Introduction
Neonatal asphyxia is responsible for 20.9% of neonatal deaths. Although 90% of newborns make the transition from intrauterine to extrauterine life without assistance, about 10% need help to start breathing at birth, and roughly 1% require extensive resuscitation [1-4]. The success of neonatal resuscitation relies heavily on healthcare providers’ knowledge and skills. Therefore, the education and training of healthcare professionals in neonatal resuscitation are crucial to ensure the best outcomes for newborns needing immediate medical care [5]. While traditional simulation-based education programs like the neonatal resuscitation program (NRP) are effective in improving learning outcomes, gaps in non-technical skills, such as communication, teamwork, situational awareness, decision-making and leadership persist [6]. The current simulation-based education model demands substantial resources, including specialized equipment, mannequins and instructors, making it time-intensive, expensive and not widely available in many healthcare settings [7, 8]. As a result, innovative educational methods like virtual simulation and serious games (SGs) are being explored as potential supplements to traditional neonatal resuscitation training [9, 10].
SGs have expanded their utility beyond entertainment, finding applications in various fields such as art, military, healthcare, and medical education [11-13]. The numerous benefits of SGs in educational settings, such as enhancing learner engagement and motivation, improving information retention, and fostering critical thinking skills, have significantly contributed to their widespread adoption [14-16]. In neonatal resuscitation training, SGs offer advantages like controlled, risk-free learning environments, opportunities for repetitive practice, customized training, objective assessment and feedback, easy accessibility, and a less stressful learning experience [17]. Various studies have investigated the impact of SGs on the education and training of healthcare providers in neonatal resuscitation [10, 18-19]. For example, Sarvan and Efe demonstrated that SGs effectively enhanced nursing students’ skills in performing ventilation and chest compressions [10]. Conversely, Yeo et al. found that a web-based game did not significantly improve the knowledge scores and technical skills of healthcare professionals in neonatal resuscitation [19].
Acknowledging the mixed results of SGs on educational outcomes, this systematic review evaluates their role in enhancing healthcare professionals’ understanding and application of neonatal healthcare providers. This review underscores the effectiveness of SGs’ adoption in neonatal resuscitation training outcomes such as knowledge and skill enhancement. 

Methods
Databases and search strategy
This systematic review was conducted based on the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched PubMed (Medline and PMC), Scopus, Web of Science, Cochrane Database of Systematic Reviews, ProQuest (dissertation and thesis global databases), and gray literature (Google Scholar and manual search) up to July 25, 2024. Search terms were determined after consultation with relevant experts in information technology, medical informatics, and neonatal care. Table 1 presents the search strategy used in the PubMed database.


The risk of bias was systematically examined through the Joanna Briggs Institute’s specialized evaluation tools designed for quasi-experimental and randomized controlled study designs. 

Eligibility criteria
The population, interventions, comparisons, and outcomes framework for the research question was formulated as follows: Population=healthcare professionals; intervention=immersive or non-immersive serious game/digital game/video game; comparison=any comparison mentioned in the studies; outcome=learning outcomes.
Studies that investigated the effect of SGs on medical students’ knowledge of the neonatal resuscitation process were included in this systematic review. Other types of information technology (e.g. computer simulation and non-game-based virtual reality, non-digital games), non-English papers, protocols, conference/congress abstracts, review papers, letters to editors, and a lack of access to the full text of articles were excluded.

Study selection and data extraction 
The EndNote software, version 8 was used to manage the results of the search strategy. After eliminating the duplicated papers, two independent authors (PF and TSS) checked the eligibility of the results in three stages: Title, abstract and full text. Disagreements were resolved through discussion between the authors and if an agreement was not reached, the third author assisted in resolving it. We extracted data from the included papers using a Table in Microsoft Excel, including information, such as author(s)/year, aim, samples, study design, intervention type, assessment variables, assessment tools, technical characteristics of selected studies and main findings.

Quality assessment
The Joanna Briggs Institute checklist was used for quality assessment of included papers by two independent researchers [22, 23]. This checklist was applied to both randomized controlled trials (RCTs) and quasi-experimental studies. The RCT checklist contained 13 questions, while the quasi-experimental studies checklist had 9 questions. These questions were answered with the following options: “Yes,” “No,” “Unclear,” or “NA.”

Results
Study selection
The selection pathway for the studies was illustrated using a flowchart, which adheres to the guidelines recommended by the preferred reporting items for systematic reviews and meta-analyses (Figure 1). A total of 289 records were located in various gray literature and database sources. Meanwhile, 201 records remained after duplicates were eliminated. Out of the 41 papers that were evaluated for eligibility, 11 records were found to be eligible for inclusion.

Data extraction
The samples of this research consisted of 11 studies. The fundamental characteristics of the selected studies included the elements of authors (year), country, aim/title, study type, samples, study design, Mean±SD age of samples, assessment variables, assessment tools, intervention duration, main findings (Table 1) and the technical aspects included the elements of authors (year), product name, design software, hardware, game type, scenario/content of the game (Table 2).









Characteristics of the selected studies
A total of 11 studies were identified in relation to the effectiveness of SGs in improving the knowledge of the neonatal resuscitation process in healthcare providers. According to Table 1, all studies were conducted between 2020-2024. But most of them were related to 2022 (5 studies), which indicates the growing trend of serious game design in teaching the process of neonatal resuscitation in 2022.
In this systematic review, we identified five RCTs and an equal representation of both experimental and quasi-experimental studies, with three articles from each category. Among the included studies, three originated from Canada and two from Italy. The remaining selected articles were conducted in America, South Korea, Turkey, China, Kenya, and Singapore, with each country contributing one article. One study was related to Lagos, Nigeria, Busia, and Western Kenya. The objective of the included studies was to investigate the impact of the game on the resuscitation knowledge of healthcare providers. Healthcare professionals (n=282[38%]) were an important part of the people evaluated in the studies (7 and 11). The samples related to pediatric/neonatal residents (n=100[13%]) (studies 6 and 2) were ranked second. In the research focused on nursing personnel (n=192[29%]), studies involving undergraduate nursing students (study 8) accounted for ninety (14%), while nursing students (study 5) were the subject of 83(13%) and registered nurses (n=4 19[3%]). In other included studies (studies 9.1 and 10), undergraduate medical students (n=81 [11%]), healthcare providers (HCPs) (n=51 [7%]), and had the lowest number of samples, respectively. 
In the context of evaluating the impact of SGs on neonatal resuscitation training, the most frequently assessed variables seem to be knowledge and skills. These are central to the training’s effectiveness and are consistently mentioned across various assessment variables. They are not only fundamental in gauging the immediate learning outcomes (as seen in studies 3, 7 and 8) but also in determining the long-term retention and application of the training (studies 8 and 11). Additionally, the emphasis on knowledge gain, retention, and transfer, as well as the influence of a growth mindset on performance (study 10), underscores the importance of these core variables. Thus, knowledge and skills serve as the cornerstone for assessing the efficacy of SGs in enhancing neonatal resuscitation training outcomes. 
In four of the included studies (as seen in studies 5, 6, 7, and 8), the neonatal resuscitation knowledge test was used to evaluate the groups that represent its significance in assessing the theoretical knowledge of neonatal resuscitation.

Technical characteristics of selected studies
The use of unity game design software has only been mentioned in two games, the virtual reality neonatal resuscitation gamification program (study 5) and DIANA (study 6), while other included studies do not mention any game design software. Unity is a powerful tool that lets creative minds build exciting worlds and interactive experiences, from video games to virtual reality adventures [32]. 
In most of the included studies (as seen in studies 4, 6, 7, 8 and 9) the hardware considered for serious gaming was mostly desktop computers, laptops, and smartphones. Among the included studies (studies 5 and 7) were two immersive games. Regarding the scenario or content, most of the games were designed based on the NRP algorithm. The immersive VR neonatal resuscitation gamification program (study 5), specifically designed to train nursing students in neonatal resuscitation, offered the most scenarios (14 scenarios). Only in study No.3, the games used motivational design principles, such as storytelling and quests, to engage learners and build confidence (Table 3).






Study outcome
Examining the main findings of the included studies showed that SGs, including virtual reality simulations, have significantly enhanced neonatal resuscitation knowledge, problem-solving abilities, self-confidence, and learning motivation among healthcare professionals (study 5). SGs that were not of the virtual reality type were found to be just as effective as traditional training in memorizing algorithms and retaining knowledge for infant resuscitation, with added benefits like user appreciation, and ease of use among pediatric/neonatology residents (study 6). SGs consistently led to higher post-test scores in knowledge, skills, satisfaction, and self-confidence among undergraduate nursing students, demonstrating improved learning outcomes (study 8). Specifically designed games, such as NEOGAMES, have been shown to support the long-term retention of critical information and skills of undergraduate medical students related to neonatal resuscitation (study 9). Digital simulators effectively facilitate healthcare professionals in gaining, maintaining, and transferring knowledge, with a growth mindset positively influencing performance enhancement (study 10). Table 2 shows more details. In addition, the main findings from the selected articles are visually summarized in Figure 2.
Quality assessment and critical appraisal
In a review of eleven studies five RCTs and an equal representation of both experimental and quasi-experimental studies, with three articles from each category (Table 4).


Researchers carefully examined potential biases in scientific studies by using the Joanna Briggs Institute’s thoughtful evaluation tools, focusing closely on quasi-experimental and randomized controlled research approaches. The RCTs had 13 checklist items, while the quasi-experimental studies had nine. The studies adhered to internal validity criteria, such as blinding and follow-up. However, issues arose with two RCTs by Bardelli et al. and Ezenwa et al. [25, 30] which provided unclear answers to initial questions, suggesting a need for clearer reporting on study populations and interventions. Additionally, three studies by Ezenwa et al. [30] Sarvan et al. [10] and Yeo et al. [19] lacked data on certain RCT design elements, necessitating an explanation for these omissions. Moreover, Yeo et al.’s study [19] showed a discrepancy in the baseline comparability between control and intervention groups, indicating a possible bias. Overall, while most studies demonstrated good internal validity, some lacked clarity and completeness in their reporting, warranting further examination.

Discussion 
This systematic review explored the effectiveness of SGs in educating healthcare professionals on neonatal resuscitation. The studies included in this review employed various game formats (digital and virtual reality) and targeted different learner groups, including nurses, medical students, healthcare professionals, and residents. Studies showed that SGs, including virtual reality simulations, have significantly enhanced neonatal resuscitation knowledge, problem-solving abilities, self-confidence, and learning motivation among healthcare professionals. Overall, the findings suggest that SGs hold promise as a valuable addition to traditional neonatal resuscitation training.
Several studies reported significant improvements in knowledge scores following serious game interventions compared to control groups [10, 18, 21, 27, 28, 31]. Notably, Lu et al. [31] (2021) demonstrated knowledge retention benefits, indicating that SGs can enhance both immediate learning and long-term retention. Studies observed positive impacts on practical skills related to neonatal resuscitation [10, 27, 30]. SGs provide an interactive and engaging platform for practicing essential skills, contributing to better performance in clinical scenarios. Some recent systematic reviews outlined that SGs can revolutionize medical education by enhancing engagement, interactivity, and effectiveness, while also catalyzing innovative technology development and research [33]. SGs leverage technologies such as web and mobile applications, game engines, augmented reality, virtual reality, mixed reality, and artificial intelligence. However, challenges include the need for adequate technological infrastructure, complex effectiveness assessments, and integration into existing curricula. These approaches combine learning activities (such as feedback, testing and spaced repetition) with active and immersive participation and autonomy, resulting in positive experiences for students [34].
Billner-Garcia et al. [27] 2022 found that the game-based training was motivating and engaging for participants. Enhanced motivation may lead to better learning outcomes and sustained interest in neonatal resuscitation training. Their study has some strength points including engaging modules that cater to busy schedules and Storytelling and quests enhance motivation. On the other hand, limited information on design software and hardware restricts replicability. Also, their game focuses on knowledge checks and may not provide extensive practice opportunities for complex skills. Highly immersive virtual reality offers a realistic training environment and including 14 diverse scenarios for comprehensive learning were the advantage of Yang et al. [28] 2022 study. Also, their game requires specialized virtual reality equipment that potentially limits accessibility. These studies emphasize the value of game-based approaches in neonatal resuscitation training, supporting the idea that motivation and engagement play crucial roles in improving learning outcomes. However, it’s essential to consider the limitations, such as replicability challenges and the focus on knowledge checks rather than extensive practice opportunities for complex skills.
SGs offer advantages in terms of accessibility and scalability compared to traditional simulation-based training [29, 30]. SGs are highly suitable for transferring knowledge or stimulating behavioral changes. They provide an interactive environment that allows learners to practice and compete while retaining information. This accessibility ensures that learners engage with the content more frequently and for longer periods [35]. Unlike pure simulation-based training, which often requires physical resources and specialized equipment, SGs can be easily scaled up. They can be accessed remotely, allowing learners to train at their own pace and adapt to individual needs. This scalability is particularly valuable in addressing the global shortage of health workers and improving efficiency through effective training interventions [36]. 
Yeo et al. [19] 2020 did not find a significant effect of a web-based game on knowledge and skills retention compared to controls. Highlighting the need for further research, it underscores the importance of optimizing serious game design for long-term learning outcomes. In a study by Johanson et al. [37] 2023, researchers explored the impact of modifying serious game design elements on learning outcomes. They found that tailoring game mechanics, feedback mechanisms, and difficulty levels significantly improved knowledge retention and skill acquisition over time. Another review of SGs in medical education was conducted. Their findings highlighted the importance of personalized content, adaptive challenges, and engaging narratives. When serious game design aligned with these principles, learners demonstrated better retention and application of knowledge [38].
The studies included in this review employed a variety of designs, with RCTs providing the strongest evidence [10, 29, 30]. Future research would benefit from a larger number of high-quality RCTs to strengthen the evidence base. Also, Different HCP groups were targeted across studies. Further research is needed to explore the effectiveness of SGs for specific professions and skill levels. Tailoring serious game interventions to the unique needs of different learner groups could enhance their impact. A systematic review by Ijaz et al. [39] 2019 evaluated the performance of SGs as a training tool for healthcare professionals. The review included RCTs and found that SGs can be an effective alternate or complementary component of the healthcare training curriculum. However, existing assessment methodologies may not accurately depict the effectiveness of games, emphasizing the need for more robust RCTs and research designs. 
The studies reviewed used various game formats. Further investigation is needed to identify the most effective design elements for neonatal resuscitation training. Elements, such as interactivity, feedback mechanisms, and realism play a crucial role in shaping the learning experience. While some studies assessed knowledge retention, limited research explored the transfer of learned skills to real-world clinical scenarios [18]. Future studies should investigate how well skills acquired through SGs translate into actual practice. A meta-review by Damaševičius et al. [40] 2023 analyzed 53 survey papers on SGs and gamification. It revealed that SGs and gamification techniques are increasingly used for a wide range of health conditions. The focus is shifting toward mobile and digital platforms, virtual reality, and personalized interventions. Schrader [41] 2023 highlighted that SGs allow educators to virtually model real-world tasks, enabling learners to interact and learn by doing. These games encourage risk-taking and different learning approaches with lower consequences of failure. Tailoring serious game interventions to specific learner groups enhances their impact on cognitive, affective, motivational-behavioral, and social levels. 
The studies included in the review explored a variety of serious game designs for neonatal resuscitation education. In Figure 3, we provide a breakdown of the product names, functionalities, and potential strengths and weaknesses. Overall, the studies showcase a range of serious game designs with the potential to enhance neonatal resuscitation training. A systematic review conducted in 2022 provided design and implementation recommendations for developing and implementing SGs in nurse education to enhance students’ knowledge and performance, based on the evidence reviewed. They claimed that the use of SGs improved nursing students’ and nurses’ knowledge and performance [20]. Another study revealed that serious gaming significantly enhances educational outcomes in nursing compared to conventional methods such as lectures, reading materials, and clinical simulations. This approach not only supports but also strengthens the teaching and learning framework within the field of nursing by providing robust scientific backing for the integration of SGs [21]. So, future research could explore the effectiveness of combining different design elements (e.g. storytelling, feedback mechanisms, immersive environments) to optimize learning outcomes. Additionally, investigating the cost-effectiveness and scalability of these games, particularly in low-resource settings, would be valuable.

Conclusion
The future vision for SGs in neonatal resuscitation education includes the integration of more advanced technologies like virtual reality and augmented reality, which can provide immersive and interactive learning experiences. The authors believe that these games can revolutionize medical education by making it more engaging and effective, thus potentially improving patient outcomes. Using SGs in neonatal resuscitation training provides a flexible, scalable and cost-effective solution for continuous education. These methods can effectively bridge the gap between theoretical knowledge and practical skills, ensuring that healthcare professionals are better prepared for real-life scenarios. In Iran, the adoption of SGs for medical education is still in its nascent stages. However, given the increasing emphasis on modernizing medical training, these innovative methods could gain traction and become an integral part of the curriculum shortly. The health system can benefit greatly from these educational methods by reducing training costs, improving the efficiency of training programs, and enhancing the overall quality of care provided by well-trained professionals. Integrating SGs with traditional training methods could offer a comprehensive and effective approach to training healthcare providers. SGs demonstrate significant promise as complementary tools for neonatal resuscitation education, showing the potential to enhance knowledge acquisition, skill development, motivation, and engagement among healthcare professionals. However, this review acknowledges several limitations, including variability in study designs, outcome measures, publication bias, and limited data on the long-term retention of skills and knowledge. Future research should focus on optimizing game design, investigating long-term learning outcomes and assessing the transfer of skills to clinical practice.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the Tabriz University of Medical Sciences, Tabriz, Iran (Code: IR.TBZMED.REC.1399.692). The participants were made aware of the research goals and the various stages of the study. They were assured that their information would remain confidential. Additionally, they had the right to withdraw from the study at any time, and if they wished, they could receive the results of the research.

Funding
This research was extracted from PhD dissertation of Parisa Farshid, approved by the Department of Health Information Technology, School of Management and Medical Informatics, Tabriz University of Medical Sciences. This study was financially supported by Tabriz University of Medical Sciences, Tabriz, Iran (Grant No.: 64450).

Authors contributions
Conceptualization, methodology: Parisa Farshid, and Kayvan Mirnia; Data Collecttion: Parisa Farshid; Investigation: Parisa Farshid, and Kayvan Mirnia, and Elham Maserat; Analysis: Parisa Farshid, and Kayvan Mirnia, and Elham Maserat and Peyman Rezaei-Hachesu; Supervision: Taha Samad-Soltani, and Parisa Farshid; Writing the original draft: Parisa Farshid, Kayvan Mirnia and Taha Samad-Soltani; Review and editing: Taha Samad-Soltani, Parisa Farshid; Final approval: All authors.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors extend their sincere appreciation to Tabriz University of Medical Sciences, Tabriz, Iran for its invaluable financial support of this research endeavor.


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