Article Text

Using active learning strategies during a quality improvement collaborative: exploring educational games to enhance learning among healthcare professionals
  1. Marianilza Lopes da Silva1,
  2. Flavia Fernanda Franco2,
  3. Jessica Alves Vieira3,
  4. Juliana Fernandes da Silva4,
  5. Guilherme Cesar Silva Dias Santos5,
  6. Beatriz Marques da Cunha6,
  7. Fernando Enrique Arriel Pereira6,
  8. Natalia Nardoni5,
  9. Francielle Bendersky Gomes4,
  10. Brunno Cesar Batista Cocentino3,
  11. Roberta Gonçalves Marques2,
  12. Natalia Souza de Melo1,
  13. Ademir Jose Petenate1,2,3,4,5,6,
  14. Andreza Pivato Susin Hamada1,2,3,4,5,6,
  15. Cristiane Maria Reis Cristalda7,
  16. Luciana Yumi Ue7,
  17. Claudia Garcia de Barros2,
  18. Sebastian Vernal1,2,3,4,5,6
  19. on behalf of the Saúde em Nossas Mãos Collaborative study group
    1. 1Hcor, São Paulo, SP, Brazil
    2. 2Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
    3. 3Hospital Sírio-Libanês, São Paulo, SP, Brazil
    4. 4Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
    5. 5BP - A Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
    6. 6Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
    7. 7Ministério da Saúde, Brasilia, DF, Brazil
    1. Correspondence to Dr Sebastian Vernal; vernal.carranza{at}


    Background The Breakthrough Series model uses learning sessions (LS) to promote education, professional development and quality improvement (QI) in healthcare. Staff divergences regarding prior knowledge, previous experience, preferences and motivations make selecting which pedagogic strategies to use in LS a challenge.

    Aim We aimed to assess new active-learning strategies: two educational games, a card game and an escape room-type game, for training in healthcare-associated infection prevention.

    Methods This descriptive case study evaluated the performance of educational strategies during a Collaborative to reduce healthcare-associated infections in Brazilian intensive care units (ICUs). A post-intervention survey was voluntarily offered to all participants in LS activities.

    Results Seven regional 2-day LS were held between October and December 2022 (six for adult ICUs and one for paediatric/neonatal ICUs). Of 194 institutions participating in a nationwide QI initiative, 193 (99.4%) participated in these activities, totalling 850 healthcare professionals. From these, 641 participants responded to the survey (75.4%). The post-intervention survey showed that the participants responded positively to the educational activities.

    Conclusion The participants perceived the various pedagogical strategies positively, which shows the value of a broad and diverse educational approach, customised to local settings and including game-based activities, to enhance learning among healthcare professionals.

    • Medical education
    • Quality improvement methodologies
    • Infection control

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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    • Understanding the preferences, life experiences and motivations is crucial to adults learning success.

    • Game-based pedagogical strategies during Breakthrough Series’ learning sessions can help healthcare professionals make education more enjoyable and interactive while reinforcing key concepts and improving retention.


    • The new learning approaches applied here were a positive experience for healthcare workers during a quality improvement Collaborative preventing healthcare-associated infections in a middle-income country.


    • Our various pedagogical strategies may be a basis for other Collaboratives and infection prevention projects in developing countries.


    The motivations for learning often differ between adults and children or teenagers, with adult learning being subject to more complex and varied life experiences. For example, prior knowledge may make it easier to understand new concepts, but it can also lead to biases or assumptions that must be unlearned or re-examined.1 Adults may also have different learning styles and preferences. Some may prefer more structured, formal learning environments, while others thrive in informal or self-directed settings.1 2 Moreover, adult learners often have specific goals or reasons for pursuing education, such as career advancement or personal growth. Understanding and supporting these motivations can be key to helping adult learners succeed.1 2

    Learning sessions (LS) are collaborative activities within the Breakthrough Series (BTS) model3 to promote education, professional development and quality improvement (QI). These sessions typically involve bringing together healthcare professionals, patients and other stakeholders to share knowledge and experiences, engage in discussion and work together to identify solutions to common challenges. The structure and content of LS can vary depending on specific group goals and needs.3

    Educational games can be an effective tool for promoting engagement and active learning in medical education. Games can help make education more enjoyable and interactive while reinforcing key concepts and improving retention.4 5 This report includes a description of the usual active-learning strategies applied in LS, including a scenario-based approach involving role-playing and reflection to promote the integration of theory into daily practice, in addition to new strategies: two educational games, a card-based game and an escape room-type game, for training in the clinical skills and competencies necessary to prevent healthcare-associated infections (HAIs).



    The Collaborative Saúde em Nossas Mãos (SNM) is a large QI initiative implemented in Brazil using BTS methodology to prevent HAIs in intensive care units (ICUs).6


    Implementing evidence-based changes to clinical workflow and patient care processes is crucial for the success of HAI prevention projects. Professional training and empowerment are mandatory to improve patient care outcomes and create a safe patient culture, especially in intensive care settings.

    Study design

    A descriptive case study evaluating the application of diverse educational strategies during a new SNM cycle (2021–2023).


    The main objectives of the regional LS were to generate new ideas, strengthen execution and deepen knowledge. An educational game is a strategy designed to teach or reinforce a particular subject or skill. Game-based approaches can include quiz or trivia games, simulation games, puzzle games, etc.4 5 Here, two types of games were customised and adapted to enhance the learning about hand hygiene and plan-do-study-act (PDSA) cycles. ICU workers were divided into groups to stimulate teamwork, communication skills, social interaction and interactive learning.

    QI teams were compounded by interdisciplinary members representing key disciplines: physicians, nursing, respiratory therapists, technical nursing and at least one member certified in improvement science. The QI teams managed the games and acted as mentors during the activities, according to a predefined driver diagram based on the theory of change (data not shown).

    The first game involved arranging a series of symbol cards (representing procedures) in the correct order for clinical situations related to HAI control that were projected on a large screen by the QI team. Further rules and instructions for this activity are in the user manual (online supplemental material 1S). The second game was based on the ‘escape room’ scenario, in which players solve puzzles and riddles to escape a situation related to HAI prevention that is explained by the QI teams. Further rules and instructions can be found in the user manual development for this activity (online supplemental material 2S).

    Supplemental material

    Supplemental material


    The number of sessions and participants in these activities were recorded. A post-session survey was offered to all professionals. The survey was made available to all participants via QR-code at the end of each session using Google Forms, USA. Participation was anonymous, self-responded and voluntary. Table 1 describes the questions applied to assess the LS activities. Additionally, an open question was also included, and answers were coded and categorised into four labels: positive feedback, more activities inquiry, more time requested and miscellaneous. Quantitative and qualitative analyses were performed using the R statistics package, USA.

    Table 1

    Type of questions included in the post-intervention survey

    Regarding the game-based objectives, we present the ongoing results of two indicators: hand hygiene compliance and the number of PDSA cycles reported by the participating ICUs. Hand hygiene compliance was calculated as previously reported.6

    Patient and public involvement

    Patients and/or the public were not involved in this research’s design, conduct, reporting or dissemination plans.


    Seven regional 2-day LS were held between October and December 2022 (six for adult ICUs and one for a paediatric/neonatal ICU). Of the 194 institutions participating in the SNM at that time, 193 (99.4%) joined these activities, totalling 850 healthcare professionals, including physicians, nurses, physiotherapists and nursing technicians. The different activities, including the new game-based strategies, are presented in table 2. The card and escape room games were performed as planned (figure 1).

    Table 2

    Educational activities were carried out at the learning sessions during the quality improvement Collaborative

    Figure 1

    Picture characterising the setting of the educational activities, including the material used for the card (A) and escape room games (B).

    641 participants responded to the survey (75.4%). Figure 2 shows the survey results, indicating a high degree of satisfaction with the quality of the activities, with scores exceeding 88% (good or excellent experience), ranging from 88.2% in the assessment of duration to 90.5% in methods and performance. Most respondents rated relevance, organisation and clarity at 4 or 5 points (99.8%, 98.6% and 98.6%, respectively), denoting substantial satisfaction with the pedagogical undertakings.

    Figure 2

    Quantitative results of the post-session survey related to learning session activities. (A) Quality answers, (B) rating answers, (C) satisfaction answer.

    For open questions, 370 answers (57.7%) were registered. From them, more activity inquiries and more time requests were evidenced (39 and 101, respectively). Positive feedback (table 3) was evident in 34.6% of the responses, encapsulating reflections on acquired techniques, motivational enhancement, the recognition of nursing technicians’ contributions and the newfound appreciation for the dynamism of interdisciplinary collaboration.

    Table 3

    Qualitative analysis: primary quotes by category

    In terms of the targeted game-based educational objectives, there was an appreciable increase in hand hygiene compliance from a baseline of 62–73% over 6 months leading to April 2023. Concurrently, the SNM has documented 6676 PDSA cycles that are directly pertinent to the prevention of HAIs, hand hygiene improvement, utilisation of QI tools and the conduct of huddles.


    Regarding divergences among the participants, choosing the most suitable pedagogical strategies for Collaborative LS is challenging. Thus, the pedagogical proposals must be broad and diverse and consider the needs and motivations of each participant.1 2 This issue can be even more difficult in a large country such as Brazil, where sociocultural variations in distant areas may require adaptations according to local settings. All these adaptations were considered to make the regional LS activities feasible and more engaging, which is critical for the success of any Collaborative.

    LS offers an environment where ‘everyone learns, everyone teaches’.3 7 8 Conservative strategies such as unidirectional (paternalistic) interaction, exhibitions and classes have been replaced in recent years by more dynamic strategies in which experience, interaction and critical thinking become the central axes of medical education.4 5 9–12 ‘Learning by doing’ has become a widely used pedagogical tool, mainly in the health area, where different skills and abilities are honed in fictitious scenarios or on a day-to-day basis under the supervision of mentors.13 14 Interaction with peers, discussion and one-on-one coaching can provide a solid foundation for knowledge retention.7 8 11 14 The environment created in LS, in which participants can show their strategies (storyboarding), decisions, plans, problem-solving, and decision-making, creates an ideal environment for exchanging ideas, favouring interactional learning.7 14

    The progressive growth of medical knowledge has led to the need for continued medical education, including periodic updates about the best scientific evidence, which are a fundamental pillar of Collaboratives and crucial for infection control.15–19

    Games are already widely used in the academic environment as an educational tool, mainly in undergraduate medical and nursing courses.4 5 9 10 20 However, to the best of our knowledge, reports have yet to be published on game-based strategies in Collaborative LS. Both the card game and the escape room game were well-received by our participants, as they have been in other initiatives.10


    Being part of a nationwide initiative, this Collaborative was not designed as a separate research project; thus, it is not exempt from academic limitations. The assessment of knowledge acquisition/retention would have been desirable; however, the educational activities during our Collaborative were more related to practical knowledge rather than theoretical. Implementing participants’ evidence-based skills is critical for the Collaborative’s success; then, to accurately assess the intervention’s impact in loco, we include two process indicators related to the game-based activities.

    An interview with closed/directed questions would also have been helpful. However, open feedback procedures lead to free and spontaneous responses, facilitating the expression of positive or negative feelings about the activities. Moreover, demographic analysis of the participants, such as age, years of experience in the profession and experience with HAI control, should be included in subgroup analyses in future studies.

    As repercussions of HAI involve a more comprehensive and multifaceted intervention, including prevention bundle compliance, healthcare professional training and hand hygiene adhesion, among others, further details will be presented in our final QI report.


    The particularities of adult learning should not only be considered in the academic environment but also to achieve better learning during QI Collaboratives. Applying various pedagogical strategies was perceived positively by the health professionals in our sample, which shows the value of a broad and diverse educational approach, customised to local settings and including game-based activities, to enhance learning among healthcare professionals.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

    Ethics statements

    Patient consent for publication

    Ethics approval

    For this academic article, access to the Saúde em Nossas Mãos (SNM) database was approved by the local human research ethics committees (Certificado de Apresentação de Apreciação Ética - CAAE 66698023.7.0000.0071), with the consent of the SNM coordinator and the authorisation of the ministry responsible. The available database presented indicators of quality improvement processes and survey answers and did not exhibit any data referring to or mentioning the participants involved.


    We thank all the healthcare professionals working in the participating intensive care units; this project only succeeded with their empowerment and motivation. We also appreciate the technical and administrative teams of PROADI-SUS, which supported the development of this project.


    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


    • Collaborators Saúde em Nossas Mãos collaborative study group: Ana Paula Neves Marques de Pinho, Bruno de Melo Tavares, Daniela Pino Vinho, Helena Barreto dos Santos, Karen Cristina da Conceição Dias Silva, Luciana Gouvea de Albuquerque Souza, Nidia Cristina de Souza, Wladimir Garcia Silva (Hospital Alemão Oswaldo Cruz, São Paulo, Brazil); Andreia Lopes de Lima, Camila Bertoldo Pinheiro, Graziella Pacheco Velloni, Lais Silvestre Bizerra Baltazar, Livia Muller Bernz (BP - A Beneficência Portuguesa de São Paulo, São Paulo, Brazil); Andrea Keiko Fujinami Gushken, Cristiana Martins Prandini, Erica Deji Moura Morosov, Ingvar Ludwig Augusto de Souza, Marcelo Luz Pereira Romano, Samara de Campos Braga (Hcor, São Paulo, Brazil); Cilene Saghabi, Claudia Vallone Silva, Dejanira Aparecida Regagnin, Maria Yamashita, Patricia dos Santos Bopsin, Priscila Martini Bernardi Garzella, Youri Eliphas de Almeida (Hospital Israelita Albert Einstein, São Paulo, Brazil); Aline Brenner, Ananda Yana Zamberlan Alvarez, Gynara Rezende Gonzalez do Valle Barbosa, Patrick Jacobsen Westphal, Rafaela Moraes de Moura, Teilor Ricardo dos Santos, Viviane Aparecido Zopelaro de Melo (Hospital Moinhos de Vento, Porto Alegre, Brazil); Amanda Brassaroto Gimenes, Beatriz Ramos, Edileusa Novaes, Renata Gonsalez dos Santos (Hospital Sírio-Libanês, Sao Paulo, Brazil).

    • Contributors All authors contributed to data curation, formal analysis, investigation, methodology, validation, visualisation and writing. CMRC, LYU and CGdB also contributed to conceptualisation, project administration and supervision. SV, guarantor.

    • Funding This work was supported by public resources from the Ministry of Health through PROADI-SUS and with philanthropic resources from the participating institutions: Hospital Alemão Oswaldo Cruz, BP – A Beneficência Portuguesa de São Paulo, Hcor, Hospital Israelita Albert Einstein, Hospital Moinhos de Vento and Hospital Sírio-Libanês.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.