Effectiveness of an Interactive Training Program on Emergency Management Competencies Among New Nurses in China: A Controlled Trial Assessing Knowledge, Skills, and Communication

Effectiveness of an Interactive Training Program on Emergency Management Competencies Among New Nurses in China: A Controlled Trial Assessing Knowledge, Skills, and Communication | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of an Interactive Training Program on Emergency Management Competencies Among New Nurses in China: A Controlled Trial Assessing Knowledge, Skills, and Communication Shupei Fang, Yuanyuan Zhao, Qianqian Chen, Jingwen Jian, Yuedan Xu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6135147/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Effective emergency management is essential for ensuring optimal patient outcomes, with newly enrolled nurses playing a crucial role in the early detection and intervention of critical conditions. However, in China, these nurses often encounter challenges stemming from limited clinical experience, inadequate training in emergency skills, and the lack of standardized training programs tailored to the country's unique healthcare needs. Addressing these gaps through innovative training methods is critical for enhancing patient safety and the quality of care. This randomized controlled trial aims to evaluate the effectiveness of integrating the Conceive-Design-Implement-Operate (CDIO) framework with escape room pedagogy to improve the emergency management competencies of newly enrolled nurses. The anticipated findings are expected to provide evidence-based recommendations for nursing education in China and contribute to the overall enhancement of healthcare quality in the nation. Methods This study adopts a quasi-experimental pre-test-post-test design. Participants were divided into two groups: a control group (control group, n = 85) receiving traditional lecture-based training, and an experimental group (experimental group, n = 84) undergoing the CDIO-escape room intervention. Outcomes were evaluated using theoretical exams, operational assessments, the Clinical Emergency Response Ability Questionnaire, and the Supportive Communication Scale. Results Post-intervention results revealed statistically significant improvements in the experimental group across all metrics: theoretical knowledge (83.11 ± 4.46 vs. 80.82 ± 5.13, p = 0.002), practical skills (90.28 ± 3.02 vs. 85.81 ± 2.72, p < 0.001), emergency response (19.95 ± 1.20 vs. 18.05 ± 1.17, p < 0.001), and supportive communication (47.35 ± 2.02 vs. 43.64 ± 2.26, p < 0.001), compared to the control group. These improvements were statistically significant for all outcomes. Conclusions The CDIO-escape room model effectively combines systematic training with immersive problem-solving dynamics, thereby addressing gaps in clinical preparedness. This dual-model approach aligns with China’s standardized nursing education guidelines and provides a scalable framework for global implementation. Trial registration Not applicable. Emergency Management CDIO Escape Room Nurses China Figures Figure 1 Background Training in emergency management skills is vital for ensuring that nurses are prepared to respond effectively in critical situations. These skills encompass an integration of knowledge, practical abilities, and cognitive thinking [1]. Research consistently demonstrates that structured training programs focused on emergency management significantly enhance nurses' theoretical knowledge, practical skills, emergency response capabilities, and communication proficiency [2-4]. However, newly enrolled nurses often face challenges during rescue operations due to limited clinical experience, insufficient familiarity with first aid techniques, inadequate ability to anticipate changes in patient conditions, and underdeveloped communication skills [5, 6]. In response to these challenges, the National Health Commission of China issued the Training Outline for Newly Enrolled Nurses (Trial) in 2016, which guided medical units at all levels to conduct standardized training for newly enrolled nurses, particularly in emergency management skills [7]. Traditional lecture-based learning methods ensure a standardized approach to content delivery [8]. However, they may fall short in addressing the hands-on skills and real-world applications critical for clinical practice [9, 10]. In the 21st century, adopting innovative teaching and learning strategies has become essential in nursing education [11]. Healthcare institutions are actively exploring and implementing various innovative teaching models, such as the BOPPPS teaching model [12], flipped classrooms [13], and simulation-based training [14]. While these methods offer valuable insights, they often fall short in fostering the combination of theoretical knowledge, practical application, and adaptability required in real-world clinical scenarios. For instance, the BOPPPS model, though effective in enhancing theoretical knowledge and practical skills, may lack the flexibility needed to cultivate adaptability in dynamic clinical environments due to its structured design [15, 16]. Similarly, the flipped classroom approach necessitates that students independently acquire substantial theoretical knowledge before class, which can increase stress levels and hinder comprehension for some learners [13, 17]. Simulation-based training, while effective in replicating clinical settings, is resource-intensive and may not fully capture the unpredictability of real emergencies [18-20]. These limitations pose challenges to the comprehensive implementation of such teaching models. The CDIO (Conceive-Design-Implement-Operate) model, introduced in 2000, is a progressive educational framework originally developed for engineering education. It emphasizes hands-on, practical learning aligned with real-world tasks [18, 21]. In nursing education, scholars have found that the CDIO model enables learners to better master theoretical knowledge and practical skills while enhancing independent learning, first aid proficiency, and communication abilities [8, 20]. Another innovative approach is the escape room, an interactive educational method where participants solve a series of puzzles and riddles within a limited time to achieve a specific goal, such as escaping from a themed room [22]. The American Association of Medical Colleges has highlighted that escape rooms can enhance students' experiential learning by providing a dynamic and interactive environment [23]. For instance, a study [24] used an escape room to orient paraclinical medical students to simulated medical environments, finding that it significantly improved students' confidence and preparedness for subsequent simulation activities. Similarly, another study [25] employed an escape room in reproductive endocrinology and infertility education, concluding that it enhanced teamwork, critical thinking, and knowledge retention. Previous study [26] explored the use of escape rooms for training acute care professionals in Crew Resource Management and teamwork, demonstrating that this method effectively improved participants' teamwork and communication skills. Collectively, these studies suggest that escape rooms can significantly enhance emergency response capabilities, communication skills, and overall learning experiences in medical education. Despite their individual merits, existing studies have predominantly evaluated the CDIO model and escape room pedagogy in isolation [2, 23, 27], thereby neglecting their synergistic application within nurse training programs [28]. In China, significant gaps persist in integrating these approaches, and their individual implementation is often constrained by small sample sizes and limited scope [21, 29]. Moreover, current research often lacks an evidence-based framework for evaluating how these methods address the unique challenges faced by newly enrolled nurses. Little attention has been given to the synergistic effects of integrating these strategies to enhance nurses' preparedness for the dynamic and unpredictable nature of clinical emergencies. This study aims to address these gaps by investigating the combined use of the CDIO model and escape room pedagogy in standardized training programs for newly enrolled nurses. Specifically, it seeks to determine how this integrated approach can improve clinical emergency skills and communication, which contributes to the development of innovative, evidence-based training strategies that align with the demands of modern nursing education and practice, particularly for China. Methods This study adopts a quasi-experimental pre-test-post-test design to compare the effectiveness of the CDIO model combined with escape room pedagogy versus traditional lecture-based learning methods in enhancing newly enrolled nurses’ clinical emergency response abilities. Participants were recruited from Wenzhou Central Hospital, China, and were divided into two groups: the control group (receiving standard training as outlined in the new nurse syllabus) and the experimental group (undergoing the CDIO model integrated with escape room pedagogy). Prior to and following the training intervention, both groups were assessed using a series of measures, including theoretical and practical evaluations, the Supportive Communication Scale, and the Clinical Emergency Response Ability Questionnaire. The study design is illustrated in Fig. 1 . This study has received an ethical approval from the Wenzhou Central Hospital Institutional Review Board (Approval No. 2022Y094). All participants were required to provide informed consent for participation. Participants and Sampling According to the sample size calculation formula for comparing two sample means: $$\:n=2{\left[\frac{{(Z}_{\alpha\:/2}+{Z}_{\beta\:})\sigma\:}{\delta\:}\right]}^{2}$$ A two-sided α = 0.05, β = 0.1, Zα/2 = 1.96, and Z β = 1.282. Based on previous literature [ 8 ], a total score of δ = 3.26 and a standard deviation of σ = 4.45 were adopted. The required sample size for each group is 40 participants. To account for a potential 10% loss to follow-up, the adjusted sample size is a minimum of 44 participants per group. A random number table is used for random allocation. The inclusion criteria are: (1) an associate degree or bachelor’s degree in nursing; (2) participation in standardized training as required; (3) no prior training in the emergency department; (4) a signed informed consent form. The exclusion criteria are: (1) new nurses who have already completed standardized training at other hospitals; (2) those who withdraw from the study and are unable to complete the training for any reason. Intervention Design The intervention compared two approaches to new nurse training. The control group followed the standard training outlined in the new nurse training syllabus, consisting of 16 hours of theoretical instruction delivered in a classroom setting during the first two months, followed by 8 hours of practical skills training in the third month. Practical training covered four core competencies: cardiopulmonary resuscitation (CPR), closed intravenous transfusion, micro-infusion pump operation, and cardiac monitoring operation. The experimental group followed the same syllabus, incorporating an innovative teaching strategy that combined the CDIO model with escape room pedagogy. Faculty Preparation The teaching team comprised experienced professionals, including one director of nursing education, five head nurses with senior titles, seven clinical teaching secretaries, and five volunteers. To ensure consistency and minimize bias, the director conducted a standardized training session for all faculty members before the intervention. This training covered the principles of the CDIO model, the structure and implementation of escape room pedagogy, and standardized criteria for evaluating assessments.To create effective and engaging escape room scenarios, the teaching team collaboratively developed and refined five scripts, each targeting a critical clinical scenario: anaphylactic shock, acute leukemia, multiple trauma from a car accident, cerebral hemorrhage, and acute pancreatitis. The script development process involved three stages: initial design by head nurses and students, expert review and pilot testing, and final approval by the teaching director. Volunteers acted as standardized patients during the escape room activities to simulate realistic nurse-patient interactions, while clinical teaching secretaries managed task assignments and provided guidance to the participants. Escape Room Preparation The escape room activities were conducted in 15 rooms across two floors of the Clinical Skills Center. Each clinical scenario was assigned to three rooms, resulting in a total of five distinct escape room scripts. Supplies for the escape rooms included skill assessment tools and game props, such as clue cards, lock boxes, iPads, timers, and combination locks. Student Grouping and Procedure The nurses were divided into 21 groups, with approximately four participants in each. Before the activity began, participants gathered in a designated waiting area, where they submitted their mobile devices and other materials to ensure focus and prevent distractions. Each group randomly drew a slip from a box to determine their assigned clinical scenario. Five slips corresponded to the theme of prophylactic shock, while four slips each represented the themes of acute leukemia, multiple trauma, cerebral hemorrhage, and acute pancreatitis. After the first group began their escape, subsequent groups were staggered at 15-minute intervals to draw their scripts and enter a preparation room, where they reviewed key materials for 15 minutes. Upon completing their escape room challenge, groups exited through a separate passage to maintain confidentiality and prevent communication with other participants. Clinical teaching secretaries maintained order throughout the activity, ensuring the smooth execution of the training. Measures and Instruments All assessments were conducted before and after training for both groups of nurses to ensure consistency and comparability. 1. Assessment Scores: Theoretical and operational assessments were developed based on the New Nurse Training Guidelines by five nursing experts. Operational scores focused on four core procedures: cardiopulmonary resuscitation, closed intravenous transfusion, micro-infusion pump operation, and electrocardiogram monitoring. A percentage-based scoring system was used, with the final score being an average of the four procedures. Nursing experts conducting the assessments were blinded to the experimental details. 2. Clinical Emergency Response Ability Questionnaire: The 28-item validated questionnaire [ 30 ] with an internal consistency of Cronbach’s α coefficient of 0.93 is adopted to evaluate emergency response abilities across five dimensions: theoretical knowledge, critical care observation, first aid response, first aid handling, and emergency management. Items are scored on a 5-point Likert scale, ranging from 1 (completely inconsistent) to 5 (completely consistent), with higher scores indicating stronger emergency skills. 3. Supportive Communication Scale: Adapted from Whetten’s scale [ 31 ], the 20-item instrument measures interpersonal communication skills across three dimensions: guidance and counseling, providing effective negative feedback, and supportive communication. Items are scored on a 6-point Likert scale, with higher scores reflecting stronger communication skills. The scale demonstrates strong reliability, with an internal consistency of Cronbach’s α coefficient of 0.84. Teaching plan The teaching plan integrates the CDIO model with escape room pedagogy, focusing on "emergency response skills and communication skills" (Table 1 ). It consists of four phases: Conceive (C) builds theoretical knowledge through lectures and clinical observation (14 hours). Design (D) involves group discussions and expert-guided creation of escape room scripts, enhancing first aid, communication, and teamwork skills (4 hours). Implement (I) includes practical exercises where groups rehearse tasks based on selected scripts, fostering the application of knowledge and problem-solving (3 hours). Operate (O) concludes with outcome presentations, expert feedback, and reflective journals, promoting critical thinking and improvement in communication skills (3 hours). Table 1 A training program based on the CDIO model of escape room pedagogy Phase Goals Steps Contents Methods Class time Conceive (C) 1.Increase theoretical knowledge. 2.Develop independent learning skills. Understand the knowledge level of new nurses and conceptualize teaching goals, content, and tasks. Theoretical knowledge and training on the four operations were conducted during months 1 and 2. Task were assigned in the 1st week of month 3. The new nurses were granted autonomy for clinical observation and practice, and they reviewed relevant literature and data. Theoretical lectures Demonstration Group discussion 14 hours Design (D) 1.Improve supportive communication skills. 2.Improve teamwork skills. Design the learning program implementation and operation process. Discussions were held in groups to design the escape room scripts. The head nurse guided the development of these scripts, and a team of experts was organized to validate them and select five to serve as question banks. Panel discussion Script design Teachers’ guidance Expert validation 4 hours Implement (I) 1.Improve first aid skills. 2.Develop problem-solving skills. Translate project plans into concrete actions. Randomly select one script and based on its content, collaborate on the rehearsal and divide labor to complete the project tasks. Script exercise Teacher assessment 3 hours Operate (O) Enhance critical thinking skills. Conduct program effectiveness tests, analyze causes, and makes continuous quality improvements. Groups report their results, and the instructor critiques and provides feedback New nurses submit their reflective journals, which the teacher reviews and corrects. Slides report Expert critique Reflective diary 3 hours Implementation steps Nurses progressed through the escape room scenario by answering questions and performing tasks based on the script’s storyline. Correct answers and the successful completion of tasks were necessary to receive the next clue card. Participants needed to respond appropriately to changes in the patient’s condition and complete challenges in all three rooms. Each room contained 3–5 tasks, totaling 5 theoretical questions and practical assessments. Throughout the process, emphasis was placed on nurse-patient communication and delivering humanistic care. The entire challenge was time-limited to 30 minutes, with penalties for exceeding the time limit. Top-performing participants received appropriate prizes. Data Collection and Analysis Prior to the implementation of the training, both groups of nurses completed assessments using the Assessment Scores, the Clinical Emergency Response Ability Questionnaire and the Supportive Communication Scale. In the second week following the conclusion of the training, the nurses in both groups repeated these evaluations and scales. To ensure objectivity in data collection, three teaching secretaries with ≥ 5 years of clinical nursing experience independently conducted all assessments. Each assistant received a standardized 8-hour training protocol covering instrument administration procedures, scoring criteria, and bias mitigation strategies. Discrepancies in ratings were resolved through panel discussions with a fourth blinded senior researcher. Data analysis was performed using SPSS 26.0 statistical software. Continuous variables were expressed as mean ± standard deviation (SD) following confirmation of normality. A t-test was applied to compare mean values between different groups; if the variances were unequal, an adjusted t-test was applied. A difference was considered statistically significant when p < 0.05. Results In January 2023, Wenzhou Central Hospital recruited 87 new nurses, followed by another 84 new nurses in January 2024,. Based on the inclusion and exclusion criteria, a total of 169 eligible participants were included in the study, with 85 nurses assigned to the control group and 84 nurses assigned to the experimental group. There were no cases of missing data or dropouts during the study period. The control group received traditional lecture-based training from June to October 2023, while the experimental group underwent training based on the CDIO model combined with escape room teaching methods from June to October 2024. The entire project lasted for three months, ensuring a comprehensive assessment of the training effectiveness. Participant characteristics Table 2 shows that the control group consisted of 85 participants, including 3 males and 82 females, with an average age of 23.25 years (± 0.75), ranging from 22 to 24. In terms of educational background, 33 participants had a bachelor's degree, while 52 held an associate degree. The experimental group included 84 new nurses, comprising 4 males and 80 females, with an average age of 23.29 years (± 0.75), also ranging from 22 to 24. Regarding educational qualifications, 36 participants had a bachelor's degree and 48 had an associate degree. There were no statistically significant differences in general demographic data between the two groups prior to training, indicating their comparability. Table 2 Demographic and baseline homogeneity tests (x ± s) Group Age Gender [N (n%)] Educational Background [N (n%)] Male Female Bachelor's degree associate degree Control 23.25 ± 0.75 3(3.5%) 82(96.5%) 33(38.8%) 52(61.2%) Experimental 23.29 ± 0.75 4(4.8%) 80(95.2%) 36(42.9%) 48(57.1%) t or x 2 -0.33 0.16 0.29 p 0.81 0.69 0.59 Comparative analysis of control and experimental groups The comparison of theoretical and operational scores between the two groups is shown in Table 3 . Post-intervention, the experimental group demonstrated significantly higher theoretical knowledge (83.11 ± 4.46 vs. 80.82 ± 5.13, p = 0.002) and operational skills (90.28 ± 3.02 vs. 85.81 ± 2.72, p < 0.001). Table 3 Comparison of new nurse assessment scores between the two groups (x ± s) Group Theoretical score Mean score of operation test Before training After training Before training After training Control 79.98 ± 5.92 80.82 ± 5.13 82.59 ± 2.83 85.81 ± 2.72 Experimental 79.93 ± 5.35 83.11 ± 4.46 82.44 ± 3.02 90.28 ± 3.02 t 0.550 3.085 0.352 10.107 p 0.956 0.002 0.726 < 0.001 Comparison of clinical emergency competencies between the two groups is shown in Table 4 . The experimental group exhibited superior performance in critical care observation (19.95 ± 1.20 vs. 18.05 ± 1.17, p < 0.001), first aid management (14.86 ± 1.09 vs. 13.86 ± 1.01, p < 0.001), and emergency management (41.96 ± 1.68 vs. 40.06 ± 2.31, p < 0.001). Table 4 Comparison of clinical emergency response ability scores of new nurses in two groups (x ± s) Group Theoretical knowledge Critical care observation First aid response Before training After training Before training After training Before training After training Control 9.39 ± 1.31 9.24 ± 0.91 17.81 ± 1.38 18.05 ± 1.17 15.58 ± 1.06 15.56 ± 0.96 Experimental 9.13 ± 1.18 9.79 ± 0.89 17.73 ± 1.43 19.95 ± 1.20 15.58 ± 1.01 15.88 ± 0.87 t 1.341 3.973 0.395 4.954 0.043 2.249* p 0.182 < 0.001 0.694 < 0.001 0.966 0.026 First aid handling Emergency management Before training After training Before training After training Control 13.44 ± 1.47 13.86 ± 1.01 39.41 ± 2.66 40.06 ± 2.31 Experimental 13.56 ± 1.56 14.86 ± 1.09 39.60 ± 2.56 41.96 ± 1.68 t 0.534 6.172 0.457 6.133* p 0.594 < 0.001 0.648 < 0.001 * the value of t ′ The comparison of supportive communication skills between the two groups is shown in Table 5 . Post-training, the experimental group achieved higher scores in tutoring/counseling (12.81 ± 1.22 vs. 12.13 ± 0.92, p < 0.001), effective negative feedback (22.94 ± 1.29 vs. 21.69 ± 1.24, p < 0.001), and overall supportive communication (47.35 ± 2.02 vs. 43.64 ± 2.26, p < 0.001). Table 5 Comparison of supportive communication skills scores for new nurses in two groups (x ± s) Group Tutoring & counseling Effective negative feedback Supportive communication Before training After training Before training After training Before training After training Control 11.71 ± 1.18 12.13 ± 0.92 21.05 ± 2.02 21.69 ± 1.24 42.13 ± 2.65 43.64 ± 2.26 Experimental 11.74 ± 1.32 12.81 ± 1.22 21.14 ± 2.20 22.94 ± 1.29 42.23 ± 2.49 47.35 ± 2.02 t 0.167 4.089* 0.295 6.410 0.245 11.254 p 0.867 < 0.001 0.768 < 0.001 0.807 < 0.001 * the value of t ′ Discussion This study investigated the effectiveness of integrating the CDIO model with escape room pedagogy in the standardized training of newly enrolled nurses. The findings demonstrate that this innovative training approach significantly enhanced participants' theoretical knowledge, operational skills, clinical emergency response abilities, and supportive communication skills. These results align with the study's primary objective of addressing the challenges faced by newly enrolled nurses in clinical practice and provide new evidence supporting the synergistic benefits of integrating these methods. A key innovation of this study lies in its dual-model design, which addresses gaps in existing literature where CDIO and escape rooms were applied in isolation [ 8 , 20 , 34 , 35 ]. For example, a study [ 8 ]developed a CDIO training program for arrhythmia education in nursing students, focusing primarily on enhancing theoretical knowledge and clinical skills. However, the study did not delve into the long-term impact of immersive practical training on students' clinical decision-making abilities.Similarly, another study [ 34 ]demonstrated that standalone escape rooms in reproductive endocrinology education yielded only marginal improvements in declarative knowledge (Cohen’s d = 0.22 ) , highlighting the limitations of gamification without systematic scaffolding. In contrast, by merging CDIO's systematic training with the immersive realism of escape rooms, this intervention replicates the unpredictability of clinical emergencies while maintaining pedagogical rigor. This aligns with work by other studies [ 36 , 37 ], which demonstrated that hybrid models integrating structured frameworks with gamification enhance engagement, and clinical decision-making. Furthermore, our design offers scalability beyond previous applications. While previous studies have relied on resource-intensive simulations and generic case archives, the scenarios developed in this study adapt low-fidelity principles to diverse clinical contexts (e.g., acute pancreatitis, multiple trauma), enabling cost-effective global implementation [ 38 ]. This quasi-experimental study has several strengths. First, it allowed direct comparisons between traditional and innovative training methods in real-world clinical settings, ensuring ecological validity. Second, the use of validated tools, blinded evaluators, and a large sample improved measurement accuracy and reduced bias. Third, cluster randomization by nursing groups minimized cross-contamination. Fourth, including nurses from diverse units increased sample representativeness. Finally, standardized facilitator training ensured consistent intervention delivery, aligning with best practices [ 39 ]. This study has several limitations that must be acknowledged. First, the single-center design and homogeneous sample limit the generalization of the findings, necessitating future multi-center trials with diverse populations. Second, while the training lasted for three months, long-term skill retention was not assessed, highlighting the need for longitudinal studies to evaluate sustained competency gains. Third, although the escape room's modified elements enhanced engagement, design flaws—such as insufficient atmospheric immersion and underutilized multimedia resources—may have reduced its full impact. Incorporating advanced technologies like virtual reality could address these shortcomings, as demonstrated by a study of VR simulations in nursing education [ 40 ]. Nevertheless, the findings provide valuable insights into the effectiveness of the training model, warranting further exploration and refinement through multi-center studies, longitudinal assessments, and the incorporation of advanced technologies to enhance its impact. The findings of this study hold significant implications for nursing education, particularly in China, where the National Health Commission prioritizes standardized training to improve emergency preparedness. The CDIO-escape room model not only aligns with these objectives but also fosters reflective practice through post-activity journals, offering an effective alternative to traditional lecture-based methods. By integrating scenario-based training into standardized curricula, this approach enhances critical thinking, problem-solving, and communication skills essential for emergency nursing practice. Globally, it provides an applicable framework for addressing competency gaps in high-stakes environments, urging educators to transition from passive didactic methods to immersive, learner-centered pedagogic. Nursing educators and policymakers should consider adopting such interactive training models to better prepare new nurses for real-world clinical challenges. Conclusions The integration of the CDIO model with escape room pedagogy represents an informativeness advance in nursing education, effectively bridging theory and practice while cultivating critical competencies in emergency response and communication. The results highlight the value of combining structured frameworks with dynamic, modified learning to address the evolving demands of clinical training. Future research should prioritize optimizing scenario design, expanding sample diversity, and exploring broader implementation in diverse clinical settings to further refine and optimize nurse training programs. By aligning innovation with cultural and contextual needs, this approach offers a calculable blueprint for enhancing nursing education in varied healthcare environments. Declarations Data availability The datasets supporting the results and conclusions of this article is included within the article and its additional files . The original data is available upon reasonable request from the corresponding author. Acknowledgments The authors sincerely thank the Nursing Department and the Clinical Skills Center of Wenzhou Central Hospital for providing the essential resources and support necessary to conduct this study. Funding This study was funded by Wenzhou Science and Technology Bureau (No.2023Y0749). Author information Ms. Shupei Fang, Nursing Department, Wenzhou Central Hospital, Wenzhou, Zhejiang, PR China Dr. Yuanyuan Zhao, The School of Smart Health and Wellness (Health Medical College), Zhejiang Dongfang Polytechnic, Wenzhou, Zhejiang PR, China Ms. Qianqian Chen,Nursing Department, Wenzhou Central Hospital, Wenzhou, Zhejiang, PR China Ms. Jingwen Jian,Nursing Department, Wenzhou Central Hospital, Wenzhou, Zhejiang, PR China Ms. Yuedan Xu,Nursing Department, Wenzhou Central Hospital, Wenzhou, Zhejiang, PR China Authors’ contributions FSP was responsible for the core research and drafting the initial manuscript. ZYY as an expert, provided overall project guidance and writing guidance. CQQ and JJW were responsible for data collection and statistical analysis. XYD was in charge of overall supervision and final manuscript review.All authors have made significant intellectual contributions to the study’s development and have granted their approval for the final manuscript’s submission to the journal. Ethics delarations Ethical approvals for this study have been obtained from the Ethics Committee for Research Involving Human Subjects, Wenzhou Central Hospital Medical Research Ethics Committee (Approval No. 2022Y094).The respondent’s Information Sheet was provided, and Informed Consent Form completed before participation in this study. All methods were performed in accordance with the Declaration of Helsinki and other relevant guidelines and regulations. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Azimirad M, Magnusson C, Wiseman A, Selander T, Parviainen I, Turunen H. 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Gómez-Urquiza JL, Gómez-Salgado J, Albendín-García L, Correa-Rodríguez M, González-Jiménez E. Cañadas-De la Fuente GA: The impact on nursing students' opinions and motivation of using a Nursing Escape Room as a teaching game: A descriptive study. Nurse Educ Today. 2019;72:73–6. Anguas-Gracia A, Subirón-Valera AB, Antón-Solanas I, Rodríguez-Roca B, Satústegui-Dordá PJ, Urcola-Pardo F. An evaluation of undergraduate student nurses' gameful experience while playing an escape room game as part of a community health nursing course. Nurse Educ Today 2021, 103. Molina-Torres G, Cardona D, Requena M, Rodriguez-Arrastia M, Roman P, Ropero-Padilla C. The impact of using an anatomy escape room on nursing students: A comparative study. Nurse Educ Today 2022, 109. Carmack J, Jochum J, Moore ES, Toon J. Interprofessional diabetes escape room with nursing and athletic training students. J Interprofessional Educ Pract 2022, 27. Martin A, Gibbs S. An Escape Room to Orient Preclinical Medical Students to the Simulated Medical Environment. MedEdPORTAL 2022, 18:11229. Quek LH, Tan AJQ, Sim MJJ, Ignacio J, Harder N, Lamb A, Chua WL, Lau ST, Liaw SY. Educational escape rooms for healthcare students: A systematic review. Nurse Educ Today. 2024;132:106004. Jaspers GJ, Borsci S, van der Hoeven JG, Kuijer-Siebelink W, Lemson J. Escape room design in training crew resource management in acute care: a scoping review. BMC Med Educ 2024, 24(1). S Z, J Z, H Y, M S: Reliability test of a questionnaire to assess the clinical emergency care competence of non-emergency department nurses. China Med Innov 2016, 13(34):92–5. Whetten DAGP. Identity in organizations:Building theory through conversations. Sadeghi M, Nematollahi M, Farokhzadian J, Khoshnood Z, Eghbalian M. The effect of scenario-based training on the Core competencies of nursing students: a semi-experimental study. BMC Nurs 2023, 22(1). Ho MH, Yu LF, Lin PH, Chang HR, Traynor V, Huang WC, Montayre J, Chen KH. Effects of a simulation-based education programme on delirium care for critical care nurses: A randomized controlled trial. J Adv Nurs. 2021;77(8):3483–93. Fedorcsak P. Moderate benefit of escape room game on learning outcome in medicine. BMC Med Educ. 2024;24(1):1353. Chen D, Liu F, Zhu C, Tai C, Zhang Y, Wang X. The effect of an escape room game on college nursing students' learning attitude and game flow experiences in teaching safe medication care for the elderly: an intervention educational study. BMC Med Educ. 2023;23(1):945. Ropero-Padilla C, Rodriguez-Arrastia M, Martinez-Ortigosa A, Salas-Medina P, Folch Ayora A, Roman P. A gameful blended-learning experience in nursing: A qualitative focus group study. Nurse Educ Today 2021, 106. Roman P, Ruiz-Gonzalez C, Rodriguez-Arrastia M, Granero-Molina J, Fernández-Sola C, Hernández-Padilla JM. A serious game for online-based objective structured clinical examination in nursing: A qualitative study. Nurse Educ Today 2022, 109. Pollard CL, Wild C. Nursing leadership competencies: Low-fidelity simulation as a teaching strategy. Nurse Educ Pract. 2014;14(6):620–6. Miller CJ, Smith SN, Pugatch M. Experimental and quasi-experimental designs in implementation research. Psychiatry Res 2020, 283. Plotzky C, Lindwedel U, Sorber M, Loessl B, König P, Kunze C, Kugler C, Meng M. Virtual reality simulations in nurse education: A systematic mapping review. Nurse Educ Today 2021, 101. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Mar, 2025 Editor assigned by journal 04 Mar, 2025 Submission checks completed at journal 04 Mar, 2025 First submitted to journal 01 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6135147","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":423891986,"identity":"5b46e569-cd71-40cf-93f3-8fa7673d8f8d","order_by":0,"name":"Shupei Fang","email":"","orcid":"","institution":"Wenzhou Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shupei","middleName":"","lastName":"Fang","suffix":""},{"id":423891987,"identity":"b20c7051-6f11-4b71-90bb-177006139961","order_by":1,"name":"Yuanyuan Zhao","email":"","orcid":"","institution":"Zhejiang Dongfang Polytechnic","correspondingAuthor":false,"prefix":"","firstName":"Yuanyuan","middleName":"","lastName":"Zhao","suffix":""},{"id":423891988,"identity":"32d2a5ed-875f-4d11-ab1e-c5ce1f32e0bf","order_by":2,"name":"Qianqian Chen","email":"","orcid":"","institution":"Wenzhou Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qianqian","middleName":"","lastName":"Chen","suffix":""},{"id":423891990,"identity":"a5935623-3f7a-40b6-bf1d-815a2b0bfd16","order_by":3,"name":"Jingwen Jian","email":"","orcid":"","institution":"Wenzhou Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jingwen","middleName":"","lastName":"Jian","suffix":""},{"id":423891992,"identity":"0fbb3966-8773-47d3-af4b-af093001da24","order_by":4,"name":"Yuedan Xu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYBACfvmDDYf/VNjI2bc3EKlFcgbzwQc8Z9KMDXgOEKnF4AZbsgFv26HEDRIJxLrsdo+ZhATbAcbtko833mCosYkmqINxzhkzCQOeO8yWs9OKLRiOpeU2ENLCzJBjJpEg8YyN4TaQwdhwmLAWNpCWAwaHeRhuniFSC49EWrJhQ8JhCYMbPERqkeA5fPAxw4E0A8keoF8SiPGL/fHGhsOM/2zq+9kPb7zxocaGsBZkYEB81CC0kKpjFIyCUTAKRgYAAFh0Qixs+ED0AAAAAElFTkSuQmCC","orcid":"","institution":"Wenzhou Central Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yuedan","middleName":"","lastName":"Xu","suffix":""}],"badges":[],"createdAt":"2025-03-01 14:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6135147/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6135147/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78238940,"identity":"d239d05d-a1c8-4cea-ac32-9940d155f548","added_by":"auto","created_at":"2025-03-11 08:50:59","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":172420,"visible":true,"origin":"","legend":"\u003cp\u003eThe study design\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6135147/v1/650695069b49d56280ec4cf5.jpg"},{"id":78241776,"identity":"91bb8e63-6526-4952-ad27-f4116b1e2566","added_by":"auto","created_at":"2025-03-11 09:07:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1224313,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6135147/v1/229b3ece-d8a9-4bec-ad2f-512f9cbfa784.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of an Interactive Training Program on Emergency Management Competencies Among New Nurses in China: A Controlled Trial Assessing Knowledge, Skills, and Communication","fulltext":[{"header":"Background","content":"\u003cp\u003eTraining in emergency management skills is vital for ensuring that nurses are prepared to respond effectively in critical situations. These skills encompass an integration of knowledge, practical abilities, and cognitive thinking [1]. Research consistently demonstrates that structured training programs focused on emergency management significantly enhance nurses' theoretical knowledge, practical skills, emergency response capabilities, and communication proficiency [2-4]. However, newly enrolled nurses often face challenges during rescue operations due to limited clinical experience, insufficient familiarity with first aid techniques, inadequate ability to anticipate changes in patient conditions, and underdeveloped communication skills [5, 6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn response to these challenges, the National Health Commission of China issued the Training Outline for Newly Enrolled Nurses (Trial) in 2016, which guided medical units at all levels to conduct standardized training for newly enrolled nurses, particularly in emergency management skills [7]. Traditional lecture-based learning methods ensure a standardized approach to content delivery [8]. However, they may fall short in addressing the hands-on skills and real-world applications critical for clinical practice [9, 10]. In the 21st century, adopting innovative teaching and learning strategies has become essential in nursing education [11]. Healthcare institutions are actively exploring and implementing various innovative teaching models, such as the BOPPPS teaching model [12], flipped classrooms [13], and simulation-based training [14]. While these methods offer valuable insights, they often fall short in fostering the combination of theoretical knowledge, practical application, and adaptability required in real-world clinical scenarios.\u0026nbsp;For\u0026nbsp;instance, the BOPPPS model, though effective in enhancing theoretical knowledge and practical skills, may lack the flexibility needed to cultivate adaptability in dynamic clinical environments due to its structured design [15, 16]. Similarly, the flipped classroom approach necessitates that students independently acquire substantial theoretical knowledge before class, which can increase stress levels and hinder comprehension for some learners [13, 17]. Simulation-based training, while effective in replicating clinical settings, is resource-intensive and may not fully capture the unpredictability of real emergencies [18-20]. These limitations pose challenges to the comprehensive implementation of such teaching models.\u003c/p\u003e\n\u003cp\u003eThe CDIO (Conceive-Design-Implement-Operate) model, introduced in 2000, is a progressive educational framework originally developed for engineering education. It emphasizes hands-on, practical learning aligned with real-world tasks [18, 21]. In nursing education, scholars have found that the CDIO model enables learners to better master theoretical knowledge and practical skills while enhancing independent learning, first aid proficiency, and communication abilities [8, 20]. Another innovative approach is the escape room, an interactive educational method where participants solve a series of puzzles and riddles within a limited time to achieve a specific goal, such as escaping from a themed room [22]. The American Association of Medical Colleges has highlighted that escape rooms can enhance students' experiential learning by providing a dynamic and interactive environment [23]. For instance, a study [24] used an escape room to orient paraclinical medical students to simulated medical environments, finding that it significantly improved students' confidence and preparedness for subsequent simulation activities. Similarly, another study [25] employed an escape room in reproductive endocrinology and infertility education, concluding that it enhanced teamwork, critical thinking, and knowledge retention. Previous study [26] explored the use of escape rooms for training acute care professionals in Crew Resource Management and teamwork, demonstrating that this method effectively improved participants' teamwork and communication skills. Collectively, these studies suggest that escape rooms can significantly enhance emergency response capabilities, communication skills, and overall learning experiences in medical education.\u003c/p\u003e\n\u003cp\u003eDespite their\u0026nbsp;individual merits,\u0026nbsp;existing studies have predominantly evaluated the CDIO model and escape room pedagogy in isolation\u0026nbsp;[2, 23, 27],\u0026nbsp;thereby neglecting their synergistic application within nurse training programs\u0026nbsp;[28]. In China, significant gaps persist in integrating these approaches, and their individual implementation is often constrained by small sample sizes and limited scope\u0026nbsp;[21, 29]. Moreover, current research often lacks an evidence-based framework for evaluating how these methods address the unique challenges faced by newly enrolled nurses. Little attention has been given to the synergistic effects of integrating these strategies to enhance nurses' preparedness for the dynamic and unpredictable nature of clinical emergencies.\u003c/p\u003e\n\u003cp\u003eThis study aims to address these gaps by investigating the combined use of the CDIO model and escape room pedagogy in standardized training programs for newly enrolled nurses. Specifically, it seeks to determine how this integrated approach can improve clinical emergency skills and communication, which contributes to the development of innovative, evidence-based training strategies that align with the demands of modern nursing education and practice, particularly for China.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study adopts a quasi-experimental pre-test-post-test design to compare the effectiveness of the CDIO model combined with escape room pedagogy versus traditional lecture-based learning methods in enhancing newly enrolled nurses\u0026rsquo; clinical emergency response abilities. Participants were recruited from Wenzhou Central Hospital, China, and were divided into two groups: the control group (receiving standard training as outlined in the new nurse syllabus) and the experimental group (undergoing the CDIO model integrated with escape room pedagogy). Prior to and following the training intervention, both groups were assessed using a series of measures, including theoretical and practical evaluations, the Supportive Communication Scale, and the Clinical Emergency Response Ability Questionnaire. The study design is illustrated in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. This study has received an ethical approval from the Wenzhou Central Hospital Institutional Review Board (Approval No. 2022Y094). All participants were required to provide informed consent for participation.\u003c/p\u003e\n\u003ch3\u003eParticipants and Sampling\u003c/h3\u003e\n\u003cp\u003eAccording to the sample size calculation formula for comparing two sample means:\u003c/p\u003e\n\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\n \u003cdiv class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e$$\\:n=2{\\left[\\frac{{(Z}_{\\alpha\\:/2}+{Z}_{\\beta\\:})\\sigma\\:}{\\delta\\:}\\right]}^{2}$$\u003c/div\u003e\u003c/div\u003e\u003cp\u003eA two-sided \u0026alpha;\u0026thinsp;=\u0026thinsp;0.05, \u0026beta;\u0026thinsp;=\u0026thinsp;0.1, Z\u0026alpha;/2\u0026thinsp;=\u0026thinsp;1.96, and Z\u003csub\u003e\u0026beta;\u003c/sub\u003e = 1.282. Based on previous literature [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e], a total score of \u0026delta;\u0026thinsp;=\u0026thinsp;3.26 and a standard deviation of \u0026sigma;\u0026thinsp;=\u0026thinsp;4.45 were adopted. The required sample size for each group is 40 participants. To account for a potential 10% loss to follow-up, the adjusted sample size is a minimum of 44 participants per group. A random number table is used for random allocation. The inclusion criteria are: (1) an associate degree or bachelor\u0026rsquo;s degree in nursing; (2) participation in standardized training as required; (3) no prior training in the emergency department; (4) a signed informed consent form. The exclusion criteria are: (1) new nurses who have already completed standardized training at other hospitals; (2) those who withdraw from the study and are unable to complete the training for any reason.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eIntervention Design\u003c/h2\u003e\u003cp\u003eThe intervention compared two approaches to new nurse training. The control group followed the standard training outlined in the new nurse training syllabus, consisting of 16 hours of theoretical instruction delivered in a classroom setting during the first two months, followed by 8 hours of practical skills training in the third month. Practical training covered four core competencies: cardiopulmonary resuscitation (CPR), closed intravenous transfusion, micro-infusion pump operation, and cardiac monitoring operation. The experimental group followed the same syllabus, incorporating an innovative teaching strategy that combined the CDIO model with escape room pedagogy.\u003c/p\u003e\u003c/div\u003e\u003ch3\u003eFaculty Preparation\u003c/h3\u003e\u003cp\u003eThe teaching team comprised experienced professionals, including one director of nursing education, five head nurses with senior titles, seven clinical teaching secretaries, and five volunteers. To ensure consistency and minimize bias, the director conducted a standardized training session for all faculty members before the intervention. This training covered the principles of the CDIO model, the structure and implementation of escape room pedagogy, and standardized criteria for evaluating assessments.To create effective and engaging escape room scenarios, the teaching team collaboratively developed and refined five scripts, each targeting a critical clinical scenario: anaphylactic shock, acute leukemia, multiple trauma from a car accident, cerebral hemorrhage, and acute pancreatitis. The script development process involved three stages: initial design by head nurses and students, expert review and pilot testing, and final approval by the teaching director. Volunteers acted as standardized patients during the escape room activities to simulate realistic nurse-patient interactions, while clinical teaching secretaries managed task assignments and provided guidance to the participants.\u003c/p\u003e\u003ch3\u003eEscape Room Preparation\u003c/h3\u003e\u003cp\u003eThe escape room activities were conducted in 15 rooms across two floors of the Clinical Skills Center. Each clinical scenario was assigned to three rooms, resulting in a total of five distinct escape room scripts. Supplies for the escape rooms included skill assessment tools and game props, such as clue cards, lock boxes, iPads, timers, and combination locks.\u003c/p\u003e\u003ch3\u003eStudent Grouping and Procedure\u003c/h3\u003e\u003cp\u003eThe nurses were divided into 21 groups, with approximately four participants in each. Before the activity began, participants gathered in a designated waiting area, where they submitted their mobile devices and other materials to ensure focus and prevent distractions. Each group randomly drew a slip from a box to determine their assigned clinical scenario. Five slips corresponded to the theme of prophylactic shock, while four slips each represented the themes of acute leukemia, multiple trauma, cerebral hemorrhage, and acute pancreatitis. After the first group began their escape, subsequent groups were staggered at 15-minute intervals to draw their scripts and enter a preparation room, where they reviewed key materials for 15 minutes. Upon completing their escape room challenge, groups exited through a separate passage to maintain confidentiality and prevent communication with other participants. Clinical teaching secretaries maintained order throughout the activity, ensuring the smooth execution of the training.\u003c/p\u003e\u003ch3\u003eMeasures and Instruments\u003c/h3\u003e\u003cp\u003eAll assessments were conducted before and after training for both groups of nurses to ensure consistency and comparability.\u003c/p\u003e\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003e1. Assessment Scores:\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTheoretical and operational assessments were developed based on the New Nurse Training Guidelines by five nursing experts. Operational scores focused on four core procedures: cardiopulmonary resuscitation, closed intravenous transfusion, micro-infusion pump operation, and electrocardiogram monitoring. A percentage-based scoring system was used, with the final score being an average of the four procedures. Nursing experts conducting the assessments were blinded to the experimental details.\u003c/p\u003e\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003e2. Clinical Emergency Response Ability Questionnaire:\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe 28-item validated questionnaire [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e] with an internal consistency of Cronbach\u0026rsquo;s \u003cem\u003e\u0026alpha;\u003c/em\u003e coefficient of 0.93 is adopted to evaluate emergency response abilities across five dimensions: theoretical knowledge, critical care observation, first aid response, first aid handling, and emergency management. Items are scored on a 5-point Likert scale, ranging from 1 (completely inconsistent) to 5 (completely consistent), with higher scores indicating stronger emergency skills.\u003c/p\u003e\u003cp\u003e3. Supportive Communication Scale:\u003c/p\u003e\u003cp\u003eAdapted from Whetten\u0026rsquo;s scale [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e], the 20-item instrument measures interpersonal communication skills across three dimensions: guidance and counseling, providing effective negative feedback, and supportive communication. Items are scored on a 6-point Likert scale, with higher scores reflecting stronger communication skills. The scale demonstrates strong reliability, with an internal consistency of Cronbach\u0026rsquo;s \u0026alpha; coefficient of 0.84.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eTeaching plan\u003c/h2\u003e\u003cp\u003eThe teaching plan integrates the CDIO model with escape room pedagogy, focusing on \u0026quot;emergency response skills and communication skills\u0026quot; (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). It consists of four phases: \u003cstrong\u003eConceive (C)\u003c/strong\u003e builds theoretical knowledge through lectures and clinical observation (14 hours). \u003cstrong\u003eDesign (D)\u003c/strong\u003e involves group discussions and expert-guided creation of escape room scripts, enhancing first aid, communication, and teamwork skills (4 hours). \u003cstrong\u003eImplement (I)\u003c/strong\u003e includes practical exercises where groups rehearse tasks based on selected scripts, fostering the application of knowledge and problem-solving (3 hours). \u003cstrong\u003eOperate (O)\u003c/strong\u003e concludes with outcome presentations, expert feedback, and reflective journals, promoting critical thinking and improvement in communication skills (3 hours).\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eA training program based on the CDIO model of escape room pedagogy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\"\u003e\u003cp\u003ePhase\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\"\u003e\u003cp\u003eGoals\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\"\u003e\u003cp\u003eSteps\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\"\u003e\u003cp\u003eContents\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\"\u003e\u003cp\u003eMethods\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\"\u003e\u003cp\u003eClass time\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\"\u003e\u003cp\u003e\u003cstrong\u003eConceive (C)\u003c/strong\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003e1.Increase theoretical knowledge.\u003c/p\u003e\u003cp\u003e2.Develop independent learning skills.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003eUnderstand the knowledge level of new nurses and conceptualize teaching goals, content, and tasks.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003eTheoretical knowledge and training on the four operations were conducted during months 1 and 2. Task were assigned in the 1st week of month 3. The new nurses were granted autonomy for clinical observation and practice, and they reviewed relevant literature and data.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003eTheoretical lectures\u003c/p\u003e\u003cp\u003eDemonstration\u003c/p\u003e\u003cp\u003eGroup discussion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003e14 hours\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\"\u003e\u003cp\u003e\u003cstrong\u003eDesign (D)\u003c/strong\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003e1.Improve supportive\u003c/p\u003e\u003cp\u003ecommunication skills.\u003c/p\u003e\u003cp\u003e2.Improve teamwork\u003c/p\u003e\u003cp\u003eskills.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003eDesign the learning program implementation and operation process.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003eDiscussions were held in groups to design the escape room scripts. The head nurse guided the development of these scripts, and a team of experts was organized to validate them and select five to serve as question banks.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003ePanel discussion\u003c/p\u003e\u003cp\u003eScript design\u003c/p\u003e\u003cp\u003eTeachers\u0026rsquo; guidance Expert validation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003e4 hours\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\"\u003e\u003cp\u003e\u003cstrong\u003eImplement (I)\u003c/strong\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003e1.Improve first aid\u003c/p\u003e\u003cp\u003eskills.\u003c/p\u003e\u003cp\u003e2.Develop\u003c/p\u003e\u003cp\u003eproblem-solving skills.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003eTranslate project plans into concrete actions.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003eRandomly select one script and based on its content, collaborate on the rehearsal and divide labor to complete the project tasks.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003eScript exercise\u003c/p\u003e\u003cp\u003eTeacher assessment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003e3 hours\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\"\u003e\u003cp\u003e\u003cstrong\u003eOperate (O)\u003c/strong\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003eEnhance critical thinking skills.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003eConduct program effectiveness tests,\u003c/p\u003e\u003cp\u003eanalyze causes, and makes continuous quality improvements.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003eGroups report their results, and the instructor critiques and provides feedback New nurses submit their reflective journals, which the teacher reviews and corrects.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003eSlides report\u003c/p\u003e\u003cp\u003eExpert critique\u003c/p\u003e\u003cp\u003eReflective diary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\"\u003e\u003cp\u003e3 hours\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003c/div\u003e\u003ch3\u003eImplementation steps\u003c/h3\u003e\u003cp\u003eNurses progressed through the escape room scenario by answering questions and performing tasks based on the script\u0026rsquo;s storyline. Correct answers and the successful completion of tasks were necessary to receive the next clue card. Participants needed to respond appropriately to changes in the patient\u0026rsquo;s condition and complete challenges in all three rooms. Each room contained 3\u0026ndash;5 tasks, totaling 5 theoretical questions and practical assessments. Throughout the process, emphasis was placed on nurse-patient communication and delivering humanistic care. The entire challenge was time-limited to 30 minutes, with penalties for exceeding the time limit. Top-performing participants received appropriate prizes.\u003c/p\u003e\u003ch3\u003eData Collection and Analysis\u003c/h3\u003e\u003cp\u003ePrior to the implementation of the training, both groups of nurses completed assessments using the Assessment Scores, the Clinical Emergency Response Ability Questionnaire and the Supportive Communication Scale. In the second week following the conclusion of the training, the nurses in both groups repeated these evaluations and scales. To ensure objectivity in data collection, three teaching secretaries with \u0026ge;\u0026thinsp;5 years of clinical nursing experience independently conducted all assessments. Each assistant received a standardized 8-hour training protocol covering instrument administration procedures, scoring criteria, and bias mitigation strategies. Discrepancies in ratings were resolved through panel discussions with a fourth blinded senior researcher.\u003c/p\u003e\u003cp\u003eData analysis was performed using SPSS 26.0 statistical software. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) following confirmation of normality. A t-test was applied to compare mean values between different groups; if the variances were unequal, an adjusted t-test was applied. A difference was considered statistically significant when \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn January 2023, Wenzhou Central Hospital recruited 87 new nurses, followed by another 84 new nurses in January 2024,. Based on the inclusion and exclusion criteria, a total of 169 eligible participants were included in the study, with 85 nurses assigned to the control group and 84 nurses assigned to the experimental group. There were no cases of missing data or dropouts during the study period. The control group received traditional lecture-based training from June to October 2023, while the experimental group underwent training based on the CDIO model combined with escape room teaching methods from June to October 2024. The entire project lasted for three months, ensuring a comprehensive assessment of the training effectiveness.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that the control group consisted of 85 participants, including 3 males and 82 females, with an average age of 23.25 years (\u0026plusmn;\u0026thinsp;0.75), ranging from 22 to 24. In terms of educational background, 33 participants had a bachelor's degree, while 52 held an associate degree. The experimental group included 84 new nurses, comprising 4 males and 80 females, with an average age of 23.29 years (\u0026plusmn;\u0026thinsp;0.75), also ranging from 22 to 24. Regarding educational qualifications, 36 participants had a bachelor's degree and 48 had an associate degree. There were no statistically significant differences in general demographic data between the two groups prior to training, indicating their comparability.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and baseline homogeneity tests (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eGender [N (n%)]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eEducational Background [N (n%)]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBachelor's degree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eassociate degree\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82(96.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33(38.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e52(61.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(4.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80(95.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36(42.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48(57.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e or x\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eComparative analysis of control and experimental groups\u003c/h2\u003e \u003cp\u003eThe comparison of theoretical and operational scores between the two groups is shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Post-intervention, the experimental group demonstrated significantly higher theoretical knowledge (83.11\u0026thinsp;\u0026plusmn;\u0026thinsp;4.46 vs. 80.82\u0026thinsp;\u0026plusmn;\u0026thinsp;5.13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) and operational skills (90.28\u0026thinsp;\u0026plusmn;\u0026thinsp;3.02 vs. 85.81\u0026thinsp;\u0026plusmn;\u0026thinsp;2.72, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of new nurse assessment scores between the two groups (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTheoretical score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMean score of operation test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBefore training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAfter training\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.98\u0026thinsp;\u0026plusmn;\u0026thinsp;5.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.82\u0026thinsp;\u0026plusmn;\u0026thinsp;5.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.59\u0026thinsp;\u0026plusmn;\u0026thinsp;2.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85.81\u0026thinsp;\u0026plusmn;\u0026thinsp;2.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.93\u0026thinsp;\u0026plusmn;\u0026thinsp;5.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.11\u0026thinsp;\u0026plusmn;\u0026thinsp;4.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.44\u0026thinsp;\u0026plusmn;\u0026thinsp;3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90.28\u0026thinsp;\u0026plusmn;\u0026thinsp;3.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.550\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.085\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.352\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.107\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.956\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.726\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComparison of clinical emergency competencies between the two groups is shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The experimental group exhibited superior performance in critical care observation (19.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20 vs. 18.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), first aid management (14.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09 vs. 13.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and emergency management (41.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68 vs. 40.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.31, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of clinical emergency response ability scores of new nurses in two groups (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTheoretical knowledge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCritical care observation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFirst aid response\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore training After training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore training After training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBefore training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAfter training\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31 9.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38 18.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.13\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18 9.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.43 19.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.341 3.973\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.395 4.954\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.249*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.182 \u0026lt; 0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.694 \u0026lt; 0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.966\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFirst aid handling\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eEmergency management\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore training After training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore training After training\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47 13.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.41\u0026thinsp;\u0026plusmn;\u0026thinsp;2.66 40.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56 14.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.56 41.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.534 6.172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.457 6.133*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.594 \u0026lt; 0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.648 \u0026lt; 0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* the value of \u003cem\u003et\u003c/em\u003e\u0026prime;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe comparison of supportive communication skills between the two groups is shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Post-training, the experimental group achieved higher scores in tutoring/counseling (12.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.22 vs. 12.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), effective negative feedback (22.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29 vs. 21.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and overall supportive communication (47.35\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02 vs. 43.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.26, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of supportive communication skills scores for new nurses in two groups (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTutoring \u0026amp; counseling\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eEffective negative feedback\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eSupportive communication\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBefore training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAfter training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBefore training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAfter training\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.71\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.05\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.13\u0026thinsp;\u0026plusmn;\u0026thinsp;2.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e43.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.14\u0026thinsp;\u0026plusmn;\u0026thinsp;2.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.23\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e47.35\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.089*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.410\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.254\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.867\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.768\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.807\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* the value of \u003cem\u003et\u003c/em\u003e\u0026prime;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the effectiveness of integrating the CDIO model with escape room pedagogy in the standardized training of newly enrolled nurses. The findings demonstrate that this innovative training approach significantly enhanced participants' theoretical knowledge, operational skills, clinical emergency response abilities, and supportive communication skills. These results align with the study's primary objective of addressing the challenges faced by newly enrolled nurses in clinical practice and provide new evidence supporting the synergistic benefits of integrating these methods.\u003c/p\u003e \u003cp\u003eA key innovation of this study lies in its dual-model design, which addresses gaps in existing literature where CDIO and escape rooms were applied in isolation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. For example, a study [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]developed a CDIO training program for arrhythmia education in nursing students, focusing primarily on enhancing theoretical knowledge and clinical skills. However, the study did not delve into the long-term impact of immersive practical training on students' clinical decision-making abilities.Similarly, another study [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]demonstrated that standalone escape rooms in reproductive endocrinology education yielded only marginal improvements in declarative knowledge (Cohen\u0026rsquo;s \u003cem\u003ed\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.22\u003cem\u003e)\u003c/em\u003e, highlighting the limitations of gamification without systematic scaffolding. In contrast, by merging CDIO's systematic training with the immersive realism of escape rooms, this intervention replicates the unpredictability of clinical emergencies while maintaining pedagogical rigor. This aligns with work by other studies [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], which demonstrated that hybrid models integrating structured frameworks with gamification enhance engagement, and clinical decision-making. Furthermore, our design offers scalability beyond previous applications. While previous studies have relied on resource-intensive simulations and generic case archives, the scenarios developed in this study adapt low-fidelity principles to diverse clinical contexts (e.g., acute pancreatitis, multiple trauma), enabling cost-effective global implementation [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis quasi-experimental study has several strengths. First, it allowed direct comparisons between traditional and innovative training methods in real-world clinical settings, ensuring ecological validity. Second, the use of validated tools, blinded evaluators, and a large sample improved measurement accuracy and reduced bias. Third, cluster randomization by nursing groups minimized cross-contamination. Fourth, including nurses from diverse units increased sample representativeness. Finally, standardized facilitator training ensured consistent intervention delivery, aligning with best practices [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study has several limitations that must be acknowledged. First, the single-center design and homogeneous sample limit the generalization of the findings, necessitating future multi-center trials with diverse populations. Second, while the training lasted for three months, long-term skill retention was not assessed, highlighting the need for longitudinal studies to evaluate sustained competency gains. Third, although the escape room's modified elements enhanced engagement, design flaws\u0026mdash;such as insufficient atmospheric immersion and underutilized multimedia resources\u0026mdash;may have reduced its full impact. Incorporating advanced technologies like virtual reality could address these shortcomings, as demonstrated by a study of VR simulations in nursing education [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Nevertheless, the findings provide valuable insights into the effectiveness of the training model, warranting further exploration and refinement through multi-center studies, longitudinal assessments, and the incorporation of advanced technologies to enhance its impact.\u003c/p\u003e \u003cp\u003eThe findings of this study hold significant implications for nursing education, particularly in China, where the National Health Commission prioritizes standardized training to improve emergency preparedness. The CDIO-escape room model not only aligns with these objectives but also fosters reflective practice through post-activity journals, offering an effective alternative to traditional lecture-based methods. By integrating scenario-based training into standardized curricula, this approach enhances critical thinking, problem-solving, and communication skills essential for emergency nursing practice. Globally, it provides an applicable framework for addressing competency gaps in high-stakes environments, urging educators to transition from passive didactic methods to immersive, learner-centered pedagogic. Nursing educators and policymakers should consider adopting such interactive training models to better prepare new nurses for real-world clinical challenges.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe integration of the CDIO model with escape room pedagogy represents an informativeness advance in nursing education, effectively bridging theory and practice while cultivating critical competencies in emergency response and communication. The results highlight the value of combining structured frameworks with dynamic, modified learning to address the evolving demands of clinical training. Future research should prioritize optimizing scenario design, expanding sample diversity, and exploring broader implementation in diverse clinical settings to further refine and optimize nurse training programs. By aligning innovation with cultural and contextual needs, this approach offers a calculable blueprint for enhancing nursing education in varied healthcare environments.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets supporting the results and conclusions of this article is included within the article and its \u003cem\u003eadditional files\u003c/em\u003e. The original data is available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors sincerely thank the Nursing Department and the Clinical Skills Center of Wenzhou Central Hospital for providing the essential resources and support necessary to conduct this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by Wenzhou Science and Technology Bureau (No.2023Y0749).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMs. Shupei Fang, Nursing Department, Wenzhou Central Hospital, Wenzhou, Zhejiang, PR China\u003c/p\u003e\n\u003cp\u003eDr. Yuanyuan Zhao,\u0026nbsp;The School of Smart Health and Wellness (Health Medical College), Zhejiang Dongfang Polytechnic, Wenzhou, Zhejiang PR, China\u003c/p\u003e\n\u003cp\u003eMs. Qianqian Chen,Nursing Department, Wenzhou Central Hospital, Wenzhou, Zhejiang, PR China\u003c/p\u003e\n\u003cp\u003eMs. Jingwen Jian,Nursing Department, Wenzhou Central Hospital, Wenzhou, Zhejiang, PR China\u003c/p\u003e\n\u003cp\u003eMs. Yuedan Xu,Nursing Department, Wenzhou Central Hospital, Wenzhou, Zhejiang, PR China\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFSP was responsible for the core research and drafting the initial manuscript. ZYY as an expert, provided overall project guidance and writing guidance. CQQ and JJW were responsible for data collection and statistical analysis. XYD was in charge of overall supervision and final manuscript review.All authors have made significant intellectual contributions to the study\u0026rsquo;s development and have granted their approval for the final manuscript\u0026rsquo;s submission to the journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003edelarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approvals for this study have been obtained from the Ethics Committee for Research Involving Human Subjects,\u0026nbsp;Wenzhou Central Hospital Medical Research Ethics Committee (Approval No. 2022Y094).The respondent\u0026rsquo;s Information Sheet was provided, and Informed Consent Form completed before participation in this study. All methods were performed in accordance with the Declaration of Helsinki and other relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAzimirad M, Magnusson C, Wiseman A, Selander T, Parviainen I, Turunen H. A clinical competence approach to examine British and Finnish nurses' attitudes towards the rapid response system model: A study in two acute hospitals. 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JMIR Serious Games. 2022;10(2):e34222.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarmiento-Rojas J, Aya-Parra PA, Perdomo OJ. Proposal of Design and Innovation in the Creation of the Internet of Medical Things Based on the CDIO Model through the Methodology of Problem-Based Learning. \u003cem\u003eSensors (Basel)\u003c/em\u003e 2022, 22(22).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDong X, Zhang Z, Zhang X, Lu M, Zhao Y, Lin Y, Zhang Y. Effects of an online training program on cardiovascular health behavior modification on nursing students' health education competency. Nurse Educ Today. 2023;127:105829.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang X, Zhou Y, Song Z, Wang Y, Chen X, Zhang D. Practical COVID-19 Prevention Training for Obstetrics and Gynecology Residents Based on the Conceive-Design-Implement-Operate Framework. Front Public Health. 2022;10:808084.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDogu N, Boztepe H, Topal CA, Sonmez M, Yuceer B, Bayraktar N. Comparison of the escape room and storytelling methods in learning the stress response: A randomized controlled pilot study. Nurse Educ Pract 2025, 82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026oacute;mez-Urquiza JL, G\u0026oacute;mez-Salgado J, Albend\u0026iacute;n-Garc\u0026iacute;a L, Correa-Rodr\u0026iacute;guez M, Gonz\u0026aacute;lez-Jim\u0026eacute;nez E. Ca\u0026ntilde;adas-De la Fuente GA: The impact on nursing students' opinions and motivation of using a Nursing Escape Room as a teaching game: A descriptive study. Nurse Educ Today. 2019;72:73\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnguas-Gracia A, Subir\u0026oacute;n-Valera AB, Ant\u0026oacute;n-Solanas I, Rodr\u0026iacute;guez-Roca B, Sat\u0026uacute;stegui-Dord\u0026aacute; PJ, Urcola-Pardo F. An evaluation of undergraduate student nurses' gameful experience while playing an escape room game as part of a community health nursing course. Nurse Educ Today 2021, 103.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMolina-Torres G, Cardona D, Requena M, Rodriguez-Arrastia M, Roman P, Ropero-Padilla C. The impact of using an anatomy escape room on nursing students: A comparative study. Nurse Educ Today 2022, 109.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarmack J, Jochum J, Moore ES, Toon J. Interprofessional diabetes escape room with nursing and athletic training students. J Interprofessional Educ Pract 2022, 27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin A, Gibbs S. 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Nurse Educ Pract. 2014;14(6):620\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller CJ, Smith SN, Pugatch M. Experimental and quasi-experimental designs in implementation research. Psychiatry Res 2020, 283.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlotzky C, Lindwedel U, Sorber M, Loessl B, K\u0026ouml;nig P, Kunze C, Kugler C, Meng M. Virtual reality simulations in nurse education: A systematic mapping review. Nurse Educ Today 2021, 101.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Emergency Management, CDIO, Escape Room, Nurses, China","lastPublishedDoi":"10.21203/rs.3.rs-6135147/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6135147/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEffective emergency management is essential for ensuring optimal patient outcomes, with newly enrolled nurses playing a crucial role in the early detection and intervention of critical conditions. However, in China, these nurses often encounter challenges stemming from limited clinical experience, inadequate training in emergency skills, and the lack of standardized training programs tailored to the country's unique healthcare needs. Addressing these gaps through innovative training methods is critical for enhancing patient safety and the quality of care. This randomized controlled trial aims to evaluate the effectiveness of integrating the Conceive-Design-Implement-Operate (CDIO) framework with escape room pedagogy to improve the emergency management competencies of newly enrolled nurses. The anticipated findings are expected to provide evidence-based recommendations for nursing education in China and contribute to the overall enhancement of healthcare quality in the nation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study adopts a quasi-experimental pre-test-post-test design. Participants were divided into two groups: a control group (control group, n\u0026thinsp;=\u0026thinsp;85) receiving traditional lecture-based training, and an experimental group (experimental group, n\u0026thinsp;=\u0026thinsp;84) undergoing the CDIO-escape room intervention. Outcomes were evaluated using theoretical exams, operational assessments, the Clinical Emergency Response Ability Questionnaire, and the Supportive Communication Scale.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePost-intervention results revealed statistically significant improvements in the experimental group across all metrics: theoretical knowledge (83.11\u0026thinsp;\u0026plusmn;\u0026thinsp;4.46 vs. 80.82\u0026thinsp;\u0026plusmn;\u0026thinsp;5.13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), practical skills (90.28\u0026thinsp;\u0026plusmn;\u0026thinsp;3.02 vs. 85.81\u0026thinsp;\u0026plusmn;\u0026thinsp;2.72, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), emergency response (19.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20 vs. 18.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and supportive communication (47.35\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02 vs. 43.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.26, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), compared to the control group. These improvements were statistically significant for all outcomes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe CDIO-escape room model effectively combines systematic training with immersive problem-solving dynamics, thereby addressing gaps in clinical preparedness. This dual-model approach aligns with China\u0026rsquo;s standardized nursing education guidelines and provides a scalable framework for global implementation.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Effectiveness of an Interactive Training Program on Emergency Management Competencies Among New Nurses in China: A Controlled Trial Assessing Knowledge, Skills, and Communication","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-11 08:50:54","doi":"10.21203/rs.3.rs-6135147/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-06T07:56:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-04T10:00:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-04T09:58:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-03-01T14:04:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4997fc52-0893-4bf1-8bf2-5d110cf36bf3","owner":[],"postedDate":"March 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-03-12T16:08:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-11 08:50:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6135147","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6135147","identity":"rs-6135147","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}