Serious games and blended learning; effects on performance and motivation in medical education

In medical education, with its exponential growth in knowledge and increasing demands on the competencies required by doctors, there is a need for more efficient training models [1]. Blended and online learning are powerful learning concepts, which can be used in different formats. Blended learning may combine the advantages of online and classroom learning. Its use is increasing quickly and a precipitous growth is predicted [2]. The first aim of this thesis was to compare the effectiveness of a blended training design with classroom training for the acquisition of knowledge. One of the promising new online formats to train complex skills in a motivating way is provided by serious games. Little is yet known about the effectiveness and optimal design of serious games in health care training [3‐6]. The second aim of this thesis was to investigate the effectiveness and critical design features of serious games for performance improvement and motivation. This thesis consists of five research studies and an evaluation framework for serious games [7].

Study 1: In order to compare the effectiveness of a blended training design with classroom training, we performed a retrospective study and compared the effectiveness of a postgraduate course for nurses in a conventional classroom-based design (11-day course) with a blended course design, consisting of two-thirds classroom training (7 days) and one-third online self-study. Results on the knowledge tests and evaluation questionnaire were compared for both groups and costs of both types of postgraduate training for participating organizations were calculated.

Study 4: As the previous study was inconclusive on the design choices that were responsible for the performance improvement, in this study we focused on the question of what the effects are of adding high-fidelity cases (a simulation game) versus low fidelity (text-based) cases to an instructional e‑module on the cognitive skills and motivation of fourth-year medical students. We set up a three-group randomized design: a control group working on an e‑module; a cases group, combining the e‑module with low-fidelity text-based patient cases; and a game group, combining the e‑module with a high-fidelity simulation game, with the same cases. Cognitive load and motivation were evaluated after the intervention. After a 2-week study period, assessors (who were blinded for the condition) rated students’ cognitive emergency care skills in two mannequin-based scenarios, using the assessment instruments resulting from study 2.

Study 5: The fifth study focused on the question of whether undergraduate medical students develop better patient safety knowledge and awareness and are more motivated after using a serious game (Air Medic Sky-1), typically highly interactive, or after using an e‑module, typically less interactive, on the same patient safety topics. Fourth-year medical students were randomly assigned to either a serious game, containing video lectures and patient missions, or an e‑module, containing text-based lectures on the same topics. A third group acted as a historical control group without extra instruction. Students were tested on knowledge, self-efficacy and motivation. During their clinical rotation they reported perceived stress and patient-safety awareness on a weekly basis.

Our results that blended learning is as effective as classroom-based learning are consistent with systematic reviews in the general domain [13]. Blended learning enables adaptation to the learner’s knowledge level, flexibility in time and scalability of learning. An important consideration in a blended design is securing online preparation by students. Our combined results on a serious game in emergency care, where the game improved residents’ cognitive skills, but did not improve inexperienced students’ skills, indicate an ‘expertise reversal effect’ [14]: a rich learning environment, such as a highly interactive game, may benefit experts, but is counter-productive for novice learners (interaction between prior knowledge and complexity of format). Although serious games with realistic tasks often enhance motivation, they are as such not sufficient for improving performance. Games may support skills learning, provided task complexity matches the learner’s competency level. Design-based research should shed more light on how game design may enhance skills learning. Another interesting field for further study is the question which game features enhance motivation? Features that are mentioned in the literature are: control and interaction, a story-line and challenges [15].

One piece of advice for PhD students on how to successfully complete a PhD project:

Choose a subject and research focus which fits your passion and genuine interest. You will find PhD research is fun to do, at times challenging, but a rewarding learning experience.