Serious games and gamified strategies are used to teach nursing, but the evidence from Latin America, written largely in Portuguese and Spanish, had not been synthesized. This narrative review described the serious games and gamified strategies used in undergraduate nursing education in Latin America between 2013 and 2025 and summarized what was reported about learning, perception and validation. 38 studies were included, conducted in Brazil (34), Peru (2), Chile (1) and Ecuador (1) were organized in four thematic axes. Development or validation studies and experience reports accounted for 12 studies each, and no randomized trial was identified. The 20 studies that stated the number of students had a median of 40 (range 11 to 114). Board or card games were the most frequent format (12 studies). Knowledge gains were reported by studies with pre-post tests or group comparisons, whereas most studies reported satisfaction, engagement or content validity indices, such as 88.5% for a mental health game. Small samples and the absence of controlled designs limited the strength of the evidence. The regional literature is mainly descriptive and concentrated in Brazil. Controlled designs, shared outcome measures and the use of reporting guidelines would allow comparison with international meta-analyses.
Los juegos serios y las estrategias gamificadas se emplean para enseñar enfermería, pero la evidencia de América Latina, escrita en buena parte en portugués y español, no se había sintetizado. Esta revisión narrativa describió los juegos serios y las estrategias gamificadas utilizados en la formación de pregrado en enfermería en América Latina entre 2013 y 2025 y resumió lo informado sobre aprendizaje, percepción y validación. Se incluyeron 38 estudios, realizados en Brasil (34), Perú (2), Chile (1) y Ecuador (1). Los estudios de desarrollo o validación y los relatos de experiencia sumaron 12 estudios cada uno, y no se identificó ningún ensayo aleatorizado. Los 20 estudios que indicaron el número de estudiantes tuvieron una mediana de 40 (rango de 11 a 114). Los juegos de mesa o de cartas fueron el formato más frecuente (12 estudios). Los estudios con pruebas previas y posteriores o con comparación de grupos informaron mejoras del conocimiento, mientras que la mayoría informó satisfacción, participación o índices de validez de contenido, como 88,5 % para un juego de salud mental. Las muestras pequeñas y la ausencia de diseños controlados limitaron la solidez de la evidencia. La literatura regional es principalmente descriptiva y se concentra en Brasil. Los diseños controlados, las medidas de desenlace compartidas y el uso de guías de reporte permitirían la comparación con los metaanálisis internacionales.
Serious games are games designed to teach rather than to entertain, and their effect in health professions education has been tested mainly in randomized trials. A systematic review of 27 randomized and 3 cluster randomized trials with 3634 participants could not pool results because populations, interventions and outcomes differed.(1) In nursing, a review of 70 studies with 8348 participants reported that game-thinking approaches, which include serious games and gamification, improved academic achievement (pooled effect size 0.99).(2) A meta-analysis of 19 experimental studies among undergraduates found standardized mean differences of 1.24 for knowledge and 0.50 for skills.(3)
The Latin American share of this evidence is harder to see. A scoping review of serious games produced for nursing teaching identified seven articles, six of them from Brazil,
The review followed the criteria of the SANRA scale for narrative reviews.
Studies were included when they were conducted in a Latin American country, involved undergraduate nursing students as participants or intended users, and described the development, validation, application or evaluation of a serious game or gamified strategy. Experience reports and qualitative studies were eligible. Reviews, games for patients or adolescents, continuing education of nurses and studies with participants outside Latin America were excluded; a Brazilian game evaluated with students in Portugal was left out for this reason. Eligibility was judged on titles and abstracts because full texts were not retrieved, and 38 studies formed the core of the synthesis. Reviews and studies from other regions served only as supporting literature.
The synthesis included 38 studies published between 2013 and 2025 and conducted in four Latin American countries. Brazil contributed 34 studies, Peru 2, and Chile and Ecuador 1 each. Publication was concentrated in recent years, with 7 studies in 2013 to 2018, 11 in 2019 to 2022 and 20 in 2023 to 2025. No study from Mexico, Colombia, Argentina or Cuba was retained (Table 1).
Development or validation studies and experience reports were the most frequent designs, with 12 studies each. Cross-sectional evaluations of student perceptions amounted to 7, qualitative studies to 5 and pre-post designs to 2. No randomized trial was found. Only 20 studies stated the number of students, with a median of 40 and a range of 11 to 114 (Table 1).
Table 1. Design, country and sample size of the 38 studies included in the synthesis.
Design | Studies (n) | Brazil | Other countries | Students: studies (range) |
|---|---|---|---|---|
Development or validation | 12 | 12 | 0 | 5 (15-114) |
Experience report | 12 | 12 | 0 | 4 (11-54) |
Cross-sectional evaluation | 7 | 5 | 2 | 5 (21-91) |
Qualitative study | 5 | 4 | 1 | 4 (12-97) |
Pre-post design | 2 | 1 | 1 | 2 (11-57) |
Total | 38 | 34 | 4 | 20 (11-114) |
Note: n = number of studies. Students = studies that stated the number of students, with the range of that number.
Board or card games were the most frequent format, with 12 studies, followed by digital games or applications with 7 and escape rooms with 4. One study used a role-playing game, and 14 abstracts did not state the format. Board and card formats were applied to concrete clinical content, and their use was mostly described in single courses (Table 2).
Table 2. Game formats reported in the 38 studies.
Format | Studies (n) | Examples of content |
|---|---|---|
Board or card game | 12 | Wounds, medication, nursing process, nursing theories, physical examination |
Digital game or application | 7 | Older adult health, immunization, violence against women, basic procedures |
Escape room | 4 | Leadership, pressure injury, stomatherapy, helping relationship |
Role-playing game | 1 | Professional practice |
Not stated | 14 | Course-level gamified strategies, validation of games |
Note: The format was coded from the abstract; studies whose abstract did not state it are listed as not stated.
The stage of the curriculum was stated in 8 abstracts and ranged from the second year to the tenth semester. Second-year students played the UNO-style game,(7) third-period students the role-playing game (8) and fourth-period students the medication game.(9) Fifth-semester students took part in the gamified theory course,(10) and students in the eighth to tenth semesters validated Health Unit in Focus.(11) The Transfusion Game was proposed for students at advanced stages,(12) and the Ecuadorian and Chilean activities involved students of the second cycle and the seventh semester.(13,14)
The 38 studies appeared in 26 different outlets, and no outlet published more than 3. Revista de Saúde Digital e Tecnologias Educacionais and Contribuciones a las Ciencias Sociales published 3 each, and JMIR Serious Games, Revista Brasileira de Enfermagem and Texto & Contexto - Enfermagem published 2 each. One study was a book chapter,
Public institutions were named in 8 abstracts and private institutions in 3. Public settings were universities in Brasília, Pará and Rio de Janeiro,
Memory games on ulcers and dressings were played by 40 and 54 students in two different courses.(25,26) A card game modeled on UNO, with 110 cards on terminal cleaning and bed making, was used by 22 second-year students working in pairs.
Other board games addressed the Leininger cultural care theory,
Seven studies reported digital games. Health Unit in Focus was an application with 75 clinical cases in pharmacology, metabolic syndrome and semiology.
Escape rooms were applied to four topics. A series of ten sessions on leadership involved 97 students,
Gamified strategies that were not single games formed a separate group. A heuristic evolution system in a scientific methodology course ran in six classes over three semesters,
Several topics followed the life course. Health Unit in Focus targeted the care of older adults,
Clinical content varied. Wound care and pressure injury appeared in three studies,
The distribution of designs changed over time. Of the 20 studies published in 2023 to 2025, 7 were experience reports, 6 development or validation studies and 3 cross-sectional evaluations. Both pre-post designs and all 4 escape rooms belonged to the same period. In 2013 to 2018, 3 of the 7 studies were development or validation reports, and 2 described digital games (Table 2).
Few studies measured learning against a reference. Group comparison was used once, pre-post tests three times, and a pre-test followed by the game once. In the Leininger game study, students who used only the game scored better than those who attended only the lecture, and students who received both obtained intermediate scores.(16)
In the pressure injury escape room, knowledge increased between the pre-test and the post-test (p = 0.001) and self-reported confidence rose (p = 0.015).
The Genially escape game in Ecuador was assessed with a pre-test, a post-test and a satisfaction survey among 57 students, and post-test correct answers ranged from 79% to 100%.
An online quiz on enteral catheterization set a satisfactory index at 70% per question. The index was reached in 7 of the clinical questions (58.3%), 8 of the technical ones (50%) and 3 of the legal ones (37.5%).
Course-level strategies were assessed through participation. The gamified scientific methodology course was associated with better attendance and punctuality and with a positive self-assessment by students, and its authors stated that stricter evaluations with a control group were still required.(18) Gamified dynamics in a theory course were described as favoring engagement and clinical reasoning, with signs of better performance in related assessments.
In Lima, among 91 students, gamification was applied at a medium level in 40% and at a low level in 30%. Social skills were high in 33%, medium in 37% and low in 30%.
Satisfaction was the outcome measured in the largest number of studies. With the EGameFlow scale, 44 students rated NeuroGame-Card with means of 6.43 for clarity of goals and 6.50 for knowledge improvement, and all of them (100%) considered that games help learning.
Qualitative studies described how students experienced the games. After ten escape room sessions, the 97 students reported positive perceptions of leadership learning in focus groups.
Profile variables were examined in one study. Of 44 players, 86.4% had affinity for games and 79.5% for team games, and these variables predicted EGameFlow domains.
The metacognitive events described by the 26 students who played the electrolyte disorders game were classified in phases of anticipation, performance control and reflective self-regulation.
The Pandora's Box game was reported to motivate reflection and new knowledge among 62 students.
Content validity was reported for several games. A mental health game obtained an overall content validity index of 88.5% from 11 experts and 114 students, and two items below 78% were reformulated.
Other validations used consensus or approval. A patient safety game was validated in two Delphi rounds with 10 and then 6 judges, and all items exceeded 0.80.
Design frameworks were named in several reports. Health Unit in Focus followed the Game-Based Intervention Reporting Guidelines,
Development stages were described in detail for three games. Semio em Jogo went through planning, prototyping and production and had three sequential phases on vital signs, biosafety and physical examination.
Expert panels differed in size across validations. Immunitates was assessed by 49 experts and 15 students, with Cronbach alpha of at least 0.86 in all evaluations.
The diagnostic reasoning game was described in three stages: construction of the board game, content analysis of clinical cases by 19 experts and application with 11 students.
Teacher-made games were validated informally in some courses. The UNO-style game was prepared by one teacher and reviewed by two others.
In four studies the games were built by the people who taught with them. Teaching monitors designed the puerperal care game
Implementation conditions were reported sparsely. Remote delivery during the pandemic was feasible with five online games,
The four studies from Spanish-speaking countries differed in design from the Brazilian corpus. Two were cross-sectional evaluations, one was qualitative and one was a pre-post design, and none was a development report or an experience report.
Among the five designs that tested learning, the four with a stated sample had 11, 11, 57 and 67 students.
Convergence was greatest for perceived usefulness. Favorable opinions of games or gamified activities were recorded in Brazil, Chile and Peru, among students of different courses and semesters.
Divergent or weak findings were few. Stress did not differ in the pressure injury escape room, the association between gamification and social skills was low in Lima, and the legal dimension of the enteral catheterization quiz had the lowest share of satisfactory questions.
The gaps were specific. No randomized trial was identified, no abstract reported costs or design time, and only one study asked for control groups.
The main finding is that the Latin American evidence on serious games in undergraduate nursing education consists of many small descriptive studies, concentrated in Brazil, and few that measured learning. Thirty-four of 38 studies came from one country, and 24 were development, validation or experience reports. The corpus documents activity and student acceptance, yet no effect can be estimated from it. This pattern differs from the international literature, where randomized designs predominate.
The positive direction of the regional studies agrees with international syntheses. A Brazilian systematic review of six experimental studies concluded that nursing students exposed to serious games obtained better learning results than those taught by lectures, reading or simulation.
Skills and confidence outcomes offer a second point of comparison. A meta-analysis of randomized trials reported a moderate effect on skills (Hedges g = 0.756) and on self-confidence (g = 0.698), although the confidence interval for self-confidence was wide.
Engagement findings were also concordant. Gamification was associated with higher academic motivation and confidence among undergraduate nursing students, with pooled differences of 0.86 for motivation and 1.11 for confidence in randomized trials.
Several results did not match the international pattern. A meta-analysis of randomized trials found a knowledge effect of 0.492 whose confidence interval included zero and a heterogeneity of 92%.
Knowledge retention illustrates the difference in depth. The review of 17 papers on game-based learning included retention among its themes, and the larger review of 70 studies pooled academic achievement across many designs.(2,49) In the regional corpus, outcomes were measured at the end of the activity, and a delayed test was not described in any abstract. A game that raises the post-test score may therefore not change what students retain when they reach clinical placements.
Three explanations account for the difference. First, international effects derive from randomized trials with control groups, whereas the regional corpus contains none. Second, the regional games were mostly built for a single course and tested once, so that content, facilitator and assessment were not separated. Third, outcomes were self-reported opinions in most studies, while objective knowledge tests were described in 6 of 38. The review of 70 studies shows that effects vary by outcome and by design, which supports this reading.
Validation should not be read as evidence of effect. Twelve studies validated content, appearance or usability, and the indices varied: 88.5% overall for the mental health game, 71.2% of items rated adequate for the nursing record game, and 51 of 60 challenges with satisfactory indices for PedCresce.
Online delivery was described in three studies, one of them designed for remote teaching during the COVID-19 period.
The geographic gap deserves a separate comment. A review of nursing serious games reports their geographical distribution,
The growth of the regional corpus follows the international trend. Twenty of the 38 studies were published in 2023 to 2025, and a bibliometric study of gamification in health education reported that 2018 marked a break in the number of publications and that the highest annual count, 101 publications, occurred in 2023.
Virtual simulation shows a similar regional profile. Only Brazil, Chile, Colombia and Cuba had published on virtual simulation in nursing education in the region.
Active learning provides the common frame of the regional reports. Several authors placed their games within active methodologies, as facilitators of teaching, of theory learning or of the construction of knowledge.
The topics covered also differ from earlier mapping. The Brazilian scoping review listed mental health, patient safety, neonatology, child health, drug administration and arterial gasometry.
Outcome measurement explains much of the difficulty in comparing studies. A scoping review of 28 studies grouped the evaluation indicators of nursing serious games into three knowledge, ten competence and five emotional indicators, applied before, during or after the intervention.
Favorable conclusions predominated among the abstracts with reported results, and null or unfavorable findings were limited to the stress outcome, the low correlation with social skills and the legal questions of the quiz. This profile is typical of descriptive reports written by the teams that created the games, and publication bias cannot be excluded. Registration of evaluation protocols before the first application would make null results visible. The same applies to the design of the comparison: a control group taught the same content by lecture, as in the Leininger study, is feasible in a single course.
Language and indexing are probable contributors to the geographic pattern. Only 4 of 38 studies came from Spanish-speaking countries, although Chile, Colombia and Cuba have published on virtual simulation.
The review has strengths that qualify these limitations. Searches ran in three languages and in five sources, experience reports and low-technology games were admitted, and every count in the text derives from a coding table that can be audited. The synthesis is also transparent about what the abstracts did not report. These features give a map of the regional production that reviews centered on randomized trials do not provide.
The conclusions are also limited by the sample sizes and by the absence of follow-up. Studies with 11 or 12 students cannot support inference.(20,30) Multicenter designs with pre-registered outcomes would solve this. A reporting framework would help as well. One study followed the Game-Based Intervention Reporting Guidelines,
The choice of format should follow the learning objective, and the regional reports suggest a provisional matching. Board and card games were used for content that students must recall and apply, such as dressings, medication, cranial nerves and nursing diagnoses.
For teaching practice, the evidence supports the use of low-cost games as a complement to classes on procedures and diagnostic reasoning, with attention to facilitator time and to the assessment of retention. For research, the priority is to move from validation of single games to comparative designs, with shared knowledge tests and satisfaction scales. Authors in Spanish-speaking countries could also publish in indexed journals the validations that now remain in institutional outlets. With this, the regional evidence would become comparable with the meta-analyses that now guide nursing educators.
Faculty who wish to adopt games can start from the validated materials already published, which include content validity indices above 0.80 in several reports.
Latin American undergraduate nursing education has used board and card games, digital games, escape rooms and gamified course strategies, mostly in Brazil and with clinical content centered on wound care, the nursing process and medication. Reported effects were knowledge gains in small pre-post or group-comparison studies, together with high satisfaction and content validity, but no randomized trial was identified and the evidence does not permit estimates of effect. Implementation was feasible with low-cost materials and remote delivery, and controlled multicenter designs, shared outcome measures and reporting guidelines are the gaps to close.
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Drafting – original draft: Sheila Ailin Cabrera, Nathaly Moreno Betancourt, Reyna Mendoza Ramírez.
Writing–review and editing: Sheila Ailin Cabrera, Nathaly Moreno Betancourt, Reyna Mendoza Ramírez.