Innovative Methodologies in University Teaching: Pilot Experience of an Escape Room in Nursing Students

Abstract

The presence of playful elements in learning environments is increasingly frequent in university settings. The objective of this study was to evaluate the gaming experience of the participants of an escape room activity developed in the second year of the Bachelor of Science in Nursing program. An escape room activity was carried out, based on 10 tasks, on the thematic content of the subject ‘History, Theory and Methods of Nursing II’, with students in the second year. After the game experience, the Gameful Experience Scale (GAMEX) questionnaire of 27 items in the validated version in Spanish and for nursing students was applied. An open-ended question was also included to allow the students to give their opinion on aspects of improvement, or their feelings during their performance, and a thematic analysis was utilized for this qualitative approach. A total of 107 students participated in the escape room activity, and 75 individuals acceded to the request to be surveyed. The results in the Enjoyment dimension showed that five of the six questions were assessed with the maximum score by the majority of respondents. In the Absorption dimension, between 15% and 25% of the sample did not manage to abstract themselves from the real world. In the dimensions of Creative Thinking and Activation, up to 70% managed to feel imaginative, creative, or exploratory, feeling active and excited. Nearly 85% of the sample reported the Absence of Negative Affect (hostility, annoyance, or frustration) during the game. In the Dominance dimension, up to 70% of the sample considered feeling influential during the game. Two categories were identified after analyzing the participants’ responses: room for improvement in the activity and feelings during the activity. In conclusion, the escape room is positioned as a useful tool for university teaching in nursing. This didactic game allows students to have fun while learning, and to value the knowledge and techniques provided by the subject while being able to work as a team.

1. Introduction

Innovation in teaching methodologies is one of the keys to improving the competencies obtained by nursing students in university classroom teaching [1]. To this end, in recent years, numerous strategies have emerged that aim to redesign the way of teaching in the university context [2,3]. This trend has made creative techniques, such as the presence of games or playful elements in learning environments, more and more frequently [4,5]. Gamification is a growing tool in recent years that uses game elements in non-playful contexts to make the experience feel like a game and engage users [5,6]. Thus, interest in educational games is growing [1] because, through motivation, students’ attention and thinking can be captured in the classroom [3,5].

In this way, the use of so-called ‘serious games’ can be beneficial for clinical reasoning and decision-making [7,8], thus being useful and satisfactory for students [5], and complementary to traditional practice and training in other simulations [9,10]. One of the examples of serious games is the escape room game. This innovative pedagogical approach is based on problem-solving and focuses on the student’s autonomous learning competencies to resolve a realistic or fictitious situation posed by the teacher. The escape room methodology is based on a series of stages where students must resolve challenges, questions, or enigmas in order to access the next challenge. To conclude, a definitive test permits the participants to escape, solving the situation posed at the beginning of the activity. Participants have to find a solution collaboratively [11], and they have a specific and limited time to do so [3].

In the context of education, different experiences have already been noted following the introduction of escape rooms as instruments to increase motivation for learning in the university teaching context [12,13], and, specifically in the region of Andalusia (Spain), different approaches based on escape room activities have also been followed with nursing students [1,5]. One case is found in Seville, where this activity has been carried out at the Red Cross University Nursing Center, within the course ‘History, Theories and Methods of Nursing II’, taught in the second year of the Bachelor of Science in Nursing program. After the execution of this escape room activity with nursing students, interest arises in assessing the participants’ gameful experience [11] regarding the positive emotional implications and qualities involved in using a gamified activity in a non-game context [6]. The assessment of the experience with the game will allow the lecturer to refine the design of the activity, and, therefore, this evaluation should be carried out using validated methods to determine whether the proposal has been truly successful and to what extent it has fostered meaningful learning. Hence, the objective of this pilot study was to evaluate the gameful experience of nursing students in an escape room activity in the university teaching context.

2. Materials and Methods

2.1. Study Design

The procedure was carried out in two phases. In the first, an escape room activity was performed with the students during the already scheduled university class (two hours) at the end of the semester, and, after the game, a short, descriptive and cross-sectional study was carried out using an online survey method.

2.2. Context and Participants

A total of 107 students participated in the escape room activity, and they were asked to participate in the survey after the game. All participants were enrolled in the Bachelor of Science in Nursing program at the Red Cross University Nursing Center of Seville, and were taking the subject ‘History, Theory and Methods of Nursing II’, taught in the first semester of the second year. The escape room activity was not compulsory for the academic program and students attended this activity voluntarily, although the event was promoted in previous days to increase students’ motivation.

The Escape Room consisted of 10 stages based on the thematic content of the subject ‘History, Theory and Methods of Nursing II’. After passing each test, a clue was obtained, and, by joining the 10 clues, the final code to win was formed. The tests dealt with nursing theory and models, patient assessment and vital signs, questionnaires and validated assessment scales (e.g., Barthel, Zarit, and Glasgow), nursing diagnoses, planning, taxonomy of nursing outcomes (NOC) and nursing interventions (NIC), and critical thinking. These contents were applied through crossword puzzles, cryptograms, logic and calculation games, a multiple-response test, or critical reading, among other activities. For example, the cryptogram was made with NIC, and many numerical codes had to be deciphered through searches in the NOC book or the virtual application.

The professor of the subject acted as the only organizer and moderator of the entire activity. Due to this, a unique, manageable space was chosen for the activity where all participants could be sharing the space at the same time. Specifically, this was a wide, multifunctional classroom with a capacity of 140 people and chairs enough to allow all students to sit. This classroom was adapted, creating islands of tables with chairs around it, where all the students could sit or stand around their group, if they wanted to, but allowing mobility throughout the classroom and sufficient space between groups. All stages were carried out on these group tables. The moderator was positioned in an upstanding platform to visualize the classroom and the groups.

The groups were formed freely by the students who had attended classes that day, since the activity was not compulsory and was carried out during the course of the master class (the game lasted for 2 h). The groups had a maximum of 5 people and a minimum of 3 people. Each group chose a spokesperson to move around the class while the rest of the group remained in their team-base. The spokesperson had to move to the moderator’s position to collect each of the 10 tasks, and to bring the answers and check if they were correct. All groups competed at the same time.

2.3. Instruments and Variables

The chosen questionnaire was the Gameful Experience Scale (GAMEX), containing 27 items [6], in the validated version in Spanish [14] and for nursing students [5]. The response options were Likert-type (from 1, strongly disagree, to 5, strongly agree), with variations depending on the evaluated dimension. This questionnaire is composed of 6 dimensions around the experience of the participants in gamified environments: Enjoyment (composed of 6 items; measures the degree of enjoyment of the user during the activity); Absorption (formed by 6 items; aims to know the power of abstraction from reality that the experience produces in participants as well as time-awareness or lack thereof during the experience), Creative Thinking (analyzes, through 4 items, the development of creative thinking or creativity fostered by the experience, and the mastery or confidence that the user has in themselves during it), Activation (measures, through 4 items, the level of activation that the user considers to have experienced during the activity), Absence of Negative Affect (made up of 3 items; assesses whether users have manifested or felt negative emotions while playing), and Dominance (made up of 4 items; assesses feelings about being in control of the situation). All these dimensions showed high internal consistency, as indicated by Cronbach’s α: Enjoyment (α = 0.96); Absorption (α = 0.91); Creative Thinking (α = 0.88); Activation (α = 0.87); Absence of Negative Affect (α = 0.85); and Dominance (α = 0.84) [6].

An open-ended question was also included to allow the students to give their opinion on aspects of improvement, on their feeling during their performance, or on positive aspects. This question was not compulsory.

2.4. Survey Procedure

The information was collected with a virtual survey via Google Forms^® after the escape room. The informed consent and the questionnaire were provided through a link that was added to the virtual educational platform of the university center, in the section dedicated to the course, which was accessible to students.

2.5. Data Analysis

Quantitative data were analyzed descriptively using SPSS v26 software to obtain frequencies and percentages, along with the mean and standard deviation (SD) of each dimension. The qualitative side of this research utilized a thematic analysis to approach students’ views, opinions, knowledge, and experiences through the game, in order to identify and interpret patterns or themes. For this, an open-ended question developed by the research team was added at the end of the survey. Two investigators with expertise in the methodology and who had no prior relationships with the participants took part in the data codification using Microsoft Excel 2021 (18.0). This thematic analysis involved a word-by-word reading of the students’ responses, highlighting specific words in the text that captured key ideas or thoughts, performing triangulation, translating them into codes that grouped several of these ideas or thoughts, and employing an inductive approach to categorize the students’ interview responses. A third investigator was consulted in case of disagreement. Data saturation was reached when no new categories emerged, confirming that further data collection would not produce additional significant categories.

2.6. Ethical Statements

The individuals voluntarily agreed to participate in the survey via written consent, and they were informed of the content and objective of the research, as well as the anonymized and confidential treatment of their answers. This study followed the Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects in its review adopted by the 64th General Assembly, Fortaleza (Brazil), October 2013. This pilot study was approved by the Research Committee of the Red Cross University Centre with code CICR-20N-2023.

3. Results

The response rate was 80% (n = 75). The mean age was 22.13 years (SD = 4.10) and 88.4% of the sample were women.

The outcomes for the GAMEX scale can be seen in Table 1.

In the Enjoyment dimension, the majority of respondents selected the maximum score in the Likert-type scale for five of the six questions (5, ‘in complete agreement’), with a mean score of 4.70 (SD = 0.58). These questions asked about aspects such as fun, whether they liked or enjoyed playing, or whether playing was pleasant or entertaining.

In the Absorption dimension, the mean score of the dimension was 4.15 (SD = 0.90). More than a half of the sample managed to abstract themselves from the classroom context during the activity. Likewise, 45.3% managed to forget their immediate environment, and 50.7% lost track of time during the game. For the rest of the variables, the results were more evenly distributed across answers with values 4 and 5 on the Likert scale for the variables ‘after playing, I returned to the real world’, ‘playing took me away from everything’, and ‘I was oblivious to what surrounded me’.

In the Creative Thinking dimension, 56% of the sample stated that they had felt creative during the activity. On the other hand, 48% felt that their imagination had been awakened. And 87% agreed or strongly agreed that, while playing the game, they had been able to explore and inquire. The mean score of this dimension was 4.32 (SD = 0.75).

The Activation dimension highlighted that up to 69.3% of the students had managed to feel active while playing, 42.7% had felt nervous, 56% had felt excited, and up to 80% agreed or strongly agreed that they had felt frantic. The mean score of this dimension was 4.31 (SD = 1.74).

The Absence of Negative Affect, measured inversely (Mean: 1.74; SD = 1.09), showed that 69.3%, 64%, and 48% of the sample, respectively, scored 1 and 2 (‘strongly disagree’ or ‘disagree’) in terms of having felt annoyed, hostile, or frustrated.

Finally, the Dominance dimension showed fewer differences across the groups: 40% of the sample neither agreed nor disagreed with feeling dominant during the game; 44% agreed that they had felt influential during the activity; 50.7% agreed that they had felt autonomous; and 57.3% said they had felt confident during the game. The mean score of this dimension was 3.63 (SD = 0.99).

Regarding the qualitative assessment of the open-ended question, participants emphasized that they would like to repeat the activity given the usefulness of the game to review the subject. The importance of having less ambient noise, having reviewed the subject previously, or the difficulty in progressing in some stages was also emphasized. The topics and some statements that supported the thematic analysis can be seen in Table 2.

4. Discussion

The European Higher Education Area, implemented during the Bologna Process in 2010, mentioned that specific actions would be started to guarantee and support the quality of teaching, favoring inclusive and innovative approaches that would promote student participation, as well as flexibility in academic management, the promotion of research, and the development of international relations [15]. In contrast to the classic form of teaching, new educational methodologies try to get students more actively involved in their learning [2,3,9,16], seeking greater motivation and commitment on their part [1,2,4,11].

As mentioned above, escape rooms can improve the academic performance and the acquisition of emotional competences for students in the health sciences university framework [2,11], while increasing their engagement with their learning outcomes, including participation in clinical research projects and varied interactive learning methods. In fact, the positive results found regarding the usefulness of the escape room for teaching in health professions [17] are in line with other studies in medicine [18,19], physiotherapy [20,21], pharmacy [22], occupational therapy [23], or psychology [24]. Students must grasp how learning is relevant and meaningful to their own lives. Additionally, teachers must use different strategies to ensure that each student learns at a level that fits their needs [25].

In this sense, the results of this game-based activity show that the participants had a productive experience, emphasizing positive emotions, as reflected in other studies with nursing students [1,5,11]. The GAMEX scale showed scores from 4 to 5 in the Likert scale in most of the categories, suggesting a high level of the gameful experience, with students reporting a moderately high level of activation, absorption, enjoyment, dominance, and critical thinking. Accordingly, an absence of negative affects was noted, with responses of 1 or 2 in the Likert scale in this category. The present findings correspond with the outcomes reported by other researchers in Spain [11,26] who used the same scale after two escape room activities with nursing students.

The experience of a virtual escape room for nursing students has also previously been evaluated with positive results [27], and other examples showed a moderately high level of Enjoyment and Creative Thinking, as well as the Absence of Negative Affects according to the GAMEX scale [3,5].

Nursing students have found a didactic, enjoyable, and well-structured methodology that gets them to participate in a collective effort towards their own educational process [11]. The participants in this research also commented that the escape room is a good opportunity to work as a team, to communicate in class, and to get out of the routine of the master class. For this reason, they demand more games like this throughout their learning process, in line with the arguments posed by Lynch-Sauer et al. [9].

Another important feature is that the escape room allowed all team members to feel equally important and leading, as group guidance could be shared throughout the stages [28]. Thus, the main skills of each team member could be equally timely or relevant [29]. In this context, successful teams are those that best combine and leverage the skills of all their members [30]. Therefore, although some individuals are more accustomed to playing different games, others may have equally relevant skills, favoring reciprocal learning [28] and the adoption of different roles (explorer, calculator, meticulous, etc.) [31].

This study recognizes as a limitation that the impact of the escape room on the academic performance of students has not yet been analyzed. This activity did not contribute to the final marks of the subject, and participation was voluntary. For this reason, it has not been possible to ensure a direct influence between the gameful experience and learning outcomes. Some authors contemplate the possibility of using the escape room as an evaluation method to assess the acquisition of knowledge or the strengthening of competencies in the subject after the game [30,32]. Nevertheless, the game-based experiences that have been performed to date have not been assessed within a framework of reliability or validity oriented to evaluation.

Moreover, the competencies and skills that are developed in the escape room are also generally acquired in clinical simulation environments [9,33]; however, the cost of a simulation classroom and the required materials is more expensive, while an escape room in a university classroom only needs investment in some easily accessible elements or consumables [19,34].

Another aspect to consider was the importance of the time for the preparation of the game, as well as the involvement of the teachers in the activity from the start of the project [32]. Even so, after playing the first game, the process is usually much easier for the teachers in subsequent experiences [34]. Likewise, it would have been interesting to know whether the motivation of students to learn about the subject had changed when they noticed the usefulness and practical character of this knowledge [35]. However, this analysis must be carried out in greater depth, by collecting a larger number of responses from the sample. As part of this, a limitation in the methods is noted in this pilot study, as the response to the open-ended question was not compulsory for the participants, so a low amount of qualitative data was captured. Although a thematic analysis does not prescribe a minimum or maximum number of responses, and data saturation was reached in this pilot study, it would be highly interesting to assess the students’ escape room experience qualitatively, so stronger methods should be applied in this line of research to analyze the participants’ opinions and beliefs after the game.

As a proposal for the future, this line of research aims to promote the use of the escape room as a tool not only for learning, but also for evaluating competencies in university students. For this, it is necessary to improve and reinforce the structure and mechanisms of this pedagogical methodology. The importance of promoting game-based dynamics among the university community is echoed, and, to this end, it is relevant to develop assessment indicators or criteria to evaluate the specific competencies of university nursing students using these techniques. To advance innovation, the effectiveness of escape rooms on learning outcomes needs to be determined [34], as well as their effects on students’ social and communication skills [35]. At the same time, the characteristics of the activity must be standardized to ensure its reproducibility in various environments [35]. Finally, it would also be useful to analyze the opinions of nursing professors on the use of escape rooms in the university context [1].

5. Conclusions

The escape room as a didactic tool has specific characteristics and is among the latest educational trends in nursing education. The results of this research have revealed relevant positive levels in the six categories of the GAMEX scale among the students after the escape room activity. These findings highlight that most of the students managed to feel active and motivated by learning while having fun and working in groups. In addition, it can be noted that students underlined the usefulness of the game in reviewing the subject contents and in acquiring new knowledge and skills.

The scientific evidence regarding this methodology has raised the need to determine its validity and reproducibility in varied environments in order to implement it systematically. It is also necessary to establish the criteria to assess the motivation of the students to learn as a result of the game experience.

The escape room is positioned as a useful tool for undergraduate and postgraduate academic programs. In addition, the students appreciate having experienced this activity during their university period. The dedication of the teachers to applying creative methods is also considered fundamental. Finally, it is crucial for management bodies to support teaching innovation to help integrate game-based activities into higher education.

Author Contributions

Conceptualization, J.F.-R., R.R.-C., M.G.-B. and P.F.-L.; methodology, J.F.-R., R.R.-C., M.G.-B. and P.F.-L.; software, J.F.-R., R.R.-C., M.G.-B. and P.F.-L.; validation, J.F.-R., R.R.-C., M.G.-B. and P.F.-L.; formal analysis, J.F.-R., R.R.-C., M.G.-B. and P.F.-L.; investigation, J.F.-R., R.R.-C., M.G.-B. and P.F.-L.; resources, J.F.-R., R.R.-C., M.G.-B. and P.F.-L.; data curation, J.F.-R., R.R.-C., M.G.-B. and P.F.-L.; writing—original draft preparation, J.F.-R., R.R.-C., M.G.-B. and P.F.-L.; writing—review and editing, J.F.-R., R.R.-C., M.G.-B. and P.F.-L.; visualization, J.F.-R., R.R.-C., M.G.-B. and P.F.-L.; supervision, J.F.-R., R.R.-C., M.G.-B. and P.F.-L.; project administration, J.F.-R., R.R.-C., M.G.-B. and P.F.-L. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki. This study was approved by the Research Commission of the Red Cross University Center with code CICR-20N-2023.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data are contained within the article.

Conflicts of Interest

The authors declare no conflicts of interest.

Footnotes

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Tables

Table 1

Description of GAMEX scale results.

	1 Strongly Disagree	2 Disagree	3 Neither Agreement nor Disagreement	4 Agree	5 Totally Agree	Mean (SD)
Enjoyment						4.70 (0.58)
Dis1	N/A	N/A	N/A	8 (10.7%)	67 (89.3%)	4.89 (0.311)
Dis2	N/A	N/A	1 (1.3%)	13 (17.3%)	61 (81.3%)	4.77 (0.583)
Dis3	N/A	N/A	1 (1.3%)	15 (20%)	59 (78.7%)	4.77 (0.452)
Dis4	N/A	N/A	N/A	17 (22.7%)	58 (77.3%)	4.77 (0.421)
Dis5	N/A	N/A	N/A	13 (17.3%)	62 (82.7%)	4.83 (0.381)
Dis6	N/A	2 (2.7%)	17 (22.7%)	21 (28%)	35 (46.7%)	4.19 (0.881)
Absorption						4.15 (0.90)
Ab1	N/A	1 (1.3%)	13 (17.3%)	19 (25.3%)	42 (56%)	4.36 (0.816)
Ab2	N/A	4 (5.3%)	12 (16%)	25 (33.3%)	34 (45.3%)	4.19 (0.896)
Ab3	1 (1.3%)	3 (4%)	16 (21.3%)	28 (37.3%)	27 (36%)	4.03 (0.930)
Ab4	N/A	3 (4%)	17 (22.7%)	26 (34.7%)	29 (38.7%)	4.08 (0.882)
Ab5	N/A	6 (8%)	16 (21.3%)	24 (32%)	29 (38.7%)	4.01 (0.966)
Ab6	1 (1.3%)	3 (4%)	8 (10.7%)	25 (33.3%)	38 (50.7%)	4.28 (0.909)
Creative Thinking						4.32 (0.75)
Pc1	N/A	N/A	11 (14.7%)	28 (37.3%)	36 (48%)	4.33 (0.723)
Pc2	N/A	1 (1.3%)	3 (4%)	29 (38.7%)	42 (56%)	4.48 (0.704)
Pc3	N/A	2 (2.7%)	7 (9.3%)	32 (42.7%)	34 (45.3%)	4.31 (0.753)
Pc4	N/A	2 (2.7%)	14 (18.7%)	27 (36%)	32 (42.7%)	4.19 (0.833)
Activation						4.31 (1.74)
Act1	N/A	N/A	1 (1.3%)	22 (29.3%)	52 (69.3%)	4.68 (0.498)
Act2	2 (2.7%)	7 (9.3%)	15 (20%)	19 (25.3%)	32 (42.7%)	3.96 (1.120)
Act3	1 (1.3%)	6 (8%)	8 (10.7%)	30 (40%)	30 (40%)	4.09 (0.975)
Act4	N/A	N/A	4 (5.3%)	29 (38.7%)	42 (56%)	4.51 (0.601)
Absence of Negative Affect						1.74 (1.09)
Aan1	52 (69.3%)	16 (21.3%)	2 (2.7%)	2 (2.7%)	3 (4%)	1.65 (1.121)
Aan2	48 (64%)	22 (29.3%)	2 (2.7%)	1 (1.3%)	2 (2.7%)	1.64 (1.009)
Aan3	36 (48%)	27 (36%)	7 (9.3%)	2 (2.7%)	3 (4%)	1.95 (1.138)
Dominance						3.63 (0.99)
Dom1	6 (8%)	13 (17.3%)	30 (40%)	21 (28%)	5 (6.7%)	3.08 (1.024)
Dom2	4 (5.3%)	7 (9.3%)	17 (22.7%)	33 (44%)	14 (18.7%)	3.61 (1.064)
Dom3	1 (1.3%)	4 (5.3%)	20 (26.7%)	38 (50.7%)	12 (16%)	3.75 (0.840)
Dom4	N/A	4 (5.3%)	7 (9.3%)	43 (57.3%)	21 (28%)	4.08 (0.767)

SD: Standard Deviation; N/A: No answer. Enjoyment: Dis1: Playing was fun; Dis2: I liked playing; Dis3: I really enjoyed playing; Dis4: My experience with the game was pleasant; Dis5: I think playing was very entertaining; Dis6: I would play this game for myself, not just when asked; Absorption: Ab1: Playing made me forget where I was; Ab2: I forgot about my immediate surroundings while playing; Ab3: After playing, I felt like returning to the ‘real world’ after a trip; Ab4: Playing ‘took me away from everything’; Ab5: While playing, I was completely oblivious to everything around me; Ab6: While playing, I lost track of time; Creative thinking: Pc1: Playing sparked my imagination; Pc2: While playing, I felt creative; Pc3: While playing, I felt like I could explore things; Pc4: While playing, I felt adventurous; Activation: Act1: While playing, I felt active; Act2: While playing, I felt nervous; Act3: While playing, I felt frantic; Act4: While playing, I felt excited; Absence of negative affect: Aan1: While playing, I felt annoyed; Aan2: While playing, I felt hostile; Aan3: While playing, I felt frustrated; Dominance: Dom1: While playing, I felt dominant/I had the feeling of being in control; Dom2: While playing, I felt influential; Dom3: While playing, I felt autonomous; Dom4: While playing, I felt confident.

Table 2

Thematic analysis of the answers in the open-ended question.

Category	Subcategory	Support Statement
Room for improvement	Nothing to improve	‘Nothing to improve. Everything was great!’(Student 8, 21 years old)
	Too much noise	‘During the game, the only thing that distracted me was the noise from both my teammates and the others (…)’ (Student 15, 49 years old)
	Game explanation	‘Perhaps, I would better explain some of the challenges or what is being sought’ (Student 22, 28 years old)
Feelings	Enjoyment	‘I loved it; I had a great time and laughed a lot. I am grateful for these moments with my colleagues (…)’ (Student 14, 24 years old)
	Willing to repeat	‘I’d love to repeat it, hands down!’ (Student 21, 18 years old)
	Learning support	‘It was a very enriching and positive experience for reinforcing knowledge in a creative way’ (Student 43, 21 years old)

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