Educational board game for training dental and dental hygiene students in patient safety issues

Abstract

Background

Game-based learning has become increasingly popular in medical education. This study used an originally designed board game to train dental and dental hygiene students in patient safety, investigating the educational value of game-based learning.

Methods

A quasi-experimental pretest–posttest design with three groups of students was adopted (two classes of dental hygiene students and one of dental students). The students received a self-designed board game intervention for patient safety issues. Before and after the intervention, the students took a test to evaluate their knowledge improvement. They also completed a questionnaire that assessed their impressions of and attitudes toward the board game’s educational value postintervention.

Results

The participants comprised 27 fifth-year dental students, 23 fourth-year, and 25 third-year dental hygiene students, including 38 men and 37 women. One-way analysis of variance revealed no significant differences in baseline scores for the levels of recall, comprehension, application, and overall knowledge among the three groups of dental and dental hygiene students. Paired t-tests were used to compare the pretest and posttest knowledge scores. The results indicate that there were statistically significant improvements in the levels of recall, comprehension, application, and overall knowledge scores among the three groups. However, the group with dental hygienists as instructors showed significantly greater improvement than the other two. Moreover, the students reported that the most improved abilities were in “create a patient-safety culture and implementincident management” and “prevent patient falls and injuries”. Most students agreed that the board game was an effective educational tool and showed positive attitudes toward patient safety.

Conclusion

The board game effectively improved knowledge and awareness of patient safety among dental and dental hygiene students.

Background

In 2003, the hospital accreditation system in Taiwan underwent a significant reform, which had a profound impact on the healthcare system. However, dental care was only incorporated into hospital accreditation standards in 2015, which was the first time that dental patient safety and the quality of dental services were formally recognized and prioritized [1]. The unique characteristics of dentistry differentiate it from other healthcare fields, leading to a delayed focus on patient safety issues within this domain. However, with the advancement of various dental surgical procedures and the increasing complexity of patient cases, the risks faced by patients have escalated. Consequently, dental practitioners have begun to implement patient safety measures in dental practice [2]. Despite these developments, newly graduated dental students often have a limited understanding of patient safety goals. Educators have increasingly acknowledged the critical importance of educating students on the concept of dental patient safety [3]. However, there remains a scarcity of published studies specifically addressing patient safety education in dental curricula. A literature review indicated that discussions surrounding patient safety and safety culture are more prevalent in the field of medicine than in dentistry [4].

Lectures are the most commonly used method for teaching students about patient safety. Other frequently employed teaching approaches include case-based exercises, active learning exercises and discussions, and simulation practices, which often involve the use of standardized patients and role-playing [5]. Although dentistry is in the early stages of addressing patient safety issues [6], studies have indicated that dental students highly value the content taught in patient safety education and that their knowledge and interest in the subject can be significantly enhanced [7]. To further promote dental patient safety, Bailey et al. [8] proposed seven steps, emphasizing that refining the awareness of patient safety culture and shaping organizational culture should begin at the school level, even before students enter clinical internships, which can subsequently improve the quality of care in teaching hospitals during the clinical phase.

Two major types of learning theory guide the use of games in education: behavioral theories and constructivist theories of learning [9]. Constructivism defines knowledge as being built on an existing foundation through interactions between learners and their environments. A board game refers to a form of game played by placing or moving pieces on a flat surface. Thus, chess is a typical board game. Furthermore, previous studies showed that chess skills are related to four cognitive abilities: fluid reasoning, comprehension-knowledge, short-term memory, and processing speed [10]. Recently, game-based learning has increased, and board games have become viable tools for this educational approach. Depending on the game’s design goals, some games are primarily aimed at imparting educational knowledge, whereas others focus on training in cognitive functions. Research indicates that using board games as a tool can enhance the understanding of knowledge, improve interpersonal interactions among participants, and increase motivation to participate [11].

Similarly, board games have been used in Taiwan to train nursing students in medication knowledge [12]; psychiatric nursing knowledge [13]; and fire safety knowledge, attitudes, and behaviors [14]. Internationally, there are additional examples, such as Pisano et al. [15] designing “The Bloody Board Game” to teach resident physicians how to diagnose anemia and integrate cost-effective strategies into medical practice; Bridges et al. [16] creating “Beat the Shock Clock” for teaching pediatric and emergency medicine residents about pediatric infectious shock; and Achatz et al. [17] developing a tabletop simulation game for training in “Terror Attack and Disaster Surgical Care” courses. Moreover, Wahab et al. [18] designed a board game to assist pharmacists in learning about potentially inappropriate medications for older adults. Ward et al. [19, 20] designed “PlayDecide Patient Safety” an open-access discussion game with a role-playing component, aimed at raising patient safety culture awareness among young doctors. Numerous studies [12,13,14,15,16,17,18,19,20] have highlighted the effectiveness of board games as educational tools for enhancing professional knowledge among healthcare providers. However, despite the widespread adoption of case-based scenario games in dental education [3], there is a notable lack of similar applications that specifically target dental students in the context of patient safety. This gap in the literature underscores the need for innovative approaches to dental education, particularly concerning critical issues such as patient safety.

Despite the successful integration of serious board games in various fields of healthcare education, similar applications in dental education have yet to be explored at the international levels. Furthermore, patient safety education within dental curricula is fragmented, with no dedicated courses comprehensively addressing this critical issue. Dental and dental hygiene students receive only 1 to 2 h of lectures on patient safety as part of their pre-clinical training. Before entering clinical practice, they must understand the Hospital Patient Safety Annual Goals set by the Ministry of Health and Welfare. In response to this gap, this study developed and implemented a serious board game, “DentSafe,” designed to teach dental and dental hygiene students about patient safety as they prepare for their clinical internships. The primary objective of this study is to evaluate the effectiveness of incorporating “DentSafe” into pre-internship courses to enhance students’ understanding and application of patient safety principles in dental practice.

Methods

Game development

The board game, “DentSafe,” was designed by JHW (one of the co-authors of this paper) (Fig. 1). The proposed board game is based on the complete dental treatment process, including patient interviews, history taking, dental treatment, oral hygiene instructions, medical records, and prescribed medicines. The interview process involved the correct identification of patients. Before the invasive dental procedure, the surgical site was checked and a time-out was performed; a sign-out was conducted after the procedure. The board game consists of case and event cards. During the game, players continually encounter challenges from event cards that require them to complete dental treatments.

Fig. 1

Screenshots from DentSafe instructions

The educational objectives of the game are to implement the “Hospital Patient Safety Annual Goals by the Ministry of Health and Welfare,” which include (1) promoting effective communication between professionals and patients; (2) creating a patient-safety culture and implementing incident management; (3) improving surgical safety; (4) preventing patient falls and reduce injury severity; (5) improving medication safety; (6) implementing infection control; (7) improving tubing safety; and (8) encouraging patients and caregivers to participate in patient-safety efforts.

Ethics

This study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital (Letter No. KMUHIRB-SV(I)-20210068 and KMUHIRB-SV(II)-20220059). Written informed consent was obtained from all the participants.

Study design and participants

This study adopted a quasi-experimental pretest–posttest design with three groups of students: two classes of dental hygiene students and one class of dental students. As shown in Table 1, the dental hygiene students include the classes of 2019 (fourth year) and 2020 (third year), and dental students (fifth year). Students were informed that their participation in the study was voluntary and that not participating would not affect their grades or assessments. The student participation rate for DH2019 was 76.67%, with the rate for dental students at 90.00%. The participation rate for DH2020 was 86.21%. According to their intervention time, students of DH 2019 were intervened first in pre-clinical training, which was instructed by dental hygienists. Then, the dental students were intervened during their clerkship training when they rotated to the Department of Family Dentistry, and DH 2020 intervened in the Behavioral Dentistry class. The instructors of dental students and DH 2020 were four trained students of DH 2020 who volunteered to assist with the study; therefore, they were excluded from the DH 2020 sample.

Table 1 Sources of participants, intervention fields, and instructors

Measures

Before and after the intervention, students took a test to evaluate their knowledge improvement. They also completed a questionnaire assessing their impressions of and attitudes toward the board game’s educational value.

Knowledge assessment

The knowledge assessment sheet included three levels of knowledge: recall, comprehension, and application. The recall level includes the dental examination process, with a total score ranging from 0 to 4. The comprehension level included the five moments for hand hygiene and wheelchair transfer techniques, with a total score ranging from 0 to 20. The application level contains power outages during surgery, information system failure, the main purpose of time-out before surgery, and key points of fire emergency response, with a total score ranging from 0 to 4. An overall score ranging from 0 to 28 was obtained (Supplement 1).

Questionnaire after playing DentSafe

After finishing the game, the participants were asked to complete a questionnaire that included their impressions of and attitudes toward the board game’s educational values. The questionnaire’s content included the following three parts: (1) their attitude toward patient safety issues after playing DentSafe, including six items designed by JHW according to the literature on patient safety, measured on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree; Cronbach’s alpha, 0.879); (2) the educational values of DentSafe, including six items that were modified from Wang et al. [21, 22], measured on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree; Cronbach’s alpha, 0.860); (3) the improvement of abilities by playing DentSafe, including eight items that were designed based on the content of DentSafe, and each item was rated by yes or no; and (4) three open-ended questions regarding the most satisfying and difficult parts of the gaming process, and the room for improvement (Supplement 2).

Data analysis

Statistical analyses were performed using SPSS software (version 20.0; IBM Corp., Armonk, NY, USA). Sample characteristics were compared by group using the chi-square test and one-way analysis of variance (ANOVA). Associations between sex, age, and overall knowledge scores were analyzed using an independent t-test and Pearson’s correlation. Regarding the analysis of knowledge improvement, a one-way ANOVA was used to analyze the pre- and post-assessment of each type of knowledge score between the groups, a paired t-test was used to compare the improvement of each type of knowledge score within each group, and Hedges’g was used to measure the effect size. Furthermore, we used the chi-square test to compare attitudes toward patient safety issues, the educational value of DentSafe, and the improvement of abilities between each group. Finally, qualitative analysis was conducted to summarize the students’ recommendations.

Results

Participant characteristics

Of the 75 students who participated in this study, 23 (30.67%) were DH2019 students, 27 (36.00%) were dental students, and 25 (33.33%) were DH2020 students. There was a higher proportion of women among dental hygiene students (n = 29, 60.42%) and a significantly higher proportion of men among dental students (n = 19, 70.37%), the percentages were split evenly in total. The mean age of dental students (23.41 ± 2.043) was significantly higher than that of dental hygiene students (Table 2).

Table 2 Sample characteristics

Knowledge improvements

The independent t-test and Pearson correlation showed that sex and age were not significantly associated with the pre- and post-overall knowledge scores. Table 3 shows the improvement in the knowledge of the three groups of students. Before playing the board game, one-way ANOVA revealed that the baseline scores for recall, comprehension, application, and overall levels of knowledge showed no significant differences among the three groups. The highest correct rate of baseline knowledge was the comprehension score (ranging from 75.0 to 80.4%), followed by the overall score (ranging from 62.82 to 63.86%) and the recall score (ranging from 44.00 to 59.25%). The application score showed the lowest correct rate of 1.00–5.50%. After the intervention, paired t-tests revealed that all four scores significantly increased among the three groups. Furthermore, a one-way ANOVA was conducted to compare the post-assessment scores, revealing no statistically significant differences in recall and comprehension scores among the groups (P = 0.433 and 0.628, respectively). The effect sizes for recall scores ranged from 0.866 to 1.198, while those for comprehension scores ranged from 0.390 to 0.802. However, significant differences were found in the application and overall scores (P < 0.001 for both), with the DH2019 group obtaining significantly higher scores compared to the other groups. The effect sizes for the application and overall scores in the DH2019 group were 7.828 and 2.338, respectively.

Table 3 Knowledge improvement after playing board games

Attitudes toward patient safety issues

After the intervention, all groups showed positive attitudes toward patient safety issues (Fig. 2). Only the item “The board game improved my understanding of patient safety issues” showed a significant difference that DH2020 was lower than the other groups; the other items revealed no significant differences between the groups.

Fig. 2

Attitudes toward patient safety issues after playing DentSafe

Usability for education

The educational values reported by the students are shown in Fig. 3. Except for the item “Board game learning is necessary,” which showed a relatively lower agreement, the other items showed positive agreement, and the overall satisfaction with board game learning was high. None of the items showed significant differences between the groups.

Fig. 3

Educational values of DentSafe

In relation to the improvement of abilities reported by the students after intervention (Fig. 4), the most frequent was “Create a patient-safety culture and implement incident management” (n = 66, 88.00%), followed by “Prevent patient falls and reduce injury severity” (n = 55, 73.3%) and “Implement infection control” (n = 47, 62.7%); moreover, “Improve tubing safety” was the least frequent item (n = 14, 18.7%). The comparison between the groups revealed that “Create a patient-safety culture and implement incident management,” “Prevent patient falls and reduce injury severity,” and “Improve tubing safety” had statistically significant differences.

Fig. 4

Improving abilities by playing DentSafe

Qualitative analysis

The results of the qualitative analysis of student feedback on the game are presented in Table 4. The students thought that the game process was interesting and educational, but the game rules needed improvement.

Table 4 Students’ feedback on the game process

Discussion

The use of educational board games in training of healthcare professionals has proven to be a valuable tool, with the fundamental characteristics of games such as participation, individual interaction, the significance of rules, and the integration of emotions and knowledge, which play critical roles in the learning process. These features not only underscore the effectiveness of games as educational tools, but also satisfy the intrinsic psychological needs for autonomy, competence, and social connection [23].

In this study, Hedges’ g was used to calculate the effect size, with the following classifications: 0.2 was considered small; 0.5 was considered moderate; 0.8 was considered large; 1.2 was considered very large; and 2 was considered a huge effect [24, 25]. The improvements in the recall level score of the three groups all reached a large effect size. The effect sizes for the comprehension level score varied between groups, ranging from small to large, while the application score showed more variation, with effect sizes ranging from moderate to huge. The overall score indicated that the DH2019 group had a huge effect size, whereas the other groups (dental students and DH2020) had a large effect size.

The significant improvement in patient safety knowledge scores after the educational board game intervention compared with baseline scores across the three groups highlights its effectiveness as a teaching method. This finding is consistent with other studies that have demonstrated the efficacy of board game-based learning in increasing knowledge [12, 26, 27]. Medical education games provide instructors with valuable tools to create supportive and engaging learning environments. When well-designed and subject-specific, these games enable students to master materials more efficiently than traditional lectures [28]. Given the importance of patient safety in healthcare, including dentistry, and the lack of formal patient safety training for clinical dental interns during undergraduate education, it is essential to teach these concepts to undergraduate dental students and newly graduated dentists. The positive impact of game-based learning on patient safety concepts observed in this study corroborates the results of other studies that utilized gamified educational interventions to instill patient safety concepts in dentists with less than 5 years of work experience [3]. The scope of patient safety is extensive and multifaceted. This study was developed in alignment with the eight goals outlined in the “Hospital Patient Safety Annual Goals,” issued by the Ministry of Health and Welfare, in contrast to Song’s research [3], which focused on sentinel events predominantly observed in dental practice. The current study emphasizes the importance of patient safety awareness within the hospital system, aiming to enhance students’ understanding of patient safety culture and the measures in place to prevent medical errors during dental procedures. In addition, the board game demonstrated substantial efficacy for knowledge acquisition. Its design allows for its application across a large cohort of students, ensuring both cost-effectiveness and high teaching efficiency, thereby fostering self-directed learning. However, student feedback has highlighted areas for improvement, specifically the revision of game rules and augmentation of event card quantities. These enhancements are intended to increase the frequency of event cards, thereby further improving the pedagogical effectiveness of scenario-based questions within the game.

Tutors’ competencies also had a positive impact on student learning outcomes. Notably, the patient safety knowledge scores in the DH2019 group were significantly higher than those in the other groups postintervention, suggesting that learning under the guidance of experienced instructors had a greater effect on students. Under the instruction of dental hygienists, the correct rate of their knowledge application level score reached 90.25% post-intervention, which was far superior to other groups (20.25% and 18.00%) and closest to the educational goal of this serious game. This finding is in alignment with the evolving role of teachers as facilitators of learning [29], who use their professional knowledge to verify existing information and guide students in identifying key issues relevant to their future practices. Our findings are consistent with those of Van Berkel and Dolmans, who found that tutors promoting active, self-directed, contextual, and collaborative learning enhanced the use of problems and meaningful contexts in problem-based learning (PBL) and improved group functioning [30]. According to Davis, expert facilitators contribute to better student performance in small-group sessions than non-expert facilitators. In our study, experienced clinical personnel provided clearer descriptions and explanations of clinical scenarios, allowing students to develop a deeper understanding of real-world clinical practice. Their expertise helped bridge the gap between theoretical knowledge and practical applications, enhancing student ability to contextualize patient safety principles within authentic clinical settings [31]. Therefore, incorporating tutors’ skills into clinical faculty development is crucial as student satisfaction with clinical rotations is significantly correlated with their satisfaction with their tutors [32].

Serious games are practical educational tools that facilitate learning and enable individuals to reach higher levels of Bloom’s Taxonomy. Lean learning, guided by practice and objective elements, is often driven by active learning methodologies [33]. A previous serious game designed by our team has demonstrated that the knowledge and understanding gained through serious game learning can be applied or assessed to solve problems, reaching the intermediate levels of Bloom’s Taxonomy [22]. In this study, the board game significantly enhanced the acquisition of foundational knowledge, but the application of patient safety concepts in clinical settings was influenced by the guidance provided by the tutor. This study implies that students require the guidance and interaction of clinical instructors to perform tasks and acquire skills effectively, reaching intermediate levels of Bloom’s Taxonomy (applying). After participating in the board game, students identified the critical considerations during the preoperative, intraoperative, and postoperative phases of the dental surgical procedure. For example, the students learned the importance of verifying patient identity, confirming the surgical site, and ensuring that informed consent was signed by the patient before the procedure. The students from the DH2022 group reported lower ability improvements in “creating a patient safety culture and implementing incident management,” “preventing patient falls and reducing injuries,” and “improving tubing safety.” This may be correlated with students’ lack of clinical internship experience and the relatively insufficient clinical experience of the tutors. The DentSafe board game offers limited enhancement of non-cognitive skills, highlighting the need for students to participate in clinical observations and integrate these experiences into the board game-based curriculum.

This study had certain limitations. First, the study was conducted at a single university, which may have limited the generalizability of the findings. Additionally, patient safety concerns encompass both cognitive and non-cognitive dimensions, while the DentSafe board game primarily focuses on knowledge acquisition. Non-cognitive aspects, such as attitudes toward patient safety, showed positive outcomes but were not comprehensively addressed. Further educational interventions are required to reinforce and deepen the establishment of a strong patient safety culture. Moreover, the board game was developed as a foundational patient safety course for dental and dental hygiene students with varying levels of clinical experience. While this provides a broad introduction, future iterations can incorporate customized learning experiences tailored to role-specific competencies and clinical exposure levels. This would help maintain engagement among more experienced students while ensuring appropriate challenges for beginners. Furthermore, the variability in clinical experience among pre-licensed students may influence their engagement with the board game, their ability to process scenarios, and the applicability of lessons to real-world settings. Future studies should consider stratifying students based on their clinical exposure to enhance the generalizability of their findings. Despite these limitations, student participation in the board game has demonstrated enhanced engagement and improved learning outcomes. Future studies with larger sample sizes and multi-institutional participation are recommended to further explore its effectiveness and address these considerations.

Conclusions

The DentSafe board game effectively improved knowledge and awareness of patient safety among dental and dental hygiene students. Its high cost-efficiency, portability, and mobility, which enhance both its economic and educational value. DentSafe promotes self-directed learning among students, and its efficiency was significantly increased when used under the supervision of clinical personnel.