be very complex. Keeping the knowledge in the game updated will also be a challenge.

"A treatment that is correct now might change later. This is one of the problems of presenting concrete answers in a video meant to be used for a long time. But a textbook has many of the same problems," says Johnsen.

"Jeg får ikke puste" is now a set part of the nursing education at UiA. Johnsen’s faith in the project is great, and she wants to develop more video-based games to be used in education.

The students who worked on the project is Svein Even Skogen, Daniel Møller-Stray, Christina Terese Lien and Elise Birgitsdatter Haugland. The work on "Jeg får ikke puste" is made in cooperation with the University of Sheffield, UK and the University of Nebraska, Omaha, US. The PhD project is funded by the Faculty of Health and Sports Sciences and the Norwegian Nurses Organisation. 


Registered nurses' clinical reasoning in home healthcare clinical practice: A think-aloud study with protocol analysis. Nurse Education Today 40 (2016) 95-100.

Teaching clinical reasoning and decision-making skills to nursing students: Design, development, and usability evaluation of a serious game. International journal of Medical Informatics 94 (2016) 39-48.

Nursing students' perceptions of a video-based serious game's educational value: A pilot study. Nurse Education Today 62 (2018) 62-68.