Evaluation of a 3D serious game for advanced life support retraining

https://doi.org/10.1016/j.ijmedinf.2013.05.007Get rights and content

Highlights

  • Our study shows that a 3D serious game can be effectively used for ALS retraining.

  • The game allowed participants to gain and maintain ALS knowledge and skills.

  • The serious game positively engaged participants.

  • Participants also reported willingness to frequently retrain with the 3D serious game.

Abstract

Objective

Advanced life support (ALS) knowledge and skills decrease in as little as three months, but only a few ALS providers actually attend retraining courses. We assess the effectiveness of a 3D serious game as a new tool for frequent ALS retraining.

Methods

We developed a 3D serious game for scenario-based ALS retraining. The serious game, called EMSAVE, was designed to promote self-correction while playing. We organized a retraining course in which 40 ALS providers played two cardiac arrest scenarios with EMSAVE and took a test with 38 multiple-choice questions before and after playing. We administered the same test again 3 months later to evaluate retention. Participants also rated EMSAVE and the overall retraining experience.

Results

After using EMSAVE, the number of correct answers per participant increased by 4.8 (95%CI +3.4, +6.2, p < 0.001) and all but one participant improved. After 3 months, despite an expected decrease in ALS knowledge and skills (−1.9 correct answers, 95%CI −0.6, −3.3, p < 0.01), there was a significant retention benefit (+2.9 correct answers per participant, 95%CI +1.5, +4.2, p < 0.001). Moreover, all but one participant regarded EMSAVE as a valuable tool to refresh ALS knowledge and skills, and 85% of participants were also willing to devote 1 h/month to retrain with the serious game.

Conclusions

A 3D serious game for scenario-based retraining proved effective to retrain in ALS and supported retention of acquired knowledge and skills at 3 months. EMSAVE also positively engaged and motivated participants.

Introduction

Resuscitation Councils endorse advanced life support (ALS) training courses in which ALS instructors (i.e., doctors and registered nurses who show distinguished ALS knowledge and skills, followed courses for instructors, and are regularly involved in ALS courses) train ALS providers (i.e., doctors and registered nurses who can be required to frequently or occasionally provide ALS to patients). More precisely, ALS instructors teach knowledge, decision-making and practical skills to new ALS providers or update already trained providers about new ALS guidelines, which are released every five years.

ALS training courses usually last a few days and effectively improve resuscitation competence [1], [2], [3], yet there is invariably a significant decrease over time of the knowledge and skills acquired [3], [4], [5], [6], [7], [8]. To ensure that ALS providers maintain their competence, ALS retraining courses (i.e., one-day courses in which ALS providers can refresh their knowledge and skills about ALS guidelines they are already trained on) are recommended [9].

Unfortunately, although ALS providers are generally aware of their need for retraining, only a few actually attend ALS retraining courses [10], [11]. Motivational and financial issues, along with time constraints imposed by work shifts, make it difficult to devote a full day to retraining. Moreover, even with sufficient resources, many centers plan retraining events once every two years, while several studies suggest that ALS knowledge and skills decrease in as little as 3 months [8], [12], [13], [14]. Therefore, new approaches to facilitate compliance with the suggested retraining schedules and prevent knowledge and skills decrease are needed.

Computer-based training systems could offer a solution to these issues, since they allow trainees to follow different lessons individually and over time without the financial overhead and logistic issues involved in organizing a training course [15], [16], [17], [18], [19], [20], [21]. In addition, computer-based training systems can employ virtual reality (VR) techniques to create 3D virtual environments that are believable reproductions of the real world. In these environments, trainees can learn by directly interacting with virtual characters and objects as recommended by constructivist theories [22], [23]. Moreover, they can take advantage of: (i) realistic 3D graphics and sound that create an immersive experience which could be difficult and expensive to simulate in traditional training courses, (ii) different camera viewpoints and multimedia resources that illustrate important aspects of simulated patients, (iii) changes in virtual patients that give real-time feedback about trainees’ actions, and (iv) animations that help in understanding complex situations and cause–effect relationships [23].

VR systems for medical training have traditionally concentrated on the fidelity of the patient or organ simulation and of the actions that can be performed on them [24], [25], [26]. However, this may not be sufficient to motivate or engage learners [27]. Moreover, medical VR systems often require expensive special hardware and software [24], [25]. To overcome such limitations, there is a growing interest on building training systems, called serious games [28], that employ video game techniques to better engage trainees and to be used on low-cost PCs [29].

To build a serious game, an immersive and engaging story that embeds instruction is fundamental [28]. Moreover, serious games can exploit the familiarity of people with the interaction styles of entertainment video games to make the training system easier to use and more attractive. While playing, trainees may improve their skills with repeated attempts at completing game levels, failing and succeeding, understanding which strategies are successful [27].

The aim of our study was to assess the effectiveness of a 3D serious game as a novel tool for frequent ALS retraining. In particular, the objective of the study was to assess the possible gain in ALS knowledge and decision-making skills after a retraining session with the serious game as well as retention three months later. In addition, we investigated the perceived effectiveness of the serious game and ALS providers’ willingness to keep retraining with it.

Section snippets

Serious game

The study used EMSAVE, a single-player serious game we designed to refresh trainees’ ALS knowledge and decision-making skills by means of 3D scenario-based simulation.

This section summarizes the main features of EMSAVE, which are also illustrated by a video in the supplementary material.

Participants

Forty ALS providers enrolled in the study, 25 (62.5%) female and 15 (37.5%) male. Age ranged from 24 to 49 years, the median was 36, and the mean was 35.5 (SD = 6.4).

As shown in Table 1, all participants used computers. In particular, 86% of participants used them for more than 5 years. About one third of participants used computers a few times a week and about two thirds every day.

Most participants regularly used applications for office, Internet, and e-mail as well as applications related to

Need for retraining

As previously reported, several ALS providers in the considered sample had never received ALS retraining despite their perceived need to frequently attend retraining sessions. Such need is further motivated by the results of the pre-test which revealed lack in ALS knowledge and skills (about a third of questions were correctly answered by less than half of participants). In addition, decrease in knowledge and skills in 3 months affected about 60% of questions, highlighting the importance of

Authors’ contributions

EC and LC conceived and obtained funding for the research project that includes the described study. FB, LC and ACV designed the 3D serious game used in the study, and FB and ACV developed it. All authors contributed to the design and the organization of the study. DP and TP handled recruitment of participants. FB, ACV, DP and TP supervised the conduct of the study and data collection. FB and LC analyzed the data. FB, LC, TP, and ACV drafted the manuscript, and all authors contributed to its

Conflict of interest statement

No author has conflicts of interest.

Acknowledgments

The research project was co-financed by the Friuli Venezia Giulia region. The co-financing institution had no role in the design and conduct of the study, collection, management, analysis, and interpretation of data or the preparation, review, or approval of the paper.

References (36)

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