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Games, Virtual Environments, Mobile Applications and a Futurist's Crystal Ball

  • Eric B. Bauman
    Affiliations
    Assistant Dean, DeVry Medical International's Institute for Research and Clinical Strategy
    Chair, Department of Educational Technology and Game-Based Learning
    Associate Director, Center for Excellence in Simulation Education, Iselin, NJ 08830
    Fellow, Department of Curriculum & Instruction, School of Education, University of Wisconsin-Madison, Madison, WI 53715
    Managing Member, Clinical Playground, LLC, Madison, WI 53705
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      During the last decade, the educational genre of simulation has arguably matured. Simulation no longer represents a novelty to clinical education. Rather, it is now a vetted standard educational practice for nursing and clinical education at all levels. Manikin-based simulation laboratories are now ubiquitous fixtures in all areas of clinical education. Meanwhile, game-based learning, mobile applications (apps), and virtual reality are on track to take a similar trajectory. Simulation-based education is the template, providing a crystal ball for educators as they integrate innovative technology such as game-based learning, mobile apps, and virtual reality into future educational practice.
      Simulation-based education has always included screen-based simulation.
      • Maran N.J.
      • Glavin R.J.
      Low- to high-fidelity simulation – A continuum of medical education?.
      defined categories of simulation including computer-based systems and virtual reality.
      • Lane J.L.
      • Slavin S.
      • Ziv A.
      Simulation in medical education: A review.
      explicitly defined screen-based simulations (sims) in their discussion of types of available simulation technology.
      • Ziv A.
      • Wolpe P.R.
      • Small S.D.
      • Glick S.
      Simulation-based medical education: An ethical imperative.
      also included screen-based simulation as one of several categories to describe “… tools and approaches used in simulation-based medical education” (p. 784). Current and future iterations of screen-based technology represent a natural evolution of screen-based simulation.
      Recent advances in technology have led to an explosion of sophisticated multi-media and digital educational content. Furthermore, although manikin-based simulators remain relatively expensive, delivery platforms that support complex digital environments, videogames, and mobile apps are increasingly more accessible and affordable to students, faculty, and researchers. Today's games, sims, apps, and digital environments are on track to useful ubiquity, following in the footsteps of what we now accept as systems and components of contemporary sims. Educators who vet, then embrace game-based learning, mobile apps, and virtual reality are in position to advance clinical curricula to better prepare students for modern and future practice.

      Overview of Games, Simulations, Applications, and Environments: Why They Matter to Today's Educators

      Games and Game Mechanics

      Games are goal-oriented and rule-based events that engage players through consequence. The consequences provide a system of rewards for achievement within the game and often provide a negative repercussion for actions that do not subscribe to the goals or rules of the game (

      Deterding, S., Dixon, D., Khaled, R., & Nacke, L. (2011, September). From game design elements to gamefulness: Defining gamification. In Proceedings of the 15th international academic MindTrek conference: Envisioning future media environments (pp. 9-15). ACM.

      ). The consequences found in games, particularly videogames, are often driven by game mechanics. Game mechanics allow the player to interact with the game or within the game environment (
      • Sicart M.
      Defining game mechanics.
      ). Think of game mechanics as the impetus for something else to happen. For example, one turn or the occurrence of a discrete event based on a player's action might trigger a predetermined event based on the rules of the game (
      • Poundstone W.
      Game theory.
      ). In short, game mechanics work to engage learners within the digital environment and promote progress within the game experience.

      Sims [Simulations]

      Think of a simulation as the imitation of something that is real. Sims represent key design elements or variables of a system or process that occur in the real world. Whether recreated in a theatrical manner in a created space (

      Bauman, E. (2007). High fidelity simulation in healthcare. Ph.D. dissertation, The University of Wisconsin – Madison, United States. Dissertations & Theses @ CIC Institutions database. (Publication no. AAT 3294196 ISBN: 9780549383109 ProQuest document ID: 1453230861).

      ), such as a bricks-and-mortar simulation laboratory or with a computer in a digital space, simulation uses artificial history or narrative to support and recreate real-world paradigms (
      • Banks J.
      • Carson J.S.
      • Nelson B.L.
      • Nicol D.M.
      Descrete-event system simulation.
      ).
      • Aldrich C.
      Learning online with games, simulations, and virtual worlds: Strategies for online instruction.
      describes sims as structured scenarios designed to develop competencies that can be applied to real-world practice. Sims excel at supporting nonlinear, dynamic content, which encourages learners to engage in complex analysis and decision-making within a dynamic environment.
      From the perspective of nursing and clinical education, the process of simulation, use of simulators, and a carefully created learning environment serve as an alternative to the real-world clinical environment. Simulation, whether facilitated in a bricks-and-mortar laboratory, or within a virtual or a hybrid mixed reality, permits educators to exert control over carefully designed clinical learning scenarios (

      Bauman, E. (2007). High fidelity simulation in healthcare. Ph.D. dissertation, The University of Wisconsin – Madison, United States. Dissertations & Theses @ CIC Institutions database. (Publication no. AAT 3294196 ISBN: 9780549383109 ProQuest document ID: 1453230861).

      ,
      • Squire K.
      From content to context: Videogames as designed experience.
      ,
      • Ziv A.
      • Ben-David S.
      • Ziv M.
      Simulation based medical education: An opportunity to learn from errors.
      ).

      Apps [Applications]

      Apps are software artifacts often designed specifically for mobile devices. Educators should not see app-based learning on mobile devices, such as smart phones and tablets as taboo in the traditional classroom. Furthermore, smart devices have an increasingly important role to play as interactive tools that support clinical education, clinical practice, and patient safety. Educators can and should create and leverage apps for mobile devices to support existing curricula goals and objectives, much the same way they embraced manikin-based simulation to become an integral part of nursing and other forms of clinical education.

      Environments

      It is important to understand that not all digital environments represent game-based platforms. Not all learning that takes place through the use of digital technology constitutes game-based learning. Educators have used eLearning platforms to support distance learning programs and traditional bricks-and-mortar universities for many years. eLearning is commonly thought of as the learning that takes place online and may include, but is not limited to the use of learning management systems, games, videoconferencing, or immersion within virtual worlds (
      • Pastore R.
      Elearning in education: An overview.
      ,
      • Bauman E.B.
      Game-based teaching and simulation in nursing & healthcare.
      ), while game-based learning maps back to curriculum, designed to support academic achievement.

      Virtual Worlds and Environments

      Virtual worlds are digital environments that exist synchronously; meaning multiple players may inhabit a digital space in real time together. Some refer to these environments as virtual reality environments. Complex virtual environments sometimes referred to as virtual worlds are capable of hosting multiple people or players, represented as avatars, facilitated by networked computers (
      • Bell M.
      Toward a definition of virtual worlds.
      ,
      • Bauman E.B.
      Game-based teaching and simulation in nursing & healthcare.
      ). Massively multiplayer online games use virtual worlds to stage or allow participants to play a game.

      Game-Based Platforms

      Game-based platforms leverage game mechanics. Mechanics often take place within the scope of a narrative. Narratives should situate content and engage players through game mechanics including but not limited to a system of rules, rewards, and consequences to encourage players to accomplish specific tasks and objectives. Videogames are staged in virtual environments (
      • Bauman E.
      Virtual reality and game-based clinical education.
      ,
      • Bauman E.B.
      Game-based teaching and simulation in nursing & healthcare.
      ). This said, not all virtual environments are game based. For example, the popular virtual reality environment Second Life® (Linden Labs, San Francisco, CA) is a virtual world, yet while it provides a stage, it lacks essential mechanics of a game.
      Educators should see sims, videogames, apps, and virtual environments as part of a layered learning model (
      • Bauman E.B.
      • Adams R.A.
      • Pederson D.
      • Vaughan G.
      • Klompmaker D.
      • Wiens A.
      • Squire K.
      Building a better donkey: A game-based layered learning approach to veterinary medical education. GLS 10 conference proceedings.
      ). In this model, technology supports rather than replaces traditional didactic teaching and learning. In this way, interactive apps, videogames, and even virtual environments map back to curricula objectives and support complex bricks-and-mortar activities such as manikin-based simulation and supervised clinical rotations. When multi-media learning experiences are well designed, they are capable of becoming powerful cognitive aids to support future practice and continuing professional development (
      • Jeffries P.R.
      • Bauman E.B.
      • Shaefer J.J.
      The future of simulation in healthcare.
      ).
      Learning has become increasingly mobile, and less emphasis is placed on the physical location in which learning takes place. Innovative learning platforms, including mobile apps and virtual reality are now capable of supporting custom-designed learning (
      • Squire K.
      From content to context: Videogames as designed experience.
      ), supported by knowledge management infrastructure to drive student experience and achievement (

      Leung, C. H., & Chan, Y. Y. (2003, July). Mobile learning: A new paradigm in electronic learning. In Advanced learning technologies, 2003. Proceedings. The 3rd IEEE international conference on (pp. 76-80). IEEE.

      ).

      Best Practices

      Contemporary teachers wishing to incorporate game-based learning whether doing so within a virtual environment, through videogames, or by leveraging mobile apps and other technologies are at the forefront of a paradigm shift. Best practices related to the integration of game-based teaching and learning and other innovative technologies related to nursing and clinical sciences curricula remain a moving target. Best practices will continue to evolve while researchers create a body of evidence to support the integration of innovative multi-media technology for clinical education.
      At the highest level, game-based teaching and learning, as well as innovative technology including learning taking place within virtual environments should engage and motivate students through situated interactive experiences. At all levels, any technology used within the curriculum, whether it is traditional manikin-based simulation or multi-media digital technology must map back to course objectives. Faculty must ensure that students understand how playing an educational game or using technology not only supports academic achievement but also how playing the game or using technology will help students reach their overarching goals. Games and other types of innovative technology should provide an opportunity for learners:
      • To explore hypotheses within the curriculum and profession that the learner hopes to join.
      • To provide situated activities and experience in ways that are not practical or possible within the context of traditional educational modalities (
        • Kiili K.
        Digital game-based learning: Towards an experiential gaming model.
        ).
      • To identify reoccurring patterns based on situated phenomena within the context of discovery, probing, exploration, and the application of the learners intuitive and tacit knowledge (

        Bauman, E. (2007). High fidelity simulation in healthcare. Ph.D. dissertation, The University of Wisconsin – Madison, United States. Dissertations & Theses @ CIC Institutions database. (Publication no. AAT 3294196 ISBN: 9780549383109 ProQuest document ID: 1453230861).

        ,
        • Gee J.P.
        What video games have to teach us about learning literacy.
        ).
      Designed experiences occurring within the context of videogames, virtual environments, and other types of innovative multi-media will support objectives found in the curriculum. These experiences provide predictable outcomes based on learner performance (
      • Squire K.
      From content to context: Videogames as designed experience.
      ). The most innovative technologies will extend the curriculum beyond the confines of the traditional classroom by creating digital spaces to promote the suspension of disbelief and produce sufficient authenticity or environmental fidelity to allow for deep meaning making (

      Bauman, E. (2007). High fidelity simulation in healthcare. Ph.D. dissertation, The University of Wisconsin – Madison, United States. Dissertations & Theses @ CIC Institutions database. (Publication no. AAT 3294196 ISBN: 9780549383109 ProQuest document ID: 1453230861).

      ,
      • Bauman E.
      Virtual reality and game-based clinical education.
      ,
      • Bauman E.B.
      Game-based teaching and simulation in nursing & healthcare.
      ).

      Driving Intrinsic Versus Extrinsic Motivation in Your Curriculum

      Leveraging game mechanics and integrating game-based learning into your curriculum requires faculty to juxtapose intrinsic versus extrinsic motivational factors related to competency development and behavioral change. Extrinsic motivation is based in tangible reward, such as a grade. It is based on meeting faculty-assigned goals. Extrinsic drivers in the curriculum are generally hierarchical and determined outside the competency paradigm. In other words, if and when a student completes a given assignment or course, they will be moved in a linear manner to another course or assignment. In this way access to content, knowledge is privileged. Progression through a curriculum or training program often occurs based on program needs and convenience rather than a student's ability to demonstrate situated competency or readiness for practice.
      From an intrinsic perspective, reward comes from mastery of content that is meaningful and situated. Learners are intrinsically motivated when they successfully complete projects that represent value to self. Intrinsic motivators promote autonomy and agency (
      • Deterding S.
      The lens of intrinsic skill atoms: A method for gameful design.
      ,

      Deterding, S., Dixon, D., Khaled, R., & Nacke, L. (2011, September). From game design elements to gamefulness: Defining gamification. In Proceedings of the 15th international academic MindTrek conference: Envisioning future media environments (pp. 9-15). ACM.

      ). Assignments and goals should be clear to the learner. Progress through the curriculum, while guided by faculty, must be intuitive. When a student shifts from an extrinsic motivational locus to an intrinsic motivational locus, progress occurs through performance that demonstrates competency and is supported by just-in-time learning. Just-in-time information and the learning that takes place from its immediacy should not be privileged. In other words, students should always have access to the content regardless of where a student sits within the curriculum timeline. Games and applications are agnostic and do not artificially privilege information based on student rank or program affiliation, content is simply available to support the game experience. In other words, intrinsically motivating educational activities, particularly those leveraging games and other multi-media technologies should be available to support, promote, and scaffold the learning experience rather than exist as a removed or disconnected homework assignment.
      Intrinsic motivators endorse and reinforce behavior that students are already committed to in the future and promote agency. Intrinsically motivated learners will achieve competency, not because they were told to do so. Rather, they achieve and demonstrate competency because doing so provides them with a sense of inclusion within the cohort and profession they are committed to joining (
      • Bauman E.B.
      • Ralston-Berg P.
      Serious gaming using simulations.
      ).
      Games, sims, virtual environments, and apps that engage students should leverage intrinsic motivational elements. Good games provide a sense of player agency, such that player action and decision-making matters. Students must see educational games, sims, virtual environments, and apps as immediately relevant and situated to the practice cohort that he or she hopes to join. Multi-media activities that are seen as skill and drill exercises that do not intuitively map back to the curriculum, and future practice are likely to be poorly received and even ignored by students.

      Difference Between Educational and Entertainment Games

      The goal of an entertainment-based game is to keep the player engaged in the game environment for as long as possible. This is true of both long-format console and personal computer games, as well as casual games played on mobile devices. Games built for entertainment purposes are similar to movies. In general, although artistic and entertaining, both are created to make a profit. The moviegoer or consumer of entertainment games readily trades currency for entertainment. In the case of videogames, game-related profit increases as game downloads (for purchase) increase. In addition, profit increases based on in-game purchases, advertising, and subscription fees.
      In contrast, the goal of an educational game is to prepare players for the real world. A successful educational game will move players from the digital environment to the real world as quickly and efficiently as possible. Although both entertainment games and educational games must engage their players, educational games strive to situate content using game design and mechanics to prepare learners, students, players for success within and throughout the curriculum. A good educational game supports and reinforces didactic content and prepares students for additional experiential learning activities such as traditional manikin-based simulation and supervised clinical rotations. The best games may also become cognitive aids that support clinical practice and continuing education. However, the key differentiator when comparing entertainment and educational games is that the educational game prepares the learner for something beyond the game environment. The educational game, in the purest sense has no secondary motive other than to promote educational outcomes.

      Discussion and Conclusion

      Evaluation

      Games are machines designed to encourage players to gain competence (
      • Deterding S.
      The lens of intrinsic skill atoms: A method for gameful design.
      ). Nursing and other clinical professions define successful outcomes based on the notion of competence. The terms competence and competencies are deeply embedded into the language of nursing education in both the pre-licensure and post-graduate learning venues. Digital games, applications, and virtual environments leveraging game mechanics and relatively standard digital evaluation software are capable of collecting vast amounts of data.
      For example, standard evaluation tools built into game-based learning platforms are capable of collecting much more than a student's quiz score. Digital games (and applications) often measure time-in-state or how long a player spent on any particular part of a game or how long it took a player to play through a level of a game or the game in its entirety. In addition, it is possible to record the total number of times and total time a player has spent playing a game or application. Game designers can create scoring matrixes, which allow for multiple attempts to encourage knowledge acquisition and competency development. In other words, the player need not be scored in a binary manner as either correct or incorrect. In this way, evaluation becomes both summative and formative.
      From the summative perspective, game mechanics not only provide support for and deliver curriculum, they also evaluate skill acquisition and knowledge transfer. Well-designed games and applications existing within digital environments provide a situated context for evaluation. Thus, in-game (or in-app) evaluation within an authentic, contextually situated narrative may provide a primer for how students will perform during actual real-world encounters.
      From the formative perspective, students who do not demonstrate the ability to answer a question or meet an objective on the first attempt have an opportunity to move forward based on just-in-time information gained from trying but not immediately succeeding. The formative perspective is also important for faculty who have integrated games and applications and other types of innovative multi-media into their curricula. By reviewing aggregate data, faculty may be able to glean feedback about how they can revise and improve curricula to promote program objectives and student success.

      Vetting and Fit

      As games, mobile apps, and various digital environments become more popular, innovative faculty are often open to the idea and even keen to integrate game-based learning opportunities and multi-media activities into their curriculum. Our role as faculty is first and foremost to evaluate games, apps, and multi-media environments for appropriateness and accuracy. Just as we should not teach pharmacology with materials provided by a pharmaceutical company, we should not promote or embed unvetted or biased content in the form of games, sims, apps, and virtual environments into our curricula.
      We must also look at the triad of cost, time, and complexity when we select innovative multi-media technologies to support nursing and health sciences curricula. For example, if a game works well, it is easy to use and requires little infrastructure for support but costs one million dollars to license and implement on your campus, it may not be adopted because the cost is prohibitive. If a game is affordable, contextually accurate, but clunky, such that faculty struggle to deploy it and students find it difficult to play from a user interface perspective, it likely will not meet your program's objectives (
      • Bauman E.B.
      • Ralston-Berg P.
      Serious gaming using simulations.
      ). Students must see that games, apps, and other innovative technologies are worth their time. Students must find the multi-media technologies intrinsically motivating. They must be part of the package of technology-based instruction that will prepare them in meaningful ways for high stakes evaluation that grants them access roles they hope to fill.

      Conclusion

      Teachers, scholars, and educational designers immersed in the digital revolution are familiar with Prensky's work juxtaposing the digital native and digital immigrant (
      • Prensky M.
      Digital natives, digital immigrants.
      ,
      • Prensky M.R.
      Teaching digital natives: Partnering for real learning.
      ). Prensky argues that we must find ways to engage students in the context of structured learning in the same ways that they engage themselves in their social, personal, and recreational lives. Faculty-centered traditional academia simply does not and cannot approach engagement with the type of active play and user agency that exists in a digitally connected environment. The 21st century digital experience offers choices that drive engagement and promote learner agency (
      • Prensky M.
      Listen to the natives.
      ).
      We must ask ourselves as teachers if our current educational practice mirrors or prepares students for modern clinical practice. As educators do we not have an obligation to teach and guide students in ways that prepare them for the type of practice that they will work in? We must strive to optimize student preparedness and success, while meeting employers' needs and patients' best interests. In short, contemporary nursing practice requires a mastery of digital literacy.
      Our role as teachers is evolving. We should no longer consider ourselves the tellers of knowledge. We should see ourselves as subject-matter experts with vast experience in educational pedagogy. Our role in the context of technology, particularly digital technology such as sims, games, apps, and virtual environments should be to teach learners how to vet for accuracy, insist on curricular fit, and promote a sense of digital wisdom (
      • Prensky M.
      H. sapiens digital: From digital immigrants and digital natives to digital wisdom.
      ).
      Those who embrace and obtain a sense of digital wisdom will be able to evaluate new technology and identify both the positive and negative consequences of leveraging innovative digital tools. Embracing digital wisdom means using technology-driven innovation existing within the context of the modern digital world to extend and enhance our capacity for knowledge acquisition, data processing, and decision-making (
      • Prensky M.
      H. sapiens digital: From digital immigrants and digital natives to digital wisdom.
      ).
      • Prensky M.
      Brain gain: Technology and the quest for digital wisdom.
      argues that the notion of digital wisdom transcends and moves beyond the digital immigrant and digital native paradigm. Teachers with vast experience who began their academic careers many years ago may be digital immigrants, but they are capable of attaining and leveraging digital wisdom to guide the digital native or contemporary learner.
      Leveraging digital teaching tools is imperative to the contemporary nursing and health care paradigm. It is no longer possible to teach pre-licensure and graduate curricula within the confines of the lecture, textbook, and clinical rotation template. The amount of information that students and clinicians must access and apply to meet the complex needs of diverse clinical settings and encounters may no longer be possible without extending our innate cognitive abilities by leveraging innovative digital technology to include but is not limited to sims, games, mobile apps, and virtual environments.
      The original Star Trek series foreshadowed automatic sliding doors and handheld mobile devices. However, predicting the future of innovation is difficult at best, other than to say that it is predictably unpredictable. To this end, we as faculty should embrace games, mobile, apps, virtual environments, and other emerging multi-media technologies just as we did manikin-based simulation. The rate of technology development and integration continues to accelerate exponentially before our eyes and within single generations. There will always be the next big idea in clinical education. Rather than seeing every new idea and type of technology as a discrete newcomer to the educational process, we should see new and emerging technology as tools within the genre of educational technology to be carefully vetted and leveraged to extend our teaching ability.

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