Learning Nurse Newsletter - March 2014

Welcome to the March 2014 edition of the Learning Nurse Newsletter. We publish occasionally to keep nurses, nursing students, nursing educators and other interested parties informed about is what happening at LearningNurse.org. (For more timely updates, follow us on Twitter.)Nursing games

Games in Nursing Education

The most popular page on the Learning Nurse website is Educational Nursing Games. This page has now surpassed our Learning Nurse Tests and Quizzes which has been on top since 2008.

So what is so special about a “game” that makes it such a popular learning activity with both students and professional nurses? Nicola Whitton in her book Learning with Digital Games describes the characteristics of a “game.” These include:

  • A challenge that requires skills with an attainable goal and known rules
  • Complete absorption in the activity
  • Clear goals
  • Immediate feedback
  • Concentration on the task at hand
  • A sense of control and not worrying about losing control
  • Loss of self-consciousness
  • Transformation of time

The more the above elements are present, the more enjoyable, engaging and immersive an activity is (p. 42). For most, learning is already a positive experience. It looks like by adding a few of these features makes it even more enjoyable.

We became intrigued with educational nursing games in early 2013. We had amassed a huge amount of content in our popular quizzes. I wanted to see whether these could be converted to games. Our first attempts at developing games were to purchase two game templates from eLearningBrothers.com. These games were Flash based so required Adobe Flash Professional to create the content. I learned how to program in Adobe Flash and developed several games. Since there was no tracking, we do not have any data on their use or results.

At the same time, we were getting complaints that our quizzes and games were not playable on the iPad. So believing the hype, we decided to convert to HTML5 which was supposed to be universally accessible. We purchased two HTML5 game templates from eLearningBrothers. One advantage was that the content could be added using any browser, and did not required any additional software are specialized knowledge. One game – Trivia – was a dressed-up multiple choice game. The other game – WordGuess – required answering questions by typing the answer in a keypad. The first game relied on recognition, while the second game relied more on recall.

We soon found that the HTML5 games required a few enhancements. We discovered that our games were being used by nursing programs as assignments. Nursing students had to complete a game and hand it in as an assignment. Therefore, we modified the games so that students could enter their name at the beginning for it to be printed on the results page. We also made some other additions to better facilitate the use of games in assignments.

The other significant addition we made was to modify the scripts so that the results – Game name, user name, score and date/time – were sent to a database table. This enables us to track what is happening and do analyses like those shown below.

However, creation and use of HTML5 games did have some challenges. First of all, some older browsers cannot display HTML5 content correctly. Most current browsers – Microsoft’s Internet Explorer, Firefox, Chrome and Safari all seem to work well. Another challenge was that the game developers were not able to help us with the database tracking system. We had to contract an independent programmer to write the javascript, php and MySQL codes to get this functionality to work.

Another problem we encountered was that with the most recent upgrades to the Firefox and Chrome browsers, our HTML5 games stopped working! We had to contract with our programmer to develop “fixes” to get them working again. So beware – HTML5 is not without its problems! In the six years we have had Adobe Flash quizzes on our site, we never had any issues when browsers changed, etc. We expect that Flash will be around for a while yet. It’s a good thing, as HTML5 has some maturing to do yet!

When Articulate’s StoryLine e-learning software came out, we adopted it for developing online courses. It is a great program for creating interactive instruction, but it does take some time to become proficient with its many features and capabilities. We purchased a StoryLine template from eLearningBrothers and created a number of simple games. These template-based games did not take full advantage of StoryLine’s capability so we began to develop our own games. We are quite pleased with the quality of games can be easily developed. These SL games appear to be very popular with our site visitors. The major limitation with the StoryLine games is that currently there is no simple way to send the results to a database table. (However, it will send results to your Learning Management System – LMS). Since we don’t use a LMS, we can’t monitor usage or results. We are exploring ways to fix this shortfall.

So what is the status of our nursing games at this writing? We have a total of 112 games with some 3,655 questions. Of these, 42 games are the SuperNurse (Trivia) type, a fancy multiple choice / true-false game. Some 53 games are WordGuess, where answers are typed in. Finally, we have 17 StoryLine based games that rely mostly on drag and drop activities.

To give you a better sense about our educational nursing games, we did a brief analysis of the games’ data we have collected so far. Here is what we found.

Nursing Games Data Analysis

We implemented a tracking system for the HTML5 games on August 16, 2013. As of mid-March 2014, we had data on over 25,000 nursing games!

We do NOT track the results of the StoryLine games yet. However, our traffic statistics indicate that the StoryLine games are by very popular. We estimate that almost as many of these have been completed in the same time period.

What conclusions can we draw from the nursing games data so far?


Let’s start by examining which HTML5 games are most, and least, popular.  Here are the 15 most played games.

  • Abdominal Pain (3,280) This may be because it is the first game listed on the page.
  • Blood Components (1,375) The third game listed on the page.
  • Patient Assessment I (1,157)
  • Chest Pain (1,023)
  • Body Fluids Disorders (920)
  • Back Pain (700)
  • Childhood Diseases (639)
  • Anatomy Terms I (598)
  • Mental Health Disorders (566)
  • Wound Care (563)
  • Digestive System (544)
  • Pediatric Nursing (514)
  • Urinary System (454)
  • Professional Boundaries (418)
  • Patient Assessment II (390)

All of these games, except for Anatomy Terms I, are of the SuperNurse (multiple choice) type.

The 10 least played games are:

  • Cytology Terms (32)
  • Dermatology Terms (30)
  • Organ Systems II (27)
  • CAM Terms (26)
  • Medication Practices Terms (24)
  • Histology II (20)
  • Sociology Terms (20)
  • Fungi Terms (19)
  • Histology Terms (19)
  • Embryology Terms (8)

All of these games, except Histology II, are the WordGuess type. Also, it should be noted that Cytology, Histology and Embryology games were only recently posted.

According to our data, the SuperNurse games are four times more popular than the WordGuess games – 18,793 vs. 5,114 completed. An average of 447 people played each SuperNurse game compared to 100 players for each WordGuess game. One possible reason is that the SN games are more familiar and perceived to be easier than the WG games.  


Next, an analysis of the games’ scores was done. Here are the averages for the top 15 scoring games.

  • Cardiology (85.6%)
  • Hormones (83.3%)
  • Drug Abuse Terms (82.6%)
  • Endocrine Terms (81.4%)
  • Body Directions (81.2%)
  • Diabetes Terms (79.4%)
  • Microbiology Terms (79.4%)
  • Mental Health Terms (77.9%)
  • Anatomy Terms III (76.9%)
  • Brain Terms (76.3%)
  • Organ Systems II (76%)
  • Pediatric Disorders II (75.6%)
  • Drug Categories (75.5%)
  • Pressure Ulcers Terms (75.4%)
  • Gastroenterology Disorders (74%)

All of these nursing games are of the WordGuess type.

Now here are the 10 games with the lowest average scores.

  • Digestive System (49.7%)
  • Wound Care (49.1%)
  • Dizziness (48.4%)
  • Wound Dressings (46.4%)
  • Histology II (45.5%)
  • Diarrhea (43.7%)
  • Fungi Terms (43.7%)
  • Medication Practices (42.6%)
  • Skeletal System I (40.9%)
  • Embryology Terms (34.1%)

These games were a combination of both SN and WG types.

The performance data is the reverse the popularity results. The WG games averaged 68% as compared to 56% for the SN games. Perhaps these results are due to experienced and knowledgeable nurses more willing to try the WG games.

If you are interested in seeing all the data from our analyses of the game results, please see attached results by game name, results sorted by frequency, results by average score, and results by type of game

Conclusions and Recommendations

Based on our experiences and results with the nursing games, here are my conclusions and recommendations:

1.   Definitely considering adding games to your learning toolbox. It makes learning more fun and enjoyable.

2.   Yes, you too can create educational games. Using inexpensive eLearningBrothers templates, you can take some of your nursing quizzes and make them into games. You do not have to hire a programmer, or spend a great deal of money.  

3.   Despite a few limitation, stick with HTML5 games. They are the easiest to develop, and “should” be viewable on most computers and mobile devices.

4.   If you are feeling a bit more adventurous, and want to develop games from scratch, I would recommend StoryLine. The product has an excellent set a tutorials and a very helpful and supportive community. However, there is a bit of learning curve to become comfortable with using it.

New, Improved and Planned

Here are the changes and additions we have made to the Learning Nurse website since our last newsletter.

1.   Website – In August of 2013 we switched to our newly designed and upgraded Joomla CMS website. So as not to interrupt access to our nursing resources, we created a new website at LearningNurse.org. We then closed our old site at LearningNurse.com and redirected the address to the new site.

The new Learning Nurse site has a fluid width so as to better accommodate screen sizes of mobile devices such as iPads and iPhones. We re-organized the content into a more logical and accessible structure and gave it an updated look and feel. We also added additional security features to the website to prevent hackers and spammers from accessing the site.

2.   Games – One of the major additions to the Learning Nurse site was the addition of educational nursing games. See article above for details and our experiences.

3.   Apps – We were getting requests to make our nursing resources more available and useable on mobile devices, especially the iPad, iPhone, Android devices and tablets. Our quizzes are Adobe Flash based and do not work on Apple and Android devices. One benefit of apps is that they are designed for the screen size of each mobile device. The other significant benefit is that once downloaded, no Internet connection is required so learning can take place anywhere.

In partnership with another company, we took our most popular quizzes and created 12 apps that are available for Apple, Android and Kindle devices. These nursing apps are sold at the Apple, Google and Amazon online stores.

4.   Pressure Ulcers eCourse – Some time ago, we received an inquiry as to whether we had any nursing resources on pressure ulcers. We did not, but the topic was specific and important enough that we thought it would be worth looking at developing something. With the help of a couple of content specialists and a sponsor, we have researched and assembled the information necessary to create a multifaceted and comprehensive online course.

Modules 1 and 2 of the course are now finished and available for testing and feedback. So far, the course contains 22 different learning components including narrated videos, podcasts, interactive activities, print resources and quizzes. Our intent is address the diversified teaching and learning needs of our global audience. Another objective is to assess what types of learning resources / activities are most desired and effective for nurses’ learning. We are planning to have the entire course completed by the fall of 2014.

In terms of plans for the Learning Nurse website, we are focusing on two major challenges.

1.   Game tracking – Currently we do not have any way to track the results of our StoryLine games. Therefore, we do not know which are most popular, nor how learners do on them. We are exploring ways to send the StoryLine scores to our games database table.

2.   Quiz system – Our 163 nursing quizzes were created using two software programs – Quiz Creator and Quiz Builder. Both programs send the results to a database table which we can then analyze. We adopted Quiz Builder because it provides a certificate, a quiz report and tracks the number of rights/wrong for each question. This is very useful as it allows for item analysis and thus improvement of the effectiveness of the quizzes.

However, both of these quizzes are Flash based and therefore not viewable on Apple or Android devices. (This has been partially addressed by having many of the quizzes converted to HTML5 games.) Both programs are several years and in need of updates.

Another request that we are getting occasionally is the ability to register for an account so that the quiz results and certificates are always available to the learner. We have not yet found the quiz program that meets all of our needs. Also, the other big challenge will be the expense and time required to convert the 163 quizzes with nearly 12,000 questions to the new quiz format. However, we are hoping to have some solution in the next year or so.

Learning Nurse Users

Analyzing the Learning Nurse website statistics from January 1 to December 31, 2012 shows the following:

  • 175,000 unique visitors (IPs), an increase of 86% over 2011
  • 290,000 visits with 3.4 million page views and 332 GB of traffic

For 2013, the numbers were:

  • 208,000 unique visitors (IPs), an increase of 19% over 2012
  • 328,000 visits with 3.6 million page views and 326 GB of traffic

In August of 2013, we redeveloped the Learning Nurse website and implemented additional security measures. This may have reduced our bandwidth use and moderated traffic by blocking spammers and hackers to the site.

The geographical locations of Learning Nurse visitors were approximately as follows:

  • 55% from the United States
  • 15% from Canada
  • 6.5% from Australia
  • 5.6% from Great Britain
  • 2.7% from India
  • 2.7% from New Zealand
  • 1.0% from Philippines
  • The remaining 11.5% came from such countries as United Arab Emirates, Netherlands, Pakistan, Saudi Arabia, Ukraine, France, Qatar, Vietnam, Greece, South Africa, Ireland, Portugal, Barbados, Germany, China, Morocco and Japan.  

The Learning Nurse website has a loyal following with many repeat visits. This is demonstrated by:

  • Some 54% of visitors come directly from a bookmark or URL entry; this is down from about 80% a few years ago
  • 26% come to the website from a search engine – Google, Yahoo and Bing; “nursing quiz(zes)”, “learningnurse” and “nursing games” are the most common search terms
  • Some 15% of traffic comes from links on other websites with Pinterest and Facebook being the top referrers; this percentage has increased significantly over the past few years
  • About 48% of visitors this year have bookmarked the website.

Despite the fact that our visitors are increasing every month, we are still a ways to go to reach the approximately 5 million English speaking nurses on this planet.


Quiz Results

In August of 2013, we upgraded the Learning Nurse website. We archived the 315,000 quiz results that we had collected between March 23, 2008 and August 14, 2013.  Here is a brief analysis of the quiz data.

The 20 most popular nursing quizzes over the five year period were:

  • Anatomy Terminology (45,955)
  • Disease Terminology (23,669)
  • Medical Terminology (16,393)
  • Patient Assessment (10,495)
  • Anatomy and Physiology (9,044)
  • Safe Medication Principles (8,165)
  • Cardiovascular System (7,354)
  • Word Roots (7,181)
  • Tablet Dosage Calculations (6,136)
  • Endocrine System (6,037)
  • Diabetes I (5,773)
  • High Blood Pressure (5,618)
  • Respiratory System (5,424)
  • Medication Abbreviations (5,347)
  • Nursing Practice I (5,339)
  • Blood Components ((5,262)
  • Cardiology Terms (5,245)
  • Urinary System (4,785)
  • Pediatric Nursing I (4,715)
  • Wound Care (4,510)

The 10 least popular quizzes were:

  • Fatigue (311)
  • Limb Pain (278)
  • Dizziness (268)
  • Botanical Medications (246)
  • Dangerous Drug Combinations (243)
  • Phobias (239)
  • Rectal Disorders (160)
  • Herb-Drug Interactions (108)
  • Antifungal Drugs (108)
  • Antiviral Drugs (77)

It should be noted that many of these quizzes were only added in the last year or so. This may be one reason to explain their low participation rates. The full list of quiz results sorted by frequency can be seen here.

The quiz data was also analyzed to determine average / mean scores. The 20 quizzes with the highest average scores were:

  • Injection Dosages Calculations (89.9%)
  • Fluid Dosage Calculations (89.4%)
  • Tablet Dosage Calculations (88.3%)
  • Medication Abbreviations (87.3%)
  • Intravenous Flow Rates (86.8%)
  • Metric Conversions (82.9%)
  • Cardiology Terms (82.3%)
  • Antidotes (76%)
  • Anatomy Terminology (74%)
  • Fatigue (73.8%)
  • Safe Medication Principles (73.3%)
  • Reproductive System (73.3%)
  • Professional Practice (73.2%)
  • Mobility and Falls (72.4%)
  • Managing Patient Rage (72.3%)
  • Infusion Therapy (71.4%)
  • Chest Pain (71.4%)
  • Disease Terminology (70.9%)
  • Childhood Diseases (70.7%)
  • Medical Terminology (70.5%)

The 10 quizzes with the lowest average scores were:

  • Phobias (50.2%)
  • Mental Status (49.4%)
  • Substance Misuse (49%)
  • Diarrhea (47.6%)
  • Diagnostic Tests I (47.3%)
  • Cancer Risks (45.7%)
  • Antibacterial Drugs (45%)
  • Dangerous Drug Combinations (44.4%)
  • Nutritional Disorders (43.8%)
  • Antiviral Drugs (42.9%)

It is up to the nursing profession to determine whether the lack of knowledge in these areas should be of concern. The full list of quiz results sorted by average scores can be viewed here.


About Learning Nurse

The Learning Nurse Resource Network (LearningNurse.org) was created by Steppingstones Partnership, Inc. and went online in April 2008. The purpose of this nursing professional development resource is to make available free, informal, accessible and convenient learning opportunities for nurses. Because of the shortage of nurses in many facilities, it is very difficult to get away for traditional courses and workshops. This is particularly true in smaller and rural areas where it nearly impossible to obtain leave and funding to attend professional development events.

Although the Learning Nurse was originally designed for all levels of practicing nurses, it has become popular with nursing students, graduate students and nurses returning from leaves. Many of the visiting nurses take time during breaks in their night shift to review and refresh their nursing knowledge and skills using our quizzes, educational games and e-learning modules.

That’s it for now. If you have any questions, comments or suggestions, please let me know. Thanks for your continuing interest and support.

Best regards,

Russ Sawchuk
Webmaster and Editor

Note: Permission is granted to reprint all or part of the information in this newsletter provided that the source – LearningNurse.org – is credited.


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