Broadly speaking, studies have tended to test the outcomes of gamification using a combination of different game design elements simultaneously (e.g. Armstrong & Landers, 2017; Bai et al., 2020; Mazarakis & Bräuer, 2022; van Gaalen et al., 2021) often with mixed results (Mazarakis & Bräuer, 2022). Mazarakis et al (2022) speculate that a possible explanation for both positive, neutral and negative outcomes, might be due to the interaction of different design elements, either through a reinforcing or negating effect. Even where meta-analyses find generally positive to neutral outcomes with respect to engagement and motivation, the reasons why remain unclear due to the absence of (non-confounded) control groups (e.g. van Gaalen et al., 2021).

Several well-controlled studies, do however, provide some useful insight. In their review of health education literature, for example, Van Gaalen et al (2021) found a small number (8) of well controlled studies where the use of assessment and conflict/challenge attributes, especially competition and scoring, seemed to positively influence learning.

Bai and colleagues (2020) reviewed 24 articles related to gamified learning in students from K-12, and found an overall positive effect on academic performance. Most of the interventions examined used multiple game elements, the most common being badges + leader boards + point. The use of multiple elements simultaneously was not found alter the magnitude of effect one way or another, but interventions between 1-3 months had a stronger effect than interventions lasting more than 1 semester (Bai et al., 2020). Positive effects were attributed to goal setting, recognition needs, performance feedback, and enthusiasm. Student dislike for gamification, where it occurred, was attributed to lack of additional utility of the gamified content, and anxiety or jealousy related to leader boards (Bai et al., 2020).

Mazarakis et al. (2022) examined individually and in various combination, the effects of badges, feedback, progress bar and narrative on motivation to progress through a quiz. The authors found that the use of any element on its own significantly improved progress through the quiz compared to a control group, and the use of a progress bar produced a strong positive effect compared to other elements. The addition of feedback to the other elements only marginally improved the results (Mazarakis & Bräuer, 2022).

Considering narrative as a design element Armstrong and Landers (2017) found that the addition game fiction to the learning content, both improved satisfaction reactions to training, while maintaining similar levels of declarative learning to the control group. Nevertheless, procedural knowledge suffered compared to the control group with the reasons unclear. Several possible explanations were posited, including the possibility that game fiction may have distracted from the content (e.g. cognitive load); and that game fiction may only positively impact learning outcomes when interacting with other game elements not present in the study (Armstrong & Landers, 2017).

Landers et al (2019) found that competition, even as a sole game element in gamification, improved performance.

Other elements, such as points, leader boards, and badges have also been shown to have a significant effect on motivating behaviour, either singly or in combination (Bai et al., 2020; Mazarakis & Bräuer, 2022).

Nevertheless, some of those effects can be negative, especially with leader boards, but also with points, badges, and competition, which were noteworthy examples for eliciting negative reactions from participants across a range of reviewed studies (Almeida et al., 2021; Toda et al., 2018). Mazarakis and Bräuer (2022) state that points, badges and leader boards can harm in multiple ways motivation and performance, and Bai et al (2020) describe qualitative feedback from students regarding how leader boards provoked anxiety and feelings of jealousy in school students.

Competitive elements, while motivating for some, might also detract from learning. For instance, van Gaalen (2021) suggests that competition might hamper learning by turning projects into a race at the expense of internalisation of knowledge and skills. In a related finding, a review of gamification in health care patient education, cheating to obtain rewards was found in some of the participants (Al-Rayes et al., 2022).

Moreover, rewarding previously unrewarded activity can potentially lead to a shift from intrinsic to extrinsic motivation and even a loss of interest in the activity when rewards are no longer given (van Gaalen et al., 2021).

Diefenbach and Müssig (2019) reviewed the counterproductive effects of a gamified task manager application, finding that all of the 45 users experienced negative psychological reactions, principally in relation to the perceived inappropriateness of the rewards system. In detailing the implications for gamification design, the authors pointed to what they regard as the main problem, namely the limited number of game design elements used, and a scarce understanding of how those elements affect the user’s experiences. Attention to user experience and to the interplay of game mechanics, dynamics, with ongoing iteration and finetuning of the design is fundamental to the game design process (Walk et al., 2017), but appears to be lacking in much gamification design (Diefenbach & Müssig, 2019).

Considering the facilitators, barriers, and motivators of paramedic continuing professional development as describe by Hobbs et al (2021) it is clear that gamification has both promise and potential pitfalls. Some health care workers and paramedics express low confidence in their own abilities, or have had prior negative training experiences, resulting in fear of participating in class activities or of asking questions. For those people especially, the public display of capability using leader boards, badges and points, or the overt use of competition may be more harmful than helpful.

Instead, carefully guided and adaptive learning modules that engage interest in a non-threatening way via thoughtfully designed use of levels, achievements, and peer support may offer a better user experience and with more positive outcomes. For participants expressing fear over acquiring new skills that they are unsure of, and might ‘muck up’ in the field, a more hands-on approach that involves initial 'overlearning' followed by spaced repetition (Arthur Jr et al., 1998), then review using immersive VR training (Lohre et al., 2021) may overcome barriers and enhance capabilities, while at the same time addressing any decay over time in capability.

Video games in which learning content has been embedded into the architecture of the gamified experience – so called ‘intrinsic integration’ –  has been shown to significantly improve maths outcomes (Habgood & Ainsworth, 2011), and could be a promising approach for those paramedics who suffer from mathematics anxiety and an inability to undertake drug calculations. In cases were participants have an adverse reaction to the subject matter, embedding the learning into an enjoyable and engaging activity seems likely to improve associative response when engaging with the topic.

The upshot is that gamification shows considerable promise to aid teaching and learning but is likely to work best when tailored to address specific audience needs, and being mindful and considered about possible negative outcomes. As the model proposed by Landers et al. (2018) indicates (see Figure 1, Part 3, Theory), game elements and other educational interventions are mediated by contextual and personal factors some of which the education designer can control, and some of which cannot be controlled, but which nevertheless need to be carefully considered.

Recent literature describing video game analysis and design considerations is clear on the central role of the player/participant to the success of any game design. For once the player engages with the game:

“The player can sense, feel and think whatever she wants about the experience. She can like it or hate it, enjoy it or find it boring, get what she hoped for or did not expect, be challenged or taken to the emotional brink. The better the designers know the target audience, and the better the game targets that audience, the better it will be received. However, predicting whether a game will “prove immersive still involves a degree of chance. This is also why building a game by objective design criteria cannot ensure its commercial success—although it helps rather than hinders—and why knowing the emotional expectations of the audience is critical to any measure of success ” (Walk et al., 2017, pp. 48-49).