The use of an escape room simulation in undergraduate community health nursing course: a single group pre-post evaluation

The use of an escape room simulation in undergraduate community health nursing course: a single group pre-post evaluation | 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 The use of an escape room simulation in undergraduate community health nursing course: a single group pre-post evaluation Lufei Young, Xi Ning, Yinghao Pan, Tiffany Jackson, Meredith Troutman-Jordan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6873159/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Community health nursing (CHN) clinical practice is essential for pre-licensure nursing students to develop the competence and confidence needed to deliver safe and effective care in patients’ homes. However, clinical placements are often hindered by limited site availability, preceptor shortages, and inconsistent quality. Escape room simulation (ERS) has emerged as an innovative strategy to address these challenges and provide meaningful learning experiences. Despite its growing use, there is limited evidence on the impact of ERS in enhancing nursing students’ readiness for home-based community settings. To address this gap, this study evaluated the effects of ERS on students’ competence and confidence in CHN. A quasi-experimental, single-group pre/post design was used with 56 full-time undergraduate nursing students. Data were collected at three time points: before ERS (T1), immediately after (T2), and ten weeks later (T3). Instruments included the CHN Competency Checklist, CHN Confidence Scale, and ERS Perception Scale. A linear mixed-effects model showed statistically significant increases in both competency (t = 6.413, p < .001) and confidence (t = 8.142, p < .001) from T1 to T2, with sustained or slightly improved scores at T3. Spaghetti plots revealed reduced variation in competence over time, suggesting consistent benefit across participants, while confidence growth showed greater variability, indicating individual differences in response. Students with lower baseline scores exhibited the most notable gains. Most had no prior ERS experience but reported high satisfaction. Findings support the integration of ERS into CHN curricula to enhance student preparedness, especially when clinical placements are limited. Escape Room Simulation Competence Confidence Community Health Nursing Pre-licensure Nursing Education Figures Figure 1 Figure 2 Introduction Clinical practice is essential for nursing students to acquire the necessary skills, confidence, and competence in providing safe and effective patient care. However, there are often challenges and barriers that can hinder clinical placements, such as issues related to the lack of appropriate clinical sites, diversity in patient populations, clinical preceptor shortages and high turnover. In prelicensure nursing programs, students are typically required to complete a certain number of clinical practice hours as part of their education and training. It's becoming increasingly difficult for nursing programs to locate clinical practice sites. The challenges and barriers include shortage and high turnover of clinical preceptors, overloaded and understaffed clinical sites with increasing restrictions, competition between programs, and geographic barriers. Furthermore, most nursing students are placed at well-established and sustained clinical sites in major cities that predominantly served populations (e.g., insured, employed, well-resourced), which limits their exposure to diverse populations in the underserved or marginalized communities they will encounter in their future nursing careers. This lack of exposure and diversity can 1) hinder efforts to promote health equity and inclusion, and reduce health disparities; 2) leave them ill-prepared to provide culturally sensitive care to a wide range of patients with unique healthcare needs; 3) hamper the development of inter-professional practice competencies; and 4) contribute to nursing workforce shortage due to high turnover, leading to increased financial loss and reduced care quality in healthcare settings. Besides the impact on nursing students and healthcare institutions, the difficulties in clinical placements for nursing students can also have a significant impact on nursing schools, programs, and faculty/staff in various ways: reduced enrollment capacity, disruption and delay of curriculum planning and new programs, financial implications, increased faculty and staff workload to coordinate clinical placements, strain on relationships with healthcare facilities and community partners. All of these can impact the overall quality of education, contributing to a significant barrier to the first university strategic plan focus (i.e., student success) and leading to ill-prepared graduates for real-world nursing practice. To address these issues, nursing programs and healthcare institutions have been looking for alternative approaches to supplement clinical experiences when clinical placements are scarce or disrupted. One of the alternative approaches is to use escape rooms to develop nursing students' clinical skills and knowledge (Adams et al., 2018 ; Robertiello et al., 2021 ). The literature evidence on escape rooms in higher education is growing (Anguas-Gracia et al., 2021 ). Escape rooms refer to team-based game activities required to escape a locked room by solving clues. The game requires the participants to use problem-solving skills, critical thinking, and a team-based approach to accomplish tasks and specific goals in a specified amount of time (Allen, 2017 ; Fotaris & Mastoras, 2019 ; Urcola-Pardo et al., 2018 ). The use of escape rooms as an innovative pedagogical strategy has gained traction across diverse health disciplines, including medicine, nursing, pharmacy, dentistry, and radiology. These game-based, team-oriented learning experiences are designed to simulate real-world clinical scenarios, encouraging learners to work collaboratively under time constraints to solve complex, context-specific puzzles. Studies have consistently reported high levels of student engagement, motivation, and satisfaction, suggesting that escape rooms serve as effective adjuncts or alternatives to traditional didactics and simulation-based training (Abensur Vuillaume et al., 2021 ; Zhang et al., 2018 ; Turner et al., 2021 ). In medical education, escape rooms have been used to improve teamwork, communication, and clinical reasoning among residents and medical students, particularly in emergency medicine, internal medicine, and board exam preparation contexts (Gillespie, 2021 ; Podlog et al., 2020 ; Khanna et al., 2021 ). In pharmacy and dental education, escape rooms have facilitated knowledge integration and skill application in areas such as diabetes management and interprofessional collaboration (Kavanaugh et al., 2020 ; Zaug et al., 2022 ). The design and implementation of these games range from live-action to virtual formats, offering adaptability and resource efficiency, which makes them attractive for widespread adoption across institutional settings. In terms of nursing education, escape room simulations (ERS) can help students develop clinical competencies, improve teamwork skills and solve clinical problems (Eppmann & Klein, 2018). In addition, it allows for the application of knowledge to practice in a safe, visual, highly interactive, and experiential learning environment. It was reported that the escape room approach was an effective adjunct to traditional clinical practice by offering a fun, socially interactive, motivating, and novel learning environment. In addition, the escape room approach increased the flexibility of program and curriculum development (Fotaris & Mastoras, 2019 ). However, the evidence on its applicability to healthcare education remains limited (Eppmann & Klein, 2018). A comprehensive literature review showed conflicting results and significant heterogeneity in purpose, room design, and evaluation methods, which makes direct comparison difficult (Fotaris & Mastoras, 2019 ; van Gaalen et al., 2021 ). Furthermore, the effectiveness of escape room simulations (ERS) in community health nursing (CHN) education has not been adequately reported. Given the increasing complexity and demands of community-based care, it is essential for nursing education programs to prepare graduates who are equipped to meet the evolving needs of diverse populations. Currently, there is limited evidence on the use of escape rooms as an educational tool for developing student competencies in CHN. To address these gaps and challenges, an ERS intervention was purposefully designed to enhance nursing students’ competence and confidence in becoming effective community health nurses. The purpose of this study is to evaluate the impact of ERS as a supplement to traditional clinical placement within an undergraduate CHN course. If proven effective, this approach could serve as a valuable strategy to better prepare students to care for underserved and hard-to-reach populations, which are often underrepresented in conventional clinical settings. To accomplish the purpose, the Specific Aims were: To evaluate the impact of the ERS on student confidence in community health nursing practice To evaluate the impact of the ERS on student competence in community health nursing practice To evaluate student experience in the ERS Methods Design We chose a quantitative quasi-experimental design with a single group pre and post-test to evaluate the impact of ERS on undergraduate students’ confidence and competency in community health nursing practice. This design allowed the project implementation and data collection without interrupting the existing nursing curriculum (Moore & Campbell, 2021 ). Sample and setting The participants were a convenience sample of nursing students who registered in a community health nursing course during the spring semester. Fifty-six participants were enrolled to the study. The ethics approval was obtained from the university Institutional Review Board (IRB). The informed consent was obtained from participating students. All participants were informed of their voluntary participation status. Upon receiving the signed inform consent, the study was conducted at the School of Nursing, Simulation Lab. Description of the escape room simulation The escape room simulation (ERS) was originally developed by a team of faculty and researchers with extensive expertise in community health nursing education, research, and practice. Its design was supported by funding from the National League for Nursing (Powers et al., 2022 ; Powers et al., 2025 ). The original ERS aimed to evaluate interprofessional collaboration within community-based care settings. For this study, the simulation was adapted and redesigned to specifically assess core competencies and confidence in community health nursing (CHN), guided by the Quad Council Coalition (QCC) of Public Health Nursing Organizations’ competency framework (Campbell et al., 2020 ). The revised simulation emphasized several critical areas of CHN practice, including comprehensive assessment in home settings, awareness of social determinants of health (SDOH), transdisciplinary role flexibility (requiring nurses to assume roles typically associated with social work, occupational therapy, physical therapy, legal, and pharmacy), risk identification, and implicit bias awareness. Unlike the controlled and structured environment of acute care, community health nurses often operate in complex, unpredictable home and community settings with limited oversight or immediate support. As such, students must demonstrate a broad skill set, self-reliance, and confidence to navigate these multifaceted environments. The ERS was conducted in the School of Nursing’s simulation lab, with rooms staged to closely resemble home environments. Fourteen groups of four students each were formed, and each group was allotted 20 minutes to work through a simulated clinical case scenario. Each escape room incorporated health-related puzzles and realistic props, including mannequins, medication bottles, food items, durable medical equipment, and home furnishings, along with written cues designed to prompt students to assess risk factors, prioritize care, identify relevant community resources, and complete appropriate documentation. To support the development of CHN competencies and confidence, the ERS provided students with opportunities to simulate home visits with older adults, conduct comprehensive assessments, and identify environmental, physical, and psychosocial risks to safety and well-being. These immersive experiences also encouraged students to consider cultural contexts, make appropriate referrals, and exercise sound clinical judgment. Through these activities, students strengthened critical thinking, problem-solving, and team-based communication skills essential for delivering safe, empathetic, and culturally responsive care in community-based settings. The ERS emphasized the CHN roles of assessment, prioritization, documentation, reporting, referral, self-awareness, other-awareness, and environmental awareness. Table 1 outlines the components of the ERS session, corresponding learning objectives. Table 1 Escape Room Simulation Setup Puzzle Role and Responsibility Learning Objectives Hazardous living Students assess a simulated home environment for potential risks, hazards, and signs of abuse. Identify and evaluate environmental, physical, and psychological risks. Recognize signs of abuse and neglect. Develop strategies for reporting and addressing safety concerns. Food safety Students evaluate the availability and quality of food in a simulated home setting. Assess the adequacy of food supplies and nutritional quality. Identify indicators of food insecurity. Recommend community resources and referrals. Medication Students review a simulated medication record, then assess patient medication practices. Detect and address medication errors. Implement proper medication management strategies. Develop plans for safe medication administration and patient education. Prior to ERS activities, the clinical faculty who led each group were provided with the ERS moderator guide. The participants were oriented to the room, tasks, puzzles, instructions and clues. They were aware that the overall objective was to escape as a team. Each ERS activity started with an introduction and description of each scenario in each “room”. After the participants successfully escaped, a 30-minute debrief session was moderated by trained faculty using the Debriefing Assessment for Simulation in Healthcare (DASH) guideline to support reflective learning (Niu et al., 2021 ). Measures and data collection procedure To determine the impact of ERS, we performed data collection at three time points: pre-ERS (T1), post-ERS (T2), 10 weeks after ERS session (T3). The instruments we used for data collection include 1) demographic form; 2) CHN competency checklist; 3) CHN confidence scale; and 4) Escape room experience perception scale. Prior to the ERS activity, the participants completed the demographic form, CHN competency checklist and confidence scale. At the end of the session, participants were asked to complete the CHN competency checklist, confidence scale, and escape room experience perception scale. Finally, 10 weeks after the ERS session, participants completed the CHN competency checklist and confidence scale. Community Health Nursing Competency Checklist . This instrument includes 18 clinic competency skills for community health nursing practice required by the Quad Council Coalition (QCC) of Public Health Nursing Organizations (6). Students will report their competency for each skill by responding “Yes” or “No”. Each student’s competency will operationalized as the sum score the number of “Yes”. The Cronbach's alpha for the competency questionnaire was calculated based on the pre-ERS measurements and found to be 0.89. This high alpha value indicates excellent internal consistency. Community Health Nursing Confidence Scale . This scale includes 18 items that are required skills for community health nursing practice. Students were asked to rate their belief in their ability to perform the listed clinical skills. Student self-reported their perceived confidence level on a 100-point scale, ranging in 10-unit intervals from 0 (“Cannot do”); through intermediate degrees of confidence, 50 (“Moderately certain can do”); to complete confidence, 100 (“Highly certain can do”). The higher sum score indicates greater confidence in practicing community nursing care. The Cronbach's alpha for this confidence questionnaire is 0.95 according to the pre-ERS data, indicating excellent internal consistency. Escape Room Experience Perception Scale. The scale contains 12 items that are divided in 4 domains: 1) Enjoyment, 2) Feasibility and Usefulness, 3) Relevance, and 4) Outcome and Effectiveness. Each item was measured on Likert-type scale ranging from 1 (strongly disagree) to 5 (Strongly agree). The higher sum score indicates the more positive learning experience during escape room simulation. This scale was administered following the conclusion of the escape room simulation session. The scale has a Cronbach's alpha of 0.97, which indicates outstanding internal consistency. Data analysis All analyses were conducted using R studio (version 2023.06.1 + 524) with a significance level of 0.05. Descriptive analyses were performed to describe the study participants, student competencies, confidence and ERS experiences and perceptions. Frequencies and percentages were used for categorical variables, while means and standard deviations (SD) were used for continuous variables. A linear mixed effect model was employed to determine the effects of the escape room on competency and competency over three measure points (pre-ERS [T1], post-ERS [T2], and 10 weeks after ERS session [T3]). Linear mixed models are an extension of simple linear models to allow for analyzing data that are measured repeatedly over time. In particular, the model is specified as: $$\:{Y}_{ij}={\mu\:}_{\text{j}}+{\alpha\:}_{i}+{ϵ}_{ij}$$ where \(\:i\) is the index of the student ( \(\:i\:=\:1,\:...,\:56\) ) and \(\:j\) is the time index ( \(\:j=1\) represents pre-intervention, \(\:j=2\) represents post-intervention, \(\:j=3\) represents T3, 8 weeks after intervention). Let \(\:{Y}_{ij}\) denote the competency or the confidence at the jth time point for the ith student, \(\:{\mu\:}_{\text{j}}\) is the fixed effect for each time point, while \(\:{\alpha\:}_{i}\) is the random effect for each student \(\:i\) , assumed to be independent and identically distributed (i.i.d.), following a normal distribution with mean 0 and variance \(\:{\sigma\:}_{\alpha\:}^{2}\) . The random error terms \(\:{ϵ}_{ij}\) are assumed to be i.i.d., following a normal distribution with mean 0 and variance \(\:{\sigma\:}^{2}\) . We also assume that \(\:{\alpha\:}_{i}\) and \(\:{ϵ}_{ij}\) are independent. From model (1), it is easy to obtain that the expected competency for pre-, post, and T3 interventions is \(\:{\mu\:}_{1}\) , \(\:{\mu\:}_{2}\) and \(\:{\mu\:}_{3}\) , respectively. In particular, we can re-write model (1) as $$\:{Y}_{i1}={\mu\:}_{1}+{\alpha\:}_{i}+{ϵ}_{i1}$$ $$\:{Y}_{i2}={\mu\:}_{2}+{\alpha\:}_{i}+{ϵ}_{i2}$$ $$\:{Y}_{i3}={\mu\:}_{3}+{\alpha\:}_{i}+{ϵ}_{i3}$$ Some further explanation: \(\:{Y}_{i1}\) represents the competency level at pre-intervention for the ith student, \(\:{Y}_{i2}\) represents the competency level at post-intervention for the ith student, \(\:{Y}_{i3}\) represents the competency level at T3 for the ith student. In addition, R studio along with ggplot2 package were used to make spaghetti plots for the growth of CHN confidence and competency (Figs. 2 and 3). Results Participants characteristics A total of 56 full-time students (53 female and 3 male) participated in the ERS activity. All participants completed all 3 data collections. Participant characteristics are presented in Table 2 . A total of 56 participants’ data were included in this analysis. The mean age of the sample was 22 years (SD = 2.795; range 21–42 years). Participants include 53 (94.6%) female and 3(5.4%) male. The racial demographics of the participants included 29 (51.8%) White, 11(19.6%) Black, 7 (12.5%) Hispanic and Asian respectively. A total of 41 (73.2%) participants speak English only, while 12 (21.4%) participants are multilingual. The average years of schooling are 16 (SD = 2.084; range 14–31 years). They were all full time students with average of 11 hours per week (SD = 11.188, range 0–40 hours). Most participants (82%) had unlicensed nursing work experience in various healthcare settings, including acute care (34%), ambulatory clinics, nursing home, assisted living, home health (7% respectively). The average length of employment was 41 months (SD = 24, range 2–96 months). Majority (23%) did not have previous escape room simulation experience. If they did, the average ERS experience was about 3 hours (SD = 2.713, range 0–10 hours). Table 2 Participants Characteristics Variables M ± SD or N (%) Range Year of age 21.84 ± 2.795 21–42 Female 53 (94.6) Race White 29 (51.8) Black 11 (19.6) Hispanic 7 (12.5) Asian 7 (12.5) Middle Eastern 1 (1.8) Multi-race 1 (1.8) Language English 41 (73.2) Arabic 1 (1.8) Mandarin 1 (1.8) Vietnamese 1 (1.8) Multilingual 12 (21.4) Year of Education 16.14 ± 2.084 14–31 Full-time student 56 (100%) Current work (weekly hr.) 10.88 ± 11.188 0–40 Pre-nursing work experience (yes) 46 (82.1) Working places 3.78 ± 2.9 1–8 Acute care 19 (33.9) Ambulatory clinics 4 (7.1) Skilled nursing facilities 1 (1.8) Rehab centers 1 (1.8) Nursing home 4 (7.1) Assisted living 4 (7.1) Home health 4 (7.1) Multi-site 8 (14.3) Length of employment (months) 41.22 ± 24.235 Previous escape room experience (Yes) 13 (23.2) Previous escape room experience (hrs.) 2.77 ± 2.713 0–10 Group assessment descriptives The scores on Community Health Nursing (CHN) Competency Checklist and Confidence Scale were analyzed using data collected at pre (T1), post (T2), and 10 weeks after ERS activity (T3). The scores of Escape Room Experience Perception Scale were collected at T2. Tables 3 presents the minimum, median, mean, maximum, and standard deviation of CHN competence, confidence and perceived ERS experience at each data collection point. The participants’ average competence score at T1 was 14.98, with a standard deviation of 3.88. The competence score rose to 17.39 (SD = 1.27) at T2 and further to 17.85 (SD = 0.62) at T3, indicating a notable improvement in participants' competence after ERS. Similarly, the average confidence score at T1 was 1295.56, with a standard deviation of 276.08. By T2, the score increased to 1535.98, accompanied by a smaller standard deviation of 204.09, and continued to rise to 1689.45 at T3, with a significantly lower standard deviation of 111.26. This demonstrates the role of ERS in strengthening participants' confidence levels. Along with the increased mean competence score, the standard deviation decreased (SD T1 = 3.88, SD T2 = 1.27, SD T3 = 0.62). Likewise, the increase in mean confidence scores was accompanied by a decrease in standard deviation (SD T1 = 276.08, SD T2 = 204.09, SD T3 = 111.26). This pattern of rising mean scores with declining standard deviations suggests not only overall improvement in CHN competence and confidence, but also reduced variability among participants. In other words, students became more aligned in their performance and perceptions over time. In this study, the ERS experience contributed to both increased competence and confidence, while narrowing the gap between high- and low-performing students. This indicates the ERS intervention was not only effective but also equitable in promoting consistency in student learning outcomes across participants. The Escape Room Experience Perception Scale was administered immediately after the ERS session at T2 (Table 3 ). Participants reported an average score of approximately 60 (SD = 8.19), indicating high satisfaction with the ERS activities. They perceived the experience as helpful and effective in supporting their clinical learning and practice in community health nursing. Table 3 Descriptive statistics for student’s competence, confidence scores and escape room experience perception scale CHN competence Min Median Mean Max SD Pre-competence (T1) 4.00 16.50 14.98 18.00 3.88 Post-competence (T2) 13.00 18.00 17.39 18.00 1.27 10 week-competence (T3) 14.00 18.00 17.85 18.00 0.62 CHN confidence Pre-confidence (T1) 450 1315 1295.56 1700 276.08 Post-confidence (T2) 1040 1545 1535.98 1800 204.09 10 week-confidence (T3) 1380 1720 1689.45 1800 111.26 Perceived ERS experience Escape room experience perception scale (T2) 13.00 63.00 59.96 65 8.19 Individual competence and confidence growth by Spaghetti plots Figures 1 and 2 are the spaghetti plots used to visualize individual growth and between individual variability in CHN competence (Fig. 1 ) and confidence (Fig. 2 ). The spaghetti plots were made using ggplot2 in R, a powerful package for creating elegant data visualizations. A spaghetti plot (also called a line plot with individual trajectories) is a type of data visualization used to show how individual participants’ CHN competence and confidence change over time across multiple measurement points (before the ERS activity session [T1], immediate after the ERS session [T2] and 10 weeks after the session [T3]). Each line corresponds to one participant ("strand of spaghetti") and represents each participant's competence and confidence scores across three time points. The x-axis shows the time points (e.g., before ERS session, immediately after the session, and 10 weeks after the session). The y-axis shows the score (e.g., CHN competence in Fig. 1 or CHN confidence in Fig. 2 ). All lines are plotted together, showing individual growth and between-individual variability over time. CHN competence plot (Fig. 1 ) shows how each student's perceived community health nursing (CHN) competence changes across three time points. The majority of lines trend upward from left to right, especially from pre- to post-ERS session, indicating a clear increase in competence. CHN confidence plot (Fig. 2 ) tracks changes in CHN confidence levels across the same intervals. Again, most lines increase, especially from pre- to post-ERS session. Beyond individual growth patterns, the spaghetti plots use a color gradient to represent the degree and direction of change over time in competence and confidence. The spectrum, from bright green to teal/blue-green, denotes the strongest improvement across the three time points. These lines typically begin with low baseline scores at T1 (pre-ERS) and rise sharply at T2 (immediate post-ERS), with continued growth at T3 (follow-up), indicating high responsiveness to the ERS session. Light to medium blue represents moderate responsiveness, with visible improvement at T2 and sustained or stable gains at T3. Orange to yellow-green indicates mild responsiveness, with limited gains after the ERS session and modest retention over time. Brown, olive, and dull yellow signify little or no improvement. These lines may remain flat or decline by T3, suggesting possible regression, unsustained effects, or other contributing factors such as burnout, lack of engagement, or data anomalies. In Fig. 1 (Competence), participants with lines colored in green show the most substantial improvements in competence. Those in orange or yellow often started at higher baseline scores, limiting their potential for growth and resulting in smaller changes. A few participants show no improvement or a slight decline at T3 (flattened or downward trajectories), indicated by dull colors such as brown or olive. Notably, one participant's trajectory remains at the maximum score across all three time points, indicating a ceiling effect and no perceived benefit from the ERS session. In Fig. 2 (Confidence), participants with bright green lines generally start with lower confidence and demonstrate marked improvement by T3. Conversely, orange or brownish lines remain flat or show minimal change, while a few trajectories dip or plateau at T3, indicating stalled or regressed confidence levels. These are represented in subdued tones like olive or dull yellow. Inferential analysis for Specific Aim 1 and 2 The participants’ CHN competence scores significantly improved when compared between pre and post scores (t-statistic = 6.413, p-value < 0.001) (Table 5 ). The estimated average competency scores for the pre-ERS, post-ERS, and T3 are 14.982, 17.392, and 17.870, respectively. The 95% confidence intervals for the differences in means (Post – Pre and T3 - Pre) both exclude 0, indicating that these differences are statistically significant. An approximate 95% confidence interval for the standard deviation \(\:{\sigma\:}_{\alpha\:}\) ranges between 0.862 and 1.795. Table 5 Regression analysis for competence Coefficients Stand error p-value 95% CI Fixed effect parameter Intercept (pre-competency) 15 0.319 < 0.001 (14.4, 15.6) Post-competency – pre-competency 2 0.376 < 0.001 (1.7, 3.1) T3-competency – pre-competency 3 0.378 < 0.001 (2.1, 3.6) Random effect parameter SD (study_id) 1 (0.8, 1.8) SD (residuals) 2 (1.7, 2.3) A statistically significant increase was also noted in students’ confidence in community health nursing practice after the completion of ERS activity (t-statistic = 8.142, p-value < 0.001) (Table 6 ). The estimated average confidence scores at the pre-ERS, post-ERS, and T3 time points are 1290.687, 1535.982, and 1694.177, respectively. A 95% confidence interval for the standard deviation σ_α ranges between 105.966 and 189.578. The variations in students’ demographic variables such as Previous ERS experience did not affect the differences in both confidence and competency scores between 3 measure points. Table 6 Regression analysis for confidence Coefficients Stand error p-value 95% CI Fixed effect parameter Intercept (pre-confidence) 1291 29.0 < 0.001 (1234, 1347) Post-confidence – pre-confidence 245 30.1 < 0.001 (186, 304) T3-confidence – pre-confidence 403 31.8 < 0.001 (341, 466) Random effect parameter sd (study_id) 146 (106, 190) sd (residuals) 157 (136, 181) Discussion Nursing education faces persistent challenges in securing adequate clinical placements, especially those that expose students to diverse, underserved populations. To address this gap, our study explored the use of an escape room simulation (ERS) as an innovative educational strategy to enhance undergraduate nursing students’ competence and confidence in community health nursing (CHN) practice. We implemented a team-based ERS activity designed to simulate home visits and community-based care scenarios, measuring student outcomes at three time points. Findings revealed significant improvements in both competence and confidence immediately after the ERS and sustained ten weeks later, with reduced variability across participants. Students also reported high satisfaction with the experience. These results suggest that ERS is not only an effective method for supplementing clinical learning but also holds promise in preparing students to deliver culturally sensitive, community-based care. Our project contributes to the growing body of literature on experiential learning in nursing education, aligns with university priorities for student success and diversity, and offers a scalable model for addressing clinical placement barriers while enhancing faculty and student engagement. Contributions to existing literature evidence Despite growing interest, few studies have rigorously evaluated the impact of escape rooms on measurable student outcomes beyond immediate perceptions. Most published research relies on post-activity surveys that assess satisfaction, perceived knowledge gain, and engagement, with limited data on sustained competency development or longitudinal learning effects. This gap is especially evident in undergraduate nursing education, where only a small number of studies have explored escape room interventions for pre-licensure students (Gómez-Urquiza et al., 2022 ). In the context of community health nursing (CHN), one study by Anguas-Gracia et al. ( 2021 ) evaluated Spanish nursing students’ experience with an escape room integrated into a CHN course. Students overwhelmingly viewed the activity as enjoyable and motivating, reporting increased learning interest and appreciation for its novelty. However, this study focused primarily on affective responses and did not assess changes in clinical competence or confidence over time. Similarly, Gómez-Urquiza et al. ( 2022 ) conducted a qualitative observational study that highlighted escape rooms as a positive experiential tool to assess emergency care competencies, teamwork, and decision-making. Yet again, objective outcome measures were lacking, and the application was not specific to CHN practice. To our knowledge, no published studies have longitudinally examined the effects of escape room simulations on pre-licensure nursing students’ competence and confidence in community health nursing. Our study addresses this gap by aligning ERS intervention with CHN learning objectives and evaluating its outcomes across three time points. Unlike prior work, we captured both immediate and sustained changes in student performance, demonstrated reduced variability in learning outcomes, and linked student experience to measurable growth in CHN readiness. These findings contribute new evidence to the field and suggest that escape room simulations can serve as an equitable, scalable, and pedagogical strategy to support clinical learning, particularly in settings where access to diverse or sufficient clinical placements is limited. Significance and Implication of studying individual response to ERS intervention Another significant gap addressed by our study is the use of individual growth plots to examine variations in how each student responds to the same ERS intervention differently, an approach not previously reported in similar studies. We employed spaghetti plots to visualize individual trajectories of competency and confidence across three measurement points. This method allows for a detailed analysis of within-subject change over time, in contrast to the group mean comparisons commonly used in existing literature. By capturing individual-level responses, this approach helps identify patterns of responsiveness (e.g., high-responders, low-responders, or non-responders), offering deeper insights into the intervention's effectiveness and informing targeted improvements within the undergraduate nursing curriculum. Through individual growth plots, we identified significantly different growth patterns in students’ competence and confidence following a single session of ERS. The growth trajectories of all 56 participants are illustrated in Figs. 1 (competence) and 2 (confidence). Notably, fewer distinct individual lines appear in the competence plot, largely due to overlapping or converging trajectories, which suggests a uniform response among participants. This pattern indicates that the ERS session had a relatively consistent impact on students’ community health nursing (CHN) competence, with minimal variation across individuals. In contrast, the confidence plot reveals a greater dispersion of individual lines, reflecting more pronounced variability in how participants responded to the same intervention. These findings suggest that while the ERS uniformly enhanced competence, its effect on confidence varied considerably among students. Several factors may explain the wider variation in confidence growth following a single ERS session. First, competence is typically associated with the acquisition of specific knowledge or skills. Because the ERS was designed to target defined learning objectives, it is likely that most students improved in a consistent, predictable manner. Confidence, on the other hand, reflects a psychological perception of one’s abilities. It is influenced not only by content mastery but also by personality traits, prior experiences, levels of anxiety, social comparison, and self-efficacy. Thus, students may interpret and respond to the same learning experience in vastly different ways. Second, the baseline confidence scores displayed much greater variability compared to baseline competence scores, suggesting that this variability may persist or even increase over time. Third, the nature of group dynamics and simulation-based learning may influence competence and confidence differently. As ERS sessions are often interactive and team-based, students’ perceptions of group cohesion and teamwork quality may have a greater impact on their confidence than on their perceived competence. This divergence in growth trajectory suggests that while the ERS session was effective in promoting consistent skill development (competence), enhancing confidence may require additional instructional strategies. To foster more uniform gains in confidence, educators might consider incorporating structured reflection or debriefing sessions to help students process their experiences constructively. Additionally, individualized feedback can reinforce students’ strengths, and creating psychologically safe learning environments may further support the development of self-efficacy. In summary, competence improved consistently because it was closely aligned with the ERS session’s learning objectives. In contrast, confidence varied widely due to the influence of internal, social, and emotional factors unique to each learner. These findings underscore the importance of addressing both cognitive and affective domains in the design of experiential learning activities. Limitations and strategies Several limitations should be acknowledged. First, we used a convenience sample of students, which may limit the generalizability of our findings to other institutions or regions. Although randomized controlled trials (RCTs) are considered the gold standard for evaluating intervention effects, implementing an RCT in an educational setting is often impractical and ethically challenging. It would be infeasible and potentially inequitable to offer the ERS to one group of students while withholding it from another group within the same cohort. A waitlist control design is similarly unworkable, as students transition to subsequent semesters and graduate, making delayed exposure to the intervention impossible. Therefore, a pre- and post-intervention design remains the most feasible and ethically sound approach for evaluating educational interventions such as ERS. Second, our assessment of competence, confidence, and student experience was limited to two time points, immediately following the ERS session and 10 weeks later. While this allowed us to detect short-term retention and delayed effects, it does not capture long-term learning outcomes. To address this, we plan to develop a tracking system to follow up with students after graduation to assess sustained application and retention of knowledge, skills and confidence gained from the ERS. Our data also revealed a less steep growth in competence and confidence between T2 and T3, suggesting that multiple ERS sessions throughout the program may be necessary to reinforce learning and prevent regression. Individual growth plots revealed that students’ competence trajectories showed less variation than confidence trajectories, indicating that while skill development was more consistent, confidence building may require more individualized support. This points to the need for tailored advising and mentoring strategies to support students with lower responsiveness. Third limitation is the absence of a qualitative component in our study. Student experiences were measured only through quantitative tools, which may overlook the depth and nuance of their learning. Incorporating focus group interviews or analyzing debriefing session transcripts in future studies could provide richer insights and help refine the ERS design to better meet learners’ needs. For students who exhibited flat or declining growth trajectories, qualitative approaches may illuminate underlying barriers or challenges that cannot be captured through quantitative measures alone. Fourth, we also collected limited background data to reduce participant burden, but this may have resulted in overlooking potential confounding variables that could explain individual differences in responsiveness and the sustainability of ERS effects. Future studies will incorporate additional demographic and contextual variables to explore these potential covariates. Importantly, the tools we used to measure confidence and competence, although internally consistent, have not yet been validated for psychometric properties such as construct validity or test-retest reliability. Without established validity and reliability, longitudinal tracking of intervention effects remains limited. We are committed to ongoing data collection to refine and validate these assessment instruments. Lastly, this study did not assess team dynamics or the impact of debriefing sessions. These factors may significantly influence ERS outcomes. In future research, we plan to include structured evaluations of team interaction and debriefing quality. We will also apply triangulation methods, using multiple data sources and methodologies to validate our findings and strengthen the reliability and depth of our evaluation. Conclusions There is limited evidence on the use of escape rooms as an innovative educational tool for developing students’ competencies in community health nursing. Our study contributes to pre-licensure nursing education by addressing this gap and adding to the growing body of literature on escape rooms in nursing education. The findings demonstrate that escape room simulations have a significant positive effect on nursing students’ competence and confidence in community health nursing. We propose that escape rooms offer an effective and innovative approach to enhance clinical competency, enrich learning experiences, and provide meaningful exposure to underserved and hard-to-reach populations. Moreover, escape rooms help address several systemic challenges in nursing education. They can alleviate faculty workload, reduce clinical placement limitations, and accommodate diverse student learning needs. As safe, interactive, and engaging environments, escape rooms allow students to practice clinical decision-making without the pressures of real-world consequences. Within these simulated experiences, students can make mistakes, receive comprehensive feedback, and benefit from guided mentoring. They also develop critical thinking, apply theoretical knowledge in realistic scenarios, and build both confidence and competence in a risk-free setting. Furthermore, escape rooms foster the development of team communication and collaboration skills, ultimately preparing students to become confident, competent practitioners in various community health settings. Abbreviations ERS: Escape room simulation; CHN: Community health nursing Declarations Acknowledgement: The authors would like to sincerely thank the undergraduate nursing students who participated in this study for their time, engagement, and valuable feedback. We extend our appreciation to Emily Gullena for her mentorship and expertise in using the Debriefing Assessment for Simulation in Healthcare (DASH) tool to assess the quality of our debriefing sessions. Special thanks to Melinda Pierce and Ashton Atmore for their vital simulation support in preparing and facilitating the escape room activities. We gratefully acknowledge Dr. Kelly Powers and her team for their contributions to the original design of the escape room simulation, which provided the foundation for this project. We also thank Rachel Caputo for her assistance and coordination throughout the implementation of the study. Their collective support was instrumental in the success of this work. Author contributions : LY led the development of the grant proposal and secured funding for the project. She modified and implemented the study design, coordinated project execution, contributed to the original study concept, and led manuscript writing, revision, and submission. She was also responsible for study design, data oversight, and overall project administration. XN contributed to manuscript development and revision, conducted data analysis, and generated tables, graphs, and the analysis report. YGP contributed to manuscript development and revision, assisted in developing the data analysis plan, identified appropriate analysis software and statistical methods, and supported the generation of the data analysis report. TJ provided the conceptual framework and clinical expertise to guide the study design. She was involved in securing funding, recruiting and retaining student participants, project administration, coordinating with the simulation center, facilitating data collection, and managing administrative aspects of the project. MTJ contributed to the design of the intervention, assisted with grant proposal writing and budgeting, and supported drafting and revising the manuscript. All authors reviewed and approved the final manuscript. Funding: The authors received program funds from University of North Carolina Charlotte, Scholarship of Teaching and Learning (SoTL) grant program. Data Availability Statement: This study involved undergraduate nursing students, a population considered vulnerable in educational research. In accordance with the institutional review board (IRB) regulations and to protect participant confidentiality and privacy, the data collected cannot be shared with external research teams. Access to the data is restricted as per IRB-approved protocols. References Abensur Vuillaume, L., Laudren, G., Bosio, A., Thévenot, P., Pelaccia, T., & Chauvin, A. (2021). A didactic escape game for emergency medicine aimed at learning to work as a team and making diagnoses: Methodology for game development. JMIR Serious Games, 9 (3), e27291. https://doi.org/10.2196/27291 Adams, V., Burger, S., Crawford, K., & Setter, R. (2018). Can you escape? Creating an escape room to facilitate active learning. Journal for Nurses in Professional Development , 34 (2), E1-E5. Anguas-Gracia, A., Subirón-Valera, A. B., Antón-Solanas, I., Rodríguez-Roca, B., Satústegui-Dordá, P. J., & Urcola-Pardo, F. (2021). An evaluation of undergraduate student nurses’ gameful experience while playing an escape room game as part of a community health nursing course. Nurse Education Today, 103 , 104948. https://doi.org/10.1016/j.nedt.2021.104948 Allen, M. (Ed.). (2017). The SAGE encyclopedia of communication research methods . SAGE publications. Campbell, L. A., Harmon, M. J., Joyce, B. L., & Little, S. H. (2020). Quad Council Coalition community/public health nursing competencies: Building consensus through collaboration. Public Health Nursing , 37 (1), 96-112. Eppmann, R., Bekk, M., & Klein, K. (2018). Gameful experience in gamification: Construction and validation of a gameful experience scale [GAMEX]. Journal of interactive marketing , 43 (1), 98-115. Fotaris, P., & Mastoras, T. (2019). Escape rooms for learning: A systematic review. In Proceedings of the European Conference on Games Based Learning (pp. 235-243). Gillespie, M. (2021). Escape the EM boards: Interactive virtual escape room for GI board review. Journal of Education and Teaching in Emergency Medicine, 6 (2), SG8–SG45. https://doi.org/10.21980/J8H63F Gómez-Urquiza, J. L., Hueso-Montoro, C., Correa-Rodríguez, M., Suleiman-Martos, N., Martos-Cabrera, M. B., Gómez-Salgado, J., & Albendín-García, L. (2022). Nursing students’ experience using an escape room for training clinical skills and competencies on emergency care: A qualitative observational study. Medicine (Baltimore), 101 (30), e30004. https://doi.org/10.1097/MD.0000000000030004 Kavanaugh, R., George, S., Lamberton, N., Frenzel, J. E., Cernusca, D., & Eukel, H. N. (2020). Transferability of a diabetes escape room into an accelerated pharmacy program. Currents in Pharmacy Teaching and Learning, 12 (6), 709–715. https://doi.org/10.1016/j.cptl.2020.01.022 Khanna, A., Ravindran, A., Ewing, B., Zinnerstrom, K., Grabowski, C., Mishra, A., & Makdissi, R. (2021). Escape MD: Using an escape room as a gamified educational and skill-building teaching tool for internal medicine residents. Cureus, 13 (9), e18314. https://doi.org/10.7759/cureus.18314 Moore, L., & Campbell, N. (2021). Effectiveness of an escape room for undergraduate interprofessional learning: a mixed methods single group pre-post evaluation. BMC medical education , 21 , 1-8. Niu, Y., Liu, T., Li, K., Sun, M., Sun, Y., Wang, X., & Yang, X. (2021). Effectiveness of simulation debriefing methods in nursing education: A systematic review and meta-analysis. Nurse Education Today , 107 , 105113. Podlog, M., Husain, A., Greenstein, J., & Sanghvi, S. (2020). Escape the trauma room. AEM Education and Training, 4 (2), 158–160. https://doi.org/10.1002/aet2.10410 Powers, K., Brandon, J., & Chen, F. (2025). Teaming Up for Community Health simulation intervention: A quasi-experimental study. Nursing Education Perspectives , 46 (1), 30-36. http://dx.doi.org/10.1097/01.NEP.0000000000001253 Powers, K., Brandon, J., & Townsend-Chambers, C. (2022). Preparing nursing students for home health using an escape room: A qualitative study. Nurse Education Today , 108 (Jan), Article 105215. https://doi.org/10.1016/j.nedt.2021.105215 Robertiello, G., Genee, J., & Marrera, A. (2021). Escape the sim! An escape room innovation to orient learners to the simulation environment. Nursing Education Perspectives , 42 (3), 195-196. Turner, A., Tichter, A. M., & Pillow, M. T. (2021). Let's escape didactics: Virtual escape room as a didactic modality in residency. Journal of Education and Teaching in Emergency Medicine, 6 (2), SG46–SG56. https://doi.org/10.21980/J8CH2X Urcola-Pardo, F., Blázquez-Ornat, I., Anguas-Gracia, A., Gasch-Gallen, Á., & Germán-Bes, C. (2018). Perceptions of nursing students after performing an individual activity designed to develop their critical thinking: The “critical card” tool. Nurse education in practice , 29 , 35-40. van Gaalen, A. E., Brouwer, J., Schönrock-Adema, J., Bouwkamp-Timmer, T., Jaarsma, A. D. C., & Georgiadis, J. R. (2021). Gamification of health professions education: a systematic review. Advances in Health Sciences Education , 26 (2), 683-711. Zaug, P., Gros, C. I., Wagner, D., Pilavyan, E., Meyer, F., Offner, D., & Strub, M. (2022). Development of an innovative educational escape game to promote teamwork in dentistry. European Journal of Dental Education, 26 (1), 116–122. https://doi.org/10.1111/eje.12678 Zhang, X. C., Lee, H., Rodriguez, C., Rudner, J., Chan, T. M., & Papanagnou, D. (2018). Trapped as a group, escape as a team: Applying gamification to incorporate team-building skills through an 'escape room' experience. Cureus, 10 (3), e2256. https://doi.org/10.7759/cureus.2256 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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-6873159","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":470329012,"identity":"98e1cbd9-10c3-4047-bfb7-f1b3696829c6","order_by":0,"name":"Lufei Young","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBACPgj1r76fgQdIF0CFefBoYYNQBxhnNoCUGTBI8BCtZcMBorVIJB+TLvh1h9n4+NmDnysMbOrs2RsYH7xtw6clLU16Zt8zNrMzecmSZwzSJHh4DjAbzsWrJcdMmreHmcfsBo+BZIPBYQkeiQQ2aV4itEgYz+Ax/gnWIv+A/TdBLTw/DhsYSPCYQW1hYGPGq4XnWbI1b0NagsSZHDPLBoM0yZ4zic2Sc87h1sLPnnzwNs8fmwT+9jPGNxsqbPjZ2w8f/PCmDLcWBoEEBgZGVGcwNuBRD7LmAJD4g1/NKBgFo2AUjHAAAOeRR658k6Z+AAAAAElFTkSuQmCC","orcid":"","institution":"University of North Carolina at Charlotte","correspondingAuthor":true,"prefix":"","firstName":"Lufei","middleName":"","lastName":"Young","suffix":""},{"id":470329013,"identity":"3e6b93d1-05a9-4eb4-8dd1-5ad2d8c20fd5","order_by":1,"name":"Xi Ning","email":"","orcid":"","institution":"Colby College","correspondingAuthor":false,"prefix":"","firstName":"Xi","middleName":"","lastName":"Ning","suffix":""},{"id":470329014,"identity":"8826506c-537a-4e3b-aed2-f42d5d9b207c","order_by":2,"name":"Yinghao Pan","email":"","orcid":"","institution":"University of North Carolina at Charlotte","correspondingAuthor":false,"prefix":"","firstName":"Yinghao","middleName":"","lastName":"Pan","suffix":""},{"id":470329015,"identity":"72af38c5-e1d2-4924-bdd6-988f9e13750b","order_by":3,"name":"Tiffany Jackson","email":"","orcid":"","institution":"University of North Carolina at Charlotte","correspondingAuthor":false,"prefix":"","firstName":"Tiffany","middleName":"","lastName":"Jackson","suffix":""},{"id":470329016,"identity":"d17e72a8-aea7-405e-8940-dbe722dab927","order_by":4,"name":"Meredith Troutman-Jordan","email":"","orcid":"","institution":"University of North Carolina at Charlotte","correspondingAuthor":false,"prefix":"","firstName":"Meredith","middleName":"","lastName":"Troutman-Jordan","suffix":""}],"badges":[],"createdAt":"2025-06-11 15:08:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6873159/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6873159/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85071582,"identity":"4c8f6807-5e6b-4c6f-b0cb-20229485c917","added_by":"auto","created_at":"2025-06-20 15:40:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":131842,"visible":true,"origin":"","legend":"\u003cp\u003ePlot of individual participant’s competence score changes between T1, T2 and T3\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6873159/v1/a5a12a5579135dc360e795e8.png"},{"id":85071590,"identity":"8c3c9846-f10c-4c9b-9e0c-bbd6b138e515","added_by":"auto","created_at":"2025-06-20 15:40:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":202716,"visible":true,"origin":"","legend":"\u003cp\u003ePlot of individual participant’s confidence score changes between T1, T2 and T3\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6873159/v1/d5fbd5b4083938b55031c7c0.png"},{"id":85129189,"identity":"3daafa4e-d051-4d5d-90b9-cf70dc233969","added_by":"auto","created_at":"2025-06-22 02:46:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1163600,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6873159/v1/ee65be6d-87f8-44f7-8ebd-a9af44f66fda.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The use of an escape room simulation in undergraduate community health nursing course: a single group pre-post evaluation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClinical practice is essential for nursing students to acquire the necessary skills, confidence, and competence in providing safe and effective patient care. However, there are often challenges and barriers that can hinder clinical placements, such as issues related to the lack of appropriate clinical sites, diversity in patient populations, clinical preceptor shortages and high turnover. In prelicensure nursing programs, students are typically required to complete a certain number of clinical practice hours as part of their education and training. It's becoming increasingly difficult for nursing programs to locate clinical practice sites. The challenges and barriers include shortage and high turnover of clinical preceptors, overloaded and understaffed clinical sites with increasing restrictions, competition between programs, and geographic barriers. Furthermore, most nursing students are placed at well-established and sustained clinical sites in major cities that predominantly served populations (e.g., insured, employed, well-resourced), which limits their exposure to diverse populations in the underserved or marginalized communities they will encounter in their future nursing careers. This lack of exposure and diversity can 1) hinder efforts to promote health equity and inclusion, and reduce health disparities; 2) leave them ill-prepared to provide culturally sensitive care to a wide range of patients with unique healthcare needs; 3) hamper the development of inter-professional practice competencies; and 4) contribute to nursing workforce shortage due to high turnover, leading to increased financial loss and reduced care quality in healthcare settings.\u003c/p\u003e \u003cp\u003eBesides the impact on nursing students and healthcare institutions, the difficulties in clinical placements for nursing students can also have a significant impact on nursing schools, programs, and faculty/staff in various ways: reduced enrollment capacity, disruption and delay of curriculum planning and new programs, financial implications, increased faculty and staff workload to coordinate clinical placements, strain on relationships with healthcare facilities and community partners. All of these can impact the overall quality of education, contributing to a significant barrier to the first university strategic plan focus (i.e., student success) and leading to ill-prepared graduates for real-world nursing practice.\u003c/p\u003e \u003cp\u003eTo address these issues, nursing programs and healthcare institutions have been looking for alternative approaches to supplement clinical experiences when clinical placements are scarce or disrupted. One of the alternative approaches is to use escape rooms to develop nursing students' clinical skills and knowledge (Adams et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Robertiello et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The literature evidence on escape rooms in higher education is growing (Anguas-Gracia et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Escape rooms refer to team-based game activities required to escape a locked room by solving clues. The game requires the participants to use problem-solving skills, critical thinking, and a team-based approach to accomplish tasks and specific goals in a specified amount of time (Allen, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Fotaris \u0026amp; Mastoras, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Urcola-Pardo et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The use of escape rooms as an innovative pedagogical strategy has gained traction across diverse health disciplines, including medicine, nursing, pharmacy, dentistry, and radiology. These game-based, team-oriented learning experiences are designed to simulate real-world clinical scenarios, encouraging learners to work collaboratively under time constraints to solve complex, context-specific puzzles. Studies have consistently reported high levels of student engagement, motivation, and satisfaction, suggesting that escape rooms serve as effective adjuncts or alternatives to traditional didactics and simulation-based training (Abensur Vuillaume et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Zhang et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Turner et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In medical education, escape rooms have been used to improve teamwork, communication, and clinical reasoning among residents and medical students, particularly in emergency medicine, internal medicine, and board exam preparation contexts (Gillespie, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Podlog et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Khanna et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In pharmacy and dental education, escape rooms have facilitated knowledge integration and skill application in areas such as diabetes management and interprofessional collaboration (Kavanaugh et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Zaug et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The design and implementation of these games range from live-action to virtual formats, offering adaptability and resource efficiency, which makes them attractive for widespread adoption across institutional settings.\u003c/p\u003e \u003cp\u003eIn terms of nursing education, escape room simulations (ERS) can help students develop clinical competencies, improve teamwork skills and solve clinical problems (Eppmann \u0026amp; Klein, 2018). In addition, it allows for the application of knowledge to practice in a safe, visual, highly interactive, and experiential learning environment. It was reported that the escape room approach was an effective adjunct to traditional clinical practice by offering a fun, socially interactive, motivating, and novel learning environment. In addition, the escape room approach increased the flexibility of program and curriculum development (Fotaris \u0026amp; Mastoras, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). However, the evidence on its applicability to healthcare education remains limited (Eppmann \u0026amp; Klein, 2018). A comprehensive literature review showed conflicting results and significant heterogeneity in purpose, room design, and evaluation methods, which makes direct comparison difficult (Fotaris \u0026amp; Mastoras, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; van Gaalen et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, the effectiveness of escape room simulations (ERS) in community health nursing (CHN) education has not been adequately reported. Given the increasing complexity and demands of community-based care, it is essential for nursing education programs to prepare graduates who are equipped to meet the evolving needs of diverse populations. Currently, there is limited evidence on the use of escape rooms as an educational tool for developing student competencies in CHN. To address these gaps and challenges, an ERS intervention was purposefully designed to enhance nursing students\u0026rsquo; competence and confidence in becoming effective community health nurses. The purpose of this study is to evaluate the impact of ERS as a supplement to traditional clinical placement within an undergraduate CHN course. If proven effective, this approach could serve as a valuable strategy to better prepare students to care for underserved and hard-to-reach populations, which are often underrepresented in conventional clinical settings.\u003c/p\u003e \u003cp\u003eTo accomplish the purpose, the Specific Aims were:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo evaluate the impact of the ERS on student confidence in community health nursing practice\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo evaluate the impact of the ERS on student competence in community health nursing practice\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo evaluate student experience in the ERS\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eWe chose a quantitative quasi-experimental design with a single group pre and post-test to evaluate the impact of ERS on undergraduate students\u0026rsquo; confidence and competency in community health nursing practice. This design allowed the project implementation and data collection without interrupting the existing nursing curriculum (Moore \u0026amp; Campbell, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample and setting\u003c/h3\u003e\n\u003cp\u003eThe participants were a convenience sample of nursing students who registered in a community health nursing course during the spring semester. Fifty-six participants were enrolled to the study. The ethics approval was obtained from the university Institutional Review Board (IRB). The informed consent was obtained from participating students. All participants were informed of their voluntary participation status. Upon receiving the signed inform consent, the study was conducted at the School of Nursing, Simulation Lab.\u003c/p\u003e\n\u003ch3\u003eDescription of the escape room simulation\u003c/h3\u003e\n\u003cp\u003eThe escape room simulation (ERS) was originally developed by a team of faculty and researchers with extensive expertise in community health nursing education, research, and practice. Its design was supported by funding from the National League for Nursing (Powers et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Powers et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). The original ERS aimed to evaluate interprofessional collaboration within community-based care settings. For this study, the simulation was adapted and redesigned to specifically assess core competencies and confidence in community health nursing (CHN), guided by the Quad Council Coalition (QCC) of Public Health Nursing Organizations\u0026rsquo; competency framework (Campbell et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The revised simulation emphasized several critical areas of CHN practice, including comprehensive assessment in home settings, awareness of social determinants of health (SDOH), transdisciplinary role flexibility (requiring nurses to assume roles typically associated with social work, occupational therapy, physical therapy, legal, and pharmacy), risk identification, and implicit bias awareness. Unlike the controlled and structured environment of acute care, community health nurses often operate in complex, unpredictable home and community settings with limited oversight or immediate support. As such, students must demonstrate a broad skill set, self-reliance, and confidence to navigate these multifaceted environments.\u003c/p\u003e \u003cp\u003eThe ERS was conducted in the School of Nursing\u0026rsquo;s simulation lab, with rooms staged to closely resemble home environments. Fourteen groups of four students each were formed, and each group was allotted 20 minutes to work through a simulated clinical case scenario. Each escape room incorporated health-related puzzles and realistic props, including mannequins, medication bottles, food items, durable medical equipment, and home furnishings, along with written cues designed to prompt students to assess risk factors, prioritize care, identify relevant community resources, and complete appropriate documentation.\u003c/p\u003e \u003cp\u003eTo support the development of CHN competencies and confidence, the ERS provided students with opportunities to simulate home visits with older adults, conduct comprehensive assessments, and identify environmental, physical, and psychosocial risks to safety and well-being. These immersive experiences also encouraged students to consider cultural contexts, make appropriate referrals, and exercise sound clinical judgment. Through these activities, students strengthened critical thinking, problem-solving, and team-based communication skills essential for delivering safe, empathetic, and culturally responsive care in community-based settings. The ERS emphasized the CHN roles of assessment, prioritization, documentation, reporting, referral, self-awareness, other-awareness, and environmental awareness. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e outlines the components of the ERS session, corresponding learning objectives.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEscape Room Simulation Setup\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePuzzle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRole and Responsibility\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLearning Objectives\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHazardous living\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudents assess a simulated home environment for potential risks, hazards, and signs of abuse.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIdentify and evaluate environmental, physical, and psychological risks.\u003c/p\u003e \u003cp\u003eRecognize signs of abuse and neglect.\u003c/p\u003e \u003cp\u003eDevelop strategies for reporting and addressing safety concerns.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudents evaluate the availability and quality of food in a simulated home setting.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAssess the adequacy of food supplies and nutritional quality.\u003c/p\u003e \u003cp\u003eIdentify indicators of food insecurity.\u003c/p\u003e \u003cp\u003eRecommend community resources and referrals.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudents review a simulated medication record, then assess patient medication practices.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDetect and address medication errors.\u003c/p\u003e \u003cp\u003eImplement proper medication management strategies.\u003c/p\u003e \u003cp\u003eDevelop plans for safe medication administration and patient education.\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\u003ePrior to ERS activities, the clinical faculty who led each group were provided with the ERS moderator guide. The participants were oriented to the room, tasks, puzzles, instructions and clues. They were aware that the overall objective was to escape as a team. Each ERS activity started with an introduction and description of each scenario in each \u0026ldquo;room\u0026rdquo;. After the participants successfully escaped, a 30-minute debrief session was moderated by trained faculty using the Debriefing Assessment for Simulation in Healthcare (DASH) guideline to support reflective learning (Niu et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eMeasures and data collection procedure\u003c/h3\u003e\n\u003cp\u003eTo determine the impact of ERS, we performed data collection at three time points: pre-ERS (T1), post-ERS (T2), 10 weeks after ERS session (T3). The instruments we used for data collection include 1) demographic form; 2) CHN competency checklist; 3) CHN confidence scale; and 4) Escape room experience perception scale. Prior to the ERS activity, the participants completed the demographic form, CHN competency checklist and confidence scale. At the end of the session, participants were asked to complete the CHN competency checklist, confidence scale, and escape room experience perception scale. Finally, 10 weeks after the ERS session, participants completed the CHN competency checklist and confidence scale.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCommunity Health Nursing Competency Checklist\u003c/em\u003e. This instrument includes 18 clinic competency skills for community health nursing practice required by the Quad Council Coalition (QCC) of Public Health Nursing Organizations (6). Students will report their competency for each skill by responding \u0026ldquo;Yes\u0026rdquo; or \u0026ldquo;No\u0026rdquo;. Each student\u0026rsquo;s competency will operationalized as the sum score the number of \u0026ldquo;Yes\u0026rdquo;. The Cronbach's alpha for the competency questionnaire was calculated based on the pre-ERS measurements and found to be 0.89. This high alpha value indicates excellent internal consistency.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCommunity Health Nursing Confidence Scale\u003c/em\u003e. This scale includes 18 items that are required skills for community health nursing practice. Students were asked to rate their belief in their ability to perform the listed clinical skills. Student self-reported their perceived confidence level on a 100-point scale, ranging in 10-unit intervals from 0 (\u0026ldquo;Cannot do\u0026rdquo;); through intermediate degrees of confidence, 50 (\u0026ldquo;Moderately certain can do\u0026rdquo;); to complete confidence, 100 (\u0026ldquo;Highly certain can do\u0026rdquo;). The higher sum score indicates greater confidence in practicing community nursing care. The Cronbach's alpha for this confidence questionnaire is 0.95 according to the pre-ERS data, indicating excellent internal consistency.\u003c/p\u003e \u003cp\u003e \u003cem\u003eEscape Room Experience Perception Scale.\u003c/em\u003e The scale contains 12 items that are divided in 4 domains: 1) Enjoyment, 2) Feasibility and Usefulness, 3) Relevance, and 4) Outcome and Effectiveness. Each item was measured on Likert-type scale ranging from 1 (strongly disagree) to 5 (Strongly agree). The higher sum score indicates the more positive learning experience during escape room simulation. This scale was administered following the conclusion of the escape room simulation session. The scale has a Cronbach's alpha of 0.97, which indicates outstanding internal consistency.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAll analyses were conducted using R studio (version 2023.06.1\u0026thinsp;+\u0026thinsp;524) with a significance level of 0.05. Descriptive analyses were performed to describe the study participants, student competencies, confidence and ERS experiences and perceptions. Frequencies and percentages were used for categorical variables, while means and standard deviations (SD) were used for continuous variables. A linear mixed effect model was employed to determine the effects of the escape room on competency and competency over three measure points (pre-ERS [T1], post-ERS [T2], and 10 weeks after ERS session [T3]). Linear mixed models are an extension of simple linear models to allow for analyzing data that are measured repeatedly over time. In particular, the model is specified as:\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:{Y}_{ij}={\\mu\\:}_{\\text{j}}+{\\alpha\\:}_{i}+{ϵ}_{ij}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ewhere \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:i\\)\u003c/span\u003e\u003c/span\u003e is the index of the student (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:i\\:=\\:1,\\:...,\\:56\\)\u003c/span\u003e\u003c/span\u003e) and \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:j\\)\u003c/span\u003e\u003c/span\u003e is the time index (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:j=1\\)\u003c/span\u003e\u003c/span\u003e represents pre-intervention, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:j=2\\)\u003c/span\u003e\u003c/span\u003e represents post-intervention, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:j=3\\)\u003c/span\u003e\u003c/span\u003e represents T3, 8 weeks after intervention). Let \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{Y}_{ij}\\)\u003c/span\u003e\u003c/span\u003e denote the competency or the confidence at the jth time point for the ith student, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\mu\\:}_{\\text{j}}\\)\u003c/span\u003e\u003c/span\u003e is the fixed effect for each time point, while \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\alpha\\:}_{i}\\)\u003c/span\u003e\u003c/span\u003e is the random effect for each student \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:i\\)\u003c/span\u003e\u003c/span\u003e, assumed to be independent and identically distributed (i.i.d.), following a normal distribution with mean 0 and variance \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\sigma\\:}_{\\alpha\\:}^{2}\\)\u003c/span\u003e\u003c/span\u003e. The random error terms \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{ϵ}_{ij}\\)\u003c/span\u003e\u003c/span\u003e are assumed to be i.i.d., following a normal distribution with mean 0 and variance \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\sigma\\:}^{2}\\)\u003c/span\u003e\u003c/span\u003e. We also assume that \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\alpha\\:}_{i}\\)\u003c/span\u003e\u003c/span\u003e and \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{ϵ}_{ij}\\)\u003c/span\u003e\u003c/span\u003e are independent. From model (1), it is easy to obtain that the expected competency for pre-, post, and T3 interventions is \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\mu\\:}_{1}\\)\u003c/span\u003e\u003c/span\u003e, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\mu\\:}_{2}\\)\u003c/span\u003e\u003c/span\u003e and \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\mu\\:}_{3}\\)\u003c/span\u003e\u003c/span\u003e, respectively. In particular, we can re-write model (1) as\u003cdiv id=\"Equb\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equb\" name=\"EquationSource\"\u003e\n$$\\:{Y}_{i1}={\\mu\\:}_{1}+{\\alpha\\:}_{i}+{ϵ}_{i1}$$\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Equc\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equc\" name=\"EquationSource\"\u003e\n$$\\:{Y}_{i2}={\\mu\\:}_{2}+{\\alpha\\:}_{i}+{ϵ}_{i2}$$\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Equd\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equd\" name=\"EquationSource\"\u003e\n$$\\:{Y}_{i3}={\\mu\\:}_{3}+{\\alpha\\:}_{i}+{ϵ}_{i3}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome further explanation: \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{Y}_{i1}\\)\u003c/span\u003e\u003c/span\u003e represents the competency level at pre-intervention for the ith student, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{Y}_{i2}\\)\u003c/span\u003e\u003c/span\u003e represents the competency level at post-intervention for the ith student, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{Y}_{i3}\\)\u003c/span\u003e\u003c/span\u003e represents the competency level at T3 for the ith student. In addition, R studio along with ggplot2 package were used to make spaghetti plots for the growth of CHN confidence and competency (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and 3).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eParticipants characteristics\u003c/h2\u003e \u003cp\u003eA total of 56 full-time students (53 female and 3 male) participated in the ERS activity. All participants completed all 3 data collections. Participant characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. A total of 56 participants\u0026rsquo; data were included in this analysis. The mean age of the sample was 22 years (SD\u0026thinsp;=\u0026thinsp;2.795; range 21\u0026ndash;42 years). Participants include 53 (94.6%) female and 3(5.4%) male. The racial demographics of the participants included 29 (51.8%) White, 11(19.6%) Black, 7 (12.5%) Hispanic and Asian respectively. A total of 41 (73.2%) participants speak English only, while 12 (21.4%) participants are multilingual. The average years of schooling are 16 (SD\u0026thinsp;=\u0026thinsp;2.084; range 14\u0026ndash;31 years). They were all full time students with average of 11 hours per week (SD\u0026thinsp;=\u0026thinsp;11.188, range 0\u0026ndash;40 hours). Most participants (82%) had unlicensed nursing work experience in various healthcare settings, including acute care (34%), ambulatory clinics, nursing home, assisted living, home health (7% respectively). The average length of employment was 41 months (SD\u0026thinsp;=\u0026thinsp;24, range 2\u0026ndash;96 months). Majority (23%) did not have previous escape room simulation experience. If they did, the average ERS experience was about 3 hours (SD\u0026thinsp;=\u0026thinsp;2.713, range 0\u0026ndash;10 hours).\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\u003eParticipants Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e or \u003cem\u003eN\u003c/em\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear of age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.84\u0026thinsp;\u0026plusmn;\u0026thinsp;2.795\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u0026ndash;42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (94.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (51.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle Eastern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMulti-race\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (73.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArabic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMandarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVietnamese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultilingual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear of Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.14\u0026thinsp;\u0026plusmn;\u0026thinsp;2.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u0026ndash;31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-time student\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent work (weekly hr.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.88\u0026thinsp;\u0026plusmn;\u0026thinsp;11.188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-nursing work experience (yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (82.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking places\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.78\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmbulatory clinics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkilled nursing facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRehab centers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNursing home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssisted living\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMulti-site\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of employment (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.22\u0026thinsp;\u0026plusmn;\u0026thinsp;24.235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious escape room experience (Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious escape room experience (hrs.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.77\u0026thinsp;\u0026plusmn;\u0026thinsp;2.713\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;10\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\n\u003ch3\u003eGroup assessment descriptives\u003c/h3\u003e\n\u003cp\u003eThe scores on Community Health Nursing (CHN) Competency Checklist and Confidence Scale were analyzed using data collected at pre (T1), post (T2), and 10 weeks after ERS activity (T3). The scores of Escape Room Experience Perception Scale were collected at T2. Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the minimum, median, mean, maximum, and standard deviation of CHN competence, confidence and perceived ERS experience at each data collection point. The participants\u0026rsquo; average competence score at T1 was 14.98, with a standard deviation of 3.88. The competence score rose to 17.39 (SD\u0026thinsp;=\u0026thinsp;1.27) at T2 and further to 17.85 (SD\u0026thinsp;=\u0026thinsp;0.62) at T3, indicating a notable improvement in participants' competence after ERS. Similarly, the average confidence score at T1 was 1295.56, with a standard deviation of 276.08. By T2, the score increased to 1535.98, accompanied by a smaller standard deviation of 204.09, and continued to rise to 1689.45 at T3, with a significantly lower standard deviation of 111.26. This demonstrates the role of ERS in strengthening participants' confidence levels.\u003c/p\u003e \u003cp\u003eAlong with the increased mean competence score, the standard deviation decreased (SD\u003csub\u003eT1\u003c/sub\u003e = 3.88, SD\u003csub\u003eT2\u003c/sub\u003e = 1.27, SD\u003csub\u003eT3\u003c/sub\u003e = 0.62). Likewise, the increase in mean confidence scores was accompanied by a decrease in standard deviation (SD\u003csub\u003eT1\u003c/sub\u003e = 276.08, SD\u003csub\u003eT2\u003c/sub\u003e = 204.09, SD\u003csub\u003eT3\u003c/sub\u003e = 111.26). This pattern of rising mean scores with declining standard deviations suggests not only overall improvement in CHN competence and confidence, but also reduced variability among participants. In other words, students became more aligned in their performance and perceptions over time. In this study, the ERS experience contributed to both increased competence and confidence, while narrowing the gap between high- and low-performing students. This indicates the ERS intervention was not only effective but also equitable in promoting consistency in student learning outcomes across participants.\u003c/p\u003e \u003cp\u003eThe Escape Room Experience Perception Scale was administered immediately after the ERS session at T2 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Participants reported an average score of approximately 60 (SD\u0026thinsp;=\u0026thinsp;8.19), indicating high satisfaction with the ERS activities. They perceived the experience as helpful and effective in supporting their clinical learning and practice in community health nursing.\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\u003eDescriptive statistics for student\u0026rsquo;s competence, confidence scores and escape room experience perception scale\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\"\u003e \u003cp\u003eCHN competence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMin\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMax\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-competence (T1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-competence (T2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10 week-competence (T3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eCHN confidence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-confidence (T1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1295.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e276.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-confidence (T2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1535.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1800\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e204.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10 week-confidence (T3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1720\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1689.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1800\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e111.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003ePerceived ERS experience\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEscape room experience perception scale (T2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIndividual competence and confidence growth by Spaghetti plots\u003c/h2\u003e \u003cp\u003eFigures \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e are the spaghetti plots used to visualize individual growth and between individual variability in CHN competence (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and confidence (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The spaghetti plots were made using ggplot2 in R, a powerful package for creating elegant data visualizations. A spaghetti plot (also called a line plot with individual trajectories) is a type of data visualization used to show how individual participants\u0026rsquo; CHN competence and confidence change over time across multiple measurement points (before the ERS activity session [T1], immediate after the ERS session [T2] and 10 weeks after the session [T3]). Each line corresponds to one participant (\"strand of spaghetti\") and represents each participant's competence and confidence scores across three time points. The x-axis shows the time points (e.g., before ERS session, immediately after the session, and 10 weeks after the session). The y-axis shows the score (e.g., CHN competence in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e or CHN confidence in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). All lines are plotted together, showing individual growth and between-individual variability over time.\u003c/p\u003e \u003cp\u003eCHN competence plot (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) shows how each student's perceived community health nursing (CHN) competence changes across three time points. The majority of lines trend upward from left to right, especially from pre- to post-ERS session, indicating a clear increase in competence. CHN confidence plot (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) tracks changes in CHN confidence levels across the same intervals. Again, most lines increase, especially from pre- to post-ERS session.\u003c/p\u003e \u003cp\u003eBeyond individual growth patterns, the spaghetti plots use a color gradient to represent the degree and direction of change over time in competence and confidence. The spectrum, from bright green to teal/blue-green, denotes the strongest improvement across the three time points. These lines typically begin with low baseline scores at T1 (pre-ERS) and rise sharply at T2 (immediate post-ERS), with continued growth at T3 (follow-up), indicating high responsiveness to the ERS session. Light to medium blue represents moderate responsiveness, with visible improvement at T2 and sustained or stable gains at T3. Orange to yellow-green indicates mild responsiveness, with limited gains after the ERS session and modest retention over time. Brown, olive, and dull yellow signify little or no improvement. These lines may remain flat or decline by T3, suggesting possible regression, unsustained effects, or other contributing factors such as burnout, lack of engagement, or data anomalies.\u003c/p\u003e \u003cp\u003eIn Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (Competence), participants with lines colored in green show the most substantial improvements in competence. Those in orange or yellow often started at higher baseline scores, limiting their potential for growth and resulting in smaller changes. A few participants show no improvement or a slight decline at T3 (flattened or downward trajectories), indicated by dull colors such as brown or olive. Notably, one participant's trajectory remains at the maximum score across all three time points, indicating a ceiling effect and no perceived benefit from the ERS session.\u003c/p\u003e \u003cp\u003eIn Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (Confidence), participants with bright green lines generally start with lower confidence and demonstrate marked improvement by T3. Conversely, orange or brownish lines remain flat or show minimal change, while a few trajectories dip or plateau at T3, indicating stalled or regressed confidence levels. These are represented in subdued tones like olive or dull yellow.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInferential analysis for Specific Aim 1 and 2\u003c/h2\u003e \u003cp\u003eThe participants\u0026rsquo; CHN competence scores significantly improved when compared between pre and post scores (t-statistic\u0026thinsp;=\u0026thinsp;6.413, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The estimated average competency scores for the pre-ERS, post-ERS, and T3 are 14.982, 17.392, and 17.870, respectively. The 95% confidence intervals for the differences in means (Post \u0026ndash; Pre and T3 - Pre) both exclude 0, indicating that these differences are statistically significant. An approximate 95% confidence interval for the standard deviation \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\sigma\\:}_{\\alpha\\:}\\)\u003c/span\u003e\u003c/span\u003e ranges between 0.862 and 1.795.\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 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRegression analysis for competence\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoefficients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStand error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFixed effect parameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\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\u003eIntercept (pre-competency)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(14.4, 15.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-competency \u0026ndash; pre-competency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.376\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.7, 3.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3-competency \u0026ndash; pre-competency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.378\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(2.1, 3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRandom effect parameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\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\u003eSD (study_id)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(0.8, 1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSD (residuals)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e(1.7, 2.3)\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\u003eA statistically significant increase was also noted in students\u0026rsquo; confidence in community health nursing practice after the completion of ERS activity (t-statistic\u0026thinsp;=\u0026thinsp;8.142, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The estimated average confidence scores at the pre-ERS, post-ERS, and T3 time points are 1290.687, 1535.982, and 1694.177, respectively. A 95% confidence interval for the standard deviation σ_α ranges between 105.966 and 189.578. The variations in students\u0026rsquo; demographic variables such as Previous ERS experience did not affect the differences in both confidence and competency scores between 3 measure points.\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 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRegression analysis for confidence\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoefficients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStand error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFixed effect parameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\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\u003eIntercept (pre-confidence)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(1234, 1347)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-confidence \u0026ndash; pre-confidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(186, 304)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3-confidence \u0026ndash; pre-confidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(341, 466)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRandom effect parameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\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\u003esd (study_id)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(106, 190)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esd (residuals)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(136, 181)\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"},{"header":"Discussion","content":"\u003cp\u003eNursing education faces persistent challenges in securing adequate clinical placements, especially those that expose students to diverse, underserved populations. To address this gap, our study explored the use of an escape room simulation (ERS) as an innovative educational strategy to enhance undergraduate nursing students\u0026rsquo; competence and confidence in community health nursing (CHN) practice. We implemented a team-based ERS activity designed to simulate home visits and community-based care scenarios, measuring student outcomes at three time points. Findings revealed significant improvements in both competence and confidence immediately after the ERS and sustained ten weeks later, with reduced variability across participants. Students also reported high satisfaction with the experience. These results suggest that ERS is not only an effective method for supplementing clinical learning but also holds promise in preparing students to deliver culturally sensitive, community-based care. Our project contributes to the growing body of literature on experiential learning in nursing education, aligns with university priorities for student success and diversity, and offers a scalable model for addressing clinical placement barriers while enhancing faculty and student engagement.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eContributions to existing literature evidence\u003c/h2\u003e \u003cp\u003eDespite growing interest, few studies have rigorously evaluated the impact of escape rooms on measurable student outcomes beyond immediate perceptions. Most published research relies on post-activity surveys that assess satisfaction, perceived knowledge gain, and engagement, with limited data on sustained competency development or longitudinal learning effects. This gap is especially evident in undergraduate nursing education, where only a small number of studies have explored escape room interventions for pre-licensure students (G\u0026oacute;mez-Urquiza et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the context of community health nursing (CHN), one study by Anguas-Gracia et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) evaluated Spanish nursing students\u0026rsquo; experience with an escape room integrated into a CHN course. Students overwhelmingly viewed the activity as enjoyable and motivating, reporting increased learning interest and appreciation for its novelty. However, this study focused primarily on affective responses and did not assess changes in clinical competence or confidence over time. Similarly, G\u0026oacute;mez-Urquiza et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) conducted a qualitative observational study that highlighted escape rooms as a positive experiential tool to assess emergency care competencies, teamwork, and decision-making. Yet again, objective outcome measures were lacking, and the application was not specific to CHN practice.\u003c/p\u003e \u003cp\u003eTo our knowledge, no published studies have longitudinally examined the effects of escape room simulations on pre-licensure nursing students\u0026rsquo; competence and confidence in community health nursing. Our study addresses this gap by aligning ERS intervention with CHN learning objectives and evaluating its outcomes across three time points. Unlike prior work, we captured both immediate and sustained changes in student performance, demonstrated reduced variability in learning outcomes, and linked student experience to measurable growth in CHN readiness. These findings contribute new evidence to the field and suggest that escape room simulations can serve as an equitable, scalable, and pedagogical strategy to support clinical learning, particularly in settings where access to diverse or sufficient clinical placements is limited.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSignificance and Implication of studying individual response to ERS intervention\u003c/h2\u003e \u003cp\u003eAnother significant gap addressed by our study is the use of individual growth plots to examine variations in how each student responds to the same ERS intervention differently, an approach not previously reported in similar studies. We employed spaghetti plots to visualize individual trajectories of competency and confidence across three measurement points. This method allows for a detailed analysis of within-subject change over time, in contrast to the group mean comparisons commonly used in existing literature. By capturing individual-level responses, this approach helps identify patterns of responsiveness (e.g., high-responders, low-responders, or non-responders), offering deeper insights into the intervention's effectiveness and informing targeted improvements within the undergraduate nursing curriculum.\u003c/p\u003e \u003cp\u003eThrough individual growth plots, we identified significantly different growth patterns in students\u0026rsquo; competence and confidence following a single session of ERS. The growth trajectories of all 56 participants are illustrated in Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (competence) and 2 (confidence). Notably, fewer distinct individual lines appear in the competence plot, largely due to overlapping or converging trajectories, which suggests a uniform response among participants. This pattern indicates that the ERS session had a relatively consistent impact on students\u0026rsquo; community health nursing (CHN) competence, with minimal variation across individuals. In contrast, the confidence plot reveals a greater dispersion of individual lines, reflecting more pronounced variability in how participants responded to the same intervention. These findings suggest that while the ERS uniformly enhanced competence, its effect on confidence varied considerably among students.\u003c/p\u003e \u003cp\u003eSeveral factors may explain the wider variation in confidence growth following a single ERS session. First, competence is typically associated with the acquisition of specific knowledge or skills. Because the ERS was designed to target defined learning objectives, it is likely that most students improved in a consistent, predictable manner. Confidence, on the other hand, reflects a psychological perception of one\u0026rsquo;s abilities. It is influenced not only by content mastery but also by personality traits, prior experiences, levels of anxiety, social comparison, and self-efficacy. Thus, students may interpret and respond to the same learning experience in vastly different ways. Second, the baseline confidence scores displayed much greater variability compared to baseline competence scores, suggesting that this variability may persist or even increase over time. Third, the nature of group dynamics and simulation-based learning may influence competence and confidence differently. As ERS sessions are often interactive and team-based, students\u0026rsquo; perceptions of group cohesion and teamwork quality may have a greater impact on their confidence than on their perceived competence.\u003c/p\u003e \u003cp\u003eThis divergence in growth trajectory suggests that while the ERS session was effective in promoting consistent skill development (competence), enhancing confidence may require additional instructional strategies. To foster more uniform gains in confidence, educators might consider incorporating structured reflection or debriefing sessions to help students process their experiences constructively. Additionally, individualized feedback can reinforce students\u0026rsquo; strengths, and creating psychologically safe learning environments may further support the development of self-efficacy. In summary, competence improved consistently because it was closely aligned with the ERS session\u0026rsquo;s learning objectives. In contrast, confidence varied widely due to the influence of internal, social, and emotional factors unique to each learner. These findings underscore the importance of addressing both cognitive and affective domains in the design of experiential learning activities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and strategies\u003c/h2\u003e \u003cp\u003eSeveral limitations should be acknowledged. First, we used a convenience sample of students, which may limit the generalizability of our findings to other institutions or regions. Although randomized controlled trials (RCTs) are considered the gold standard for evaluating intervention effects, implementing an RCT in an educational setting is often impractical and ethically challenging. It would be infeasible and potentially inequitable to offer the ERS to one group of students while withholding it from another group within the same cohort. A waitlist control design is similarly unworkable, as students transition to subsequent semesters and graduate, making delayed exposure to the intervention impossible. Therefore, a pre- and post-intervention design remains the most feasible and ethically sound approach for evaluating educational interventions such as ERS.\u003c/p\u003e \u003cp\u003eSecond, our assessment of competence, confidence, and student experience was limited to two time points, immediately following the ERS session and 10 weeks later. While this allowed us to detect short-term retention and delayed effects, it does not capture long-term learning outcomes. To address this, we plan to develop a tracking system to follow up with students after graduation to assess sustained application and retention of knowledge, skills and confidence gained from the ERS. Our data also revealed a less steep growth in competence and confidence between T2 and T3, suggesting that multiple ERS sessions throughout the program may be necessary to reinforce learning and prevent regression. Individual growth plots revealed that students\u0026rsquo; competence trajectories showed less variation than confidence trajectories, indicating that while skill development was more consistent, confidence building may require more individualized support. This points to the need for tailored advising and mentoring strategies to support students with lower responsiveness.\u003c/p\u003e \u003cp\u003eThird limitation is the absence of a qualitative component in our study. Student experiences were measured only through quantitative tools, which may overlook the depth and nuance of their learning. Incorporating focus group interviews or analyzing debriefing session transcripts in future studies could provide richer insights and help refine the ERS design to better meet learners\u0026rsquo; needs. For students who exhibited flat or declining growth trajectories, qualitative approaches may illuminate underlying barriers or challenges that cannot be captured through quantitative measures alone.\u003c/p\u003e \u003cp\u003eFourth, we also collected limited background data to reduce participant burden, but this may have resulted in overlooking potential confounding variables that could explain individual differences in responsiveness and the sustainability of ERS effects. Future studies will incorporate additional demographic and contextual variables to explore these potential covariates. Importantly, the tools we used to measure confidence and competence, although internally consistent, have not yet been validated for psychometric properties such as construct validity or test-retest reliability. Without established validity and reliability, longitudinal tracking of intervention effects remains limited. We are committed to ongoing data collection to refine and validate these assessment instruments.\u003c/p\u003e \u003cp\u003eLastly, this study did not assess team dynamics or the impact of debriefing sessions. These factors may significantly influence ERS outcomes. In future research, we plan to include structured evaluations of team interaction and debriefing quality. We will also apply triangulation methods, using multiple data sources and methodologies to validate our findings and strengthen the reliability and depth of our evaluation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThere is limited evidence on the use of escape rooms as an innovative educational tool for developing students\u0026rsquo; competencies in community health nursing. Our study contributes to pre-licensure nursing education by addressing this gap and adding to the growing body of literature on escape rooms in nursing education. The findings demonstrate that escape room simulations have a significant positive effect on nursing students\u0026rsquo; competence and confidence in community health nursing. We propose that escape rooms offer an effective and innovative approach to enhance clinical competency, enrich learning experiences, and provide meaningful exposure to underserved and hard-to-reach populations. Moreover, escape rooms help address several systemic challenges in nursing education. They can alleviate faculty workload, reduce clinical placement limitations, and accommodate diverse student learning needs. As safe, interactive, and engaging environments, escape rooms allow students to practice clinical decision-making without the pressures of real-world consequences. Within these simulated experiences, students can make mistakes, receive comprehensive feedback, and benefit from guided mentoring. They also develop critical thinking, apply theoretical knowledge in realistic scenarios, and build both confidence and competence in a risk-free setting. Furthermore, escape rooms foster the development of team communication and collaboration skills, ultimately preparing students to become confident, competent practitioners in various community health settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eERS: Escape room simulation; CHN: Community health nursing\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u003c/strong\u003e The authors would like to sincerely thank the undergraduate nursing students who participated in this study for their time, engagement, and valuable feedback. We extend our appreciation to Emily Gullena for her mentorship and expertise in using the Debriefing Assessment for Simulation in Healthcare (DASH) tool to assess the quality of our debriefing sessions. Special thanks to Melinda Pierce and Ashton Atmore for their vital simulation support in preparing and facilitating the escape room activities. We gratefully acknowledge Dr. Kelly Powers and her team for their contributions to the original design of the escape room simulation, which provided the foundation for this project. We also thank Rachel Caputo for her assistance and coordination throughout the implementation of the study. Their collective support was instrumental in the success of this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e: LY led the development of the grant proposal and secured funding for the project. She modified and implemented the study design, coordinated project execution, contributed to the original study concept, and led manuscript writing, revision, and submission. She was also responsible for study design, data oversight, and overall project administration. XN contributed to manuscript development and revision, conducted data analysis, and generated tables, graphs, and the analysis report. YGP contributed to manuscript development and revision, assisted in developing the data analysis plan, identified appropriate analysis software and statistical methods, and supported the generation of the data analysis report. TJ provided the conceptual framework and clinical expertise to guide the study design. She was involved in securing funding, recruiting and retaining student participants, project administration, coordinating with the simulation center, facilitating data collection, and managing administrative aspects of the project. MTJ contributed to the design of the intervention, assisted with grant proposal writing and budgeting, and supported drafting and revising the manuscript. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors received program funds from University of North Carolina Charlotte, Scholarship of Teaching and Learning (SoTL) grant program.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u0026nbsp;\u003c/strong\u003eThis study involved undergraduate nursing students, a population considered vulnerable in educational research. In accordance with the institutional review board (IRB) regulations and to protect participant confidentiality and privacy, the data collected cannot be shared with external research teams. Access to the data is restricted as per IRB-approved protocols.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbensur Vuillaume, L., Laudren, G., Bosio, A., Th\u0026eacute;venot, P., Pelaccia, T., \u0026amp; Chauvin, A. (2021). A didactic escape game for emergency medicine aimed at learning to work as a team and making diagnoses: Methodology for game development. \u003cem\u003eJMIR Serious Games, 9\u003c/em\u003e(3), e27291. https://doi.org/10.2196/27291\u003c/li\u003e\n\u003cli\u003eAdams, V., Burger, S., Crawford, K., \u0026amp; Setter, R. (2018). Can you escape? Creating an escape room to facilitate active learning. \u003cem\u003eJournal for Nurses in Professional Development\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(2), E1-E5.\u003c/li\u003e\n\u003cli\u003eAnguas-Gracia, A., Subir\u0026oacute;n-Valera, A. B., Ant\u0026oacute;n-Solanas, I., Rodr\u0026iacute;guez-Roca, B., Sat\u0026uacute;stegui-Dord\u0026aacute;, P. J., \u0026amp; Urcola-Pardo, F. (2021). An evaluation of undergraduate student nurses\u0026rsquo; gameful experience while playing an escape room game as part of a community health nursing course. \u003cem\u003eNurse Education Today, 103\u003c/em\u003e, 104948. https://doi.org/10.1016/j.nedt.2021.104948 \u003c/li\u003e\n\u003cli\u003eAllen, M. (Ed.). (2017). \u003cem\u003eThe SAGE encyclopedia of communication research methods\u003c/em\u003e. SAGE publications.\u003c/li\u003e\n\u003cli\u003eCampbell, L. A., Harmon, M. J., Joyce, B. L., \u0026amp; Little, S. H. (2020). Quad Council Coalition community/public health nursing competencies: Building consensus through collaboration. \u003cem\u003ePublic Health Nursing\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(1), 96-112.\u003c/li\u003e\n\u003cli\u003eEppmann, R., Bekk, M., \u0026amp; Klein, K. (2018). Gameful experience in gamification: Construction and validation of a gameful experience scale [GAMEX]. \u003cem\u003eJournal of interactive marketing\u003c/em\u003e, \u003cem\u003e43\u003c/em\u003e(1), 98-115.\u003c/li\u003e\n\u003cli\u003eFotaris, P., \u0026amp; Mastoras, T. (2019). Escape rooms for learning: A systematic review. In \u003cem\u003eProceedings of the European Conference on Games Based Learning\u003c/em\u003e (pp. 235-243).\u003c/li\u003e\n\u003cli\u003eGillespie, M. (2021). Escape the EM boards: Interactive virtual escape room for GI board review. \u003cem\u003eJournal of Education and Teaching in Emergency Medicine, 6\u003c/em\u003e(2), SG8\u0026ndash;SG45. https://doi.org/10.21980/J8H63F \u003c/li\u003e\n\u003cli\u003eG\u0026oacute;mez-Urquiza, J. L., Hueso-Montoro, C., Correa-Rodr\u0026iacute;guez, M., Suleiman-Martos, N., Martos-Cabrera, M. B., G\u0026oacute;mez-Salgado, J., \u0026amp; Albend\u0026iacute;n-Garc\u0026iacute;a, L. (2022). Nursing students\u0026rsquo; experience using an escape room for training clinical skills and competencies on emergency care: A qualitative observational study. \u003cem\u003eMedicine (Baltimore), 101\u003c/em\u003e(30), e30004. https://doi.org/10.1097/MD.0000000000030004 \u003c/li\u003e\n\u003cli\u003eKavanaugh, R., George, S., Lamberton, N., Frenzel, J. E., Cernusca, D., \u0026amp; Eukel, H. N. (2020). Transferability of a diabetes escape room into an accelerated pharmacy program. \u003cem\u003eCurrents in Pharmacy Teaching and Learning, 12\u003c/em\u003e(6), 709\u0026ndash;715. https://doi.org/10.1016/j.cptl.2020.01.022 \u003c/li\u003e\n\u003cli\u003eKhanna, A., Ravindran, A., Ewing, B., Zinnerstrom, K., Grabowski, C., Mishra, A., \u0026amp; Makdissi, R. (2021). Escape MD: Using an escape room as a gamified educational and skill-building teaching tool for internal medicine residents. \u003cem\u003eCureus, 13\u003c/em\u003e(9), e18314. https://doi.org/10.7759/cureus.18314 \u003c/li\u003e\n\u003cli\u003eMoore, L., \u0026amp; Campbell, N. (2021). Effectiveness of an escape room for undergraduate interprofessional learning: a mixed methods single group pre-post evaluation. \u003cem\u003eBMC medical education\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e, 1-8.\u003c/li\u003e\n\u003cli\u003eNiu, Y., Liu, T., Li, K., Sun, M., Sun, Y., Wang, X., \u0026amp; Yang, X. (2021). Effectiveness of simulation debriefing methods in nursing education: A systematic review and meta-analysis. \u003cem\u003eNurse Education Today\u003c/em\u003e, \u003cem\u003e107\u003c/em\u003e, 105113.\u003c/li\u003e\n\u003cli\u003ePodlog, M., Husain, A., Greenstein, J., \u0026amp; Sanghvi, S. (2020). Escape the trauma room. \u003cem\u003eAEM Education and Training, 4\u003c/em\u003e(2), 158\u0026ndash;160. https://doi.org/10.1002/aet2.10410 \u003c/li\u003e\n\u003cli\u003ePowers, K., Brandon, J., \u0026amp; Chen, F. (2025). Teaming Up for Community Health simulation intervention: A quasi-experimental study. \u003cem\u003eNursing Education Perspectives\u003c/em\u003e, \u003cem\u003e46\u003c/em\u003e(1), 30-36. http://dx.doi.org/10.1097/01.NEP.0000000000001253\u003c/li\u003e\n\u003cli\u003ePowers, K., Brandon, J., \u0026amp; Townsend-Chambers, C. (2022). Preparing nursing students for home health using an escape room: A qualitative study. \u003cem\u003eNurse Education Today\u003c/em\u003e, \u003cem\u003e108\u003c/em\u003e(Jan), Article 105215. https://doi.org/10.1016/j.nedt.2021.105215\u003c/li\u003e\n\u003cli\u003eRobertiello, G., Genee, J., \u0026amp; Marrera, A. (2021). Escape the sim! An escape room innovation to orient learners to the simulation environment. \u003cem\u003eNursing Education Perspectives\u003c/em\u003e, \u003cem\u003e42\u003c/em\u003e(3), 195-196.\u003c/li\u003e\n\u003cli\u003eTurner, A., Tichter, A. M., \u0026amp; Pillow, M. T. (2021). Let\u0026apos;s escape didactics: Virtual escape room as a didactic modality in residency. \u003cem\u003eJournal of Education and Teaching in Emergency Medicine, 6\u003c/em\u003e(2), SG46\u0026ndash;SG56. https://doi.org/10.21980/J8CH2X \u003c/li\u003e\n\u003cli\u003eUrcola-Pardo, F., Bl\u0026aacute;zquez-Ornat, I., Anguas-Gracia, A., Gasch-Gallen, \u0026Aacute;., \u0026amp; Germ\u0026aacute;n-Bes, C. (2018). Perceptions of nursing students after performing an individual activity designed to develop their critical thinking: The \u0026ldquo;critical card\u0026rdquo; tool. \u003cem\u003eNurse education in practice\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e, 35-40.\u003c/li\u003e\n\u003cli\u003evan Gaalen, A. E., Brouwer, J., Sch\u0026ouml;nrock-Adema, J., Bouwkamp-Timmer, T., Jaarsma, A. D. C., \u0026amp; Georgiadis, J. R. (2021). Gamification of health professions education: a systematic review. \u003cem\u003eAdvances in Health Sciences Education\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e(2), 683-711.\u003c/li\u003e\n\u003cli\u003eZaug, P., Gros, C. I., Wagner, D., Pilavyan, E., Meyer, F., Offner, D., \u0026amp; Strub, M. (2022). Development of an innovative educational escape game to promote teamwork in dentistry. \u003cem\u003eEuropean Journal of Dental Education, 26\u003c/em\u003e(1), 116\u0026ndash;122. https://doi.org/10.1111/eje.12678 \u003c/li\u003e\n\u003cli\u003eZhang, X. C., Lee, H., Rodriguez, C., Rudner, J., Chan, T. M., \u0026amp; Papanagnou, D. (2018). Trapped as a group, escape as a team: Applying gamification to incorporate team-building skills through an \u0026apos;escape room\u0026apos; experience. \u003cem\u003eCureus, 10\u003c/em\u003e(3), e2256. https://doi.org/10.7759/cureus.2256 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Escape Room Simulation, Competence, Confidence, Community Health Nursing, Pre-licensure Nursing Education","lastPublishedDoi":"10.21203/rs.3.rs-6873159/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6873159/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCommunity health nursing (CHN) clinical practice is essential for pre-licensure nursing students to develop the competence and confidence needed to deliver safe and effective care in patients\u0026rsquo; homes. However, clinical placements are often hindered by limited site availability, preceptor shortages, and inconsistent quality. Escape room simulation (ERS) has emerged as an innovative strategy to address these challenges and provide meaningful learning experiences. Despite its growing use, there is limited evidence on the impact of ERS in enhancing nursing students\u0026rsquo; readiness for home-based community settings. To address this gap, this study evaluated the effects of ERS on students\u0026rsquo; competence and confidence in CHN. A quasi-experimental, single-group pre/post design was used with 56 full-time undergraduate nursing students. Data were collected at three time points: before ERS (T1), immediately after (T2), and ten weeks later (T3). Instruments included the CHN Competency Checklist, CHN Confidence Scale, and ERS Perception Scale. A linear mixed-effects model showed statistically significant increases in both competency (t\u0026thinsp;=\u0026thinsp;6.413, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and confidence (t\u0026thinsp;=\u0026thinsp;8.142, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) from T1 to T2, with sustained or slightly improved scores at T3. Spaghetti plots revealed reduced variation in competence over time, suggesting consistent benefit across participants, while confidence growth showed greater variability, indicating individual differences in response. Students with lower baseline scores exhibited the most notable gains. Most had no prior ERS experience but reported high satisfaction. Findings support the integration of ERS into CHN curricula to enhance student preparedness, especially when clinical placements are limited.\u003c/p\u003e","manuscriptTitle":"The use of an escape room simulation in undergraduate community health nursing course: a single group pre-post evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-20 15:40:47","doi":"10.21203/rs.3.rs-6873159/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7b93e7f1-0d84-4ea9-937e-6726c298418b","owner":[],"postedDate":"June 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-22T02:38:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-20 15:40:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6873159","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6873159","identity":"rs-6873159","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}