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].

Creating Psychological Safety in Learning Environments

by Emily Keveryn, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital - North Mississippi

Student engagement is often something teachers and educators strive to achieve for lots of reasons — to have students actively thinking about the material and responding to questions, to validate that what is being taught is being understood, and to promote positive attitudes toward the material. But why is there a lack of engagement so common in many learning environments? As a teacher, it may be easy to forget how stressful or daunting the feeling of speaking up in front of a group of peers or instructors is.  For students, this is one of the most common barriers to active engagement in group learning settings. Having an environment where students feel comfortable enough to interact without concerns of sounding silly or being embarrassed is challenging to achieve, especially in very large groups and, conversely, in very small groups too. 

Amy Edmondson, an American scholar of leadership, teaming, and organizational learning, coined the term "psychological safety” to describe “the feeling that one is comfortable expressing and being themselves, and sharing concerns and mistakes without fear of embarrassment, ridicule, shame, or retribution.”^1,2 While Edmondson’s research focuses on psychological safety in teams in business and healthcare settings, many of the ideas and behaviors she observed are relevant to the classroom and other learning environments. It is human nature to want to be accepted, heard, and understood.  And, perhaps more importantly, to avoid rejection, embarrassment, or punishment.  Therefore, fostering a psychologically safe learning environment is critically important and it creates a climate where the material and learning process is engaging, exciting, and lively!

Whether it is in a large classroom, during medical rounds, interacting with an intern on a job site, or in any situation where an educator is teaching something, psychological safety must be present for many reasons.  It encourages learning by making the learner comfortable asking questions when they may not understand the material. It stimulates innovation by encouraging higher-level thinking and understanding.  And it provides a sense of belonging whereby learners feel they can express their thoughts on a subject without being ridiculed or feeling rejected. In one study that addressed psychological safety in a simulation with medical residents in a trauma scenario, researchers found that increased stress impaired knowledge recall and decreased clinical performance.  The medical resident’s performance was measured using a standardized assessment form and a global rating checklist.³ In another study, researchers found that feeling psychologically safe reduced anxiety in nursing students who were participated in simulation activities.  Anxiety was measured by pre- and post-surveys completed by the students.⁴ While these studies looked at psychological safety during simulation activities, the results strongly suggest that the environment, psychologically speaking, has a significant impact on learners' ability to perform activities, recall information, and feel confident.

Timothy Clark writes that there are four stages of psychological safety that individuals go through that reflect basic human needs: inclusion safety, learner safety, contributor safety, and challenger safety.⁵ Inclusion safety is the feeling of belonging and being accepted. One way to provide this type of safety is to learn and use students' names, welcome them to the classroom, and include the learner, and listen to their input. This can be challenging when educating multiple learners, balancing the time between each. Learner safety, which may arguably be the most important stage for educators, occurs when individuals feel comfortable asking questions, receiving feedback, asking for help, and even making mistakes. By actively listening and offering gentle, clear guidance, educators can increase learner safety. This stage is especially important when trying to encourage the learner to speak up and not fear retribution. Contributor safety satisfies the need to feel like we are contributing in a meaningful way and making a difference. When a learner feels included and safe to make mistakes, they feel more inclined to contribute and use the knowledge that they possess to make a difference. This builds off of learner safety, which bolsters confidence in asking questions, and encourages the learner to contribute ideas without fear. Lastly, challenger safety encourages individuals to use what they have learned and strive to make things better in the learning environment and beyond. Challenger safety occurs when students feel they can directly challenge the status quo, recommend an idea or a process, without feeling like the suggestion or comment may damage their reputation.

The Do’s and Don’ts of Psychological Safety:

DO	DON’T
Stay attentive to what is happening and if things seem to be feeling unsafe for some students, listen carefully to understand what may be causing others to feel this way, and ask questions to clarify how they feel.	Don't let uneasiness stop you from discussing what needs to be discussed - if you are feeling uncomfortable, it is likely they are too!
Offer encouragement and support to ensure that each learner knows they are heard and will not be subject to ridicule or embarrassment.	Don’t use sarcasm or emotive language, it can cause others to feel as though we may not be taking them seriously.
Reinforce a conversational culture by making it safe for anyone to talk about anything.	Don’t be defensive or apathetic; it will likely result in the situation continuing and the learner being afraid to speak up again

Psychological safety in learning environments is often something that educators struggle to achieve but is one of the best ways to increase student engagement, interaction, and learning. By role modeling an open and comfortable environment, we are also are fostering the skills within our learners as they learn how to interact with patients and colleagues … and students in the future! Educators need to understand the stages and the ways to create a psychologically safe learning environment to ensure learners get the greatest benefit from the learning process. 

References:

1. Edmondson A. Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly 1999; 44: 350–383.
2. Edmondson A. The Fearless Organization: Creating Psychological Safety in the workplace for learning, Innovation and Growth. Hoboken, NJ: Wiley; 2018.
3. Harve A, Bandiera G, Nathens AB, and LeBlanc VR. Impact of stress on resident performance in simulated trauma scenarios. Journal of Trauma and Acute Care Surgery 2012; 72: 497–503.
4. Ignacio J, Dolmans D, Scherpbier A, et. al. Comparison of standardized patients with high-fidelity simulators for managing stress and improving performance in clinical deterioration: A mixed methods study. Nurse Education Today 2015; 35: 1161–1168.
5. Clark TR. The 4 stages of psychological safety: Defining the path to inclusion and Innovation. Oakland, CA: Berrett-Koehler Publishers, Inc.; 2020.

Student Pharmacists as Pediatric Asthma Educators

by Caroline Adrian, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Review and Summary of: Elliott JP, Marcotullio N, Skoner DP, et al. Impact of student pharmacist-delivered asthma education on child and caregiver knowledge. Am J Pharm Educ. 2014 Dec 15;78(10):188.

 As a student pharmacist, I recognize the importance of medication adherence in the management of chronic conditions. However, when I was diagnosed with asthma as a child, I did not understand the concept of maintenance therapy. I didn't understand that I needed to use my inhaled corticosteroid every day to prevent exacerbations. Frankly, I didn't even know what that inhaler was for, so I frequently missed doses. Looking back, I wish someone had taken the time to educate me about asthma and the medications I needed to use so I might have had better symptom control. I recently discovered a study¹ that looked at the impact of student pharmacists as asthma educators to both children and their caregivers. I was eager to learn more.

This cross-sectional study enrolled children and caregivers who attended at least 1 of 6 For Your Good Health, LLC asthma camps at Duquesne University over a two year period. The asthma camp series was developed to teach children, ages 5-17 years, and their caregivers asthma self-management skills. The camps were directed by an interdisciplinary team of physicians and pharmacists and staffed by student pharmacists and university athletes. Camps were held on Saturdays from 9:00 am to 2:00 pm, with asthma screenings and education being conducted during the morning session. The primary objective was to evaluate the impact of student pharmacist-delivered asthma education on child and caregiver knowledge about asthma. The secondary objective was to assess child and caregiver baseline asthma knowledge and its correlation with asthma control.

The hands-on educational activities implemented at each asthma camp were developed by sixth-year Doctor of Pharmacy students under the guidance of two faculty members. The activities focused on the 4 key components of effective asthma management: avoidance of triggers, medication compliance, proper inhaler technique, and the importance of an asthma action plan. Some of the activities included interactive skits to teach proper inhaler technique, game shows highlighting the differences between controller and reliever medication, and a memory game of asthma triggers. One group of students built a large cardboard house that contained common asthma triggers for their activity. They worked with the children to make the house more "asthma-friendly," discussing how to limit exposure to each of the triggers. Caregivers were not required but strongly encouraged to attend with their children.  The participants rotated through 4 stations of activities that lasted up to 15 minutes each. 

An asthma knowledge questionnaire was administered separately to the children and to the caregivers at the beginning and end of each asthma camp to assess the effectiveness of the educational program. Of the 87 children enrolled in the study, 76 completed both the pre- and post-intervention questionnaires. Only 45 caregivers participated in the educational intervention with 42 completing the pre- and post-intervention questionnaires. Statistical analyses compared the pre and post-intervention scores. 

The study found that the asthma education program was effective in increasing asthma knowledge among children. However, the student pharmacist-delivered education was not effective in increasing asthma knowledge among caregivers. Many of the caregivers who participated did not have children with asthma and the investigators also noted that many caregivers opted to socialize amongst themselves rather than participate in the educational components of the For Your Good Life camp. It was unclear to me whether the investigators designed the educational intervention with the caregivers in mind, or if they designed the intervention to focus on the children alone with hopes that the caregivers would be willing to participate. It seems the educational intervention was engaging for the children but perhaps not of great interest to adults. However, the investigators found a strong association between caregiver pre-intervention scores and asthma control in their children, suggesting that caregiver knowledge of asthma plays a role in asthma control.

This study found that the educational program was beneficial to the children who participated as well as the student pharmacists. The student pharmacists were able to practice their role as future educators by developing and implementing novel educational activities. A weakness of this study was that the investigators used different student pharmacists at the camps and this may have led to differences in how the educational activities were conducted. A limitation of this type of educational intervention is that the development and implementation of such a camp requires a significant amount of time and resources.

This was the first study to assess the effectiveness of student pharmacists as asthma educators in a pediatric population. Other studies have shown student pharmacists can effectively educate adults with chronic illness.^2,3 Other studies have found that asthma education of children and caregivers can lead to better symptom management and fewer acute exacerbations,⁴ and educational programs for asthma self-management in children alone can also lead to improved lung function and fewer trips to the emergency department.⁵

This is a great way for educators to engage student pharmacists to conduct hands-on learning experiences teaching children about asthma. Similarly, structured learning activities may be beneficial in teaching children about other disease states as well. Diabetes and epilepsy are also common chronic conditions in children where student pharmacists can assist in delivering fun educational programs to kids. 

References:

1. Elliott JP, Marcotullio N, Skoner DP, et al. Impact of student pharmacist-delivered asthma education on child and caregiver knowledge. Am J Pharm Educ. 2014 Dec 15;78(10):188.
2. Letassy N, Dennis V, Lyons TJ, et al. Know your diabetes risk project: Student pharmacists educating adults about diabetes risk in a community pharmacy setting. J Am Pharm Assoc (2003). 2010 Mar-Apr 1;50(2):188-94.
3. Shrader S, Kavanagh K, Thompson A. A diabetes self-management education class taught by pharmacy students. Am J Pharm Educ. 2012 Feb 10;76(1):13.
4. Agusala V, Vij P, Agusala V, et al. Can interactive parental education impact health care utilization in pediatric asthma: A study in rural Texas. J Int Med Res. 2018 Aug;46(8):3172-3182.
5. Guevara JP, Wolf FM, Grum CM, et al. Effects of educational interventions for self-management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003 Jun 14;326(7402):1308-9.

Passive versus Active Learning

By Josephine Heinz, Pharm.D., PGY1 resident, Sinai Hospital of Baltimore

I remember the long hours I sat through my pharmacokinetic classes wondering what all the symbols my instructor was talking about meant. Wow, I thought, does all this really happen in a patient? Most of the equations were meaningless abstractions to me and it didn’t make any more sense to me at the end of the lecture.

Healthcare concepts are most often learned through traditional methods where the instructors figuratively pour information onto their students and students sit passively hoping they could retain all the knowledge and recall it for an exam. I had flashbacks to my experience as a pharmacy student when I read an article by Robert Dupuis and Adam Persky (Am J Pharm Educ 2008; 72(2): Article 29.) The investigators applied the principles of active learning to enable students to develop critical thinking, self-direction and practical application of information related to pharmacokinetics. Students were divided into small groups, assigned cases and had to present it to the entire class in the presence of the instructor. Individual responsibility was also emphasized by assessing each student’s preparedness for the presentation by quizzing them before class and also comprehensive examinations. Members of each group were chosen by the instructor based on their knowledge and skills rather than permitting students to make the groups for themselves. By placing students with various knowledge and skills together, this allowed students to understand how others think through problems. In their study, the authors compared the new teaching strategy to a traditional, passive approach of teaching the material. They found that not only did the students like this active teaching approach better; they could also relate the concepts to clinical practice and felt comfortable and confident when addressing real patient cases.

This study answered some questions that perplexed me as a pharmacy student. The traditional educational paradigm is like a "Container-Dispenser model" – it assumes the transference of knowledge is primarily the instructor's job and students' minds are like empty receptacles (Bonwell CC, Eison JA. Active learning: Creating excitement in the classroom. ASHE-ERIC Higher Education Report No. 1. Washington, DC: The George Washington University, School of Education and Human Development; 1991). Students are expected to passively absorb information in silent isolation during a lecture and later on, recall the knowledge when given a test or assessment. A lot of passive teaching occurs in pharmacy schools, and most students only get to apply the knowledge they have acquired during experiential rotations in the final year of the curriculum. This leaves the students feeling frustrated and inadequate because they cannot answer commonly encountered medication problems. This year, during my residency, I’ve heard students say “I just want this rotation to be over,” because they feel they have no time to sit down and read through all the lecture notes they have accumulated over the years. This is a concern for our profession. Do we have to force all graduates from doctor of pharmacy programs to get an additional year of practical training, or can we address the current curriculum to include more self-directed and active learning?

I recommend that we follow the example of Dupuis and Pesky by incorporating more active learning strategies into the pharmacy curriculum. Active learning is more than just "doing" but requires the student to "think about the things they are doing.” With active learning, the responsibility for learning shifts from the instructor to the student. Let us create an environment similar to what students will face in the real world so that they do not flounder when they get into practice. The challenge today is to encourage students to move beyond standard technical solutions and apply clinical reasoning. Active learning promotes the development of abilities in addition to knowledge, attitudes that employers require, and behaviors that better meet the demands of professional practice.

[Editor's Commentary: Active learning strategies - engaging students in meaningful activities - work. Active learning strategies generally require students to find the information (facts) for themselves and to apply this newly acquired (and their existing) knowledge to solve a problem. Many teachers (at schools of pharmacy and elsewhere) have embraced these strategies and use them extensively throughout their courses. Others are experimenting and use these strategies sporadically. Still others are unwilling or, perhaps, afraid to try. Admittedly, active learning strategies are a bit messy and the teacher must relinquish control of the content and the process. And if you extensively employ active learning strategies you can't tell students about all the great knowledge YOU possess. And isn't teaching all about sharing your wisdom with others? Not exactly. The teacher's knowledge and wisdom is no doubt important. It should help guide the creation of meaningful learning activities and authentic assessments of performance. Teachers and experts are great resources to students during their learning voyage. But telling people about everything YOU know isn't particularly helpful ... and it won't help a student construct their own understanding of the material and how to apply it. If you want to include more active learning strategies in your classroom, check out the Active-Learning Inventory Tool created by Jenny Van Amburgh and her colleagues at Northeastern University. -S.H.]