Imagine you are a new graduate nurse (NGN) who has only been on the unit for a few days. You go with your preceptor to watch a central line dressing change and during the procedure your preceptor breaks sterility by accidentally touching the bedside railing. They look at you, shrug their shoulders, and continue with the dressing change hoping that the patient didn’t notice the error. Do you say something to your preceptor? Does the see something, say something apply here? More urgently, is the patient at risk of harm because of this error? Absolutely!

In our organization, we onboard many NGNs each month. Our acute care hospital and children’s hospital partner together to provide similar onboarding experiences to NGNs specializing in oncology.

Environmental Scanning: Why Are We Doing This?

In pursuit of a zero-harm culture, nurses play an important role in speaking up when recognizing errors that could potentially risk patient safety. The willingness of a nurse to speak up is known as their “voice behavior” (Alingh et al., 2019). As nursing professional development (NPD) practitioners, we recognized that there was a lack of voice behavior, especially among NGNs. In alignment with the Nursing Professional Development Standard 8 – Advocacy, NPD initiatives must actively promote high-quality and safe care by fostering a healthy practice environment that empowers NGNs to engage in voice behavior and advocate for safety. Often, NGNs crave a sense of belonging and support from their peers (Lyman, Gunn, & Mendon, 2020) Additionally, lack of confidence in their practice can  prevent NGN’s from speaking up and holding peers accountable for unsafe practices and increasing the likelihood of patient harm. Observation and direct feedback revealed a gap in voice behavior with new NPD initiatives must actively promote high-quality and safe care by fostering a healthy practice environment that empowers NGNs to engage in voice behavior and advocate for safety. and experienced clinical nurses expressing discomfort in giving feedback to preceptors, peers, and leaders to help close this gap, we developed an educational gamification activity designed to increase peer accountability among nurses.

About the Game

Gamification, defined as the application of game design elements—such as point scoring, competition, and rules of play in non-game contexts to enhance user engagement and motivation, has proven to be a valuable tool in nursing education. By incorporating these interactive and motivational strategies into learning environments, gamification has demonstrated improvements in student engagement, knowledge retention, and confidence (Kotp et al., 2025).For this activity, we wanted a simulated environment in which nurses would have the opportunity to observe nursing teammates performing common nursing tasks with a twist inspired by the popular game “Among Us”: a multiplayer game where players are working together on a spaceship.

During the simulation pre-brief, each nurse was given a card listing a nursing task, such as changing a central line dressing or performing foley care. Also, on this card is an assigned role — either a “crewmate” or “imposter.” Crewmates are responsible for completing the task appropriately, while imposters are responsible for discreetly sabotaging the task.

After nurses received their cards with the assignments, they were partnered with another nurse. Everyone was instructed not to share their role assignments with their partners, only the nursing task that they must complete. The duo was instructed to complete the tasks listed on their cards, while observing each other to determine if their partner does the task appropriately and per the facility policy.

After all tasks and observations are completed, the group reconvened, and nurses were encouraged to share if they believed their partner was a crewmate or an imposter.  Additionally, nurses shared their actual role assignment, and if they were an imposter, they also shared how they discreetly sabotaged the nursing task they were assigned.

A key component of the debrief focused on the significance of speaking up and promoting peer accountability within the nursing profession. Learners were encouraged to identify and discuss barriers to voicing concerns in patient care situations, and to share practical strategies for initiating real-time conversations and providing feedback when substandard care is observed. Using the TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) curriculum (Agency for Healthcare Research and Quality, 2024), participants explored respectful and non-accusatory approaches to addressing peers. Additionally, they were introduced to the CUS communication tool—Concerned, Uncomfortable, and Safety issue—and reviewed examples of its application in clinical settings.

Outcomes

Immediately after completing the game, we surveyed participants anonymously to measure how likely they were to closely watch peers perform a nursing procedure and intervene if it was performed incorrectly. We also asked participants to rate their comfort level in giving feedback on a scale from one to five (one being very uncomfortable and five being comfortable) both before and after the activity. Lastly, participants were asked to describe how the activity made them feel to assess psychological safety.

Prior to completing the activity, 60% of participants were very likely to watch their peers perform a nursing procedure, while only 20% were very likely to say something to their peers if they performed the procedure incorrectly. After the activity, 90% of participants were very likely to watch their peers closely, while 80% were very likely to speak up to their peers if performing the procedure incorrectly. The average comfort level in verbally giving feedback to another nurse increased from 3.7 to 4.4 on a scale of 1 to 5.

Additionally, participants had generally positive feelings towards the activity. Several of the responses included language such as “enjoy,” “confident,” “fun,” and “aware.” Many of the participants mentioned that they have a greater appreciation or awareness of the importance of accountability in their practice. One participant wrote, “It helped me realize how important it is to hold each other accountable as nurses. Small slip ups with some of the tasks we do can lead to patient harm, so I will be more likely to be more aware of how I am completing tasks as well as my peers.”

Discussion

We have found this game to be an extremely helpful tool in opening the conversation on the importance of speaking up and peer accountability. Nurses have a professional obligation to speak up when we see actual or potential patient harm. Nurses have a professional obligation to speak up when we see actual or potential patient harm, as outlined in Provision 4 of the ANA code of ethics. This activity provided a space to strengthen observation skills and practice delivering real-time feedback.  

While we provided this activity during a class for NGNs, this is a game that can easily be adapted for experienced nurses. The activity can also be used with preceptors and/or charge nurses to practice observation skills and provide real time feedback to others.

References

Agency for Healthcare Research and Quality. (2024, October). TeamSTEPPS 3.0. U.S. Department of Health & Human Services. https://www.ahrq.gov/teamstepps-program/index.html

Alingh, C. W., Wijngaarden van, J., Voorde van de, F. C., Paauwe, J., & Huijsman, R. (2019). Speaking up about patient safety concerns: The influence of safety management approaches and climate on nurses' willingness to speak up. BMJ Quality & Safety, 28(1), 39–48. https://doi-org.wake.idm.oclc.org/10.1136/bmjqs-2017-007163

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/

Darawad, M. W., Mansour, M., & Al-Niarat, T. (2020). Organisational empowerment and assertive communication behaviours: a survey of Jordanian newly qualified nurses. British Journal of Nursing, 29(7), 419–425. https://doi-org.wake.idm.oclc.org/10.12968/bjon.2020.29.7.419

Kee, K., & de Jong, D. (2022). Factors influencing newly graduated registered nurses’ voice behaviour: An interview study. Journal of Nursing Management, 30(7), 3189–3199. https://doi-org.wake.idm.oclc.org/10.1111/jonm.13742

Kotp, M. H., Bassyouny, H. A. A., Aly, M. A., Ibrahim, R. K., Hendy, A., Attia, A. S., Mekdad, A. K., Hafez, A. A., Farghaly Abdelaliem, S. M., A. Baghdadi, N., Hendy, A., & Ismail, H. A. (2025). Game on or game over? Gamification from 360-degree perspective, perception, confidence, and challenges in simulation based nursing education: mixed-method study. BMC Nursing, 24(1), 1–14. https://doi.org/10.1186/s12912-025-03253-z

Lyman, B., Gunn, M. M., & Mendon, C. R. (2020). New graduate registered nurses' experiences with psychological safety. Journal of Nursing Management, 28, 831–839. https://doi-org.wake.idm.oclc.org/10.1111/jonm.13006

Zhang, X., Chen, Q., Hu, Y., Zhao, X., Huang, X., & Oh, Y. (2025). Analysis of the Current Situation and Influencing Factors of Nurses’ Voice Behavior in Neonatal Intensive Care Units of Grade A Tertiary Hospitals in Sichuan Province: A Multicenter Cross‐Sectional Study. Journal of Nursing Management, 2025, 1–15. https://doi-org.wake.idm.oclc.org/10.1155/jonm/8175652