SIMAGES 2016.2 – Serious Games in Graduate Nursing Education

Serious Games in Graduate Nursing Education: Considerations for Game Designers

Joshua Peery and Pamela Reis

At the NASAGA conference in 2015, Joshua Peery presented an academic poster session about his work using a game application to train healthcare workers.  This is a summary of his presentation, – Editor



The Virtual Clinic Learning Environment (VCLE) is a serious game application designed for advanced practice nursing education at East Carolina University College of Nursing. Teaching with serious games such as the VCLE affords unique methods and conditions for instruction that are not easily replicated with more traditional educational modalities. While serious games add a new dimension to pedagogy, they must still hold true to the core concepts of knowledge mastery. In order to make a successful serious game, a designer must understand the theoretical basis for how learning is achieved.

Bloom’s Variables and Other Considerations in Serious Game Design

Educational psychologist Benjamin Bloom’s 1968 paper, “Learning for Mastery, Instruction and Curriculum,” focused on determining how individual differences in learners impact teaching processes (Bloom, 1968). Bloom outlined five variables to be used in strategies for mastery of learning: aptitude for particular kinds of learning, quality of instruction, ability to understand instruction, perseverance in learning, and time allowed for learning.These variables are important to any educational endeavor and, as such, result in a better educational product if used by serious game designers in the design process. To understand Bloom’s concepts as they apply to serious games in education, we offer the following explanation.

Aptitude, in the context of serious games as a pedagogical approach refers to having a set of users in mind and tailoring your strategies to the needs and capabilities of individual users in order to optimize learning outcomes.Quality of instruction in serious games means choosing/vetting subject matter experts that will provide rigor in the educational content. If the information to be delivered through serious games is ill-conceived, inaccurate, or irrelevant the quality of the instruction suffers. Likewise, the user must be able to understand the instruction, or in the case of serious games, the user interface/user experience of the serious game must be straightforward, practical, and designed with the specific users in mind. Finally, the nature of serious games and their ability to be used remotely, asynchronously, and re-played in reusable learning units, allows for easier perseverance in learningand flexibility in the time spent learning.

In addition to Bloom’s variables, serious game designers must also ask themselves these questions about the game they are creating:

  • Does learning feel like play?
  • Are the experiences interconnected?
  • Does the player learn by doing?
  • Is failure reframed as iteration?
  • Is feedback immediate and ongoing?
  • Is the challenge constant and consistent?

Through Bloom’s variables and careful attention to the questions above, a serious game designer has a solid set of “rules” by which to design serious games.

Play. The question about whether or not learning feels like gaming is important to acknowledge for learners who are familiar with entertainment games. In Salen and Zimmerman’s Rules of Play (2003), the authors define “meaningful play,” as a condition very much like learning. Meaningful play is “what occurs when the relationships between actions and outcomes in a game are both discernable and integrated into the larger context of the game (p.35).” Thus an important aim of serious game design is to have the user experience be as close to the feeling of play in order to increase the level of engagement with the subject matter.

Interconnections. Play, like learning involves having context between experiences in a game to reinforce the content being taught. For example, a STEM serious game could begin with teaching triage in a lesson about epidemics, followed by applying what was learned about triage to an emergency response situation involving earthquakes and plate tectonics. Revisiting issues introduced in one game experience again in the following game provides context and interconnections we should seek as designers.

Learn by Doing. The ability of serious games to simulate real-life situations enables the designer to direct users toward executing tasks related to the learning objective. An instructor can, theoretically, teach learners how to manage construction times, labor, and materials using a book or other traditional media source. However, if the user is presented with a game in which they have to apply these principles in building a virtual skyscraper, the realistic nature of the experience can be much more compelling. Serious games can allow students to learn by doing when the logistics of such an activity are prohibitive or impossible in a real life setting.

Failure as Iteration. Similar to being able to learn by doing, serious games allow for mistakes in judgement, or failure to react appropriately in a given situation, to occur within a low-risk setting.  Errors in judgement can be used as teaching tools when reframed within the context of the game as iteration. Serious games should be able to parse student errors. Errors can then be rectified with follow up from the game itself or from the instructor receiving data from the game.

Immediate and Ongoing Feedback. Serious games should provide the user with immediate, frequent, and ongoing evaluation of their performance. Ideally, students are given both positive and negative feedback as the gaming activity progresses. Students can feel motivated by positive feedback and cognizant of what they need to study further to change the negative feedback to positive.

Constant and Consistent Challenge. Finally, consistency in the challenge that students experience in the learning activity is integral to making serious games for education. This is a departure from traditional game design where challenges usually mimic a roller coaster for the sake of pacing. While a fast-paced, dynamic, and dramatic experience is desired for entertainment games, it is counter-productive to the learning process. Thus, challenges built into educational serious game activity should scale with the subject matter when it is delivered by traditional educational modalities. When game design focuses on learning outcomes, while observing the aforementioned elements, mastery of learning is possible.

The Virtual Clinic Learning Environment in Graduate Nursing Education

The VCLE is a serious game application used in masters’ and doctoral degree education of nursing students. The VCLE is designed using Bloom’s variables with consideration of the additional questions outlined above. The primary purposes of the VCLE are as follows:

(1) to create a low-risk environment for students to practice critical reasoning and problem solving

(2) to allow students with disparate schedules and locations to learn online at their own pace

(3) to present content designed to reflect patients and situations that students may not otherwise encounter

(4) to create highly reusable content that can be shared with international audiences to expand global health opportunities.

The VCLE uses virtual patient avatars, introduced in a simulated clinic setting, that the players interview. Each section of the game is programmed to guide players in the methods used to formulate a diagnosis and management plan. Specific aspects that are critical to formulating a correct diagnosis and plan of care are tested within each case.

Narrative game mechanics are chosen to test knowledge of the subject matter and to provide social interaction experiences (such as culturally-relevant patient-provider communication scenarios). Player narrative input from myriad choices drives the Non-Player Character’s (NPC) reaction and scoring. A section may require more than one correct answer, while avoiding the selection of incorrect responses. Failure to select a correct answer is scored negatively. Every section is scored independently with the players’ results/answers and rationales displayed, for both right and wrong responses, before continuing to the next section of the game. To add to the experience, players have access to a built-in text editing journal with case notes available at any time during the game.

Content for the VCLE is created via the CaseBuilder, a menu-driven, content creation tool that allows subject matter experts, with no formal game design background, to create cases for the VCLE. The open-ended ability to add as many questions and variables as desired creates enormous flexibility for faculty to craft complex and varied patient encounters for student experiences. The CaseBuilder is also used by students to design cases of their own, allowing for further mastery of problem-based learning and critical reasoning.

To date the VCLE has been used in-house at East Carolina University College of Nursing. The project was sponsored by grant funds from the Division of Nursing, Bureaus of Health, Health Resources and Services Administration, Department of Health and Human Services Grant# D09HP25923-01-00. The VCLE has undergone several iterations since its inception, with plans to migrate the platform to Unity 3D v.5 and WEBGL in 2016 in order to future proof the game and to be able to do away with relying on the Unity web browser plugin.

Feedback from students to date has been positive overall. On a scale of 1-7, with 7 being most positive, the range of mean scores for nurse practitioner and nurse-midwifery students is as follows.


This Virtual Clinic case enabled me to:

Response Range of Mean Scores
Better understanding my role as an Advance Practice Nurse 5.25 – 5.29
More effectively implement therapeutic interventions 5.26 – 5.75
Formulate an appropriate diagnosis 5.75 – 5.85
Synthesize knowledge, skills, and competencies for APRN practice 5.81- 6.14


Through student feedback we have identified areas for further development of the product. Enhancements that are currently underway are:

  • A consultation / interprofessional conference room to allow students to learn and demonstrate interprofessional collaboration competencies and skills.
  • A section for NPC Patient Reaction to Diagnosis to add the simulated patient experience.
  • An expanded User Interface language selection for international expansion.
  • An integrated survey builder that will allow users to create custom surveys
  • An interface for geographic case selection based on patient demographics.
  • A curated case library that will allow faculty and students to select avatars to be used in their cases from a library of diverse avatar archetypes.

Through ongoing and extensive testing of the ample features of the platform, we conclude that the VCLE holds promise as a robust pedagogical tool that can be used in academic and health care industries. We hope that our experience in creating this user-friendly and clinically relevant serious game product lends support for acceptance of serious games in education that link to sound pedagogical strategies and approaches.



Bloom, B.S. (1968). Learning for mastery: Instruction and curriculum. Evaluation, 1(2).

Salen, K. & Zimmerman, E. (2003). Rules of play. Game design fundamentals. Cambridge, MA: MIT Press.



Joshua Peery, MA. Lead Game Designer, Instructional Technology. East Carolina University.

Joshua Peery is a video games industry veteran with several game titles launched, including AAA and indie titles. He is the Lead Game Designer for Instructional Technology in the College of Nursing at East Carolina University where he is focused on Serious Games and health applications.

Pamela Reis, PhD, CNM, NNP-BC, Assistant Professor, College of Nursing, East Carolina University.

Pamela Reis is a nurse-midwife and an Assistant Professor of Nursing at East Carolina University College of Nursing. She is the Project Director of a HRSA grant that explores the use of technology in interprofessional education with a focus on women’s health issues. She is interested in the application and evaluation of web-based interprofessional education platforms and in the use of virtual environments in health care consumer education.

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