Introduction

In recent years, there has been an increasing interest in using serious games for education. Serious games, defined as games used for purposes other than entertainment [1], have various advantages over traditional didactic learning. They provide learners a safe and authentic setting to learn and a place where learners can make mistakes without the risk of adverse patient consequences [2]. Serious games have the potential to create motivated learners who actively pursue learning on their own [3].

Using serious games to educate healthcare students is not a new idea. Serious games have been used to educate medical students on the management of acute tachyarrhythmias [4], practice of cardiopulmonary resuscitation [5], and training in emergency telemedicine [6]. The results of these studies demonstrate that serious games have the potential to be an effective learning tool. Although both medicine and pharmacy are healthcare disciplines, the results from studies done on medical serious games cannot be generalised to pharmacy serious games. Compounding extemporaneous (non-commercially available) products, dispensing medications and counselling patients are some elements of pharmacy practice [7] that are not in medical games, but pharmacy students need to learn. Pharmacy educators have been encouraged to use serious games to supplement learning for pharmacy education [2], and we are no different.

In the new Pharmacy curriculum at our institution, students have the opportunity to gain various 21^st century skills and competencies [8, 9] through pharmacy professional skills training activities, such as learning and innovation skills (e.g. health communication, critical thinking and problem solving, collaboration and teamwork), digital literacy skills (e.g. information literacy, information and communication technology literacy) and life and career skills (e.g. flexibility and adaptability, social and cross-cultural interaction, responsibility and accountability) (Figure 1). However, with a large cohort size of ~200 students per batch, it becomes increasingly difficult for facilitators to train, assess and provide detailed feedback on the competency skills of each student. Convinced about the tech-savviness of the Millennial generation of students [10], the department embarked on a variety of technology-enhanced learning initiatives, with the hopes of reducing the workload and manpower costs of delivering these professional skills training lessons.

Amidst the controversies as to the types of educational technologies that could replace traditional learning methods [11, 12, 13], studies had also suggested that players’ enjoyment and interest in the game could affect their learning outcomes [14]. As such, one of the major technology-enhanced learning initiatives by the department was to develop an in-house serious game, called “Retrozfect” (or RZT), for training of 21^st century skills. Our research question was two-fold – would the game enhance student learning of 21^st century skills in an engaging way, and whether the game should replace or supplement the traditional curriculum in pharmacy professional skills training?

Methods

Game Description

This multiplayer online role-playing game was set in a post-apocalyptic fantasy world infested by zombies. Players took on the role of pharmacist avatars and worked both individually and collaboratively in a team to complete the game tasks in order to find a cure for humankind (Figure 2). The game was developed in English and designed using a “cognitive authenticity” approach [15]. Players would be immersed in a fantasy game setting, but the simulations of in-game scenarios were authentic to real-life practices and the increasing complexity of the game challenged the players in terms of their cognitive loads (Figure 1). Although this game was developed in a fantasy setting, authentic learning scenarios were interspersed throughout the game, in which players would have to dispense medications and counsel the villagers (virtual patient avatars) in a “potionarium” (pharmacy equivalent). Through a “choose-your-own-adventure” format, players would select a series of possible dialogue and action choices by picking up various visual and auditory cues from the game scenarios and virtual patients. They would then need to search an in-game reference resource to find out, compound and prepare the required medicinal product using the Leap Motion – a sensor device that detected the motion of the players’ hands and fingers so as to allow them to interact with the game world [16]. The outcomes of these virtual patient encounters could be positive or negative, depending on the players’ decision-making process, thus making them take responsibility and accountability for their actions. Players would need to consider various issues from the patients’ perspectives in order to successfully complete the virtual patient encounters. Several game tasks also required players to strategize and work together in order to achieve certain in-game objectives and rewards. If a wrong selection choice or course of action was made, a feedback box would pop up explaining their mistakes and players would have to replay the game scenario with penalties to their game scores. In order to provide a more immersive experience for players, certain game scenarios also allowed the choice of using the Oculus Rift Virtual Reality (VR) headset during gameplay [17].

Figure 2 

Summary of the in-house developed multiplayer online role-playing game.

Discussion

Studies have shown that students need to like a serious game in order for them to be motivated learners and be interested in the game’s content [20]. Our in-house developed game (RZT) was designed with the preferences and motivations of our pharmacy students in mind. Our previous studies suggested that students liked to play a fantasy game with an adventurer storyline and an unlocking mechanism in-game reward system; viewed in a three-dimensional perspective and played in a collaborative game style [21, 22]. From these findings, we decided to develop RZT using a blended learning approach, building on De Freita’s Four-dimensional Gamification Framework and an Authentic Learning Environment [23, 24]. We deliberately created a fantasy world and storyline in RZT to pique the interest of students yet allowing them to learn the skills they needed through a “cognitive authenticity” approach, whereby they had to complete game tasks that were authentic to what they should know in actual pharmacy practices. To this end, the in-game feedback and post-game debrief played critical roles in clarifying the learning objectives for students. The results of this study reinforced our previous findings and showed that we were on the correct trajectory of game development. In fact, the name “Retrozfect” was conceived from one of the students who reflected that he had gained the knowledge and skills RETROspectively by trying to save humankind from the Zombie inFECTion. Nonetheless, we could not emphasize more on the importance of continuous involvement of end users to educators, educational designers and developers of digital education products/systems.

Among the 21^st century skillsets, the most useful skillsets that students managed to learn from RZT were health communication (patient counselling), and critical thinking (pharmaceutical calculations). Interestingly, students ranked patient counselling skills higher than history-taking skills, even though a high proportion had indicated that the game helped them understand how to perform history-taking. We postulate that this was due to the provision of detailed feedback on what went wrong when students made a mistake during counselling. In comparison, the virtual patients could only provide answers to the questions asked by students during the history-taking stage, as they would need to use the information obtained for the later stages of gameplay (product preparation, dispensing and counselling).

Students ranked information literacy skills (applying drug information from monographs and learning pharmacotherapy of drugs) lower than health communication skills. Through the “cognitive authenticity” concept, herbs in the game were given hypothetical nicknames in line with the fantasy setting, but their parameters (e.g., indications, side-effects, pharmacokinetics, pharmacodynamics, storage conditions, counselling points, etc) mimicked real drugs. For example, paracetamol/acetaminophen was nicknamed “Pyrotolamol” and sildenafil was nicknamed “Kaijunhorn” instead. Our team debated long and hard over whether real drug names or hypothetical nicknames should be used in RZT, but decided to go for the latter for 2 main reasons – (i) the game was meant to be implemented in the lower year undergraduate curriculum which was mainly focused on pharmaceutical chemistry and pharmaceutics/dosage form design, thus students would not have encountered many drugs by the time they played the game; and (ii) for certain herbs in the game, we had to add in some fantasy elements so that the game storyline would not be disjointed (e.g., the indication for anti-zombie preparations was to “attack the zombie virus”, but its mechanism of action mimicked that of anti-retrovirals). Although our results showed that, in general, students felt that RZT was able to help them understand how to recommend appropriate drugs, the lower ranking of information literacy skills by students made us aware that it would be essential to discuss the drug analogies in greater detail and tease out the real and fake parameters for students during debrief when the actual game is implemented in class.

Our results did not show any significant improvement in the pre- and post-quiz scores. This could be because the quizzes were mainly assessing the students’ knowledge on the information literacy skills. The quizzes consisted of 10 multiple-choice questions, in which students had a 25% chance of guessing the correct answer. Furthermore, as this gaming session was based on voluntary recruitment of students after their exams, they might not have taken the test seriously since the scores would not impact their grades in any way. Most of them would have participated in this study to have some fun with their friends instead. This was supported by the large proportion (53.3%) who indicated that they did not want the game to be part of their formal assessments. Students felt that they learned most about health communication and critical-thinking from gameplay, therefore a consideration moving forward would be to use standardized rubrics and simulated patient-assessors in mock counselling and dispensing scenarios [25, 26], which might be more appropriate to assess students’ competency in these skillsets.

It was surprising that even though most students had indicated that RZT trained them in pharmaceutical calculations, the learning of extemporaneous preparation skills was still ranked the lowest among all the learning objectives. This mismatch could be because they did not consider the exercises on pharmaceutical calculations as part of their holistic training in extemporaneous preparation skills. Instead, they were fixated on the actual actions of making the products using the leap motion (e.g., pounding, stirring, mixing, grinding, pouring). The low ranks could have been compounded by the fact that many of them were using the Leap Motion for the first time, thus contributing to a steep learning curve. Moreover, doing hand actions in “thin air” might not have felt as realistic as holding actual compounding apparatus. Additionally, whenever they made a mistake in preparing the products, they had to repeat the whole process again, which not only impacted on their game score, but caused more frustration and dissatisfaction. If such usability issues were not addressed, it could lead to the game losing its motivational effects [27]. Our results were similar to other studies demonstrating that participants would become more familiar with using the Leap Motion with practice [28]. Hence, an in-game tutorial that familiarized players with the Leap Motion could be incorporated in future game iterations.

The GEQ scores of several domains, such as competence, sensory and imaginative immersion, flow and positive affect, were higher in pure groups than mixed groups. This was no surprise as studies have suggested that gameplay would be more enjoyable and motivating when players play with people who are familiar [29, 30]. Participants in pure groups were more likely to be more familiar with each other since they were from the same year of study. The Oculus Rift had also added on to their immersive experience. However, almost half of the participants complained of giddiness after using the device, similar to other studies [31]. In order to be inclusive of all students, 2 versions of the game could be developed – with and without the use of the device. We would also need to consider the possibility for students to form their own groups instead when the game is introduced into the curriculum.

When our game was presented at various conferences [32, 33, 34, 35], we could see that attendees were interested to adapt our game for their own teaching purposes. As our game was developed with the intention to store our students’ academic information (e.g. grades) through in-game assessments, it had to be played within the university’s secure intranet servers. Hence, other institutions would need to modify the game to fit their own institution servers. Furthermore, in this game, we had only created five scenarios that were specific to the pharmacy setting and focused on what our students needed to know in the local Singapore context. In order to cater the game for other healthcare students, there is a need to develop a wider variety of scenarios that are contextualized to the different healthcare professions in different countries. This is also an opportunity for multidisciplinary collaborations so that the game can potentially be developed and used for education among partner institutions in the future.

In light of the recent coronavirus disease (COVID-19), universities worldwide had to suspend face-to-face teaching, which led many academics to explore innovative ways to digitally engage and educate their students. Serious games, such as the one described in this study, have the potential to be an engaging educational platform to improve student learning during such times. For example, there are instances in which serious games have been developed to educate healthcare students about the coronavirus, pandemic-related topics, and safe practices and behaviors [36, 37, 38, 39, 40]. In a German study identifying the perceptions of medical undergraduates regarding their learning during COVID-19, one-third had indicated that serious games should be used during the pandemic [41]. As shown by our results, incorporating multilevel, multiplayer collaborative elements within the game can make the game more interactive and engaging, and can boost the morale and cohesiveness of the players as they learn together. Furthermore, serious games have the potential to facilitate knowledge retention over a longer period of time [36]. As we move towards the post-COVID “new normal”, we encourage educators to explore serious games as an innovative method of digital teaching to engage the new generations of students entering healthcare.

Limitations

A main limitation of this study was the small sample size involved; thus our results might not be generalizable to larger student cohorts and to students from other institutions. Furthermore, due to the voluntary recruitment of students after their exams, their responses might not be representative of the entire pharmacy cohort, as there was an under-representation of year 1 and 4 undergraduates. Students from the different years of study might have different perceptions on the usefulness of the game due to their variability in terms of pharmacotherapy knowledge and exposure to pharmacy practice skills. For example, year 4 students would have had more experience and practice in patient counselling by virtue of their modules. Future studies should recruit a larger cohort of participants with equal representation across all years of study.

As this study was conducted during the holiday break after the exams, the full game had to be completed in a day in order to get sufficient numbers of participants who were interested to come. In actual implementation, students would likely play the game over a period of 5 weeks or more as part of their laboratory practical sessions. It would be possible that their in-game experience might be different if the game was played over a longer period of time instead. Future studies should consider a mixed-methods approach in order to obtain both quantitative and qualitative information about the participants’ gaming experience over a few weeks. Furthermore, our academic faculty were interested when they heard about the game, therefore it is our intention to obtain feedback from the lecturers who are interested to play the game in the future.

Conclusion

RZT is an in-house serious game developed to train 21^st century skills in pharmacy students. We managed to merge a fantasy setting with authentic game tasks to train these skills through a “cognitive authenticity” approach. Students perceived that they managed to learn the 21^st century skillsets of health communication and critical thinking through the in-game patient counselling and pharmaceutical calculation scenarios. However, majority preferred the game to be used as a supplement to the traditional methods of learning. With correct implementation, RZT has the potential to become a useful supplementary teaching tool for training health communication and critical thinking skills at our institution.