The Mechanisms Underlying the Effects of Puzzle‐Based Examinations on Anatomy Students: A Clarification Study

AIM: While puzzle-based examinations are increasingly used to promote engagement in anatomy education, the mechanisms underlying their effects on learning and emotional responses remain insufficiently understood. This clarification study aimed to examine how puzzle-based examinations are associated with students' motivation, cognitive processing, and stress regulation, interpreted through the lenses of Self-Determination Theory (SDT), Cognitive Load Theory (CLT), and the Control-Value Theory of Achievement Emotions (CVT). METHODS: A mixed-methods design was employed with 71 third-year dental students who undertook a puzzle-based anatomy examination. Quantitative data were collected using validated scales assessing intrinsic motivation, cognitive load, and test anxiety in relation to the examination experience. Qualitative data were obtained via open-ended questionnaires and thematically analysed. Codes and themes were deductively mapped to SDT, CLT, and CVT frameworks. RESULTS: Students demonstrated increased intrinsic motivation (mean change +18%, p < 0.01), reduced test anxiety (-15%, p < 0.05), and moderate intrinsic cognitive load. Qualitative analysis yielded three mechanism-related themes: (1) Autonomy and competence support (SDT) - the playful, self-paced problem-solving fostered engagement; (2) Optimised cognitive load (CLT) - visual cues and hints reduced extraneous load, enabling deeper processing; (3) Positive achievement emotions (CVT) - novelty and challenge generated enjoyment and reduced anxiety for most students, though time pressure occasionally triggered negative emotions. CONCLUSIONS: These findings suggest that puzzle-based exams are associated with students' learning experiences through mechanisms related to autonomy, competence, cognitive load management, and achievement emotions. These findings offer a theoretical explanation for the associations observed in relation to puzzle-based examinations, supporting their broader application in medical education. Future research should test these mechanisms experimentally and across diverse educational contexts.