Robert Mills Gagné proposed that learning is a dynamic process formed by interacting internal cognitive activities and the external environment, through which learners construct a comprehensive cognitive structure containing meaning, attitude, and motivation (1). Gagné creatively put forward the “9 Events of Instruction” model to optimize this process, closely integrating instructional design with human cognitive processing mechanisms and emphasizing the correspondence between external teaching interventions and internal learning stages (2).

Gagné’s 9 Events of Instruction construct a complete teaching loop in a linear sequence, with the core of activating and guiding internal cognitive processing through external events (3). Specifically, the model starts with “Gain Attention” to stimulate learning motivation, then establishes cognitive expectations through “Inform Learners of Objectives”; subsequently, it achieves knowledge connection with “Stimulate Recall of Prior Learning,” inputs new information with “Present Stimulus,” and promotes meaning construction with “Provide Learner Guidance.” In the output phase, “Elicit Performance” tests the level of understanding, “Provide Feedback” reinforces correct responses, “Assess Performance” measures the degree of goal achievement, and finally, “Enhance Retention and Transfer” realizes the internalization and application of knowledge (4). This theoretical framework reveals the scientific logic of teaching activities. It provides a systematic and operable path for modern instructional design, with its influence continuously permeating fields such as educational technology and curriculum development.

The application research of Gagné’s 9 Events of Instruction is mainly focused on university subject studies (5–7). It has broken the traditional teaching design where educators unilaterally impart knowledge and learners passively accept it. Educators, based on different subjects and with learners as the main body, advocate cultivating learners’ interest in learning and giving full play to their initiative during the teaching process. The learning design focuses on breaking down complex knowledge into simple knowledge, making abstract knowledge more tangible, and presenting it in the best way that learners can accept, following a process from easy to difficult, shallow to deep, and step by step (8). In the final stage, assessment and feedback are carried out to point out the existing shortcomings and problems, further deepening learning (9).

Health professions education requires high theoretical learning ability and practical operation skills. At the same time, the content of health professions education courses is more abstract and complex than other subjects, making learning more challenging (10). The traditional teaching method (Lecture-based Learning) is mainly educator-centered, with learners passively listening under the conventional teaching guidance, leading to unstable knowledge mastery and poor overall teaching effect (11, 12). Moreover, the traditional teaching method focuses on textbook content, emphasizing theoretical knowledge while neglecting practical training. This method is increasingly unsuitable for medical teaching emphasizing clinical practice (13).

How to change teaching methods to make complex medical knowledge easy to understand and leave a deep impression on learners with fragmented knowledge is a problem faced by current teaching reform (14). Traditional teaching models can no longer fully adapt to the continuous development of medical education and the rapidly increasing volume of course knowledge. Gagné’s 9 Events of Instruction has achieved good educational results in health professions education (15, 16), but its application is relatively late and lacks high-level evidence. This study aims to evaluate the effectiveness of Gagné’s 9 Events of Instruction compared to traditional medical teaching in health professions education, including KES, PS, LC, and TS.

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (17) and included a systematic review and a meta-analysis. The completed PRISMA checklist is provided as Supplementary material S1. Additionally, this review was conducted by the Cochrane Handbook for Systematic Reviews of Interventions (18).

Contemporary health professions education faces numerous challenges, requiring learners not only to master clinical expertise and skills but also to develop capabilities to adapt to medical advancements and innovations (35). Traditional health professions education predominantly adopts an “educator-led, learner-passive” model (36), which neglects learners’ central role and self-directed learning abilities, often resulting in learners’ failure to apply theoretical knowledge in clinical practice and a significant disconnect between theory and application. Although Gagné’s 9 Events of Instruction has demonstrated positive educational outcomes in higher education systems (37), its implementation in health professions education remains nascent. Primarily, health professions education emphasizes the transmission of foundational knowledge and technical skills while insufficiently fostering learners’ autonomous learning and innovative capacities, leading educators to prefer conventional lecturing methods when selecting pedagogical strategies. Secondly, open and interactive teaching approaches demand educators’ professional competence and advanced classroom management skills, requiring substantial teaching resources to guide and regulate learners’ progress in open-learning environments effectively. Finally, significant disparities exist in medical curricula standards and educational levels across different regions. Consequently, enhancing the quality of medical talent cultivation and improving the effectiveness of health professions education constitutes a critical challenge in contemporary health professions education.

The meta-analysis results demonstrated that compared to the LBL group, Gagné’s 9 Events of Instruction group exhibited significantly higher scores in KES, PS, LC, and TS, indicating that this instructional approach enables learners to transform acquired theoretical knowledge and practical skills into procedural knowledge of intellectual skills and cognitive strategies applicable in clinical practice. Furthermore, by systematically dividing the learning process into nine stages—Gain Attention, Inform Learners of Objectives, Stimulate Recall of Prior Learning, Present Stimulus, Provide Learner Guidance, Elicit Performance, Provide Feedback, Assess Performance, and Enhance Retention and Transfer—the Gagné framework achieves a “spiral learning progression” through iterative guidance, evaluation, and re-evaluation, thereby assisting educators in innovating pedagogical concepts and dynamically adjusting instructional pacing (38). Additionally, given the extensive knowledge domains in health professions education, the LBL method fails to encourage learners to explore their attention, learning, memory, and cognition processes. The meta-analysis revealed that learners in Gagné’s 9 Events of Instruction group demonstrated superior knowledge mastery and enhanced self-directed learning capabilities compared to their LBL counterparts.

The combined effect sizes of KES (SMD 1.55, 95% CI: 0.81–2.29; p < 0.00001), PS (SMD 1.83, 95% CI: 1.19–2.47; p < 0.00001), LC (OR 4.92, 95% CI: 3.13–7.73; p < 0.0001), and TS (OR 7.86, 95% CI: 3.22–19.20; p < 0.0001) demonstrate that Gagné’s 9 Events of Instruction is significantly more effective than traditional LBL pedagogy. This effectiveness likely stems from Gagné’s framework, stimulating learning through external cues, fostering learners’ anticipation for new knowledge and skills, and generating intrinsic motivation (39). The approach proactively mobilizes learners’ self-directed learning initiatives and subjective agency, enabling them to derive intellectual enjoyment from theoretical studies and enhance educational outcomes. Additionally, within conventional teaching environments, learners’ curiosity about this novel instructional model intensifies their learning motivation and engagement, contributing to superior KES and TS achievements. By shifting the paradigm from educator-centered “teaching” to learner-centered “learning,” Gagné’s framework positions learners as active constructors of knowledge and meaning (40). Educators in this model transition from passive knowledge dissemination to prioritizing the stimulation of learning interests, encouraging learners to explore their cognitive processes of attention, knowledge acquisition, memory retention, and critical thinking. Consequently, the intervention group’s pedagogical superiority over traditional LBL methods becomes markedly evident.

When analyzing the KES and PS outcome measures, significant heterogeneity was observed among the included studies. To explore this phenomenon, the outcome measures of KES and PS were stratified into five subgroups: Study design, Training levels, Course type, Course contents, and Majors. Subgroup analysis of the Study design for KES revealed no heterogeneity in the RCT group (I² = 0%), suggesting that heterogeneity in KES may be associated with the Study design. However, significant heterogeneity persisted in KES across subgroups of Study design, Training levels, Course type, and Majors, indicating the minimal influence of these factors on KES heterogeneity.

For PS, subgroup analyses of Training levels, Study design, Course type, Course contents, and Majors also demonstrated persistent heterogeneity, highlighting complex variability across these dimensions. Consequently, future studies should investigate additional potential sources of heterogeneity. Significant heterogeneity in KES and PS remained unresolved after subgroup analyses. Possible explanations include variations in educational proficiency, curriculum structure, assessment difficulty, and learners’ academic capabilities. The intricate interactions among these factors may contribute to outcome variability, underscoring the necessity to rigorously account for these influences in future research designs to enhance consistency and reliability.

In recent years, Gagné’s 9 Events of Instruction has been extensively trialed in higher education and demonstrated efficacy in enhancing health professions education outcomes (41). This instructional strategy employs a nine-phase framework to design learning activities, which helps educators deconstruct and analyze instructional processes to improve learners’ academic achievements in health professions education and supports the establishment of innovative curriculum development concepts. It promotes course innovation, achieves outcome-oriented curriculum construction goals, and fosters the formation of multi-format, diversified instructional models.

However, this systematic review and meta-analysis have several limitations: ① The included studies generally exhibited relatively low quality and small sample sizes, necessitating the inclusion and publication of more large-scale, multi-center, high-quality research. ② Significant heterogeneity in KES and PS may be attributed to factors such as variations in course types, educator proficiency, instructional design, assessment content, and learners’ academic capabilities. ③ Methodological constraints inherent to educational interventions—specifically, the inability to implement allocation concealment or blinding for participants and instructors—may have introduced selection and information biases. ④ Heterogeneity in outcome evaluation metrics across studies limited the analysis of additional shared indicators. ⑤ While standardization challenges across rating systems were mitigated through SMD calculations, incomplete reporting of standard deviations or scoring details in some studies may compromise effect size precision. Future research should adopt standardized rating systems and publicly share raw data to facilitate robust cross-study comparisons.

This systematic review and meta-analysis demonstrates that, compared to LBL, Gagne’s 9 Events of Instruction exhibits significant advantages in health professions education. The method effectively enhances learners’ KES, PS, LC, and TS, with these benefits likely stemming from its systematic design that strengthens cognitive processes and stimulates learning motivation. Despite existing study heterogeneity (e.g., variations in course types and evaluation criteria) and limitations in research quality (such as small sample sizes and methodological biases), the results still support the application value of Gagne’s 9 Events of Instruction in health professions education. Future research should prioritize high-quality, multicenter randomized controlled trials to further validate its long-term efficacy and optimize instructional design, addressing challenges in integrating theory and practice within medical education.