Stamp collecting game improves internship performance and experience in medical education

Abstract

Background

To explore the improvement of internship performance and experience by application of stamp collecting game in neonatal department.

Methods

A two-arm parallel-group pilot randomised controlled trial (RCT) was conducted with a 1:1 allocation ratio among students rotating in neonatalogy department of Children’s Hospital affiliated to Zhejiang University School of Medicine between August 1, 2023 and November 30, 2023. This study was registered on the Chinese Clinical Trail Registry under reference number: ChiCTR2300075842 (https://www.chictr.org.cn/). The stamp collecting game was introduced to the experimental group during rotation, while the control group received standard education as usual. Both groups participated in the daily tasks of the internship, attended two clinical courses, and took a post rotation test. The primary outcome was the total score of students’ self-evaluation, encompassing proactivity, sense of participation, and harvest degree. Secondary outcomes included subjective evaluation provided by instructors and the test score post-rotation.

Results

A total of 94 enrolled students completed the rotation, with 50 in the control group and 44 in the experimental group. Self-evaluation questionnaires from 81 students were collected. The total score of self-evaluation was significantly higher in the experimental group compared to the control group (11.81 ± 1.47 vs. 10.59 ± 1.91, p = 0.002). Specifically, the experimental group exhibited significantly higher levels of sense of participation and harvest degree, though not proactivity. Regression analysis indicated that the stamp collecting game explained 13.1% (R² = 0.131) of the increase in the total score of self-evaluation, corresponding to a 0.398 times increase (β = 0.398). Additionally, instructors subjectively noted higher levels of proactivity and proficiency among students in the experimental group, who also achieved significantly higher post-rotation scores compared to the control group (p < 0.001).

Conclusions

The implementation of a stamp collecting game enhances internship performance and experience in medical education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07764-w.

Introduction

The insufficiency of pediatricians in China presents a pressing challenge. Survey shows a shortage of 200,000 pediatricians nationwide [1]. Despite considerable governmental investments in the healthcare sector, the persistent high dropout rate among pediatricians has reached 12.6% [2]. With low job satisfaction because of lower income, high workload and intense patient-physician relationship relative to other specialties [1, 3], pediatrics is not the preferred choice of medical specialisation in China, therefore pediatric education is facing great challenge [4]. A national survey of clinical undergraduates showed that medical student satisfaction was relatively low, while students’ engagement in clinical rotations is the factor with the most significant influence [5].

To prevent more medical students from opting out of pediatrics, we have been exploring ways to enhance their rotation experience, increase their engagement, and encourage a more proactive approach to learning during pediatric rotations. Traditional education has paid scant attention to the psychology of learning [6, 7], therefore students tend to remain relatively inactive or even passive. Along with a shift from teacher-centered to student-centered learning [8, 9], educators no longer serve solely as distributors of knowledge, but become facilitators of learning and assessors of competency [10, 11].

Studies have demonstrated that intrinsic motivation leads to higher creativity, cognitive flexibility, conceptual learning, and improved well-being [12]. Gamification, a strategy leveraging game-based learning mechanics to captivate users, emerges as a promising solution [13, 14]. Gamification may act as a catalytic agent that offers students with an extrinsic incentive [12] and rekindle intrinsic motivation [15, 16]. Scholarly evidence highlights its potential to increase students’ satisfaction, motivation, and academic performance [17–22].

In the clinical training program at Zhejiang University School of Medicine, undergraduate students in clinical medicine are required to complete rotations in three wards at the affiliated Children’s Hospital within a span of six weeks, with only one week dedicated to neonatology. This brief period makes it challenging for students to fully engage in their clinical internships. Therefore, we need a method that can quickly capture students’ interest and effectively address this issue.

Badges and point systems are among the most commonly implemented mechanics of gamification [23, 24]. Badges are awarded by achieving certain accomplishments, usually combined with points system, they can help students set goals for themselves and encourage goal-related behaviors [25, 26].

In this study, we opted for readily accessible stamps in place of more elaborate badges, innovatively created a stamp collecting game integrated with a comprehensive list of essential skills for neonatal clinical proficiency. This list encompasses technical competencies crucial to medical practice as well as the humanistic aspects of patient care. Students earn stamps by completing the corresponding content, with top achievers recognized as victors. In order to collect more stamps, students need to spend more time in the ward to complete more tasks.

This strategy is simple and easy to implement—just provide a postmark and print a checklist for each student. Compared to other gamification methods, such as web-based games [19, 27, 28], escape rooms [21, 22], or similar approaches that require software development or specialized teaching tools, our stamp collecting game offers a low-cost and highly adaptable alternative. This study aims to evaluate the effectiveness of this intervention in enhancing internship performance and enriching the overall learning experience.

Methods

Trail design

We conducted a parallel-group, two-arm, pilot randomized controlled trial with a 1:1 allocation ratio among the students rotated in neonatalogy department of Children’s Hospital affiliated to Zhejiang University School of Medicine between August 1, 2023 and November 30, 2023. Data analysis was conducted from December 2023 to February 2024. To report our results, we adhered to the CONSORT extension for randomized pilot and feasibility trials, ensuring comprehensive and transparent reporting.

Sample size calculation

The sample size was calculated using the software PASS 21.0.3 (NCSS, LLC, Utah, USA). Considering a Type I error of 0.05 and a Type II error of 0.20 (80% power), the total sample size required for these two groups at effect size of 0.25 was set at 37.

Participants’ recruitment and randomization

Subjects included in the study were fifth year undergraduate clinical medical students, primarily from Zhejiang University, with a smaller number of exchange students from Chongqing Medical University, Hangzhou City University and Shantou University Medical College. They completed the clinical theory courses required prior to rotations, including pediatrics, anatomy, physiology, and other related subjects. International students and those who declined to participate were excluded from the trail. Enrolled students were randomly assigned to the experimental group (Stamp collecting program) or the control group (no intervention). An independent researcher performed this assignment using a random number generated by Excel.

Educational program

All students were required to complete a one-week rotation in the neonatalogy department. On the first day, both groups of students received an orientation to the department and were then assigned to medical groups to participate in daily tasks. During this week, they must attend two clinical courses: Neonatal Resuscitation Training and Teaching Rounds, each lasting two class hours on the first and the fourth days of the rotation, respectively. In the Neonatal Resuscitation Training, students should be able to independently perform the basic procedure of neonatal resuscitation with correct technique after the instructor’s explanation and demonstration. During the Teaching Rounds, each student took turns presenting on different topics. Their proactivity and proficiency were evaluated by the instructors during the course. Prior to the orientation, each student in the experimental group received a stamping list outlining the learning content that could be observed or participated in during the internship. This list encompassed various aspects, including medical history taking, physical examination, medical record writing, doctor-patient communication, medical or nursing procedures, and humanistic care, as detailed in Supplementary Table 1. Upon completion of a specific procedure or task, students received a stamp corresponding to their accomplishment. At the end of each week after collecting stamps, the student with the most stamps for that week emerged as the winner of the game. While the control group received standard orientation as usual.

Evaluation method

Self-evaluation of students

After the rotation, two groups of students each completed a questionnaire with three questions to subjectively rate the proactivity, sense of participation and harvest degree. Each rating was on a scale from 1 to 5, with 1 being the lowest and 5 the highest, as detailed in Supplementary Table 2.

Subjective evaluation from instructors

Subjective evaluation from instructors referred to the grading of students’ performance during courses, including two key indicators: proactivity (engagement in learning) and proficiency (knowledge/skill mastery). Instructors rate these aspects on a scale from 1 to 5, based on the following criteria.

Proactivity:

• 1’: Totally not active, reluctant to participate even if prompted

• 2’: Relatively inactive, marginally participate after strongly prompted

• 3’: Moderate, willing to participate with encouragement

• 4’: Relatively proactive, willing to participate with positive attitude

• 5’: Very proactive, request for participation with particularly positive attitudes and excellent performance

Proficiency

• 1’: Totally not proficient, can’t complete even if prompted

• 2’: Poorly proficient, barely complete after strongly prompted

• 3’: Moderate, able to complete with help

• 4’: Basicly proficient, able to complete autonomously and basically correct

• 5’: Well proficient with excellent performance

Objective evaluation

The previous test scores of all enrolled students before rotation of enrolled students were extracted from previous examinations and compared. After rotation all enrolled students underwent a test, from which the scores of neonatal portion were extracted, converted to a percentile scale and compared.

Outcomes

The primary outcome was the total score of students’ self-evaluation, which encompassed the evaluation of proactivity, sense of participation, and harvest degree. These self-evaluation scores provided insights into the students’ perceptions and reflections on their learning experience during the rotation in the neonatology department.

The study also considered two secondary outcome measures. Firstly, the subjective evaluation provided by instructors, which focused on assessing students’ proactivity and proficiency during Neonatal Resuscitation Training and Teaching Rounds. This evaluation aimed to capture the instructors’ observations and impressions of the students’ performance and engagement in the specific training and teaching activities. Secondly, the test score obtained by the students after completing the rotation was considered as another secondary outcome. This score reflected the students’ academic performance and knowledge retention following the neonatology rotation.

Statistical analysis

The data were analyzed using Statistical Package for the Social Sciences (SPSS; version 27.0; SPSS Inc., Chicago, IL, USA). Continuous variables were presented as mean (SD) or median (IQR), while categorized variables were described as percentages. Differences in sociodemographic characteristics of study participants and outcome data at baseline were analyzed using Pearson’s chi-squared test or Fisher exact test for nominal data, and Student’s t-test or Wilcoxon test for continuous data. Multiple regression model was employed to analyze the association between Stamp collecting program and the evaluation outcomes. Attendance rate was involved as a variable in the model. Statistical significance was determined by p-values less than 0.05.

Results

From a total of 123 students screened, 25 were excluded: 23 were interenational students, 2 declined to participate. Among the 98 students included and randomized, 4 from the experimental group were excluded from this study due to objective reasons that precluded full attendance of the courses. Eventually, 94 students were enrolled in the final analysis, including 50 in the control group and 44 in the experimental group. In the students’ self-evaluation questionnaire, a total of 81 questionnaires were collected, including 44 in the control group and 37 in the experimental group (Fig. 1).

Fig. 1.

Trial Flowchart

There were no statistically significant differences observed in gender distribution, student source, or previous test scores between the two groups. The attendance rate throughout the entire rotation in the control group was significantly higher compared to that in the experimental group (Table 1).

Table 1.

Baseline characteristics of the students

	Control group (n = 50)	Experimental group (n = 44)	p
Gender, n/N (%)
Male	32/50 (64.0)	25/44 (56.8)	0.477
Female	18/50 (36.0)	19/44 (43.2)
Attendance rate, median (IQR) (%)	100.0 (90.0, 100.0)	90.0 (90.0, 100.0)	0.004
Student source, n/N (%)
Zhejiang University	32/50 (64.0)	27/44 (61.4)	0.698
Other colleges	18/50 (36.0)	17/44 (38.6)
Previous test score, mean (SD)	79.00 (10.0)	76.55 (10.9)	0.258

Self-evaluation of students

Of the 44 questionnaires from control group, 14 (31.8%) students rated their sense of participation as “2”, 17 (38.6%) students as “3”, 13 (29.5%) students as “4”, and none rated it as “5”. Whereas among the 37 questionnaires from the experimental group, none rated it as “2”, 13 (35.1%) students as “3”, 21 (56.8%) students as “4”, and 3 (8.1%) students as “5” (Fig. 2).

Fig. 2.

Schematic diagram of students’ self-evaluation results. A.Radar representations of the students’ self-evaluation scores. B, C. Number of students rate the score from 1 to 5 on sense of participation and harvest degree

We observed a statistically significant difference in the total score of self-evaluation between the experimental and control group, which were 11.81 ± 1.47 and 10.59 ± 1.91, respectively. The experimental group exhibited significantly higher levels of sense of participation and harvest degree based on self-rated questionnaires. However, there was no significant difference in proactivity between the two groups (Table 2).

Table 2.

Primary outcomes

Outcome	Control group (n = 44)		Experimental group (n = 37)		p
Self-evaluation, mean (SD)
Total score of self-evaluation	10.59 (1.91)		11.81 (1.47)		0.002
Proactivity	3.86 (0.63)		3.97 (0.60)		0.430
Sense of participation	2.98 (0.79)		3.73 (0.61)		< 0.001
Harvest degree	3.75 (0.81)		4.11 (0.70)		0.038

Subjective evaluation from instructors

The experimental group demonstrated significantly higher proactivity levels compared to the control group across both courses. Additionally, in Neonatal Resuscitation Training, the experimental group exhibited significantly greater proficiency than the control group, whereas no significant proficiency difference was observed between the two groups during Teaching Rounds. Furthermore, the total score of the experimental group was significantly higher than that of the control group (Table 3).

Table 3.

Secondary outcomes

Outcome	Control group (n = 50)		Experimental group (n = 44)		p
Subjective evaluation, mean (SD)
Neonatal Resuscitation Training
Proactivity	3.70 (0.79)		4.43 (0.50)		< 0.001
Proficiency	3.80 (0.73)		4.14 (0.51)		< 0.010
Teaching Rounds
Proactivity	3.66 (0.66)		4.20 (0.70)		< 0.001
Proficiency	3.88 (0.69)		4.09 (0.68)		0.139
Total score of subjective evaluation	15.04 (2.29)		16.86 (1.56)		< 0.001
Objective evaluation, mean (SD)
Neonatal portion after rotation	81.58 (10.54)		92.27 (9.85)		< 0.001

Objective evaluation

There was no significant difference of the previous test scores before rotation between the two groups. The neonatal portion scores of the test after rotation were significantly higher in the experimental group (Table 3).

Impact of the stamp collecting game on evaluation outcomes

The relationship between the stamp collecting game and evaluation outcomes was shown in Tabel 4. Acorrding to the regression analysis, the game had a positive influence on students’ overall self-evaluation score, sense of participation, and harvest degree, while exhibiting a limit impact on proactivity. The stamp collecting game explains 13.1% (R² = 0.131) of the increase in the total score of self-evaluation, resulting in a 0.398 times increase (β = 0.398). Instructors’ evaluations revealed increased proactivity, and most outcomes were significantly related to the game, except for proficiency in Teaching Rounds. After the rotation, the stamp collecting game accounted for 19.2% (R² = 0.192) of the increase in the level of test scores in the experimental group, which represented a 0.447 times improvement compared to control group.

Table 4.

Power of stamp collecting game on the evaluation outcomes

Outcome	R	R2	F	β	t	p
Self-evaluation
Total score of self-evaluation	0.391	0.131	7.027	0.398	3.648	<0.001
Proactivity	0.241	0.034	2.407	0.158	1.377	0.172
Sense of participation	0.479	0.229	11.615	0.499	4.796	<0.001
Harvest degree	0.297	0.065	3.785	0.289	2.553	0.013
Subjective evaluation
Neonatal Resuscitation Training
Proactivity	0.519	0.269	16.745	0.534	5.752	<0.001
Proficiency	0.270	0.053	3.590	0.280	2.677	0.009
Teaching Rounds
Proactivity	0.401	0.142	8.698	0.413	4.153	<0.001
Proficiency	0.164	0.006	1.258	0.169	1.580	0.118
Total score of subjective evaluation	0.118	-0.008	0.646	0.098	0.909	0.366
Objective evaluation
Neonatal portion after rotation	0.457	0.192	12.027	0.447	4.628	<0.001

Discussion

Our study aimed to address the lack of enthusiasm and engagement among medical students during pediatric rotations by introducing gamification into the learning process. We introduced a stamping list outlining essential skills for neonatal clinical work, which students could reference during rotations. This approach facilitated a deeper immersion for students in the clinical environment, thereby diminishing feelings of unfamiliarity and fear commonly associated with pediatrics.

Our main findings highlight the positive impact of stamp collecting game on students’ sense of participation and harvest degree, as evidenced by significantly higher levels reported in the experimental group compared to the control group, according to the students’ self-evaluation questionnaires. Notably, the control group exhibited generally low ratings for sense of participation, with 31.82% of students rating it as low as “2,” and none rating it as high as “5.” In contrast, the experimental group showed a reduction in low scores, with the majority rating their sense of participation as “4,” and even some rating it as “5.” This suggests that the implementation of the stamp collecting game effectively bridged the gap between interns and clinical work, significantly enhancing their sense of participation. This aligns with previous research findings. For instance, Valenzuela-Pascual et al. [19] conducted a study utilizing a gamified web platform, demonstrating improvements in students’ motivation, satisfaction, and knowledge acquisition. Similarly, Hakulinen et al. [29] observed that the implementation of badges positively influenced student behavior, leading to increased time spent in online classes.

Although the experimental group demonstrated a higher level of proactivity in self-evaluation compared to the control group, the difference did not reach statistical significance. However, in the subjective evaluations provided by instructors, the experimental group exhibited significantly higher levels of proactivity across both courses. Students in the experimental group were more actively engaged in class discussions, participated in interactions more frequently, and were more willing to share their opinions. In numerous previous studies, gamification strategies such as badges have been linked to increased motivation and positive attitudes [30–32]. The discrepancy between students’ self-evaluation and instructors’ subjective evaluation may be due to the limitations of a small sample size and students’ inherent reluctance to openly acknowledge negative learning behaviors. In future research, we plan to refine the design of the stamps and integrate them with other gamification strategies in larger-scale experiments.

Overall, stamp collecting game had a significant positive impact on the total score of self-evaluation. Suggesting this strategy of gamification can serve as an effective tool for improving students’ learning experience in medical education settings.

Both groups demonstrated notable performance in terms of knowledge acquisition. The experimental group demonstrated significantly higher proficiency in Neonatal Resuscitation Training. This may be attributed to the hands-on nature of the course, which allowed students to quickly grasp essential skills. The role of enthusiasm in the classroom was particularly evident during this training, highlighting its impact on learning effectiveness. However, there was no discernible statistical variance in proficiency between the two groups during Teaching Rounds. This observation could be attributed to the limited duration of the rotation, potentially impeding interns’ comprehensive clinical skill development. The test scores in the experimental group were significantly higher compared to the control group. This means that the students in the experimental group have indeed gained better knowledge mastery. While many studies support the idea that gamification can enhance learning outcomes [33, 34], some research presents different findings [35]. Kyewski and Krämer [36] implemented badges in an online class and found no significant effect on students’ academic performance. Similarly, Balci et al. [30] compared the effectiveness of badges and leaderboards and found that exposure to both gamification tools (badges and leaderboards) or just one (either badges or leaderboards) did not lead to significant differences in quiz performances. These conflicting results highlight the need for further research to better understand the principles and interactions of different gamification strategies.

While the study has several strong points, it also encounters some limitations. The primary constraint is the small sample size, which stands out as the most significant drawback. During our pilot study, we observed a considerable interaction among students, leading to contamination between the intervention and control groups. Such an issue could potentially impact the accurate estimation of the intervention’s impact in our upcoming full-scale RCT.

Conclusion

In this study, we introduced a retro yet almost zero cost stamp collecting game into clinical teaching. Both subjective evaluation from instructors and self-evaluation of students showed an encouraging performance. In conclusion, stamp collecting game improves proactivity and sense of participation of interns in medical education.

Authors’ contributions

The project was conceived and supervised by Y.Z. and M.H. M.H. managed students‘ participation. L.Y. assisted in teaching and data collection. W.S. performed the statistical analyses. M.H. wrote the manuscript. T.Y. and W.S. participated in the revision of the article. All authors read and approved the final manuscript.

Funding

This work was supported by The “14th Five-Year Plan” Teaching Reform Project of Zhejiang Province General Undergraduate University under Grant jg20220041.

Data availability

The datasets supporting the conclusions of this article are included within the article (and its additional file).

Declarations

Ethics approval and consent to participate

This study was approved by the ethics committee of the Children’s Hospital, Zhejiang University School of Medicine (2023-IRB-0204-P-01). Considering that signing the informed consent might lead to a breach of the participants’ privacy and affect the trial results, and given that the risks posed to the participants by this experiment are no greater than minimal risk, we applied for and received approval for a waiver of the informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.