Title: Investigating Game-Based Learning in Higher Education through the Case of a Serious Game to Teach Environmental Hazard and Safety Assessment to Undergraduate Nursing Students
Author Name: Philip Ehrenberg
Selected Case (Published Article):
Volejnikova-Wenger, S., Andersen, P., & Clarke, K.-A. (2021). Student nurses’ experience using a serious game to learn environmental hazard and safety assessment. Nurse Education Today, 98, Article 104739. https://doi.org/10.1016/j.nedt.2020.104739
1. Introduction
Game-based learning is a topic that continues to entertain great amounts of interest globally, with increasing attention paid to the different ways that well-designed serious games enable different types of learning. In particular, games’ power to promote complex intellectual skills like problem solving, cognitive strategies, and other higher learning outcomes, particularly when utilizing elements of situated learning, is considered a key affordance (Van Eck et al., 2018). Moreover, games can promote these learning outcomes through a more immersive and engaging format than traditional, didactic instruction, while providing a safe space for failure and experimentation through repeated gameplay loops. Still, games as learning tools have not always lived up to this potential, as Boyle et al. (2016) found in a systematic literature review suggesting games for learning were most frequently used as tools to support more basic knowledge acquisition. Further, more investigation is needed into how specific game features efficaciously support learning, as well as what elements contribute to engagement in games specifically and how that ludic engagement then impacts learning.
In higher education, one potential model for instructional design is the significant learning model that promotes learning experiences that “will facilitate and encourage awareness, connection, integration, and commitment by learners” through the independent categories of foundational knowledge, application, integrations, human dimension, caring, and learning how to learn (Litchfield, 2018). This becomes even more crucial when coupled with the field of medical education, where curricula must meaningfully integrate problem-solving skills with foundational scientific knowledge, risk assessment, interpersonal communication, sensory perception, and a mentality for ongoing research and lifelong learning (Locatis, 2018). To that end, case-based simulations are frequently utilized in medical education and viewed through that lens, it seems serious games have much to offer medical curricula in higher education settings.
The selected case by Volejnikova-Wenger et. al (2021) investigates the use of a serious game to teach undergraduate nursing students about environmental hazards and safety assessments in community and residential healthcare settings. Beyond simply assessing the efficacy of knowledge transfer or the acquisition of particular behaviors or skills, this study attempted to understand the way different game and player elements interacted to impact the learning process. Their results are the KnavEL Model, which identifies themes of Knowledge, Navigation, Engagement, and Learning.
2. Overview of the Case
A game, Safe Environments, was designed by faculty at the University of the Sunshine Coast in Queensland, Australia in conjunction with the studio Bondi Labs, an industry partner with experience developing occupational simulators and simulation games. The researchers were broadly interested in the phenomenological experience of playing a simulation game for medical education and whether this method would be an effective way to train students and healthcare workers around the subject matter of environmental hazards and safety assessments. Falls and home hazards are an issue that the World Health Organization continues to raise concerns about and that has a substantive medical cost around the world, but at the time of development there were no standardized evidence-based tools available to train and assess risk identification and mitigation skills.
Note: In-game screenshot of risks and hazards interface. From Bondi Games, https://www.bondilabs.com/safe-environments-1
While the game could be used in the university’s nursing program or in other training settings, the impetus for designing the game was not to improve a specific performance gap or fulfill an institutional need. Rather, they aimed to address a generally significant topic, to further research on the experience of playing a game and learning through doing so, and to continue innovating in the use of simulations and serious games for medical education (Kennedy, 2016).
3. Solutions Implemented
Safe Environments has players adopt the role of a caregiver in a healthcare setting such as a retirement home. A brief case report on a patient is given, including demographic details and a medical history including relevant diagnoses. Then the caregiver is placed in a 3D environment rendering that patient’s setting. Players must navigate the environment, identify and assess randomly generated hazards for the risk they pose to that specific patient, and recommend preventative measures. Performance is tracked and analytics are provided to the player in the form of a leaderboard that scores hazard identification, risk assessment, proposed mitigations, and the time it took to complete the level. There are dozens of patient profiles and environmental hazards are randomized for each playthrough, so players are incentivized to repeat the game to experience more content and permutations, and players cannot brute force their way through the game. As the designers put it, “Identification of areas for improvement and repeat play provide opportunities to improve and build confidence and competence in assessing and managing environmental safety” (Volejnikova-Wenger et al., 2021).
Note: In-game screenshot of patient profile. From Bondi Games, https://www.bondilabs.com/safe-environments-1
As designed, Safe Environments seems to utilize numerous advantages of serious games for learning. It prompts case-based problem solving that is situated in an authentic, real-world context. It requires incorporating previous knowledge about signs of hazards with the specifics of a given patient and then applying rules and strategies to assess and mitigate risks; it is not simply imparting verbal knowledge and then quizzing the player. The game also encompasses many of the elements required in holistic medical education, namely risk assessment and sensory perception through its use of an authentic 3D environment. The patient profiles also humanize the challenge and induce caring, incorporating the more affective categories of a significant learning model.
For this study, the game was tested with eight female undergraduate students enrolled in an undergraduate nursing science program. All participants were volunteers who responded to a recruitment invitation posted to a program-affiliated social media page. The age range of participants was 18 to 54, and only 25% (2) reported having regularly played computer games. Playing the game was preceded by two modules: one emphasized the importance of the subject matter by highlighting the impact of falls and other incidents resulting from environmental hazards, and the second set up the game by explaining the goals and controls. As the study was assessing the player’s self-reported experience of playing the game and what they thought about it, the researchers conducted interviews following a play session, which were coded and analyzed for themes. There was no post-play evaluation to provide a more objective assessment of knowledge transfer or skill acquisition.
4. Outcomes
Generally, the game and experience playing it was well-received by the study participants. Coding the interviews yielded themes that the study authors grouped into four overarching categories: Knowing, Navigating, Engaging, and Learning. Put together, this enabled to authors to articulate the KNavEL conceptual model which encompasses the full game-playing experience and depicts a non-linear movement from category to category as learning takes place. Knowing addressed elements of previous knowledge, both subject matter and computer experience. Navigating involved interaction with the game, from traversing the environment to keyboard and mouse skills. Engaging entailed immersion, motivation to play, challenge, and enjoyment. Finally, Learning referred to, crucially, the participants’ perceptions that they had learned, including consolidating information and extending its application.
In their interviews, participants offered several noteworthy insights. Reflecting on their prior learning experience in medical education, one participant said “there [was] a lot of videos, sitting down [in] a classroom reading and writing, but I don’t think [they] teach you, what happens in real life with real clients” (Volejnikova-Wenger et al., 2021, p. 3), pointing to the game’s authenticity and practical experience. The immersive real-world setting with real-world problems was also found to be engaging, as the need to reflect on specific patient cases and the relevant environmental hazards sparked critical thinking. Participants found the game suitably challenging, with a difficulty level that engaged them but did not become frustrating. Moreover, the scoring and feedback made them want to replay the game seeking better placement on the leaderboard. In this respect, the game seemed induce constructive competitiveness that was more self-motivating than self-defeating. Finally, participants reported more awareness of the dangers of falls and hazards in these settings. One participant directly connected her play experience to her work environment, saying “I’m going to work tomorrow …I have a quadriplegic client. I’m already thinking about a few things that I saw in her house” (Volejnikova-Wenger et al., 2021, p. 5), internalizing the game’s lessons and transferring them to her job.
Note: In-game screenshot of scenario score. From Bondi Games, https://www.bondilabs.com/safe-environments-1
Where participants expressed the most frustration was around Navigation. Some of the game’s demands in navigating a virtual 3D space with some amount of manual dexterity proved challenging, especially as a majority of participants did not have substantive experience with computer games. Coupled with multiple interfaces requiring assessment, a checklist, knowledge that they were being scored, and the importance of the topic, there was a substantive risk of disorientation. This is a recurring challenge for serious games, particularly those aimed at a diverse workforce with a wide range of prior computer experience and has key implications for design, testing, and appropriate scaffolding so as not to disadvantage non-digital natives (Volejnikova-Wenger et al., 2021, p. 4).
5. Implications
As a preliminary inquiry, this study featured a small number of participants. Regarding limitations, there was some age and international diversity among participants, but all were volunteers the majority did not have much computer game experience. It is unclear how different demographics might have perceived the game and playing it: those with more extensive game experience might have found elements boring, or those required to play it for a course might have been so frustrated by navigation that it would have negatively impacted the other elements of the KnavEL model. As the study principally investigated the phenomenology of game playing, it would also be curious to see the game assessed for its learning outcomes and long-term impacts. One can imagine multiple models for how the game could be implemented – it could act as a practice tool or standardized summative assessment, or it could be dramatically expanded so as to include more modules that incorporate more didactic lessons – in short, it could continue to supplement an existing curriculum, or it could be expanded to entail one entirely. Further study certainly seems warranted.
More broadly, I appreciate the authors’ attempts to look beyond basic knowledge transfer and to build a more comprehensive model for the nonlinear cognitive processes that occur when working through a serious game. It is notable that the KnavEL conceptual model and the themes drawn out in these interviews map neatly onto both the key elements of a comprehensive medical education advanced by Locatis (2018) and the significant learning model Litchfield (2018) points to for higher education. Altruism and personal investment in their patients can be key motivators for those that choose to pursue medical education, so it is encouraging to see those emerge as an Engaging theme after playing Safe Environments. It is possible to similarly map training in risk assessment, sensory perception, and application of foundational knowledge and skills onto this study’s themes in Knowledge and Navigation.
Perhaps most significantly, I take seriously the concern of Van Eck et al. (2018) that there continues to be too much focus on whether games can teach rather than how they can teach different audiences varying topics in effective ways. In their literature review, Boyle et al (2016) point to this tension numerous places: despite the recognized affordances, most games still focus on knowledge acquisition; simulation games seem overwhelmingly represented, leading one to wonder how other game genres can be designed, tested, and implemented; and there is more work to be done in understanding what game features are engaging and in what circumstances they can best support learning. The KNavEL model, at this early stage, begins to suggest a path forward for interrogating players’ experiences with a game, what cognitive processes emerge as themes, and how those collectively impact learning.
References
Bondi Games. Safe Environments. https://www.bondilabs.com/safe-environments-1
Boyle, E. A., Hainey, T., Connolly, T. M., Gray, G., Earp, J., Ott, M., Lim, T., Ninaus, M., Ribeiro, C., & Pereira, J. (2016). An update to the systematic literature review of empirical evidence of the impacts and outcomes of computer games and serious games. Computers & Education, 94, 178–192. https://doi.org/10.1016/j.compedu.2015.11.003
Kennedy, G. (2016, September 22). Health meets gaming in new USC technology. UniSC News. https://www.usc.edu.au/about/unisc-news/news-archive/2016/september/health-meets-gaming-in-new-usc-technology
Litchfield, B. C. (2018). Instructional design in higher education. In R. A. Reiser & J. V. Dempsey (Eds.), Trends and issues in instructional design and technology (4th ed., pp. 185-191). Pearson.
Locatis, C. (2018). Performance, instruction, and technology in health care education. In R. A. Reiser & J. V. Dempsey (Eds.), Trends and issues in instructional design and technology (4th ed., pp. 168-175). Pearson.
Van Eck, R., Shute, V. J., & Rieber, L. (2018). Leveling up: Game design research and practice for instructional designers. In R. A. Reiser & J. V. Dempsey (Eds.), Trends and issues in instructional design and technology (4th ed., pp. 277-285). Pearson.
Volejnikova-Wenger, S., Andersen, P., & Clarke, K.-A. (2021). Student nurses’ experience using a serious game to learn environmental hazard and safety assessment. Nurse Education Today, 98, Article 104739. https://doi.org/10.1016/j.nedt.2020.104739