Board games have been a part of cultures worldwide for many centuries as a way to socialise, pass the time, develop relationships around a common activity and as a way of enhancing social capital (Heron et al, 2018a). There is evidence of games being played using moving pieces as early as 6th century AD (Nakao, 2019). Board games are usually played on a table and involve two or more individuals in a range of activities with an end purpose. Bayeck (2020) suggested that they allow for interactions that result in individuals engaging and practising teamwork and creative thinking, stating: ‘Board games simplify complex issues, which make them appropriate to further explore learning and concepts’ (Bayeck, 2020:411).
This article describes the development, implementation and evaluation of an innovative nurse teaching initiative centred on the use of educational board games cafes. Noting the current popularity of board gaming, games covering a variety of clinical themes were purchased and used within a cafe-style environment with Year 1 student nurses at a large UK university. The authors present the context and model of the cafe, as well as evaluation and feedback from students. Recommendations for future developments and dissemination into other settings is presented.
Background
There has, in recent years been what has been described as a ‘modern renaissance’ (Heron et al, 2018b) of tabletop games and a rise in what can be described as designer board games with an increasing number of players. Beautifully designed games with dedicated fans and spin-off TV channels devoted to watching gameplay have proliferated. Bayeck (2020) suggested that this rise in popularity may be associated with online overuse or fatigue.
There has been a corresponding growth in the number of specialist board games cafes, the first opening in the UK in London in 2014, as well as pop-ups and one-off events organised in community centres and at gaming conventions (Johnston, 2019). The usual format is that customers pay a small hourly fee to play a range of available board games while drinks and food are served. The popularity of board games cafes may be linked with the increase in the number of young people choosing not to drink alcohol for personal, health or cultural reasons and searching for alternative ways to socialise other than pubs and clubs (Bakkar, 2018).
Board games within education
In the past decade, several theoretical and practical perspectives have emerged on using games within educational contexts such as:
- Gamification (Deterding et al, 2011; Kapp, 2012),
- Pervasive games (Montola et al, 2009),
- Serious games (Ritterfeld et al, 2009)
- Game-based learning (Tobias et al, 2014).
Despite varying approaches, their nexus is the use of the principles of gaming or games themselves as tools to influence learning, and increase the motivation and engagement of students. All these methodologies place the learner at the core of the education process, encouraging participative, experimental and cooperative techniques that use vital 21st century skills (critical thinking, creativity, collaboration and communication), as well as motivation improvement (Gonzalo-Ingelsai et al, 2018). Within education, games can enhance learning by stimulating players' interest and motivation (Nakao, 2019) and provide an opportunity for learning in a different way. They can also be an opportunity for educators to create a fun, safe environment where learners can meaningfully connect (Hromek and Roffey, 2009).
Research finds that playing games is highly beneficial in the development of skills in children, but the paramount idea in the use of games is that of learning through fun (Hromek and Roffey, 2009). Fun and humour have been found to stimulate creativity as the brain moves into a more relaxed state; therefore facilitated games can enable individuals to problem solve more successfully when relaxed (Hromek and Roffey, 2009).
Playing appropriately designed games may also simulate decision-making processes and can enrich existing teaching strategies. Within healthcare education, traditional lectures may not reflect the levels of complexity required in practical applications or real-life situations encountered in the work setting (Bochennek et al, 2007). Although there is evidence about the benefits of gaming within education (McEnroe-Petitte and Farris, 2020), there is less literature describing the use of tabletop board games. The available evidence on the use of games to facilitate learning in other academic disciplines, such as maths (Smith and Golding, 2018) and chemistry (Gonzalo-Ingelsai et al, 2018), has shown positive outcomes. The data show that board games enable participation in learning activities that are fun and motivate players to learn (Bayeck, 2020). Landers et al (2019) acknowledged the value of gamification and its use in learning environments: it helps develop independent thinking, critical decision-making and an understanding of how to apply rules and regulations – skills that are paramount for individuals working in health care. According to Landers et al (2019), the use of games in education is invaluable, however they point out that the full benefits are difficult to critically evaluate, due to compounding factors that inform the learning experience.
Within health education specifically there is a paucity of research data on the use of tabletop board games and their benefits in student learning. Burke (2001) evaluated the benefits of using of an adapted board game centred on infection control to reinforce initial training; the intervention group of healthcare workers who took part in the gaming activity was found to have significantly higher scores on the knowledge test than the control group who did not participate. Another study by Telner et al (2010) involved health professionals undergoing continuing professional development on stroke: the study group participated in a board game and the controls received traditional case-based learning. Although knowledge scores were comparable between the two groups, those who had participated in the board game reported greater enjoyment of the learning experience.
Swiderska et al (2013) used an educational board game with medical students and suggested that the knowledge scores were higher in the game group, while Charlier and De Fraine (2013) found that students preferred the game format to the lecture format, although there was no difference in learning outcomes. McIntyre and Yeoman (2016) reported positive outcomes from use of a pressure ulcer awareness board game among staff in one UK health trust; they found that using games could be fun, stimulating and a non-threatening way for staff to reflect and interact. A systematic review (Noda et al, 2019) of board games as a tool for learning and improving health outcomes found that games were shown to enhance the interpersonal interactions and motivation of participants, and to promote learning. Another systematic review by Abdulmajed et al (2015) concluded that using board games in health education successfully increased participants' knowledge, skills and performance, identifying that participants are reactive to new learning styles.
Game playing can increase students' knowledge of a subject and provides immediate feedback on learning, enabling tutors to gauge how much information has been understood, and where improvements can be made on concepts that were less understood. However, further exploration is needed to determine whether such approaches lead to longer term behavioural changes and their impact on learning.
Therefore, from the limited data available, it is reasonable to suggest that educational games can increase the performance of students in the classroom. However, there is currently no literature on the use of games in cafe-style environments within educational settings.
Development and delivery of the initiative
Changes in the university undergraduate nursing curriculum at the University of Nottingham that commenced in September 2019 meant that Year 1 students were spending more time undertaking simulated clinical learning. The idea to develop the model of a board games cafe environment in a classroom setting was to provide students with an additional learning opportunity to undertake simulated learning in a fun and engaging way, influenced by the popularity of gaming cafes opening in Nottingham city centre. The initiative was felt to combine learning opportunities with a chance for students to socialise, and had the added benefit of being low cost. The cafe approach was considered a viable learning strategy and adapted to ensure that the experience met learning outcomes relevant to the stage of learners.
The model was initially piloted with a group of volunteer students in the final year of their undergraduate studies. This enabled the modification of parts of games that were considered too difficult for Year 1 students and provided an indication of how enthusiastic students might be about the idea. The cafes opened during the second half of semester one; places were restricted, so students were required to sign up online.
Twenty-four students across all four fields of nursing (adult, child, mental health and learning disability) joined each 2-hour cafe and at least three staff were available throughout each session to serve drinks, respond to questions and join in the games. To provide a relaxed environment, a choice of hot drinks and biscuits were served and music played in the background. The tables were arranged to ensure that groups of no more than 8 students could play a game. The games were constructively aligned with the topics that students had already covered in the curriculum, to enable them to build on their learning in a more experiential way. Students were provided with games centred on hydration, the drug round, and infection control, which were purchased from a clinical board games producer. Two editions of the classic children's game Operation were used, with the inclusion of anatomy and physiology questions that students needed to answer before getting a turn. Textbooks and copies of the British National Formulary were available, to offer students the chance to look up answers they were unsure about. Throughout the session, staff were able to ask questions and facilitate discussion in support of the students' learning. At the end of the session, evaluation of individual learning was explored with the students.
Three successful cafes took place before the university closed due to COVID-19. Feedback was gained through simple qualitative questionnaires. The model has recommenced post-pandemic; the mode of delivery has remained unchanged due to previous positive feedback and evaluation, but some new games have now been added.
Results
Following a simple analysis of student feedback, the following themes were extracted. Written consent was gained for photographs and comments to be shared.
Different and safe way to learn and build confidence
Students articulated the value of this model as an alternative way through which to develop their understanding of basic nursing concepts covered in the curriculum. Students found this hands-on, interactive method suited their individual learning styles:
‘It gives me added practice of learning clinical skills. I work well with repetition; it often takes a few goes of learning things before it sinks in with me. I also tend to learn better through other ways. It was a relaxed environment, which in itself made it easy to learn.’
Adult field student
‘I've engaged and learnt information in a different way.’
Mental health field student
Several students found that they benefited from an environment that felt safer and more relaxed. They liked the informality of the cafe environment, compared with traditional teaching models:
‘The thought of it being a more relaxed, informal environment away from seminar groups or big lecture theatres probably appealed to me the most. I thought this would be beneficial to my learning because it takes the pressure away from feeling as though you are asking a “silly” question.’
Mental health field student
‘Unlike sessions where you are stuck in a lecture for a long time, for instance, this session gave a great sense of enjoyment and [was in ] a relaxing environment.’
Adult student
For some students, the content of the board games themselves met specific learning needs, enabling them to build confidence for some of the course requirements that can be anxiety provoking, such as practice placements:
‘The drugs round activity in particular really benefited our learning, as we have a medication calculation exam coming up in June, so this gave an opportunity to practise more.’
Child field student
‘I feel attending cafes could also help me before going out on placement – I have gained extra clinical knowledge to hopefully enable me to be safe and competent.’
Adult field student
Social opportunities
The social benefits of the cafe approach were highly evident from the student feedback. Nursing students can feel disconnected from the wider university, struggling to engage with the opportunities on offer, and there is often a lack of focus to encourage and support wider participation in activities (Heaslip et al, 2017). This may be due to shift patterns, as well as the number of mature nursing students who have caring responsibilities, which make socialising difficult. For example, students said:
‘I thought that it was a brilliant opportunity to meet new friends.’
Child field student
‘I don't get to take part in many of the more “fun” activities that the uni has on, as they're often after 3pm for some reason. By this time, I'm wanting to get home to see my daughter. Any of the weekend activities or social events are also difficult through having a family and being an older student, so again this was a nice way of incorporating a bit of fun, learning and socialising together. This was also a bit of a push out of my personal comfort zone as I sometimes feel anxious in social situations.’
Child field student
Being involved in the cafes and observing the students having fun together was a particular pleasure of running the cafes for the authors and other academic staff involved. The atmosphere was light-hearted, with a buzz of chatter and laughter. In terms of knowledge retention, evidence suggests that individuals are more likely to remember information when associated with emotions and positive memories (Uitto et al, 2018), so the benefits of fun should not be underestimated. One participant wrote:
‘I decided after the first one to return for the second session – I honestly had so much fun as the environment was friendly.’
Adult field student
Another simply said:
‘There were a lot of laughs.’
Because the cafes were open to all first-year students within the undergraduate nursing programmers, the chance to meet and learn from each other at the cafes was valued. One participant noted:
‘It was an opportunity to meet with students from different fields and learn from different perspectives that is not always possible.’
Adult field student
Academic staff witnessed supportive interactions between students during the games. Students with more experience and knowledge were supporting others, and there were some great examples of students encouraging quieter members of the team to throw the dice, read a question or have a go at an answer. Such interactions can contribute to a sense of belonging and build bonds between students as they navigate the demands of the nursing degree.
Teamwork and development of relationships
The presence of academic staff and students together in this fun and informal environment was highly valued in the feedback. Staff, who provided feedback informally, found it to be an excellent way to get to know students and have informal conversations in a non-threatening way. Students responded well to the nurturing environment, with many using their evaluation questionnaires to thank us for the drinks and biscuits. This simple offering helped to break down hierarchical barriers, allowing staff to pass on clinical knowledge and act as nursing role models within a compassionate, psychologically safe setting.
‘The tutors who organised the cafes have always been approachable and friendly, as were the other tutors who popped in to help during the sessions.’
Child field student
An academic staff member who attended found that ‘a key strength of this approach was the opportunity for students to learn key terms in an interactive, collegiate, and safe environment’.
Discussion
The feedback from students shows that participation in the cafes provided students with a diverse and unique learning opportunity. The value of peer-to-peer knowledge exchange and mutual support is clear and the experience can be student led without faculty resources required. In common with some of the existing literature (Akl et al, 2013), students were responsible for their own learning; although staff were present, the games were run and played by the students themselves, who took responsibility for how much they gained from the activities.
The experience of learning in this way draws on Kolb's (1984) core education theory, enabling learners to reflect on their previous experiences and conceptualise learning in a simulated environment. The discussions arising from questions in the games allowed learners to transfer understanding from other experiences, as well as to link to knowledge they had acquired during the programme. For example, the Hydration Game used scenarios in which the learners were able to apply core principles from what they had learnt, but also adapt other knowledge about the importance of meeting an individual's hydration needs.
This way of educating also speaks to Bandura's (1986) social cognitive theory, whereby learners develop expertise by observing and sharing knowledge and behaviour from others, which is then stored to inform later actions (Lavoie et al, 2018). However, McEnroe-Pettite and Farris (2020), in their literature review, suggested that there are disadvantages to using gaming: this includes practical issues such as space and cost, as well as the risk that some learners may find competition threatening. Noisy environments may also be challenging for neurodiverse learners. Although it is important to acknowledge and consider such concerns when using games to facilitate learning, the authors' evaluation was sufficiently positive to warrant recommendation of the model as part of teaching programmes in both university and clinical settings.
Since the pandemic, much healthcare education has shifted towards a hybrid model of delivery, using more online content, and these cafes are a reminder that there is much to be gained by low-tech, traditional activities. Healthcare programmes aim to enhance communication and interpersonal skills, and nursing work relies on excellent teamworking (Rosengarten, 2019). The authors found that teamworking skills were enhanced through the use of the board games model, developing transferable skills that may not have been captured via traditional teaching methods (Smith and Golding, 2018). Bramer (2020) encourages educators to consider alternative methods of teaching that can complement online education methods, to support the development of students' communication skills.
It is important to note that the cafes provided an inclusive environment and were attended by a wide demographic of students. Feedback about the opportunity for students with caring responsibilities to be able to engage in a social event was powerful.
Future possibilities
Initially, the cafes have been used only with Year 1 students, but the model can be used with students at all stages of undergraduate and postgraduate teaching, as well in post-registration sessions. The gaming approach can be embedded throughout a course because of the availability of games that cover complex skills, such as managing clinical priorities. There is also an opportunity to invite students in the final year of their course to the cafes to support junior students and for interprofessional learning. The model has been disseminated across the wider university and can be adapted to the needs of each nursing branch programme.
The purchasing of the games required an initial outlay of £300, and there was also the cost of the drinks and biscuits. However, these costs can be justified due to the demonstrable impact that the model has on the learning of students, as well as the opportunities it offers. Although a wide range of games is available, the authors have identified some gaps, notably around mental health field skills. Future plans for the nursing programmes at the University of Nottingham include games being stored in the library for students to borrow and play at their leisure.
This model is also appropriate for use in clinical practice areas. It offers the opportunity to provide staff with time out and can help facilitate teamworking, in addition to enhancing clinical knowledge and supporting staff wellbeing. This could be particularly helpful for building confidence and embedding newly qualified nursing staff in multidisciplinary teams. The model also offers the opportunity to utilise peers, as well as more senior clinical staff, to provide guidance and support learning, with the aim of helping students to make stronger links between theoretical concepts and clinical practice, particularly during the transition from novice to expert (Benner, 1982).
In terms of further research, Abdulmajed et al (2015) found that there was no continuous monitoring of longer term progress, performance and learning behaviour of students in relation to learning through games in the current literature. So although there are clearly exciting opportunities and much potential for learning using games, more robust evaluation methods are required to gauge the impact of the learning approach and possible future benefits for patient care.
Conclusion
Feedback from the clinical board games cafe model suggests that participation has had a positive impact on the learning and confidence of the students involved. The cafes assisted with teamworking, social integration and the development of relationships between staff and students. There was also compelling feedback about the inclusive nature of the cafes and how much the university's diverse student cohort benefited from this. Having constructive alignment between the games and module or practice content provides students with the opportunity to revise and embed new clinical knowledge. The use of board games deserves consideration within the curriculum and practice development across nursing programmes in the UK.
KEY POINTS
- Undergraduate nursing students at the University of Nottingham were invited to play clinically focused board games in a cafe-style environment
- Student evaluation suggested that students welcomed the opportunity to discuss clinical issues in a safe and fun space
- Participation increased confidence, teamworking skills and embedded learning
- This model can be adapted for many settings and can complement other teaching methods
CPD reflective questions
- How is learning enhanced by using gaming principles?
- Can the nurturing and relaxed nature of board games cafes be used to help meet the needs of a diverse student body?
- Are there ways that gaming can be incorporated into your existing curriculum or teaching?