The protection of persons from all forms of violence is a rising concern of health care providers, but intimate partner violence (IPV) remains socially tolerated and ignored in many places (Beck et al., 2020). IPV is defined by the World Health Organization (2017) as "behavior by an intimate partner or ex-partner that causes physical, sexual or psychological abuse or controlling behavior" (WHO, 2017). Each year in the United States, there are more than 10 million incidents of IPV, with the deaths of more than 1,800 affected individuals (Beck et al., 2020; US Department of Justice, Federal Bureau of Investigation, 2015). Nurses, who are often the first to interact with those affected, need to know the signs and symptoms of IPV, assessment techniques, and interview skills to promote safe outcomes.

Studies evaluating IPV education for nurses largely occur in the hospital setting or graduate school (Crombie et al., 2016). Educational methodologies used to teach IPV identified in studies and articles include lecture, PowerPoint, role-play, group discussion, and self-directed learning modules. Evaluations of IPV teaching methodologies often use a pretest/posttest design or surveys (Crombie et al., 2016). The researchers for the current study used the "self-efficacy theory," which acknowledges that how people think and behave can influence their motivation to learn (Bandura & Schunk, 1981). This study extends the current knowledge on IPV teaching methodologies by assessing whether storytelling or gaming best helps students achieve IPV learning outcomes.

METHOD

The purpose of this quasi-experimental study was to fill an important gap in the science of understanding best methodologies for teaching IPV education in an undergraduate community health course. The research question guiding this study was: Do games or storytelling affect knowledge acquisition (short-term memory) and/or knowledge retention (long-term memory) in undergraduate nursing students learning about IPV? Researchers for this study hypothesized that both methodologies would be beneficial teaching-learning tools and would improve IPV knowledge acquisition and retention. Approval for this study was obtained from the appropriate institutional review board.

Two instructors with IPV knowledge and experience with their select methodology conducted this intervention. Each instructor created a 50-minute presentation that included history of IPV, cycle of violence, characteristics of IPV survivors and perpetrators, nursing interventions, cultural issues, and state laws on reporting IPV. The first instructor created a fact-based ghost story to teach IPV concepts. To accompany the story, she used a PowerPoint, pictures, and props. Storytelling uses words and actions to reveal elements and images of a story while encouraging the listener's imagination (National Storytelling Network, n.d.).

The second instructor created Bingo cards and questions using the same key IPV concepts. For the Bingo game, the instructor described an IPV-related example or definition, and students placed a chip on their cards if they had the correct nursing action or term. A gift was given to the first person who had a chip in every box of one row on the card and yelled "Bingo." Game-based learning employs the mechanics of playing a game embedded with educational information to engage, motivate, and generate cognitive benefits (Sardi et al., 2017).

The convenience sample consisted of 81 prelicensure nursing students enrolled in a community health course in a small historically black college and university in the Southeast. Students enrolled in the community health course were required to attend the lecture, but study participation was voluntary. All students agreed to participate in the study.

A two quasi-experimental group study was conducted. Group 1 had 43 participants; Group 2 had 38. Each group was divided into two sections, with one section having exposure to 10 minutes of IPV education. Groups were identified as Group 1a, Storytelling, no previous IPV education; Group 1b, Gaming, with previous IPV education; Group 2a, Gaming, no previous IPV education; and Group 2b, Storytelling, with previous IPV education.

Students in Group 1 were predominantly black (62.8 percent); others were white (16.3 percent), other (11.6 percent), Asian (7 percent), and Hispanic (2.3 percent). The majority of students (58.8 percent) were 18 to 24 years old. Group 2 had fewer black students (42.1 percent), with a greater proportion of white students (36.8 percent); a similar number identified as other (10.5 percent), Asian (5.3 percent), and Hispanic (2.6 percent). Fifty percent of these students were 18 to 24 years old.

Prior to the intervention, Group 1 and Group 2 completed three pretest questions on IPV. Immediately following the intervention, students received the same three questions to evaluate knowledge acquisition. To eliminate the risk of memorization and test score inflation, three similar yet different IPV knowledge-based questions were included on the final exam. Pretest, posttest, and final exam questions were tested for face validity by content experts. To evaluate knowledge retention, three final exam questions were embedded into the students' final exam three weeks following the intervention.

RESULTS

Pretest, posttest, and final exam scores were compared between and within Group 1 (Storytelling, no previous IPV education, and Gaming, with previous IPV education) and Group 2 (Storytelling, with previous IPV education, and Gaming, with no previous IPV education). A paired-samples t-test was used to compare differences in the pretest and posttest percent correct scores and between the posttest and final exam percent correct scores. An analysis of variance compared all three pretest, posttest, and final exam scores between Group 1 and Group 2. Statistical significance was assessed using p < .5.

Group 1 Results

Of the 43 participants, 39 completed the posttest. There was no significant difference between pretest and posttest in the storytelling group, t(13) = 0.971, p = .349. There was a significant difference in pretest and posttest in the gaming group with previous IPV experience, t(24) = -3.412, p = .002. No statistical differences were found between pretest and final exam scores. When comparing pretest, posttest, and final exam by group, only the posttest was significantly different, F(1, 37) = 36.765, p < .001.

Group 2 Results

Of the 38 participants, 37 completed the posttest. There was a significant difference in pretest and posttest in the gaming group with no IPV exposure, t(17) = -3.449, p = .003. There were no other differences noted in the gaming or storytelling group. When comparing pretest, posttest, and final exam by group, only the posttest was significantly different, F(1, 35) = 12.899, p = .001.

We examined posttest mean percentiles compared to final exam mean percentiles. In the storytelling group, mean percent scores improved from posttest to final exam in both groups (Group 1, 45 percent vs. 57 percent; Group 2, 72 percent vs. 79 percent). Gaming mean percent scores decreased from posttest to final exam (Group 1, 92 percent vs. 73 percent; Group 2, 93 percent vs. 74 percent).

DISCUSSION, IMPLICATIONS, AND LIMITATIONS

We examined the effectiveness of storytelling and gaming on knowledge acquisition and retention of IPV-related content. In addition, we compared scores to determine if previous exposure of IPV content influenced posttest scores. The posttest scores increased from pretest scores in both gaming groups: those with IPV exposure and those without. Gaming was a more effective teaching strategy than storytelling for knowledge acquisition for this group of students. However, the gaming group did not retain this knowledge. These results differed from the Spence (2019) study, which found gaming improved knowledge retention. Although pretest/posttest scores in the storytelling group were not statistically significant, the final exam percentage of correct answers increased in both storytelling groups. Thus, storytelling may be more effective in knowledge retention. These results were similar to a study by Webb-Corbett et al. (2013), which found students viewing new media simulation stories had no statistically significant improvement in knowledge acquisition; however, one of the two viewed simulated stories was statistically significant for knowledge retention.

Strategies to improve knowledge acquisition and retention of IPV content are essential to ensure best practices for detection and intervention. Recognizing that combining strategies may burden classroom time, research should also focus on the aspects of each strategy that promote knowledge acquisition and retention. Exploration of different methods is also warranted to better understand what works best for teaching highly sensitive topics like IPV.

This convenience sample had 75.7 percent of participants identifying as black, Hispanic, Asian, or other. After reviewing demographics, English as a second language was not acknowledged and may have affected learning outcomes. Some students may have more natural ability to retain knowledge, but student ability was not reflected in the study. Learning preferences were also not addressed in the study. With regard to question development, the pretest, posttest, and final exam questions were recall rather than application questions; therefore, it is unknown what students would do in practice. Lastly, there were only three questions; although these were validated by content experts and used in previous courses, it is uncertain as to whether sentence structure was enough for students to draw conclusions.

CONCLUSION

IPV-related nursing interventions can impact client outcomes; therefore, education is needed prior to entering the workforce. The results of this study suggest gaming with previous IPV knowledge may improve knowledge acquisition and storytelling may enhance knowledge retention. Although there is literature supporting the use of lecture, PowerPoint, role-play, group discussions, and self-directed learning modules in teaching IPV education, more research is needed to explore storytelling and gaming in the education of undergraduate nursing students.

REFERENCES