članek Gamification in nursing: a literature review Igrifikacija v zdravstveni negi: pregled literature

Introduction: With new generations of students entering the educational system and calling for novel adult-learning approaches, such as gamification, traditional didactics seem to be diminishing in importance. The aim of this paper is to introduce gamification as a novel concept in adult learning and to present its impact on nursing education. Methods: Through a combination of 2dSearch, Publish or Perish and PubMed2XL applications and the set criteria, we used the Google Scholar and Medline / PubMed search engines to compile, analyse, and synthesise studies related to gamification in correlation with the educational process in the field of nursing. To assess the level of methodological quality of research, we used the Mixed Methods Appraisal Tool (MMAT). Results: The final analysis included nine studies related to gamification in nursing course units. Most often, game elements in the form of badges and feedback were included. Most research studies reported a positive impact of gamification on nursing students in the form of increased motivation and engagement, with only one survey reporting a negative impact in the form of inappropriateness and inefficiency . The evaluation of the included studies according to the MMAT tool showed a medium level of methodological quality. Discussion and conclusion: Gamification is a relatively new concept in nursing education and represents the potential for a more advanced way of conveying information. In the future, research should be carried out to clarify the concept of gamification and examine the possibilities of its implementation in the educational environment in Slovenia.


Introduction
Despite the fact that the world has entered an era of new technological advances, the education system seems to be lagging behind (Cohen, 2011;Baker, et al., 2012;de Sousa Borges, et al., 2014;Dicheva, et al., 2015).There is therefore an urgent need for reforms and new challenges in contemporary adult education.The development of technology has also brought about the development of new technologically supported approaches in education.In this context, gamification presents a particularly novel and appealing approach.Gamification or game-based learning is a topical and relatively new concept which refers to the use of game elements in various real-world activities (Deterding, et al., 2011;Kim, 2015;Sardi, et al., 2017).The concept was mentioned by Nick Pelling as far back as 2002, but it was not before 2010 that the term entered general use.Gamification refers to a specific process of thinking through games and game mechanisms with the aim of actively engaging individuals in problem solving activities (Zichermann & Cunningham, 2011).Gamification is a powerful tool, as it attracts an individual's attention and also significantly affects one's behaviour and engagement in activities.
Gamification refers to the use of game elements (Khaleel, et al., 2016) which allow the user to perform the task more efficiently and make it more enjoyable (El-Hilly, et al., 2016).It incorporates game elements into non-game-related situations in order to improve student engagement and convey the relevant knowledge (Des Armier Jr., et al., 2016).The presence of technology in lesson plans has led to a shift from traditional lectures to interactive learning environments.These represent a platform for the development of the learning process by incorporating game elements which attract users' attention, increase their motivation to achieve goals, as well as promote competitiveness, effective teamwork, and improve interpersonal communication (Boskic & Hu, 2015).Dicheva and colleagues (2015) find that the game elements most commonly used in the educational context are visual status, social engagement, freedom of choice, and quick feedback.To date, only a few studies have dealt with the principles of goals and personalisation.Subhash and Cudney (2018) find that the game elements most commonly used are points, badges, and leaderboards.Digital badges are a common element of educational games, and they also serve as an innovative approach to gamification in nursing, as they incorporate social interactions.As more advanced types of praise or evidence, digital badges serve to convey information on students' learning achievements, skills, and competences (White & Shellenbarger, 2018).
In adult education, gamification takes users back to their childhoods when they used games and play to learn and gain various skills.The tendency of being interested in innovation and actively adapting and building one's skills and knowledge is not limited only to childhood, but forms an important part of human nature itself, which, in turn, promotes efficiency, perseverance and wellbeing throughout one's lifetime (Ryan & Deci, 2000;Lespiau & Tricot, 2019).Gamification can therefore serve as a tool for assessing one's cognitive (understanding, perception, cognition), socio-emotional (internal and external motivation, self-efficacy, ambition, social comparison) and psychomotor skills within different areas of nursing.Research (Banfield & Wilkerson, 2014;Morillas Barrio, et al, 2016;Dankbaar, 2017) shows that through the use of gamified education, one's intrinsic motivation develops more strongly than one's extrinsic motivation.Alsawaier (2018) also states that the use of gamification in the educational process could help motivate and engage students as it would contribute to changing their attitudes towards learning.
The use of gamification in education shows great potential as it improves its quality, cost-effectiveness, and flexibility (Gentry, et al., 2019).It also allows students to choose the time and pace of their own learning process (Brull & Finlayson, 2016).Numerous studies (Brull & Finlayson, 2016;Hamari, 2016;Sanchez, et al., 2020) report the use of gamification at all levels of the educational process (from elementary to university levels).Most students from the new generations now studying nursing (Skiba, et al., 2016) have grown up using completely different modern technology than previous generations (Sackmann & Winkler, 2013).In teaching these students new knowledge and skills, traditional approaches (e.g., lectures with the help of a PowerPoint presentation) are no longer sufficient (Boskic & Hu, 2015).Instead, the educational process aimed at younger generations must incorporate novel adult-learning approaches.Research shows (Simões, et al., 2013;Turan, et al., 2016) that students who use gamification show higher academic achievement than those who use traditional learning approaches.The same has also been reported for the field of nursing (Kinder & Kurz, 2018).Gamification creates a safe environment in which nursing students can engage in patient care without potential negative consequences for the patient.Cheong and colleagues (2014) find that students hold a positive attitude toward gamification.
In scientific research, the theoretical framework is of vital importance as it makes research work relevant and credible (Lederman & Lederman, 2015).As a philosophy of education, experiential education (i.e., the theory of experiential learning) represents the fundamental theoretical framework for gamification as an educational approach which connects one's cognitive, socio-emotional and psychomotor skills into a meaningful whole.The best results are achieved using two or more philosophies of education (Banfield & Wilkerson, 2014).Despite these technologically advanced times, contemporary traditional didactics are still rooted in "teacher-centred teaching", i.e. lectures during which students are required to sit, listen and take notes, and which mostly take place without any personal interaction between the student and the teacher.On the other hand, the educational approach based on experiential education is exactly the opposite: students are placed at the centre of the educational process, which is therefore referred to as "student-centred teaching" (Balliu & Belshi, 2017).Possessing solid knowledge of the theories of learning allows the teacher to experiment and introduce various learning approaches, such as serious games and gamification-based learning (Uskov, et al., 2016).In theory, learning supported by gamification represents an approach aimed at changing user behaviour.This theory also emphasises that a change in user behaviour can occur when there is a quality connection between the lesson and its outcomes, and when the learning process is directly influenced.The goal of gamification in the learning process is not to replace lessons, but to supplement and improve them (Landers, 2014).Conklin (2005) draws attention to the categorisation of educational objectives according to Bloom's taxonomy and its hierarchical structure, which encourages students to improve their cognitive skills and attain a higher-level of abstract knowledge with regard to specific learning objectives (Anderson, et al., 2009;Adams, 2015).Bloom's taxonomy comprises three domains: the cognitive, affective (emotional), and psychomotor domains (Bloom, 1956).Ben-Zvi (2010) proposes Bloom's taxonomy as a framework for evaluating the learning outcomes of the educational objectives achieved through experiential learning.In this context, the learning outcomes facilitate the assessment of the achieved educational objectives.Bloom's taxonomy is a model which can be used to report learning outcomes (Bloom, 1956).According to Alsawaier (2018), the inclusion of gamification in the learning process has a significant impact on student achievement.In addition to Bloom's taxonomy, some scholars also rely on other classifications of educational objectives, for example, the classification by Robert J. Marzan (Rutar Ilc, 2003).However, more research needs to be conducted to better understand the possibilities of integrating gamification into nursing curricula based on the selected taxonomy (Gallegos, et al., 2017).
According to our data, gamification as a more advanced approach in adult learning has not yet been included into any course units in the field of nursing in Slovenia.With this literature review of international research studies, our aim is to present the potential use of gamification in various course units in the field of nursing in Slovenia.

Aims and objectives
The overall objective of this review article is to present gamification as a novel concept in the field of nursing education.The specific aims of this review article are as follows: -to report the advantages and drawbacks of including gamification in the educational process in nursing; -to present the effect of gamification on the cognitive, socio-emotional and psychomotor characteristics of nursing students; -to assess the level of methodological quality of the studies which have applied gamification in the educational process in the field of nursing.
The research question was formulated on the basis of the PIOST guidelines (Population, Intervention, Output, Study, Time) (Polit & Beck, 2018) and reads: What is the impact of integrating gamification into nursing modules (I) on the cognitive, socio-emotional and psychomotor characteristics (O) of nursing students (P)?We included research articles in English (S) published after 2012 (T).

Method
In the first stage of our study, we applied the descriptive research method and used search strings along with inclusion and exclusion criteria to compile the corpus of relevant literature.When creating the search string, we used the 2dSearch application for a better visualisation of search results, and the Publish or Perish (Version 7) and PubMed2XL (Version 2.01) applications for data retrieval.In the second stage of the study, the literature selected for further analysis was critically evaluated using the Mixed Methods Appraisal Tool (MMAT) tool, Version 8 (Hong, et al., 2018).

Review methods
Literature screening was conducted in July 2019.We used the Google Scholar and Medline / PubMed search engines which provide free access, allowing for repeatability of this literature review, along with a sufficient number of databases (e.g., PubMed / Medline) for the topic searched.In the process of literature screening, we created a search string in English and included the Boolean operators AND and OR.The final search string was: ("elements of game" OR "game mechanics" OR "system design elements") AND ("nursing modules" OR "nursing education" OR "nursing teaching" OR "nursing courses").We used the 2dSearch tool to create the search string for a better visualisation of the search hits.
To retrieve data from the Medline / PubMed search engine, we used the PubMed2XL application (Version 2.01) (Isaak, 2016), and the Publish or Perish application (Version 7) for the results from the Google Scholar search engine (Harzing, 2007(Harzing, , 2019)).The spreadsheet database was created using MS Excel 2016.Following the initial filtering, two authors analysed all the search hits at three levels, namely by title, abstract and full text using the so-called dummy coding (Bech & Gyrd-Hansen, 2005), where "1" means that the hit qualifies for the next level, and "0" means that the search hit is excluded at this level.The search hit, i.e., the study which received all three points in this screening, was included in the final analysis.

Results of the review
Using the search string, we retrieved a total of 193 search hits (Medline / PubMed, n = 15; Google Scholar, n = 178).We included 9 search hits or studies in the final analysis (Figure 1).To show the impact factors (IF) of the research studies included, we used the Journal Citation Reports database from 2018, available on the Co-operative Online Bibliographic System and Services.

Quality assessment of the review and the description of data processing
In the final step, three authors individually appraised the included studies using the MMAT tool, which had already been used in review studies and had proven appropriate for appraising the methodological quality of research.In doing so, we followed the prescribed MMAT User Guide (Hong, et al., 2018).The MMAT tool comprises a total of 19 criteria for the appraisal of quantitative and qualitative research and mixed methods research, divided into five sets or criteria: the qualitative set, randomised controlled set, nonrandomised set, observational descriptive set, and mixed methods set (Halcomb, 2019).While the calculation of the overall score is not recommended, it is, instead, advisable to present estimates for each individual criterion.In our case, we gamified the final results of the MMAT and incorporated game elements in the form of star(s) (a coloured star denoted that the criterion had been met; an uncoloured star denoted that the criterion had not been met; a half-coloured star denoted that the criterion could not be appraised).We used the Inkscape tool (version 0.92.4) to visualise the results.

Results
The research studies were most often co-authored by two authors and were cited an average of 8.56 times (s = 7.55) per year.All studies were published in journals dealing with a variety of topics in the field of nursing.Six of the journals had an IF from the Journal Citation Reports categorisation.The article by Roche and colleagues (2018) was published in Computers Informatics Nursing (Wolters Kluwer Health, Inc.), which was the journal with the lowest IF (2018) = 1.029.The article by Davidson and Candy (2016) was published in Worldviews on Evidence-Based Nursing (Wiley Online Library) which was the journal with the highest IF (2018) = 2.500 (Table 1).
The research studies were conducted within different educational modules of nursing degree programmes.The common objective in all these studies was to examine the applicability of gamification and to demonstrate its impact on nursing students.The results show that the positive impact of gamification in nursing students is expressed in the form of motivation, engagement, interest, learning and knowledge, while the negative impact of gamification manifests itself in the form of inefficiency and inappropriateness of game-based learning and lack of student commitment.Four studies specifically mention the underlying methodology in the form of the theories of learning: Bloom's taxonomy (n = 1), the ARCS model (the attention, relevance, confidence, and satisfaction model of motivation) (Keller, 1987) (n = 1) and simulation-based learning (Cato, 2012) (n = 2) (Table 2).
Table 2 also shows the most frequently included game elements in nursing education, such as badges (n = 7, 77.78 %), feedback (n = 5, 55.56 %), and point systems with leaderboards (n = 4, 44.44 %).The frequency of inclusion of each game element in the research studies analysed is also shown in Figure 2 (a).
As shown in Figure 2 (b), over half of the studies (n = 7, 77.78 %) included several games elements at the same time.
Out of the eight studies which mentioned the use of badges.commendations, or badges and commendations (Figure 2, a -vertical lines), only two studies implemented badges and / or commendations as the only game element (Figure 2, b -vertical lines only).A total of six studies also included other game elements in addition to badges and/or commendations: in two studies, these were point systems or leaderboards (Figure 2, b -intersection of fields with vertical and wavy lines); in one study, these were challenges and / or feedback (Figure 2, bintersection of fields with vertical lines and dots); in three of the studies, these were both point systems or leaderboards and challenges and / or feedback (Figure 2, b -intersection of fields with vertical and wavy lines and dots at the centre).One study, which included game elements of all three groups (badges and / or commendations, point systems or leaderboards, and challenges and / or feedback), also included the social impact (Figure 2, b -intersection of the fields with vertical lines, wavy lines and dots and the circle, without a pattern at the centre).Game elements were most often expressed through virtual (e.g., digital learning environment in the form of games, quizzes, forums, etc.) and simulation (e.g., puppets and games) environment.
Most of the articles reviewed applied a mixed methods approach (n = 5).Following the initial MMAT review, all of the studies included were eligible for further MMAT appraisal, as they address two research questions on average.The main appraisal of the studies showed the average level of quality of the included methodologies according to the MMAT.The study conducted by Foli and colleagues (2016), which is based on a mixed methods approach, achieved the highest score by individual criteria (five stars) and  the highest overall average score of methodological quality (4.5 out of 5 points) according to the MMAT criteria (Table 3).

Discussion
We performed a search, analysis and synthesis of professional and scientific literature in the field of integrating gamification into nursing curricula.Of the 9 studies included, a total of 8 reported or advocated the positive impact of gamification in the learning process of nursing education.Our results are similar to those obtained by other systematic reviews (Mora, et al., 2017;Subhash & Cudney, 2018) in the field of gamification in that they reported the inclusion of similar game elements, such as badges, points and feedback, and concluded that they are suitable for integration into higher education.Game elements have a positive effect mainly on increasing motivation (Moritz, 2017;Castro & Gonçalves, 2018;Garnett & Button, 2018;White & Shellenbarger, 2018) and interest (Garnett & Button, 2018).They also contribute to preparedness for the clinical environment (Chia, 2013;Garnett & Button, 2018), reduce the fear of the unexpected (Garnett & Button, 2018) and contribute to greater engagement (Moritz, 2017;Castro & Gonçalves, 2018).In most cases, students find the inclusion of gamification in the learning process interesting, as they feel it contributes to an enhanced learning experience (Kurz & Kinder, 2017;Roche, et al., 2017;Mackavey & Cron, 2019).Conversely, Gallegos (2017) finds that gamification can also negatively affect the experience and satisfaction of nursing students.A similar finding was also reached by Fan and colleagues (2015).In their research, students found teaching through giving examples as more appropriate.Numerous studies have shown that students have a positive attitude towards the use of gamification in learning (Boeker, et al., 2013;Nevin, et (Hung, et al., 2017).Teachers have a great influence on the motivation of students, which is why it is important for them to use modern, novel and innovative technologies in the learning process and thus attract students' attention.Teachers were also found to report positive experiences with the novel learning approaches using gamification (Brom, et al., 2009;Noraddin, 2015;Kopcha, et al., 2016;Alabbasi, 2018).Teachers are aware of the need to motivate students and to integrate new approaches into conventional learning environments (Noraddin, 2015).Alabbasi (2018) collected data from teachers involved in a postgraduate teaching programme on the use of gamification in online learning.While the results of this study show a positive perception regarding the use of gamification, some believe it can negatively affect students.In recent years, since gamification has become part of education, most research studies have reported positive results related to its inclusion in the learning process.Toda and colleagues (2018) focused their research interest primarily on the negative effects of gamification on students.On the basis of a systematic cartographic research, they identify four negative effects, namely: loss of efficiency, loss of engagement, unwanted behaviour, and declining effects.Among the negative effects most commonly mentioned is the loss of effectiveness resulting from tasks and situations in which gamification hinders or harms students' learning process.Other studies (De-Marcos, et al., 2014;Naik & Kamat, 2015) report on the loss of achievement, which some perceive as a consequence of the presence of demotivating effects (Barata, et al., 2013;Hanus & Fox, 2014;Attali & Ariev-Attali, 2015).On the basis of their analysis, Toda and colleagues (2018) found that the negative effects occurred mainly due to the lack of appropriate methodologies or frameworks for planning and introducing the role into the learning context (Faiella & Ricciardi, 2015), which was also shown through the MMAT assessment of the quality of methodologies used in the analysed studies.According to MMAT, the results of our literature review show the most common limitations: non-inclusion of taxonomies and learning theories, poorer connections between individual methodologies, deficient qualitative or quantitative data analyses, various discrepancies in data interpretation and poorly designed discussions according to the chosen methodology.
The examined studies also show that gamification integrates well into courses such as informatics (Castro & Gonçalves, 2018), pharmacy (Sera & Wheeler, 2017) and anatomy in nursing (Roche, et al., 2018), i.e., into courses in which the teaching material is based more on quantitative rather than qualitative data.Our results show that, according to MMAT, the highest quality assessment was obtained by studies (Foli, et al., 2016) which include both types of data.
Furthermore, we note that gamification cannot be included in every course unit in the field of nursing, and teachers must be very careful in introducing it as the main or complementary teaching method, and choose a proven technologically advanced assessment environment.A telling comparison is the use of gamification in the form of the Rezzly simulation game, for which research by Gallegos and colleagues (2017) reported negative feedback by students who described it as inappropriate and inefficient in learning theoretical nursing.The study conducted by Moritz (2017), however, reports a positive attitude of students towards gamification, as efficiency in learning the topics of clinical nursing increased through the use of the Rezzly simulation game.
Gamification has recently assumed an important role in education within various areas of nursing.Nevertheless, the traditional method of teaching remains at the forefront, as it represents one of the simpler and more easily accessible forms of education.Some of the many reasons for this are the focus of the educational and research institution (i.e., research and development, purchasing newer simulation and educational equipment, etc.), teachers' personal traits (enthusiasm for innovation, age, staying up to date, accuracy, computer literacy, time barrier, etc.) and the lag in overall technological development (ranging from the inefficiency of commercial game-based products to the lack of credible research in this field).In addition to being willing to integrate information and communication technologies and gamification into their work, teachers should also be offered prior training and specialised support for counselling work and solving potential technical and operational problems (Castro & Gonçalves, 2018).Moreover, teachers are often reluctant to try new learning approaches for fear of wasting time and obtaining lower scores in student assessment (Royse & Newton, 2007;Roche, et al., 2018).As a result, more research should be invested into exploring the possibilities of implementing this concept, testing the acceptance of gamification by teachers and students, and the level of motivation and performance of students who using game elements in specific nursing course units.
The aim of this literature review was to gain insight into the use of gamification in the field of education in nursing and to gauge the possibilities of its transfer into the Slovene environment.Despite the many benefits of this literature review, there are also certain limitations to our study.While we did perform a literature review, we did not conduct the entire process of a systematic search, analysis and synthesis of the literature.As a result, there is a possibility that not all articles related to gamification in the educational process within nursing were included in the review.Nevertheless, the number of articles we based this study on was similar to those reviewed in the already published 2020 study by Noyes and colleagues (2020), which focuses on a systematic analysis of the impact of digital badges in the process of health education.In the future, it would be interesting to conduct a systematic literature review in the field of gamification in the educational process of nursing and an in-depth analysis of the findings.

Conclusion
Gamification is a fairly new concept in nursing education.It challenges teachers to make teaching more interesting and engaging.The studies conducted to date have been carried out abroad, which is why the findings should be interpreted with caution and the new method of gamification should also be tested before its implementation into the Slovene educational environment.Most studies report positive effects of gamification applied in the educational process in the field of nursing, manifested in the form of increased motivation and active participation of nursing students.On the other hand, the negative effect of gamification should not be disregarded, as, if not appropriately applied, the approach may result in student inefficiency and lack of commitment.Since gamification in terms of a regular advanced form of education has not yet been officially integrated in either international or Slovene nursing curricula, it presents a challenge for both researchers and teachers.

Figure 2 :
Figure 2: Frequency of included game elements (2a) and simultaneous use of game elements with positive and negative effects (2b)

Table 2 :
Content characteristics of included research Legend: No. -number; ARCS -attention, relevance, confidence, and satisfaction model of motivation

Table 3 :
Quality score in research with game elements(stars)

. Type of research Number of RQ Evaluation of the quality of research according to individual criteria Overall average quality of research
Legend: No. -number; RQ -research question et al., 2015), while very little research has focused on faculties and teachers