Integrating academic and professional integrity: a co-designed serious game for nursing students - a multi-methods study

Abstract

Academic integrity constitutes a cornerstone of higher education, epitomising values such as honesty, trust, fairness, respect, and responsibility. However, breaches in academic integrity persist among nursing students. Current responses to breaches predominantly adopt reactive and punitive measures, lacking proactive initiatives that cultivate active learning. Moreover, traditional didactic teaching methodologies may fail to resonate with the digital-native characteristics of contemporary students. Consequently, a discernible gap exists regarding novel approaches to instilling and upholding academic integrity within nursing education. The aim of this study is to explore and evaluate whether a co-designed serious game linking academic integrity and professionalism promotes motivation for self-perceived learning for first year undergraduate nursing students at one university in Northern Ireland. Using multi-methods, this study employed a pre-post validated 34-item Motivated Strategies for Learning Questionnaire before and after students played the game, and qualitative focus groups that explored the students’ experience of playing the game and impact on academic practice. Quantitative results (n = 233) showed significance across the 6 sub-scales of the Modified Strategies for Learning Questionnaire including self-efficacy, peer learning and help-seeking. Three themes were developed from focus groups (n = 39) in relation to usability, professional values and transferable skills. The study findings indicate the game had a positive impact on motivation, critical thinking, and self-regulation among participants and successfully correlated academic integrity with universally shared nursing values, such as honesty, accountability, and openness. Suggesting that the integration of case-based learning within a serious game offers a proactive, rather than punitive, approach to academic misconduct education, with potential applicability across diverse cultural and professional contexts.

Introduction

Academic integrity, a fundamental pillar of academia, is built upon a commitment to the values of honesty, trust, fairness, respect, responsibility, and courage (International Center for Academic Integrity [ICAI], 2021). To promote integrity, higher education institutions must make their policies and procedures around academic integrity clear from the outset, being proactive in promoting integrity rather than reactive to dishonesty (Holden et al. 2021). If higher education institutions focus exclusively on the punitive aspects of dishonesty by reacting only to breaches of academic integrity, then students will not understand why it is important to pursue original thought or the value of integrity in their future employment (Holden et al. 2021; Lee 2022).

Nursing as a profession is regulated with statutory requirements. Irrespective of the country in which nurses are educated or practice, the values of integrity and honesty are paramount to the nursing profession (International Council of Nurses 2021). Institutions providing nurse education are particularly sensitive to the dishonest behaviour of nursing students, as it violates these core professional values (Lynch et al. 2017; Smart and Creighton 2022).

Nursing students are not immune from breaches of academic integrity. A study of (n = 3360 nursing students found 65% reported to have dishonest behaviours in the classroom, 54% in the clinical setting and over half of the students reported undertaking three or more dishonest behaviours in their nursing programme (Krueger, 2014). The dishonest behaviours have been identified as a spanning across both the classroom and clinical setting, with a variation on severity, these include cheating, not reporting the actions of others, sabotage to negatively impact others work, failing to follow set guidelines and false or inaccurate documentation of patient data (McClung and Schneider 2018). Studies have identified between 47 and 60% of nursing students identified themselves as having plagiarised their assignments, whereby they take credit for work that is not their own or do not correctly cite their references (Theart and Smit 2012; Krueger 2014). In a recent survey of post-graduate nursing students 44% (79 of a sample n = 179) reported that they had engaged in academic misconduct behaviours, in particular, plagiarism with 38% (n = 68) acknowledging that academic misconduct may impact patient care (Bloomfield et al. 2021). Plagiarism in nurse education raises both safety and ethico-legal concerns as graduates are certified as competent to practice based on proof of knowledge and skills procured through dishonest means (Coffey and Anyinam 2012). This raises a concern that the student may not have the requisite knowledge to provide effective care for people who use health services and a risk that the dishonest behaviour may be re-enacted with an implication for public safety (Klocko 2014). Bloomfield et al. (2021) recommend ‘the importance of measures to enhance academic integrity…on an ongoing basis in nursing programmes’ (p.6). Educating students about the serious nature of academic misconduct, the penalties that can ensue, and the implications for professional life is a vital part of preparing students for lifelong learning.

Lynch et al. (2022) conducted interviews with nurse educators on the values of academic integrity and professionalism of nursing students. Findings highlighted the concerns about the transfer of dishonest behaviour in higher education to professional practice and the impact on public safety. This has been evidenced in several studies that nursing students who are dishonest in university were more likely to be dishonest in practice (Guerrero-Dib, 2020; McClung and Schneider 2018; Winrow et al. 2015; Krueger 2014). Birks et al. (2018) identified a link between academic and professional misconduct, with a third of students admitting most commonly to plagiarism in the university setting and either discussing confidential information or falsifying vital signs documentation in the clinical practice environment.

A strategic institutional approach is therefore crucial for maintaining academic integrity and effectively addressing the multiplicity of issues involved. Slade et al. (2016) proposed eight institutional areas that need to be addressed (Fig. 1) which are grounded in literature and best practice, including tools to build robust policy development, support for staff, educating students and staff as well as strengthening assessment design.

Fig. 1

Institutional approach to academic integrity

In a large online survey of students (n = 15,304) Bretag et al. (2014) found 89.2% respondents agreed they had sufficient information about academic integrity, and 82.6% acknowledged that this level of information was sufficient to avoid a breach. However, what was more concerning was that only 68.2% believed they had enough support and training in the application of academic integrity to the avoid academic misconduct. This finding indicates that giving students information is not enough, rather they need ‘a range of hands-on, engaging activities’ repeated across their study programme’ (p.1165).

Many students have grown up using digital technology, therefore educators need to adapt learning techniques to accommodate new and innovative approaches and technologies. Online mastery modules involving a series of tasks in relation to academic integrity for example knowledge about plagiarism or university policies were introduced, requiring students to achieve high levels of accuracy (80–100%) in order to pass. Research demonstrated a reduction in plagiarism by a decrease in numbers of referrals for this area of academic misconduct (Curtis et al. 2013). Gamification and serious games in education is another method of adapting to this trend as games are perceived to be more engaging, novel and offer a different means of exploring problematic situations (Kiryakova et al. 2014). Serious games can be defined as ‘any computerised game whereby the main aim is not entertainment’ (Sawyer and Smith 2008). The classification of serious games is important as this aligns with the intended purpose, these categories include simulation, educational, training, health and persuasive (Bunt et al. 2024). The pedagogical approach of using serious games in education is defined as ‘game-based learning’ and is based on not simply the act of developing games for students to play but designing interactive learning activities that can convey concepts, guiding students towards an end goal (Spires 2015). Serious games have been employed to positively change how students engage with activities to achieve learning outcomes in health care education (Gorbanev et al. 2018). For example, serious games played asynchronously can enhance nursing students’ knowledge and empathy in dementia care (Craig et al. 2023; Mitchell et al. 2021a, b) and promote self-efficacy and behavioural change in the uptake of vaccinations (Mitchell et al. 2021a, b). Studies suggest that those participants who engage in serious games have higher knowledge gain and an increase in positive engagement in learning (Lamb et al. 2017, 2018; Schmitz et al. 2014). Alongside cognitive skills, both problem-solving and decision-making abilities can be improved (Brom et al. 2010). Users of serious games can experience changes in attitudes and behaviours such as motivation towards learning, application of knowledge to technical skills and willingness to learn (de Freitas and Maharg 2011; O’Neil and Perez 2008).

Case-Based Learning (CBL) is a commonly used modality for learning in science-based curricula, however, is rarely integrated into digital serious games (Addy et al. 2018). CBL methodology promotes learning through analysis of a situation that has been or is likely to be experienced. The methodology uses student-centred scenarios, resulting in improved learning outcomes and decision making-skills (Kanbay and Okanli, 2017). Although aforementioned as a rare integration into serious games, the use of case-based scenarios in relation to academic integrity and nursing values could be deemed an appropriate learning methodology to pairing the educational and proactive approach. This paired approach is promoted in best academic practice and in development of a serious game.

While the maintenance of academic integrity remains fundamental within higher education, it presents persistent challenges among nursing students. Existing responses to breaches in academic integrity often appear to lack proactive measures. They appear to be aimed at fostering active learning of what consistutes academic misconduct, while traditional pedagogical methods may prove insufficient in engaging digital-native learners, particularly in the contemporary educational setting post-pandemic. This presents a notable gap in relation to implementation of novel methodologies for instilling and upholding academic integrity within nursing education.

As a result, the aim of this study was to explore and evaluate whether a co-designed serious game about academic integrity and professionalism promotes self-perceived learning for first year undergraduate nursing students.

The study objectives were to:

• Evaluate students’ motivation for self-perceived learning before and after playing the serious game.

• Explore the student experience of playing the serious game and the impact on academic practice.

Methodology

This study employed a multi-methods research design, combining both quantitative and qualitative approaches to explore and evaluate a serious game intervention in enhancing academic integrity and professional values among nursing students. The quantitative phase involved the administration of the validated Modified 34-item Motivated Strategies for Learning Questionnaire (MSLQ) (Soemantri et al. 2018) before and after participants engaged with the serious game, supplemented by the System Usability Scale (SUS) post-game assessment (Brooke 1996) to determine usability. In the qualitative phase, focus groups were conducted to explore participants’ perceptions and experiences with the serious game. By integrating quantitative and qualitative methods, this study aimed to provide a comprehensive understanding of the intervention’s impact, capturing both quantitative changes in learning strategies and qualitative insights into participants’ experiences and perspectives.

Co-design process

The development of the digital serious game focused on academic integrity for undergraduate nursing students followed a systematic and collaborative co-design approach. This approach was rooted in best practices from co-design methodology (Santin et al., 2019; Crooks et al. 2023), ensuring that student voices were integral to the game’s design and that the content reflected their perceived needs. The process is summarised in seven main steps, leading to the creation of the serious game.

Step 1: formation of the co-design team

The co-design team consisted of 20 undergraduate nursing students who volunteered to participate in the project. Students were recruited from the second year of their study as had experience of the assessment process. Recruitment was via the undergraduate year lead, who acted as a gatekeeper for the research team. There was no material incentive for participating in the co-design process, however, students gained research knowledge, acknowledgement on future publications and improved leadership skills such as communication, organisation skills and teamwork. Their involvement ensured that the perspectives of the target audience were central to the game’s development. This diverse group of students brought a range of experiences and insights.

Step 2: co-design workshops and content exploration

Three online co-design workshops were conducted in consecutive weeks throughout March 2022. The workshops were facilitated by xx, xx and xx. These workshops helped the team to identify the key themes and challenges related to academic integrity that the students felt were most important to address in the game. During these sessions, the co-design team explored various scenarios and educational content that could be included in the game, ensuring that it was both relevant and engaging, for example the importance of study skills, feedback and university academic offences procedures.

Step 3: student feedback and iterative development

Between workshops, the co-design team members actively sought feedback from their student cohort groups. This approach allowed for a wide range of perspectives to be incorporated, ensuring that the game content was comprehensive and reflected the diverse needs of the student population. The feedback collected was brought back to subsequent workshops, where it was analysed and used to refine the game’s design and content.

Step 4: integration of real-world scenarios

To enhance the authenticity of the game, real-world scenarios related to academic integrity were integrated into the gameplay. These scenarios were drawn from the students’ own experiences and the feedback they gathered from their peers. This step ensured that the game was not only educational but also relatable and directly applicable to the students’ academic lives. Scenarios related to university academic offences processes and the link between academic integrity and professional integrity.

Step 5: development of prototype 1

The insights and feedback gathered during the workshops were synthesised into a draft version of the game. This prototype, or beta version, featured key elements identified as essential by the students, such as interactive scenarios, quizzes, and decision-making challenges related to academic integrity. The co-design team worked together to ensure that the game’s content was aligned with the learning outcomes, providing an engaging and educational experience.

Step 6: user testing and refinement

The next phase of the development process was user testing. The prototype game was made available to a larger group of nursing students, who were invited to test the game in this multi-methods study. This testing phase included the collection of data through validated questionnaires and focus groups, which were then analysed to identify areas for improvement.

Step 7: final game development

Post-study, the final phase involved refining the game based on the feedback from user testing. The co-design team, in collaboration with the co-design group, adjusted the game’s content, structure, and interactivity to ensure it effectively met the educational needs of undergraduate nursing students. For example, the final version of the game included more information about the use of generative artificial intelligence.

The intervention

The serious game was built and hosted online by software developer, Focus Games Ltd.

The serious game can be freely accessed at https://www.academicintegritygame.co.uk/. The digital serious game was available as an HTML5 web application, with a supporting website which worked on any device through a web browser. Participants were presented with four headings, displayed on the home screen: academic offences, feedback, study skills and professionalism (Fig. 2). The nursing students involved in the co-design process, had significant input to the style, content and delivery throughout the planning stage and then reviewed again post development by the software developer. The link between the impact of academic integrity and professional conduct in nursing was achieved through scenarios and quizzes in a cartoon format. The colour scheme was chosen by the students as it was bright and engaging, the characters pictured and named in the scenarios were inclusive and wearing institutional uniforms or t-shirts (Fig. 3), to be relatable to the student population. Students felt this was important to enhance empathy and engagement with the characters in each scenario during game play. The four sub-sections of the serious game are described as follows:

• The academic offences section included a scenario of a student who was suspected of an academic offence and the university procedure for investigation.

• The feedback section took the user through how to effectively use rubrics and tutor or peer feedback, both as resources to improve assessment performance in future.

• The professionalism section linked the example of a student committing an academic offence in university followed by a patient error in practice whilst recording observations, leading to a fitness to practice hearing (Fig. 4).

• The study skills section gave tips and resources to develop effective study habits, time management and self-care strategies.

In addition to this, in all parts of the intervention, users work their way through the game by clicking on objects and further information icons. Each of the four sections also contain multiple choice questions that involve decision-making, critical reasoning and moral values, with the correct answer available immediately. Multiple attempts at the game are permitted and a certificate is emailed to the student on completion, which is also a marker of participation due to the asynchronous use of the serious game itself. The certificate of completion was important to the student co-design team as recognition for participation, as was the ability to engage with the game more than once.

Fig. 2

Landing page of serious game

Fig. 3

Example of student-designed interface

Fig. 4

Fitness to practice scenario

Ethical approval

Ethical review and approval were provided by xxxxxx University Belfast, Medical, Health and Life Sciences Faculty Research Ethics Committee MHLS 22_82 (08/07/22). All students received participant information sheets before deciding to participate in the evaluation and informed consent was gained from all participants. All methods were performed in accordance with the Declaration of Helsinki (World Medical Association 2001).

Recruitment and sampling

A non-probability convenience sampling method of first year undergraduate nursing students in one university in Northern Ireland was chosen. This cohort had not submitted any assessments, were studying nursing for the first time and had not been involved in the game’s co-design. All nursing students across three fields of nursing (adult, learning disability, children and young people) (n = 302) were invited to participate in the study via a gatekeeper, who was not affiliated with the study, via email. The email clarified that participation in the study was entirely voluntary and had no impact on the module grade. The serious game was embedded into an existing year one module, Professionalism in Nursing, as it aligned with the curriculum on values and was situated on the digital educational platform used in the university, Canvas.

Data collection

Phase 1

The validated Modified 34 item- Motivated Strategies for Learning Questionnaire (MSLQ) (Soemantri et al. 2018) was used as a pre/post-test. The questionnaire consisted of six sub-scales of questions: internal goal orientation, self-efficacy, critical thinking, self-regulation, help-seeking and peer learning. The questions were answered using a 7-point Likert scale. The answers were recorded immediately before engaging with the serious game on academic integrity and then immediately after. The MSLQ was chosen as it was developed to assess motivation for learning and learning strategies based on reflective learning in tertiary education students (Soemantri et al. 2018) and this aligns with the study aim. The MSLQ demonstrated acceptable internal consistency when applied to higher education courses, represented by Cronbach alpha values (Duncan and Mckeachie 2005; Kosnin 2007). The System Usability Scale (SUS) (Brooke 1996) post-test questionnaire was used as a validated method of assessing the suitability of the serious game.

Phase 2

Following use of the serious game students were invited to participate in focus groups four weeks later. Focus groups were chosen as they facilitate interaction between participants creating a greater depth of understanding by open expression, clarification of views, and enabling the exploration of diverse perspectives (Kitzinger 1995). Questions asked were categorised into three headings; ‘what were your overall impressions of the game? did the game help you to improve your academic practice? and what are the limitations of the game?’ with follow up questions for clarification (Supplementary File 1). A Consolidated criteria for reporting qualitative studies (COREQ): 32 item checklist was completed by the focus group facilitators, xx and xx (Tong et al., 2007) (Supplementary File 2).

Data analysis

Phase 1: quantitative

Scores for the Modified 34-item MSLQ (Soemantri et al. 2018) were calculated as total scores and then six component scores were calculated: internal goal orientation, self-efficacy, critical thinking, self-regulation, help seeking and peer learning. All analyses were carried out using SPSS version 27. Seven paired t-tests were conducted, to examine change from pre-test to post-test for total MSLQ and for the six component scores.

A Bonferroni correction was applied to the alpha value when determining the statistical significance of the results of these analyses to reduce the risk of false positives associated with multiple comparisons (Bland and Altman 1995). Alpha (0.05) was divided by the total number of analyses in this study (7) to give an alpha value of a = 0.007. Results of the pairwise comparisons in this study, therefore, were only considered to be statistically significant if their associated p-value was 0.007 or below.

Phase 2: qualitative

The data underwent transcription verbatim and were subjected to a reflexive thematic analysis approach, following the guidelines outlined by Braun and Clarke (2017). This analytical method entailed a recursive, six-stage process. Initially, the research team immersed themselves in the data by repeatedly reading and documenting initial reflective notes. Subsequently, the team generated initial codes, with a focus on identifying patterns of shared meaning across the dataset. Collaboratively, the team formulated initial themes, engaging in discussions and debates to consolidate different codes into broader conceptual ideas. Following this, the themes underwent iterative review and refinement, with the team critically evaluating their alignment with the coded data. Further refinement involved defining and naming the themes. Ultimately, the analysis was developed into a written report. Throughout the analytic process, the team engaged in reflexive discussions, acknowledging, and examining how their own backgrounds, assumptions, and perspectives may have influenced the interpretation of the data. This reflexive approach was pivotal in ensuring the analysis remained grounded in the participants’ experiences, mitigating the potential risk of undue influence from the researchers’ preconceptions (Braun and Clark, 2017).

Results

Phase 1: quantitative

An analysis sample size of n = 233 was present after matching pre-test (n = 261) and post-test data sets (n = 258) via the provision of student numbers. The reduction in sample size from pre-test to post-test is due to a small number of participants not completing the post-test. The reduction in sample size from post-test to analysis was due to participants supplying an incorrect or incomplete student number, this was an essential identifier used to pair the pre-post test questionnaire responses.

Descriptive statistics show that overall MSLQ post-test scores (M = 179.49, SD = 22.84) were higher than pre-test scores (M = 174.90, SD = 22.98). All sub-component scores showed increases from pre-test to post-test. Table 1 provides an overview of these findings.

Table 1 Pre-test and post-test scores for MSLQ and components

Overall, the MSLQ scores, along with critical thinking, self-regulation, help-seeking, and peer learning, showed minor but statistically significant increases in the paired sample t-tests presented in table 2, with a significance level of p < 0.007 (adjusted using the Bonferroni correction to account for multiple comparisons). However, changes in internal goal orientation and self-efficacy from pre-test to post-test did not reach statistical significance at the required alpha level.

Table 2 Paired sample t-test comparisons for MSLQ and component scores

Table 3 Technology acceptance and ease of use

With regards to the post-test on acceptability, 80% of participants responded positively to questions about perceived usefulness of the academic integrity game (i.e., they agreed or strongly agreed with positively worded items, and disagreed or strongly disagreed with negatively worded items). However, items about ease of use were slightly less positive. Specifically, 11.6% of participants agreed or strongly agreed with the item “I needed to learn a lot of things before I could get going with this resource” and 14.3% felt they found the game “cumbersome to use”. Please see Table 3 for full details of the post-test.

Phase 2: qualitative

All year one nursing students (n = 273) within the September cohort of the lead author’s institution were eligible for inclusion. Students were invited to self-register for a focus-group interview slot after completing the post-test questionnaire. A separate link, using Eventbrite, was visible to students that wished to participate in a focus group. Students who wished to participate selected a date and time convenient to them. Upon Eventbrite registration, students received an information sheet and were required to provide digitally signed consent on the day of the focus-group interview. Details of focus group participation were communicated to students at the conclusion of the post-questionnaire. It was made clear that participation in the focus groups was optional and would not affect their module grade.

A total of 42 participants signed up for the focus group interviews and 3 participants withdrew from the study prior to data collection without providing a reason. Participants in the four focus groups included undergraduate adult nursing students who began their degree in September 2022 (three months prior to data collection). The focus groups lasted between 30 and 45 min in duration, with each group consisting of 8–10 participants (n = 39).

Following thematic analysis of the data, three themes developed. The first theme was around usability of the serious game, which focused on how students accessed and used the resource. The second theme related to nursing values and how the serious game linked key learning about academic integrity to professional nursing practice. The third and final theme was about transferable learning, with participants reflecting on the use of serious games as an innovative way to learn in higher education.

Theme one: usability of the serious game

One of the most consistent themes to emerge from the data was the accessibility of this serious game for students. Participants felt that the game made important academic information readily available, interesting and easy to digest. Participants articulated that they felt empowered to develop their academic skills after playing the serious game and could even go on to develop their academic skills beyond what they learned in the game. For example, one participant noted that after playing the academic integrity game they made a face-to-face appointment with their university’s learning and development service to discuss writing assignments using third person passive tense. In terms of the usability of the resource, all four focus groups discussed how they found the layout of the serious game helpful and how it was easy to find the information they needed as noted in the excerpts that follow.

“I found that it was like easy to use, and it gave you like the information straight away. It wasn’t like trying to go through loads of different websites trying to find the information. Like you got straight up, and it was easy to understand, and it was straight to the point in a way.” (Focus Group 1. Participant 6)

“It was laid out pretty easily and it showed you about the plagiarism, which went into more detail, and it just shows you like how much you don’t know if you know what I mean. Yeah, it’s brilliant”. (Focus Group 3. Participant 9)

The accessibility of this serious game was something that resonated with most participants across all focus groups. During the focus groups, participants spoke about how easy it was to access this resource as part of their education in a fun and dynamic way. They favoured the use of digital technology as an interactive and engaging teaching method compared to other modes of asynchronous learning, for example, recorded lectures, audio podcasts, videos or reading materials. This is noted in the excerpts that follow.

“Yeah, like I really enjoyed it. Like they said, I find reading long documents can be very boring, so having that interactive one really helped me to remember it all for the assignment.” (Focus Group 4. Participant 5)

“I found when I was doing my assignment I kept looking back at the recorded lectures as well. So, I kept looking back and just if I, you know, I was stuck on a question or if I’m not too sure how to do this again. I would always go back to it [Academic Integrity Serious Game]. So, it was really helpful in the sense of knowing how to do it and how to write essays and, you know, knowing how to write it essentially as well.” (Focus Group 3. Participant 2)

Another aspect that enhanced the usability of the serious game was the opportunity for students to work through the serious game independently and at their own pace. Further to this, several nursing students also commented positively on the use of the cartoon graphics presented throughout the game. The use of these cartoons appeared to provide students with confidence to engage with the serious game. The excerpts that follow highlight how this impacted students.

“I just enjoyed the interactive bit of it, and it was just easy to learn from it”. (Focus Group 2. Participant 1)

“I thought it was great as well. And I wouldn’t have been able to do my assignment probably without it because I don’t think I really knew much about all the references… So, I thought it was great”. (Focus Group 3. Participant 7)

Overall, the participants felt that the serious game about academic integrity had high usability. Many participants noted that the asynchronous, digital, cartooned format also helped to maintain student interest in the subject area and support their confidence in understanding the material and re-using the resource.

Theme two: nursing values

The second theme to emerge from the data was the correlation between academic integrity and professional nursing values. Many students within the focus groups stated that they were not expecting to see the correlation between academic practice and nursing practice embedded within this resource, for example one participant noted their initial surprise at learning that plagiarism in an assignment could have parallels with the nursing value of integrity. On playing the serious game, many students went on to comment on how they began to recognise how their core nursing values are linked to general academic integrity. A key area which stood out was the importance of being open and honest in your academic work in the same way one would be with their patient as noted by the participant below.

“Yes, definitely, because you need to be like honest and trustworthy and not cheat during your assignments in order to like progress as a nurse. So, it’s definitely enforced [nursing] values on everyone that’s played the game… there’s a lot of like transferable skills [to practice] that was learned.” Focus Group 1. Participant 11)

As illustrated, students were able to relate the academic integrity resource to their professional ethical guidance, which is stipulated by the Nursing and Midwifery Council (NMC) in the United Kingdom. A further example of this explicit link between academic and professional conduct was noted in the excerpt below in reference to being open and honest and the duty of candour:

“It was like about, um, like duty of candour, like candour. It was like just being honest. Like I think in one of the scenarios it was something like they didn’t realise that what they’ve done was plagiarism and then they just sort of explained that that the panel or whatever it was. It was like a genuine mistake. So it’s just like being honest about things and so they’re not like sort of set up for when you’re on placement and stuff, you make mistakes like you just need to be honest and it can be dealt with rather than like shying away from it. So, I thought that was quite good.” (Focus Group 2. Participant 9)

In addition to the importance of honesty, students also reflected key values related to accountability and autonomy that were of importance. All four focus groups made reference to the fact that the academic integrity serious game helped students to draw parallels with these two key values. In the case of autonomy, students articulated that the serious game impressed upon them the importance of it being everyone’s responsibility for attaining the skills they needed at an individual level. One example of this was considered in the context of knowing when to ask for help and using external resources such as the student development service and the subject librarian.

With regards to accountability, participants also clearly highlighted that the serious game left them in little doubt that they were accountable for their own academic integrity and therefore they could not use poor health, poor study skills or poor engagement with the course as reasons for poor academic practice. Several students across the focus groups explicitly noted that this was highlighted very clearly within the module on academic offences. In this section within the serious game, the module presented a case of a student who plagiarises their assignment because of poor technique and not because they purposively set out to cheat. Irrespective of the intent, the student in the scenario still had to face an academic offences panel. These values are noted in the excerpts below.

“Every single module, they’re all interlinked and it’s all about integrity. It’s all about trust. Learning more about it, I think everybody can have a broad understanding of what it is, but when you’re going into the nursing and you’re seeing it being practically used, um, it’s just reinforcing. So yeah, it was good. It kind of always keeping you accountable”. (Focus Group 1. Participant 2)

“Really, what they did [developers of the game] was quite clever. I thought the game was about getting a higher mark in an exam, but it was so much more holistic, like, trying to reflect professionalism in how we nurse and how we do exams”. (Focus Group 3. Participant 8)

Overall, students felt this resource reinforced their key nursing values and helped them progress both academically and professionally during their undergraduate studies. The key values of honesty, integrity, autonomy and accountability were explicitly highlighted by nursing students and this serious game appeared to support participants in role-modelling these values within their academic practice.

Themes three: transferable learning

The final theme emerged from the data related to how student participants translated their learning from the serious game to their academic practice. There was consensus across all four focus groups that the academic integrity serious game was a unique way to learn and it actively helped them in the preparation of their academic assessments. For example, one student gained insight into searching for literature related to their nursing studies after playing the serious game.

“Yes, after playing, I used the different databases that were available to find stuff for the assignment. I didn’t realise how many [databases] there was and I wouldn’t have only for the game”. (Focus Group 1. Participant 5)

In other examples, nursing students described how the serious game increased their awareness about good study skills and their importance in achieving higher grades.

“There was a module in the game about study skills and I liked this. It was like getting the foundations in place before building the house if you know what I mean?”. (Focus Group 4. Participant 1)

“I actually use the SMART goals acronym, I have it written on my whiteboard in my room now. It was something I learned from the game” (Focus Group 2. Participant 10)

“The game linked out to other websites which I liked. I checked out one about Harvard Referencing and another one about how to download e-books from the library and that was pretty sweet” (Focus Group 4. Participant 7)

In addition to learning about transferrable skills, students spoke about how they perceived that the serious game would be useful throughout their time at university. All four focus groups strongly recommended that the academic integrity serious game be provided to nursing students throughout all three years of their programme as noted in the excerpts below.

“I think it was very informative and easy to use. It was fun. It’s something you could look back on before you start every assignment as well”. (Focus Group 3. Participant 7)

“…There is a lot going on in this course, so definitely, I’d expect it would be something I would come back to when we get another assignment…to remind myself…you know”. (Focus Group 1. Participant 7)

“Yeah, I thought it was great and a really good resource to have and especially to be able to Maybe look another time again before our next assignment as well, just to kind of refresh, but yeah, very happy”. (Focus Group 4. Participant 2)

Overall, this theme illustrated that student participants applied their learning to their academic practice. Furthermore, student participants identified that this serious game was one that they would play again in the future.

Discussion

This is the first co-designed digital serious game specifically addressing academic and professional integrity in nursing. While previous efforts have focused on helping students avoid academic misconduct (Birks et al. 2020), exploring game-based scenarios for contract cheating (Khan et al. 2021), or promoting best practices in research conduct (Goddiksen et al. 2024), this game integrates these elements within the context of higher education for nursing students.

The study’s first objective was to assess students’ motivation for self-perceived learning before and after interacting with the serious game. Descriptive statistics revealed higher post-test scores compared to pre-test scores across all six sub-scales of the Motivated Strategies for Learning Questionnaire (MSLQ) (Soemantri et al. 2018): internal goal orientation, self-efficacy, critical thinking, self-regulation, help-seeking, and peer learning. This improvement aligns with the use of Case-Based Learning (CBL) scenarios throughout the serious game. McLean (2016) describes CBL as employing clinical scenarios in healthcare to connect with relevant knowledge bases, a method reflected in the game by immersing students in realistic academic conduct processes and clinical situations. Azizi-Fini et al. (2015) argue that CBL effectively enhances critical thinking and problem-solving skills through reflective practice.

Statistical significance was found in four of the six sub-scales: critical thinking, self-regulation, help-seeking, and peer learning, which aligns with the CBL design of the serious game. However, no statistical significance was observed in the self-efficacy sub-scale. This may be due to the questionnaire focusing on self-perceived learning and self-efficacy rather than directly assessing integrity as a value itself. While core nursing values—such as honesty, trust, fairness, respect, responsibility, and courage (ICAI, 2021; Smart and Creighton 2022)—are like those promoted by the International Centre for Academic Integrity (ICAI), nursing students may find it challenging to apply these values to their academic work. Yet, as Ferla et al. (2010) highlight, self-perceived competence in education influences motivation, learning, and academic performance, making it a crucial area for study. Further, Addy et al. (2018) note that while there is substantial data supporting the benefits of engagement in gameplay, its effectiveness in actual learning remains uncertain. However, integrating CBL into serious games may appeal to a broader range of learners who may not engage with traditional educational methods.

The study’s second objective was to explore the student experience of playing the serious game and the impact on academic practice. The post-test and focus groups data illustrated that participants in this study found the digital serious game to be an acceptable and positive educational intervention. This aligns with findings from previous studies that demonstrate the effectiveness of serious games as educational interventions for learning (Anderson et al. 2024; McConnell et al. 2024; Mitchell et al. 2024). This study therefore supports the potential of serious games as a valuable tool for enhancing nursing students’ comprehension of critical topics like academic and professional integrity. As with similar serious game interventions, incorporating serious games into nursing education provides an engaging, interactive learning experience that fosters active participation and knowledge retention (Craig et al. 2024; Mitchell et al. 2021a, b). By immersing themselves in the gameplay, students can navigate real-world scenarios and apply theoretical knowledge to practical situations, thereby reinforcing the essential concepts and values necessary for their professional development in nursing.

A key finding of the study was the connection participants made between academic integrity and their future clinical practice as nurses. By linking their academic behaviours as nursing students to those expected in clinical practice through the serious game, participants were able to reflect on how these actions could influence their values around honesty in both academic and clinical setting. This finding aligns with results from a virtual simulation study on ethical dilemmas, where nursing students applied moral and ethical reasoning to the scenarios, enhancing their ability to make informed decisions in clinical practice (Honkavuo et al., 2021). The co-designed serious game within this study therefore appears to demonstrate clear connections between professional values, academic integrity, and decision-making related to both study skills and clinical practice, focusing specifically on honesty, integrity, and the importance of raising concerns. Rather than aiming to prevent errors altogether, the co-designed game emphasised the importance of accountability, openness, and honesty when mistakes do occur. This preventive educational approach is considered more beneficial than criminalising student behaviour (Reddy and Johnson 2023). The findings of this study also suggest that the serious game helps students bridge the gap between academic decision-making and their future clinical practice. Additionally, serious games are already recognised for supporting academic rigor and preparing students for real-world work challenges (Murillo-Zamorano et al. 2021).

Strengths and limitations

A notable strength of this study is the high response rate, suggesting a strong level of engagement and interest in the serious game intervention. Additionally, the use of a serious game represents a novel approach to addressing academic integrity and professional values in nursing education, offering an alternative from traditional teaching methods. The positive results observed, including statistically significant improvements in critical thinking, self-regulation, help-seeking, and peer learning, as well as the qualitative feedback highlight the potential for players to consider how professional values can be transferred into academic practice, are notable strengths. These findings suggest the potential for this intervention to be transferable and beneficial in other educational settings. Furthermore, the digital nature of the serious game offers advantages in terms of sustainability and accessibility, content can be adapted to encompass changes to policies or procedures and the link is via an HTML, therefore freely accessible on any digital device. Additionally, its relevance to all nursing students, regardless of their year of study, enhances its potential for widespread adoption and impact.

One limitation of this study pertains to the potential for selection bias in the data collection process. It is worth noting that participants who volunteered for the focus groups may have been those who were particularly enthusiastic about the intervention, potentially leading to a more positive depiction of their experiences. Consequently, the feedback provided may not fully represent the diverse range of perspectives, and there is notably a lack of critical opinions regarding aspects such as usability, implementation challenges, and long-term sustainability of the serious game. To obtain a more comprehensive understanding of the intervention’s effectiveness and identify potential areas for improvement, future studies may benefit from employing a different sampling strategy. By including participants with varying levels of enthusiasm and potentially more critical viewpoints, it is likely to provide a more balanced evaluation and provide valuable insights for educators and practitioners seeking to implement similar interventions in educational settings.

Conclusion

This study introduced a serious game to connect academic integrity and professionalism for nursing students. The game positively impacted motivation, critical thinking, and self-regulation. It linked academic integrity to nursing values, encouraging honesty, accountability, and openness. Students found the serious game provided skills that were transferable and applicable. The serious game appears to bridge academic learning and nursing practice, fostering integrity and making the connection between professionalism and academic integrity within nurse education.