Content area
Objective
This study aimed to evaluate the impact of escape games on nursing students' intravenous (IV) drug administration knowledge and skills while exploring their learning experiences.
BackgroundDrug administration is one of the most critical responsibilities in nursing, requiring knowledge and precision. Traditional teaching methods may not sufficiently address gaps in clinical skills and knowledge retention. This highlights the need for innovative approaches like escape games to enhance student learning, particularly in high-risk tasks like IV drug administration.
DesignA mixed-methods study with an explanatory sequential design was conducted. Methods: The study was conducted with 80 nursing students at the Faculty of Nursing, University X, from March to June 2024. The students were randomly divided into two groups: the intervention group, which participated in escape games designed to reinforce IV drug administration skills, and the control group, which received traditional education. Quantitative data were collected through the Objective Structured Clinical Examination (OSCE) as pre-test, post-test, and follow-up tests. Qualitative data were gathered through semi-structured, face-to-face, in-depth interviews and then analyzed using content analysis.
ResultsQuantitative analyses showed that the intervention group significantly outperformed the control group in post-test and follow-up test scores (p < 0.05). Qualitative findings revealed that students found escape games enjoyable, motivating, and effective in improving knowledge retention and stress management skills.
ConclusionEscape games proved to be an effective method for enhancing nursing students' IV drug administration knowledge, skills, motivation, collaboration, and stress management, supporting their use in nursing education.
Nursing is a health discipline responsible for the planning, implementing, and evaluating care services to protect and improve the health of individuals, families, and communities ( Sümen et al., 2022). Nurses must have professional competence due to their critical role in patient safety ( Dinç., 2010; Sarp, 2018; Sümen et al., 2022). Professional competence and professional self-development in nursing start with undergraduate education and continue throughout working life ( Karahan and Sultan, 2018; Öner et al., 2019).
Raising nurses' awareness of patient safety is very important ( Kim and Lee, 2020). In global nursing education, patient safety is integrated into the curriculum based on health care ( WHO., 2012). However, errors occur frequently in nursing practice, especially in medication administration ( Alzoubi et al., 2023; Baran and Korhan, 2023; Kırşan et al., 2019). These errors are often due to a lack of communication between health professionals ( Mercer et al., 2016; Salmasi et al., 2015). Errors, especially during intravenous (IV) drug administration, can lead to more rapid and severe consequences as the drug enters the circulation directly. These errors can negatively affect patients' health, prolong treatment, and even be fatal ( Seymour et al., 2017; Skidmore-Roth, 2020). Therefore, nursing students must have the necessary medication safety competence before starting clinical practice ( Musharyanti et al., 2019).
Some studies show that nursing students are at risk of making medication errors during clinical rotations ( Bickel et al., 2020; Chenot and Daniel, 2010; Musharyanti et al., 2019). These errors are due to problems such as a lack of accurate drug information, inadequate clinical skills, and inadequate utilisation of the experience of senior nurses ( Jin et al., 2023; Reid-Searl et al., 2010). Most newly graduated nurses do not consider themselves competent to administer medications safely because they have limited knowledge about pharmacology and drug safety ( Adhikari et al., 2014). Nursing students need appropriate role models to ensure medication safety ( Vaismoradi et al., 2011).
Educators must adopt innovative methods to enhance knowledge retention. Escape games, originally for entertainment, are interactive activities improving teamwork, problem-solving, and cooperation ( Rouse, 2017; Veldkamp et al., 2020). Their growing educational use has proven effective in boosting motivation, communication, and teamwork ( Borrego et al., 2017; Veldkamp et al., 2020). Escape games have been widely used in the education of nursing and health professionals in recent years. Fusco et al. (2022) showed that escape games increase information recall in health education ( Fusco et al., 2022). Similarly, Gutiérrez-Puertas et al. (2020) found that these games improved clinical skills and cooperation abilities ( Gutiérrez-Puertas et al., 2020). Escape games are a unique learning technique in nursing education; they improve students' teamwork, motivation, and communication skills and reinforce their critical thinking and problem-solving skills ( Borrego et al., 2017; Veldkamp et al., 2020). Escape games enhance knowledge retention and clinical skills by promoting active participation, problem-solving, and critical thinking while reinforcing teamwork and decision-making ( Borrego et al., 2017; Veldkamp et al., 2020).
Escape games actively engage students in learning, making the experience more effective and memorable ( Borrego et al., 2017; Veldkamp et al., 2020). This study uniquely evaluates nursing students' knowledge, skills, and learning experiences in IV drug administration through escape games, addressing a gap in the literature.
1.1 Hypotheses of the quantitative part of the studyH1: Students who participate in escape games will show significantly higher levels of knowledge on the IV drug administration knowledge test than students who do not.
H2: Students who participate in escape games will demonstrate significantly higher skill levels in the IV medication administration processes on Objective Structured Clinical Examination (OSCE) skill scores than students who do not participate .
1.2 Research questions of the qualitative part of the study- What challenges or obstacles do students face when participating in escape games, and how do they overcome them?
- What specific feelings do students experience at different stages of escape games, and how do these feelings affect their engagement and learning?
- What specific suggestions do the students have for improving the escape games method to make it more effective and enjoyable for future students?
2.1 Study design
This study is a mixed-method study conducted with an exploratory sequential design. This exploratory sequential mixed-method study combined quantitative data on students' IV drug administration skills with qualitative insights into their experiences and emotions during escape games, offering both general outcomes and in-depth perspectives.
2.2 ParticipantsThe study population was first-year Atatürk University Faculty of Nursing students between March and June 2024. The study's quantitative data sample size was calculated in the G-Power 3.1.9.4 programme based on 90 % power, 0.05 significance level, and 0.50 medium effect size. It was determined that there were 72 students, 36 intervention groups, and 36 control groups. To compensate for possible data loss, the sample size was increased by 10 %, and 80 students (40 intervention and 40 control groups) were included in the study ( Suresh and Chandrashekara, 2012). The research was completed without any loss of sampling in the process. Qualitative data were finalised with 20 students by ensuring data repetition and saturation as a result of the interviews.
2.3 Protocol registrationThe quantitative part of the study was conducted as a randomised controlled experimental trial and registered with ClinicalTrials.gov under the number "NCT06487884". The design followed the CONSORT 2010 guidelines ( Saint-Raymond et al., 2010), and the Flow Diagram is presented in Fig. 1.
2.4 Randomisation and blindingOne class was assigned as the intervention group (Branch B) and another as the control group (Branch A) through a lottery among three branches to avoid interaction between groups. Using stratified randomisation based on pre-test scores, 80 students were evenly distributed into groups via random.org, ensuring homogeneity and limiting bias.
Complete blinding was not possible as researchers conducted the intervention. An independent statistician performed statistical analyses for objective data assessment to minimise bias. Researchers acted as observers during the intervention, ensuring students followed procedures without influencing outcomes. Hints were provided equally to all participants per instructions, ensuring fairness.
2.5 Inclusion criteriaTaking the Fundamentals of Nursing course for the first time, not being an exchange programme student, having Turkish as a native language, not having received training in intravenous drug administration, and not being absent during the data collection dates.
2.6 Exclusion criteriaNot participating in the research or wanting to leave the research is to have a graduation (high school, associate degree, bachelor's degree) in a health-related field.
2.7 Data collection tools and featuresThis study's data were collected using qualitative and quantitative data collection tools. The Student Information Form, Intravenous Drug Administration Achievement Test, and Checklist were used for quantitative data, while the Semi-structured Interview Form and voice recorder were used for qualitative data.
2.8 Quantitative data collection tools2.8.1 Student information form
This form, prepared by the researchers in line with the literature ( Aras and Ciftci., 2021; Avşar et al., 2023; Ordu and Caliskan., 2023), consists of 13 questions to determine the sociodemographic characteristics of the students.
2.8.2 Intravenous drug administration achievement testThe researchers prepared this test in line with the literature ( Aştı and Karadağ, 2022; Lynn, 2018). The test includes 20 multiple-choice questions about the outcomes of IV drug applications. The test was sent to 7 faculty members who are experts in the field for evaluation. The content validity of the test was evaluated using the Davis Technique, and the Content Validity Index (CVI) values of the questions were found to be in the range of 0.80–1.00. This shows that the test is valid and usable ( Davis, 1992). The answering time for the questions is 25 minutes, and each question is worth 5 points. The highest score that can be obtained from the test is 100, and the lowest score is 0.
2.8.3 Intravenous drug administration checklistIn the study, the Intravenous Drug Administration Checklist, which was developed by the researcher in line with the literature ( Aştı and Karadağ, 2022; Lynn, 2018) and used in the OSCE exam, was used to evaluate students' professional skills. The objectives of the course content structured this list and consists of four checklists that question the steps of the procedure based on the literature in detail: IV Drug Administration Steps, Withdrawal of Drug from Ampoule, Withdrawal of Drug from Vial, and Initiation of IV Fluid Therapy. The checklists were dichotomised as "observed" and "not observed" on a 100-point system. The observed category was scored as "correct" and "incorrect/incomplete." The content validity of the lists was evaluated using the Davis technique, which took expert opinion, and the CGI values were found in the range of 0.80–1.00. This shows that the lists are valid and usable ( Davis, 1992).
2.9 Qualitative data collection tool2.9.1 Semi-structured interview form and voice recorder
The researchers developed the form to collect qualitative data. Expert opinion was obtained through 6 open-ended questions designed for students to share their experiences and views. In-depth interviews were recorded with a Kingboss digital voice recorder with a memory capacity of 8 GB and a recording capacity of up to 650 hours, and the data were transcribed.
2.10 Data collectionThe researchers collected research data between March and June 2024.
2.11 Quantitative data collectionThe researcher held face-to-face, in-depth interview meetings with the students and informed them about the purpose of the study, the game instructions, and the process. Communication was also maintained via WhatsApp group. The same faculty members and staff provided theoretical and practical laboratory training on IV drug administration. Then, the student's initial skills were evaluated using the OSCE examination method, the Student Information Form, the IV Drug Applications Achievement Test (pre-test), and the IV Drug Applications Checklist.
2.12 Pre-applicationEight randomly selected students were involved in a pre-application to test the comprehensibility of the data collection forms, the questions in the game, and time estimations. These students were not included in the actual implementation. In the pre-application, the completion time of the games was determined to be 45 minutes.
2.12.1 Intervention groupTen groups of four participated in escape games across four stations in the skills laboratory, performing IV drug administration, drug withdrawal from ampoules and vials, and IV fluid therapy based on scenarios. Each station included games like "Crossword Puzzle," "Matching," "Fill in the Blank," and "Spin the Wheel." Clues from hidden boxes at each station formed the password to unlock the final box and escape. As a referee, the researcher corrected mistakes and allowed group members to assist each other. The referee warned players for mistakes and provided hints upon request, adding 30 seconds to the game time per hint. The group with the shortest completion time won a prize. The game's visuals are shown in Image 1. After completing the games, students' skills were assessed using the OSCE method with the IV Drug Applications Achievement Test and Checklist. For the OSCE, four stations assessed students' ability to withdraw medication from ampoules (Station 1) and vials (Station 2), administer IV medication (Station 3), and initiate IV fluid therapy (Station 4). Students had 3–5 minutes per station, completing all tasks within 15 minutes. Two investigators evaluated each student using standardized checklists without intervening. To test the retention of the knowledge acquired by the students, OSCE was administered again four weeks later using the IV Drug Applications Achievement Test (follow-up test) and IV Drug Applications Checklist (follow-up test). According to the literature, the follow-up test can be applied 4–6 weeks after the post-test to test retention ( Akdeniz, 2019; Bilgin and Alper, 2022). All OSCE assessments within the scope of the study were performed in the Skills Laboratory of Atatürk University Faculty of Nursing. The skills of IV drug administration, withdrawal from ampoule, withdrawal from vial, and initiation of IV fluid therapy were evaluated at four stations.
2.13 Escape game completion times and tipsEscape game completion times ranged from 25 minutes 34 seconds to 36 minutes 18 seconds, with groups receiving 0–3 hints during the game.
2.13.1 Control groupWritten informed consent was obtained, and the study's purpose was explained to participants individually. The escape game questions were presented via PowerPoint in the classroom using a traditional question-answer method. An OSCE exam, based on the Intravenous Drug Administration Achievement Test and Checklist, was conducted in the clinical laboratory, with each student individually assessed under standardized criteria. The OSCE was repeated after four weeks to test knowledge retention, ensuring impartiality throughout the process.
2.14 Qualitative data collectionQualitative data were collected by a trained doctoral student (A.K.) through face-to-face, in-depth interviews of 10–15 minutes at Atatürk University Faculty of Nursing. The interviews were conducted in a quiet and appropriate environment outside class hours. Participants were taken to the laboratory individually so they would not influence each other. The participants' permission was obtained by stating that the recordings would only be used for research purposes. The voice recorder was used with the participants' permission, and confidentiality was ensured. The researcher took notes when necessary. Since data saturation was reached, the qualitative part was completed with 20 students. Voice recordings were transcribed. Each student was given a sequence number for anonymity.
Interviews were conducted in a comfortable, quiet, and natural setting to reduce social desirability bias. Confidentiality was ensured through anonymised and coded responses. Participants were interviewed individually, and audio recordings were taken with consent. The researcher avoided leading questions, encouraging candid responses, and all measures aimed to enhance data accuracy and reliability.
2.15 Data evaluationQuantitative data were analyzed using SPSS 22. Sociodemographic characteristics were described with frequency and percentage analyses, and group comparisons were made using Chi-Square, Fisher Exact, and related tests. Normality was evaluated with Skewness and Kurtosis, and t-tests and ANOVA were applied for normal distributions. Bonferroni tests identified differences, effect sizes were calculated with Cohen's d and Partial Eta Square, and regression analysis assessed the escape game's impact, with significance set at 0.05. Theme derivation and validation followed a four-stage systematic content analysis. Data were manually coded, grouped into categories, and structured into coherent themes. The COREQ guide ensured accuracy, and independent researchers verified the themes ( Tong et al., 2007). Regular meetings ensured internal consistency and reliability.
2.16 Integration of qualitative and quantitative dataIn the mixed method design used in the study, the integration of qualitative and quantitative data was carried out by connecting the data. While quantitative data provided measurements of students' IV drug administration skills and knowledge levels, qualitative data were used to examine students' experiences and perceptions of this process in more depth. After the quantitative data were collected, the qualitative data were analysed in the light of these data, and both data sets were used to complement each other. For example, after analysing the students' performances in the skills tests, the emotional experiences and difficulties encountered by the same students in this process were evaluated through qualitative interviews. Thus, a link was established between both forms of data, and the results were analysed about each other.
2.17 Ethical principles of researchEthical approval was obtained from the Atatürk University Ethics Committee (0.01.00/581) and the Faculty of Nursing (E-80131151–000–2400038527). Students were informed about the study's purpose, data confidentiality, and their right to withdraw at any time. The principles of informed consent, volunteerism, and privacy were upheld per the Helsinki Declaration. Participants signed a confidentiality agreement, agreeing not to interact with other groups, and non-compliance would result in removal from the study.
3 Findings3.1 Quantitative findings
In the intervention group, 90 % of the students were between 18 and 20, 72.5 % were female, 57.5 % had a GPA between 2.01 and 3.00, 72.5 % chose the nursing department willingly, and 82.5 % felt they belonged to the profession. In the control group, 75 % found clinical practice adequate, 52.5 % found theoretical knowledge inadequate, 97.5 % had not heard of the escape game method, and 97.5 % liked educational games. In the control group, 82.5 % were between 18 and 20, 67.5 % were female, 70 % had a grade point average of 2.01–3.00, 92.5 % chose the nursing department willingly, and 92.5 % felt they belonged to the profession. 80 % found clinical practice sufficient, 75 % found theoretical knowledge sufficient, 97.5 % had not heard of the escape game method, and 95 % liked educational games. Chi-square analysis showed that the two groups were homogeneous regarding descriptive variables ( Table 1).
In intergroup comparisons, while there was no significant difference between the "Achievement Test" pre-test scores (p > 0.05), the post-test and follow-up test scores were higher and more important in the intervention group compared to the control group (p < 0.05) ( Table 2). Similarly, while no significant difference was found in the pre-test scores of Withdrawal of Medication from Ampoule, Withdrawal of Medication from Vial, IV Drug Administration, and Initiation of IV Fluid Therapy, significant differences were found in favour of the intervention group in the post-test and follow-up test scores (p < 0.05) ( Table 3).
In intragroup comparisons, significant differences were found between the pre-test, post-test, and follow-up test scores of the Achievement Test, Withdrawal of Medication from Ampoule, Withdrawal of Medication from Vial, IV Drug Administration, and Initiation of IV Fluid Therapy in both intervention and control groups (p < 0.05). These differences were generally due to changes between pretest-posttest and pretest-follow-up tests (p < 0.05) ( Table 2, Table 3).
Table 4 presents the findings of the Regression Analysis with Representative Variables conducted to determine the effect of the educational escape game implementation on the dependent variables. The five models were statistically significant (p < 0.05). When the regression coefficients were examined, it was found that the educational escape game had a significant effect on the achievement test (β=0.810, p < 0.001), drug withdrawal from ampoule (β=0.925, p < 0.001), drug withdrawal from vial (β=0. 925, p < 0.001), IV Drug Administration (β=0.927, p < 0.001) and Initiation of IV Fluid Therapy (β=0.970, p < 0.001) ( Table 4).
3.2 Qualitative findingsParticipants' views on game-based learning were grouped under two main themes: “Opinions on Learning with Escape Games” and ”Feelings and Suggestions about the Game.” These themes consisted of five sub-themes and 26 codes: “Preconceptions,” “Game Experiences,” “Favorite Game,” “Emotions” and “Suggestions” ( Table 5). While the first theme included the participants' views on the educational process, the second theme addressed their emotional reactions and suggestions regarding the game process. This structure allows for a clear distinction between the educational and emotional dimensions of the method.
3.3 Subtheme 1: prejudices regarding the gameParticipants expressed concerns and hesitations about the escape game method due to unfamiliarity. Five main prejudices were identified, including "fear of failure," " finding it boring/unnecessary," "concerns about the game's difficulty," " lack of confidence in their knowledge," and "feeling shy or embarrassed." Many participants had no prior knowledge of escape games, and their initial reactions were shaped by a fear of failure and uncertainty about its value in learning.
For instance, one participant remarked:
- • V1: "I thought I could not do the game because I had little knowledge." Others echoed this sentiment:
- • V5: "I thought it would be difficult. So I hesitated, but it was not like that."
- • V14: "Initially, I thought it was an unnecessary game."
- • V19: "I thought my knowledge was insufficient while doing the practices. I was worried about participating because I would be embarrassed by my friends."
These comments reflect a general unease about trying new methods that challenge existing learning paradigms, yet there was a shift once participants engaged in the activity.
3.4 Subtheme 2: game experiencesDespite initial hesitations, participants reported overwhelmingly positive experiences during the games. The subtheme of "Game Experiences" revealed nine distinct codes, such as "measuring/reinforcing knowledge and skills," " teamwork," " gaining speed/practicality," " developing self-confidence," " stress management in emergencies," " learning new information," " learning while having fun," " interacting with different people," and "providing permanent knowledge."
For example, one participant emphasised the value of teamwork:
- • V2: "I saw the importance of teamwork and communication. I had fun and learnt."
Others found that the experience fostered self-confidence and quick thinking:
- • V8: "It was memorable, and gaining new information increased my self-confidence."
- • V17: "The experience I gained at this game's end was speed. My brain was working very fast. I could think of more than one thing at the same time."
These responses highlight how the games reinforced clinical knowledge, improved practical skills, and fostered a collaborative learning environment.
3.5 Subtheme 3: most enjoyed gameParticipants identified tasks they found most enjoyable or impactful during the escape games. Four key activities stood out: "crossword puzzles," " dosage calculations," " withdrawing medication from the ampoule," and "intravenous access."
Some of the participants expressed the activity they enjoyed the most as follows:
- • V4: "The one that affected me the most was opening intravenous access because it is a job that I enjoy."
- • V16: "The game I was most impressed by was dose calculation."
- • V13: "Among the games, I liked the crossword puzzle the most."
Another reflected on the novelty of a task:
- • V10: "The one that affected me the most was withdrawing medication from the ampoule because I had never broken an ampoule before."
These activities provided participants with a hands-on learning experience directly related to clinical skills, making them enjoyable and educational.
3.6 Subtheme 4: feelingsParticipants' emotional responses were also critical aspects of their experiences. The subtheme "Feelings" included five codes: "excitement," " satisfaction," " enjoyment," " motivation/feeling competent," and "panic/stress." Participants described mixed feelings, with excitement and satisfaction being the most frequently mentioned, although some also experienced stress and nervousness.
One participant described their excitement:
- • V2: "It was fascinating. It was a different experience for me."
Others shared their feelings of both stress and enjoyment:
- • V9: "I was very excited, nervous and stressed."
- • V18: "I was stressed and panicked. However, despite all this, I had much fun."
These reflections show how the controlled yet challenging environment of the games provided an emotional space for students to engage with their learning, allowing them to manage stress while building competence.
3.7 Subtheme 5: suggestionsParticipants offered several suggestions for improving the escape game experience in their feedback. Three main ideas emerged under the subtheme "Suggestions," which included "integrating escape games into lessons," " having more stations," and "intervention with real patients." Participants believed incorporating these games into regular practical lessons could further enhance learning while advocating for more complex setups and realistic applications.
One participant suggested:
- • V1: "There should be more games. It can be played by setting up more stations in a larger environment."
Others envisioned expanding the games to real-life scenarios:
- • V16: "We could do it on a real patient. This would require us to be more careful. It would take a little time, but it would be good."
These suggestions demonstrate the potential of escape games to evolve into a more integrated and realistic educational tool, enhancing cognitive and practical learning.
4 DiscussionThe study's findings, which were conducted to determine the knowledge, skill levels, and learning experiences of nursing students in IV drug administration with escape games, were compared and interpreted with those of other studies in the literature. The study found that escape games effectively enhance nursing students' knowledge, skills, and retention in IV drug administration. These games surpassed traditional engagement and information retention methods by promoting active learning, critical thinking, and teamwork. Students described them as both enjoyable and instructive, facilitating the practical application of concepts.
The fact that the intervention group's post-test and follow-up test scores were statistically higher than the control group proves that escape games are compelling. Similarly, Fusco et al. (2022) observed that escape games improved the ability to recall information, Millsaps et al. (2022) observed that it increased acute stroke knowledge when used with simulation, and Kubin (2020) observed a 60 % increase in students' knowledge levels after the activity ( Fusco et al., 2022; Kubin, 2020; Millsaps et al., 2022). While qualitative findings showed that escape games increased IV drug administration knowledge, ensured knowledge retention, and reinforced learning through peer communication, Morrell and Eukel (2020) determined that these games increased knowledge of the cardiovascular system and improved student engagement ( Morrell and Eukel, 2020). The findings show that escape games effectively enhance students' knowledge, skills, critical thinking, and problem-solving in clinical education.
In this study, escape games were found to play an essential role in the clinical skill development of nursing students. The intervention group's post-test and follow-up test scores were significantly higher than the control group, indicating that escape games are effective on psychomotor skills and support the permanent learning of these skills. Bayram and Caliskan (2019) emphasised the importance of active teaching methods in psychomotor skills training, while Gutiérrez-Puertas et al. (2020) and Fusco et al. (2022) reported that escape games improve clinical skills and cooperation skills ( Bayram and Caliskan, 2019; Fusco et al., 2022; Gutiérrez-Puertas et al., 2020). Gómez-Urquiza et al. (2019) stated that escape games enable students to learn by having fun and increasing technical competencies ( Gómez-Urquiza et al., 2019). The findings show that escape games are effective in nursing education, improving psychomotor skills, teamwork, and decision-making under stress, while allowing students to apply theoretical knowledge in practice.
This study also interacts with students' theoretical and practical skills by revealing the significant relationship between IV drug administration knowledge and skill scores . The need for studies examining this relationship with escape games in the literature emphasises that this study makes an innovative contribution and that more research is needed. In this direction, although their methods were not similar, Lee et al. (2016) did not find a positive relationship between knowledge and skill scores in their study examining the effects of mobile video clips on learning motivation and competence in nursing students ( Lee et al., 2016). Eren et al. (2020) found a weak positive relationship between knowledge and skill scores in a study examining nursing students' knowledge and skill levels in peripheral IV catheter placement ( Eren et al., 2020). The diversity in research findings may result from varying methods and tools. Escape games enhance knowledge and skill integration by offering an active learning environment, though their effectiveness should be validated in other settings. This contrast underscores the value of diverse educational methods, with escape games potentially offering unique advantages over traditional or digital approaches.
The qualitative data showed students felt excited, satisfied, and motivated during escape games, though some experienced stress and panic. Teamwork and problem-solving tasks boosted confidence, while time constraints added pressure but enhanced learning. Escape games reinforced theoretical and practical knowledge, promoting long-term retention and improving problem-solving skills.
Macías-Guillén et al. (2021) found that students found escape games fun, and their motivation increased ( Macías-Guillén et al., 2021). Cain (2019) stated that these games increase participation in discussion and problem-solving processes and provide high satisfaction ( Cain, 2019). Escape games effectively build knowledge, skills, and student motivation. While challenging scenarios may cause panic and stress, they also foster emotional resilience. Thus, incorporating escape games into education can support cognitive and emotional development, helping students manage stress in a controlled environment.
4.1 Limitations of the studyThe study's limitations include that it was conducted in a single centre, that not all parameters could be controlled during the research process, and that students could access information on the subject through different platforms. In addition, the study could not be fully blinded because the researchers conducted the intervention and acted as referees during the escape games. This may carry a particular potential for influence due to the involvement of the researchers in the process. However, to minimise this effect, the data were analysed by an independent statistician unfamiliar with the distribution of the groups. Although the inability to complete blinding is considered a methodological limitation, the careful implementation of the randomisation process and the use of independent statistical analyses are essential steps to increase the reliability of the study's results.
4.2 Conclusion and recommendationsThis study demonstrated that escape games effectively enhanced nursing students' knowledge and skills in intravenous drug administration, with significantly higher post-test and follow-up scores in the intervention group, supporting long-term skill retention. Qualitative findings indicated that positive emotional reactions during the games boosted motivation and learning. Escape games are recommended for broader use in nursing education, with suggestions to explore long-term effects and enrich scenarios with diverse clinical cases. Practical challenges, such as resource needs, time management, and trainer preparation, should be addressed through material adaptation, short modules, and trainer training. Multicenter studies with diverse samples are advised to assess escape games' broader educational and clinical benefits.
4.3 Relevance to clinical practiceIntegrating escape games into nursing education enhances clinical skills, critical thinking, teamwork, and confidence by allowing students to apply theoretical knowledge in dynamic settings. The findings show improved cognitive, psychomotor, stress management, and decision-making skills, suggesting their inclusion in curricula could develop competent healthcare professionals and improve patient care. Further research is needed to explore their long-term impact and optimise use in varied contexts.
Funding sourcesThis work was supported by Atatürk University Scientific Research Projects Coordinatorship with grant number TDK-2023–12991.
CRediT authorship contribution statementAsena KÖSE: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Gülay İPEK ÇOBAN: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization.
Declaration of Competing InterestThe authors declare no potential conflicts of interest concerning this article's research, authorship, and publication.
AcknowledgementThe authors thank all students who participated in the study and the Atatürk University Scientific Research Projects Coordination Office for their financial support.
Appendix A Supporting informationSupplementary data associated with this article can be found in the online version at doi:10.1016/j.nepr.2024.104228.
Appendix A Supplementary materialSupplementary material
Supplementary material
Supplementary material
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| Age | 18–20 | 36 | 90.0 | 33 | 82.5 | x
2= 0.949
p = 0.330 a |
| 21 and above | 4 | 10.0 | 7 | 17.5 | ||
| Sex | Female | 29 | 72.5 | 27 | 67.5 | x
2= 0.238
p = 0.626 a |
| Male | 11 | 27.5 | 13 | 32.5 | ||
| Grade average | 1.00–2.00 | 1 | 2.5 | 4 | 10.0 | x
2= 4.761
p = 0.099 c |
| 2.01–3.00 | 23 | 57.5 | 28 | 70.0 | ||
| 3.01–4.00 | 16 | 40.0 | 8 | 20.0 | ||
| Have you heard of the escape game before | Yes | 1 | 2.5 | 1 | 2.5 | p = 1.000 b |
| No | 39 | 97.5 | 39 | 97.5 | ||
| Liking to play educational games | Yes | 39 | 97.5 | 38 | 95.0 | p = 1.000 b |
| No | 1 | 2.5 | 2 | 5.0 | ||
| Willingness to come to the nursing department | Yes | 29 | 72.5 | 37 | 92.5 | |
| No | 11 | 27.5 | 3 | 7.5 | ||
| The feeling of belonging to the profession | Yes | 33 | 82.5 | 37 | 92.5 | x
2= 1.829
p = 0.176 a |
| No | 7 | 17.5 | 3 | 7.5 | ||
| Feeling competent in clinical practice | Yes | 30 | 75.0 | 32 | 80.0 | x
2= 0.287
p = 0.592 a |
| No | 10 | 25.0 | 8 | 20.0 | ||
| Finding theoretical knowledge sufficient for practice | Yes | 19 | 47.5 | 30 | 75.0 | |
| No | 21 | 52.5 | 10 | 25.0 | ||
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| | | | | | ||
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| | | 53.25 ± 10.35 | 50.75 ± 8.44 | 1.184 | 0.240 | 0.265 |
| | 74.00 ± 10.93 | 53.75 ± 9.72 | | | | |
| | 75.38 ± 11.57 | 49.38 ± 9.61 | | | | |
| | 1–2, 1–3 | 1–2, 2–3, 1–3 | ||||
| | | | | |||
| | | |||||
| | | | | | ||
| | | |||||
| | ||||||
| | | 51.30 ± 7.55 | 49.05 ± 7.00 | 1.382 | 0.171 | 0.309 |
| | 82.85 ± 8.65 | 51.90 ± 7.44 | | | | |
| | 83.40 ± 8.46 | 50.35 ± 6.38 | | | | |
| | 1–2, 1–3 | 1–2, 1–3, 2–3 | ||||
| | | | | |||
| | | 52.45 ± 7.21 | 49.95 ± 6.43 | 1.637 | 0.106 | 0.366 |
| | 83.05 ± 7.67 | 51.90 ± 7.58 | | | | |
| | 83.50 ± 7.87 | 50.25 ± 6.75 | | | | |
| | 1–2, 1–3 | 1–2, 1–3, 2–3 | ||||
| | | | | |||
| | | 57.50 ± 5.74 | 55.75 ± 5.98 | 1.335 | 0.186 | 0.299 |
| | 83.00 ± 7.62 | 56.96 ± 6.55 | | | | |
| | 83.20 ± 7.16 | 52.65 ± 5.15 | | | | |
| | 1–2, 1–3 | 1–2, 1–3, 2–3 | ||||
| | | | | |||
| | | 29.15 ± 6.09 | 30.34 ± 4.91 | −0.960 | 0.340 | 0.215 |
| | 67.30 ± 6.39 | 33.80 ± 5.13 | | | | |
| | 66.98 ± 6.42 | 32.25 ± 4.82 | | | | |
| | 1–2, 1–3 | 1–2, 1–3, 2–3 | ||||
| | | | | |||
| | | | | | | | |
| | 1 | Constant | 46.375 | 1.681 | 27.584 | | |
| Educational Escape Game Application - Intervention | 29.000 | 2.378 | 0.810 | 12.197 | | ||
| | |||||||
| | 1 | Constant | 47.350 | 1.185 | 39.960 | | |
| Educational Escape Game Application - Intervention | 36.050 | 1.676 | 0.925 | 21.513 | | ||
| | |||||||
| | 1 | Constant | 48.250 | 1.159 | 41.628 | | |
| Educational Escape Game Application - Intervention | 35.250 | 1.639 | 0.925 | 21.505 | | ||
| | |||||||
| | 1 | Constant | 52.650 | 0.986 | 53.395 | | |
| Educational Escape Game Application - Intervention | 30.550 | 1.394 | 0.927 | 21.908 | | ||
| | |||||||
| | 1 | Constant | 32.250 | 0.897 | 35.935 | | |
| Educational Escape Game Application - Intervention | 44.725 | 1.269 | 0.970 | 35.239 | | ||
| | |||||||
| | | | |
| | | Fear of failure | 1, 5, 6, 7, 9, 10, 11, 18 |
| Finding it boring/unnecessary | 3, 6, 13, 14, 15, 20 | ||
| Concerns about the game's difficulty | 1, 2, 5, 8, 9 | ||
| Lack of confidence in their knowledge | 1, 4, 9, 18, 19 | ||
| Feeling shy or embarrassed | 5, 8, 11, 19 | ||
| | Measuring/reinforcing knowledge and skills | 1, 3, 5, 6, 7, 9, 10, 11, 15, 16, 18, 19, 20 | |
| Teamwork | 2, 5, 6, 7, 8, 9, 11, 13, 16, 17, 20 | ||
| Gaining speed/practicality | 4, 5, 9, 10, 14, 17, 18, 20 | ||
| Developing self-confidence | 3, 6, 8, 12, 15, 16, 20 | ||
| Stress management in emergencies | 4, 5, 9, 12, 14, 19 | ||
| Learning new information | 8, 11, 12, 13, 14, 19 | ||
| Learning while having fun | 2, 7, 13, 17, 19 | ||
| Interacting with different people | 2, 3, 6, 11, 15 | ||
| Providing permanent knowledge | 7, 8, 9, 17 | ||
| | Crossword puzzle | 1, 2, 8, 9, 13, 14, 18, 19, 20 | |
| Dosage calculations | 3, 5, 7, 15, 16, 17 | ||
| Withdrawing medication from the ampoule | 3, 10, 16 | ||
| Intravenous access | 1, 4, 12 | ||
| | | Excitement | 1, 2, 3, 4, 5, 7, 8, 9, 10, 12, 15, 17, 19 |
| Satisfaction | 1, 2, 3, 5, 7, 8, 9, 10, 14, 15, 16, 19, 20 | ||
| Enjoyment | 7, 13, 17, 18, 19, 20 | ||
| Motivation/feeling competent | 5, 11, 14, 20 | ||
| Panic/stress | 3, 9, 15, 18 | ||
| | Integrating escape games into lessons | 1, 2, 4, 7, 12, 13, 14, 16, 17, 19 | |
| Having more stations | 1, 4, 5, 6, 9 | ||
| Intervention with real patients | 3, 6, 14, 16 |
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