Design for Transfer Figural Transfer Through Metaphorical Recontextualization in Games for Health

Derek A. KuipersDerek A. Design forDesign Transfer

Design for Transfer Figural Transfer through Metaphorical Recontextualization in Games for Health

www.designfortransfer.nl Derek A. Kuipers

1 2 Design for Transfer

Figural transfer through metaphorical recontextualization in Games for Health

Proefschrift

ter verkrijging van de graad van doctor aan de Rijksuniversiteit Groningen op gezag van de rector magnificus prof. dr. C. Wijmenga en volgens besluit van het College voor Promoties.

De openbare verdediging zal plaatsvinden op

woensdag 2 oktober 2019 om 16:15 uur

Life is Strange (2015) door Follow the story of Max Caulfield, a photography senior who discovers she can rewind time while saving her best friend Chloe Price. The pair soon find themselves investigating the mysterious disappearance of fellow student Rachel Amber, uncovering a dark side to life in Arcadia Bay. Dirk Albert Kuipers Meanwhile, Max must quickly learn that changing the past can sometimes lead to a devastating future. geboren op 3 mei 1975 Image: © Deck Nine, Feral Interactive, All Rights Reserved. te Wieringerwerf Promotor To the greatest Metaphor of all Prof. dr. J.P.E.N. Pierie

Copromotor Dr. J. T. Prins

Beoordelingscommissie Prof. dr. M. Vriens Prof. dr. H.B.M. van de Wiel Prof. dr. M.P. Schijven

2 3 Voor Janneke. Jij kunt alles.

Colofon: Ontwerp & Opmaak: Jan-Wessel Hovingh Druk: Zalsman Druk, Groningen ISBN: 978-94-034-1854-4 4 5 Chapters

H1 Introduction and Rationale 9

H2 The Role of Transfer in Designing Games and Simulations for 19 Health: Systematic Review

H3 Design for Transfer 39

H4 iLift: A health behavior change support system for lifting and 51 transfer techniques to prevent lower-back injuries in healthcare

H5 Mobile Adaptive Therapeutic Tool In psycho-Education (M.A.T.T.I.E.) 85

H6 Maximizing Authentic Learning and Real-world Problem Solving in 97 Health Curricula through Psychological Fidelity in a Game-like intervention: Development, Feasibility and Pilot Studies

H7 Play It Safe: A Situational Game for Occupational Safety 123

H8 Design Research in Health Education: Don’t Jump to Conclusions 145

H9 Summary, Key Findings, and Future Perspectives 159

H10 Samenvatting, Conclusies en Perspectief 183

Appendices 206

6 7 H1: Introduction and Rationale

Beyond Eyes (2015)

Beyond Eyes is a modern fairy tale about finding courage and friendship. Step by step, uncover an incredible world, carefully guiding Rae, a young blind girl, on a life-changing journey.

8 9 BLOAD”CAS:”,R, Simulations and Games We must have been around 6 years old, my For quite some time now serious games motivating than the instructional methods It is important to be clear about the dis- brother and I, when everything was a game are held in high esteem for having great used in the comparison group. This is a tinction between simulations and games. to us. Tree houses were sky castles, rafts potential for education and learning [2]. remarkable result, keeping in mind that the Key features of simulations are that they were pirate ships and everything we built Studies on serious gaming offer insights on scientific interest in games as a learning represent real-world systems [17], whereas from Lego came to life. We were not alone how these should be designed to facilitate tool stems primarily from the strong mo- games do not have to. The term game-like in this, as to the best of my knowledge all learning, and why they are unique to use in tivational properties of a game [14]. This interventions used throughout this thesis our contemporaries engaged in play back learning situations, e.g., [3,4,5]. provokes the idea that this inevitably has to refers to the space between simulations then. Playing was an autotelic experience These studies share an analytical perspec- do with the design of these serious games and games: game-like simulations or sim- [1], done without instructions or supervision. tive on such games through trying to under- themselves. ulation games. The past two decades have We discovered and gave meaning to the stand them, explicating their mechanics, or seen rapidly growing interest in using sim- world through play. It is said that children finding out how they perform juxtaposed to If game-based learning is regarded as an ulation for purposes of improving patient learn by playing, and that could well be the existing approaches. Reality shows that in emergent paradigm of digitally mediated safety and patient care through a variety case. But at the time, we didn’t play to learn many cases the serious game lacks the feel learning [15,16] in formal and professional of applications [18], but games for Health something, we just played for fun. of a leisure game and cannot provide the contexts, what conceptual work can the hardly seem to gain a foothold in Health same levels of flow and immersiveness. design of these games be based upon? Why education. Not long after our tree house construction do so many serious games in Health hard- period, we were the first in our little village Some scholars point out that in general, ly resemble the games I grew up with? If with a home computer: an MSX-1 with its game research lacks quality [6,7] and that good video games are regarded as learning Design for Transfer sometimes precarious tape recorder. The serious games are not more effective in machines [11], it seems justified to go into video games we played on this magical de- terms of learning than other instruction more detail on how to keep them good, also This thesis argues that the results achieved vice fitted seamlessly into our fantasy world methods [8]. An often-observed phenom- as a serious game. Broadening the field of with games and game-like interventions are not so much due to the capacities of and virtually extended our playground. It’s enon is that despite rules and guidelines education with technologies such as video the medium itself, but are diminished due remarkable how many details I still remem- [9,10], efforts in making a serious game do games not only raises questions on their to persisting difficulties in, from an instruc- ber of those video games: the end bosses, not result in a good game [11], mostly be- appearance and mechanics, but surely tional perspective, making existing learning the quests and even the music. Even though cause the unique motivational features of needs rigorous research on how serious content suitable for use in games. I am it was over 30 years ago, the in-game expe- games are lost in the design process, whilst content can be integrated in a game without giving here a somewhat exculpatory version riences felt real and meaningful. But: was the foremost reason to use serious games harming the unique features games offer of reality, with the aim of highlighting the playing those games meaningful? Did I learn is their alleged motivational appeal [12]. A for learning, since the connection between issue at hand. Transfer theory distinguish- anything from playing them? Did it some- recent meta-analysis of the cognitive and game design with a focus on entertainment es between mere learning and transfer how influence my behavior in the now? motivational effects of serious games [13] and instructional design with a focus on [19]. Mere learning is about remembering Somehow I know it did. showed that serious games are not more learning is not a natural one [13]. knowledge, with the aim of passing a test.

10 11 Often this knowledge is, in fact, de-contex- transfer by metaphorical recontextualiza- Outline of the thesis EXPLORE tualized knowledge and can be seen as the tion of mere knowledge, for the purpose of findings of someone else. The learner only learning via the road of figural transfer. The Figure 1 provides a schematic overview of In a systematic review, Chapter 2 describes has to take note of it and try to remember reason for further exploring this subject is the following chapters and their interre- the literature found specifically on the and reproduce it as correctly as possible. the assumption that metaphorical recon- lationships. The chapters can be divided second class of transfer types in the design A test environment can be seen as a target textualization of mere knowledge fits in a into three themes (explore, experiment and of serious games and simulations. Focusing context, but that is not what transfer theory more natural way with how learning takes edify), which are explained in more detail on game-like interventions for Health and is about. The recontextualization of mere place in games. If in-game learning occurs below. The image shows two tracks, where Health care, this study aimed to (1) deter- knowledge in a simulation is based on -with by figural transfer [20] using metaphorical the blue route involves the exploration, mine whether the second class of transfer simulations being seen as representations recontextualization can be seen as a key conceptualization, and application of trans- is recognized as a road for transfer in game- of real-world systems- imitating the source element for success in learning and game- fer theory in games for Health, the orange like interventions, (2) review the applica- context as accurate as possible. When play. This defines the premise of this thesis simulating an operating room or following and in case of proven effect and feasibility, route describes the by-catch of the design tion of the second class of transfer type in medical protocols, it is of the utmost impor- a focus on figural transfer contributes to the research and the unforeseen effects of the designing game-like interventions, and (3) tance that the learning within the simula- field of serious gaming research by adding gaming artifacts as boundary objects in assess studies that include second-class tion context matches the required compe- a new possibility in approaching designing the social system for which the game-like transfer types reporting transfer outcomes. tencies needed in the target context. In an serious games. interventions are designed. almost self-evident way, this thinking about learning leads to the simulations we know The results and explorations of this dis- Figure 1: a schematic overview of the chapters in this thesis in their mutual relationship. from Health, the army or aviation: learning sertation may be of interest to Health ed- occurs via the road of literal transfer. ucation innovators, curriculum developers The difficulty of applying learning content and Health experts who are involved in the in games depends on the way in which this development of serious games and game- explicit, mere knowledge is given a place like interventions. In addition, this research in the game itself. When we think of mere hopes to contribute to the discourse regard- knowledge as a derivative from an existing ing the design of serious games in general context, and we consider the game as a and thus also to be relevant for game de- new context, this mere knowledge must be signers outside Health contexts. recontextualized. Placing mere knowledge as is in serious games leads to flow-break- ing pop-ups, textual interventions during game-play and quiz-like games. With the preservation of the unique motivational and immersive properties of games in mind, the focus of this thesis is on design for figural

12 13 Building on the findings of the previous EXPERIMENT chapter, Chapter 3 provides an in-depth Chapter 4 describes the substantiation, In the systematic review, we found that in cal fidelity as the sole carrier. With physical exploration of the use of Design for Transfer development, and evaluation of a serious games for Health a distinction is made be- and functional fidelity limited to an absolute in simulations and serious games, aligning as- game as an essential part of a Health Behav- tween high fidelity and low fidelity. In fact, minimum (hence the indication zero-fidel- sociated concepts in the Game Transfer Model ioral Change Support System (hBCSS). The this distinction is a major design decision, ity), the transfer can only take place in a (GTM). It describes the importance of concep- prototypical game BackSpace is designed to because it directly translates into the design figurative way: the learning context exists tual continuity in serious game design, defined facilitate figural transfer of a specific form of the game itself. Second class transfer only in the head of the player. Building on by the congruence of fidelity-elements and of behavioral change in order to prevent low could possibly become manifest in a low the experience gained in underpinning and elaborates on the differences between realis- back pain in nurses. Data gathered in the fidelity design because abstractions or met- investigating the gaming artifacts for Health ticness and realism. Furthermore, this article final field test showed an in-game training aphorical recontextualization do not neces- in the previous studies, this chapter also in- coins the term fidelity dissonance as a possi- effect, causing players to exhibit correct sarily have to be created with high fidelity. troduces a framework for conducting design ble influential factor in the problem of making techniques for static lifting and transferring The reasons for choosing low fidelity in research into serious games. serious games good games. techniques but also revealed the necessity games for Health turned out to be different: for future social system development, es- reducing cognitive load by omitting detail, Chapter 7 describes the design choices Because almost no games for Health were pecially regarding intervention acceptance. lowering production costs or a focus on and theoretical constructs that have led to the development of an occupational safety found that were deliberately designed on the Social system factors showed a strong training skills. In addition to the distinction impact on the game’s persuasive capacities in figural and literal transfer, design choices game, going by the name Play it Safe. Play it basis of a desired or expected transfer type, and its autogenous intent. with regard to fidelity are rarely explained, Safe is a tower defense game that uses situ- within this thesis the possibilities of Design argued or consciously utilized. ational data collected by employees during for Transfer are explored through a number Chapter 5 delineates the conceptualization their daily work, to impact the parameters of cases. By means of design research, game- and development of an assistive applica- Chapter 3 describes the importance of of the video game. The game, as a behavior- like interventions are designed for a number tion that focuses on learning social prob- congruence of these three fidelity types: al change support system (BCSS), utilizes of Health-related contexts, all with a con- lem-solving skills for adolescents with a mild physical fidelity, functional fidelity and metaphorical re-contextualization to create scious transfer-focused approach. intellectual disability. This article describes psychological fidelity, in which the basic parameters for similar decision making and substantiates a number of meticulously idea is that the level (low, middle, high) of encountered in the work environment and made design choices to bring together target these fidelity types can differ from each implicitly reinforce the training of the STAR groups, learning objectives and environmen- other independently, as long as there is con- protocol and conservative decision making. tal variables in a game-like intervention for ceptual continuity in the game design. This Play it Safe aims to improve employees’ psycho-education. A guiding principle is a is the starting point for Chapter 6. situational awareness, creating a shared design-for-transfer requirement, bridging the mental model and bottom-up accountabil- transfer problem by instigating a near trans- In Chapter 6 a prototype of a so-called ity, meant to improve and align (shared) fer approach in alignment with the possibili- zero-fidelity simulator is developed with safety behaviors. ties of the target group. the aim of discovering whether a learning experience can be elicited with psychologi-

14 15 EDIFY References Chapter 8 aggregates lessons learned from earlier chapters and addresses the problem 1. Jackson SA, Marsh HW. Development and Validation of a Scale to Measure Optimal Experience: The Flow- of the classical conception of implementa- State Scale. Journal of Sport and Exercise Psychology. 1996;18: 17–35. tion in design projects. It describes a novel 2. Annetta LA. Video Games in Education: Why They Should Be Used and How They Are Being Used. framework for future design research proj- Theory Pract. 2008;47: 229–239. ects for digital innovation in Health. More- 3. Gee JP. What video games have to teach us about learning and literacy. Computers in Entertainment. 2003;1: 20. over, designers of Health curricula as well 4. Shaffer DW. How Computer Games Help zaChildren Learn. 2006. 5. de Freitas S, Maharg P. Digital Games and Learning. Bloomsbury Publishing; 2011. as educators in Health innovation are called 6. O’Neil HF, Wainess R, Baker EL. Classification of learning outcomes: evidence from the computer games upon to address the transformation of the literature. Curriculum Journal. 2005;16: 455–474. social system as an integral part of a design 7. Baranowski T. Games for health research—past, present, and future. Prävention und Gesundheitsförderung. process for successful integration of the 2018; doi:10.1007/s11553-018-0657-y developed artifacts. 8. Clark RE, Yates K, Early S, Moulton K. An Analysis of the Failure of Electronic Media and Discovery-Based Learning. Handbook of Improving Performance in the Workplace: Volumes 1-3. 2010. pp. 263–297. The essence and conclusions of all chapters 9. De Castell S, Jenson J. OP-ED Serious play. Journal of Curriculum Studies. 2003;35: 649–665. will be summarized in Chapter 9 including 10. Wouters P, van Oostendorp H, Boonekamp R, van der Spek E. The role of Game Discourse Analysis and cu- a modest draft on future perspectives in riosity in creating engaging and effective serious games by implementing a back story and foreshadowing. Design for Transfer for games for Health. Interact Comput. 2011;23: 329–336. 11. Gee JP. Learning by Design: Good Video Games as Learning Machines. E-Learning and Digital Media. 2005;2: 5–16. 12. Malone TW. Toward a Theory of Intrinsically Motivating Instruction*. Cogn Sci. 1981;5: 333–369. 13. Wouters P, van Nimwegen C, van Oostendorp H, van der Spek ED. A meta-analysis of the cognitive and motivational effects of serious games. J Educ Psychol. 2013;105: 249–265. 14. Garris R, Ahlers R, Driskell JE. Games, Motivation, and Learning: A Research and Practice Model. Simul Gaming. 2002;33: 441–467. 15. Prensky M. Digital Natives, Digital Immigrants Part 1. On the Horizon. 2001;9: 1–6. 16. Squire KD. Video game–based learning: An emerging paradigm for instruction. Performance Improvement Quarterly. 2008;21: 7–36. 17. Crookall D, Saunders D. Communication and Simulation: From Two Fields to One Theme. Multilingual Matters; 1989. 18. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004;13 Suppl 1: i2–10. 19. Salomon G, Perkins DN. Rocky Roads to Transfer: Rethinking Mechanism of a Neglected Phenomenon. Educ Psychol. Routledge; 1989;24: 113–142. 20. Royer JM. Theories of the transfer of learning. Educ Psychol. Routledge; 1979;14: 53–69.

16 17 H2: The Role of Transfer in Designing Games and Simulations for Health: Systematic Review

Published: Kuipers DA, Terlouw G, Wartena BO, van’t Veer JT, Prins JT, Pierie JP. The Role of Transfer in Designing Games and Simulations for Health: Systematic Review. JMIR serious games. 2017 Oct;5(4).

Gris (2018)

Gris is a hopeful young girl lost in her own world, dealing with a painful experience in her life. Her journey through sorrow is manifested in her dress, which grants new abilities to better navigate her faded reality. As the story unfolds, Gris will grow emotionally and see her world in a different way, revealing new paths to explore using her new abilities. Image: © Nomada Studio, All Rights Reserved.

18 19 Abstract Introduction

Background: The usefulness and impor- interventions, and (3) assess studies that Conclusions: Games and simulations hold the promise of tance of serious games and simulations in include second-class transfer types report- being learning machines [1] because of the learning and behavior change for health and ing transfer outcomes. In studies on game-like interventions for ability to build in learning principles. They health-related issues are widely recognized. health and health care, transfer is regard- can harvest unique features to motivate, Studies have addressed games and simula- ed as a desirable effect but not as a basic trigger, and facilitate learning processes, tions as interventions, mostly in comparison Methods: principle for design. None of the studies opening up new possibilities for design- with their analog counterparts. Numerous determined the second class of transfer ing learning for health care professionals A total of 6 Web-based databases were complex design choices have to be made or instances thereof, although in 3 cases a and patients. With the positive effects on systematically searched by titles, abstracts, with serious games and simulations for nonliteral transfer type was present. We learner motivation and learning outcomes and keywords using the search strategy health, including choices that directly con- also found that studies on game-like inter- in mind [1–4], educators must think of new (video games OR game OR games OR gaming tribute to the effects of the intervention. ventions for health do not elucidate design ways to make serious subject matter suit- OR computer simulation*) AND (software One of these decisions is the way an in- choices made and rarely provide design able for game play. A transformation of design OR design) AND (fidelity OR fidelities tervention is expected to lead to desirable principles for future work. Games and sim- current forms and beliefs on learning may OR transfer* OR behaviour OR behavior). The transfer effects. Most designs adopt a first- ulations for health abundantly build upon be needed to make a more natural connec- databases searched were identified as rele- class transfer rationale, whereas the sec- the principles of first-class transfer, but the tion between the serious and the game. vant to health, education, and social science. ond class of transfer types seems a rarity in adoption of second-class transfer types serious games and simulations for health. proves scarce. It is likely to be worthwhile to explore the possibilities of second-class Transfer Results: transfer types, as they may considerably A possible way to make such a connection Objective: A total of 15 relevant studies were included, influence educational objectives in terms of can be found in thinking in terms of transfer. future serious game design for health. This study sought to review the literature covering a range of game-like interventions, Although there are a wide variety of view- specifically on the second class of transfer all more or less mentioning design param- points and theoretical frameworks regarding types in the design of serious games and eters aimed at transfer. We found 9 studies transfer in the literature, transfer is seldom simulations. Focusing on game-like inter- where first-class transfer was part of the Keywords: a starting point in developing serious games. ventions for health and health care, this design of the intervention. In total, 8 studies transfer; computer simulation; video games; Studies on serious games [5,6] have identi- study aimed to (1) determine whether the dealt with transfer concepts and fidelity serious games; games for health; fidelity; fied design principles for flow and immersion second class of transfer is recognized as a types in game-like intervention design in abstract learning; immersion; metaphor as major contributors to the gaming experi- road for transfer in game-like interventions, general; 3 studies dealt with the concept of ence and presumably beneficial for learning. (2) review the application of the second second-class transfer types and reported However, the way games facilitate learning class of transfer type in designing game-like effects, and 2 of those recognized transfer as a design parameter.

20 21 is often regarded as a black box. From an game or simulation environments try to shelf games, in serious game design, the al design—physical, functional, and psycho- educational and technological perspective, represent the real world as literal as possi- usage of mindful abstractions and meta- logical fidelity. A game or simulation there- transfer is a key concept in learning theory ble, they aim for first-class transfer. The first phorical representations is not common fore can be low in physical and functional and education [7]. The purpose of (medical) class of transfer encompasses instances of practice, despite the fact that it forms a fidelity but can be high in psychological education is transfer: the application of literal, specific, nonspecific, vertical, lateral natural fit with the second class of transfer fidelity. It is also possible that a simulation skills, knowledge, or attitudes that were or and low-road transfer. theories. Earlier research has shown [9] that by design is high in functional and physical learned in one situation to another context. transfer is hard to establish and that the fidelity but lacks psychological fidelity. In the The concept of transfer is widely recognized, The second class of transfer theories may be design of education should be key to opti- literature, the degree of fidelity often refers but ample evidence shows that transfer harder to grasp. According to Royer [7], figur- mize the conditions under which transfer to physical fidelity alone. Therefore, in this from learning experiences often does not al transfer (belonging to the second transfer can occur. Although transfer of learning is a study, cases of cognizant design decisions occur. The prospects and conditions of class) involves situations where a known well-established concept in the educational toward lower fidelity types may prove inter- transfer are crucial educational issues. complex of ideas, concepts, and knowledge domain, the extent to which transfer may esting, as they might include second class of is juxtaposed against some new problem guide the development of game-like inter- transfer types. If we regard games and simulations as or situation. Figural transfer uses existing ventions in health has rarely been explored. learning contexts that can be designed world knowledge to think or learn about a This may be especially true for second-class and specifically tailored for (at least a type particular issue. Clear examples of the usage transfer types: optimizing a game-like Aim of) transfer, it seems legitimate to focus of figural transfer can be found in figural intervention design to accommodate the Focusing on the design of game-like inter- attention on how transfer has been taken language such as metaphor or simile. Trans- principles of figural transfer. ventions for health and health care, this into account in designing game-like health fer occurs because of a successful memory study aimed to (1) find out whether the interventions. search triggered by a figural learning con- second class of transfer is recognized or text, assisting in understanding the transfer Fidelity Types present as a road for transfer in game-like context. In some situations, the second class The most visible examples of the designers’ interventions, (2) review the application of of transfer requires a debrief to explicate ex- Two Classes of Transfer uptake of transfer in game-like interventions the second class of transfer type in design– periences and connections made. This class ing game-like interventions, and (3) assess Transfer theory determines two classes of are apparent in the application of fidelity encompasses high-road transfer [8]. studies that include second-class transfer transfer, both encompassing a variety of types: the way fidelity is used in a game-like types reporting transfer outcomes. transfer types [8]. The first class takes the intervention or simulation demonstrates the position that the more the learning context Optimizing Transfer Conditions expected road to transfer. A dominant per- resembles the target context, the more likely spective on fidelity in serious game design is Games and simulations for health abun- transfer is to occur. The conditions for trans- that high fidelity is conditional for learning dantly build on the principles of first-class fer are met when the learning experience and transfer, corresponding with the first literal transfer, but the adoption of sec- shares common stimulus properties with class of transfer. According to Alexander ond-class transfer types has proven to be the target context. This means that when [10], fidelity has dimensions beyond the visu- scarce. In contrast to commercial off-the- 22 23 Methods Figure 1. Flowchart of the results of the initial searches, screening, and selection processes. Databases and Search Strategy In total, 6 databases were searched for ical study, either piloting a game-like inter- potentially relevant abstracts: PubMed, vention or validating the aspired effects; or Scopus, ERIC, PsycINFO, Information Science (3) otherwise focused on a newly developed & Technology Abstracts, and EMBASE. These game or simulation, created specifically for databases covered a wide range of pub- the study in question. Papers were included lished research from the field of health and when title and abstract were considered social care. A combination of search terms to be at least indicative of the presence of were used to identify relevant papers under second class of transfer. Papers meeting any the following categories: (video games OR of the above criteria were selected for full- game OR games OR gaming OR computer text screening. simulation*) AND (software design OR design) AND (fidelity OR fidelities OR transfer* The following exclusion criteria were used OR behaviour OR behavior), where * rep- for full-text screening: (1) non–peer- resents a wildcard to allow for alternative reviewed papers such as abstracts, con- suffixes. Search strategies were customized ference posters, or trade journals; (2) full for each database. Searches included papers text not available; (3) language other than published between database inception and English and Dutch; (4) papers that referred October 2016. The search was conducted be- to transfer as transfer of data or disease; (5) tween October 3, 2016 and October 21, 2016. not sufficient information; (6) repurposed commercial off-the-shelf games; (7) low fidelity as a means to reduce production Study Selection and Inclusion and costs; (8) nondigital games and simulations; Exclusion Criteria and (9) papers using high fidelity solely as a description of the artifact rather than We included studies that discussed either as a founded design decision. Also, in our digital simulations osr games designed for screening, we considered the transfer class health providers or on health topics. We in relation to the fidelity type: high fidelity included only original reports or papers that as a means for achieving literal transfer led (1) addressed the design of a serious game to exclusion. or digital simulation; (2) involved an empir- 24 25 Table 1. Details of included papers. Screening Process to assess the interrater reliability of paper inclusion. We found good agreement be- Author Title Transfer Fidelity and transfer Year a After removing the duplicates, the papers tween the 2 reviewers (κ=.78, 95% CI 0.655- class rationale were screened based on title and abstract 0.883). A total of 11 papers were excluded at Dankbaar, Alsma, Jansen, Van An experimental study on the effects of a simulation First Low fidelity, reducing 2016 using Rayyan [11]. In total, 2 reviewers (DK full-text screening for various reasons. The Merrienboer, Van Saase, and game on students’ clinical cognitive skills and motivation cognitive load and GT) independently reviewed the title total number of included papers is therefore Schuit [12] and abstract for relevance against the Kuipers, Wartena, Dijkstra, iLift: A health behavior change support system for lifting First Low-road transfer, skill au- 2016 15. See Figure 1 for a flowchart of the results Terlouw, van T Veer, Van Dijk, and transfer techniques to prevent lower-back injuries in tomatization, metaphorical formulated inclusion/exclusion criteria. Pa- of the initial searches, screening, and selec- Prins, and Pierie [16] healthcare pers were only included on the agreement tion processes. Table 1 shows an overview of Jalink, Gores, Heineman, Pierie, Face validity of a Wii U video game for training basic First Low-road transfer, skill au- 2016 and Ten Cate Hoedemaker [17] laparoscopic skills tomatization, metaphorical of both DK and GT; a third reviewer (BW) included studies. Connors, Chrastil, Sanchez, and Action video game play and transfer of navigation and First Low-road transfer, spatial 2014 resolved any disagreements. The degree Merabet [18] spatial cognition skills in adolescents who are blind recognition of agreement was calculated by a kappa Rosenberg, Baughman, and Virtual superheroes: using superpowers in virtual reality Second Figural, metaphorical 2013 statistic. Full-text papers were retrieved Second-Class Transfer in Bailenson [21] to encourage prosocial behavior Schrader and Bastiaens [13] The influence of virtual presence: effects on experienced First Low fidelity, reducing 2012 after this step. Both reviewers (DK and GT) Game-like Interventions for cognitive load and learning outcomes in educational cognitive load reviewed each included full-text article. computer games Disagreements in this stage about inclusion Health and Health Care De Freitas and Dunwell [22] Understanding the representational dimension of Second Figural, metaphorical 2012 learning: the implications of interactivity, immersion and were discussed until an agreement was We studied the full-text papers on how fidelity on the development of serious games reached. Finally, to check whether any eli- transfer was regarded and described in Knoll and Moar [19] The space of digital health games Blended Locative, situational 2012 gible paper had been overlooked during the serious games or simulations. All 15 studies Rooney [23] A theoretical framework for serious game design: explor- Blended, Abstraction, situational 2012 review process, our check included studies’ mentioned transfer in the initial concept ing pedagogy, play, and fidelity and their implications for Both the design process references for additional papers. of the design and described forthcoming Toups, Kerne, and Hamilton [24] The team coordination game: zero-fidelity simulation Second Cognitive fidelity, skill 2011 consequences, mostly expressed in terms abstracted from fire emergency response practice acquisition of fidelity. Although we assumed that the Hochmitz and Yuviler-Gavish Physical fidelity versus cognitive fidelity training in proce- First Cost reduction 2011 Results second class of transfer would be identified [25] dural skills acquisition Stone [26] The (human) science of medical virtual learning First Low fidelity, execution 2011 Search Results in varying ways, we found several other environments skills, reducing cognitive reasons to use abstract concepts and low load Our initial search yielded 19,564 records. Af- fidelity. In the following section, we have Wood, Beckmann, and Birney Simulations, learning, and real world capabilities First Situational 2009 ter removing all duplicates (5226), 14,338 re- [14] categorized the papers, based on similari- Markovic, Petrovic, Kittl, and Pervasive learning games: a comparative study First Varying fidelity under 2007 cords remained for title and abstract screen- ties in conjoining characteristics. Edegger [20] conditions ing, leaving 26 potential suitable papers for Alessi [27] Fidelity in the design of instructional simulations Both Varying fidelity under 1988 full-text assessment. We used Cohen kappa conditions

a) Refers to the aspired transfer type described or sought after with the game-like intervention.

26 27 Reducing Cognitive Load ing motor and spatial skills, hosted by low context awareness in a true-to-life experi- class as the in-game representation of the physical fidelity metaphors. ence on the one hand and on the other hand illness and the power to conquer this illness Out of the selected studies, 3 [12–14] ques- adding virtual game elements. Both studies are metaphorical rather than literal [22]. The tioned the necessity of high fidelity to For example, the game Underground care- conclude by accentuating the promise of game play shows little physical or functional achieve transfer. The basic theory is that fully mimics basic laparoscopic skills, pervasive game play for transfer of knowl- fidelity to real-world processes, and mea- high-immersive gaming environments including custom-made laparoscopic tool edge [20] and transfer of behavior ([19,20] sured effects can only be explained in terms decrease learning outcomes. The studies shells. The movements in the game are but provide no implications for the design of of changed mental conceptions, referring to argue that reducing complexity prevents carefully calibrated to faithfully represent virtual elements for future pervasive games. an instance of second-class (figural) trans- extraneous cognitive load. In these situa- actual laparoscopic skills. These skills are fer. However, the design considerations were tions, low fidelity and deliberate abstrac- acquired in a literal way. It is noteworthy not elucidated either in this study. tions are aiming—by design—for managing that the tools and movements share high The Application of the the trainees’ working memory capacity. This functional fidelity properties, whereas the The third study [24] describes the Team is grounded in the cognitive load theory [15]. physical fidelity is low or even nonexistent. Second Class of Transfer Coordination Game, a simulation to practice team coordination during fire emergency The same goes for iLift, where the lifting Of the studies, 3 describe game designs ap- response situations. The Team Coordination and transfer techniques maintain a mimetic plying the second class of transfer, and one Motor and Spatial Skills Training in Game is a simulation that offers a game en- correspondence to real-world tasks, al- study [21] describes a video game to stim- Metaphorical Contexts vironment that requires the use of effective though the game metaphor encompasses ulate prosocial behavior. It examines how team communication skills, without concrete physical and psychological fidelity: catching playing an avatar with superhero abilities in- elements of the mimicked environment. This In our initial selection process, papers that sheep or helping little robots escape from creases prosocial behavior in the real world. nonmimetic game offers a two-dimension- presented literal transfer axiomatically a mine shows no medical content. These The study indicates that the in-game su- al environment that shows low-fidelity to were excluded. Out of the included stud- games use metaphorical contexts to host perhero metaphor leads to greater helping real-life fire emergency environments. In ies, 3 [16–18] were regarded more closely meaningful play for training skills. behavior outside the game. The game there- the game, 3 avatars in the role of seeker are because they use metaphorical game en- searching for specific goals, while avoiding fore builds on the second class of transfer, vironments, possibly indicating the pres- threats. A player in the role of coordinator although the study does not explicate design ence of second-class transfer types. These Situational Games directs the seekers based on observing the considerations regarding transfer. game-like interventions were designed environment from a different angle. Limited Pervasive game design provides a different for skills training (ie, laparoscopic surgery, game time creates a certain amount of stress approach toward transfer. Of the papers, De Freitas et al [22] describe Re-Mission, and pushes the players to work effectively. spatial cognition skills, lifting and transfer 2 [19] advocate pervasive games, where a video game designed for young people The study suggests that players were able to techniques). In these scenarios, emphasis is fusing the virtual world with the real-world with cancer to encourage them to take their restore learned behaviors in communication placed on a high degree of validated func- positions them in between the first and sec- medication. The game metaphor, where the and stress management in an alternative en- tional fidelity, aimed at faithfully mimicking ond class of transfer. One could argue that player has to combat cancer cells, seeks to vironment, remixing and repurposing them, the desired skills. These games facilitate situational games seek to provide what we reinforce behavioral change toward medica- suggesting a transfer effect. first-class low-road transfer by automat- like to call blended transfer by emphasizing tion use. Re-Mission fits the figural transfer 28 29 Although the game offers a so-called ze- true. Despite the fact that the second class A randomized trial with 197 intervention Design for Transfer in Health ro-fidelity physical environment, it uses of transfer is not explicitly stated in those group participants showed a significant communication instruments that have the studies, they implicitly confirm the second increase in cancer-related knowledge and We tried to determine whether the second same characteristics as real-world radios. class of transfer as a promising concept in self-efficacy scores and offers empirical class of transfer types is recognized or This implies at least a modicum of functional serious game design for learning. support for the efficacy of a game-like inter- present as a road for transfer in game-like fidelity. Furthermore, the game is based on vention in improving behavioral outcomes in interventions for health. In our initial communication strategies and stress levels adolescents and young adults with cancer. search, we expected to find studies in which from real-world fire emergency situations, Effects of Design for Figural thinking about a desired transfer outcome which suggests some level of psychological Using a mixed-method approach, the Team would form a guiding principle in the design fidelity. The Team Coordination Game simu- Transfer Coordination Game [24] also reported of game-like interventions. Moreover, clear– lation study offers clear design implications, The virtual superhero study [21] only reported some transfer effect, in addition to an in- er distinctions in suitable transfer types and labeling and elaborating on abstraction from a transfer effect just after playing the game. game effect (n=64). The study suggested established examples of figural transfer (or reality as a guiding principle, which differs The study did not cover long-term effects but that players were not only able to restore forms thereof) were anticipated. Both as- from the other studies included. showed in an experimental 2×2 design that learned behaviors in communication and sumptions were proven wrong, and we had participants (n=60) in the flying superhero stress management in an alternative envi- to broaden our inclusion criteria to capture condition displayed significantly increased ronment but also capable of remixing and studies regarding design considerations, Psychological Fidelity prosocial behavior compared with partici- repurposing them. The article—in several including transfer. pants who were in the helicopter condition. substudies—describes a variety of positive In total, 7 studies [12,22–27] mention psy- The study mentions several possibilities for effects on communication and organiza- Our results show that transfer is mainly chological fidelity as, if not the most, an the differences found between the testing tional skills, carried over from the game mentioned as a desired outcome, not as a important design parameter in serious conditions: different experiences of immer- environment to live training. guide in the design process. The appear–ance games and simulations. In addition, these siveness, involvement versus observation of most included game-like artifacts can be studies claim that representing the real discrepancy, and primed concepts and stereo- explained by the designer’s fidelity approach. world as literal as possible is less important types related to superheroes in general. As obvious as this seems, this fidelity ap- for learning. The definition of psychological Discussion proach also expresses assumptions about fidelity in these studies varies slightly [25], The study reporting on Re-Mission [22] To our knowledge, this is the first review to the way the transfer is expected to take but all studies mention the abstraction did not elaborate on the efficacy of the explore the aspired transfer in designing place. As described before, we found several of certain real-world concepts and a pro- intervention. Another study [28] focused game-like interventions in health. We tried to reasons for choosing low fidelity over high cess of recontextualization. Of the studies in greater detail on the transfer effects of find and describe examples of the application fidelity and vice versa. As none of the studies considered, one [24] added suspension of Re-Mission and found that playing the game of second-class transfer types by answering were designed for achieving transfer via a disbelief as an important characteristic increased young cancer patients’ feelings of 3 research questions, discussed below. specific type or class of transfer, the ques- of psychological fidelity: one’s temporary self-efficacy or beliefs in their own ability to tion arises why the design for transfer per- allowance to believe something that is not control and cope with the disease. spective has received no attention. 30 31 By nature, design-centered research focus– The Presence of the Second Limitations es more on the design itself and puts less emphasis on the eventual aspired outcome. Class of Transfer Although this review is based on an exten- Although it is too strong to state that the sive search of a large number of health and As described, we searched for particular functional and physical needs as well as design itself of game-like interventions in computer science databases, we hardly examples of aspired transfer in the second promote immersion. At this point, we hy- health is not taken into account in thinking found any studies of second-class transfer class of transfer types, and found none. In pothesize that figural transfer builds upon about desirable transfer outcomes, our types in game-like interventions for health. 3 studies, the reported effects can only be immersion or virtual presence and subse- search results show that describing the Studies tend to focus on the effectiveness explained via the road of a second-class quent suspension of disbelief [24]. In more game-like interventions in terms of transfer of game-like interventions and the research transfer type but are described in other abstract game-like interventions, meta- variables is uncommon. One might argue methods used, not on design factors that terminology. Most studies report about phors provide a storyline, a context, and that the design of a drug is essential to lead or contribute to measured effects. Due psychological fidelity [12,22–27], virtual a reason for engaging in play. In this way, its workings and that the same principle to the very few direct hits, we focused on presence [13], and immersion [21,22] as psychological fidelity is reappointed by the applies for game-like interventions. The the subconscious application of the sec- important conditions for desired outcome. concept of suspension of disbelief, instigat- design of the artifacts as exercised in the ond class of transfer types by thoroughly ed by the metaphor itself. virtual superhero game [21], Re-Mission screening titles and abstracts. The papers An interesting observation is that the in- [22], and the Team Coordination Game that were included were subject to inter- cluded papers show that functional and simulation [24] is intentional and differs pretation, discussion, and consensus of the physical fidelity can be high or low for vary- strongly from game-like interventions as Second-Class Transfer reviewers (DK, GT, and BW). To counteract ing, well-founded reasons and that psy- Underground [17] or Digital Economy [20]. subjectivity, papers were independently chological fidelity is regarded as a variable Outcomes These differences arise from a broad and reviewed by 2 reviewers (DK and GT) and that preferably should be high. The Team As the literature on transfer has consistently ill-defined range of variables but inevitably were only included on consensus from both Coordination Game simulation [24] adopts confirmed, long-term transfer effects are reveal the design–er’s intent with regard to reviewers. Remaining conflicts between a different position in stating that the gam- hard to measure. This might be particularly how the intervention should carry over the the reviewers were resolved by the third ing artifact has zero psychological fidelity. the case for the second class of transfer. All effect. Herein lies the rationale for design reviewer (BW). However, the way deliberate abstractions 3 examples report transfer effects, albeit for transfer. are described and how these resulted in the short term and only vaguely proven. As sec- design of the game itself strongly suggests ond-class transfer is the result of the effects Conclusions second-class transfer. interventions trigger in one’s head, the transfer outcomes are individual, often nonlinear, Studies about serious games and game-like The 3 studies we identified exemplifying and even unpredictable if the second class is interventions for health do not provide a an instance of figural transfer introduced a not implemented with due care. Precisely be- conscious rationale for designing the ar- metaphorical approach with recontextual- cause of this, we anticipated more conscious tifacts for optimizing transfer conditions. ized fidelity types. These game metaphors and elucidated design examples. We did not find any example of a game-like seem to address and replace both high 32 33 intervention that was the result of a cog- References nizant design process focusing on transfer outcomes. In general, we found that definitions of low and high fidelity form the 1. Gee JP. Learning by Design: Good Video Games as Learning Machines. E-Learning and Digital Media. strongest influencers on the design of ar- 2005;2:5–16. tifacts, mostly exemplified in visual quality 2. Shaffer DW. How Computer Games Help Children Learn. 2006. or a true-to-life approach. High fidelity was 3. De Freitas S. Learning in immersive worlds: A review of game-based learning. Jisc; 2006; 4. Kiili K. Foundation for problem-based gaming. Br J Educ Technol. 2007;38: 394–404. aspired to for its first class, literal transfer 5. Annetta LA. The “I’s” have it: A framework for serious educational game design. Rev Gen Psychol. 2010;14: aspects without exception. None of the 105–112. studies explained second class of transfer 6. Kiili K, de Freitas S, Arnab S, Lainema T. The Design Principles for Flow Experience in Educational Games. or instances thereof, although in 3 instanc- Procedia Comput Sci. 2012;15: 78–91. es, implicit design choices suggested other– 7. Royer JM. Theories of the transfer of learning. Educ Psychol. Routledge; 1979;14: 53–69. wise. It is notable that studies on game-like 8. Perkins DN, Salomon G. Transfer of learning. International Encyclopedia of Education 2nd edition. Oxford, interventions for health do not elucidate England: Pergamon Press; 1992. pp. 6452–6457. the design choices made, as they bridge the 9. Gee JP. What video games have to teach us about learning and literacy. Comput Entertain. 2003;1: 20. designer’s intent and the aspired transfer 10. Alexander AL, Brunyé T, Sidman J. From gaming to training: A review of studies on fidelity, immersion, pres- outcome. ence, and buy-in and their effects on transfer in pc-based simulations and games. Training Impact Group. academia.edu; 2005; Available: http://www.academia.edu/download/30709818/2005_Alexander_Brunye_ Sidman_Weil.pdf Acknowledgments 11. Elmagarmid A, Fedorowicz Z, Hammady H, Ilyas I, Khabsa M, Ouzzani M. Rayyan: a systematic reviews web app for exploring and filtering searches for eligible studies for Cochrane Reviews. Evidence-informed public The authors would like to thank Olga van health: opportunities and challenges Abstracts of the 22nd Cochrane Colloquium. John Wiley & Sons Hyder- Dijk from Medical Centrum Leeuwarden abad, India, India; 2014. pp. 21–26. (NL), who developed the search strategy for 12. Dankbaar MEW, Alsma J, Jansen EEH, van Merrienboer JJG, van Saase JLCM, Schuit SCE. An experimental the systematic review. study on the effects of a simulation game on students’ clinical cognitive skills and motivation. Adv Health Sci Educ Theory Pract. 2016;21: 505–521. 13. Schrader C, Bastiaens TJ. The influence of virtual presence: Effects on experienced cognitive load and learn- Conflicts of Interest ing outcomes in educational computer games. Comput Human Behav. 2012;28: 648–658. 14. Wood RE, Beckmann JF, Birney DP. Simulations, learning and real world capabilities. Clarke T, editor. Educa- None declared. tion Training. 2009;51: 491–510. 15. Sweller J. Cognitive load theory, learning difficulty, and instructional design. Learning and Instruction. 1994;4:295–312.

34 35 16. Kuipers DA, Wartena BO, Dijkstra BH, Terlouw G, van T Veer JTB, van Dijk HW, et al. iLift: A health behavior change support system for lifting and transfer techniques to prevent lower-back injuries in healthcare. Int J Med Inform. 2016;96: 11–23. 17. Jalink MB, Goris J, Heineman E, Pierie J-PEN, Ten Cate Hoedemaker HO. Face validity of a Wii U video game for training basic laparoscopic skills. Am J Surg. 2015;209: 1102–1106. 18. Connors EC, Chrastil ER, Sánchez J, Merabet LB. Action video game play and transfer of navigation and spatial cognition skills in adolescents who are blind. Front Hum Neurosci. 2014;8: 133. 19. Knöll M, Moar M. The space of digital health games. Int J Comput Sci Sport. researchgate.net; 2012;2012. Available: https://www.researchgate.net/profile/Martin_Knoell/publication/259870996_The_Space_of_ Digital_Health_Games/links/0a85e52e4f69c72b9c000000/The-Space-of-Digital-Health-Games.pdf 20. Marković F, Petrovic O, Kittl C, Edegger B. Pervasive learning games: A comparative study. New Review of Hypermedia and Multimedia. 2007;13: 93–116. 21. Rosenberg RS, Baughman SL, Bailenson JN. Virtual superheroes: using superpowers in virtual reality to encourage prosocial behavior. PLoS One. 2013;8: e55003. 22. de Freitas S, Dunwell I. Understanding the representational dimension of learning: the implications of interactivity, immersion and fidelity on the development of serious games. In: Yiyu C, editor. Interactive and Digital Media for Education in Virtual Learning Environments. Nova Science Publishers; 2011. pp. 71–90. 23. Rooney P. A Theoretical Framework for Serious Game Design. International Journal of Game-Based Learning. 2012;2: 41–60. 24. Toups ZO, Kerne A, Hamilton WA. The Team Coordination Game: Zero-fidelity Simulation Abstracted from Fire Emergency Response Practice. ACM Trans Comput -Hum Interact. New York, NY, USA: ACM; 2011;18: 23:1–23:37. 25. Hochmitz I, Yuviler-Gavish N. Physical fidelity versus cognitive fidelity training in procedural skills acquisition. Hum Factors. 2011;53: 489–501. 26. Stone RJ. The (human) science of medical virtual learning environments. Philos Trans R Soc Lond B Biol Sci. 2011;366: 276–285. 27. 2Alessi SM. Fidelity in the design of instructional simulations. Journal of computer-based instruction. psycnet.apa.org; 1988;15: 40–47. 28. Kato PM, Cole SW, Bradlyn AS, Pollock BH. A Video Game Improves Behavioral Outcomes in Adolescents and Young Adults With Cancer: A Randomized Trial. Pediatrics. 2008;122: e305–e317.

36 37 H3: Design for Transfer Meaningful Play through Metaphorical Recontextualisation

Published: Kuipers DA, Wartena BO, Dijkstra A, Prins JT, Pierie JP. Design for transfer. InInternational Conference on Serious Games Development and Applications 2013 Sep 25 (pp. 239-246). Springer, Berlin, Heidelberg.

Dys4ia (2012)

Dys4ia is a retro arcade-y piece of interactive art by transsexual author Anna Anthropy about her six-month experience with hormonal therapy. Raw and emotional, but surprisingly humorous, for good or for bad, this is the kind of game that will get people thinking and talking.

38 39 Abstract Introduction good game design. Amongst others, important features of games are the game’s abil- This paper explores the use of design Broadening the field of education with rela- of a video game as a medium for learning a ity to adapt to the skill level of the player, for transfer in simulations and serious tively new technologies as video games not choice for essential design principles comes facilitate interactivity and enable discovery games. Key in this study is the hypothesis only raises questions on their appearance along, and (2) in order to maintain these learning under the user’s control. In fact, principles, educators must explore and that meaningful play can be achieved by and mechanics but surely needs rigorous many studies on serious games show guide- research on how serious content can be adopt new views and insights on learning. designing for figural transfer by the use lines and design principles for good serious integrated into a game, without harming the of metaphorical recontextualization. The game design, so, what is keeping us from unique features games offer for learning. Game Transfer Model (GTM) is introduced doing so? It is the medium itself and here Education needs good games as a tool for designing and thinking about ‘Other than pure entertainment’ is part of aforementioned characteristics that make serious game design, stretching the pos- Well-designed games have the ability to the common definition of a serious game. games suitable for learning. sibilities from high-fidelity simulations to tempt and challenge people to engage in The ‘serious’ adjective is needed to ensure complex and difficult tasks, without forcing metaphorical fantasy worlds. Key for an the game will train, educate or inform. It them to do so. Gee [3] believes it is the way in-game learning experience is the presence also leads to an oxymoron, since games Design for transfer of conceptual continuity defined by the are inherently fun and not serious e.g., [1]. that games are designed that makes them congruence of fidelity-elements. The GTM Serious seems at odds with play, and play deeply motivating. Not just motivating to With the positive effects on learner moti- differentiates between realisticness and is central to games [2]. Most serious games play a game, but to learn, to get better. He vation and learning outcomes in mind [7,8]; realism. Where simulations use the road of have been deliberately designed for learning states that good games are good games be- [9], educators must think of new ways to literal transfer and therefore relies on real- or are so-called commercial off-the-shelf cause they touch a core element of human make serious matter suitable for gameplay. A isticness and high-fidelity, figural transfer video games (COTS). The latter case opens beings: a biologically need for learning. transformation of current forms and beliefs can be a guiding principle for serious game opportunities for existing games to add to Studies on serious games frequently men- on learning may be needed to make a more design, using metaphorical recontextual- the educational field, causing the inevitable tion the importance of flow experience [4] natural connection between the serious ization to maintain conceptual continuity. comparison between an educator’s point of as a central prerequisite for enjoyment, and the game. A possible way to make such Conceptual continuity aligns fidelity and view on games and the world of the leisure being the optimal balance between chal- connection can be found in thinking in terms games. In many cases, the serious part of enables the game to connect its serious lenge and skill. By nature, games provide of transfer. Although there’s a wide variety serious games seems to justify the sacrifice content to the realities of life. this balance, being adaptive and adaptable of viewpoints and theoretical frameworks of fun, entertainment, and aesthetics in or- at the same time. Flow state induces a state regarding transfer in the literature, seldom der to achieve a desired goal by the player. of mind, causing players to have a height- transfer is a starting point for education- An often-observed phenomenon is that de- Keywords: ened sense of presence through individual alists in developing serious games. As in spite rules and guidelines, efforts in making many cases of innovation, people tend to Serious video games; figural transfer; game serious games don’t result in a good game, identity [5] engagement in the content, and transfer model; metaphorical recontextu- mostly because the unique motivational intrinsically motivating to succeed in the use known repertoire in a new environment: alization; fidelity dissonance; conceptual features of games are lost in the process. challenge of the game’s goal. Annetta [6] an interesting case of transfer in itself. continuity; meaningful play. This paper argues that (1) with the choice mentions flow as an underlying goal of all There is a clear distinction between mere

40 41 learning and learning for transfer [10]. One Conceptual continuity and could argue that modern education is mostly occupied with mere learning: passing tests Fidelity Dissonance and preparing for exams. How transfer takes Flow state [4], as well as suspension of dis- Traditionally, the assumption has been that impact on the transferred skill or knowl- place or even if transfer occurs, is mostly belief [12], are psychological states of mind, higher-fidelity is better than lower- fidelity, edge [17]. This paper, however, makes a not an issue. This paper argues that a focus often mentioned to be essential to game- which in the case of simulations might be clear distinction between realisticness and on transfer gives new perspectives on se- play, or in the other words, can be induced true. High-fidelity environments can pro- realism. Where realisticness deals with the rious game design. Royer [11] mentions two by gameplay. It is these unique attributes vide an authentic context in which learners degree of real-world similarity, realism can classes of theories on the subject of transfer. that rely heavily on well-made design can learn-by-doing. This makes knowledge be found in conceptual continuity, in the The first is based on the idea that an original choices. Musician and composer Frank more meaningful and therefore has a higher game’s ability to correspond its serious con- learning event and a transfer event have Zappa (1940-1993) introduced the term con- to share common stimulus properties. The ceptual continuity, by which he probably did second class of theories explains the occur- Figure 1. Shows a simulation game seeking common stimulus properties, using literal transfer for learning. not have serious game design in mind, but rence of transfer in terms of mental effort referred to the importance of congruence uncanny valley and cognitive process. He also differentiates in art. In game design, each element of the LITERAL MIMETIC between literal transfer and figural transfer, game is carefully chosen in order to put the realisticness a ranging with reminds in some ways to the player in the correct mindset to experience low-road and high-road transfer, as de- the game. In that way, games need concep- conceptual continuity scribed by Salomon & Perkins [10]. Royer [11] tual continuity in order to facilitate suspen- physical functional states that ‘most of the material in the past sion of disbelief. ﬁdelity ﬁdelity

literature on learning transfer could be in- SIMULATION cluded under the concept of literal transfer’, In research, to some extent, the degree of implying a modest role for figural transfer psychological realism is held to be conditional for transfer in the educational field. Figural transfer may ﬁdelity to occur. Fidelity is believed to be of impor-

share similarities with high-road transfer, TRANSFER tance in terms of relevance for learning and but it seems to have a place in its own right. transfer [13], denoting the degree of simi- It involves the use of existing world knowl- larity between the training situation and the edge or schemata as a tool for thinking about operational situation, which is simulated or learning about, a particular problem or [14]. According to Alexander [15,16] fidelity issue. This idea resonates with constructivist has dimensions beyond the visual design of metaphoricalness ideas about learning and cognitive theory a game. Notions of simulation fidelity in- FIGURAL ABSTRACT and certainly becomes interesting when held clude physical, functional and psychological next to game instances. inﬁdelity fidelity [15]. 42 43 tent with the realities of life [18]. One could ing a space where it is possible to position part of serious games, serious games mostly causing the serious content to take on differ- argue that realism correlates with artifact educational content on a scale between can be positioned in the upper regions of the ent appearances. The shift from simulation acceptance and credibility, underpinned by literal and figural transfer. On the top of the model. Introducing figural transfer in the de- to play initiates the need for a metaphorical the congruence of the three types of fidelity. model, the literal transfer corresponds with sign of serious games hands the education- approach recontextualization within the GTM simulation, at the bottom figural transfer is alist tools to explore new (or forgotten) ways the process of recontextualizing abstrac- connected to play. Depending on the desired to get serious content across and enables tions into meaningful game-play is called Game Transfer Model educational outcome and profile of the learn- game designers to integrate serious content metaphorical recontextualization. In order to er, a sound judgment has to be made on “the in more playful ways in games as depicted facilitate figural transfer authentic elements The game transfer model (GTM) combines what and the how” of transfer. Almost by de- in figure 2. The conceptual continuity circle of the learning objectives are presented in a transfer and video game instances, suggest- fault, and possibly influenced by the serious lowers in the model towards figural transfer, metaphorical context. Players are presented

Figure 2. Shows a game artifact, facilitating figural transfer for learning by using metaphorical recontextualization. Figure 3. Shows the occurrence of fidelity dissonance, caused by incongruence in fidelity-types. uncanny valley uncanny valley LITERAL MIMETIC LITERAL MIMETIC realisticness realisticness

functional fidelity SIMULATION SIMULATION conceptual continuity physical fidelity dissonance physical functional fidelity fidelity fidelity TRANSFER TRANSFER psychological psychological fidelity fidelity

metaphoricalness metaphoricalness FIGURAL ABSTRACT FIGURAL ABSTRACT inﬁdelity inﬁdelity

44 45 serious matter in new and rich contexts, trig- as well as the overall player experience. Conclusions & Implications gering a need for understanding, generating Therefore when distancing oneself from a meaning and encouraging participation. This simulation towards a serious game designing for Game Design process where players are making sense of the befitting metaphor is essential. When Manifestations of mere learning can con- resulting in a game that’s unable to get hold contexts within they function by constructing designing a game with transfer purposes, tribute to a fidelity dissonance, when imple- of the player in terms of flow and motiva- mental representations or concepts of them whether it is a simulation or serious game, mented unaltered from existing work forms tion. In simulation games this conceptual shows resemblance with Argyris’ theory on conceptual continuity is key. The dimensions into gameplay. When designing a game for continuity is reached by creating a high double-loop learning [19]. of fidelity can differ in their respective levels learning purposes, whether it being a simu- fidelity and realistic environment, whilst as well as their position on the grid of the lation or serious game, conceptual continui- in serious games, the metaphorical recon- Recognizing and evaluating abstracted es- game transfer model, however, the conti- ty is key. Conceptual continuity can be textualization is used to keep conceptual sentials in a metaphorical recontextualized nuity of those levels through the gameplay reached by aligning the dimensions of continuity and realism within a less realistic environment is key to figural transfer. The influences the conceptual continuity. During fidelty in order to establish a sense of game environment. use of metaphors is a known didactic prin- gameplay, movement in the levels of fidelity realism and believability. Serious game ciple, probably as old as humanity itself. The or their position related to each other can designers should reach their serious goals This also implies that by default games that Greek word (metaphorá) actually vary to some extinct, but more rigid move- μεταφορά by focusing on transfer types and corre- are using a reinforcement or motivational means ‘to carry over‘ or ‘to transfer’. Figural ments on the grid of the game transfer model spond- ing game entities. The combination paradigm [22] within serious games lack transfer uses simile or metaphors as a carri- cause the conceptual continuity to fall apart. of learning abilities of the target audience conceptual continuity. When the er to create and raise mental images, allow- Figure 3 shows the occurrence of what in the desired learning outcomes and content game-goals and educational goals fail to ing new insights and knowledge to land in GTM is called fi–delity dissonance: an incon- specifications result in a position on the grid intertwine, fidelity dissonance is a direct prior schemata. In-game learning can occur gruence in fideity concepts, causing a distur- of the game transfer model. This position result. Therefore a blended paradigm is the by figural transfer using metaphorical recon- bance in the game experience. It’s this pitfall marks the center of the conceptual conti- more befitting paradigm for meaningful textualization as a key element for success in serious game design that contributes to nuity circle and positions the fidelity types. play. By exploring and embracing figural in learning and gameplay. When creating the absence of suspension of disbelief and The dimensions of fidelity can differ in their transfer as a mechanism for learning, seri- a game the use of metaphors is common makes it hard to stay in the flow channel respective levels as well as their position on ous games can be more than simulations or practice to distance yourself from reality. A [20]. Finally, the endpoints of the scale are the grid of the game transfer model, how– drill & practice games. Metaphorical recon- metaphorical recontextualization constitutes labeled uncanny valley [21] and infidelity. The ever the congruence of those levels through textualization can be key to change the fu- using a metaphor to place a real-life/simu- uncanny valley describes the phenomenon the gameplay influences the conceptual ture of serious games, giving the education lated skill or knowledge partitions and re-ar- of experienced uncanniness evoked by a continuity. Whenever these points show in- professional as well as the game designers range the construct by the use of a metaphor. high degree of fidelity. On the other hand, the congruence, a fidelity dissonance may occur, new tools to develop seriously good games. This re-arrangement process through the term infidelity is used to describe a situation use of a metaphor influences the constructs’ where fidelity is thus low, the game loses its qualities, the games’ validity, and fidelity potential for learning.

46 47 References

1. Ritterfeld U, Cody M, Vorderer P. Serious Games: Mechanisms and Effects. Routledge; 2009. 20. Shute VJ, Ventura M, Bauer M, Zapata-Rivera D. Melding the power of serious games and embedded assess- 2. Watts C, Sharlin E, Woytiuk P. Matchmaker: Interpersonal Touch in Gaming. Lecture Notes in Computer ment to monitor and foster learning. Serious games: Mechanisms and effects. Science. 2009. pp. 13–24. books.google.com; 2009;2: 295–321. 3. Gee JP. Learning by Design: Good Video Games as Learning Machines. 21. Mori M, MacDorman KF, Kageki N. The Uncanny Valley [From the Field]. E-Learning and Digital Media. 2005;2: 5–16. IEEE Robot Autom Mag. 2012;19: 98–100. 4. Csikszentmihalyi M. Flow. New York: Harper & Row; 1990. 22. Ritterfeld U, Cody M, Vorderer P. Making the Implicit Explicit: Embedded Measurement in Serious Games. 5. Witmer BG, Singer MJ. Measuring Presence in Virtual Environments: A Presence Questionnaire. Presence: Serious Games. Routledge; 2009. pp. 344–365. Teleoperators and Virtual Environments. 1998;7: 225–240. 6. Annetta LA. “The ”I’s“ have it: A framework for serious educational game design”: Correction to Annetta (2010).Rev Gen Psychol. 2010;14: 250–250. 7. Shaffer DW, Gee JP. How Computer Games Help Children Learn. Macmillan; 2008. 8. De Freitas S. Learning in immersive worlds: A review of game-based learning. Jisc; 2006; 9. Kiili K. Foundation for problem-based gaming. Br J Educ Technol. Wiley Online Library; 2007;38: 394–404. 10. Salomon G, Perkins DN. Rocky Roads to Transfer: Rethinking Mechanism of a Neglected Phenomenon. Educ Psychol. 1989;24: 113–142. 11. Royer JM. Theories of the transfer of learning. Educ Psychol. Routledge; 1979;14: 53–69. 12. Coleridge ST. Biographia literaria, chapter XIV. West Sussex, England: Littlehampton Book Services. 1817;1975. 13. Noble C. The Relationship Between Fidelity and Learning in Aviation Training and Assessment. 2002; Avail- able: https://ntrs.nasa.gov/search.jsp?R=20020074981 14. Hays RT, Singer MJ. Simulation Fidelity in Training System Design: Bridging the Gap Between Reality and Training. Springer Science & Business Media; 2012. 15. Alexander AL, Brunyé T, Sidman J, Weil SA. From gaming to training: A review of studies on fidelity, immersion, presence, and buy-in and their effects on transfer in pc-based simulations and games. DARWARS Training Impact Group. 2005;5: 1–14. 16. Lukosch H, van Bussel R, Meijer SA. Hybrid Instructional Design for Serious Gaming. J Comput Mediat Commun. 2013;10: 1–8. 17. Frick CMRTW, Reigeluth CM. Formative research: A methodology for creating and improving design theories. Instructional-design theories and models. 1999;2. 18. Galloway AR. Social realism in gaming. Game Studies. 2004;4: 2004. 19. Argyris C, Schon DA. Theory in practice: Increasing professional effectiveness. Jossey-Bass; 1974.

48 49 H4: iLift: A health behavior change support system for lifting and transfer techniques to prevent lower-back injuries in healthcare

Published: Kuipers DA, Wartena BO, Dijkstra BH, Terlouw G, van t Veer JT, van Dijk HW, Prins JT, Pierie JP. iLift: A health behavior change support system for lifting and transfer techniques to prevent lower-back injuries in healthcare. International journal of medical informatics. 2016 Dec 1;96:11-23.

Papo & Yo (2013)

Quico’s best friend, Monster, is a huge beast with razor-sharp teeth, but that doesn’t scare Quico away from playing with him. That said, Monster does have a very dangerous problem: an addiction to poisonous frogs.

50 51 Abstract 1 Introduction Objective 1.1 Background Lower back problems are a common cause An expert panel conducted analysis of vid- capacities of the game and its place within The Dutch National Compass for Public of sick leave of employees in Dutch care eo-recorded playing activities. (c) Field ex- the health behavior change support system. Health shows data from several stud- homes and hospitals. In the Netherlands periment: We performed a dynamic analy– An expert panel on lifting and transferring ies [1–3]. This points toward lower back over 40% of reported sick leave is due to sis in order to investigate the feasibility of techniques validated the provoked in-game problems having a significant impact on back problems, mainly caused by carrying the prototype through biometric data from activities as being authentic. (c) Regression insurance funds, and with all likelihood, will out heavy work. The goal of the iLift project player sessions (n = 620) by healthcare analysis showed an increase of the game continue to do so in the near future. An es- was to develop a game for nursing per- professionals (n = 37). score and dashboard score when more timated rate of 40% of reported sick leave sonnel to train them in lifting and transfer sessions were played, indicating an in-game is due to lower back problems, and about techniques. The main focus was not on training effect. A post-hoc test revealed that 2.4 million adults [4] in the Netherlands testing for the effectiveness of the game Results from an average of 10 playing sessions or suffer from chronic lower back pain. This itself, but rather on the design of the game (a) Occupational Therapists, Nurses, and more, the dashboard score and the game is defined by an employee’s absence from as an autogenous trigger and its place in a Caregivers did not recognize a lack of score align, which indicates behavioral work extending for more than 3 months. behavioral change support system. In this knowledge with training in lifting and trans- change towards executing appropriate stat- Between 2000 and 2020, with population article, the design and development of such ferring techniques. All groups considered ic lifting and transferring techniques. growth and ageing this will increase the a health behavior change support system is their workload, time pressure, and a cultur- percentage of people suffering from neck addressed, describing cycles of design and ally determined habit to place the patient’s and back problems by 14% [4]. The caus- evaluation. well being above their own as the main Conclusions es of lower back problems however, are reason not to apply appropriate lifting and nonspecific, both physical demands as Data gathered in the final field test shows transferring techniques. This led to a shift in personal and psychosocial variables are an in-game training effect, causing players Methods focus from a serious game teaching lifting associated with an increased likelihood of to exhibit correct techniques for static lifting and transferring techniques to a health below back pain [5]. This makes it difficult to (a) To define the problem space, use context and transferring techniques but also re- havior change support system containing a prevent or cure lower back problems with and user context, focus group interviews vealed the necessity for future social system game with the intention to influence behav- a single intervention. In health care, nurses were conducted with Occupational Thera- development and especially regarding inter- ior. (b) Building and testing (subcomponents spend an important part of their time lifting pists (n = 4), Nurses (n = 10) and Caregiv- vention acceptance. Social system factors of) the prototype resulted in design choices and transferring, often beside the beds of ers (n = 12) and a thematic analysis was showed a strong impact on the games per- regarding players perspective, auditory their patients. Because of this, lower back performed. We interviewed experts (n = 5) suasive capacities and its autogenous intent. on the subject of lifting and transferring and visual feedback, overall playability and problems are very common among these techniques. (b) A design science research perceived immersiveness. This design pro- professionals. Within (Dutch) health care approach resulted in a playable prototype. cess also addressed the behavior-shaping institutes and care homes, healthcare pro-

52 53 fessionals are trained in applying lifting and Serious gaming holds the promise of being argue that it is the blend of educational and associated with static lifting and transfer transfer techniques (from now on referred a powerful tool for facilitating learning and entertaining elements itself that define the techniques. The static lifting movements, in to as LTTs). Most of these training modules encouraging behavior change [16]. The term overall quality of a serious game and is particular the bend angle and the duration, exist of an (e)module containing theoretical serious game [17] used in this study, follows therefore an imperative design principle. are assessed through the Kinect. Through ex- aspects on the theme and a practicum led the presumption of Jenkins [18] which states Systemic affordances of a video game lead periential learning the player gets confronted by a physiologist. However, observations that games are designed to be integrated to specific and tailored design choices re- with the prescribed limits of the lifting ther- [3] show that displayed work routines re- into the socio-technical and social system garding the presence and form of educational mometer set against own garding LTTs do not meet the regulations, they are intended to be used in. This view on content within the game, in order to achieve movement through the score system (further suggesting a possible ineffective approach serious games, being more than a stand- natural education-entertainment blends. A described in 3.1.3). The intent of the game in current training programs. alone application, brings the social environ- dominant intervention to educate healthcare is to trigger behavioral inoculation, letting ment in the design space. This is a notion practitioners about the dangers of exceeding the player experiment with new behaviors, that Oinas-Kukkonen [7] also emphasizes the limits of static lifting is the Dutch nation- providing challenging tasks and goals. During 1.2 Objectives as an important factor in BCSS-design. Most al standard called the Lifting Thermometer. playing time, the player is scaffolded towards The main objective of iLift is the exploration studies on serious gaming focus on the For the design of the game befitting ele- compliance and safe in-game behavior by of the design of a hBCSS, supporting LTTs effects of the intervention, rather than on ments regarding static and dynamic lifting precise and tailored feedback. Huizinga [23] education, tailored around a video game. its design and specific mechanics leading up techniques of this lifting thermometer were coined the term magic circle, adopted and Oinas-Kukkonen [6,7] defines a BCSS as: a to a desired effect. As is the case with BCSS put into metaphors. As an added feature the ameliorated by Salen and Zimmerman [24], socio-technical information system with design, serious games are often regarded as game uses the psychological mechanism of where immersion [25], engagement [25], and psychological and behavioral outcomes a black box, leaving the systemic affordanc- behavioral inoculation [22]. a state of flow [26] are recognised as key ele- designed to form, alter or reinforce atti- es and weaknesses unspoken. ments in the game experience. Klabbers [27] tudes, behaviors or an act of complying The game offers an experimental environ- mentions that gameplay triggers a variety of without using coercion or deception. All The iLift study focuses on the design of ment wherein players are triggered and cognitive processes. This experience-in-ac- BCSSs are designed with persuasive intent, the game and its context, as a response to enabled to perform incorrect movements tion asks for a need for understanding the socio-technical platforms differ in their an often uttered critique that the serious Fig. 1. Ilift BCSS architecture architecture and inherent qualities [8]. Con- intentions of a game undermines its enter- sidering BCSSs background in web science, taining nature. Wouters et al. [19] conclude it comes as no surprise that game systems that more research is required on factors such as a BCSS diverge in their architecture that connect the worlds of game design and [9,10,11] through, amongst others; procedur- instructional design. The blending paradigm al rhetorics [12], motivational affordances [20] suggests the merging of entertainment [13,14] and their mechanics, dynamics and and education, where learning becomes aesthetics [15]. incidental and implicit. Kuipers et al. [21]

54 55 (game rules and focal point) and generates a BCSS. The system can affect attitudes, Table 1. Analysis of the persuasion context meaning (on in-game occurrences). To do behaviors or compliance. Fig. 1 shows the so, players use explicit, tacit, enculturated iLift BCSS architecture, wherein the different Intent Persuader The persuader in the hBCSS is the game Back Space, designed to offer a compelling and enjoyable experi- and local knowing [27]. Amory [28] states artifacts (game, dashboard and e-module) ence. The games motivational affordances underlines its autogenous intent.

that players can assimilate tacit knowledge and their desired behavioral outcomes are Change type(s) iLift consists of three artifacts, each with a different intent. The games intent is to reinforce compliance: through the process that is reconstructed presented in relation to the behavior change indulging in the game leads to an in-game training effect and an automated application of static LTTs. The after emerging from the state of flow. Other dashboard is designed for altering behavior: the dashboard prompts and explicates in-game scores and support system as a whole. provides tailored feedback on performed behavior and offers suggestions to alter in-game behavior. The serious games studies emphasize the im- hBCSS refers to an eModule only then when in-game performance is under set boundaries and dash- portance of appropriate debriefing [29]. All Fig. 1 is best understood in terms of the O/C board consultation does not lead to altered in-game behavior. The eModule delivers specific information on the consequences of long-term inadequate usage of LTTs and is designed to form attitudes towards aforementioned constructs and concepts Design Matrix [6], elucidating a C-Change as LTTs. shaped the ideas for an iLift hBCSS, includ- being a change in compliance, a B-Change Designer bias The designer bias becomes clear after consulting the dashboard. ing an in-game experience, a dashboard as a change in behavior and an A-Change with game data explicitation with visuali- as a change in attitude. These change types Event Use context The target group considered workload, pressure of time and the habit to place patients well being above their own as the main reason not to apply LTTs. The importance of applying LTTs however was recognized sation and an underlying theoretical frame- can be laid out in three expected outcomes, at a personal level, but knowingly neglected in the social context. work on lifting and transfer techniques. being reinforcement (R-Outcome), alteration (A-Outcome) and formation (F-Out- User context The game mechanics enables the user to set personal in-game goals and the dashboard offers peer come). The design of the iLift hBCSS exists comparison. Competition can be an effective way to influence both the user as the use context. 1.3 iLIFT as a hBCSS of 3 artifacts as depicted in Fig. 1. Each of the artifacts has a dedicated task regarding Technology To promote transfer (of learning) the game is played on the workplace. The artifacts are designed to Aforementioned discrepancy between the context match users operational skills and knowledge. An example of this is the choice for the Kinect. This ges- behavioral influence. First, the user enters observed situation [3] and an active im- ture sensing input device enables the player to control the game with body postures and gestures, with- the system with a game designed to re- out having any knowledge of how games work. Moreover, we regard the choice for a game as persuader plementation of LTTs by caregivers places and its design an important part of the technology context. inforce compliance. Second, a connected the focus on behavioral aspects. Teaching Strategy Message The persuadee voluntarily complies with the games rules and gradually learns about the set boundaries dashboard interprets in-game achieve- healthcare professionals theories on LTTs, and limits of LLTs. These rules are the effectuation of the message: playing the game shapes and auto- ments and translates biometrical data into mates LLTs through behavioral inoculation. along with safety measures and protocols, explicit and tailored information, designed seldom translate into an adequate prac- to change behavior. Third, an eModule tical execution of this knowledge. A BCSS Route The route at first is indirect. The system does not clarify its intent to teach LTTs, but presents itself as a provides the user theoretical and normative game. If the route was more direct at this point, the game could be regarded as a training instrument and is designed for behavioral change, using background information, instigated by poor lose its persuasive character corollary. Mixed messages occur after involving in the game: the dashboard persuasive technologies in conjunction with explains how in-game results correspond with LTTs and how progression is possible by adjusting in- dashboard scores. The eModule is meant game behavior. Direct messages are found in the eModule, containing tailored information and warnings specific end-user characteristics in a social to establish the formation of new attitudes of consequences of long-term inadequate usage of LTTs. system context. Oinas-Kukkonen [7] poses towards off-limit LTT behavior. formation, alteration and reinforcement as three potential behavioral outcomes for

56 57 1.3.1 The persuasion context 1.3.2 C-change: serious game 1.3.3 B-change: dashboard

The following section discusses the per- To reinforce compliance and offer a focus (see Section 3.1.2.). The perpetuated persua- An external dashboard is developed to suasion context of the iLift hBCSS. To un- on the experience, a serious game is played. siveness of the game seeks for an enjoyable explicate in-game events and biometri- derstand the information processing event, The nature of a game relates to the desired experience, designed to shape and refine the cal data, and is designed to alter behavior Oinas-Kukkonen et al. [8] emphasize the persuasive requirements of a BCSS. Design desired LTTs. towards the actual usage of lifting and importance of understanding the persua- choices for the iLift game were designed transferring. This dashboard provides sion context. To understand and accommo- with an eye for: (1) a specific transfer type Persuasive system principles enabling feedback on how in-game efforts translate date the complicated psychological events (here transfer of learning is meant, not primary task support within the game, are to real life situations, including longitudinal in a person’s mind during persuasive com- LTTs), and (2) players needs, abilities and found in reduction, tunneling, simulation and inherent consequences like the increased munication, insight in the intent, the event socio-cultural aspects and (3) serious goals rehearsal. The game simulates the postures chance of lower back problems. It sup- and the strategy of the BCSS is needed. The and topic characteristics [11]. Bogost [12] and reaching movements that are common ports social comparison by setting players intent deals with the persuader and the argues that video games hold unique per- in static LTTs and reduces reality to a simpli- achievements against efforts by peers. The change type, the event addresses the con- suasive power that prompts so-called pro- fied environment. Within the iLift hBCSS the game processes playing data to graphical texts of use, user and technology. Finally, cedural rhetorics, which he defined as being process of tunneling starts with a voluntarily and textual feedback. This feedback informs the strategy describes the message and the the art of persuasion through rule-based entree, positioning the game as an autoge- the player to what extent behavioral change message route. Table 1 elaborates on the representation. Players are challenged to nous technology [30]. Gradually the system (i.e. exercising) is needed. Furthermore, the persuasion context addressed in this study. enact on rules and logics offered by game- provides the means to reflect on one’s be- dashboard can offer player specific tailored play by trying to structure and understand a havior and supports experiment towards theoretical information (Section 3.2) trig- The next step in persuasive system devel- playing experience. Kuipers et al. [21] link the target behavior. The game play continuously gered by in-game data, redirecting the play- opment or evaluation is, according to desired persuasive nature of a game befitted provokes physical action, enabling the user er to an e-learning module. Achieved dash- Oinas-Kukkonen et al. [8], to describe the for BCSSs to the players perceived con- to rehearse and refine in-game behavior. board scores determine the tone of voice in persuasive systems design principles. ceptual continuity of the game, defined as Design principles in the game that enable texts, displayed references to sections of Drawn from the work of Fogg [30], the set congruence (of levels of) physical, functional dialogue support are praise, rewards and the e-learning module and the shown con- of design principles can be categorized in 4 and psychological fidelity [31]. iLift uses liking. The game offers rewards in points, dition of your playing character. The combi- support types, namely: primary task sup- gameplay to trigger, shape and rehearse immediate visual and auditory feedback nation of a different data presenting mode port, dialogue support, system credibility static LTTs in a metaphorical environment. on action. Design principles referring to offers a thorough insight into own in-game support and social support. The individual The core principles, rules and logics of the elements of social support are competition behavior. workings of the artifacts with their intend- benchmark [32] of static LTTs were trans- (going for the high score) and recognition, ed behavioral change types, outcomes and lated into game elements. The iLift game because playing the game is often done in a From a persuasive system design perspec- support types are further discussed in the experience is designed to trigger figural social setting with colleagues. Table 2 shows tive [8], the dashboard employs elements of sections below. transfer [33] of LTTs by offering a series of the iLift game in terms of persuasive system primary task support, like tailoring, person- carefully chosen and calibrated metaphors principles and support types [8]. alization and self-monitoring.

58 59 The user is called by name, texts are tailored 1.3.4 A-change: eModule Table 2. The iLift Game persuasive support types in conjunction with players performance The e-module is the third artifact in the Primary task support Dialoque support System credibility Social support and graphs show progress over the course hBCSS, designated to form attitudes based support of time. Performed dialogue support tasks on tailored and personal theoretical in- are reminders, suggestions and (para)social Reduction Praise Competition sights. Rooted in constructivist ideas on Game role. A passport photograph of the player just-in-time learning, theoretical informa- Tunneling Rewards Recognition depicted as a robot is shown, attempting tion only then is presented when a weighted para-social relationship [34]. Reminders Simulation Liking and corrected dashboard score (see 3.2.1) and suggestions come in short hinting and requires so. Within their organizations nurs- Rehearsal activating texts. For instance; “51 points is es and caregivers are familiar in working not a very good score. Try to comply to the within an e-learning environment. On-the- Table 3. The iLift Dashboard persuasive support types feedback the game offers, somehow you’re job training is facilitated by an extensive losing points during your play. Take a look Primary task support Dialoque support System credibility Social support platform, hosting a variety of medical and at your graphs and find out in which ways support safety related modules. The iLift hBCSS you can alter your playing behavior. Try to incorporates an e-learning platform known Tailoring Reminders Social learning consciously behave differently in the next Dashboard to players. The basic idea of using familiar gameplay session. Good luck!”. Personalization Suggestion Social comparison technology as an e-learning environment at

the end of the message route is based on in- Self monitoring (para)social role Competition Social learning, social comparison, norma- herent system qualities, respectively; trust- tive influence and competition are instigat- Rehearsal worthiness, expertise, authority and verifi- ed by the visual information of the graphs. ability. These system qualities contribute to Not only the representing the player’s score Table 4. The iLift eModule persuasive support types the acceptance and perceived value of pro- over time, but also by showing results of vided substantiating theoretical behavior the other players achievements, instigating underlayment. All of the above contributes Primary task support Dialoque support System credibility Social support peer comparison. The picture of the avatar to system credibility: the players are used support robot portrays a gradation of happiness cal- to learning and being tested using the same Tailoring Trustworthiness Normative ibrated with the dashboard as a normative platform as the eModule. The module Static eModule influence, even displaying a short circuited Personalization Expertise Influence Loads iLift is made by the same authors that robot with a broken back. Table 3 shows wrote most modules on the platform and Authority the iLift dashboard in terms of persuasive validated by domain experts. Primary task system principles and support types. Verifiability support is provided by personalizing and

60 61 tailoring the information at an individual sessions with occupational therapists, edu- and guidelines offered by Hevner [45] was 2.2 Preliminary studies level: users are directed to designated parts cational technologists and serious game de- followed to attain rigor and relevance in the within the module, befitting theoretical signers. The focus of these iterations, shift- design cycle, as illustrated by Hevner [46] in 2.2.1 Use context: focus groups explicitation of dashboard concerns. The ed during the process accordingly to the Fig. 3. The centre of this figure depicts a de- Three homogeneous focus groups were e-Module holds strong normative influence non-linear steps as described by Simon [37], sign cycle, informed by building and analyz- conducted in order to inventorize peoples capacities due to an ofttimes admonish- including ideation, prototype development ing design artifacts. DSR also addresses the shared experiences. The main purpose ing character, placing an emphasis on the and prototype selection. The prototype need for real-life contextual understanding during these sessions was to gather infor- importance of the formation of attitudes was evaluated in play test sessions with (cf. transfer in training [47]), distillate design mation on the cause and position of LTTs towards longitudinal use of incorrect lifting end-users, including an immersion study, patterns (Design patterns cf. [48] and test- within their organisations. The three groups and transfer behaviors. Table 4 shows the again providing input for the design and ing (parts of) the prototype in situ (cf. Play used were Occupational Therapists, Nurses eModule in terms of persuasive system development of the prototype. After each as research [49]). Here Oinas-Kukkonen’s and Caregivers. Two groups mentioned that principles and support types. session, observational data and players notion of Use context corresponds with the the topic of LTTs had not been given suffi- feedback was analysed and led to a partial environment as depicted in Fig. 3. cient attention or that it was found prob- redesign or reconfiguration of the game. The lematic that training and practical sessions 2 Methods final version of the prototype of the game, had to be achieved outside working hours. including the dashboard and eModule then The iLift hBCSS as described in this article, The Occupational Therapists commented on were used in a field study. consists of three artifacts, all attempting to work in regard to different forms of Fig. 2. Overview of our methodological approach. Adapted from Tripp & Bichelmeyer (1996). change. The design science research approach (DSR) is described in Section 2.1. In 2.1 Design research content 2.2 the preliminary studies evaluating and The emphasis in the field of medical infor- determining the use, user and technology matics lies in; improving the health of peo- User context (focus groups) Set Objectives context are described. Fig. 2 depicts an ple through its contributions to high-quality Technology context, construct prototype (SCRUM) adapted version of the rapid prototyping ISD efficient health care and to innovative Utilize prototypes (play, expert panel, immersion study) model [35]. Mapping our research methods research in biomedicine and related health on the corresponding phases of the model, and computer sciences [38]. Design Practice gives an overview of the methodological [39,40],[41] and Research through Design form/matter approach. As illustrated in Fig. 2, we started [42,43] contribute greatly to this afore- with analysing the user context with focus mentioned quality. Evaluation is a central time groups. The data from the focus groups was component in conducting rigorous Design analyzed and used as input for Scrum [36] Science Research [44]. The DSR-approach

62 63 the fact that the lack of time and importance 2.2.2 User context: play research The iterative prototyping phase included attached to the matter are part of the prob- several informal evaluations with occupa- lem. Nurses and Caregivers however, do not A total of 10 nurses and caregivers were view. Since the persuasive character of the tional therapists, educational technologists descry a deficit of training of physical exam- involved during the development of the first game has an important instigating function and serious game designers. All the collect- ination skills, nor a deficiency in knowledge dome game. They were asked to play early in the hBCSS as a whole, ascertained on the ed suggestions and comments contributed of training in lifting and transfer techniques. versions of the game. Their feedback on immersive and engaging qualities of the to greatly improve the prototype, leading to All groups considered workload, pressure the design of the game, game play, players game had to be established. the serious game described in Section 3.1 in of time and a cultural determined need to perspective, auditory and visual feedback this paper. place patients well being above their own was gathered and led to adjustments of the as the main reason not to apply appropriate game. At the end of the iterative develop- 2.2.3 User and technology context: techniques when and where necessary. ment of the game, an immersion question- expert panel 2.3 Field study naire was administered to 6 representatives A preliminary prototype of Back Space was The in this study developed hBCSS proto- of the target audience, followed by an inter- reviewed by an expert panel in lifting and type, was evaluated at three different loca- transfer techniques. From the first iteration tions: hospital Medical Centre Leeuwarden, towards a playable prototype, one of the Fig. 3. Hevner’s [46] design science research cycles. elderly care centre Noorderbreedte and care experts on LTTs was on the design team to institute ZuidOostZorg. A total of 60 players make sure static LTTs were implemented were invited to play the game, all nursing correctly. Twelve healthcare practitioners professionals, caregivers and healthcare were video-recorded whilst playing the workers. Focus group results pointed out game, without a brief about the proposed that lack of time was prompted a factor goal of the game. The recorded movements influencing the ill-performed LTTs in daily of players were analysed and compared to routine. Therefore we had to make sure the benchmark movements of healthcare prac- game was played on the workplace within titioners. The authenticity and similarity working hours. Players themselves chose to real-life lifting behavior was confirmed suitable time slots over a working day to by the creators of the lifting thermometer. play. Participants were informed about their Their findings led to minor adjustments of dashboard results by email. Caregivers and the game to deal with players reaching ac- nurse practitioners enrolled in the study, 36 tivities that were a little too high and visual female and 1 male. The hBCSS was deployed orientation on the screen instead on a bed at three different organisations, of the 37 causing the head position to be too upright. players 14 were employed by Medical Cen- Movements were checked on authenticity of tre Leeuwarden, 17 by Noorderbreedte and the LTTs conform to bed adjacent activities. 64 65 3 by ZuidOostZorg. Six iLift play sets were 3.1.1 Gameplay distributed over six locations of three participating care institutes and hospitals. The game introduces a female character area results in three points, the yellow zone sary to play the game (Fig. 7). The game in- After an introduction on the usage and called Emily. Emily travels on a hoverboard, grants two points and a sheep from the red terface provides visual clues on how to apply purpose of the game, participants were floating inches above the ground (Fig. 4). Her zone leads to one point. Stepping sideways the correct technique to lift the barrel. The instructed to play multiple sessions of the journey starts in a pleasant mystery world, to get to sheep on the outer corners of more accurate this technique is executed, first dome game of iLift. Within a six week inviting her to discover how to operate her the grid is rewarded over spinal shear and the more water is preserved for Emily’s next period an individual logged-in player ide- board by trying to follow rural paths through torsional loads. Abrupt gestures will scare task: watering and growing extraterrestrial ally played 2 or 3 times a week, 3 rounds cosmic meadows. She will find herself in sheep and make them move backwards on fruits. Again from a first person perspective, per sessions. For procedural guidance and a dome-like world floating in space, with the grid, into the red zone, making them the water cannon is operated. Aiming at a substantive technical support members of bridges over creeks, gardens and a little harder to catch. With bending over, a gauge, garden below, Emily shoots water beams the research team and development team store (Fig. 5). Throughout the level she finds placed on the top left corner of the screen, to make seeds germinate. Concise shots were available. artifacts, worth some virtual money. In the mimics the actual bend angle of the player make the plants grow and eventually bear store Emily can exchange her findings for whilst reaching out for sheep. An auditory fruit. When ready, Emily can go to the garden upgrades and adjustments to her world, signal, which bears strong resemblance to a below and harvest her space fruit. Because 3 Design of prototype varying from waterfalls, alien trees, mush- car parking assist system, provides the play- the fruits grows on various heights on the rooms and other ornaments. She also finds er with feedback on the depth and length plants, again Emily is challenged to apply 3.1 Serious game design two long, winding roads leading out of the of the bow, made from the waist. The game befitting LTTs or use an assisting device dome. Each of these roads lead to a small- carefully registers the duration and angle of when needed. Operating the water cannon, The serious game is designed for reinforcing er dome, hosting a sub level of the game, the inclination of the upper body, respond- lifting the water barrel and harvesting fruit compliance, as a catalyst in a BCSS devel- in which Emily can earn extra credits for ing with corresponding feedback. Crossing all mimic meticulously actual dynamic LTTs. oped for behavioral change towards the sustaining her world. The first dome holds safety boundaries will result in a life loss The game mechanics scaffold the players in- execution of transfer and lifting techniques a game wherein Emily steps into a robot event. Each session grants the player three game behavior: dynamic LTTs are re-contex- in the workplace. The focus in this part suit, specialised in capturing space sheep. lives, but the game actively scaffolds the tualised and repurposed in a game context. of the study is on the design of the game In this smaller domes Emily’s perspective players behavior to avoid precarious situa- itself, with a special interest in maintaining changes to a first person view, showing both tions. Several real life issues regarding static the inherent entertaining capacities of the of her hands (Fig. 6). In order to catch sheep LTTs at the actual working by the bedside are 3.1.2 Used metaphors medium in order to meet BCSSs persuasive Emily has to reach out and apply dedicated metaphorical re-contextualised in this part Here the design of the game within the first demands. Here the main features of the moves to do so. The game provides visual of game, providing a playful reason to per- dome is discussed, since this part was the game are summarized, additional video and auditory feedback to guide the player form the desired techniques in a controlled main object of the field test. The serious material can be found in the supplementary into successful in-game behavior. The space and pleasurable fashion. In the second dome part in serious games was implemented by section. sheep appear randomly on a grid, divided in Emily has to lift a big water barrel to fuel a metaphorical re-contextualisation, support- three zones. Catching a sheep in the green water cannon. Here dynamic LTTs are neces- ed by theory on figural transfer (of learning).

66 67 The shape of the grid in first dome game 3.1.3 In-game score reminds of a bed, demarcated by fences as Fig. 4. Emily on her hoverboard visits the store. Fig. 5. Overview of back spaces customizable dome world. foot and headboard. The game score is comprised of the following formula: x0 = g3 + y2 + r . Catching a The three-colour area of play corresponds sheep in the green (g) area results in three with the theoretical benchmark of static points, sheep from the yellow (y) zone LTTs, all characteristics that are condition- grants two points and a sheep from the red al for mimicking the actual working along (r) area one point. Crossing the boundaries the bedside, showing high physical fidelity. for spinal shear and torsional load results Here the hBCSS is designed to reinforce in life loss and ends the game session after compliance, so the actuated and repeatedly the third loss. triggered physical in-game behavior needs to be meticulously accurate in comparison to desired real life performance. User group 3.2 Dashboard preferences are addressed in the actual A dedicated online dashboard presents and task itself: taking care of animals has kin- calculates an individual dashboard score ship with players daily routine in terms of by the use of the player’s game score, using care. Making abrupt gestures or reaching Fig. 6. Emily trying to catch space sheep. Fig. 7. Applying dynamic LTTs in the second dome world. input from an online database connected to too hastily for sheep scares them away, the back-end of the game (Fig. 8). Specific hinting at perceived patient’s discomfort data on player in-game behavior is ex- when being lifted and or transferred rashly. tracted from the game and stored in a local A life-loss event is triggered when in-game database as part of the back-end of the iLift limit-overstepping behavior takes place, set game configuration. The iLift dashboard off by a combination of a performed forward shows the player a corrected game score, bending angle and bending time. The spine entailing individual achievements and spe- of the robot represents the player’s back cific occurrences during game play. These and will show damage, debris and smoke key components are derived from existing after a life-loss. After three encroachments LTTs, and integrated in the iLift game. The the spine of the robot will be broken and the dashboard score can take on values from session ends. 0 to 100, where 100 equals exemplary in- game behavior, analogous to adequate LTTs and 0 refers to a destructive playing style. Pushing the limits may result in higher game

68 69 scores, but the dashboard formula corrects of 30% of the player’s game score, based for adverse strategies by deducting points. on Knibbe [32] a score between 0 and 12 In order to calculate dashboard score; (x1) s results in a deduction of 0 to 30% of the player’s game score (x0) gets corrected player’s game score. Each life lost event on four variables: bend time (b), number of results in a deduction of 15% of the player’s life loss events (l), the colors of the caught game score, with a maximum of 30%, a in one session. For yellow sheep applies a 3.3 eModule sheep (g,y,r) and the number of scared third life lost event ends the game session ratio of 3:5 on red sheep, only yellow sheep sheep (s). The bend time is the number of and results in a termination of the player’s caught in a game session would lead to a At the end of the message route the eMod- seconds that the player has exceeded the score. The number of picked up yellow and deduction of 18% of the player’s game ule is positioned for added system credi- safety boundaries. Exceeding the safety red sheep also leads to a correction of the score. In the formula the proportionally bility support and placing emphasis on the boundaries for 12 s or more during a game player’s game score, which can rise up to number of yellow and red sheep caught in importance of the need for new attitudes session results in a maximum deduction 30% deduction, if only red sheep are caught relation to the number green sheep caught towards LTTs (Fig. 9). This resonates with are calculated to get the appropriate cor- certain key issues behind persuasive sys-

Fig. 8. The Dashboard, as presented to players. rection. Finally, a correction is made on the tems, as postulated by Oinas-Kukkonen [6]. number of scared sheep. This correction is a The eModule offers a direct route of per- deduction of up to 10% on the players total suasion, next to the indirect route the game score at 8 scared sheep or more. A score be- facilitates. This part of the hBCSS also aims tween 0 and 8 leads to a correction of 0 to at unobtrusiveness: the eModule leaves no 10% deduction on the player’s game score. doubt on the intentions of the system as a whole. Only when the C-change (game) and B-change (dashboard) does not result in 3.2.1 Dashboard score observable improved in-game behavior the user will encounter the eModule. The dashboard score as is a corrected, non-standardized game score; The module holds information on several The deducting variables that determine the key topics regarding static LTTs. It covers dashboard score are: topics like: what is static lifting, when static b = bend time in seconds, 0 ≤ b ≤ 12, loads are overburdened, effects of spinal l = life loss in occurrences, 0 ≤ l ≤ 2, torsion and reaching on intervertebral discs, g = (green sheep caught), recognise symptoms of static load lifting y = (yellow sheep caught), problems in an early stage, guidelines on r = (red sheep caught), static LTTs, active knowledge on preventing s = (scared sheep in occurrences 0 ≤ s ≤ 8) lower back problems and understanding 70 71 to play the game multiple times during the per player and presents it to the player in an period of 3 weeks. As described in Sections online environment, which can be assessed Fig. 9. The iLift hBCSS eModule. 3.1.3 In-game score, 3.2.1 Dashboard score online by the player using the same account the game score and the dashboard score credentials used for logging in the game. differ in their respective composition and behavior change goals. The experimental design of the study is to compare and contrast 4.1.2 Apparatus the interaction between these two types of Back Space uses a Microsoft Kinect [50] game-scores. How is the game score, which gesture sensing input device to enable the can be high without inducing the desired player to control the game with body pos- lifting techniques, with the dashboard-score tures and gestures. The Kinect is connected which gets higher based on the correct lift- to a personal computer, running Windows 7. ing behaviors of the players. Every tenth of a second a plurality of gestures and movements are stored after every session in a relational database hosted on 4.1.1 Procedures the computer, providing immediate feedback Participants were asked to fill in their name on game play. Once a week all player ses- on a consent form and sketch to take place sions are sent via an online connection to in front of the play set. After a once-only the dashboard server. A 40 inch 1080p Sam- instruction on the workings of the game, the sung LE40 widescreen monitor is mounted participants logged in with upfront provid- on a movable carriage together with the ed account credentials, using a mouse and personal computer, the Kinect sensor and a keyboard. The participants used hand ges- audio set. Back Space was developed using tures to start the game. The game then was the Unity game engine, Microsoft Visual played for 3 min, 3 times in a row, for 2 or 3 c++. Modeling was done using Autodesk 3ds times a week. After each play session the Max. Participants viewed the display from a in-game score was shown and the player distance of approximately 2.5 m, dependable that spinal torsion in combination with bend 4 Evaluation of prototype angles form significant risks. The module logs out. Mostly the participants played in on the mounting angle of the Kinect. exists of cases, presentations, question- 4.1 Experimental design groups. The game gathered all biometric naires, illustrations, animations and tests. data per player per session and stored it in a In three different healthcare organisations, database. Each week the system sends the participants were asked to partake in the data of all players to the dashboard server. experiment by their local primus inter pares The dashboard server interprets the data 72 73 4.1.3 Measurements 4.2.2 Session-based analysis 36.20 ; SD = 12.52, p = 0.007). A LSD post-hoc 5.1 Using a game to reinforce test revealed that the 1-10 group scored compliance In-game-score (cf. 3.1.3) and dash- A linear regression was performed to ana- statistically significantly lower on the board-score (cf. 3.2.1) were used as lyse the predictive values of the amount of dashboard-score than the 11-20 (M = 24.05 Regression analysis, reported in Section main measures. session on game score and dashboard ; SD11.50, p = 0.044) and 20+ group (M = 4.2.2, shows that the number of sessions a score. Amount of sessions played sig- 30.15; SD = 11.17, p = 0.011). person plays the game is a significant pre- nificantly predicted the game score, b = dictor of higher game scores and dashboard .108t(618) = 23.87, p < .001. Amount of ses- 4.1.4 Data analysis 5 Discussion scores. For the design of the game this sions played also explained a significant means that the game succeeded in allowing SPSS 22.0 was used to perform a linear proportion of variance of the game score, The main focus of this study was to build regression analysis to analyze the growth and discover how and if a serious games players to engage and persist in playing the R2 = .178, F(1, 618) = 134.01, p < .001. Amount and predictive factors through the amount persuasive capacities can be used in a game for at least 54 sessions (maximum of sessions played also significantly pre- of sessions for both the game score and hBCSS for LTTs. In this section we first dis- sessions played). Important to the game dicted the dashboard score, b = .108t(618) = dashboard scores. A one-way ANOVA were cuss the results that indicate the persuasive artifact is that the repeatedly encouraged 11.053, p < .001. Amount of sessions played performed on both the dashboard score effects of the game. Second, we relate these in-game movements adequately mimic the also explained a significant proportion of and game score to compare the categorized effects to the specific design choices made actual LTTs performed in the workplace. variance of the dashboard score, R2 = .165, amount of sessions (1–10, 10–20, 21+). in the manufactured artifacts. Third, we dis- The expert panel validation described in F(1, 618) = 121.68, p < .001. cuss how implementation issues affected Section 2.2.3 affirmed that the first dome the uptake of the hBCSS in the organisation. game accurately captures the static LTTs. 4.2 Results Games for health are often placed in skills- This makes in-game activities genuine static 4.2.3 Group-based comparison LTTs. Therefore, the increase of game scores 4.2.1 Game and dashboard scores labs, away from the influence of daily work The participants were divided into 3 ses- routines. This project offers an opportunity results in the desired increase in training The 37 participants played the game in a sion-based clustered groups based on the to the field of nurse practitioners in the way outcome: progression in the game can only range between 3 and 54 sessions, scoring amount of game sessions (1-10 session(n = that feedback and clear goals are presented be achieved with complying to desired between 0 and 229 points (M = 75.9, SD = 16), 11-20(n = 10) session and 20+ (n = 11)). to them in real time, giving rich feedback behavior. Although we involved the end-us- 35.16) on the game score, between 0–144 (M There was a significant main effect found that otherwise is presented in a less engag- ers throughout the design process holding = 52.22, SD = 11.34) on the dashboard score. between these groups on the in-game ing and immersive form. roles as testers, users and informants, the A total of 620 play sessions were performed score (F(2, 34) = 4.77, p = .015)) and Dash- autogenous intent of the game alone might by 37 players. board Score (F(2, 34) = 4.26, p = .022). A LSD not be enough to become a part of day-to- post-hoc test revealed that the 1-10 group day routine. This may imply that current scored statistically significantly lower on practices of LTTs can not be changed by per- the game score than the 11-20 (M = 27.59 suasion that focuses on LTTs themselves, ; SD = 12.49, p = 0.04) and 20+ group (M = but that persuasion should target the culture of neglecting one’s own well being. 74 75 5.2 Changing behavior with a 6 Limitations dashboard As focus groups made clear in preliminary tool for learning was foreign to the target studies, other factors than a lack of knowl- audience, and therefore not easily accepted. The scores on the weighted dashboard this study can not claim that the registered edge were causes of leniency in performing The fact that the game ostensibly dealt with scale are indicators of conscience in-game behavioral changes can solely be addressed desired LTTs in daily work routines. Circum- LTTs was not recognized by some players static LTTs related behavior. A positive to users consulting the dashboard, since stantial aspects like workload, time-pres- and undermined the will to participate in effect in dashboard scores points out de- empirical basis is limited and a more rigor- sure and cultural habits are also primary the field test. A final assignable cause of creasing score deduction by key indicators ous research design is needed to make such causes. Those outcomes befitted the iLifts subject dropout was due to an outbreak of of unwanted in-game behavior, meaning in- claims. project goals and led to forthcoming design the highly contagious Norovirus, causing game behavior evolves towards benchmark choices, including the inclination towards severe delay in available playing time during performance. In Section 4.2.2 we compared a serious game as a possible solution. One the six week field test period in one of the the game score and the dashboard score set 5.3 Forming attitudes with an could argue that the persuasive design participating nursing homes. Although re- against the number of play sessions. Play- eModule elements were developed in full concerta- quested upfront, in two cases the appointed ers with less than 10 sessions, scored sig- tion with end users and LTTs professionals. locations for playing the game were not nificantly lower on the dashboard compared Aforementioned statistical data affirms On the other hand, the question whether equipped with an internet connection, caus- to the game score. This indicates that early the games capacity to act out as a tool for care professionals in general were willing ing the game not to work. After developing play sessions triggered more incorrect LTTs training with behavior shaping qualities. The to engage in game-based-learning, was the prototype the briefing and introduction behavior, causing score deduction. From 10 dashboard score proves a valid indicator of not addressed: the project dictated a game of the game was given by the development session and up, the dashboard score aligned behavioral change and monitors the sound- should fill the design gap. This may have team. The implementation and deployment with the game scores as they got higher, ness of the way growth in game scores is caused an underrepresentation of care of the hBCSS was executed by the involved meaning that the game scores are achieved achieved. We found during this study that professionals with a more sceptical attitude care homes and hospitals. In retrospect, we within set boundaries. The scaffolding an A-change might be the intent needed to towards the project, although there are noticed that the recruitment of participants mechanisms of the game and the behavioral have impact on the daily working routines. studies that report opposite findings [17]. and the deployment during the test period influence of the dashboard feedback led to Existing methods for learning and training A weakness in the research approach was of the hBCSS in the use context did not meet the alignment of both score types, making LTTs did not lead to such an effect and it is that the employees enrolled in the field test the BCSSs demand that persuasion cannot the dashboard score an embedded assess- it unlikely that the eModule alone, as posi- were not properly instructed concerning be coercive. Where participation should be ment of game behavior. The LSD post-hoc tioned within the iLift architecture, will be the aim of the game. Here the 5th postulate an action of one’s own volition, users were test revealed changed behavior to achieve able to do so. Due to project limitations the [8] that states that persuasive systems assigned by the organisations, limiting user better in-game performance. Although influence of the eModule on the formation of should always be open might be of influ- autonomy [14,51,52]. Rather divergent from presented research data seems promising, new attitudes were not covered in this study. ence: unintentionally we did not reveal the daily routines, employees were instructed designer bias behind the game of the hBCSS. to play the game during working hours. The use of a game within the hBCSS as a Earlier mentioned cultural aspects made

76 77 it for some participants hard to accept Author contributions that time spent playing a game might disadvantage clients and patients. For a full 7 Conclusion 8 Recommendations and DK and BD conceived and obtained funding understanding of the capacity of the iLift for the research project that includes the In this study we developed a serious game future work hBCSS, the design should be evaluated and described study. BD designed the prelimi- for LTTs. We sought after designing the incrementally developed towards social One of the observations of this study is nary trails, handled recruitment of partic- game in conjunction with the design prin- system acceptance and a shared mental that care professionals foster the culture ipants and contributed to the organisation ciples of persuasive system design and understanding of the chosen approach. of prioritizing patients’ health and comfort of the study. DK contributed to the design deploying its inherent autogenous char- It is an open question to what extend the and in the process tending to neglect one’s of the game artifact. BD and GT build the acter. We succeeded in developing a game findings of our study can be generalized to own well-being. This implies that current dashboard formula. BW and GT analysed the that persuades end-users in complying to similar contexts, mainly because the field practices of transfer and lifting cannot be data. DK and BW drafted the manuscript, JV, the game’s rules and were able to influence test results were never translated into new changed by persuasion that merely fo HD, JP and JPP contributed to its revision. behaviors towards better LTTs. By using design parameters because of limited proj- cuses on the practices themselves. The iLift metaphorical re-contextualisation we ect resources. A final remark has to be made hBCSS showed promising results in utilizing developed a serious game that was persua- about the reach of this study. The evaluative C-change and B-change, but the field test Conflict of interest sive and enjoyable to play whilst preserving elements as described, deal with measuring revealed a necessity for A-change. To make serious intent. This design principle seems No author has conflicts of interest. the effects of the iterations. The field test claims about effects of the iLift domain-independent and can be applied has to be seen as a first iteration with the hBCSS, our next step in the research will in other contexts outside healthcare. We hBCSS in the social context. In Section 7 we be evaluating the system in full with nurse found that in healthcare using a game as Summary points draw several conclusions from this field practitioner students, leaving out the social persuader in a hBCSS can be effective, but test, but we also learned that the design of system barriers as described. We found an What is already known only then when the designer bias is made the hBCSS itself as well as the social system in-game learning effect, but there are still clear upfront. Furthermore, we conclude 1. Existing lifting and transfer techniques are in need of further development. In this some significant issues to overcome for this that when designing a persuasive system (LTTs) training programs appear to be stage of the process it is too soon to make hBCSS intervention to have a bigger impact. for healthcare, cultural aspects (the use ineffective since 70% of caregivers and statements concerning the effectiveness Future work will include a new experiment context) form a rigorous influence that has nursing professionals report lower back of the system as a whole or the long-term amongst nursing practitioner students with problems. to be reckoned with, especially in regard to effects of this intervention. the game and dashboard, with the sole pur- 2. Video games harvest systemic and mo- technology acceptance. pose of measuring adapted behaviors tivational affordances that encompass outside the hBCSS environment. persuasive elements closely related to design principles for BCSS design. 3. In health studies, the actual workings of BCSSs as well as serious games are often regarded as black boxes.

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82 83 H5: Mobile Adaptive Therapeutic Tool In psycho-Education (M.A.T.T.I.E.).

Design principles for a persuasive application tailor-made for adolescents with a mild intellectual disability

Published: Wartena BO, Kuipers DA, Drost J, van‘t Veer J. Mobile Adaptive Therapeutic Tool In psycho-Education (MATTIE). Design principles for a persuasive application tailor-made for adolescents with a mild intellectual disability. Proceedings of ISAGA 2013. 2013. Valiant Hearts: The Great War (2014)

Valiant Hearts: The Great War is the story of 4 crossed destinies and a broken love in a world torn apart. Dive into a 2D animated comic book adventure, mixing exploration, action and puzzles. Lost in the middle of the trenches, play as each of the 4 strangers, relive the War and help a young German. Image: © Ubisoft Entertainment, All Rights Reserved.

84 85 Abstract Keywords to social dilemmas; Adjustment, Limit-over- In studying existing psycho-educational stepping, Bargaining, and Withdrawal. In a material the appearance of the materials This paper introduces the conceptualization Mobile-assisted Learning; Mild Intellectual social conflict, adolescents with MID show a do not differ from conventional methods in and development of an assistive technology Disability; Psycho-Education; Parasocial bias towards using the full range of regular education and therefore the effect focussing on social problem-solving skills, interaction, Persuasive Technology; Social response patterns resulting in the prev- can presumably largely be attributed to the as an addition to the field of psycho-educa- adjustment; Self-efficacy; Social Innovation; alence of the choice for either limit-over- skills of the person conveying that message, tion. This assistive technology in the form of Transfer stepping or withdrawal. Problems in social rather than the material itself. The form an application goes by the name of MATTIE, adjustment are further exasperated by in which psychoeducation currently takes Dutch slang for ‘friend’ and an abbreviation difficulty in generalizing learned skills and place also seem to deviate from the six key for Mobile Adaptive Therapeutic Tool In concepts [12] problems with theory of mind principles found by De Wit et al. [12] leading psycho-Education. MATTIE was tailor-made Background and befitting for adolescents with a mild in- or perspective taking [13,14,15,16], i.e. the to a successful intervention for the target tellectual disability and their therapists. The In the Netherlands, a Mild Intellectual Dis- ability to see the world through the eyes of audience; application introduces a simulated facetime ability (MID) is defined as an IQ between 50 someone else. These limited social cognitive call by an actor that is in a social predic- and 85 and limitations in social adaptability skills combined with a multitude of social 1. Extensive assessment ament wherein social decision-making is [1]. One of the main differences between contexts, lead to a contextual problem, i.e., 2. Adapt to their level of communication warranted. The patient is asked to advise these adolescents with the general pop- using the social decision making that fits the in the presented dilemma, making a deci- ulation is the way in which they encode specific social context or situation. 3. Make the practice or exercise material sion and is afterward confronted with the and process social situations; i.e. social concrete outcome. Important design choices in the information processing [2]. The limitations The current form of therapy that amongst 4. Structure and simplify workings of the application are the choice of within the social information-processing other subjects encompasses this is psy- actors alike the target audience enhancing manifest in low inhibition and sensitivity cho-education. Bäuml and Pitschel-Walz 5. Social network and generalization of the parasocial interaction, the presenta- as well as vulnerability towards portraying defined psycho-education as ‘systematic, skills tion of cases outside of the therapeutic anti-social behavior [3]. Several studies structured, didactic information on the 6. Create a safe and positive learning setting, empowerment, and self-efficacy [4,5,6,7,8] suggest that behavioral problems illness and its treatment, including integrat- of the patient through role reversal and an environment of adolescents with average intelligence ing emotional aspects in order to enable answering system befitting the information are related to their social problem-solv- processing of the target audience. Further- patients – as well as family members – to ing skills. Furthermore, adolescents with The specific needs of adolescents with MID more, it gives therapists the opportunity to cope with the illness’, in this case, MID [17]. have valuable input for their sessions and learning problems display a shortage in The effect of psycho-education on the pop- legislates reaching out for alternate ap- an adaptive system that gives them the alternative solutions to social problems ulation with MID is relatively unknown [12] proaches, especially on the terrain of appear- control over the cases that are presented to [9]. This is confirmed through the attitudes mixed effects were found [18,19]. ance and transfer. The role of the therapists the patient, thus picking the content befit- towards social limits [10,11] of adolescents and the way and form psycho-educational ting the specific needs of the patient. with a Mild Intellectual Disability. The social content is brought across largely deter- limits are defined as four response patterns mines the way in which it will be perceived.

86 87 To fully utilize the strengths of the patient from the therapeutic setting by the thera- Figure 1: Schematic overview of the procedural application flow of MATTIE. as well as the therapist, serious media can pist, gives control over the timing and the play an instrumental role and transform the content of the video cases presented to healthcare setting through social innovation. the patient, giving the therapist access to This paper presents the design process of the patients decision making outside the an application, designed to aid the resolve therapeutic setting. The therapist is able to conflicts in social situations experienced to prompt a case with specific content on a by adolescents with a Mild Intellectual Dis- desired moment in time to the mobile device ability, from this point on referred to as the via MATTIE to the patient. Cases can be se- patient, and the remediation of their social lected by theme or optional social response adaptability by their therapists. patterns. Carefully selected and well-timed cases form a psycho-educational stimulus, The Mobile Adaptive Therapeutic Tool In triggers self-awareness, places relevant psycho-Education (MATTIE) is a mobile ap- topics top-of-mind and create a precedent plication hosting videos with short, realistic for transfer to take place. This makes MAT- cases with topics familiar to adolescents, TIE a powerful instrument to intervene in dealing with social situations which require place and time in the real-world context of social problem-solving skills. These social the patient. situations are recontextualized in separate cases, presented as facetime calls. Each As a starting point, the functional triad [20] video is played out by an actor with strong was used in thinking about the use and similarity to the patients. After presenting a application of persuasive technology. Per- social dilemma, two possible solutions are suasive technology is defined as technology suggested by the avatar. These options are that is designed to change attitudes or be- two out of four optional response patterns haviors of the users through persuasion and certain behavior, e.g., by offering structure language, assumption of established social to social dilemmas [10,11]. To strengthen social influence. Fogg [21] mentioned three or guidance in decision-making. Functioning roles or even physical presence. and reinforce the social adaptability of the layers of persuasive principles that can as media, interactive technologies can use patient; a) the application gives feedback be embedded in interactive technologies: both interactivity and narrative to create Because MATTIE is an application that was on the outcome of the decision made for tools, medium and social actors. They form persuasive experiences that support re- tailor-made for the target audience and the virtual character and; b) the therapist a functional triad in media technology, each hearsing a behavior, empathizing or explor- their therapists, design choices based on reiterates the decision making process and or all-together triggering basic ways that ing causal relationships. Finally, interactive several theoretical constructs were made. the motivations behind it at a later time. people respond to computing technologies. technologies can function as a social actor, A back-end database system, operated As a tool, media can make it easier to realize cueing social responses through their use of

88 89 Design Choice 1: Design Choice 2: Design Choice 3: in self-representation, without any “real” consequences. The video call shows a boy or Design for Transfer Creating Parasocial Empowerment & a girl of similar age, background and social status, with whom the patient identifies Traditionally, transfer of learning [22,23] Interaction Self-efficacy through Role and who is likely to influence the person’s is often defined as applying what one has The form and way in which a message is Reversal beliefs and behavior. Every presented case learned in one situation to another situ- presented largely determine the way in sketches a realistic dilemma, always ending ation. Unusual and unwanted disruptive Since MATTIE enters the realm of the pa- which it will be perceived. In case of a par- with this one, same question: what would behavior in terms of choices, aptitudes or tient; some precaution has to be taken into ticular target audience, the form should also you do? interests, often occurs away from the thera- account. One of the most important factors amend to the specific social information peutic environment. Thinking about transfer is the establishment of the aforemen- processing of people with MID. An important issues, the ideas on influencing the patient tioned PSI. As a token of respect and being issue in the design of MATTIE was to ensure in a real-world setting seems promising. deliberately modest about the influence and optimize parasocial interaction [25]; the Design Choice 4: Using modern mobile technology makes it MATTIE claims to have in the non-thera- social interaction and potential for bonding possible to position the psycho-educational peutic setting, a non-directive and casual Feedback and Remediation between media user (patient) and media content from the therapeutic setting into delivery system is needed. To make the figure (virtual character). By introducing When the patient makes a choice in as- the real world, placing it right there where mobile intervention valuable and authentic video cases, showing non-abstract, real sistance to the media figure on film, it is you want it to come into effect. Regard- at the same time, the patient is hailed for characters in a way an actual facetime call deemed important that the potential con- ing the mental capabilities of the patient help, instead of telling the patient what to would appear on a mobile device, abstrac- sequences of that advice are revealed. Case a low-road transfer [24] variance is in do or not to do in specific situations. This is tions that would forego the mental capabil- development feedback is presented in a place. One of the key issues in learning is a role reversal from the established order ities of the adolescents with MID are avert- short video fragment, simulating the out- the difficulty the patient encounters when in the therapeutic environment where the ed. Thereby MATTIE is able to avoid any hint come of the case-bound advice followed by being in complex social situations involv- patient is the advisee instead of the adviser. of a psycho-educational instrument, insti- the avatar. Depending on the case, feedback ing decision-making and applies lessons This naturally empowers the patient, plac- gating parasocial interaction (PSI). Providing appears realistically timed within minutes learned from an earlier context into a new ing emphasis on the value of the patients’ an indubitable relation between the MID and or even hours after the advice given. Con- one. We try to bridge this transfer problem capabilities and trust in one’s competence MATTIE maximizes authentic and uninhibit- fronting the patient with consequences of by instigating a near transfer approach by to give just advice. This empowerment will ed responding. Finally, trustingly providing the advice provides a natural and value-free design, whereby it’s crucial to be spot on hypothetically influence the belief of the the adolescents with a modern mobile stimulus for rethinking the case and the regarding tone of voice, design, and content patient in his or her own ability to succeed device generates an easy commitment. patients’ role herein. In the real-world since the intervention takes place in their in specific situations, enhancing the pa- context the patient experiences control over world. Authenticity and realism seem key in tients’ self-efficacy [26]. Furthermore, the situations, freedom in social decision-mak- this interaction, so a strong focus on design role reversal naturally forces perspective ing, wherein the therapeutic context offers seems just. Design choices have to be made taking and leaves room for experimentation a safe environment for evaluating outcomes carefully and be serving to transfer. 90 91 with therapists. By remediating the pro- cases in the real world context inoculating ent ways, the patients mentioned an active designed to foster transfer, PSI as well as cessed social decisions, retrieving details on response patterns that deviate from the engagement with the presented dilemmas enhance self-efficacy and empowerment the context they were made in and seeking social desirable answers given in the safe and a curiosity about the well-being and through role reversal and experimentation after social cues to increase self-efficacy of and structured therapeutic environment. outcome of the cases. One patient spoke in self-representation. The result was a the patient, the therapist can use MATTIE as This gives therapists the opportunity to go about amity towards the avatar. The test product that is a serious therapeutic; i.e. an effective therapeutic tool, offering new beyond the given response patterns and group seemed without exception positive an application that operates on a trade-off leads for psycho-education. use the situation the patient was in whilst about carrying the mobile device, know- between control of parameters by the ther- ingly a simulated call could emerge. Three apist whilst acting as an assistive aid for the he or she was responding in the therapeutic mentions were made about a sensation of patient. Preliminary results are promising session. Prompting cases in the real-world restlessness when waiting for a new case to but further research is needed. context thereby provides therapist useful Design Choice 5: be prompted. insights in the social response patterns Use of MATTIE outside of the outside of the therapeutic setting. The therapists were clear in their findings: Future Work Therapeutic setting MATTIE bridges a gap between the patients’ world and the therapeutic environment. In Novelty provides the initial motivation for Though a person’s cognitive limitations Preliminary Results particular, the willingness of their patients the target group to engage with MATTIE. have a large part in decision making, the to talk about the presented cases and the Since they use the mobile tool in their own environment wherein a person is when A small trial was conducted with the proto- effects of given advice stood out. The real time and space, it’s important to think about making a decision also influences the deci- type of the application. The patients (n=8) value was found in the acquired leverage to therapy adherence and establishing a sus- sion making, i.e. bounded rationality [27,28]. were given a mobile device (iPod) with the make personal topics discussable through tainable parasocial relationship. Gamifica- The therapeutic setting is a structured, MATTIE application readily installed. Each the video cases. tion uses the engaging elements of game- relatively safe, environment wherein the of them signed a waiver, promising to take play, renown for its strong motivational patient is free from the temptations of the care of the mobile device, solely use it for characteristics. outside world. The outside world is often; a) MATTIE and returning it after a week. Up- Discussion front the therapists (n=5) supported by the unstructured, because relatives often have With the heretofore-mentioned character- To bridge the novelty effect and create development team, programmed the cases the same mild intellectual disability and; istics of the target audience in mind, a series acceptance into by the healthcare sector, using the back-end database system, ad- b) unsafe, because peers can easily coerce of desirable specifications for the multi- rigorous testing will have to take place. the patient to display antisocial behavior. justed to the patient’s agenda for a week. media application was put together, based After a week non-directive interviews were In order to establish the application as an This disconnect between the therapeutic on the current state of the literature on conducted with the patients and the ther- evidence-based intervention, within the environment and the outside world leads to mild intellectual disability and educational apists. From both parties, the first findings psycho-educational curriculum, further social desirable answers in the therapeutic technology. Persuasive design was used to were promising at least. The patients were attempt to create an intervention that is tai- research on the applications influence on setting that are not necessarily a reflection sorry to hand in the device in the first place. lor-made assistive technology for the target self-efficacy, PSI and attitudes towards of the behavior in the real-world context. More important was the collective notion of audience as well as an adaptive therapeutic social limits will have to take place. Therefore MATTIE prompts and presents its experienced bonding to the avatar. In differ- tool for the therapist. The application was 92 93 References

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94 95 H6: Maximizing Authentic Learning and Real-world Problem Solving in Health Curricula through Psychological Fidelity in a Game-like intervention: Development, Feasibility and Pilot Studies

Published: Kuipers DA, Terlouw G, Wartena BO, Prins JT, Pierie JP. Maximizing Authentic Learning and Real-World Problem-solving in Health Curricula Through Psychological Fidelity in a Game-Like Intervention: Development, Feasibility, and Pilot Studies. Medical Science Educator. 2018:1-0.

NieR:Automata (2017)

NieR: Automata tells the story of androids 2B, 9S and A2 and their battle to reclaim the machine-driven dystopia overrun by powerful machines.

96 97 Abstract Keywords it is necessary to create space for experi- how these choices shaped the artifact. Here, menting with different forms of games and the simulator itself is also briefly described. High fidelity is regarded as a hallmark of ed- Serious games; health education; fidelity; simulations. In particular, when it comes to Finally, in the solution space, we discuss the ucational games and simulations for health simulation; learning innovation fidelity, there seems to be limited scope as preliminary results obtained from the first education. Primarily physical and functional to the appearance of game-like interven- assessments. fidelity are associated with authenticity, tions. Studies on game-like interventions resulting in the pursuit of a real-to-life for medical education do not investigate simulation and suggesting the imposition 1 Introduction 1.1 Problem Space the specific design choices made and rarely of a generally accepted and often uncon- Growing interest in game-like interventions provide design principles used to create the The field of health innovation education scious design rationale that assumes that to educate and train health professionals is intervention. The consensus is that games encompasses socio-technological issues, the greater fidelity of a game or simulation apparent from the number of serious games including technology acceptance [6], us- to the real world, the more authentic the for health education should aim to achieve a and simulations that are used in medical er-centeredness [7] and a learners’ mindset intervention is perceived. true-to-life, high fidelity representation [5]. education [1]. In the literature, many studies towards design science research [8]. At- Psychological fidelity receives significant- have evaluated game-like interventions In the following chapters, we will describe: titudes and mindsets are important com- ly less attention, although it is correlated developed and used explicitly for health 1) the reasons for the exploration of a ponents of this competencies, especially strongly to credibility, suspension of disbe- education and training. However, the use low-fidelity simulator, 2) the way in which within health innovation curricula and in so- lief, and engagement. The BABLR simulator of games in medical education is relatively the design research process was carried called 21st-century skills [9,10] on a broader reduces physical and functional fidelity to new, and the full potential of serious game out, and 3) the first results obtained with scale. In traditional health curricula, these a minimum and explores the use of psy- applications in medical education should the simulator. Terminology originating from tacit elements of competencies are hard to chological fidelity as the main carrier of be explored further [2]. Similar to the de- disciplines other than medicine will be brief- teach, train and measure in concrete, literal an authentic learning experience. BABLR velopment of pharmaceutical therapies, ly explained. BABLR, the name of the simu- form [11]. was assessed using 26 participants with serious games are held to the same rigorous lator, is not an abbreviation, but a corrupted varying backgrounds in health innovation scientific standards as those in randomized Dutch word that shares common ground It might be useful to elaborate briefly on the and social work. In several pilot studies, trials [3], but the design rationale of serious with English terms such as chatterbox reason why design research is needed in we collected data on perceived realistic- games or game-like interventions are rarely or babbler. This name seems appropriate health. Current health curricula teach natu- ness and real-world relevance. Results explored [4]. In regards to the development ral or analytical sciences that are appropri- show that experts, as well as participants, because the simulator provides text-based of therapeutic drugs or medical procedures, ate for the study of inductive and deductive acknowledge BABLR for its engagement, scenarios, focused on communication. The immersiveness, and motivational qualities. the quest for efficacy is necessary and term artifact, as used in this article, refers phenomena, with a focus on reconstruction Practical implications of these findings for justified. Without diminishing the impor- to the simulator in the prototypical phase. the past [12], in other words: studying what future research into developing low-fidelity tance of effect studies, in the case of de- already exists. On the other hand, design simulations with high psychological fidelity signing game-like interventions for health We describe supporting theories in the research focuses on shaping the future will be discussed. education, it is too early to state whether problem space, in the design space, we ex- by addressing so-called wicked problems, specific approaches do or do not work. Thus, amine the formulation of design choices and that require creative and innovative solu-

98 99 tions [13]. To deal with these wicked design to authentic and ill-defined activities with Fidelity is believed to be of importance in to a minimum and using psychological issues, health curricula should, therefore, real-world relevance [23] connects prob- terms of relevance for learning and trans- fidelity as the main carrier of an authentic teach forms of abductive reasoning [14]. lem-based-learning principles to design fer [28], denoting the degree of similarity learning experience. The literature describes the application of research. The goal of the BABLR simulator is between the training situation and the abductive research methods imperative to to offer (as low-fidelity as possible) authen- operational situation, which is simulated 1.3 Supporting Theories deal with unstable requirements and con- tic scenarios, in which students solve [29]. According to Alexander [30], fidelity straints, to be flexible in case of unforeseen wicked design problems. In this sense, has dimensions beyond the visual design A first supporting theory (ST) that informs interactions among problem and suggested BABLR is a training tool for using, training of a game. Notions of simulation fidelity the design of the artifact is that of solution, and a dependency on creativity and explicating the tacit elements of a de- include physical, functional and psycho- double-loop learning [32]. In short, the and teamwork [15], all properties that do signer’s mindset. logical fidelity [31]. Physical fidelity is the concept of double-loop learning demands not have an explicit place in health edu- fidelity of the simulated physical elements for tacit knowledge to become explicit. cation. Therefore, health curricula should in a simulated representation, e.g., virtual Initial actions of players arise from their emphasize a designer’s mindset amongst 1.2 Design Principles intestines that resemble those in a real body mental models with regard to how to act in presented situations. Double loop learning students and equip them with skills such as The reason for labeling the BABLR simula- in a laparoscopic surgery simulator. ‐ occurs when an error is detected and cor- prototyping, concept visualization and new tor as a low-fidelity game-like intervention rected in ways that involve the modification strategies to engage problems as design stems from the ideas on design for transfer The same goes for functional fidelity: how of one’s underlying norms, beliefs, and opportunities for innovation [16]. [24] and zero-fidelity [25]. The elaboration are the functions from the source environ- objectives, rather than just adapting to the of these principles goes beyond the scope of ment translated into a virtual environment? situation. A possible starting point to make the above this article, but the main idea is that where A simulation of a rat should react identically possible can be found in the problem-based realisticness is concerned with the degree as a laboratory animal to interventions from Further substantiation is found in the nar- learning paradigm, well known and adopt- of similarity with the real world, realism can outside. Both types of fidelity are about the rative transportation theory [33]. Narrative ed in the current health education system be seen as perceived realisticness. Rele- realisticness of simulated reality. Psycho- transportation occurs whenever the player [17–20]. Problem-based-learning in health vant in this respect is that realism can be logical fidelity, however, can be seen as the experiences a feeling of entering a world curricula produces the “desired habits perceived as long as the player experiences degree of similarity between the mental evoked by the narrative because of empathy of mind, behavior, and action to become coherence in the design of the simulator, experience in a simulator and the simulated for the story characters and imagination competent, caring, and ethical health care and forgets that a simulator is being played reality. Does a simulation evoke the desired of the story plot [34]. This theory actually professionals” [21]. Defined as “learning on [26]. The latter is called suspension of degree of stress or urgency, are the experi- shows that suspension of disbelief can be that results from the process of working disbelief [27] and is the desired working enced feelings of pain, inability or joy true to achieved by means of a strong narrative, or toward the understanding or resolution of ingredient for the performance of the simu- reality? scenario. This offers possibilities for the in- a problem” [20,22], it forms a match with lator itself. In research, to some extent, the tended low-fidelity character of the BABLR what we are expecting to achieve with the degree of realism is held to be conditional This theoretical starting point forms the ba- simulator. Narrative transportation is held BABLR simulator. Exposing health students for transfer to occur. sis for the exploration of the BABLR simula- to be more unintentionally affective than tor, reducing physical and functional fidelity intentionally cognitive in nature. To enable 100 101 double-loop learning (tapping into and mon reason to choose low fidelity over high the second class of transfer is not explicitly focus on the substantiation and justification explicate tacit knowledge), the design of the fidelity. Where we found low fidelity as a stated in those studies, they do utilize sec- of design choices. The research and devel- BABLR artifact must, therefore, implement conscious basis for the design, the objective ond class transfer in serious game design. opment of the BABLR artifact are structured dedicated feedback loops that facilitate always was the reduction of cognitive load The above provides sufficient support to around spaces laid out in the layers in seri- reflection-in-action [35]. These built-in [40] or the assumption that reduced fidel- assume that when it comes to acquiring ous media design model (LiSMD), depicted in feedback loops must be an integral part ity is most suitable for learning motor and attitude and mindset aspects of health the left side of Figure 1. The term artifact re- of the experience, to avoid disturbing the spatial skills. One study coined the concept curricula competences, this can be achieved fers to the prototype of the simulator in this experienced realisticness of the simulation. of zero fidelity in a game without concrete by a simulator specifically designed to specific phase. Common to design research elements of the simulated environment [25] achieve its goals by means of second class practice, the prototypical instance of the In early simulations, psychological fidelity and is consequently almost the only study of transfer. artifact itself is regarded as an emergent was considered as a byproduct of high fi- of a game-like artifact where a substantive boundary object [47], endeavoring towards delity [36]. This way of thinking implies that reason is put forward in favor of the use of a befitting answer to the problem-solution low fidelity does not have any psychological low fidelity. 1.4 Working Theory binary. The artifact is placed, as it were, be- value, although there are also studies that The working theory is the above theories tween the problem situation and the desired argue for low fidelity simulations, provided There are certainly examples of research captured in one design hypothesis, bridging situation to see if and in which form it can that they maintain a direct connection with into game-like artifacts that deliberately the problem space with the design space be a solution. This process of appropriation real-world tasks [37]. In research, to some bring physical and functional fidelity back (see the left side of Figure 1), laying out the is facilitated by a design research frame- extent, the degree of realism is held to be to the minimum, especially in the field of contours of the first version of the artifact. work as shown on the right half of Figure 1. conditional for transfer to occur. employee selection [41]. As mentioned The design hypothesis here states that the The literature describes the difference earlier, Psychological fidelity is an import- artifact to be designed should contribute to between first class transfer types and ant design parameter in serious games and the acquisition and explicitation of attitudes 2.1 Design Space simulations [25]; [42–45]. In addition, these second class transfer types. The first class and mindsets belonging to a new genera- Within the design space, we adopted a studies all claim that representing the real consists of transfer types that advocate a tion of innovative health professionals. The design science research approach [13] for world as literal as possible is less important literal method of transfer. The second class artifact can achieve this with a low fidelity articulating the design choices for building for learning. The definition of psychological contains figural, sometimes more difficult simulation game, which with minimal means the BABLR artifact. This framework [48] fidelity in this studies varies slightly, e.g. to explain, forms of transfer. Our previous evokes a lifelike world, in where the players is adapted from the rapid prototyping ISD cognitive fidelity [46], but all studies men- research [38] on second class of transfer are enticed to perform meaningful actions. model [49] and facilitates the development tion the abstraction of certain real-world [39] types showed that low fidelity is rarely of the BABLR artifact through an itera- concepts and a process of recontextualiza- consciously applied as a design rationale for tive-incremental process. The focus of the tion. Suspension of disbelief as an import- the development of game-like interventions iterations shifted during the process along ant characteristic of psychological fidelity: 2 Methods for health education and is usually asso- to non-linear design steps [50], including oneself’s temporarily allowance to believe ciated with physical or functional fidelity This chapter describes the way in which ideation, prototype development, and pro- in something that is not true-to-life. Despite alone. Cost saving is by far the most com- design research is applied, with the main totype testing. The first step involved the 102 103 Figure 1: Layers in serious media design (LiSMD) & Design Research Framework.

Eect

SOLUTION SPACE Evidence based Practice Pattern of Use

Intervention

artefact (α) artefact (β) artefact v.1.0 Artefact Assess needs, analyze content & context Set Objectives DESIGN SPACE Construct prototypes (design) Design Research Utilize prototypes (research) (DC) Design Social system development Choices design gap Working Theory (WT)

Supporting Theories (ST) PROBLEM SPACE Practice based Evidence

Design Principles (DP)

104 105 development of the LiSMD-model (left side that there was a lot going on within the com- Pilot 1 In addition to acquiring early indicators of of Figure 1). The initial version of the model munication agency. The aim of this scenario success of the overall functioning of the was constructed through a synthesis of A first 8 day-pilot in which 6 students par- was to find and interpret the communication scenarios (perceived realisticness, expected various concepts and best practices, aligned ticipated from the bachelor of social work, problems, and then successfully use a com- learning effects, and engagement), each with the main findings from DPs and STs as all attending an eSocialwork specialization munication model to guide the situation in session gave the designers of BABLR insight mentioned in Sections 1.2 and 1.3. course. Afterward, all participants were the right direction. During a joint debrief, the into how to improve the artifact itself. The invited to partake in an evaluation session. experiences were discussed and shared. low-fidelity character of the simulator is A questionnaire was used to ask the players 2.2 Procedure and Participants characterized by the fact that BABLR’s front about the perceived realisticness of the end is actually nothing more than the re- Expert Panel scenarios, the expected learning effect, and Pilot 3 spondent’s mail client. Most of the changes engagement. Conditional for participating in Five field experts were selected on the basis During the third pilot project, 9 social work are done to the back-end of the prototype, the evaluation was a minimum of 2 interac- of a variety of expertise, such as specific professionals played a dedicated BABLR not visible to the players. In particular, the tions every 24 hours. All participants were knowledge about the practice of health scenario for 4 weeks. These profession- manageability of the various storylines in rewarded with a cinema voucher. In addition and social work, knowledge about serious als were employees of the Tinten Welfare which individual players can find them- to the participants’ gaming experience, the games and simulations or knowledge about Group, a large social work organization (550 selves in a scenario proved to be a real aim of this pilot was also to verify the over- education in the field of healthcare. BABLR employees), located in the North-East of the challenge. Following the experiences with all system performance, to test playability uses text-based scenarios, tailored to the Netherlands. The participants were part of the pilot studies, far-reaching changes have and the lead time of the given scenario. target group, each with its own internal a district team in the city of Emmen, and had been made to the initial versions of BABLR. trajectory and objectives. A potential sce- different specializations within the social The design choices, the final prototype, and nario that would be playable with BABLR domain, such as youth worker, social work- the early indicators of success are present- Pilot 2 was presented during panel sessions, in er or community worker. The district team ed in the following chapter as a result of the which the entire scenario in full detail was Ten bachelor students from different study participated as a whole in this pilot and was design research process. presented in a walkthrough of the storyline. programmes at the NHL Stenden University appointed by the Tinten Welfare Group’s The experts were then invited to share their of Applied Sciences, The Netherlands, par- head of education. All participants were initial reactions and findings on the scenar- ticipated in the second pilot. A shortened informed beforehand that the pilot was part 3 Results io in question. In a final, semi-structured scenario concerning communication styles of a study. A formative evaluation was con- 3.1 Design Choices questionnaire the field experts we asked had been developed for this pilot in order to ducted after two weeks and an extensive about their reactions to, respectively, the introduce students to BABLR. For one week debrief took place at the end of the session. As described in the introduction, BABLR is perceived realisticness of the scenarios, the the students played the role of a junior com- Again, the purpose of the third pilot was designed as a low-fidelity simulation game expected learning effect, and engagement. munications officer, who just started a new to gather information about the perceived (DC). In order to optimize accessibility, the job. During the game, however, the various realisticness of the scenarios, expected starting point was to be able to play the contacts with the virtual opponents showed learning effects, and engagement. simulation without third-party software

106 107 (DC). The player plays the simulation from The implemented BABLR scenarios provide be difficult to find. In this search, players’ Moderators will modify and agree to these his or her own mail account. The text-based complex socio-technological quests that actions become more tangible. The players’ proposed responses as appropriate. Each nature of communicating via email makes it give utterance to authentic decision-mak- vigorousness towards virtual opponents, player develops a certain understanding possible to establish narrative transporta- ing, promoting collaboration, technology the quickness of establishing connections, with his or her virtual opponents. For ex- tion through scenarios (DC) which pre-se- acceptance and leadership skills, all needed seeing through motives, keeping key fig- ample, opponents can be happy or irritated lects on psychological fidelity alone. The to be successful practitioners in the field of ures on-board and ultimately completing and react from this state of mind. It is up to scenarios are carefully crafted and based health innovation. the scenario, are regarded as indicators of the player to recognize these emotions and on authentic practical situations engag- proven competent behavior. respond accordingly. ing players in real-to-life affairs (DC). All The prototype was evaluated in playtest scenarios are set in the context of health sessions with end-users, including an im- BABLR back-end and social work and place the player in a mersion study, again providing input for the Scenarios key position of a change agent (DC). In this design and development of the prototype. The emails with responses from virtual capacity, the player must solve complex After each session, observational data and team members are sent from the BABLR The scenarios are separate entities that can problems in the areas of project manage- players feedback were analyzed and led to mail client. The game moderators can log be embedded in the BABLR environment. ment, communication skills, and innovative a partial redesign or reconfiguration of the in to the back-end via a web browser. Play- This way BABLR can host multiple scenar- design-based research projects. scenarios and back-end of the artifact. ers can be added to BABLR, players can ios, which can also be played simultane- be divided into groups and players can be ously with multiple teams. It is beyond the admitted in a specific scenario. In addition, scope of this article to discuss the design 3.2 The BABLR prototype BABLR front-end the moderators can monitor and influence and origin of the scenarios in detail, but it suffices to rapport that each is divided into BABLR is designed to provide an authentic Each scenario starts with a short introduc- the course of a scenario from this back-end. five parts, or acts [51], which some refer to experience in a role-playing environment tion email, wherein the player is welcomed The content of the reactions of the virtu- as a dramatic arc: exposition, rising action, for students. A total of 26 players from as a new team member. The mail email al team members is partly automatically climax, falling action, and dénouement. different disciplinary backgrounds have explains the task to be tackled and presents provided by BABLR, but also augmented The scenario developed for pilot 1, called used this learning tool with tailored scenar- the virtual team members and their job and refined by a moderator. This is primarily FOCUS, is about a health care institution, for ios to collaborate with others on authentic profiles. The scenario starts to unfold when to ensure that the players experience the which a digital innovation (serious game) problems in the field of health innovation. the player contacts the virtual team mem- highest possible degree of authenticity in has to be developed. Whereas the health All scenarios contain elements from project bers, again by email. Each character holds the conversations, but also to sometimes care institution itself seemingly has strong management, personal leadership, uncer- specific information, which the player has to lead players back to the golden path in the ideas about the artifact to be, during the tainties and resistance in change processes retrieve, combine and interpret, leading to scenario. The system knows where in the scenario the player has to find out that and change agency through design research the next move. Ideally, a golden path should timeline of the scenario the player is situat- end-users of this serious game have totally techniques. be followed that leads to solving the wicked ed and, based on that information, predicts different needs. The solution to this scenar- problem, but the scenario is that complex the most appropriate response of a virtu- io lies in reframing the problem, resulting that it is imminent that this ideal line will al character to an email from the player. 108 109 Figure 2: The sphere display, depicting in-game interactions between the player and virtual team members. Sphere Display 3.3 Intervention A final part of the system is the sphere This paragraph describes the early indica- display (Figure 2). On an additional monitor, tors of success, which preface final state- the BABLR back-end projects the individual ments on the effect of the BABLR simulator. timelines of a group of players in horizon- The LiSMD-model intervention layer (see tally distributed vertical lines. A single line the left side of Figure 1) bridges the design represents one player. Colored spheres are space and the solution space. At this point, shown on this line, corresponding with the only statements can be made about demon- email traffic flow. Each virtual team mem- strated appropriateness and effect, based ber has its own sphere color. With several on the pilots as described in Chapter 2. The successive interactions in short order, a artifact transcends its prototypical status sphere increases in size. The last send and can, therefore, be seen as an interven- email is shown as a pulsating sphere, which tion from this phase on. indicates a required action by the moderator. The spherical display ensures that moderators have an overview at a glance of Perceived usefulness the progression of a group of players, where obstacles arise, and to whom they should In response to the scenario, the experts in- send a message on behalf of a virtual team dicated that it appeared to be very recogniz- member. The sphere display is the only able and lifelike, that the issue to be solved graphical component of BABLR, but it is not was relevant, and that a number of char- in a totally different solution. The scenario The TINTEN scenario used in pilot 3 can be visible to players. The only thing players acters from the storyline could be linked to in pilot 2 is named BABEL, and deals with completed by informing each other about an see of BABLR is the email traffic. After the people they actually knew. In addition, they misunderstandings within a communication ongoing case as social workers. The aim of completion of a scenario, or on a set end underlined the importance of the possibility agency. The key to playing this scenario can this scenario is to illustrate that operating date, players and moderators will evaluate of training extra-curricular skills in a safe be found in addressing mutual disputes and from a too one-sided perspective on a case and reflect on the course of the simulation, environment. The ability to evoke real-life applying a communication model provided can be counterproductive and even dangerous critical incidents and personal experiences learning situations that are difficult to recre- by a specific virtual character. and that the complete picture is necessary to in a debriefing session. ate in existing health curricula was identified provide the right care in complex social situa- as a strength of the BABLR concept. After the tions. After obtaining this overall picture, it is concept has been submitted to the experts, possible to work towards the end by choosing they were asked to give an initial response a collective, coordinated method. to the design. During the questioning, the

110 111 strengths and weaknesses of the artifact it may be quickly over the top.” “Of course Table 1. Average scores for artifact scoring conditions, both from experts and students were examined until a clear argumentation you try to let the important moments and was given. Expert 1 was the first to mention escalations happen, but that can easily be– that the prototype mainly deals with the re- come too much (...) or maybe it becomes too Pilot N Characteristics Mean lational aspect of such projects. In addition, difficult.” Design - viewed a prototype expert 4 mentions the replayability as a major plus point, as well as “the ability to travel Expert Panel 5 field experts several routes, make different choices, the Motivation / engagement Preview - tested a scenario feedback mechanisms that ensure that there are consequences for the choices and the Within the expert group the main reaction 1 group focuses on the player’s experience: “In this 7 bachelor students social work ability to gain experience with such projects.” questionnaire and interview As a possible weakness, expert 1 mentions simulation you really engage the student in that the system or the scenarios can steer a unique experience within a vivid scenario”, - perceived realisticness 4.34 / 5 and “We [expert 5’s association] have realis- too much: “If there is too much steering, it - motivation / engagement 3.75 / 5 is tricky (...) that really has to be taken into tic-looking simulations and they work well, account.” Also, expert 3 mentions the lack but as soon as they [students] get out again, - perceived usefulness 4.01 / 5 it [the experience] is over. That’s just for a of actual visual designs to respond to: “I am - expected learning effect 3.42 / 5 of course also a designer, I think it would be brief moment, but in this simulation, you very nice if students could also respond to can really keep them [the players] involved Users - participated in a trial for a longer period of time...” The flexibility visual designs in terms of content (...) you 1 group of the scenarios and storylines were also could, of course, put that into a scenario.” 10 bachelor students mentioned as a strong point. The time-con- group-interview Expert 2 comments: “This is really very suming role of the facilitator as part of the recognizable from my practice”. The sim- simulation was identified as a weakness: ilarities with practice and the degree of “In order to keep it [the simulation experi- 1 group ence] realistic, you [the facilitator] have to 9 social work professionals realism are regarded as strengths. “I also questionnaire and group-interview think that gaining experience is a very strong respond to the content and respond to what point, very well done.” In addition, expert 2 the player says. That is good, but it will also - perceived realisticness 3.87 / 5 take time.” recognizes the phases of design thinking - motivation / engagement 3.05 / 5 principles as well as their application within the prototype. Expert 2 sees a possible risk - perceived usefulness 3.25 / 5 in the construction of the scenario “because - expected learning effect 3.39 / 5

112 113 Perceived realisticness “they are really forced into the role of project 4 Discussion manager, they have to be proactive (...) that When asked: “Do you expect the students a policy advisor [virtual character] with is very valuable.” Expert 1 notes: “You have From the start of this design research proj- will experience the simulation as realistic conviction, otherwise you will lose him. At to discuss and reflect on the choices you ect, the pre-set goal was to examine if it and authentic?”, all the experts responded least, that would be the case in real life. It have made in order to create a good learning was possible to design a game-like inter- affirmatively. Expert 1 said: “Yes, very real- would be nice if different approaches could experience”. A consensus was found on the vention with psychological fidelity as the istic. On several levels, both social and in have a different effect”, and: “I think that importance of a real-life debrief, because main carrier of an authentic learning experience. In the artifact, any tangible form, terms of routes, there are many possibili- insight into the status of relations would be “physical contact moments and reflection either in functions or physical elements, ties.” Expert 3 added: “Yes, this is very realis- of added value.” are also important for learning.” was avoided. The LiSMD-model was used to tic. Also in the scenario, the persons [virtual support the design choices, the theoretical team members] are very recognizable and The three pilots generated both practical basis is described in sections 1.1, 1.2 and also their behavior is very true to life (...) a Expected learning effects and substantive results. The scenarios 1.3. For a series of three pilot studies with behavioral therapist [virtual character] who When asked about expected learning ef- proved to be generic enough to engage the different target groups, tailored scenarios is critical, yes, I experienced that so often fects, the experts confirmed the principle of players from different studies and vocation- have been developed, all around hard-to- myself.” In addition, the expert 4 suggested learning through an immersive experience al backgrounds. During the debrief, individ- train tacit elements of so-called 21st-cen- that the relationship between players and “because you can really keep them involved ual progress was shown and the players tury skills. Five content experts and 26 the virtual team members could differ per for a longer period of time, they can gain a shared their strategies. In a few occasions, players responded to four test items after session, while these relationships might lot of experience.” Expert 5 also mentions the participants found the scenarios hard playtests and scenario-walkthroughs. The be one of the most important parts of the the aspect of gaining experience as an im- to play but were curious about the outcome BABLR prototype is currently in the inter- simulation: “Yes, you have to approach such portant point for learning. Expert 2 adds that when they were not able to finish the sce- vention phase of the LiSMD, showing prom- nario. Furthermore, the participants indicat- ising results in terms of perceived realistic- Figure 3: Boundary spanning as the core of learning. ed that sometimes they would prefer to be ness, motivation & engagement, perceived usefulness and expected learning effects. able to meet or call the virtual team mem-

bers from the scenario in person in order to A point of discussion may be whether the be able to talk to them directly. At the time proven early indicators of success will actu- of the debrief, it only became clear to some ally feed through into final measurements. players that they were dealing with virtu- Here we can state on the basis of the first al opponents. Table 1 shows the gathered results, that the artifact in this line of growth feedback in debrief sessions after finishing will meet the set objectives. This design the playing periods. study shows that it is possible to achieve authentic learning in real-world issues by using purely high psychological fidelity as the main carrier. What cannot be demonstrated

114 115 at this stage of development is whether the One final comment concerns the role of Acknowledgments Publisher’s note use of BABLR will lead to transfer or lasting the facilitator in BABLR. During the pilots, This study was carried out on behalf of Springer Nature remains neutral with regard learning effects, mainly because the artifact the facilitators were the same people who the research groups iHuman and Serious to jurisdictional claims in published maps and is not yet ready to generate data in the upper developed and investigated the artifact. Gaming, both research groups of the NHL institutional affiliations. 2 layers of the LiSMD-model. Despite the fact that the field experts indi- Stenden University of Applied Sciences. The cated that the scenarios approached reality BABLR artifact was developed for usage in Drawing from the work on transportation adequately, it seems advisable to assign the [52], it can be argued that players’ experi- a health innovation curriculum course for role of the facilitator from the perspective ence within the BABLR artifact in the case a master’s degree in digital innovation in of both health innovation education and the of high-transportation influences existing health and social work. The authors express professional field. In this way, BABLR will beliefs, even though the player knows that their thanks to Dr. Job van ’t Veer and Dr. be able to function even more clearly as a the story is fictional. Transportation defined Hylke van Dijk for support and funding. boundary object. as immersion into a text or drawing into a You rock. different place corresponds to the immersion and perceived realisticness properties For the generalization of these findings, shown in BABLR. In this uptake, we found it will be necessary to further explore the Compliance with Ethical Standards BABLR to act as a boundary object, providing concept of psychological fidelity as the main ongoing, two-sided actions and interactions carrier of learning of tacit concepts of cog- Conflict of Interest between activity systems, even when the nition in game-like interventions in other inserted narrative (scenario) is a meaningful, contexts and guises. When doing so, the The authors declare that there is no conflict but recontextualized rhetoric. We learned LiSMD-model can provide a cross-domain of interest. that the BABLR simulator acts as a boundary perspective, combining medical contexts to object, as depicted in Figure 3, where the act educational and design theories. The model of boundary spanning facilitates the actual can be used to create space for experi- Ethical Approval learning. The literature describes this type menting with different manifestations of of learning activities as dialogical learning For this type of study, formal consent is not game-like interventions and other serious mechanisms, triggering identification, coor- required. dination, reflection, and transformation [53]. media and offers a generic design research It is this process of dialogical learning that approach for future work. The LiSMD-model to a large extent ties in with attitudes and might even be a boundary object in itself, Informed Consent bridging the strict separation between mindsets sought after in 21st-century skills, Informed consent was obtained from all as described in section 1.1. medical science and design [54]. individual participants included in the study.

116 117 References

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120 121 H7: Play It Safe: A Situational Game for Occupational Safety

Published: Wartena BO, Kuipers DA, van Dijk HW. Play It Safe; A Situational Game for Occupational Safety. In Subconscious Learning via Games and Social Media 2015 (pp. 11-26). Springer, Singapore.

Gone Home (2013)

June 7th, 1995. 1:15 AM. You arrive home after a year abroad. You expect your family to greet you, but the house is empty. Something’s not right. Where is everyone? And what’s happened here? Unravel the mystery for yourself in Gone Home, a story exploration game.

122 123 Abstract Keywords awareness to the next level, serious gaming Play it Safe the involved game-play and might prove to be a valuable tool in em- game-mechanics as the goals of the game. This chapter describes the design choices Occupational safety; Serious games; Sit- ployees’ toolboxes. Serious gaming offers The final part discusses the possibilities of and theoretical constructs that have led to uational gaming; Conceptual continuity; a new and engaging way to demonstrate situational games and the initial experienc- the development of an occupational safety Behavior change support system; Situation an adaptive interaction with the immediate es with Play it Safe and the Count Yourself game, going by the name Play it Safe. Play it awareness; STAR relevance of situations and contexts from Lucky campaign. Safe is a tower defense game that uses situ- the work-floor. In this way, serious gaming ational data collected by employees, during can mix reality with an open practice envi- their daily work, to impact the parameters 1 Introduction ronment in an emergent feedback-loop that of the video game. These data are gathered triggers the players to have safety, which 2 Safety Matters Accidents happen, however, responsible through a safety campaign named, Count is forefront in the mind at the moments employers are constantly attempting to After physiological needs, the second step in Yourself Lucky (CYL) to quantify the amount that warrant vigilance while improving the create safer environments by improving the hierarchy of needs [3] on Maslow’s pyra- of times employees used the supplied safety awareness as well as the safety measures to diminish the number of mis- mid is safety. Occupational safety has been a safety technique (Stop, Think, Act, Review environment. This all through noticing and haps and accidents. The Incident Frequency priority in the workplace since the beginning (STAR)). Play it Safe, as a form of situational registering lapses or slips and their proba- Rate (IFR), the main measure of safety in of the 19th century. Over the last decade, gaming and as a behavioral change sup- ble causes. industry, varies among sectors, as do the safety structures placed great emphasis port system (BCSS), through metaphorical risk factors inherent in certain jobs. Mea- on rule-based and behavior-based safety. re-contextualization attempts to create This chapter describes the trials and tribu- sures to maximize safety (knowledge, skills, This approach is described as Model 1 [4], a parameters for similar decision making lations of the design and development pro- protocols, conditional safety structures, and predominantly top-down approach. In Model encountered in the work environment and cess of a serious game, named Play it Safe, safety interventions) contribute to lowering 1 workers attain knowledge, skills and act implicitly reinforce the training of the STAR with the goal of behavioral change towards IFR. Not all companies are proactive when as rule-based operators who follow golden protocol and conservative decision making. occupational safety aspects inherent to dy- it comes to safety or equipped with ample rules that are strictly enforced top-down. Play it Safe aims to improve employees’ namic high-risk jobs and environments. Part precautions in the work environment and In Model 2 these same rules apply, however situational awareness, creating a shared two describes a short outline of occupation- culture. However, even companies at the top they are seen as guidelines for the compe- mental model and bottom-up accountabil- al safety trends and related work in the field of the HSE culture-ladder who have taken tent professional [4]. They are dynamic and ity, meant to improve and align (shared) of serious gaming, as well as a short outline ample precautions, have a finite effect on rein-forced bottom-up, resulting in safety safety behaviors. of the focus of Play it Safe. Part two focuses safety [1]. solutions coming from employees instead of on the design process of and implications management. Independent of the position of of situational gaming, part three focuses on Even when equipped with all the right tools safety in an organization, the safety climate Behavior Change Support Systems (BCSS), in the correct environment the human factor and culture of the company implementing Stop Think Act Review (STAR) and the sur- can be the cause of failure [2]; as routine the safety interventions have been found to rounding safety campaign; Count Yourself kicks in, vigilance checks out. To bring safety be a key indicator for the attempted inter- Lucky. Part four describes the video game vention [5]. In addition to the safety climate 124 125 and culture, a large part of safety science 2. Rule-based behavior: based on stored Fig. 1. Adapted from Endsley’s Situation Awareness Model [8], Model used from www.situationawareness.nl focuses on conditional safety. procedures, gained through experience

and learning. It works through recogni- Conditional safety entails making the envi- tion, association of state/task and then ronment as well as the equipment used as using the stored rule for the task. safe as possible. This is realized by providing instructions, use of warning signs and 3. Knowledge-based behavior: when con- protective clothing, making the equipment fronted with unfamiliar situations, where and the work environment as safe as pos- explicit thought is necessary to develop sible. The primary cause of error and (near) a plan, exercise it and see if it works. It accidents is the human operator. Therefore works through identification, decision of in safety science, Human Error [6] model- task and planning. ing, based on the underlying strengths and limitations of the human operator, is used to The different levels of reasoning can be design protocols, rules, machinery and over- accessed simultaneously, but are triggered all resilient systems to minimize accidents. by different aspects of contexts and situa- Unsafe acts can be divided into execution tions. The mental model that workers have errors (correct plan, wrong execution) and of the situation around them, i.e. Situation planning errors (incorrect plan). Execution Awareness (SA, Figure 1) [8], and the deci- errors can be divided into slips (attention sions made depending on that situation, are failure) and lapses (memory failure), plan- highly influenced by the performance lev- ning errors can be either rule-based or els used by the operators. SA origins from knowledge-based mistakes (unintentional military aviation [9] but since then has been decision to act against rules or standards) used and researched in a wide range of con- and violations (deliberate decisions to act texts and fields. Endsley defines SA as ‘the a worker is planning to undertake, is vital in and safe behaviors. Besides an individuals against rules or standards). To gain further perception of elements in the environment planning and undertaking an action. When SA, there is also Team or Shared SA (TSA/ understanding of human error Rasmussen within a volume of time and space, the com- making the decision to perform a task, it is SSA) [10,11], the understanding between [7] developed the human performance mod- prehension of their meaning, and the projec- vital to base that decision on a correct state team members of each other’s mental el, consisting of the following levels: tion of their status in the near future”. This of the necessary elements in the environ- model of the situation. A high level of shared process is automatic. However, perception, ment around you. Therefore a review of the SA between team members provides a work 1. Skill-based behavior: an automatized comprehension, and projection of how a sit- activities undertaken and possible devia- environment in which the needs and way of sensory-motor performance that one uation will evolve, depending on the action tions of the projected state of the environ- approaching tasks and situations of oth- can perform without conscious control. ment around you, are relevant for vigilance ers are understood and taken into account

126 127 [10,11]. Therefore a high SA is a vital part of These are predominantly simulation games 2.2 Play it safe and transmedial applications. The idea is to safety on the work floor, both individually as for safety training, depending heavily on a gather situational data and play the game well as in a team [12] and will make it a safer match between content and context, a high The Play it Safe project was established in close proximity or on the location and in place/increase workplace safety [13]. level of fidelity and a low level of play (or to address the needs of several small and the context where the initial problems arose. no play at all). Problems with these simula- medium-sized enterprises working in high- The basic assumption of the effectiveness tions are that they; risk and highly dynamic task-environments. of a situational game for serious purposes is 2.1 Simulations and Games for occu- Each company faces a similar dilemma; that situation provides an authentic setting pational safety despite specific rule-based behavior and the that engages a player, helps to realize the 1. Almost automatically create a mismatch specific task-related knowledge being avail- logic, and triggers the player into action. Games and simulations for occupational between the desired blend of entertain- able and reinforced, accidents still occurred. The authenticity provides the necessary safety have been used in a variety of fields ment and learning [24] within the game, meaning and appreciation. The situation with a wide range of goals, including; missing out on the positive effects of Play it Safe aims at creating top of mind plays a role in multiple dimensions of per- entertainment on learning [25]. safety awareness for workers in the con- suasion, i.e., striving to persuade players 2. Require extensive training needs analy- struction and maintenance industry. The 1. Virtual Training in Construction Plants sis (TNA) methodologies [25,26]. workers operate in small teams with vari- [14], Fig. 2. This model describes the desired transfer model of the game 3. Can only be used for specific goals and able constitution and at varying locations. 2. Virtual Training to increase SA during and the reality outside the game as experienced by the player. situations. A created scenario within a Obviously, these workers know the safety Cardiopulmonary Resuscitation [15], simulation will only be useful for a spe- rules, but in the heat of the moment slips, 3. Evacuation Drills [16–18], cific target group and will only encom- lapses and errors occur. Play it Safe focuses on preventing accidents using a cognitive 4. Hazard Recognition [19], pass limited tasks and environments. In an occupational safety game it would intervention called STAR (Stop, Think, Act, 5. Intervention to reduce work-stress and be impossible to simulate and program Review), for procedural tasks, focusing on raise work-engagement [20], every possible accident or near accident the context outside the game rather than 6. Training and education of operations on inherent to the particular task in the the content within the game by the use of ships and off-shore platforms [21], particular work sector. situational data retrieved through the count yourself lucky campaign. 7. Design in Construction [22], Therefore, instead of focusing on the out- 8. Training for working at heights for mine- comes of specific risks of specific task-re- sites [23]. lated accidents, the more practical and 3 Situational Gaming feasible goal might be to intervene in the mental model an employee applies to ap- Situational games [27] are games in which proach general tasks, environments, and real-life data is used to affect the parame- situations. ters of the game, often by the use of cross-

128 129 to change their behavior. The framework By introducing real-life data in the game Fig. 3. Shows the ubiquitous workings of the STAR-protocol as a) 4.1 STAR: Stop, Think, Act, Review helps to make the role and possibly the they link the target context to the learning situational safety detection tool b) a game-mechanic and c) the impact of situation explicit during the design context (the game), enabling transfer be- Play it Safe uses the safety intervention STAR textual intervention. of serious games. Situation contributes in tween similar, but not identical contexts. combined with situational aspects, i.e. events a positive way in reaching the underlying from the work floor are integrated to have objective of the game. For Play it Safe sit- Near transfer can be categorized under lit- effect in the game. STAR (Stop, Think, Act, Re- uational gaming was used to attempt to eral transfer: transfer by the means of simi- view) is a mental protocol to facilitate safety increase safety awareness amongst work- larity, as opposed by figural transfer: trans- awareness. This mental protocol attributes ers. Eventing, thus taking real-life events fer as a result of using some part of existing the creation of awareness of a situation to into the gameplay, is suggested to be a good world knowledge for thinking about a par- three entangled processes: perception, com- starting point for any situational game [27]. ticular problem. The game transfer model prehension, and projection. These processes Situation and context determine the effect projects a game as a conceptual continuity attribute the enclosing environment, the of a trigger. Triggers, when carefully timed in a continuum, stretching from mimetic physical context. The mental model is com- and chosen, provide the spark to activate simulation to abstract gameplay (see Figure pleted with a decision making process and a change in behavior [28]. By adhering to a 2). Within boundaries, the position of the effectuation of an intended action. The action person’s situation, triggers become authen- game on the Game Transfer Model [30] has obviously affects the state of the immediate tic and actions become meaningful [29]. The to correspond with design choices dedicat- behaviors or an act of complying without environment. STAR is being and has been used player can identify itself with the matter. The ed to facilitate transfer in a situational game using coercion or deception”. The computer in several fields [34–36] and is closely mod- use of situational data in Play it Safe reflects aiming at raising safety awareness among game Play it Safe is not a stand-alone inter- eled on SA (see Figure 5). STAR has different the belief that transfer should be considered employees through re-contextualization of vention, to be a BCSS, it needed a transme- modes of use (see Figure 3); as a design parameter. Kuipers et al. [30] the STAR-protocol and situational input. dial function [33] as a trigger to create the argue that core principles (in this case the situational input and a complementary tool 1. As a standard protocol to be used with STAR protocol) in a game should be care- for assessment and participation to gather every task (Skill-based behavior) fully designed in conjunction with a specific this input. Through the project, state of the transfer type in mind, aligning the players’ 4 Behavior Change Support art sensors and other elaborative options 2. As a critical task protocol to be used only needs and abilities, including sociocultural System; Count yourself lucky were proposed, however, they proved to be with tasks that are deemed to be a risk aspects, serious goals, and topic character- infeasible in a highly dynamic high-risk work and require full attention (Rule-based istics. The process of translating situational with STAR and Play it Safe. environment. Many companies, for instance, behavior) did not allow smartphones because the data into game elements is called recontex- A Behavior Change Support System (BCSS) 3. As an emergency protocol to be used digital disruptions could prove dangerous tualization, defining the pinnacle of serious was defined by Oinas-Kukkonen [30–32] as: when something goes wrong and one during working hours. Therefore an analog game design: the subjective soundness and ”a socio-technical information system with finds him/herself in an unfamiliar situa- solution was found. recognizability of the recontextualization is psychological and behavioral outcomes de- tion (Knowledge-based behavior) essential for transfer of safety awareness. signed to form, alter or reinforce attitudes, 130 131 4.2 Count yourself lucky with STAR Fig. 4. Shows a screenshot of Play it Safe being played. In the implementation of Play it Safe, STAR The EMP, however, is a re-contextualized was utilized and integrated into all of the STAR protocol that lets the players do two aforementioned modes. STAR was also used essential things, in the game; to detect deviations from the projected outcome of situations and record these with 1. Assess when the in-game situation be- a tally counter (CYL), that amount was then comes too dynamic to project a clear out- used as an in-game reward. During the play come, i.e. being unable to project the situa- it safe campaign STAR was used as a safety tion state after the action is undertaken. protocol and detection tool in the workplace; (see Figure 3); 2. While using the EMP players are forced to Review the situation and reorder the 1. A safety protocol to use while perform- elements in the situation and the appro- ing critical tasks and after some practice priate actions that can resolve it. become part of skill-based, rule-based The ubiquitous implementation of STAR and knowledge-based behavior. This (see Figure 3) trains players outside of the was attempted through mere learning game to use a mental protocol to integrate on a leaflet and demonstrations. into their daily working behavior, while at 2. A detection tool for situations that de- the same time acting as a detection tool for viated from the projected outcome of situations that deviate from their projected action (through the Review in STAR), of outcome. This facilitates the players to take oneself or others. These deviations were a closer look at their daily working envi- used as the input of the CYL score, keep- ronment and the boundaries to work safely ing score daily on a tally counter. within them, as well as noticing the limitations or shortcomings of conditional safety The motivation to use one’s tally counter in structures. The CYL campaign is motivated the CYL campaign (besides bottom-up ac- by the in-game reward system while in all colleagues are using the same protocol Because the video game is played during countability and communication culture) is to the game the STAR reinforces the already the Shared/Team SA is trained and barriers lunch-breaks in the workplace, the sit- gain an in-game advantage. Through the use learned protocol in unrealistic situations in individual SA can be discussed as require- uations become more tangible and the of an EMP in the game that makes it possible that train the players SA. ments for a high Team SA, creating an open implementation of the CYL score can be- to progress with more ease in the game. communication culture where bottom-up come a trigger to discuss workplace safety initiatives are harnessed. amongst colleagues. Furthermore, because

132 133 5 Play it safe; The Computer 5.1 Gameplay 5.2 Game Objects Game When the player starts the game he/she Energy Cores Workers can build as many towers as time allows, The energy cores are the main assets in the To create towers it is necessary to have Play it Safe (see figure 4) is a touch-screen before a first wave of enemies arrives. The game. Workers try to defend them and the workers to built and restore the before tablet-based video game of the Tower arrival of enemies is usually preceded by an enemies attempt to steal them. They are mentioned towers. There are three types of Defense genre, the objective of a tower alarm but as with any action in the game, kept in the base spaceship. workers. defender is to protect one’s base against there are exceptions that keep players on 1. Builders build and repair towers. an enemy that wants to steal the supplies their toes. Towers are built by workers, stored in that base. To succeed in this ob- 2. Firemen extinguish towers when they when chosen workers have a primary objec- Base jective the player builds towers, tactically are on fire. tive to build, towers will be finished quicker. The home base of the game avatars is a placed around the area to kill the stream of When towers are built, workers can be spaceship wherein the energy cores are 3. Mechanics fix mechanical damage in enemies. Play it Safe differs from traditional placed in the towers so that alien robots will stashed. Members from the workforce enter the towers. tower defense games, with the addition of not hurt them. After or during these attacks the game through the base when the player workers that build and fix the towers and they can be directed to fix broken towers, starts to build towers. the possibility to use an Electro Magnetic The player can distinguish between the however, there is a risk they will get hurt. Pulse (EMP) as a strategic advantage. The three types by the visual appearance of the Enemies approach in waves, so usually, story behind the game is that a spaceship Enemies workers. Their entire workforce has a single there is time after a first wave to regroup has crashed upon a distant planet that is in- There are two kinds of mechanized bug-like primary objective as well as a fitting suit to and fix or build extra towers. During waves habited by bug-like aliens who are attracted aliens. Both types can steal energy cores, perform this primary task. It is possible to pressure builds and it gets harder and hard- to energy cores that you need to power and however, the Eaters will attack towers and assign tasks to avatars that are not their er to keep control over workers while keep- repair the ship. To defend the crew and ship workers on their way to steal the cores, primary objectives; the avatars will, how- ing track of the states of the environment against the bug-like aliens, guard towers whereas the collectors will go straight for ever, be slower and less successful in per- as well as enemies. It is possible to use the are built that automatically shoot the bug- the energy cores. forming these non-primary tasks and thus EMP mechanic to regain control over the like mechanized aliens. in more danger. When either fire, radiation game environment and regain situational from a tower or an enemy hurts a worker, leadership over the workforce. If the player 1. Eaters, their main objective is to their health state declines and they eventu- keeps the energy cores in the game, he/she destroy towers, by gnawing on them. ally die. To heal workers they can be directed wins, if the player loses all of them he/she 2. Collectors, their main objective is to into an undamaged tower, where they will loses. Extra points and badges can be won walk into the base pick up an energy be healed. for using workers for their primary objec- core and walk away with it, towards tives, using the EMP and not letting your their own base. workforce get hurt.

134 135 to the workplace. In the Game-world there Fig. 5. Shows the proposed schematic behavior and attitude-changing model. 5.3 Game Mechanics are observable (enemies) and non-observ- Count yourself lucky score able (ground-integrity) threats as well as simulated time-pressure, which forces the The player is asked to fill in the day score of the previous working day on the start players to keep reassessing their plans and screen of the game. This score is used to actions with regard to the ever changing determine the amount of EMPs available to the environment. Not to recognize specific the player in the game. or realistic threats, but to gain insight and perspective on the need for oversight into Ground inspection the aspects of a situation, i.e. situation To build towers the integrity of the ground awareness and the necessity of conser- can be checked with a special option to use vative decision making within a dynamic a looking glass that gives the percentage environment. of the ground-integrity. This influences the towers deterioration process. Mitgustsch [37] distinguishes three stages of learning through serious games aligning Electro Magnetic Pulse (EMP) with Bateson [38] stages of learning; 1) in, 2) The EMP can be used either to freeze all through and 3) beyond the game. In the case enemies as well as workers or to just freeze of Play it Safe the transformational learning their enemies, depending on successfully process is; using the touch screen hold mode on the intended icon. In either situation, it gives the player time to use STAR and gain a new 1. In the game learning: the player carries oversight in the game, which can be lost due out random tasks at hand and leads a to the pace in the game. workforce that can change into various states. Through trial and error, the player reacts to the game environment and Towers 5.4 Transformational Learning learns to play the game. Before building a tower the integrity of the sight. Whenever enemies damage towers, Through the use of metaphorical recon- 2. Through the game learning: the player ground to be built on must be checked. The their states deteriorate and markers (elec- textualization [30] Play it Safe uses near will learn what the limits and barriers higher the integrity of the ground, the more tricity sparks or fire) are visible before they transfer to create a metaphorical low-fidel- of their situational awareness are and resilient the tower will be against enemy eventually collapse or are repaired. The ity game-world in which less explicit and when they reach these parameters. attacks. Towers can be placed anywhere on workers can hide in the tower from enemies extensive parameters apply in comparison the map and shoot intruding enemies on closing in on them.

136 137 3. Beyond the game learning: at this stage, 6 Discussion is expanded to real-life contexts outside Because of the ubiquitous nature and trans- This transmedial BCSS aims to impact cerning safety matters during these group of the game. The player recognizes the medial character of the BCSS, a schematic compliance towards safety rules, lasting activities. The simple task of making a barriers for high situation awareness in breakdown of the active elements is given. behavior change through creating a Team conscious note can be a tangible trigger to their daily working environment. And is Play it Safe implements four modes of use SA by using the mental protocol STAR and enhance situated cognition through situated continuously training the use of STAR in [39] of one BCSS through situational gaming: ultimately an attitude change in creating a play [41]. As a situational game Play It Safe skill- rule- and knowledge-based behav- bottom-up safety culture, making safety a makes the environment the trigger in and iors to reduce errors, slips and lapses, As an intervention; STAR is implemented to tangible concept that all members of a team outside of the game, utilizing safety on the and ultimately the companies IFR. attempt to improve individual SA and Team are involved in and feel accountable for. work floor through the game. SA. Through the use in and outside of the SA and STAR are used to overcome the in- game the recognition of a loss of overview Play it Safe harnesses the motivating and game challenges without being explicitly or cognitive overload in working situations rewarding aspects of in-game appraisal Acknowledgments taught, creating an implicit training tool. is trained and reinforced. for out-game actions (CYL), as well as im- The work described in this paper has been Play it safe the computer game combined plicitly reinforcing the actions outside of supported in part by the RAAK SIA project with CYL and the explicit STAR-training, to- As a trigger; through the use of the CYL the game, in the game itself. Thereby Play Play it Safe (273). The authors gratefully gether function as a transmedial BCSS that campaign. Wherein the employee through it Safe can be considered a recursive BCSS, thank the project members for the numerous attempts to abide by the dynamic demands the use of a tally counter, keeps track of the not to create high vigilance at all time, but to discussions and their valuable contributions of the socio-technical environment. situations in which he/she lost the overview recognize the barriers inherent to an incom- to the design and testing of Play it Safe. of the situation. plete view of a situation. Performing knowledge-based behavior while wrapped up in As an assessment; for employees and other tasks can be dangerous at any time safety leaders through the scores of the [40]; therefore an insight in the precursors game, as well as the individual or shared of cognitive overload can be a powerful tool CYL scores. Which both act as a self-assess- for safety awareness. ment and give feedback about the number of unsafe events on the work floor. In the preliminary trials, safety-leaders, on site of the respective companies, noticed As a tool for participation; through the CYL an increase in interactions and respective campaign empowering users to inform tally counters scores when group activities safety managers about unsafe practices, took place than when solitary tasks were equipment, behaviors or specific situations performed. The CYL campaign seemed to or context. increase the communication culture con-

138 139 References

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142 143 H8: Design Research in Health Education: Don’t Jump to Conclusions

Lessons Learned From Digital Innovation in Health in The Netherlands

Kuipers DA; Wartena BO, Terlouw G; Van Dongelen R; Prins JT; Pierie JPEN. Design Research in Heatlh Education: Don’t Jump to Conclusions. Health Culture Society (2019). Manuscript submitted for publication.

The Stanley Parable (2013)

The Stanley Parable is a first-person exploration game. You will play as Stanley, and you will not play as Stanley. You will follow a story, you will not follow a story. You will have a choice, you will have no choice. The game will end, the game will never end.

144 145 Abstract tion [2]. There seems to be little discussion In contrast to printed books or the first mo- about the opportunities and need for infor- torized coach, information technology is not In recent years, a number of design re- for digital innovation in health. Moreover, mation technology to meet these challeng- just one single concept: the development search projects relating to digital innovation designers of health curricula as well as es. Home automation, telemedicine, and of information technology (abbreviated in health and welfare have been carried educators in health innovation are called online support are becoming increasingly to IT, often referred to in the Netherlands out within the NHL Stenden University of upon to address the transformation of the common. Yet there are countless examples and Belgium as ICT) has also expanded its Applied Sciences. These design research social system as an integral part of a design of digital innovations that do not make it definition. While Van Dale, the Netherlands’ projects included a fall prevention game process for a successful integration of the into daily practice and run aground in devel- foremost dictionary, still describes IT as for the elderly (HaSeGa), a game to prevent developed artifact. opment or implementation [3]. ‘everything to do with the automated acqui- lower-back injuries for caretakers (iLift), an sition and processing of information’, there app for psycho-education in social limits Keywords The emergence of information technology is a noticeable shift towards psychometric for young people with a mild intellectual design research; health education innova- has been one of the most important ad- characteristics [3,4] often expressed in disorder (MATTIE) and a vitality game for tion; socio-technical system development; vancements of the last century. It was wide- terms of adoption [5] and acceptance [6]. the elderly (Fox hunting). Even though the game-like interventions; digital innovation ly accepted, with hints of skepticism, that This article explores observations made in project teams, target groups, and project the role of technology, and of computers, in a number of so-called ‘games for health’ objectives were different in all projects, the particular, would be inescapable in our daily IT projects of the iHuman research group analysis showed that there were strong 1 Prelude lives, revealing unlimited possibilities. More [7–11] in which the social component of similarities in the lack or even absence of so than with the launch of earlier techno- technological innovation has proved to be attention for the importance of social sys- The aging of society and the decline of the logical innovations, such as the printing the biggest challenge, both among end-us- tem development. Although all projects birth rate will be the primary reasons for press, electricity or television, information ers on an individual level, but also on mana- resulted in a prototype or artifact that had the rise in care and support requests in the technology has had an impact on the social gerial and cultural levels as well. been enthusiastically responded to during coming years. Greater medical knowledge system. The social system may have react- the design research processes, the artifacts has led to an ever-increasing life expec- ed out of fear or resistance to the unknown 1.1 Affinity themselves never became integrated into tancy in the Netherlands [1]. Far-reaching in the past, but the so-called disruptive the socio-technical contexts for which they changes in the organization of care and wel- nature of the continued advancement of In the 1990s, implementation was often were designed. fare support have been adopted in answer information technology has definitely led to the final stage in a development process, to these developments. Take, for instance, a wide range of challenges. Now, in the 21st particularly in terms of technical expansion. This article aggregates lessons learned the decentralization of care, the transition century and especially in the world of care The final user only became acquainted with from those projects, addresses the problem of youth care to the municipal authorities, and welfare, we would, therefore, expect the artifact through an on-screen tutorial of the classical conception of implementa- the step-by-step design and arrangement greater interest in these socio-technolog- or a user manual. For the rest, the imple- tion in design projects and offers a frame- of the Social Support Act and a growth in ical challenges, not least in the light of the mentation focused on the installation of work for future design research projects the number of activities focused on preven- developments around eHealth. the artifact and efficient operation. When problems arose, they truly were of a tech-

146 147 nical nature and could only be solved by the 1.2 Implementation social system for which it was developed. software vendors themselves. This is where It is emphatically not the intention that the the current uncertainty with regard to A frequent term, which seems to have re- forthcoming challenge is seen as a condi- artifact is implemented or judged by means technology in the areas of Health Care and placed implementation, is ‘the rolling out of tion. The preconditions are presumed and of an impact study: the design process is Welfare springs from. Problems with tech- an innovation, strategy or software package’. the innovation must take place within these still ongoing. The DIS takes artifact α, and nology are interpreted as a personal short- This metaphor may at least address the frameworks. In this article, we want to make through prototypical research arrives at coming: technology is difficult and intended insight that implementing is a process, but a distinction between the development of artifact β. for boffins, end users may find it puzzling or also raises questions. Freshly laid tarmac is the artifact (a serious game, app, e-health have no affinity with it. rolled out with a roller, a roll of carpet just application) and the development of the so- gives the floor a new look. You could argue cial system (services, culture, department) 2.2 Design in-the-Large In this day and age, this reflex can no longer that when there is an update of an alarm for which the artifact is intended [12]. Like design-in-the-small, the design-in-the- be said to be entirely justified: new itera- system or when it comes to the commis- large (DIL) is a phase. The DIL [13] deals with tive development methods have made it sioning of new coffee machines in the office the further development of the prototype possible to remove teething problems from canteen, one could well speak of rolling out. 2 The DIS/DIL Perspective towards finalization, but in conjunction software at an early stage and if something But when an innovation comes with a dif- 2.1 Design-in-the-Small with, and fed by the social system. As said: does not work correctly, the supplier has ferent way of working or has a substantial at the start of the DIL, the prototype is still simply not done his job properly. Technology influence on an existing way of thinking, the The design-in-the-small (DIS) [13] is a phase under development, but refined enough to is here to stay. The issue now is whether the term ‘rolling out’ is almost disrespectful and in the design process, with the instrumen- be tested live. What is special is that at the technology does the right things correctly, at the very least naive. tal perspective as its core, and the aim of moment it occupies its position in the social or rather, whether it’s well-designed. The iteratively arriving at a design of an artifact. system, the artifact becomes, and evokes, latter is crucial: as long as the healthcare or Expectations and insights regarding the It is iterative in the sense that the artifact more than can be expected from the pro- welfare professional continues to approach possibilities of technology rarely correspond grows into a fixed form by means of proto- totype. In this situation, it can be said that IT as something out of their control, opinion with reality, and the projected promises types (predecessors). An artifact is a prod- the medium is the message [14]. The expe- or input, implementation will remain the often fail to materialize. In that sense, the uct consciously created by human action in rienced artifact grows into an intervention highest achievable feat. Lack of affinity with experiences with eLearning in the world of the broadest sense of the word: it can be a (Figure 1), and with all its systemic affor- technology as an excuse not to interfere in education spring to mind. The most import- traffic square, a mobile application, a ser- dances [10] the message is received more the development of new applications could ant similarity in our view is the perspective vice, a building or a law, for example. In this broadly and possibly explained differently be interpreted as unprofessional behavior. from which the potential innovation comes phase, an artifact is developed to improve, than intended from its DIS. ‘flying our way’. Logically, the existing real- or better understand, a situation. The DIS, Meanwhile, the various actors within the ity is taken as a given and the artifact itself as shown in Figure 1, ultimately leads to a social system experience the prototype as a takes precedence. The use of the inescap- prototype of a certain justified ‘completion’ joint, negotiable zone: they attribute mean- able word – precondition – is typical. The (artifact β), mature enough to be tested ing to the artifact from their own cultures. organization standing on the edge of the autonomously as an intervention in the The artifacts arising from the design activ- 148 149 and attuned to, the prototype. Herein lies Figure 1: Design-based Research, Design-in-the-Small and Design-in-the-Large, adapted from Klabbers (2003b) 3.1 Layers in Serious Media Design the basis of social system development: the target context, the large, also changes. The position of the design study is further It is precisely because of this process, the explained in Figure 2. The so-called wick- development of the social system in con- edness of issues [19,20] can be approached junction with the artifact, that the DIL differs systematically by creating clarity as to significantly from an implementation phase where in the process the study takes place. or roll-out. Through further development of Studies in the problem space are about the prototype, through the DIL, the artifact β the systematic exploration of the problem, expands to artifact v1.0. target group and theoretical justification departing from existing interventions and leads to a so-called design hypothesis. 3 Theory Development & Figure 2: Layers in Serious Media Design Testing Within the domains of care and welfare, Eect the terms practice-based evidence (PBE)

and evidence-based practice (EBP) provide SOLUTION SPACE footholds for the typification of research Evidence based Practice Pattern of Use activities. Figure 1 shows how PBE and EBP Evaluative Research relate to the outlined DIS/DIL perspective. Intervention ities become boundary objects [15], which tions made in the DIS may turn out differ- The position of EBP is important to clarify. Artefact lead to a shared understanding, trust, com- ently, and specific conditions in the DIL may A common discussion during the projects concerns the effectiveness of the digital mitment and ultimately a common language impede on the operation of the artifact. The DESIGN SPACE DIL provides rich insights into the opera- innovation: how and when do we know if ‘it Design Research that connects the worlds of the designer (DC) works’? This question on effectiveness of- Design and the target context. The social system tion of the artifact in situ and will lead to a Choices Generative Research Generative relates to the prototype and provides new further honing of the prototype, thus going ten literally results in a jump to conclusions, whereby the design space (see Figure 2) is Working and often unforeseen information that can further than implementation alone [18]. Theory (WT) be used to improve the artifact itself. The However, the influence described above is skipped. This important issue needs emphasizing when it comes to design research. It is artifact is domesticated by the user. The twofold: the disruptive nature of innovation Supporting Theories (ST) only after its DIS and DIL that an artifact v1.0 PROBLEM SPACE artifact influences the user, and the user means that it is not limited to the artifact Practice based Evidence alone, but the social system itself is also an is ready to be assessed from an empirical determines which elements of the artifact Design Principles (DP) they will employ [16,17]. However, assump- object of development. It is designed with perspective. Research Explorative

150 151 In the design space, the Design Research 3.2 Design Research Framework (DRF) Framework (Figure 3) becomes the leading framework. In the DIS phase, the design Specific to the design study, within the process. The closure of the design gap is ear focal areas of design thinking, such hypothesis is concretized into design design space is the Design Research Frame- the result of framing (Schön, 1983). It is not as define, iterate, and ideate [23–25]. The principles that are converted into proto- work (DRF, Figure 3). This model is based about pre-determining the current situation framing stage (as part of the DIS) with its types-of-disposable-quality. In the DIL on the Instructional Design Model for rapid versus a desired situation, but about a deep analyses has already been described above, phase, the artifact grows to a certain matu- prototyping [21], which originates from understanding of needs, (existing) content as has the importance of social system rity at the same time, while its effectiveness the field of education. The reflex to think and context. In this phase (DIS), reasoning development (as part of the DIL). The inter- and suitability have already been demon- in terms of end solutions (often guiding a should be resource-free (without a concrete action between the construct and utilize strated to a very large extent. In the solu- design process) is deliberately curbed by solution in mind), with the current situation prototype stages is the driving force of the tion space, one can use the implemented the DRF through methodically exploring the and the desired situation preferably defined design study. Depending on the position in artifact to research the usage patterns and existing situation (assessment of needs, from the perspective of the end user. the DRF (DIS/DIL), the prototype is continu- empirical effectiveness of the intervention. analysis of content and context). This al- In the DRF, articulating the design gap co- ously informed by research results from the most always leads to a diversion and an incides with artifact β, a key moment in the iterations. It is important that a continuous in-depth investigation of the initial issue. A design study. This moment seems to be balance is struck between rigor and rele- common mistake is to interpret the design halfway through the project, but this can vance here [26] by correctly applying the gap as a single activity preceding the design vary from project to project and depends on right methods at the right time. the wickedness of the issue at hand. Until eHealth projects (like many other design Figure 3: Design Research Framework (DRF), adapted from Tripp & Bichelmeyer (1990) then, prototypes are preferable of a dispos- driven projects) are by definition highly com- able quality and do not contain the DNA of plex and bound to predetermined limits by DIS DIL the end product. They are used to quickly grant providers. Detailed formulations of final validate ideas and concepts and serve as objectives and products are almost always artefact (α) artefact (β) artefact v.1.0 in-between objects: after all, the designer’s demanded in advance, which effectively paradox can only be solved through abduc- means that the most drastic decisions are Assess needs, analyze content & context Set Objectives tion [22]. The DIS works towards an even- taken when the knowledge available within Construct prototypes (design) tually consistent closure of the design gap the project is at its minimum. In practice, these Utilize prototypes (research) with a corresponding prototype (artifact β). prerequisite learning outcomes are an obsta- Social system development cle to fully exploring an issue, with the result Figure 3 shows a spiral that interacts with that valuable insights are not investigated or design gap the running phases of the DRF. The spiral taken into account. A related consequence is represents the iterative and incremental the steering towards the end result or intend- time character of the design study. The focus of ed effects too quickly. these iterations is in line with the non-lin- 152 153 The DRF offers tools (including timing and Acknowledgments References dynamic role) to bring end-users, designers, producers, and other stakeholders closer This article draws on the experience gained together around the innovation of a shared from a number of innovative design re- 1. Levensverwachting; geslacht, leeftijd (per jaar en periode van vijf jaren) [Internet]. CBS StatLine; 18 mei 2018. digital future. It clarifies the research and search projects in health and healthcare. Available: https://statline.cbs.nl/StatWeb/publication/?PA=37360ned design process and gives something to hold Each project had its own structure and 2. Non M, Torre A, Mot E, Eggink E, Bakx P, Douven R. Keuzeruimte in de langdurige zorg [Internet]. CPB on to in the project organization. associated funding, for which acknowledg- / SCP; 2015 Oct. Available: https://www.scp.nl/Publicaties/Alle_publicaties/Publicaties_2015/ ments were made in an appropriate man- Keuzeruimte_in_de_langdurige_zorg ner at the time. The number of students, 3. Opleiding en onderzoek op grensvlak van technologie en zorg. Nederlandse Federatie van Universitair Me- dische Centra NFU / 3TU.Federatie; 2011 Sep. 3.3 Design Research in Education end-users, content experts and project 4. Oinas-Kukkonen H. Humanizing the web: change and social innovation. Springer; 2013. staff involved is too large to mention here. The application of design research in Health 5. Rogers EM. Diffusion of Innovations, 4th Edition. Simon and Schuster; 2010. The authors want to express their thanks to Education requires students and teachers 6. Venkatesh V, Morris MG, Davis GB, Davis FD. User acceptance of information technology: Toward a unified- to have specific knowledge and skills. Mere everyone involved, especially to Dr. Job van view. Miss Q. JSTOR; 2003; 425–478. knowledge of the DRF or design research, ‘t Veer for additional funding. 7. Van Dijk HW, Wartena BO, Wiersma G, Botger J. Chasing the sinusoid: Extrinsic motivation and monitoring of in general, does not suffice. It is the own friction loaded squat exercise training. Gerontechnology. 2014;13. doi:10.4017/gt.2014.13.02.183.00 social system, the educational practice, Declaration of Interest 8. Wartena BO, van Dijk HW. Bias Blaster – Aiding Cognitive Bias Modification- Interpretation through a bub- that needs to be co-developed in order to ble shooter induced gameflow. In: Schouten B, Fedtke S, Bekker T, Schijven M, Gekker A, editors. Games for be able to employ design research in Health The authors report no declarations of Health. Wiesbaden: Springer Fachmedien Wiesbaden; 2013. pp. 47–60. Education successfully. A growth mindset interest 9. Wartena BO, Kuipers DA, Drost J, van‘t Veer J. Mobile Adaptive Therapeutic Tool In psycho-Education (MAT- [27] also seems to be a necessary condition TIE). Design principles for a persuasive application tailor-made for adolescents with a mild intellectual disability. Proceedings of ISAGA 2013. 2013; for teachers to give the design space a place 10. Kuipers DA, Wartena BO, Dijkstra BH, Terlouw G, van T Veer JTB, van Dijk HW, et al. iLift: A health behavior in health curriculums: here, too, design-in- change support system for lifting and transfer techniques to prevent lower-back injuries in healthcare. Int J the-large seems necessary. Med Inform. 2016;96: 11–23. 11. Terlouw G, Dijkstra BH, Ernsten N, Dijkstra A, Matsuguma H. The bit-game, a serious exergame designed to support exercise and assess the 30-second chair stand test automatically. Gerontechnology. 2014;13. doi:10.4017/gt.2014.13.02.141.00 12. Stewart J, Williams R. The wrong trousers? Beyond the design fallacy: social learning and the user. Hand- book of Critical Information Systems Research. books.google.com; 2005; 195. 13. Klabbers JHG. A framework for artifact assessment and theory testing. Simul Gaming. SAGE Publications Inc; 2006;37: 155–173. 14. McLuhan M. 1996 Understanding Media. The Extensions of Man. 1964; 15. Carlile PR. A Pragmatic View of Knowledge and Boundaries: Boundary Objects in New Product Development. Organization Science. INFORMS; 2002;13: 442–455.

154 155 16. Poole MS, de Sanctis D. Understanding the use of Group Decision Support Systems: The Theory of Adaptive Structuration. Organizations and communication technology. Sage Publications; 1990; 173. 17. Schwieger D, Melcher A, Ranganathan C, Wen HJ. Applying adaptive structuration theory to health information systems adoption: A case study. Int J Healthc Inf Syst Inform. IGI Global; 2006;1: 78–92. 18. Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A’Court C, et al. Beyond Adoption: A New Framework- for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies. J Med Internet Res. 2017;19: e367. 19. Buchanan R. Wicked problems in design thinking. Design issues. JSTOR; 1992;8: 5–21. 20. Rittel HWJ, Webber MM. Dilemmas in a general theory of planning. Policy Sci. Springer; 1973;4: 155–169. 21. Tripp SD, Bichelmeyer B. Rapid prototyping: An alternative instructional design strategy. Educ Technol Res- Dev. 1990;38: 31–44. 22. Dorst K. The core of “design thinking”and its application. Design studies. Elsevier; 2011;32: 521–532. 23. Brown T. Change by design. Harper Collins; 2009; 24. Plattner H, Meinel C, Leifer L. Design Thinking: Understand – Improve – Apply. Meinel C, Leifer L, Plattner H, editors. Springer Berlin Heidelberg; 2010. 25. Simon HA. The sciences of the artificial. MIT press; 1996. 26. Hevner A, Chatterjee S. Design Science Research in Information Systems. In: Hevner A, Chatterjee S, editors. Design Research in Information Systems: Theory and Practice. Boston, MA: Springer US; 2010. pp. 9–22. 27. Yeager DS, Dweck CS. Mindsets That Promote Resilience: When Students Believe That Personal Characteris- tics Can Be Developed. Educ Psychol. Routledge; 2012;47: 302–314.

156 157 Chapter 9: Summary, Key Findings, and Future Perspectives

Brothers - A Tale of Two Sons (2013)

A man, clinging to life. His two sons, desperate to cure their ailing father, are left with but one option. They must set out upon a journey to find and bring back the “Water of Life” as they come to rely on one another to survive. One must be strong where the other is weak, brave where the other is fearful, they must be... Brothers. Image: © Starbreeze Studio / 505 Games, All Rights Reserved.

158 159 Epitome In the literature surrounding serious games, an inherently non-serious medium. This thesis asserts that this design rationale of a serious game foreshadows the type one often finds reference to the so-called After almost fifty years of further research, focusing on realism, while perhaps being of transfer that said game will ultimately serious game oxymoron. Finding its origins Games for Health (GfH), due to their inherent a perfectly reasonable choice in approach, incite. This approach, encapsulated within in ancient Greek language, an oxymoron is characteristics and opportunities, are still upholds the current way of regarding se- the moniker design for transfer, has been a rhetorical device wherein two semanti- seen as promising regarding the possibility rious games as oxymoronic, and therefore the driving premise behind four studies cally opposite words are combined into one of their application in educational settings. attention should be shifted toward different focussed on designing non-literal serious self-contradictory paradox (oxus meaning However this application is as of yet far from forms of serious gaming. Apart from the gaming prototypes for Health. sharp and moros meaning blunt). commonplace. More precisely: the digital aforementioned simulations that are defined games and game-like interventions that by their truthlikeness and a literal reflection Abt (1970) was the first to identify the con- have been applied within Health contexts of our reality, we must not forget the exis- Two tracks cept of serious gaming as oxymoronic, due are for the most part simulations wherein tence of games that follow a different design As shown in Figure 1 from the introduc- to the contradictory nature of striving to- verisimilitude seems to be an almost neces- rationale, focussing more on figurative, met- tion chapter, there are two tracks that run wards serious goals through making use of sary condition. aphorical contexts as carriers of the gaming through this thesis. The blue route deals experience. It is predominantly this last type with the exploration, conceptualization, and of game that seems most promising for application of transfer theory in the de- Figure 1: a schematic overview of the chapters in this thesis in their mutual relationship. effectuating lasting behavioural change and sign of games and game-like interventions other educational goals. regarding various serious goals. It is the key findings and conclusions from the blue track Having systematically reviewed medical (Research for Design) that form the heart of this dissertation. databases, it has become clear that games

of the latter category –those relying on In order to carry out the experiments, a de- figurative rather than literal contexts- are sign research approach was followed to in- almost completely unrepresented within vestigate multiple variants of the game-like Health applications. Tackling this matter interventions for suitability and effect by through the conceptual lens of educational means of prototypes. It was precisely this transfer offers the theoretical foundations applied way of research in various Health for designing and applying this as of yet contexts that yielded interesting by-catch- vastly unexplored type of serious Games for es, which are visualized in orange in Figure Health. Fundamental to the Game Transfer 1. However, these by-catches are not merely Model, as introduced in this thesis, is the accidental and are thus to be understood as assumption that the external appearance Research through Design [1].

160 161 Pt I: Blue even in indie game development, very at- In Chapter 2, a systematic review was exe- The Layers in Serious Media Design frame- tractive and effective games are developed cuted through a literature search in medical work (LisMD) was developed in order to (Research for Design) at a fraction of the budget available for databases for game research specifically elucidate the design research process of the educational instrumentation in general. aimed at more abstract, non-literal games. Games and game-like interventions are gaming prototypes described in this thesis. From almost 20,000 articles on serious widely regarded as an important carrier of While an educational-scientific perspective This research explored a possibly novel ed- games for Health, we found 3 studies in learning and are even mentioned as a new is already represented by the GTM, which ucational angle on how learning and behav- which the designed games utilized non-lit- identifies a new route for design rationale, paradigm for e-learning. Although the use- ioral change can be embedded in a game. eral game elements. We found that in stud- the LisMD-framework works as a blueprint, fulness and possibilities of this technology Transfer theory offers an interesting start- ies on game-like interventions for Health a constructional plan of arrangements so are beyond dispute and there is sufficient ing point for this, in particular, the idea that and Health care, transfer is regarded merely to say, for creating a design research pro- support from scientific research, there is one can design specifically and intentionally as a desirable effect, not as a guiding prin- cess for serious game-like interventions. All no widespread use of games in Health. Of for learning to take place via a certain trans- ciple for design. None of the studies deter- the while, mutual values from both Health course, the acceptance of such media as a fer road. Serious games, in general, tend to mined the second class of transfer or in- Science and Design Practice are taken into serious educational instrument plays a role, be literal, preferably high fidelity simula- stances thereof. Games and simulations for account. but, certainly, in Health and Health care, tions of known reality. This literal approach Health abundantly build upon the principles truly meritable examples of serious games The findings of this thesis are of the utmost of games for Health relies, whether inten- of first-class transfer, but the adoption of are rare, apart from simulations for training importance for both designers of games for tionally or not, on (a form of) literal transfer. second-class transfer types proves scarce. purposes. There (as of yet) is no wide adop- Health as well as innovators in education Key for literal transfer to occur is the degree One of these 3 studies explained the design tion of games and game-like interventions because: a) these findings have deep im- of similarity of the simulation and the tar- rationale, the other studies did not describe within Health curricula. plications for enhancing the way in which geted context. Verisimilitude is conditional why or on what grounds this particular type instances of serious gaming can be more for its expected effectiveness. of game was chosen. It appears to be a wicked problem to design directly matched with specific educational or behaviour-changing goals, and b) these serious games that retain the unique and At the same time, this rationale excludes The question remains whether this pref- findings prove that there are many possi- motivational characteristics that make other forms of transfer, the so-called sec- erence for literal instantiations of serious bilities for enlarging the arsenal of serious games as a learning tool interesting in the ond-class transfer types, which could make games is a conscious one or that it is sim- games and game-like interventions within first place. From an analytical perspective, other, non-literal, manifestations of serious ply because of not considering or knowing the field of Health. Moreover, this thesis game research studies the successes of ma- games possible. Game types that do not alternative transfer types. In addition, the explicates the need for more attention to jor game titles and then concludes that our literally represent reality or lack an instant- proven one-sided transfer approach in the design research and abductive research own serious games have adopted a number ly recognizable link with reality, are rarely design of serious games for Health can be methods in Health curricula, in order to of characteristics, but lack the real look and considered as serious games for learning or regarded as an obstacle in the endeavor prepare for future challenges. feel of ‘a good game’. Development budget behavioral change. to embed serious content into a game: the is mentioned as an important factor for this, notorious) serious gaming oxymoron [2]. but that alone is not a tenable argument:

162 163 serious games and require a specific edu- Chapter 3 combines insights from various Figure 2: The Game Transfer Model links transfer types to instantiations of simulation, ranging between realisticness and metaphoricalness. cational perspective. It is important to point scientific disciplines (media and cognitive uncanny valley out that the notion of learning and especial- psychology, educational technology and LITERAL MIMETIC ly the transfer of learning to the target con- game design) to construct the Game Trans- realisticness text seems to be a steering mechanism in fer Model (GTM, Figure 2). This model forms the design of games or game-like interven- the theoretical framework and design hy- tions, and may be the cause of a one-sided pothesis for a number of prototypical game- approach in game design. This dissertation like interventions, in which experiments are is about the exploration and application conducted with design for figural transfer. conceptual continuity of precisely the counterpart of the known physical functional SIMULATION literal simulation of reality. Tailored to what ﬁdelity ﬁdelity needs to be learned, it can be an intentional Passage choice to opt for non-literal game design. An example of a metaphorical, abstract Educational science provides the theoretical game is Passage. Passage is a very mini-

TRANSFER psychological underpinnings for such an approach in the mally designed side-scroller game, which ﬁdelity form of transfer theory, where the various can be played in a few minutes. You are an forms of transfer of learning are divided avatar, who has to maneuver through a into a clear, literal way and a more difficult two-dimensional maze as your life unfolds. to capture abstract way. You become aware of the passage of time

metaphoricalness through decreasing vividness of colors, the FIGURAL ABSTRACT Figure 3: The protagonist a few moments before the death of his spouse. inﬁdelity Image: © Jason Rohrer, All Rights Reserved.

and curious quests. These games can be Loss of sense of time, loss of self-aware- considered serious when in-game actions ness and environment, heightened ability, or experiences are meaningful for the target control and agency, providing an autotelic context. Making these meaningful actions experience and suspension of disbelief are explicit often happens before or after play- coveted game features known from the lit- ing the game, which in literature is referred erature. These properties are linked to mo- to as the motivational or reinforcement tivational qualities, often found in imagina- paradigm [3]. Pre- or debrief sessions are an tive worlds, providing intriguing adventures essential part of the design of this type of 164 165 finding/marriage-and death- of a partner, the serious goals are achieved by a second class transfer. The awareness of the impor- As stated in Chapter 3, a key driver of suc- and your own external characteristics that class of transfer type. As proposed in the tance of and insight into one’s own lifting cess for a good serious game is conceptual indicate the dissipation of your life. All of theoretical exploration in Chapter 3, a pro- and moving behavior was triggered by figur- continuity. Congruence in fidelity types is this happens relatively quickly and you cess of metaphorical recontextualization al elements. In Chapter 5, the Design for therefore made conditional. To further become aware of it while playing. Due to the has been initiated for this purpose. In each Transfer rationale led to a design for a explore the possibilities of designing for fixed duration of the game and the player’s project, the essence of the issue at hand was game-like simulator for training social figural transfer, an experiment with a proto- steady aging, regardless of the in-game investigated and, together with content problem-solving skills in adolescents with a typical game-like simulator was conducted, choices, the game ends with the death of experts, possibilities for a non-literal ap- mild intellectual disability, as an addition to as described in Chapter 6. Magnifying the the avatar. In the game, the player spends proach were explored. In all cases, a design the field of psycho-education. A specific notion of low fidelity to a somewhat over- five minutes experiencing a character’s research approach was used to find the best characteristic of mild intellectual disability stated extent, this study deals with a ze- entire lifetime, but that is more than enough suitable metaphor for the target group in (MID) is that transfer of learning hardly ro-fidelity stimulator, building on existing to evoke a powerful emotional experience. question and the intended results. The occurs with this target group. Cause and theories about reducing fidelity. Usually, Passage is an example of a game without preservation of the described conceptual effect relationships are barely established fidelity is about abstracting all physical and high fidelity graphics, deliberately set up continuity to prevent fidelity dissonance was and lessons learned do not transfer to new functional elements. But there is a third very minimal, which nonetheless still main- fortuitous. The iLift game experience (Chap- contexts. Existing psycho-education is given type of fidelity, which forms the soul of the tains an immersive character. Although the ter 4) is designed to trigger figural transfer in a therapeutic setting, whereby transfer (in game experience: psychological fidelity. In game has not been designed as a serious of lifting and transfer techniques (LTTs) by whatever form) to the real-world context is the literature, psychological fidelity receives game, it does provide a number of lessons. offering a series of carefully chosen and taken for granted. The literature on MID significantly less attention, although it The reminder of life being volatile and thus calibrated metaphors. The game mechanics describes that abstractions (and therefore correlates strongly to credibility, suspen- the importance of being considerate to one scaffold the players’ in-game behavior: possibly metaphors) are too complex for this sion of disbelief, and engagement. The another within its relatively short span, static LTTs are recontextualized and repur- target group and that learning should take BABLR simulator reduces physical and perhaps even leading to a revaluation of posed in a game context. Within this replace in line with the world of perception as functional fidelity to a minimum (hence the one’s own existence are possible benefits search, we have been able to demonstrate much as possible. In the design, we maxi- label zero-fidelity) and explores the use of after playing. that, in terms of Health behavioral change mized authenticity and realism, not just in psychological fidelity as the main carrier of supporting systems (hBCSS), compliance the appearance of the presented video an authentic learning experience. Future and behavioral change have been realized. In cases, but also in timing and in the presenta- learning and meaningful experiences gained A game is a context is a metaphor retrospect, also driven by the course of the tion in the personal, non-therapeutic setting, within the zero-fidelity simulator can, due project, the gaming artifact has worked in a contributed to the optimization of transfer to the lack of both physical and functional In Chapters 4, 6 and 7, the Game Transfer blended transfer manner. The LTTs were conditions. Maintaining conceptual continui- fidelity, only be attributed to transfer via a Model (GTM) was used as a starting point for automated by repeatedly playing and mim- ty was key in the successful design for near figural, second class transfer type (high designing game-like interventions in various icking the actual necessary techniques in a transfer: a first class, literal transfer type. road, backward reaching). Chapter 7 de- contexts. In these design-oriented projects, true-to-life manner. Learning and behavioral scribes the design choices and theoretical GTM was applied to design games, wherein change are achieved by low road [4], first- constructs that have led to the development

166 167 of an occupational safety game, going by The main problem with the game was that texts, experiments were conducted with measure, mainly because it is never exactly the name Play it Safe. I was initially hesitant use context was not sufficiently taken into designing for figural transfer. Because of the clear when and in what form it will manifest to include this chapter in this dissertation account in the design -and thus recontextu- difficult to capture nature of transfer, it is itself. Measuring the effects of education is because the intended results were not alization- of the gaming artifact. The main usually measured on mere learning, some- therefore often limited to measuring mere achieved. In no way have any predictors of reason for the use of a metaphor was not thing that is often seen in serious games: learning, or ‘memory tests’ versus ‘different success been found, that could indicate the prompted by the desire to consciously de- the decontextualized offering of explicit learning experiences’ [6]. occurrence of transfer towards increased sign for a specific transfer type, but by the knowledge in a gamified form. These are the situational awareness. Nevertheless, the idea that a generic metaphor could be ap- games in which serious goals do not or The use of metaphor is a well-known didac- article is included, because the experiment propriate for all kinds of security issues. This hardly coincide with the systemic affor- tic principle, probably as old as humanity with designing for a second class transfer resulted in a game metaphor that was far dances of (good) games: the baby is thrown itself. The Greek word μεταφορά (meta- type has been of value in exploring the from recognizable to the intended end user, away with the bathwater, while we are left phorá) actually means ‘to carry over‘ or ‘to Game Transfer Model. Play it Safe is a tow- making it unrelatable to any context and with only mediocre games, that are margin- transfer’. A metaphor is a designed context er-defense game that uses situational data thus untransferable. This conclusion is an ally enjoyable to play. within which everything is connected, has collected by employees during their daily important lesson in intentionally designing meaning or within which truths are packed, work, to impact the parameters of the game. for non-literal transfer: the metaphor must If a serious game is seen as a context of its waiting to be discovered. A game can very This data is gathered through a safety bring together use context, user context, and own, designed to optimize transfer condi- well be such a designed context. campaign called Count Yourself Lucky (CYL) technology context [5] in a consistent whole tions, the serious goals must be meaning- to quantify the amount of times employees while addressing the right problem. fully recontextualized, whether or not in a used the supplied STAR-safety protocol metaphorical way. Monitoring conceptual Key findings (Stop Think Act Review). Play it Safe aimed In summary, it can be concluded that meta- continuity, carefully weighing up fidelity 1. In designing serious games or game- to improve employees situational aware- phorical recontextualization is effective as a types in accordance with the goals to be like interventions for Health, transfer ness, creating a shared mental model and design principle for designing serious achieved and a deliberate, predetermined of learning or skills is seen merely as bottom-up accountability, meant to improve games and game-like interventions for choice for the entertainment-educational a desirable outcome, not as a guiding and align shared safety behaviors. In the Health. An important notion is that learning blending paradigm , will lead to better principle to aim for. game, the real-life data for decision-making or behavioral change in such Health con- games. Introducing figural transfer in the 2. The intentional application of second encountered in the work environment is texts occurs through second class or trans- design of serious games hands the educa- class transfer does not occur in the recontextualized and was expected to fer types, and more specifically figural tionalist tools to explore new (or under-ex- design of serious games or game-like subconsciously reinforce the training of the transfer. The main reason for considering posed) ways to get serious content across artifacts in Health, which excludes the STAR-protocol and conservative deci- design for figural transfer in thinking about and enables game designers to integrate most immersive and successful game sion-making in real-life. serious game design is that it offers oppor- serious content in more playful ways. types. tunities for designing close to the nature of It is a known fact that transfer is difficult to what a game can be. In a number of con-

168 169 3. The occurrence of transfer of learning Pt II: Orange (Research Figure 4: The Re-Mission video game was created by HopeLab specifically for young cancer patients. is problematic to measure, which is why through Design) Image: © Realtime Associates / Hopelab, All Rights Reserved. tests are often limited to determining the presence of mere learning. The result The Game Transfer Model is a demonstrat- is that mere learning in serious games ed practicable addition to the discourse almost always results in literal or de- surrounding the design of serious games contextualized instantiations of serious for Health. In numerous conversations and games. presentations, the model has invariably been supported and approved, and the 4. The application of metaphorical recon- experiments from this thesis yield enough textualization is a complex and creative early predictors of success to justify further step in translating design choices into a research. However, in a hypothetical state, manifestation of the game-like artifact. it remains a theoretical construct, and thus Based on educational principles regard- without tangible implications. The aim of ing second class of transfer, the GTM this thesis is to assess the merits of the expands and advances the possibilities design hypothesis labeled Design for Trans- of serious game design for Health in fer in different Health contexts.Pt I of this accordance with the innate properties of chapter described these contexts and their video games. conclusions, pt II reports on a number of noteworthy by-catches, especially regard- 5. Moderators for triggering learning ex- ing the models developed to bridge the gap periences e.g. wishful identification, between Health and Design. parasocial interaction, narrative transportation, immersion and presence, flow Research and development of interactive experience, mastery of challenges, and digital Health interventions, like games for suspension of disbelief are particularly Health, require expertise in identifying user suited to be enhanced through abstract, needs, utilize abductive design techniques second class transfer game types. and call for the ability to appropriate pro- Chapter 2 describes a systematic review in Health, designed for children with leukemia. totypes towards proven effective interven- which examples were sought of the pres- Video-game play includes destroying can- tions. Two of the central areas of expertise ence of figural transfer in serious games cer cells and dealing with common treat- required are Health (broadly defined) and for Health. In advance of the review, we had ment-related adverse effects. The player Design Practice. In carrying out the experi- knowledge of the existence of the video controls the microscopical nanobot Roxxi ments, it turned out that these two worlds game Re-Mission [7]. Re-Mission is a well- to battle cancer in the body of a fictional still seem far apart. I will endeavor to illus- known example of a successful game for cancer patient. She does this by shooting trate this with an example. 170 171 bad cells with a chemo-blaster, using rock- tional elements are reduced and the focus Framework is placed in the design space of takes place in the Design Space is illustrated ets loaded with medicines, floating through is mainly on where the first version proved the LiSMD which monitors both the iterative by the Design Research Framework. This the lymphatic system. Re-Mission makes successful: boosting positive emotion, in- and incremental character as well as the gives further substance to the way in which obvious use of non-literal metaphors, and, creasing self-efficacy, and shifting attitudes required rigor-relevance balance within the design research informs the gradual build- from the perspective of this research, clear- toward chemotherapy. design research process. up of an artifact. Thirdly, LiSMD ensures that ly uses second class transfer in achieving known evidence-based knowledge is given its results. In a number of studies, the effect Although Health and Design share some In Chapter 6, LiSMD is presented in its a clear place in the design process. In line of the game is convincingly demonstrated, research methods and values, interdis- entirety and used within the BABLR context. with the serious intentions of the artifact especially in terms of increased therapy ad- ciplinary research invariably poses chal- In the previous contexts, initial ideas and to be designed, the active ingredients from herence and self-efficacy among the target lenges: values, assumptions, terminology, precursors of the framework have been an appropriate, existing Health intervention group. However, the studies on Re-Mission methodology, and culture make interdis- used. Chapter 8 is devoted to the difference did not surface in our systematic review, ciplinary collaborations challenging, often or theory form the starting point. However, in Health and Design culture and provides even after broadening the scope of the resulting in sub-optimal project outcomes the goal is not to provide a digital, game-like further substantiation for the LiSMD as search strategies. A closer look at the main [9]. Testing and validating, on and with the translation of an already existing, analog studies on Re-Mission showed a focus on shop floor, the Design for Transfer hypoth- an in-between object and an explanation approach, but to create a new artifact with the effects of the game. These were mea- esis, as conceptualized in the GTM in actual thereof. The LiSMD framework fulfills a an innovative approach to the issue at hand, sured by comparing them to a knowledge Health practice settings, required a common number of functions. First, it can be used as combining the critical appraisal from Health test in a control group: testing mere knowl- language necessary to get design research a means of communication, particularly to and the abductive character of Design. edge. A mentioned working ingredient for approach understood and accepted in the unite the world of Health and Design. Be- the expected effectiveness of the game was contexts of Health Innovation. sides the professional, cultural, and voca- In summary, the LiSMD model provides a found in the self-modeling theory [8], with- tional differences, there is an important dis- cross-domain perspective and overview of out further exploration of how this theory In an effort to address these aforemen- tinction in research philosophy. The LiSMD key areas for achieving an innovative and leads to the chosen design of the game. tioned differences, design through research places explorative, generative and evalua- effective artifact with serious intent. Besides Studies on Re-Mission do not describe why (orange track) resulted in the development tive research in its own spaces, each with the theoretical foundation and use of prac- the game looks as it does, nor do they give and application of an overarching model. its specific methods and position in a design tice-based evidence from the problem space, generalizable clues or design principles for Whereas the Game Transfer Model (GTM) research process. Secondly, the LiSMD can the model places focus on the design space, future serious games for Health. forges a specific, unexplored connection be used as a guideline in design research by between educational transfer theory and in which iterative and incremental design interpreting the layers in the spaces as (not Not explicating the design of Re-Mission, serious game design and is, therefore, a research works towards early predictors of necessarily consecutive) steps to be taken makes the chosen appearance of the inter- specific addition explicitating design ratio- success. This leads to a blueprint of an arti- vention, which has proven to be successful, nales within the design space, the Layers in the process. Documenting the methods fact which, besides being the carrier of the almost seem to be based on coincidence. in Serious Media Design is a framework for used and the subsequent findings per layer working ingredients in a new form, is also a This is obviously not the case since in the well-founded design, appropriation, ensures the explicitation and substantiation concept trialed on appropriateness and so- Re-mission 2, in the successor of the first integration, and testing of (digital) artifacts of the design process. The iterative and cial acceptance before entering the solution game, the purely knowledge-based educa- with serious intent. The Design Research incremental character of the research as it space. In this way, the artifact will be fitted to

172 173 uncanny valley

Figure 5: Layers in Serious Media Design (left) and its relation- LITERAL MIMETIC realisticness ship with Design Research Framework (right)

& Game Transfer Model (top right). conceptual continuity

physical functional SIMULATION ﬁdelity ﬁdelity E ect

TRANSFER psychological ﬁdelity SOLUTION SPACE Evidence based Practice Pattern of Use

metaphoricalness Evaluative Research FIGURAL ABSTRACT Intervention inﬁdelity

Generative Research Generative Choices design gap Working Theory (WT)

Supporting Theories (ST) PROBLEM SPACE Practice based Evidence

Design Principles (DP) Explorative Research Explorative

174 175 meet the serious objectives and the chance abductive reasoning, and a designer’s attention is devoted to the matter in current portance stature, however when it comes to of an effective intervention will be optimized. mindset are competencies that belong to curricula. en lijkt niet een punt van aandacht designing and innovating within Health con- All this offers a new understanding of what is the Health professional of the future. in huidige curricula. The values of Design are texts, these values are decidedly constrain- now called implementation. more easily understood when taking into ing in their effect, rather than conducive. The 4. Studies on proven effective games or account the contexts of, for example, the fact of the matter is that almost no attention game-like interventions for Health development of serious games for Health or at all is devoted to explicating the design should explicate their design rationale, e-Learning purposes. Especially considering rationale behind serious games for Health. Key findings so generalizable design knowledge be- the ageing nature of our world’s population comes usable for future G4H. Successful and an ever increasing reliance on (health) So long as scientific publications constrain 1. LiSMD offers a framework within game-like interventions are the result technology, values of design are ever more their area of research to solely the question which shared language, perspectives of a well-executed design research indispensable in the process theorizing of effect, rather than the preliminary design on research and design practices are process, from which lessons must be about future proof Healthcare. of serious games, knowledge regarding combined and can, therefore, play a learned to advance the field of Health effectively designing serious games will supporting role in (the discourse on) de- Innovation. As addressed in Chapter 6, problem-based remain marginal and insufficient. However, sign-oriented research processes aimed learning, defined as learning that results this dissertation’s message reaches further at designing artifacts with a serious from the process of working toward the than just the specific practicalities regard- approach, such as games for Health or Future work understanding or resolution of a problem ing serious games within the field of Health. digital innovations in general. [11], offers leads. Exposing Health students What has been described here about the 2. Especially design-in-the-large is lacking ‘Designerly ways of knowing’ may sound in multidisciplinary teams to authentic and matter of serious gaming is a symptom of in Health innovation projects, where im- insubstantial, but is exactly what Health ill-defined activities concerning design a far larger problem of negligence toward plementation often replaces the crucial culture should be looking at in its search issues with real-world relevance [12] may those skill sets and insights that derive from phase of social system development. So- for innovation through serious digital in- connect problem-based learning principles outside Health research itself. Therefore cial system development within Health terventions. Health research has a rich to design research. this thesis also serves as a call to action innovation aiming for artifact devel- history in the sciences: studying the natural for all those working on development and Furthermore, it must be concluded that innovation (of educational and technological opment should be an integral part of a world with profound cultural values such as objectivity, rationality, neutrality, and a Health, when regarded as a subculture in (products/mediums/media)), to be receptive design process for successful adoption. concern with truth. Values of Design can be and of itself, has now reached a crossroads to insights from other fields of study, that 3. Designers of Health curricula and profound in practicality, ingenuity, empathy, where it must either choose the path of might at first seem strange and startling, fessionals in the field of Health innova- and concern for appropriateness [10]. In complacency toward its long-established but in the end may very well have a great tion are called upon to pay attention to order to master these values and appropri- habits, protocols and lines of thinking, or, chance of sparking much needed innova- a cross-domain perspective. In partic- ate research methods, the manner in which instead of opting for a remissive attitude tion. Through the experiences of the exper- ular, the introduction and use of design people are educated is just as important toward positive change, choose the path iments conducted in this dissertation, it has research for achieving innovation and as the matter which is transferred. The of innovative thinking. Of course, it can not become clear that one one must be wary of finding solutions for wicked problems above is in itself a wicked problem for fu- be denied that Health’s rich history and its too easily conforming to currently prevailing require attention. Creative confidence, ture Health education, however insufficient ingrained values are of unmistakable im- lines of thinking with regards to education 176 177 and research, as they are rigid obstacles on sibilities from high-fidelity simulations to created and should be included to find more the way toward progress. metaphorical fantasy worlds. The latter targeted application areas. is important because it can substantially Another suggestion that may be helpful in expand the possibilities of serious game Another question is whether metaphori- thinking about, designing, and embedding design and is more compatible with the cal recontextualization suits every target game-like artifacts and serious games for innate properties of a video game. By means group, especially if it seems to concern Health is to see innovative attempts to this of game-like prototypes, the design hypoth- metacognitive skills in particular. The as- end as boundary objects. Even though there esis that meaningful play can be achieved sumption at the time of writing is that this is are different theories about what boundary by designing for figural transfer by the use not the case. Further consideration should objects are and how they work [13],[14], of metaphorical recontextualization was be given to appropriate transfer types in the idea that a shared object gets signified tested. The experiments proved that these respect of characteristics of the receiving from different activity systems, promotes so-called second class of transfer types target group. dialogue and mutual understanding. Fu- of games can actually lead to learning or ture research should focus on whether the behavioral change, but at the same time Finally, it remains necessary to further test LiSMD framework in its current state fulfills revealed a number of contextual prerequi- the GTM in several Health projects, prefera- its role as a boundary object or whether it sites. Conditional for a successful learning bly in studies in which prototypes - in terms should be refined by further trials in a novel experience in a nonmimetic game-like of the LiSMD- reach the solution space. Here context. Yet, I would like to conclude this environment is the preservation of in-game we will be able to determine whether the point with the title of Chapter 8: don’t jump conceptual continuity defined by the con- early predictors of success from the design to conclusions, and to approach this subject gruence of fidelity-elements, which em- space actually result in user patterns with as a design issue itself, a wicked problem. phasizes the importance of the quality and associated data and lasting learning effects. The fact that the design research frame- inventiveness of the game design itself. work, as used and discussed in this disser- Game on. tation, is based on a specific educational Further research is needed into the classi- design model [15], could serve this purpose. fication of what can and cannot be learned through second class transfer games Then, for future research into design for for Health. Creative problem-solving ap- transfer, there are a number of distinct proaches, decision making, lateral thinking, research directions to formulate. This dis- solution-oriented learning, identity devel- sertation explains and substantiates how opment, and cognitive self-regulation are design for transfer can be seen in literal promising concepts for figural manifesta- and figural game instantiations. The Game tions in games for Health and game-like Transfer Model (GTM) is introduced as a simulations, but this is by no means a means for designing and thinking about comprehensive list. A mapping to specific serious game design, stretching the pos- medical and Health topics has not yet been

178 179 References

1. Frayling C. The Crafts in the 1990s [Internet]. Journal of Art & Design Education. 1990. pp. 91–100 doi:10.1111/j.1476-8070.1990.tb00755.x 2. Abt CC. Serious Games. University Press of America; 1987. 3. Ritterfeld U, Cody M, Vorderer P. Serious Games: Mechanisms and Effects. Routledge; 2009. 4. Salomon G, Perkins DN. Rocky Roads to Transfer: Rethinking Mechanism of a Neglected Phenomenon [Internet]. Educational Psychologist. 1989. pp. 113–142. doi:10.1207/s15326985ep2402_1 5. Oinas-Kukkonen H, Harjumaa M. Persuasive Systems Design: Key Issues, Process Model, and Sys- tem Features [Internet]. Communications of the Association for Information Systems. 2009. doi:10.17705/1cais.02428 6. Bransford JD, Schwartz DL. Chapter 3: Rethinking Transfer: A Simple Proposal With Multiple Implications [Internet]. Review of Research in Education. 1999. pp. 61–100. doi:10.3102/0091732x024001061 7. Website [Internet]. [cited 12 Apr 2019]. Available: Website [Internet]. [cited 11 Dec 2018]. Available: HopeLab, TRI, Realtime Associates. Re-Mission. Palo Alto, CA: HopeLab; 2004. Available at: www.re-mission.net/site/ game/ index.php. Accessed June 16, 2008 8. Dowrick PW. A review of self modeling and related interventions [Internet]. Applied and Preventive Psychol- ogy. 1999. pp. 23–39. doi:10.1016/s0962-1849(99)80009-2 9. Blandford A, Gibbs J, Newhouse N, Perski O, Singh A, Murray E. Seven lessons for interdisciplinary research on interactive digital health interventions. Digit Health. 2018;4: 2055207618770325. 10. Cross N. From a Design Science to a Design Discipline: Understanding Designerly Ways of Knowing and Thinking. Design Research Now. pp. 41–54. 11. Savery JR. Overview of Problem-based Learning: Definitions and Distinctions. Interdisciplinary Journal of Problem-Based Learning. 2006;1. doi:10.7771/1541-5015.1002 12. Herrington J, Oliver R, Reeves TC. Patterns of engagement in authentic online learning environments. Aus- tralasian Journal of Educational Technology. 2003;19. doi:10.14742/ajet.1701 13. Star SL, Griesemer JR. Institutional Ecology, `Translations’ and Boundary Objects: Amateurs and Profes- sionals in Berkeley’s Museum of Vertebrate Zoology, 1907-39 [Internet]. Social Studies of Science. 1989. pp. 387–420. doi:10.1177/030631289019003001 14. Engeström Y. Expansive Learning at Work: toward an activity theoretical reconceptualization [Internet]. Journal of Education and Work. 2001. pp. 133–156. doi:10.1080/13639080123238 15. Tripp SD, Bichelmeyer B. Rapid prototyping: An alternative instructional design strategy [Internet]. Educa- tional Technology Research and Development. 1990. pp. 31–44. doi:10.1007/bf02298246z

180 181 Hoofdstuk 10: Nederlandse samenvatting, Conclusies en Perspectief

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182 183 Epitoom Twee sporen In de literatuur over serious games wordt digitale serious Games for Health (GfH) nog realiteit, bestaan er games van een andere Figuur 1 toont de twee sporen die door dit vaak gerefereerd aan de serious game oxy- steeds als veelbelovend gezien, maar is de aard en verschijningsvorm, games waarin proefschrift lopen. De blauwe route gaat moron. Een oxymoron is een uit het Grieks inzet ervan in onderwijs geen gemeengoed. figuratieve, metaforische contexten dragers over de verkenning, conceptualisering en afgeleide stijlfiguur waarbij twee woorden Specifieker: de digitale games en game-like zijn van de game ervaring. Het is dit type toepassing van transfertheorie in het ont- worden gecombineerd die elkaar in hun interventions binnen Health die wel ingezet game dat vaak aangehaald wordt om de werp van games en game-achtige inter- letterlijke betekenis tegenspreken, hier oxus worden, zijn veelal simulaties, waarin gelijke- serious gaming belofte voor leren en ge- venties met betrekking tot uiteenlopende (scherp) en mōros (stomp). Abt (1970) was nis met de werkelijkheid voorwaardelijk lijkt. dragsverandering te onderstrepen. serieuze doelen in Health contexten. Het zijn de eerste die de serious game als oxymoron de bevindingen en conclusies uit het blauwe typeerde, vanwege de spanning in het na- Dit proefschrift vertrekt vanuit de stelling- In een systematic review binnen medische spoor (Research for Design) die de kern van streven van serious goals met een inherent name dat deze, al dan niet bewuste, design databases is vastgesteld dat games van dit proefschrift vormen. niet-serieus medium. Bijna 50 jaar aan on- rationale de serious game oxymoron mede deze laatste categorie vrijwel niet voorko- derzoek later worden de eigenschappen van in stand houdt. Naast deze voornoemde men in de Health context. Voortbouwend Voor het uitvoeren van de experimenten is en bijbehorende kansen voor leren middels simulaties van een letterlijke, herkenbare hierop, biedt het redeneren in termen van een eigen design research proces doorlopen onderwijskundige transfer een theoretische om meerdere varianten van de game-like basis voor het ontwerpen en toepassen van interventies te onderzoeken op geschiktheid Figuur 1: een schematisch overzicht van de hoofdstukken van dit proefschrift en hun onderlinge samenhang. dit onontgonnen type serious games for en effect door middel van prototypes. Juist Health. De gedachte dat de verschijnings- deze toegepaste manier van onderzoek in vorm (het ontwerp zelf) van de serious verschillende Health contexten leverde game een voorafschaduwing is van het interessante bijvangsten op, aangeduid in verwachte transfer type waarmee de game Figuur 1 met het oranje spoor. Deze bijvang- effectief zou moeten zijn, vormt de basis sten zijn echter niet toevallig en worden op- van het Game Transfer Model (GTM), zoals gevat als resultaten van Research through geïntroduceerd wordt in dit proefschrift. In Design [1]. een 4-tal studies is het design for transfer perspectief leidend geweest voor het ont- Om het doorlopen design research pro- werp van serious gaming prototypes voor ces van de in dit proefschrift beschreven Health met een niet-letterlijk karakter. prototypes inzichtelijk te maken, is het Layers in Serious Media Design framework (LiSMD) ontwikkeld. Waar het GTM vanuit een onderwijskundig perspectief een

184 185 nieuwe design rationale expliciteert, biedt deze technologie niet betwijfeld wordt en Dit onderzoek verkent een mogelijk nieuwe Hoofdstuk 2 beschrijft een systematic re- het LiSMD-framework een inrichting voor er voldoende steun vanuit wetenschappelijk educatieve invalshoek over hoe leren en view, uitgevoerd binnen medische databa- een design research proces voor serious onderzoek blijkt, is brede inzet van games gedragsverandering in een serious game ses, naar specifiek abstracte, niet-letterlijke game-like interventions, met inachtneming for Health geen gemeengoed. Natuurlijk kunnen worden ingebed. Transfertheorie games of game-like interventies. Uit bijna van wederzijdse waarden vanuit Health speelt de acceptatie van dergelijke media biedt hiervoor een interessant uitgangs- 20.000 artikelen over serious games for Science en Design Practice. als educatief instrument een rol, maar, punt. In het bijzonder het idee dat een game Health vonden we drie studies naar serious zeker in Health zijn er, afgezien van simu- bewust ontworpen kan worden om via een games met een niet-letterlijke weergave De bevindingen in dit proefschrift zijn van laties voor opleidingsdoeleinden, zelden bepaald transfertype serieuze doelen te van de werkelijkheid. Verder laat deze studie belang voor ontwerpers van serious games aansprekende voorbeelden te vinden van bereiken. Serious games in het algemeen zien dat in artikelen over game-like inter- voor Health en onderwijsinnovators omdat: serious games. Er is geen sprake van een zijn vaak letterlijke games, bij voorkeur high venties for Health, transfer wordt gezien als a) serious gaming instantiaties gericht ge- brede adoptie van games en game-achtige fidelity simulaties van de gekende werkelijk- een wenselijk effect, niet als een uitgangs- koppeld kunnen worden aan specifieke leer- interventies binnen Health curricula. heid. Deze letterlijke benadering van games punt voor het ontwerp ervan. Er blijkt uit en/of gedragsverandering vraagstukken, en for Health berust, al dan niet bewust, op een geen van de studies een bewuste keuze voor dat b) het arsenaal van in te zetten serious Het lijkt een wicked problem om serious (een vorm van) literal transfer. De sleutel gebruik van de zogenaamde tweede klasse games en game-like interventies binnen games te ontwerpen die de unieke en mo- voor literal transfer is de mate van gelijkenis transfertypes, de categorie waarbij transfer Health educatie aanmerkelijk vergroot kan tiverende eigenschappen behouden die van de simulatie met de beoogde doel con- op een niet-letterlijke wijze verloopt. Games worden. Daarnaast vraagt dit proefschrift games als leermiddel interessant maken. text: natuurgetrouwheid is dan voorwaar- en simulaties for Health leunen wat betreft ruimte voor design research en abductieve Vanuit een analytisch perspectief bestu- delijk voor de verwachte effectiviteit. verwachte effectiviteit op de condities voor onderzoekstechnieken in Health curricula deert wetenschappelijk game-onderzoek transfer uit de eerste klasse transfertypes: om toekomstige uitdagingen het hoofd te de successen van grotere speltitels en Deze redenering lijkt dominant in het denken de adoptie van tweedeklas transfertypes kunnen bieden. concludeert dat serious games een aantal over de verschijningsvorm (instantiaties) blijkt schaars. Eén van de drie gevonden kenmerken hebben overgenomen, maar niet van games for Health. Wat zou er gebeuren studies met een niet-letterlijke serious de echte look en feel van ‘een goed spel’ als andere vormen van transfer, uit de zoge- game benadering heeft de design rationale hebben. Ontwikkelingsbudget wordt ge- naamde second class transfertypes, ingezet toegelicht. De overige studies beschrijven Deel I: Blauw noemd als een belangrijke factor hiervoor, worden die andere, niet-letterlijke uitingen niet waarom of op welke gronden voor een (Research for Design) maar dat is niet altijd een houdbaar argu- van serious games mogelijk zouden maken? specifieke ontwerp is gekozen. ment: zelfs bij de ontwikkeling van indie Game-types die niet letterlijk de werkelijk- De vraag is of deze voorkeur voor letterlijke Games en game-like interventies worden in games worden aantrekkelijke en effectieve heid vertegenwoordigen of niet een direct instantiaties van serious games een bewus- het algemeen gezien als een kansrijke rich- games ontwikkeld tegen een fractie van het herkenbare link met de werkelijkheid heb- te rationale kent of dat deze voortkomt uit ting voor leren, en worden zelfs getypeerd beschikbare budget voor educatieve instru- ben, worden zelden overwogen als serious het niet kennen of overwegen van alterna- als een nieuw paradigma voor e-learning. menten in het algemeen. games voor leer- of gedragsverandering tieve transfertypes. Daarnaast kan de in dit Hoewel het nut en de mogelijkheden van

186 187 werelden, met fascinerende narratieven en van de meestal ingezette, letterlijke simu- Figuur 2: Het Game Transfer Model koppelt transfertypes aan verschijningsvormen van simulatie, lopend van werkelijkheidsgetrouw tot metaforisch. uitdagende quests. Deze games kunnen als latie van de werkelijkheid en stelt dat, afge- uncanny valley serious worden gezien op het moment dat stemd op wat en door wie er geleerd moet handelen, gedrag of opgedane ervaringen worden, het een bewuste ontwerpkeuze kan LITERAL MIMETIC realisticness in de game betekenisvol zijn voor de doel zijn om te kiezen voor een niet-letterlijke in- context. Het expliciteren van deze beteke- stantiatie van een serious game. Onderwijs- nisvolle acties wordt voor of na het spelen kundige transfertheorie ondersteunt deze van een game gedaan, en wordt getypeerd designbenadering door het onderscheid in als het motivational of reinforcement pa- letterlijke en figuurlijke vormen van transfer. conceptual continuity radigma [3]. Pre- of debrief sessies vormen

SIMULATION hierbij een essentieel onderdeel van het In Hoofdstuk 3 worden inzichten vanuit physical functional fidelity fidelity ontwerp van de game en vragen een edu- verschillende wetenschappelijk disciplines catieve inbedding. Het is belangrijk om erop (media- en cognititieve psychologie, toege- te wijzen dat de opvatting over hoe het paste onderwijskunde, game design rese- geleerde transfereert naar een doel context arch) samengebracht in het Game Transfer TRANSFER psychological fidelity een sturend mechanisme lijkt te zijn bij het Model (GTM, Figuur 2). Dit model vormt het ontwerpen van games of game-achtige in- theoretische framework en tevens de de- terventies. Daarmee houdt het verband met sign hypothese onderliggend aan een aantal de eenzijdige aanpak bij het ontwerpen van prototypische games en game-achtige games. Dit proefschrift gaat over het ver- interventies, waarmee experimenten zijn metaphoricalness kennen en toepassen van de tegenhanger uitgevoerd met design voor figural transfer. FIGURAL ABSTRACT infidelity Figuur 3: De protagonist, enkele momenten voor het verliezen van zijn partner. Afbeelding: © Realtime Associates / Hopelab, All Rights Reserved. hoofdstuk aangetoonde eenzijdige trans- controle en zelfstandigheid, het bieden van ferbenadering in het ontwerp van serious een autotelische ervaring en het fenomeen games for Health worden beschouwd als suspension of disbelief (het toelaten van een obstakel in het streven om serious con- de verbeelding) zijn zeer gewenste, door tent in een game te verankeren: de beruchte wetenschap toegedichte, kenmerken van serious gaming oxymoron [2]. games. Deze eigenschappen zijn gekoppeld aan motivationele aspecten en worden Het verliezen van tijds-, zelf- en omge- vaak aangetroffen in games waarin spelers vingsbewustzijn, verhoogde vaardigheden, ondergedompeld worden in imaginaire 188 189 Passage Een game is een context is een aantonen dat, in termen van Health Behavi- zoveel mogelijk in lijn moet liggen met de oral Change Supporting Systems (hBCSS), eigen belevingswereld. In het ontwerp Een goed voorbeeld van een game met metafoor compliance en behavioral change zijn opge- hebben we daarom de transfer condities een metaforische, abstracte vormgeving treden. In retrospectie, mede door het ver- geoptimaliseerd door te streven naar een zo is Passage. Passage is een side-scroller In Hoofdstuk 4, 6 and 7 wordt het Game loop van het project, heeft het gaming authentiek en realistisch mogelijke game. game, met een zeer minimale vormgeving, Transfer Model (GTM) gebruikt als uitgangs- artifact niet door louter figural transfer De gebruikte video cases waren zeer realis- en slechts een speeltijd van een paar mi- punt voor het ontwerpen van game-like effect gesorteerd, maar was er sprake van tisch qua toon, avatars en scenario. Ook de nuten. In het spel ben je een avatar, die interventies in verschillende Health contex- blended transfer. De LTTs werden door het timing van het aanbod via de eigen mobiele zich een weg moet proberen te vinden door ten. In deze projecten is het GTM gebruikt herhaaldelijk spelen op een natuurgetrouwe telefoon in de persoonlijke, niet-therapeuti- een tweedimensionaal doolhof. Tijdens het met als doel de beoogde serious goals te wijze geautomatiseerd, waardoor sprake sche setting droeg bij aan de transfer condi- spelen dringt langzaam het besef door dat behalen middels tweede klasse transferty- was van low road [4], first-class transfer. tie. Het behoud van de conceptual continuity je leven verstrijkt. Kleuren worden fletser, je pes. Zoals geïntroduceerd in Hoofdstuk 3, is Het bewust worden van het belang van het stond centraal in het succesvolle ontwerp ontmoet en verliest een partner en je eigen metaforische recontextualisatie hiertoe toepassen van de juiste LTTs voor de eigen voor near transfer: een first class, literal lichaam vertoont steeds meer uiterlijke ingezet. In ieder experiment is, samen met gezondheid, werd getriggerd door figural transfertype. content experts, getracht de essentie van kenmerken van aftakeling. Dit alles voltrekt elementen. In Hoofdstuk 5 heeft de Design het leer- of gedragveranderingsvraagstuk zich erg snel en je hebt nauwelijks tijd om te for Transfer rationale geleid tot een ont- Zoals vermeld in Hoofdstuk 3, is conceptual begrijpen wat je aan het overkomen is. Door te vangen om vervolgens de mogelijkheden werp voor een game-achtige simulator voor continuity een belangrijke succesfactor voor de vooraf bepaalde speeltijd en de conti- voor een niet-letterlijke aanpak te explore- het trainen van sociale- en probleemoplos- een goede serious game. Congruentie in nue degradatie van de avatar, eindigt het ren. In alle studies is een design research sende vaardigheden bij adolescenten met fidelity types is daarbij voorwaardelijk. Om spel, los van de keuzes van de speler, in een aanpak gebruikt, onder andere voor het een lichte verstandelijke beperking, als de mogelijkheden van het ontwerpen voor onvermijdelijke dood. In het spel doorloopt ontwerpen van de best passende metaforen aanvulling op de bestaande psycho-educa- figural transfer verder te onderzoeken, is de speler in slechts 5 minuten de gehele voor de betreffende doelgroep en beoogde tie. Een specifiek kenmerk van een lichte een experiment met een prototypische levensloop van de avatar, maar dit blijkt doelen. Het bewaren en streven van de in dit verstandelijke beperking (MID) is dat trans- game-achtige simulator uitgevoerd, zoals hoofdstuk beschreven conceptual continuity ruim voldoende voor een heftige emotionele fer (van leren) bij deze doelgroep nauwelijks beschreven in Hoofdstuk 6. Deze studie, die reactie op het ervarenere. Passage is een ter voorkoming van fidelity dissonance was optreedt. Oorzaak-gevolg relaties worden de grenzen van de inzet van low fidelity voorbeeld van een spel dat bewust met mi- voorwaardelijk. De iLift game ervaring nauwelijks gelegd en eventueel geleerde opzoekt, gaat over een zero-fidelity stimu- nimale middelen maximale impact bereikt. (Hoofdstuk 4) is ontworpen voor zorgpro- lessen transfereren niet naar nieuwe con- lator, voortbouwend op bestaande theorie- Ook al is deze game niet ontworpen als een fessionals om via figural transfer til- en texten. Bestaande psycho-educatie wordt ën over het reduceren van fidelity. Meestal serious game, het draagt wel degelijk een verplaatsingstechnieken (LTTs) aan te leren gegeven in een therapeutische setting, gaat fidelity over het abstraheren van fysie- aantal lessen in zich. De betrekkelijkheid middels een zorgvuldig geconstrueerde en waarbij transfer (in welke vorm dan ook) ke en functionele elementen. Maar er is nog van het leven, het belang en waarderen van gekalibreerde metafoor. De game begeleidt naar de doel context als vanzelfsprekend een derde vorm van fidelity, die het hart van de ander nu het nog kan, en zelfs een diepe en ondersteunt de spelers’ in-game (be- wordt beschouwd. De literatuur over MID de spelervaring vormt: psychologische reflectie op het huidige leven worden ge- weeg)gedrag door het aanbieden van recon- beschrijft dat abstracties (en dus mogelijk fidelity. In de literatuur krijgt psychologi- textualiseerde statische LTTs in een nieuwe noemd als belangrijke resultaten. metaforen) te complex zijn voor deze doel- sche fidelity beduidend minder aandacht, context. In dit onderzoek hebben we kunnen groep om te doorgronden en dat het leren hoewel het sterk samenhangt met het

190 191 verliezen van tijds-, zelf- en omgevingsbe- vloer) die door werknemers tijdens hun waardoor het geen relatie had met de begeerlijke eigenschappen om games te wustzijn en het ervaren van suspension of dagelijks werk zijn verzameld om de para- situationele data, noch met de doelcontext overwegen als tool) van games, resulterend disbelief. De BABLR simulator reduceert meters van het spel te beïnvloeden. Deze en daarmee niet-transferabel. Deze con- in onnatuurlijk aanvoelende games. fysieke en functionele fidelity tot een mini- gegevens werden verzameld door middel clusie vormt een belangrijke les in het mum (vandaar de term zero-fidelity) en van een veiligheidscampagne genaamd ontwerpen voor niet-letterlijke transfer: de Als een serious game wordt opgevat als een verkent het gebruik van psychologische Count Yourself Lucky (CYL), waarmee het metafoor moet gebruiks-, gebruikers- en context in zichzelf, moeten de serious goals fidelity als de voornaamste facilitator van aantal keren dat medewerkers het meege- technologische context [5] samenbrengen op een betekenisvolle manier worden gere- een authentieke leerervaring. Opgedane leverde STAR-veiligheidsprotocol (Stop in een consistent geheel en daarbij het contextualiseerd met geoptimaliseerde leerervaringen binnen de zero-fidelity Think Act Review) inzetten, zijn gekwantifi- juiste vraagstuk adresseren. transfercondities, al dan niet op een metafori- simulator kunnen, door het gebrek aan ceerd. Play it Safe richtte zich op het verbe- sche wijze. Het bewaken van de conceptual zowel fysieke als functionele fidelity, alleen teren van het situationeel bewustzijn van Samenvattend kan worden geconcludeerd continuity, het zorgvuldig afwegen van fidelity worden toegeschreven aan transfer via een werknemers, het creëren van een gedeeld dat metaforische recontextualisatie effec- types in overeenstemming met de te bereiken figural, tweedeklas transfertype (high road, mentaal model en aanzetten tot bottom-up tief is als ontwerpprincipe voor het ontwer- doelen en een bewuste, vooraf bepaalde backward reaching). verantwoording, veiligheidsgedrag te pen van serious games en game-like inter- keuze voor het entertainment-educational verbeteren en dit op elkaar te laten af- venties voor Health. Een belangrijke notie blending paradigm [3], zal leiden tot betere Hoofdstuk 7 beschrijft de ontwerpkeuzes stemmen. In het spel wordt real-life data hierbij is dat leren of gedragsverandering serious games. De introductie van figural en het theoretisch construct onderliggend voor besluitvorming in de werkomgeving plaatsvindt middels second class transfer transfer in het ontwerp van serious games aan de ontwikkeling van een serious game gerecontextualiseerd, met de aanname dat types, specifiek via figural transfer. De geeft vanuit onderwijskundig perspectief een voor veiligheidsbewustzijn op de werk- de training van het STAR-protocol en resul- belangrijkste reden voor het overwegen van nieuwe (of onontgonnen) wijze om serious vloer, genaamd Play it Safe. In eerste in- terende besluitvorming in de praktijk onbe- design voor figural transfer in het denken content te benaderen en stelt game designers stantie aarzelde ik om dit hoofdstuk in dit wust zou worden versterkt. over serious game design is dat het moge- in staat om serious content op een meer proefschrift op te nemen omdat de beoog- lijkheden biedt om dicht bij de aard van wat game-eigen manier te integreren. de resultaten niet zijn behaald. Er zijn geen Het grootste probleem met het spel was een game kan zijn te ontwerpen. In een Het is bekend dat transfer moeilijk te meten vroege voorspellers van succes gevonden dat de gebruiks- en gebruikerscontext aantal Health contexten zijn experimenten is, vooral omdat het nooit precies duidelijk is die kunnen wijzen op het optreden van onvoldoende gekend is in het spelontwerp uitgevoerd met game ontwerpen gericht op wanneer en in welke vorm het zich zal transfer vanuit in-game acteren naar een en dus in de recontextualisering richting figural transfer. Omdat (het optreden van) manifesteren. Het meten van de effecten vergroot situationeel bewustzijn bij de het gaming artefact. De belangrijkste reden transfer moeilijk meetbaar is, wordt deze van onderwijs beperkt zich daarom vaak tot kandidaten. Toch is het artikel opgenomen, voor het gebruik van een metafoor werd vaak gemeten aan de hand van mere know- het meten van louter leren, of ‘geheugen- omdat het experiment met het ontwerpen niet ingegeven door de wens om bewust te ledge (in de vorm van expliciete, reprodu- tests’ versus ‘verschillende leerervaringen’ voor een tweede klasse transfertype van ontwerpen voor een specifiek transfertype, ceerbare kennis), veel voorkomend in se- [6]. waarde is geweest voor het bereik van het maar door het idee dat een generieke rious games: het gedecontextualiseerd Game Transfer Model (GTM). Play it Safe is metafoor geschikt zou kunnen zijn voor aanbieden van expliciete kennis in een Het gebruik van een metafoor is een bekend een tower-defense game die gebruik maakt allerlei beveiligingsvraagstukken. Dit re- gamified vorm. Dit zijn de games waarin didactisch principe en waarschijnlijk zo oud van situationele gegevens (waargenomen sulteerde in een spelmetafoor die voor de serious goals niet of nauwelijks samengaan als de mensheid zelf. Het Griekse woord mogelijke onveilige situaties op de werk- eindgebruiker verre van herkenbaar was, met de systemic affordances (inherent μεταφορά (metafoor) betekent eigenlijk

192 193 ‘over te dragen’ of ‘te overbruggen’. Een tieve stap in het vertalen van ontwerp- Figuur 4: De Re-Mission video game gemaakt door HopeLab, gericht op jonge kankerpatienten. metafoor is een ontworpen context waarin keuzes naar een manifestatie van het Afbeelding: © Realtime Associates / Hopelab, All Rights Reserved. alles met elkaar verbonden is, betekenis game-like artefact. Gebaseerd op onder- heeft en waarin waarheden zijn verpakt, in wijskundige uitgangspunten met betrek- afwachting van verkenning of ontdekking. king tot second class transfer, breidt het Een game leent zich er bij uitstek voor om Game Transfer Model de mogelijkheden een dergelijke, ontworpen context te zijn. van serious game design for Health uit met een type games wat ontworpen kan worden met behoud van inherente ei- Key findings genschappen van het medium zelf. 1. Bij het ontwerpen van serious games of 5. Moderators voor het triggeren van game-like interventies for Health wordt leerervaringen zoals wishful identifi- de transfer van kennis of vaardigheden cation, parasocial interaction, narrative slechts als een wenselijk effect gezien, transportation, immersion en presence, niet als een leidend principe om naar te flow experience, mastery of challenges streven. en suspension of disbelief zijn bijzonder 2. De bewuste inzet van second class geschikt om te worden gefaciliteerd door transfer komt niet voor bij het ontwer- abstracte, second class transfer games. pen van serious games of game-like artefacten in Health, waardoor de meest immersieve en succesvolle speltypen Deel II: Orange (Research worden uitgesloten. 3. Het optreden van transfer van leren is through Design) problematisch om te vast te stellen, Het Game Transfer Model (GTM) biedt een daarom zijn effectmetingen vaak beperkt aantoonbaar praktische aanvulling op het tot het vaststellen van mere learning. discours rond het ontwerp van serious Om dat te kunnen faciliteren, vindt het games for Health. De experimenten uit dit leren in serious games bijna altijd plaats zonder tastbare implicaties. Het doel van dit over bijvangsten, in het bijzonder met betrek- proefschrift resulteren in voldoende vroege in letterlijke of gedecontextualiseerde proefschrift is om de waarde van de design king tot de modellen die ontwikkeld zijn om de voorspellers van succes om verder onder- instantiaties van serious games. for transfer-ontwerphypothese in verschil- kloof tussen Health en Design te overbruggen. zoek te rechtvaardigen naar de inzet en lende Health contexten te beoordelen. 4. De toepassing van metaforische recon- consequenties ervan. In hypothetische vorm van dit hoofdstuk beschrijft deze con- Onderzoek en ontwikkeling van interactieve textualisatie is een complexe en crea- Deel I blijft het echter een theoretisch construct, texten en hun conclusies, Deel II rapporteert digitale gezondheidsinterventies, zoals

194 195 games for Health, vereisen expertise in het met behulp van met medicijnen geladen Door het niet expliciteren van het ontwerp work (LiSMD, Figuur 5). Waar het Game identificeren van gebruikersbehoeften, het raketten, al zwevend door het lymfesys- van Re-Mission, kan het idee ontstaan dat Transfer Model (GTM) een specifieke, nog gebruik van abductieve design technieken teem. Re-Mission maakt overduidelijk ge- de uiterlijke verschijning van de game op niet onderzochte verbinding legt tussen en verlangen de inzet van prototypes als bruik van een metaforische benadering van toeval berust of er niet toe doet. Dit blijkt educatieve transfertheorie en serious game onderzoeksinstrument om toe te werken de werkelijkheid en is effectief, vanuit het niet het geval, omdat in Re-Mission 2, in de design en daarmee een explicitering van naar uiteindelijk bewezen effectieve inter- perspectief van dit onderzoek, door second opvolger van de eerste game, de puur op ontwerprichtlijnen binnen de design space venties. De twee centrale expertisegebieden class transfer. In een aantal studies is het kennis gebaseerde educatieve elementen vormt, biedt het LiSMD een framework voor zijn Health (breed gedefinieerd) en Design. effect van het spel overtuigend aangetoond, zijn gereduceerd en de focus vooral ligt op het gefundeerd ontwerpen, testen, afstem- Bij het uitvoeren van de experimenten (Deel in termen van verhoogde therapietrouw en waar de eerste versie succesvol in is geble- men en integreren van (digitale) serious I) bleek dat deze twee werelden elkaar nog zelfredzaamheid bij de doelgroep. De stu- ken: het stimuleren van positieve emoties, artefacten. Het LiSMD-framework wordt veel te brengen hebben. Ik zal dit proberen dies over Re-Mission kwamen echter niet het verhogen van zelfvertrouwen en veran- opgevat als het resultaat van Research te illustreren met een voorbeeld. naar boven in onze systematic review, zelfs derende houding ten opzichte van de te through Design (oranje spoor) en bewaakt niet na verbreding van de reikwijdte van de ondergane chemotherapie. zowel het iteratieve en incrementele karak- Hoofdstuk 2 beschrijft een systematic gebruikte zoekstrategieën. Een nadere ter alsook de vereiste rigor-relevante ba- review waarin de aanwezigheid en toepas- beschouwing, buiten de review om, van de Hoewel Health en Design in onderzoeksme- lans binnen het ontwerponderzoek. sing van figural transfer in serious games belangrijkste studies over Re-Mission toon- thoden zeker overeenkomsten kennen, for Health is verkend. Voorafgaand aan de de een focus op de effecten van het spel. levert interdisciplinair ontwerponderzoek In Hoofdstuk 6 wordt het LiSMD in zijn review wisten we van het bestaan van de Deze werden gemeten door ze te vergelijken steevast uitdagingen op: waarden, aanna- geheel gepresenteerd en ingezet in het game Re-Mission [7], een goed voorbeeld met een kennistest in een controlegroep: mes, terminologie, methodologie en cultuur kader van het BABLR prototype. In de eerde- van een game for Health met overduidelijke het testen van kennis, of, zoals eerder maken samenwerking uitdagend, wat vaak re experimenten zijn de eerste ideeën en abstracte en gerecontextualiseerde eigen- genoemd mere learning. Een genoemd resulteert in suboptimale projectresultaten voorlopers van het framework gebruikt. schappen. Re-Mission is ontworpen voor ingrediënt voor de verwachte effectiviteit [9]. Het testen en valideren, op en met de Hoofdstuk 8 is gewijd aan het verschil in kinderen met leukemie, en wordt vaak van het spel werd gevonden in de self-mo- werkvloer, van de Design for Transfer hypo- Health en Design cultuur en geeft verdere aangehaald als een voorbeeld van een deling theory [8], zonder dat verder is on- these, zoals geconceptualiseerd in het GTM, duiding aan het LiSMD als een in-between succesvolle en effectieve serious game. Het derzocht of beschreven hoe deze theorie vergde een gemeenschappelijke taal om object. Het LiSMD-framework kent een spel draait om het vernietigen van kanker- heeft geleid tot het ontwerp van het spel. begrip, acceptatie en uitvoering van ontwer- aantal facetten. Ten eerste kan het gebruikt cellen en het leren omgaan met veelvoorko- Studies over Re-Mission beschrijven niet ponderzoek mogelijk te maken in de context worden als communicatiemiddel, bedoeld mende behandelingsgerelateerde bijwer- waarom het spel eruit ziet zoals het doet, van Health innovation. om de onderzoeksperspectieven van Health kingen. De speler bestuurt de noch geven ze aanwijzingen of ontwerpen Design samen te brengen. Naast de microscopische nanobot Roxxi om kanker in principes voor toekomstige serious games Het streven om deze verschillen te adresse- professionele, culturele en beroepsmatige het lichaam van een fictieve kankerpatiënt for Health. ren, heeft geleid tot de ontwikkeling en verschillen is er een belangrijk onderscheid te bestrijden. Ze doet dit door slechte cellen toepassing van een overkoepelend model: in onderzoeksfilosofie [9,10]. Het LiSMD te beschieten met een chemo-blaster en het Layers in Serious Media Design frame- positioneert explorative, generative en

196 197 uncanny valley

Figuur 5: Layers in Serious Media Design (links) & Design Re- LITERAL MIMETIC realisticness search Framework (rechts) en de positie van het Game Transfer Model (rechtsboven). conceptual continuity

physical functional SIMULATION ﬁdelity ﬁdelity E ect

TRANSFER psychological ﬁdelity SOLUTION SPACE Evidence based Practice Pattern of Use

metaphoricalness Evaluative Research FIGURAL ABSTRACT Intervention inﬁdelity

Generative Research Generative Choices design gap Working Theory (WT)

Supporting Theories (ST) PROBLEM SPACE Practice based Evidence

Design Principles (DP) Explorative Research Explorative

198 199 evaluative research in eigen spaces, elk met Samengevat, biedt het LiSMD-framework Key findings eigen specifieke focus met bijbehorende een domeinoverstijgend perspectief met methoden en positie in het totale ontwer- een overzicht van de sleutelgebieden voor 1. Het LiSMD biedt een framework waar- designer’s mindset zijn eigenschappen ponderzoek proces. Ten tweede kan het het komen tot een innovatief en effectief binnen gedeelde taal, perspectieven die behoren tot de Health professional LiSMD als leidraad in het ontwerponderzoek serious artefact. Naast de theoretische op onderzoek en design praktijk wordt van de toekomst. worden gebruikt door de lagen in de ruimtes onderbouwing en het gebruik van practi- gecombineerd en biedt een ondersteu- 4. Studies naar bewezen effectieve games te interpreteren als (niet noodzakelijkerwijs ce-based evidence uit de problem space, nende rol in (het discours over) ontwerp- of game-like interventies for Health opeenvolgende) stappen die in het proces legt het model de nadruk op de design gerichte onderzoeksprocessen gericht zouden onderliggende design rationales moeten worden gezet. Het documenteren space, waarin iteratief en incrementeel op het ontwerpen van artefacten met moeten toelichten, zodat generaliseer- van de gebruikte methoden en de daaruit ontwerponderzoek naar vroege voorspel- een serious goal, zoals games for Health bare ontwerpkennis bruikbaar wordt voortvloeiende bevindingen per laag zorgt lers van succes wordt ingezet. Dit proces of digitale innovaties in het algemeen. voor toekomstige G4H. Succesvolle voor de explicitering en onderbouwing van leidt tot een blauwdruk van een artefact dat 2. In Health innovatieprojecten ontbreekt game-like interventies zijn het resultaat het ontwerpproces. Het iteratieve en incre- niet alleen de drager is van de werkzame vaak de design-in-the-large fase, van een goed uitgevoerd ontwerpon- mentele karakter van het onderzoek zoals bestanddelen in een nieuwe vorm, maar ook waarbij een traditionele opvatting over derzoek, waaruit lessen moeten wor- dat plaatsvindt in de Design Space wordt een concept dat getest is op geschiktheid en implementatie deze cruciale fase van den getrokken om Health innovatie te geïllustreerd door het Design Research bredere acceptatie, alvorens de solution social system design vervangt. Design- bevorderen. Framework. Dit framework geeft verdere space te betreden. Op deze manier is het in-the-large omvat het social system invulling aan de wijze waarop ontwerpend artefact optimaal passend om zowel te design en behoort binnen de Health in- Future work onderzoek de geleidelijke vorming van een beantwoorden aan de serious goals alsook novatie gericht op artefact ontwikkeling ‘Designerly ways of knowing’ klinkt mis- artefact onderbouwt. Ten derde zorgt het om als interventie geadopteerd te kunnen een integraal onderdeel te zijn van een schien onbeduidend, maar is precies waar LiSMD ervoor dat evidence-based kennis een worden door de sociale contexten waarvoor ontwerpproces. Health naar zou moeten kijken in haar zoek- duidelijke plaats krijgt in het ontwerpproces. ze bedoeld is. Dit alles geeft een nieuwe 3. Ontwerpers van Health curricula en tocht naar innovatie middels serious digi- In lijn met de serious intent van het te ont- lading aan wat nu implementeren wordt professionals werkzaam binnen Health tale interventies. Health research kent een werpen artefact, vormen de actieve ingredi- genoemd. innovatie worden opgeroepen om rijke geschiedenis in de wetenschappen: het ënten uit een passende, bestaande Health gericht aandacht te hebben voor een bestuderen van de natuurlijke wereld met interventie of -theorie het uitgangspunt. Het domeinoverstijgend perspectief. Met gewortelde culturele waarden als objectivi- doel is echter niet om een digitale, game-like name de adoptie en inzet van design teit, rationaliteit, neutraliteit en een streven vertaling van een reeds bestaande, analoge research voor het komen tot innovatie en naar de waarheid. De waarden van Design benadering te bieden, maar om een nieuw het vinden van oplossingen voor wicked zitten in praktische uitvoerbaarheid, vin- artefact te creëren met een innovatieve problems verdienen aandacht. Creative dingrijkheid, inlevingsvermogen en streven benadering van het probleem in combinatie confidence, abductive reasoning en een naar passendheid [10]. Om deze waarden en met kritische beoordeling vanuit Health en het abductieve karakter van Design.

200 201 geschikte onderzoeksmethoden te beheer- Natuurlijk heeft Health een rijke historie hoe ze werken [13,14], bevordert het idee beter doet aansluiten bij de inherente eigen- sen, is de manier waarop mensen worden met gegronde waarden, onmiskenbare dat een gemeenschappelijk object door schappen van een videogame. Door middel opgeleid even belangrijk als de inhoud die noodzaak en statuur, maar daar waar het verschillende activiteitensystemen wordt van game-like prototypes werd de design wordt overgedragen. Het bovenstaande is gaat om het ontwerpen en innoveren bin- geduid, de dialoog en wederzijds begrip. hypothese getest dat meaningful play kan in zichzelf al een wicked problem binnen nen deze context, zijn deze waarden eerder Toekomstig onderzoek moet uitwijzen of worden gefaciliteerd door te ontwerpen Health curricula voor de toekomst, temeer een belemmering dan bevorderend. Feit is het LiSMD-framework in huidige vorm een voor figural transfer door het gebruik van omdat het in de huidige curricula niet een dat er nauwelijks tot geen aandacht is voor rol als boundary object kan vervullen of metaforische recontextualisatie. De experi- punt van aandacht lijkt. De waarden van het expliciteren van de design rationale dat het moet worden verfijnd door verdere menten toonden aan dat deze zogenaamde Design zijn makkelijker te begrijpen in het achter serious games for Health. Zolang beproeving in nieuwe contexten. Ik zou dit second class van transfertypes in serious licht van bijvoorbeeld het zelf ontwikkelen wetenschappelijke publicaties louter op de punt willen afsluiten met de titel van Hoofd- games daadwerkelijk kunnen leiden tot le- van serious games for Health of e-Learning effectvraag van serious games in gaan, zal stuk 8: don’t jump to conclusions. Benader ren of gedragsverandering, maar tegelijker- toepassingen. Met een ouder wordende we- de kennis van het effectief ontwerpen van dit onderwerp zelf als een ontwerpvraag, tijd een aantal contextuele randvoorwaar- reldpopulatie en een toenemende afhanke- serious games marginaal blijven. Maar het een wicked problem. Het feit dat het De- den aan het licht brachten. Voorwaarde voor lijkheid van (zorg)technologie vormen deze is breder: dit is een oproep aan eenieder die sign Research Framework, zoals dat in dit een succesvolle leerervaring in een non-mi- waarden een onmisbaar fundament voor zich in Health contexten bezighoudt met het proefschrift wordt gebruikt en besproken, metic serious game is conceptual continuity, denken over toekomstbestendige zorg. initiëren en ontwikkelen van onderwijs- en gebaseerd is op een specifiek educatief gedefinieerd door congruentie in fidelity Zoals besproken in Hoofdstuk 6, biedt technologische innovatie, om zich open ontwerpmodel [15], zou dit doel kunnen types, waarmee het belang van de kwaliteit probleemgestuurd leren (problem-based te stellen voor verworvenheden buiten de ondersteunen. en inventiviteit van het spelontwerp zelf learning), opgevat als leren dat voortvloeit Health Research context. Als er gedurende benadrukt wordt. uit het proces van werken aan het begrij- de experimenten binnen deze dissertatie op Vervolgens zijn er voor toekomstig onder- pen en oplossen van een vraagstuk [11], dit punt één ding duidelijk is geworden, is dat zoek naar design for transfer een aantal Verder onderzoek is nodig naar een clas- aanknopingspunten. Health studenten in heersende opvattingen over onderwijs en duidelijke onderzoeksrichtingen te formule- sificatie van wat wel en niet geleerd kan multidisciplinaire teams laten werken aan onderzoek een rem vormen op vooruitgang. ren. Dit proefschrift legt uit en onderbouwt worden via second class transfer games authentieke en ill-defined activiteiten met hoe design for transfer kan worden gezien for Health. Creatieve probleemoplossende betrekking tot echte, relevante ontwerp- Een andere suggestie die mogelijk be- in literal en figural serious gaming instan- benaderingen, besluitvorming, lateraal vraagstukken [12] kan problem-based leer- hulpzaam kan zijn bij het beschouwen, tiaties. Het Game Transfer Model (GTM) denken, oplossingsgericht leren, identiteit- principes verbinden met design research. ontwerpen en embedden van game-like wordt geïntroduceerd als een instrument sontwikkeling en cognitieve zelfregulering artefacten en serious games for Health is om serious game design uit te breiden van zijn veelbelovende concepten voor figural Verder moet gesteld worden dat Health, de innovatieve pogingen die gedaan worden high-fidelity simulaties tot metaforische manifestaties in games for Health en ga- opgevat als een subcultuur, de handschoen om dit doel te bereiken te zien als boundary fantasiewerelden. Dit laatste is van belang me-like simulaties, maar dit is geenszins zou moeten oppakken: kijk verder dan de objects. Hoewel er verschillende theorieën omdat het de mogelijkheden van serious een volledige lijst. Een mapping naar spe- eigen gebruiken, protocollen en zienswijzen. bestaan over wat boundary objects zijn en game design aanzienlijk kan uitbreiden en cifieke medische en gezondheidsthema’s is

202 203 nog niet gemaakt en moet worden opgeno- References men om meer gerichte toepassingsgebieden te identificeren. 1. Frayling C. The Crafts in the 1990s [Internet]. Journal of Art & Design Education. 1990. pp. 91–100 Een andere vraag is of metaforische re- doi:10.1111/j.1476-8070.1990.tb00755.x contextualisatie geschikt is voor iedere 2. Abt CC. Serious Games. University Press of America; 1987. doelgroep, vooral als het lijkt te gaan om 3. Ritterfeld U, Cody M, Vorderer P. Serious Games: Mechanisms and Effects. Routledge; 2009. 4. Salomon G, Perkins DN. Rocky Roads to Transfer: Rethinking Mechanism of a Neglected Phenomenon voornamelijk metacognitieve vaardigheden. [Internet]. Educational Psychologist. 1989. pp. 113–142. doi:10.1207/s15326985ep2402_1 De veronderstelling op het moment van 5. Oinas-Kukkonen H, Harjumaa M. Persuasive Systems Design: Key Issues, Process Model, and System Features schrijven is dat dit niet het geval is. Er moet [Internet]. Communications of the Association for Information Systems. 2009. doi:10.17705/1cais.02428 verder worden nagedacht over de passend- 6. Bransford JD, Schwartz DL. Chapter 3: Rethinking Transfer: A Simple Proposal With Multiple Implications heid van transfer types met betrekking tot [Internet]. Review of Research in Education. 1999. pp. 61–100. doi:10.3102/0091732x024001061 de kenmerken van een potentiële doelgroep. 7. Website [Internet]. [cited 12 Apr 2019]. Available: Website [Internet]. [cited 11 Dec 2018]. Available: HopeLab, TRI, Realtime Associates. Re-Mission. Palo Alto, CA: HopeLab; 2004. Available at: www.re-mission.net/site/ Tot slot blijft het noodzakelijk om het GTM game/ index.php. Accessed June 16, 2008 verder te testen in verschillende Health 8. Dowrick PW. A review of self modeling and related interventions [Internet]. Applied and Preventive Psycholo- gaming projecten, bij voorkeur in studies gy. 1999. pp. 23–39. doi:10.1016/s0962-1849(99)80009-2 waarin prototypes - in termen van het 9. Blandford A, Gibbs J, Newhouse N, Perski O, Singh A, Murray E. Seven lessons for interdisciplinary research on LiSMD - de solution space bereiken. Hier interactive digital health interventions. Digit Health. 2018;4: 2055207618770325. zullen we kunnen vaststellen of de vroege 10. Cross N. From a Design Science to a Design Discipline: Understanding Designerly Ways of Knowing and Think- voorspellers van succes uit de design space ing. Design Research Now. pp. 41–54. daadwerkelijk resulteren in gebruikspa- 11. Savery JR. Overview of Problem-based Learning: Definitions and Distinctions. Interdisciplinary Journal of Problem-Based Learning. 2006;1. doi:10.7771/1541-5015.1002 tronen met bijbehorende data en blijvende 12. Herrington J, Oliver R, Reeves TC. Patterns of engagement in authentic online learning environments. Austral- leereffecten. asian Journal of Educational Technology. 2003;19. doi:10.14742/ajet.1701

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204 205 Research Institute SHARE Schrier E Moye Holz DD Psychological aspects in rehabilitation Access to innovative medicines in a mid- Previous Dissertations (prof PU Dijkstra, prof JHB Geertzen) dle-income country; the case of Mexico and cancer medicines This thesis is published within the Research Institute SHARE (Science in Healthy Ageing and Malinakova K (prof HV Hogerzeil, prof SA Reijneveld, dr JP healthcaRE) of the University Medical Center Groningen / University of Groningen. Spirituality and health: their associations van Dijk) Further information regarding the institute and its research can be obtained from our internet and measurement problems site: http://www.share.umcg.nl/ (prof SA Reijneveld, prof P Tavel, dr JP van Woldendorp KH Dijk) Musculoskeletal pain & dysfunction in More recent theses can be found in the list below. musicians ((co-) supervisors are between brackets) Dijkhuizen A (prof MF Reneman, prof JH Arendzen, dr AM Physical fitness and performance of daily Boonstra) activities in persons with intellectual disabilities and visual impairment; towards Mooyaart JE improving conditions for participation Linkages between family background, (prof CP van der Schans, dr A Waninge, dr family formation and disadvantage in 2019 WP Krijnen) young adulthood Dierselhuis EF Bishanga DR Graaf MW de (prof AC Liefbroer, prof F Billari) Advances of treatment in atypical Improving access to quality maternal and The measurement and prediction of physi- cartilaginous tumours newborn care in low-resource settings: cal functioning after trauma Maciel Rabello L (prof SK Bulstra, prof AJH Suurmeijer, dr PC the case of Tanzania (prof E Heineman, dr IHF Reininga, dr KW The influence of load on tendons and ten- Jutte, dr M Stevens) (prof J Stekelenburg, dr YM Kim) Wendt) dinopathy; studying Achilles and patellar tendons using UTC Gils A van Tura AK Vrijen C (prof J Zwerver, prof RL Diercks, dr I van den Developing e-health applications to Safe motherhood: severe maternal mor- Happy faces and other rewards; different Akker-Scheek, dr MS Brink) promote a patient-centered approach to bidity and mortality in Eastern Ethiopia perspectives on a bias away from positive medically unexplained symptoms (prof SA Scherjon, prof J Stekelenburg, dr TH and toward negative information as an Holvast F (prof JGM Rosmalen, prof RA Schoevers) van den Akker) underlying mechanism of depression Depression in older age (prof AJ Oldehinkel, prof CA Hartman, prof P (prof PFM Verhaak, prof FG Schellevis, prof Notenbomer A Vermeiden CJ de Jonge) RC Oude Voshaar, dr H Burger) Frequent sickness absence; a signal to Safe motherhood : maternity waiting take action homes in Ethiopia to improve women’s For earlier theses visit our website. (prof U Bultmann, prof W van Rhenen, dr access to maternity care CAM Roelen) (prof J Stekelenburg, dr TH van den Akker)

206 207 Propositions

DESIGN FOR TRANSFER Figural Transfer through Metaphorical Recontextualization in Games for Health

1. Studies on games or game-like interventions for Health that have proven effective should 6. The DIS/DIL perspective should be an integral part of a design research process that explicate their design rationale, so generalizable design knowledge becomes usable for focuses on digital health innovation and provides a novel understanding of the concept of future G4H. Successful game-like interventions are the result of a well-executed design implementation by merging artifact appropriation and social system development (this research process, from which lessons must be learned to advance the field of Health thesis). Innovation (this thesis). 7. The LiSMD-framework presented in this dissertation functions as a boundary object with 2. The one-sided transfer approach in the design of G4H, as substantiated in this disser- the aim of identifying, interpreting and structuring the differences in language and values tation can be regarded as an obstacle in the endeavor to embed serious content into a of Health research and design research and is prerequisite for the advancement of digital game, consequently maintaining the notorious serious gaming oxymoron (this thesis). innovation (this thesis).

3. The design-for-transfer rationale expands and advances the possibilities of G4H design in 8. With a single poetic detail, the imagination confronts us with a new world. From then on, accordance with the innate properties of video games and thus opens up a hitherto unex- the detail takes precedence over the panorama, and a simple image, if it is new, will open plored plethora of possibilities for the design and application of game-like interventions up an entire world (Bachelard). (this thesis). 9. What is your conceptual continuity? Well, I told him right then (Fido said), it should be 4. The intentional application of second class transfer does not occur in the design of seri- easy to see, the crux of the biscuit is the apostrophe (Zappa). ous games or gamelike artifacts in Health, which excludes the most immersive and successful game types (this thesis). 10. The greatest thing by far is to be a master of metaphor; it is the one thing that cannot be learnt from others; and it is also a sign of genius, since a good metaphor implies an intui- 5. Psychological fidelity should be considered a key moderator for triggering learning expe- tive perception of the similarity in the dissimilar (Aristotle). riences e.g. wishful identification, parasocial interaction, narrative transportation, immersion and presence, flow experience, mastery of challenges, and suspension of disbelief. 11. Real science studies and makes accessible that knowledge which people at that period of These aspects are particularly suited to be enhanced through abstract, second class history think important, and real art transfers this truth from the domain of knowledge to transfer game types (this thesis). the domain of feelings (Tolstoy).

208 209 Dank Dr. Jean Pierre Pierie, Dr. Jelle Prins, Bard Wartena, Gijs Terlouw, Raymond van Donge- len, Jeroen Houttuin, Olga van Dijk, Boudewijn Dijkstra, Jan Wessel Hovingh, Dr. Job van ‘t Veer, Gert Flikkema, Harry Zengerink, Albert Sikkema, Peter Mulder, Dr. Hylke van Dijk, Dr. Ivo Wenzler, Dr. Marc Coenders, Dr. Ate Dijkstra, Dr. Hans Hummel, Dr. Jelle Drost, Dr. Debbie Jaarsma, Hein Pieter Groeneveld, Theo van der Heuvel, Peter Dannenburg, Julia Sturgeon, Luke Velderman, Tim Laning, Jan Jaap Severs, Gerard van der Lei, Paul Romkes, Margryt Fennema, Louis Zantema, Michèle Gerbrands, Jetse Goris, Janneke Kuipers, Wiebe Buis en Mariska van Knijff.

Ik heb oprecht, in welke vorm of mate dan ook, veel aan jullie gehad.

Zed (2019)

Revelation, regret and redemption in the twilight dreams of an aging artist. Set against surreal landscapes spanning one man’s life and career, ZED is a desperate quest to reconnect fading memories and create a final work for a very special person.

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