Gamification as a strategy in nursing clinical supervision for developing critical reflective thinking

Abstract

Objectives

This study aimed to analyse the benefits of a gamified clinical supervision strategy during hospital-based training, particularly regarding the development of critical and reflective thinking among undergraduate nursing students.

Methods

From April to July 2023, second-year nursing students who undertaking a nine-week clinical placement in a cardiology ward in northern Portugal were selected. Following a two-week diagnostic phase, students participated in a six-week gamified supervision programme comprising weekly 60-min sessions: infection-control decision-making; technical–procedural reasoning; guided emotional and ethical reflection; and clinical reasoning quiz on cardiology topics. Students completed weekly Structured Reflection Guide entries; supervisors recorded structured field notes after each session; and, after the intervention, students answered a post-intervention questionnaire and participated in focus groups. Qualitative data (reflections, field notes, open-ended questionnaire items, and focus-group transcripts) were analyzed using Bardin’s content analysis; quantitative questionnaire items were summarized descriptively.

Results

All seven students completed the six gamified sessions and submitted weekly reflection entries. Five students (71.4 %) completed the questionnaire. Across data sources, students reported that gamified activities supported knowledge consolidation, teamwork, and clinical reasoning. Questionnaire data showed that all respondents (n = 5, 100 %) strongly agreed that gamification enhanced their learning and should be maintained in clinical training. Reflections and focus groups revealed recurring themes related to emotional expression, sense of belonging, and difficulties using structured reflection tools, particularly in terms of comprehension and timing.

Conclusion

The gamified supervision strategy integrated into clinical training provided structured opportunities for practical engagement, collaborative work, and guided reflection. These findings suggest that gamification may support the development of reflective and critical-thinking processes in authentic clinical environments.

What is known?

• •Clinical supervision is essential in nursing education and plays a central role in learning during hospital placements.
• •Developing critical and reflective thinking is necessary to ensure safe, high-quality, and autonomous nursing care.
• •Traditional supervision strategies often struggle to engage students in actively structured reflective practice.

What is new?

• •This study implemented a gamified supervision strategy during real hospital placements with second-year nursing students.
• •The gamified activities supported students’ reflective and analytical processes, fostering engagement and collaborative learning.
• •This study offers context-specific evidence on the feasibility and educational value of gamification in clinical supervision within Portuguese nursing education.

1. Introduction

In the international landscape of nursing education, clinical training is recognised as a decisive and transformative phase, during which students transition from the safety of theoretical instruction to the complexity of real-world practice. This shift allows them to consolidate technical skills, develop clinical reasoning, navigate ethical dilemmas, and gradually shape their professional identity [1]. However, this transition is often accompanied by emotional distress, uncertainty, and performance anxiety. Students are expected to adapt to institutional routines, integrate into multidisciplinary teams, and provide care under supervision—while simultaneously managing their learning process [2,3].

To cope with such demands, nursing curricula across the globe have increasingly prioritised the development of critical and reflective thinking. These competencies support students in formulating clinical judgments, questioning established routines, and making ethically sound decisions in dynamic settings [[4], [5], [6]]. The capacity to think critically and reflectively is now widely accepted as a fundamental for ensuring patient safety, enhancing care quality, and fostering professional autonomy. Yet, it is not an automatic outcome of clinical exposure—it must be deliberately cultivated through intentional pedagogical strategies [7].

Conventional approaches to developing critical thinking during clinical internships include supervised practice, written reflections, preceptor feedback, simulation exercises, and case-based discussions [4,6,[8], [9], [10]]. Although widely used, these strategies often remain fragmented, insufficiently engaging, or overly reliant on individual motivation. They may also fail to provide students with emotionally safe and pedagogically rich environments where critical reflection can be practised collectively, and feedback is continuous [9].

In response to these challenges, gamification has emerged as an innovative pedagogical approach in nursing education. Gamification involves applying game design elements—such as rules, goals, challenges, feedback, and rewards—in non-game contexts to enhance engagement and motivation [[11], [12], [13]]. In nursing, gamified strategies have been applied primarily in classroom and simulation-based environments, showing promising results for knowledge consolidation, skills development, and teamwork [[17], [18], [19]]. However, systematic reviews consistently report limited evidence regarding higher-order competencies such as critical reflection or professional identity formation, particularly in real clinical placements [[14], [15], [16]]. While gamification generally improves engagement and short-term performance, few studies have examined its effectiveness in developing critical thinking or clinical reasoning during authentic bedside care experiences [16,18].

Despite these promising findings in controlled settings, significant gaps remain in the literature. A scoping review further emphasised that current learning strategies are insufficiently supporting the development of critical thinking among undergraduate nursing students in practice settings, calling for pedagogical innovations that promote active, reflective, and collaborative learning during clinical placements [20]. This evidences a clear knowledge gap, particularly regarding structured, gamified interventions designed to foster critical and reflective thinking in real hospital environments.

Against this international backdrop, Portugal’s nursing education has increasingly aligned with student-centred and competency-based models. Nonetheless, the integration of gamification into clinical supervision in authentic hospital settings remains largely unexplored, particularly in national pedagogical practice and research. Most existing interventions focus on laboratory-based training, with limited emphasis on cognitive-emotional development during bedside care.

In this context, the present study offers an innovative contribution by implementing a gamified supervision strategy during a hospital-based clinical internship, targeting second-year nursing students. The intervention combined playful tasks, team-based activities, and structured reflective tools to stimulate critical engagement with genuine care situations, promote emotional openness, and foster horizontal relationships within the clinical team. The research question guiding this study was: What are the benefits of using a structured gamified supervision strategy in developing critical-reflective thinking among second-year nursing students during hospital-based clinical placements? Thus, this study aimed to analyse the benefits of using gamification as a strategy in clinical supervision to enhance the development of critical and reflective thinking in nursing students.

2. Methods

2.1. Study design

This qualitative, exploratory, descriptive case study examined how a gamified supervision strategy operates in authentic clinical learning and how it influences critical and reflective thinking among nursing students during hospital placements. A case study design was chosen to enable in-depth analysis of pedagogical processes and interactions in their natural context, capturing the interplay between students, supervisors, and gamified activities across time (i.e., longitudinal observation within a bounded ward setting). This study was designed and reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) , which provide a 32-item checklist to ensure transparency and rigour in qualitative health research [21]. The case study methodology was guided by Yin’s framework for educational case study research, which emphasises the importance of studying contemporary phenomena within real-life contexts where boundaries between phenomenon and context are not clearly evident [22].

2.2. Study setting and participants

The study was conducted over nine weeks during the hospital-based clinical training of second-year undergraduate nursing students at a public higher education institution in northern Portugal, on a cardiology ward providing general nursing care to adults and older adults with cardiovascular conditions. All students allocated to this ward for the entire intervention window were invited to participate; seven students met the eligibility criteria (second-year enrolment, continuous placement on the ward during weeks 1–9, and informed consent). The cohort (six females, one male; aged 19–20 years; two working students) is representative of the eligible population in that ward, rather than a subsample of the entire grade. The intervention was implemented exclusively among those assigned to this ward; consequently, all data sources reflect the complete cohort exposed to the full intervention in this bounded clinical context. The intervention did not extend to all second-year students across multiple wards; it was implemented exclusively among those assigned to the study ward. In this instance, n = 7 indicates the total number of eligible participants, aligning with the principle of purposive total-population sampling in bounded case studies [22,23].

To enhance the credibility and trustworthiness of the study despite the small sample size typical of bounded case studies [24], multiple data sources were collected longitudinally (weekly structured reflections, supervisors’ field notes, a brief post-intervention questionnaire yielding descriptive quantitative indicators, and end-of-placement focus groups). This methodological triangulation approach—defined as the use of multiple methods, data sources, or perspectives to corroborate findings—was employed to ensure the robustness and depth of understanding [25,26]. This approach compensates for the inherent limitations of a small sample size by leveraging the richness and diversity of evidence [27].

The clinical supervision of the placement was overseen by two registered nurses (aged 30–35 years), with postgraduate qualifications in Rehabilitation Nursing and Management, respectively. Beyond bedside supervision, the supervisors actively facilitated the gamified sessions and documented structured field notes after each session, contributing to the triangulation of data sources described above.

2.3. Interventions

To ensure transparency and reproducibility, the intervention was divided into three components. 1) pedagogical team preparation and roles; 2) theoretical foundation; and 3) structured implementation in clinical practice (session frequency, duration, instructional sequence, and curricular content).

2.3.1. Formation of the pedagogical team

The intervention was implemented by two clinical supervisors, supported by two faculty members with experience in pedagogical innovation and reflective learning. During the initial two-week diagnostic phase (weeks 1–2), each of the seven students was asked to complete weekly structured reflection entries using the Structured Reflection Guide [28]. Supervisors also conducted systematic bedside observations of student performance and interactions. In the preparatory meetings held at the end of week 2, the pedagogical team conducted a comprehensive analysis of the preliminary reflective entries (two entries per student, totaling 14 entries) and supervisors’ bedside observation notes. This analysis led to the identification of three recurrent issues: 1) reflective narratives remained primarily descriptive, with limited ethical analysis; 2) reluctance to express emotions during debriefings compromised psychological safety; and 3) there were fragmented theory–practice links in clinical reasoning at the bedside.

In response to the findings above, the team co-constructed a gamified instructional strategy with shared facilitation roles (supervisors lead bedside activities and debriefing sessions; faculty ensure alignment with theory and data collection procedures) and undertook brief training on gamification mechanics and formative feedback to standardise facilitation and feedback routines.

2.3.2. Theoretical foundation of the pedagogical approach

The approach integrates Kolb’s experiential learning cycle (concrete experience → reflective observation → abstract conceptualization → active experimentation) to structure each session and debriefing [29]. Gamified pedagogy is the use of game-design elements in non-game contexts (rules, goals, feedback, challenges, symbolic rewards, and collaboration) to enhance engagement [[11], [12], [13], [14], [15], [16]].

The approach also incorporates structured reflective practice, operationalised via a Guide for Structured Reflection [28], which was specifically adapted to promote ethical reasoning, theory–practice integration, and emotional insight among nursing students during clinical placements. The guide comprises four interrelated components that scaffold progressive reflective depth. 1) Description of the situation: students identify and describe a clinically significant event or care situation encountered during the week, focusing on contextual details, patient characteristics, and the care decisions involved. 2) Reflection on the situation: students examine their emotional responses, uncertainties, and internal conflicts experienced during the situation. This component encourages articulation of feelings, identification of ethical tensions, and recognition of personal values influencing clinical judgment. 3) Theory–practice integration: students explicitly connect their actions and observations to relevant theoretical concepts, evidence-based guidelines, or professional standards. This step promotes analytical thinking by requiring justification of care decisions through conceptual frameworks learned in academic coursework. 4) Synthesis and evaluation: students evaluate their performance critically, identify learning gains, articulate alternative approaches they might consider in similar future situations, and formulate specific intentions for professional development.

Throughout the six-week intervention, this structured guide was systematically employed during debriefing sessions following each gamified activity. Supervisors used the guide’s framework to prompt deeper analysis, facilitate group discussion, and provide formative feedback. Students completed individual written reflections using the same structure, creating a longitudinal record of their evolving clinical reasoning and professional identity formation.

The design is aligned with the School’s Clinical Training Guide, ensuring that outcomes are based on competencies and that professional identity is developed progressively.

2.3.3. Implementation in clinical practice

2.3.3.1. Scope and alignment

The curriculum was meticulously structured to align with the learning outcomes and competencies of the cardiology ward, thereby eliminating the need for students to source educational materials independently. The following weekly activities have been mapped to the core competencies required on the ward: infection control and waste management, equipment setup and safety for non-invasive ventilation, medication safety, clinical reasoning in prevalent conditions, and interprofessional communication.

2.3.3.2. Timing and format

Following a two-week diagnostic phase, the programme (The Reflective Path) was implemented for a period of six consecutive weeks (weeks 3–8), with one 60 min session per week scheduled at the conclusion of the Thursday shift to minimise care disruption. The students were organised into two stable teams for the purpose of fostering a sense of belonging and peer support [30]. Each session was structured according to a four-step instructional sequence as follows: 1) briefing (5–10 min: aims, rules, roles, safety, intended learning outcomes); 2) gamified activity (25–30 min: team-based challenge aligned to ward competencies); 3) debriefing (15–20 min: guided by the Structured Reflection Guide [28], explicitly connecting the task to that week’s real cases – ethical issues, teamwork, theory–practice links); 4) documentation (5 min: weekly reflective entry; structured field notes; recording of symbolic badges on a visible game board as formative, non-summative feedback).

2.3.3.3. Content by session

(Table 1). In week 3, the Waste Sorting activity was used to practice infection-control routines in a realistic, time-bound scenario. All of students were organised into two stable teams (one team of four students and one team of three students) and presented with a sequence of mixed clinical disposables, including gloves, dressings, sharps containers, medication vials, and general waste. A visible countdown was initiated to introduce a mild time constraint. These teams engaged in collaborative deliberations and subsequently executed the sorting process, providing verbal justifications for their decisions and rectifying each other’s errors when necessary. The supervisory team was responsible for the monitoring of accuracy and rationale, and brief time penalties were applied for any misclassifications identified. The combination of shared decision-making and immediate feedback was intended to consolidate protocol knowledge while cultivating situational awareness and teamwork under constraints typical of the ward.

Table 1.

Details of gamification strategies developed during clinical training.

Game	Purpose	Gamification strategy
Waste sorting	Reinforce infection-control routines, promote teamwork, and support rapid decision-making in realistic ward scenarios.	Students worked in two stable teams to sort mixed clinical waste under a visible countdown. Teams verbally justified decisions, corrected errors collaboratively, and incurred brief time penalties for misclassifications. The team with the shortest adjusted completion time won.
Non-invasive ventilation (NIV) assembly	Develop procedural competence in NIV assembly; strengthen communication; identify knowledge gaps; consolidate safety routines.	Teams assembled an NIV circuit based on a clinical vignette. Supervisors intermittently paused the task to probe reasoning, prompt peer teaching, and clarify escalation criteria. The winning team was the one that completed assembly and safety checks fastest and most accurately.
Pass the “Paracetamol”	Facilitate emotional expression; promote ethical reflection; strengthen feedback literacy; foster psychological safety.	Students used a symbolic “paracetamol bottle” to share significant clinical events in turn, discussing emotions, ethical tensions, and decisions involved. The chosen peer offered one positive point and one aspect for improvement, modelling balanced feedback in a safe environment.
How many do you want?	Strengthen clinical reasoning in cardiology; support prioritisation and anticipation of complications; promote collaborative learning.	Teams selected numbers linked to clinical scenarios (e.g., acute heart failure, acute coronary syndrome, atrial fibrillation, hypertensive crisis). Members alternated responses involving assessments, interventions, and risk anticipation. Opposing teams posed follow-up questions. The team with the most correct answers won.

In week 4, the Non-Invasive Ventilator (NIV) Assembly exercise centred on technical safety and communication. Each team was provided with an identical set of non-invasive ventilation components (mask interfaces, tubing, humidifier chamber, filters) and a brief clinical vignette that required the preparation of the device for a patient with respiratory compromise. The task was structured as a competitive event, with teams tasked with assembling, verifying, and verbalising safety procedures (e.g., leak checks, humidification, filter placement) before signalling readiness. Supervisors intermittently paused the activity to probe reasoning, prompt peer teaching when gaps emerged, and clarify escalation criteria. Furthermore, the supervisory team highlighted the escalation criteria that would be applied in cases where the issues at hand were deemed to be more severe. The objective of the session was to enhance procedural reliability and shared mental models by alternating rapid assembly with reflective questioning.

The fifth and sixth weeks of the programme were dedicated to Pass the “Paracetamol”, a structured dialogue designed to enhance ethical sensitivity and feedback literacy. The use of a symbolic “paracetamol bottle” to facilitate turn-taking in recounting significant events from the week’s exercises, with particular emphasis on emotions, ethical dilemmas, and the decisions made, was a notable aspect of the study. The bottle was then passed to a peer, who articulated one positive aspect of the narrative and one element that could be improved, modelling balanced, compassionate feedback. The role of the supervisor was to ensure psychological safety, to provide links to relevant theory and professional standards, and to support students in transforming emotion-laden experiences into learning goals. For example, students discussed situations such as witnessing a patient’s sudden clinical deterioration and feeling unprepared to respond; experiencing moral distress when family members disagreed with the care plan; struggling with the emotional impact of caring for a terminally ill patient; managing feelings of inadequacy when unable to alleviate a patient’s pain; and navigating conflicts between following protocol and responding to individual patient needs. Through guided peer feedback and supervisor facilitation, students progressively articulated their emotional responses, identified underlying ethical tensions (such as autonomy vs. beneficence, or professional boundaries vs. empathetic engagement), and formulated concrete strategies for future practice.

The cycle was concluded in weeks 7 and 8 with the administration of “how many do you want”, an alternating quiz designed to integrate theoretical knowledge with clinical reasoning. The selection of numbers by the teams revealed prompts on prevalent cardiology conditions and required students to articulate nursing assessments and interventions, justify prioritisation, and anticipate complications. The utilisation of brief follow-up inquiries by the opposing team served to sustain the cognitive challenge and promote the elucidation of concepts. For example, prompts included clinical scenarios such as: a patient admitted with acute heart failure presenting with dyspnoea and peripheral oedema—students were required to identify priority nursing assessments (vital signs, fluid balance monitoring, oxygen saturation), justify immediate interventions (positioning, oxygen therapy, diuretic administration), and anticipate potential complications (pulmonary oedema, electrolyte imbalances). Other scenarios addressed acute coronary syndrome, requiring students to differentiate chest pain characteristics, explain the rationale for ECG monitoring and troponin measurement, and outline the Morphine, Oxygen, Nitrates, Aspirin (MONA) protocol with appropriate safety considerations. Additional topics included atrial fibrillation management (recognizing irregular rhythm, anticoagulation rationale, and stroke prevention), hypertensive crisis (blood pressure parameters, medication selection, and organ damage assessment), and post-cardiac catheterization care (vascular access site monitoring, bleeding risk, and patient mobility restrictions). Through these structured exchanges, the supervisors emphasised three core aspects: diagnostic reasoning, risk recognition, and the translation of evidence-based guidelines into bedside actions.

2.3.3.4. Reflection artefacts and final assignment

Throughout the programme, each student documented one meaningful clinical situation per week using the Structured Reflection Guide [28]. These entries were composed immediately following the session to capture fresh insights, and were revisited during debriefings to establish connections between emotions, ethical reasoning, and theory–practice integration. Supervisors maintained structured field notes to record behaviours related to initiative, clarity of reasoning, collaboration, and the perceived safety of discussions. This process created an audit trail of the learning process. In Week 9, students submitted a final written reflection that synthesised progress across the placement, identified shifts in their professional identity, and specified concrete intentions for future practice. The game board, on which the participants accumulated symbolic badges, served as a continuous visual cue of engagement and teamwork. The board functioned strictly as formative feedback, with no summative grading attached.

A flowchart outlines a six-step process for local instructional design that supports the intervention. These steps include initial reflection, a training “guide for structured reflection”, gamification, a final reflection, a semi-structured survey, and a final reflection using the guide. This approach involves a sequence of briefing, game challenges, debriefing, and documentation, followed by weekly reflections and a final synthesis. This structure is not a universal requirement of gamified pedagogy; rather, it is our operationalization of recognised gamification elements, i.e., goals, rules, feedback, challenge, and collaboration, embedded within an experiential learning and reflective practice framework [28,29]. The diagram has been developed to render the pedagogical logic transparent and reproducible, and to demonstrate how each component is intended to facilitate engagement and increasingly sophisticated reflection.

2.4. Instruments

To evaluate learning processes and outcomes, with a particular focus on the development of critical and reflective thinking, a multimethod battery of tools was employed. This comprised structured written reflections, a post-intervention questionnaire, supervisors’ field notes, and end-of-placement focus groups. The instruments were selected to capture convergent evidence from self-reports and observed behaviours, thereby enabling triangulation between formative (process-oriented) and summative (outcome-oriented) indicators.

2.4.1. Structured Reflection Guide (SRG)

The primary instrument used for monitoring the depth of reflection was a Structured Reflection Guide, adapted from Santos and Fernandes [28]. It was expected that students would complete one SRG entry every week and produce a comprehensive final entry at the conclusion of the placement. The guide prompted students to identify a significant clinical situation, articulate the ethical tensions and clinical decisions involved, connect actions to relevant concepts and guidelines, and examine emotions and their influence on reasoning and behaviour. Furthermore, it was observed that the programme encouraged students to articulate the knowledge they had acquired and the manner in which they intended to apply it to future endeavours. The SRG was utilised as a framework for debriefing, wherein supervisors methodically revisited entries to assess the quality of ethical reasoning, the explicitness of theory–practice links, and the presence of transformative reflection. Over several weeks, the SRG facilitated the transition from predominantly descriptive accounts to more analytical and critical appraisals of practice.

2.4.2. Post-intervention semi-structured questionnaire

Following the conclusion of the six gamified sessions (week 9), the students completed an online questionnaire (Google Forms®) designed to generate both descriptive quantitative and qualitative data. The instrument consisted of three multiple-choice items that asked students to rate their perceived changes in knowledge consolidation, critical thinking, and teamwork, alongside three open-ended prompts that explored emotional engagement, self-efficacy in addressing clinical challenges, and the perceived benefits and drawbacks of the gamified pedagogy. Quantitative responses were provided in the form of simple frequency distributions, which complemented the qualitative corpus. Open-ended narratives were imported for thematic analysis, alongside reflections and focus group transcripts [31].

2.4.3. Supervisors’ field notes

Throughout the programme, clinical supervisors were required to maintain structured field notes immediately following each session. The documentation of observable indicators included the following: students’ initiative during discussions, clarity and justification of clinical reasoning, reciprocity and peer support within teams, adherence to safety routines during activities, and the perceived emotional safety of debriefings. The purpose of the present set of notes is to act as an audit trail of implementation fidelity. In addition to this, they also provide independent observations which are intended to corroborate or challenge the self-reports made by the students in the SRG and questionnaire.

2.4.4. Focus groups

In week 9, focus groups were conducted with students, and a separate session was held with supervisors to obtain in-depth evaluations of the intervention. The discussion guide invited participants to reflect on perceived growth in critical thinking, the usefulness and constraints of the SRG, the specific ways in which the gamified activities supported clinical reasoning and teamwork, and the overall acceptability of the approach in a hospital context. The sessions were audio-recorded, transcribed verbatim, and anonymised before analysis. The findings yielded substantial insights into the mechanisms of change, as evidenced by the observation that providing feedback during the “Pass the Paracetamol” task led to the normalization of emotional expression and ethical deliberation. These data contributed to the interpretation of the questionnaire and reflection findings.

2.4.5. Integration and data management

The implementation of instruments followed a predetermined schedule, with weekly SRG entries conducted during weeks 1–8 and the questionnaire and focus groups administered in week 9. All materials were pseudonymised at the point of origin, with separate storage of identity keys accessible only to the research team. During the analysis, a triangulation approach was employed, utilising a combination of instruments. The SRG entries evidenced individual trajectories of reflective depth. Field notes captured behavioural correlates during sessions. The questionnaire provided descriptive indicators of perceived change. Ultimately, the focus groups provided insight into how and why change occurred. This integration served to enhance the credibility and dependability of the findings, whilst aligning the measurement points with the instructional sequence delineated in Section 2.3.3.

2.5. Data collection

The data were collected over a period of nine weeks (April–July 2023). Reflective narratives were to be completed every week throughout the placement, with a comprehensive final reflection submitted in the final week. Supervisors were responsible for recording structured field notes immediately following each session. The notes documented observable indicators of engagement, reasoning, collaboration, and emotional safety. The post-intervention questionnaire was administered in week 9, and focus groups were audio-recorded and transcribed verbatim. Participation was voluntary for all subjects.

2.6. Data analysis

Thematic content analysis was conducted using Bardin’s method [31], which involves four stages: pre-analysis, coding, categorization, and interpretation. NVivo® was used to manage and code qualitative data, and descriptive statistics from the questionnaire were calculated in SPSS® v29 (frequencies, percentages, and means). Findings were integrated across data sources (reflections, field notes, questionnaires, and focus groups) to enable methodological triangulation and strengthen the credibility of the interpretations.

2.7. Ethical considerations

All participants received verbal and written explanations about the study and its goals. Written informed consent was obtained. The Ethics Committee approved the study for Research in Life and Health Sciences (ECRLHS) under protocol number 133/2022 (May 13, 2022). The study was part of the broader project Clinical Nursing Supervision: Collaborative Experiences (ECO), which promoted partnerships between the University of Minho's School of Nursing and regional healthcare institutions to foster innovation in clinical education.

3. Results

3.1. Implementation fidelity and participation

All seven students assigned to the ward completed the six weekly sessions and submitted the requisite reflective entries. Attendance was 100 % across all sessions, with activities conducted as scheduled (Section 2.3.3), at an average duration of 60 min, and with two stable teams throughout. Supervisors were tasked with producing structured field notes following each session, and five of the seven students (71.4 %) completed the post-intervention questionnaire in week 9. Focus groups were organised in the same week. No adverse events or protocol deviations were recorded.

3.2. Students’ experiences and reflections

To capture the evolution of the students’ perceptions and reflective capabilities throughout the clinical training, initial and final reflections were analyzed and compared. Appendix A illustrates emergent categories, such as emotional growth, autonomy, confidence, and the student-supervisor relationship, along with their associated units of analysis.

Students described the clinical placement as a challenging and transformative experience. In terms of evolution and personal growth, early reflections referred to a demanding environment that required emotional resilience (e.g., “Challenging and rigorous internship” E1; “It required a much greater emotional support” E3). Final reflections revealed a heightened sense of maturity and development, as evidenced by statements such as “I feel I have grown both professionally and individually” (E5). Under the theme of autonomy and organisation of care, initial responses highlighted insecurity and limited familiarity with routines (“Less autonomy” E5; “It took me a while to get used to the unit” E4). These evolved into expressions of competence and confidence (“This internship taught me to be more autonomous, confident, and a better team player” E5). Concerning confidence in the clinical context, initial responses frequently mentioned anxiety and apprehension due to the unfamiliar clinical environment and severity of patient conditions. Final reflections documented increased self-assurance and emotional regulation, with students noting, “I became more confident and self-assured” (E3), and “I managed to deal better with my emotions and not be as affected by the situation” (E2).

Regarding confidence in the supervisors, students consistently expressed strong appreciation for the guidance received. Both initial and final reflections emphasised the accessibility, professionalism, and unconditional support of the supervisors. Notably, E3 stated, “And here, there is also the unconditional support from our supervisors. Nothing would have been the same without them.”

3.3. Students’ evaluation of gamification strategy

Out of the seven students involved in the clinical placement, five completed the semi-structured questionnaire (response rate: 71.4 %). All respondents (n = 5, 100 %) strongly agreed that gamification enhanced their learning and advocated for its continued use in clinical training. No students selected neutral or negative responses.

3.4. Perceived benefits of gamification

Students highlighted gamification as a facilitator for active learning, engagement, emotional expression, and group cohesion. Their responses, coded through content analysis, are presented in Appendix B. In terms of learning, students reported that the interactive and relaxed nature of games facilitated understanding and retention. They noted that games made learning more enjoyable and practical, enhancing both knowledge acquisition and technical skills (e.g., “It helped me assimilate the knowledge more easily” E2). Regarding sense of belonging, students acknowledged that gamification promoted group cohesion, improved communication, and strengthened interpersonal relationships. Statements emphasised the contribution of these activities to creating a supportive peer environment (e.g., “It helped bring our group closer together” E1). Concerning the category of facilitated learning context, participants recognised that gamified sessions created an emotionally safe space that fostered openness and mutual support. Students valued these moments of shared reflection and motivation, which helped them overcome common challenges (e.g., “These are moments that … help students overcome their main difficulties” E3).

3.5. Difficulties using the structured reflection guide

Despite attending a training session, some students experienced difficulties in applying the “guide for structured reflection” [28]. The main barriers identified were difficulties in understanding the guide and its applicability (n = 3, 60 %) and limited use restricted to the evaluation period (n = 2, 40 %). The fact that no students identified insufficient training or lack of supervisor support as barriers suggests that.

3.6. Students’ suggestions for improvement

To further enhance the application of the reflective guide, students proposed practical enhancements based on their experiences. As shown in Appendix C, suggestions were categorised into four themes: time, supervisor support, context, and relevance.

Students suggested allocating more time to develop the final reflections, noting that the simultaneous occurrence with evaluation activities compromised the depth of engagement. Recommendations for supervisor support included earlier involvement and opportunities to discuss drafts before submission. Regarding context, students emphasised the importance of distinguishing between reflective writing tasks and formal evaluations to alleviate stress and enhance relevance. Under relevance, some students indicated that the guide's format did not always align with personal meaning-making and advocated for more flexibility in choosing reflection topics.

3.7. Application of the structured reflection guide

At the end of the clinical placement, students were asked to develop a final structured reflection based on the Guide. Appendix D presents the categories and analysis units derived from their narratives. While all five students completed a reflection exercise, the depth and completeness of their responses varied. In the description of the situation, 60 % of students (n = 3) clearly described a significant event, whereas the others offered a general evaluation of their experience. Descriptions were often emotionally charged and linked to complex clinical experiences, such as patient death or acute deterioration. In the reflection stage, responses revealed varying degrees of emotional engagement and self-awareness. Students discussed their emotional reactions, internal conflicts, and the challenges of balancing professionalism with empathy. For example, students admitted difficulties in managing their emotions and maintaining professional boundaries during intense clinical experiences. In the final component, synthesis and evaluation, all students expressed some form of personal or professional growth. They reported acquiring new perspectives and emotional resilience. However, none fully addressed the more complex indicators, such as the confrontation of multiple viewpoints or systematic evaluation of their initial reactions.

4. Discussion

Our study supports the growing international evidence that gamification, when intentionally embedded within clinical supervision, serves as a transformative pedagogical strategy in nursing education [[14], [15], [16]]. Beyond promoting technical competence, gamified approaches foster emotional resilience, professional identity, group cohesion, and self-reflective capacity—core dimensions of holistic nursing practice.

The evolution observed in students’ reflections throughout the nine-week placement provides empirical evidence of this transformation. Students’ narratives shifted from initial expressions of anxiety, insecurity, and limited autonomy—captured in statements such as “Challenging and rigorous internship” (E1) and “Less autonomy” (E5)—to final reflections emphasising confidence, emotional regulation, and professional maturity: “I became more confident and self-assured” (E3) and “This internship taught me to be more autonomous, confident, and a better team player” (E5). This progression illustrates how the integration of gamification into clinical supervision contributes not only to the acquisition of technical skills but also to emotional and interpersonal growth, addressing the affective dimensions often neglected in traditional clinical education models.

Quantitative indicators corroborated these qualitative findings. The unanimous agreement among all questionnaire respondents (n = 5, 100 %) that gamification enhanced their learning and should be maintained in clinical training reflects the high acceptability and perceived value of the intervention. While the response rate (71.4 %) was modest, the consistency of positive perceptions across multiple data sources—weekly reflections, focus groups, and questionnaires—strengthens the credibility of these findings through methodological triangulation.

Unanimously, participants perceived both technical games (e.g., the Waste Sorting Game, NIV Assembly Game) and reflective games (e.g., Pass the Paracetamol) as meaningful tools that enhanced engagement and deepened learning. Students specifically identified gamification as facilitating knowledge consolidation (“It helped me assimilate the knowledge more easily” E2), fostering group cohesion (“It helped bring our group closer together” E1), and creating emotionally safe spaces for reflection (“These are moments that … help students overcome their main difficulties” E3). These themes demonstrate that gamification contributed not only to cognitive engagement but also to emotional and social integration within the clinical learning environment—outcomes that extend beyond traditional measures of academic performance. These findings align with results from studies across Europe, North America, and Asia, which confirm that game-based learning enhances motivation, critical thinking, and knowledge retention [[14], [15], [16],18]. Moreover, our study revealed marked affective and interpersonal gains—such as reduced anxiety, increased confidence, and stronger peer support—findings that resonate particularly with research from Canada and Scandinavia, where psychological safety and empathy are valued components of clinical education [19,30,32,33].

What sets this study apart is the deliberate and participatory design of the pedagogical intervention. The diagnostic phase, conducted during weeks 1–2, involved analyzing 14 preliminary reflection entries (2 per student) and systematic bedside observations, enabling the pedagogical team to identify three recurrent issues: predominantly descriptive reflections lacking ethical analysis, reluctance to express emotions during debriefings, and fragmented theory–practice links. This evidence-based approach to intervention design—responding directly to identified student needs rather than implementing generic gamification strategies—represents a contextualised, bottom-up model that contrasts with standardized approaches often described in the literature. The bottom-up, contextualised development of both the games and the structured reflection guide ensured alignment with students’ actual needs and the clinical realities they encountered. This contrasts with more standardized, top-down gamification models described in the literature, which often struggle to adapt to learners’ contexts or fail to achieve an affective impact [15,16]. Our co-constructed approach aligns with literature on supportive clinical learning environments and psychological safety [26,27], emphasising collaboration, contextual responsiveness, and learner agency.

Our study reinforces the notion that gamified learning reaches its full potential when explicitly designed to integrate affective and interpersonal learning objectives—an approach increasingly valued in social sciences and human-centred professions. Moreover, lessons from healthcare—such as the importance of longitudinal, supervisor-supported reflection—may be transferable to technical fields, potentially enriching their pedagogical models.

Despite the overall positive reception of the gamified intervention, the study uncovered significant challenges in applying the Structured Reflection Guide (SRG). Three out of five respondents (60 %) reported difficulties understanding the guide and its applicability, while two (40 %) indicated its use was restricted to the evaluation period. Notably, no students identified insufficient training or lack of supervisor support as barriers, suggesting that the limitations stemmed from the complexity of the guide and the timing of its application rather than from the quality of facilitation. Students’ suggestions for improvement reinforced this interpretation: they requested more time for reflection development, earlier supervisor involvement with opportunities to discuss drafts, separation of reflective tasks from formal evaluation contexts, and greater flexibility in choosing reflection topics to align with personal meaning-making processes. These findings point to the need for continuous and integrated support in reflective writing throughout the clinical training period, rather than a single-session intervention. Enhanced scaffolding, iterative feedback, and opportunities for guided practice may help students internalise the reflective process more effectively. Students reported difficulties with comprehension, timing, and relevance—echoing critiques that reflection must be scaffolded over time, with supervisor facilitation and peer support, to become transformative rather than perfunctory [[34], [35], [36]]. These findings are consistent across disciplines, pointing to a universal need for reflective practices that are continuous, contextual, and supported by educator development.

Analysis of students’ final structured reflections revealed variable depth and completeness of their reflections. While 60 % (n = 3) clearly described significant clinical events, others offered general evaluations. In the reflection stage, students demonstrated emotional engagement and self-awareness, discussing internal conflicts and attempts to balance professionalism with empathy during intense experiences such as patient deterioration or death. However, none fully addressed complex indicators such as confronting multiple viewpoints or systematically evaluating initial reactions. These findings suggest that while the structured guide promoted reflective depth—evidenced by students’ ability to articulate emotions, identify ethical tensions, and formulate learning goals—further longitudinal support and iterative practice are necessary to enable students to fully operationalise each stage of the reflective process, particularly the more sophisticated analytical and evaluative components.

Methodologically, the single-site, non-randomised design and relatively small sample size limit generalisability. These limitations, common to exploratory studies in educational innovation, underscore the need for multicentre research with comparative groups and longitudinal follow-up to establish broader validity and replicability. However, the bounded case study design enabled in-depth, longitudinal observation of pedagogical processes within an authentic clinical context. This methodological strength facilitated a rich, contextualised understanding of how gamification operates in real-world supervision. The modest questionnaire response rate (71.4 %), while limiting quantitative generalisation, was offset by comprehensive qualitative data collection across multiple time points and sources, achieving methodological triangulation and enhancing trustworthiness.

Drawing from our findings and global literature, we propose the following recommendations for educational practice in nursing and beyond. 1) Integrate gamified strategies systematically: embed diverse, meaningful gamified activities throughout clinical education to promote not only technical but also emotional and collaborative development. 2) Foster co-creation: involve students, educators, and clinical supervisors in designing and adapting gamified and reflective tools to local needs and cultural contexts —as demonstrated by our diagnostic phase approach, which identified specific student needs and tailored interventions accordingly. 3) Embed longitudinal reflection: shift from isolated reflective exercises to scaffolded, ongoing reflective processes with structured peer and supervisor support —ensuring that reflection is integrated continuously rather than concentrated in evaluation periods, as students in our study recommended. 4) Ensure psychological safety: select activities that foster emotional expression, shared vulnerability, and trust, foundational for affective learning and professional growth —exemplified in our study by the Pass the Paracetamol activity, which students credited with creating safe spaces for emotional disclosure. 5) Invest in supervisor training: equip educators to facilitate reflective and gamified learning experiences with sensitivity to group dynamics and emotional processes. 6) Validate multidimensional assessment tools: develop or adapt tools to measure not only knowledge but also reflective ability, critical thinking, empathy, and emotional regulation. 7) Adapt across disciplines: recognise the value of these strategies in other professional fields—particularly those seeking to strengthen communication, identity formation, and wellbeing among learners.

5. Conclusion

This study demonstrates that integrating gamification into clinical nursing supervision delivers substantial benefits extending beyond knowledge acquisition to encompass emotional resilience, self-confidence, and peer support. The co-created, context-sensitive interventions fostered a psychologically safe atmosphere essential for reflective practice and holistic professional development. However, challenges in consistently applying structured reflection highlight the need for continuous, scaffolded support throughout clinical training. Future research should investigate these strategies across diverse clinical and cultural settings using multidimensional evaluation tools to assess their effectiveness. Nursing education programs are encouraged to embed longitudinal, gamified learning paired with ongoing supervisory support to prepare nurses for the complex, human-centred demands of contemporary healthcare practice.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

CRediT authorship contribution statement

Sílvia Caldas: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing - original draft, Writing - review & editing, Project administration. Regina Gonçalves: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Data curation, Writing - review & editing. Renata Silva: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Data curation, Writing - review & editing, Supervision, Project administration. Adriana Taveira: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Writing - review & editing, Supervision, Project administration. Ana Paula Macedo: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Writing - review & editing, Supervision, Project administration.

Declaration of competing interest

The authors have declared no conflict of interest or any potential competing interest.

Appendices. Supplementary data

The following are the supplementary data to this article: