A conceptual framework of game-informed principles for health professions education

A “serious game” is a game that has “an explicit and carefully thought-out educational purpose” [1]. There has been a growing interest in recent years in the educational use of serious games in both higher education [2] and in health professions education [3–5]. While there is a long history of games being used for training purposes in other professions (such as management and the military [1]), games have not yet become a part of the core repertoire for training health professionals. Attempts to resolve uncertainty about the place of serious games in health professions education through evidence synthesis have described the problem but have not necessarily helped to clarify matters. For instance, although they provide many examples of the use of games in the training of health professionals, both Smith [6] and Akl et al. [7] concluded that games are not intrinsically good or bad, their efficacy is highly context-bound, and even when they are shown to be effective, there are still questions as to whether they are efficient given their associated development costs. Similarly, Graafland et al. observed that, although there are studies that show that certain kinds of games can be used to positively effect in health professional education, the evidence base for this is somewhat lacking [5].

Rather than simply repeating these conclusions or giving yet more examples of games in health professions education (HPE), I will instead consider the basis for using serious gaming as a source of concepts and techniques to guide educational practice and to encourage critical engagement with and a more in-depth consideration of games and gaming in the field of health professions education. To that end, I will set out a faceted framework of game attributes, differentiate between gaming and simulation, and describe some of these game facets’ educational affordances. I have provided a glossary of terms used in this paper as an aid to grounding this work.

I will start with the general phenomena of “play” and “games”. The young of many mammalian species engage in activities that are considered to be play. By doing things individually and collectively that approximate to adult “serious” activities, they develop adult skills without having to deal with the consequences of these activities while they are still learning. To that end, play is not simply a diversion or a reflection of immaturity: “play is essential to development… [it] allows children to use their creativity while developing their imagination, dexterity and physical, cognitive and emotional strength” [8]. Given that play is intrinsically linked to early learning it is not unreasonable for us to seek to leverage these potential advantages for professional educational purposes.

Play and games share a number of features; they are both abstracted from the real world, and they depend on a psychosocial moratorium where reality is willingly suspended, thereby allowing participants to explore alternative and new ways of being and acting. To suspend reality and accept an alternative way of thinking and being is to play or game, and for reality to intrude is to fall back to a quotidian reality. Both play and games can be individual or social activities, and they both involve abstraction in terms of selecting from reality or imagination what elements they will (and will not) include.

However, and despite these similarities, there are essential differences between them: “play is an open-ended territory in which make-believe and world-building are crucial factors; games are confined areas that challenge the interpretation and optimizing of rules and tactics” [9]. While play is not expected to lead to any particular outcome (other than being pleasurable or distracting), a game is bound by goals, rules, and challenges. To play a game is to accept its rules and challenges, while to engage in play is to change boundaries at will or to do without them altogether [10]. Boundaries are therefore a critical component of games. This is reflected in the heinous crime of cheating; an intentional and tacit transgressing of a game’s boundaries for personal advantage. Play on the other hand has little or no concept of cheating.

We should also differentiate between game templates (from which any number of game instances can be run) and specific game instances (time- and context-bound instantiations of a game template). For example, the game template of chess specifies the board, the pieces, the allowed moves for each piece, the limits of play (two opponents alternating moves between them), the rules of check, the objective of seeking to place the opponent in checkmate, and the three possible end points of conceding, stalemate, or checkmate. From this simple template, a vast number of game instances can be played, as the rich tradition of chess game writing illustrates. However, although the game template establishes the boundaries for a game instance, it does not determine how an instance will unravel. Without some form of emergence, a game is simply an algorithm that can be learned. Indeed, perceiving an underlying algorithm in education and attempting to play it rather than the task at hand has parallels in the rather negative concept of “surface learning” [11].

Serious games differ from other kinds of games by having “an explicit and carefully thought-out educational purpose” [1]. It is important therefore to consider the educational affordances of serious games (how they facilitate learning) as well as their outcomes (what they help the learner or teacher to achieve). For instance, games may be used to increase learner engagement [20, 21] or to facilitate transfer from learning to practice [6, 22]. Indeed, while there are good motivational reasons for employing games or elements of games in HPE (typically as a means of increasing learner engagement), transfer to practice is perhaps the more important goal (at least in the context of this journal), and as such, we return to the principle of simulation in games for HPE.

Given the similarities between simulation and games, it is not surprising that there is some debate about whether games and simulations are discrete phenomena [23, 24]. In the healthcare education context: “when … gaming characteristics [such] as conflict, players, rules and payoff are combined with simulation, they result in the representation of a particular decision making process. Only those games that depict reality in precise and regulated ways are simulations” [23]. However, it may be that the reliable depiction of reality is not the essential difference between games and simulation (at least in the context of simulation-based learning), not least because serious games and simulation-based learning seemingly overlap in many ways. We need therefore to consider the translation between games and professional practice a little more carefully.

Educational affordances

Both isomorphism and anisomorphism have educational uses and, in the case of serious games, should be selected in a configuration that can best help learners to converge on the intended educational objectives. Indeed, each of the different game facets can afford different instructional or educational benefits, as outlined in Table 2. This reflects the central tenet of game-informed learning, that it is not games that are (or are not) educationally effective, it is the different facets of games that can confer educational advantage. However, as with any instructional modality, these advantages are not causal in effecting learning and the extent to which they are realized depends on a number of factors, including the perceptions of the participants and the relationships between playing a game and the broader educational program or environment within which this occurs.

Facet	Educational affordances
Competition	Motivates learner to improve their performance by challenging them to make iterative changes to their approach to a task or situation guided by feedback and other performance indicators [12, 41, 47]
Conflict	Structured opportunities to learn how to deal with conflict—how to identify it, how to work when there is conflict (particularly when it disrupts collaboration between participants), and/or how to resolve conflict. Given the potential for stress, conflict involves higher cognitive load and is introduced only once a learner can handle a conflict-free situation [12, 42]
Chance/luck	Either simulation of chance factors in real-world practice (such as whether a patient has a particular condition or will respond to a particular treatment) or as a way of adding unpredictability to game play and thereby adding to the complexity and/or difficulty of a game [12, 15]
Experience	Increases immersion in the game (by making it more realistic or familiar), builds familiarity with particular kinds of situations, or augments the complexity and/or difficulty of a game [12, 47, 48]
Performance	To facilitate skill development (physical and cognitive) with direct transfer to practice and to rehearse and refine skills in different and emerging situations [12, 38, 39, 46]
Simulation	Depends on task related to simulators (things that simulate—media) and simulations (activities that simulate) [12, 34, 39, 49]
Make-believe	Allows participants to explore roles and situations, to develop their professional identities, and to develop empathy by “walking in someone else’s shoes” (psychosocial moratorium). The use of make-believe should be credible and align with practice situations, which in healthcare professional education is typically articulated in the form of case narratives and role profiles [12, 14, 38, 50]
Tactics and strategies	Should converge with those required in professional practice. Should not encourage “gaming” in the sense of misrepresenting performance by manipulating the underlying game boundaries at the sake of the intended learning outcomes [15, 51]
Media	Media choice depends on the task and the intended learning outcomes; it should align or converge with real-world professional practice [15, 16]
Symbols and actions	Should converge with professional practice, increasing isomorphism and reduced abstraction over time [17–19, 43]
Complexity	Should reflect scaffolding principles of increasing autonomy and convergence with real-world professional practice [38, 44, 45]
Difficulty	Should reflect scaffolding principles of increasing autonomy and convergence with real-world professional practice [38, 44, 45]

Not only is the use of different game facets in designing educational artifacts and activities a matter of selecting and combining them according to their instructional affordances, the design and use of serious games as a whole can be understood in terms of instructional design: “the process of deciding what methods of instruction are best for bringing about changes in student knowledge and skills for a specific course content and a specific student population” [29]. To that end we can map the elements of instructional design [30] to the instructional design affordances of serious games and game facets (see Table 3).

Elements of instructional design	Serious game affordances
Learners and learning processes	Games should be designed to be used. The design and use of serious games needs to align with learners’ needs, their capabilities, and their expectations. The focus should be on engineering compelling educational experiences.
Learning and performance contexts	Serious games should be:
	1) Appraised as learning and performance contexts in and of themselves
	2) Appraised in terms of their intended roles and impacts in the broader educational contexts in which they are used
	3) Appraised in terms of their facilitation of learning transfer to practice contexts
Content structure and sequence	Serious games can extend the instructional design repertoire by adding facets and templates for the creative and deliberate use of simulation and make-believe, symbols and symbolic actions, game boundaries and rules, and attention to learning experiences.
Instructional strategies	Serious games can extend the instructional design repertoire by adding facets and templates for the creative and deliberate use of competition and conflict, chance and luck, physical and cognitive performance, tactics and strategies, and complexity and difficulty.
Media and delivery systems	Gaming media can extend the instructional design repertoire, both by association (such as using the label of “game” for motivational reasons) and for their direct affordances (such as the use of multiplayer virtual worlds).
Designers and design processes	Serious games can present constructive challenges to instructional design norms and practices as well as extending the instructional designers’ repertoire.

By mapping back and forward between serious games and instructional design principles and affordances, we can move to an understanding of serious games as a loosely bound category of educational activity designs that can have different educational uses based on the game facets they employ and on their alignment with learner needs and the educational contexts within which they work (see Fig. 1).

As much as serious games can afford instructional and motivational advantages, they are sometimes seen as rather immature or lacking in serious intent. This is reflected in a widespread, if tacit, sense that the use of games in health professions education does not reflect well on the gravitas of clinical practice and that to use them in this context requires us to clearly differentiate between serious and non-serious games. Unfortunately, this dichotomous perspective obscures the more important issue that “game” is a rather ill-defined aggregate of activity designs and components that can be realized in a multitude of ways, many of which already intersect with mainstream instructional strategies.

A central goal for this paper has been to encourage both a critical engagement with and a more in-depth consideration of games and gaming in the field of health professions education. Rather than listing game types or exploring them from a taxonomic perspective, I have set out a framework of game facets, I have used these facets to differentiate between gaming and simulation, and I have described them in terms of their educational affordances. In doing so, this kind of faceted approach can address the fundamental category problem of asking whether games are educationally effective. Different games employ different game facets in different ways; it is the educational avoidances of the facets that are used in any given instance that confer educational advantage. This reflects pattern-based faceted thinking [31] associated with other kinds of activity design such as PBL [32], team-based learning [33], and simulation [34]. Not only does this approach give more flexibility and precision in considering games for educational purposes, these facets can be understood as part of the broader instructional design repertoire for health professions education. After all, many of these facets are already to be found in health professions education activity designs. For instance, competition, whether with oneself or with others, is intrinsic to most contemporary assessment practices, and simulation is to be found almost everywhere within the field of health professions education [35].

It might be argued therefore that there is nothing particularly new about games and gaming in health professions education, and it is only the emphasis on certain facets or the particular configurations of facets that differentiates game activities from more mainstream practices in health professions education. However, the novelty of videogame, gamer culture, and the many devices that can be used to play games seems to have blinded us to the true nature of serious games and it has confused the debate over their use in health professional education. As educators, we need to make deliberate and informed use of game facets as part of our instructional design repertoire.

For instance, games are distinct and bound in ways that other health professional education activities are not. Games have clear success and failure criteria, they have specific and somewhat abstract rules, they depend on the use of structured feedback both within and between game instances, and they require participants to engage in the psychosocial moratoria of role-play, competition, and conflict. This suggests that games and game facets involve much larger (and potentially better) use of anisomorphism to create compelling experiences and drive learning than other activity types in the health professions education repertoire. It is an interesting paradox that learning in games can be driven by divergences from practice while mainstream thinking in simulation-based learning is so concerned with its convergence with professional practice.

In focusing on game facets and their instructional uses, I have perforce neglected other issues in and around the use of games in health professional education that are nevertheless deserving of attention. I will consider two of these briefly. Firstly, health professionals, in particular health professions learners, may be less experienced in gaming because of the effort required to build a credible profile to gain entry to a professional school. Because they tend to be relatively inexperienced in video games, they are likely to be less disposed to select them as a preferred modality of learning. It would be wrong therefore to make a generational assumption that younger people are intrinsically positively disposed towards the use of games. Secondly, perhaps the biggest elephant in the room is that of the economics of developing and using games in health professional education: “the time and skills required to set up such environments can still be a barrier to adoption as can the variability in student hardware and connectivity” [6]. However, the faceted approach would suggest that we should not assume that games will cost more in general. Answering economic questions depends on what facets are used, how they are combined, and how they are realized in a game template.

It is also important to note that this paper differs from other theoretical perspectives on serious games that have been proposed in fields outside of health professional education. Indeed, there have been many connections made between serious games and learning theories such as behaviorism, situated learning, transfer theory, and problem-based learning [36–38]. However, these have tended to focus on the alignment and fit between game and theory rather than on the faceted approach I have presented in this paper. Where game facets or elements have been considered, attention has tended to focus on the differences between game and pedagogical elements rather than on their educational affordances [39].

This reflects a more extensive consideration of educational games in education as a whole than there has in health professions education, with work in the latter tending to focus on particular games and their applications with the assumption that they have intrinsic and beneficial educational affordances [7, 40]. There are some exceptions, for instance, the connections between games and activity theory have been considered within health professions education [18] as well as in other fields [19]. van Staalduinen’s exposition of game properties is particularly notable as it takes a similar faceted mapping approach to that set out in this paper [41]. While there are similarities between the two models in terms of common facets (such as conflict, rules, and feedback), van Staalduinen’s model concentrated on the more operational aspects of actual games (such as pieces, players, and communication) rather than on the broader principles set out in the typology advanced in this paper. A key difference then is whether we should focus on the specifics of things that are explicitly considered to be games or instead on game-informed principles that can be realized in activities that are not games per se. In the context of exploring the connections between game and simulation in support of health professions education, my argument has been that a game-informed approach is perhaps the more useful of the two.

I acknowledge some limitations to the work presented here. I have taken somewhat hypothetico-deductive approach in synthesizing and shaping key concepts around serious gaming and deriving a framework and set of game-informed principles for health professions education. In doing so, I have not presented an evaluation of this model, nor have I tested it robustly in practice. Indeed, it would be hard to do so in any comprehensive way given its broad reaching scope. I have also not undertaken an exhaustive audit of the literature on serious games from outside of health professions education. The many examples that I have drawn upon indicate a paucity of application to our field and its particular needs and dynamics that may account for the lack of uptake compared with other professional training paradigms. Indeed, taking an instructional design perspective (as presented here) has enabled a critical stance on both the advantages and limitations of different serious game facets that does talk to some of the key concerns within the field.

I started this essay with the observation that, while there have been many calls for, and champions of, games in health professions education, the category of “serious games” was broad and their educational affordances ill-defined. It would be easy then to suggest that the answer to this is more research into particular uses of serious games in training health professionals. However, as I have set out, the catechism of “more research is needed” is too simplistic, not least because there has already been much research in to the educational use of games; the long-running Medicine Meets Virtual Reality conference (www.nextmed.com) and the US military-funded TATRC program (www.tatrc.org) are just two indicators of this effort. Rather, the main lesson here is the need and opportunity to see past the current sturm und drang of video games and gaming to the advantages that game-informed learning can afford health professional education. A key implication of the model I have presented is to connect individual and collections of game facets to educational theory and evidence. I have not done so here as this is in itself a significant task as, while there are links with extant work, it is not in the context of game facets. For instance, topics such as transfer [38], competition [11], conflict [42], shared symbols [43], complexity [44], scaffolding [45], and performance [46] have been previously explored. A systematic exposition of these connections is nevertheless a logical next step in pursuing this line of inquiry, as is the exploration of those elements that have a less robust evidential basis such as the use of chance.

A judicious use of gaming facets has the potential to extend and enhance the instructional design repertoire in health professions education, and in doing so it can act as a challenge to orthodox thinking that would see the unit of instructional value as the game rather than as its different facets. Moreover, a clearer focus on different game facets allows for the exploration of broader issues such as the educational value of activities that diverge from real world practice as well as those that converge with it.

Different game facets have different educational affordances, many of which are to be found in other kinds of activities. Rather than questioning whether or not things that are recognizably “games” should be used (or used more) in health professions education, we should be considering what it is about games that makes them useful or compelling educationally; to what extent and in what way different game facets are present or absent in our practice and research; and how they can be used to effect desirable educational outcomes. And yes, more work is needed in this area.