1 Introduction

In the digitalizing and transforming world, game-based learning (GBL) has become a prominent teaching and learning (T&L) strategy that can help students gain knowledge and skills and develop attitudes in vocational education and training, such as in nursing education in recent years (Chang et al., 2024). Within the scope of GBL in nursing education, many methods such as interactive games, simulations or scenarios based on virtual reality are used to simulate real-life clinical cases (Kuruca Ozdemir & Dinc, 2022). The most important feature of these methods is that they allow students to apply and repeat the knowledge in a safe, controlled environment (Yang et al., 2023). In addition, considering that today’s millennial and Generation Z students are closely connected with information and communication technologies in their daily lives, it has become inevitable to integrate these methods into education (Brown et al., 2019; Ivanović, 2024).

Nursing students formed one of the most important student groups that had a disruption in their education during the pandemic process (Dewart et al., 2020). Since nursing students’ presence in the clinical environment during the COVID-19 pandemic would pose a risk for patients, students, and health professionals, their clinical training could not be carried out and their learning experiences were adversely affected (Dewart et al., 2020). In addition, students’ opportunities to learn psychomotor skills were significantly hindered. The lack of clinical and laboratory practices pushed the trainers to seek different training methods in the pandemic process (Ion et al., 2021). Among these methods, in addition to games and simulation methods, escape room games (ERGs) have become increasingly popular in applied disciplines (Anguas-Gracia et al., 2021; Reed & Ferdig, 2021; Zhang et al., 2018).

The concept of a game is defined as “a system in which players engage in an abstract challenge, defined by rules, interactivity and feedback that results in a quantifiable outcome and elicits an emotional reaction” (Kapp, 2012) Gamification is described as “the use of game design elements in non-game contexts to stimulate interest, satisfaction and behavioral change” (Larson, 2020; Rosa-Castillo et al., 2023). Several studies (Gallegos et al., 2017; García-Viola et al., 2019; Ivanović, 2024; Ramadhan et al., 2023; Rosa-Castillo et al., 2023; Tavares, 2022; van Gaalen et al., 2021) concluded that the use of gamification techniques in education had various positive effects such as supporting active learning and participation, solving clinical problems, gaining experience in a low-risk environment, creative thinking, increasing satisfaction and motivation. All the aforementioned makes gamification techniques an ideal innovative teaching strategy for interactive learning, which is one of the reasons why we want to use them in the context of nursing education. Hence, for this study, GBL is to be understood as the use of escape room games (ERGs) in learning different nursing courses through gameplay: its design and use to achieve a measurable outcome.

2 Literature review

In this part, the theoretical framework on which this study is based, gamification and game-based learning, is presented. Afterward, previous studies focusing on the use of educational games in education and nursing education is presented to clarify the current study.

2.1 Gamification and game based learning

Gamification is the use of game elements in a non-game context and has recently become a frequently T&L strategy in higher education (Akyar & Demirhan, 2022; Ferriz-Valero et al., 2020; Lin et al., 2024; Mohammed et al., 2024). The use of this new and innovative strategy in the educational context has often been to increase students’ engagement, motivation, and satisfaction with learning, as well as to achieve specific learning goals (Rosa-Castillo et al., 2022; Taub et al., 2020; Tonbuloğlu, 2024). Gamification in an educational context offers a learning experience that actively involves the learner in the teaching-learning process by enhancing certain variables such as extrinsic motivation, joy, feedback, teamwork, and active learning(Díaz-Ramírez, 2020; Ferriz-Valero et al., 2020; Joy et al., 2023) Gamification is reported to provide an immersive and interactive learning experience for students compared to the traditional didactic classroom environment(Krishnan et al., 2023; Oestreich & Guy, 2022).

Game-based learning focusing on learning through games rather than learning to play games or creating a game, is a new and innovative approach used in a wide range of disciplines and it offers new opportunities to rethink how the learner learns knowledge and skills (Karakoç et al., 2022; Tavares, 2022; Xu et al., 2023). In the context of vocational education, GBL often includes specially designed and structured game learning materials to develop students’ thinking skills, encourage self-directed learning, and improve learning by having fun by doing/experimenting (Azizan et al., 2021) There are many recent studies showing that GBL increases motivation, engagement, satisfaction and academic achievement of vocational students (Azizan et al., 2021; Chang et al., 2020, 2022; Lin et al., 2024; Ma et al., 2021; Roodt & Ryklief, 2019).

2.2 Serious games as a teaching and learning strategy

Serious game (SG) is defined as a game that is designed for purposes other than or in addition to pure entertainment (Becker, 2021). Educational SGs are computer-based programs that use gaming principles for learning, training, and skill development by integrating real-world scenarios into a video-based gaming environment, including entertainment to facilitate students’ understanding of difficult topics (Abensur Vuillaume et al., 2021; Filippas & Xinogalos, 2023). There is a strong body of research suggesting the use of these games as an interactive, collaborative, learner-oriented and constructivist educational technique in applied disciplines (Glover & Bodzin, 2021; Ma et al., 2021). SGs using real-life scenarios and providing experience-based learning, allow students to practice repeatedly in a safe environment and gain experience and learning from their mistakes (Guerrero et al., 2022; Kim & Kim, 2022). Studies examining the effectiveness of SGs reports that it encourages students’ participation and teamwork, makes learning environments more enjoyable, supports the acquisition of knowledge and psychomotor skills, and contributes to the improvement of problem solving, clinical decision-making, analytical thinking, and communication skills (Bayram & Caliskan, 2019; Chee et al., 2019; Glover & Bodzin, 2021; Haruna et al., 2023; Razaghpoor et al., 2024; Sarvan & Efe, 2022; Thangavelu et al., 2022). In recent years, educational escape room games have become a new form of SGs widely used from primary to higher education levels.

2.3 Escape room games in education

ERGs are live-action games where players use contextual knowledge to complete tasks and solve puzzles to achieve a goal, such as escaping a room or completing a final puzzle (Gómez-Urquiza et al., 2019; Morrell & Ball, 2020; Reed & Ferdig, 2021). Escape rooms are team games based on real-world scenarios and players work together to find clues, solve puzzles, and complete tasks in a limited amount of time, with only one goal – escape! (Reed & Ferdig, 2021).

Today, teachers around the world have recognized the value of escape rooms as an educational tool and are implementing the method in a wide range of settings, from primary school to higher education to professional development programs (Sanchez & Plumettaz-Sieber, 2019) Educational escape rooms are an effective way to engage students in the active learning process, providing them with meaningful learning opportunities. Students’ progress through this process by solving various puzzles, which directly improves their problem-solving abilities. Collaborative learning is a key element of educational escape rooms. While students learn to work together to achieve a common goal, they also gain critical skills such as time management, resource utilization, and developing their talents (López-Pernas et al., 2023). A different purpose is the ER as a research environment, for example, to observe students’ information search behavior (Choi et al., 2017), learning processes in student teams (Järveläinen, 2019) or the use of teamwork and leadership skills among students (Li et al., 2018), and improving students’ design skills (Li et al., 2018). This highlights that the use of ERGs in education is more than just a fun activity, it has the potential to develop in-depth learning, problem-solving and collaborative working skills (López-Pernas et al., 2023).

2.4 Escape room games in nursing education

Nurse educators have successfully used escape rooms to teach more difficult physiology and nursing concepts such as care of the cardiac (Morrell & Ball, 2020), renal (Wynn, 2021), septic (Hawkins et al., 2020), and obstetric patients (Frost et al., 2020; Tassemeyer et al., 2021). Recent studies confirm that ERGs can improve learning (Kubin, 2020; Morrell & Ball, 2020), professional practice skills (Gu et al., 2022; Kubin, 2020; Morrell & Ball, 2020), and help in exams (Gómez-Urquiza et al., 2019), motivate to study (Anguas-Gracia et al., 2021; Gómez-Urquiza et al., 2019; Molina-Torres et al., 2022) in the context of nursing education.

Furthermore, escape rooms have been successfully employed to enhance teamwork and interprofessional communication (Sarage et al., 2021). These studies indicate that ERGs have positive effects on clinical thinking, knowledge, attitudes and skills, deep learning, teamwork, and communication skills. Furthermore, ERGs allow students to solve the case in a certain time and learn by doing (Anguas-Gracia et al., 2021; Gómez-Urquiza et al., 2019; Molina-Torres et al., 2022).

2.5 Importance of oncological emergencies and rationale for developing an educational escape room

Considering the increasing data on cancer incidence and prevalence all over the world, it will be inevitable that all nurses will be involved with cancer patients and their cancer-related health problems at some time during their careers (Lockhart et al., 2020). One of the most common problems is undoubtedly the emergencies encountered during the treatment process, called oncological emergencies (OEs). OEs can occur in any clinical setting and will become more frequent as the incidence of cancer increases (Klemencic & Perkins, 2019). OEs can occur at any time during cancer treatment and care (Lewis et al., 2011). It is recommended that oncology nursing content be included in the nursing curriculum of all nursing students to provide safe and quality nursing care for cancer patients and their families with the necessary nursing knowledge and skills (Burrell et al., 2023). Therefore, students in the healthcare field, especially nursing students, should have knowledge and skills about Oes (Wattana et al., 2021). Although the management of OEs is accepted as part of the nursing education content, the theoretical and clinical education of students in OEs may still be limited (Lockhart et al., 2020).

Oncological Nursing course is part of the Undergraduate of Nursing curriculum at the X University. This elective course, which consists of three ECTS and lasts 14 weeks, is included in the spring semester program of the faculty and is frequently carried out with second- and third-year nursing undergraduate students. It aims to gain current, theoretical, and applied knowledge about cancer, nursing care skills to the patients and their families with a holistic understanding and a systematic approach, work in cooperation with the healthcare team and other disciplines, train nurses who have interpersonal and intercultural communication skills. The content of the course includes the importance of cancer, the epidemiology of cancer in the world, and the country from OEs to palliative care. It provides students with theoretical knowledge of various common and unique diseases of patients, as well as including emergencies that can occur in any clinical setting. However, there are no studies in the literature that use or examine a different method other than classical education methods related to this course and its subjects. Therefore, learning processes can be improved through gamification to facilitate the integration of theoretical and clinical education on this subject that undergraduate nursing students may encounter in any clinical environment in their professional life. Recognizing this research gap in the literature on this important topic, a team of academics from X University Faculty of Nursing developed an innovative T&L strategy, an educational escape room on a digital platform on the topic of Oes. This article focuses on the implementation of an oncological emergency themed virtual escape room game in a nursing undergraduate program.

3 Method

The present pilot study mainly aimed to develop, implement, and evaluate an innovative teaching strategy to reinforce students’ learning, support their active participation in the lesson, increase their motivation, satisfaction, and self-confidence in learning. This section presents the study design, descriptive characteristics of the participants, the data collection procedures, and data analysis.

3.1 Study design

This pilot study adopted the use of a one-group quasi-experimental post-test only design where a single group of participants was subjected to an educational escape room game on the topic of oncological emergencies. The one-group posttest-only design is a type of quasi-experiment in which the outcome of interest is measured only once after exposing a non-random group of participants to a certain intervention (Kviz, 2020). The single group post-test design is particularly useful when the intervention needs to be developed and tested quickly (Privitera & Ahlgrim-Delzell, 2019).

The independent variable was the educational escape room game intervention. The dependent variables were motivation, student satisfaction and self-confidence in learning, recognition of design features in simulation. The controlled variables were two teaching hours of 50 min each, the teaching content delivered to all students at the same time, the teacher who taught the OEs topic, and the game content limited the most common OEs (intracranial pressure (ICP), superior vena cava syndrome, tumor lysis syndrome, and febrile neutropenia). The confounding factors were the gender of the students and their previous knowledge and experience with educational games.

3.2 Participants

The universe of the study consisted of undergraduate nursing students who completed the “Oncology Nursing Undergraduate Course” of a University Faculty of Nursing, who completed the fall semester of the 2020–2021 academic year. The main purpose of choosing this student group is that although the students have basic knowledge and skills in nursing care, they still do not have sufficient professional competence in terms of intervening with patients. The sample consisted of a single group. The sample size was calculated using the sample size calculation program (G-Power 3.1.9.2). Accordingly, by taking α = 0.05 (Type I error), the minimum number of students to be sampled was calculated as 40 students at 90% power and 5% significance level.

The selection criteria included those students who were (i) enrolled in the Oncology Nursing Course, (ii) 18 or older, (iii) completed the Fundamentals of Nursing and Medical Nursing course, and (iv) willing to provide consent to participate in the study. Students were reached via e-mail addresses and/or WhatsApp messages obtained from student affairs. A volunteer participation form containing information about the research and their approval for participation was sent via e-mail addresses and/or WhatsApp messages.

A total sample of 76 undergraduate nursing students participated in this study. The mean age of the students was 22.32 years (± 0.99) and most of them were female (88.2%). While 51.3% of the students knew any ERG, 78.9% of them participated in any application using the ERG before (Table 1).

Table 1 Descriptive characteristics of the students (N = 76)
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3.3 Experimental procedure

The study was conducted about Oncologic Emergencies within the scope of Oncology Nursing course given to undergraduate nursing students. The study was conducted in two stages: (i) development and implementation of ERG (ii) testing the game on students and assessing the outcomes.

Stage 1

An ONCEM (ONCological Emergencies) ERG was developed for the subject of “Oncological Emergencies, students were informed about the game and then the game was made available to them for a week.

Stage 2

After each student completed the ERG, their motivation, satisfaction, and self-confidence in learning, and satisfaction levels were evaluated.

3.4 ONCEM game design and procedures

The ONCEM ERG was developed online using an interactive web-based tool (Genially platform) by study team, around a case study demonstrating the management of OEs. Within the scope of this case, the students were expected to apply the nursing interventions that require urgent intervention to the patient who was hospitalized with an OE, in order of priority. A confidentiality agreement was signed with the students to ensure and maintain the confidentiality of all information in-game and not share their experiences with other friends. Then, they were offered the opportunity to play a sample ERG and the link was shared with them after the technical and content-related problems with the game were resolved.

The ERG was called ‘Hospital Escape’, and the player’s objective was to save the patients from the fire by treating the fire in the hospital. The ERG is available on Genially by clicking on the next link:

https://view.genial.ly/60e19c1e1270e00da6da9807/interactive-content-hastaneden-kacis.

The main goal was to enable the players to intervene quickly and accurately while rescuing the patients from the fire in the hospital. After the game was designed, it was tested with three undergraduate students and four doctoral students, and the study was completed. The subjects that students had to perform in the game to solve riddles and puzzles, unlock padlocks, and find certain objects included increased intracranial pressure (ICP), superior vena cava syndrome, tumor lysis syndrome, and febrile neutropenia. With the fire on the last floor of the 4-story hospital, the students first went to the patient room on the relevant floor. They went downstairs by collecting the clues for the patient and applied the first intervention. They encountered four patients with different cases on each floor.

For example, the students applied the nursing interventions in order of priority to open a three-step padlock for the ICP emergency: (1) checking vital signs, (2) checking the oxygen saturation, (3) pupil assessment. The following clues were given for this clinical emergency: first clue: “impaired state of consciousness”, the second clue: “projectile vomiting”. The clues were hidden in different places such as the electrocardiography device, medicine boxes, serum set, and patient file in the patient’s room (Figs. 1, 2, 3 and 4). After treating and removing the patients on the lowest floor of the hospital, they became a hero. Students played the game unlimitedly for a week. After completing the game, students were given access to the data collection tools by clicking on a link added at the end of the game.

Fig. 1
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Patient room screen

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Fig. 2
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Question screen

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Fig. 3
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Information screen

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Fig. 4
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Final screen

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Students did not have the opportunity to answer these tools unless they completed the game.

3.5 Instruments

In the current study, various instruments were used to determine students’ motivation, satisfaction and self-confidence in learning, recognition of design features in simulation. The instruments included the following:

3.5.1 Introductory information form

It was created by the study team to determine some socio-demographic characteristics of the students. There was a total of six questions regarding socio-demographic characteristics (age, gender, ERG experience, etc.) in this form.

3.5.2 Instructional materials motivation survey (IMMS)

The scale was originally developed by Keller (2010) to assess the students’ motivation and it comprises 33-item. This scale has 4 dimensions: (1) Attention (Cronbach’s alpha = 0.89), (2) Relevance (Cronbach’s alpha = 0.81), (3) Confidence (Cronbach’s alpha = 0.90), (4) Satisfaction (Cronbach’s alpha = 0.92) (Keller, 2010). Each item is measured on a Likert-type scale ranging from 1 (not true) to 5 (very true) (Keller, 2010). This means that the minimum score on the 33 items survey is 33, and the maximum is 165. The Turkish version of the scale has good psychometric properties with good reliability and validity; Cronbach’s alpha for the whole scale is 0.93, ranging from 0.74 to 0.83 for each separate dimension (Dinçer & Doğanay, 2016).

3.5.3 Student satisfaction and self-confidence in learning scale (SSSCLS)

The SSSCLS in its Turkish version was used to assess the students’ satisfaction and self-confidence in learning (Karacay & Kaya, 2017). The scale was originally published by (Jeffries & Rizzolo, 2006) and comprises 13 items classified into 2 dimensions: (1) Satisfaction with instruction (Cronbach’s alpha = 0.94), (2) Self-confidence with learning (Cronbach’s alpha = 0.87) (Jeffries, 2012). Each item is measured on a Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). This means that the minimum score on the 13-item survey is 13, and the maximum is 65. The Turkish version of the scale has good psychometric properties with good reliability and validity; Cronbach’s alpha for the whole scale is 0.88, ranging from 0.83 to 0.84 for each separate dimension.

3.5.4 Simulation design scale (SDS)

The SDS in its Turkish version was used to assess the features of specific areas in the simulation practice and the importance of features of specific areas on learning (Unver et al., 2017). The scale was originally developed byJeffries & Rizzolo (2006) and comprises 20-item classified into 5 dimensions: (1) Objectives and information, (2) Student support, (3) Problem-solving, (4) Guided reflection or feedback, and (5) Fidelity (Jeffries & Rizzolo, 2006). Each item is measured on a Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). This means that the minimum score on the 20 items survey is 20, and the maximum is 100. An increase in the total score in the first part of the scale indicates that the best simulation design elements were applied in the simulation; an increase in the total score in the second part indicates that the importance given by the student to the simulation experience is high. The Turkish version of the scale has good psychometric properties with good reliability and validity; Cronbach’s alpha for the whole scale is 0.90, ranging from 0.73 to 0.86 for each separate dimension. Higher scores indicate increased recognition of design features in simulation.

3.6 Data analysis

The data were analyzed with IBM SPSS Ver. 26.0 software (SPSS, Inc., Chicago, IL, USA). The total scale and sub-dimension scores of the students were considered the calculation criteria. Accordingly, the Shapiro-Wilk normality test was applied to scale scores to decide on the analyses to be applied. As a result of the test, it was seen that the scale scores did not provide the normality test assumptions. Therefore, non-parametric tests were used in the analysis process. While the descriptive data (age, IMMS, SSSCLS, and SDS scores) were presented by means and standard deviations (SD), categorical variables (gender, previous knowledge, and experiences about the ERG) were tabled as frequencies with percentages. The Mann-Whitney U test was used to compare the mean scores of all scales and categorical variables. In addition, the internal consistency of all scales was calculated using Cronbach’s alpha value for each dimension and the whole instrument.

4 Results

This section provides the results based on quantitative data. In the first part, undergraduate nursing students’ scores received from the instruments, and in the second part, findings related to the comparison of students’ motivation, satisfaction and self-confidence in learning, and recognition of design features in simulation scores according to some variables were presented.

4.1 Instrument scores of undergraduate nursing students

The students’ motivation was explored through the IMMS, satisfaction and self-confidence in learning by SSSCLS, and recognition of design features in simulation by SDS. The results from the scales and their sub-dimension scores are presented in Table 2. The mean scores obtained from all the scales were generally higher scores. Cronbach’s alpha for the whole IMMS was 0.98 and ranged from 0.91 (Relevance) to 0.95 (Attention) for each separate dimension. Cronbach’s alpha for the whole SSSCLS was 0.92 and ranged from 0.79 (Self-confidence with learning) to 0.97 (Satisfaction with instruction). Cronbach’s alpha for the whole SDS was 0.94 and ranged from 0.61 (Support) to 0.91 (Fidelity).

Table 2 Average scores and SD for each dimension of the all scales and reliability for each dimension and the all scales
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4.2 Comparison of instruments scores according to some characteristics of students

Statistical analysis results were evaluated to examine the differences between some characteristics of the students and the scores they obtained from the instruments. Table 3 shows the IMMS and its sub-dimensions’ scores. The results showed that the satisfaction sub-dimension scores of the students who had previous knowledge about the ERG were significantly higher than the other students (p = 0.027).

Table 3 Comparison of IMMS and sub-dimensions by variables
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The results of SSSCLS indicated that the total scale and both sub-dimension scores of the students who joined any application using ERG were significantly higher than the other students (p = 0.003; p = 0.001; p = 0.011, respectively) (Table 4). Gender differences were observed in the total SDS, problem-solving, and guided reflection/feedback dimension scores (p = 0.014; p = 0.010; p = 0.014, respectively). No significant gender differences were found in the other dimensions. In addition, the problem-solving sub-dimension scores of the students who had previous knowledge about the ERG were also significantly higher than the other students (p = 0.023) (Table 5).

Table 4 Comparison of SSSCLS and sub-dimensions by variables
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Table 5 Comparison of SDS and sub-dimensions by variables
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5 Discussion

In nursing education, where courses are remarkably intensive with theoretical and practical content, the teaching skills such as problem solving, critical thinking and, quick and accurate decision making in critical situations is critical for professional development. In applied disciplines, the application of EERGs has become a distinct popular trend in recent years. While recent studies have reported improved learning performance, clinical judgment, problem solving and critical thinking skills in nursing students using escape room concepts (Bonaduce, 2024; Yang et al., 2023), to our knowledge, this is the first OEs-themed ERG actually designed to assess motivation, confidence and satisfaction in learning, use of best design components in game and game experience, and not to test content knowledge within the subject. This pilot study mainly aimed to develop, implement, and evaluate an innovative teaching strategy to reinforce students’ learning, increase their motivation, satisfaction self-confidence in learning. Our findings revealed that the students participating in the ERG were highly motivated, satisfied, and self-confident with learning, and they were also satisfied with the game.

Recent studies confirm that ERGs can improve learning (Kubin, 2020; Morrell & Ball, 2020), professional practice skills (Kubin, 2020; Morrell & Ball, 2020; Ruting et al., 2021), and help in exams (Gómez-Urquiza et al., 2019), motivate to study (Gómez-Urquiza et al., 2019; Anguas-Gracia et al., 2021; Molina-Torres et al., 2021) in the context of nursing education. Consistent with these studies, it was found that students’ motivation and game-related satisfaction levels were high after the game experience. In these previous studies, the students’ motivation, satisfaction, and self-confidence levels were mostly evaluated with the questionnaire method. However, in this study, the motivation, satisfaction, and self-confidence in learning, satisfaction levels with the game were evaluated with different objective scales specific to learning material and simulation experience. We believe that this could be an important element, especially as it was developed specifically for students for a particular topic in the oncology nursing syllabus. This may also have encouraged students’ engagement and influenced their motivation and satisfaction as they entered the game and found items and clues related to OEs.

It is emphasized that gamification in nursing education can improve student satisfaction and experience by improving the acquisition of knowledge, skills, and attitudes, and by promoting critical thinking and problem-solving skills (Gómez-Urquiza et al., 2019). Molina-Torres et al. (2021) found that the satisfaction score of the nursing students who learned the anatomy module with the ERG was higher than average (Molina-Torres et al., 2021). Moreover, students’ opinions and reported experiences were very positive for other games as well (Johnsen et al., 2018; Koivisto et al., 2018; Maheu-Cadotte et al., 2018). Similarly, the satisfaction sub-dimensions of the IMMS and problem-solving of the SDS scores of the students who knew the ERG were significantly higher than the students who did not know the ERG. A possible explanation for this could be that having previous knowledge of such games may make playing the game easier, and this may contribute to students’ higher satisfaction and problem-solving level with their experience.

The concept of self-confidence refers to the belief in being able to initiate the activities necessary to do or achieve something and to get results (Souza et al., 2020). In other words, it can be defined as the self-efficacy of nursing students to achieve goals related to cognitive, psychomotor, and attitudinal skills and abilities (Baptista et al., 2014; Karacay & Kaya, 2017). In the current study, it was found that students who had a previous ERG experience had significantly higher scores from the sum of SSSCLS and all its sub-dimensions. Although there is no study examining the effect of the ERG on the satisfaction and self-confidence levels of students in learning, it is reported that simulation-based education may create positive outcomes for students in terms of these two variables. A large-scale study of third-year nursing students revealed that students who received increased simulation training reported higher levels of professional self-confidence (Fuglsang et al., 2022). Another study of nursing students’ experiences with high-fidelity simulation revealed students who simulated 4–12 times per academic year reported being more likely to learn with increasing confidence (Najjar et al., 2015). In this context, in line with our study on the usefulness of the ERG method in OEs course, which is one of the simulation-based approaches for nursing courses, it is thought that it would be beneficial to use this innovative education method in other courses in the undergraduate nursing program as a complementary T&L strategy.

As one of the interesting findings of this study, gender differences were observed in the ERG design for SDS, and its problem-solving and guided reflection/feedback dimension. No gender differences were found in the original SDS (Unver et al., 2017) and previous studies (Olaussen et al., 2020; Verkuyl & Hughes, 2019). However, our female students achieved higher scores on the total SDS, problem-solving and guided reflection/feedback dimension. Accordingly, this difference can be explained by the fact that the learning styles of male and female students are different. Isik and Kuzudisli (2015), found that the learning style of female students was predominantly certain order, namely learning by doing (Isik & Kuzudisli, 2015). This finding is consistent with the features of ERGs such as completing sequential tasks, getting immediate feedback, discovering clues, learning by doing, problem-solving, and opening doors (Isik & Kuzudisli, 2015; Morrell & Ball, 2020). Another possible explanation for this difference could be related that male students may consider themselves leaders while playing a game (González Calvo & Bernalte Benazet, 2011). Therefore, male students may have been less satisfied with the simulation design and put less effort into problem-solving.

6 Conclusion

The current study on the use of an OEs-themed escape room as a T&L strategy has provided promising insights. In nursing education, traditionally dominated by theoretical and practical intensive content, current study findings underline the value of this innovative strategy in helping students to improve motivation, satisfaction, and confidence in learning. The positive outcomes are in line with the existing literature on gamification and escape rooms in education and support the idea that integrating elements of fun, and enjoyment is an important key to fostering student active engagement and reinforcing experiential learning. In addition, it can be useful in gaining many cognitive and psychomotor skills such as motivation to learn, satisfaction and self-confidence in learning, problem-solving, active learning, and task completion. The use of ERG-based learning and teaching methods in other nursing courses and subject areas should be encouraged, and its impact on students’ learning experience, academic and clinical performance specific to these areas should be investigated with a study in a control group design.

7 Limitations

This study had some limitations. First, the study was conducted with convenience sampling at only one institution to recruit students, therefore, the results may not be generalizable to the other nursing students. This may also have limited the ability to establish a causal relationship between the study’s intervention and outcome variables. In addition, the use of only a quasi-experimental post-test design without a control group may have also contributed to this limitation. Second, the scales were specific to all simulation methods rather than scales designed to measure users’ ER-specific gaming experience, limiting the possibility of comparing our results with those of previous studies. Furthermore, the fact that these instruments are based on self-reported measurements is also a limitation. While an almost self-reported questionnaire is a commonly used approach in similar previous studies, the extent of the inherent social desirability response bias and recall bias can not be predicted. Finally, since many possible confounding factors (including personal and environmental) affect motivation, satisfaction and self-confidence in nursing students, were not considered.

8 Implications for practice

Combining active learning with practical simulation, this study showed that the ERG enhanced motivation, satisfaction and self-confidence among nursing students. The contribution of the results obtained from this study to nursing education is that studies on the use of ERG developed for a specific subject in education is particularly limited, so this study would contribute to filling this gap in the literature. It is important to investigate nursing students’ learning motivation, satisfaction and self-confidence towards such innovative T&L strategies, because these strategies are the mediators that determine whether to integrate into theoretical and practical courses in the field of nursing or not.

Considering the limitations of the current study mentioned above, further studies involving a larger number of students in more than one institution are recommended. In addition, future randomized controlled studies considering confounding factors could be planned to more clearly explain the causal relationship between the intervention and outcomes, and to increase the reliability of the results. Furthermore, long-term follow-up studies can also be considered to investigate the long-term effects of game-based T&L strategies on nursing students’ motivation, satisfaction and self-confidence. By implementing these recommendations in nursing education through future studies, the quality of nursing education can be improved and their use in other nursing fields can be disseminated. In addition, it may be recommended to investigate, implement and expand the scope of this method in other disciplines.