Creative Education, 2010, 1, 51-57
doi:10.4236/ce.2010.11008 Published Online June 2010 (
Copyright © 2010 SciRes. CE
Helping Oncology Nurses Advise Younger Patients
about Self Care: Feasibility of Using Animated and
DVD Formats for Nurse Instruction
Ivan Beale1, Vivien Lane2
1School of Psychology, University of New South Wales, Sydney, Australia; 2Information Technology, University of Sydney, Sydney,
Received December 21st, 2009; revised April 20th, 2010; accepted May 20th, 2010.
This study explored the perceptions of oncology nurses about the usefulness of a video-game or an animated DVD in-
tervention designed to teach young patients about self care. The study also measured the effects of these interventions
on nurses’ cancer knowledge and perceived self-efficacy to communicate with patients about self-care. Twenty-two on-
cology nurses were randomly assigned either to use a video game “Re-Mission” or to view instructional animations
from the game on DVD. They completed tests and rating scales before and after, then rated the acceptability of the
game or DVD. Only ten participants completed the study. For these ten, ratings of the acceptability and credibility of
the game or DVD were moderately positive, regardless of age or nursing experience. Self-efficacy for communicating to
patients about self-care increased following use of the game or DVD. Cancer knowledge was not affected. It was con-
cluded that oncology nurses in Australia are not generally enthusiastic about the concept of instruction via video game
and animated DVD formats, although those who participated rated the experience positively.
Keywords: Digital-Based Learning, Nurse Instruction, Video Game, Media Acceptability
1. Introduction
Currently, patients diagnosed with cancer are likely to
receive a range of information about their disease and its
treatment, but there has been surprisingly little research
on what that information should be, or when or how it is
best to provide it [1-2]. A recent survey found that cancer
patients in general regard specialist nurses as their pre-
ferred source of quality information, as opposed to other
sources [3], so it is important that nurses are capable as
providers and communicators.
1.1 Self Care
Cancer patients may experience many adverse symptoms
arising directly from the disease itself or as side effects
of treatment, especially chemotherapy or radiotherapy.
To a large extent, patients’ quality of life reflects their
ability to learn certain strategies, which used either as
preventive or reactive measures, can reduce the potential
impact of these adverse symptoms. Such symptoms
might range from psychological or cosmetic issues such
as hair loss or deviations from normal appearance to se-
vere pain and life-threatening infections. A patient’s in-
tentional use of actions to improve or maintain health and
well-being is referred to as “self care”, a concept that has
a central place in nursing theory [4-5] and has been sub-
ject to considerable research. There is evidence that the
learning and effective practice of self care skills during
treatment of cancer can improve both psychosocial and
physical outcomes [6-8]. But patients’ behaviour is also
influenced by individual educational factors such as
knowledge about self care skills, the source of such
knowledge, the modality by which the knowledge is im-
parted [2], and training in the use of the skills [1]. For
adults being treated for cancer, there is evidence that self
care skills most used are typically self-taught and based
on commonsense rather than on professional advice and
that these self care measures often are ineffective [9].
1.2 Nurse Training in Patient Self-Care
It appears that good self care improves treatment out-
comes, and that oncology nurses are the preferred pro-
viders (by patients) of self-care information. There is
evidence that nurses are in general consistent in the can-
cer information [10] and the self-care information [11]
Helping Oncology Nurses Advise Younger Patients about Self Care: Feasibility of
Using Animated and DVD Formats for Nurse Instruction
they believe is important to provide to patients. However,
there is little research published on alternative methods
of teaching nurses about patients’ self-care needs, or how
to communicate effectively with patients about self-care
issues. A survey of oncology nurses in the U.S. indicates
that they are amenable to receiving professional informa-
tion through electronic media such as CD-ROM and the
Internet [12]. There are some recent indications that
nurses generally are becoming more game-oriented
(board games) in their educational preferences [13,14], as
well as more internet-oriented [15]. Also, a greater use of
internet and other digital technology for nursing educa-
tion is being strongly promoted. What seems to be lack-
ing though, are empirical studies of how nurses respond
when asked to engage with these new initiatives in digi-
tally-based education. In particular, there seem to be no
published studies of nurses’ views of interactive video
game or animated DVD formats as conduits for profes-
sional information or interaction with patients about
treatment issues. Since younger patients appear to be
receptive to the idea of using these types of media as part
of their treatment, it is desirable to know the views of
nurses also. If nurses are positive about the potential of
these media for their own education and for their interac-
tions with patients, the use of the media with patients is
more likely to have beneficial outcomes than would be
the case if nurses take a negative view. Nurses’ percep-
tion aside, it would be useful to know whether nurses
benefit directly from using these digital media either in
knowledge gains or in greater confidence to carry out
nursing tasks.
1.3 This Study
This research investigates the credibility/acceptability of
two alternative interventions involving presenting educa-
tional material about cancer and patient self-care to on-
cology nurses. The research also examines the effects of
these two interventions on nurses’ knowledge about can-
cer treatment and on their perceived efficacy to commu-
nicate with young patients about self-care during treat-
ment. One of the interventions is an interactive video
game called Re-Mission [16], designed primarily to as-
sist young cancer patients (15-30 years old) to under-
stand and practise self-care during treatment. The other
intervention is a series of non-interactive video anima-
tions that discuss the self-care issues central to the Re-
Mission game.
A major objective for the Re-Mission game was to fa-
cilitate communication about cancer and self care be-
tween patients and their treating health professionals.
However, Re-Mission might also assist nurses to under-
stand cancer and the self-care issues experienced by pa-
tients. Also, experience with Re-Mission might assist
nurses to communicate effectively with patients about
their treatment and self-care issues, especially if patients
are themselves using Re-Mission.
Players of the Re-Mission game are exposed to its edu-
cational content throughout a series of game-play mis-
sions which may take 10 hours or more to complete.
While this time commitment might be appropriate for
patients undergoing treatment, it may be an unrealistic
expectation for many nurses who already have heavy
demands on their time. However, much of the educa-
tional content of Re-Mission exists in the game as non-
interactive animated sequences that can be presented
outside the game in DVD format of about one hour’s
duration. While lacking possible educational advantages
of interactivity associated with game-play, this Re-Mission
DVD may have advantages of its own. For example, it
may be played on equipment that most nurses would
have ready access to and does not require computer or
video-game literacy, whereas the Re-Mission game re-
quires a computer with advanced graphics capability and
a degree of computer confidence. Also, the shorter play-
ing time of the DVD potentially is an attractive feature
for nurses with busy lives.
1.4 Re-Mission—A Brief Description
Re-Mission is a 3-D video game which can be played on
a computer by a player using a hand-held game controller.
The game comprises 20 “missions”, in which the player
can enter alternative 3-D virtual environments represent-
ing selected locations inside the bodies of “virtual cancer
patients”. Examples are lymph vessels, bone marrow,
spinal cord, blood vessels, lungs and brain. Within these
environments, the player pursues the goal of the chosen
mission by controlling an avatar, in this case a humanoid
character called a “nanobot”, ostensibly specialized to
fight cancer.
The environments contain features with which the
nanobot can interact. For example, a lymph vessel, com-
prising several sections connected by valves, contains
animated characters which are realistic representations of
various cells that might be found in the lymph system of
a lymphoma patient. Game-play consists of guiding the
nanobot to complete a mission to destroy cancer cells or
bacteria while avoiding injury or weakness. Cells are
destroyed using weapons powered by chemotherapy.
Bacteria are destroyed using antibiotic. The nanobot
must prompt the patient to comply with the prescribed
drug regime, in order for the nanobot to have ammuni-
tion for weapons. Also, the patient must be prompted to
eat or drink to maintain a sufficient level of health.
The characteristics of the “virtual patients”, cancer di-
agnoses and treatment issues represented in Re-Mission
have been selected to maximize the relevance of the
game to the issues experienced by young people with
cancer. The efficacy of Re-Mission as a psychoeduca-
Copyright © 2010 SciRes. CE
Helping Oncology Nurses Advise Younger Patients about Self Care: Feasibility of 53
Using Animated and DVD Formats for Nurse Instruction
tional intervention for self-care and adherence which has
been evaluated in an international multi-site trial and
other more-focused studies conducted with cancer pa-
tients [17-19]. Re-Mission is available free to patients
and clinicians from the developers, a non-profit research
institute (available at According to
the developers, Re-Mission has been distributed on re-
quest to more than 200,000 patients and health providers
worldwide, indicating that it might be widely used by
young cancer patients.
1.5 Re-Mission as a Communication Tool
To the extent that Re-Mission is popular with young
cancer patients, it could provide a useful context for dis-
cussion of treatment issues between patients and their
families or friends, and between patients and their treat-
ment providers. Patients might find it relatively easy to
bring up treatment issues with others if they can do so by
discussing game-play scenarios, as opposed to talking
directly about their own problems. In particular, discus-
sions between patients and nurses, about adherence and
self-care generally, might be assisted by using Re-Mis-
sion scenarios. Such discussions would require that the
nurses, as well as the patients, have experience with
Re-Mission content. However, the acceptability to nurses
of this approach is unknown and requires investigation.
The current study explored this acceptability issue by
giving nurses experience with Re-Mission content, either
as a game or DVD, then administering a questionnaire
about their perceptions of the likely value of that experi-
ence in their work with patients undergoing treatment.
Additionally, the study measured resulting changes in
cancer knowledge and perceived self-efficacy to com-
municate with patients about self care.
1.6 Re-Mission as an Education Aid in Oncology
The scenarios in the content of Re-Mission portray a
number of self-care issues that have been rated as impor-
tant issues by oncology professionals and patients [10,
11]. Both the game and the videos incorporated in it also
provide extensive information about cancer and its
treatment that is informed by recent surveys of health
professionals and patients regarding patients’ information
needs. It is possible that nurses using the Re-Mission
game or video will have their knowledge and under-
standing reinforced or extended by this experience. There
is substantial evidence that these sorts of learning ex-
perience help the consolidation, generalization and abil-
ity to apply knowledge previously gained from other
sources, such as reading and lectures [1,2].
2. Method
2.1 Participants
The participants were nurses currently work in or receiv-
ing training related to oncology nursing at two hospitals
in a large metropolitan city in Australia.
2.2 Design
Randomized groups were used in a so-called “mixed
effects” design that included a within subjects condition
and a between subjects condition. The within subjects
condition (repeated measures) consisted of two levels,
pre-intervention (Pre) and post-intervention (Post). The
between subjects condition consisted of two levels,
Re-Mission game (G) and Re-Mission DVD (V). Condi-
tion “G” consisted of unrestricted access for one month
to the Re-Mission video game loaded on a minicomputer.
Condition “V” consisted of unrestricted access to a DVD
containing all the animated informational video excerpts
contained in the Re-Mission game. Sample size (N = 22)
was based on Cohen’s method of using standardized ef-
fect sizes as a basis for calculating the required sample
size [20]. Power calculations indicate that 10 participants
in each of the two conditions would be sufficient to de-
tect contrasts representing large effect sizes (at alpha =
0.05 and power = 0.8) in the proposed analyses. Given
the practical rationale for this study, only large effect
sizes on any dependent measure are likely to be of inter-
2.3 Procedure
Ethics approval for the project was sought and obtained
from the ethics review committees at both hospitals
where nurses were recruited. The study was certified as
meeting consensual ethics criteria for safety, possible
conflicts of interest, confidentiality and informed consent.
Nurses were informed about the project by the research-
ers, and the project was also advertised on a website used
for postgraduate nurse education ( One of the researchers, a senior
nurse educator, recruited participants singly or in small
groups over a 2-year period. Participants were told that
the minimum duration of their direct involvement in the
project would be about one month. They were sequen-
tially allocated to either the G or V conditions using a
randomization sequence generated by a computer algo-
rithm in BASIC.
1) Pre-test: All participants completed the following:
Self-care knowledge test. This was an 18-item
multi-choice test of knowledge related to self-care during
treatment for cancer. The items in this test were based on
previously published data from surveys of oncology
nurses about the relative importance of different self care
Copyright © 2010 SciRes. CE
Helping Oncology Nurses Advise Younger Patients about Self Care: Feasibility of
Using Animated and DVD Formats for Nurse Instruction
Copyright © 2010 SciRes. CE
practices. The test had been shown to have discriminative
validity when used with young cancer patients, but had
not previously been used with nurses [17]. The maximum
score on this test is 18.
Communication self-efficacy rating scale. This was
a 27-item rating scale that asked respondents how easy or
hard they found it (on a 7-point scale) to communicate
with patients about each of 27 self-care items, such as
“balancing rest and exercise to avoid fatigue” and “regu-
larly washing hands to avoid infection”. The construction
of this scale is based on the theory of self-efficacy de-
veloped by Bandura and on Bandura’s recommendations
for the measurement of self-efficacy for health-related
behaviours [21]. The items were selected from a longer
list used in a survey of health professionals involved in
the care of cancer patients, considered by respondents to
be most important for effective care during treatment
[10]. The validity and reliability of this scale as used in
the current study with nurses is not known. However,
when the same items were previously used in a scale
designed to measure young cancer patients’ perceived
self-efficacy for self-care, the scale was found to have
discriminative validity for differentiating between pa-
tients receiving, or not receiving, a self-care knowledge
intervention [18]. The single measure used to indicate
performance on this scale is the mean rating across all 27
items. A mean score of 7 would indicate the highest pos-
sible level of perceived ease of communication with pa-
tients about self care.
A demographics questionnaire. This questionnaire
requested information on age, gender, cancer nursing
experience and qualifications, and video game experi-
2) Intervention: Participants were asked to use either
the game (condition G) or the DVD (condition V) pro-
vided for at least one hour per week if possible.
3) Post-test: All participants repeated the Self-care
knowledge test and the Communication self-efficacy
rating scale. In addition they completed another measure,
the Acceptability/credibility rating scale. This scale was
adapted from a scale previously used to measure accept-
ability and credibility of the Re-Mission video game by
young cancer patients (see Table 1), shown in a previous
study to have adequate psychometric properties when
used in a context similar to the current study [17].
2.4 Research Hypotheses
1) Acceptability/credibility ratings will not be different
for Conditions G and V.
2) Ratings of acceptability/credibility of both the
Re-Mission game (condition G) and the Re-Mission
DVD (condition V) as a communication aid will be posi-
tive (mean rating between 3 & 5).
3) Scores on the knowledge test will be higher at
post-test than at pre-test.
4) Scores on self-efficacy rating scale will be higher at
post-test than at pre-test.
5) After adjustment for pre-test score levels on both
the knowledge test and the self-efficacy scale, post-test
levels will not be different for Conditions G and V.
In addition to allowing for specific hypotheses to be
tested, the study also provided an opportunity to explore
possible associations between demographic variables
(age, nursing experience) and relevant dependent vari-
ables such as acceptability. It was also possible to meas-
ure the magnitude of associations between acceptability,
knowledge and self-efficacy.
Table 1. Items from the Acceptability/Credibility Rating Scale. Data shown are the Mean, SD, Minimum and Maximum
Rating for each Item. N = 10 for each Item
Item Mean SD Min Max
1 I think it is OK for cancer nurses to use Re-Mission as part of their professional development/
training 3.7 0.82 2 5
2 I would recommend Re-Mission to other cancer nurses 3.6 0.97 2 5
3 I think I benefited from using Re-Mission 3.4 1.07 2 5
4 I think that Re-Mission provided an easy way to learn about self-care during cancer treatment3.5 0.97 2 5
5 I believe Re-Mission helped me to understand cancer treatment and side effects 3.6 0.84 2 5
6 I think Re-Mission takes about the right amount of time to complete to be a practical way of
learning 3.0 1.50 1 5
7 Overall, I liked Re-Mission 3.6 1.17 1 5
8 I think most Australians would understand the American words and accent in Re-Mission 4.0 0.47 3 5
ote. On rating scale 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree
Helping Oncology Nurses Advise Younger Patients about Self Care: Feasibility of 55
Using Animated and DVD Formats for Nurse Instruction
3. Results
Twenty-two participants were recruited over two years.
Of these, only ten (five in each condition) returned both
the pre- and post-test questionnaires and tests. The char-
acteristics of those completing the study were: age (M =
39.30y, SD = 11.49, range 23-53y); nursing experience
(M = 6.60y, SD = 6.90, range 0.1-20y).
3.1 Data Analysis
Hypotheses 1 & 2. On the Acceptability/credibility rating
scale, the maximum possible rating on each item was 5.
A rating of 5 would indicate strong agreement with a
positive statement about the acceptability or credibility of
the game or DVD. Table 1 shows the wording of the
items and the mean rating and SD, across conditions G
and V, for each item in the rating scale. The mean ratings
vary between 3.0 (item 6) and 4.0 (item 8). Apart from
item 3, which indicates a neutral position, the means for
items indicate an overall weak positive rating of the
Re-Mission game or video. The mean across all items
was 3.55 (SD = 0.80). The difference between means on
any item for conditions G and V was non-significant by
independent t-test (p > 0.05).
Hypotheses 3 & 5: On the Self-care knowledge test,
the maximum possible score was 18. Across conditions
G and V, the mean score at Pre-test was 15.2 (SD = 2.35)
and at Post-test was 15.8 (SD = 1.69). The difference
between Pre- and Post-test means was not significant by
correlated t-test (p > 0.05). The difference between
means for conditions G and V at either Pre-test or
Post-test was non-significant by independent t-test (p >
0.05). A repeated measures ANOVA with condition (G
vs. V) as a between-subjects factor showed that the dif-
ference between Pre- and Post-test means was not sig-
nificantly different for the G and V conditions (p > 0.05).
Hypotheses 4 & 5: On the Communication Self-effi-
cacy rating scale, the maximum possible rating on each
item was 7. The score analyzed for each participant was
the mean rating across all 27 items. Across conditions G
and V, the mean rating at Pre-test was 5.34 (SD = 0.87)
and at Post-test was 5.83 (SD = 0.88). The difference
between Pre- and Post-test means was significant by
correlated t-test (t(9) = –3.59, p = 0.006). The difference
between means for conditions G and V at either Pre-test
or Post-test was non-significant by independent t-test (p
> 0.05). A repeated measures ANOVA with condition (G
vs. V) as a between-subjects factor showed that the dif-
ference between Pre- and Post-test means was not sig-
nificantly different for the G and V conditions (p > 0.05).
Associations between variables: Exploratory correla-
tional analyses were conducted, using appropriate para-
metric or nonparametric procedures, to test for signifi-
cant associations between variables. Of particular interest
was whether ratings on the acceptability/credibility scale
were significantly influenced by variables such as age,
nursing experience, self-care knowledge, self-care effi-
cacy, or Pre-Post changes in knowledge or self-efficacy.
The only significant correlations found were a set of
negative correlations between scores on the knowledge
test and ratings on most items of the acceptability/credi-
bility rating scale, especially at Post-test. The higher the
knowledge score, the lower the rating given on all items
except item 7, where the correlation was not significant.
Correlations at Post-test (Pearson r) were item 1, –0.61;
item 2, –0.67; item 3, –0.75; item 4, –0.75; item 5, –0.69;
item 6, –0.71; item 8, –0.56 (all p < 0.05).
4. Discussion
Hypotheses 1 & 2 relate to the nurses’ perceptions of
acceptability/credibility of the intervention they received
(condition G or V) as an aid to communicating with pa-
tients about self care. Relevant to these hypotheses is the
great difficulty experienced by the researchers in recruit-
ing participants, and the high attrition rate of those re-
cruited (over 50%). Those who did complete the study
mostly did not provide very positive ratings of Re-Mis-
sion’s acceptability/credibility, either as a game (condi-
tion G) or video (condition V). The test for Hypothesis 1,
that the acceptability/credibility ratings for condition G
and condition V would not be different, was weaker than
was planned. This is because the low numbers of partici-
pants completing the study severely reduced the statisti-
cal power of the study to detect even medium-sized dif-
ferences between conditions G and V on any of the de-
pendent measures. It therefore remains possible that there
are real differences between these two conditions that
could not be detected in this study.
Hypothesis 2, that participants’ ratings of acceptabil-
ity/credibility of Re-Mission as a communication aid will
be positive, is only weakly confirmed by the evidence.
Although those completing the study mostly gave posi-
tive ratings on the acceptability/credibility items (< 3),
the low recruitment and completion rates suggests that
most nurses approached were disinclined to get involved
or to maintain their involvement. The conditions of the
ethics approval for this study did not permit the re-
searchers to ask nurses why they were disinclined, but
some volunteered comments that suggested widespread
disinterest in computer games and animated videos
amongst this group. Had it been possible to use incen-
tives to encourage participation in the study, it is likely
that more nurses would have participated in and com-
pleted the study.
Hypothesis 3, that scores on the self-care knowledge
test will be higher at post-test than at pre-test, was dis-
confirmed, indicating that neither intervention could be
said to lead to an increase in knowledge. Hypothesis 4,
Copyright © 2010 SciRes. CE
Helping Oncology Nurses Advise Younger Patients about Self Care: Feasibility of
Using Animated and DVD Formats for Nurse Instruction
that scores on self-efficacy rating scale will be higher at
post-test than at pre-test, was confirmed. This effect was
of moderate size, representing a mean Pre-Post increase
in self-efficacy ratings of about 0.5 of a scale unit. While
this effect is consistent with a positive influence of Re-
Mission content on perceived self-efficacy, the absence
of a control for extraneous influences on self-efficacy
means that other explanations of the increase in self-ef-
ficacy are equally plausible.
Hypothesis 5, that conditions G and V would not have
different effects on either knowledge or self-efficacy, are
consistent with the non-significant values obtained in the
analyses conducted. Although the statistical power of the
tests conducted was low consequent to the low comple-
tion rate, this result is at least consistent with the conclu-
sion that neither condition had more effect than the other
on either knowledge or self-efficacy.
An additional finding from exploratory analyses was
that acceptability/credibility ratings were not positively
correlated with post-test self-efficacy scores. However,
participants with higher knowledge scores, especially at
the Post-test, tended to rate their intervention lower on
the acceptability/credibility rating scale. Essentially,
those with better knowledge about self-care were less
positive about the value of the intervention in this context.
This effect was specific to knowledge as measured in this
study, and was not associated with age, oncology nursing
experience, or perceived self-efficacy to communicate
about self care.
We conclude that the Re-Mission game and Re-Mission
videos are found to be moderately acceptable/credible to
the small proportion of oncology nurses who are willing
to try them, especially to those whose knowledge about
self care is limited. Using the game or video may result
in significant improvement in perceived self-efficacy to
communicate with patients about self care. However, our
results indicate that nurse educators may find substantial
resistance amongst nurses to educational initiatives in-
volving the use of animated games or videos. This is in
contrast to the positive view of digital and game-based
education strategies prevalent in the nursing education
literature [13,15]. It may reflect the difference between
stated and revealed preferences, for example, asking
nurses their preferences between hypothetical alterna-
tives, versus requesting them to participate in actual
educational activities. Alternatively, the findings of the
current study may be specific to the Australian context,
for example, Australian nurses might be less “digitally
literate” than their North American counterparts.
5. Acknowledgements
This research was supported in part by HopeLab, Red-
wood City, California. HopeLab gave permission for the
use Re-Mission materials in this study.
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