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Health care professionals must understand the laws and regulations that guide their practice. Training can often be dense and tedious, resulting in less than optimal levels of learner interest and engagement. Gamification provides a unique opportunity to improve the learning experience, promote ease of use, and sustain gained learner knowledge. [J Contin Educ Nurs. 2025;56(2):50–52.]
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In the evolving landscape of continuing education for health professionals, game-based learning is an important strategy to increase overall learner engagement in remote learning environments (Krishnamurthy et al., 2022; Mohamad et al., 2017). This educational approach adapts well to adult learning needs by providing immediate feedback and flexibility to meet varied levels of existing knowledge and skill. Gamification may be a particularly effective approach to engage learners in important and necessary materials, such as laws and regulations that guide professional practice.
Recognizing its potential, the School Health Institute for Education and Leadership Development (SHIELD) at Boston University School of Public Health used gamification principles to facilitate game-based learning and enrich one of its existing online courses.
As a school health professional workforce training center, SHIELD is funded by the Massachusetts Department of Public Health. Medication Administration in a School Setting: School Nursing Practice in Massachusetts is an online course designed by SHIELD's nursing professional development (NPD) specialists for Massachusetts school nurses (
Over the years, SHIELD has revised this course multiple times to improve user experience and reflect updated medication practices. In the most recent revision, SHIELD decided to employ gamification to boost learner experience with the eBook content. In earlier versions of this course, learners could easily skip reading the eBook, potentially limiting familiarity with this essential resource.
The main goal of gamification was to encourage effective interaction with the eBook, beginning within the course and extending into nursing practice. A secondary goal was to create a responsive course experience for the wide range of knowledge that nurses brought with them to the course. For example, the game would require novice learners to engage fully with the eBook but allow experienced nurses to move through familiar material quickly while reinforcing their knowledge.
Game Creation
The course contains a pretest, a link to the eBook, an interactive training module developed with Articulate Storyline 360, a posttest, a resource page, credit in the form of 2.75 American Nurses Credentialing Center contact hours, and a certificate. The eBook outlines key information that every school nurse must know, such as the regulations and oversight of medication administration and delegation in Massachusetts, the school nurse's role and responsibilities, and guidance for individual student situations.
The former version of the course captured the user's increased knowledge gained from the pretest to the posttest. To check that the level of knowledge gained remained consistent in this version of the course, we kept these tests.
We hired a design consultant to create an eBook review game with adult learning principles. In addition, multiple school nurses tested the game before its official launch. The game includes five levels, each related to a specific medication practice topic discussed in the eBook. To improve engagement, a progress bar is shown so learners can keep track of their place in the game, and digital badges are awarded for completing each of the five levels. Bright colors and upbeat background music enhance the learning experience.
The game draws from a pool of more than 100 questions that are randomly posted. Game questions were developed directly from the eBook. Two NPD specialists with expertise in school nursing oversaw the process, writing and reviewing the questions to make sure they met nursing practice standards. This large question pool ensures the content can remain fresh and engaging for those retaking the course. Game advancement requires a success rate of at least 70% at each level. Learners must answer at least four questions correctly at each of the five levels to successfully complete the game (Figure 1). While playing, learners are prompted to refer to the eBook to answer the questions.
Course Evaluation
We evaluated the course by first looking at the evaluation feedback on users' experience with the course, which asked users if the game aided their learning. Second, we compared pretest and posttest data to examine knowledge gained.
Findings
Both quantitative and qualitative analyses were used to evaluate the course. Between July 2022 and June 2023, a total of 828 learners completed the course. Nearly all respondents (96.4%, n = 798) agreed or strongly agreed that the eBook game aided their learning. A thematic analysis using Braun and Clarke's approach found three major themes for user feedback: engaging, interactive, and easy to use and understand (Braun & Clarke, 2006). One learner wrote, “The eBook game was a great way to make reading the book interactive.” Another shared, “. . . the eBook game made learning and recalling the content a bit more entertaining and engaging than traditional reading and testing.”
A secondary pre-/posttest analysis showed that posttest scores were 13% higher than the pretest scores for 635 matched participants. This overall knowledge gain was consistent with previous versions of the course.
Discussion
Learning about laws, regulations, procedures, and practice requirements can be daunting, taxing, and inherently disengaging for health care professionals. Gamification offers a creative solution to engage learners in this dense and often tedious material. By combining game-based learning with adult learning principles, we met two key goals: improving user experience while meeting diverse learning needs (novice to experienced) and ensuring that learners referenced a critical resource.
Our findings show that gamification can be applied effectively to dense material to improve the overall learning experience, promote ease of use, and sustain gained learner knowledge. Evaluation data have shown positive results. Learners reported that playing the game was beneficial to their learning, and the knowledge check requirements for game advancement (passing at ≥ 70% at each level) prompted users to reference the eBook.
Future Implications
This training currently includes a pretest and a posttest, an eBook game with a link to the eBook, and a self-paced interactive scenario with a case-based lesson. This format allows learners to carefully review and take their time completing the content. Updating and maintaining the content is also readily manageable with knowledge of the learning management system. The course design has proven effective in training novice to experienced learners and can be scaled to a larger audience. Anecdotally, learners have informed us they have completed the course in a group setting, which has allowed them to review the questions and discuss their answers together.
Limitations
Some limitations to consider are the cost and time required to transition to a game format, including the development of an extensive question bank that must be carefully reviewed and vetted. Nevertheless, our experience can serve as a valuable example for other NPD specialists encountering challenges with keeping learners engaged with content delivered through traditional lecture or assigned reading methods. In addition, NPD specialists can consider how using game-based learning can highlight key content areas and allow for scaffolded learning. Gamification and game-based learning approaches also offer unique opportunities for integrating learning into workflows for busy health professionals, as demonstrated by the anecdotes from nurse leaders using the game to review key areas rather than requiring nurses to review the entire course.
Conclusion
Game-based learning is a training strategy that can increase learner engagement, particularly when the mate- rial is dense and tedious. By gamifying a static, but important component of our course, we met our goals of improving learner engagement and ensuring they referenced a critical resource. Evaluation data indicate that learners were satisfied with the training and enjoyed learning through the game. Gamification was an effective design approach to engage learners in key material that they could easily bypass in earlier versions of the course.
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