Gamified learning for resuscitation education: EIT 6412; TFSR

Conflict of Interest (COI) Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none recused as no COI declared.

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: None declared a COI.

CoSTR Citation

Donoghue A, Sawyer T, Toft L, Olaussen A, Greif R on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force (EIT). Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR), 2023 November 30. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic literature search of gamified learning vs. other forms of non-gamified learning conducted by an information specialist with involvement of clinical content experts. Evidence collected from the literature was reviewed and considered by the EIT Task Force. These data were taken into account when formulating the Treatment Recommendations.

Systematic Review

Webmaster to insert the Systematic Review citation and link to Pubmed using this format when it is available if published

Publication in progress

PICOST

Prospero Registration: CRD42023483540

Consensus on Science

Details of the screening process are shown in the PRISMA diagram (Figure 1).

There were 13 studies ^1-13 six randomised trials^{2,3,6,9,10,11} and seven observational studies^{1,4,5,7,8,12,13}; study details are shown in the data extraction table (Table 1). Risk of bias assessments are shown in Table 2. The overall quality of evidence was rated as low to very low for all outcomes primarily due to a very serious risk of bias. The individual studies were all at a critical risk of bias due to confounding. Because of this and a high degree of heterogeneity, no meta-analyses could be performed.

11 studies used gamification elements involving digital platforms: 6 studies used an online or screen-based platform^{1, 2, 7, 9, 12, 13}, 3 studies used a digital leaderboard^{3, 8, 9}, and 2 studies used smartphone applications.^{6, 11} One study used a board game and one study used a card game.^{4, 5}

11 studies involved healthcare providers as learners^1-11; 2 studies examined laypeople (high school students) as learners^{12, 13}. 3 studies examined performance between groups or teams^{5, 6, 13}; the remaining 10 studies examined individual performance. 6 studies used adult scenarios ^{2, 6, 10-13}; 3 used pediatric scenarios^{3, 8, 9}; 4 used neonatal scenarios.^{1, 4, 5, 7}

For the critical clinical and patient outcomes, we were unable to find any studies addressing this research question.

For the important outcome of Skill -- CPR overall performance, we included four randomized controlled trials (RCTs)^2,3,9,10 with 900 intervention subjects and 789 controls. One observational study of 92 subjects was included¹³. One RCT in nursing students using an online competitive platform for CPR performance found improved scores compared with non-users (p<0.05).² Two RCTs in pediatric healthcare providers used a leaderboard to monitor competition in CPR performance during refresher training sessions; one single center study found significantly better performance in leaderboard group (p<0.001)⁹; the other multicenter RCT found no effect.³ One RCT in laypeople using team competition in CPR performance during training found better CPR performance in the competition group than controls (p<0.05).¹⁰

One observational study of laypeople using a screen-based competition at CPR performance found improved performance 6 months post training (score 23% vs. 16%, p<0.05).¹³

For the important outcome of Skill – chest compression rate and depth, we included one observational study of 65 high school students participating in a CPR "tournament" during Basic Life Support (BLS) training via a screen-based interface. Immediately post training, chest compression (CC) depth (45 vs 31 mm, p<0.01) and CC rate (111 vs 94, p<0.01) were improved from baseline. At 3 months, depth and rate remained improved over baseline but no different than immediately post training.¹²

For the important outcome of Knowledge – Neonatal Resuscitation Program, we included two observational studies of healthcare providers. One study of a board game using Neonatal Resuscitation Program (NRP) knowledge showed improved scores after playing (61% vs 49%, p<0.001).⁴ One study of a screen-based point system-based game in NRP led to higher scores 6 months post training (p<0.001) but no difference immediately post training.⁷

For the important outcome of Knowledge – Advanced Life Support, we included two RCTs in healthcare providers with 145 intervention subjects and 144 controls. One RCT using a phone-based team game involving identifying keywords found greater improvement in scores on a multiple-choice question test following life support training (p<0.05).⁶ One RCT using a smartphone-based game involving Advanced Life Support (ALS) scenarios with a point system during and before an ALS course found higher scores on an ALS algorithm test among game users (17 vs 16, p=0.01).¹¹

For the important outcome of Skill – ALS scenario score, we included one RCT in healthcare providers with 53 intervention subjects and 52 controls. Intervention subjects used a smartphone-based game involving ALS scenarios before and during an ALS course. Scores were not significantly different between groups (79% vs 66%, p=0.09)¹¹

For the important outcome of Skill – NRP scenario score, one observational study of using an online gaming portal involving NRP training found improved scores following game use (p<0.001).¹

For the important outcome of Skill – time to positive pressure ventilation in NRP scenario, one observational study of using an online gaming portal involving NRP training found faster time to positive pressure ventilation in a neonatal scenario (p=0.04).¹

For the important outcome of Skill – pediatric epinephrine dosing, we included one observational study of nurses using a leaderboard during a study period of repeated practice at preparing weight-based epinephrine dosing. Over the study period, average time to dose prep decreased by 27 seconds (p=0.02); the proportion of learners completing the task in < 2 minutes increased from 23% to 59% (p=0.03).⁸

For the important outcome of Knowledge – pediatric epinephrine dosing, we included one observational study of nurses using a leaderboard during a study period of repeated practiced at preparing weight-based epinephrine dosing. Over the study period, the proportion of learners knowing the correct concentration of epinephrine increased from 19% to 71% (p<0.001).⁸

For the important outcome of affective responses, one RCT using a smartphone-based game in ALS training led to better self-reported confidence among users.¹¹ One study of a card game to enhance NRP knowledge had high levels of perceived usefulness among surveyed learners post-study.⁵

For the important outcome of Process: costs and resources utilization, we were unable to identify any relevant studies.

Treatment Recommendations

The Task force suggests the use of Gamified Learning (GL) to be considered as a component of resuscitation training for all types of basic and advanced life support courses (weak recommendation, very low certainty of evidence).

Justification and Evidence to Decision Framework Highlights

In making this suggestion, the EIT taskforce considered the following:

• All of the studies were very heterogeneous with respect to subjects, type of intervention, type of control, and outcome measure
• Risk of bias assessment showed that evidence was of very low certainty
• All studies included in this review reported at least one domain of learner outcome (skill, knowledge, attitude) with a positive result when GL elements were included
• The included studies provide evidence for the use of GL in basic and all advanced life support courses.
• Most studies involved an intervention requiring a digital platform (e.g. video-based, smartphone-based); no studies reported any information about cost, implementation outside their study group, or wider dissemination to other settings or learners

Knowledge Gaps

We identified several knowledge gaps in the literature:

• A more consistent definitions of 'gamification' across research studies (e.g. use of video-based content delivery alone does not necessarily constitute a 'game' although this term is frequently used to describe such training elements) is needed.
• No studies were found on dissemination of GL elements, as well as platforms to varied learner groups and settings.
• Studies on costs, resources and time requirements for implementation of GL are lacking.
• The association between GL elements and differences in stress and/or cognitive load needs to be investigated.
• No evidence exists on the impact on care delivery and/or patient outcomes.

Note to Webmaster: CoSTR posting should be linked to ETD summary table

Attachments:

EIT 6412 Gamified Learning Et D table

EIT 6412 Gamified Learning Summary of evidence

EIT 6412 Data and ROB tables

EIT 6412 Gamified learning PRISMA

References

1. Billner-Garcia RM and Spilker A. Development and Implementation of a Game-Based Neonatal Resuscitation Refresher Training: Effect on Registered Nurse Knowledge, Skills, Motivation, Engagement. Journal for Nurses in Professional Development 2022; 20: 20. DOI: https://dx.doi.org/10.1097/NND.0000000000000953.

2. Boada I, Rodriguez-Benitez A, Garcia-Gonzalez JM, et al. Using a serious game to complement CPR instruction in a nurse faculty. Computer Methods & Programs in Biomedicine 2015; 122: 282-291. DOI: https://dx.doi.org/10.1016/j.cmpb.2015.08.006.

3. Chang TP, Raymond T, Dewan M, et al. The effect of an International competitive leaderboard on self-motivated simulation-based CPR practice among healthcare professionals: A randomized control trial. Resuscitation 2019; 138: 273-281. DOI: https://dx.doi.org/10.1016/j.resuscitation.2019.02.050.

4. Cutumisu M, Patel SD, Brown MRG, et al. RETAIN: A Board Game That Improves Neonatal Resuscitation Knowledge Retention. Frontiers in Pediatrics 2019; 7: 13. DOI: https://dx.doi.org/10.3389/fped.2019.00013.

5. Gordon DW and Brown HN. Fun and games in reviewing neonatal emergency care. Neonatal Network - Journal of Neonatal Nursing 1995; 14: 45-49.

6. Gutierrez-Puertas L, Garcia-Viola A, Marquez-Hernandez VV, et al. Guess it (SVUAL): An app designed to help nursing students acquire and retain knowledge about basic and advanced life support techniques. Nurse Education in Practice 2021; 50: 102961. DOI: https://dx.doi.org/10.1016/j.nepr.2020.102961.

7. Hu L, Zhang L, Yin R, et al. NEOGAMES: A Serious Computer Game That Improves Long-Term Knowledge Retention of Neonatal Resuscitation in Undergraduate Medical Students. Frontiers in Pediatrics 2021; 9: 645776. DOI: https://dx.doi.org/10.3389/fped.2021.645776.

8. King CE, Kells A, Trout L, et al. Gamification educational intervention improves pediatric nurses' comfort and speed drawing up code-dose epinephrine. Journal of Pediatric Nursing 2023; 71: 55-59. DOI: https://dx.doi.org/10.1016/j.pedn.2023.03.013.

9. MacKinnon RJ, Stoeter R, Doherty C, et al. Self-motivated learning with gamification improves infant CPR performance, a randomised controlled trial. BMJ Simulation & Technology Enhanced Learning 2015; 1: 71-76. DOI: https://dx.doi.org/10.1136/bmjstel-2015-000061.

10. Otero-Agra M, Barcala-Furelos R, Besada-Saavedra I, et al. Let the kids play: gamification as a CPR training methodology in secondary school students. A quasi-experimental manikin simulation study. Emergency Medicine Journal 2019; 36: 653-659. DOI: https://dx.doi.org/10.1136/emermed-2018-208108.

11. Phungoen P, Promto S, Chanthawatthanarak S, et al. Precourse Preparation Using a Serious Smartphone Game on Advanced Life Support Knowledge and Skills: Randomized Controlled Trial. Journal of Medical Internet Research 2020; 22: e16987. DOI: https://dx.doi.org/10.2196/16987.

12. Semeraro F, Frisoli A, Loconsole C, et al. Kids (learn how to) save lives in the school with the serious game Relive. Resuscitation 2017; 116: 27-32. DOI: https://dx.doi.org/10.1016/j.resuscitation.2017.04.038.

13. Toft LEB, Richie J, Wright JM, et al. A New Era of Lay Rescuer CPR Training: An Interactive Approach for Engaging High Schoolers. J Am Coll Cardiol 2022; 80: 2251-2253. 2022/12/02. DOI: 10.1016/j.jacc.2022.09.040.