Introduction

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ChooseTop of pageAbstractIntroduction <<Strengths, Possibilities,...Games for Veterinary Use:...Future Prospects in Veter...DiscussionConclusionReferencesCITING ARTICLES

In recent decades, the digital world has been changing phenomenally. Modern applications and technologies are playing a more and more important role in present-day society and the use of digital tools in education (e.g., games and simulators) is expanding.¹ Today's students have grown up with computer games and it is obvious that the popularity of these games is increasing.^2,3

Thus far games continue to be seen as an unserious activity.^4,5 However, there is growing interest in the use of games for educational purposes.⁶ Game-based learning (GBL) is described as the use of games in education⁷ and could possibly contribute to a new educational approach in which lecture-based learning is still the standard.² GBL is a type of problem-based learning (PBL) where problem scenarios are placed in a gaming context.⁸ For the educational sector, it is a learning methodology worthy of exploration, given the popularity of games and the possibilities that exist in view of current technological developments.^3,4,7

GBL is already in use in several disciplines. For example, in the US army game technology is seen as an important tool in the education of modern soldiers.^6,9,10 Furthermore, twenty-first century pilots, astronauts, and sailors are trained using modern simulation methodologies, and even the world of business already uses some educative gaming tools.^6,11,12 Areas such as electronics, weather forecasting, engineering, emergencies, and navigation are using modern simulation technologies as well.⁹ It seems that games are increasingly important in modern ways of learning, and it is thus not surprising that over the last years the idea of educational computer games has received much more interest, given the rising amount of supporting publications.¹² Meanwhile, several journals already focus specifically on this topic.⁹ The growing enthusiasm has resulted in projects, initiatives, and commercial companies that aim to make a clear division between the commercial domain and the educative domain of games.⁶ Commercial games are designed for recreation and amusement, while games used in the GBL methodology are designed for learning, teaching, and training purposes and thus serve as educative tools. As a result, the term serious gaming was launched for those games that have an educative aim.⁹

Academic attention to games as learning tools does not only apply in the disciplines mentioned above, but also applies in the areas of health and medicine.^5,6 Serious gaming in health care education has already been introduced in various ways, and the number of universities that offer game-related programs worldwide is remarkably on the rise.³ Applications such as the Ann Myers Medical Center, Forterra's OLIVE (On-Line Interactive Virtual Environment) engine, the Virtual Hospital, and the Labyrinth system^5,6 are examples of educational games used in health care. Furthermore, several gaming tools such as a breast module,⁸ a pathology game,² cell biology instruction games,¹³ and other multimedia programs are currently obtainable. Many of these application games are based on virtual patients and realistic scenarios that had been created.⁵ Virtual patient means “computer programs that simulate real-life clinical scenarios in which the learner acts as a health care professional obtaining a history and physical exam and making diagnostic and therapeutic decisions.”^14(p.446) To clarify, this is not the same as other forms of simulation, such as standardized first-aid dummies.¹⁴

Returning to the example of educational games, they fluctuate from single-player to multi-player games, and there are different types available. They have diverse sets of features depending on the educational purpose and the exact goal of the game itself⁴ and could vary from simple, interactive computer board games to more complicated, virtual, three-dimension (3D) simulation games. Examples of the latter are virtual-patient simulators,¹⁴ computer-based laparoscopic and robotic surgical simulators,¹⁵ and other virtual reality simulation tools, some of which are easier to use than others.¹⁵ A medical simulation is “a device or set of conditions that aims to imitate real patients, anatomic regions, or clinical tasks, and/or to mirror the real life situations in which medical services are rendered.”^12(p.465) Consequently, a device of such a simulation is called a simulator.¹² For example, simulators are obtainable for “catheter insertion, epidural lumbar puncture, spine biopsy, breast biopsy, neurosurgical probe insertion, and prostate needle biopsy.”^16(p.438)

Serious games exist for different disciplines in health care education. There are more or less complicated games in use for different types of surgery,^1,15–17 radiology,¹⁸ radiography,¹⁹ physiology,²⁰ anesthesia,¹¹ gynecology and obstetrics,²¹ pathology,² and biology^13,22 as well as games that allow students to train for specific actions^23–26 or learn to diagnose and act in given scenarios.⁸ Different types of the available educational games also vary in accessibility. While some are accessible to all Internet users, others are restricted to specific areas that require users to log in or purchase applications. All of these different types of games can be incorporated in education in various ways. Some games possibly will function as recommended extra training in addition to textbooks (facultative role), while others might function as a required part of practical education. One simple example of a required educational simulator is found in aviation. No airline pilot today can be certified without training in high-end simulators.⁹ The benefits of aviation simulators are well-known.^11,12 One can also imagine required simulators in health care education (e.g., surgery simulators), but according to health care and veterinary education, the allocated role that games receive depends primarily on the universities themselves since GBL is not yet a standard in current education.

GBL has not made a real breakthrough in health care and veterinary education, which has partly to do with present shortcomings that will be discussed later. Nowadays, the traditional lecture-learning methodology²¹ is still standard.

Strengths, Possibilities, and Weaknesses of GBL: A Consideration of Serious Gaming

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Several studies consider the potential of GBL. Different authors have investigated the effect on students and describe some arguments for and against serious gaming. Proponents claim that games could be relevant in, for example, health care education as potentially valuable learning resources.⁶ However, there are more issues to be considered in addition to this positive sketch. An important aspect in the consideration of serious games is the quality of the game.^5,6 How can we ensure that the game is good enough as a learning tool? For an effective learning environment, Norman (1993) had suggested seven requirements (Table 1).²⁷

Table 1 The seven requirements Norman (1993) suggested for an effective learning environment5

Kasvi (2000) suggests that educational computer games fulfill all of these requirements.²⁸ Nevertheless, games differ in quality and the appropriateness of an educational game depends to a large extent on its quality for the given purpose. Collaboration between educational sectors and the game industry is, therefore, an important factor. Expectations must be clear for both parties. For example, it is evident that the creation of good quality games is very expensive and requires a lot of time,⁶ especially for complex realistic virtual simulation games. This seems to be quite logical, but as a result of different economic paradigms in the entertainment and education industries, this is one of the reasons why collaboration between these two sectors is still problematic.⁶ For better collaboration between these parties a few things seem to be necessary. First, the gaming industry must be willing to produce games for educational purposes. One reason for the gaming industry to cooperate with this project could possibly be to reverse the current view of their products, which are frequently correlated with sex and violence and are often considered to be an unserious waste of time.⁶ Second, the education sector must accept the enormous costs of producing a game. Therefore, the education sector must weigh the costs against the pedagogical effectiveness of GBL. To stimulate the integration of games in education, teachers must recognize their pedagogical effectiveness; they must recognize the value, possibilities, and benefits of this innovating learning resource.⁵

Computer games could affect cognitive processes.³ “My knowledge of English comes from playing Monkey Island and not from English classes,” claims one student.^4(p.389) Another student said, “playing adventure games fostered development of my observation skills and problem solving skills.”^4(p.389) As illustrated in these examples, GBL can have several effects on cognitive processes and, indeed, the literature found that playing games will improve cognitive processes and additionally—in long-term practice—improve spatial performance as well.³ A very recent study by Kanthan and Senger (2011) demonstrates that digital games for learning can offer several more benefits.² In this study, digital gaming is described as “an effective, fun, active, and encouraging way of learning, providing immediate feedback and measurable process.”^2(p.135) This study, as well as others, claims that GBL increases students’ motivation to learn^2,4–6 and student engagement.² Intrinsically motivating games provide more enjoyment and thus can have a stress-reducing effect.^2,8 Other studies describe students’ improved motivation to play the game more than once. This way, games encourage repetitive game playing⁶ if, for example, players are awarded points and receive high scores or prizes.²⁹ In turn, the repetitive game playing of an educational game would likely have some beneficial effects on student learning outcomes. Increased motivation would facilitate the learning process and make learning a much easier procedure for the student. But there is more: GBL offers an opportunity to “reinforce concepts and terminology,” “aided students to ‘feel more confident about [their] knowledge,’ and helped students to ‘recognize areas of weakness,’” according to several student responses.^2(p.135) In the modern world, students demand a more active, multisensory, experiential learning methodology and GBL can be illustrated as this kind of methodology.² GBL improves student understanding² and computer-based instructional simulation (CBIS) programs surely have their opportunities.¹³ The underlying assumption for using CBIS in education is that computers can provide a more active and wider range of learning, given today's technological capabilities.¹³ For example, certain especially complicated biological processes are much easier to understand when presented in games rather than illustrated in textbooks.^13,20 An example of such a CBIS program was developed for students to determine if it could improve their knowledge, understanding, and perception of cell theory in school biology.¹³ In the study, student groups could choose to follow a cell theory course taught through a CBIS program or through the traditional learning method.¹³ After a four-week period of lessons, the student groups were all questioned and asked to write the same test on topics discussed during the course. The results were compared and demonstrate some significant differences.¹³ Students using the CBIS program scored better on perception and understanding than students who did not. This study shows that CBIS programs positively affect the development of students' understanding and perception.¹³ Consequently, GBL does have potential and it can serve as an effective learning tool.

The studies mentioned above are not the only ones that have examined the effectiveness and potencies of GBL. Numerous studies have investigated the effectiveness of GBL and many of them describe an improved academic performance. One of them—an interactive game that simulates patients with clinical breast problems—is said to have “considerable educational potential in a variety of educational settings.”^8(p.306) The study reports positive results in student feedback as well as in pre-game and post-game tests. Therefore, the computer-assisted board game was seen as an effective learning tool to simulate clinical problems.⁸ In another study, an educational game was introduced in an obstetrics and gynecology curriculum and compared to the traditional, lecture-based learning method.²¹ Even here, results conclude that learning from games is effective, enjoyable, and stimulating.²¹ Likewise, several recent studies have had more or less similar results. Comments such as “students in classes using the game scored significantly higher means than classes that did not” prove the efficacy of GBL.¹⁰ Notably, in this study only students under the age of 40 show these results. There was no significant difference among students above the age of 40.¹⁰ It seems that the use of GBL is more useful for students who have grown up with modern technology and are accustomed to it. Older students might have more trouble understanding how the game works and may thus spend more time learning how to play rather than actually playing the game and learning simultaneously. Nevertheless, another study by Friedl et al. had quite different results with regard to the effectiveness of serious games, but it concluded that GBL significantly improves students' performance.³⁰ In this study, the educational value of a multimedia module about aortic valve replacement was compared with a print medium of identical content.³⁰ The study suggests that there is no difference in factual knowledge between these two learning methods. However, students who had followed the multimedia module demonstrated significant improvement in practical performance during heart operations, where spatial performance is a very important factor.³⁰ Even this example illustrates that games can be an effective learning tool, although in a different way.

As noted above, there is more available other than relatively simple computer board games. Surgical skills can be acquired by using more or less complex virtual simulation techniques. The greatest advantage of virtual simulation for purposes such as these is that future surgeons can practice their surgical skills without fearing real-life consequences for their virtual patients.⁸ Simulation technologies are thus seen as an active trial-and-error learning method that takes place in a “safe virtual world.”^4,5 As a consequence, this new modern way of learning is especially useful for high-risk surgeries or surgeries that are not very common and thus normally achieve little training experience. Virtual reality simulation does have more major benefits such as the experience gained through training with these simulators. More training means more experience and therefore an increase in individual skills. In the military and aerospace industry, this has already been demonstrated,^1,12 but now it also seems to apply to health and medicine education, and especially to surgical education. Thus, errors can be minimized in real-life situations and, as we know, the focus in clinical health teams is for a great part on risk reduction.¹¹ One study noted that “recent advancements in surgical modeling and virtual reality (VR) technologies have resulted in simulators that can help train doctors to obtain a higher degree of precision, reliability, safety, and cost efficiency.”^16(p.438) The higher degree in precision, reliability, safety, and cost efficiency could be noted as a big advantage of using simulation games as training tools. It must be clear that simulation games are not designed only for students. Even certificated doctors can use these systems to maintain or train certain skills. An increase in individual skills (mentioned above) after using virtual simulation games has been demonstrated in several studies. Several studies in surgical education conclude that the use of specifically designed surgical simulation games improves surgical skills. Therefore, special virtual surgery simulation games are seen as effective training tools.^3,5,10,15,17 Moreover, according to several publications, there are more reasons why we should use virtual simulators. Virtual simulators are more realistic than several traditional educational media^6,8 and “improve cognitive and behavioral skills better than traditional methods do.”^14(p.446) In addition, they solve some of the ethical and patient-safety issues and make it possible to train outside the operating room (OR).¹ This way, it is much easier to control and adjust the learning environment, which can be altered for each student's needs to create the desired effect.¹ This is especially useful when university clinics “lack ‘good educational cases’”^31(p.361) at a given time. According to the literature, computer models would be “the perfect practice patients,” available at any time.^1(p.790),12 Given all of these benefits, it has been demonstrated that GBL can serve as a very promising learning method that can enrich the health care curriculum.

Although many studies are quite optimistic about GBL, one should be cautious.²⁹ Weaknesses and shortcomings of GBL are described as well. Enormous vigilance toward the game itself is needed for the integrated learning experience. A possible hazard that might exist for some games is that the actual learning becomes subordinate to the game playing,²⁹ in which case the player's focus is on playing the game rather than learning from it. Skipping the educational text is one example of a player going straight for the game experience and thereby neglecting the intended learning objective.²⁹ This can be avoided by programming the game in such a way that the player cannot skip educational texts, but there are still numerous games that are not programmed this way. An alternative misuse of GBL occurs when the intended intrinsic motivation becomes extrinsic motivation. This kind of improper use of educational games takes place when, for example, students are pleased by “shooting cancer cells as an arcade game.”^6(p.156) In this case, the intended learning objectives will not be accomplished. Sometimes, the latter also occurs when the game application is labeled as voluntary.⁷ When educational games are used as recommended learning tools and not as required ones, the use will depend on students' motivation, which can be quite different. Another shortcoming of GBL might be the learning principle of some games. In several games drill-and-practice is more important than understanding the underlying mechanisms.²⁹ This means that the player will learn what is right and what is wrong but might still not understand why. Players may also fail to understand the underlying mechanisms of some games if a teacher's presence for a specific educational game is not immediately necessary. As one can imagine, without a teacher a more detailed description of subjects might be omitted, learning might be limited to what the game offers, and thus, depending on the quality of the game, underlying mechanisms might be neglected. The quality of the game as a possible shortcoming has already been mentioned within the discussion of the collaboration between educational sectors and the game industry. To facilitate the development of good quality games, the goal and learning objective must be clear. Designers must also deal with hardware, software, and personnel issues, including system compatibility, speed, storage capacity, operating system, and access and availability.¹⁸ In addition to the earlier stated seven requirements for an effective learning environment,⁵ games should be user-friendly, time-effective, accessible, and able to maintain the engagement and progression of the learner.² To ensure progression in the game—and thus to prevent the learner's frustration—several possibilities are available. By using timers, clues, partial solutions, or rewards, progression can be monitored and guaranteed.² However, as we noted earlier, the creation of good quality games is very expensive and requires a lot of time.⁶ Both of these factors constitute an important limitation for a real breakthrough in GBL.

In addition to the attention paid to games and virtual simulators, a critical view is also needed for the different types of students who use these applications. Even a good quality game can have different effects on various students.² There are several differences in students' educational levels and motivation. On this topic the literature suggest that “digital gaming is most effective on students with less self-motivation and lower grades.”^2(p.141) Consequently, it is important to understand that the benefits investigated might not apply to all students. Finally, to optimize the use of GBL we need qualified teachers.²⁹ Training, therefore, is necessary to ensure that teachers provide a useful contribution to the game and students.⁹ It is thus important to note that GBL should be seen as an additional tool that can help enrich the learning environment and not as stand-alone methodology that can replace instructors and textbooks. Therefore, there are still too many limitations to GBL.

Games for Veterinary Use: What Do We Have and Does it Work?

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Several types of GBL, some of which have already been mentioned, such as digital games and simulators, are available for veterinary education. Students have the possibility to use computer modules that vary from game-based tutorials to simple question-and-answer programs as anatomy, histology, and physiology modules. Furthermore, more integrated examples of GBL are in use (e.g., multimedia programs for veterinary surgery,²⁶ physiology,²⁰ radiography,¹⁹ and orthopedic radiology¹⁸). In addition, learning programs such as Gluconeogenesis and Cardiac Muscle Practical Simulation are available.³² Also available are a computer module for “teaching students how to pass a nasogastric tube in the horse,”^23(p.447) a tutorial for regional perineural anesthesia,³³ and more complex simulations (e.g., rectal palpation simulators,²⁴ a computer program called Emergency Case Simulator,³² a virtual veterinary emergency department,³⁴ an online virtual veterinary clinic for small animals,³⁵ and a simulation game called SHOOT! in which the player is trained in the process of sedating virtual animals so they can be slaughtered³⁶). A few of these learning tools will be considered below.

An example of case simulation programs is the online veterinary clinic for small animals.³⁵ This online course allows students from several universities to create an account using a login name and password, thus participating in an “online problem-solving classroom.”^35(p.93) Students had the possibility to work alone or in groups. For students who wished to communicate in a direct way, there was a text-based chat room available.³⁵ The online course contained numerous cases which have to be passed in a similar way to the case simulation program described earlier.³⁵ Students taking the online course were asked, based on the information they gained from description, history, and physical examination, to state the most likely diagnosis and explain what information in the history and physical examination supports this diagnosis.³⁵ Students were able to ask for help and receive responses from other students and real-life instructors.³⁵ Therefore, instructors played a very active role in this virtual clinic and, in addition to their role as instructors, they could also play the role of clients and possibly refuse tests for specific reasons, such as cost.³⁵ After all, in order to pass the course, students had to meet several criteria, including student participation and number of correct answers and conclusions presented during the course.³⁵

A more complex form of GBL in veterinary education is the use of a bovine rectal palpation simulator.²⁴ The simulator is developed based on input and feedback from various veterinary surgeons and other professionals. In this simulator, the student palpates a virtual reproductive tract of a cow, simultaneously receiving touch feedback from a haptic device.²⁴ The instructor is able to see the student's movements inside the virtual cow on a computer.

Lastly, in 2008 Stunning Creations developed a very innovative veterinary education game called SHOOT! specifically for veterinary students at the University of Utrecht.³⁶ The aim of this virtual reality simulator game is to train students to shoot and slaughter cattle and horses, which sometimes needs to be done by veterinarians in specific emergency slaughter situations (Figure 1). This game makes it possible to train for this process, whereas real-life training would be ethically unacceptable.³⁶ The game guides the player through the process of shooting and slaughtering an animal as he or she encounters different scenarios. For example, during the game the player must choose the right attributes, make the right decisions, and use correct methods when undertaking several actions. The game is programmed in such a way that when the player makes wrong decisions, he or she will encounter several dilemmas later in the game. The farmer sometimes provides the player with clues and tips.

Figure 1 The shooting pit in the game SHOOT!

As previously noted, there already exist many examples of game applications in veterinary education. Several studies have reported numerous benefits of and limitations to these innovative learning tools. Many of the benefits, strengths, limitations, and weaknesses of GBL that have been previously described also apply to veterinary education and some of them apply specifically to this profession. For example, in the study of the bovine rectal palpation simulator, the simulator is seen as a valuable learning tool. For a good understanding of rectal palpation in a cow, a great deal of practice is required to help students develop the necessary skills.²⁴ The need for practice requires a lot from education animals and, therefore, a simulator might provide relief. A follow-up study that compared traditional rectal palpation in a cow with the haptic simulator reports better performance outcomes in those students who trained with the haptic cow with regard to the palpation of several structures.¹² As previously mentioned, students had a very positive response to this virtual simulator and described it as helpful and useful. Students thought that their knowledge and 3D orientation had improved after using this virtual cow simulator.²⁴ Furthermore, using a simulator such as the haptic cow can also make instruction more effective. In the traditional method, which uses real cows, effective instruction can sometimes be difficult because the student's hand is not visible and because, at least to begin with, the student may be unable to describe the palpated structures accurately.²⁴ However, one of the main advantages of using games and simulations in veterinary education relates to patient safety.²⁶ Numerous studies emphasize that virtual simulators certainly will improve animal welfare. If simulators are used, fewer animals are needed for educational practice. Furthermore, the virtual simulator can be seen as a safe, controlled learning environment for the patient, the student, and the farmer.²⁴ As in human medicine studies, GBL in veterinary medicine research is seen as an interactive,^26,35 useful,¹⁹ acceptable, and attractive³⁷ way of learning. The physiology module likewise mentioned an increased interest in learning.²⁰ The computer module, in teaching veterinary students how to pass a nasogastric tube in a horse,²³ showed similar results. Those who used this module instead of traditional instruction were shown to achieve better performance, learning, and preparedness. As in human medicine, GBL is very useful when university clinics lack appropriate cases and allows instructors to use their time more efficiently.³² Whereas traditional education sometimes cannot ensure the participation of all students in a specific case (e.g., as a result of animal welfare, ethical issues, or too few cases for the number of students), simulation can allow all students to participate as a particular case can be repeated²³ without giving rise to these issues.

In veterinary medical education, however, the disadvantages of GBL are reported as well as the benefits. Some educational games cause frustration among players, for example, if they reject students' answers on the basis of small spelling mistakes,³³ whereas a real-life teacher would likely accept these same answers as correct. Furthermore, a technical limitation to online gaming tools, such as the virtual small-animal clinic described above, might be the variable speed of Internet connections.³⁵ Slow connection can cause frustration instead of the intended increase in satisfaction related to using this learning methodology. Virtual reality simulators also have several limitations. To take the bovine rectal palpation simulator as an example again, more than a few shortcomings have already been revealed. Like various virtual reality simulators, even the haptic cow has a lack of reality.²³ The simulator “did not include any representation of the rectum, feces or peristalsis”^24(p.80) because this was too difficult to incorporate. Furthermore, the bovine simulator only has a single point of contact for the haptic device. For a realistic rectal palpation of several structures, more than one finger is needed. For instance, the ovary must be palpated between fingers and thumb. As a result, this simulator is only helpful for basic skills, such as palpating the uterus and thereby diagnosing pregnancy in a specific later stadium. The palpation of several structures, such as the ovary, is not possible using this simulator. Therefore, other simulators must be created in the future.²⁴ It is important to note that games and virtual simulators cannot fully replace living animals.²⁴ Even if a very realistic simulator is created in the future, which allows for the palpation of all structures, vigilance is still needed. Real animals show different appearances and cannot completely be standardized in a virtual simulator. Although a standardized simulator does not become tired or embarrassed,¹² those who only practice with simulators are not conscious of the variation and unpredictability of real-life animals.^12,26 This could result in a “misleading sense of confidence, hiding the messy, uncertain, and unpredictable nature of clinical reality.”^37(p.598) Thus, creating good virtual reality simulators is not as easy as it looks. According to Scalese and Issenberg (2005), medical simulations only lead to effective learning when the majority of 10 listed features are incorporated.¹² These features are summarized in Table 2. Despite these features and current rapid technological developments, we should be cautious that education will not be driven only by technology, rather than pedagogy.³² Too narrow a focus on technical skills can overlook crucial elements of clinical care, such as communication and professionalism.^37,38 Nevertheless, games and virtual simulators can provide a valuable contribution to educational practice. They can especially enrich traditional learning³² as a form of additional training without raising concern about animal welfare and other ethical issues. GBL has great potential,³⁷ at least as a supplement to current traditional ways of learning.

Table 2 Ten features of medical simulations that lead to effective learning

Future Prospects in Veterinary Education: What Can We Expect?

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Currently, human medicine has already integrated more types of GBL than the veterinary universities. Since veterinary medicine is a smaller enterprise than human medicine, there are less publications and studies available for this profession.¹² Thus, GBL for veterinary education is still in an early stage, as the small number of animal simulators specifically designed for veterinary use indicates.¹² Nevertheless, studies expect that in the future the amount of GBL and simulators used in veterinary education will rise and play a more important role in the curriculum.³⁷ Analogous concerns for animal welfare, food safety, and public health may lead to greater funding opportunities for the research and development of simulation technologies in veterinary education.¹² Although further research in the effectiveness of GBL as well as the integration and maintenance of, for example, virtual reality simulators is very expensive, some of these limitations might disappear as modern technologies advance. As in human medicine, new testing and accreditation requirements might spur the further development of such technologies.¹² It seems that the already shown potential, possibilities, and benefits of GBL will be decisive in the future implementation of this innovative way of learning. Although, as noted earlier, technological developments cannot fully replace living animals, they will lead to more realistic types of GBL, thereby providing an excellent additional learning tool in veterinary education. For now, the real breakthrough is still some years away,²⁹ but further research in the educational use of computer games for veterinary medicine and technological developments will lead to the increasing implementation of GBL in veterinary curriculum.³⁷ Universities must eventually make this decision, considering the cost effectiveness of specific types of GBL.¹⁸

Discussion

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Several years ago a significant amount of money was spent on GBL without the presence of evidence-based research.¹⁰ One could have reservations about this, but in fact many studies have finally shown the potential of this new way of learning. It can certainly be stated that one can learn from educational computer games.²⁹ However, several of these studies have some serious shortcomings: many of them do not have a control group, use very small sample sizes, and lack integration with previous research.²⁹ In addition, not all of these studies prove with certainty a positive effect on learning even if students do report it. Sometimes conclusions of positive learning effects are drawn too quickly; students might have thought that they had learned more but this conclusion, in fact, is subjective and thus not evidence-based.²⁹ However, the most serious flaw is that several studies actually do not compare GBL with other teaching styles.²⁹ Thus, when drawing conclusions from the literature, some caution is necessary.

Conclusion

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Whereas other disciplines recognized the potential of games and simulators for educational purposes much earlier, educational games in the veterinary curriculum are still in an early stage. Nevertheless, interest is increasing and there are already several games and virtual reality simulators available in the veterinary curriculum. However, despite positive research results, many shortcomings to and limitations of GBL remain. Technologic developments in the future might tide over these limitations and the literature expects that educational games will play a more and more important role in future veterinary education.