Exploring how the incorporation of video game design elements into an online thoracic vasculature...

JBC Vol. 39, No. 2 2013 www.jbiocommunication.orgE50

Exploring How the Incorporation of Video Game Design Elements Into An Online Thoracic Vasculature Study Aid Affects Use Patterns

of Undergraduate Anatomy Students

Andrea Gauthier and Michael Corrin

This preliminary study investigates whether incorporating game design elements into an online anatomical study aid results in increased use by undergraduate students learning human vascular anatomy. Students exposed to the gamified study aid participated in more usage sessions (p=0.046), attempted (p=0.001) and completed more tasks (p=0.004), and spent more time with their study aid (p=0.011). Further research should explore the holistic effect of these study aids on study habits as well as evaluate their educational effectiveness.

IntroductionSince the early 1960’s, educational researchers have shown

that integrating game design into education can have a positive impact on students’ interest and engagement in school and studying (Randel et al. 1992). Engagement in an educational game activates dopamine reward pathways in the brain and, as a result, students are more likely to take on more difficult subject matter during game-play than during regular academic work (Howard-Jones and Demetriou 2009). In many cases, introducing games into a curriculum has enhanced learner engagement throughout the academic term, leading to more frequent studying and better exam performance (Charsky and Ressler 2011; Kanthan and Senger 2011; Massey and Brown 2005; McCarroll et al. 2009; Wirth and Breiner 1997).

Specifically, video games in education cater to the current generation of individuals who, on average, spend 10,000 hours playing video games by the age of 21 (McGonigal 2011). Gamification is the process of integrating game design elements into an educational or training program to support the learning experience (Landers and Callan 2011). This may include the integration of a storyline, achievements, rules and penalties, scoring systems, and leaderboards (Westwood and Griffiths 2010; Charsky 2010). If integrated into a curriculum-based study aid, these commercial game elements have the potential to increase the frequency with which students participate in lengthy, meaningful and intellectual study as opposed to a study aid without these elements.

The study of anatomy involves the acquisition of knowledge by rote. Vascular anatomy can be particularly challenging because of diverse branching patterns, anastomoses, vessel supply, and spatial relationships between structures. In anatomy education, current methods of studying include the review of lecture notes and textbooks, prosections, plastinations, and dissection (Żurada et al. 2011). In the past, traditional and digital games have been used as supplementary resources to aid in factual knowledge retention and engagement in anatomy classrooms. The game Speed-Muscle, for example, which is based on the concept of speed dating, was implemented in an undergraduate kinesiology course where students took on the personality of a given muscle and had to find its perfect match, the antagonist to its action (McCarroll et al. 2009). Along with final grade improvement, the game was shown to encourage participation, and establish an active learning environment. Corpus Morphus, a multiple-choice anatomy board game, resulted in increased mean test scores and a positive reception by its users by instilling competition in a social study session (McIntire 1995). The games Path to Success and The Path is Right were created as curriculum-specific online games for the University of Saskatchewan’s undergraduate pathology course (Kanthan and Senger 2011). These games were shown to improve academic performance, increase engagement and reduce stress. These studies have demonstrated that integrating games into human anatomy curriculum as supplementary resources can greatly enhance interest, enjoyment, and engagement, but there is little evidence that shows whether or not game design encourages study-aid use outside the classroom (Garris et al. 2002; Wilson et al. 2009).

This preliminary study investigates whether the incorporation of game design elements into an online human vascular anatomy study aid results in increased use by undergraduate anatomy students. We hypothesize that students exposed to the gamified study aid will engage in study aid use more frequently and for longer periods than students exposed to a similar study aid without game design elements.

MethodsWe created a curriculum-specific digital study aid intended to

complement traditional resources used in studying. Using a drill and practice instructional methodology, the study aid quizzes

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Exploring How the Incorporation of Video Game Design Elements Into An Online Thoracic Vasculature Study Aid Affects Use Patterns of Undergraduate Anatomy Students

students on the vascular anatomy of the thorax – blood vessels of the heart, lungs and chest wall. The study aid’s quizzing mechanic involves the completion of ten challenges or vascular sequencing tasks. Each task requires the student to define a path from one location in the circulatory system to another based on the vascular branching patterns of the thorax, thereby testing his/her knowledge of nomenclature, vessel supply, and anastomoses (see Table 1 for a task example). It includes access to an accurate and interactive 3D model of vasculature (Figure 1B) and (Figure 2B) to show the spatial relationship of these structures to each other, and aid in the completion of a task. A random task generator is also integrated to provide diversity in problems, and to encourage re-use. This study aid, called the Vascular Anatomy Study Aid (VASA), would act as our control tool (Figure 1).

A version of this study aid was then “gamified” by integrating gaming elements found in commercial video games. These included a scoring system, leaderboard, characters and storyline, game goals and achievements, rules and penalties, collectible objects, as well as high quality graphics and sounds. The same ten tasks, random task generator, and 3D model that were used in the standard study aid were implemented in this version for consistency. Three game mechanics are worth noting: 1) The player was required to complete their task before running out of energy. Moving against the flow of blood or accessing the 3D model for help would reduce the player’s energy, forcing the player to choose their route strategically. Running out of energy resulted in task failure, and the player would have to restart the task; 2) Clogs would present themselves in the vasculature as the player navigated the system. The player would either have to find a way around the clog via anastomoses, or use a collected plunger item to dislodge it and pass through, further exercising different path-finding solutions; 3) Three crest-pieces were hidden in the vascular world at different locations, and could be picked up during the completion of any task. Collecting all three pieces would result in bonus points, and give them access to the 3D model study aid outside of game-play. This game-study aid, Vascular Invaders (VaISA), would act as our experimental tool (Figure 2A), (Figure 2B), (Figure 2C) and (Figure 2D). The anatomical content in both VASA and VaISA were validated by an anatomy expert, Dr. Michael Wiley, at the University of Toronto.

Participants were English-speaking males and females over the age of 18 years enrolled in ANA300Y (Human Anatomy and Histology) in the summer 2012 session at the University of Toronto. Students were able to participate in all steps of the study through a Web browser. They were first required to complete a General Information questionnaire, which collected data on age,

Figure 1A. Vascular Anatomy Study Aid (VASA) interface. Screenshot of a task in progress.

Figure 1B. Screenshot of a 3D model accessed during task completion.




gender, major area of study, and previous exposure to anatomy and gaming. With this information, students were divided into the experimental group and the control group homogeneously using a minimization technique described by Scott et al. (2002).

Participants were then presented with their assigned study aid – the VASA for the control group and VaISA for the experimental group – and were asked to use their study aid as much or as little as they liked over a period of six days. Usage statistics were digitally collected during this time period (Table 2). Students were notified that all statistics and results would remain anonymous. Due to the limited participation and resulting small sample size, non-parametric Mann-Whitney U tests were performed for all analyses. The following comparisons would be made using one-tailed Mann-Whitney U tests with level of significance equal (α) to 0.05 (Dinov 2013):

Study aid usage statistics:• Total number of times logged in (or usage sessions).• Total number of completed vascular sequencing tasks.• Total number of attempted vascular sequencing tasks, which is

the sum of: - Completed tasks. - Partially completed tasks where more than one directional decision was made and then the user either quit the application or switched tasks. - Failed tasks (experimental group only).• Cumulative time spent using the study aids (in minutes) from time of login to last click, minus periods of inactivity greater than five minutes.

ResultsOf the initial 30 participants who filled out the General

Information questionnaire, 16 continued on to try their study aid at least once, and could therefore be included in the usage statistics analysis. The control group consisted of ten individuals, and was composed of eight females and two males. The experimental group consisted of six students, all of whom were female.

The experimental group participated in significantly more

Figure 2D. Screenshot – Accessing the leaderboard.

Figure 2A. Vascular Invaders study aid (VaISA) interface. Screenshot of a task in progress.

Figure 2B. Screenshot of a 3D model accessed during task completion

Figure 2C. Screenshot – Encountering a clogged vessel.




usage sessions than the control group (U=14.5, nc=10, ne=6, p=0.046; control mean=1.3; experimental mean=2.833). They also completed significantly more tasks (U=6.5, p=0.004; control mean=4.1; experimental mean=17.333), as well as attempted significantly more tasks (U=2, p=0.001; control mean=6.6; experimental mean=41.5). The experimental group also spent a significantly greater amount of total time with their assigned aid (U=9, p=0.011; control mean=31.45 minutes; experimental mean=93.336 minutes) (Figure 3).

The experimental group participants checked the leaderboard an average of 3.167 times, and used an average of 16 collectable items during the usage period. These included plungers to unclog vessel passageways (6.5 mean used), portals to

warp to various locations in the world (5.333 mean used), and undo items to go backwards without losing energy (4.167 mean used). Three of the six participants collected all three crest-pieces to unlock the bonus 3D model for use outside of game-play. On average, players failed 19.5 tasks by running out of energy (Figure 4).

DiscussionDespite the equivalent educational content and quizzing

mechanic in Vascular Invaders and the Vascular Anatomy Study Aid, students exposed to the former attempted and completed more tasks as well as participated in more frequent study aid sessions compared to students in the latter. Participants’ total completed tasks and total study aid sessions were deemed to be most indicative of study aid use, because task completion requires the user’s focused attention and multiple tool use sessions suggest that the user was motivated to return to the study aid. These results support our hypothesis that undergraduate anatomy students are more likely to use a digital study aid that includes game-design elements than one without them.

Although total time using the study aid was recorded and the individuals in the VaISA group spent a significantly longer time with the study aid than did the VASA group, the value of this measure is limited. Although the measure provides us with information about the amount of time spent actively using the study aid, the measure does not accurately suggest actual user ‘time-on-task’ (time spent actively completing vessel path tasks). Furthermore, it takes approximately twice as long to complete a task in VaISA due to between-vessel animation events not present in VASA. However, VaISA users, applications were on average open three times as long as VASA users, and we feel that this difference cannot be explained by the short introductory narrative sequence and between-vessel animations present in VaISA alone.

Figure 3. Comparison of usage statistics between students exposed to the gamified study aid (experimental group) and students exposed to the standard study aid (control tool). A) Total completed tasks - the experimental group completed a significantly greater number of tasks than did the control group (p=0.004); B) Total attempted tasks - the experimental group attempted a significantly greater number of tasks than did the control group (p=0.001); C) Usage sessions - the experimental group returned to their application significantly more times than the control group (p=0.046); D) Total time spent (in minutes) - the experimental group spent a greater amount of time overall with their tool (p=0.011).




We believe that the study participants used VaISA more than VASA because of the game-design elements integrated into the former. Several design features of VaISA were included to make it more game-like, but were not critical to the successful completion of the vascular sequence connection tasks; this includes features like the leaderboard, collectable items, and hidden crest-pieces. If these features did not engage users, we would expect to observe negligible use. However, VaISA participants actively engaged with these aspects of the tool.

For example, experimental group participants accessed the leaderboard an average of 3.16 times. User access of a leaderboard on multiple occasions suggests they may be motivated by competition and a desire to see where they stand among peers. Similarly, VaISA participants used an average of 16 items during the usage period. The hidden items and crest-pieces were designed to encourage players to diverge from their regular path and explore different branching patterns and anastomosal routes, but were not required in order to complete a task. This suggests that the players actively engaged in finding and using the items to benefit their score and game-play experience. Half the experimental group participants went to the trouble of finding the hidden crest-pieces to unlock the supplementary 3D model, showing a desire to achieve game-goals.

Our findings support research suggesting that student interest, enjoyment and engagement in an educational application can be improved by incorporating game attributes such as goals, rules, challenges, and fantasy elements (Garris et al. 2002; Malone 1980). However, based on our results we are unable to conclude which of the attributes present in VaISA and absent in VASA were related to increased use of the former.

LimitationsThe ability to generalize from these results is limited by the

gender composition of the participants and the relatively low study participation rate, which in turn led to small sample sizes. Homogeneity in gender distribution was not achieved. The study participants were mostly female (14 of 16), and the entire experimental group was composed of females. Thus, our results and conclusions may be interpreted as only applicable to female undergraduate students. This imbalance was difficult to control, because we were working within a narrow timeframe that forced us to recruit from a relatively small pool of students limited by enrolment in the summer Human Anatomy and Histology course (84 students total). To make these results more generalizable to male and female undergraduate students, future studies should begin with a larger pool of students from which to draw participants; this would likely result in a relative increase in the number of male participants.

Since the study aids are intended as supplementary materials and not as teaching tools, the scheduling of this research study required that students would be exposed to the anatomical material in the classroom prior to being introduced to the study aids. Students were presented with the material following an examination, and reported that they were not inclined to study again until later in the semester. Due to the tight schedule of this research project, administration of the study later in the semester was not possible. Ideally, participants should have been provided with the study aids immediately after they were presented with instruction on thoracic vasculature in the classroom, and should have been permitted to use the study aid up to the date of an examination that included questions on the relevant material. We feel that it is likely that this approach would have yielded larger sample sizes and participation, as the study aids would be available when motivation for their use was highest.

It is difficult to explain which aspects of the gamified study aid contributed most to its greater use. VaISA has many features absent in VASA including a leaderboard (peer competition), achievements (personal rewards), a narrative and higher quality aesthetics (user affect).

Perceived study aid quality or aesthetic “attractiveness” may have been a contributing factor in the relatively low level of usage observed in the VASA group compared to the VaISA group. VaISA incorporates more visual and auditory complexity in its graphics, animations, music and sound effects; these may make VaISA more attractive and engaging than the simpler VASA. However, van der Heijden (2003) found that “actual usage is dominantly explained by intention to use” and that “visual attractiveness” makes a much smaller contribution to usage. Since our participants were motivated to use our study aids to improve actual performance on ANA300 tests, it suggests that the most important differences in use cannot be easily attributed to visual attractiveness alone. Nonetheless, future studies should aim to further minimize aesthetic differences between the control and experimental study aids, to reduce the possible confounding influence of that variable.

Figure 4 . Gameplay statistics for students exposed to the gamified study aid (experimental group). A) Collectable items used for each player (mean=16); B) Number of times the leaderboard was accessed by each player (mean=3.167); C) Number of tasks failed by running out of energy for each player (mean=19.5).




While participants exposed to VaISA used the leaderboard, in-game items, and viewed achievements, our data and statistical measures do not permit us to make conclusions about what features present in VaISA and absent in VASA led to increased use of the former. In order to better understand which factors most heavily influence use, future studies should consider study designs that severely limit the differences between the non-gamified and gamified study aids. For example, the control study aids presented could be identical save for the addition of a leaderboard in the gamified application. Many trials could be performed comparing the control study aid with study aid versions containing a single additional game-design element. Comparison of results between trials would suggest which game-design elements made the largest contribution to use. In addition, a final trial could be run using a version of the study aid incorporating all game-design elements and the data collected for this final trial could then be compared to the results from each of the other trials. This would permit us to determine if use patterns were summative or emergent.

Lastly, our study aid uses a drill and practice mechanic, but it would be useful to test if our results are more generalizable using other study aids with different approaches to teaching and game-play.

Future directionsWhile the results of this study support our hypothesis that

the incorporation of game design elements into a supplemental anatomical study aid for undergraduates results in increased usage, we need to develop an understanding of how study aid use is related to student study practices and academic performance.

Future studies might look at how gamified study aids affect study habits from a holistic perspective. Does time spent using the gamified study aid result in a redistribution of time spent on other study related tasks? Do students integrate extra time into their studying schedule to accommodate game-play? Recent studies suggest that undergraduate students self-report difficulties with time management (Whittle and Murdoch-Eaton 2004). Adding potentially addictive activities like video games to the curriculum, educational or not, may negatively affect student study habits and performance (Ogletree and Drake 2007; Skoric et al. 2009).

The evaluation of games as educational tools is essential; without evidence of their learning benefits, games will remain known as entertaining, motivational tools, but will be instructionally unvalued (O’Neil et al. 2005; Wilson et al. 2009; Moreno 2012; Papastergiou 2009). Further research should examine the relationship between time spent using gamified study aids and academic performance. Are the game-design elements distractors from the task of learning the material efficiently? Can game design elements be incorporated in a manner that improves engagement and use, but does not interfere with learning objectives?

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ConclusionThe findings of this preliminary study indicate that a gamified

study aid design encourages more frequent and lengthy usage in comparison to a non-gamified design. It was found that this heightened engagement was likely due to the presence of gamification elements such as a leaderboard, collectable objects, game goals, rules, and penalties that increased students’ interest, enjoyment and engagement. However, further similar studies should be performed with larger samples, over a more appropriate time-span and in more controlled settings to evaluate the educational effectiveness of these study aids and to recommend the employment of gamification techniques for broader application.


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AuthorsAndrea Gauthier (B.A.A., M.Sc.BMC) is a recent graduate from the Master of Science in Biomedical Communications (BMC) program at the University of Toronto. She is currently working as an associate in Biomedical Communications at Bridgeable Research + Design in Toronto, Ontario, as well as conducting research into the role of games in science education. [email protected]

Michael Corrin (B.F.A, B.A, B.Sc.Hons., M.Sc.BMC) is a lecturer specializing in interactive educational media design in BMC. He teaches in the Biomedical Communications (BMC) graduate program at the University of Toronto. He is a member of the Perioperative Interactive Education (PIE) group in the Department of Anesthesia and Pain Management at Toronto General Hospital, which creates and evaluates online teaching tools for residents and fellows in anesthesiology, cardiology and cardiac surgery. [email protected]

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