Method for Evaluating the Quality of Serious Games in Medical

Education

Francisco Anderson Mariano da Silva

, Wellington Candeia de Araújo

Thiago Prado de Campos

and Tiago Silva da Silva

Institute of Science and Technology (ICT), Federal University of São Paulo, Brazil

Center for Science and Technology, State University of Paraíba (UEPB), Brazil

Federal University of Technology, Paraná, Brazil

Keywords: Serious Games, Medical Education, Usability Evaluation, User Experience, Motivation, Knowledge

Acquisition.

Abstract: The integration of serious games into medical education, particularly in surgical training, has proven to be a

promising approach for enhancing skills and knowledge acquisition. This study introduces the MAQJSEM

(Method for Evaluating the Quality of Serious Games in Medical Education), a comprehensive evaluation

method designed to address critical dimensions such as motivation, user experience, usability, and knowledge

acquisition. The development process involved a systematic literature review, followed by validation through

a pilot study and expert evaluations. MAQJSEM was applied to a mobile application focusing on surgical

training, and its evaluation revealed the method’s robustness and practicality in assessing serious games

within this context. Notable findings include the importance of incorporating emotional and immersive

elements, as well as clear instructions and intuitive usability features. Expert feedback led to the refinement

of dimensions and items, enhancing the clarity and relevance of the method. MAQJSEM contributes

significantly by offering a validated and adaptable tool for improving serious games in medical education.

The method supports developers and educators in creating engaging and pedagogically effective tools,

fostering skill development and preparation for real-world challenges in the medical field.

1 INTRODUCTION

This paper presents an innovative method for

evaluating serious games in medical education, with

a special focus on surgical training. Serious games,

introduced by Clark C. Abt in the 1970s, have become

established as pedagogical tools that combine

motivational and interactive elements, fostering

engagement, immersion, and continuous feedback

(Abt, 1987). In healthcare, events like Games for

Health highlight their potential in training

professionals (Drummond & Tesnière, 2017).

However, their effectiveness depends on rigorous

evaluations to ensure quality and identify areas for

improvement.

https://orcid.org/0000-0001-9797-7552

https://orcid.org/0000-0003-2102-7993

https://orcid.org/0000-0003-1038-4004

This study aims to answer the research question:

"What are the relevant aspects for evaluating serious

games in medical education, especially surgical

training, and how can a method be developed and

validated to measure their quality?" To address this,

we propose the Method for Evaluating the Quality of

Serious Games for Medical Education (MAQJSEM),

designed to assess key dimensions such as

motivation, user experience, usability, and

knowledge acquisition.

The method was developed based on theories of

motivation (Keller, 1987), user experience (Savi,

2011), usability (Petri et al., 2019; Nielsen & Molich,

1990), and studies on serious games in medical

education, particularly Graafland, Schraagen, &

Schijven (2012) and Meijer et al. (2019). Validation

da Silva, F. A. M., de Araújo, W. C., de Campos, T. P. and da Silva, T. S.

Method for Evaluating the Quality of Serious Games in Medical Education.

DOI: 10.5220/0013433800003929

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 27th International Conference on Enterprise Information Systems (ICEIS 2025) - Volume 2, pages 605-613

ISBN: 978-989-758-749-8; ISSN: 2184-4992

605

was conducted in two stages: (i) a pilot study, in

which the method was applied to a serious game with

feedback from gaming and medical experts, and (ii) a

face and content validation study, ensuring that the

assessment criteria were relevant and comprehensible

to the target audience.

Key results include the incorporation of

dimensions such as immersion and emotions,

restructuring questions for clarity, and adding items

related to tutorials and sound—critical factors for

engagement and learning. This approach enhances the

evaluation of serious games and lays a foundation for

future studies, fostering advancements in the use of

these tools in medical education.

This paper is structured as follows: Section 2

presents related work, highlighting previous

approaches to evaluating serious games in medical

contexts. Section 3 details the methodology for

developing and validating MAQJSEM. Section 4

presents the proposed method, while Sections 5 and 6

describe studies conducted to evaluate and validate it.

Finally, Section 7 concludes with reflections on the

study’s implications and future research directions.

2 RELATED WORKS

Several studies propose methods to evaluate serious

games, each addressing different aspects. Rocha,

Bittencourt, and Isotani (2015) developed a

questionnaire for self-assessment and learner

reactions regarding simulation and training. Rocha

(2017) outlined criteria for balancing content,

simulation, game elements, and evaluation.

Schroeder and Hounsell (2015) introduced SEU-Q to

assess serious games as tools, while Petri, von

Wangenheim, and Borgatto (2019) proposed

MEEGA+ for educational games in science.

Other works expand evaluation dimensions.

Oliveira and Rocha (2020) developed “Avalia JS” for

serious game planning. Rodrigues et al. (2021)

assessed a game targeting childhood obesity, while

Pires et al. (2015) created an instrument for

evaluating playfulness in healthcare games. Feitosa

(2018) designed a quiz-based game for dental

biosafety, and Santos (2018) introduced PAJDE,

focusing on learning potential in educational games.

These studies highlight approaches and the need for

tailored evaluation tools.

Campos (2024) applied a similar validation

approach, developing UUXE-ToH to assess

touchable holograms. The study emphasized iterative

refinements and expert feedback to ensure quality

applicability.

While these studies provide valuable insights, none

specifically address the pedagogical challenges of

surgical training. MAQJSEM was developed to fill

this gap by integrating validated elements from

methods—focusing on motivation, user experience,

usability, and knowledge acquisition—while

adapting them to surgical education. Its validation

through expert feedback has positioned it as a robust

tool for assessing serious games in training,

contributing to advancements in surgical education.

3 METHODOLOGY

This section outlines the development and validation

process of the MAQJSEM method. The research

followed three key stages: a literature review to

identify essential evaluation criteria, the formulation

of the method based on established theoretical

frameworks, and validation through a pilot study and

content and face analysis by experts. This ensured the

method's accuracy, applicability, and alignment with

medical education needs.

This research aimed to develop and validate the

MAQJSEM, an evaluation method focusing on

surgical training. The methodology followed a

structured process (Figure 1), including:

3.1 Systematic Literature Review

(SLR)

Conducted according to Kitchenham et al. (2009),

complemented by consultations with theses and

dissertations. This step identified gaps and

incorporated contributions from key authors such as

Keller (1987), Savi et al. (2011), Bedwell et al.

(2012), Rocha (2014), Petri et al. (2019), Graafland et

al. (2012), and Meijer et al. (2019).

3.2 Method Development

The method was developed based on Costa (2011)

and DeVellis (2017), emphasizing clear definitions,

item selection, and validation processes.

3.3 Validation Process

3.3.1 Pilot Study

As highlighted by Benassi, Cancian, & Strieder

(2023), pilot studies are a crucial tool in perception

research, as they help identify flaws, challenges, and

opportunities for improvement, which can then be

addressed before the main research phase. The goal

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was to identify and correct flaws in question

construction and ensure coherence across

dimensions. To address any potential unfamiliarity

with serious games, the researcher participated in an

introductory lecture designed to contextualize the

evaluation process. Feedback from this phase led to

adjustments in dimensions, question clarity, and the

structure of the method.

3.3.2 Face and Content Validation Study

It ensures that questionnaire items are representative

of the domain and understandable to the target

audience. Content validation involves expert analysis

to confirm coverage of theoretical constructs, while

face validation assesses clarity and appropriateness

from respondents' perspectives through quantitative

and qualitative feedback. These procedures enhance

the instrument’s reliability and validity before larger

studies, following psychometric assessment

standards.

Figure 1: Items construction and validation process.

4 MAQJSEM

The MAQJSEM method is grounded in a robust

theoretical foundation, integrating approaches and

methodologies from the reviewed literature. Central

to its development are the ARCS model (Attention,

Relevance, Confidence, and Satisfaction) for

evaluating motivation, usability heuristics, and

studies on user experience in games. It also

incorporates categories for identifying serious games

and the MEEGA+ method, designed for assessing

educational games in fields such as Computer Science

and surgical skill training. Contributions from the

medical field were included, emphasizing knowledge

evaluation and surgical practices, bridging

educational and practical dimensions.

As a result of the systematic literature review

(SLR), 70 items were developed and organized into

four main dimensions: Motivation, User Experience,

Usability, and Knowledge Acquisition. These items

form the basis for a comprehensive evaluation

framework that assesses both student motivation and

the effectiveness of educational content delivered by

serious games.

4.1 Dimensions of the MAQJSEM

The development of the evaluation method was

structured around four main dimensions, each

addressing specific aspects of the serious games

experience in medical education:

Motivation: Evaluates how the game keeps

students engaged, focusing on the attractiveness of

challenges, feedback and rewards, and social

interaction. User Experience: Analyzes aesthetics,

design, immersion, and the connection with

characters and scenarios. Usability: Examines ease of

use, including intuitive interfaces and responsive

controls. Knowledge Acquisition: Assesses the

game's impact on learning medical concepts,

developing surgical skills, and preparing for real-

world situations.

Figure 2 presents a visual representation of these

dimensions and how they interconnect within the

evaluation method.

Figure 2: Method Design.

The creation of items for evaluating game quality

was based on models and research previously

discussed, such as Keller (1987), Savi et al. (2011),

Petri et al. (2019), Nielsen and Molich (1990), and

Graafland et al. (2012–2019). These sources

particularly emphasized the application of serious

games in medicine.

Table 1 summarizes the key elements and authors

that informed the development of the evaluation

categories, which were refined and translated into

specific questions tailored to medical education

through serious games.

Method for Evaluating the Quality of Serious Games in Medical Education

607

Table 1: Key Elements and Authors for Development.

Categories Authors and Quality

Indicators

Motivation Kelle

(1987)

User

Experience

Savi et al. (2011), Bedwell et

al. (2012)

Usability Petri et al. (2019), Nielsen &

Molich (1990)

Knowledge

Acquisition

Graafland et al. (2012, 2013,

2014, 2015, 2017, 2018) and

Meijer et al. (2018, 2019,

2021, 2022).

Rocha (2014)

Source: Author, 2024

5 PILOT STUDY

This section outlines the pilot study to evaluate the

MAQJSEM method’s initial effectiveness, identify

improvements, and assess its feasibility in real-world

applications.

5.1 Instruments and Procedures

The pilot study assessed the preliminary feasibility

and clarity of the MAQJSEM method before full-

scale validation, identifying potential ambiguities in

the first version of the questionnaire

, refine its

structure, and ensure its applicability in evaluating

serious games for medical education.

The participant (P1), a specialist with a bachelor's

and master's degree in Computer Science and in the

final semester of a Ph.D. in the field, contributed over

15 years of experience in the development and

evaluation of accessibility, usability, and user

experience for websites and mobile applications. This

expertise ensured precise and applicable results,

strengthening the study’s robustness.

The game Operate Now: Hospital (Azerion

Casual, 2017) was selected due to its focus on

surgical scenarios and task-based gameplay, aligning

with the method’s objectives. Though not a medical

student, the participant’s usability expertise provided

critical insights into the questionnaire’s clarity and

structure. Future studies will extend validation to

medical students and professionals to further refine

the method in real training contexts.

The study involved the participant downloading,

installing, and using the game over a three-day

period, followed by an evaluation using the

https://figshare.com/s/739ddf3f3245fd6a3c27

MAQJSEM method. Additionally, the participant

provided feedback on the method itself, further

supporting its refinement.

The evaluation was conducted via a Google Form

containing 70 items distributed across four

dimensions. Each item was assessed on a five-point

Likert scale (from strongly disagree to strongly

agree). At the end of each dimension, an open-ended

question allowed the participant to suggest

improvements. After completing the form, the

participant participated in a semi-structured interview

to clarify doubts and provide additional insights.

The interview was recorded, transcribed, and

analyzed using Atlas.ti software to identify emerging

patterns and categories that informed the instrument’s

refinement. Content analysis (Bardin, 2016), a widely

used qualitative research technique, was employed to

code and interpret the data.

After the pilot study, the method’s structure was

reorganized, with wording and content adjustments to

enhance clarity and relevance in evaluating serious

games for medical education, resulting in the post-

pilot version

5.2 Results and Discussion

The quantitative evaluation reinforced the method’s

robustness and highlighted areas for improvement.

P1's responses showed strong agreement with key

aspects of the method. For instance, in the Motivation

dimension, 70% of responses were in the "Strongly

Agree" category for items addressing attention-

capturing activities and the relevance of skills taught.

In the UX dimension, 90% "Strongly Agreed" on the

aesthetic appeal and engaging graphics of the game.

Similarly, 90% "Strongly Agreed" that instructions

and tutorials were clear and effective in Usability. In

Knowledge Acquisition, 80% of responses confirmed

the game reinforced medical concepts and provided

learning.

The interview with P1 provided valuable insights

and suggestions for refining the method. P1

emphasized the clarity of the method's objectives,

describing them as well-defined and comprehensive.

Key feedback included recommendations to address

emotions, game efficiency, and UX, along with

adjustments to items related to immersion, usability,

and emotional aspects. These inputs guided the

reclassification of items, removal of unnecessary

questions, and enhancements to question clarity.

The method's clarity was praised, particularly its

transparency in evaluating criteria such as motivation

https://figshare.com/s/4854c73dfebc9206a652

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and usability. However, P1 recommended

reallocating items to better align with categories and

improving questions targeting medical and surgical

education. Motivation was emphasized as critical for

maintaining user engagement and fostering learning,

with suggestions to link concentration and

engagement to outcomes.

P1 highlighted UX as a key focus area,

recommending adjustments to aesthetics-related

items and the inclusion of questions about emotions

to enhance game immersion. Accessibility was also

addressed, with suggestions to incorporate items on

fatigue and usability to account for diverse user

profiles. Engagement was deemed vital, with

feedback encouraging a stronger connection between

concentration, immersion, and learning.

Knowledge acquisition, the core goal of serious

games, was assessed for its role in developing

surgical skills. The relationship between confidence,

game progression, and learning was emphasized.

Immediate feedback was noted as particularly

important for reinforcing learning, with a suggestion

to prioritize rapid responses to user actions.

Socialization was also highlighted as a valuable factor

for knowledge sharing among students and healthcare

professionals. Graafland and Schijven (2018)

reinforces this, noting the efficacy of serious games

in clinical simulations and skill development. P1

further suggested involving medical field experts for

more precise evaluations in future stages.

6 CONTENT AND FACE

VALIDATION STUDY

6.1 Instruments and Procedures

This study was approved by the Research Ethics

Committee, adhering to ethical guidelines to ensure

participant safety and research integrity. Conducted

between September 1 and October 30, 2024,

participants were selected via email invitations sent to

specialists in serious games, computing, and

medicine. Despite invitations to female specialists, all

responses came from male participants. This may

reflect a gender imbalance in serious game

development or the availability of female researchers

for this stage. Future studies should investigate this

issue, examining gender representation in medical

educational game research and promoting greater

diversity among evaluators.

Interviews were conducted via Zoom between

September 20 and October 27, 2024. Participants

unfamiliar with serious games attended an

introductory lecture, while experienced ones installed

and evaluated Operate Now: Hospital, followed by a

semi-structured interview.

The process involved completing an Google

Forms questionnaire to evaluate the post-pilot version

of MAQJSEM. The form had 70 items across four

dimensions: motivation, user experience, usability,

and knowledge acquisition. Each item was rated on a

Likert scale, with open-ended questions at the end of

each dimension for improvement suggestions.

Following the questionnaire, participants engaged

in semi-structured interviews to clarify doubts and

provide further insights. The interviews were

recorded, transcribed, and analyzed using Atlas.ti

software, identifying key categories and patterns.

This iterative process ensured the method was refined

to meet evaluators' expectations and practical needs.

6.2 Results and Discussion

This subsection presents expert assessments,

interview insights, and key decisions that refined the

post-validated version.

6.2.1 Quantitative Results

Nine experts answered the MAQJSEM evaluation

form. The quantitative data from the experts'

evaluations showed that, in general, experts classified

the questions in each dimension as relevant for that

dimension's evaluation. On average, for each

question, eight (8.2) experts indicated that it was

relevant. 25 questions were unanimously classified as

relevant. The question indicated as not relevant by the

most experts was Q18, with 3 indications. Eight

questions were classified as not relevant twice.

In the group of questions in the Motivation

dimension (Figure 3a), 6 questions were unanimously

identified as relevant, 5 were classified as not relevant

once, and two questions were classified as not

relevant twice. Regarding the UX dimension (Figure

3b), three questions were unanimously classified as

relevant; 10 questions were classified as not relevant

once; 5 questions were identified as not relevant

twice; and 1 question was identified as not relevant

by three experts. In the group of questions in the

Usability dimension (Figure 3c), 7 questions were

unanimously identified as relevant, and the other 6

had only one classification as not relevant.

Method for Evaluating the Quality of Serious Games in Medical Education

609

Figures 3: a) Motivation, b) User Experience and c) Usability.

Regarding the Knowledge Acquisition dimension

(Figure 4), 7 questions were unanimously classified

as relevant; 16 questions had only one classification

as not relevant, and only one question was classified

by two experts as not relevant.

Figure 4 - Knowledge Acquisition.

In summary, the evaluation by nine experts

confirmed the overall relevance of the MAQJSEM

questions, with most receiving unanimous or near-

unanimous agreement. While a few questions, such as

Q18, were flagged as less relevant, the findings

highlight the questionnaire's effectiveness in

addressing its intended dimensions, with

opportunities for minor refinements.

6.2.2 Qualitative Results

The data obtained through the semi-structured

interviews allowed the identification of central

categories for evaluating the method. The main

categories identified include general and specific

suggestions, method objectivity, method utility,

proposals for including new statements, and

dimensions for emotional and immersive experience.

In the general and specific suggestions category,

P5 stated that "the instructions on how to apply the

method should be more detailed, especially for users

unfamiliar with serious games." P6 noted that

"dimensions such as motivation are well-addressed,

but the usability dimension could include more items

about customization and accessibility."

In the method objectivity category, P1

highlighted that "the method's objectives are well-

defined and comprehensive, making it easier for users

to understand and apply." However, P2 suggested that

"some questions could be rephrased to better address

surgical learning."

In the method utility category, P3 mentioned that

"the method is practical and well-structured, but it

would be interesting to include more elements that

directly connect the game’s practice to real work

environments." P4 reinforced that "the method meets

evaluation demands but could include additional

criteria to measure emotional experience."

In the proposals for including new statements

category, P7 suggested that "it would be interesting to

include questions related to the impact of sound on

user experience, as this can influence immersion." P8

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recommended adding questions about the

effectiveness of tutorials: "Tutorials are important for

guiding new users, and the method could explore this

aspect further."

In the dimensions for emotional and immersive

experience category, P9 emphasized that "questions

focusing on how emotions are evoked during

gameplay could provide insights into user

engagement and learning retention." P10 added that

"immersion levels should be assessed based on how

realistic the scenarios feel and how much they

encourage concentration and focus during gameplay."

These findings from the semi-structured

interviews provided fundamental results for

adjustments to the method, ensuring it became more

robust and aligned with the needs and expectations of

evaluators and future users.

6.3 Processing and Decisions

After analyzing the validation study, several

improvements were implemented to enhance the

method’s comprehensiveness and effectiveness. To

address overlooked aspects, new sentences were

incorporated, focusing on critical areas such as sound

quality and tutorial effectiveness. For example,

sentences were added to assess whether the sound

quality supports the intended experience and whether

the tutorial effectively guides users in navigating the

game and performing tasks confidently.

Redundant sentences were removed to streamline

the questionnaire, making it more concise and

reducing respondent fatigue. Examples of excluded

sentences include those that overlapped in purpose,

such as statements related to the improvement of

surgical skills and the game's visual aesthetics. This

optimization ensured that each question uniquely

contributed to the evaluation without unnecessary

repetition.

To provide targeted feedback, questions related to

knowledge acquisition were divided into conceptual

and practical aspects. This distinction allowed for a

more precise evaluation of theoretical understanding

versus hands-on application, reflecting the dual focus

of knowledge development in serious games.

The inclusion of medical experts in the validation

process ensured that the content aligned with practical

realities and professional standards. This

collaboration refined the questionnaire to meet the

specific needs of evaluating serious games in medical

education. As a result of this study, the questionnaire

was refined and reached its post-validation version

https://figshare.com/s/378ade76028fd661a165

A limitation of MAQJSEM is the absence of

direct comparisons with established methods in

systems engineering, which often include robust

frameworks for evaluating interactive software.

Models such as ISO/IEC 25010, used to assess

software quality, could be adapted for evaluating

serious games in medical contexts.

Although MAQJSEM was validated using a

mobile-based serious game, its structured evaluation

framework allows for adaptation to different

technological contexts, including Virtual Reality

(VR) and Augmented Reality (AR) applications. The

core dimensions of motivation, user experience,

usability, and knowledge acquisition apply across

various training environments, making the method

flexible for different serious gaming platforms.

Future studies should explore its effectiveness in

immersive VR and AR simulations, particularly for

surgical training, where hands-on experience and

spatial awareness are crucial. Such adaptations would

further validate the robustness and applicability of

MAQJSEM in diverse medical education settings.

7 CONCLUSIONS

This study developed and validated MAQJSEM, a

method for evaluating the quality of serious games in

medical education, focusing on surgical training.

Through a systematic approach based on literature

review, pilot study, and expert validation, the method

was refined to ensure clarity, precision, and practical

applicability. MAQJSEM integrates motivation, user

experience, usability, and knowledge acquisition,

providing a robust tool to assess and optimize the

pedagogical impact of serious games.

The results highlight the potential of serious

games as allies in medical education, emphasizing the

importance of designs that meet students' pedagogical

and contextual needs. The method offers developers

a valuable instrument to ensure their educational

solutions fulfill medical training requirements,

particularly in complex fields such as surgery.

7.1 Limitations

Limitations include the small validation sample,

absence of female experts, and focus on a specific

mobile application. Future studies should explore

MAQJSEM in other technological contexts, such as

augmented (AR) and virtual reality (VR), and assess

its adaptability to a broader range of serious games.

Method for Evaluating the Quality of Serious Games in Medical Education

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The lack of complementary studies validating the

questionnaire remains a limitation. Future research

should conduct additional validations to strengthen

the method’s reliability and applicability across

different scenarios.

7.2 Future Work

Moving forward, future research will focus on

expanding the application of MAQJSEM to a broader

range of serious games in medical education,

including those designed for different specialties and

technological platforms such as VR and AR.

Additionally, a large-scale validation study involving

medical students and professionals will be conducted

to assess the instrument’s effectiveness in real-world

training environments. This will help refine the

method further and ensure its adaptability to various

educational and clinical contexts.

As a contribution, MAQJSEM advances the

literature by proposing a specific evaluation method

for serious games in medical education, combining

methodological rigor with practical applicability.

This method can positively impact the development

of effective educational games, supporting the

training of well-prepared physicians.

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