Serious games for health: three steps forwards
A major factor in education is the time allowed to the learning process, a longer time being associated with better learning outcomes [3, 4]. Because video game players spend many hours per week on their computer, video games were considered as an interesting educational method [5]. By incorporating some learning content into video games, it was thought that players using these “serious” games would still enjoy the game while learning for hours [6]. This proposal led to important disappointments about both the enjoyment that serious games may provide and their learning effectiveness. Arden: The World of Shakespeare is a classical illustration of such a failure. This project was intended to be a massively multiplayer online learning game for teaching undergraduate learners the works of William Shakespeare. It was designed to be a plug-in for the off-the-shelf game Neverwinter Nights. When the game was launched, the virtual world turned out to be a great looking but players were dissatisfied with the gameplay and abandoned the game. This led the MacArthur Foundation which initially founded the game to pull out of this ambitious project [7].
Thus, developing a motivating serious game requires the developer to be interested in the motivation of the end users. Following the self-determination theory of Deci and Ryan, three types of learners can be defined: the amotivated, the extrinsically motivated, and the intrinsically motivated learners [8]. The amotivated learners do not value the activity of learning and do not believe that it will yield a desirable outcome. When asked to use a serious game, the only aspect they enjoy is the “sensory delight” related to the graphical environment and sound effects used in the game, known in the gaming business as “Eye Candy” [6]. Once this transient enjoyment fades, they quickly abandon the serious game. The extrinsically motivated learners do not value the activity of learning but do believe that it can yield a desirable outcome, for example obtaining a high examination score at the end of the training. Their difficulty is to find the energy to learn in order to achieve a future, desirable outcome. Finally, intrinsically motivated learners enjoy the activity of learning itself and/or are interested in the subject matter: from their perspective, the serious game represents one opportunity among many others (conferences, textbooks, etc.) to learn.
Therefore, in our opinion, for both amotivated and intrinsically motivated learners, serious games have little or no motivational value compared to conventional instruction methods, because these tools represent the same kind of constraint for the former and the same kind of opportunity to learn for the latter. This may explain why a meta-analysis of the motivating effect of serious games found that serious games were not more motivating than conventional instruction methods [9].
However, we think that serious games may be interesting for extrinsically motivated learners. These learners consider the learning process as a painful but necessary step to reach a desirable, enjoyable outcome. For this category of learners, serious games allow them to experiment this enjoyable outcome virtually, in advance, while they are learning. In other words, serious games combine the enjoyment of this future outcome made virtually present with the learning activity (Fig. 1).
The three main points to discuss during the development of a serious game. Firstly, users need to be motivated to play the serious game in order to access the learning content. Motivating serious games integrate the extrinsic motivation of the player for a specific outcome (e.g. practicing as a medical doctor) into the learning activity (e.g. a simulation game on the management of cardiac arrest), making this learning activity desirable (apparition of intrinsic motivation for the learning activity). This phenomenon was called “the convergence of motivations.” Secondly, the learning potential of serious games should be maximized. The “four pillars of learning,” a framework derived from cognitive science finding [12], may be useful for developers and educators to enhance the learning effectiveness of their games. Finally, serious game should be evaluated in order to progress towards evidence-based education
This combination was present in a very successful serious game developed in the health area, the Re-Mission game. In this game developed for young cancer patients, players controlled a humanoid nanorobot which had the mission to destroy different types of cancer at a cellular level, while learning the importance of compliance to chemotherapy. Most of these young cancer patients were likely to be extrinsically motivated learners, with a profound hope to reach a very desirable outcome, being rid of their cancer, although not enjoying learning about the importance of being compliant with their chemotherapy. The strength of the game was to make this desirable outcome virtually present, by allowing players to destroy several cancers, while delivering important messages about compliance to chemotherapy. The serious game could preserve both its enjoyment, as attested by the more than 200,000 copies delivered, and its learning effectiveness, demonstrated in a randomized controlled trial involving 375 patients which revealed that playing this game was associated with better knowledge, self-efficacy, and adherence to oral chemotherapies [10].
By contrast, there are several examples of serious games that failed to be motivating because their developers thought that putting algebra problems in a 3D virtual world or placing the periodic table of the elements in a shooting arcade would motivate students to play while learning [7]. In these situations, which did not involve any desirable outcome, students considered serious games as poorly motivating as their traditional lectures.
Combining the motivation for the activity of learning itself (intrinsic motivation) with the motivation for a future desirable outcome (extrinsic motivation) is thus essential to develop motivating serious games (Fig. 1). It may explain the enthusiasm of medical students for simulation games in which they play the role of medical doctors [11]. The association of their final objective—practicing as a doctor—made virtually present and possible, with a learning activity—making decisions to save the life of a virtual patient—is promising to motivate these students to learn.
Developers of games in the health area should consider this “convergence of motivations” if they want their product to be motivating from the perspective of their learners. However, even a serious game played for hours can fail to reach its educational purpose if developers neglect to consider the key instructional features which will allow the learning process and which are developed below.