Activity Five

Student Driven Exploration of Anesthetic Monitoring Using Gamification

By Denise Forbes

Background:

A significant number of students in the course, 5158 Anesthesia and Analgesia, have difficulty interpreting the factual information taught during this course, which limits their ability to evaluate the actual condition and well-being of their anaesthetized patient when performing their assessment of anesthetic monitoring, the culmination of their coursework at the end of the year.  This is demonstrated by students submitting anesthetic records and videos in which they failed to identify or explain patient abnormalities, or did not modify their anesthetic protocol in response to anesthetic complications.  As this is a key component of performing well as a qualified veterinary nurse anesthetist, failing to develop this ability to think critically and analyze the patient’s situation indicates that a core portion of the learning outcome desired of this course is being missed.

To facilitate a greater degree of student critical thought and better practical application of the principles of anesthesia, which in turn would reduce patient risk and improve the probability for favorable outcomes with anesthesia, the desirable goal would be to get the students thinking at a much earlier date about the meaning and interpretation of anesthetic monitoring information. This may be accomplished by introducing case studies, based off of real life anesthesia cases, for the students to work through in the classroom over a period of time.  Incorporation of these case studies into a game format online, or gamification of this learning process would improve student engagement and use of these case studies. The need to interpret data within the game to achieve high scores or win, would in turn improve the interpretive anesthesia monitoring skills of the student.

The Horizon Report (2013) identifies games and gamification as a mid-term horizon, with an expected increasing use within the next 2-3 years.   Games may be full immersion in nature where the student creates an avatar to represent them in a fully developed virtual environment.  Gamification is defined as using or adding game-like components to a learning experience or educational delivery format.  Both ideas have the potential to increase student engagement with the course material and participation in the learning process, provided that they are well designed.  Poorly designed games would also have the risk of alienating students and discouraging further participation.  It would therefore be critically important to devise well thought out and developed games before initiating them.  Gamification, however, could be instituted in an incremental fashion by first introducing elements of a game in the classroom, even before transferring it to a computer or internet platform.  In fact, implementing portions of the game in the classroom might serve to weed out poorly designed ideas, or those which were ineffective in stimulating the students’ interest. Effective game ideas could then be expanded upon or digitally enhanced and pieced together to develop an in depth and extensive learning game.

Format:

A small group of students could be given an online access to a set of anesthesia record documents from a real case seen in practice and the objective would be to be able to fully interpret every detail of this record by the end of the working time frame.  Smaller groups would be best, in fact it might be ideal to involve only 2 students per case study so that both students would feel some responsibility to contribute to the work, and students would be less likely to opt out of participation as they might if they were part of a larger group.

Various copies of anesthetic records of a real patients could be modified to look like a kind of treasure map.  .At first glance, the document would seem to contain a lot of foreign looking material because students are not familiar with most of the terminology or abbreviations used in anesthesia, or with how the graphs work.  Students would have to decipher (interpret) different portions of this record during their progress in the course.  Teams could be awarded a gold doubloon for each item that they correctly deciphered (interpreted), with a scoreboard for all of the participating teams being posted in the online classroom. Each time a team completes a task of analyzing a graph or chart of monitoring information, they will receive a gold doubloon and move forward on the results tally.  When all graphs or charts are correctly interpreted, the first team to complete the task could be given a special award of winning the treasure chest.   During their participation in the game, students would have to source information to correctly analyze the data.  For example, one area on the document would delineate a graph of SpO2 recordings during the anesthetic period.  Students would have to research, what is SpO2, what is considered a normal SpO2 during anesthesia, and what does it mean if SpO2 becomes abnormal as well as what should be done about an abnormal SpO2.  Picture representations of associated items, such as a pulse-ox monitor which measures SpO2 could be located nearby for the students to click on, and access information about this machine, what it records and why. Links to additional sources of information about related topics would also be located nearby each chart or graph.  The treasure map design would encourage students to progress along a “path” of learning encountering each of the important topics of monitoring along the way.  Completion of each task would be required before the team is allowed to progress to the next station so that the learning would progress in a logical fashion to encourage a sequence of actions on the part of the learning to be performed in real life when they are monitoring a live patient.

Gamification of analyzing the anesthetic record would increase the participation of the students because of competition to complete the tasks and a desire to win the game.  Students would need to interpret the information correctly to choose the correct answer, or give the correct response as to what action should be taken. The format of a competitive game, in which the students can proceed at their own pace, but are encouraged to move forward by following the path by obtain smaller rewards progressing towards a goal of treasure at the end would enhance the student’s desire to participate, and to complete the program. Working in groups of two would encourage collaborative learning and participation. 

An second phase, or alternative game format might be a more real life (SIM) game where students have to actually monitor a patient, and react to programmed changes in the patient’s status, in order to keep them anesthetized and alive through a surgical procedure, in the face of real time difficulties.  The reward for this game might be a scoring of the students’ anesthetic death rates and a ranking based on this figure.

Requirements:

Initially, if only the smaller portions of the game were presented in the classroom, only a few props and some real anesthetic patient records would be required.

The requirements for progressing to a computer game technology would be that the students would need to have access to computers which they could use in a shared participation fashion. This could be achieved by allowing students to bring their own computers to class and by having WiFi internet access for students in the classroom.  As a large percentage of our students already own laptop computers, it is anticipated that over fifty percent of students would be able to bring a laptop to class, so teams of two students sharing would be feasible. The other requirement would be for development of an attractive game format that functions well, which would require some technological expertise.

Advantages: 

The use of games or gamification of course material offers several advantages over the standard lecture format of delivery.  One of the most significant advantages is that there is a high potential for encouraging increased student participation in the learning process at a much earlier time frame in the course.  Games have demonstrated the ability to increase participation by the use of rewards and recognition for achievement. As discussed in the Horizon Report (2013), games and gamification changes the chore of studying into the challenge of solving a problem. They encourage exploration of the subject material to learn how to make something work, or solve the puzzle.  They encourage progression along a learning pathway by awarding points or achievement levels, and by offering a goal or prize to be won. The popularity and effectiveness of self-directed study in an on-line learning environment is now being demonstrated by the use of reward systems such as Mozilla’s Open Badge Project as discussed in Oblinger (2012), which allows participants to collect badges for obtaining levels in any registered organization’s game or incentive program. Participants can even build a portfolio of their awards, which might be useful tool for an educational program with many courses or topics of knowledge.

Gamification also encourages and rewards self-directed study because the student is positively rewarded by choosing which direction to progress, and by exploring down various pathways which lead to additional challenges and the rewards of achieving success with each challenge.  Students with difficulty in a subject have the opportunity to continue exploring or attempting the challenge until success is achieved.  They are not penalized for unsuccessful attempts, but redirected towards new paths of additional learning.

Disadvantages:

A poorly designed game could produce quick rejection by today’s students, particularly those with experience in sophisticated, elaborate virtual worlds such as those in high tech, well developed games that are available today, such as World of Warcraft. 

The initial cost of developing a game, especially a well-designed, elaborate SIM environment could easily be prohibitively expensive.

It might be difficult to be sure that all course requirements are included and achieved unless the game was one facet of a multidimensional learning approach.

References:

http://www.nmc.org/pdf/2013-horizon-report-HE.pdf  NMC Horizon Report 2013 Higher Education Edition

Oblinger, D (2012).  Game Changers: Education and Information Technologies. USA: Educause. Retrieved from http://www.educause.edu/research-publications/books/game-changers-education-and-information-technologies