How to use game-based learning to improve patient outcomes

WITH EDUCATION, nursing staff can improve their knowledge of patient safety, infection prevention, and organizational policies. But how effective is game-based learning? This quality improvement project aimed to answer that question when a team of nurses implemented an interactive game-based learning event targeting nursing-sensitive indicators related to improving adherence to chlorhexidine gluconate (CHG) treatments and reducing central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and patient falls.

The problem

Hospital-acquired infections (HAIs) remain a frequent health challenge within the acute care setting, resulting in prolonged hospital stays, increased healthcare costs, and elevated rates of morbidity and mortality. A 2016 analysis by Forrester and colleagues estimated that, in the United States, the cumulative cost of HAIs such as surgical site infections, CLABSIs, CAUTIs, and ventilator-associated pneumonia ranged from $7.2 million to $14.9 million, highlighting the impact of HAIs on the healthcare system.

Patient falls, including falls with injuries, also pose challenges for healthcare facilities. National inpatient fall rates, as reported by Pate and colleagues, vary from two to eight occurrences per 1,000 patient-days. These incidents may result in minor injuries (such as pain) or major injuries (including fractures and death), emphasizing the prevalence and severity of falls among hospitalized patients. Pate and colleagues referenced a study conducted in 2015, which estimated the mean cost of a patient fall at $6,669, with costs increasing if an injury resulted from a fall. This estimate closely aligns with the Agency for Healthcare Research and Quality’s (AHRQ) 2017 report, which noted an average cost of $6,694 per fall.

In 2022, clinical and operational leaders examined HAI and patient falls at Atrium Health (part of Advocate Health in Charlotte, North Carolina) at its two hospitals: Carolinas Medical Center (an 874-bed quaternary, research and academic medical center) and Atrium Health Mercy (a 196-bed community hospital). The examination found CLABSI rates to be higher than the national average in ICU and non-ICU areas at both facilities. In addition, a steady rise in CAUTIs and patient falls and falls with injury occurred in both facilities the previous year.

Real-time rounding on nursing units by the hospitals’ clinical and operational leaders revealed a decrease in nurses’ adherence to evidence-based infection prevention bundles and assessment of invasive device necessity criteria. They also noted low adherence to infection prevention strategies, such as daily CHG treatments.

When nursing practice leaders at Atrium Health introduced a new comprehensive systemwide evidence-based fall risk assessment tool to reduce patient fall rates, an online module delivered staff education about the program; however, post-implementation audits revealed low assessment and scoring accuracy and little adherence with appropriate interventions. These findings revealed knowledge and skill gaps, highlighting a need for an alternative education approach. Atrium Health nursing staff and leaders have described the reliance on self-learning modules and virtual courses, which developed out of necessity during the COVID-19 pandemic, as leading to module overload and decreased knowledge and skill retention.

The evidence

The QI project team (four clinical nurse specialists, three service line educators, one infection prevention nurse, and one operational consultant) conducted a comprehensive literature review to identify best practices in adult education delivery. They found that incorporating gamification into professional education aligns well with adult learning principles and offers many benefits. For example, research by Coughlin and colleagues indicates that escape rooms provide an innovative approach that engages adult learners by encouraging individual decision-making, enhancing critical reasoning, and fostering teamwork. A quasi-experimental design study, conducted by Yang and team, suggests that game-based education enhances learning performance, problem-solving skills, and critical thinking skills.

According to Gates and Youngberg-Campos, the interactive nature of game-based learning encourages collaboration among learners and enables the validation of multiple skills and application of knowledge. Millsaps and Swihart found that engaging in realistic clinical scenarios, in which nurses must connect multiple pieces of a clinical picture and overcome barriers in daily practice to deliver safe care, allows for the translation of knowledge into clinical practice and promotes creativity, teamwork, and critical thinking.

Daniels and colleagues describe escape rooms as offering a safe and effective way to simulate the clinical environment; when thoughtfully designed, they can lead to practice change. Gabriel and colleagues created an escape room to provide sepsis education. Post-activity evaluations by nurses rated the experience at a 4.92 out of 5. The researchers found a notable improvement in sepsis performance measures 2 months later.

Bonn and colleagues implemented a virtual escape room to engage nurses in quality improvement. After the activity, 85% of learners reported improved knowledge of nursing-sensitive indicators, and 83% felt the format enhanced the learning experience. Coughlin and colleagues used the escape room methodology in a preceptor workshop to enhance communication, engagement, and knowledge of new preceptors. After participation, 100% of learners felt the experience improved their comprehension of the preceptor role. Overall, evidence suggests that escape rooms effectively address cognitive, psychomotor, and affective domains of learning and significantly impact the quality and safety of care delivery.

The project

After the literature review, the project team recommended an interactive, game-based learning event to the chief nursing executive (CNE) as a back-to-basics approach for facilitating nurse engagement and applying best practices in delivering high-quality nursing care. The desired culture change required interpersonal communication, teamwork, and group accountability.

To gain support for the QI project from clinical leaders, facility educators, and senior leadership, the QI project team developed a proposal highlighting the underperformance in nurse-sensitive indicators, observations from hospital-wide rounds, and the need for in-person training to enhance knowledge and skill retention. Leadership approved implementation of a 2-hour educational event, offered several times each day over 4 weeks, for all adult in-patient nurses employed at the two facilities.

Clinical nurse specialists (CNSs), service line educators (SLEs), infection prevention (IP) nurses, and a strategic and operational consultant were recruited as content experts for the QI project team. Their roles included developing educational objectives and serving as facilitators for the educational activity.

Based on performance data related to facility infection and fall rates, the team focused on improving quality measures associated with CLABSI, CAUTI, patient falls, and infection prevention best practices. The project team then divided into four groups to develop content and game-based learning strategies related to those measures. They designed each station to address specific objectives using established evidence-based care bundles or standards.

To accommodate facilitator roles and ensure consistent content delivery at each station throughout the duration of the educational activity, the project team developed facilitator guides. The guides included detailed instructions for running each station, the rules of each game-based activity, and directions on how to set up and break down each station. The guides helped ensure a standardized experience for participants and supported a smooth execution of the activity.

Two escape rooms and two interactive games were created for the event. Each station required 30 minutes of interaction, resulting in 2 hours of learning. The escape rooms incorporated case studies, return demonstrations, and puzzles to reinforce content related to CLABSI and CAUTI prevention. The interactive game format encouraged teams of nurses to critically think through infection and fall prevention content. (See The games.)

The organization’s primary nurse planner approved continuing education hours for RNs who completed the activities. A post-survey developed by the project team measured the event’s impact on individual nursing practice and nurse satisfaction with interactive, game-based learning.

The project lead secured space for morning and afternoon sessions; the team assessed supplies needed for each station and worked collaboratively to acquire equipment from various departments. Senior leadership allocated a small budget for supplies (such as marketing materials, a projector, a computer, and locks for the escape room) not readily available to the team. Nurses used an online scheduling platform to register for the event. As nurses arrived for the activity, they received assignments to groups of six participants and rotated throughout the four stations.

The results and sustainment

The project team used the Kirkpatrick Model Levels of Evaluation to assess the project’s educational outcomes. Level I of the model focuses on participants’ reactions to an educational activity, including overall satisfaction. Of the 1,115 nurses who attended, 20% completed an evaluation, which yielded a satisfaction rating average of 4.57 out of 5 (1=strongly dislike, 5=strongly like). Over 91% of participants indicated their willingness to attend similar nursing education activities in the future. Facilitators observed that learners remained engaged, participated in the activities, and indicated that the content was relevant to their nursing practice.

Level II measures the extent of change in participants’ knowledge, skills, or attitude. After participation in this education event, 95% of nurses reported a gain in knowledge, with facilitators noting active learning through nurses demonstrating skills, reviewing content, and asking appropriate questions. As a result of this educational activity, over 96% of participants reported a change in practice.

The highest level of the Kirkpatrick Model, Level IV, measures the impact on care delivery, including improved quality and cost reduction. The project team evaluated outcome measures at 3-, 6-, and 12-month intervals post-education to determine the impact of this activity on reducing CLABSI and CAUTI standardized infection ratios (SIRs), total falls and falls with injury, and increasing CHG treatment adherence. The SIR is a summary measure used to track HAIs at national, state, or local levels over time, adjusting for various facility- and patient-level factors that contribute to risk within each facility. A SIR >1 indicates that more HAIs were observed than predicted; a SIR <1 indicates that fewer HAIs were observed than predicted.

To evaluate the effectiveness of this project, the team analyzed data from a baseline period of January through December 2022, a 4-week intervention period in January and February 2023, and a post-implementation period of March 2023 through February 2024. The project team observed favorable outcomes at 3 months post-implementation in both facilities. Notably, CLABSI and CAUTI SIR decreased below 1, indicating lower infection rates than predicted by national benchmarking. CHG treatment adherence also showed a positive trend while total falls per 1,000 patient days remained stable at Carolinas Medical Center and decreased at Atrium Health Mercy. This intervention demonstrated sustained practice changes at 12 months post-implementation, as evidenced by continued positive trends in outcome measures. (View results at bit.ly/anj1125GameOn)

Both facilities saw favorable trends with sustained reductions in CLABSIs, CAUTIs, and patient falls since completion of this initiative, demonstrating a positive return on investment. According to the AHRQ, the average cost of a CLABSI event is $48,108, a CAUTI event is $13,793, and a patient fall event is $6,694. When totaling the reduction in the number of events, and associated costs, this education demonstrated a potential cost avoidance of $716,445.

To quantify the economic impact and value of this professional development activity, the team reviewed the return on investment (ROI). Activity costs—including participant compensation of 2 hours’ paid time, facilitator compensation, and supply costs—totaled $182,449.50. Potential financial benefits to the organization amounted to $533,995.50, resulting in an ROI of 292%, indicating a positive impact.

The opportunities

Participating nurses demonstrated a desire to engage in game-based learning activities for future educational events. However, this approach doesn’t come without challenges. Identifying a space large enough to accommodate game-based learning activities can prove difficult. Neither of the Atrium Health facilities had a large enough space, so the event took place at the organization’s off-site training center. Although the project didn’t accrue any additional costs, hosting off-site events poses other sorts of barriers for participants, including travel time, inability to attend sessions around clinical shifts, and other scheduling challenges. Equitable access to future game-based learning activities requires a secure space within the hospitals.

In-person professional development activities involving large numbers of employees and multiple facilitators can prove costly; however, the benefits far outweigh the costs. In addition to the positive outcomes, one of the most valuable gains was increased collaboration among the SLEs, CNSs, and IP nurses who served as content experts and facilitators. These roles continue to work together to evolve and enhance the quality and safety of nursing care.

After the intervention, other teams in the hospital—such as educators and CNSs—adapted and incorporated it into various ongoing continuing education offerings to further sustain positive changes. Practice areas can individualize content and scale the process at a microsystem level to improve nursing quality outcomes. With the rapid turnover of nurses in the inpatient setting, healthcare organizations must reinforce evidence-based care standards and emphasize the impact nurses have on patient safety and quality. The event has inspired nursing professional development practitioners and nursing leaders within Atrium Health to implement more game-based learning approaches.

The authors work at Atrium Health in Charlotte, North Carolina. Kiersten Brelewski is a clinical nurse specialist. Heather Brown is a service line clinical nurse educator. Erin Tisera is a service line educator in the surgical trauma division. Latasia Belin is a clinical nurse specialist. Sarah Rutledge is a clinical nurse specialist. Nicole Pappaterra is a nursing professional development practitioner. Lacey Spangler is a clinical nurse specialist.

American Nurse Journal. 2025; 20(11). Doi: 10.51256/ANJ112528

References

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Key words: quality Improvement, game-based learning, nursing sensitive indicators