Gamification to Motivate Students

by Antoniya R. Holloway, PharmD, PGY1 Community Pharmacy Practice Resident, Mississippi State Department of Health

Ask anyone in my pharmacy school graduating class, and I believe they would tell you that the most anticipated part of a long therapeutics lecture was the sound of the Kahoot! theme song. Despite how glazed-over our eyes became during medicinal chemistry discussions, my classmates and I always seemed to perk up at the mention of a fun, competitive opportunity to demonstrate what we had learned. More educators are using games and other competitive activities to fuel student engagement and motivation during instruction.¹ This instructional design method is termed “gamification.”

Gamifying education, aka gamification, is described in one of two ways: (1) the act of rewarding learners with gameplay after a tedious lesson, or (2) the act of infusing game elements into a lesson to make it more enjoyable.²Although using incentives to motivate learners is not a new concept, gamification of classrooms was ignited in the era of e-Learning.¹ The Smithsonian Science Education Center lists five prominent benefits of gamification:²

1. Increased level of learner engagement in classrooms
2. Increased accessibility for students diagnosed with autism
3. Improved cognitive development in adolescents
4. Improved physical development in adolescents
5. Increased opportunities for learning outside of classrooms

The question is not whether there are theoretical benefits in gamifying education, but whether there are long-term educational benefits to learners.  And whether there are specific methodological approaches to gamifying education that can be standardized and implemented in a similar fashion.

The International Journal of Educational Technology in Higher Education published a systematic review in 2017 examining 63 papers to evaluate research studies and emerging gamification trends and to identify patterns, educational contexts, and game elements.¹ The results were stratified into 5 categories: educational level, academic subject, learning activity, game elements, and study outcome.

Education level

Educators must understand that although gamification can be implemented at any grade level, more sophisticated platforms that require higher levels of technique may be too complicated for younger learners to navigate. Most papers included in this review were conducted at the university level (44 papers), while fewer (seven papers) were conducted at the K-12 level. Authors propose that this disproportion is because college professors have more control over their courses than teachers following state-mandated curricula and because college students have better-developed computer skills.

Academic subjects

The systematic review included gamification studies related to over 32 academic subjects in six categories. Many papers (39%) targeted computer science/information technology (CS/IT) and multimedia and communication (12%). Although the results are inconclusive, it could be speculated that gamification is more suitable for CS/IT courses compared to other subjects.

Types of Learning Activities 

A mix of instructional activities was used in 16 studies instead of the sole activity. Half were online courses, and the other half had a web-based learning component (aka hybrid courses that included both face-to-face and online instruction). This supports the conclusion that even though some courses are traditional in nature, educators could modernize courses by incorporating an online gaming component.

Game Elements

Game design elements described in this systematic review were classified by the game dynamics, mechanics, and components. Game “dynamics” prioritize emotions and relationships while “mechanics” prioritize competition, feedback, and reward. Components are the basic levels of dynamics and mechanics using leaderboards, points, and badges. All of the studies used one or more gaming elements, but there were no standardized gaming elements nor standardized definitions of gaming elements used across all studies.

Study Outcomes

Specific learning and behavioral outcomes were also stratified into categories: knowledge acquisition, perception, behavior, engagement, motivation, and social. Because of the diversity of studies, outcome results were further stratified as (A) affective, (B) behavioral, or (C) cognitive. Educators should note that different game elements (or combinations of elements) and individual factors (personal or motivational factors) influence the outcomes of gamification.  Thus, what works for one learner may not work for others.

The authors of the included studies in the systematic review concluded that gamification produced learning gains (performance, motivation, retention, and engagement) and that learners appreciated the gamification features,¹ but the validity and reliability of these claims are questionable. For example, twenty studies either had too small a sample size or too short an evaluation period. Using performance as an outcome is inconclusive, as performance can be influenced by other non-motivational factors like mental capability and prior knowledge.

Theoretical Perspective

Several papers conclude that focusing on game elements like points and rewards rather than an individual’s desire to play is not a fail-proof way to change learning outcomes. A “user-centered" approach may be more conducive as educators develop gamified content due to the wide variety of personal factors.³ One study suggested shifting from the introduction of game elements into course lessons and, instead, developing a “gameful” experience throughout the course.⁴ The authors of the systematic review conclude that there is insufficient understanding of the motivational mechanisms of gamification. A theoretical framework is necessary to standardize how gamification is implemented and to differentiate which mechanisms create successful outcomes.

This systematic review reinforces the observation that learners generally “like” gamified education and that gamification of learning content increases learner motivation. But it does not provide a concrete answer as to whether gamification leads to long-term improvements in outcomes. I believe educators should consider implementing gamification to increase participation and engagement for health professional students, especially during the foundational years of their professional curricula. However, educators must be aware that the lack of a standardized approach to gamification and individual learner preferences will yield variable outcomes.

References

1. Dichev C, Dicheva D. Gamifying education: What is Known, What is Believed and What Remains Uncertain: A Critical Review. Int J Educ Technol High Educ 2017; 14 (9).
2. Mandell B, Deese A. STEMvisions Blog. Five Benefits of Gamification. Washington, DC: Smithsonian Science Education Center. 2016 March 10 [cited 2022 Oct 10].
3. Hansch A, Newman C, Schildhauer T. Fostering Engagement with Gamification: Review of Current Practices on Online Learning Platforms. HIIG Discussion Paper Series [Internet]. HIIG Discussion Paper Series No. 2015-4 [cited 2022 October 10].
4. Songer RW, Miyata K. A Playful Affordances Model for Gameful Learning [Internet]. TEEM '14: Proceedings of the Second International Conference on Technological Ecosystems for Enhancing Multiculturality; 2014 October [cited 2022 October 10].

Cultivating Cultural Humility

by Amy Ly-Ha, PharmD, PGY1 Community Pharmacy Practice Resident, University of Mississippi School of Pharmacy

Growing up in the Vietnamese culture, whenever I had a minor illness, my parents engaged in the practice of cạo gió, also known as coining. The intent of the practice is to dispel negative energy from a sick individual.  Coining involves spreading medicated oil onto the skin and rubbing a coin over this area until a red abrasion mark forms. To those who are unfamiliar with the practice, these marks may look frightening and can be mistaken as abuse. As a child, I did not pay much attention to these marks on my body. Once, I came home from school feeling feverish. My mother performed coining and brought me to the doctor’s office the next day. Upon conducting a physical examination, the physician noticed the red stripes on my back. Rather than making accusations of abuse, the physician skillfully interviewed my mother and listened to her explanation. Looking back, I now recognize the significance of this encounter. Not only did the physician display a willingness to listen to my parents, but she also demonstrated an openness to my family’s cultural traditions. This physician modeled cultural humility, a concept that I believe all healthcare professionals should possess to create an environment conducive to optimal patient care.

The widespread implementation of cultural diversity training in various health professions education aligns with the growing diversity of our patient populations. There are many aspects to cultural diversity training. Commonly taught in health professions degree programs today, cultural competency embodies the ability to provide care to people with diverse values, beliefs, and behaviors.¹ Cultural competency requires several skills, including recognizing the unique needs of every patient, realizing that culture impacts health beliefs, and respecting cultural differences. A culturally competent healthcare professional is able to negotiate and restructure therapeutic plans in response to a patient’s cultural beliefs and behaviors.² And while cultural diversity training is clearly important, health professionals must also demonstrate cultural humility.

Cultural humility, a term first coined in 1988, is a lifelong process of ongoing self-reflection and self-critique.³ It emphasizes awareness of one’s possible biases and a willingness to be taught by patients. Unlike cultural competency, the goal of cultural humility involves “relinquish[ing] a provider’s role as a cultural expert and adopt[ing] patient-centered interviewing to create a mutual therapeutic alliance.”² One barrier to teaching cultural humility includes the difficulty of assessing students’ growth in this area. Despite this, I recommend that educators implement the following elements to foster cultural humility in their students.

Element 1: Develop Culturally Relevant Curricula

A culturally relevant curriculum incorporates aspects of culture throughout a curriculum, thus valuing various cultures and encouraging intercultural understanding.⁴ Introducing students to different cultures throughout their education, in and outside the classroom, enables students to learn how to navigate through diversity. By embedding cultural diversity training at strategic times throughout a curriculum, educators can include reflective exercises intended to build cultural humility. 

When developing and implementing a culturally relevant curriculum, one must be aware of the potential to introduce unconscious bias in lessons and assessments. For example, a recently published research study investigated the presence of unconscious bias in student assessments at a Doctor of Pharmacy program.⁵ Assessing questions from the academic year of 2018 to 2019 for first-, second-, and third-year pharmacy classes, the investigators examined 3,621 questions. Only a small fraction of these questions referenced race (N=40); however, race was relevant to only two questions. The study also found that specific races were more often associated with specific health conditions. For example, in the analyzed set, the researchers found that all questions related to human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) were associated with African-Americans. Thus, as this study documents, the routine use of race as a descriptor in instances where it lacks significance may propagate racial bias.⁵ Therefore, providing culturally relevant curricula requires educators to acknowledge their own biases, mitigate them, and display intentionality as they develop and implement instructional materials.

Element 2: Create Opportunities for Cultural Socialization

Cultural socialization is the process in which individuals learn about the customs and values of other cultures. Within the classroom, instructors can create simulations that foster cultural humility. For example, scenarios that prompt students to confront challenging situations and recognize their own biases can help facilitate cultural humility. Furthermore, instructors can create discussion boards to encourage students to share their cultural practices, values, and beliefs.

Immersive experiences outside of the classroom can reinforce direct instruction. These opportunities include community outreach events, introductory and advanced practice-based experiences, and international service trips. Placing students in these environments encourages students to go outside their comfort zone and strengthen their confidence. By creating and introducing experiences for cultural socialization, educators can broaden their students’ perspectives.

Element 3: Promote the Practice of Self-Reflection

The emphasis on introspection sets cultural humility apart from cultural competency. Instructors should encourage students to regularly reflect on and learn from their experiences. Activities that promote reflective practices include journaling and meditation. Online resources like the Implicit Association Tests can also serve as tools to help students recognize their unconscious biases.⁶ By encouraging reflection and providing opportunities to talk about experiences, educators are developing the habits of mind needed for learners to continue this practice throughout their careers.

Implementing the three elements can promote cultural humility within students. Fostering cultural humility and incorporating cultural competency training in health professions education is critical to achieving accessible and comprehensive healthcare for all.

 

Sources:

1. American Hospital Association [Internet]. Becoming a Culturally Competent Health Care Organization. AHA; 2016 Jun [cited 2022 Sep 16].
2. Rockich-Winston N, Wyatt TR. The Case for Culturally Responsive Teaching in Pharmacy Curricula. Am J Pharm Educ 2019; 83(8): Article 7425.
3. Tervalon M, Murray-García J. Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education. J Health Care Poor Underserved 1998; 9(2):117-25.
4. International Bureau of Education [Internet]. Culturally Responsive Curriculum; [cited 2022 Sep 16].
5. Rizzolo D, Kalabalik-Hoganson J, Sandifer C, Lowy N. Focusing on Cultural Humility in Pharmacy Assessment Tools. Curr Pharm Teach Learn 2022;14(6):747-50.
6. Project Implicit [Internet]. Select a Test; [cited 2022 Sep 30].