The educational game SonoQz improves diagnostic performance in ultrasound assessment of ovarian tumors.

INTRODUCTION: Our objective was to determine whether the educational game SonoQz can improve diagnostic performance in ultrasound assessment of ovarian tumors. MATERIAL AND METHODS: The SonoQz mobile application was developed as an educational tool for medical doctors to practice ultrasound assessment, based on still images of ovarian tumors. The game comprises images from 324 ovarian tumors, examined by an ultrasound expert prior to surgery. A training phase, where the participants assessed at least 200 cases in the SonoQz app, was preceded by a pretraining test, and followed by a posttraining test. Two equal tests (A and B), each consisting of 20 cases, were used as pre- and posttraining tests. Half the users took test A first, B second, and the remaining took the tests in the opposite order. Users were asked to classify the tumors (1) according to International Ovarian Tumor Analysis (IOTA) Simple Rules, (2) as benign or malignant, and (3) suggest a specific histological diagnosis. Logistic mixed models with fixed effects for pre- and posttraining tests, and crossed random effects for participants and cases, were used to determine any improvement in test scores, sensitivity, and specificity. RESULTS: Fifty-eight doctors from 19 medical centers participated. Comparing the pre- and posttraining test, the median of correctly classified cases, in Simple Rules assessment increased from 72% to 83%, p < 0.001; in classifying the lesion as benign or malignant tumors from 86% to 95%, p < 0.001; and in making a specific diagnosis from 43% to 63%, p < 0.001. When classifying tumors as benign or malignant, at an unchanged level of sensitivity (98% vs. 97%, p = 0.157), the specificity increased from 70% to 89%, p < 0.001. CONCLUSIONS: Our results indicate that the educational game SonoQz is an effective tool that may improve diagnostic performance in assessing ovarian tumors, specifically by reducing the number of false positives while maintaining high sensitivity.

Game design elements of serious games in the education of medical and healthcare professions: a mixed-methods systematic review of underlying theories and teaching effectiveness.

Serious games, as a learning resource, enhance their game character by embedding game design elements that are typically used in entertainment games. Serious games in its entirety have already proven their teaching effectiveness in different educational contexts including medical education. The embedded game design elements play an essential role for a game's effectiveness and thus they should be selected based on evidence-based theories. For game design elements embedded in serious games used for the education of medical and healthcare professions, an overview of theories for the selection lacks. Additionally, it is still unclear whether and how single game design elements affect the learning effectiveness. Therefore, the main aim of this systematic review is threefold. Firstly, light will be shed on the single game design elements used in serious games in this area. Second, the game design elements' underlying theories will be worked out, and third, the game design elements' effectiveness on student learning outcome will be assessed. Two literature searches were conducted in November 2021 and May 2022 in six literature databases with keywords covering the fields of educational game design, serious game, and medical education. Out of 1006 initial records, 91 were included after applying predefined exclusion criteria. Data analysis revealed that the three most common game design elements were points, storyline, and feedback. Only four underlying theories were mentioned, and no study evaluated specific game design elements. Since game design elements should be based on theories to ensure meaningful evaluations, the conceptual GATE framework is introduced, which facilitates the selection of evidence-based game design elements for serious games.

Unlocking knowledge: a meta-analysis assessing the efficacy of educational escape rooms in health sciences education.

Educational escape rooms within health sciences education are gaining traction as a unique and engaging game-based strategy for reviewing instructional content. Educational escape rooms cultivate valuable skills such as teamwork, communication, creativity, attention to detail, and the ability to apply knowledge under time pressures. While several studies have independently assessed learners' knowledge gains after educational escape room interventions, the present work meta-analyzes the efficacy of educational escape rooms across studies and student learners within health sciences education. A systematic search across seven databases was performed by a health sciences librarian from inception to March 24, 2023. Record screenings, full-text reviews, and data extractions were managed within Covidence. MERSQI criteria were used to assess study quality. Pooled effect sizes (Standardized Mean Differences = SMD) were estimated through meta-analysis to summarize learner performance outcomes after educational escape room interventions. Eleven studies followed a longitudinal pretest-posttest design, and five studies followed a control-treatment group design. Learners' posttest scores after participating in an educational escape room were statistically higher than their pretest scores as indicated by a large positive summary effect size (SMD ≥ 0.893; p <0.001). Educational escape rooms were also effective for treatment group participants (n = 508), who significantly outperformed (SMD = 0.616; p <0.001) control group participants (n = 555). Most escape rooms were employed as a mechanism for reviewing educational content. This meta-analytic review suggests escape rooms are effective educational interventions for increasing knowledge gains among health sciences learners and highlights common implementation practices to help guide educators interested in this game-based learning approach.

Cracking the code: using educational gaming for high-level thinking in physiology education.

The multidisciplinary nature of physiology requires students to acquire, retain, apply, and evaluate knowledge from different scientific disciplines. Optimal learning techniques, such as active learning, interleaving topics and conditions, and recall, can greatly enhance the speed and effectiveness with which students achieve this type of higher-order thinking. However, developing and implementing optimal learning techniques in the classroom can be both time-intensive and challenging for the instructor. In addition, students may be resistant or slow to accept novel learning processes. One way to potentially introduce these learning techniques in a fun and engaging way is through educational gaming, or using a game or game elements intentionally to support learning. In this article we present an easy-to-implement adaptation of the Codenames board game for the physiology classroom. The activity requires minimal preparation while addressing high-level learning outcomes. Postintervention surveys of students were collected in three different health-related academic programs, both graduate and undergraduate, at two different institutions. Results suggest that participating in the activity both actively engaged the students and pushed them toward high-level, integrative thinking regardless of class level.NEW & NOTEWORTHY An easy-to-implement word game (Codenames) was used to engage students in higher-level Bloom's thinking about physiology. The gameplay required students to recall, apply, evaluate, and debate as they developed and guessed clues as part of the game. Students found the activity fun, engaging, and challenging. The activity is relatively easy to implement both online and in person, requiring at minimum a simple list of vocabulary terms.

Development and evaluation of the active learning game "Who Am I?-Cellular Signal Transduction Edition": the positive impact on undergraduate education.

The teaching of physiology plays a crucial role in the education of health care professionals. However, traditional approaches to physiology classes in undergraduate health courses in Brazil often result in passive student participation. Research has shown that active methodologies are more effective in the learning process. In this study, we introduce the game "Who Am I?-Cellular Signal Transduction Edition" as an educational tool. This game follows a popular format with well-known rules and aims to enhance understanding of basic concepts related to hormones, cell signaling, and the functioning of the endocrine system. Our findings demonstrate that the game improves student knowledge and fosters enthusiasm and active engagement among participants. Additionally, student feedback has indicated a high level of appreciation for the game. By incorporating active learning strategies and a gamified approach, "Who Am I?-Cellular Signal Transduction Edition" provides a practical and enjoyable way of teaching physiology. This innovative educational tool has the potential to revolutionize physiology instruction. Demonstrating significant improvement in students' understanding, the game underscores its efficacy in enhancing knowledge acquisition and comprehension of cellular signaling and endocrine physiology topics.NEW & NOTEWORTHY We developed "Who Am I?-Cellular Signal Transduction Edition" to assist students in comprehending concepts of cellular signal transduction. This simple and cost-effective tool is perfect for educational settings with limited resources, and it encourages active learning for both small and large groups. Pre- and posttests have shown that it effectively enhances knowledge of hormonal actions and cellular signaling. Positive feedback from students emphasizes its value in reinforcing understanding and improving classroom engagement, making it a promising educational tool.

Creation and evaluation of an educational escape room for preclinical training on 3D printing in dentistry.

INTRODUCTION: The benefit of pedagogical escape rooms for dental students' stimulation, interest and knowledge strengthening has been suggested by several studies. However, in previous studies, only a few students were evaluated. This study aims to confirm the purpose of this innovative pedagogical tool in terms of learning consolidation and team building from students' perceptions. We directly incorporated an educational escape game into the fundamental academic formation as a practical-work course for fifth-year dental students. MATERIALS AND METHODS: The present escape game focused on 3D printing, whose implementation fit the different steps of an escape game well. This study was conducted in March 2022. All fifth-year dental students (n = 212) were divided into 5-6 student groups to match the conditions of an escape game. Before entering the room, each student had to complete a cross-sectional knowledge true/false test of 8 questions to assess their general level. Additionally, an 18-question appreciation survey was completed when leaving the room. RESULTS: The students perceived the 3D-printing escape game to be relevant and especially expressed the benefit of being part of a team to exchange and build knowledge. These results suggest knowledge strengthening. The instructional benefit of this process seemed to exceed its mere fun and appealing aspect. CONCLUSION: Our results with a large number of students showed that, from the students' perception, the educational escape game significantly improved knowledge and team-building. It created a supportive learning environment and increased students' motivation. It can provide a fun and effective way to diversify instruction.

The impact of an online educational game on breast cancer awareness among university female students, Malaysia: a pilot study.

BACKGROUND: Breast cancer is one of the world's most prevalent cancer and the most common type of cancer in Malaysia. Interestingly, breast cancer in young women is more aggressive compared to older women and the survival rate among these groups of individuals is poor. Thus, breast cancer awareness is essential among young women as early detection is possible and treatment will be effective during which the disease is curable. Hence, the purpose of this study is to design and evaluate the impact of an educational game on breast cancer awareness among female university students in Malaysia. METHODS: This is a one-group pre-and post-intervention pilot study. It was conducted in Private and public higher education institutions around Malaysia. An online education game was created and used as the intervention. A self-administered questionnaire was administered to the participants during the pre-and post-intervention test to evaluate the online educational game on breast cancer awareness. RESULTS: A total of 52 responses were collected. The mean age of the participants was 21.98 (SD = 1.896) years. The findings showed a statistically significant median increase (p < 0.05) in breast cancer knowledge scores among participants in the post-intervention. A median increase in breast cancer knowledge score of 6 was shown when participants were exposed to the online education game (24.00) compared to before they were exposed to it (17.00). CONCLUSION: Using online educational games effectively raised awareness of breast cancer among university students. Online games can be used as a health educational tool to promote awareness of a topic of interest, as digital games can be accessed easily, game content can be tailored made or updated, and improve participant engagement in learning.

Implementation of a hepatitis-themed virtual escape room in pharmacy education: A pilot study.

As we enter a world of blended learning in higher education, an increased need for adaptation of teaching strategies to enhance engagement has been recognised to amplify learning outcomes online. Gamification has been identified as a creative tool to engage the current cohort of learners who are also characteristically tech-savvy. To this end, escape room games have gained considerable traction in medical and pharmacy education to promote learning, critical thinking and teamwork. In this pilot study we describe the implementation of a 60-minute, web-based hepatitis-themed escape room game within a Year 3 Pharmacotherapy unit at Monash University. A total of 418 students participated in this activity. Students' knowledge gain on the topic was assessed through a pre- and post-intervention assessment, whereby a statistically significant improvement was seen in the knowledge score following implementation of the gaming activity (58.66% pre-intervention vs. 72.05% post-intervention, p < 0.05). The innovative learning activity was also well perceived by the students. Virtual escape room game is a viable pedagogical approach to teach and reinforce clinical concepts among pharmacy students. With the evolving landscape of education and learner demographics, investment in technology- enhanced game-based learning is a promising trajectory to support students' growth in a learner-centered environment. A comparison between virtual escape room game and traditional teaching will further inform effectiveness of the gamification on long term knowledge retention.

Educational interventions improving knowledge about epilepsy in preschool children.

OBJECTIVE: Sufficient public knowledge about epilepsy is a starting point for reducing epilepsy-related stigma and improving quality of life of people with this condition. Thus, interventions aimed at improving such knowledge are greatly needed. However, there is a significant lack of such interventions and none have been applied to preschool children. We aimed to develop effective interventions using the educational board game Action Zone! and a technique known as educational story, and by focusing on the acquisition of knowledge about epilepsy in children aged 5-6 years with no previous knowledge of epilepsy. METHODS: Knowledge about epilepsy was measured using a 20-item test consisting of questions selected from educational game and an 11-item test used successfully in our previous intervention study focused on children aged 9-11 years. Both measures exhibited acceptable internal consistency with Cronbach's alpha of 0.72 and 0.67. In total, 296 children participated in three intervention studies (educational game, educational story, and a revised version of educational story). Level of knowledge was assessed immediately after each intervention and again one month later. RESULTS: We found that all interventions were effective (p = 0.001) in comparison of retest results with baseline of zero level of knowledge based on the statements of children before intervention. Intervention based on educational game resulted in a higher percentage of correct responses in comparison with educational story (p = 0.020). However, the revised version of educational story developed using participatory action research was superior in comparison with the original version (p < 0.001) and fully comparable with educational game (p = 0.864). CONCLUSIONS: The results showed the aforesaid interventions were significant and effective ways to establish basic knowledge about epilepsy in the given age group.

Pedagogy, Partnership, and Collaboration: A Longitudinal, Empirical Study of Serious Educational Gameplay in Secondary Biology Classrooms.

The use of serious educational games has the potential to increase student learning outcomes in science education by providing students with opportunities to explore phenomena in ways that vary from traditional instruction; yet, empirical research to support this assertion is limited. This study aimed to explore deeply what learning gains were associated with the use of three serious educational games (SEGs) created for use in secondary biology classrooms that partner teachers implemented during a 2-week curriculum unit. This longitudinal, mixed method study includes a control year, in which we examined how six highly qualified teachers taught students (n = 407) a 2-week curriculum unit addressing cellular biology without the SEGs, followed by 2 years in which the teachers integrated the SEGs into the curriculum unit with students (n =871). Data were collected from multiple sources, including a validated content pre- and post-test measure, embedded gameplay data, participant observation, teacher interviews, and focus groups. Quantitative findings showed significant learning gains associated with students who experienced the game condition during year 2, when compared with the control condition. During the replication year (year 3), learning gains increased again, compared with year two. Although the SEGs did not change between years 2 and 3, teachers were provided real-time access to students' performance during gameplay. Thematic analysis of observation notes, teacher interviews, and student performance in-game identified four affordances teachers identified related to the use of serious educational games in their classrooms and the extended partnership model employed. Implications for researchers and game designers are discussed.

Immersive virtual-reality computer-assembly serious game to enhance autonomous learning.

Immersive virtual reality (VR) environments create a very strong sense of presence and immersion. Nowadays, especially when student isolation and online autonomous learning is required, such sensations can provide higher satisfaction and learning rates than conventional teaching. However, up until the present, learning outcomes with VR tools have yet to prove their advantageous aspects over conventional teaching. The project presents a VR serious game for teaching concepts associated with computer hardware assembly. These concepts are often included in any undergraduate's introduction to Computer Science. The learning outcomes are evaluated using a pre-test of previous knowledge, a satisfaction/usability test, and a post-test on knowledge acquisition, structured with questions on different knowledge areas. The results of the VR serious game are compared with another two learning methodologies adapted to online learning: (1) an online conventional lecture; and (2) playing the same serious game on a desktop PC. An extensive sample of students (n = 77) was formed for this purpose. The results showed the strong potential of VR serious games to improve student well-being during spells of confinement, due to higher learning satisfaction. Besides, ease of usability and the use of in-game tutorials are directly related with game-user satisfaction and performance. The main novelty of this research is related to academic performance. Although a very limited effect was noted for learning theoretical knowledge with the VR application in comparison with the other methodologies, this effect was significantly improved through visual knowledge, understanding and making connections between different concepts. It can therefore be concluded that the proposed VR serious game has the potential to increase student learning and therefore student satisfaction, by imparting a deeper understanding of the subject matter to students. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10055-021-00607-1.

MANTRA: development and localization of a mobile educational health game targeting low literacy players in low and middle income countries.

BACKGROUND: Mobile technology is increasingly important for delivering public health interventions to remote populations. This research study developed, piloted, and assessed a serious game for mobile devices that teaches geohazard, maternal, and neonatal health messages. This unique mHealth intervention aimed at low-literacy audiences in low resource settings is part of the Maternal and Neonatal Technologies in Rural Areas (MANTRA) project: Increasing maternal and child health resilience before, during, and after disasters using mobile technology in Nepal. METHODS: The serious game was developed through a co-creation process between London and Kathmandu based researchers by email and video-calling, and face-to-face with local stakeholders in Nepal. The process identified core needs, developed appropriate pictograms and mechanics, and tailored the pilot serious game to the local cultural context. Evaluations and feedback from end users took place in rural villages and suburban Kathmandu in Province Three. Field evaluation sessions used mixed methods. Researchers observed game play and held focus group discussions to elicit qualitative feedback and understand engagement, motivation, and usability, and conducted a paired pre- and post-game knowledge assessment. RESULTS: The MANTRA serious game is contextualized to rural Nepal. The game teaches 28 learning objectives in three modules: maternal health, neonatal health, and geohazards, through picture matching with immediate audio and visual feedback. User feedback from focus groups demonstrated high engagement, motivation, and usability of the game. CONCLUSIONS: This MANTRA study is a unique mHealth intervention of a serious game to teach core health and geohazards messages to low-literacy audiences in rural Nepal. Although the mobile game is tailored for this specific context, the developmental process and insights could be transferable to the development of other games-based interventions and contextualized for any part of the world. Successfully targeting this low-literacy and illiterate audience makes the MANTRA development process the first of its kind and a novel research endeavor with potential for widespread impact and adoption following further game development. TRIAL REGISTRATION: This project was approved by the University College London Ethics Committee in London, United Kingdom [10547/001], and the Nepal Health Research Council in Kathmandu, Nepal [Reg. No. 105/2017]. All participants provided informed written consent.

Integrating synapse, muscle contraction, and autonomic nervous system game: effect on learning and evaluation of students' opinions.

This work describes the educational game "Integrating Synapse, Muscle Contraction, and Autonomic Nervous System," which was developed to assist students in understanding and integrating concepts related to the physiology of synapses, muscle contraction, and the autonomic nervous system. Analysis was made of the effect of the game on learning and the students' opinions about it. Dentistry students were divided into control and game groups. They attended lectures about the topics, after which the control group students were submitted to a test, whereas the game group performed the game activity before undertaking the test. The mean score was significantly higher for the game group, compared with the control group (P < 0.05). Pharmacy students also attended lectures about these topics; in the next class, the students performed a pretest and the activity with the educational game. After the game, a posttest was applied. The mean scores were significantly higher for the posttest than for the pretest (P < 0.05). Students of medicine attended the lectures and performed the activity with the educational game, without the learning assessment. All of the students answered a question, using a 5-point Likert-type scale, concerning whether they thought the activity with the game was useful for learning. The mean scores obtained by the dentistry, pharmacy, and medicine students were 4.7 ± 0.6, 4.9 ± 0.3, and 4.3 ± 0.1, respectively. The educational game increased the learning of the undergraduate students, in agreement with their opinions of the strategy.

Effect of an active learning methodology combined with formative assessments on performance, test anxiety, and stress of university students.

The aim of this study was to evaluate the effect of an active methodology combined with a lecture on undergraduate student learning and levels of stress and anxiety. The active learning methodology consisted of a lecture of 50-min duration, study at home with a textbook, an educational game activity, and three formative assessments on the topic of the cardiac cycle. In a following class, the students provided saliva samples to evaluate their levels of stress, received an anxiety test, and then undertook an exam to assess their understanding of the cardiac cycle. The traditional teaching methodology consisted of two lectures (∼2-h duration) on blood pressure control systems, delivered orally. In the third class, the students provided saliva samples, received an anxiety test, and then undertook an exam to assess their understanding of blood pressure control systems. The level of stress was assessed with the concentrations of the stress biomarkers cortisol and alpha-amylase in saliva. Anxiety was assessed with the State-Trait Anxiety Inventory (STAI) questionnaire. The students achieved significantly higher average scores in exams when the active learning strategy was applied compared with the use of traditional theoretical classes. The active methodology resulted in significantly lower levels of stress and anxiety, as well as improved student performance, compared with the use of traditional lectures.

Educational gaming for dental students: Design and assessment of a pilot endodontic-themed escape game.

INTRODUCTION: The concept of escape games dedicated to dental students is a new learning experience that has not yet been extensively explored. The aim of this pilot study was to assess the impact and perceived value of an endodontic-themed escape game as assessed by fourth-year dental students. METHODS: This study was conducted at the University of Nantes, Faculty of Dental Surgery using a cross-sectional pre- and post-test research design to assess students' changes in performance. Students in the fourth year of dental surgery study (n = 18) were divided in four groups for this study. The answers to the pre-test/post-test were 50 true/false questions. Moreover, a 20-question perception survey was given to all the participants after completion of the escape game. The study data were collected in May 2019. An unpaired t test analysed the mean differences between the groups. RESULTS: The results showed a statistically significant increase in post-test results (75.33% ± 10.17% of correct answers) compared to the pre-test results (67.33% ± 5.94% of correct answers) P < .05. Analysis of variance revealed that this change in score was not significantly different between the four groups. The students perceived the endodontic-themed escape game to be relevant. A one-sample t test indicated that students' mean (SD) perception 4.4 (0.7) was statistically significantly higher than the mean value of the evaluation scale P < .001. The students found this educational game to be a useful experience that helped them recall/apply knowledge whilst promoting teamwork. CONCLUSION: Therefore, this type of game can enhance students' learning and motivation.

A systematized review on diabetes gamification.

Background: Gamification is an effective tool used to enhance the quality of education and training, to create motivation and enthusiasm, and to maintain competitiveness in the targeted population. Given that, the present study is an attempt to review gamification used in the field of diabetes systematically and its effects on the target group. Methods: Articles were retrieved from eight databases via an electronic advanced search. The data were imported to Endnote; and to assess the quality of the articles, PRISMA and CASP were used. Finally, according to the inclusion criteria, the appropriate articles were selected. Results: This study indicates that physical activity and nutrition were the most frequent diabetic subgroups in diabetes gamification. In addition, all diabetes gamification programs were designed to educate, teach skills and make behavior improvement in diabetics. Conclusion: Diabetes gamification have the capacity to change health behaviors among all age groups and can create an innovative, attractive and interactive learning environment accompanied by fun and engagement. Professor, Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran; Librarianship and Medical Information Science, Iran University of Medical Sciences, Tehran, Iran.

Increased learning by using board game on muscular system physiology compared with guided study.

The aim of this work is to describe the "Muscular System Game," created to assist in the teaching-learning process concerning the physiology of the muscular system, and to evaluate its effect on the learning of university students. Participating in this study were first-year undergraduate students of the pharmacy course (game group, n = 21, 5 men and 16 women, age 23.57 ± 4.92 yr) and the nursing course (control group, n = 22, 2 men and 20 women, age 22.90 ± 4.93 yr), who had the same level of preparation. After theoretical classes concerning the physiology of the muscular system, all students were instructed to study the topic. In the next week, the students of the game group performed the activity with the board game, and the students of the control group undertook a guided study activity, which contained a list of exercises with the same questions used in the game, to be answered by groups. In the week following these activities, all of the students answered evaluation questions about the topic. The scores obtained for the two groups in the evaluation were compared using Student's t-test for unpaired samples, considering a significance level of 0.05. The score obtained for the control group (5.78 ± 0.38) was significantly lower than the score for the game group (7.50 ± 0.47; P < 0.05). The results obtained indicating that the use of an educational board game about the physiology of muscle contraction resulted in significantly improved learning, compared with the use of guided study.

Hunger Games: Interactive Ultrasound Imaging for Learning Gastrointestinal Physiology.

Ultrasound is playing an increasingly important role in medical student education. Although most uses of ultrasound have focused on learning purely anatomic relationships or augmentation of the physical examination, there is little documentation of the value of ultrasound as a learning tool regarding physiology alone or in association with anatomy. We devised an interactive learning session for first-year medical students using ultrasound to combine both anatomic and physiologic principles as an integration of gastrointestinal and vascular function. The incorporation of our activity, The Hunger Games, provides the foundation for a powerful integration tool for medical student education.

Effect of a puzzle on the process of students' learning about cardiac physiology.

The aim of the present study was to evaluate the effects of using a puzzle to learn about cardiac physiology. Students were divided into control and game groups. In class 1, the control group had a 2-h theoretical class about cardiac physiology, including a detailed description of the phases of the cardiac cycle, whereas the game group had a 50-min theoretical class without the description of the cardiac cycle. In class 2, the control group did an assessment exercise before an activity with the cardiac puzzle and the game group answered questions after the above-mentioned activity. While solving the puzzle, the students had to describe the cardiac cycle by relating the concepts of heart morphology and physiology. To evaluate short-term learning, the number of wrong answers and grades in the assessment exercise were compared between the control and game groups. To evaluate medium-term learning, we compared the grades obtained by students of the control and game groups in questions about cardiac physiology that formed part of the academic exam. In the assessment exercise, the game group presented a lower number of errors and higher score compared with the control group. In the academic exam, applied after both groups had used the puzzle, there was no difference in the scores obtained by the control and game groups in questions about cardiac physiology. These results showed a positive effect of the puzzle on students' learning about cardiac physiology compared with those not using the puzzle.