The digital escape room developed for nursing students: GestDia

Abstract

Background

Digital escape rooms have been developed during the pandemic, which improves students’ cooperation, communication skills, and critical thinking skills, effects on learning in nursing education.

Method

This study aimed to evaluate the GestDia escape room to assess students’ motivation and self-confidence in learning. A descriptive quantitative interventional study was carried out. The study population was nursing students in their third semester (n = 45). The students filled out the Instructional Materials Motivation Survey and Student Satisfaction and Self-Confidence in Learning Scale.

Results

The mean scores obtained from motivation, satisfaction, and self-confidence scales were generally higher. Males scored higher on all scales than females, though these differences were not statistically significant (p > 0.05).

Conclusion

In general, although games increase students’ motivation, satisfaction, and self-confidence, they can lead to gender differences. In the digital world, integrating escape rooms into nursing education can add joy to students’ learning process.

Introduction

The education sector has begun to adopt various innovative methods in recent years, which align with the expectations of the new generation and the rapid increase in digitalization. Technology-based methods such as gamification, virtual reality, and digital games are becoming increasingly popular. These methods make learning more interactive and fun, allowing students to maintain attention longer and absorb information more effectively. Generation Z, the young generation, benefits significantly from such educational tools thanks to their predisposition to technology and natural interest in digital content [1].

In higher education, role-playing, simulations, card games, board games, and video games are all effective methods [2]. These methods enable students to apply theoretical knowledge practically and interactively, encouraging more active participation in the learning process. In nursing education programs, developing students’ critical thinking and practical problem-solving skills after they have basic knowledge is considered a critical professional dimension. Without this foundational knowledge, nurses may have difficulty applying their skills effectively [3].

Gestational diabetes is a condition that occurs during pregnancy and usually disappears after birth, but it carries serious health risks for both mother and baby. Therefore, the need for healthcare personnel specializing in this field is increasing [4]. Gestational diabetes nursing education is an important topic addressed in the Obstetrics and Gynaecology course in the nursing curriculum. However, this issue is often overlooked among nursing students as it is rare in the hospital. Students are mostly Generation Z, and their learning preferences explain their lack of interest in traditional teaching methods and their preference for interactive, technology-enabled learning experiences.

Educational escape rooms

Escape rooms are defined as live-action team-based games where players discover clues, solve puzzles, and accomplish tasks in one or more rooms within a limited time frame, typically aiming to achieve a specific goal, often by escaping from the room [5]. While most escape rooms are typically used for entertainment purposes, their usage in educational settings has gained prominence in recent years. Educational escape rooms have been utilized across various disciplines, resulting in observed increases in students’ levels of knowledge, communication, critical thinking, decision-making abilities, and learning motivation [6,7,8]. In recent years, many educators have begun developing digital escape rooms utilizing digital tools, primarily due to their cost-effectiveness and accessibility [9]. In digital educational escape rooms, players also solve a series of puzzles independently or collaboratively to achieve the goal of escaping from a virtual environment.

Escape rooms in nursing education

In nursing education, attention has been drawn to the importance of self-directed and lifelong learning in developing the skills and attitudes required in complex and ever-changing healthcare environments to meet professional development needs [10, 11]. In this context, game-based learning methods in nursing education are becoming increasingly popular in education systems. One of the reasons for this is that learning through games provides a game-play experience that motivates students [12]. Escape rooms as serious games are innovative and versatile tools for acquiring professional qualifications in higher education that can be used in various subjects and other teaching methods [13]. The purpose of the escape room is to make it easier for the student to reach the goals of the course and the program by using a theoretical framework at its core [14,15,16].

Escape rooms are used in two different ways, physical and online. Physical escape rooms, where the environment is used as part of the scenario, have been shown to increase clinical reasoning, collaboration, and prioritization skills, but transforming an entire room may not be practical [17, 18]. Digital escape rooms (DER) have been designed, developed, and delivered during the pandemic, positively affecting learning in nursing education [16, 19]. For this reason, online escape rooms are more convenient and easier to access than physical escape rooms. It has shown us how important online simulation methods are in increasing the quality of education during the pandemic period. For this reason, the effectiveness of the online escape room was evaluated in our study.

Among the existing studies related to escape rooms, adult nursing [20], cardiac nursing [14], obstetric nursing [21], sepsis [22], student anxiety [15], quality and safety education in nursing [20], students’ opinions and motivation [23], teamwork and communication [24, 25], stroke recognition [3], anatomy [26], pathophysiology [27], therapeutic communication [28], and nurse practitioner [29] are included. In these studies, it has been determined that escape rooms can help students improve their problem-solving, communication [25], collaboration, and critical thinking skills [30], while also enhancing their confidence and promoting learning [31].

Escape room in obstetrics and gynecology nursing

In the Obstetrics and Gynecology Nursing Course, students are provided with a teaching environment that will enable them to develop cognitive, affective, and psychomotor behaviors. In this context, the student aims to provide the necessary knowledge and skills for the protection and promotion of the health of women, fetuses, and newborns [32]. The variety and frequency of practice are essential in transforming students’ knowledge theoretically in the course environment into behavior in clinical practice areas. Clinical practices allow students to experience different cases and contribute to developing knowledge and skills. However, due to the high number of students in Turkey, there are difficulties in clinical practice. The most important of these difficulties is that, due to needing more specific case examples related to Obstetrics and Gynecology Nursing, the student cannot perform appropriate nursing care and cannot have sufficient experience after graduation. As a result, it adversely affects the patient’s treatment, nursing care, patient privacy and safety, and hospitalization times. In addition, the fear of making mistakes caused by practicing on real individuals without feeling ready enough causes students to experience anxiety. Educators must understand students’ learning processes and know how to transfer practical applications to the clinical setting. In today’s conditions, where knowledge, skills, and attitudes are constantly renewed, nursing education should be designed by the era [33, 34]. Accordingly, educators should focus on escape room designs, recognizing the importance of motivation in engaging students in effective learning [29].

From research completed in nursing education, the use of escape rooms has been implemented globally, but their use remains limited in Turkey. There is only one study widely cited internationally regarding the use of escape rooms in Obstetrics and Gynecological Nursing education [35]. In addition to this, another study that applies an escape room in the maternity area was conducted by Yang, Chang, and Jen (2023), who developed an online escape room learning activity [36]. Their study concluded that escape rooms are an effective teaching strategy that fosters problem-solving and critical thinking skills, supports teamwork and communication, and provides educators with opportunities to assess clinical skills. However, no studies have yet been conducted in Turkey on this subject. Therefore, the current study is considered unique and was designed to add to the existing global body of research and to contribute to the literature by offering a perspective from Turkey to enhance overall validity. In this context, the aim of this research is to develop, implement, and evaluate an innovative teaching strategy for the Obstetrics and Gynecology Nursing course.

Materials and methods

A single-group quasi-experimental study was carried out. The study is a single group semi-experimental study using post-test. The study population was nursing students (Turkey). All participants were third semester nursing students (n = 200). The nursing undergraduate program in Turkey lasts four years. The students participating in this study were third-semester students who had completed their foundational nursing courses and had begun their specialty courses, including obstetrics and gynecology nursing. The participants were selected based on the research purpose, the available resources in conducting the intervention with a web-based escape room, and the willingness of the students enrolled in “Obstetrics and Gynecology” (n = 45) to conduct the intervention. The study sample consisted of students who had knowledge of gestational diabetes in the Obstetrics and Gynecology Nursing course and had no prior escape room experience. The escape room was not included in the course average, and no financial reward or other incentive was offered.

Procedure

GestDia is a digitally enhanced escape room game on the topic of gestational diabetes (GDM). Web-based escape rooms were developed and evaluated to investigate whether digital escape rooms can influence the motivation to teach about GDM.

The escape rooms were developed on the internet as they are easily accessible and can be used without the problem of time and place. The escape rooms were created using Genially’s digital platform, which allows the creation of click-and-point rooms, thus favoring the creation of an interactive experience that promotes student immersion. To create the scenarios proposed in the Escape Room, images and illustrations from the FreePik and Giphy resource bank were used, for which there is a premium license for free use (Figs. 1, 2 and 3).

The main advantage of placing the escape room on the Internet is that all nursing students experience the game at the end of the investigation.

The steps to realize the escape room is as follows:

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A face-to-face course was given at the university. The game master explained in general what the escape room is, how the Genially platform is used, and how this escape room is collaborative.

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Students were given one week to play the game individually whenever and wherever they wanted.

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The game administrator shared his phone number during the entire escape room implementation period in case students were contacted to ask for technical support. There was no limit to the number of clues, as it was important for them to feel like they could get feedback and get out of the escape room even if they had never played before.

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After the students passed the final test and managed to get out of the escape room, they individually completed the post-test questionnaire.

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Design of the escape room game

GestDia was designed to facilitate access to the patient and prevent adverse outcomes due to the fire by providing the necessary information in the patient file, specifically for individuals diagnosed with gestational diabetes who were present in the same room at the time of the hospital fire. GestDia is accessible on Genially by following the subsequent link:https://view.genial.ly/629341fa3a832e00117be4a9/interactive-content-gestasyonel-dm.

In GestDia, nursing students successfully solved four puzzles within a 10–15 min timeframe. The game’s content was conveyed through lectures, activities, and case studies. No new information was introduced during the game to enhance student confidence and facilitate progress. Students received the escape room link via email. They began by viewing a narrative video depicting a patient’s arrival at the hospital. Following that, the game rules were outlined. Students completed four puzzles, which included multiple-choice questions and clinical reasoning activities related to gestational diabetes management, insulin administration, and nursing interventions. To solve the puzzles, students gathered clues such as patient files, lab results, and vital signs within the patient’s room. Feedback was provided to students for incorrect answers. A countdown feature was integrated into the game, requiring students to solve the puzzles within a set timeframe.

Outcomes and measurements

Upon finishing the game, students could access the data collection tools by clicking on a link provided after the game. The following data collection tools were used to gather the data. Participant characteristic form: The participant characteristics form consists of four questions regarding student’s age, gender, previous digital gaming experience and prior knowledge levels regarding gestational diabetes.

Instructional Materials Motivation Survey (IMMS) was originally developed by Keller (2010) and comprises 33 items classified into 4 dimensions (Attention, Relevance, Confidence, Satisfaction). Each item is rated on a scale from 1 (not true) to 5 (very true). and the lowest possible score is 33, and the highest is 165 [37]. The Turkish version of the scale cronbach’s alpha for the scale is 0.93, with subdimensions ranging from 0.74 to 0.83 [38].

The Student Satisfaction and Self-Confidence in Learning Scale (SSSCLS) was used to assess the students’ satisfaction and self-confidence in learning. The scale was originally published by the National League for Nursing (2006) and comprises 13 items classified into 2 dimensions [39]: Satisfaction with instruction, 2) Self-confidence with learning. Each item is measured on a Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree) and a minimum score of 13 and a maximum is 65. The Turkish version of the scale Cronbach’s alpha for the whole scale is 0.88, ranging from 0.83 to 0.84 for each separate dimension [40].

Data analysis

An online survey created with Google Forms was utilized to gather data. The current study’s calculation criteria were the students’ overall scale and sub-dimension scores. In order to choose which analyses to use, the Shapiro-Wilk normality test was used for the scale scores. The test revealed that the scale results did not support the normalcy test hypotheses. Non-parametric tests were thus applied throughout the analysis phase. While the categorical variables (gender, prior knowledge, and experiences with the games) were tabulated as frequencies with percentages, the descriptive data (age, IMMS, SSSCLS, and SDS scores) were given by means and standard deviations (SD). The mean scores of all scales were compared using the Mann-Whitney U test. All analyses were conducted using SPSS 25.0 software, and the level of statistical significance was set at p < 0.05.

Results

A total sample of 45 student nurses participated in this study. The participants’ mean age was 21.4 ± 1.2 years. A total of 45 nursing students participated in the study, of whom 86.7% (n = 39) were female and 13.3% (n = 6) were male. Regarding prior digital gaming experience, 31.1% (n = 14) of the students reported frequent engagement with digital games, 48.9% (n = 22) indicated occasional use, and 20% (n = 9) had no previous gaming experience. When asked about their prior knowledge of gestational diabetes, 17.8% (n = 8) stated they had detailed knowledge, 60% (n = 27) had superficial knowledge, and 22.2% (n = 10) reported having no prior knowledge. All participants (100%) stated that they had never previously participated in an educational digital escape room activity. All students were in their third year of the nursing undergraduate program.

The Instructional Materials Motivation Survey, and Satisfaction and self-confidence in learning scale points are presented. The results from the scales and their sub-dimension scores are presented in Table 1. The mean scores obtained from all the scales were generally higher scores. Males scored higher on all scales than females, though these differences were not statistically significant (p > 0.05).

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Discussion

Digital escape rooms are an effective method for reinforcing educational content on gestational diabetes. However, to our knowledge, this is the first on Gestational Diabetes subject must be published in the literature. This study presents the design and implementation of this subject digital escape room conducted with a limited and small sample group. The research focused specifically on identifying the design stages of the escape room and evaluating the perceptions and feedback received from student nurses upon completing this educational activity. This innovative method has the potential to revolutionize nursing education. It will reinforce subject-specific knowledge, critical thinking, and communication skills.

The participants’ overwhelmingly positive motivation, satisfaction, and self-confidence align with the literature on escape rooms, which describes them as enjoyable and engaging. Every student who participated well received the current gestational diabetes-themed escape room. This is aligned with the literature, which also reports that students embraced previously developed educational escape rooms positively [7, 22, 23]. Escape rooms games that incorporate fun and enjoyment are the key to encouraging and motivating learners to participate enthusiastically [41].

While male students scored higher on all scales compared to female students, it is important to note that these differences were not statistically significant (p > 0.05) and should be interpreted with caution due to the small male sample size (n = 6) compared to females (n = 39). These non-significant trends may reflect various factors such as technological familiarity, gaming experience, or chance variation, but cannot be considered meaningful differences based on the current study design.

Some contextual factors may help explain these observed trends. According to data from the Turkish Statistical Institute, the rate and duration of digital game play are generally higher among males compared to females. This greater exposure to digital environments may contribute to increased familiarity and confidence in technology-based activities such as the online escape room. Additionally, existing literature suggests that male nursing students may exhibit higher self-perceived leadership and confidence traits in both professional and gamified settings. A recent study by Kotp et al. (2025) found that male nursing students demonstrated significant improvements in leadership and confidence through participation in gamified simulation-based education [42]. These gender-based differences in self-perception and engagement with technology may have influenced the self-reported outcomes in this study; however, given the lack of statistical significance, these interpretations remain speculative and warrant further investigation with a larger and more balanced sample.

Attention and trust sub-dimensions of the motivation scale related to instructional materials are associated with perceived intrinsic motives such as curiosity, rules, and challenge. Malone and Lepper (2021) stated that within the framework of intrinsic motivation, the most important motivation for playing educational games is generally the element of challenge [41]. This study applied challenge mechanics to address motivational emotions in the design of GestDia. Previous research has shown that men’s motivation to play computer games tends to be higher than women’s. Consistent with these findings, higher scores by male students in the sub-dimensions of attention and trust in this study support this view.

Equality of internet access and participation between genders is also a factor that may explain why male students score higher on motivation and satisfaction scales compared to female students. In contemporary settings, there is little difference between genders in terms of internet access; however, the difference lies in the willingness to participate in internet-based activities. A meta-analysis has reported that despite equal access, female users have a lower representation in online activities, including gaming. Moreover, the analysis suggests that women’s interest and curiosity towards online games tend to be lower compared to men [43].

Conclusion

The study found that student nurses reported high levels of motivation, satisfaction, and self-confidence after participating in the GestDia online escape room activity. However, due to the absence of a pre-test or control group, causal inferences regarding the effect of the intervention cannot be made. The findings suggest positive student perceptions of this innovative teaching method, but further controlled studies are needed to establish its educational effectiveness.

Limitations

This study has several significant limitations that affect the interpretation and generalizability of findings:

Study design limitations

The absence of a control group limits the ability to attribute improvements in motivation and self-confidence directly to the GestDia escape room intervention. Without pre-intervention measurements, we cannot determine whether observed scores represent actual changes or baseline student characteristics.

Sample limitations

The study was conducted on a small (n = 45) and homogeneous sample group of third-semester nursing students from a single university, which significantly limits the generalizability of results to broader and more diverse nursing student populations.

Methodological limitations

The study’s exploratory design using freely accessible Web 2.0 tools was determined by participant convenience rather than rigorous sampling methods. This introduces potential self-selection bias, as students who opted to participate may have had greater interest in technology-based learning.

Measurement limitations

The study evaluated only immediate post-intervention effects using self-report measures. Long-term knowledge retention and actual learning outcomes were not assessed, limiting conclusions about educational effectiveness.

Demographic considerations

While gender differences emerged in the data, the small male sample size (n = 6) compared to females (n = 39) limits the reliability of these comparisons. Other demographic and psychosocial variables that might influence learning outcomes were not adequately controlled.

Temporal limitations

The study represents a single-point assessment without follow-up to evaluate sustained effects or knowledge retention over time.

Data availability

The data are available upon request to the corresponding author after signing appropriate documents in line with ethical application and the decision of the Ethics Committee.

Abbreviations

DER:

Digital escape rooms

GDM:

Gestational Diabetes

IMMS:

Instructional Materials Motivation Survey

SSSCLS:

Student Satisfaction and Self-Confidence in Learning Scale

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