Nurse Education in Practice 70 (2023) 103657

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Nurse Education in Practice

journal homepage: www.elsevier.com/locate/issn/14715953

Effectiveness of a nursing board games in psychiatric nursing course for

undergraduate nursing students: An experimental design
Chia-Shan Wu a, 1, Mei-Fang Chen a, Huei-Lih Hwang a, Bih-O. LEE b, c, *, 2
a
Department of Nursing, National Tainan Junior College of Nursing, Tainan, Taiwan
b
College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
c
Center for Medical Education and Humanizing Health Professional Education, Kaohsiung Medical University, Kaohsiung, Taiwan

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: To examine the effectiveness of a psychiatric nursing board game in an undergraduate psychiatric nursing
Board game course.
Psychiatric nursing Background: Didactic teaching fails to assist students in deepening their understanding of abstract concepts in
Learning outcome
psychiatric nursing. The game-based learning of professional courses can address the demands of digital-age
Nursing students
Innovative teaching
students, which may improve their learning outcomes.
Design: A parallel two-arm experimental design was adopted in a nursing college in southern Taiwan.
Methods: The participants were fourth-year students enroled in a college nursing programme in southern Taiwan.
Simple random sampling was used to divide the class into intervention and control groups. The former partic­
ipated in an eight-week game-based intervention course, while the latter continued to receive traditional in­
struction. In addition to collecting the students’ demographic data, three structural questionnaires were
developed to examine the variation in students’ nursing knowledge and attitudes toward psychiatric nursing, as
well as their learning satisfaction before and after the intervention.
Results: There were a total of 106 participants, with 53 in each group. After the intervention, the two groups were
significantly different in terms of their psychiatric nursing knowledge, attitudes and self-reported learning
satisfaction. The intervention group’s scores were significantly higher than those of the control group across all
three dimensions. This suggests the positive effects of the board game intervention on students’ learning
outcomes.
Conclusion: The research outcome can be applied in formative and undergraduate nursing education in teaching
psychiatric nursing globally. The game-based learning materials developed can be used to train psychiatric
nursing teachers. Future studies should recruit a larger sample and increase the follow-up time for assessing
students’ learning outcomes, as well as examine the similarities and differences in the learning outcomes of
students from different educational systems.

1. Introduction
The World Health Organisation (WHO) lists mental disorders as one
of the serious threats to humans in the 21st century. This highlights the
importance of mental health promotion and developments in mental
disorder prevention, treatment, rehabilitation and care (Machin &
Moran, 2018; WHO, 2020). Patients with mental disorders face several
problems including mental health issues and ageing (Rong et al., 2018).
The chronic state of patients’ illness gradually affects their cognition,
emotion and thinking skills, as well as their roles and behaviour in the
community and social functioning. In addition, mental disorders exac­
erbate patients’ decline in their interpersonal relationships and their
self-care abilities, to the point that they require hospitalisation because
of recurrent mental health problems. These result in complex issues
among patients and their family members in the social, psychological,
economic and healthcare aspects (Andresen et al., 2011; Li and Tsai,
2017). Mental disorders and mental health are two issues of concern
worldwide.

* Correspondence to: College of Nursing, Kaohsiung Medical University, 100, Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan.
E-mail address: biholee@kmu.edu.tw (B.-O. LEE).
1
ORCID iD: 0000–0002-9624–3888
2
ORCID iD: 0000–0003-1903–8378

https://doi.org/10.1016/j.nepr.2023.103657
Received 17 October 2022; Received in revised form 23 March 2023; Accepted 4 May 2023
Available online 9 May 2023
1471-5953/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
C.-S. Wu et al.
In Taiwan, psychiatric nursing is a mandatory course in undergrad­
uate nursing courses, as well as a mandatory subject in the National
Registered Nurse Licensure Examination. Currently, psychiatric nursing
education is only covered briefly in undergraduate nursing education
courses. For instance, the duration of a psychiatric nursing course in
nursing programmes is merely 3–4 h per week and the duration of
psychiatric nursing clinical placement is merely a total of 120–160
hours. Nursing students often perceive psychiatric nursing as abstract
and one that requires the consolidation of the knowledge acquired
during the first to third years of study. Thus, students must possess
fundamental knowledge of psychiatric medicine, psychology, sociology,
internal medicine, general surgery and nursing (Liao et al., 2021).
Because of the characteristics of psychiatric disorders, it is difficult for
students to understand and interact patients with psychiatric disorders
(Lu, 2020; Wu et al., 2019). Even if the students understood the concepts
and knowledge acquired through textbooks, they would still feel
extremely uneasy and helpless when caring these patients in clinical
practice due to inadequate professional training (Lu, 2020; Wu et al.,
2019).
The teaching contents in existing psychiatric nursing curricula are
mostly designed by teachers. In didactic teaching, students often find it
difficult to understand abstract concepts, in addition to getting
distracted in class and therefore fail to meet the course objectives (Wu
et al., 2022). Considering the increasingly varied health problems and
nursing care needs of patients, as well as to strengthen students’ learning
motivations and their skills and knowledge, it is necessary to develop
and evaluate psychiatric nursing educational models proactively and
innovatively (Wu et al., 2022). Classroom instruction may be inadequate
in this regard because undergraduates do not have a firm grasp of mental
disorder-related concepts and they often do not understand the concepts
taught in the class (Chiu et al., 2021). To this end, it is increasingly
important to design and incorporate different teaching approaches in
psychiatric nursing.
Nursing education in Taiwan consists of undergraduate programmes
and vocational programmes. After graduating from junior high school,
students who complete the junior college nursing programme receive an
associate degree (Tsai et al., 2022). The graduation rate of junior college
students is 39.8% and these students are an important human resource
in clinical nursing tasks. According to the Ministry of Education
Department of Statistics’ query system on the standards for classifying
subjects in colleges and universities, there were 14,091 nursing gradu­
ates in the 2020 academic year, 5601 (39.74%) of whom were junior
college graduates (Ministry of Education, 2022). Psychiatric nursing
education reform is, thus, important to help students align their
knowledge with clinical practice effectively.
2. Background
Wu et al. (2019) interviewed 20 nursing students majoring in psy­
chiatry and found that common psychiatric nursing-related stressors
faced by students include incompetence in diagnosing and managing
symptoms and patient conditions, unfamiliarity with antipsychotics and
their side effects and lack of patient communication skills. Further an­
alyses revealed that the possible difficulties faced by nursing students
regarding their caregiving skills include getting overwhelmed or
confused by patients’ psychiatric symptoms and caregiving problems,
having medication-related queries and being unfamiliar with the diag­
nostic criteria of the Diagnostic and Statistical Manual of Mental Dis­
orders, Fifth Edition (DSM-5). In contrast to physical health problems,
the medical and caregiving demands of psychiatric-mental health
problems are often underestimated and overlooked (Rong et al., 2018;
Wu et al., 2019; Lu, 2020). Given that the nursing curricula are often
centred on physical illnesses, more efforts are needed to enhance the
planning of mental health-related nursing courses, teaching resources
and clinical placements (Rong et al., 2018; Batchelor-Aselage et al.,
2014).
2
Nurse Education in Practice 70 (2023) 103657
In game-based learning (GBL), students learn about concepts
through a series of meticulously designed GBL strategies as part of
scaffolding (Hou, 2018; Kapp, 2012; Lin and Lai, 2017). These GBL
mechanisms are known to improve learners’ willingness and drive to
succeed, thereby strengthening their learning motivation (Wang, 2012;
Lu et al., 2018). GBL through board games is a popular approach
because it encourages teamwork and interaction and is convenient,
inexpensive, portable and independent of the number of players, age,
weather, or devices (Luchi, 2019). Research has shown that appropriate
integration of learning content into gaming environments improves
students’ learning performance and participation, promotes a happy
gaming experience and increases their learning interests and motiva­
tions (Brull and Finlayson, 2016). Another study reported that GBL can
help nursing students to identify meaningful connections in complex
nursing concepts. Educators are tasked with conveying and integrating
knowledge or concepts into game-based learning so that learners can
easily comprehend the learning content, convert their knowledge into
practical action and achieve positive learning outcomes based on
meaningful experiences acquired during the learning process (Chang
et al., 2022; Day-Black et al., 2015; Hou, 2018).
Studies have demonstrated the effectiveness of GBL in healthcare
education. An early study on nursing education found that 90 %
(Bayer-Hummel, 2010) and 93.4 % (Stanley and Latimer, 2011) of
learners perceive GBL in learning as interesting and meaningful. GBL
provides nursing students with a secure and useful spatial environment
where they can repeatedly and freely experiment without having to
worry about failure or making incorrect judgements. As a result, stu­
dents have less learning-related stress and anxiety (De Freitas, 2006;
Ghoman et al., 2020; Oblinger, 2004). Accordingly, the introduction of
GBL in nursing education can facilitate more active learning experiences
for students (Xu et al., 2021). According to Xu et al. (2021) literature
review of 53 studies on GBL related outcomes in 4612 nursing students
across 16 countries, board games had the most forward-looking influ­
ence on students’ learning outcomes. Regarding the types of interven­
tion in nursing-related board games, most comprised simulation games
(28 %), followed by serious games (13 %), escape rooms (11 %) and
board games (6 %). In terms of the duration of intervention, most lasted
an hour (36 %), followed by one to two hours (19 %). Regarding the
teaching assessment method, most studies employed questionnaires (66
%). Regarding the post-intervention learning outcomes, most learners
perceived the games as fun (28 %), followed by learners reporting
improved learning satisfaction (22.6 %) and proactive learning moti­
vations (22.6 %).
GBL groups have varying numbers of participants. To encourage
group discussions, the number of participants per group can be
increased from three to four to five to ten. If there are many students in a
class, each group should consist of no more than 16 individuals at most
(Hou, 2016). Luchi et al. (2019) examined the effects of implementing a
musculoskeletal system game on the learning outcomes of undergrad­
uate students. The intervention group consisted of 21 students (phar­
macy course) and the control group consisted of 22 students (nursing
course). The board game intervention was implemented for one week
only, but the students’ grades significantly differed. Therefore, the
implementation of board game interventions in psychiatry education
seems promising for improving students’ learning outcomes.
According to previous qualitative studies, nursing students often
encounter stress and barriers in learning psychiatry courses (Lu, 2020;
Wu et al., 2019). The GBL methods enables students to understand
common psychiatric symptoms, medications and patient communica­
tion skills, as well as enhances their learning motivations and enables
the future application of their acquired knowledge to clinical practice
(Wu et al., 2019). To date, even though the limited systematic literature
reviews have demonstrated the efficacy of GBL in nursing education,
most of these studies did not perform meta-analyses to tabulate the
actual outcomes of implementing board game interventions in nursing
education (Gauthier et al., 2019; Xu et al., 2021). Consequently, this
C.-S. Wu et al. Nurse Education in Practice 70 (2023) 103657

study examined the change in knowledge, attitudes and self-reported Table 1

learning satisfaction following a psychiatric nursing course incorpo­ Instructional contents of the board game intervention.
rating GBL. Week Unit Objectives Contents of
intervention
3. Methods Week Causes, symptoms, Identifying the causes Game card
3 diagnosis, and and symptoms of mental (symptom card)
3.1. Design classification of disorders
mental disorders
Week Therapeutic Utilising therapeutic Skills training
This study employed a two-arm parallel pre-post-test experimental 4 interpersonal communication (simulated and
design. relations and techniques Building situated training)
therapeutic therapeutic Theme cards
3.2. Setting and sample communication interpersonal relations (situational cards)
Week Treatment and Understanding common Game cards
5 nursing care of treatments for mental (medications, side
The participants of this study were 106 fourth-year students enroled mental disorders (I) disorders (drug therapy effects, and
in a college nursing course and divided into two classes. The nursing effects and side effects) symptoms cards)
course was held in a classroom with space for between 50 and 60 stu­ Week Treatment and Understanding common Game cards
dents. Simple random sampling was used to determine the intervention 6 nursing care of treatments for mental (medications, side
mental disorders (II) disorders (drug therapy effects, and
and control groups. The former underwent an eight-week GBL course effects and side effects) symptoms cards)
involving a board game, while the latter underwent traditional Week Nursing care of Utilisation of nursing Game cards
instruction. 8 patients with thought care procedures for (symptoms,
As this psychiatric nursing course was mandatory, all students were disorders patients with thought medications cards)
disorders Theme cards
required to take it. The only inclusion criterion for this study was the
(schizophrenia
willingness of students to participate and sign a consent form. Students cards)
were informed that they were not required to complete the survey if they Week Nursing care of Utilisation of nursing Game cards
chose not to participate in the study. No participants declined to take 10 patients with thought care procedures for (symptoms,
part in this study. disorders patients with thought medications cards)
disorders Theme cards
The sample size was calculated using G power 3.010 software (Faul (schizophrenia
et al., 2009). The alpha value was 0.05, the power 0.80 and the effect cards)
size 0.55, based on the results of a two-tailed test in a previous study Week Nursing care of Utilisation of nursing Game cards
(Chen and Tsai, 2022). Accordingly, the sample size in this study was 11 patients with care procedures for (symptoms,
affective disorders patients with affective medications cards)
adequate, as the estimated size required was 106 (53 participants in
disorders Theme cards
each group). (depression and
bipolar disorder
3.3. Nursing course incorporated with GBL as the intervention cards)
Week Nursing care of Utilisation of nursing Game cards
12 patients with anxiety care procedures for (symptoms,
The first author of this study has 18 years of teaching and clinical disorders patients with anxiety medications cards)
experience in psychiatry. Based on previous studies and the author’s disorder Theme cards
teaching experience, a psychiatric nursing board game was developed (anxiety cards)
according to a design framework that incorporates mental disorders
(thought disorder, affective disorder, behavioural disorder), medical
group. The GBL sessions were held for 30–40 min in accordance with the
diagnoses (schizophrenia, depression, bipolar disorder) and drug ther­
curriculum. The control group continued to undergo the current
apies (antipsychotics, antidepressants, mood stabilisers, anxiolytics)
instructional models including didactic learning, skills training, video-
that are easily confused by students, as well as therapeutic communi­
assisted learning, case studies and discussions.
cation techniques.
This course used GBL to incorporate five psychiatric nursing care-
related scenarios. The GBL consisted of components including game 3.4. Research ethics
cards, option cards, theme cards, game rules and a user guide (Appendix
1). The cards deepen students’ knowledge about various aspects of Research Ethics Committee approval was obtained from the Insti­
psychiatric nursing and improve their learning outcomes through tutional Review Board (IRB No xxxxxx). Prior to the intervention, the
different game modes. Following the design of the intervention, five researchers explained the research purpose to obtain the participants’
experts (two psychiatric nursing experts, two nursing teachers and a consent. The researchers also provided a confidentiality commitment,
researcher who is an experienced board game designer were invited to including the anonymity and confidentiality principles of the research
review the game to provide suggestions for improvement. The board data. Participants were informed that their grades would not be affected
game was finalised after necessary revisions were made. if they declined participation at any time during the survey.
The course undertaken by the fourth-year students is a mandatory
course held in the semester and it offers 3 credits and 54 course hours. 3.5. Measures
The GBL was conducted for eight weeks throughout the 18-week course,
during students’ spare time. Each game session lasted 30–40 min. The Three structural scales were used as measures before and after the
course units of the intervention included symptoms of mental disorders, GBL intervention. The three scales were administered once before the
diagnosis and classification, drug therapy and side effects, scenario- semester and once toward the end of the semester. The participants’
based training on therapeutic communication techniques and nursing demographic data were collected before the course began.
care of patients with thought disorders and anxiety disorders (Table 1).
The instructors in the intervention were the first author and a 3.5.1. Demographic data
research assistant. The first author explained the rules and contents of The demographic data included the students’ age, sex, duration of
the GBL to the students and divided them into six groups of eight to nine online time each day and experience in and duration of playing other
members. Each member took turns to host and guide the GBL in their board games.

3
C.-S. Wu et al. Nurse Education in Practice 70 (2023) 103657

3.5.2. The psychiatric nursing knowledge scale 4. Results

This study adopted the Geropsychiatric Symptoms and Health
Problem Nursing Knowledge Scale (GPN-K) developed by Wu (2021).
The GPN-K includes 25 questions that assess students’ abilities to eval­
uate older adults’ symptoms of mental and physical illnesses and stu­
dents’ knowledge about measures to be taken while practising nursing,
including the drugs for treatment. Every right answer was scored with
one point and a higher total score indicated possessing a higher level of
knowledge. A confirmatory factor analysis (CFA) of the GPN-K showed
good fitness and validity (Wu et al., 2021). In this study, the content
validity index (CVI) was 0.95 and Cronbach’s α was 0.78.
3.5.3. The geropsychiatric psychological symptoms and health problem
nursing attitude scale (GPN-A)
This study adopted the 19-item GPN-A developed by Wu (2021). The
items were measured on a five-point Likert scale (1 = strongly disagree,
2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). The higher the
score, the more proactive the students’ attitudes toward older patients
with mental disorders. The scale had an overall CVI of 0.95 and Cron­
bach’s α of.84, which reflects its excellent validity and reliability. In this
study, the CVI was 0.95 and the Cronbach’s α was 0.89.
3.5.4. The self-reported learning satisfaction scale
Based on previous studies, this study developed a 13-item self-
reported learning satisfaction scale for students, with the aim of evalu­
ating students’ learning satisfaction in psychiatric nursing. The items
were measured on a five-point Likert scale (1 = strongly disagree, 2 =
disagree, 3 = neutral, 4 = agree, 5 = strongly agree). The higher the
score, the higher the students’ learning satisfaction. As this was a self-
developed scale, its expert validity was first assessed by five experts
before its administration and then ten students assessed its readability to
determine whether the contents were clearly articulated and easy to
complete. In this study, the CVI was 0.94 and the Cronbach’s α was 0.97.
3.6. Data collection
4.1. Demographic characteristics
A total of 106 fourth-year nursing students were recruited in this
study. Both intervention and control groups had a 100% participation
retention rate. There were 53 students in the intervention group (mean
age = 18.47 ± 0.504 years) and 53 in the control group (mean age =
18.43 ± 0.500 years). More than 90 % of the students were female (101,
95.28 %) and there were five (4.72 %) male students. Thirty-one (58.50
%) intervention group and 21 (41.50 %) control group students reported
having played board games before the study. The mean duration spent
online was 6.47 ( ± 3.78) hours for the intervention group and 5.97 ( ±
3.67) hours for the control group. The statistical analysis showed no
significant differences in the demographic data between both groups,
indicating a high homogeneity between the groups (Table 2).
4.2. Pre- and post-intervention changes in the students’ psychiatric
nursing knowledge
Regarding the GPN-K scores, there were no significant differences (t
= − 1.60, p = .112) in the psychiatric nursing knowledge of both groups
before the GBL intervention (T0). However, there were significant dif­
ferences (t = − 2.06, p = .042) in the psychiatric nursing knowledge of
both groups after the GBL intervention (T1).
The within-group comparison of the intervention group showed that
following the GBL intervention, the psychiatric nursing knowledge of
the students in the intervention group significantly improved (t = 8.57,
p < .001) from a pre-test (T0) score of 51.62 to a post-test (T1) score of
64.3. The control group’s psychiatric nursing knowledge was also
significantly different between T0 and T1 (t = 6.04, p < .001).
4.3. Pre- and post-intervention changes in the students’ psychiatric
nursing attitudes

The data collection period began in September 2022 and concluded
in January 2023. The study period per semester was 18 weeks. The pre-
and post-tests were administered during the first and 18th weeks,
respectively. Before and after the GBL, participants’ demographic data
and responses to the three scales were collected by a part-time research
assistant who did not have any knowledge about which group a
participant belonged to. During the study period, students in the inter­
vention and control groups were unaware of their group assignment to
evaluate the true effects of the intervention course. The participants
completed the pre-intervention test (T0) in 20 min at the beginning of
semester and the post-test (T1) in 20 min at the end of the semester. The
data were collected in the classroom. To prevent experimenter effects,
the first author was not present in the classroom when the students
completed their responses.
3.7. Data analysis
Regarding the psychiatric nursing attitudes scores, there were no
significant differences (t = − 1.89, p = .062) between the two groups
before the GBL intervention (T0). However, there were significant dif­
ferences (t = − 3.28, p = .001) in the psychiatric nursing attitudes be­
tween the two groups after the GBL intervention (T1).
The within-group comparison of the intervention group showed that
following the GBL intervention (T1), the students’ nursing attitudes
toward psychiatric patients significantly improved (t = 3.46, p = .001)
to a score of 71.30. The control group students’ psychiatric nursing at­
titudes did not significantly differ (t = 0.96, p = .342), as their post-
intervention score (T1) was only 66.19.
Table 2
Demographic data of the two groups (N = 106).
Intervention group Control group (n = X2 or t p
(n = 53) 53)

The collected data were coded and filed, and statistical analysis was number/ % or number/ % or
mean SD mean SD
performed using SPSS 23.0. The analyses covered: (a) the reliability,
Cronbach’s α, Pearson’s correlation coefficient and t-test critical value; Age (years) 28 52.83 30 56.6 0.152 0.845
18 25 47.17 23 43.4
(b) the frequency distribution, mean and standard deviation of the
19
participants’ basic information and dependent variables, as well as the Gender 6 11.32 4 7.55 0.210 1.000
test of homogeneity of the two groups’ pre-test responses; and (c) two- Male 47 88.68 49 92.45
sample t-tests and paired t-tests to determine differences in the Female
learning outcomes of the two groups. A p-value smaller than 0.05 was Board-game 31 58.50 22 3.957 0.120
experience 22 41.50 31
considered to indicate significance. Yes
No
Time spent 6.47 3.78 5.97 3.67 -0.691 0.491
online
(hour/day)

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C.-S. Wu et al. Nurse Education in Practice 70 (2023) 103657

4.4. Pre- and post-intervention changes in the students’ self-reported There were significant differences in the two groups’ nursing atti­
learning satisfaction tudes toward patients with psychiatric disorders after the GBL inter­
vention. The intervention group’s attitude scores were significantly
Regarding the students’ self-reported learning satisfaction, there higher than those of the control group, which indicates that, compared
were no significant differences (t = − 0.36, p = .754) between the two with typical teaching strategies and activities, the GBL intervention
groups before the GBL intervention (T0). However, there were signifi­ enhanced nursing students’ attitudes toward patients’ symptoms and
cant differences (t = − 2.87, p = .005) in the self-reported learning health problems. This finding has important implications for first-time
satisfaction of the two groups after the GBL intervention (T1). In psychiatric nursing students. In previous studies, although first-time
particular, the intervention group’s post-intervention (T1) score was psychiatric nursing students’ empathy was enhanced through clinical
higher than that of the control group. placements, they continued to have stereotypical impressions and atti­
The within-group comparison of the intervention group showed that tudes toward patients with mental disorders. The students were unable
following the GBL intervention, the students had significantly higher (t to improve their attitudes through clinical placements or problem-based
= 4.08, p < .001) self-reported learning satisfaction. The control group learning and some even held negative attitudes toward the patients
students’ self-reported learning satisfaction was not significantly (Choi et al., 2016; Wu et al., 2022). The present study implemented an
different (t = 0.044, p = .965) following the intervention. The results are eight-week continuous psychiatric nursing board game intervention to
presented in Table 3. help students develop positive attitudes toward patients with mental
disorders, thus highlighting the value of the intervention. Our findings
5. Discussion are consistent with previous studies that found that the learning atti­
tudes of the intervention group that received GBL were better than those
This study examined the effectiveness of a novel GBL psychiatric of the control group that received traditional learning (Castro et al.,
nursing intervention on students’ knowledge, attitudes and self-reported 2019; Chang et al., 2020; Hwang and Chang, 2020).
learning satisfaction and found that the intervention achieved the ex­ There were significant differences in the two groups’ self-reported
pected benefits. A feature of this study is that the pre-test and post-test learning satisfaction after the GBL intervention. The intervention
measurements were taken before and at the end of a semester (18 group’s self-reported learning satisfaction was significantly higher than
weeks) and the intervention addresses the students’ needs because the that of the control group. This finding is consistent with previous
intervener (teacher) is experienced in psychiatric education and clinical studies, wherein the learners perceived that GBL had proactive effects on
practice. The study results are expected to provide new empirical evi­ their learning motivation and self-directed learning (Blanié et al., 2020;
dence that can be applied in psychiatric education and research. Breitkreuz et al., 2021; Lu et al., 2018). Our findings also suggest that
In this study, there were significant differences in the two groups’ student-centred teaching strategies stimulated students’ creative
nursing knowledge regarding patients with psychiatric disorders after thinking and improved their decision-making skills and interest in
the GBL intervention. Even though there were significant within-group learning. Additionally, given that nursing education in Taiwan has long
differences between the intervention and control groups, the interven­ been rigorous and traditional, some students may prefer traditional
tion group’s scores were significantly higher than those of the control classroom instruction instead of innovative teaching methods. Thus,
group. This is consistent with previous studies that found that GBL en­ students’ preferences toward different teaching methods should be
hances students’ understanding of the learning contents (Tan et al., considered when evaluating their self-reported learning satisfaction and
2017; Ghoman et al., 2020). In a study by Luchi et al. (2019), un­ GBL can be introduced into psychiatric nursing education on a rolling
dergraduates who engaged in a musculoskeletal system game inter­ basis.
vention had higher grades than the control group. As highlighted by Based on the results of this study, incorporating GBL into psychiatric
Day-Black et al. (2015), GBL can assist the young generation students to nursing education is a feasible approach. The salient results of this study
identify meaningful connections in complex nursing concepts and can be attributed to the meticulous study design. The duration of
thereby comprehend learning contents, apply their knowledge to prac­ intervention in most of the previous GBL studies was one hour (36%),
tical settings and achieve positive learning outcomes based on the followed by one to two hours (19 %)(Xu et al., 2021). Most of the in­
meaningful experiences acquired during the learning process. terventions involved simulation games or serious games and the pre- and
post-intervention outcomes were evaluated using questionnaires. Based
Table 3 on GBL concepts, this study applied a board game that promotes group
Difference in outcome variables within and between the intervention and con­ interaction and is portable, inexpensive and independent of the setting,
trol groups. the number of players, age and weather (Chen and Tsai, 2022; Hsieh
Variables T1-T0 T0 T1 et al., 2018; Li et al., 2019). Similar to previous studies, GBL is an
interactive approach that improves learners’ attention and interest by
t p Mean SD Mean SD
integrating simple yet entertaining instruments that help students
Nursing 8.565 < 51.62 10.12 64.30 10.81 convert their acquired knowledge and information into long-term
knowledge 0.001***
memories, thereby transforming otherwise dull and repetitive learning
Intervention
group experiences into meaningful ones. In addition to students becoming
Control group 6.035 < 47.55 15.49 58.79 16.20 closer with each other through game-related interactions, students’
0.001*** learning motivation and behaviours about preventive medicine were
t (p) -1.60 (0.112) -2.06 (0.042*) also enhanced (C.L. Lin and Swei, 2017; J.M. Lin and Swei, 2017; Lin
Nursing attitude 3.462 0.001** 67.98 7.85 71.30 8.46
Intervention
et al., 2017). The intervention in this study was rigorously implemented
group for eight continuous weeks and the pre-post-test evaluation of the
Control group .959 0.342 65.36 6.41 66.19 7.59 learning outcomes spanned a semester (18 weeks). Thus, the evaluation
t (p) -1.89 (0.062) -3.28 (0.001**) results reflect the long-term effectiveness of the intervention, rather than
Self-learning 4.082 55.06 6.95 58.53 6.27
just the short-term effectiveness.
<
satisfaction 0.001***
Intervention
group 5.1. Implications
Control group .044 0.965 54.61 7.85 54.64 7.61
t (p) -.36 (0.754) -2.87 (0.005**)
5.1.1. Teaching practice
Note: *p < .05, **p < .01, ***p < .001. As the younger generation may need to learn through multiple

5
C.-S. Wu et al.
teaching methods, the research outcome can be applied to undergrad­
uate nursing education in cross-country psychiatric nursing instruction.
The finding also suggests incorporating a dual instructor into the GBL of
psychiatric nursing education.
To enhance the role of teachers as a guide and to foster student-
teacher interactions, each group may contain six students (Chen and
Tsai, 2022; Ko et al., 2021). However, the degree of integration, its
method and frequency and the game type need to be structured and
customised better to accommodate nursing students from different
educational systems. The GBL developed in this study can also serve as a
reference in the future when designing course activities and developing
nursing teacher training programmes, which would allow them to
actively participate in innovative teaching and resource sharing, thus
enhancing their teaching effectiveness.
5.1.2. Teaching research
Future studies should employ a more rigorous experimental design to
enable an in-depth examination of the effectiveness of GBL. The sample
size and follow-up period should be increased to examine the sustain­
ability of students’ learning outcomes, as well as their professional
performance when providing clinical care to patients with mental dis­
orders. The students in this study were undergraduate nursing students
who were relatively younger. When implementing similar interventions,
future studies should adopt different designs based on the age of the
students and the educational system in each country.
5.1.3. Limitations
The participants of this study were recruited from the same school,
which restricts the generalisability of the study results. The outcomes of
the intervention were only evaluated before and after its implementa­
tion and therefore, it is difficult to examine its long-term effects on
nursing students. In addition, certain items on the knowledge and atti­
tude scales used in this study referred to older adults with mental ill­
nesses. It may restrict the transformation of the outcome to teaching
practice or teaching research.
6. Conclusions
This study’s findings can be applied to undergraduate nursing edu­
cation in teaching psychiatric nursing across international borders. This
study incorporated a psychiatric nursing board game intervention into
psychiatric nursing education and found that the intervention improved
students’ nursing knowledge, attitudes toward patients with mental
disorders and their self-reported learning satisfaction. The findings
suggest that the intervention is effective for improving psychiatric
nursing education. The results add to the empirical evidence on psy­
chiatric education and can be applied to psychiatric education and
research in the future. We recommend employing a dual instructor
system when implementing the board game in psychiatric education, to
improve student-teacher interactions and achieve better learning out­
comes. The teaching material designed in this study can be used to train
psychiatric education teachers. Future educational studies should in­
crease the sample size and follow-up period to examine the sustain­
ability of students’ learning outcomes, as well as the similarities and
differences in the learning outcomes of students from different nursing
education systems.
Funding
This study was funded by the 2021 Ministry of Education in Taiwan.
IRB
NCKU HREC-E-110–367–2.
6
Nurse Education in Practice 70 (2023) 103657
CRediT authorship contribution statement
Study conception and design: CSW, BOL. Data collection: CSW, HLH.
Data analysis and interpretation: CSW, MFC, BOL. Drafting of the article:
CSW, BOL. Critical revision of the article: All authors.
Declaration of Competing Interest
To the authors best knowledge there is no conflict of interest to
declare.
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