To identify all the categories of health care professionals who may be expected to don PPE in the prehospital setting, the module developers interviewed chief ambulance officers, chief medical officers, paramedics, and emergency physicians working in Swiss EMS.

Given the general objective and the target audience, we performed individual interviews to assess specific learning objectives that the gamified e-learning module needed to fulfill. At this stage, specialists from the Geneva University Hospitals infection control program were included in the discussion.

Use of game mechanics should not be a goal per se but a means to ensure that the intended learning objectives are met. We therefore searched the scientific literature using the PubMed engine with combinations (using the Boolean operator “AND”) of the medical subject headings (MeSH) keywords serious games, prehospital, and infection control and the non-MeSH keywords gamification, e-learning, and electronic learning. Potentially relevant articles were retrieved based on their titles and abstracts. References from the most authoritative and relevant articles were manually screened to identify papers our initial search may have overlooked. Articles that were not written in English or French were excluded.

Factors contributing to learner engagement as well as to skill and knowledge acquisition were collected before being individually assessed according to their potential impact. As game mechanics may not apply to all aspects of knowledge acquisition, it was necessary to identify specific elements that could benefit from the use of such mechanics. Specialists from the infection control program as well as chief ambulance and medical officers were again consulted at this stage.

Infection control specialists were included early in the design phase of the module to validate the learning content and its coherence with local COVID-19 control guidelines. Due to the rapid and incessant growth of knowledge regarding COVID-19 and the need to preserve PPE, the advice of these specialists was essential.

The gamified e-learning module was designed according to the scientific foundations established in the previous stage.

To apply game mechanics to the learning objectives that could most benefit from this method, the learning mechanics-game mechanics (LM-GM) model proposed by Arnab [15] in 2015 was used. In this model, learning mechanics are determined according to learning objectives and are then transformed into game mechanics to achieve the intended goal. The scientific foundations for the module were therefore first translated into learning mechanics and then, when appropriate, into game mechanics.

When making design decisions, it was necessary to consider the particular context of the COVID-19 pandemic along with the specific target population. The time taken to complete the whole module and the type of media included in the module were assessed in this regard. Ease of access to the module, including the platforms and support that could be used, was also considered.

This stage required the integration of all the data collected during the scientific foundation and design foundation stages. The learning objectives were reviewed, and learning mechanics were decided according to theoretical basis. Decisions regarding gamification of specific sections of the e-learning module were reassessed. An iterative approach to the construction of the module was used, incorporating regular feedback from the different previously identified stakeholders (infection prevention and control consultants, chief ambulance officers, chief medical officers, paramedics, and emergency physicians).

During the iterative development loops and at the end of the development process, the module was tested for usability according to theoretical bases acquired during the scientific foundations stage.

Five categories of health care professionals working in the prehospital setting were identified: emergency physicians, paramedics, emergency medical technicians, nurses, and ambulance drivers [16,17]. Although they are not strictly health care professionals, ambulance drivers are trained in providing basic life support measures and may encounter situations that require them to don PPE. Therefore, we considered a vast array of professionals who present important variability regarding both medical knowledge and technical skills.

The frequent guideline updates consecutive to the general increase in knowledge and understanding regarding severe acute respiratory coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, and its mode of transmission prompted the definition of specific objectives (Table 1).

A literature search resulted in the selection and inclusion of 12 articles [8,9,12-15,18-22]. Based on these results, the module developers, along with the stakeholders, decided which learning mechanics would be used to fulfill the different learning objectives (Table 1).

A pretesting strategy was used for one of the learning objectives (incubation time), as this method has been shown to improve knowledge retention [19] (Figures 1-4). Following this type of interaction, providing the correct answer seems to be insufficient, and more detailed feedback has been shown to yield better results regarding knowledge acquisition [18].

One important aspect was to prevent learners from skipping content, which would cause them to miss parts of the learning material [21] (Figures 5 and 6). In addition to setting triggers designed to restrict further access without engaging with the interactive content, the content was segmented in multiple slides and slide layers to keep the learner engaged [20].

As some skills are better demonstrated and some related knowledge is more readily acquired through video [9], a movie demonstrating the correct PPE donning and doffing sequences was recorded. Portions of this video were then embedded in the module, particularly in its gamified portion (Figures 7 and 8) [23].

Finally, as health care personnel spend increasing amounts of time on their smartphones or tablets, and as these devices use many different and sometimes incompatible operating systems, the module was developed to be accessible on as many platforms as possible [22,24].

A movie including the complete PPE donning and doffing sequences was recorded according to the latest prevention guidelines. To obtain realistic media to create the gamified donning and doffing sequences, a photo shoot was performed in front of a green screen, and the background was removed using chroma key technology [25]. Graphics such as stick figures were obtained from PresenterMedia (Eclipse Digital Imaging Inc).

The module was developed using Storyline 3 (Articulate Global), which enables publication in the HTML5 markup language; therefore, the module is compatible with most devices, including tablets and smartphones.

Based on our prior decisions, game mechanics were applied to the donning and doffing sequences, which presented the greatest learning challenges. According to Bloom’s revised taxonomy, three thinking skills matched this learning objective: applying, understanding, and retention [26]. The applying skill was linked to the action/task learning mechanic, which was translated into the “selecting/collecting” and “movement” game mechanics. Understanding was promoted by questions and answers and by instantaneous feedback, which are part of both learning mechanics and game mechanics. Retention was included using the “discover,” “explore,” and “repetition” learning mechanics and the “cutscenes/story” game mechanic.

Highly interactive sequences using photographs and embedded videos were created for three different COVID-19 risk settings: no suspicion of COVID-19, suspected or confirmed COVID-19 with no need to perform a high-risk procedure, and need to perform a high-risk procedure regardless of COVID-19 status. For each donning sequence, the learner was given the same six choices, including five different PPE options and a hand hygiene procedure option. Each option was represented by a photograph of the material that would be used and the name or abbreviation given to this material, all of which were grouped within circles (Figures 9-11). Learners made their choices by dragging one of the options onto the photograph of the EMS provider. Immediate written feedback was provided at the top of the screen (Figures 9-11).

When the choices were related to complex sequences, videos were launched automatically in lightbox slides (Figure 12). Once the correct PPE was chosen, the appearance of the EMS provider immediately changed to acknowledge the correct answer, thereby giving direct and visual feedback to the learner (Figure 13). Donning sequences were completed by slides repeating the correct donning sequences for the lead EMS provider (Figure 14) and by displaying the adequate PPE the EMS teammate and the patient should wear. The doffing sequences followed the same design, but in reverse: at the start of the sequence, the EMS provider wore PPE according to the risk setting. The circles containing PPE options were next to the provider, sometimes overlapping the photograph (Figure 15), and the learner was required to drag them away both in the right sequence and into the correct disposal bag (either a regular bin or a bag that could be stored to allow equipment decontamination and reuse). Specific PPE-related questions were asked using true/false interactions (Figure 16).

Once created, each sequence was thoroughly tested by all the other authors, who systematically provided feedback on each successive iteration. Usability issues were screened using the Davids heuristic evaluation procedure [27]. One major feature was added as a result of this procedure, namely the creation of a menu at the end of the module. This menu allowed learners to directly access any section of the module so they could review any specific element at will. Once all feedback was taken into account and the module was thoroughly debugged, a final version was validated by all the authors, among whom are chief ambulance and medical officers as well as infection prevention and control specialists who also act as consultants for the World Health Organization (WHO).

The gamified e-learning module can be accessed directly on the internet [23]. It can also be directly and freely downloaded from the website as a SCORM package or as a standalone web package, both of which are archived in independent ZIP files. The module can be reused freely under the Creative Commons 4.0 BY-NC-SA (Attribution-NonCommercial-ShareAlike) license [28].