Serious gaming in women’s health care
Dr LD de Wit-Zuurendonk, MD, Department of Obstetrics and Gynaecology, Máxima Medical Centre, Postbus 7777, 5500 MB, Veldhoven, the Netherlands. Email email@example.com
Please cite this paper as: de Wit-Zuurendonk L, Oei S. Serious gaming in women’s health care. BJOG 2011;118 (Suppl. 3): 17–21.
Computer-based (serious) gaming is a new field in medical education, which has the potential to become an important tool for healthcare professionals for learning a range of clinical skills. To evaluate the current status of serious gaming in medicine, we performed a systematic literature review. In June 2011, we undertook a search in PubMed and Embase databases with the MeSH terms video games, education, training, gaming and healthcare. Thirty relevant papers were identified, reviewed and summarised. The studies showed that serious gaming is a stimulating learning method and that students are enthusiastic about its use. Studies have shown that previous recreational gaming is associated with greater surgical skill, especially for laparoscopy. In addition to surgical skills, serious gaming is potentially a good method for learning clinical decision-making and patient interaction. Games are already being developed for teaching specific clinical skills, for example in cardiology and orthopaedics for example. Initial studies suggest that serious gaming is likely to be an effective training method; however, there is a paucity of studies showing the conclusive clinical benefit of serious gaming. Future studies should focus on demonstrating the clinical effectiveness of serious gaming on skills used in patient care.
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High-quality teaching is very important for effective health care. Friedman1 described the importance of using new media in medical education. In past decades, simulation has been used as a method for training, education and certification in different professions. In the medical field, it has developed with human and animal cadavers, human actors or dolls. With ever-increasing computational power, simulation options are increasing. Computer-based (serious) gaming and virtual reality have become viable methods for education and training. Games can help to develop a range of skills: surgical procedures, strategic planning, interactive communication, team collaboration, group decision-making and negotiating skills.2,3
Gaming per se is not a new simulation method for training. Even before computers, there were games, such as Kriegsspiel, which was used to train military officers in the 19th century. Clark Abt4 used the term ‘serious gaming’ for the first time in his 1970 book: ‘Serious Games’. His general definition of the term ‘serious gaming’ is:
Reduced to its formal essence, a game is an activity among two or more independent decision-makers seeking to achieve their objectives in some limiting context. A more conventional definition would say that a game is a context with rules among adversaries trying to win objectives. We are concerned with serious games in the sense that these games have an explicit and carefully thought-out educational purpose and are not intended to be played primarily for amusement.
In 2005, Stokes postulated a new definition for serious gaming: ‘games that are designed to entertain players as they educate, train, or change behavior’.5 Nowadays, the term is used to cover a spectrum of computer-based simulations for training or education in a single- or multi-user environment.
Serious gaming is used in different fields: military, aviation, education, city planning and health care. In health care, two main areas of serious gaming can be distinguished: for professionals or patients. Although serious gaming for patients is beyond the scope of this review, it is worth mentioning briefly. Both Saposnik et al.6 and Mouawad et al.7 have demonstrated that Wii-based serious gaming is an effective alternative to established rehabilitation therapy and promotes motor recovery after stroke. Another area of patient-oriented serious gaming is disease management and prevention.8,9 A number of studies have described the successful use of serious games to prevent obesity and type 2 diabetes.10–12
Serious gaming is increasingly being used as a medium to train healthcare professionals to learn or maintain skills in patient care. It is a safe environment in which several integrated skills can be learned. With respect to professional development, users can learn a range of skills with computer gaming simulation. These can be manual skills needed for surgical procedures (such as laparoscopy) or clinical skills, such as decision-making and the sequence of therapeutic interventions (e.g. in the management of eclampsia). Experience can also be gained at the environmental level which is usually centred in a (virtual) room in which a clinical event takes place. It is even possible to create virtual-reality environments with avatars (computerised people/patients) for interactive communication.
Educational theory and serious gaming
In 1970, Knowles described four elements important to adult learning:13
- • Adults are autonomic and want independence in their learning. Gaming promotes an active form of learning and allows independence.
- • Adults use their past experience. Gaming facilitates this by offering different scenarios according to experience.
- • Adults are goal-orientated. Gaming is designed around completion of a level or task.
- • Adults tend to be problem-based learners and not content-orientated learners. Gaming provides learning experiences that players can relate to realistic clinical problems.
Other theories also support serious gaming as a method for the education and training of healthcare professionals. In his ‘cognitive theory of multimedia learning’, Mayer14 describes that people receive and process new information via two separate but interdependent pathways. These interdependent pathways are for verbal and visual inputs. These pathways are additive, such that information provided as both images and words will be better learned than information provided through either pathway alone. Learning can be maximised when information is received through both visual and verbal inputs. Serious games provide both inputs and could therefore be an exceptional method of learning. Another theory supportive of serious gaming is Siemens’‘theory of connectivism’. This theory proposes that learning is not a static process to a specific goal, but ‘a process of walking through degrees of realignment within a dynamic environment’.15 Serious games facilitate learning through this mechanism. More recently, Rogoff16 and Gee17 pointed out that games are effective because learning takes place within contexts that are meaningful.
Published studies of use in clinical training
We performed a systematic search from inception to June 2011 in the database PubMed that includes the Cochrane Library and Embase databases, with the MeSH terms serious gaming and women’s health. This search resulted in zero hits. We then broadened our search to studies that are relevant to the gynaecology and obstetric fields by using the terms gaming and health care. This search resulted in 125 hits, 30 of which were relevant. A second related search with the terms video game, training and education gave 390 hits, 15 of which were relevant. We only included studies in English and with an abstract. We included all types of study. We focused on education and learning skills of healthcare professionals and did not include patient education or video game addiction. All articles from the search were read and scored independently by two reviewers. The results of the systematic search are listed in Tables S1–S7,23–26,36–58 which are available online.
From the studies listed in Tables S1–S7, we found that many doctors are experienced in gaming from childhood games and that the skills learned translate to medical simulation (Table S2). The studies also showed that many participants enjoy this style of training, although some find it stressful (Table S1). Other studies showed that serious gaming was associated with improved skills in laparoscopic virtual reality (Table S3) and better decision-making in simulation (Table S5), suggesting that it could be a good method for the training and teaching of several skill types; however, only a small number of studies have looked to compare serious gaming with other educational techniques (Table S7). The only study that showed a significant difference between traditional methods and serious gaming was by Knight et al.,18 who demonstrated that serious gaming is more effective in triage training. They compared a traditional card-sort exercise and a serious game for triage casualties. Ninety-one doctors, nurses and paramedics were randomised into two training groups. Forty-four participants used a traditional method and the remaining 47 participants played the serious game. Both the tagging accuracy (putting the correct triage tag to the casualty) and the step accuracy (following the correct procedure) of participants who performed the serious game were significantly higher. No difference in time taken was found, but the participants who played the game were more enthusiastic about the learning method. Evidence that this can be translated to better patient outcomes remains to be seen. Although there is as yet little definitive proof that serious gaming is a better method for the training and education of healthcare professionals and students, initial results are promising. Before simulation became an established training method, there was substantial criticism of simulation as a learning and training technique. Nevertheless, simulation is now accepted as an effective method for training skills in medical professions. Gaming simulation is gaining acceptance as a training method, but its effectiveness has not been conclusively demonstrated. Moreover, in areas outside of health care, there is more evidence that gaming is effective. Aviation studies have demonstrated a better performance of staff when trained with a computerised game.19,20
Theoretical and practical benefits of gaming for training
There are three main aspects of serious gaming that suggest that it will be effective for training in health care.
- • Competitive element. It has been shown that the voluntary use of a simulation laboratory does not lead to active participation. The competitive element of a serious game improves the engagement with training through simulation.21
- • Entertainment. Having fun attracts and holds players’ attention on the video game. Sustained exposure leads to improved performance and behavioural change.18
- • Feedback. Debriefing contributes to meaningful connections between the gaming experience and the real world. Debriefing is a common part of training in non-clinical gaming.
The theoretical practical advantages of serious games compared with more traditional simulation are as follows.
- • Gaming is often learned in adolescence and is seen as being enjoyable.
- • Games are easily portable and transferable.
- • Games are cheap to distribute through digital media. A serious game can even be played through the Internet remote from the training centre.
- • The game can be saved at any moment and restarted later.
- • Participants can create a digital portfolio, which records progress in skill development for use in appraisal (and possibly certification).
- • Games are less expensive for testing different scenarios compared with older simulation methods.
To evaluate and validate the effectiveness of a new training method or programme, the four levels of Kirkpatrick can be used.22 In 1959, Kirkpatrick described a model to evaluate the effectiveness of a training method. His theory stands on four levels of outcome evaluation: participant reaction (level 1), improved learning (level 2), clinical behaviour change (level 3) and outcome results (level 4). Several publications have demonstrated that people who have trained with a serious game have comparatively greater enthusiasm and are more stimulated, which results in increased training time (level 1) and evidence of learning gain.23–26 Although there are currently limited examples of studies showing the effectiveness of serious gaming (in women’s health), surgical technique gaming appears to be effective on skills in simulation (level 2).18,27,28 Our literature search did not find any studies with proof of behavioural change in clinical practice (level 3), or of fewer adverse events, increased work quality or higher productivity (level 4). Future research on serious gaming must focus on levels 3 and 4.
Criticism of serious gaming
There are several criticisms made of serious gaming as a method for learning and training medical skills.29,30 One common criticism is that the dynamic colourful world of a computer game will distract the student’s attention from the learning process. Prensky31 and other proponents of serious gaming believe that the present generation contains a different type of learner, and probably it was ever thus. Current and future professionals grew up with digital media and have developed a much better aptitude to relate a virtual world to reality. Nevertheless, for serious gaming to become accepted, these criticisms must be addressed, as much as the need to demonstrate the clinical effectiveness of serious gaming.
Place of gaming in simulation training
In women’s health, team rehearsals have been found to be associated with improved clinical outcomes of obstetric emergencies, such as postpartum haemorrhage, eclampsia and shoulder dystocia.32,33 Team rehearsals require a team to gather, however, and individuals cannot learn alone in their own time. Serious gaming has several attributes that are essential in learning:34 repetition, reinforcement, association and the use of multiple senses. Of these, repetition is a particularly valuable feature, especially in comparison with emergency drills simulation, which is generally repeated infrequently. Moreover, participants can initially find drills stressful. Gaming simulation cannot replicate the realism of team dynamics within the emergency room, but it can be accessed at work or home, at any time, by an individual, and it can allow doctors, midwives and care assistants to gain confidence by sampling the rhythm of an emergency in privacy, in preparation for full face-to-face rehearsals. The same might also apply to surgical procedures. Even for experienced professionals, it might help to practise a healthcare activity, be it an emergency team event or elective procedure, within a computer game just before a drill or operating list.
Skill drills and teamwork training have been recommended by the Royal College of Obstetricians and Gynaecologists.35 Studies on the true effectiveness and cost-effectiveness of teamwork training are emerging,39 but the organisation and costs of this type of training for postgraduates are considerable. Therefore, the time has come to consider lower cost solutions for the education and training of healthcare professionals. As shown above, the potential advantages of serious gaming are numerous. Advances in gaming technology have made it possible to create immersive two- and three-dimensional simulations on video screens even for home use. The entertainment, ease of access and competitive element of serious games will lead to more exposure to learning experiences. With the help of multiplayer technology, games might be suitable to practise teamwork as well as individual skills. Before we can introduce serious gaming on a broad scale, we have to deal with several technical challenges and, more importantly, it is necessary to prove conclusively that it is an effective method for learning, training and certification. High-quality research is imperative.
Serious gaming is being increasingly considered for use in education, training and, possibly, certification for healthcare professionals. The use of a game-based environment has the potential to actively stimulate the learning of skills in a flexible and fun way at low cost. Serious games potentially allow for the creation of scenarios that cannot be easily realised in the real world or through traditional simulation.
The improvement of medical skill is an important goal of any training programme. It seems likely that serious gaming will become an important addition to simulation training for a range of clinical skills. The acceptance of serious gaming in medical education programmes will depend on the demonstration of effectiveness in terms of improved patient outcomes.
Disclosure of interests
LDWZ has nothing to disclose. SGO is Medical Director of MedSim, Eindhoven, the Netherlands. MedSim is a medical education and simulation centre. None of the authors own stock, or hold stock options, in any obstetric emergency training company.
Contribution to authorship
LDWZ and SGO jointly researched, drafted and approved the manuscript.
Details of ethics approval
Not applicable for this review.
Reviewed by Robert Fox, Consultant Obstetrician, Taunton & Somerset NHS Trust, UK and Tim Draycott, Consultant Obstetrician, North Bristol Trust, UK.