Does gamification improve learning?

On average, yes, modestly. A 2020 meta-analysis by Sailer and Homner found small positive effects on cognitive learning outcomes (g = 0.49), motivational outcomes (g = 0.36) and behavioral outcomes (g = 0.25). Only the cognitive effect held up when the analysis was limited to the most rigorous studies.

Does gamification work in nursing education?

The reviews are positive but cautious. A 2025 systematic review and meta-analysis of 70 studies in nursing education reported improved academic achievement, with a larger effect on knowledge than on skills. A 2019 systematic review of randomized trials in health professions education found serious games and gamification at least as effective as controls, but rated the evidence low or very low quality for every outcome.

What kind of gamification works best?

The parts that are really retrieval practice and feedback: quiz games, unfolding cases and escape rooms built on course objectives. In Sailer and Homner's meta-analysis, combining competition with collaboration (teams) and adding a story did better on behavioral outcomes than competition alone. Mandatory badges and public individual rankings are the riskiest elements.

Is gamification really effective for learning? What the studies show, including in nursing education

Q: Can gamification hurt learning?

It can. Hanus and Fox (2015) compared a course with mandatory badges and a leaderboard against the same course without them. Students in the gamified version reported lower satisfaction and lower intrinsic motivation, and earned lower final exam grades. A review of game-based learning in undergraduate nursing also noted that timed games can raise student anxiety.

Points, badges, leaderboards, escape rooms, Kahoot before the exam. Gamification has been sold to faculty as the fix for disengaged students for more than a decade. It deserves the same question we'd ask of any intervention: does it work, for whom, and at what cost?

The short answer from the research is that it helps a little on average, the evidence is weaker than the enthusiasm, and the design matters more than the label.

What the large meta-analysis found

The most cited summary is a 2020 meta-analysis in Educational Psychology Review by Sailer and Homner. They pooled controlled studies of gamified learning and reported:

Outcome	Effect size (Hedges' g)	Studies
Cognitive (knowledge, application)	0.49	19
Motivational	0.36	16
Behavioral (what learners do)	0.25	9

They describe all three as small effects. The detail that matters most is what happened when they looked only at the methodologically strongest studies: the cognitive effect held, while the motivational and behavioral effects became less stable. Put plainly, the best evidence is for learning, and the weakest is for the thing gamification is usually sold on, which is motivation.

They also looked at which design features mattered. For behavioral outcomes, adding a story ("game fiction") and combining competition with collaboration did better than competition alone.

What the health professions and nursing reviews found

According to PubMed-indexed reviews:

Health professions, randomized trials. Gentry and colleagues (2019) reviewed 30 randomized trials with 3,634 participants. Serious games and gamification appeared at least as effective as controls, and in many studies more effective, for knowledge, skills and satisfaction. But the authors rated the evidence low or very low quality for all outcomes, and found too little to say whether one type of game works better than another.
Health professions, all designs. van Gaalen and colleagues (2021) reviewed 44 studies. No study reported a negative outcome, and gamification that used assessment plus challenge increased how much students used the learning material. They also noted that most studies lacked well-defined control groups and didn't explain why the game elements should work.
Nursing, meta-analysis. Nylén-Eriksen and colleagues (2025) pooled 70 studies with 8,348 participants and reported improved academic achievement, with a larger effect on knowledge than on skill performance.
Nursing, digital serious games. Lee and colleagues (2024) analyzed randomized trials and found gains in knowledge, confidence and performance, with high variation between studies and short intervention periods. They advise caution in interpreting the results.
Undergraduate nursing, student experience. Tavares (2022) reviewed 17 papers. Students generally liked game-based learning and most studies reported better learning, but time-limited games often increased anxiety, and the benefits faded with repeated use.

Two cautions apply across these reviews. Studies with positive results are more likely to be published, and a new, fun activity is often compared against a lecture that nobody tried to improve. Both inflate the apparent benefit.

The study where it backfired

Hanus and Fox (2015) compared two versions of the same course. One required students to earn badges and displayed a leaderboard. The other was identical without those elements. Students in the gamified course reported lower satisfaction and lower intrinsic motivation, and they earned lower final exam grades. The authors point to social comparison on the leaderboard and the loss of autonomy from making badges mandatory.

This fits a much older finding. A meta-analysis of 128 experiments by Deci, Koestner and Ryan (1999) found that tangible rewards offered for doing a task tend to undermine intrinsic motivation for it. Nursing students already have a strong reason to learn pharmacology. Paying them in points to do it can replace that reason with a weaker one.

Why the label is the problem

"Gamification" covers very different things:

A quiz game is retrieval practice with immediate feedback. Practice testing is one of the best-supported study techniques there is (Dunlosky and colleagues, 2013).
An escape room built on a patient case is problem solving in a team under time pressure.
A badge for logging in five days in a row is a reward for behavior, with no learning in it.
A leaderboard is public ranking.

The first two work for reasons that have little to do with games. The last two are the game layer on its own, and they carry the risk. When a gamified activity improves exam scores, it is usually because students retrieved and applied content more often than they otherwise would have.

Practical rules for a nursing course

Start from an objective, not a platform. Write down what students should be able to do afterwards. If the game can't be tied to an objective, it's a break, which is fine, but call it that.
Make the core of it retrieval and feedback. Questions at the level the exam will ask, with the rationale shown after each one.
Use teams. Competition between teams with collaboration inside them did better than individual competition in the meta-analysis, and it spares the student who is always last.
Keep it optional or low-stakes. Don't attach grades to winning, and don't make badges a requirement.
Skip public individual rankings. Show the top few teams, or show each student only their own progress.
Watch the clock. Timers add anxiety. Use them when time pressure is the point, as in a code scenario, and not for first exposure to hard content.
Debrief it. Five minutes on why the right answers were right converts a fun activity into learning.
Check whether it worked. Compare how students did on the exam items for the objectives you gamified against the ones you didn't.

So, is it effective?

Somewhat, when the game is a vehicle for practice, feedback and teamwork. Not reliably, when it is points and badges laid over the same content. The honest summary of the literature is small average gains, low-quality evidence, a real risk of harm from mandatory rewards and public rankings, and very little information about long-term retention.

That last gap is one you can close in your own course. If you played a review game on fluid and electrolytes, the item analysis from the next exam will show whether those questions were answered better than last term's. MapMyExam reads that item analysis for you and shows how each objective performed, so you can keep the activities that moved the numbers and drop the ones that didn't. Your first exam is free.