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Abstract Education of healthcare professionals is of primary importance for patient safety. In some health related professions, education and training have to be practiced during the entire working period and not only limited to school years.
The use of new technology such as virtual reality and e-learning brings new possibilities with significant improvement in learning outcomes.
Serious gaming describes a technology that can educate and train while entertaining users. This type of training can be very useful for health professions because it improves learning outcomes creating a learner oriented approach and providing a stealth mode of teaching. In some fields it represents an ideal instrument for continuous health professions education also in terms of costs because it is cheaper than traditional training methods that use cadavers or mannequins.
In this paper we make a scoping review of serious games developed for health professions and health related fields in order to understand if they are useful tools for health related fields training. Many papers confirmed that serious gaming is a useful technology that improves learning and skills development for health professionals. Introduction Training and education of healthcare workers are of primary importance for patient safety.
In a study estimated that preventable medical errors accounted for — patient deaths annually in US hospitals [ 1 ]. This study proved the importance of a more accurate medical education and subsequently many actions were taken to reform the field of medical education. Continuous training is useful and sometimes necessary, especially in surgery, but it has a high associated cost and sometimes could not be ever achievable.
This is because such kind of training requires human and animal cadavers, human actors, or dolls to exercise practitioner skills. New technologies such as virtual reality and e-learning applications bring new possibilities not only in the field of medical training but also for other health professions and could lead to valuable improvement in learning outcomes [ 2 — 4 ].
Friedman described the importance of using new media in medical education [ 5 ]. Besides traditional surgical simulators that use computer technology to offer the medical personnel a tool for skills training, there is another tool that uses also computer technology that healthcare workers can practice with: These technologies can be also useful for patients, in order to teach them procedures regarding their health habits.
For example, a serious game was used to teach healthy alimentary habits in patient with diabetes. From our point of view several benefits are associated with a serious game: To solve this problem we needed to investigate the universe of serious game developed for healthcare.
We found and classified many papers regarding serious game developed for healthcare, in order to describe the state of the art of serious gaming in healthcare and to understand if a similar application paradigm could be useful for our purposes and in general for professional training in health related ambit. A more conventional definition would say that a game is a context with rules among adversaries trying to win objectives. We are concerned with serious games in the sense that these games have an explicit and carefully thoughtout educational purpose and are not intended to be played primarily for amusement.
By comparing the definition of edutainment and the definition of serious game we can conclude that these two expressions refer to the same matter.
A more recent definition that uses explicitly terminology of computer technology in the definition of a serious game could be found in [ 8 ]: Playing a serious game must excite and involve user while ensuring the acquisition of knowledge.
Unlike traditional teaching environments where the teacher controls the learning teacher centered , the serious games present a learner centered approach to education in which the trainee controls the learning process interactively [ 10 ]. Such engagement may allow the trainee-player to learn via an active, critical learning approach. Game-based learning provides a methodology to integrate game design concepts with instructional design techniques to enhance the educational experience [ 11 ].
Games inherently support experiential learning by providing students with concrete experiences and active experimentation [ 12 ]. In Figure 1 we propose the game spectrum classification reported by Qin et al. At one end of this imaginary line there are classical simulators, developed for skills training and providing maximum realism.
This type of simulators tries to replicate the real world. On the other end of the line there are games developed for fun and entertainment that are completely imaginary.
In the middle of the line are serious games and simulation games. Serious games are developed for nonentertainment purposes and designed for skills development. They offer a good dose of realism together with the entertainment factor of a traditional game, while simulation games are typically placed in imaginative or fictitious environments. The computer game spectrum. If we compare serious games with traditional simulators we can focus the differences between them on four fundamentals factors: The entertainment factor of a serious game denotes the main boundary between these two technologies.
In traditional simulators there is no entertainment because the application is only developed for user training. In a serious game the user is entertained by the need to improve his performance, measured by the scoring mechanism and by the challenge to reach a precise goal. The development costs of serious games are reduced if compared to development costs of classic simulators. This is because they do not use custom technology solutions but the same technology on which entertainment games are based and development time are generally shorter.
The deployment cost of a serious game is also reduced because the supporting technology hardware and software is widely diffused. Today this technology is also available in many smartphones so serious games can also be played on this type of device.
Review Methodology In this paper we make a scoping review of serious games developed for healthcare and health professions. The first aim of our research is to describe the state of the art of serious games developed for health related applications.
We want also to understand if a serious game approach can be useful for health related training and what kind of benefits it can provide if compared with other types of learning tools. We tried to answer the following questions. To write this review we searched for serious games developed for healthcare and health professions topics over the web. Our research was limited not only to scientific papers but also to any type of web contents describing serious game solutions developed for healthcare ambit.
We have included in our research also items that do not result in a scientific publication in order to have a complete panorama of developed serious games for healthcare. We excluded papers focused on traditional simulators although developed for healthcare; our results include only papers describing explicitly the use of serious game paradigm. In these papers we searched for results of studies that evaluate the usefulness of this approach in healthcare and health professions training.
Unfortunately only a few papers report such results. Many papers presented only the serious game development and its application area without describing the innovation components of the work nor giving data from evaluation studies. Two previous papers [ 14 , 15 ] were used as the starting point of our review.
To present and discuss the collected information we decided to classify serious games by health application area surgery, nursing, etc. For each paper we describe the application that was developed, its main characteristic, and eventually results of related evaluation studies.
Serious Game Review In the following subsections we present the review of serious games developed for healthcare and health professions. We grouped them by application area. Surgery Sabri et al. Total knee replacement or total knee arthroplasty TKA is a surgical procedure whereby the painful arthritic knee joint surfaces are replaced with metal and polyethylene components.
They substitute bone and cartilage providing patients with painful, deformed, and unstable knees pain relief and improvement in function [ 17 ]. The serious game described permits training of orthopaedic surgical procedures to orthopaedic surgical residents outside the operating room with a multiplayer modality. The game was designed to evaluate if a serious gaming approach will enhance complex surgical skill acquisition.
The user is required to successfully complete the TKA procedure focusing the attention on the sequence of step to perform while minimizing time and maximizing the score. They begin the game in the operating room and with a first-person viewpoint. Other avatars such nurses, assistant, and patient appear in the scene. The user should know the correct order of the steps of TKA procedure as well as the tool used to begin each step. Each step begins with the selection of a specific tool.
If the user selects the correct tool and so performs the correct step, he will be asked a multiple-choice question to test his knowledge of that step.
Otherwise, if the user performs an out of order step, he is corrected by an animated angry assistant. At the end of procedure the score is presented to the player. The game uses a 3D rendering engine based on OpenGL and is developed to give more realism as possible.
To achieve maximum realism models were being developed using the Maya 3D modeling software with visual effects software, 3DS Max modeling software with rendering software, and the ZBrush tool. The paper does not present any test results made on serious game users. Blood management is particularly important in surgical procedures, especially in orthopaedic procedures, because in this context bleeding is common and can be fatal.
The game uses a haptic interface and is structured in three parts. The first consists of a fountain placed on a plane and the second of a fountain placed on a curved surface.
The user should stop the fountain water loss using a virtual tool. These two tasks permit the users to adapt to 3D environment and develop the required hand-eye coordination using the haptic interface. Third part of the game is the orthopaedic-surgery game. In this part three modalities were provided: The training mode is designed to teach trainee the correct steps to execute the procedure. Player has to complete the assigned operation.
Hints on the correct steps are given and no time limit is imposed. Conversely in time-attack mode the player must finish the task correctly within a time limit or the virtual patient will die. In collaborative mode several players work together connected in a network to complete a task. The game uses a mass-spring model for soft tissue deformation modeling and a blood flow distribution model based on human physiology mixed with smoothed-particle hydrodynamics SPH to allow for real-time interactive bleeding management.
Haptic rendering is used to simulate the contact between surgical tools and soft tissue. To evaluate how the game enhances blood management skills authors asked a group of trainees to perform vessel-sealing training sessions. Final score was determined evaluating two parameters: An off-target contact error is generated when the user touches with the vessel sealer soft tissues placed outside bleeding location.
Game evaluation was realized in two experimental sessions simulating a Class I hemorrhage and a Class IV hemorrhage. In this second experiment 21 undergraduate students were divided into two groups. First group was composed of 11 students group 1.