The quantitative studies were systematically evaluated following the Cochrane Handbook for Systematic Reviews of Interventions, and the report adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [19]. The study protocol was preregistered on PROSPERO (CRD420250652129) [20]. Ethical approval and informed consent were not necessary, as this study did not include individual patient data.

This study systematically searched 8 major electronic databases, including Cochrane Library, PubMed, CINAHL (EBSCO), Embase, Web of Science, CNKI, Wanfang, and SCOPUS. The search strategy was refined with the assistance of health information librarians, using Boolean logic operators to integrate index terms (including MeSH, Emtree, and CINAHL subject terms) with free text terms. The complete search strategy is detailed in Multimedia Appendix 1. To prevent excessively narrowing the search scope, outcome indicators were excluded from the selection criteria for search terms. The search period was confined to the time frame from database inception to February 10, 2025, and the literature was restricted to English and Chinese. Additionally, the search was augmented by manually screening references from included studies and pertinent review literature.

To establish the framework for inclusion criteria, we used the PICO-SD model for this systematic review. The components of the study were as follows: (1) Population: nursing students or registered nurses; (2) Intervention: educational programs incorporating core gamification elements (eg, themed games, virtual reality simulations, tabletop games, escape rooms, serious games, etc); (3) Comparison: traditional teaching methods (theoretical lectures) and nongamified e-learning; (4) Outcome: knowledge acquisition, skill performance, learner satisfaction, and evaluation of teaching effectiveness; and (5) Study design: randomized controlled trials (RCTs), nonequivalent control group designs, and single-group pretest and posttest studies. Exclusion criteria comprised (1) editorials, letters, conference abstracts, dissertations, and gray literature; (2) studies focused solely on virtual simulation that lacked game mechanics; (3) mixed-sample studies involving other health care professionals or nonnursing professionals; and (4) nonempirical research designs (eg, theoretical explorations and protocol designs).

The quality of studies included in RCTs was evaluated using the Risk of Bias Assessment Tool for Randomized Controlled Trials developed by the Cochrane Collaboration [21]. Conversely, non-RCTs (quasi-experimental studies) were assessed for methodological quality using the Joanna Briggs Institute tool for quasi-experimental studies [22]. The literature quality was independently evaluated for each project by 2 systematically trained researchers (SB and HZ), with any discrepancies resolved by a third reviewer.

All retrieved documents were imported into EndNote 20 for deduplication and classification management [23]. A structured data extraction form, tailored to meet the study objectives, was developed through discussions among the research team and included the following core elements: authors/year, country, study design, population and sample size, intervention, comparison, outcome, and key findings. The literature-screening process was conducted in 2 stages: initially, 2 uniformly trained researchers (SB and HZ) independently performed the initial title and abstract screening, followed by a full-text rescreening of potentially eligible literature. Any disagreements were resolved through third-party arbitration to reach a consensus. The final data extraction was carried out by 1 researcher (SB) and subsequently cross-checked by the other 2 members to ensure accuracy.

Following the search and data screening, we will organize and summarize the research data in a tabular format. First, due to the diversity of research design components and outcome measures, meta-analysis was deemed unfeasible. Therefore, we used Campbell’s narrative synthesis (synthesis without meta-analysis) to integrate the evidence [24]. Second, the extracted data were analyzed to assess the effectiveness of interventions using various types of games, aiming to ascertain whether gamified instruction positively influenced outcomes. Finally, the extracted data were examined for indicators of effectiveness, summarizing the categories of effectiveness indicators and offering recommendations for the future implementation of gamification in disaster nursing education.

Following the initial screening, 246 studies were identified, of which 171 remained after deweighting. A further 117 were excluded based on the title and abstract review, leaving 54 studies. Subsequent full-text screening led to the exclusion of 40 studies due to inaccessibility, incomplete information, or irrelevance to the topic. Additionally, 3 studies were sourced from the references, culminating in the inclusion of 16 studies [19]. The modified PRISMA flowchart (Figure 1) delineates the comprehensive study selection process.

This systematic review encompasses a total of 16 research studies, published between 2010 and 2024. The fundamental characteristics of the included literature are shown in Table 1.

Among the 16 studies, geographical distribution reveals that 7 originated from China [26,29,30,33-35,38,39], 3 from Iran [28,31,36], 2 from Korea [25,27], 2 from Indonesia [37,38], 1 from Turkey [32], and 1 from the United Kingdom [40]. Notably, 93.75% (15/16) of the studies were conducted in Asian countries, highlighting the region’s active engagement in gamified teaching and learning. Regarding temporal distribution, only 2 studies were published between 2010 and 2018, while the number surged to 14 post-2019, indicating a significant increase in interest in gamified teaching within disaster nursing education. The study population comprised nursing students (n=1268) and registered nurses (n=392), with participant numbers per study ranging from 27 to 331, totaling 1660 participants in this systematic evaluation. Concerning game types, 6 categories of games were used in disaster nursing education, either in the intervention group or the control group. Specifically, 5 studies used tabletop games [26,27,36-38], 2 used serious games [32,40], 3 incorporated virtual reality mobile game−based app [25,29,30], 2 used featured theme games [31,35], 2 involved 3D games [33,39], and the remaining 2 used simulation games (interactive/VR) [28,34]. In terms of technological trends, upper-middle-income countries demonstrate a preference for integrating VR/3D technology with game elements for educational purposes, whereas low-income countries tend to favor low-cost tabletop games.

Furthermore, among these 16 studies, 6 used a quasi-experimental 1-group pretest and posttest design [25-27,32,33,37], 9 used a quasi-experimental 2-group pretest and posttest design [28-31,34,36,38-40], 1 study implemented an RCT [35], and 2 conducted various comparative analyses between games [34,35].

Research has shown that gamified instructional interventions exhibit differentiated characteristics in different disaster education scenarios. Tabletop games can significantly increase participants’ motivation, infectious disease awareness, and disaster care knowledge by simulating mass casualty events, infectious diseases, and natural disasters [26,27,36]. Serious games focus on reinforcing the theoretical system of disaster response capabilities by targeting the prevention of infectious diseases and the teaching of emergency triage [32,40]. Virtual reality mobile game−based app optimizes disaster evacuation training by relying on virtual reality technology to effectively improve triage accuracy, disaster classification knowledge, and student satisfaction [25,29,30]. The thematic game focuses on crisis management and disaster response capacity development, enhancing behavioral fluency and disaster care knowledge application through knowledge-behavior transformation mechanisms [31,35]. The 3D game is based on high simulation of mass casualty and trauma scenarios, which improves ease of use and extends the knowledge dimension of disaster relief [33,39]. Simulation games (interactive or virtual reality) are used in complex scenarios such as disaster triage and chemical disasters to strengthen skills, self-efficacy, and triage knowledge through immersive training, highlighting the synergistic optimization of practical ability and psychological state empowered by technology [28,34]. Table 2 summarizes the intervention effects of different types of games across various application scenarios.

The purpose of this study was to highlight the impact of interventions and assess their effectiveness. The 16 studies included in this review assessed the effectiveness of gamified instruction through a multidimensional perspective, focusing on key indicators such as theoretical performance, skill acquisition, participant satisfaction, long-term knowledge retention, and self-efficacy.

The primary objective of this review was to assess the effectiveness of gamified instruction in disaster nursing education and its associated indicators. Although the indicators of effectiveness and the quality of the studies varied, all interventions demonstrated a positive impact on health care workers’ outcomes. Specifically, these interventions significantly improved theoretical knowledge, practical skills, engagement and knowledge retention, satisfaction with the intervention, and self-efficacy.

Research has shown that the use of gamified teaching methods in disaster nursing education demonstrates significant results [43,44]. However, gamification differs from digital game design in that it promotes knowledge acquisition and behavioral improvement not only through competition and reward motivation but also through contextual simulation and feedback mechanisms [31]. Tabletop games, for example, cost less than digital games, can simulate situations repeatedly at less cost, and are easy to rehearse, with participants recognizing their roles and responsibilities, which is consistent with previous research findings [26]. Of course, tabletop games have certain limitations. Studies have pointed out that tabletop exercises cannot replace the experience gained from actual disaster response exercises and that learners must have some prior knowledge of disaster response to achieve effective learning outcomes [36]. Therefore, tabletop games are more appropriate for learners with some experience in disaster response, and they are not a particularly effective teaching method for less experienced nurses.

In addition, the core of digital games as complete metadata information systems lies in the systematic description and dynamic interaction of game elements through structured data models, and their design goals are more focused on constructing self-consistent virtual experiences rather than direct educational transformations [45,46]. For example, serious games and 3D video games are also effective in enhancing knowledge and skills. For less experienced nurses, these games are easy to pick up, more engaging, and can increase the cognitive load to some extent [33]. However, these games may also increase extraneous loads, such as prolonged engagement requiring sustained attention and endurance. While limited by device penetration and system stability, they may affect learning outcomes [44]. Therefore, although digital games can provide richer learning experiences, their implementation faces certain technical and resource challenges.

In the future, it is necessary to balance technical complexity with pedagogical use, such as optimizing cognitive load distribution through hierarchical design and developing standardized tools (eg, cross-platform simulation systems) to lower the hardware threshold, to maximize the pervasiveness and effectiveness of gamified interventions in disaster care teaching.

Research indicates that the predominant methods for evaluating the effectiveness of gamified instruction involve comparing knowledge and skill differences between intervention and control groups, or assessing changes in knowledge preintervention and postintervention within a single group. Unlike prior reviews of gamified instruction in disaster education [47], the studies included in this review primarily demonstrated the effectiveness of gamified instruction by reporting levels of theoretical knowledge, whereas earlier studies emphasized the availability of game types and outcomes.

This review yields positive conclusions regarding the efficacy of gamified teaching in enhancing the theoretical knowledge and skills of nursing professionals. In 5 studies, standardized questionnaires that were tested for reliability and validity were used to measure theoretical knowledge, thereby ensuring the robustness of the assessment results [28,31,34-36]. However, some studies used self-designed questionnaires, which may complicate the comparison and interpretation of results. Consequently, future research should prioritize the use of standardized, validated assessment tools. Furthermore, 3 studies evaluated skill acquisition through the OSCE, a scientific and objective method that accurately assesses participants’ practical skills in critical areas such as triage, disaster management, and emergency response [28,31,39]. This assessment type is crucial as it enhances the practicality and applicability of disaster nursing education. Additionally, 5 studies indicated that participants generally held a positive attitude toward the gamified teaching format, suggesting that gamified instruction possesses significant advantages in stimulating learning interest and enhancing motivation [26,29,32,33,37]. The promotion of gamified teaching in disaster nursing education is widely accepted and recognized.

However, considerable variation exists in assessment results concerning the long-term effects of gamified instruction, which may arise from several factors. First, differences in intervention duration can influence knowledge retention. For instance, a 5-week instructional intervention that developed an app and incorporated various gamification elements, such as collaboration, storytelling, and competition, resulted in relatively stable knowledge retention 1 month postintervention [31]. In contrast, a study using a brief 2-hour educational game demonstrated a significant decline in knowledge retention 1 month after the intervention [36]. Second, the richness of gamification elements was strongly correlated with knowledge retention outcomes. A singular game model (eg, relying solely on contextual narratives) may diminish long-term effects [36], whereas an instructional design that integrates multidimensional game mechanisms (eg, resource management, time pressure, and immediate feedback) is more conducive to long-term knowledge stabilization [31]. Third, the construction of learning scenarios also impacts knowledge retention. Research indicates that self-directed learning models lacking instructor guidance and external situational support, which primarily depend on stand-alone mobile software, experienced a sustained decline in knowledge retention after 6 weeks [32], underscoring the importance of creating an external learning environment to maintain learning outcomes. Additionally, the heterogeneity of study populations, variations in the reliability of assessment tools, and the diversity of gamified instructional formats (eg, apps, physical games, virtual reality, etc) may further restrict the comparability of results across studies.

Through a systematic review of existing studies, we identified several limitations in the application of gamification methods in disaster nursing education, despite their noted successes. First, regarding research design, the majority of studies used quasi-experimental frameworks, lacking robust evidence from RCTs, and many had small sample sizes, potentially compromising the validity of their findings. Furthermore, significant variability in the implementation of gamified instruction, assessment tools, and training durations across studies has resulted in limited comparability of outcomes [48]. Second, the impact of cultural and educational backgrounds on the effectiveness of gamification warrants consideration. For instance, pedagogical approaches that prove effective in technologically advanced virtual reality settings may not translate well to resource-limited environments [43]. Third, the existing literature has not evaluated cost-effectiveness, hindering the ability to ascertain the relationship between costs and benefits. Finally, while gamified instruction is typically conducted in simulated environments, existing studies have not assessed its clinical performance in real-life disaster scenarios, which are characterized by unique tensions, stresses, and complexities, as well as various uncontrollable factors that may influence performance in disaster care.

In summary, to enhance the scientific and practical value of disaster nursing education research, future studies should focus on optimizing the following aspects: First, it is recommended to establish a standardized assessment framework, uniformly adopting indicators such as knowledge retention rates and mastery of practical skills, along with measurement tools such as the Structured Clinical Assessment Scale. Longitudinal assessments should be conducted at predefined intervals (eg, 1 month and 3 months postintervention) to improve result comparability. Additionally, adaptive gamified instructional programs should be designed based on local cultural contexts and technological resources. Second, research design should prioritize multicenter RCTs and increase sample sizes to enhance external validity. The synergistic effects of gamified teaching and other methods (eg, situational simulation and didactic approaches) should also be explored to construct a diversified educational framework that considers efficiency and population characteristics. Furthermore, studies should examine the differences between gamified teaching and actual clinical performance, particularly in real disaster scenarios, while remaining vigilant to the risks of overimmersion and distraction in virtual environments. Finally, most existing studies focus on short-term effect assessments; while lightweight game elements (eg, points and badges) may motivate participants in the short term, they often fail to promote long-term memory integration due to a lack of in-depth narratives and contextual coherence. Therefore, future studies should further validate the long-term effects of various training modalities.

This study adhered rigorously to the PRISMA framework to ensure methodological integrity. However, several limitations were identified. First, the quality of the original studies was constrained, with 68.75% (11/16) of the included studies exhibiting a high risk of bias. Key issues included the absence of control groups, unvalidated assessment tools, and a singular focus on outcome measures. Second, literature inclusion was biased. Due to the research team’s language proficiency limitations, only Chinese and English literature was considered, excluding gray literature and potentially omitting significant evidence from non–English-speaking regions. Third, the reliability of measurement instruments was questionable, as some studies failed to explicitly detail the tools used for knowledge assessment and their reliability and validity, precluding assumptions of high reliability for the outcome measures. Fourth, sample representativeness was limited; to ensure population homogeneity, studies with mixed health care workforces were excluded, which may diminish the applicability of findings to interprofessional teams. Fifth, there exists a risk of extrapolating findings, as existing evidence predominantly originates from Asian countries, and the empirical application of gamified teaching in disaster care remains nascent, thereby constraining the generalizability of results. Notably, while the stringent inclusion criteria for quasi-experimental and experimental studies enhance the level of evidence, they also reduce the analyzable sample size. Future research should broaden methodological inclusiveness to strengthen the relevant evidence.

By systematically integrating multidimensional evidence and proposing a classification framework for the first time, this study addresses a significant gap in the field, which has lacked a comprehensive evaluation of effectiveness, and provides clear guidance to educators regarding the selection of gamification tools (eg, virtual reality for simulating high-stakes scenarios and tabletop gaming for resource-constrained environments).

Overall, the systematic review indicates that gamified teaching holds substantial value for both nursing students and registered nurses, enhancing not only disaster care knowledge but also practical skills (eg, triage, evacuation decision-making, and infectious disease management). However, the successful implementation of gamified instruction hinges on the careful selection of target learners, learning content, and suitable gamified elements. Furthermore, future research should explore a hybrid teaching model and develop a unified system of assessment indicators (eg, standardized OSCE scales and long-term follow-up protocols) to mitigate interstudy heterogeneity, enhance result comparability, and facilitate the broader application of gamified teaching in disaster nursing education.