Gamification in midwifery education: a systematic review

Abstract

Background and objectives

Midwifery education requires the integration of thought and practical knowledge and skills. Therefore, new education methods, including gamification based education, might be able to improve midwifery education. The aim of this systematic review was to evaluate the effectiveness of gamification in midwifery education.

Materials and methods

This systematic review was conducted on both observational and experimental (quasi-experimental and randomized controlled trials) published articles in PubMed, SCOPUS, and Web Of Science till March 2024. All articles in English language that evaluated gamification-based education in midwifery or nurse-midwifery education were evaluated.

Results

Of the primary 268 articles, 6 articles (three cross-sectional and three intervention studies) were eligible for review. All studies used serious game method for educating on different aspects of care. Both digital and non-digital games were found to be more effective than traditional education in the reviewed studies. Satisfaction with game based education was lower than traditional method in one study.

Conclusions

Gamification based education can be a promising method for educating midwifery and nurse-midwifery students due to their efficiency in improving students’ knowledge and skills especially in practical fields.

Introduction

Playing is a part of human nature that motivates individuals to participate in group work [1]. Today new methods of education have been emerged and used. One of these new education methods is gamification. Gamification is defined as the use of game elements in non-gaming fields. Gamification can increase motivation for learning in individuals [2]. The aim of teaching using gamification is to increase internal and external motivations and learners’ communication, while maintaining independence and mastering the educated title in a serious environment [3]. Education through gamification especially through digital games can improve creativity and problem solving skills and can also increase the knowledge of the player due to integration with the game [4].

The advancements in technology in all fields including education has necessitated the integration of new technologies in education. However, the benefits of these technologies for education should be proven to outperform their limitations in order to be used by educators. Gamification was found to have a significant effect on students’ engagement and learning outcomes. For instance, a systematic review by Deterding et al. (2011) reported that gaming mechanisms could guide motivation and engagement in education [5]. A systematic review by McCoy et al. (2016) on the use of gamification-based education in Medicine, pointed out that gamification can be effective in improving knowledge, engagement, and cooperation among medical students [6]. Similarly, Kapp (2012) and McCall et al. (2016) stated that gamification-based education can improve clinical skills and the use of acquired knowledge in nursing students [7, 8]. Although majority of studies on gamification highlighted positive effects in education, some studies reported that gamification-based education might result in harm and frustration in individuals [9]. Although the use of gamification has been emphasized in healthcare, there is scarcity of data regarding the efficacy of gamification-based education in midwifery.

Midwifery is among the important fields in Medicine and Healthcare [10]. Midwifery education requires the integration of theoretical and practical knowledge. Therefore, education based on gamification can be a novel strategy to improve the learning outcomes in midwifery students and to provide an integrative education environment for these students. The potentials of education based on gamification in midwifery include increasing motivation, increasing knowledge retention, and improving critical thinking and problem solving skills, especially in emergency situations.

Benefits of gamification-based education, including improving problem solving and decision making skills, and increasing the level of knowledge, are among the objectives of education in the field of healthcare and medicine. A scoping review on randomized controlled trials on gamification-based education in higher education reported that the benefits of this type of education were improving the knowledge, skills, and motivation [11]. It was also stated that since gamification-education is a human-focused education method, it can be more beneficial in terms of improving motivation and integration in the education process compared to function-focus education methods [12]. Although some studies have shown benefits for gamification-based education in improving knowledge and skills in the fields of Medicine and Health Sciences, there is still scarcity of evidence for the proper implementation of this technology in education [13]. For instance, there is not enough evidence in terms of the best education method that should be used for gamification-based education for education purposes in Medicine and Health sciences and the effect of these education methods on the attitudes of the learners [13, 14]. Furthermore, the mechanism of the effects of gamification in improving knowledge and skills has not yet been fully studied [15]. Furthermore, there is inconsistency between the published articles in terms of some effects of gamification, including attitudes and satisfaction [14, 15].

Considering the limitations of the studies and scarcity of evidence, it is not yet determined that whether digital or non-digital gamification education differ in terms of efficacy in Medicine and Health Science education. Therefore, this systematic review was conducted with the aim of synthesizing the currently available data on the use of various gamification-based education methods of different design and methodologies in midwifery education. This study also aimed to evaluate and identify the best methods of education using gamification and determine the potential challenges in using this education method and provide insights for educators and stakeholders in the field of midwifery education. To do this, a systematic search was conducted in published articles in peer-reviewed journals on gamification-based education in midwifery and the results of the studies were synthetized and discussed to provide answers to the research questions.

Methods

Search design and eligibility

This systematic review was conducted on published articles in scientific databases, including PubMed, SCOPUS, and Web Of Science till March 2024. The search keywords were gamification, game based education, and midwifery. The search terms and their synonyms were retrieved in a test search in PubMed and were combined using the Boolean operators “AND”, and “OR”. Synonyms were identified based on trial search and reviewing the keywords of the identified articles in the database. Furthermore, synonyms were also found from thesaurus dictionary and included in the search terms if they resulted in new articles. The primary search strategy was formed and tested in PubMed and the search strategy was used in SCOPUS and Web Of Science based on the search engine settings (Supplementary material). The inclusion criteria were all articles published in English language by March 2024 that included data on the use of gamification based education in midwifery. Exclusion criteria were abstracts, seminar reports, commentaries, and unavailability of the full text article.

Selection process

Search was conducted in the mentioned databases and the retrieved articles were merged and the duplicated publications were removed using the EndNote software version 8. Screening of the title and abstract was performed independently by two researchers. The full text of the included articles from the previous stage was reviewed by the two researchers independently and the articles that met the inclusion criteria were selected. Any disagreement between the researchers was resolved based on group discussion with other reviewers and voting. In the final stage, data were extracted from each article and summarized. Two researchers performed data extraction and in case of disagreement, decision was made by consensus between all reviewers. The collected data from the articles included author names, publication year, study design, sample size, intervention or exposure, intervention duration, measured outcomes, and study findings. All the steps of the review was performed using the Endnote software. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of the study is presented in Fig. 1.

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Risk of bias

Risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools based on the study type. Each study was evaluated using the JBI checklist appropriate for the study design [16]. The JBI was used due to its simplicity and efficacy in evaluating the major issues in the quality of studies. Although it has been shown to be less efficient in studies with control or unexposed groups and for meta-analysis, due to the heterogeneity of the studies and the nature of the research question, JBI was considered appropriate for quality assessment [17]. Decision on the inclusion or exclusion of the study was made based on the scores each study obtained from the total possible score and studies that scored higher than 60% of the total scores were included (Table 1). quality of studies was acceptable [18,19,20,21,22,23].

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Results

Of the total 268 retrieved articles, 6 articles were reviewed in this systematic review. The summary of the reviewed articles is presented in Table 2.

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The quasi-experimental study by Danna et al. (2023) was conducted on nurse-midwives and nursing students in Malawi and Zambia. The aim of the study was to evaluate the effectiveness of board game (DIGNITY) based education on the understanding and practice of respectful maternal and neonatal care. The study used pre- and post-test design using questionnaires and interviews at follow up. The study showed effectiveness of the game based education on the level of knowledge of the students about respectful maternal and neonatal care. Students also reported improvement in their respectful care practice [21].

Another quasi-experimental study by Katebi et al. (2020) was conducted on midwifery students in Iran to evaluate the efficacy of gamification based education in case-based education in emergency care. The researchers used crossword puzzles for education through a smart phone application. The outcome measures were knowledge and performance of the students in terms of emergency care and their satisfaction with the education method. Outcomes were evaluated in the form of open ended questions asked during interviews with the students. The study showed that gamification based education improved knowledge and practice of the students compared to the traditional method of education. They suggested gamification based education could be implemented in education curricula to enhance knowledge level and its retention as well as improving practical skills of the students [20].

In a cross-sectional study by Georgieva-Tsaneva et al. (2021) on nursing and midwifery students in Bulgaria, the effects of online game based education was evaluated in midwifery education. Data was collected from 486 students through Google Form. Students were asked about the online learning platforms, including video contents and games. The study showed that the quality of healthcare training could be enhanced by integrating online education with traditional methods [23].

In another cross-sectional study, Georgieva-Tsaneva et al. (2021) evaluated the effect of online game based education in health care education of 206 nursing and midwifery students. The online game included training videos on serum infusion, intradermal, subcutaneous, intramuscular and intravenous injections. The game provided 24 multiple-choice questions. Each questions had four choices and the game provided feedback through colors (green for correct answer and red for wrong answer). The outcome measures were the type of game and amount of time spent playing the game. The researchers suggested that serious games that benefit from video algorithms can improve knowledge, practice, and self-competence among nursing and midwifery students [22].

In a randomized controlled trail study by Michelet et al. (2020) on 28 midwifery students, the effectiveness of a combination of screen-based simulation, video training, and android puzzle on the students’ knowledge retention (after two months), self-efficacy neonatal resuscitation. Students were randomly assigned to game based education (two sessions of screen-based simulation with two months interval) or traditional education. The intervention group received two scenarios at the end of video-based simulation in the first session and one scenario in the second session. The outcome measures were self-efficacy and non-technical and technical skills, evaluated by the Neonatal Resuscitation Performance Evaluation (NRPE) score. In the first session, non-technical skills were higher among the students in the intervention group compared to the control group, while self-efficacy was higher in the intervention group compared to the control group after the second session. Technical skills did not differ between groups [18].

In a quasi-experimental study by Haghani et al. (2018), the efficacy of game based education on social psychology education to Iranian midwifery undergraduate students was evaluated. The intervention and control groups received two sessions of game based education and two sessions of lecture, respectively. The outcome measures were level of knowledge, and satisfaction, which were evaluated through questionnaires at the end of each intervention. The level of satisfaction with game based education was reported excellent by 16% of the students and average to fine by the rest. Majority of students 987%) reported that game based education was more effective than traditional method. The level of knowledge was also higher among students who received game based education [19].

Discussion

This study aimed to evaluate the effects of using gamification-based methods on learning outcomes, including level of knowledge, performance, satisfaction, quality of education, clinical competence, and self-efficacy, among midwifery and nurse-midwifery students. This review evaluated 6 studies, overall 980 midwifery and nursing students, and determined that the level of satisfaction, quality of education, self-efficacy in clinical competency tests, and skill level of midwifery and nurse-midwifery were higher among those who received gamification-based education compared to those who received the usual education methods.

The included studies in this systematic review were conducted in European, Asian and African countries. The education topics in the reviewed studies were newborn resuscitation training, midwifery psychology course topics, clinical emergency training in midwifery, and care-based training on preserving the dignity of the mother and baby. Of the 6 studies, four studies used semi-experimental pre-test and post-test design with a control group (one of these studies used mixed method), and two studies used cross-sectional design. Although quasi-experimental studies are of particular importance compared to other studies due to the similarity between the study methods and to real world education condition, combining several types of studies in a systematic review can also help evaluate the study subject from different perspectives [24].

The common genre of games in the reviewed studies was serious learning-based games. These types of games emphasize on events and aim to attract learners, providing educational content, recalling previous data, integrating educational content, and providing feedback to the learner [22]. Most of the serious games with educational purpose provide quick feedback through green or red color in the answers; therefore, these games are associated with higher learner satisfaction, especially in performance learning. Serious games can increase and improve self-efficacy [2]. However, regardless of the similarity in genre, the way games were designed in the reviewed studies differed and could be divided into two general categories: digital and non-digital games. Digital games included video games, games installed on Android phones, and non-digital games in the form of colored cards or cards containing important messages.

The methods of playing games in the reviewed studies included digital methods in two studies (video game), games on smartphones with Android platform, and non-digital games (games with colored cards). One of the non-digital games in this study was called DIGNITY and was designed to teach respect for the dignity of mothers and babies in Africa. In another non-digital game, the stages of human psychological development based on Erikson’s theory were taught using colored cards to midwifery students in Iran.

DIGNITY is a type of novel game that was developed by Dr. Maclean and was evaluated with the cooperation of midwives in England and Africa. In this non-digital game, learners have to pass through bridges and paths and receive cards. The bridges facilitate reaching to the final stage. Questions are asked from the learners through printed cards in the paths. The duration of the game is limited and the participant who gives the most correct answers is the winner. The educational content expressed in DIGNITY game was quality of care based on preserving the dignity of mother and fetus. The designers also aimed to preserve the learned knowledge by designing the game. Although the nature of digital and non-digital games seems to be different in education, both methods have similar educational impact and learners express greater satisfaction with game-based learning than with learning through conventional methods. Furthermore, a meta-analysis conducted on the educational achievements of learners through game-based learning indicated that the educational achievements in both types of digital and non-digital games are almost comparable [25].

The study by Danna et al. had both the quantitative and qualitative parts. The reasons for accepting the non-digital game were determined in the thematic part of the analysis as “appropriate time to learn and work together”, “easy learning through practice”, “quick feedback tor correct mistakes”, and “improvement of attitude in the quality of care” [21]. The study by Haghani et al. (2018) in Iran showed that the learners considered gamification-based learning as waste of time and did not have a desire to learn actively and were more fund of the lecture method. Another difference between the studies can be the cultural differences between the study participants. As the studies included in this systematic review were conducted in different countries, including Bulgaria, Malawi, France, and Iran, a wide cultural difference exists between the studies that may affect the impact of game-based education. All the studies evaluated in this systematic review indicated that the knowledge, skills, and satisfaction of midwifery students increased following the use of gamification, and only the study conducted in Bulgaria stated that midwifery students stated that online learning was not useful alone due to the lack of access to the lecturer and suggested that online game-based education be combined with conventional methods. Similarly, some studies in Iran showed that most midwifery students preferred teacher-centered learning over game-based learning, while midwifery students in European countries were more satisfied with gamification compared to conventional methods of education. The reason for this difference may be due to the cultural differences of the societies, and the possible delay in the cultural adaptation to new technologies in some countries like Iran [26].

This systematic review showed that educational outcomes, including knowledge, skills, and satisfaction, of Iranian midwifery students were higher compared to other studies. The reason for this difference can be attributed to factors related to the characteristics of the game as well as the education subjects. It can be hypothesized that students may express satisfaction when the subject is interesting to them and the game rules are simple and straightforward. For example, clinical and practical course topics are more interesting to midwifery students compared to theoretical courses. This might affect the level of satisfaction with the education method [27, 28]. All studies that were evaluated in this systematic review employed practical courses, neonatal resuscitation, obstetric emergency training, maternal and newborn care, and theoretical courses in health care education and social psychology.

However, the learning outcomes were higher in the gamification-based education compared to the common method of education. This study suggested the use of new educational methods and especially serious games to gradually replace traditional methods with active learning [19]. Although the basis of gamification-based education is on digital games, but due to the cost and logistical problems, sometimes the digital method cannot be used. Qiao et al. (2023) showed that, the learners’ level of knowledge and performance did not significantly differ between non-digital games and the digital and non-digital mix games. They also showed that state of learning progress was the same in both groups [29]. As the nature of both the non-digital and digital games is through engagement with educational content, it seems that the learning outcomes in serious digital and non-digital games do not differ, and that being digital or non-digital may affect the acceptance of learners. It seems that the acceptance rate is higher in digital game-based education compared to non-digital game-based education [29] Using game space and conducting educational interventions in some educational topics and discussions can increase educational effects and be cost effective, especially in cultures where the educated topic is considered as taboo [30].

Digital games can be combined. For instance, Katebi et al. (2020) incorporated the use of a baby resuscitation simulator, a video game, and an application called TheApp into their gamification-based education [20].

The reviewed studies used different methods in designing the digital games, for example, Katebi et al. (2020) designed their game based on the Android platform, and the nature of the game was using the puzzle method. Ketabi et al. (2020) aimed to evaluate the level of knowledge and performance of midwifery students in terms of theory and practice during emergency situations using the gamification application (TheApp) method and the common method (lecture). The educational content of TheApp was collected based on experts opinion from the midwifery curriculum. The knowledge status of the participants was evaluated with ten clinical questions, which were filled by the participants in the application itself. Therefore, the application provided feedback through reporting the test results to the participants. In the second part, the students’ performance was determined by presenting questions about the performance of the participants at bedside. Participants also received feedback in this part. Katebi et al. (2020) indicated an increase in students’ knowledge and performance in the TheApp group compared to the lecture method [20].

Another digital game that was reviewed in this systematic review was the gamification-based education tool designed by Michelet et al. (2020) to teach newborn resuscitation using a simulator. The designers used debriefing method in the education of newborn resuscitation. This platform also assessed participants’ knowledge and skills. The debriefing method is one of the most important methods of increasing knowledge, and incorporating this method in gamification can also affect skills. The procedure of the game included 15 min of the working conditions and the scenario followed by the evaluation of the participants’ performance by putting the participant in the situation. The taxonomy of the questions ranged between simple to complex. The study found that the level of knowledge and skills of the students in the gamification-based education group was significantly higher compared to the control group. They also showed that the participants’ self-efficacy was higher than the control group 2 months after the end of the project. However, self-efficacy was lower in the gamification-based education group compared to the control group 6 months after the project [18]. It should be noted that a meta-analysis and systematic review conducted by Denden et al. ((2024) indicated that individual characteristics of learners, including personality traits, age, and gender, can play a very important role in the effectiveness of games. For example, game-based education is more effective in women compared to men. Furthermore, the previous experience of learners, and the psychological characteristics of learners can play a role in the effectiveness of games [31]. However, since in most countries midwifery is chosen by girls and women, the gender factor is not mentioned in the aforementioned studies. Furthermore, none of the studies mentioned the psychological characteristics of the participants and their previous experience with learning in a game environment.

One of the limitations of this systematic review was the inclusion of studies with different designs, methods, and sample sizes. Although the inclusion of observational and interventional studies together in the review can provide a better view of the possible theories and mechanisms for the effectiveness of an intervention, the difference in the sample sizes and designs and methodology to assess the outcomes prevented us from performing a meta-analysis on the findings. Therefore, the unique findings in some studies, especially in terms of satisfaction, may not be generalizable and requires further investigation. Another limitation of this study was that only one study evaluated the combination of game-based education and common methods in satisfaction and educational outcomes. Therefore, no definite conclusion can be drawn for the effectiveness of the combination methods due to the limited evidence.

Conclusion

Nowadays, the use of modern methods in education, especially in the clinical field, has become very important. Gamification is one of the new tools in midwifery pedagogy. Increasing the concentration and problem solving skills and improving the understanding of the problem are among the most important achievements of game-based education. Based on the evaluation of the 6 studies in this systematic review, gamification-based education through both the digital and non-digital methods can be beneficial.

Although the number of studies evaluated in this systematic review was limited, the use of gamification is expanding surprisingly in the field of midwifery. There is a need for further studies in this filed in order to provide a better understanding on the effective education methods in game-based education. This systematic review also showed that digital games can be more effective in improving the satisfaction level of midwifery students compared to non-digital fames. Therefore, it is suggested that new gamification methods be incorporated especially in the clinical and emergency midwifery education. The use of scape room can be a good choice for game-based education that could be evaluated in further studies.

Data availability

As this study is a systematic review, no new data were generated. The data used, such as tables summarizing study characteristics and the items are available within the manuscript.

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