The power of play-based learning: evaluating the impact of collaborative gamified quizzing on medical students’ learning through the lens of Kirkpatrick’s framework

Abstract

Background

Modern medical education emphasizes the use of technology-driven innovative approaches to enhance academic achievement, addressing inherently high cognitive load and demanding schedules. Gamification is one of these approaches that enhances learning by influencing behaviors or attitudes that support educational outcomes. This study aims to assess the efficacy of digitized team-based Kahoot! gamification in enhancing students’ learning experiences and academic outcomes using Kirkpatrick’s model.

Methods

It was a mixed methods study on first-year undergraduate medical students (N = 101). Quantitative component employed a within-subject quasi-experimental design with Kahoot! gamified intervention incorporated into the cardiovascular system module of first-year MBBS curriculum. Impact on learning was evaluated by comparing the scores of cardiovascular (experimental) and respiratory (control) system modules in mid-stake end-of-block assessment. Students’ perspectives were evaluated using self-designed questionnaire. Qualitative component of this study involved the utilization of open-ended questions in the students’ feedback questionnaire and focus group discussions with the faculty members involved in design, conduction, and observation of Kahoot! sessions.

Results

Median assessment score percentage was significantly higher in cardiovascular system module compared to respiratory module (Wilcoxon signed-rank test, p = 0.002; effect size r = 0.31; median paired difference = 4.89%, 95% CI [1.72–6.95]). These sessions recorded full student attendance. The questionnaire responses indicated a favorable perception of the Kahoot! gamification sessions among students, in terms of reaction, acceptance, perceived learning, behavior change, and collaboration. Faculty members also viewed this technique positively in the context of teaching and learning.

Conclusion

Collaborative gamified quizzing through Kahoot!, shows promise in enriching medical education as a valuable supplement to traditional teaching by potentially boosting engagement, deepening critical thinking, promoting teamwork, and supporting academic performance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-08766-y.

Introduction

Modern medical education is a collaborative process anchored in diverse educational approaches. These include experiential, introspective, proficiency-driven and problem-based learning, systematic assessments, and technology integration to enhance educational quality and academic achievement [1, 2]. The amalgam of these innovative approaches aims to make medical learning both engaging and enjoyable. This can address the inherently high cognitive load, demanding schedules, and competing academic responsibilities [3]. Conversely, didactic traditional methodologies offer limited student interactions, making it difficult for them to connect with the content [4]. To address these challenges, unconventional educational strategies are gaining popularity in medical education due to their potential to offer an enriching and dynamic learning experience for medical students [5]. The innovative strategies include game-based methods, virtual reality setups, role plays, and simulations. These allow students to develop their skills in safe and controlled environments without compromising on patient safety [6].

Gamification is one of the promising pedagogical tools that infuses game-like elements into non-gaming contexts. This approach integrates challenges, rewards, and feedback loops to enhance motivation, confidence, engagement, and learning outcomes, meanwhile being less effort intensive/ draining on the personnel involved [7]. It largely emphasizes the use of gaming experience for attaining important educational and affective objectives rather than just entertainment and enjoyment [8]. Gamification activities have a strong capacity to support educational and developmental outcomes. According to the gamified learning theory by Landers, gamification enhances learning indirectly by influencing behaviors or attitudes that support educational outcomes. It acts as a mediator – promoting behaviors such as increased time on task – or as a moderator, enhancing the effectiveness of well-designed instructional content [9]. Nonetheless, the success of gamification depends not only on the game elements used, but also on the relevance of the behavior targeted and the quality of instructional design [10]. Thus, gamification has the potential to enhance well-designed instructional strategies, serving as a valuable supplement rather than a standalone solution. Additionally, gamification can be beneficial for both personal and social learning activities, having the potential to boost teamwork skills in addition to knowledge acquisition [4]. Vygotsky emphasized the importance of social interaction and scaffolding within the ‘zone of proximal development’. Gamified learning environments that involve team participation reflect this by promoting collaboration, peer teaching, and shared problem-solving within a supportive structure [11]. Collaborative learning significantly contributes to the advancement of students’ cognitive skills [12]. Thus, incorporating game-like elements and collaborative teamwork together can transform learning into a more engaging, dynamic, and effective experience.

In recent years, technological advancement and advent of artificial intelligence have driven integration of digital tools across various domains of education worldwide [13]. In healthcare education specifically, this digital transformation has opened new avenues for incorporating game-based tools that enhance interaction and learner engagement [14]. Cultivating digital literacy and adaptability among early-year medical students is therefore essential to prepare them for rapidly evolving tech-enabled healthcare environment from the outset of their training [15]. In this context, the digitization of gamification can have synergistic effects on its effectiveness [13], considering high technology acceptance among ‘digital natives’: generation Z [16]. There are numerous online gamification platforms such as Kahoot!, Socrative, Quizizz, Quizlet, etc [17, 18]. Among these, Kahoot! has gained popularity in medical education as a dynamic, technology-driven tool for formative assessment. Its visually engaging interface, real-time feedback, and competitive format have been shown to facilitate active participation and create a positive learning environment [19].

In our study, Kahoot! platform was introduced as a formative assessment tool for early-year undergraduate medical students, with the aim of enhancing engagement through a digitized interactive and collaborative approach. The activity was purposefully designed with team-based participation to make all students feel included and to ease the pressure of individual performance. This approach sought to encourage peer learning and social interaction for deeper understanding, while using the motivational aspects of gamification.

Despite its growing global adoption, there is less information about the effects of using digital gamification platforms such as Kahoot! on academic performance in organized, team-based environments in undergraduate medical curriculum. This study aims to assess the efficacy of digitized team-based gamification in enhancing students’ learning experiences and academic outcomes using Kirkpatrick’s model. Our research also examines the perspectives of both students and faculty regarding this intervention using mixed methods study design. This study contributes to the existing literature by evaluating the effectiveness of a collaborative, Kahoot!-based quizzing within a cohort of early-year undergraduate medical students, integrating academic performance outcomes with student and faculty perceptions across all four levels of Kirkpatrick’s model.

Methods

This study implemented a gamified learning intervention utilizing Kahoot! in the cardiovascular system module of a first-year medical curriculum. The methodology is summarized in Fig. 1.

Fig. 1.

Methodology implemented for the study in first-year MBBS cohort (N = 101)

Ethical considerations

The study was approved by institutional review board of National University of Sciences and Technology (IRB #2025-IRB-A-71/71). Study was performed in accordance with institutional ethical guidelines and the principles of the Declaration of Helsinki. Participation in the Kahoot! sessions and feedback collection were voluntary. Informed consent was obtained before collecting data for both the quantitative and qualitative analyses.

Clinical trial number

Not applicable.

Study design

It was a mixed methods study. The quantitative component of the study employed a within-subject quasi-experimental design to assess the impact of collaborative Kahoot!-based gamified intervention on students’ academic performance. This intervention was incorporated into the cardiovascular system module. Two interactive Kahoot! sessions were conducted as part of the learning activities, designed to enhance learning, promote engagement, and teamwork through a competitive quiz format. Student feedback was collected after the implementation of this strategy using a self-designed questionnaire, having both quantitative and qualitative components. Scores in summative assessment (mid-stake end-of-block exam) were also compared between cardiovascular system module (experimental condition – with gamified intervention) and respiratory system module (control condition – without gamified intervention) of the same students. The whole block consisted of two consecutive modules, with respiratory system module delivered first over five weeks, immediately followed by cardiovascular system module delivered over six weeks. The intervention was implemented across selected academic themes (physiology sessions), while maintaining comparable themes without gamification to serve as control groups for comparative analysis. To ensure comparability, both themes were part of the same academic block and were reviewed by subject specialists to confirm equivalent difficulty level, instructional design, teaching strategies, and assessment blueprinting; moreover, the same module team delivered both themes using standardized lesson plans to minimize variability in teaching. The only difference was the in-class assessment which was gamified in the experimental group.

The qualitative component of this study involved the utilization of qualitative questions in the students’ feedback questionnaire and focus group discussions with the faculty members involved in design, conduction, and observation of Kahoot! sessions.

Participants

The Kahoot! sessions were conducted with first-year undergraduate MBBS students (N = 101), at the institute. All the students participated in the sessions. The participants were grouped into thirty teams with three to four members per team to encourage peer collaboration and collective problem-solving. Team formation was done keeping diversity considerations including gender balance and variations in prior academic performance to ensure equitable participation.

In the cardiovascular system module, Kahoot!-based gamification was integrated as an in-class assessment tool to complement the learning process, representing the experimental condition. In contrast, the respiratory system module was delivered using the institute’s standard instructional methods without any gamification, serving as the control condition. The same cohort of students served as both the control and experimental group under these two distinct instructional conditions. This within-subject design was adopted to control inter-individual differences such as prior knowledge, learning ability, and motivation, thereby enabling a direct comparison of instructional strategies on the same group’s performance.

The faculty members included in the study were the ones involved in planning, conducting, and observing the gamified Kahoot! sessions.

Institutional standard module delivery and control conditions

The respiratory system module (control conditions) was delivered as part of the same academic block as the cardiovascular system module (experimental conditions) and followed identical institutional curriculum governance and quality assurance processes. Learning outcomes, content scope, and instructional sequencing for selected themes in both modules were finalized through structured curriculum committee meetings involving relevant stakeholders and subject specialists, ensuring alignment in depth, complexity, and expected cognitive level.

Both modules employed comparable teaching-learning strategies selected based on learning outcome requirements, including large group interactive sessions and small group instructional formats, and were delivered by the same teaching team using standardized lesson plans. This approach minimized variability in instructional delivery and faculty-related influences.

Assessment development for the block followed a uniform process, including formal blueprinting by a dedicated assessment committee, pre-hoc review by subject specialists, and approval by relevant authorities. The block examination included same number of MCQs from each module with equivalent weightage and comparable cognitive-level distribution.

Collaborative Kahoot! Gamification sessions

Two Kahoot! gamification sessions were conducted in the cardiovascular system module. One session was conducted midway through the module, and second session was conducted in the last week of module, a week before the mid-stake end-of-block assessment. Each Kahoot! gamification session was conducted in two interactive and engaging rounds. Each round featured forty-fifty multiple-choice questions (MCQs), with four answer options per question (both sessions had fifty questions in first round and forty questions in second round). MCQs were carefully crafted by the subject specialists to align with the cognitive levels 1, 2, and 3 of Bloom’s taxonomy, ensuring that they addressed basic knowledge recall, comprehension, and application. Difficulty level of questions was increased in round two. MCQs were displayed on a central screen for a duration of sixty to ninety seconds, allowing sufficient time for discussion and consensus among team members. Each team used a single device to log into the Kahoot! platform, while other members were not allowed to use personal devices. This approach ensured that the focus remained on collaboration within the group rather than reliance on external resources. To heighten engagement, certain questions deemed critical, or challenging were assigned double points. Additionally, the scoring system rewarded streaks for consecutive correct answers, requiring strategy and sustained focus.

Each session was allocated a total duration of approximately one hour and forty minutes, as scheduled in the official timetable. The sessions were conducted in a lecture hall with a seating capacity of one hundred and fifty, providing a structured and formal environment. Teams were seated apart to minimize distractions and prevent interference between groups. Background music from the Kahoot! platform was utilized to create an engaging atmosphere and to mask inter-group discussions. This ensured that teams could deliberate and collaborate without external influences. Certificates were awarded to the top three teams in each round to acknowledge their performance and encourage a sense of accomplishment. Afterwards, feedback was provided to the students, including the correct answer of MCQs along with their explanation.

Assessment of students’ academic performance

To evaluate the impact of Kahoot! sessions on students’ academic performance, the scores in mid-stake end-of-block assessment of cardiovascular system (experimental conditions) and respiratory system (control conditions) modules were compared. The mid-stake end-of-block assessment included an equal number of MCQs from the respiratory and cardiovascular system modules, with equivalent weightage and a comparable cognitive-level distribution comprising approximately 20% C1, 60% C2, and 20% C3 questions. Subject specialists meticulously reviewed and approved these questions to ensure accuracy, relevance, and comparability across themes of both the modules. The questions were entirely different from the MCQs used during Kahoot! sessions. Students recorded their responses on optical mark recognition (OMR) sheets, and the results were obtained from the examination department of the institute.

Attendance recording of students

Attendance for the Kahoot! gamification sessions was recorded using both manual attendance sheets and the institution’s biometric system. Although attendance was not mandatory specifically for the Kahoot! gamification sessions, these sessions were conducted during scheduled teaching hours and contributed to overall module attendance. The sessions were aligned with the regular timetable and delivered on days that also included other instructional activities.

Evaluation of students’ perceptions

Student perceptions of Kahoot! gamification sessions were collected through a self-designed questionnaire, following informed consent. The questionnaire was developed following a thorough literature review, iteratively refined for clarity and relevance, and structured into two sections. Section I (quantitative) featured Likert-scale questions evaluating students’ perceptions, using a 1–5 scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. Section II (qualitative) included open-ended questions. The items were designed to align with the Kirkpatrick’s evaluation framework, addressing Level 1 (reaction and acceptance), Level 2 (perceived learning), and Level 3 (behavior change and collaboration) (Supplementary Table S1), while Level 4 outcomes were assessed separately through academic performance. The questionnaire underwent review by four experts in medical education to ensure content validity and comprehensive coverage of all intended constructs. Quantitative Likert-scale responses were complemented by qualitative open-ended data, allowing triangulation of overarching trends with students’ detailed perceptions. Cronbach’s alpha confirmed the internal consistency of quantitative items at 0.93. For the scales of reaction, acceptance, learning, and behavior and collaboration the Cronbach’s alpha values are 0.82, 0.88, 0.825, and 0.86, respectively. Factor analysis was not undertaken due to exploratory purpose of the questionnaire, the limited number of items per construct, and the single cohort sample size.

Evaluation of faculty members’ perceptions

To evaluate faculty members’ perceptions of Kahoot! gamification sessions, data were collected through focus group discussions, following informed consent. During these sessions, participants responded to a predesigned set of questions (Supplementary Table S2). Three focus group discussions were held, each comprising five faculty members. Two moderators were present in each focus group. The questions were developed through an extensive literature review and aimed to explore faculty perspectives on impact of Kahoot! gamification sessions on student learning, behavior, and academic performance.

Theoretical framework

This study employed Kirkpatrick’s four-level training evaluation model as the theoretical framework to assess the effectiveness of Kahoot! gamification in our setting. This model was selected because it can provide a systematic evaluation of both immediate and sustained impacts of educational interventions. Its hierarchical nature aligns with the complexity of learning processes, where positive reactions can influence learning outcomes, which in turn affect behavioral changes and ultimately contribute to broader educational results [20]. This framework is particularly relevant for evaluating gamified learning interventions as it captures multiple dimensions of effectiveness beyond traditional academic metrics.

Level 1 (Reaction)

This level was assessed using both quantitative and qualitative questionnaire items focused on exploration of students’ acceptance and perspectives regarding engagement, motivation, and enjoyment of Kahoot! gamification sessions. It also included faculty’s perceptions related to learner’s reaction.

Level 2 (Learning)

In this level, students’ self-reported reflections regarding learning gains and perceived conceptual clarity were evaluated using both quantitative and qualitative questionnaire items. Furthermore, focus group discussions with faculty members were conducted to gather observations on changes in student understanding of the module content.

Level 3 (Behavior)

For this level of Kirkpatrick’s model, observed behavioral indicators such as increased participation, teamwork, and attendance were noted across sessions. Students’ and faculty’s perspectives were also included to support observed behavior changes.

Level 4 (Results)

Mid-stake end-of-block assessment scores of the students in cardiovascular system module were compared with scores in respiratory system module (which served as a control) to determine whether the gamified sessions influenced overall academic outcomes. Both modules are comparable in terms of content complexity and assessment difficulty.

The levels are summarized in Fig. 2.

Fig. 2.

Indicators to assess the Kahoot! gamification intervention using Kirkpatrick’s four-level training evaluation model

Data analysis

Data were analyzed using IBM’s statistical package of social sciences (SPSS V22). Descriptive statistics were used to present quantitative data. Comparative analysis between the cardiovascular system and respiratory system modules’ scores in mid-stake end-of-block assessment was performed to evaluate the intervention’s effectiveness. p < 0.05 was considered statistically significant. Qualitative data from student feedback and faculty focus groups were subjected to thematic analysis to identify recurring patterns and insights regarding the sessions’ impact. Themes were identified inductively through iterative review of the data. Two members of research team independently reviewed and coded the data. Initial codes were compared and refined through discussion, and disagreements were resolved by consensus. Data saturation was considered achieved when no new themes emerged during iterative review of the responses. Data is available from Open Science Framework (OSF) repository (https://osf.io/qct3w/?view_only=2274bfc4d7a8459994aaf3b48ddb4b00).

Results

Both quantitative and qualitative analysis of gamification session was carried out, the findings of which are reported below.

Quantitative findings

Academic scores

To evaluate the effectiveness of the Kahoot! gamification session, assessment score percentages in mid-stake end-of-block exam were compared between cardiovascular system (experimental) and respiratory system (control) modules, within same cohort of students. Normality of the paired score differences was assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests. The results indicated that the paired differences did not follow a normal distribution (Kolmogorov-Smirnov p < 0.001, Shapiro-Wilk p = 0.021). Therefore, a paired non-parametric test was used. Assessment score percentages were summarized using the median and interquartile range. A Wilcoxon signed-rank test demonstrated a statistically significant difference (W = 3498, Z = 3.125, p = 0.002) between respiratory system (median = 62.96%, interquartile range = 16.67) and cardiovascular system (median = 67.86%, interquartile range = 21.43) score percentages. The Hodges-Lehmann estimator showed a median paired difference of 4.89% points (95% CI: 1.72–6.95). The effect size was r = 0.31, indicating moderate effect and reflecting a meaningful impact of the intervention (Fig. 3). These findings suggest that the Kahoot! gamification sessions may have contributed to modest improvement in academic performance of students.

Fig. 3.

Median and interquartile range of mid-stake end-of-block assessment score percentages in respiratory system (control) and cardiovascular system (experimental) modules. Statistical comparison was performed using the Wilcoxon signed-rank test (p < 0.05 considered significant)

Student attendance in Kahoot! Gamification sessions

The Kahoot! gamification sessions were conducted at the end of different themes in the module. Notably, these sessions recorded full student attendance, the only session throughout the day to reach 100% participation. In contrast, attendance in other instructional sessions, such as small group discussion, large group interactive, and practical sessions remained lower. This strong turnout highlights that the interactive nature and perceived usefulness of the gamified activity may have supported higher participation and student interest in gamified learning, a sentiment further reinforced by multiple requests for more frequent gamification sessions in the future.

Students’ perceptions

Students’ feedback was collected online using Google forms after mid-stake end-of-block exam (before the formal announcement of exam results). A total of 84 respondents, 44 female and 40 males respectively, responded to the questionnaire (response rate: 84.8%). The mean age of participants was 19.7 ± 1.4 years. Overall, the results showed a positive outlook in the domains of acceptance, reaction, perceived learning, behavior change, and collaboration (Table 1).

Table 1.

Descriptive analysis of students’ responses to the quantitative questionnaire items (N = 84)

Questionnaire Items	Frequency percentage (%)					Mean ± SD	Median (Interquartile range)
	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Reaction (Level 1)
The Kahoot! gamification sessions kept me actively involved.	39.3	41.7	16.7	1.2	1.2	4.17 ± 0.83	4(1)
The Kahoot! gamification sessions motivated me to learn more about the subject.	40.5	38.1	17.9	2.4	1.2	4.14 ± 0.88	4(1)
I am satisfied with how the Kahoot! gamification sessions were conducted.	35.7	38.1	21.4	2.4	2.4	4.02 ± 0.94	4(2)
Acceptance (Level 1)
I would like to participate in more Kahoot! gamification sessions.	40.5	38.1	19	2.4	0	4.17 ± 0.82	4(1)
The Kahoot! gamification sessions should be a mandatory part of the curriculum.	38.1	29.8	22.6	8.3	1.2	3.95 ± 1.03	4(2)
Learning (Level 2)
The Kahoot! gamification sessions enhanced my understanding of key concepts.	23.8	39.3	27.4	8.3	1.2	3.76 ± 0.95	4(1)
The Kahoot! gamification sessions were effective in increasing my knowledge.	35.7	46.4	13.1	3.6	1.2	4.12 ± 0.86	4(1)
The Kahoot! gamification sessions helped me with knowledge retention.	26.2	42.9	17.9	11.9	1.2	3.81 ± 1	4(2)
The Kahoot! gamification sessions’ instant feedback enabled me to identify my areas of weakness.	33.3	44	16.7	4.8	1.2	4.04 ± 0.89	4(1)
I believe my exam scores improved as a result of these sessions.	16.7	34.5	35.7	8.3	4.8	3.5 ± 1.02	4(1)
Behavior and Collaboration (Level 3)
I feel more exam-ready after participating in Kahoot! gamification sessions.	23.8	39.3	20.2	16.7	0	3.70 ± 1.01	4(1)
Collaborating with peers during the Kahoot! gamification sessions was valuable.	32.1	42.9	20.2	2.4	2.4	4 ± 0.92	4(2)
The Kahoot! gamification sessions helped me develop a more inclusive and collaborative approach.	23.8	50	21.4	4.8	0	3.93 ± 0.8	4(1)
The skills gained from Kahoot! gamification sessions will assist me in working collaboratively in the future.	27.4	50	16.7	4.8	1.2	3.98 ± 0.86	4(1)

Qualitative findings

Students’ feedback

Student perceptions regarding Kahoot! gamification sessions were assessed using qualitative questions, with responses coded into different domains and analyzed thematically.

Competencies attained

Students were asked whether they felt that gamification sessions contributed to the development of any specific competencies. Their responses highlighted a broad range of competencies that they have gained through the session.

1. Many students emphasized the growth in their ability to work effectively with peers in a group setting. They opined that the team-based Kahoot! quiz sessions helped them understand their peers better, learn from them, and resolve disagreements. Students responded: “I gained the ability to work effectively within a team”, “These sessions helped me build teamwork skills and practice patience”, and “Effective collaboration and engagement with peers.” Additionally, by participating in team-based gamification sessions, the students became more attuned to the individual challenges their peers were facing. Instead of focusing solely on personal performance, they began to recognize moments when a teammate might be struggling with a concept or decision – and took initiative to assist, “It helped me become better at considering other people’s weakness and help them with what they struggled in.”

2. The students noted that the quiz’s time-bound nature helped them develop time management and quick-thinking skills. They explained that it provided valuable practice in quickly retrieving information within a limited time, which could be beneficial in future academic or professional settings. Students responded: “The quiz helped me develop time management skills by learning to answer questions quickly and efficiently” and “I improved my ability to think quickly and recall information accurately under time constraints.”

3. Students opined that the Kahoot! gamification sessions appeared to promote their critical thinking and problem-solving abilities. Several responses highlighted that the interactive and fast-paced format encouraged deeper cognitive engagement and strategic thinking. One student remarked: “Being able to retrieve information from memory and using it for critically thinking on complex concepts”, suggesting that the session tested recall and pushed students to synthesize and apply knowledge in real-time – an essential skill in medical education and clinical decision-making. Another participant noted: “Answering questions by eliminating the wrong options and saving time effectively” This illustrates the use of analytical elimination and decision-making strategies, indicating that students are learning to critically evaluate multiple choices, not just memorize answers. A particularly insightful comment referenced Paulo Freire’s educational philosophy: “Problem-posing skills which according to Paulo Freire is best among the lot.” This reflects the student’s recognition of a dialogic and reflective learning process, where learners engage not only with content but with the underlying challenges and implications of the questions themselves.

4. Many students believed that engaging in peer discussions during problem-solving enhanced their communication skills, allowing them to express their thoughts more clearly and concisely. These interactions promoted patience and tolerance when listening to and considering others’ perspectives. Furthermore, working in peer groups encouraged leadership skills, as students took responsibility for their answers and guided and led group discussions. The interactive, team-based format appeared to create a supportive space for expressing ideas and participating actively. As one student noted, “it helped convey my concepts to my fellows more appropriately and concisely,” highlighting growth in both clarity and precision of communication.

5. Several students reported that the session contributed to a noticeable boost in their self-confidence and morale. Others simply mentioned “improved confidence” and the ability “to be confident in your answers,” suggesting the session played a role in strengthening their assurance while responding under pressure. These reflections point to the value of gamified learning in enhancing interpersonal effectiveness. The repeated exposure to challenging content in a supportive setting helped students feel more assured in expressing ideas and making decisions.

Academic impact

Students were also asked about the impact of Kahoot! gamification on their academic performance. The majority felt that gamification significantly contributed to achieving the desired learning outcomes, as it helped them identify their strengths and weaknesses while also exposing them to different ways in which concepts could be tested in exams.

1. Many of the students appreciated that Kahoot! gamification sessions proved to be an opportunity for them to revisit the key concepts in the low-pressure environment, one student responded, “Helped me revise the syllabus and key concepts”, other said: “It’s best for rapid revision”. Most students opined that the interactive, competitive, and engaging nature of the session, coupled with instant feedback, motivated them to learn more effectively and promoted self-sufficiency. These sessions aided them in reinforcing the previously learned material and supported long-term memory via repetition and recall, as a student mentioned “It was a practice session in a healthy environment without any pressure of marks”. Students found the session to be a quick and structured review tool, helping consolidate their understanding and reinforce long-term retention through repetition.

2. Some students responded that these sessions served as a systematic tool, enabling them to assess their knowledge and guide further study, one student responded: “I got to know my weak points and the ways I need to think while solving MCQs”, another student said, “My weak points were highlighted”, and “helped me identify areas of weakness.”

3. Students reported that the sessions provided them with exposure to a wide variety of exam-style questions, which could be helpful in refining their answering techniques and familiarity with formats. Students responded: “I learned to use techniques to get answers correct in MCQ-based paper setting”, “Better understanding of question layout”, and “It gave us the opportunity to revise the topics that are going to be included in exams ahead.” Many students believed that the sessions would have a positive impact on their academic performance and exam scores, and they expressed increased confidence in their exam preparation as a result of these sessions.

Learning engagement and motivation

1. Many students believed that the gamified format sparked intrinsic interest, making learning enjoyable and less burdensome. Students responded, “It made learning fun” and “Very interesting and we learned a lot from this activity.” The reward-oriented, game-based nature of the sessions kept students highly engaged, making the learning experience more enjoyable and memorable compared to traditional methods. “Any change in routine and environment helps to make academic learning a lot more engaging and enjoyable.”

2. Some of the students believed that the friendly competition in Kahoot! gamification sessions encouraged active participation and a desire to excel. A student responded, “The competitive environment made me enhance my responding ability more sharply” and others labelled it as “Healthy competition among students.” The friendly competition in the Kahoot! session made learning more exciting and pushed them to stay focused and try harder. They felt it helped them think faster, use their knowledge better, and improve teamwork under pressure. The challenge of racing against time and working with others encouraged personal growth and boosted motivation. One student responded, “Teamwork and answering questions being a race against time made the event such a beneficial thing for our physiology prep. It created an environment of competition which pushed everyone to give it their best to come out on top!” and the other said, “The competitive environment created during the activity made it possible to work as part of the team and accepting your mistakes where you’re wrong. So, it will be best in the long run.”

Professional development

Students were asked about the potential benefits of the sessions for their professional growth. A vast majority responded positively, highlighting several key aspects that they believed would help them become better doctors. They emphasized that the skills acquired during the activity would be helpful in mitigating current and future challenges in their careers.

1. Students believed that the session simulated high-pressure conditions, preparing students to make quick yet sound judgments, mirroring clinical realities. Students responded, “Thinking under pressure and making decisions within seconds” and “Taking right decisions in a limited time develops your diagnosing skills.” The fast-paced nature of the activity was perceived as beneficial in enhancing critical thinking and analytical skills by the students. Both these factors are fundamental to the medical field. Students explained that they engaged in multifaceted interpretation of questions, developing the flexibility needed for diagnostic thinking. Student opined that this gamification session “Helped me understand how differently questions on the same topic can be asked.”

2. Furthermore, they believed that team-based and interactive format encouraged a cooperative mindset thus making them more inclined towards active learning approaches, which is pivotal in a clinical setting. Team setting during the time-bound sessions prompted leadership growth and responsibility. Students responded, “Teamwork, leadership, and decision-making till our clinicals start”, another one said, “Trusting my fellows and correcting them with a humble approach” and “Leading peers and resolving differences helped cultivate interpersonal and leadership skills.”

3. The sessions were perceived to enhance memory through active engagement and emotionally resonant experiences. Students responded, “The things we learn through actions are more retainable” and “Gamification helps contribute to long-term memory.” Active learning and emotional engagement can create memory hooks that are likely to support retention well beyond the session.

The results aligned with Kirkpatrick’s training evaluation model are summarized in Fig. 4.

Fig. 4.

Thematic analysis of positive perceptions of students regarding Kahoot! gamification sessions aligned with Kirkpatrick’s training evaluation model. (Level 1 captures reaction-based affective outcomes. Level 2 reflects cognitive gains, skills, and self-perceptions regarding learning. Level 3 represents applied behaviors or observable changes in learners’ actions)

Negative aspects

Some students pointed out certain drawbacks of the activity. They found the sessions to be overwhelming due to the workload and suggested dividing them into multiple shorter sessions. A couple of students mentioned that background music during the activity was distracting and suggested reconsidering its use (Level 1).

Faculty feedback

The perceptions of faculty regarding the gamification technique were explored through qualitative questions in focus group sessions. Their responses were coded, and a thematic analysis was performed. The findings aligned with Kirkpatrick’s training evaluation model are presented in Table 2. Perceptions related to benefits to faculty and drawbacks of activity, were analyzed descriptively and not mapped to the framework, as these domains fall outside the learner-outcome focus of the Kirkpatrick’s model.

Table 2.

Qualitative findings of focus group discussion sessions with faculty members using thematic analysis

Themes	Subtheme	Findings and Quotes
Benefits to student
Skills and professional development	Teamwork (Level 3)	The faculty observed that peer discussion and shared decision-making in selecting the correct answer encouraged students to work collaboratively, potentially promoting teamwork that is an essential skill for future medical practitioners. One of them stated, “Students learned how to work as a team and understood each other better.” Another one said, “By virtue of gamification, students learned how to work and win as a group, in a tension free environment.” Faculty members agreed that the cooperative element in the gamification sessions can aid group members in understanding each other’s thinking in a better way, helping build a collaborative environment. One responded, “Gamification preaches tolerance and patience, which seems missing among doctors” and “I may have a better relationship with my colleagues, if these activities were conducted for us.”
	Time management (Level 3)	Most of the faculty members observed that in the time-bound Kahoot! gamification activity, which requires participants to apply their knowledge and reach conclusions swiftly, may help enhance their ability to make quick and informed decisions – a vital skill for healthcare professionals.
	Interpersonal communication (Level 3)	Faculty members agreed that team-based nature and peer discussions during the quiz helps the student convey their message clearly and precisely which may facilitate in development and enhancement of communication in the long run. One member responded, “Group-based activity leads to more interaction, helping better communication.”
Academic advantages	Critical thinking (Level 2)	Faculty members believe that the non-conventional nature of this modality, as it is interactive and enjoyable, facilitates the students in gaining knowledge and understanding concepts, and how differently they can be tested could lead to better knowledge application. One opined, “Gamification fosters brainstorming, by connecting different concepts in a little span of time” and other said, “Interactive group discussions among students helps in finding out why answers are either right or wrong leading to better understanding.” Thus, Kahoot! gamification can be an effective way to promote participant’s analytical and critical thinking capabilities by engaging them in a dynamic, problem-solving environment that is different from traditional methods.
	Active learning and knowledge retention (Level 2)	The respondents observed that the competitive, interactive nature of the activity augmented by reward system may greatly enhance students’ interest in academics and promote active learning. Furthermore, these sessions can be a way to assess different learning objectives in unconventional, interesting, and innovative ways, aiding in reinforcing key concepts and rapid revision.
	Effective feedback (Level 2)	Faculty generally felt that the immediate marking of questions during the activity could help boost students’ confidence when they answer correctly, while also allowing them to recognize areas for improvement in a low-pressure, engaging setting.
Behavior change/ advantages	Motivation and enthusiasm (Level 1)	Most faculty members felt that the game-like environment, combined with healthy competition and an enjoyable atmosphere, helped sustain students’ interest in academics and motivated them to prepare more thoroughly. This heightened engagement may encourage greater enthusiasm and drive for future learning. As one faculty member noted, “It is such an engaging activity that I plan to incorporate it into my own teaching strategy as well.”
	Confidence building (Level 2)	The faculty members pointed out that students got immediate responses to their answers, so they can celebrate when they’re right and learn quickly when they’re not – without fear of grades or judgment. This can help normalize error as part of the learning process. A reward-based system encourages students to participate actively; this may inculcate self-sufficiency in them. One member told, “The reward and recognition of gamification, motivates the students to work hard.” They further added that in Kahoot! collaborative quiz everyone answers every question at the same time, which helps reduce the anxiety of speaking up in class or being singled out. Even shy students find it easier to engage when there’s no spotlight. One member said, “The playful, rewarding design of this session created a sense of accomplishment among students even with small wins.” That can lift a student’s morale and make them more willing to take academic risks, reinforcing a “growth mindset.”
	Fun and stress-free environment (Level 1)	Faculty members noted that the gamification session stood out as an innovative, enjoyable, and relaxed learning experience. Unlike conventional, often draining academic formats, this approach offered students a refreshing break while still engaging them meaningfully. The winning teams were happy while also teams who performed relatively poorly were not demoralized but rather enthusiastic, which may be due to low-stakes and stress-free environment. One member said, “Its essence lies in providing enjoyment and fun instead of stress, unlike other techniques.”
	Sportsmanship and team building (Level 3)	Faculty members observed that the activity appeared to instill a healthy sense of competition while emphasizing shared goals and collective success may benefit the peers to develop a competitive spirit while emphasizing team success over individual accomplishments. Students were not trying to outscore each other individually; they were working together as teams, striving for success through cooperation, communication, and shared strategy. This dynamic inculcates a spirit where team success is prioritized over personal recognition.
Benefits to faculty members
Pedagogical effectiveness	Real-time instructional reflection	Faculty opined that this strategy could be a great tool for real-time reflection on teaching methods where faculty receive direct feedback on how well their teaching methods have worked in a stress-free environment. If students struggle with specific questions or content, it provides an opportunity to refine strategies and develop targeted instructional plans for future sessions.
	Time efficiency	Most faculty suggested that instant marking feature and feedback on answers reduces the need for extensive paper-based grading, which may allow faculty to utilize their time more effectively and appropriately in addressing learning gaps.
	Revision support	Some faculty noted the session also refreshed their own conceptual understanding and revealed students’ weak areas. A faculty member shared that the experience, “It helped in revision of their own concepts and will influence their future teaching strategies.”
Engagement	Icebreaker for faculty and students	Some faculty members suggested that by blending game elements and inclusive participation, Kahoot! gamification quiz enhanced rapport among faculty and students, helping to ease communication and encourage interaction.
	Enjoyable experience	Faculty members also really enjoyed the game-based environment as it provided them with a break from their usual routine. One member said, “Listening to students was the most enjoyable part of the session.”
Disadvantages/drawbacks of activity
Assessment-related limitations	No individual assessment	Faculty were of the perception that in this group-based activity, individual student performance may not be accurately judged. One member said, “Sessions should be of both types (individual and group) otherwise individual assessment won’t be possible.”
	Complacency	Some faculty members noted that quick responders dominated the activity, which may cause less-active students to become complacent, however, the fun elements keep the motivation high.
Implementation and logistical challenges	Faculty workload	Some faculty felt that preparation for MCQs for the session is time consuming and energy intensive process that increases the burden on the faculty.
	Optimal number of sessions	An ideal number of sessions for both students and faculty should be identified so that it doesn’t overwhelm anybody and should implemented in a healthy balance with other techniques. One member opined, “If anything becomes repetitive than its gist is lost.”
Educational balance and student focus	Subject neglect	Some faculty felt that this reward-based activity might lead students to focus too much on this activity, at the expense of other subjects. One member said, “The competitive nature of the activity might lead students to prioritize it disproportionately over other academic responsibilities.”

Discussion

This study evaluated the impact of collaborative gamified quizzing using Kahoot! on undergraduate medical students’ learning, using the Kirkpatrick’s model as a framework. Our results showed that both students and faculty responded positively to this approach, with reported benefits extending from engagement and understanding to behavioral change and improved academic outcomes. These findings align with the core principles of the Kirkpatrick’s model, suggesting that gamification can have a meaningful impact when thoughtfully integrated into the curriculum.

Level 1 (Reaction). The participants’ reactions to the gamified sessions were largely favorable. Students found the activity enjoyable, motivating, and more engaging than traditional methods. They appreciated the stress-free environment and described the sessions as fun yet educational. Faculty members also noticed that students appeared more attentive and participative. These observations reflect a favorable reaction, the first level of the Kirkpatrick’s model. Similar results were reported in a study where medical students experienced higher levels of engagement and enjoyment during Kahoot!-based pathology sessions [21]. Another study found that gamified learning improved classroom atmosphere and increased participation in anatomy classes [22]. Likewise, van Gaalen et al., reported that gamification in health professions education consistently increased student satisfaction and classroom energy [23]. Some researchers have reported that the game-based methods were perceived to be less effective by the students, especially when the competition element causes stress or discomfort [24]. These differences may arise from variations in implementation design, individual learning preferences, or prior exposure to game-based tools. In qualitative analysis several students noted that the high number of quiz questions and longer session duration made the activity feel overly intense and suggested dividing the activity into shorter segments. Faculty feedback reinforced these concerns, emphasizing the importance of identifying an optimal number and frequency of gamified sessions so that activities do not become repetitive or cognitively taxing. Similar design-related challenges have been reported by López-Jiménez et al., who cautioned that excessive item volume, rapid pacing, and prolonged or densely structured gamified response system sessions may increase cognitive load and can overwhelm learners if not carefully balanced [25, 26]. This highlights the importance of thoughtful design and moderation when integrating gamified learning into medical curricula. According to cognitive load theory, excessive task demands may overload working memory, reducing attention span and satisfaction, and thereby undermining learning effectiveness [27]. Recent research in gamified learning also highlights that an excessive volume of questions can elevate cognitive load and diminish motivation if the activity is not carefully paced [28, 29]. In future implementations, dividing the quiz into shorter segments or reducing the number of items per session could help optimize engagement and support better learning outcomes.

Level 2 (Learning). In terms of learning, students reported improved understanding of physiology concepts and better knowledge retention. The real-time feedback provided during the Kahoot! gamification sessions helped them identify their strengths and address misconceptions. Faculty observed that students engaged in meaningful peer discussions, promoting deeper learning. These outcomes reflect the second level of the Kirkpatrick’s model, which focuses on learning gains such as knowledge acquisition and conceptual clarity. Similar effects have been noted in other studies using game-based tools in medical education, where interactivity and formative assessment have been shown to strengthen cognitive outcomes [30, 31]. In contrast, Hanus and Fox found that when game elements placed more emphasis on performance and competition than on content learning, students experienced a decline in intrinsic motivation, reduced satisfaction, and no significant gains in academic achievement [32]. These findings suggest that poorly integrated gamification, especially when misaligned with intrinsic learning goals, may diminish its educational value and even backfire if not implemented thoughtfully. To address these limitations, our sessions were carefully designed to align quiz content with session objectives, and competition was embedded within collaborative group work, maintaining the focus on learning rather than performance alone.

Level 3 (Behavior). Beyond cognitive gains, students and faculty highlighted behavioral changes resulting from the sessions. Students described enhanced teamwork, leadership, time management, and communication skills. Many believed the activity prepared them to work collaboratively and manage stress; skills crucial for future medical practice. Faculty observed that students were more cooperative and willing to share ideas, and that the activity encouraged active listening and patience. Interestingly, behavioral engagement was also evident before the session began. Kahoot!-based activities had been used previously in an earlier module, and when students were informed that a similar format would be used in the cardiovascular system module, many expressed excitement and looked forward to participating. Despite generally low attendance in other sessions on the same day, a good number of students made a deliberate effort to attend the gamified sessions. This suggests that such activities may positively influence students’ learning-related behaviors, including motivation to attend and engage actively, consistent with a previous report by Felszeghy et al. [7]. These shifts align with the behavioral level of the Kirkpatrick’s model, which focuses on observable changes in learners’ action, such as how they collaborate, communicate, and make purposeful choices that support their learning. Literature supports the idea that well-structured gamified activities can promote the development of professional competencies and behavioral attributes, such as collaboration and resilience, especially when conducted in a low-stress environment [23]. Still, some educators argue that these sessions may not suit all learners equally, especially if group composition is unbalanced or dominated by high-achieving individuals [22]. In our study, this concern was also raised, highlighting the importance of careful group formation to ensure equitable participation.

Level 4 (Results). Finally, when comparing student performance between modules with and without gamification, we found a statistically significant but modest in magnitude improvement in exam scores in the module where Kahoot! gamification sessions were used. This suggests that collaborative gamified quizzing may not only enhance engagement and understanding but can also translate into measurable academic outcomes. This aligns with the final level of the Kirkpatrick’s model, which considers whether learning leads to improved results. Recent evidence supports this connection, with multiple studies reporting improved exam scores and content retention when gamification is used alongside traditional instruction [7, 33]. Padilha et al. observed enhanced exam performance when virtual game-based methods were combined with clinical learning [33]. Similarly, Felszeghy et al. observed enhanced histology exam scores following implementation of online game-based quizzes [7]. However, another study emphasized that while gamified tools like Kahoot! can improve short-term engagement, they must be used thoughtfully to prevent superficial learning or fatigue over time [34]. In our study, students themselves recommended that the frequency and timing of sessions be carefully managed to avoid fatigue. This underscores the need to strike a balance between innovation and routine to maintain student interest and learning quality.

The quantitative and qualitative findings in this study complement each other within the framework of Kirkpatrick’s model. Quantitative results demonstrated significant improvements in learners’ engagement, satisfaction, perceived knowledge gains, and academic performance, while the qualitative feedback provided deeper insights into the factors contributing to these outcomes, such as teamwork, motivation, and enjoyment. This triangulation strengthens the interpretation of impact by linking measurable learning outcomes with participants’ lived experiences, thereby providing a more comprehensive understanding of the effectiveness of the gamified strategy [20, 35].

This study had several limitations. It was conducted within a single institution and focused on physiology sessions in selected modules, which may limit the generalizability of the findings to other disciplines or contexts. The effect size for academic performance was moderate, indicating that the observed gains, though statistically significant, were modest. Moreover, the questionnaire was self-designed and validated internally, as comparable external sample could not be obtained during the study period to allow for external validation. Although the questionnaire demonstrated good internal consistency and content validity, factor analysis was not performed due to the exploratory nature of the instrument, the limited number of items per construct, and sample size considerations; therefore, the internal structure of the questionnaire should be interpreted with caution. While student behavior was partly evaluated through observable attendance patterns, other behavioral indicators were based on self-reported perceptions. The study did not assess long-term retention or individual contributions within group-based activities. Group-based assessments may have masked individual differences in participation and learning, limiting the ability to fully capture individual outcomes. Because this was a quasi-experimental design using two different themes, causal inference is limited. Some residual confounding related to content difficulty, timing, or academic load may still exist and cannot be excluded. Although we aligned both themes within the same block and used the same teaching team, standardized lesson plans, and matched assessment structures, complete equivalence cannot be ensured and the findings should be interpreted in this context.

Future work should explore long-term effects and address the limitations of group assessment by incorporating both individual and collaborative elements. Multi-institutional studies using randomized designs, longitudinal follow-up, and mixed methods approaches with objective behavioral measures are recommended to provide a more comprehensive evaluation of gamification in medical education.

Conclusion

Our findings suggest that collaborative gamified quizzing using tools like Kahoot! offers a promising strategy for supporting meaningful learning in medical education. Interpreted through the Kirkpatrick’s framework, this approach potentially addresses multiple layers of student development, by supporting learner engagement and motivation (Level 1, based on student and faculty feedback), promoting deeper understanding and perceived learning gains (Level 2, informed by student and faculty perceptions), encouraging collaborative behavior and active participation (Level 3, supported by student and faculty feedback and attendance patterns), and enhancing academic performance (Level 4, with modest but meaningful improvement). While these results reflect the experience of a single cohort within a specific disciplinary and institutional context, they offer practical direction: structured, collaborative gamification can be sustainably integrated as a formative, engagement focused complementary strategy to supplement traditional methods.

Authors’ contributions

Hira Moin: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Writing – original draft. Sarim Zafar: Data Curation, Investigation, Software, Writing – original draft. Rizwan Ashraf: Formal analysis, Investigation, Resources, Validation, Writing – review & editing. Sadaf Majeed: Formal analysis, Methodology, Writing – original draft. Munazza Asad: Investigation, Project administration, Writing – review & editing.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The feedback questionnaire and focus group guide are provided as supplementary materials. Data is also uploaded on OSF repository ( [https://osf.io/qct3w/?view_only=2274bfc4d7a8459994aaf3b48ddb4b00](https:/osf.io/qct3w/?view_only=2274bfc4d7a8459994aaf3b48ddb4b00) ).

Declarations

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.