Preface for the Special Issue “Trends in Educational Gamiﬁcation: Challenges and Learning Opportunities”

Readers of the journal Education Sciences probably agree that playing games comes naturally—we all know how to play some game—however, because of the complexity of gaming, it is almost exclusively limited to mammals with regard to all animals: almost 80% of mammals use some sort of game for learning [...]

Introduction
Readers of the journal Education Sciences probably agree that playing games comes naturally-we all know how to play some game-however, because of the complexity of gaming, it is almost exclusively limited to mammals with regard to all animals: almost 80% of mammals use some sort of game for learning. Specifically with regard to humans, ever since we achieved some degree of civilization, we have played games for its proposed intellectual challenge and its entertainment value. Currently, it is difficult to participate in progressive modern societies without encountering some form of game play. In fact, the commercial video gaming industry now surpasses the movie and music industries in sales around the world, and more money is spent on games than on the other two combined. Therefore, if we consider games to be a natural activity, then applying games to education converts education into a universal activity. This is the key feature behind the use of Game-Based Learning (GBL) strategies.
In this regard, over the last ten years, the way in which education and training is delivered has considerably changed not only due to a new technologic environment-plenty of social networks, MOOCs, etc.-but also because of the appearance of new methodologies. Such new methodologies are shifting the focus from the teacher to the student, with the aims of awakening relational aspects as well as promoting imagination and divergent thinking. One new approach that holds considerable promise in helping engage learners is, indeed, game-based learning (GBL). The interest in research on GBL approaches has been continuously growing in the last decade. Particularly, since 2013, gamification in education has become a vivid and quickly developing area of research, with hundreds of new relevant publications coming out every year [1,2].
Researchers have reported that educational gamification strategies are being successfully applied in a wide variety of academic domains and educational levels, such as in studying English as second Language in higher education [3], in integrating subjects [4] such as mathematics and programming [5], or in working on mathematical and scientific problems [6]. Particularly, the skills and procedures used in certain games [7] have meaningful similarities with those used to solve mathematical problems. On the other hand, GBL is also used to boost relational aspects, such as increasing motivation [8], or to promote engagement with specific topics [9].
Furthermore, game design involves didactic-professional knowledge [10], so its use can deliver profit to both students and teachers and can be used to develop professional skills in future teachers. However, since teachers have a conceptual misunderstanding of gamification and STEAM education, they report insecurity and a lack of training for engaging in such educational methodologies [11]. In this regard, while a growing number of institutions are beginning to see the validity of GBL, many challenges still need to be overcome before this type of learning can become widespread.
This Special Issue of Education Sciences, titled "Trends in Educational Gamification: Challenges and Learning Opportunities", was developed to illuminate the inner workings of immersive games. Therefore, the primary aim of this Special Issue was to provide a focus for people working on the abovementioned research frames by providing a platform on which reflections on how to move gamification studies a step forward can be compiled. We invited researchers to submit original research on the deployment of gamified systems embedding novel game elements as well as rigorous quantitative and qualitative user studies that may also explore theoretical reflections grounded in empirical results. We also encouraged the scientific community to submit research covering all academic levels (pre-K12 to university) as well as a variety of games: board games, videogames, and live-action games, among others.
The 11 articles presented in this Special Issue deal with a wide range of aspects in Educational Gamification. We organized the discussions in a comprehensive manner so that each specific contribution can be highlighted. In this regard, as the Lead Editor and coordinator of this Special Issue, I proposed a collaborative structure to write this preface, so that experts can contribute to each of sections. Collaborative writing is a process of producing a written work as a group where all team members contributed to the content and the decisions about how the group will function. Therefore, one of my tasks as the leading editor was to coordinate and communicate with the different team members (the authors of the publications in this Special Issue) and, thus, to assign the redaction of specific sections-fitting each author's expertise-to produce and deliver a proper analysis. Finally, I highlight that the opportunity to coordinate and participate in this Special Issue has served as a great stimulus to revisiting recently conducted works and has given me the chance to work with colleagues with whom I had never conceived of sharing the same floor. I am thankful to all of the contributors of this Special Issue, and I hope to cooperate with them again in the future. José Piñero Lead Editor and coordinator of the SI

The State-of-the-Art Jakub Swacha
No scientific study should begin without first checking existing knowledge. This becomes challenging in areas undergoing rapid development, such as the one covered by this Special Issue: Educational Gamification, where the sheer amount of publications is overwhelming. In this context, a bibliometric survey is useful as it enables a researcher to consider thousands of publications within a reasonable time. This fast pace comes at a price: such a survey deals only with the most easily accessible data pertaining to each document, so in most cases, it is infeasible to answer detailed research questions. However, it is perfectly capable of answering general questions such as those regarding research topics, active researchers and research institutions, and their interconnections, which is often exactly what we need to grasp what is going on in that field of study.
In the bibliometric survey on Educational Gamification presented in [1], an exclusive approach was followed in an attempt to include only work that was highly relevant to the topic (i.e., preferring false negatives over false positives). At the cost of ignoring some relevant work, this approach allowed for papers of low relevance yet high visibility, such as highly cited papers on gamification or education but not on Educational Gamification, to be avoided and thus to not pollute the results.
As a researcher focused on just a narrow section of Educational Gamification, pertaining to teaching computer programming, I have found the work on the bibliometric survey both revealing and rewarding, especially as some of the results were far from expected. I hope that my paper provides readers with a good picture of the field before they delve into the details presented in the excellent papers forming the rest of this Special Issue.

Game Design Eduardo Quevedo Gutiérrez and Alberto Zapatera Llinares
Game design (applied to education) is the art of applying design and aesthetics to create a game with formative and entertainment purposes. Increasingly, elements and principles of game design are also applied to other interactions in the form of gamification. Academically, game design is part of game studies, while game theory studies strategic decision making (primarily in non-game situations). Games have historically inspired seminal research in the fields of probability, artificial intelligence, economics, and optimization theory. Applying game design to itself is a current research topic in metadesign.
The game design process associated with a computer can extend its purposes to the considered programming language. Using a simple and accessible programming language such as Scratch (proposed in our contribution as a didactic tool to teach functions) favors redesign (in Scratch, this process is known as reinvention). This scheme promotes the Creative Learning Spiral based on five components: Imagine, Create, Play, Share, and Reflect. Therefore, the authors understand that the integration of computational thinking in the school curriculum, including gamification as a methodology to implement it, promotes creativity and helps students learn the basics of programming languages. In this scope, game design serves as a means to an end. In fact, the approach carried out in our contribution considering the learning of functions through programming with Scratch is a game in and of itself. It allows the student to try different options until a problem solution is reached without fear of making mistakes in the process. This is very interesting since not being able to reach a final solution may involve the student's motivation to continue playing and improving; on the contrary, in the education system, usually mistakes are penalized, which can lead to demotivation. The authors will continue researching this topic to promote student motivation.

Live-Action Games: Educational Escape Rooms Nadja Belova
Whoever plays, steps out of everyday experience; in a sense, overrides it; and immerses themselves in a game world. This phenomenon is addressed in the concept of the "flow theory" [10]. Here, the state of "flow" is described as total absorption by a task that is both challenging and enjoyable. Such a totally immersive recent game trend is the so-called escape room. Escape rooms are a relatively new game concept that has been gaining popularity since around 2012 and can be considered a sort of hype in the science education community in the last five years. Educational Escape Rooms are a sort of live-action teambased game where players discover clues, solve puzzles, and accomplish tasks in one or more rooms in order to achieve a specific goal (usually escaping from the room) in a limited amount of time. To gain an overview of the state of science education research on this topic, we conducted a literature review. During the work in this review, subconsciously, the following questions always arose: Is this method really worth the hype? Are such immersive but also very elaborate methods really more effective-in terms of learning outcomes and competence development? As of now, it seems that the answer is that we do not know. We were able to identify not only some gaps in Educational Escape Room development (especially a need for scenarios that are easily adaptable to different educational settings) but also a major research gap when it comes to more empirical evidence on their actual effects. This is the area where research will definitely have to provide more results in the near future and to systematize the results because not all activities are automatically good even if everyone participates in it.

Board Games Elena Arboleya-García
Some educators spotted that board games are under-utilized in education. Games can engage students with different learning styles and can inspire individual creativity. They create non-threatening environments through tangible elements, hands-on tasks, or mutual learning, where lower levels of knowledge and failed tasks can be turned into a meaningful-learning acquisition. However, interdisciplinarity is also needed. It offers students a better understanding of the teaching-learning processes, as they could be able to identify and connect information from the separate subjects of the school curriculum.
Based on these statements, we conceived 'The Game of The Sea' to bring marine environment and ocean knowledge closer to students. From our educative experiences, as students first and educators second, we noticed that, throughout the stages of primary and secondary education, science subjects (in particular, those related to biology) provide education that is not properly connected between each level. Therefore, students are not able to construct long-term memories about this specific topic. The design and implementation of 'The Game of The Sea' entails the creation of a network of knowledge from different levels and from different subjects (not only scientific ones) addressed in the school curriculum. Once this integrative knowledge was acquired, our students obtained a better awareness of marine environment and we could confirm that we contributed to teaching environmentally responsible citizens.
Board games and interdisciplinarity represent the missing tools in our toolboxes, in particular, with regard to secondary education. In contrast with primary education, games are usually not considered a common didactic tool by teachers in secondary education despite games providing the possibility of improving traditional lectures and their relationships with students. The research presented on this Special Issue introduces the background needed to incorporate games into school curricula and to encourage educators to embrace that possibility of adopting these tools.

STEAM Education Paula López-Serentill
STEAM Education has recently become a trend in educational development that promotes learning throughout and for the interdisciplinary enterprise between Science, Technology, Engineering, the Arts, and Math. Teaching relevant, in-demand skills that will prepare students to become innovators in an ever-evolving world is paramount not only for the future of the students themselves but also for the future of the country. STEAM also empowers teachers to employ project-based learning that crosses each of the five disciplines and fosters an inclusive learning environment in which all students can engage and contribute. Within STEAM education, one useful tool is gamification, which is reported as a powerful tool for teachers at all levels in the educational system.
Our results show that a high percentage of math teachers think that this kind of activity has positive effects on students' development, improving their affective domain toward mathematics and required skills for mathematical competency. Notwithstanding, many teachers reported insecurity and a lack of knowledge, which is why we consider it necessary to promote STEAM training and, in particular, the use of gamification as another tool in the mathematics classroom.

Conclusions
During the last decades, we have witnessed the frenetic development of technologies, as well as the expansion and rise in the video game industry, board games, and escape rooms. The possibilities of innovating within the classroom using playful environments with didactic intentions have increased remarkably. The need for teachers to find new learning scenarios that align with the interests of students has led to the emergence and consolidation of two methodologies in the classroom based on the educational use of games: game-based learning and gamification. Therefore, a question emerges: How can the scientific community help these innovative movements really improve learning in the classroom?
The scientific community is responsible for exploring the educational potential of these new learning environments in depth and for providing empirical evidence on the educational possibilities they present. Although research on the educational use of games has produced results indicating that games can be healthy contributions to all educational areas, their possibilities have not yet been explored in depth. Regardless of the nature of the game (software, applications, video games, programming environments, board games, or escape rooms), more empirical evidence is required to reveal the added value of game-based learning situations compared with other types of learning. In this regard, we believe that more evidence may be of interest in progressing research on the educational use of games: especially studies on how these learning environments affect motivation and involvement, cooperation, creativity, and problem solving; studies on the different possibilities of use, specifically how they promote learning, how to practice and integrate what has been learned, how to problematize a situation, how to evaluate what has been learned, what causes triggering situations, etc.; studies that contribute to the systematization of principles for design and management; and studies on the design of disciplinary and interdisciplinary learning situations that are transferable to different educational levels, contexts, and training situations.
Finally, we believe that this Special Issue provides interesting key points that can help in understanding the effective use of educational games. In this Special Issue, the reader will find a varied and representative sample of current research issues related to the educational use of games from different disciplines, such as mathematics, music, English as second language, and marine biology, among others; to a diverse sample of games such as escape rooms, board games, and the Scratch programming environment; and to different methodological approaches, bibliometrics, bibliographic reviews, ethnographies, exploratory studies, case studies, etc. Funding: This research received no external funding. Specific information is available on each manuscript that is included on this Special Issue.


Clinical Skills Tutoring Program (CSTP): Developing a Curriculum for Medical Student Clinical Skills Peer Tutors

Introduction There are few curriculum materials designed to provide training and support for peer tutors to become effective clinical skills teachers. We designed the Clinical Skills Tutoring Program (CSTP) curriculum to guide tutors to help their students reflect on clinical skills performance, create an individualized learning plan, and engage in improvement based on feedback to achieve clinical skills competencies. Methods Curriculum content was delivered through an in-person training session, formal curriculum written content, online resources, and longitudinal support from faculty directors. Tutors (fourth-year medical students) received surveys to evaluate the in-person training session, curriculum resources, and overall program experience. Student participants (medical students of any year) completed a survey to rate their satisfaction in working with their tutors. Results There were 12 tutors in cohort 1 and 18 tutors in cohort 2. Survey response rates ranged from 50% to 70% among tutors. The tutors were satisfied with the in-person training session, program experience, curriculum resources, support from directors, development of learning goals with the student, and clinical skills practice with the student (mean Likert ratings greater than 4 out of 5). Student participants were satisfied with their experience creating learning goals and receiving feedback from their tutors. Discussion The tutor curriculum fills a gap by training and supporting tutors before and during their work with students needing further resources and remediation in one or more clinical skills domains. The curriculum can be implemented and further adapted by other tutoring programs locally and nationally.

Introduction
In medical school, students are longitudinally assessed on clinical skills performance with standardized patient assessments 1 and clinical rotations. Some students require additional time and practice to achieve clinical skills competencies and may benefit from remediation. Remediation is a complex and time-intensive process that involves diagnosing the learner while exploring potential social and emotional concerns. 2,3 Incorporating a peer teaching program can supplement existing faculty resources and increase the bandwidth for one-on-one instruction in remediation. By featuring a novel formalized curriculum designed to facilitate peer tutoring through goal setting and support, this program addresses an important gap in the literature: the role of peer coaching on clinical skills for students in need of further skills development.
Peer tutors can play a valuable role in assisting medical student remediation by utilizing shared cognitive and social experiences to create a safe, inclusive learning environment where the student feels more confident to ask questions, share concerns, and make mistakes. Studies find that students feel more comfortable and have their personal struggles better understood when working with a peer tutor, 4 resulting in increased confidence, 5 engagement, and ownership of their learning. 6 Peer tutor programs have been found to be beneficial in the development of medical knowledge, 7 clinical skills, 5 and student self-efficacy. 8 These programs also benefit peer tutors by improving their skills in teaching and communication while solidifying their own clinical knowledge. 7,9 At our institution, the primary drivers for the development of this program were (1) literature as described above supporting peer tutoring, (2) interest in studying how the benefits of peer tutoring could be applied in a novel context of clinical skills peer tutoring for remediation and skill building, and (3) a need to augment clinical skills resources beyond faculty availability. Faculty coaches have roles that include other tasks, such as career mentorship and facilitating systems improvement projects, so it is important to be able to offer additional clinical skills resources to a subset of students who require added time and coaching to achieve competence in one or more clinical skills domains.
Peer tutor programs do not consistently provide training to their tutors. 10,11 This makes it challenging for tutors to obtain skills in self-reflection and to understand how to become an effective clinical teacher. 12 Peer tutors may also receive inadequate instruction on core teaching skills essential to remediation such as delivering effective feedback. 13 Prior published versions of peer tutor curricula incorporate teaching and feedback models adapted for problem-based learning 14 and preclinical content. 15,16 When it comes to clinical skills, which we define as skills in conducting patient encounters including history taking, physical exam, professional communication, and diagnostic reasoning, there are few formal curriculum materials designed for peer teaching. We proposed a curriculum that would guide medical student peer tutors in helping their students achieve successful remediation by reflecting on past clinical skills performance, creating an individualized learning plan, and adapting their strategy based on feedback, specifically in the realm of clinical skills.
We conducted a focused literature review of teaching and learning theories supporting the use of peer tutors and found to be beneficial in student remediation. This served as the theoretical backbone of our curriculum. A needs assessment was conducted using semistructured focus groups with key stakeholders, including medical education faculty experts, departmental leadership, and clinical coaches, to develop the six core educational objectives of the curriculum. At our institution, medical students are paired with longitudinal clinical faculty coaches who serve as direct teachers and mentors for all 4 years. These coaches are the initial instructors for clinical skills and play an important role in observing and providing early feedback to students. The focus group interviews were conducted not only to elicit perspectives from faculty with expertise in this area but also to ensure that tutors would be trained in teaching skills and serve as tutors in a way that was aligned and collaborative with structures and resources already existing in the medical school for the student.
We designed the Clinical Skills Tutoring Program (CSTP) to provide curriculum materials, formal training, and longitudinal support for peer tutors to be effective clinical skills teachers to medical students referred to the program for remediation. We hypothesized that the peer tutors would be satisfied with the curriculum and that the students would be satisfied with their experience working with formally trained tutors.

Participants
Fourth-year medical students were invited to apply to be tutors. The application survey focused on assessing their clinical skills, personal teaching experiences, and faculty references to gauge prior clinical performance and teaching abilities. In this publication, tutors are defined as the applicants who were subsequently selected by faculty leadership based on review of their application and who participated in the program. Student participants were medical students from all years of training referred to our program by faculty leadership and attending physicians. Top reasons for referral included a nonpassing grade for a clinical rotation (preceptorship, core clerkship, subinternship), an unsatisfactory performance on standardized clinical examinations, difficulties in acquiring clinical skills milestones as observed by faculty, or extended length of time away from clinical medicine (e.g., leave of absence). Unlike the first cohort, which included only referred students, the second cohort included students who were invited to self-refer to the program if they could identify specific learning goals in clinical skills domains. This was a change we implemented due to the COVID-19 pandemic and reported needs among students who had fewer clinical skills learning opportunities.
Tutors were either true peers (same year in medical school) or, more commonly, near-peers (1-3 years apart in medical school) to the student participants. Tutors were compensated $20 per hour for training sessions, preparation time, and tutoring time. Paid preparation time was limited to 1 hour for every 2 hours of tutoring time. Tutors were expected to meet with their student approximately twice a month for 2-4 months (the frequency and duration varied depending on the learning goals of the student), and the amount of contact with the student's coach was variable depending on the needs/wishes of the student. Tutors made a 1-year commitment when they applied to the program, and they shared their availability for the year (e.g., tutors were not expected to be available during busy clinical rotations). At the end of the second cohort, one tutor was selected to be the Lead Tutor and was paid for an additional 5-10 hours per month to provide administrative support to the program. The program was not part of an elective; it was a paid extracurricular activity.

Curriculum Content
The formal tutor curriculum written content (Appendix A) contained learning materials, references, and examples for tutors to be successful in achieving the core educational objectives for this program. The curriculum introduced tutors to concepts such as social and cognitive congruence, 17 two main learning theories that supported peer tutoring by teaching how to establish rapport and trust with students. Tutors also received training on learning theories supporting student remediation, including the self-regulated learner 18 and master adaptive learner models. 19 Additionally, tutors were instructed on the importance of confidentiality in this program. For example, names of students were never discussed during monthly tutor learning/community-building sessions, and tutors learned that both the tutor and the student were emailed separately to confirm that the pairing was working (e.g., no dual relationship/conflict of interest) prior to finalizing each pairing. The formal curriculum was supplemented with additional documents. A tutor curriculum supplement (Appendix B) provided further figures and examples to augment the core reading material. The nuts and bolts document (Appendix C) was created to offer helpful tips for new tutors in navigating the logistics of the program, such as reaching out to the student or communicating with program directors. Lastly, a tutor checklist (Appendix D) was designed to consolidate the anticipated workflow of a peer tutor and the tasks they were expected to complete in the arc of the relationship with the student.
We identified increased peer collaboration and information sharing as an area for improvement based on our results collected from the first cohort of tutors. For our second cohort, we incorporated formal monthly tutor community-building sessions to increase the opportunities for teaching skills development, information sharing, and peer support. These sessions were facilitated by program directors and discussed topics decided on among tutors as high yield in working with their students, such as how to provide high-quality feedback.

Delivery of Curriculum Content
The tutor curriculum materials were delivered to the tutors through multiple modalities: an initial in-person tutor training session, formal tutor curriculum written content, online resources (including clinical skills educational materials), and longitudinal support from faculty directors. The in-person tutor training session was conducted prior to tutors being matched with a student and was mandatory. This 2-hour session provided an overview of program goals, expected tutor responsibilities, tutor curriculum documents, and how to access learning materials, as well as micro-skills practice on content related to core learning objectives including reviewing performance reports, refining an individualized learning plan, and providing feedback to a student (Appendix E: facilitator guide). During the session, the tutors received the formal tutor curriculum written content and received access to the Collaborative Learning Environment (CLE), an online webpage containing files, documents, and links providing instruction on each of the educational objectives. The page was designed as an easy-to-access online space where tutors could revisit tutor curriculum materials and access supplemental reading materials taking a deeper dive into the educational objectives. In addition, the CLE housed teaching materials for clinical skills (e.g., history taking, physical exam, and diagnostic reasoning) for tutors to share with their students, while providing a platform for tutors to share teaching materials they developed or found to be beneficial. The CLE had links to common resources such as Bates physical exam videos, Step 2 CS materials (prior to the elimination of this exam), and schoolspecific clinical skills learning content. Each student-tutor pair was assigned a private online folder where students shared their learning plans, tutors provided additional teaching materials, and any other content could be stored or exchanged between the pair. Lastly, tutors received longitudinal support from faculty directors through email and phone check-in meetings.
Evaluation Methodology Evaluations were completed for cohort 1 (January 2020-May 2020) and cohort 2 (June 2020-December 2020). Two surveys were distributed to the tutors to evaluate the tutor curriculum and training materials. The first survey evaluated the usefulness of components of the initial in-person training session and was given to tutors within 1 week following the session (Appendix F). Tutors received a second survey after completion of their participation in the program (May 2020 for cohort 1, December 2020 for cohort 2) to evaluate their satisfaction with specific components of the curriculum, program support, and development of teaching skills with the student (Appendix G); this was sent within days to weeks of completing work with their student. After concluding their work with a tutor, the student participants received a survey (Appendix H) that evaluated their satisfaction with the overall program experience, relationship with their tutor, development of learning goals with the tutor, support from program directors, effectiveness of their tutor in providing clinical skills coaching, and clinical skills practice with the tutor. All surveys used 5-point Likert scales and contained additional space for free-response feedback. All survey links and responses were anonymous.
Additional input for the purposes of program improvement was obtained from tutors through a semistructured focus group. The aims of the focus group were to (1) explore the tutor's personal experience of working as a peer tutor; (2) elicit feelings related to training, mentorship, and resources available for tutors; and (3) gather feedback on program strengths and areas for improvement. We reviewed the transcript of the focus group discussion for the purposes of programmatic evaluation; the goal was to identify strengths and areas for continuous quality improvement in the program and tutor curriculum. This project was deemed exempt by the University of California, San Francisco, Institutional Review Board.

Results
The first cohort of the CSTP began in January 2020. We received a total of 15 tutor applications and selected 10 fourth-year medical students as peer tutor participants. For the second cohort starting in June 2020, we received 25 tutor applications and expanded the program to select 18 tutors. Tutors were selected based on survey responses that demonstrated interest in medical education and teaching, prior experiences as a teacher, and excellence in clinical skills. In the first cohort, 12 medical students from years 1-4 were referred by faculty to the program as student participants for clinical skills remediation. Tutors spent an average of 7-10 hours per month dedicated to the program when they were paired with a student, with an average of 4-6 hours per month spent on direct tutoring and 3-4 hours per month spent on training and preparation.
In the first cohort, five of 10 tutors responded to the in-person training survey. In the second cohort, 12 of 18 tutors responded to the survey. Tutors from both the first and second cohorts found the components of the training session very to extremely useful. Overall, the training session received an average rating of 4.5 (1 = not at all useful, 5 = extremely useful; 4.5 is between very and extremely useful). Facilitation of the session (average rating: 4.8, between very and extremely useful), training session materials (average rating: 4.6, between very and extremely useful), discussion of tutor curriculum and objectives (average rating: 4.6, between very and extremely useful), and micro-skills practice sessions (feedback simulation average rating: 4.6, between very and extremely useful; reviewing learning plan average rating: 4.6, between very and extremely useful; and reviewing score report average rating: 4.6, between very and extremely useful) all received evaluations that suggested the tutors found the components useful for preparation (Table 1).
Following the tutors' involvement in the program, we received survey feedback on the program experience and tutor curriculum from seven of 10 tutors in the first cohort and 12 of 18 tutors in the second. The average rating of the overall experience as a tutor was 4.7 (1 = extremely dissatisfied, 5 = extremely satisfied). The majority of tutor curriculum components received ratings of 4.0 and above, suggesting broad satisfaction ( Table 2). The lowest rating of 3.6 was identified in the first cohort when evaluating opportunities for community building with other tutors, suggesting this as a key area for improvement. After implementing community-building sessions for our second cohort of tutors, the average rating improved to 4.4, suggesting greater tutor satisfaction.
We received survey responses and feedback from five of 12 student participants in the first cohort and 11 of 33 in the second cohort. The average rating of the overall program experience was 4.9 (1 = extremely dissatisfied, 5 = extremely satisfied). Student participants were satisfied with their relationship with tutors (average rating: 4.8). In addition, students were satisfied with how trained tutors approached clinical skills remediation through development of learning goals (average rating: 4.9), delivering clinical skills coaching (average rating: 4.9), and facilitating clinical skills practice (average rating: 4.5; Table 3). Feedback collected from focus groups (six participants in the first focus group, two participants in the second) identified key themes of strengths and areas for improvement in the tutor curriculum and program design that helped in guiding the evaluation and future direction of the program ( Table 4). The tutors noted curriculum structure, director support, and learning resources as three content areas that contributed positively to their development as teachers and to their ability to achieve the core educational objectives. Tutor suggestions for improvements in the curriculum design included incorporating opportunities for tutor check-ins, community building, collaboration, and information sharing. Tutors felt that learning from their colleagues' experiences and sharing strategies in working with students could further improve their personal growth as educators. Tutors also requested access to more specific resources to share with their students, especially in preparation for inpatient third-year rotations.

Discussion
The CSTP introduced a tutor curriculum providing formal training and longitudinal support for peer tutors to become effective clinical skills teachers for other medical students. The tutors were trained to achieve six core educational objectives that involved developing effective skills in goal setting and providing iterative feedback to facilitate their students' growth into self-regulated learners. Under the guidance of their tutors, students learned strategies to create and update their individualized learning plan. 20 In our program, tutors were satisfied with the in-person training session and tutor curriculum documents, while student participants were satisfied with their experience working with trained tutors.
The response rate for surveys was lower than anticipated. The lower response rate was due to multiple factors; timing of surveys was likely a significant driver of this. For example, surveys coincided with graduation for some tutors and summer break for others. Survey fatigue may also have played a role. Finally, a majority of tutors attended the focus groups where they were able to provide detailed verbal feedback; they may have felt that they did not have further feedback to share on the survey. Of the students, many started on busy clinical rotations (e.g., thirdyear clerkships) right after the program; the stress and added cognitive load of the COVID-19 pandemic may also have played a role.
We expanded the program to 18 tutors in the second cohort and continued to find high tutor satisfaction with the in-person training session and tutor curriculum. An added benefit of incorporating the monthly community-building sessions is being able to identify new, evolving tutor needs and iteratively revise the curriculum rapidly. However, we must remain vigilant in ensuring that the quality of longitudinal support and tutor experience is not compromised when growing the program to a larger size. With the smaller first cohort of student participants, each tutor was paired with a single student, which maximized the individual attention and program support that the student and tutor received. Our second cohort had multiple tutors working with more than one student simultaneously, which demonstrated that the tutor curriculum and program design continued to provide sufficient support for tutors and student participants alike.
The program was designed with the goal of implementing a curriculum that improved the knowledge, skills, and confidence of tutors to be successful clinical skills teachers. When we introduced the curriculum to our first tutor cohort, we sought to ensure that the program demonstrated utility and potential benefits that supported future growth and sustainability. We achieved this by assessing usefulness and satisfaction related to curricular materials. We were reassured by the survey and interview data obtained from two cohorts that the curriculum was satisfactory to tutor and student needs. Our future direction is to specifically assess the development of teaching skills and confidence in mastering educational objectives using a combination of tutor self-assessments and students' evaluations of their tutors. We will also conduct semistructured

Key Themes Illustrative Quotes
Strengths Curriculum structure "The structure was fantastic with a formal, real curriculum. Also, having the opportunity to use real standardized patients for practice with my student was really fantastic." "Another highlight is the excellent introduction session and the incredibly well-thought-out written materials that accompanied it." Director support "Having done tutoring for other programs, it was really helpful to have faculty members for support compared to feeling alone in other programs. It was good to touch base in orientation and before working with the student, which made me feel well-supported as a tutor." "I think it was fantastic in having a mentor to bounce ideas off of, especially getting a sense of the student's goals was really helpful, finding what resources I had access to, and how to tackle the student's learning goals. I wish I had taken greater advantage of this resource." Learning resources "I really appreciate all the links on the CLE webpage to helpful resources. My student has found these helpful and many of my favorite independent learning resources, books, and modules were there. It is impressively well-curated for a first edition CLE page." Areas for improvement Tutor check-ins; community building; collaboration; information sharing "My only recommendation is to hold meetings or check-ins with the tutor to brainstorm on how to bring out the best of the student. Every student is different, and I personally felt like I hit a wall with my student on how much we can improve." "I suggest having a check-in towards the middle of the program to get tutors together to discuss how everyone has been running their sessions, which can generate more ideas and help pairs continually improve their sessions." Specific resources "I think having a concrete list of tips of certain types of practice (e.g., specific and high-yield tips for how to coach students who are struggling with their presentation on the wards) might be a nice addition." "I would like to see more specific resources such as example history and physical exam write-ups, additional standardized or 'real life' cases to use during sessions." Abbreviation: CLE, Collaborative Learning Environment.
one-on-one interviews with student learners to receive their feedback on whether tutors were effective in meeting specific tutor milestones. A long-term vision would be to measure a student participant's objective clinical skills performance before and after working with a peer tutor to associate clinical skills success with specific components of our program.
There are multiple ways the CSTP can be expanded or applied to a different learner group. For example, the program could expand to more learners (e.g., beyond remediation context); in doing so, it would be important to consider the bandwidth of the program directors and ensure that the program was still able to provide a high-quality experience for student participants and tutors. Additionally, the program could be expanded to residency or fellowship programs.
In terms of sustainability, it is critical to consider the resources available, particularly in terms of faculty program director time.
One innovation that has been successful is recruiting a Lead Tutor. The Lead Tutor is a student participating in the program for a second year (e.g., they participated as a tutor during their gap year and then opted to stay on for their fourth year of medical school). As noted in the Methods section, the Lead Tutor is paid for approximately 5-10 hours per month and can provide essential program support in areas such as tutor payments, arranging monthly tutor community sessions, and providing the tutor perspective while answering questions during recruitment periods. Faculty time for the scope of program described here was approximately 10-20 hours per month in the first 4-6 months and 3-5 hours per month after that. For institutions that choose to use the CSTP curriculum provided, the initial higher effort in the first 4-6 months will likely not be needed as this additional time was dedicated to designing and creating the actual program. For sustainability, it is important to have buy-in from administration and support for tutor payments and other administrative tasks such as room scheduling.
It is also important to consider the local context of an institution when developing and sustaining a program such as the CSTP. For example, our institution has a robust coaching program.
Coaches are assigned to two cohorts of approximately six students each in different years; they do clinical skills teaching, systems improvement projects, and clinical reasoning learning in the first 2 years, while providing mentorship and career advising for all 4 years of medical school. In relation to the CSTP, coaches have played important roles including referring students to the program, providing additional context for a student's learning goals, and serving as references for tutors who apply to the program. Implementing this program in a context without such faculty coaches is quite feasible. To do so, it would be important to form close relationships with medical school leaders who know students well (e.g., dean for students, director of clinical skills) and to advertise the program widely (e.g., to clerkship directors and other course directors).
In summary, we designed a tutor curriculum to train peer tutors on teaching skills including building rapport, providing effective feedback, creating learning goals, and guiding students through self-regulated learning principles. The curriculum design resulted in high satisfaction ratings from both tutors and student participants. The inclusion of a formal curriculum may be beneficial in assisting peer tutors with successful navigation of the peer relationship, remediation of the student learner, and maturation of core teaching skills. Our educational objectives and learning materials can help standardize the expectations of a peer tutor while being adapted and implemented by other tutoring programs.


COACHING MODULE DEVELOPMENT TO BECOME TOUGH PERSONS FOR SIXTH-GRADE ELEMENTARY SCHOOL STUDENTS (BASED ON IGNASIAN SPIRITUALITY)

From the results of pre-study questionnaires distributed to seventeen sixth-grade elementary students of SD Sanjaya Tritis Pakem District and SD Cahaya Bangsa researchers obtained data that they had difficulty concentrating in learning because they prefer to play games. In fact, they will face the Regional Education Standardization Assessment (ASPD). Researchers were encouraged to help them doing mindfulness exercises so that they can exercise self-control when facing difficulties or temptations, with the guidance of “Becoming a tough person based on Ignatian Spirituality” module developed by the researchers. The development of the coaching module was carried out by researchers using the five-step ADDIE model, namely: (1) Analysis: distributing questionnaires to obtain information about the duration of time the sixth-grade elementary students spent to study and play games; (2) Design: compiling a grid of coaching modules. (3) Development: compiling a coaching module which then validated by a lecturer and teacher. The average score of the two validators showed a good result, which is 3.4 (from a range of values 1-4), meaning that the coaching module can be tested and published. (4) Implementation: the researchers conducted a trial at SD Sanjaya Tritis Pakem District which was attended by 15 students. (5) Evaluation: from the results of reflection, the students wrote down their intentions to manage the desire to play so they can focus on learning.

Introduction
There are four Universal Apostolic Preferences (abbreviated as UAP) that serve as guidelines for the work of the Society of Jesus for the next ten years (2019-2029), namely: (1) "Transmitting Discretion and Spiritual Exercises", which aimed to introduce Exercises to each Jesuit apostolate and education. (2) "Walking with the Excluded", which is intended so that we have the sensitivity to accompany the poor or the outcast so that their lives become more humane. (3) "Accompany young people on pilgrimages to get a future full of hope", contained an invitation to accompany young people today who are facing many challenges in the digital era. (4) "Maintaining Our Home Together", which is intended for us to renew God's creation. The environmental crisis has caused damage to the created nature, thus we need to make ecological repentance (Serikat Yesus Provinsi Indonesia, 2019).
The Society of Jesus of the Province of Indonesia has also begun to move towards mainstreaming the four preferences. Jesuits and collaborators use these documents as material for prayer, reflection, and discussion in various groups and opportunities in the apostolic and educational work of the Society of Jesus. On Friday, 14 February 2020, Politeknik ATAMI Surakarta held an environmental seminar, to implement the contents of the fourth UAP, "Care for Our Home Together". In January 2021, Ayu Fridayani and Stephanus Eri Kusuma from Sanata Dharma University conducted a PkM Mandiri entitled "Generation Z's perception of the working world" related to UAP preferences "Accompanying young people to create a hopeful future" and researched the relationship of young people to the working world. Thomas E., and Debra K. Mooney (2021) integrate UAP into the context of life at Xavier University-Ohio. Based on these ideas, researchers are motivated to respond to the third preference about the importance of universities helping the younger generation in the digital era which is bombarded with many choices, so that they can do discernment in order to achieve their life goals (Padilla, 2020). According to WHO (World Health Organization), the so-called young generation is aged 12 to 24-year-old. The youth we are targeting are students in the sixth-grade of elementary school or early teens (around 12-year-old).
According to St. Ignatius Loyola, spirituality is a Spiritual Practice (SP), a mental exercise that is done diligently and regularly so that it can help us organize the path and rhythm of life according to God's plan. St. Ignatius calls his Spiritual Practice a "Practice" because he wants to emphasize an effort that is repeated regularly step by step until we can move closer to the goal of life. The word "Practice" is a process that we need to do continuously to prepare our souls and hearts to be able to escape from the attachment of disorder, to find God's will in real life for the salvation of our souls (Cordina, 2016). When we faithfully carry out Spiritual Practice, we get the opportunity to know God more and understand His will for our lives. In detail, the five characteristics of Ignatian Spirituality mentioned above are contained in Spiritual Practice's book (See Ignatius Loyola, 1993).
The SP book is a guide to understanding Ignatian Spirituality written directly from the experiences of St. Ignatius himself. SP helps us recognizing that all experiences along our life's journey are not coincidences but means to draw closer to the Creator (Rosmini, 1987). SP helps us hone our personality to "become more perfect, superior, tough" because we have a positive view of ourselves, are willing to develop all our potential, are not artificial, honest, open to ourselves and others, always oriented to a sense of humanity, who sincerely serve, praise, and glorify God (Martin, 2017). This Spiritual Practice book also contains steps to do an exam or an inner examination prayer so that we can reflect on our lives, not only becoming a passing experience, but also train us to be more sensitive to find God's will in our daily lives (Barry, 2011). Examen is a prayer or inner examination in which we are invited to find and examine the movement of the spirit (= inner movement, thought movement, feeling and will) in our daily lives to see the presence of God in our lives (Austin, 2014).
In short, the life movement of someone who does SP is the process of becoming a person who experiences God's presence and work, not only in prayer but also in life activities (Sardi, 2021). This experience will enable him to exercise discretion which leads to an election, namely the choice of a way of life or action to respond to God's work and presence with real actions, as stated by Nullens (2019) "Spiritual discernment is often oriented towards making choices, in particular the hard life changing choices. Or it can be discerning to allow the active choice to continue and to become recommitted. In the choice also lies the paradox, we can't choose just everything and some choices that have been made can't be undone." Sixth-grade elementary school students need to be trained to do discernment or awareness training because the results of the pre-research questionnaire that the researchers distributed to 17 sixth-grade students at Sanjaya Tritis Elementary School, Pakem District, and Cahaya Bangsa Utama Elementary School, Yogyakarta, showed that they found difficulties to focus or concentrate on studying, although they will soon face the Regional Education Standardization Assessment (ASPD). The awareness check consists of five steps. In the original text of the book The Spiritual Practice of St. Ignatius Loyola (SP 43), the five steps are (1) thanking God for all the gifts I have received; (2) asking for the grace to recognize and rid myself of the sins I have committed; (3) seeing if my thoughts, words, and actions are in accordance with God's will; (4) asking God for forgiveness for the shortcomings that I have made; and (5) making an intention to improve oneself with the help of His grace. The inner examination closed by praying the Lord's Prayer. This inner examination prayer made by Ignatius Loyola by Shirani was "modified" to make it more understandable by today's people. The first step, asking God to help me so I can review the journey of my life throughout this day. The second step is thanking God because He has accompanied my journey throughout my life today. The third step is asking God for guidance so that I can identify the desires, thoughts, and feelings (sad, happy, disappointed, angry, etc.) that make it difficult for me to develop. The fourth step is asking forgiveness from God for my refusal of His invitation to do good deeds. The fifth step is asking God to be willing to walk with me so that I can improve myself and worthy to be His working partner. In http://www.letsinspire.co/askinspire-apa-itudoa-examen/ the five steps of prayer are described as follows: Mindfulness training aims to make them resilient individuals. Resilience means a person's ability to survive in difficult situations while being able to easily adapt to changing circumstances (Reivich & Shatte, 2002). Resilience is seen when a person goes through a difficult experience, and knows how to deal with or adapt to it. The difficulties or challenges they face will actually strengthen their mental resilience to become a tough person (Grotberg, 1999).
An important factor that helps strengthen students' mental resilience is to increase self-efficacy (Sabouripour, 2021) and self-control (Morison, 2017). Both sparked the idea of the importance of one's efforts and processes to achieve life goals. Thus one can become a tough person who has the characteristics of (1) being confident in his own ability to be able to solve problems/self-efficacy, (2) not giving up easily when facing problems or difficulties, (3) being able to control his desires, thoughts, and emotions. feelings, and (4) willing to get back up immediately if they experience failure. According to Nulhakim (2021), if a person has high self-efficacy, he will have confidence that he is able to face and overcome challenging, stressful, or unpleasant situations and believe that he will succeed with what he does. Mayasari (2014) adds another characteristic of a tough person from a religious point of view as a person who always places every incident he experiences solely with the permission and will of God. According to her, one way to help someone become a tough person is to train him to be able to create calm, focus, and be able to change the perspective when responding to unpleasant events (belief).
According to Ignatius Loyola, calming, focusing, and belief exercises can be pursued by doing SP or activities of silence, examining the heart, meditation, contemplation, oral and spiritual prayer to prepare the soul and heart to escape from all irregular attachments, then seek and find God's will for the salvation of our souls (Andalas, 2021). By conducting daily awareness checks, students are expected to be able to be grateful for their lives and be able to manage their desires, thoughts, and feelings, not only for the sake of momentary pleasures; tough against temptation.
Researchers are interested in developing a coaching module for sixth-grade elementary school students or early teens because researchers have developed a module for young people over the age of 18 in 2014 with the title Development Module to Become an Intelligent and Humanist Teacher Based on the Spiritual Exercises of Saint Ignatius Loyola (http:/ /repository.usd.ac.id/id/eprint/3899). The module was intended for PGSD students at Sanata Dharma University, in order to purify their vocation so that they can love their profession as teachers. In addition, the researcher was also inspired by the Ignatian Spirituality mentoring module "Magis Formation" issued by the Indonesian Province of Society of Jesus (2010). This module was intended for laypeople (especially young people) to live an Ignatian Spirituality that can help them relate to themselves, God, others, and the universe, so as to find true happiness or happiness that is in harmony with His will.
The developed module is intended for sixth-grade elementary school students so that they can focus on learning to be able to prepare for the Regional Education Standardization Assessment (ASPD), as well as have the awareness to know their life goals or aspirations. Because humans were created by God to develop the best potentials in themselves so that later they can become His work partners to "praise, respect, and serve God our Lord, thereby saving his soul", as stated in LR 23 (Cordina, 2016).

Method
The development of this research uses the ADDIE model (Tung, 2017) which contains five steps, namely Analyze, Design, Development, Implementation, and Evaluation.

Analyze
At this stage, the researchers distributed questionnaires to sixth-grade elementary students at SD Sanjaya Tritis, Pakem District, and SD Cahaya Bangsa Utama, Yogyakarta. The goal is to find out if they can have discernment in using their cellphones, so that they can focus on learning to prepare for the Regional Education Standards Assessment (ASPD). The following table contains a recap of answers to the questionnaire results from 9 sixth-grade elementary students of SD Sanjaya Tritis, Pakem District who have difficulty concentrating while studying: If I continue this habit, then I will most likely be able to .......... Assessment of Regional Education Standards. 9 students answered find difficulties or not pass the Regional Education Standardization Assessment.

5.
Another danger of frequent viewing of cellphones and playing games is ........ 7 students answered being addiction. 6 students answered that they got sore eyes. 1 student answered being dizzy.
The recap results from eight students at SD Cahaya Bangsa Utama are:

NO Statement
Students' Answer 1.
According to the agreement between the school and parents, in sixth-grade I am actively in school every day, I am limited to no more than 1 hour using my cellphone. However, every school holiday, I have a habit of using my cellphone to play games/watch more than ............. hours/day. 1 student answered music shows on YouTube.
1 student answered horror film shows on YouTube. 1 student answered the strategy game Clash of Clans.

4.
If I continue this habit, I will most likely be able to …… for the Regional Education Standardization Assessment.
8 students answered find difficulties or not pass the Regional Education Standardization Assessment.

5.
Another danger of frequent viewing of cellphones and playing games is ........ 6 students answered eye sore. 1 student answered that he had a disease (cancer). 1 student answered exposed to radiation.
From the results of the recap above, the researchers concluded: (a) The students in the two elementary schools were used to using cellphones for more than 2 hours/day; (b) The material they see is something to please themselves: opening Youtube and playing online games; (c) The impact: they become difficult to think, or concentrate and it makes it difficult for them to pass the Regional Education Standardization Assessment.

Design
Researchers created a grid for module creation, as follows:

No
Book Content Description 1.
Cover Contains the title, author, and illustrations of students carrying books and candles. Books are a symbol of their desire to learn. The candle symbolizes their hope for discernment so that they can focus on studying in order to achieve their goals.

2.
Editor Foreword Contains the background for writing the module and appreciation to several parties who have been involved in its preparation. 3. Isi The module contains five meetings, namely: Meeting 1 "To be grateful for the grace of life" Meeting 2 "My intelligence, strengths, and abilities" Meeting 3 "Barriers to achieving goals" Meeting 4 "Efforts to overcome obstacles to achieve goals" Meeting 5 "Spiritual practice as a basis for becoming a strong person" Reference Contains several libraries that support the content of the module.

Development
Based on this grid, the researchers developed a "Module for Development to Become a Strong Person for Sixth Grade Elementary School Students (based on Ignatian Spirituality)." The next module is validated by a lecturer who understands Ignatian Spirituality, and a 6 th -grade elementary teacher. The average value of the two validators is 3.4 (from a range of values 1-4); which means good and can be published after revision. The following is the recap: 3 Articles about ecological spirituality are less understood by teachers. Maybe the article writing diction can be simplified The first meeting contains steps that help students to be able to be grateful for the grace of life.

3.5
Quotations of the principles and foundations of the Spiritual Practice of St. Ignatius need to pay attention to the original formula. The order of prayer should start with gratitude. The second meeting contains steps so that students recognize the intelligence, strengths, and abilities that God has given them.

3.5
It might be good if there is a brief explanation about the meaning of intelligence, strengths, and abilities. In youth retreats the more common term is talent.
The third meeting contains steps so that students recognize the various impulses within themselves that can prevent them from achieving their goals.

4
Clear and easy to follow.
The fourth meeting contains steps that guide students in choosing the right strategy to overcome barriers to selfdevelopment.

3,5
The steps at this meeting seemed heavy. It's best to simplify. accordance with the content, but need to be clarified/confirmed the lines and colours.

3,4
After being validated and revised, the Module was published by Sanata Dharma University Press with the ISBN number 978-623-6103-05-0. The module cover is: The module has also received an IPR certificate with the number: 00261671

Implementation
The module trial was conducted on Friday, April 16, 2021, attended by 15 students from SD Sanjaya Tritis, Pakem District, by implementing health protocols. Students are invited to be able to reflect by filling out the exercises in the modules as shown in the following photo:

Evaluation
At the end of the meeting, students are invited to manage their desires so that they can emphasize their intention to study as a top priority, in order to achieve their goals, and present a picture about: "20 years from now I will be….": and write down their reflections, as in the following photos:

Findings and Discussion
The module is designed to contain five meetings to train sixth-grade elementary school students to become strong individuals based on Ignatian Spirituality. Meeting 1, "Grateful for the Grace of Life," contains exercises to raise awareness in students that they are individuals who are loved by God. Therefore, they are invited to reflect on God's inclusion in their lives by remembering personal figures, such as their parents and extended family, teachers, and friends who have helped them develop until now. In short, their life history and encounters with people around them are merely God's efforts to make them closer to Him and fulfill His calling.
Meeting 2, "Intelligence, Strengths, and Abilities," contains exercises so that students recognize all the advantages that God has bestowed on them, so that they can be developed in order to achieve their goals. Realizing that God loves them is, at the same time, a reminder that they too are invited to return their love. The trick is they must try to achieve their goals (so that they can become teachers, painters, YouTubers, engineers, doctors, etc.) to "serve, praise, and glorify God." Meeting 3, "Barriers to Achieving Goals," contains a guide so that students can identify internal and external impulses that can hinder them from achieving their goals. The goal is that they have the humility to make changes or leave habits that can hinder them from fulfilling God's call.
Meeting 4, "Efforts to Overcome Obstacles to Achieving Goals," contains exercises so that students have self-control strategies before obstacles arise. Some of the principles that must be lived by are: (1) the importance of thinking, (2) planning, (3) trying to do, (4) the importance of trying again, (5) evaluating, and (6) achieving success. At this meeting, students are trained to always try to purify their intentions to fill their lives with the best as a sign of devotion to praise, serve, and glorify God.
Meeting 5, "Spiritual Exercises as a Basis for Becoming a Strong Person," aims to help students have the habit of being silent for about 15 minutes or to provide time to distance themselves from various electronic devices to experience silence in prayer by carrying out five stages of mental examination or awareness checks, which are carried out every day (daily examen). By doing daily awareness checks, the person who does it can be grateful for his life and manage his desires, thoughts, and feelings solely for the sake of momentary pleasures. By doing regular awareness checks, one is enabled to become a tough person. So the module is expected to help students become tough individuals, the characteristics are: confidence in their own ability to be able to solve problems (self-efficacy), not easily give up when facing problems or difficulties, ability to control their desires, thoughts, feelings, and willing to get back up immediately if you fail.

Conclusion
First, the product preparation process in the form of "Coaching Module: Becoming a Tough Person (for Sixth-Grade Elementary School Students)" is carried out using the five ADDIE steps. Second, the quality of the module was validated by two experts. The average value of the two validators is 3.4 (from a range of values 1-4) which means good and the module can be published. As from the results of the module trial, students realized the importance of having a commitment to prioritize learning in order to achieve their goals.