Games to Improve the Clinical Skills of Nursing Students: Systematic Review of Current Evidence

Introduction

As medical science and medicine advance daily and continuously influence medical education, health care, and nursing must constantly seek innovative teaching and learning methods [1-3]. Nurses are the frontline of medical care and constitute the largest segment of the global health workforce. Considering this, it is more than crucial for nursing students to receive a thorough education during their training, which can be provided through advanced evidence-based educational programs that keep pace with current changes in the field [4].

Currently, medical and nursing students are required to acquire advanced skills during their educational courses, including high levels of skills in critical thinking, problem-solving, and analysis, to pave the way toward developing higher-order thinking skills [1]. Nursing education encounters several challenges, including limited training time, which restricts the ability to provide effective practical learning experiences. These obstacles underscore the necessity for innovative strategies that can complement traditional educational methods and improve the overall quality of nursing education [5]. With the emerging role of technologies in this century, it is essential to incorporate active learning methods that go beyond traditional reading, listening, or watching, enabling students to explore and integrate knowledge actively to develop these levels of skills [1].

E-learning, web-based learning, computer-based simulators, mobile devices, virtual reality modalities, and games are a few of the various information technologies and educational methodologies that have been incorporated into nursing education due to technological advancements that we are witnessing in the current era, augmenting the traditional educational curricula [4]. Among the diverse modalities of technology-enhanced learning, games serve as exemplary tools for facilitating collaborative activities, review, and evaluation within the classroom setting. They introduce an element of enjoyment and maintain a clear educational objective, resulting in positive learning outcomes. Furthermore, microlearning (the process of acquiring knowledge through small chunks of information that can be delivered via videos, articles, ebooks, audio clips, etc) strategies contribute to enhancing the effectiveness of educational experiences [6].

The application of gamification within the education of health care professionals is experiencing rapid growth [7]. Gamification is a strategic approach to enhance engagement by integrating game elements into educational settings. This methodology aims to develop specific skills, establish objectives that imbue learning with meaning, actively involve students, optimize the learning process, facilitate behavioral change, and promote social interaction [8].

In nursing education, there has been a notable increase in the adoption of innovative teaching methods to adapt to the aforementioned issues. One such approach that is becoming increasingly and significantly popular is game-based learning (GBL) [1]. GBL incorporates games or game-like elements, concepts, mechanisms, or designs into education. This approach integrates educational games into classroom instruction and self-directed learning, offering students an immersive learning experience that enhances their acquisition of knowledge and skills [9]. This method consists of enabling students to learn through personal experiences via gaming perspectives and platforms and allows them to manage their learning according to their progress and capabilities [1].

GBL research often references three key terms: “serious game,” “educational game,” and “digital educational game.” These terms overlap, but differ in specific ways. A serious game refers to games designed with an educational purpose, rather than for entertainment. Educational games are games specifically designed for education, including both physical and digital formats. Narrowly defined, they are electronic games developed for learning, while broadly defined, they encompass traditional games, educational software, and toys that combine fun with learning objectives. In addition, digital educational games refer to educational games that require digital platforms and technology. They promote understanding of educational content and come in various types, such as adventure, role-playing, business, and logic games. These games can support both single-player and multiplayer formats. This concept can integrate fun with learning, enhancing the educational experience by leveraging technology to engage learners and improve their mastery of the subject matter [9].

These approaches support learning by integrating activities like feedback, testing, and spaced repetition with active participation, autonomy, and positive experiences for students, promoting a more effective educational environment [10]. According to the literature available surrounding this matter, students who have experienced GBL are more likely to achieve significantly better cognitive learning outcomes. GBL creates an atmosphere of high enthusiasm, active participation, and great enjoyment, and the fusion of these is more likely linked to improving learning results [11].

By fully engaging in an activity, one can achieve a state of intense focus, which can aid the learning process and lead to an optimal experience of learning. This state is referred to as “flow.” GBL encompasses physical games like board games and digital formats, including virtual reality. These educational models engage students with challenges that promote exploratory behavior, allowing them to actively solve problems and reflect on their actions, drawing on the concept of “flow” [1]. The affordances identified in GBL are consistent with the principles of flow theory. It is anticipated that as players engage with the game and refine their skills, the level of difficulty will progressively increase. Consequently, flow theory is used in game studies to foster concentration among students during lectures, based on these principles [12].

Although nurse educators have been slow to embrace this concept, research shows that game-based learning frequently outperforms traditional teaching methods [1,7]. In addition, the COVID-19 pandemic emerged as a cause to force higher education institutions to rapidly shift to virtual teaching and learning, which necessitated maintaining student engagement while ensuring that the content and methods stayed relevant to their future careers [7].

A recent systematic review supports these points and emphasizes the necessity for more research on the use of specific games among nursing students [1]. Identifying and analyzing the increasing number of published studies in this area is important to develop a comprehensive evidence base. This systematic review aims to identify studies on educational games in nursing education that enhance students’ skills, summarize their impacts on learning outcomes, and explore the concept of game-based learning in nursing.

Methods

Overview

In this study, the authors systematically searched the 4 public databases to investigate the role of educational games in improving the clinical skills of nursing students. This paper is based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines (the PRISMA checklist is provided in Checklist 1). We also checked the bias risk of selected studies by the Newcastle-Ottawa Scale (NOS) bias assessment tool.

Data Sources

We searched the defined keywords in the databases of PubMed, Embase, Scopus, and Web of Science. The search was conducted on July 14, 2024, and all English-language studies were included in the screening. The PubMed search query and its combinations are as follows: (“games, experimental”[MeSH Terms] OR “gamification”[MeSH Terms] OR “game”[Title/Abstract] OR “gamification”[Title/Abstract] OR “educational game”[Title/Abstract] OR “serious game”[Title/Abstract]) AND (“Nurses”[MeSH Terms] OR “Nursing”[MeSH Terms] OR “Nurse Practitioners”[MeSH Terms] OR Nurses[Ti] OR Nursing[Ti] OR “Nurse Practitioners”[Title/Abstract]) AND (“Education”[MeSH Terms] OR “Education”[Title/Abstract] OR “Learning”[Title/Abstract] OR “Nursing education”[Title/Abstract] OR “Clinical skills”[Title/Abstract] OR “Virtual reality”[Title/Abstract] OR “Virtual learning”[Title/Abstract] OR “Virtual education”[Title/Abstract] OR “Virtualization”[Title/Abstract]). Similar structured queries were applied in Embase, Scopus, and Web of Science, adjusted for each database’s indexing system (Multimedia Appendix 1).

(“games, experimental”[MeSH Terms] OR “gamification”[MeSH Terms] OR “game”[Title/Abstract] OR “gamification”[Title/Abstract] OR “educational game”[Title/Abstract] OR “serious game”[Title/Abstract]) AND (“Nurses”[MeSH Terms] OR “Nursing”[MeSH Terms] OR “Nurse Practitioners”[MeSH Terms] OR Nurses[Ti] OR Nursing[Ti] OR “Nurse Practitioners”[Title/Abstract]) AND (“Education”[MeSH Terms] OR “Education”[Title/Abstract] OR “Learning”[Title/Abstract] OR “Nursing education”[Title/Abstract] OR “Clinical skills”[Title/Abstract] OR “Virtual reality”[Title/Abstract] OR “Virtual learning”[Title/Abstract] OR “Virtual education”[Title/Abstract] OR “Virtualization”[Title/Abstract])).

Study Selection

Articles related to the purpose of our study were screened and selected in 2 steps. In the first stage, the titles and abstracts of the studies were evaluated, and the relevant articles were selected for the second and deeper stage according to their titles and abstracts. In the second step, the authors reviewed the full texts of these articles. Publications that met the inclusion criteria were selected for data extraction (Article selection criteria Textbox 1).

Data Extraction

After selecting eligible articles, data extraction began. A total of 4 researchers diligently reviewed the full texts of the selected studies and pulled the required data together. Data related to the objectives of this research were extracted from selected studies. Data about the first author, country, year of publication, the aim of the study, participants, learning objectives, type and name of the game, platform, game features, and main findings of selected studies were extracted in Tables 1 and 2.

Quality Assessment and Bias Risk Evaluation

To enhance the quality, 3 authors independently evaluated the eligible studies for risk of bias to minimize any probable bias risk using the NOS risk assessment tool (Table 3). Worthy to mention that a total score of 9 in 3 categories is calculated in this numerical bias assessment tool. These three categories include selection, comparability, and exposure or outcome. Numerical values of 4, 2, and 3 are attributed to these categories, respectively. A maximum scale of 9 is going to be expected for each of the included studies by summing these numbers together.

Results

Data Sources

In this study, 801 articles were initially retrieved using the specified search strategy in the databases of PubMed, Embase, Scopus, and Web of Science.

Study Selection

In total, 44 duplicate articles were removed, and 757 studies were screened. After applying the inclusion and exclusion criteria, 719 articles were excluded, leaving 38 articles for full-text review (Figure 1).

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Data Extraction

The included articles were conducted in the countries of Brazil (n=1), Korea (n=2), Turkey (n=4), China (n=4), Netherlands (n=1), United States (n=7), Taiwan (n=3), Egypt (n=1), Iran (n=2), Spain (n=5), Morocco (n=1), Finland (n=1), Singapore (n=1), United Kingdom (n=1), France (n=1), Cyprus (n=1), and Slovenia (n=1) and were published between 2018 and 2023 (Figure 2). The final included studies were conducted over a range of years, from 2017 to 2023. Figure 3 provides a visual summary of these timeframes.

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Quality Assessment and Bias Risk Evaluation

As shown in Table 3, according to the NOS risk assessment tool, out of 38 included articles, 36 articles were of good quality (≥6), 2 articles were of fair quality (5≥, >2), and none of the articles were of poor quality (2≥).

Main Findings

Our results showed that several learning objectives can be conducted by GBL. These objectives included developing diagnostic reasoning, enhancing knowledge and cognitive skills, and improving training methods (Figure 4).

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We also showed that different platforms were used for the games. While many games used web-based platforms, few were conducted in person, and some were developed in-app formats for smartphones. Game platforms are compiled in Figure 5, providing an overview of the different game platforms. In addition, while we summarized the 3 key terms of GBL and its benefits and limitations in Figure 6, we illustrated how various platforms and game types aligned with distinct learning objectives in nursing education in Figure 7.

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Finally, multiple studies were conducted in the Asia-Pacific region, where we provided a more in-depth analysis of the region’s unique approaches to nursing education and the integration of technology. These studies, involving Asia-Pacific Islander Nursing (APIN) student populations from countries such as Korea, China, and Singapore, highlighted strong engagement with mobile and virtual reality (VR)–based GBL tools. These studies also reported improvements in clinical skills, knowledge retention, and student motivation following the use of these technologies.

Discussion

Principal Findings

We showed that a broad range of learning objectives, such as developing diagnostic reasoning, enhancing knowledge and cognitive skills, and improving training methods, can be conducted by a game-based platform. We also showed that while many games used web-based platforms, few were conducted in person, and some were developed in app formats for smartphones. The emergence of game-based learning in recent years has led to significant changes in the health education system and curricula [52]. These methods are gaining considerable attention for their potential to boost student motivation and engagement in the learning process. The educators are offered new novel methods to enhance the education process, specifically medical education, by the premise of using serious games and gamification of the learning processes.

Overview of Studies and Learning Objectives

After a thorough evaluation of 38 studies, our results indicated that the most frequent year for conducting studies was 2023, with contributions from countries like Brazil, Korea, and the United States. The United States contributed the most studies, covering topics such as sterile catheter insertion, diagnostic reasoning, and empathy training. The main learning included developing diagnostic reasoning, enhancing nursing knowledge and cognitive skills, and improving practical training methods such as cardiopulmonary resuscitation (CPR) and tracheostomy care. In addition, a focus on fostering student engagement, motivation, critical thinking, and collaborative problem-solving. Various platforms were used, ranging from web-based applications like Moodle and Amazon Web Services to advanced VR tools such as HTC Vive Cosmos and mobile apps. The key findings demonstrated that serious games and VR simulations were highly effective in boosting nursing students’ knowledge, practical skills, and confidence. These techniques also enhanced collaborative problem-solving, critical thinking, and motivation, with significant improvements in clinical reasoning and knowledge retention.

GBL and the Range of Targeted and Enhanced Skills

Studies from Brazil and Korea demonstrate that GBL effectively enhances diagnostic reasoning and CPR skills through more engaging and interactive approaches than traditional methods [19,21]. These findings are reinforced by research across countries, including Turkey, where games improved tracheostomy care, and the Netherlands, which highlighted the development of collaborative problem-solving skills through serious games [26,39]. For developing skills for high-risk medical procedures, such as extracorporeal membrane oxygenation pipeline handling and pressure ulcer management, the eligible studies used serious games [30,37]. VR-based learning, as studied in the United States and China, enables students to practice sterile techniques and clinical care in immersive environments, boosting their confidence and competence [27,38]. In addition, studies have shown how serious games can rapidly adapt to global challenges, such as improving COVID-19 protocols [42]. Finally, escape-room games have proven effective in fostering clinical reasoning, collaboration, and reducing stigma toward mental health disorders [47].

Overall, the range of skills enhanced through educational games in nursing includes technical procedures, cognitive decision-making, communication, teamwork, and professional empathy, demonstrating the broad and versatile impact of GBL. Although some of these studies were conducted in western contexts, the core educational benefits are equally relevant and transferable to Asia-Pacific nursing students.

Platforms’ and Game Types’ Association With Learning Objectives

According to our results, the following platforms and game types are linked to distinct learning objectives in nursing education:

1. Diagnostic reasoning skills games: Board games like “Enfermeiro Diagnosticador” and web-based tools enhance diagnostic reasoning [13].
2. CPR and life support training: Web-based and mobile games like mobile CPR improve CPR training through interactive simulations [13,15,23]. In addition, mobile apps like Guess It and gamified flipped classrooms enhance knowledge retention in life support and nursing fundamentals with features such as quizzes and leaderboards [24,25].
3. Clinical procedural skills: Virtual reality platforms, such as virtual reality sterile urinary catheter insertion game and pressure ulcer management virtual reality simulation, offer immersive practice for skills like catheter insertion and pressure ulcer management [27,30].
4. Teamwork, clinical competency, and emergency skills: Escape rooms and virtual emergency room simulations focus on teamwork and clinical competency by presenting problem-solving tasks in high-pressure scenarios [20,40,48].
5. Specialized skills: Role-playing games improve specialized skills, such as electrocardiogram interpretation, and foster empathy and communication [36,38].

These diverse platforms effectively align with educational goals, combining interactive, scenario-based learning with feedback and collaboration to enhance student engagement, clinical skills, and decision-making. Figure 7 illustrates how various platforms and game types align with distinct learning objectives in nursing education.

Depending on the game formats, these games show strong potential for adaptation across Asia-Pacific contexts. While VR and web-based platforms suit technologically advanced regions and might require more complex infrastructure, mobile games and gamified classrooms may be more feasible for underresourced regions of APIN settings.

Impact of GBL on Learning Outcomes and Their Broader Discussion in Nursing Education

The comparative value of simulation-based gaming versus traditional teaching methods in nursing education demonstrates the significant benefits of serious games in enhancing clinical skills, knowledge retention, and decision-making, which aligns with the previously mentioned facts from the available literature in this sector. These studies demonstrate that simulation-based gaming provides a dynamic, effective alternative to traditional methods, offering nursing students not only technical proficiency but also the critical thinking, teamwork, and decision-making skills needed in modern health care environments. These games offer flexibility, engagement, and the ability to simulate real-life scenarios in a low-risk, repeatable format, making them a valuable tool in nursing education. Ultimately, this novel method has significant potential to minimize costly bedside teaching and enhance the efficiency of medical practice design [1]. Ultimately, GBL represents a novel and transformative method that has the potential to enhance the efficiency and effectiveness of nursing education globally. Furthermore, for APIN students, GBL can offer an effective way to bridge gaps caused by limited clinical placements or cultural and language barriers. Their adaptability makes them especially valuable in diverse Asia-Pacific settings.

Challenges

Although GBL methods emerge as effective and beneficial methods, there are still significant challenges and limitations to their use [1]. One major issue is the “expertise reversal effect,” which highlights how the effectiveness of serious games varies based on the learner’s skill level. For instance, while these games may be beneficial for experts, they may not be as useful for beginners. Ensuring that new learners can still benefit from the game is crucial to their success [53]. Developing adaptive games that can adjust difficulty level according to player level can emerge as an effective solution to this challenge. Another challenge is the high cost of developing serious games, which can run into thousands of dollars. Creating these educational tools requires careful consideration of both cost and efficiency to ensure they remain feasible for widespread use [1]. Creation of games in collaboration with institutes and seeking sponsorship or grants can reduce the development costs. In addition to financial constraints, the need for training instructors to effectively implement the games and providing adequate technical support are common hurdles. Without proper training and support, the potential of serious games may not be fully realized [54]. Establishment of technical support teams and training standardized instructors can maximize the benefits of these games.

One major issue is the “expertise reversal effect,” which highlights how the effectiveness of serious games varies based on the learner’s skill level. For instance, while these games may be beneficial for experts, they may not be as useful for beginners. Ensuring that new learners can still benefit from the game is crucial to their success [53]. Developing adaptive games that can adjust difficulty level according to player level can emerge as an effective solution to this challenge.

In addition to financial constraints, the need for training instructors to effectively implement the games and providing adequate technical support are common hurdles. Without proper training and support, the potential of serious games may not be fully realized [54]. Establishment of technical support teams and training standardized instructors can maximize the benefits of these games.

Limited funding and access to professional developers, along with a lack of trained educators, can complicate these issues further and lead to a much more challenging situation in underresourced Asia-Pacific regions. Addressing these challenges is essential to making serious games a more practical and accessible tool in educational settings, particularly in medical training, where their application has the potential to significantly enhance learning outcomes if used correctly. Figure 6 provides a summary of the discussed benefits and limitations. Finally, it is noteworthy to mention that game-based learning in nursing is a novel and beneficial method, and by addressing its limitations, we hope it becomes more widespread in the future. Finally, it is noteworthy to mention that game-based learning in nursing is a novel and beneficial method, and by addressing its limitations, we hope it becomes more widespread in the future.

Lastly, it is noteworthy to mention that game-based learning in nursing is a novel and beneficial method, and by addressing its limitations, we hope it becomes more widespread in the future.

Asia-Pacific Approaches to Technology-Enhanced Nursing Education

One group of the included studies was conducted in Asia-Pacific countries, which mainly originated from Korea, Taiwan, China, and Singapore, alongside Iran. These studies highlight a regional trend of incorporating advanced digital technologies in nursing education. A wide range of platforms was used in this section of the literature, including VR technologies, web-based platforms, mobile apps, and virtual environments. The primary goals of these studies encompassed a wide range of areas, including clinical skills development, critical thinking enhancement, infection control practices, CPR training, and emergency care [21,22,29,30,33,35,37,40,43,48,55]. According to these findings, in this region, there is a strong emphasis on innovation, rapid adoption of new technologies, and a cultural value placed on education and professional development. Understanding these dynamics highlights the region’s distinct approach to advancing nursing education through technology-driven methods. However, the development, adoption, and effectiveness of GBL can be influenced by cultural factors prevalent in the Asia-Pacific context. One issue is that in collectivist societies, common in many parts of Asia, students may prioritize group harmony and respect for authorities, which can affect their engagement in interactive and competitive learning environments like GBL [56,57]. Since Western GBL approaches often emphasize individualism and assertiveness, they may not fully align with the values common in Asia-Pacific contexts. Adapting game content to focus more on collaboration, respect for authority, and cultural relevance can improve acceptance among APIN students. While this situation provides a challenging base for the implementation of GBL, the acceptance of these learning methods also varies across different cultures of Asia-Pacific countries, necessitating culturally sensitive designs and strategies. Ultimately, in low-resource regions of this area, limited access to technological infrastructure can pose challenges to the widespread adoption of GBL [58].

Limitations and Future Prospects

This study has several limitations. First, it only included English-language publications, potentially omitting valuable insights from non-English studies, which may affect the comprehensiveness of our findings. Including multilingual studies can highlight local innovations in many aspects, such as region-specific game designs or unique instructional methods. In addition, publication bias could skew results since positive studies are more likely to be published. Variability in definitions and classifications of GBL and a lack of standardized measurement tools complicate data interpretation. Finally, our research did not explore the long-term effects of GBL on nursing competencies and patient outcomes, which necessitates longitudinal studies for a comprehensive understanding. Looking ahead, future research should aim to include multilingual studies to broaden perspectives on GBL in nursing education. Longitudinal studies are essential to assess the enduring impacts of GBL on clinical competencies and patient care outcomes. In addition, developing standardized assessment tools will help unify definitions and improve the comparability of research findings, ultimately enhancing the evidence base for GBL’s effectiveness.

Conclusion

To conclude, the premise of GBL and its infiltration into nursing education represents a novel yet challenging approach that enhances student engagement, motivation, and clinical skills. The feasibility and benefits of this method lead to educators creating immersive learning environments that promote critical thinking and collaborative problem-solving. However, like any other new approach, it introduces a few challenges to the education system. Addressing these limitations is crucial for maximizing the potential of GBL in nursing education. As the field continues to evolve, future research should aim to broaden perspectives through multilingual studies and assess the long-term impacts of GBL on nursing competencies and patient care outcomes. Overall, the promising benefits of GBL could significantly enhance the quality of nursing education and ultimately improve health care delivery. In the APIN, implementing GBL requires sensitivity to cultural values. Educators should design collaborative, culturally aligned approaches and strategies, plus ensure accessibility despite resource limitations.