Abstract
Background
Burn injuries remain a major health challenge, particularly in developing countries, where insufficient clinical training has led to significant competency gaps among medical students and young physicians. Despite the demonstrated potential of serious games to enhance clinical skills through interactive simulation, little research has explored their impact on burn management education. This study was conducted to design and evaluate an educational serious game aimed at improving the clinical competence of medical students in managing diverse and complex burn cases.
Methods
This parallel-group randomized clinical trial, conducted at the Burn Department of Imam Reza Hospital in Mashhad, involved 70 medical students. Inclusion criteria were medical students from Mashhad University of Medical Sciences, about to begin burn clinical rotations, with no prior burn management experience. Participants were randomly assigned to an intervention group, which received standard training plus the serious game, or to a control group that received standard training only. Before and after their training period, students participated in clinical competency assessments that utilized the Mini-Clinical Evaluation Exercise (Mini-CEX).
Results
A total of 70 students participated in the study, with 35 allocated to the intervention group and 35 to the control group. No statistically significant differences were observed between the groups in terms of demographic characteristics (P > 0.05). Post-intervention evaluations demonstrated statistically significant improvements in all seven skills in both groups (P < 0.001). Furthermore, the intervention group exhibited significantly greater increases in both teacher and student satisfaction compared to the control group (P < 0.001).
Conclusions
The incorporation of serious games into medical education represents a transformative strategy that significantly enhances learning outcomes. These educational tools create engaging and interactive environments that not only reinforce students’ clinical skills but also prepare them with the essential competencies needed to tackle real-world challenges effectively. The ongoing exploration of innovative educational strategies is vital for further improving the quality of medical education.
Trial registration
This RCT was registered in the Iran Registry of Clinical Trials (IRCTID: IRCT20171123037599N3, https://irct.behdasht.gov.ir/trial/70898), Registration date: 10/08/2023.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09970-6.
Keywords: Clinical Competence, Burn Management, Serious Game, Medical Education
Background
Burns represent a significant global public health issue and are a leading cause of mortality and severe health complications in developing countries, accounting for approximately 180,000 annual deaths [1–3]. Proper management of burn first aid can decrease the need for surgical interventions, expedite the healing process, and reduce the burden imposed on healthcare systems [4]. However, the current training of young physicians in this field faces serious challenges. Lack of practical opportunities to encounter diverse burn types results in deficiencies in accurately assessing the severity of burns, providing appropriate treatment plans, and making suitable referrals, while late complications such as scarring and contraction are heavily dependent on timely and appropriate care [5].
Multiple evidences indicate significant shortcomings in medical students’ preparedness for managing burns. Studies show that 90% of students lack the necessary confidence to treat burns [6], and 17% are unaware of the role of chemicals in causing burns [7]. Furthermore, the performance of first aid by young physicians in some hospitals has been described as “disappointing” [8]. Investigations in Turkey also reveal that only one-third of physicians have updated their knowledge of burn treatment, with the majority possessing inaccurate information regarding first aid [9]. These deficiencies primarily stem from limited access to real patients and practical training in controlled environments [6, 10]. Reports indicate that the lack of knowledge and skills among physicians is evident even in cases of mass burn disasters [11], highlighting a dangerous gap between theoretical education and practical requirements. Although it seems possible to teach medical students how to manage burn emergencies using theoretical curricula, the knowledge of physicians may still be inadequate for addressing burn emergencies in situations requiring first aid or out-of-hospital incidents [12].
In recent years, medical education researchers have turned to the use of innovative technologies in educational processes. They are utilizing virtual reality, simulation, augmented reality, and technologies such as serious games to create an engaging and immersive environment while actively involving students in their learning [13–15]. In the quest for novel educational solutions, serious games have emerged as tools with high potential for bridging this gap. These technologies provide a safe and simulated environment to practice critical clinical skills such as taking medical history, physical examination, diagnosis, and treatment decision-making without the risk of harm to patients [16, 17]. The mechanisms of immediate feedback and the possibility of designing varied scenarios with different levels of difficulty, along with their inherent appeal and interactivity, enhance learner motivation and engagement, consequently fostering more effective learning compared to traditional methods [18, 19]. Numerous studies have demonstrated the effectiveness of serious games alongside or even superior to conventional methods in medical education [20–23].
Given the critical importance of burn management training, the documented inadequacies in current methods [5, 8–12], and the potential of serious games to address these shortcomings through practical simulation [20, 21, 24], coupled with the observation that the search conducted indicates a lack of studies examining the impact of educational serious games on improving medical students’ clinical competence in the field of burns, the present study was initiated with the aim of designing and evaluating a specific educational serious game. This game focuses specifically on simulating diverse and challenging burn scenarios and providing interactive feedback from instructors.
Method
Study design and participants
This parallel-group randomized clinical trial was conducted from February to December 2024 and included medical students undergoing clinical training in the burn department at Imam Reza Hospital in Mashhad, Iran. During the study period, a total of 78 medical students completed their burn clinical clerkship, of whom 70 met the inclusion criteria and agreed to participate in the study. These 70 participants were randomly allocated into two equal groups (intervention and control), with 35 students in each group.
To minimize the risk of contamination between groups—given that students rotate in the same clinical environment and may share educational materials—the implementation of the study was organized in a sequential manner. Participants were randomly allocated to the intervention and control groups at the beginning of the study. In coordination with the Office of Medical Education, students assigned to the control group completed their burn clerkship first and received the conventional educational method. After completion of the control-group rotation, students allocated to the intervention group entered the burn department and received the serious game–based training. Thus, the sequential timing of rotations was solely for logistical purposes and did not influence the random allocation process.
Inclusion criteria for this study encompassed medical students from Mashhad University of Medical Sciences just before starting their clinical rotation in burn department, with no prior experience in managing burn patients, and provided informed consent to participate in the study. Exclusion criteria included any medical students who, for any reason, were unwilling to cooperate within the intervention group. It is important to note that students who did not engage with the serious games component would have continued to receive the standard routine educational program. The duration of the medical students’ clinical rotation in our burn department lasts seven days.
Sample size determination
The sample size for this study was determined using G*Power 3.1.9.7 software based on an effect size approach for comparing two independent groups. A nearly large effect size, 0.75, was considered appropriate in this context. With an effect size of 0.75, an alpha of 0.05, a power of 0.80 and accounting for a 15% attrition rate, the required sample size for each group was calculated to be at least 35 individuals [25].
Participants were randomly allocated to either the intervention group or the control group using the website www.randomization.com. This website generated a random sequence of 70 letters (35 ‘A’s and 35 ‘B’s) in a 1:1 ratio. Subsequently, 35 ‘A’ cards and 35 ‘B’ cards were prepared according to the sequence provided by the website, placed into opaque sealed envelopes, and numbered consecutively from 1 to 70. Upon enrollment, each participant was assigned a sequential number. The corresponding envelope was then opened to determine the participant’s group assignment (A or B).
This RCT was registered in the Iran Registry of Clinical Trials (IRCTID: IRCT20171123037599N3, https://irct.behdasht.gov.ir/trial/70898 on 10/08/2023. Also, this study was conducted and reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT 2025) guidelines. A completed CONSORT checklist is provided as an additional file to ensure transparency and reproducibility of the study.
Blinding
In the present study, the faculty members who evaluated the medical students’ performance and the statistical consultant were blinded, in that they did not know to which intervention or control groups participants had been allocated.
Design and development of the serious educational game
The present study commenced with the systematic design and development of a serious educational game aimed at improving the clinical competency of medical students in burn management. A multidisciplinary team, comprising software engineers and academic faculty, engaged in ongoing collaboration throughout the design process. Multiple joint meetings were held to ensure that the game’s educational content was closely aligned with the current curriculum and the specific educational objectives for medical students.
To ensure content validity, the educational materials were developed based on a comprehensive needs assessment conducted through expert focus groups. Subsequently, the content was reviewed and evaluated by faculty members specializing in burn management, using established and up-to-date references in the field [26, 27]. Further expert review confirmed that the content and assessment items were accurate and appropriate for the intended population. The finalized educational content is summarized in Table 1.
Table 1.
Educational content headings of the serious game
| Content Domain | Topics Covered |
|---|---|
| Basic Concepts of Burns | Introduction to burns; thermal, inhalation, and electrical burns |
| Burn Assessment | Assessment of burn extent |
| Burn Diagnosis | Diagnosis of first‑degree burns; superficial, deep second‑degree burns; third‑degree burns; fourth‑degree burns |
| Burn Procedures | Escharotomy and fasciotomy |
| Burn Management | Calculation of fluid resuscitation volume; management of burn injuries; management of delayed burn injuries |
| Referral and Decision‑Making | Referral criteria and clinical conditions for burn patients |
| Communication and Professionalism | Approach to patient engagement and demonstration of empathy |
| Ethics in Burn Care | Ethical perspectives in professional practice |
Usability, engagement, and educational effectiveness of the prototype were assessed during a pilot phase involving medical students. Feedback obtained during the pilot phase focused on clarity of content, usability of the platform, and timing and usefulness of feedback. Based on this feedback, minor but targeted modifications were implemented, including refinement of question wording, improvement of feedback messages, and optimization of navigation. The final version of the game was then approved by the faculty review panel, confirming the suitability and validity of the educational content for enhancing medical students’ clinical competencies.
Educational framework of the serious game
The design and reporting of this technology-enhanced learning intervention were informed by the comprehensive framework proposed by Cook and Ellaway (2015) [28]. In accordance with this framework, key elements including learner characteristics, educational context, technological platform, instructional design features, and outcome evaluation were explicitly addressed.
The serious game was grounded in established educational theories, particularly deliberate practice, immediate feedback, and mastery learning. Learners engaged with the game individually and asynchronously throughout the intervention period, completing multiple time-limited clinical questions aligned with the skill domains assessed in the Mini-CEX. Repeated, goal-directed practice was facilitated by allowing unrestricted access to all questions and corresponding feedback, enabling learners to revisit content as needed. Immediate feedback was systematically provided following each response in the form of automated correctness indicators, brief explanatory text, and instructor-recorded video explanations, supporting timely error correction and reinforcement of correct clinical reasoning. Progression within the game was governed by predefined performance criteria, whereby incorrect responses required review of feedback prior to advancing, while correct responses permitted progression to subsequent content. This structure operationalized principles of mastery learning.
The intervention also incorporated elements of experiential learning by actively engaging students in simulated clinical decision-making scenarios relevant to their concurrent clinical rotations. Learner engagement was supported through time constraints, clearly defined progression rules, and iterative challenge design, rather than through competitive or extrinsic reward-based features, thereby maintaining a low-stakes learning environment. Outcome evaluation, aligned with the Cook and Ellaway framework, addressed both educational effectiveness—measured through knowledge acquisition and clinical performance using the Mini-CEX—and learner experience, including satisfaction with the intervention.
Intervention group
In the intervention group, students concurrently received routine training (including theoretical university instruction and practical clinical training with faculty in various departments such as burn clinics, operating rooms, and morning report sessions) while also utilizing an educational serious game platform. Following registration and assignment of unique login credentials, participants gained access to the software environment. Upon initial login, the platform’s educational objectives were clearly explained to users.
The first phase involved delivery of structured educational content consisting of instructional videos and relevant visual materials. After completing this content, students progressed to the gamified assessment module where they were required to answer time-limited questions. When incorrect answers were selected, the system displayed an error message without revealing the correct response, followed by explanatory feedback through instructor-recorded video explanations. Correct responses triggered positive reinforcement messages accompanied by brief explanatory feedback to reinforce learning, along with the allocation of points. Students could request additional learning resources through the platform’s communication features, receiving supplementary materials in various formats including videos, audio files, or links to specialized references.
Progression to subsequent levels required achieving a minimum accuracy threshold of 60% for each stage. The platform incorporated a scoring system that allowed participants to monitor their performance relative to peers. Access to the software was maintained for one week (coinciding with their rotation in the burn department), with usage metrics including frequency and duration of access being automatically recorded. Although a minimum engagement threshold was predefined, no participants failed to meet this criterion; therefore, no students were excluded from the final analysis.
Control group
In the control group, students only received standard training following completion of theoretical coursework, which included clinical rotations with faculty supervisors across various departments such as burn clinics, operating rooms, and morning case report sessions. Unlike the intervention group, participants in the control cohort did not have access to or utilize the serious game software platform during their training period.
Outcome measurement
Clinical performance was assessed using the Mini Clinical Evaluation Exercise (Mini-CEX), a validated workplace-based assessment tool designed for direct observation of clinical encounters followed by structured feedback; the validity and reliability of its Persian version have also been evaluated (Cronbach’s alpha coefficient of 0.94) [29–32].
The Mini-CEX framework was used to assess seven core clinical skill domains: (1) history taking, (2) physical examination, (3) communication skills, (4) professionalism, (5) clinical judgment, (6) diagnostic planning, and (7) therapeutic planning. Each domain was scored using a standardized Likert-type rating scale and recorded on a structured Mini-CEX evaluation form.
The total Mini-CEX score, calculated as the sum of the seven domain scores, was prespecified as the primary outcome of the study.
Prior psychometric studies of the Mini-CEX, including the original validation work by Norcini et al., have consistently used the total score as the main outcome measure when assessing residents’ clinical performance [32]. While domain-specific scores were also analyzed in the present study, these were treated as secondary outcomes because individual domains represent narrower skill components and are typically subject to greater variability, whereas the total score offers a more stable and comprehensive estimate of competence.
Teacher and student satisfaction were assessed using the built‑in satisfaction item of the standard Mini‑CEX form, in which both the assessor and the learner rate their overall satisfaction with the encounter on a 1–9 Likert‑type scale (1 = lowest satisfaction, 9 = highest satisfaction).
Data collection procedure
Mini-CEX assessments were conducted during routine clinical activities before and after the one-week training intervention, under comparable clinical conditions across different clinical settings, including outpatient clinics, emergency departments, and burn units. Each student was evaluated during a real patient encounter relevant to their clinical rotation by a single trained faculty assessor. To ensure consistency and reproducibility, all assessors participated in standardized training and calibration sessions prior to study initiation, covering Mini-CEX domains, scoring anchors, and expected performance standards. Each encounter was assessed by only one evaluator; therefore, inter-rater reliability analysis was not performed. All Mini-CEX forms were completed immediately after the observed encounter and subsequently entered into the study database for statistical analysis.
Each Mini-CEX session lasted approximately 15–20 min, including around 15 min of direct observation followed by 5 min of structured feedback. Each participant completed one Mini-CEX assessment at baseline and one after completion of the intervention. Performance during each encounter was evaluated across all seven Mini-CEX domains. The Mini-CEX corresponds to the “Does” level of Miller’s pyramid of clinical competence, emphasizing the assessment of learners’ ability to apply knowledge and skills in authentic clinical practice.
Statistical analyses
Data were presented as mean ± standard deviation (SD) for quantitative variables and as frequency (percentages) for categorical variables. The Kolmogorov-Smirnov test was utilized to assess the normality of quantitative variables. For comparisons between the intervention and control groups, the Chi-square test was applied to categorical variables. If the distribution of a quantitative variable was not normal, the non-parametric Mann-Whitney U test was utilized. Univariate effects of intervention on post-test outcome measures were examined using between-subject analysis of covariance (ANCOVA), adjusting for pre-test scores. To control for multiple comparisons, we applied the Holm-Bonferroni correction to the P-values. All statistical analyses were carried out using IBM SPSS software, version 25, with an alpha level set at 0.05.
Results
Study participants
The baseline characteristics of the participants in the intervention and control groups are presented in Table 2. A total of 70 participants were enrolled, with 35 allocated to each group (Fig. 1). The mean age of participants was 25.94 (± 1.08) years in the intervention group and 25.66 (± 0.97) years in the control group (P-value = 0.351). The groups also well-balanced in terms of sex distribution (P-value > 0.99). In summary, no statistically significant differences were found between the intervention and control groups in terms of age, sex, evaluation location, or type of referral at baseline (P-value > 0.05).
Table 2.
Participants’ characteristics in the intervention and control groups
| Variable | Intervention(n=35) | Control(n=35) | P-value |
|---|---|---|---|
| Age of Students; year | 0.351* | ||
| Mean ± SD | 25.94 ± 1.08 | 25.66 ± 0.97 | |
| Sex; n (%) | > 0.99** | ||
| Female | 14 (40.0) | 14 (40.0) | |
| Male | 21 (60.0) | 21 (60.0) | |
| Evaluation Location; n (%) | 0.121** | ||
| Clinic | 9 (25.7) | 17 (48.6) | |
| Ward | 8 (22.9) | 7 (20.0) | |
| Emergency Room | 18 (51.4) | 11 (31.4) | |
| Type of Referral; n (%) | 0.445** | ||
| New | 25 (71.4) | 22 (62.9) | |
| Follow | 10 (28.6) | 13 (37.1) |
* Mann-Whitney U‑test
** Chi-square test
Fig. 1.
CONSORT 2025 Flow Diagram. Flow diagram of the progress through the phases of a randomised trial of two groups (that is, enrolment, intervention allocation, follow-up, and data analysis)
Mini-CEX and Satisfaction scores
The analysis of skill scores revealed a consistent and significant effect of the intervention across all seven measured domains. While baseline scores were low and comparable between the intervention and control groups for all skills (all pre-intervention means between 1.00 and 2.74), post-intervention scores were substantially higher in the intervention group (Table 3). An ANCOVA, adjusted for baseline scores and corrected for multiple comparisons using the Holm-Bonferroni method, confirmed that the post-intervention differences were statistically significant for every skill (all corrected P-values < 0.001). The effect sizes for these differences were consistently large, as indicated by partial eta squared values ranging from 0.71 to 0.90. The adjusted mean differences between groups were most pronounced for “Therapeutic planning skill” (MD = 3.96, 95% CI: 3.64 to 4.27) and “Diagnostic planning skill” (MD = 3.70, 95% CI: 3.22 to 4.17). The smallest, yet still very large difference was observed for “History taking skill” (MD = 2.87, 95% CI: 2.47 to 3.27).
Table 3.
Analysis of Mini-CEX total score and its seven dimensions in the intervention and control groups
| Variable | Intervention n = 35 |
Control n = 35 |
MD€ (95% CI) | P-value¥ | η* | P-value£ |
|---|---|---|---|---|---|---|
| History taking skill | ||||||
| Before | 1.91 ± 0.50 | 1.74 ± 0.44 | < 0.0001 | 0.751 | < 0.001 | |
| After | 6.51 ± 0.95 | 3.65 ± 0.68 | 2.87 (2.47, 3.27) | |||
| Physical examination skill | ||||||
| Before | 1.20 ± 0.40 | 1.37 ± 0.49 | < 0.0001 | 0.719 | < 0.001 | |
| After | 6.31 ± 0.96 | 3.37 ± 0.87 | 2.95 (2.50, 3.40) | |||
| Communication skill | ||||||
| Before | 2.62 ± 0.68 | 2.74 ± 0.85 | < 0.0001 | 0.761 | < 0.001 | |
| After | 7.62 ± 1.00 | 4.51 ± 0.74 | 3.11 (2.68, 3.53) | |||
| Professional behavior skill | ||||||
| Before | 1.05 ± 0.23 | 1.11 ± 0.32 | < 0.0001 | 0.838 | < 0.001 | |
| After | 6.34 ± 0.80 | 3.02 ± 0.66 | 3.31 (2.96, 3.67) | |||
| Clinical judgment skill | ||||||
| Before | 1.06 ± 0.24 | 1.00 ± 0.00 | < 0.0001 | 0.708 | < 0.001 | |
| After | 5.60 ± 1.31 | 2.31 ± 0.75 | 3.32 (2.80, 3.84) | |||
| Diagnostic planning skill | ||||||
| Before | 1.08 ± 0.28 | 1.17 ± 0.38 | < 0.0001 | 0.781 | < 0.001 | |
| After | 6.20 ± 1.15 | 2.51 ± 0.78 | 3.70 (3.22, 4.17) | |||
| Therapeutic planning | ||||||
| Before | 1.09 ± 0.28 | 1.11 ± 0.32 | < 0.0001 | 0.904 | < 0.001 | |
| After | 6.80 ± 0.76 | 2.85 ± 0.60 | 3.96 (3.64, 4.27) | |||
| Mini-CEX total score | ||||||
| Before | 10.02 ± 1.29 | 10.25 ± 1.42 | ||||
| After | 45.40 ± 5.44 | 22.25 ± 3.03 | 23.21 (21.10, 25.33) | < 0.0001 | 0.877 | < 0.001 |
¥ ANCOVA
* Partial Eta square (ANCOVA Effect size for group)
£Adjusted based on Holm-Bonferroni method
€ Intervention minus control
The analysis of Mini-CEX total scores revealed a substantial and statistically significant improvement in clinical competency skills among participants in the intervention to the control group. Following the intervention, the intervention group achieved a mean post-intervention score of 45.40 ± 5.44, whereas the control group’s mean score was 22.25 ± 3.03. The adjustment mean difference between the groups was 23.21 points (95% CI: 21.10–25.33), strongly favoring the intervention. As determined by ANCOVA, this difference was statistically significant (P-value < 0.0001). The effect size was 0.877. This represents a large effect (Table 3).
Satisfaction scores for both teachers and students were assessed before and after the intervention, with the results detailed in Table 4. After adjusting for the baseline difference using ANCOVA and correcting for multiple comparisons, the between-group difference at post-test remained statistically significant (P-value < 0.0001). The adjusted mean difference was 3.16 (95% CI: (2.48 to 3.84), indicating a large intervention effect (η2 = 0.560). Post intervention student satisfaction increased in both groups but were significantly higher in the intervention group (7.51 ± 1.54) compared to the control group (5.48 ± 0.95). The ANCOVA, revealed a statistically significant difference (P-value < 0.001). The adjusted mean difference favored the intervention group by 2.02 points 95% CI : 1.40 to 2.63, representing an effect size of 0.391 (Table 4).
Table 4.
Teacher and student satisfaction in the intervention and control groups
| Variable | Intervention n = 35 |
Control n = 35 |
MD€ (95% CI) | P-value¥ | η* | P-value£ |
|---|---|---|---|---|---|---|
| Teacher’s satisfaction | ||||||
| Before | 1.57 ± 0.60 | 2.40 ± 1.53 | < 0.0001 | 0.560 | < 0.001 | |
| After | 7.17 ± 1.40 | 3.97 ± 1.27 | 3.16 (2.48, 3.84) | |||
| Student satisfaction | ||||||
| Before | 1.74 ± 1.40 | 1.62 ± 1.39 | < 0.0001 | 0.391 | < 0.001 | |
| After | 7.51 ± 1.54 | 5.48 ± 0.95 | 2.02 (1.40, 2.63) | |||
¥ ANCOVA
* Partial Eta square (ANCOVA Effect size for group)
£Adjusted based on Holm-Bonferroni method
€ Intervention minus control
Discussion
The present study assessed the effectiveness of a serious game in teaching burn management to medical students within the framework of a randomized trial. This evaluation was conducted using the Mini-CEX across seven skill domains. The results demonstrated a significant and statistically meaningful improvement in all skill areas for the intervention group compared to the control group. Despite both groups being homogeneous at baseline for all skills, the educational intervention led to notable differences: the intervention group experienced unprecedented progress across all skills and total score, whereas the control group exhibited a much more limited improvement. This remarkable progress attests to the game’s capacity to foster the integration of theoretical knowledge and practical skills when faced with complex clinical scenarios.
The effect sizes observed in this study were large, (partial η² = 0.71–0.90). While these findings suggest a a meaningful improvement, they should be interpreted cautiously. Such large effect sizes are not commonly observed in educational interventions and may have been influenced by several contextual and methodological factors. First, baseline Mini-CEX scores were relatively low and comparable between the intervention and control groups, suggesting limited prior competence in burn management and leaving considerable room for improvement following a focused educational intervention. The serious educational game was specifically designed to target these competencies through structured educational content and repeated formative assessment. In addition, the intervention incorporated multiple interactive learning components—including multimedia instructional content, scenario-based clinical questions, immediate feedback, and gamification elements—which may have enhanced learner engagement and facilitated rapid skill acquisition within the relatively short training period. Second, several contextual features of the study design may also have contributed to the magnitude of the observed effects. These include the short and focused nature of the intervention, the immediate timing of the post-intervention assessment, and the controlled single-center educational setting. Moreover, the intervention addressed a specific clinical topic, and the outcome measures were closely aligned with the instructional content, which may have increased the apparent magnitude of the effect. The intervention was also conducted during a concentrated one-week rotation in the burn department, a condition that may have amplified observable differences between groups. Although assessor-related bias was minimized through assessor training and blinding procedures, and Mini-CEX is a widely validated tool for assessing clinical competence, the possibility of residual contextual or assessment-related influences cannot be completely ruled out. Therefore, despite the promising findings, future multicenter studies with larger and more diverse samples, and longer follow-up periods are needed to confirm the durability, robustness, and generalizability of these effects.
These findings align with the growing importance of employing innovative educational techniques to enhance the quality of medical education. For instance, the study by Zohari et al. (2023) thoroughly examines trends in the development of gamification, game-based learning, and serious games, emphasizing the necessity for more effective integration of these strategies into educational programs [33]. This research aims to fill knowledge gaps and provide new insights, indicating that the increasing trend in these areas presents unprecedented opportunities for improving students’ learning experiences. Particularly noteworthy is the enhanced international collaboration and support for joint publications, which contribute significantly to advancing educational knowledge and technology, thereby supporting the development of innovative teaching approaches in medical education.
The evidence from this study, along with similar research, elucidates the significant role of serious games and gamification strategies in enhancing student engagement, motivation, and participation in diverse areas of medical education [34]. Implementing these strategies can meaningfully increase student interaction and involvement in various facets of medical training. By complementing traditional educational methods, these innovations enhance students’ clinical preparedness and facilitate the translation of theoretical concepts into practical skills. Advanced educational technologies provide platforms for deeper and more interactive learning experiences, transforming the educational landscape and bridging the gap between theory and practice.
Consistent with these findings, a study by Welbers et al. (2023) highlights critical elements of effective game design, namely public feedback and time constraints during sessions [35]. The intelligent implementation of these components, along with maintaining optimal engagement levels, leads to direct improvements in learning outcomes. This finding supports the current research and Xu’s study (2023) [34], underscoring the success of serious games, not merely in the presence of educational content, but in the thoughtful design of mechanisms featuring attributes like immediate feedback and challenging time constraints. Thus, the comprehensiveness of gamification research is expanded, emphasizing the necessity of incorporating psychological principles in the design of innovative educational tools.
The accomplishments achieved through the application of serious games highlight their potential to revolutionize medical education. This is further reflected in Longmuir’s study, which demonstrated that even complex areas of basic medical sciences, such as acid-base physiology, can be effectively conveyed through interactive digital environments [36]. By replacing traditional methods with flexible, self-directed learning, a deeper understanding of concepts can be achieved in a shorter time frame—confirming student perspectives regarding reduced learning time and enhanced conceptual understanding.
The stimulation of motivation and encouragement for students to engage more actively in challenges are key objectives of serious games. Research indicates that serious games serve as valuable educational tools that foster excitement and effectiveness in learning environments through interactivity and variety. These tools create dynamic and engaging contexts unique to medical education, supporting the consolidation of students’ knowledge and skills, while better preparing them to confront real-world challenges in healthcare [37, 38].
The success of the designed game is notably attributed to its intelligent application of educational mechanisms. A randomized clinical trial conducted on 42 nursing students revealed that the “Burn Assessment Mission” game significantly outperformed traditional methods (lecture + feedback) in both theoretical knowledge scores and practical skills [14]. Remarkably, these differences persist across 80% of practical exam stations, suggesting robustness even after controlling for demographic variables. The results indicate that this game, by fostering interactive and active learning, represents a superior approach to lecture-based methods in teaching critical concepts related to burn assessment.
These findings align with broader evidence in medical education. A systematic review highlights the moderate effectiveness of serious games in improving medical education, emphasizing that behavioral and cognitive approaches, akin to the framework of the present study, represent predominant pedagogical strategies in this domain [39]. Thus, the findings corroborate the conclusion that the designed game enhances interactive, active learning and offers an applicable model for other areas of health education. However, the systematic review also underscores the need for designing more advanced games and improving accessibility to further enhance learning outcomes.
The current study’s findings reveal that serious games significantly enhance medical students’ clinical competencies in managing burn patients compared to conventional methods. This aligns with the inherent nature of games, which are designed to boost motivation and performance in goal-directed activities. Supporting evidence from Farsi et al. (2021) similarly confirms the positive impact of serious games on teaching cardiopulmonary resuscitation to nursing students, showing that simulation and serious games significantly improved average knowledge and skill scores in the intervention groups compared to the control group [40].
In conclusion, the integration of serious games into medical education represents a transformative approach that significantly enhances learning outcomes. By creating engaging, interactive environments, these educational tools not only bolster students’ clinical competencies but also equip them with the necessary skills to address real-world challenges effectively. The continuous exploration of innovative educational strategies will be crucial for further advancing the quality of medical education.
Strengths and limitations
Strengths
This study demonstrates several notable strengths. The integration of a serious game into undergraduate burn education represents an innovative, learner-centered approach addressing a complex and clinically important topic. The intervention promoted active engagement, repeated practice, and feedback, contributing to meaningful short-term improvements in learning outcomes. Assessment using the Mini-Clinical Evaluation Exercise (Mini-CEX) enabled evaluation of learner performance at the “Does” level of Miller’s pyramid within authentic clinical settings, enhancing the educational relevance of the findings. In addition, the randomized controlled design strengthened internal validity and methodological rigor.
From an implementation perspective, the intervention required a one-time development investment and incurred minimal ongoing costs during routine use. It is highly reusable across cohorts, does not rely on specialized equipment or continuous financial support, and can be delivered using existing institutional resources. Importantly, the game has continued to be used beyond the completion of the study, supporting its feasibility, sustainability, and scalability within undergraduate clinical education.
Limitations
Several limitations should be acknowledged. First, this was a single-center study with a relatively small sample size, which may limit generalizability. Although the study was adequately powered for the primary outcome (total Mini-CEX score), secondary outcomes were exploratory. Second, the short follow-up period precludes conclusions regarding long-term knowledge retention, durability of competence, and sustained behavior change. While the Mini-CEX assesses performance in real clinical encounters, long-term real-world performance transfer and patient-level outcomes were not evaluated.
Third, no formal cost-effectiveness analysis was conducted, and conclusions regarding economic efficiency are therefore limited, despite the low ongoing implementation costs. Fourth, learner experience was primarily assessed through satisfaction measures; although usability was explored during pilot testing, it was not formally evaluated in the main trial. Finally, as with other serious game interventions, effectiveness may be influenced by alignment between task complexity and learner expertise, including the potential for a reverse expertise effect among novice learners.
Conclusions
In an era marked by rapid developments in medical education, innovative approaches such as game-based learning (GBL) have gained increasing significance. Notably, advancements in the development of serious game applications for managing burn patients exemplify this trend. These applications create an interactive and engaging environment, allowing medical students to enhance their skills through practical simulations. These novel educational methods place students in realistic scenarios, thereby improving clinical decision-making and effectively managing burn patients. As part of medical curricula, these applications can significantly enrich both the practical and theoretical skill sets of students. Ultimately, the integration of GBL and serious game applications into medical education not only innovates teaching methodologies but also empowers students to grasp complex medical concepts in a practical and experiential manner. This forward-thinking approach opens up new possibilities for enhancing educational outcomes and developing the clinical skills of students.
Supplementary Information
Acknowledgements
The authors gratefully acknowledge the Research Deputy of Mashhad University of Medical Sciences for their invaluable support and collaboration in facilitating this project. We also extend our sincere appreciation to the medical students whose participation and cooperation were essential to the successful conduct of this study.
Abbreviation
- Mini-CEX
Mini-Clinical Evaluation Exercise
Authors’ contributions
All of the authors have contributed to the study on conception and design, drafting the article, revising it critically for important intellectual content, and final approval of the version to be published. All authors are in agreement with the content of the manuscript.
Funding
This research was supported by Research Deputy of Mashhad University of Medical Sciences.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Research approval was obtained from the Ethics Committee of Mashhad University of Medical Sciences (code of ethics: IR.MUMS.NURSE.REC.1402.042). Written informed consent was obtained from all participants and the principles of confidentiality were observed.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.