Gamifying simulated nursing education: a digital technology approach to enhancing pedagogy and student experience

The advancement of technology has led to the emergence of novel technologically supported approaches in education: among them, gamification presents an innovative and compelling strategy (Tinôco et al, 2021), which involves the incorporation of game elements in real-world tasks. Gamification challenges academics to make teaching more captivating and engaging (Strickland and Kaylor, 2016), and offers a novel approach to problem-solving. The use of gamification in education has been shown to enhance an individual's cognitive and socioemotional skills, such as critical thinking, decision-making, communication, teamwork, cultural competence, emotional management, and empathy with patients and colleagues (Borg Sapiano et al, 2018). In nursing, it has the potential to evaluate these skills in various areas of practice. Through gamified education, intrinsic motivation is more strongly developed than extrinsic motivation. In addition, according to Meehan-Andrews (2009) and Peddle (2011) the use of gamification in the educational process may help motivate and engage students, contributing to a change in their attitudes towards learning. Other benefits of taking this approach include its potential to enhance the quality, cost-effectiveness, and flexibility of education, providing students with the ability to control the timing and pace of their own learning (Cant and Cooper, 2017).

Background

In June 2022, a team of academics used a cloud-based e-learning authoring tool to develop three games, which were designed with inspiration from the concept of an ‘escape room’. By leveraging the capabilities of the authoring tool, the team created interactive, immersive experiences that aimed to engage and educate learners as part of a simulated clinical placement.

The process of designing the games involved several steps. First, the theme and objectives were defined to establish the purpose and desired outcomes of the games. Next, a narrative was crafted to provide a storyline that would captivate players throughout their experience. Another important aspect was the development of the interactive elements to enhance player engagement. This included creating gameplay mechanics, features and functionalities to keep players actively involved. Furthermore, careful attention was given to the game structure, ensuring a logical progression that would provide a smooth, enjoyable gaming experience. Visual and audio assets were created to enhance the overall aesthetics and atmosphere of the games. This involved designing appealing graphics, animation, and sound effects to complement each game's theme and narrative.

Testing played a crucial role in the design process to ensure good functionality, playability and overall user experience. Feedback mechanisms were implemented to gather input from players, allowing for iterative refinements and improvements based on their suggestions and observations.

By following this comprehensive process, the team of academics aimed to create interactive digital escape rooms that not only entertained learners, but also provided valuable learning experiences. The games were designed to stimulate critical thinking, problem-solving skills and interactivity, while providing an immersive, enjoyable gaming experience. An outline of each game is presented in Boxes 1–3.

Box 1.Game 1 scenario: patient with exacerbation of respiratory diseaseLearners were immersed in the challenging journey of Esther, a patient who had an acute exacerbation of chronic obstructive pulmonary disease. Learners actively participated in a range of tasks, including recording Esther's physiological observations and calculating her NEWS2 score (Royal College of Physicians (RCP), 2017). A correct score granted access to the medicines' cupboard, enabling timely administration of antibiotics during the critical ‘golden’ hour.The game also provided learners with opportunities to demonstrate and improve their communication skills, such as through the task of delivering a clinical handover of care. They effectively conveyed essential patient information, including the condition, treatment and any relevant observations or changes. This task aimed to enhance communication abilities within a simulated clinical setting.In addition, learners took on responsibilities such as administering a nebuliser. They used an interactive prescription chart to understand the medication and had the chance to research it using the digital version of the British National Formulary (BNF) before administering it. These features of the game aimed to improve students' knowledge and practical skills in medication management. Moreover, the learners received guidance through the procedural stages of urinary catheter insertion, via videos incorporated in the game filmed by the university's academics.By engaging in these tasks and the interactive elements, learners actively participated in the patient's care journey, helping to enhance their understanding and application of clinical skills within a simulated environment.

Box 2.Game 2 scenario: patient with an infected leg ulcerIn this game, the learners were immersed in the narrative of John, a patient with an infected leg ulcer, which provided a distinct experience compared to Game 1. Learners had the opportunity to accompany John on his journey from the community to an acute hospital setting, giving them a comprehensive understanding of the continuum of care in his case.Throughout the game, they encountered various scenarios, reflecting real-world situations, and were presented with questions related to these. By answering the questions correctly, learners were able to progress and unlock digital clues, aligning with the concept of an escape room and adding an element of excitement to the learning experience.In addition, learners were guided through the procedural stages of performing a dressing change using ANTT (aseptic non-touch technique). Videos made by the university's academics were once again incorporated in the game, to provide visual demonstrations and instructions to support learners' understanding and application of clinical skills. By actively participating in these tasks and engaging with the interactive elements, the students were able to enhance their practical knowledge and skills within a simulated environment, further bridging the gap between theory and practice.

Box 3.Game 3 scenario: patient with atrial fibrillationThe final game centred on Malcolm, an elderly man with atrial fibrillation. The objective of this scenario was to consolidate the knowledge and skills the students had acquired in the previous games.The concept of an escape room was continued in this game. Learners were tasked with conducting an ABCDE (airway, breathing, circulation, disability and exposure) assessment (Resuscitation Council UK, 2021) based on the scenario.The assessment involved systematically evaluating Malcolm's ABCDE to identify any potential life-threatening issues and provide appropriate interventions.

Methods

Participants

The study involved 108 participants in the first year of a pre-registration nursing programme. Prior to the study, they had completed two placement blocks, totalling 15 weeks of clinical practice. The average age of participants was 33 years (range 18–57). Of the total, 98 identified as female and 10 as male. The data showed that 56 were from Black, Asian and minority ethnic backgrounds, and 52 were White British.

Students were provided with a participant information document detailing the study's purpose, procedures, potential risks, benefits and their rights and responsibilities. They were clearly informed that they were not obliged to complete the online questionnaire after each game. In addition, the document explicitly explained the participants' right to withdraw from the study at any time and provided them with the researchers' contact details.

Materials

An online questionnaire was devised and integrated into each of the three games to capture the responses of learners following completion of each game. Online questionnaires have the advantage of enabling the quick, efficient collection of data, reducing costs associated with printing, postage and data entry (Van Selm and Jankowski, 2006). Furthermore, an online questionnaire offers flexibility, in that it can be completed from any place with an internet connection, providing a convenient option for both researchers and participants.

The students were able to complete the survey effortlessly within the gaming application, eliminating the need to navigate to a separate web page or application. It was expected that integrating the questionnaire at a natural stopping point in each game would generate higher response rates, as an embedded questionnaire would be easier and more convenient to complete. Moreover, embedding a questionnaire within a digital platform or application reduces the likelihood of incomplete responses or data entry errors, improving data accuracy.

The questionnaire

A mixed-method questionnaire was intentionally employed, encompassing both structured (closed) and unstructured (open-ended) questions. This strategic choice was made to thoroughly evaluate and collect insights related to the study's objectives. It was divided into four parts, with an initial section consisting of three statements designed to assess respondents' views on one or more topics covered in each of the games. Students were able to rate their level of agreement or disagreement against the statements on a Likert scale, with responses ranging from ‘strongly agree’ to ‘strongly disagree,’ or a variation offering the options of ‘agree’, ‘neither agree nor disagree’ and ‘disagree’.

The statements were as follows:

• I have enjoyed the escape room
• The learning resources have been engaging
• I feel more confident in my clinical skills.

The survey also incorporated open-ended inquiry with the aim of delving into participants' recently acquired insights into clinical skills and capturing any comments they wanted to share about their experiences with each of the games. A thematic analysis was carried out subsequently, guided by Braun and Clarke's (2013) six-phase model for the thematic analysis of data, which is a reiterative process that supports a flexible and data driven review of the findings.

The primary analyst, who was the lead researcher (SF), conducted the thematic analysis. This encompassed the initial review and coding of data, identification of emerging themes, and overall guidance of the analysis process. Subsequently, two peer reviewers (Dawn Fletcher-Wilde and Kelly Jones), who had a strong understanding of the research context but were not directly responsible for the analysis, oversaw the analysis process.

Ethical approval

The university's Faculty Research Ethics Officer was consulted to seek ethical approval for this project, and the approval was granted.

Results

A total of 286 evaluations were collected across the three games (Table 1). Evaluation for the first game had a 100% completion response (n=108/108), for the second it was 83.3% (n=90/108) and for the third 81.5% (n=88/108).

The generated statistical data were analysed, with the results revealing that a significant proportion of participants either ‘strongly agreed’ or ‘agreed’ that they had enjoyed the gaming experience. Moreover, the results indicated that a considerable number thought that the games were engaging, and the majority reported increased confidence in their clinical skills after participation.

Statement 1: Enjoyment of the escape room

The following findings suggest that Game 1 was particularly well received, and that Games 2 and 3 had more diverse responses.

Game 1

There were a total of 108 responses in the evaluation for Game 1 (Table 1): the majority (55%) ‘strongly agreed’ with the statement that they had enjoyed the escape room, while almost 38% ‘agreed’. A small percentage (7.4%) ‘neither agreed nor disagreed’ or ‘strongly disagreed’.

Game 2

Game 2 obtained a total of 90 responses with a small number disagreeing with the statement. Just over 3% responded ‘strongly disagree’, and the same proportion chose ‘disagree’. A notable proportion of participants (40%) selected ‘strongly agree’ that they enjoyed the escape room, while 44% chose ‘agree’. A small percentage (9%) responded ‘neither agree nor disagree’.

Game 3

There was a total of 88 responses to this for Game 3. A small percentage (1.1%) ‘strongly disagreed’ and 2.3% ‘disagreed’. A total of 46.6% ‘strongly agreed’ that they had enjoyed the escape room, and 44.3% ‘agreed’ with the statement. A small proportion (5.6%) ‘neither agreed nor disagreed’. Overall, Game 3 received predominantly positive feedback, with just a few dissenting opinions.

Statement 2: Learning resources

Overall, the feedback showed that all three games generally received positive feedback regarding the engagement of the learning resources. Game 1 had the highest percentage of respondents who answered ‘strongly agree’. Game 2 had a more mixed response, with a higher percentage of respondents selecting ‘neither agree nor disagree’. Game 3 had a balanced distribution between strong agreement and agreement.

Overall, the learning resources in all three games appear top have been perceived as engaging by a significant proportion of participants, but the level of agreement differed for each game.

Game 1

The responses for Game 1 (Table 1) showed that the majority of participants (46.3%) responded ‘strongly agree’ that the learning resources were engaging; 43.5% answered ‘agree’ to the statement. A small percentage ‘disagreed’ (2.8%), while 6.5% ‘neither agreed nor disagreed’. A mere 0.9% ‘strongly disagreed’. This indicates that Game 1 had a high level of engagement for participants, with a significant majority finding the learning resources to be engaging.

Game 2

Responses for Game 2 showed that a substantial percentage (47.8%) ‘agreed’ that the learning resources were engaging, and 31.1% ‘strongly agreed’ with the statement. A small proportion ‘disagreed’ (4.4%), with 2.2% responding ‘strongly disagree’; a few students (14.4%) were neutral, responding ‘neither agree nor disagree’. These responses indicate a relatively positive response for Game 2 regarding the engagement level of the learning resources, although there was a notable number of respondents who expressed disagreement.

Game 3

Feedback for Game 3 showed that a significant proportion of respondents (43.2%) ‘strongly agreed’ that the learning resources were engaging, with 45.5% responding ‘agree’ to the statement. A small percentage expressed disagreement (1.1% each for ‘strongly disagree’ and ‘disagree’), and a few ‘neither agreed nor disagreed’ (9.1%). This suggests that Game 3 received positive feedback in terms of the engagement level of the learning resources, with a substantial majority finding them to be engaging.

Statement 3: Confidence in skills

All three games demonstrated the ability to enhance participants' confidence in their clinical skills. Game 1 had the highest level of agreement with this statement, followed by Game 3, and finally Game 2, which had a greater proportion of participants responding ‘neither agree nor disagree’ (17.8% versus 11.1% for Game 1 and 9.1% for Game 3).

Game 1

Responses for Game 1 had a significant proportion of respondents (33.3%) ‘strongly agree’ that they felt more confident in their clinical skills after playing the game, and 49.1% ‘agreed’ with the statement (Table 1). A smaller percentage (3.7%) ‘disagreed’, and an even smaller proportion (2.8%) ‘strongly disagreed’. About a tenth respondents ‘neither agreed nor disagreed’ (11.1%). These results indicate that Game 1 had a positive impact on participants' confidence in their clinical skills, with a notable majority reporting increased confidence.

Game 2

Feedback for this game showed that a majority of respondents (53.3%) ‘agreed’ that, after playing the game, they felt more confident in their clinical skills and 23.3% ‘strongly agreed’ with the statement. A small number ‘disagreed’ (3.3%), and an even fewer (2.2%) ‘strongly disagreed’. Some students ‘neither agreed nor disagreed’ (17.8%). These findings suggest that Game 2 had a positive impact on the confidence of the majority of students in their clinical skills, although a few expressed disagreement or strong disagreement.

Game 3

For Game 3, the responses showed that one third of the students (33%) ‘strongly agreed’ that they had more confidence in their clinical skills after playing the game, with more than half (55.7%) responding ‘agree’ to the statement. No respondents selected the ‘disagree’ option, with just a small percentage selecting ‘strongly disagree’ (2.3%). Just under one-tenth (9.1%) selected ‘neither agree nor disagree’. These results indicate that Game 3 had a positive impact on participants' confidence in their clinical skills, with a significant majority reporting greater confidence.

Thematic analysis

The data were thoroughly reviewed to establish familiarity with the content and develop a comprehensive understanding. Meaningful data were then identified and labelled through the application of relevant codes that captured the essence of the data. Subsequently, related codes were grouped together to ascertain potential themes, with a focus on identifying patterns, connections and similarities within the coded data. The resulting themes aimed to encapsulate emerging patterns of meaning or significant concepts derived from the data. Five themes emerged.

Theme 1. Development of clinical skills

Based on the responses provided, one clear theme that emerged is that the games support the development of new skills. The participants were able to discuss learning new skills such as catheter insertion, taking observations, calculating NEWS2 scores, understanding medication administration, practising communication with reference to the SBAR communication tool (situation, background, assessment, recommendation) (NHS England/NHS Improvement, 2021), identifying and managing conditions such as hypertension and COPD, and improving clinical assessment and decision-making.

The games provide a platform for interactive visual learning and include step-by-step tutorials, case studies, as well as offering exposure to a range of clinical skills. They also contribute to increasing students' knowledge and confidence, improving understanding of procedures, promoting best practice, and enhancing skills for future placements. Overall, the students' views were that the games were informative, engaging and beneficial for developing their clinical skills and knowledge.

‘Learnt A-E [ABCDE] skills, felt like the package covered all important details and explained in detail very well.’

Participant 1

The above comment highlights that Game 1 facilitated the development of ABCDE assessment, which is a vital clinical skill. It suggests that the game covered the important details effectively and provided detailed explanations, contributing to the development of clinical skills.

Another participant highlighted learning about the assessment of acutely ill patients, namely:

‘Escalating NEWS scores, when catheters may be needed and when to escalate to nurses, frequency of doing observations, medication management skills and use of BNF.’

Participant 2

After playing the game, participant 2 was able to demonstrate their acquired knowledge through an understanding of patient safety and identifying priorities for care: timely identification of physiological changes, skilled clinical decision-making regarding catheter use, effective communication for escalating issues to nurses, regular patient observations, and administering medication. This included effectively escalating NEWS2 scores, evaluating the suitability of catheter usage, understanding the necessary frequency of observations, improving their medication management skills, and assessing the use of the BNF.

‘It showed me how to put in a catheter correctly, which we hadn't seen before.’

Participant 3

The comment above emphasises how engaging with the game had a crucial role in enabling the student to acquire a clinical skill, specifically catheter insertion. It suggests that Game 1 introduced this previously unfamiliar skill to the student, providing an opportunity to become acquainted with the procedure.

‘I have noticed I learn better by watching other people, and this has helped a lot, making me feel like I am in the situation myself and by doing it over and over again my decision-making will become quicker.’

Participant 4

The comments from the two participants above highlight the effectiveness of the games in facilitating students to develop their clinical skills. Participant 4 discusses how they learn better by observing others, and the immersive nature of all the games made them feel as if they were experiencing the situation themselves. They consider that repeatedly practising the skills within the games helps to improve their decision-making, resulting in quicker responses in real life situations. Participant 3 further highlights the impact of the game playing by stating that they were able to learn how to correctly insert a catheter by observing the procedure within the game, despite not having seen the procedure before. This suggests that the game was effective in introducing the procedure and enabling the student to familiarise themselves with a skill that was previously unfamiliar. Together, these statements emphasise that the games played a crucial role in enabling participants to develop their clinical skills.

Theme 2. Knowledge acquisition

Several participants discussed how all three educational games enabled them to gain specific knowledge, for example:

‘… the information on the things you are doing, ie medications, knowing what they are before administering.’

Participant 5

The emphasis on the importance of understanding the effects of medications before administration in Game 2 supported students' acquisition of relevant knowledge and understanding the importance of accuracy in medication administration. Playing Game 3 therefore had a crucial role in developing the students' clinical skills, specifically it enhanced their medication management and knowledge about patient safety.

‘I gained knowledge around sepsis and how to act in such emergencies and gained more knowledge in terms of one of the causes … in John's case, it was due to the wound infection.’

Participant 6

In the above comment, the student demonstrates gaining knowledge about sepsis and its causes. The game enabled participants to acquire knowledge surrounding sepsis, which would have included understanding the causes of sepsis. In the case of John, the respondent identified that his sepsis was due to a wound infection, indicating that the participant had learnt that an infection in a wound can lead to sepsis.

Other comments that showed the acquisition of knowledge by students referred to understanding the topics of COPD and catheterisation, for example:

‘It has given [me] more insight and knowledge [about] COPD patients and treatments such as NEBS [nebulisers]. It has also allowed me to witness catheter insertion for the first time.’

Participant 7

‘I have better knowledge of [the] causes of COPD and when to consider catheterisation.’

Participant 8

Participant 7 highlights that Game 1 provided insight and knowledge of COPD patients and treatments, specifically nebulisers. In addition, the student mentions that the games allowed them to witness catheter insertion for the first time. Participant 6, on the other hand, gained knowledge of sepsis and how to respond in such emergencies. They specifically learnt about the causes of sepsis as identified in John's case as a wound infection.

The shared element in these comments is the acquisition of new knowledge through engagement with the games. All students gained insights into COPD and witnessed catheter insertion, and participant 6 also provided feedback on gaining an understanding of the role of wound infections in sepsis. These students highlight how engaging with the games provided them with valuable information in different areas of nursing, enhancing their understanding and skills in those domains.

Theme 3. Practical application

The following comment suggests that the knowledge acquired via the games played enabled students to apply NEWS2 (RCP, 2017) scoring to assess acutely ill patients in practical situations.

‘It has helped me to develop my skills in regard to NEWS2 scoring as I was not fully competent in what areas scored what.’

Participant 9

NEWS2 is a widely used scoring system, which is used to assess the seriousness of a patient's condition and identifies those who may be deteriorating or at risk of critical illness. Prior to engaging with the games, participant 9 appeared to have some knowledge of NEWS2, but lacked competence in comprehending which areas or indicators were assigned specific scores. Interacting with, and learning within, the games provided a comprehensive and structured approach to understanding NEWS2 scoring, helping participants to gain a deeper understanding of the scoring criteria and how these are practically applied in clinical practice.

‘Helped me step by step to complete a leg dressing using ANTT [aseptic non-touch technique].’

Participant 10

Learning within the games facilitated participant 10's comprehension of the process involved in performing a leg dressing using ANTT. The step-by-step guidance and detailed instructions provided as part of the games proved immensely valuable in offering support and ensuring that participants could be effective in applying their acquired knowledge. Students gained confidence in their ability to apply ANTT principles and successfully execute the leg dressing procedure, by closely following the guidance, leading to enhanced application of practical skills.

‘I have enjoyed the training method the escape room provided us, students, to practise with realistic day-to-day life dealing with the patient's conditions … the video clip was well made … very clear [and provided an] understanding [of] the nurse dealing with the patient asking for consent. I was very impressed with the nurses, they were very confident, they knew exactly what to do. I was a little uncomfortable when the nurse was performing the female urethral catheterisation … I am glad that I have had this opportunity to see how this procedure is done because now I know what to expect.’

Participant 11

The statement from participant 11 illustrates the practical application of what they learnt from the games, which they enjoyed playing, but which also allowed them to witness realistic scenarios of patient care. They specifically highlight the effectiveness of video clips in providing a clear illustration of how nurses interact with patients, including the issue of obtaining consent. Furthermore, participant 11 was impressed with the nurses' confidence and knowledge of what to do. However, the student felt uncomfortable when observing the female urethral catheterisation procedure, indicating a personal challenge. The statement acknowledges the value of witnessing the procedure within the games, as it prepared participant 11 for what to expect. This suggests that, through the games, this student gained knowledge of and familiarity with certain procedures, making them better prepared for encountering such situations in real life, and enabling them to perform these procedures effectively in clinical settings under supervision.

Overall, participant 11's feedback demonstrates the practical application of their learning from engaging with the games. They were able to observe and understand real-world patient interactions, gain insight into specific procedures, and develop a better understanding of what to expect in clinical practice. The previous comment showcases the practical application of one student's learning from the games, which is further supported by participant 12's experience:

‘I feel as if I was on the ward, learning [in] real-life situations.’

Participant 12

The two comments above highlight the students' shared experience of realism and immersion in the games, resulting in the practical application of their learning. Both participants emphasise how the games provided them with an authentic and life-like experience that closely mirrored clinical practice. Participant 11 specifically mentions the opportunity to observe and understand real-world patient interactions, indicating the practical application of their learning. This suggests that the games enabled them to gain insight into patient care and apply their understanding in real life situations.

Participant 12 describes the sensation of being in a genuine ward setting and encountering realistic situations while engaging with the games. This sense of realism and immersion demonstrates that their experience of playing the games closely reflects the practical realities of clinical practice. Together, these statements demonstrate how the games facilitated the practical application of learning by offering an immersive, realistic environment. Participants were able to observe, understand and experience scenarios that closely resembled real-world patient care, empowering them to apply their acquired knowledge and skills in a practical context.

Theme 4: Confidence and competence

The games significantly enhanced participants' confidence and competence levels. Students reported feeling more confident in their abilities and expressed an increased sense of competence in various aspects of practice.

‘I feel more confident now that I have the basic knowledge to apply to practice.’

Participant 11

‘Makes me feel more confident.’

Participant 12

‘Communication is key in nursing practice. I developed more confidence in how to engage with patients.’

Participant 13

The participants described how the games had provided them with the chance to observe demonstrations of clinical skills, such as catheterisation, ANTT and recording physiological observations. This initial exposure helped them to develop an understanding of the required procedural steps and enabled them to learn through observation before attempting to apply the skills themselves.

One student expressed their confidence in the educational effectiveness of the games, stating:

‘I feel more confident in my skills because the actor in the video showed how to take a manual blood pressure and when to escalate a situation to the medical team. [It also provided an understanding of the] Importance of the medications checks [to assess for] allergies.’

Participant 14

The games provided participant 14 with a valuable opportunity to witness clinical skills in action and to learn from observation. As a result, the student reports feeling more confident in their ability to apply these skills.

‘I believe I am more knowledgeable [than] before I stated the watching and videos … have enjoy[ed] all the topics, they all are very interesting: knowing that any interventions to our patients very important to know your skills limitations.’

Participant 5

Overall, it is evident that playing the games provided students with valuable learning experiences, increasing their confidence and competence. They reported enhanced confidence and knowledge, highlighting the importance of understanding one's skills limitations when delivering interventions. The games played a key part in boosting participants' competence, equipping them with the necessary skills and knowledge to deliver effective care.

Theme 5: Engaging learning experience

The findings consistently highlighted the engaging learning experience provided by the game.

‘I enjoy[ed the] engaging experience and the challenge.’

Participant 1

‘very well thought out piece of work and [I] very much enjoyed it. [It] was very engaging and relevant.’

Participant 2

Participants reported that Game 1 allowed them to witness novel procedures and practices, preparing them for real-life clinical situations. By incorporating gamification elements, such as interactive scenarios and challenges, the games successfully bridged the gap between theory and practice.

‘be able to gain more knowledge from theory to practice.’

Participant 3

The games format facilitated better knowledge retention and application, resulting in an improved learning experience and potentially better practical outcomes. The interactive scenarios and video content stimulated participants' cognitive processes, encouraging them to think critically about the appropriate actions to take during procedures such as catheterisation. The active engagement of participants across all three games was evident. Additionally, engaging and interacting with the games reaffirmed existing knowledge, while offering opportunities for knowledge expansion, such as exploring medication information. Furthermore, participants reported enhanced communication skills after completing the game.

The students provided feedback on the positive impact that interacting with the games had on their clinical practice, increasing their ability to deliver safe, effective care. A recurring theme was that, despite acquiring their new knowledge via an interactive online learning method, participants expressed a desire to demonstrate the clinical skills they had learnt directly after completing the games. They recognised the importance of observing procedural skills in a secure environment, which enabled them to be better prepared when encountering the interventions they had observed in real-life situations and upcoming clinical placements.

Summary

The games were effective in improving participants' ability to observe procedures, bridging the gap between theory and practice, while enhancing students' learning experience. The gamification technique, which included interactive scenarios and challenges, resulted in effective learning and better outcomes. Participants reported improvements in cognitive processes and communication skills, and recognised the importance of observing procedural skills in a safe environment to be better prepared in real-life situations. Overall, the students enjoyed playing the games, found them engaging and thought the experience had a positive impact on their clinical skills.

Discussion and implications

The authors' aim was to examine the effectiveness of employing a gamification approach to teaching and learning, with a focus on its capacity to enhance the knowledge and performance of student nurses during a simulated placement. This study has illustrated the multifaceted benefits associated with the integration of gamification techniques in nursing education, including heightened engagement, motivation and improved learning outcomes. The incorporation of game-based learning within clinical simulated placements consistently demonstrates the ability to provide an enjoyable and engaging educational approach while bolstering the confidence levels of participants.

These findings align with the conclusions drawn by Cook et al (2011), which highlighted the significant role of simulation gaming platforms in enhancing knowledge acquisition, and the development of psychomotor skills and decision-making in pre-registration nursing student. Notably, the study findings echo the remarkable improvements in performance as observed by Cook et al (2011), underscoring a consistent pattern in both research studies. Furthermore, the findings of the current study indicate that gamified interventions can be used to effectively bridge the divide between theoretical knowledge and practical application.

Gamification has enabled the migration of simulation methods from physical classrooms to the digital landscape, an educational approach that was investigated by Blakely et al (2019). The current research study indicated a widespread acceptance among students for this digital form of simulation, yielding educational benefits akin to traditional face-to-face teaching, as suggested by Cook et al (2011). However, although gamification can be used to enhance teaching and learning, it is important to emphasise that it should not supplant hands-on clinical practice. Undeniably, responding to a gamified nursing scenario through button interactions is less intricate and demanding than providing direct, tactile interventions to real-life patients.

This study has demonstrated that the use of gamification is cost-effective as it removed the need for staff facilitation, and the games developed at the authors' university offer the potential for repeated use with future cohorts. However, the efficacy of gamification in clinical simulated placements within a higher education institution (HEI) context remains an underexplored area of research.

Limitations

This study has highlighted significant findings, but it is crucial to acknowledge that the size of the cohort could affect the applicability of the results more widely. As a result, a larger scale study is necessary to yield more robust findings and insights. Future enhancements to the methodology might involve longitudinal assessments, which would allow for the measurement of the game intervention's lasting impact and the evaluation of knowledge and skills retention.

Conclusion

In recent years, gamification has emerged as a new concept in nursing education and has been the subject of study. The use of gamification techniques has been found to offer numerous benefits, including improved engagement, motivation and learning outcomes.

Gamification in nursing simulated placements has been shown to be a highly effective and engaging way to enhance the learning and development of nursing students. Incorporating game elements in nursing simulation placements helped motivate students to participate actively in the learning process and improve their decision-making skills, while increasing their confidence and competence in real-life nursing situations. Moreover, gamification can provide a safe, controlled environment for students to practise and experiment with different scenarios and approaches, without risking the safety and wellbeing of patients. It also allows for personalised learning experiences, where students can work at their own pace and time.

Overall, the integration of gamification in nursing education has the capacity to transform the learning experience of pre-registration nursing students, making it more enjoyable, engaging and stimulating. With the rapid evolution of technology and innovation, gamification is likely to gain greater prominence as an effective teaching tool not only in traditional nursing education, but also in simulated clinical placements within an HEI context.

KEY POINTS

• Safe learning environment: simulated clinical placements with gamification provide a safe space for preregistration nursing student to make decisions, observe clinical skills and learn from mistakes, without the potential risks associated with live patient care. This fosters a supportive atmosphere conducive to experimentation, exploration and continuous improvement
• Interactive and engaging learning experience: gamification enhances the engagement level of students by introducing interactive elements, challenges and rewards within simulated clinical scenarios. This not only makes the learning process enjoyable, but also encourages active participation, leading to increased knowledge retention and the development of practical skills
• Maximising placement capacity: by incorporating gamification, nursing programmes can fully utilise limited placement capacities, offering virtual clinical experiences. This strategy allows students to participate in simulated scenarios, reducing pressure on constrained physical resources and ensuring a greater number of learners can access valuable learning experiences

CPD reflective questions

• Consider the benefits of integrating gamification in the delivery of education, particularly in simulated clinical placements, as has been highlighted in this article. How has your perception of traditional nursing education shifted?
• Reflect on how novel technologies, such as the incorporation of gamification in nursing education and simulated clinical placements. How do you think this evolving technology will influence the education in future?
• As a nurse or nurse educator, consider how the outcomes of this research study on gamification could be extended to settings outside of simulated clinical placements