Game-Based Learning for Medical Staff Development
by Alana McDonald
Evidence-based practice is the foundation of medicine in Australia and doctors must work in an evidence-based way to ensure the best patient outcomes (Hoffmann, Montori, & Del Mar, 2014). There is great potential to utilise game-based learning (GBL) to support doctors in the acquisition of the skills required for evidence-based medicine (EBM). Traditionally, the continuing education of doctors has focused more heavily on the clinical aspects of EBM such as applying evidence to treatment (Frehywot et al., 2013). GBL is used to some degree in medicine, but the vast majority of games are simulations designed to teach clinical skills. While there is evidence to support the use of simulation in medical education, comparatively little literature exists discussing the ways in which GBL can support the theoretical aspects of EBM such as critical appraisal and literature searching. Medical librarians already assist doctors in this area by offering training in literature searching, assisting with systematic reviews, and frequently conducting literature searches on behalf of doctors. However, there is an opportunity for librarians to investigate GBL as a way of teaching these vital skills to doctors. This paper discusses the current implementation of GBL within an EBM framework, highlighting the gaps and opportunities for further types of games to be developed. The scope of this paper focuses solely on GBL for doctors. GBL has also been used to educate and train other clinical staff including nurses and allied health workers, however each of these populations has different educational needs and do not operate under the same EBM framework as doctors.
Information literacy and evidence-based medicine
EBM is not a new idea. Rosenberg and Donald (1995) define EBM as integrating medical information with clinical practice. In more recent years, researchers such as Ilic, Hart, Fiddes, Misso, and Villanueva (2013) have built on this idea by developing frameworks for EMB which include critical appraisal and assessment. In this way, EBM requires doctors to focus on research and medical knowledge as much as their clinical skills.
Despite this, blended and e-learning education has traditionally focused primarily on teaching clinical skills (Frehywot et al., 2013).
The Council of Australian University Librarians (2004) define information literacy as “an understanding and set of abilities enabling individuals to recognise when information is needed and have the capacity to locate, evaluate, and use effectively the needed information”. The term “information literacy” is not widely used either in medical schools or hospitals (Morley & Hendrix, 2012), however the skills required of an information literate person align well with those required of a doctor working within an EBM framework. The two terms are complimentary with both highlighting the importance of locating or acquiring, evaluating or appraising, and using or applying sources. The information literacy skills required for EBM are increasingly being taught to medical students early in their education (Brennan et al., 2014), mostly often as part of EBM units, suggesting an awareness at a university level of how important and non-negotiable these skills are to medical practice. However, it may be that as more focus is being put on acquiring these skills at university, hospitals assume doctors understand how to find and appraise information and little is done to ensure continuing education.
Game-based learning in medicine
There are many examples of games being used to improve patient outcomes and increase knowledge and education. These focus on a wide range of health topics including increasing physical activity, smoking cessation and managing diabetes (Brox, Fernandez-Luque, & Tøllefsen, 2011). Reframing the definition to fall more specifically within a health context, Fleming (2016, p. 4) defines serious games as “interventions that are games, or that utilize elements of gaming, as an integral and primary method for achieving a serious purpose, such as a health or educational goal.” Using this definition, it is therefore not surprising that the majority of games for doctors are serious games that focus on teaching a particular skill. Although serious games are relatively new to the medical environment when compared with schools and higher education, there are many benefits. Virtual simulation games are far more cost-effective than their real-world counterparts and can be played by doctors at a time that suits them, which leads to increased accessibility. Similarly, games can be designed to focus on particular scenarios and patient populations, giving doctors exposure to patients they may rarely come across in their professional practice and allowing them to maintain their skills. Doctors also have the opportunity to play these games many times until they feel confident, something which cannot be done with real-world simulation. Serious games also have the benefit of being enjoyable and engaging, which increases motivation and ultimately leads to better-trained staff and improved patient outcomes (Ricciardi & De Paolis, 2014).
By far the most popular form of GBL for doctors is simulation, which allows players to refresh or learn particular skills in a challenging, engaging environment. Simulation games help medical students and newly qualified doctors bridge the gap between theory and practice (Stanley & Latimer, 2011), and are a more sophisticated version of a form of training already commonly offered in hospitals. For example, The Sydney Children’s Hospitals Network has a simulation-based training program called Kids Simulation Australia, which offers a range of hands-on simulation activities for doctors. Simulation in serious games can be seen as a logical next step to more traditional simulation, still teaching doctors the same skills but with all the benefits GBL offers. GBL should be used to complement, rather than replace traditional means of educating doctors, however there is evidence to suggest that GBL is more effective than many traditional educational methods including script-based instruction (Boeker, Andel, Vach, & Frankenschmidt, 2013).
Examples of simulation games used in medicine include:
Pulse!! The Virtual Clinical Learvning Lab
Pulse! is an American serious game set in an emergency department, where players can practice responding to emergency situations without the risk of harming patients.
SimUrgences is a French-designed serious game that trains cardiologists and emergency department staff in the management of cardiac emergencies.
Many researchers have tried to identify the key elements of games and what makes an educational experience game-based learning using different theoretical frameworks. Chee Siang, Avni, and Zaphiris (2008) suggest that different aspects of games can be explored by three different learning theories (behaviourism, cognitive constructivism and social constructivism). No game will fit neatly into one theory; however, it is cognitive constructivism which provides us with the best framework for analysing simulations. Chee Siang et al. (2008) suggest that simulated games provide multiple story paths, require players to understand complex rules, require logical thinking, and offer multiple solutions. A simulation game such as Pulse! adheres to this by providing flexibility for players regarding how and what they do to treat patients. There may be more than one way to successfully treat a patient in medical simulations, however it is worth noting that simulations are rooted in evidence-based medicine, which generally has some form of best practice guidelines that players would be expected to follow.
Although games share some common characteristics such as goals and rules (Whitton, 2009), the specific elements vary depending on game type, and not all elements will be present in all games. Dondlinger (2007) suggests that the core elements of most games are:
- Narrative context
- Goals and rules
- Interactivity and multisensory cues
In contrast Whitton (2009) identifies the core characteristics of games as:
When looking specifically at simulations, Peddle (2011) suggests that the core elements are:
- Reasoning through a problem
- Allows users to take on roles and create their own meaning
- Rules or norms
- No real-world consequences
Although each set of elements differ, there are some common themes which can be broken down into the following categories:
- Rules and goals
- Competition and motivation
- Outcomes and feedback
- Narrative, immersion and fantasy
All of these elements can be easily applied to simulations, which operate under a set of rules and provide clear goals and motivation (saving a patient), outcomes and feedback (the patient lives/dies), and narrative or immersion (being put into a setting such as the emergency department).
As well as simulations, other types of games have been developed to target slightly different skills. Several medical journals have developed gamified apps that doctors can use to improve their skills including the JAMA Network Challenge – a peer-reviewed game for iOS by the American Medical Association, and NJEM Image Challenge by the New England Journal of Medicine. eMedOffice is a web-based collaborative serious game aimed at medical students, teaching them the basics of a GP’s medical practice. Although this game has a simulation component, visually it presents more as a typical computer game than a simulation.
The vast majority of medical games are simulations which focus on the development and maintenance of clinical skills (Ricciardi & De Paolis, 2014). There are limited other medical games and the majority of those focus on acquiring clinical knowledge. When looking at medical games through an EBM framework, most games emphasise applying evidence while the remainder generally focus on acquiring evidence. There is, therefore, an opportunity for serious games in the medical field which focus on the remaining information literacy skills required for EBM, namely the formulation of clinical questions and critically appraising evidence once it has been acquired.
Doctors are required to make quick, accurate, informed clinical decisions within an evidence-based framework (Brennan et al., 2014). Assessment in the medical field focuses primarily on competency of clinical skills (Simons, Morgan, & Davidson, 2012), and although it is expected that doctors will keep up to date with current literature and have the skills to find and critically evaluate said literature, these skills are generally neither formally assessed nor explicitly taught (O’Malley & Delwiche, 2012). Historically, information literacy has not been an area of focus for health librarians. Unlike universities, where information literacy skills are regularly taught, a core part of the health librarian role is to conduct literature searches on behalf of busy doctors (Kelham, 2014). In recent years there has been more emphasis put on teaching information literacy skills to doctors (Simons et al., 2012). More resources have been developed to assist doctors in developing their information literacy skills. In New South Wales, the Clinical Information Access Portal (CIAP) provides access for all NSW Health employees to a wide range of resources including databases, journals, eBooks and clinical guidelines. In collaboration with health librarians, CIAP has developed four information literacy e-learning modules which cover locating, searching, and integrating research. However, these modules are quite dry and time-consuming, which is a barrier for doctors who have limited time and competing demands. There is an opportunity for health librarians to become more involved in information literacy education and to identify innovative, engaging ways to teach content to doctors, bearing in mind their particular needs and challenges.
This paper extends an invitation to a hospital in New South Wales to take a step beyond e-learning and develop a serious game for doctors focusing on information literacy skills, primarily searching for information and critically appraising sources, as there are a lack of medical games currently relating to these subjects. There are a number of information literacy games that have been developed for academic libraries which may serve as a model, although the target audience and content will be different.
Library Quest (Mangan, n.d.)
Library Quest is a fun, straightforward game with a primary focus on library skills and services, rather than information literacy. It is visually engaging and humorous, and puts players in a number of scenarios where they are required to select the correct answer from options given. The narrative structure and multiple choice format is simple to design and can easily be tailored to the needs of doctors.
LibraryCraft (Utah Valley University, n.d.)
LibraryCraft is an information literacy game developed by Utah Valley University. As with Library Quest, LibraryCraft employs narrative-based gameplay and requires students to correctly answer multiple choice questions to advance. It is less visually engaging than Library Quest with a narrative that takes its cues from the world of fantasy. The player must arm themselves with knowledge to defeat a dragon terrorising a village.
Web Evaluation Game (British Columbia Institute of Technology, n.d.)
Developed by British Columbia University of Technology, this game involves five mini-games that take players through various aspects of evaluating sources. The games can be completed in any order. This game lacks the strong narrative of the previous two games, however this enables developers to create specific mini-games that teach a particular skill, rather than having to fit these in around a narrative framework.
It is hoped that the final game will be viewed by doctors as both educational and engaging, and that it will ultimately lead to increased confidence in locating and critically appraising sources.
GBL offers doctors the opportunity to improve and maintain information literacy skills, particularly information seeking and critical appraisal, in an engaging way. These skills are increasingly being taught to medical students during their degree, and it is assumed that both newly qualified and more senior doctors possess these skills and they are not formally assessed in hospitals. The majority of GBL in medicine currently focuses on clinical skills and are usually simulations designed to teach particular skills or to provide doctors with practice working with particular populations or working in high pressure environments such as the emergency department. There is an opportunity for serious games to be developed which focus on information literacy skills, both because the importance of acquiring these skills can be overlooked and because few, if any, games currently exist to target this. The opportunity exists to open up new ways to teach these skills to doctors and to broaden the scope of GBL in medicine to include these other vitally important aspects of EBM, thus resulting in improved medical practice and better patient outcomes.
Australian and New Zealand Institute for Information Literacy. (2004).Australian and New Zealand Information Literacy Framework: principles, standards and practice. Adelaide: Australian and New Zealand Institute for Information Literacy (ANZIL) Retrieved from http://www.caul.edu.au/content/upload/files/info-literacy/InfoLiteracyFramework.pdf.
Boeker, M., Andel, P., Vach, W., & Frankenschmidt, A. (2013). Game-based e-learning is more effective than a conventional instructional method: a randomized controlled trial with third-year medical students. PLoS ONE [Electronic Resource], 8(12), e82328. doi:http://dx.doi.org/10.1371/journal.pone.0082328
Brennan, N., Edwards, S., Kelly, N., Miller, A., Harrower, L., & Mattick, K. (2014). Qualified doctor and medical students’ use of resources for accessing information: what is used and why? Health Information & Libraries Journal, 31(3), 204-214. doi:10.1111/hir.12072
British Columbia Institute of Technology (n.d.). Web Eval [computer game]. Retrieved from http://cdl-prod.bcit.ca/library/weg/.
Brox, E., Fernandez-Luque, L., & Tøllefsen, T. (2011). Healthy gaming–video game design to promote health. Applied Clinical Informatics, 2, 128-142.
Chee Siang, A., Avni, E., & Zaphiris, P. (2008). Linking Pedagogical Theory of Computer Games to Their Usability. International Journal on E-Learning, 7(3), 533-558.
Dondlinger, M. J. (2007). Educational video game design: A review of the literature. Journal of Applied Educational Technology, 4(1), 21-31.
Fleming, T. M., de Beurs, D., Khazaal, Y., Gaggioli, A., Riva, G., Botella, C., . . . Riper, H. (2016). Maximizing the Impact of e-Therapy and Serious Gaming: Time for a Paradigm Shift. Frontiers in Psychiatry, 7, 65. doi:http://dx.doi.org/10.3389/fpsyt.2016.00065
Frehywot, S., Vovides, Y., Talib, Z., Mikhail, N., Ross, H., Wohltjen, H., . . . Scott, J. (2013). E-learning in medical education in resource constrained low-and middle-income countries. Human Resources for Health, 11(4).
Hannig, A., Kuth, N., Ozman, M., Jonas, S., & Spreckelsen, C. (2012). eMedOffice: a web-based collaborative serious game for teaching optimal design of a medical practice. BMC Medical Education, 12, 104. doi:10.1186/1472-6920-12-104
Hassan, I. (Creator). (2014). Introduction to EBM resources. [PowerPoint slides] Retrieved from http://www.slideshare.net/imadhassan/part-1-introduction-to-evidencebased-medicine-literature-ser
Hoffmann, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making. Journal of the American Medical Association, 312(13), 1295-1296.
Ilic, D., Hart, W., Fiddes, P., Misso, M., & Villanueva, E. (2013). Adopting a blended learning approach to teaching evidence based medicine: a mixed methods study. BMC Medical Education, 13(1), 1.
Interaction Healthcare. (2011). SimUrgences [computer game].
Kelham, C. (2014). Health care librarians and information literacy: an investigation. Health Information & Libraries Journal, 31(3), 235-238. doi:http://dx.doi.org/10.1111/hir.12071
Mangan, Rowan. (n.d.). Library Quest [online game]. Retrieved from http://www.libraryquestgames.com/.
Morley, S. K., & Hendrix, I. C. (2012). “Information Survival Skills”: a medical school elective. Journal of the Medical Library Association, 100(4), 297-302. doi:http://dx.doi.org/10.3163/1536-5050.100.4.012
O’Malley, D., & Delwiche, F. A. (2012). Aligning library instruction with the needs of basic sciences graduate students: a case study. Journal of the Medical Library Association, 100(4), 284-290. doi:http://dx.doi.org/10.3163/1536-5050.100.4.010
Peddle, M. (2011). Simulation gaming in nurse education; entertainment or learning? Nurse Education Today, 31(7), 647-649. doi:http://dx.doi.org/10.1016/j.nedt.2010.12.009
Ricciardi, F., & De Paolis, L. T. (2014). A Comprehensive Review of Serious Games in Health Professions. International Journal of Computer Games Technology, 11. doi:10.1155/2014/787968
Rosenberg, W., & Donald, A. (1995). Evidence based medicine: an approach to clinical problem-solving. British Medical Journal, 310(6987), 1122.
Simons, M. R., Morgan, M. K., & Davidson, A. S. (2012). Time to rethink the role of the library in educating doctors: driving information literacy in the clinical environment. Journal of the Medical Library Association, 100(4), 291-296. doi:http://dx.doi.org/10.3163/1536-5050.100.4.011
Stanley, D., & Latimer, K. (2011). ‘The Ward’: A simulation game for nursing students. Nurse Education in Practice, 11(1), 20-25. doi:http://dx.doi.org/10.1016/j.nepr.2010.05.010
Texas A&M University, Corpus-Christi. (n.d.). Pulse!! The Virtual Clinical Learning Lab [computer game].
Utah Valley University. (n.d.). LibraryCraft [online game]. Retrieved from https://www.uvu.edu/library/librarycraft/.
Whitton, N. (2009). Learning with Digital Games : A Practical Guide to Engaging Students in Higher Education. Retrieved from http://CSUAU.eblib.com/patron/FullRecord.aspx?p=448350