The results indicate that the escape room game approach is an effective method to improve nursing students' knowledge of PI prevention and attitudes toward the care of patients with PIs. This method also improved students' knowledge retention by promoting facilitated learning in solving complex cases.
Nursing students should acquire competency in various areas, such as knowledge, communication, psychomotor skills, and teamwork, before starting their professional careers. Nurse educators should implement new learning strategies and assessment methods in the nursing curricula to enhance students' educational experience and help them hone these skills. Updating teaching techniques can help increase student participation, improve teamwork, and facilitate the overall learning environment, as well as increase motivation and active learning in class. Active-learning modalities are an alternative to traditional teacher-centered education. They involve students actively engaging in their learning process, leading to improved knowledge acquisition, motivation, and attitudes. Therefore, it is important for nurse educators to incorporate active-learning strategies in their teaching methodologies to enhance the overall learning experience of nursing students.
Various dynamic methods, such as problem-based learning and flipped learning, are used to increase students' class participation and the permanence of the knowledge gained. Gamification in education can stimulate students' interest and motivation: it is used to make the course more attractive to students, thanks to game principles, and it encourages active learning. Another interesting approach used in education is related to games called escape rooms. Escape rooms were originally designed as a team game in which players work collaboratively to uncover clues, solve puzzles, and complete tasks in one or more rooms within a certain time limit to achieve a specific objective and progress further. Escape room games, in particular, can help students consolidate knowledge, acquire new skills, and develop specific attitudes in a controlled reality that supports learning. Escape rooms are becoming increasingly popular in higher education to complement traditional teaching methods. Students gain experience as they learn by doing, enabling them to learn theoretically and clinically and to reflect on the challenges. The WCET International Ostomy Guide also recommends the use of active methods, such as simulation or scenario-based education, for advanced didactic and skill performance.
Pressure injuries (PIs) cause many complications, negatively affect patients' quality of life, and lead to prolonged hospital stays. Unfortunately, the topics of PI prevention and management are not included in most nursing education curricula, and research indicates that nursing students have a low level of knowledge regarding PI prevention. This low level of knowledge also negatively affects nursing students' attitude levels. In other words, the low knowledge and attitude levels of nursing students create an obstacle in terms of PI prevention.
Kara et al recommend that nurse educators try different methods to improve nursing students' knowledge of PI prevention and attitudes toward PI care. In nursing education, a similar approach to an escape room is used as a learning tool, focusing on a story or case that presents a general purpose. Typically, a series of challenges must be overcome before the team can advance in the game and "escape" the room or situation. The literature suggests that using escape rooms in educational settings promotes collaboration, problem-solving, and communication and has a positive impact on the learning process, providing an interactive teaching approach. The inherent time constraints can also lead to stress, excitement, and a sense of competition. Especially in light of the COVID-19 crisis, educators are increasingly driven to explore and use diverse learning methods, including blended or online learning. Given this context, it is crucial that the majority of these educational activities be conducted virtually to ensure continuity and accessibility in the learning process, especially when in-person interactions are limited.
In this study, the authors evaluate the effect of an escape room game as an education method to increase the knowledge levels and attitudes of undergraduate nursing students toward PI risk factors and prevention.
This research was designed as a quasi-experimental pretest/posttest study. The sample consisted of 50 third- and fourth-year nursing students at Koç University who were enrolled in the elective course Chronic Wound Management, which was introduced to the curriculum during the 2021-2022 academic year. Students were included in the study if they agreed to participate. Assuming a moderate effect size of 0.05, a power of 0.80, and six predictors, the researchers calculated the required sample size to be 39 (G*Power 3.1.9.44; Heinrich Heine University). Initially, 50 students were enrolled in the course. Of these, 39 students agreed to participate in the study. However, 6 of the 39 students were excluded because they withdrew from the study before baseline data were collected. As a result, the final sample consisted of 33 students who completed the study.
This form, created by the researchers, queried students for demographic characteristics (eg, age, sex), whether the student followed developments related to PIs, and the student's self-rating of PI prevention knowledge level on a visual analog scale from 0 (lowest) to 10 (highest).
The Pressure Ulcer Knowledge Assessment Tool 2.0 (PUKAT) was developed as a knowledge assessment tool for nurses to prevent PIs within the framework of evidence-based guidelines, and its validity and reliability in Turkish have been confirmed. The tool consists of 25 multiple-choice items categorized into six themes: etiology (items 1-6), classification and observation (items 7-10), risk assessment (items 11,12), nutrition (items 13-15), prevention of pressure ulcers (items 16-23), and specific patient groups (items 24,25). The maximum score is 25, and an average knowledge score of ≥60% (15 or above) is considered satisfactory. The PUKAT 2.0 has valid and reliable psychometric properties with an intraclass correlation coefficient of 0.69. In this study, the Kuder-Richardson-20 coefficient was 0.64 for the pretest.
The Pressure Injury Prevention Knowledge Questionnaire (PIPKQ) was developed in 2020, and the Turkish version has been tested for validity and reliability. The PIPKQ consists of 31 true/false questions, with a maximum score of 31 (knowledge index = 100%). Whereas the Cronbach α was .98 in the original form of the scale, it was .65 in the pretest sample group in the present study.
The Attitude towards Pressure Ulcer Prevention Instrument (ATPUPI) scale was originally developed in Belgium and the Netherlands and has been adapted to Turkish. It includes 13 items and five subdimensions: competency, priority, effect, responsibility, and effectiveness of prevention. The ATPUPI has a minimum score of 13 and a maximum score of 52. Higher ATPUPI scores indicate a more positive attitude toward PI prevention. The original scale demonstrates a Cronbach α of .79 for internal consistency. In the data obtained from this study, the Cronbach α for the total scale was .70 in the pretest.
The State-Trait Anxiety Inventory (STAI) measures the anxiety levels of individuals 14 years and older. It consists of 40 questions, with 20 items assessing state anxiety (how one feels at the moment) and 20 items assessing trait anxiety (general feelings). Each item is rated on a 4-point Likert-type scale, with scores ranging from 20 to 80 per subscale. Higher scores indicate greater anxiety. The STAI has been adapted for use in the Turkish context. Because anxiety is an important variable affecting learning, the researchers measured students' anxiety level to determine whether it may be a confounding factor.
Before presenting the topic of PIs, which is taught as part of the Chronic Wound Management course, researchers informed students in the course about the research and obtained their informed consent. The students who agreed to participate completed the student information form, PUKAT-2.0, PIPKQ, ATPUPI, and STAI as part of the pretest data collection. These assessments were conducted during class time and were administered in a written questionnaire format.
One week after the topic presentation, which included the escape room game, students completed the PUKAT-2.0, PIPKQ, ATPUPI, and STAI again (posttest 1 data). To assess students' knowledge retention over time, students completed the PUKAT-2.0, PIPKQ, and ATPUPI a third time (posttest 2 data), 1 month after the previous data collection. Researchers evaluated changes in students' knowledge and attitudes (Figure).
Rules and Design of the Escape Room Game for Nursing Students
The escape room game was designed for a module in Chronic Wound Management, an elective course that covers theoretical-practical topics, PIs, and protective measures. Before the game, students attended a 3-hour lecture on PI classification, importance, and protective interventions, explained theoretically. During the lecture, students also received detailed information about when and how the escape room game would be played and the rules of the game.
The escape room game consisted of two stages, and each group was given 1 hour to complete the game. The students were free to form their own groups and sorted themselves into three groups of five people and three groups of six people. In the first stage of the game, students solved written puzzles related to theoretical information about PIs, including staging, nutrition, risk factors, and preventive interventions. They had 30 minutes to find the exit key and escape. In the second part of the game, students had 30 minutes to correctly stage a wound and select an appropriate dressing in a visual puzzle. This puzzle provided clues to students who answered correctly, allowing them to unlock the code "Protect the patient from PI." The students then positioned the patient correctly in bed or in a wheelchair to recover from PIs. Students who correctly positioned the patient found the key hidden in the room and escaped. The two stages of the game took a total of 3 hours.
Data Analysis
Data analyses were carried out in SPSS 24 (IBM Corp). Continuous variables were expressed as arithmetic mean, SD, and minimum and maximum values, and categorical variables were expressed as frequency and percentage. The authors used the Pearson χ test to determine the difference between two or more groups, and the t test for independent groups to determine the difference between the mean of the two groups. To examine the difference between the tests applied before and after the intervention and at 1 month later, the authors used a single-factor analysis of variance test for repeated measurements; the Bonferroni method was used in cases where there was a significant difference. The significance level was accepted as P ≤ .05.
Ethical Considerations
Ethical approval was obtained from the Private Foundation University Ethics Committee to conduct this study (no. 2022.184.IRB3.085). Student data were stored securely in accordance with ethical guidelines. The data were anonymized and kept in a password-protected database accessible only to the research team.
RESULTS
A total of 33 students -- 29 third-year nursing students and 4 fourth-year students -- voluntarily participated in the escape room game and were included in the sample. The majority of participants were women (90.9%), and the average age was 22.09 ± 1.07 years (range, 20-25 years; Table 1).
When students were asked to mark their knowledge level regarding preventing PIs on a 0 to 10 grade line, their mean self-reported knowledge level was 3.18 ± 1.65 before the intervention and 7.21 ± 1.36 after the intervention. This increase was statistically significant (P = .000). Before the intervention, when the students were asked whether they kept track of improvements related to PIs, 33.3% reported that they tracked improvements, 15.2% sometimes did, and 51.5% stated that they did not track. After the intervention, these rates changed to 69.7% reporting that they tracked improvements and 30.3% stating that they did not. However, this change was not statistically significant (χ = 0.277, P = .871; Table 2).
Students' mean state anxiety level score was 45.67 ± 9.77 preintervention and decreased to 39.67 ± 10.39 postintervention (P = .005). Similarly, students' mean trait anxiety level score decreased from 59.03 ± 5.12 preintervention to 42.97 ± 8.56 postintervention (P = .000; Table 3).
Students' mean scores on the PUKAT 2.0 were 10.27 ± 3.45 on the pretest, 19.64 ± 2.18 after the escape room game, and 18.24 ± 3.37 at 1 month later. The mean PUKAT scores after the intervention and at 1 month later were both statistically higher than the pretest score (P = .000). Although the score at 1 month was slightly lower than the score after the intervention, the difference was not significant.
Students' mean PIPKQ score was 12.15 ± 2.06 in the pretest, 20.82 ± 1.21 after the escape room game, and 20.55 ± 1.25 at 1 month later. These mean scores after the intervention and at 1 month later were both statistically higher than the pretest score (P = .000). There was no statistical difference in the mean score at 1 month versus after the intervention (Table 4).
Students' mean scores on the ATPUPI were 43.09 ± 3.57 on the pretest, 50.00 ± 1.54 after the escape room game, and 46.55 ± 3.49 at 1 month later. The mean ATPUPI scores after the intervention and at 1 month later were both statistically higher than the pretest score (P = .000). However, the mean score decreased significantly between posttest 1 (after the escape room) and posttest 2 (1 month later; P = .000). In evaluating the five ATPUPI subdimensions, the same results were found for the competency (P = .000) and responsibility subdimensions (P = .000). In the effect subdimension, the mean posttest 1 score was significantly higher than the pretest score (P = .007); however, the posttest 2 score was not statistically different from either. In effectiveness of prevention subdimension, the mean posttest 2 score was statistically lower than the pretest and posttest 1 scores (P = .000). There was no statistically significant difference between the measurements in the priority subdimension (P = .09; Table 4).
DISCUSSION
Students who participated in the escape room improved their attitudes toward and knowledge of PIs and retained this knowledge over the course of a month, as indicated by their mean posttest 1 and 2 scores. To the authors' knowledge, this is the first study to integrate an escape room as an innovative learning approach into a Chronic Wound Management course module, specifically targeting knowledge, attitudes, and preventive measures related to PIs.
Nursing students' self-reported PI knowledge increased more than twofold after the escape room game (7.21 vs 3.18 before). Further, students' state and trait anxiety both decreased significantly after the intervention. Thus, these findings indicate that participation in the escape room game significantly increased students' perceived knowledge levels and was not a source of stress or anxiety. Similarly, Molina-Torres et al reported that physiotherapy students who played an escape room game experienced reduced state anxiety levels, overload factor, and fear-anxiety factor among perceived stress dimensions. The authors emphasized that the students enjoyed their game experiences. Benefits of integrating an escape room game into education include reducing students' stress, identifying their strengths and opportunities, motivating them to learn, providing results and continuous feedback, and increasing their self-awareness.
In evaluating the mean PUKAT-2.0 and PIPKQ scale scores, students' knowledge about PIs and PI prevention initiatives significantly increased between the pretest score and the first posttest after the escape room game. When students were retested after 1 month to evaluate the permanence of the knowledge gained, their mean scores were slightly lower than on the first posttest, but the difference was not statistically significant. According to the international literature and studies performed in Turkey, nurses and nursing students generally have a low level of PI knowledge. The use of an immersive game experience as a learning strategy, such as an escape room, rather than traditional teaching techniques, can increase students' knowledge.
In addition, studies indicate that student enjoyment leads to better learning and assessment; when learning is fun and engaging, students focus on the main idea and increase their mastery of the subject. Gutiérrez-Puertas et al noted that a well-designed escape room game could potentially serve as an alternative to objective structured clinical examination, a clinical assessment method for nursing students. As was done in the present study, the literature highlights the importance of comparing students' measurements over time to evaluate the learning outcomes, especially in managing the escape room game.
In this study, students' attitudes toward PI prevention significantly increased between the pretest and first posttest. Although their scores slightly decreased in the second posttest measurement, the difference was not significant. To the authors' knowledge, this study is the first to examine the direct effect of the escape room game, which is used as an alternative teaching strategy, on students' attitudes. However, qualitative findings on using an escape room for courses involving skill practice indicate that the escape room game may be a beneficial alternative for students in courses involving professional skills. Similarly, according to a study investigating nursing students' learning and empathy toward patients through use of an online escape room show, most students thought the educational escape room was a fun and motivating learning strategy that enabled them to learn cooperatively and empathize with the mentally disabled protagonist. It is important to provide students with an engaging and stimulating active learning environment to facilitate learning in nursing courses that include complex skill practice and theoretical knowledge. Nursing education should produce realistic and accessible solutions to problems and support students; further, education should facilitate the development of professional values. The current results support the inclusion of games with active and interactive modalities, such as escape room games, in nursing curriculum to benefit nursing students and educators as an alternative teaching method.
Limitations
Without a comparison group, the researchers cannot determine whether the observed effects were due to the escape room game or some other factor, such as the novelty of the experience. It is possible that students would have scored as well on the posttests without the escape room experience. Future research should include a comparator group to confirm that the escape room improved performance beyond the traditional course. This study also had a limited number of participants and was conducted in a single education program, limiting the external validity. The authors recommend that future studies include a larger sample of students. Further, there is little evidence analyzing the use of escape room to assess PI-related learning and attitude levels, limiting the discussion of the findings.
CONCLUSIONS
Escape room games are an engaging, innovative educational resource to effectively teach nursing students about PIs and PI prevention. These games provide nursing students with an alternative approach to learn complex lessons involving theory and skill interventions and increase their knowledge. This teaching strategy is beneficial because it reduces stress factors and enables students to engage in chronic wound care in a more relaxed and enjoyable way. In addition, escape room games have the potential to positively influence students' attitudes toward PI prevention interventions, thereby improving their overall learning experience. The present study confirms that this game-based method is a practical, creative, and stress-free learning approach that can be used as an alternative to traditional-based methods in health education and assessment to increase the retention of knowledge in chronic wound care among nursing students.