One Size Does not Fit All: Gamified Escape Room Learning for Students With ADHD and Language Difficulties in a Quasi-Experimental Cohort Study.

Abstract

Aim: This study assessed the association between digital escape room-based instruction and academic performance among nursing students, with particular attention to students with attention-deficit hyperactivity disorder (ADHD) and language-related challenges.

Design: A retrospective quasi-experimental study compared the effects of digital escape room-based instruction with traditional teaching methods. Students enrolled in the 2024 and 2025 academic years received escape room instruction (intervention group), whereas students enrolled in the 2023 academic year received traditional instruction (control group). The course was taught by the same instructor throughout.

Methods: Academic performance data from 426 nursing students were analysed (intervention: n = 276; control: n = 150). Two-way analyses of covariance (ANCOVAs) examined the interaction between instructional condition and learner status (no difficulties, language difficulties or learning difficulties/ADHD), with age and gender as covariates. Outcomes included multiple-choice (MC), constructed response (CR) and total exam scores, with post hoc comparisons corrected using the Holm procedure.

Results: The Escape Room × Learner Status interaction showed significant but modest interaction effects for all outcomes: CR scores (F(2, 366) = 3.01, p = 0.05, η²p = 0.02), MC scores (F(2, 366) = 6.11, p < 0.01, η²p = 0.03) and total scores (F(2, 366) = 5.45, p < 0.01, η²p = 0.03). Students with language difficulties scored significantly lower on CR (d = -0.63, 95% CI [-0.97, -0.29]) and total scores (d = -0.57, 95% CI [-0.90, -0.23]) under escape room instruction. Students with learning difficulties/ADHD showed higher MC scores under escape room instruction (d = 0.68, 95% CI [0.17, 1.18]).

Conclusion: The findings suggest that gamified escape room instruction may have differential effects on academic performance across learner groups. Students with learning difficulties/ADHD demonstrated better performance on recognition-based tasks, whereas students with language difficulties may face challenges, particularly on tasks requiring written responses. In the context of nursing education, it is crucial to assess and adapt gamified teaching strategies to meet different learning needs rather than relying on a uniform approach. Nursing educators are encouraged to consider combining gamified learning with other teaching and assessment methods to promote inclusive and student-centered learning environments. When implementing gamified techniques, it is essential in nursing practice to tailor educational approaches to the varied learning needs of nursing students, particularly those with ADHD and other learning challenges. Multicenter research is needed to confirm these findings.

Patient or public contribution: This educational research study did not involve the participation of patients or the public in its design, execution or reporting.