(This is the final post in a series of 10. Here are links to the introduction and previous chapters: Modal Model of Memory; Naturalistic Decision Making; Communities of Practice; Emotional Intelligence (EQ); Social Constructivism; Reflective Practice; Self-Directed Learning; Bloom’s Taxonomy and Dual Process Reasoning. We need your comments / peer review to make this primer on education theory better.  Please include them in the comments section at the end of each chapter. We will acknowledge your contribution in the forthcoming eBook.)

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Gamification

Authors: Will Sanderson and Samantha L. Wood

Editors: Lalena M Yarris,  Dimitri Papanagnou, Michael Gottlieb and Teresa Chan

Main Authors or Originators: Thomas Malone, Nick Pelling, Katie Salen, Bryan Bergeron

Gamification is the use of game design in a non-game context.  Gamification has been applied to learning in order to increase motivation and engagement.  The following definitions may be helpful:Game: a form of play or sport, especially a competitive one, played according to rules and decided by skill, strength, or luck

Gaming: the playing of games

Gamification: the application of typical elements of game playing (i.e., point scoring, competition with others, rules of play) to other areas of activity

Serious Game: an interactive application that has a challenging goal, is fun to play and engaging, incorporates some scoring mechanism, and supplies the user with skills, knowledge, or attitudes useful in reality

Part 1:  The Hook

Thad, a 2nd year Emergency Medicine (EM) resident, is burnt out. It’s December, and he’s halfway through his residency;  the beginning of intern year seems like forever ago, and he’s not even halfway to being finished with his training. He has just come off of a run of particularly brutal off-service rotations (during which he guiltily ignored the stack of textbooks and articles on his desk), and he’s now happy to be back in the emergency department (ED) for a month. He hasn’t seen his fellow EM residents since September, and Thursday during conference is the first opportunity he’ll have to catch up . . . too bad he’ll have to sit through 5 hours of mind-numbing lectures in exchange for the chance to socialize with his classmates.

It’s Wednesday evening and Charlotte, Thad’s roommate, is fired up.

“This is epic.”

Charlotte picked up the latest installment in the Call of Duty series for their shared Xbox One on her way home. She’s a pro, and has already spent 3 hours tearing into the game’s Campaign mode. “You need to check this out, Thad. It’s ri-donk-ulous.”

“Can’t. Got conference in the morning.”

“Oh, c’mon. How can that compare to this? You haven’t been there in months anyway – what could you be missing? Just read one of those big brain textbooks you have, or listen to that goofy guy on that nerdy podcast you listen to.”

Thad thinks Charlotte makes a good point. And, after all, he deserves it, right? He can immerse himself in the world of modern warfare, kick Charlotte’s behind, and still not lose much if he just catches up with his reading/listening at 3pm tomorrow after he wakes up.

“You’re smarter than you look. I’m in.”

Part 2:  The Core

Overview

The most basic approach in applying games to medical education is gamification, which is the application of game-like properties to non-game situations.1  The game-like properties may include rules of play, point scoring, competition with others, chance, and reward for “winning”.

Serious Games

The term “serious game” refers to an interactive game, often played on a computing device, that has a challenging goal, is fun to play and engaging, incorporates some scoring mechanism, and supplies the user with skills, knowledge, or attitudes useful in reality.(1)  A serious game has the following characteristics:

A defined outcome that learners must achieve
Rules that limit the learner’s path to the goal
Feedback to the learner
Voluntary participation
Achievement of “flow” in skill and difficulty level.
Background

Although educators have undoubtedly been using game playing elements to enhance learners’ experience and retention for centuries, one of the first broadly distributed examples of gamification in education was the creation of “Where in the world is Carmen Sandiego?” in the mid 1980’s.  (2)

Gamification of education can intersect with other educational theories.  For example, combining behaviorism with gamification tells us that the receipt of a “reward” (points) is likely to encourage a desired behavior (answering a question correctly).(3)  A social constructivist application of gamification will place participants in teams and present them with a problem that requires collaboration and construction of new knowledge in competition against other groups.(3)

Limitations of gamification include the risk that learners will find the experience undesirable and “opt out” (for example, if learners find it distressing to answer a question wrong in conference or feel ashamed if their point total is low, they may choose not to participate; additionally learners may opt out if the “reward” is not sufficiently desirable).  Gamification is also most appropriately applied to fairly straightforward decision making rather than complex thought processing.

Serious games differ from gamification in their reliance on the learner’s intrinsic motivation to continue the game.  A serious game should continually stretch the learner by operating at the outer level of his or her competence and presenting concrete challenges that become harder as skills are mastered.  This “just out of reach” approach to motivation applies the Yerkes-Dodson Law (4) to achieve the ideal level of “stress” to encourage maximal learning conditions.  The serious game endeavors to situate the user at a state where he or she is experiencing “flow” (the psychological state of enjoyment while learning is taking place, which was theorized by Csikszentmihalyi) (5) and simultaneously challenged to master material slightly out of reach aligns with Ericsson’s concept of deliberate practice (6).

One key limitation of serious games is the need for user initiative, although the underlying principle is that once the user starts playing, he or she will find the experience enjoyable and be motivated to continue.  Additionally, the reliance of serious games on computers may exclude participants who cannot access or are not comfortable with the technology.

Modern takes or advances

Many would consider that gamification itself is already the modern take on behaviourist theories, which originated with B.F. Skinner(8).  Skinner’s work incorporated a number of facets that teachers will note are seen in gamification or other gaming platforms (e.g. positive reinforcements, small step-by-step tasks, feedback that is provided to students immediately, progressively difficult challenges).  That said, gamification should not be exclusively thought of as just a reinvention since it also integrates a fairly important social component and allows for multiple outcomes and paths to success, which is unlike Skinner’s original work. (3)

Other examples of where this theory might apply in both the classroom & clinical setting

Applications of gamification in the clinical and classroom setting can take many forms.

Some examples include:

Simulation

Simulations are activities that center on simulated use of the skill(s) to be developed. Simulations typically require a model of the situations in which the skills would be used and the variables that affect the decisions the ‘player’ makes.
Classically, simulation has not been perceived from the lens of “gaming” or gamification, as  it seeks to mimic reality. That said, more recent applications suggest simulation  can be reconceptualized to emphasize a gameplay-type approach.  Sunga et al. (2016) suggest that using simulation in a gameplay manner may be useful for learning. (9)
Virtual Environments (10)

This may also be valuable for resuscitation training. Online scenarios for recertification in online teaching platforms also resemble video games and other learning tools (11).
Creation of a trauma patient simulator with points awarded for correct actions taken and increasing level of difficulty as the learner succeeds (12)
Social and cooperative play (13)

Assignment of points for correct answers in resident conference and giving a prize to the winner.
Organization of a competitive wearable fitness device community to encourage resident wellness
Challenging a learner to a task bound by “rules of play” in the clinical setting (i.e. “I want you to go do a lung exam on Mr. Jones and then come tell me what you think we’ll see on the chest x-ray” or “Pull up the head CT on Mrs. Smith and tell me what symptoms you think she presented with”)

A Simple Model of Game Development to Support Learning

Should an educator and/or instructional designer want to apply gamification to learning and learning outcomes, the following model can assist him/her with considering necessary elements to ensure the development of  a sound, educational game. (14)

Player (i.e., Learner) Decision and Actions: The educator should first consider the skills the player needs to learn, and the specific actions that the learner would need to take to build on these skills. This process will also assist the educator in identifying any decisions the learner will need to make regarding these skills, as well as the situations, resources, and any other factors that would influence these decisions. Each of these factors should be considered as variables that will contribute the success of a successful educational intervention that leverages gamification.(14)
Feedback: The educator should build-in a process that evaluates the learner during the game, which should distinguish between correct and incorrect (or good versus bad) decisions. It should also be predetermined now these objective evaluations will affect the course of the game (i.e., does it change the score, the resources available, or future options). The educator should also decide the time with which feedback is delivered to the learner (i.e., is it delayed or is it immediate).(14)
Goals: The goals of the game should be clearly delineated. Ideally, these goals should be congruent with the educator’s learning objectives. Additionally, does the successful achievement of these goals trigger the end of the game, or does the learner continue to be immersed in the game? (14)
Mechanics / Resources: Game mechanics define how learners’ decision in the game interact with game objects (i.e., characters, issues). This is where the educator designs the game to abstract real-world concepts or learning issues into game objects. Additionally, the educator should consider any resources the learner will need to use throughout the game (i.e., time, money, lives, turns).(14)
Challenge Curve: Learning during the game will come from encountering challenges and devising methods to overcome them. Potential challenges may include, but are not limited to, the following: active opposition (i.e., the obstructive consultant); parallel competition (i.e., competing with fellow resident); limited resources (i.e., limited diagnostic testing); and limited time. Fine-tuning the progression of challenge is one of the most important aspects of ensuring a successful learning game. The length of the game should also be predetermined, as the duration of the game will dictate how much time is realistically available to allow for an increasing challenge curve.(14)
Playtest: It is advised that the educator and/or instructional designer test (or play) the game several times before it is introduced to learners. Both experiences and junior learners can also be invited to test the game. During this iterative process, feedback from participants should be incorporated into fine-tuning the game in order to ensure it meets the overarching goals and learning objectives.(14)

Annotated Bibilography of Key Papers

Akl EA, Pretorius RW, Sackett K, et al. The effect of educational games on medical students’ learning outcomes: A systematic review: BEME Guide No 14. Med Teach. 2010;32(1):16-27. (12)

This article is a systematic review evaluating the effect of educational games on medical students’ satisfaction, knowledge, skills, attitudes, and behaviors. Given the associated costs (e.g. time, resources, preparation) associated with educational games, the authors sought to determine whether a significant benefit resulted from its implementation. The resulting studies highlight the limited existing high-quality literature. The authors also provide a bibliography of other relevant studies.

McCoy L, Lewis JH, Dalton D. Gamification and Multimedia for Medical Education: a Landscape Review.  J Am Osteopath Assoc.  2016;116(1):22-34.(10)

This review article is a descriptive study of existing gaming resources available for use in medical education. The authors provide evidence supporting the value of gamification, followed by a list of 45 available resources with a table summarizing the basic design, product highlights, and how to access them. This can be a valuable early resource when seeking to utilize gamification for medical education at one’s institution.

Bíró GI. Didactics 2.0: A pedagogical analysis of gamification theory from a comparative perspective with a special view to the components of learning. Procedia-Social and Behavioral Sciences. 2014 Aug 25;141:148-51.(3)

This article discussed the unique value of gamification for the Generation Z learner, emphasizing the utilization of online resources, socialization, increased interactivity, and positive reinforcement. Next, the author compares gamification with several existing learning theories, highlighting several similarities and differences that make gamification unique. Finally, the article addresses the importance of further study and possible future directions.

Part 3:  The Denouement

BEEP BEEP BEEP BEEP

“Jeez…enough already,” Thad mutters to himself as he fumbles to turn off his phone’s wakeup alarm.

He looks at the time – 1pm. “Missed conference.”

He and Charlotte spent the rest of last night playing online multiplayer and finally crashed at 5am. He feels a little guilty for missing out on conference, but it’s always so boring.

Still, this can’t be his go-to move. He can’t just not go because it’s boring; after all, he’s a professional now, an adult, and if he doesn’t learn the stuff he needs to learn it will be his patients that suffer. There’s got to be a better way…

That afternoon, Thad texts his APD to see if she can meet up for a 15 minute coffee.

“I’ve got some ideas I want to run by you.”

Dr. Cozart has always been pretty cool and approachable, and she was happy to meet with him.

“For sure. See you at the Bean at 7pm?”

“Done. See you there.”

“What you got, Thad?”

“Well…and I’m sure you noticed this…I wasn’t at conference today. I’m not here to make excuses, and really I should’ve been there no matter what. But I’m going to be straight with you: I spent all night playing Call of Duty and it was awesome. It gives me a sense of play and competition that I just haven’t seemed to find yet in residency. So here’s my question for you: is there a way we can incorporate gaming into our resident education?”

Dr. Cozart paused. “Well, I can’t say I’m shocked that you weren’t there, but I’m really pleased you took the initiative here. I’ve been looking for a resident champion for conference to increase interest. Because let’s be honest – there’s been no interest. Our seniors are barely making the attendance cutoffs for graduation, and when residents are present they’re completely absent with respect to their attention. In fact, I could have sworn I saw one of your colleagues creating face swapping videos with a glittering pink bullmastiff on Snapchat throughout the entire thyroid storm lecture.”

“Yeah. They do that.”

“Why? Wait, don’t answer that.”

“Well I don’t know a lot about how we’d do this or any of that educational design stuff that you do, but I’d be happy to help out in any way I can. I want to learn and I want things to be better for all of us.”

“Great! Well you know we do something similar during our sim days, but I think that there are opportunities to do more. Have you heard of this thing called the “Virtual ED”?

“No.”

“Well it’s based on this concept of creating virtual online worlds, kind of like – what was the name of that game you…”

“Call of Duty.”

“Call of Duty… OK I guess kind of sort of like that. Well what you can do is have people log in to this virtual ED and act out scenarios by moving their people around the room just like they would in sim. They can be elsewhere and log into a browser. They have a microphone on their end and everyone else in the virtual room can hear everything.”

“Wait! We could split up our residency into 4 groups and have like a competition or team based thing where they all compete to try to win the VEC!!!”

“The VEC????”

“The Virtual ED Championship. Work with me here.”

“I’m trying.” Dr. Cozart was smiling. “I think you’re onto something. You’re going to need to flesh this out, but I think you’re onto something. You’ll need to find a way to tie it to our core content, as you know we’ve been getting away from that lately…”

“Awesome! The residents are going to love this. Trust me.”

“I’ll grant you the former. The latter?”

“Funny. I’ll get a proposal to you by next week.”

PLEASE ADD YOUR PEER REVIEW IN THE COMMENTS SECTION BELOW

References

1. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA 2011; 306: 978–988.
2. Hogle, J.G., 1996. Considering games as cognitive tools: In search of effective edutainment. Accessed Jan 27, 2017: Available at: https://eric.ed.gov/?id=ED425737.
3. Bíró GI. Didactics 2.0: A pedagogical analysis of gamification theory from a comparative perspective with a special view to the components of learning. Procedia-Social and Behavioral Sciences. 2014 Aug 25;141:148-51.
4. Cohen RA. Yerkes–Dodson Law. In: Encyclopedia of clinical neuropsychology 2011 (pp. 2737-2738). Springer New York.
5. Nakamura J, Csikszentmihalyi M. The concept of flow. In: Flow and the foundations of positive psychology 2014 (pp. 239-263). Springer Netherlands.
6. Ericsson KA, Krampe RT, Tesch-Römer C. The role of deliberate practice in the acquisition of expert performance. Psychological review. 1993 Jul;100(3):363.
7. Rapoport A, Chammah AM. Prisoner’s dilemma: A study in conflict and cooperation. University of Michigan press; 1965.
8. Skinner, B. F. The Technology of Teaching, Appleton-Century-Crofts, 1968.
9. Sunga K, Sandefur B, Asirvatham U, Cabrera D. LIVE. DIE. REPEAT: a novel instructional method incorporating recursive objective-based gameplay in an emergency medicine simulation curriculum. BMJ Simulation and Technology Enhanced Learning. 2016 Nov 1;2(4):124-6.
10. McCoy L, Lewis JH, Dalton D. Gamification and Multimedia for Medical Education: a Landscape Review.  J Am Osteopath Assoc.  2016;116(1):22-34.
11. Delasobera BE, Goodwin TL, Strehlow M, Gilbert G, D’Souza P, Alok A, Raje P, Mahadevan SV. Evaluating the efficacy of simulators and multimedia for refreshing ACLS skills in India. Resuscitation. 2010 Feb 28;81(2):217-23.
12. Youngblood P, Harter PM, Srivastava S, Moffett S, Heinrichs WL, Dev P. Design, development, and evaluation of an online virtual emergency department for training trauma teams. Simulation in Healthcare. 2008 Oct 1;3(3):146-53.
13. Akl EA, Pretorius RW, Sackett K, Erdley WS, Bhoopathi PS, Alfarah Z, Schünemann HJ. The effect of educational games on medical students’ learning outcomes: a systematic review: BEME Guide No 14. Medical teacher. 2010 Jan 1;32(1):16-27.
14. Johannigman, J (January 2017). “Think Like A Game Designer: Techniques for Creating Learning Games.” The Lilly Conference: Evidence-Based Teaching and Learning; Austin, Texas.

Other Further Resources

1. Alvarez J, Djaaouti D. Serious Games: An Introduction.  Questions Theoriques, Limoges, France, 2012. Available from:  http://ja.games.free.fr/These_SeriousGames/TheseSeriousGames.pdf
2. Becker K. How Are Games Educational ? Learning Theories Embodied in Games. Chang Views Worlds Play. 2005:1-6.
3. Struwig MC, Beylefeld A a., Joubert G. Learning medical microbiology and infectious diseases by means of a board game: Can it work? Innov Educ Teach Int. 2013;3297(February 2015):1-11. doi:10.1080/14703297.2013.774139.
4. Beylefeld AA, Struwig MC. A gaming approach to learning medical microbiology: students’ experiences of flow. Med Teach. 2007;29(9):933-940. doi:http://dx.doi.org/10.1080/01421590701601550.
5. Bochennek K, Wittekindt B, Zimmermann S-Y, Klingebiel T. More than mere games: a review of card and board games for medical education. Med Teach. 2007;29(9):941-948. doi:10.1080/01421590701749813.
6. Cain J, Piascik P. Are Serious Games a Good Strategy for Pharmacy Education?: OneSearch for University of South Alabama Libraries. 2015;79(4). http://eds.a.ebscohost.com.libproxy.usouthal.edu/eds/pdfviewer/pdfviewer?sid=8ad29391-b6c1-49bf-a837-e56f65fd60f4@sessionmgr4003&vid=1&hid=4208.
7. Eisenhardt KM, Bird C. Copyright © 2001 All Rights Reserved. Science (80- ). 2001.
8. Friedl KE, O’Neil HF. Designing and Using Computer Simulations in Medical Education and Training: An Introduction. Mil Med. 2013;178(10S):1-6. doi:10.7205/MILMED-D-13-00209.
9. Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for medical education and surgical skills training. Br J Surg. 2012;99(10):1322-1330. doi:10.1002/bjs.8819.
10. Kanthan R, Senger JL. The impact of specially designed digital games-based learning in undergraduate pathology and medical education. Arch Pathol Lab Med. 2011;135(1):135-142. doi:10.1016/j.ypat.2011.08.024.
11. Katie Larsen McGlarty AOPMFRPDVVAM. A Literature Review of Gaming in Gaming. Gaming Educ. 2012;(June):1-36. doi:http://dx.doi.org/10.1108/17506200710779521.
12. Knosp BB, Carver I, Hamill G, Corral J. Game-Based Learning in Medical Education. 2013;(January):2013.
13. Keeth, B. Gamification in Healthcare – Let’s play! March 16, 2017. Available at: https://bernadettekeefemd.com/2016/03/16/gamification-in-healthcare-lets-play/. Accessed March 22, 2017.
14. Pitt MB, Borman-Shoap EC, Eppich WJ. Twelve tips for maximizing the effectiveness of game-based learning. Med Teach. 2015;37(November):1013-1017. doi:10.3109/0142159X.2015.1020289.
15. Ricciardi F, De Paolis LT. A Comprehensive Review of Serious Games in Health Professions. Int J Comput Games Technol. 2014;2014:e787968. doi:10.1155/2014/787968.
16. Rondon S, Sassi FC, Furquim de Andrade CR. Computer game-based and traditional learning method: a comparison regarding students’ knowledge retention. BMC Med Educ. 2013;13(1):30. doi:10.1186/1472-6920-13-30.
17. Tolk A, Miller GT, Cross AE, Maestri J, Cawrse B. AIMS: Applying game technology to advance medical education. Comput Sci Eng. 2013;15(6):82-91. doi:10.1109/MCSE.2013.115.
18. Wang R, DeMaria S, Goldberg A, Katz D. A Systematic Review of Serious Games in Training Health Care Professionals. Simul Healthc. 2016;11(1):41-51. doi:10.1097/SIH.0000000000000118.