Number of Citations: 0

Submitted: 25 November 2024
Accepted: 18 November 2025
Published online: 7 July, TAPS 2026, 11(3), 8-16
https://doi.org/10.29060/TAPS.2026-11-3/OA3575

Pasin Tangadulrat, Jongdee Bawornpatarananon & Nisalak Upho

Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Thailand

Abstract

Introduction: Game-based learning (GBL) is a well-known method for enhanced learning. However, literature suggests varying engagement and outcomes with various types of GBL. Therefore, we aimed to evaluate the effectiveness of a Japanese-style role-playing game (JRPG) on improving the learning of fifth-year medical students.

Methods: We conducted a mixed method explanatory study using a quasi-experimental study with a historical control as the quantitative component. A JRPG was introduced to fifth-year medical students in 2023 and compared with the 2022 cohort using MCQ and MEQ scores. Student experiences were assessed through a Likert-scale questionnaire and focus group interviews analysed by thematic analysis.

Results: We recruited 57 participants. The demographic data, and overall test scores of the participants did not differ from those of their counterparts in the previous year. The mean score for the paediatric orthopaedics MCQ (five questions) test did not differ between the two groups (3.2 ± 0.9 for the 2023 class vs. 3.5 ± 0.8 for the 2022 class, p = 0.477). The 2023 class had slightly higher mean paediatric orthopaedics MEQ test scores than did the 2022 class (66.8 ± 8.8 vs. 62.8 ± 8.7, p = 0.06), with no statistically significant difference. Most students reported good experiences while playing the game, mainly saying that it was fun and interesting and helped motivate them to study more about the subject.

Conclusion: While JRPG did not significantly affect student performance, it is one of the approach that can provide good engagement, motivation, and learning experiences.

Keywords:       Game-based Learning, Japanese-style Role-playing Game, Medical Education, Paediatric Orthopaedics, Medical Learning, Academic Knowledge

Practice Highlights

• Game-based learning can enhance student engagement and motivation.
• JRPGs provide a novel and interesting teaching method
• Game genres might help simulate students’ engagement
• Students appreciate the teacher’s effort, leading to better engagement
• Further evaluation is needed to assess the impact on academic performance.

Figure 1. Various screenshots from the game, including in-game explanation of game mechanics (upper left), a multiple-choice style question (upper right), a critical learning point explanation (lower left), and part of the game story with humorous and engaging dialogue (lower right).

Table 1. Medical students’ demographic data

Figure 2. Comparison of various test score between the historical control group and GBL group. The paediatric MCQ score was scaled to 100 to better visualise the difference.

Most students strongly agreed or agreed with a positive statement regarding the game (Table 2). The proportion of students who answered “neutral” was higher than 10% for two of the statements: “I feel that the gameplay is easily understood and easy to play” and “The time taken to finish the game was appropriate”.

Table 2. Satisfaction of the students participating in game-based learning

A total of 57 fifth-year medical students participated in the GBL , and all were included in the qualitative analysis through focus group interviews. These interviews were conducted across 7 rotations, with 8-9 students participating in each session. Using thematic analysis, we coded the responses into two themes, along with their supporting subthemes and corresponding responses (Table 3).

Theme	Subtheme	Illustrative Student Quotes
GBL can stimulate students’ learning experience and engagement	Novel and interesting teaching method	– I feel it is like a switch. I know I need to study, but sometimes I feel tired and do not want to open a book. Nevertheless, the game was interesting. Therefore, I decided to play the game. After playing it, it piqued my interest in studying more, and now, I intend to read more about the subject.
	Familiarity with the game style	– It reminded me of a game called Ragnarok, which I used to play a lot when I was in middle school. I did not think that similar educational games could be created.   – The looks of the game were surprising to me, because I used to play a game like this. The in-game system and progression were also interesting to me, because I want to know if the character progression would be similar to what I had experienced in this game genre.
	Teacher’s efforts and student reciprocity	– Actually, I am not that familiar with JRPG. However, I know that making this kind of thing probably requires significant time and effort, so I feel I will give it a try for the teacher’s sake.   – I feel that the knowledge inside the game is probably really important because the teacher spent a lot of time making it. I don’t want to waste the teacher’s effort.
Theme 2: Technology-based GBL models should be optimised for the user experience	Game length and pacing	– I feel that the time it took to finish the game is too long. I was not interested in the story, but the part where I got to treat patients was interesting. It would be good if there were a skip button for the story.
	Technical issues	– I did not finish the game in one go and wanted to pause and save. However, the saved file was gone, and I had to restart from the beginning, which was very frustrating.

Table 3. Thematic analysis results, including their supporting subthemes and responses

IV. DISCUSSION

Our study reported results obtained from using a distinct type of JPRG with a case-based study. We found that most students had positive experiences using the game in addition to the current curriculum. However, this did not lead to significantly better test scores.

GBL is an interesting topic in medical education. Many studies have demonstrated that GBL can improve the engagement and learning experiences of medical students (Al-Mugheed et al., 2022; Boeker et al., 2013; Gorbanev et al., 2018). We found that the participants enjoyed playing the game and felt engaged with the subjects. The reasons for feeling engaged were attributed to many factors. First, the novelty of the game likely stimulated curiosity and intrinsic motivation, which are critical for sustained engagement in learning. This was directly evidenced in the interview results, where students expressed excitement for a new, unconventional learning method. In addition, we incorporated many recommended mechanics known to enhance GBL effectiveness, such as using a familiar game style, feedback, and competition via leaderboard (Pitt et al., 2015).

A particularly interesting finding is that familiarity with the game type may have an effect on participants’ engagement. For many students in Thailand, the JRPG format resonated due to their extensive exposure to video games from a young age (Jirasatmathakul & Poovorawan, 2000). A study of the Canadian student population also reveals that students with an East Asian background have significantly more positive experiences with GBL than other cultural groups, which may be attributed to their greater exposure to and familiarity with gaming (Jossan et al., 2021). Game types might also play a role in stimulating engagement. Role-playing games have been shown to have high engagement in younger players and persist throughout young adulthood (Ream et al., 2013). This highlights how leveraging existing gaming culture and game types could help stimulate interest in academic learning.

Lastly, we found an interesting insight regarding the teacher’s perceived effort and student reciprocity. In Asian cultures, a deep-rooted sense of gratitude towards teachers can influence student behaviour. Some students expressed feeling motivated to engage with the game as a reciprocal gesture, appreciating the significant effort involved in its development, even if the game style wasn’t initially their preference. This suggests that the perceived value and investment from the educator, beyond the game’s mechanics, can profoundly enhance student motivation and participation. However, it is crucial to acknowledge that this cultural concept may not apply in other cultural contexts, limiting the generalisability of this factor.

GBL implementations, especially those utilising new or unique technologies, must be carefully optimised for user experience. As shown in our study, some students encountered technical problems, such as issues saving game progress when playing on an iPad. While these problems were eventually addressed, they undeniably disrupted the learning experience for affected students. These technical aspects, alongside other user experience considerations, are reflected in the higher proportion of “Neutral” answers observed for questions regarding gameplay ease and the appropriateness of game length, with some students expressing that the game felt too long, and others struggling to fully grasp the gameplay mechanics.

To enhance future participant experiences, incorporating features such as a skipping or fast-forward system for narrative sections, and providing more detailed orientation on game progression and mechanics, would be beneficial. Furthermore, as medical education integrates newer technologies like virtual reality and advanced high-tech gear for educational games, it is critical that game developers thoroughly check and rigorously play-test the game prior to student deployment. This approach, coupled with immediate support for technical issues, is crucial to prevent disruptions and ensure an optimal learning environment.

Our study reported positive student experiences with a JRPG-style game, yet this did not translate into statistically significant improvements in examination scores. A slight positive trend was, however, observed in the  paediatric MEQ scores. Several factors likely explain the lack of a statistically significant effect on test scores. First, our quasi-experimental design used a historical control group and assessed knowledge at the end of the curriculum, rather than in a pre- and post-test fashion. This design introduces potential confounding variables, such as individual student study habits and knowledge retention over the rotation, which may obscure the direct impact of the intervention. A potential recall effect from the in-game questions may have influenced performance, but it is difficult to isolate this from routine self-study.

Second,  paediatric orthopaedics questions constituted only about 10% of the total examination content. With such a low weighting, any genuine knowledge gains from the game would be difficult to detect statistically. Third, as the game was an optional, adjunct activity, the “dosage” of the intervention varied significantly among students. This inconsistency in exposure makes it challenging to measure a uniform effect across the cohort. Future implementations could explore mandatory integration to ensure a consistent level of engagement. Our finding that a GBL tool did not produce significantly better test scores aligns with other studies in the field, which have also found that game-based interventions may not outperform traditional teaching methods like didactic lectures (Trevino et al., 2016). Lastly, as our qualitative data revealed, student motivation and familiarity with the JRPG style varied, likely contributing to a wider variance in learning outcomes and diluting the overall mean effect on test scores.

Although overall scores did not significantly improve, the slight increase in MEQ scores suggests a potential alignment between the game’s design and the cognitive skills assessed by that format. The game’s integrated case-based scenarios were designed to promote higher-order cognitive skills such as ‘Application’ and ‘Analysis’ within Bloom’s Taxonomy. These skills are more effectively evaluated by MEQs, which require deeper reasoning and synthesis of information, than by MCQs, which often assess knowledge recall. The trend in MEQ scores may therefore indicate that the GBL was beginning to foster the intended clinical reasoning skills, even if the effect was not powerful enough to be statistically significant.

Our findings also signify that the efficacy of a GBL tool can be deeply influenced by cultural context. The selection of the JRPG genre was a deliberate attempt to leverage its cultural relevance and nostalgic value in Thailand, where the population has a high degree of exposure to this video game genre from a young age (Jirasatmathakul & Poovorawan, 2000). However, this cultural specificity has important implications for generalisability. While familiarity may have boosted engagement for many, it may also have acted as a barrier for those unaccustomed to this game genre.

We observed that some students were motivated by a sense of reciprocity towards the instructor’s effort. In many Asian cultures, deep-seated cultural values of high power distance and collectivism shape a hierarchical teacher-student relationship. This structure, in turn, could frame the teacher’s effort as a form of benevolence that induces a specific form of gratitude, one defined by indebtedness and obligation. This, in turn, motivates a response through the fulfillment of one’s role as a diligent student. Conversely, in Western contexts, where egalitarianism and individualism are more pronounced, this specific motivational response may be less robust (Allen et al., 2024; Chen, 2023; Kee et al., 2008).

A. Limitations

First, the controls were fifth-year medical students in the previous academic year, and their selection might have influenced the test scores. However, it was deemed unethical to include a control group that did not have the chance to experience GBL, which could potentially improve their learning experience. Choosing the historical control group is reasonable because the circumstances regarding the overall curriculum and tests were similar in both academic years. This similarity was evidenced by the absence of significant differences in the overall test scores and demographic data of the students between the two groups. However, we acknowledge that subtle differences in teaching quality or emphasis on specific topics by instructors, and different in student’s motivation between the academic years (2022 and 2023) could not be entirely ruled out as potential confounding variables.

The educational expert’s role as an undergraduate coordinator for the department may influence the responses of participants in the interviews, as students may attempt to provide more positive responses due to the authoritative role of the interviewer. In addition, from the interviews, we noted that some students were more excited or were readily engaged in the game than others, potentially because of their familiarity with this type of game. Therefore, the efficacy of game formats may be culture specific. For example, students who have previously engaged in similar gaming styles, such as those from Southeast Asia, may find the game more appealing. Conversely, students who lack experience with this game type may not demonstrate the same enthusiasm level, therefore, reduce the generalisability of the method beyond Thailand.

Building on these limitations, future research should adopt more rigorous designs. Longitudinal studies would be able to assess long-term knowledge retention and the sustained impact of GBL on clinical reasoning skills. Pre- and post-test designs would also provide a more direct measure of knowledge acquisition attributable to the game, mitigating self-study or recall effects. Comparing the JRPG group with other active intervention group could help isolate its unique benefits.

V. CONCLUSION

In conclusion, JRPG-style game-based learning is one approach that can engage and motivate student learning experiences. Game types and styles may help stimulate learners’ engagement due to familiarity and experience. Lastly, the test score did not show significant improvement; therefore, future evaluations should prioritise rigorous longitudinal or pre- and post-test designs to better assess GBL’s impact on academic performance and clinical reasoning.

Ethical Approval

This study was approved by the Ethics Committee, Faculty of Medicine, Prince of Songkla University (REC-4850).

Data Availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to ethical concerns.

Funding

There is no funding for this research.

Declaration of Interest

The authors report there are no competing interests to declare.

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*Nisalak Upho
15 Kanchanavanit Road, Hat Yai,
Songkhla, 90110
Email: nisalak20@gmail.com