Designing a Mobile Learning Game to Investigate ... - Semantic Scholar

Designing a Mobile Learning Game to Investigate the Impact of Role-Playing on Helping Behaviour Birgit Schmitz, Stefaan Ternier, Marco Kalz, Roland Klemke, and Marcus Specht Center for Learning Science and Technology, Valkenburgerweg 177, 6401 DL Heerlen, The Netherlands {birgit.schmitz,stefaan.ternier,marco.kalz,roland.klemke, marcus.specht}@ou.nl

Abstract. Despite research in mobile learning games has intensified over the last decade, there is relatively little research about how individual game mechanisms influence or change behaviour. This article aims at understanding the influence of the game mechanism role-playing and investigates how it can be used to alter behavioural intention. In order to do so, we designed a mobile learning game to train Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR). With the game we aim at improving laymen’s willingness to help in case of emergency. First, we illuminate the strand of research related to role-playing in the context of BLS and bystander CPR. Second, we describe the pedagogical framework of the mobile learning game that was designed to train BLS and introduce the game engine this development is based on. Third, we present the results from a first prototype testing, which we carried out with medical professionals as well as laymen in order to test game-play usability and interface. This article concludes by outlining the experimental setting of an upcoming study, which will use the mobile learning game to evaluate the influence of the game mechanism role-playing on the willingness to provide bystander CPR in case of emergency. Keywords: games for health, mobile learning, serious games, role-playing, behavioural intention.

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Background

In industrialized nations, out-of-hospital cardiac arrest (OHCA) is one of the main causes of death [4]. Although it is known that early initiation of bystander cardiopulmonary resuscitation (CPR) significantly improves the chances of surviving an OHCA [23], one of the main problems still is the availability of trained layman rescuers [12] and low bystander CPR rates [42]. In the 1960s, this led to an extensive introduction of CPR training measures with the intention to increase confidence and the willingness to perform bystander CPR [8]. Up until now, activities in this field have strongly focused on the level of resuscitation skills, teaching methods, frequency of updates or contents of sessions. Despite these activities, the rate of bystander CPR at cardiac arrests has remained low (less than 20%) [34][42]. However important the D. Hernández-Leo et al. (Eds.): EC-TEL 2013, LNCS 8095, pp. 357–370, 2013. © Springer-Verlag Berlin Heidelberg 2013

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level of resuscitation skills at performing basic life support, it seems that training on how to provide cardiopulmonary resuscitation is not the only decisive factor. Studies found that besides the skills and knowledge related to cardiopulmonary resuscitation, other factors such as the perceived risk of infection with a communicable disease during CPR, age or disagreeable physical characteristics, e.g. the presence of blood, influence and even prevent bystanders’ willingness to provide CPR [8][23]. Besides, over the past decade studies have increasingly started to investigate the impact of psychosocial factors on bystander initiated CPR [8][10][15][23][25][35]. As Coons reports in his study, ‘the relative importance of the reasons for not performing CPR is informative’ [10, p. 334]. He points out the potential to change CPR-related attitudes and beliefs and implies different forms of educational intervention to achieve this [10]. Dwyer concedes that in order to optimize the success of CPR training and to modify behaviour, educational interventions should address participant behavioural intentions [15]. The emerging field of games for health too acknowledges this. Games for health promote health related behavioural changes [33][19]. Axelsson too argues that CPR trainings should provide for appropriate models to produce the feelings of personal responsibility and courage required to intervene and to prepare the bystander emotionally for dealing with unexpected and unwanted situations [2]. With this paper we argue that the provision for role-playing into CPR trainings enables such models. The objective of this article is to sample the use of role-playing scenarios for training measures of basic life support (BLS) and bystander CPR and to propose a model that assesses the impact of role-play on helping behaviour. The results could provide valuable information, which might inform future design decisions for BLS and CPR training measures.

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Related Work

The role-based learning game presented in this paper builds upon a large body of previous research. In the following we outline the main pillars of the game design, i.e. the concept of role-playing in health-care-education and game making environments. 2.1

Role-Playing in Health-Care Education

Kidron [28], in his study on the effectiveness of role-playing exercises, cites Solem [38] who outlined defining goals and characteristics of role-playing. According to his definition role-playing ‘deals with emotional and attitudinal antecedents of behaviour in an experiential frame of reference, emphasizes the importance of feelings as sources of behaviour and deals with participants who are placed psychologically inside the problem situation’ [28, p. 491]. Since the early nineties, experiential learning has raised great interest amongst health-care-professionals. Experiential learning includes learning through and from experience [11]. It is characterized by learning through doing, role-playing and simulation, all elements thus far shown by literature to enhance CPR training [27]. Kidd and Kendall in their review of Effective Advanced Cardiac Life Support

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Training [27] refer to the findings of Scherer et al. [37] and Burton [6] who showed that by providing learning scenarios, which include role-playing, learners are more prepared for the unpleasant realities of resuscitation attempts where their CPR skills would be called upon. ‘The fact that a resuscitation incident may involve distressed relatives; coupled with increasing evidence advocating the presence of family during resuscitation attempts; it would not be unreasonable to have actors or role-playing learners taking the part of relatives in the simulation’ [27, p. 62]. Chamberlain and Hazinski in their article on Education in Resuscitation state that ‘repeated practice in realistic role-playing scenarios with situations and environments students are most likely to encounter’ [7, p. 2578] can increase confidence and the willingness to respond to an emergency. Also, Leigh concluded that ‘by participating in simulation scenarios, students can learn to control feelings of panic and their fear of emergency situations’ [29, p. 8]. 2.2

Game Making Environments

Frameworks for the development of mobile games are currently available. Some explicitly provide for the set up of mobile learning games. Recent studies report on place-based games for language learning or location-based museum games for example that were developed on the base of platforms such as the Myst pervasive game platform [39] or ARIS [22]. Platforms such as 7scenes.com or SCVNGR [26] enable the design, development and deployment of interactive location-based mobile games and experiences. With the aid of such tools teachers are more empowered in utilizing cell phones and creating low-threshold learning opportunities [26]. The MAGICAL project [31] provides a comprehensive overview of state-of-the-art digital game making environments for both desktop and mobile applications. State-of-the-art game making environments regularly provide for both, the iPhone and the Android Operating System. Working with these systems enables students to bring their own devices to school (BYOD). Many existing platforms are open-source. They usually focus on the display of graphic objects or the handling of touch gestures and frequently embed GPS and QR codes. Few of the reviewed game making environments provide a multiplayer feature based on team play and/or roles though. In the following chapter we describe the pedagogical framework that informed the game design of HeartRun and introduce the game engine ARLearn, which almost comprehensively reflects the required features (e.g. role-based game environment).

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Pedagogical Framework and Game Design

As prior research has shown, the integration of different roles can bring about a discussion of the psychological and most likely unexpected aspects of cardiac arrest, which may affect the responsiveness of bystanders positively. With the mobile learning game HeartRun, we aim at providing a training scenario that offers a framework to test these findings. We took the decision to design a mobile learning game because we wanted to have a scenario that

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is authentic, i.e. prepares learners to react adequately in a closely related situation. Within the game just as in reality, notification systems are the base for first responders. Dispatch centres send them in case of emergency, includes different locations and different roles. Within the game just as in reality, different roles are involved in case of emergency. While one person gets the nearest automated external defibrillator (AED), another person already starts providing CPR to help the victim. A mobile game can include different locations and different roles.

The game is an additional training measure within the context of a first-aid course or a dedicated basic-life-support training [24]. In the course of the mobile learning game HeartRun, we realized the concept of role-playing by providing opportunity to act out the different roles involved in a real case of emergency. In cardiac arrest, it is important to intervene immediately to save seconds and minutes, and to give the most appropriate help possible. Comparable to an unexpected emergency, HeartRun involves instant decisions on what to do and the recall of CPR knowledge under unexpected circumstances involving time pressure and stress. This way we intend to enhance psychological preparedness of the rescuer and thus achieving a more prompt and appropriate response. Social psychology presumes that ‘the more realistic the situation is made, the closer it is to reality, the better able the subject should be to imagine what he would actually do if he were in the real situation’ [18, p. 108]. The HeartRun setting comprises an introduction phase, a mobile gaming phase and a debriefing phase, to reflect and share the game experience and to turn it into learning [13]. a) Introduction Phase. Players are presented a short introduction to the game, e.g. how to read QR codes with a telephone. They will then be provided with telephones and the game phase will start immediately. b) Game Phase. Students play in teams of two. Every team player is randomly assigned to one of the roles (AED support or bystander). When opening the game, the first message shows, which already relates to the role. According to the operating mode of ARLearn, opening and reading a message automatically triggers a new message. Messages have different types: text messages, videos, audio messages and questions (single-choice/multiple-choice). The set-up of the individual messages and the corresponding learning content is related to the Chain of Survival, i.e. (a) to prevent cardiac arrest, (b) to buy time, (c) to restart the heart and (d) to restore quality of life. The line of action described there is reflected in the sequence of messages, e.g. making sure that the victim and any bystanders are safe, checking the victim for a response by gently shaking his/her shoulders and asking loudly: “Are you all right?“ Time and location play an important role in the scenario. While Player A (AED support) heads for the AED, player B (bystander) runs to the victim to provide CPR. At the scene of emergency a manikin is provided with which player B interacts. Meanwhile, player A searches the next AED. As soon as he found it and scanned the


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QR code attached to it, the game requires him/her to bring the AED to the victim. At the scene of emergency another QR code is placed, which payer A has to scan. This synchronizes the players. Henceforth, both roles get the same information on how to correctly apply the AED. Both players follow the instructions on the screen and apply the AED to the manikin until the ambulance arrives (last message).

Fig. 1. Game screens HeartRun: first message, task, and instruction screen

Also, in the course of the game phase, the player gets an unexpected ALERT message that requires immediate action. An agitated caller pleads: “Quickly, quickly, come to the canteen. George has collapsed. I need your help, please”. This time, no additional information on how to proceed is provided. Then, the game immediately starts to count down 10 minutes and eventually ends. This part of the game has a third role integrated, the documenter. Immediately after the alert message has arrived, every player immediately needs to start action: find the next AED and get it (role of AED support), go somewhere and provide BLS (role of bystander), record the scene of action with the integrated camera of the smart phone and upload it to the system (role of documenter). After ten minutes the game automatically ends sending the message that the ambulance team has arrived and will take over the care of the victim. The countdown is integrated in order to raise awareness for the span of time, which is given to actually recall actions in relation to BLS. In the course of the game students upload photos, audio recordings and video sequences, which are considered and evaluated in the subsequent debriefing phase. c) Debriefing Phase. In this last game phase, students meet for debriefing. Within the debriefing phase, they revise and share the knowledge they acquired in the course of the gaming phase. To do so, their recording as well as ideal type of action is presented

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(gold-standard video). Learners are then required to compare both versions and reflect on things to improve. HeartRun can be played several times, with participants switching roles. This way, the game allows students to perceive the emergency situation from different perspectives. By ‘‘putting oneself into other’s shoes’’ they have the chance to experience and control both feelings of panic and fear of emergency [29].

4

The Game Engine

HeartRun was designed with the ARLearn authoring tool, an open source tool suite for educators and learners [39]. ARLearn features a client/server architecture, which enables the creation and management of a) games (reusable instructional design) and b) runs (game instantiations with real time communication) [39]. The ARLearn android client allows playing a run with mobile users. By building on the Google App Engine (GAE) stack, the server architecture offers a scalable web service for content and notification management as well as game state persistence [39]. Games based on ARLearn have a reusable game logic description that can be instantiated in numerous game-runs. Within a game, an author defines items, dependencies between items, game score rules and progress rules. A run defines users grouped in teams. ARLearn enables game-designers to bind a number of content items and task structures to locations and to use game-logic and dependencies to initiate further tasks and activities. While playing, users generate actions (e.g., “read message”, “answered question”) and responses. The object model in ARLearn is based on media items, which can be used for messages that users receive at a specified point in time or in relation to a defined event. Further specializations of these media items allow to ask questions (MultipleChoice) or to include multi media (Audio- and VideoObjects). Items can define dependsOn and disappearsOn conditions for the state transitions. A simple dependency mechanism is put in place to support these conditions: • • •

Action-based dependencies are triggered by specified actions. Time based dependencies bind time offsets to other dependencies. Boolean dependencies allow combining other dependencies to logically.

HeartRun uses most of the functionalities the authoring tool provides. The multiuser feature enabled the provision of different player roles and allowed us to send individualized information. The location-based feature for example enabled us to create a realistic game-play setting that supports team play and allows for mixtures of competitive and collaborative games. Because ARLearn supports the Android operating system (and soon also iOS), the game can be played on commonly used smartphones, which will simplify game distribution for the upcoming larger study. Prior to the forthcoming study we conducted a first prototype testing in order to identify problems that could be addressed beforehand. In the following chapter we present the results from this first prototype testing.


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Prototype Testing

We tested a first version of the game to assess (a) the HeartRun interface and game-play usability (i.e. the integrated features of the prototype) and (b) the technical functionality. Our main focus was on usability aspects such as adequacy of game features in relation to the integrated content (Chain of Survival). Therefore, we asked project staff to test-play the game. Four medical experts and three members who are concerned with project related tasks (graphical designer, project manager, and developer) volunteered for the testing. None of them had played HeartRun before. The testing was conducted on March 21st 2013 at the general consortia meeting of the EMuRgency project [16] in Leuven. 5.1

Method

We collected data by using a questionnaire and informal interviews after the game session. The questionnaire was based on the System Usability Scale (SUS). We chose the SUS because it is an accepted measure for attitudes toward system usability [30]. It is commonly used in a variety of research projects [5]. The Overall SUS provides a generic questionnaire of ten items, with odd-numbered items worded positively and even-numbered items worded negatively. The items had to be rated on a 5-point Likert-scale. We used the standard Overall SUS score, instead of the 8-item Usability scale, because the Overall SUS allows estimating perceived Learnability along with a cleaner estimate of perceived Usability [30]. Accordingly, we decomposed the score into its Usability and Learnability components. In order to further specify the feedback, we added two additional free text questions: ‘For which target group would you use the game?’ and ‘What would you suggest to improve the game?’ For the gaming session, we equipped the participants with a HTC Desire mobile phone each and randomly assigned the players to one of the two groups (AED and CPR only). Before the testing, the game was installed on the devices and SIM cards were inserted in order to set up an online connection. Prior to the game testing we briefly explained the aim of the game and gave basic instructions on how to use the device. Then the players were asked to start the game. Immediately the first message appeared and people started to play. While playing, intervention was kept to a minimum. The researcher’s role during the case study was participant observer. The data we collected were analysed with regard to game usability, learnability, technology use and students’ participation. 5.2

Results

The technical game testing delivered valuable feedback with regard to interface and gameplay usability, planned use of the game, integrated features and technical functioning thus safeguarding the upcoming larger study on the impact of role-play on learners’ intention to help. With regard to interface and game-play usability, the HeartRun questionnaire for the Overall SUS revealed a mean score of 73,57 with a median of 72,5 and a range

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from 62,5 to 85. According to standardized interpretation, a SUS score above a 68 is considered above average and on an adjective rating scale could be described as good to excellent [3]. The adjective rating scale established by Bangor, Kortum, and Miller matches the SUS scale and helps to provide a subjective label for an individual study’s mean SUS score [3]. In accordance with the proposition by Lewis and Sauro [30], we decomposed the Overall SUS score with the two questionnaire items number four and ten contributing to the Learnability scale and the remaining items contributing to the Usability scale. For perceived Learnability, i.e. the ease of getting used to the application, the questionnaire revealed a mean score of 16,43 with a median of 15 and a range from 12,5 to 20. With regard to perceived Usability, the resulting score ranged from 47,5 to 65, with a mean score of 57,14 and a median of 55. From the questionnaire it shows that users accepted the game and were motivated to use it in a training context. In the interviews participants further specified that they think the game does not replace traditional BLS training but ideally complements it. Especially the fact that players have to quickly decide what to do in a stressful situation was rated positive feature. With regard to the target group for the upcoming larger study, participants acknowledged using the game for school children at the age of 10-16 years and young laymen (up to 20 years) as well as persons who are new to a certain environment. According to suggestions from medical experts, we fit some minor wording errors. Considering system usability and game design HeartRun needs adaptation though. Especially the game usability needs some re-work according to the users. They suggested adding further assistance with the device, i.e. directions where to go on the phone and a voice-over function was mentioned. In addition, participants suggested integrating further information on the AED, e.g. an AED movie. From a technical point of view, the game ran stable. Messages showed sequentially and the two roles involved in the testing were both able to upload audio and video files. We tested the game with two players per team (one player per role for AED support and one for bystander). After the first run, players changed roles and were thus able to test both roles of the game. We neither tested the third role of the game (documenter) nor the alert function due to time restrictions. This will be part of a second prototype testing, which is due to follow. This second testing will comprise the complete course of action that applies to the experimental setting of an upcoming study. This study will use the game to evaluate the influencing factors of the willingness to provide bystander CPR in case of emergency. The study design we describe in the following chapter.

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Future Work

We will use the mobile learning game HeartRun to evaluate the influence of role-playing on behavioural intention. Because it is difficult to measure the actual behaviour (bystander CPR), intention or willingness to help is a crucial aspect when looking at bystander CPR in case of emergency [8][23].


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Over the past decade, a significant body of research has focused on identifying various factors that influence helping behaviour [8][10][15][23][25]. Among this research, the theory of planned behaviour (TPB), introduced by Ajzen [1], has received attention. First research approaches in the field indicate that this theory should be capable of explaining bystander's motivations with regard to CPR training and performance [15][41]. Ajzen’s theory implies that behavioural intention is the most influential predictor of behaviour and uses intention as a proximal measure of behaviour [1]. It suggests that behavioural intention can be induced through modification of one or more of three antecedents of intention: attitude toward the behaviour, subjective norm and perceived behavioural control. The TPB ‘proposes that the strength of an individual’s intention (or motivation) to engage in a behaviour, and the degree of control they feel they have over that behaviour (perceived behavioural control) are the proximal determinants of engaging in it’ [41]. Findings on attitude and self-efficacy (perceived behavioural control) in social psychology indicate that role-playing influences a person’s behaviour. Prior research investigated the effect of a serious game on role-taking and willingness to help [33]. Peng, Lee and Heeter aimed at understanding how interactive digital games affect role-playing and helping behaviours. They found that the presentation mode (interactive game) positively influenced participants’ willingness to help and that role-taking partially mediated this relationship [33]. They state that during the role-taking process, an individual goes beyond his or her typically egocentric means of perceiving the world to contemplate a different point of view. Also Pavey, Greitemeyer and Sparks resume that role-taking is likely to produce empathy, which in turn has been found to be a strong predictor of helping behaviour [32]. Chamberlain and Hazinski claim that realistic role-playing scenarios can increase confidence and the willingness to respond to an emergency [7].

Theory of Planned Behaviour

Fig. 2. Proposed research model

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An important factor related to CPR intervention is competence. BLS and CPR training increases laypersons’ confidence and willingness to perform bystander CPR on a stranger [8]. Even doctors who are competent in performing resuscitation may fail to apply their skills, unless they have a strong belief in their own capabilities [9]. Drawing upon findings in game studies, social psychology and medical education our research extends the Theory of Planned Behaviour by introducing variables of empathy, competence and role-playing to TPB in order to predict helping behaviour. We hypothesize that empathy, competence and role-playing influence the willingness to help in case of emergency. Figure 2 represents the proposed research model. It incorporates the three additional constructs empathy, competence and role-playing, which we assume to influence the existing variables if the TPB (attitude, subjective norm and perceived behavioural control). To explain the constructs of the model and the related hypothesis would go beyond the scope of this paper. This will be part of a subsequent article, which will report the experimental settings and results. A connatural approach was introduced by Vaillancourt et al. [41] in order to identify barriers and facilitators of CPR training and CPR performance. Their work did not consider the concept of role-playing as an independent variable for the model. 6.1

Method

To test the hypotheses, we use a true experiment with students from a secondary school. Participants are between 12 and 16 years old. The evaluation setting will include: a)

Intervention (BLS training measure including the game) directed at changing behavioural intention b) Post-test of specific and generalized value of the concepts described and behavioural intention

The study will not include a pre-questionnaire. We assume that a pre-test would indicate the concepts and conceptual interrelations we are about to investigate. Post-test data will be collected immediately after the training. The findings of Plant and Taylor support this setting. They reviewed literature to identify methods of CPR, AED and first aid training children have been successful. Results suggest that the use of CBT, ‘virtual worlds’ and ‘multiplayer online simulation’ in CPR training ‘could be an attractive training and/or retention tool to use in this age group’ [34, p. 3]. 6.2

Measures

The constructs in the model are measured with standard items adapted from previous research. All questionnaire items use a 7-point Likert-type scale where 1=completely disagree and 7=completely agree. In order to evaluate behavioural intention, we will provide a hypothetical scenario to the students. The scenario includes a short passage of information about a situation, which is likely to occur [25]. TPB items will be


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adapted from Francis et al. [17]. A checklist with predefined criteria will assess proficiency in CPR and AED skills. We will measure empathy with items adapted from the four empathy scales by Davis [14]. 6.3

Data Analysis

In order to corroborate data conformity between the empirical data and the presumed model, we will first conduct a confirmatory factor analysis (CFA). We will then use structural equation modelling (SEM) techniques to examine the causal model.

Structural Equation Modelling is commonly used in predicting and explaining health behaviour [36]. The proposed research model and hypothesis testing will be carried out using variance-based partial least squares (PLS) path modelling. This approach to structural equation modelling (SEM) techniques, as opposed to the covariance-based SEM, is a

'prediction-oriented variance-based approach that focuses on endogenous target constructs in the model and aims at maximizing their explained variance’ [20, p. 312]. Recent review results of PLS-SEM applications [21] suggest that PLS-SEM allows the use of multivariate analysis tool for small sample size (and is even advantageous), provided the fact that the fundamentals of sampling theory are considered. As the planned experiment is rather complex in procedure and with large sample sizes, this is an important factor to consider.

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Conclusion

This paper’s contribution to research in the field is based on four different pillars. Firstly, we provided an overview of related work on role-playing with regard to BLS and bystander CPR. Secondly, we exemplary described the educational framework of the mobile learning game HeartRun. Prior research on behavioural issues in BLS and CPR training informed the game design. Subsequently we depicted the technical base, the game engine ARLearn. Thirdly, we provided results from a first prototype testing, which was carried out with medical professionals as well as laymen in order to test game-play usability and interface. Eventually, this article outlined a new approach within the field of research on resuscitation. The experimental setting of a forthcoming study will use the mobile learning game, to better understand the influence of role-playing on the willingness to provide bystander CPR in case of emergency. To do so, it applies the Theory of Planned Behaviour [1]. Data from the experiment will be analysed using structural equation modelling. Acknowledgement. This publication was partly financed by the European Regional Development Fund (ERDF), regions of the Euregio Meuse-Rhine and the participating institutions under the INTERREG IVa program (EMR.INT4-1.2.-2011-04/070, http://www.emurgency.eu).

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