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Currently submitted to: JMIR Serious Games

Date Submitted: Feb 28, 2020
(currently open for review)

Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.

Normal Play or Dark Play in a Serious Game for Medical Students: Differences in Student Characteristics, Play Strategy, and Learning Experiences

  • Kiki Buijs-Spanjers; 
  • Harianne HM Hegge; 
  • Fokie Cnossen; 
  • Debbie ADC Jaarsma; 
  • Sophia E de Rooij; 



Although many studies have been published on the value of serious games for medical education recently, only little attention has been given to the role of dark play (choosing inappropriate or unethical actions in games).


To investigate potential differences in medical students who have the opportunity to play a serious game normal or dark play and to compare their reasons for choosing a play strategy and their perceptions of what they have learned from their game play.


We asked undergraduate medical students to play a serious game in which they had to take care of a patient with delirium (The Delirium Experience). After getting acquainted with the game, students could opt for normal or dark play. Student characteristics (age, gender, experience with caring for older or delirious patients, and number of completed clerkships) were collected, and the Delirium Attitude Scale and Learning Motivation and Engagement Questionnaire were administered. Reasons for choosing normal or dark play were evaluated with an open-ended question. Information on lessons they had learned from the game were collected using an open-ended question and self-reported knowledge on delirium.


160 students participated in this study (89 normal play, 71 dark play). Male students (n=26, 56.5%) had chosen dark play significantly more often than female students (n=45, 39.5%, p=0.049). We did not find significant differences between both play strategies concerning other student characteristics and measurement outcomes. Participants’ main reason for choosing normal play was to learn how to provide care to delirious patients and for dark play it was to gain insight into what a delirious patient has to endure during delirious episodes. All participants learned what to do when taking care of a delirious patient and gained insight into how a patient experiences delirium. We found no differences in self-reported knowledge.


When medical students have the opportunity to play a serious game dark play, probably half of them will choose this play strategy. Male students will more likely opt for dark play than female students. Choice of play strategy is not affected by any other student characteristic or measurement outcome. All students learned the same lessons from playing the game, irrespective of their learning strategy. Clinical Trial: N/A: Registration of the trial was not necessary in accordance with the ICMJE (International Committee of Medical Journal Editors) recommendations.


Please cite as:

Buijs-Spanjers K, Hegge HH, Cnossen F, Jaarsma DA, de Rooij SE

Normal Play or Dark Play in a Serious Game for Medical Students: Differences in Student Characteristics, Play Strategy, and Learning Experiences

JMIR Preprints. 28/02/2020:18479

DOI: 10.2196/18479


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