Undergraduate Nursing Students’ Experiences and Perceived Learning in a Digital Escape Room

Abstract

Background

Innovative teaching strategies, such as gamification, are increasingly being integrated into nursing education to promote engagement and active learning. Digital escape rooms (DERs) offer an immersive and collaborative environment, yet current evidence mainly focuses on general satisfaction, with limited exploration of factors influencing perceived learning.

Objectives

This study aimed to evaluate nursing students’ experiences and perceived learning in a DER activity and to assess the perceived learning, educational value and potential applicability of DERs to other areas of the nursing curriculum.

Method

A cross-sectional study was conducted with second-year nursing students participating in a DER based on a simulated clinical case related to the nursing process. Data collection included sociodemographic variables, the Gameful Experience Scale (GAMEX), and students’ perceptions of the activity’s usefulness and transferability.

Results

Students reported high levels of enjoyment and creative thinking during the DER activity. Most participants (94.3%) perceived the experience as beneficial for their learning and useful in exam preparation (90%). Prior academic escape room experience was associated with higher activation scores (p = 0.01), while a higher previous motivation level was significantly related to greater creative thinking (p = 0.02) and activation (p = 0.01). Opinions varied regarding the suitability of DERs for other subjects.

Conclusion

The DER provided a meaningful learning experience, supporting students’ perceived learning and engagement. However, findings should be interpreted with caution due to reliance on self-reported outcomes, convenience sampling, and the specific educational context. From a practical perspective, these results highlight the importance of careful instructional design and faculty preparation when integrating DERs into nursing curricula. Future research should further explore the role of digital competence, teamwork dynamics, and longitudinal learning outcomes.

Keywords

nursing students digital escape room GAMEX opinions experiences

Background

Educational innovation in university settings has driven the incorporation of active methodologies, complementing traditional lecture-based teaching with simulation, problem-based learning, and case studies to promote more practical, student-centred learning (Bussard et al., 2023). This pedagogical shift encourages engagement, critical thinking, and meaningful learning in increasingly complex professional contexts (Makri et al., 2021).

Within this shift toward active learning, gamification-the application of game elements and dynamics in non-game contexts-has gained increasing attention (Woodcock & Johnson, 2017). Gamification has emerged as a promising educational strategy to enhance student engagement, motivation and commitment, particularly in degree programs oriented toward professional practice (Huang et al., 2024; Malicki et al., 2020).

Among the diverse gamification strategies, one of the most prominent innovations is educational escape rooms, also known as escape games. These approaches, which can be implemented in both face-to-face and digital formats, immerse students in collaborative problem-solving activities tied to curricular content under time constraints (Makri et al., 2021; Quek et al., 2023). Digital escape rooms (DERs), in particular, offer flexible and scalable opportunities for engagement across various learning environments, while integrating narrative progression, time pressure, and sequential challenges within a structured digital setting. Compared with other active methodologies, DERs may promote emotional activation and sustained engagement alongside cognitive involvement (Ruiz et al., 2026).

Studies suggest that this type of dynamic may promote active learning, teamwork, decision-making, and critical thinking, skills considered essential in clinical practice (Fagundo-Rivera et al., 2024; Fernandes et al., 2025; Nicholson, 2018; Yang et al., 2023). For this reason, universities have begun using escape rooms, particularly in health sciences programs, although questions remain regarding their formal integration as a consolidated instructional strategy (Fusco et al., 2021; Reinkemeyer et al., 2022).

From a motivational perspective, gamified learning approaches are frequently grounded in Self-Determination Theory, which posits that learning environments that support students’ autonomy, competence, and relatedness are more likely to foster intrinsic motivation and sustained engagement (Uysal and Yildirim, 2016). DERs may address these basic psychological needs by encouraging active decision-making, collaborative problem-solving, and a sense of accomplishment through progressive challenges. Understanding DERs from this perspective may help explain variations in students’ motivation and engagement beyond surface-level satisfaction.

In nursing education specifically, DERs have been used to address a wide range of theoretical and practical topics related to clinical knowledge. A notable example is the study by Acebo-Seguín et al. (2024), which explores the application of DERs in the management of the infarction code. In this study, students reinforced essential knowledge and developed coordination and team response skills. Other studies have documented the use of DERs and demonstrated their adaptability in various clinical contexts, such as mental health (Arrue et al., 2024; Rodríguez-Ferrer et al., 2022), pressure ulcer management (Antón-Solanas et al., 2022), renal system pathologies (Joy et al., 2024), stroke management (Anguas-Gracia et al., 2021), sexual and reproductive health (Martínez-Galiano et al., 2024), and comprehensive care planning (Fagundo-Rivera et al., 2024).

However, existing research has focused on measuring learning outcomes or student satisfaction levels, without sufficiently exploring other factors that may influence the effectiveness of DERs as a teaching strategy. In particular, limited attention has been paid to students’ motivational profiles, prior experiences with escape rooms, or perceptions of the applicability and transferability of these activities beyond a single course or subject area, especially in more basic or foundational nursing subjects (Fernandes et al., 2025).

In this context, the Gameful Experience Scale (GAMEX) offers a multidimensional framework to examine students’ experiences with gamified learning activities, encompassing dimensions such as enjoyment, activation, creative thinking, and negative emotions. Framing the evaluation of digital escape rooms within this framework allows for a more theoretically grounded understanding of how different experiential components may influence students’ perceived learning, beyond general satisfaction measures (Eppmann et al., 2018). Considering the importance of student perspectives for the successful implementation of innovative teaching strategies, exploring learners’ experiences and evaluations of digital escape rooms is essential. Students’ feedback and evaluative perceptions can inform the refinement and future integration of DER activities in nursing curricula.

Therefore, the present study aims to analyse the experience of DER implementation in a nursing degree course, as well as gather student evaluations of its pedagogical potential and feasibility for structured curricular integration. Addressing these aspects is essential to support a more meaningful and contextually grounded use of this strategy in nursing education.

Objectives

The main objective of this study was to evaluate the experiences of second-year nursing students during their participation in a DER. Additionally, the study sought to analyse students’ opinions of the activity´s usefulness and its potential transferability to other educational contexts within the nursing curriculum.

Method

We used the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) cross-sectional checklist when writing the report (von Elm et al., 2007).

Design and Study Location

The study was conducted at the Nursing Department, Faculty of Medicine and Nursing of the University of the Basque Country-UPV/EHU during the 2024–2025 academic year. A cross-sectional design was used to explore nursing students’ gameful experiences while engaging with a DER, as well as to assess their perceptions of the activity´s usefulness and its potential transferability to other subjects. The implementation took place between September and December 2024, within the “Methodological Bases of Nursing” class, as part of the second-year nursing degree curriculum.

Description of the Subject

The course “Methodological Bases of Nursing” provides students with the foundational knowledge to develop clinical judgment and construct care plans by applying the nursing process. It integrates diverse nursing models and standardised taxonomies, including the North American Nursing Diagnosis Association (NANDA), the Nursing Outcomes Classification (NOC) and the Nursing Intervention Classification (NIC) (Herdman et al., 2024; Moorhead et al., 2024; Wagner & Butcher, 2024). This subject, valued at six ECTS credits, is delivered during the first semester of the second year of the nursing degree program. The full syllabus can be viewed online at (Web University of the Basque Country UPV/EHU, 2025).

Description of Sample and Strategies

The study population consisted of second-year undergraduate nursing students enrolled in the university’s nursing program. All students from one of the two second-year class groups in which the digital escape room was implemented were invited to participate (n=80). This approach is commonly used in educational research in teaching settings, where random sampling is often not feasible due to curricular and organisational constraints (Cohen et al., 2017).

Students were randomly assigned to one of the two class groups by the university’s academic management software upon enrolment in the first year of the program. The learning program, instructors, and course content were identical for both groups. In addition, the time commitment was equivalent: all students received 50 hours of lectures and 25 hours of workshops.

An a priori statistical power calculation was not performed; however, the sample size was comparable to those in previous studies examining digital escape rooms in nursing education (Acebo-Seguín et al., 2024; Anguas-Gracia et al., 2021; Antón-Solanas et al., 2022; Arrue et al., 2024; Fagundo-Rivera et al., 2024; Joy et al., 2024; Martínez-Galiano et al., 2024; Rodríguez-Ferrer et al., 2022; Ruiz et al., 2026). Given the exploratory nature of the study and its focus on students’ perceived learning and gameful experiences, the sample was deemed appropriate for addressing the study objectives (Cohen et al., 2017).

To minimise response bias, questionnaires were administered anonymously, and standardised instructions were provided to all participants.

Digital Escape Room Design

The DER used in this study was structured around a simulated clinical case involving an older adult with complex health needs and functional decline. The activity was developed using the institutional Moodle platform and followed a story-based format to promote engagement and immersion. Its instructional design aimed to address three sequential learning objectives: (1) to assess students’ theoretical knowledge of the nursing process and its phases through an initial test; (2) to promote the development of a comprehensive nursing care plan by encouraging diagnostic and therapeutic reasoning based on the simulated scenario; and (3) to strengthen clinical judgment and decision-making by requiring students to propose evidence-based interventions for the identified care needs, promoting critical and reflective thinking.

The intervention was implemented during the final week of the course, once all scheduled sessions had concluded. It took place in a classroom setting at the Nursing Department, Faculty of Medicine and Nursing of the University of the Basque Country-UPV/EHU facilities and had a total duration of two hours. All participating students engaged in a single session of the DER, working in small teams of four or five to encourage collaboration and peer-supported decision making.

The session began with an audio introduction to present the narrative context and the story. To progress through the activity, students completed a series of interactive challenges based on clinical reasoning. First, they were required to pass a knowledge test to access the patient’s full clinical record and receive the first part of a riddle. In the next phase, using the provided assessment data, they identified two nursing diagnoses and formulated corresponding goals and interventions based on standardised taxonomies (NANDA, NOC and NIC) (Herdman et al., 2024; Moorhead et al., 2024; Wagner & Butcher, 2024). Successful completion of this task unlocked the final part of the riddle, which in turn revealed two alternative care options.

Students then had to critically evaluate the supporting evidence for each option in order to make a well-founded clinical decision. Upon completing all tasks, groups were allowed to exit the room. The entire activity was conducted under a strict one-hour time limit, adding both challenge and a sense of realism to the experience.

Throughout the session, instructors from the nursing department, each with over six years of teaching experience, facilitated and monitored student progress, providing continuous formative feedback to support reasoning and reinforce procedural learning. To further enhance motivation, small rewards (such as chocolate snacks) were offered to the first group to complete each stage and the entire activity.

Data Collection

A digital “ad hoc” questionnaire was administered to collect data. First, sociodemographic and contextual information was gathered, including age; sex; prior experience with gamified learning activities (such as academic or recreational escape rooms) (yes/no); motivation level previous to the implementation of the intervention (rated on a five-point Likert scale: very high, high, neutral, low, very low); and whether students felt they had dedicated sufficient time to studying the subject (yes/no).

Participants were also asked to evaluate their perceived competence in applying the nursing process, including diagnostic reasoning, care planning, and clinical decision-making. This self-assessment was carried out using nine different items answered on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree).

To assess the instructional experience, the Gameful Experience Scale (GAMEX) (Márquez-Hernández et al., 2019), adapted to Spanish, was used. This instrument includes 27 Likert-type items and measures six dimensions: (1) enjoyment (items 1–6), (2) absorption (items 7–12), (3) creative thinking (items 13–16), (4) activation (items 17–20), (5) absence of negative effects (items 21–23), and (6) dominance (items 24–27). Responses are scored on a five-point scale ranging from 1 (never) to 5 (always) (Eppmann et al., 2018).

Finally, participants answered a series of Likert-type and dichotomous (yes/no) questions exploring their opinions about the suitability and potential applicability of this gamified activity to other nursing subjects, providing insight into their views on its broader educational value.

Academic records were also consulted to collect data on the number of enrolments for each student.

Data Analysis

The normality of the data was assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Qualitative variables were presented as frequencies and percentages, while quantitative variables were summarised as mean ± standard deviation. Confidence intervals (95%) for the GAMEX proportions were calculated using the Wilson score. To evaluate the internal consistency of the scales used in the study, Cronbach’s alpha coefficient was computed. After checking the distribution of the quantitative variables, the Student’s t-test was applied to assess any significant differences within the group, while the Mann-Whitney U test was used for those that did not meet the assumption of normality. To compare a quantitative variable across three or more groups, one-way ANOVA was employed. Associations between qualitative variables were analysed using the Chi-square test. Relationships between quantitative variables were explored using Pearson’s correlation coefficient. No missing data were reported in the final dataset. Statistical significance was considered at a p-value of <0.05. Data analysis was performed using SPSS v.28 software.

Ethical Considerations

This study is part of an institutional educational innovation project titled “Reflection on the Holistic Concept of Health and Its Relationship with the Social Determinants of Health, Human Needs, and the Nursing Methodology for Designing Evidence-Based Care in the Field of Nursing”, which aims to explore active methodologies in nursing education. The Ethics Committee of the University of the Basque Country (UPV/EHU) approved the study (code CEIKDi3_2024_028). All students were informed about the purpose and procedures of the study and provided written informed consent to participate voluntarily.

In addition, students were informed that they could withdraw at any time without penalty and without having to provide any reason. All participants provided their consent.

Results

The internal consistency of the GAMEX instrument was assessed using Cronbach’s alpha coefficients. The overall reliability of the scale was acceptable, with a global Cronbach’s alpha of 0.78. The subscales also demonstrated satisfactory internal consistency, with coefficients as follows: enjoyment (α = 0.76), absorption (α = 0.70), creative thinking (α = 0.70), activation (α = 0.71), absence of negative affects (α = 0.85), and dominance (α = 0.74). These values indicate that the instrument reliably measured the different dimensions of the gaming experience construct.

A total of 81 nursing students were initially included in the sample based on convenience sampling. However, 70 students completed the required questionnaires, resulting in a participation rate of 86.42%. The 11 students who did not complete the questionnaires were not asked to provide a reason for non-participation. The sociodemographic characteristics, prior experience, motivation levels before the intervention, and students’ learning experiences are summarized in Table 1. The sample consisted of 56 female students (80%) and 14 male students (20%), with a mean age of 24.34 ± 8.74 years. All students were enroled in the course for the first time.

Table 1.

Participant’s Sociodemographic Characteristics, Prior Experience, Motivation Levels before the Implementation of the Intervention, and Learning Experiences (n=70)

Variable	n (%)
Sex
Female	56 (80)
Male	14 (20)
Age (mean ± SD)	24.34 ± 8.74
Number of enrolments
First registration	70 (100)
Second registration	0 (0)
Prior experience of academic escape rooms
No	55 (78.6)
Yes	15 (21.4)
Prior experience of recreational escape rooms
No	33 (47.1)
Yes	37 (52.9)
Motivation level before to the implementation of the intervention
Very high	9 (12.8)
High	37 (52.9)
Neutral	15 (21.4)
Low	6 (8.6)
Very low	3 (4.3)
Playing the DER was positive for learning
No	4 (5.7)
Yes	66 (94.3)
Playing the DER was positive for the exam
No	7 (10)
Yes	63 (90)
Sufficient study time dedicated to the subject
No	28 (40)
Yes	42 (60)

Regarding prior experience with escape rooms, 21.4% of students reported having prior experience with academic escape rooms, while 52.9% had engaged in recreational escape rooms. Most students reported a high (52.9%) or very high (12.8%) motivation level before the intervention, while 21.4% indicated a neutral motivation level, and a smaller percentage showed low (8.6%) or very low (4.3%) motivation.

When asked about the perceived educational value of the DER, 94.3% of students perceived that the DER was positive for their learning, and 90% perceived that it was beneficial for the exam. Additionally, 60% of students felt they had dedicated sufficient time to studying the subject, while 40% disagreed.

Regarding knowledge of the nursing process, the majority of students felt confident in key areas, such as conducting thorough assessments (65.7%), formulating diagnoses (65.7%), and establishing or prioritising outcomes (70%). They also emphasised the importance of individualised care (94.3%) and executing the care plan as intended (95.8%). Regarding knowledge of NANDA, NOC, and NIC taxonomies, most students (67.1%) considered their understanding adequate. Additionally, all participants agreed on the importance of using standardised systems for documenting care.

The results of the escape room experiences, assessed using the GAMEX scale, are presented in Table 2, which shows the mean scores, standard deviations (SD) and confidence intervals (CI) for each dimension.

Table 2.

Results From the GAMEX Scale (n=70)

	Mean ± SD	CI (95%)
GAMEX-enjoyment dimension	4.20 ± 0.63	0.07-0.23
1. GAMEX: Playing the game was fun.	4.28 ± 0.78	0.35-0.57
2. GAMEX: I Liked playing the game.	4.52 ± 0.65	0.45-0.68
3. GAMEX: I enjoyed playing the game very much.	4.22 ± 0.72	0.28-0.51
4. GAMEX: My game experience was pleasurable.	4.44 ± 0.67	0.41-0.64
5. GAMEX: I think playing the game is very entertaining.	4.41 ± 0.71	0.41-0.64
6. GAMEX: I would play this game for its own sake, not only when being asked to play.	3.32 ± 1.08	0.08-0.24
GAMEX-Absorption dimension	3.37 ± 0.92	0.02-0.14
7. GAMEX: Playing the game made me forget where I am.	3.51 ± 1.12	0.12-0.31
8. GAMEX: I forgot about my immediate surroundings while I played the game.	3.57 ± 1.03	0.12-0.31
9. GAMEX: After playing the game, it felt like coming back to the “real world” after a journey.	3.06 ± 1.14	0.05-0.19
10. GAMEX: Playing the game “got me away from it all”.	3.14 ± 1.09	0.05-0.19
11. GAMEX: While playing the game, I was completely oblivious to everything around me.	3.27 ± 1.10	0.08-0.24
12. GAMEX: While playing the game, I lost track of time.	3.71 ± 1.11	0.17-0.37
GAMEX-Creative thinking dimension	3.75 ± 0.82	0.06-0.21
13. GAMEX: Playing the game sparked my imagination.	3.70 ± 0.95	0.12-0.31
14. GAMEX: While playing the game, I felt creative.	3.91 ± 0.88	0.16-0.36
15. GAMEX: While playing the game, I felt that I could explore things.	3.70 ± 0.92	0.12-0.31
16. GAMEX: While playing the game, I felt adventurous.	3.71 ± 0.99	0.13-0.32
GAMEX-Activation dimension	3.66 ± 0.86	0.06-0.21
17. GAMEX: While playing the game, I felt activated.	4.10 ± 0.76	0.22-0.43
18. GAMEX: While playing the game, I felt jittery.	3.40 ± 1.28	0.15-0.34
19. GAMEX: While playing the game, I felt frenzied.	3.35 ± 1.16	0.10-0.28
20. GAMEX: While playing the game, I felt excited.	3.81 ± 0.99	0.18-0.39
GAMEX-Absence of negative affect dimension	1.80 ± 0.95	0.01-0.07
21. GAMEX: While playing the game, I felt upset.	1.48 ± 0.95	0.01-0.10
22. GAMEX: While playing the game, I felt hostile.	1.94 ± 1.19	0.01-0.10
23. GAMEX: While playing the game, I felt frustrated.	1.98 ± 1.16	0.01-0.12
GAMEX-dominance dimension	3.20 ± 0.79	0.01-0.07
24. GAMEX: While playing the game, I felt dominant/I had the feeling of being in charge.	2.68 ± 1.14	0.01-0.12
25. GAMEX: While playing the game, I felt influential.	3.02 ± 1.04	0.01-0.12
26. GAMEX: While playing the game, I felt autonomous.	3.31 ± 1.01	0.03-0.16
27. GAMEX: While playing the game, I felt confident.	3.78 ± 0.79	0.07-0.22

Five out of the six dimensions achieved a mean score above 3, including enjoyment (4.20 ± 0.63), absorption (3.37 ± 0.92), creative thinking (3.75 ± 0.82), activation (3.66 ± 0.86), and dominance (3.20 ± 0.79). The enjoyment dimension had the highest mean score (4.20 ± 0.63), and the absence of negative affect dimension scored the lowest (1.80 ± 0.95), indicating minimal negative emotions, with items such as frustration and hostility scoring very low (1.98 ± 1.16 and 1.94 ± 1.19 respectively). Overall, these results reflect a predominantly positive gameful experience across most dimensions assessed.

Students’ opinions regarding the pedagogical usefulness of the gamified activity are summarised in Table 3.

Table 3.

Students’ Opinions Regarding the Pedagogical Usefulness of the Escape Room Activity (n=70)

Item	n (%)
Playing helped me learn about the subject
No	4 (5.7)
Yes	66 (94.3)
I think the game will help me on the exam
No	7 (10)
Yes	63 (90)
I remembered and applied my knowledge of the subject during the game
No	1 (1.4)
Yes	69 (98.6)
There should be more games like this during the nursing program
No	1 (1.4)
Yes	69 (98.6)
The game motivated me to continue studying, even though the exam is several weeks away
No	18 (25.7)
Yes	52 (74.3)
Do you consider the escape room game to be an appropriate learning method for this course?
No	1 (1.4)
Yes	69 (98.6)
Do you consider the escape room an innovative teaching tool?
No	2 (2.9)
Yes	68 (97.1)

The vast majority of participants perceived the DER to be a valuable learning experience, with 94.3% stating that it helped them learn about the subject, and 90% indicating that it would be useful for the exam. Almost all students (98.6%) reported being able to recall and apply their knowledge during the activity and believed that similar games should be integrated more frequently into the nursing curriculum (98.6%). In terms of motivation, 74.3% of students stated that the game encouraged them to continue studying, even though the exam was still several weeks away. Additionally, 98.6% regarded the escape room as an appropriate learning method for the course, and 97.1% described it as an innovative teaching tool. Overall, responses reflected a high level of agreement across all items related to the perceived pedagogical usefulness of the digital escape room.

Students’ opinions regarding the broader applicability of the gamified activity are detailed in Table 4.

Table 4.

Students’ Opinions of the Potential Transferability of the Escape Room to Other Subjects (n=70)

Item	n (%)
Item	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
The format of the game could be applicable to other subjects in the course.	13 (18.6)	30 (42.8)	11 (15.7)	10 (14.3)	6 (8.6)
It would be complicated to carry out this type of activity in the basic subjects of the course (pharmacology, anatomy, physiology, etc.).	0 (0)	1 (1.4)	17 (24.3)	44 (62.9)	8 (11.4)
I consider this type of activity inappropriate in a health sciences career.	39 (55.7)	24 (34.3)	4 (5.7)	2 (2.9)	1 (1.4)
This type of activity should have more importance in university education.	1 (1.4)	1 (1.4)	14 (20)	36 (51.4)	18 (25.8)

While responses were mixed on whether the format could be extended to other nursing subjects (only 22.9% agreed or strongly agreed), most participants (74.3%) believed that implementing such activities in basic subjects (e.g., pharmacology, anatomy, physiology) would be challenging. Notably, most students disagreed with the idea that this type of activity is inappropriate for health sciences education (90%). Furthermore, a significant proportion (77.2%) agreed or strongly agreed that gamified methodologies should have greater relevance within university-level education. Overall, these findings indicate differentiated perceptions regarding the transferability of the escape room format across subjects, along with a generally positive view of gamified learning activities in higher education.

The relationships between sociodemographic variables and the different GAMEX dimensions were explored. No significant differences were observed based on sex, age, enrolment or prior experience with recreational escape rooms. However, prior experience with academic escape rooms was associated with significantly higher scores in the activation dimension (p = 0.01), suggesting that prior exposure to similar activities may enhance students’ engagement during game-based learning.

Additionally, the relationship between motivation and the GAMEX dimensions was analysed separately. Significant positive associations were found between previous motivation level and the dimensions of creative thinking (p = 0.02) and activation (p = 0.01), indicating that students who reported higher motivation levels also experienced greater positive emotions and creativity during the escape room (Table 5).

Table 5.

Relationship Between Motivation Level before the Implementation of the Intervention and GAMEX Dimensions Scores (n=70)

GAMEX dimension	Motivation level before the implementation of the intervention					p*
	Very low	Low	Neutral	High	Very high
	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD
Enjoyment	3.2 ± 0.48	3.6 ± 0.97	4.03 ± 0.58	4.28 ± 0.99	4.83 ± 0.14	0.06
Absorption	2.27± 1.54	3.02 ± 1	3.42 ± 0.85	3.41 ± 0.77	3.75 ± 1.22	0.15
Creative thinking	2.25 ± 1.25	3.3 ± 0.87	3.88 ± 0.83	3.77 ± 0.64	4.27 ± 0.76	0.02
Activation	2.5 ± 0.90	3.04 ± 1.10	3.65 ± 0.80	3.67 ± 0.74	4.47 ± 0.86	0.01
Absence of negative affect	2.77 ± 0.96	1.66 ± 0.81	1.73 ± 0.97	1.78 ± 0.97	1.77 ± 0.89	0.50
Dominance	2.33 ± 0.87	3.12 ± 1.04	3.26 ± 0.82	3.20 ± 0.75	3.41 ± 0.66	0.35

p* Anova-test.

Finally, the relationships between sociodemographic variables and students’ opinions on the activity´s usefulness were examined. A significant relationship was detected with motivation level before the implementation of the intervention (p = 0.03). A positive trend was noted, with higher levels of previous motivation associated with stronger beliefs among students that the activity could help them in preparation for the exam. No significant associations were found between sex, age, enrolment status or prior experience with academic or recreational escape rooms.

Discussion

This study explored the gameful experience of undergraduate nursing students during their participation in a DER activity, implemented as part of the “Methodological Bases of Nursing” course. Using the GAMEX scale, it assessed second-year students’ engagement with the intervention, while also examining their perceptions regarding the educational value of the activity and its potential transferability to other areas of the nursing curriculum. The findings offer valuable insights into how DERs can enhance student engagement and promote broader pedagogical innovation within nursing education.

The sample consisted mostly of women (80%) with an average age of 24.34 years, consistent with the feminisation of nursing and the profiles described in previous studies (Anguas-Gracia et al., 2021; Arrue et al., 2024). Nearly half of the students reported having prior experience with recreational escape rooms, and more than half reported high levels of motivation before the implementation of the intervention. These characteristics align with findings from the latest research, which has also identified high levels of motivation among nursing students before their participation in gamified educational interventions (Arrue et al., 2024; Ferriz-Valero et al., 2020; Gómez-Urquiza et al., 2019).

Students’ self-perceptions regarding their knowledge and application of the nursing process were largely positive, particularly in relation to nursing diagnoses and the use of the nursing diagnosis, outcomes and intervention taxonomies. These findings are consistent with those of Antón-Solanas et al. (2022), who also observed a favourable perception following a gamified experience related to the application of the nursing process in the context of pressure ulcers. However, certain items, such as assessment or therapeutic judgment, showed less decisive responses, potentially indicating a lack of confidence when applying this knowledge in more complex situations.

The GAMEX questionnaire results reveal a highly positive experience for the students, especially in the dimensions of enjoyment, creative thinking, and activation, aligning with previous studies (Fagundo-Rivera et al., 2024; Martínez-Galiano et al., 2024). High enjoyment scores and the strong perception of learning usefulness reinforce evidence that escape rooms foster emotional and cognitive engagement in nursing education. Antón-Solanas et al. (2022) highlighted the perceived value of gamification for meaningfully integrating complex content. However, some students showed more moderate scores in dimensions such as absorption and dominance, possibly because, as being a digital escape room, the immersive environment is more limited compared to a physical escape room, which may have influenced students’ levels of immersion. Additionally, the design of the activity was external to the students, which could have affected their sense of control over the experience, which in turn influenced the scores for dominance and absorption. This suggests that increasing opportunities for interaction and personalisation, as well as involving students more actively in the learning process, could enhance immersion and perceived control in future DER implementations.

Regarding the relationships between the GAMEX scale scores and the sample characteristics, no significant associations were found between sociodemographic characteristics and most of the GAMEX dimensions. While previous studies, such as Anguas-Gracia et al. (2021), have linked prior experience with escape rooms to a more positive overall perception, our findings only revealed a significant association between prior experience with academic escape rooms and the activation dimension (p = 0.01). This could be explained by the effect of contextual familiarity, whereby previous exposure to similar methodologies in educational settings may enhance participants’ confidence and their positive emotional responses during the activity. (Veldkamp et al., 2020). Additionally, motivation level before the intervention was significantly associated with creative thinking (p = 0.02) and activation (p = 0.01), aligning with studies that link intrinsic motivation to positive emotional and cognitive processes (Ryan & Deci, 2020). These results highlight the importance of addressing students’ motivational readiness prior to the activity, for example, by clearly explaining learning objectives, aligning the activity with assessment requirements and explicitly linking the game to professional nursing practice.

In the current educational context, students tend to prefer more modern, student-centred teaching methodologies that incorporate technology and interactive approaches to improve the learning experience (Morales-Morgado et al., 2023). In line with emerging literature, students in our study positively evaluated the pedagogical utility of the escape room, with over 90% indicating it helped them learn the content, would be useful for the exam, and enabled them to recall and apply prior knowledge during the game. These findings echo the latest research showing how this methodology fosters critical thinking, effective communication, and teamwork (Antón-Solanas et al., 2022). Additionally, the motivational impact was notable, similar to other studies with comparable samples (Martínez-Galiano et al., 2024), with 74.3% of students stating that the activity encouraged them to continue studying weeks ahead of the exam. These results support the potential of escape rooms as complementary tools for the development of nursing competencies, aligning with the paradigm of active learning.

However, opinions about the applicability of escape rooms to other subjects were more divided. While 77.1% agreed or strongly agreed that such activities should play a greater role in university education, 74.3% disagreed with their usefulness in basic courses like anatomy or pharmacology. This reluctance may stem from the perception that such subjects require a more traditional, memorisation-based approach (Suárez-Escudero et al., 2021; Valle & Gonzalvo, 2017). Previous research suggests that applying escape rooms to highly theoretical content requires careful instructional alignment to avoid cognitive overload and ensure coherence with learning outcomes (Buchner et al., 2022). To overcome this barrier, gradual integration strategies could be considered, such as the use of simplified clinical scenarios, progressive increases in task complexity, or hybrid approaches combining short, gamified activities with more traditional instructional methods (Ruiz et al., 2026).

Nevertheless, studies suggest that the challenge of adapting educational games to more technical content may be more closely related to a lack of teaching experience in gamification. It has been shown that teacher demands, feedback, and attention to detail are key factors in student engagement (Mateos & López, 2024). Moreover, it has been demonstrated that areas with complex theoretical and procedural content can still benefit from escape rooms if they are carefully designed with realistic simulation elements (Álvarez-Sánchez et al., 2019). These contrasts highlight the need to train faculty in innovative teaching strategies and adapt activity design to the specific learning objectives of each subject.

The present study adds to the expanding literature on the use of gamification in nursing education by highlighting the positive impact of DERs on student engagement, motivation, and perceived learning. Nonetheless, several limitations must be considered when interpreting these findings. These limitations include the specific context in which the intervention was implemented, the use of a convenience sampling without an a priori statistical power calculation, and the reliance on self-reported outcomes. In particular, variables such as digital skills, familiarity with technology, prior exposure to active learning methodologies, and group interaction dynamics were not formally controlled, which may affect the generalisability of the results.

Future research should consider longitudinal designs to assess the retention of knowledge and skills over time, incorporate objective learning measures, and explore how emotional, cognitive, and social factors interact to shape students’ experiences in gamified learning environments. It would also be beneficial to investigate the role of instructor expertise in gamification design, particularly in traditionally theoretical subjects, where resistance to active methodologies may still prevail.

Conclusion

The DER demonstrated value as an innovative educational tool. Its integration into the classroom was well received by students, who recognised its usefulness for reinforcing content and maintaining motivation throughout the learning process.

Although prior experience with similar activities did not appear to significantly influence outcomes, motivation level before the intervention´s implementation was found to play a relevant role in shaping students’ engagement, highlighting the impact of individual factors in gamified learning environments. Nevertheless, it is relevant to include additional individual variables in the design of future research. Beyond the factors analysed in this study, subsequent investigations should consider the role of other key elements, such as digital skills and teamwork dynamics, which are essential for success in collaborative dynamics like DERs.

Perceptions regarding the applicability of this approach to more technical or theoretical subjects were more divided, suggesting a need for thoughtful instructional design and faculty training to ensure effective implementation across diverse curricular contexts. Strengthening teacher preparation in gamification design and the pedagogical use of digital tools may facilitate broader and more sustainable integration of DERs across the nursing curriculum. Incorporating students’ perceptions and experiences as evaluative input may further enhance the relevance and acceptability of these strategies.

Footnotes

ORCID iD

Garazi Monasterio Gangoiti

Ethical Considerations

The Ethics Committee of the University of the Basque Country/Euskal Herriko Unibertsitatea (UPV/EHU) approved the study (code CEIKDi3_2024_028). No payments or other incentives were offered to students for their participation.

Informed Consent

All students were informed about the study’s objectives and procedures and provided written informed consent to participate voluntarily.

Author Contributions

Iñigo Lorenzo Ruiz contributed to the study design, data collection, analysis supervision, and critical manuscript revisions.

Garazi Monasterio Gangoiti contributed to the design, data collection, analysis, and manuscript drafting.

Itziar Hoyos Cillero contributed to the conceptualization of the project, interpretation of findings, and final manuscript approval.

All authors reviewed and approved the final version of the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.*

Other Identifying Information

The research was conducted at the University of the Basque Country (UPV/EHU), with no external institutional affiliations influencing the study’s design or reporting.

Author Biographies

Iñigo Lorenzo Ruiz, RN, PhD, in Public Health, is a lecturer and researcher at the University of the Basque Country (UPV/EHU), Leioa, Spain. His academic and research career is centered on public health, epidemiology, and innovation in health sciences education, with a particular interest in improving teaching methodologies in nursing.

Garazi Monasterio Gangoiti, RN, Doctoral researcher in Public Health at the University of the Basque Country (UPV/EHU), Leioa, Spain. Her work centers on the study of social inequalities in health within the field of public health. In addition, she has been involved in initiatives related to teaching innovation in health sciences education, aimed at improving educational practices.

Itziar Hoyos Cillero, PhD, RN, is a lecturer and researcher at the University of the Basque Country (UPV/EHU), Leioa, Spain. Her academic and research work focuses on nursing, public health, lifestyle behaviors, health promotion, and nursing education, with a particular interest in the development and evaluation of innovative teaching methodologies in nursing education.

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